#240 – Follow three diet rules to improve health, lose weight, and prevent diseases | Dr. Swaranjit Bhasin & Dr. Casey Means

What diet should you follow? Metabolic health experts say it doesn’t matter whether you’re keto, vegan, or otherwise if you focus on three simple principles, which will help reduce your risk for cancer and nonalcoholic fatty liver disease. Dr. Swaranjit Bhasin and Dr. Casey Means discuss the biomarkers to ask your doctor about, why they matter, how to improve those biomarkers with accessible tips, and why liver health is a big key to overall health.

Helpful links

Swaranjit Bhasin, MD: https://mydoctor.kaiserpermanente.org/ncal/providers/sbhasin 

Casey Means, MD, on Instagram: https://www.instagram.com/drcaseyskitchen/ 

Casey Means, MD on Twitter: https://twitter.com/DrCaseysKitchen

2:45 — A radiologist raises a red flag about increased diagnoses in younger patients

Swaranjit Bhasin, MD, a radiologist with Kaiser Permanente, explains his concerns about the increasing diagnoses of cancer and nonalcoholic fatty liver disease in people overall but especially in younger patients.

I’ve been a radiologist for 15 years with the TPMG and Kaiser. Some people might not know what a radiologist is, so I’m just going just describe basically what we do. We’re the doctors in the background. We’re consultants for your regular physicians. Whenever they order a CT or ultrasound or x-ray, we’re the ones that interpret that study and then give a report back to your doctors. Going through my 15 years of radiology, what I’ve seen is patients are getting sicker and sicker at a younger age. And there are two particular things that I really see: One is cancers in young patients. And over my career, the cancers that I diagnose as a radiologist—[the patients] have been getting younger and younger. I routinely, sadly, diagnose breast and rectal cancer in patients in their 20s and 30s. And this has really bothered me . . . Another thing that I’ve seen more routinely is nonalcoholic fatty liver disease. And I see that in younger and younger patients and more of my patients over the years . . . These two things are why I dove down the rabbit hole of metabolic health last year. I actually had to learn all the stuff that I did not learn in med school.

8:47 — Nonalcoholic fatty liver disease is a silent but serious problem

Many people with nonalcoholic fatty liver disease, also called NAFLD, don’t know they have the condition, and it is a growing problem in the United States.

We really need to call this out and really tackle nonalcoholic fatty liver disease because it’s the silent problem. There are two main forms of fatty liver disease: One is, alcohol induced, and that’s only 5% of the population in the U.S. The other one is the nonalcoholic fatty liver disease. One in three adults has nonalcoholic fatty liver disease, and one in 10 kids have nonalcoholic fatty liver disease. Again, the root cause is insulin resistance. This is the problem. This is where you have excessive fatty deposition in the liver, and we can routinely pick that up on our imaging studies. Normally, you’ll go see your doctor, you’ll get a liver function test, and your doctor will notice that there’s some elevation in your liver function test. What they will normally do is order a follow-up examination—usually an ultrasound because there’s no radiation associated with this. And then on the ultrasound we can see that there’s increased dense echogenicity of the liver. So normally the liver and the spleen—the dense echogenicity on those two are the same. But when there’s fatty deposition, we actually get increased echogenicity in the liver. And we can see that on ultrasound routinely. Over the years, I’m just seeing more and more of this. I really want to help the patients and members. And this is where we can really make a big difference with food-as-medicine, as doctors.

12: 59 — The importance of the liver

Liver health is imperative to overall health because it performs crucial metabolic health functions.

The liver is an essential organ with multiple life-supporting functions. I’m just going to name some of them: It produces bile, which helps with digestion. It makes protein for the body. It stores iron. It converts nutrients into energy. It creates substances that help your blood clot, and it helps resist infection by making immune factors and removing bacteria and toxins from your body. And this is where listening to Dr. Robert Lustig . . . One of those toxins that can only be processed in the liver is high fructose corn syrup. This is where the diet—when we’re having the sodas and stuff—that really the only place it can be processed is in the liver, and the liver has to work overtime to clear that toxin in the body. This is where, when you get deposition of fat in the liver, all of these functions are going to be hampered, and the liver will not function properly . . . We have to sound the alarm bell on nonalcoholic fatty liver disease.

16:59 — What are your most important biomarkers?

Dr. Bhasin explains the importance of triglyceride-to-HDL ratio, fasting insulin, and hemoglobin A1c.

I always like to make everything as simple as possible. Again, getting down to the root cause. And for metabolic health, I like the three biomarkers and labs that I’ve seen on Levels Health as well. Triglyceride-to-HDL ratio is really key on checking your metabolic health. And that’s where you want to be less than 2.5—and less than 1. 5 for African Americans. But I would say everyone should aim for optimal health. Everyone should be aiming for less than 1.5. The lower the better. Why be just in good health? Why not optimal? I really dove down into what are the simplest ones that we can use. And fasting insulin is the second one that we’re not routinely ordering. And this is where I would say we have 100 million prediabetics in the U S. And 8 in 10 do not know that they have prediabetes. We’re actually not catching these folks . . . We will never pick up these folks unless we’re doing fasting insulin. So I’m trying to bring fasting insulin mainstream . . . And then the third is hemoglobin A1c. Again, this is very familiar. It gives you what your glucose level has been for the last three months. But again, we do not want to wait till the glucose level rises. We want to catch it early because, again, we know the fasting insulin rises five to ten years before glucose does. So let’s catch these folks early.

31:50 — Casey Means, MD, summarizes Dr. Bhasin’s three rules for diet

The type of diet—whether keto, vegan, or otherwise—is less important than following three simple rules, according to Dr. Bhasin.

This is so helpful. And so straightforward: avoid processed seed and vegetable oils, eat a diet low in processed carbs and sugars and that uses healthy sources of fat, and practice intermittent fasting, based on a solid foundation of time-restricted eating with about an eight-hour eating window with two good meals. It’s amazing. It’s so accessible. I think I’ve seen in either our correspondence or in your presentations that another benefit of these three rules is that they’re totally dietary agnostic. You could be vegan, Paleo, autoimmune diet, carnivore. You could be any diet and actually still follow these principles, which I think is really amazing and accessible.

33:48 — Processed vegetable and seed oils are toxic to the body

Processed vegetable and seed oils are overconsumed in the United States. Metabolic health experts recommend avoiding these since they can drive inflammation. Instead, stick to avocado oil, olive oil, and butter.

I think everyone needs to watch how these vegetable oils are made. So this is where I would recommend just going on to YouTube and just put in “How is canola oil made?” and there’s a five-minute video that pops up. Once you watch that, there’s no one that can convince you that these things are healthy, because you’re getting to the root cause, you’re learning from first principles, you’re not trusting any of the stuff that someone is marketing to you. And this is where you really have to look at the money and the incentives. Docs should really be more aware of what kind of money incentives are involved in all of these things.

41:21 — Insulin resistance can drive cancer

Only in certain circumstances will patients receive cancer screenings earlier than the age recommended via guidelines for people at average risk. However, as Dr. Bhasin notes, insulin resistance is implicated in cancer and may be driving certain cancers in younger patients.

The sad part of my job is whenever I have to diagnose someone in their 20s or 30s with breast cancer or rectal cancer, because these patients will never go through the screening process. The screening process for mammography starts at 40, and then for colon cancer, it starts at 45. So these folks would never have had a screening examination. And I’ve seen a lot of data that insulin resistance is linked to these early cancers. We really need to call out this problem in order to help tackle this. And this is where there’s a test in radiology. It’s called CT PET imaging. So what we do is we take glucose and radiolabel it and then inject it in cancer patients. And where does that radioactive glucose go? It goes to where the cancer is. So this shows that cancer really loves sugar. If you’re insulin resistant, you’re going to have more glucose circulating in your body. And this will promote any cancer cells. It will really help it grow. And this is why we’re seeing insulin-resistant patients getting more cancers at a younger age.

51:56 — The importance of autophagy in helping to prevent cancer

Intermittent fasting is a tool that can boost autophagy, but it’s not appropriate for everyone.

In 24 hours of fasting, you kick in autophagy, where your body’s own cells will go around and clean up damaged cells. If we’re not giving our body a chance to do that, we’re actually not preventing disease and preventing the cancers. And if you can go to 36 hours, the autophagy kicks in 300%. So I would encourage my patients to try to do a 24- to 36-hour fast once a year. I’ve done a couple of 24-hour fasts. I’m working up toward a 36-hour fast. But this is where we should be writing more prescriptions for fasting. Let’s get the word out.

54:40 — Who should not engage in intermittent fasting?

Intermittent fasting is not appropriate for everyone.

Pregnant patients, someone who’s trying to get pregnant, and someone who’s breastfeeding should not be fasting. Anyone taking glucose-lowering medication or if they’re on insulin injections should not fast. And then also kids should not be fasting. What I usually recommend is doing the first two steps for kids: three good meals and try to eliminate snacking in between is key.

Swaranjit Singh Bhasin (00:00:00):

This is under our control. Lifestyle changes can really impact nonalcoholic fatty liver disease. And we know that from the data that it’s reversible if we change our diet. And this is where I’ve been thinking what’s a simple approach that we can really adopt and try to deploy in our system ourselves is where I really have come up with three simple steps that can help with reversing the fatty liver disease.

(00:00:30):

And I would say yeah, genetics is… It may be a very small portion for the ones that have hereditary elevated cholesterol and they need more support, but majority of this is from our lifestyle, which has changed drastically over the last 50 to 75 years. The diet changes and the amount of ultra processed foods, up to 70% of our diet is from ultra processed calories.

Casey Means (00:00:57):

Hello and welcome to A Whole New Level. My name is Dr. Casey Means and I am so excited to introduce Dr. Swaranjit Bhasin to our episode today. Dr. Swaranjit Bhasin is a radiologist at the Kaiser Permanente Medical Group, which serves over 12 million members in the United States. Hailing from New Delhi, India, Dr. Bhasin made the Bay Area his home as a child and earned his medical degree at Medical College of Wisconsin, did his residency at St. Joseph’s Hospital in Milwaukee and Wayne State University, and then did a fellowship at UC Davis Medical Center specializing in abdominal imaging.

(00:01:34):

I’ve been so excited to bring him on the podcast because as a radiologist, he has such a unique perspective in seeing what’s happening inside patients’ bodies, and he’s noticing trends in younger and younger people towards imaging findings of both metabolic dysfunction and fatty liver disease, as well as cancer, particularly of the rectum and the breast. And he is really sounding the alarm within the Kaiser system talking about how lifestyle related diseases rooted in insulin resistance like fatty liver disease and cancer are on the rise in young people, and he’s seeing it more and more over his 15-year career.

(00:02:17):

He has actually taken it upon himself to start counseling patients on how to reverse metabolic disease through a very simple three-step plan focusing on diet, and he’s doing a lot of education within the healthcare provider world within Kaiser to really sound the alarm of metabolic dysfunction and what we can do. So today, we are going to dive into those trends and give some really practical steps of how to understand more about your health, what biomarkers are important for both fatty liver disease and metabolic dysfunction, and what you can do to improve your metabolic health.

(00:02:52):

Welcome to A Whole New Level, Dr. Bhasin. We were introduced by Dr. Robert Lustig, a wonderful mutual friend, all being under the heading I think of metabolic evangelists. And I was so struck by our initial conversation that you and I had where you were talking about how you are actually seeing some increasing signs of metabolic abnormalities on the imaging studies that you’re looking at as a radiologist.

(00:03:21):

So I really wanted to bring you on and hear more about what it is you are seeing on these images of people’s bodies that are suggesting metabolic issues. Can you tell us more about what you’re seeing in your practice and why this is concerning to you?

Swaranjit Singh Bhasin (00:03:38):

I’ve been a radiologist for 15 years with TPMG and Kaiser. And basically some people might not know what a radiologist is, so I’m just going to just describe. Basically what we do is we’re the doctors in the background. We’re consultants for your regular physicians. And whenever they order a CT or an ultrasound or an X-ray, we’re the ones that interpret that study and then give a report back to your doctors. And going through my 15 years of radiology, what I’ve seen is patients are getting sicker and sicker at a younger age, and there’s two particular things that I really see.

(00:04:18):

One is cancers in young patients. And over my career, the cancers that I diagnosed as a radiologist has been getting younger and younger. I routinely, sadly, diagnose breast and rectal cancer in patients in their 20s and 30s, and this has really bothered me in the back of my head throughout my career. Another thing that I’ve seen more routinely is nonalcoholic fat liver disease. And I see that younger and younger patients and more of my patients over the years I’ve been diagnosing with nonalcoholic fatty liver disease.

(00:04:57):

And these two things are why I really dove down the rabbit hole of metabolic health last year and I actually had to learn all the stuff that I did not learn in med school, sadly. And that’s how I came about to how we can really reverse these things.

Casey Means (00:05:17):

That is so interesting. So over the course of 15 years, you’re starting to see more and more of these concerning diseases that we would typically associate with older people in a younger population. I think that, like you just alluded to, in medical school, we really weren’t taught a metabolic framework for health and an understanding of how so many diseases and conditions we’re seeing our fundamentally rooted in metabolic issues.

(00:05:49):

And you’re seeing it from this really unique perspective of actual imaging of the organs inside the body. So can you share a little bit about how that unfolded for you, that journey to seeing certain things on imaging findings, but then making this huge unfolding of figuring out this is metabolic disease and it’s getting worse in younger people. What was that journey for you?

Swaranjit Singh Bhasin (00:06:16):

Last year, I really wanted to find the answer. How can we really help our members and our patients? Because fatty liver disease is a disease that does not have any pharma therapy. So this is one thing that we all know. I’ve heard my GI colleagues talking about this and actually one of my colleagues gave a talk on this fatty liver disease last year, and that was my wake up call that this is something that we’re going to see. By the end of this decade, there’s going to be more cirrhotics due to nonalcoholic fatty liver disease than hepatitis, and there is no medication to treat.

(00:06:58):

So this is where I really wanted to help my patients that I’m diagnosing routinely. And the way to do that is through our diet. And then when I looked at these cancers and nonalcoholic fatty liver disease, what’s the link? What’s the link between all of these chronic diseases? The link is insulin resistance. If you look at all the different things that we have, the chronic diseases, everything boils down to insulin resistance.

(00:07:31):

I’m a big fan of Elon Musk and Tesla and getting down to the root cause from first principle thinking. You want to get down to what is the really root cause and tackle that, rather than I think we’re right now taking care of different symptoms and different organs with different medications. But hey, now we have something, nonalcoholic fatty liver disease, there’s no medication. How do we help our patients? And when we help our patients with dietary changes for nonalcoholic fatty liver disease, guess what?

(00:08:08):

There’s positive side effects. There’s side effects of preventing cancers. There’s side effects of reversing heart disease and type 2 diabetes and pre-diabetes. All of this is linked together, and the root cause, again, is the insulin resistance is key.

Casey Means (00:08:25):

Well, one thing just to dig deeper on what you just said, which was that cirrhosis, which is this end stage scarring of the liver, which from my understanding is pretty much irreversible and is when you’re starting to think about liver failure and transplants and things like that, it was hepatitis, a viral illness that was really the leading cause of this. And then of course, alcoholism was a big factor.

(00:08:51):

And now we’re seeing this big rise in nonalcoholic fatty liver disease as a big cause of late stage chronic scarring from long-term inflammation of the liver. So I think what would be really helpful is just if you can explain what exactly is nonalcoholic fatty liver disease, what is going on in the liver during this process, and maybe also how it’s diagnosed.

Swaranjit Singh Bhasin (00:09:15):

And this is where I think talking to Dr. Lustig and he points it out, that this is the silent epidemic of today. We really need to call this out and really tackle nonalcoholic fatty liver disease because it’s the silent problem. There’s two main forms of fatty liver disease. One is alcohol induced and that’s only 5% of the population in the US. The other one is the nonalcoholic fatty liver disease and one in three adults has nonalcoholic fatty liver disease and one in 10 kids have nonalcoholic fatty liver disease.

(00:09:56):

And again, the root cause is insulin resistance. This is the problem and this is where you have excessive fatty deposition in the liver. And we can routinely pick that up on our imaging studies. Normally you’ll go into your doctor, you’ll get liver function tests and your doctor will notice that there’s some elevation in your liver function tests. And what they will normally do is order a follow-up examination, usually ultrasound, because there’s no radiation associated with this. And then on the ultrasound, we can see that there’s increased dense echogenicity of the liver.

(00:10:35):

So normally the liver and the spleen, the echogenicity on those two are the same. But when there’s fatty deposition, we actually get increased echogenicity in the liver and we can see that on ultrasound routinely. And sad to see, over the years, I’m just seeing more and more of this. I really want to help the patients and members and this is where we can really make a big difference with the food as medicine as doctors.

Casey Means (00:11:04):

And are you also seeing this on imaging studies that are ordered for other reasons? Are there patients who come across your screen that essentially had a CT scan or maybe an ultrasound for bowel obstruction or diverticulitis or an ovarian cyst or something and then you just happen to notice that they have a fatty liver that you’re like, whoa, why is this not in their chart, this has just not been seen? Or is that something that’s happening as well, like incidental findings of fatty liver disease, as opposed to the people who actually are sent for the imaging study for the elevated liver blood tests?

Swaranjit Singh Bhasin (00:11:47):

Definitely. We see this routinely. Through the emergency room, we use CT routinely to diagnose. If you’re coming in with abdominal pain, we’re just going to do a CT scan. If you have some chest pain, we’re considering PE. You’re going to get a chest CT scan. And on those examinations, we routinely see fatty liver and we’re calling fatty liver on those. Even chest, whenever we do a chest CT, we catch a little bit of the upper portion of the liver and on that we can tell if there’s any fatty deposition.

(00:12:25):

Not just the routine cases, I’m seeing it for other tests that are being ordered for other reasons. And this is where we should not think of fatty liver and we should not say, “Oh, we see this routinely.” We should not get used to this in healthcare. Fatty liver disease is a significant problem and we really must have a concerted effort to reverse this before it progresses on.

Casey Means (00:12:52):

It’s helpful I think to honestly just paint a picture from physician perspective of why the liver matters. It may not be obvious to people why the liver is important and why having fat in the liver could create problems. So if you’d be open to just maybe doing a little bit of a medical lesson of what does a liver do, why does fat stop it from doing what it’s supposed to do, and what’s the physiology of fatty liver disease.

Swaranjit Singh Bhasin (00:13:25):

Yeah, I hope I make my GI doctors proud, but this is where… Liver is an essential organ with multiple life supporting functions. I’m just going to name some of them. It produces bile, which helps with digestion. It makes protein for the body. It stores iron. It converts nutrients into energy. It creates substances that help your blood clot, and it helps resist infection by making immune factors and removing bacteria and toxins from your body. And this is where listening to Dr. Robert Lustig, one of those toxins that can only be processed in the liver is high-fructose corn syrup.

(00:14:09):

This is where the diet. When we’re having the sodas and stuff, the only place it can be processed is in the liver, and the liver has to work over time to clear that toxin in the body. And this is where when you get deposition of fat in the liver, all of these functions are going to be hampered and the liver will not function properly with all of our problems. You want to be in optimal health to be healthy and prevent some of these things. So this is where liver is very, very important. It’s a little bit ignored, but we cannot, we have to sound the alarm bell on this nonalcoholic fatty liver disease.

(00:14:50):

And I think Central Valley where I practice is probably the canary in the coal mine. We have significantly higher rates of diabetes and obesity in the Central Valley itself. And when you have higher rates of diabetes and obesity, they go hand in hand with nonalcoholic fatty liver disease. So again, all of these things are linked through the insulin resistance.

Casey Means (00:15:18):

So we’ve talked a little bit about how you can actually see fatty liver disease on ultrasound and CT scan. What other biomarkers like blood-based biomarkers can you use to help get a sense of whether there may be fatty liver disease or general metabolic issues?

Swaranjit Singh Bhasin (00:15:38):

Usually the liver function tests are a great place to hone in on and the ALT and AST. If I’m contemplating, oh, this looks like fatty liver, I actually review the chart and I’ll take a look at it and I’ll see what the ALT level is. And usually the numbers that we give on the labs, the range is really wide. But from all the experts that I’ve seen, Levels health is one of the areas which I use your expertise on, the number that I usually use is a number of 25.

(00:16:16):

Anything above 25 is abnormal for ALT. And if I’m seeing the findings on my imaging along with the elevated ALT above 25, that’s what I’m giving the diagnosis of fatty liver. Because sometimes on the imaging it can be very subtle finding, but this is when I jump onto the chart and take a look at the labs and see what the ALT level is.

Casey Means (00:16:42):

Amazing. Are there any other biomarkers that you look at to get a sense of is this person metabolically unwell or hint that there might be some type of metabolic process in the works?

Swaranjit Singh Bhasin (00:16:57):

This is a great question. Because when we look at someone, we cannot tell if they’re metabolically healthy. So we really need something to check under the hood. This is where I tell everyone, I always like to make everything as simple as possible. Again, getting down to the root cause. And for metabolic health, I like the three biomarkers and labs that I’ve seen on Levels health as well. The triglyceride to HDL ratio is really key on checking your metabolic health, and that’s where you want to be less than 2.5 and less than 1.5 for African Americans.

(00:17:41):

But I would say everyone should aim for optimal health. Everyone should be aiming for less than 1.5. The lower the better. Why be just good health? Why not optimal? Really dove down into what are the simplest ones that we can use, and fasting insulin is the second one that we’re not routinely ordering. And this is where I would say we have 100 million pre-diabetics in the US and eight in 10 do not know that they have pre-diabetes. We’re actually not catching these folks. Acronym I’ve heard TOFI, thin on the outside, fat on the inside.

(00:18:24):

We will never pick up these folks unless we’re doing this fasting insulin. So I’m trying to bring fasting insulin mainstream, also in our organization, discussing it, bringing it up whenever I can. And then the third is hemoglobin A1C. Again, this is very familiar. It gives you what your glucose level has been for the last three months. But again, we do not want to wait until the glucose level rises. We want to catch it early. Because again, we know the fasting insulin rises five to 10 years before glucose does, so let’s catch these folks early.

Casey Means (00:19:02):

Yeah, those are some of our favorites as well. I’m curious, I don’t know if you’ve written up or started to compile the rates at which you’re seeing these findings, whether incidental or otherwise, but you mentioned that nationally it’s about one in three adults have fatty liver disease and one in 10 kids now have fatty liver disease. I’d be curious, how is that comparing to what you’re seeing coming across your desk on scans? Do you feel like that’s pretty representative of what you’re seeing, like 33% of adults, 10% of kids? Or are you seeing higher rates based on radiologic scans?

Swaranjit Singh Bhasin (00:19:42):

I would say the location that I’m practicing in, the Central Valley, I’m actually seeing a lot higher rates than that. The rates will vary according to the geographic location and where I’m practicing it is significantly higher. I would say the adults close to 50% of the adult scans. I’m a body imager, so I usually am reading the cases for abdomen and pelvis CT and ultrasounds. Almost half of the patients that I’m reading have a nonalcoholic fatty liver disease. And I’m reading them as positive.

(00:20:23):

And again, kids, I’m seeing significant rise in amount of fatty liver in kids as well, and I would say it’s higher than the one in 10 numbers. And I’ve looked at some of the literature, the latest things, I’ve seen numbers coded as high as up to 45% of adults have nonalcoholic fatty liver disease. The higher number aligns more with what I’m seeing on the ground.

Casey Means (00:20:51):

And I know this is a question most people will think or ask is like, well, how much of this is genetic and how much of this is lifestyle? How much is preventable? How much of this is because we’re picking up more of it now? What are your thoughts on that? Should those numbers for both adults and kids be close to 0% if our diet and lifestyle were really dialed in?

(00:21:13):

Or maybe if we can shift gears and start to talk about what are the environmental risk factors for fatty liver disease? And what numbers should we be shooting for in terms of burden of nonalcoholic fatty liver disease in the population?

Swaranjit Singh Bhasin (00:21:31):

Yeah, this is where I would say this is under our control. Lifestyle changes can really impact nonalcoholic fatty liver disease. And we know that from the data that it’s reversible if we change our diet. And this is where I’ve been thinking, what’s a simple approach that we can really adopt and try to deploy in our system ourselves? And this is where I really have come up with three simple steps that can help with reversing the fatty liver disease.

(00:22:11):

And I would say yeah, genetics is… It may be a very small portion for the ones that have hereditary elevated cholesterol and they need more support, but majority of this is from our lifestyle, which has changed drastically over the last 50 to 75 years. The diet changes and the amount of ultra processed foods. Up to 70% of our diet is from ultra processed calories. This has significantly changed and that really gets to the root of the problem.

Casey Means (00:22:49):

So I’d love for you to walk through what the three steps that you have put forward are for reversing fatty liver disease, but I think more broadly it’s focused on reversing insulin resistance. And yeah, maybe you can just walk us through the protocol that you have developed and talk through how you are sharing that with patients. Because from my understanding and from when I worked in hospitals and residency and medical school, radiologists weren’t typically getting involved in management suggestions for patients.

(00:23:25):

Typically, they were sharing the result of the scan, interpretation with the primary care doctor or the specialist or whoever had ordered the scan, and that was pretty much it. There was very limited actual patient interaction. So can you talk about how you developed your three part plan and how you’re engaging with patients and how that’s different than a typical radiologist?

Swaranjit Singh Bhasin (00:23:48):

This is a little trifold actually. My son helped put this together, taking my three step CME that I’ve presented at multiple Kaisers really well received. The docs are loving the message, and a lot of them have started utilizing it themselves. So as a radiologist, I don’t have that much patient interaction. The one place I do is mammography. So radiologists are the ones that read mammograms. If we see something abnormal on your screening mammogram, what we’ll do is we’ll give a call back.

(00:24:25):

We need to have you come back. And sometimes it’s just overlapping breast tissue. So I would tell anyone, “If you get called back from your screening, don’t get worried. Most of the time it’s a negative follow-up.” So when the patient comes in, I see that everything is pressed out. Everything’s normal. I actually started sitting down with my patients now and saying, “Okay, you’re going to come back for your next screening in one year. And in between now and your next screening, I have three simple steps to help prevent cancer.”

(00:25:02):

So what I show is this is the front of the… It’s a little trifold. So I show them the front. I tell them we’re trying to reverse all of these six things right here and we’re trying to prevent cancer and dementia and what is the root cause. Usually I do this within about a minute or two, very quick, and I tell them the root cause of poor metabolic health is insulin resistance. This is the elephant in the room that I think we need to call out more in healthcare. This should be in all the conversations that we’re having.

(00:25:38):

Even the radiologist is discussing insulin resistance. So this is where we need everyone in the medical system to be involved. And here’s the simple three steps that I usually tell my patients. I tell them to avoid seed and vegetable oils, really highly processed all of these ones. I’m just going to name them so everyone hears it on the podcast, canola, corn, cottonseed, soy, sunflower, safflower, grape seed, and rice brand. So these eight are really, really unhealthy, made with a lot of chemicals.

(00:26:17):

And for each one of these steps, I had an expert come out to Central Valley and speak to our doctors in the beginning of this year. For the first step, I had Dr. Cate Shanahan come out and talk, and she really dives into these really well with a biochemistry background. And one thing she really said that really resonated with me and it really has stuck in my head, she said that the toxicologists have done studies on these and show that a large fries at any fast food chain, the toxins are equal to 28 cigarettes.

(00:26:53):

So the toxicologists are having their meetings, they’re yelling at the top of their lungs that this stuff is really, really bad, but MDs have their separate meetings and we’re not listening to each other. So we need to start listening and really adopt this message that these things are really bad. And then we really need to give healthy alternatives to our members. “Okay, doc, we’re not using this. What should we use instead?” So these are the simple six that I like to usually bring up.

(00:27:23):

There’s many other healthier ones, but again, keeping the message simple, straightforward, so it sticks, olive oil, avocado oil, butter, clarified butter, coconut oil, and beef tallow. These are the simple ones. And you can look at the processing of each one of these very simply made versus how these are made. It really shows what the difference is. Second is to eat a diet low in processed carbs and sugars that uses healthy sources of fat. And again, CDC is telling us we’re eating too much sugar.

(00:28:00):

We really need to call that out and really cut down our sugar. And this is a graph that I usually tell my members, remember this picture, again, want this message to stick. Carbohydrates, huge insulin response. So I’m just showing a picture with the blood insulin response for different macronutrients. Carbohydrates, huge peak. Protein is in the middle and fat is almost like a flat line. So this is where healthcare marketing, we should be unvilifying healthy fats. We need to do a better job in healthcare to get this message out.

(00:28:40):

And again, carbs we got to cut down and the sugars. And again, Americans are eating up to 70% of our calories from ultra processed foods. Here’s a simple method. Many have probably heard this message before, stick to the periphery of the grocery store. Because stuff in the middle, 90 to 95% are addictive substances, not even real food. So we really need to make our members aware. And whenever I make my presentations right now in Kaiser, I tell them next time you step into the aisle, I want you to remember me.

(00:29:18):

I want you to remember this message. When you’re walking through, hey, put your guard up. There’s a lot of stuff in there filled with high-fructose corn syrup and vegetable oil. So please be careful. And then the last step is practice intermittent fasting built on solid foundation of time restricted eating. This is where I think the big food marketing has been winning. I was under the impression that this was a healthy way of eating. So a couple of years before, I was actually doing this.

(00:29:52):

I was doing six small meals a day. I used to eat snacks in between meals thinking that was healthy, but this promotes insulin resistance. What most adults need to do is eat two good meals in an eight-hour window. Once we get this message out, I think most of our members really want to be healthy. They want to lose weight, they want to be in good health, but we are not getting the clear message out. I think that eat less, move more does not work. We need to throw that out and really bring about the message of intermittent fasting.

(00:30:31):

And there was a great New England Journal of Medicine article from 2019. I think it’s a sentinel article. They reviewed 80 different papers and showed all the benefits of intermittent fasting. And this is where the second step, I had Dr. Lustig come out and speak to us. And then the third step, I had Dr. Jason Funk come out and talk to us. I mean, if you have not heard Dr. Jason Funk about intermittent fasting, please jump onto YouTube and learn from the pro.

Casey Means (00:31:03):

I’m looking over at my bookshelf to see The Complete Guide To Fasting, one of the best books. It’s by Jason Funk. So helpful. Also, Obesity Code and Diabetes Code, his books, talk about fasting are amazing. Wow, incredible experts that you brought out, and this is so helpful and so straightforward. Avoid processed seed and vegetable oils, eat a diet low in processed carbs and sugars, that uses healthy sources of fat, and practice intermittent fasting based on a solid foundation of time restricted eating with about an eight-hour eating window with two good meals.

(00:31:37):

It’s amazing. It’s so accessible. I think I’ve seen in either our correspondence or in your presentations that another benefit of these three rules is that they’re totally dietary agnostic. You could be vegan, paleo, autoimmune diet, carnivore, you could be any diet and actually still follow these principles, which I think is really amazing and accessible. So this is great. I would love to double click into processed seed and vegetable oils because I have found that this one is still so controversial.

(00:32:16):

And I think probably, unfortunately, a lot of the controversy around it is because a lot of the nutrition research out there is totally compromised based on industry influence and all sorts of things. But there’s still a lot of literature out there that states that these processed vegetable oils are heart healthy choices. So can you talk a little bit about what the main points around industrially processed seed oils are of why they are totally not healthy and promote insulin resistance?

(00:32:48):

And I’ll just add one other thing, which is that I think it also confuses people because we talk about insulin resistance and we think about sugar and refined grains and, of course, seed oils… By themselves, a seed oil is not immediately going to spike blood sugar or insulin. So maybe just speaking through a little bit about why over the long-term it’s a problem and what your main points of the problematic elements of these are.

Swaranjit Singh Bhasin (00:33:12):

Right, and this is where I think everyone needs to watch how these vegetable oils are made. So this is where I would recommend just going onto YouTube and just put in how is canola oil made, and there’s a five-minute video that pops up. So once you watch that, there’s no one that can convince you that these things are healthy because you’re getting to the root cause. You’re learning from first principles. You’re not trusting any of the stuff that someone is marketing to you.

(00:33:49):

And this is where you really have to look at the money and the incentives. I think docs should really be more aware of what kind of money incentives are involved in all of these things. And I would even go back as 1971, Nixon took us off the gold standard. And if you look at the utilization of seed and vegetable oils and high-fructose corn syrup, after the ’70s, it’s just a really steady rise. And this is where the incentives, big food will market to you that these things are healthy, but you need to learn yourself.

(00:34:33):

And this is where I really follow the ethos from now is don’t trust, verify. You got to verify where are you getting the information. Even a radiologist here is telling you to do something. Don’t trust this message. You have to verify the three simple steps that I’m telling you will really work and reverse your metabolic disease and reverse all the things that I’m saying. We really have to look at the money and this is where everyone needs to watch the video. It’s an eyeopener.

Casey Means (00:35:05):

It sure is, yeah. And I mean, is the main thing that concerns you that these oils, they’re heavy in omega-6 fats and they are pro-inflammatory, or you also mentioned that the fries have a lot of toxins, are those other toxins that you’re talking about, things that are carried through from the industrial manufacturing process? Or what is the element of the seed oils that is really causing problems for human health?

Swaranjit Singh Bhasin (00:35:39):

It’s the processing itself. And if you watched the video, they’re using a lot of chemicals. During the washing, they’re using bleaching during the process, and they use deodorant because the stuff smells bad at the end of the process. It’s all a combination, and this causes excessive oxidative stress in the body. And this is where I brought in Dr. Cate Shanahan, and she’s amazing. She really explains what all the different toxins and what kind of oxidative stress it creates in the body.

Casey Means (00:36:15):

Amazing. Yeah, it’s one of those areas where for reasons that are just, I think you talked about it a little bit, of you have to follow the money on some of this stuff, but there’s still confusion being seeded, no pun intended, in consumers about what’s healthy and what’s not. And sometimes we’re all trained to be focused on evidence-based medicine and yada, yada yada, but it’s also just common sense. Watch a video about how canola oil is made and look at it.

(00:36:48):

And then just ask yourself, do you want this disgusting industrial pesticide covered sludge, this byproduct of essentially a sludge going into my body or not? And it’s almost like we’ve lost touch with common sense. It’s abhorrent. I’ve seen these videos. And it’s sacrilegious to say this as a physician, but it almost doesn’t even matter what the literature says, I do not want that in my body. And it’s like, I don’t know why, but we have really I think almost thrown out common sense to some extent when it comes to nutrition.

(00:37:26):

It’s become such a controversial topic. But I agree with you that watching about how these things are made and how horrifying it is to look at, it’s like that’s not what you want your body to be built out of. So I appreciate you. I think it’s very telling that as a physician really passionate about metabolic health, one of your three rules has to do with oils. This is not a secondary thing. It’s really a primary thing. So I’d love to hear a little bit about if you have any success stories about patients that you have shared these three simple rules with.

(00:38:05):

For people who have implemented these strategies, first of all, do you see patients adopting them? And how quickly do you think a person could see positive shifts in their liver imaging or their biomarkers if they really commit to time-restricted eating, intermittent fasting, reducing unhealthy fats and reducing or eliminating refined sugars and grains?

Swaranjit Singh Bhasin (00:38:31):

The three simple steps I’ve started since the beginning of this year, so I don’t have that much follow up, but what I did was I started with my radiology staff initially. They’re the ones that I educated first, and some of the staff really, really got enthusiastic and ran with it. I’ve had one of our staff members, she’s lost 40 pounds since the beginning of this year. A couple of radiologists have recently reached out to me. One of them told me that they lost 20 pounds in about a couple months and another one lost about 10 pounds in a month.

(00:39:16):

Then I would say, I’ve actually followed these three simple steps also for the last year or so, and I’ve noticed what I’ve… I was never really overweight, but I’ve noticed it was very easy to lose visceral fat. So I’ve lost about 10 to 12 pounds and it all went away from the belly area itself. I did all those three lab tests that I recommend for myself, and pleased to say my triglyceride to HDL ratio was under one, fasting insulin was less than six, and then hemoglobin A1C was 5.5. I think the optimal is five or less, so I can still work on that a little bit, so always room to improve.

(00:40:04):

And this is where the message is it really resonates and it really empowers the members. The members that I’ve talked to when they come in in between screening, they really, really appreciate the message and they’re willing to do the three steps. So I’ll probably see the same members maybe in a year from now if they do get called back and if I see them on the follow-up, so I would know a little bit more.

(00:40:33):

And this is where I’m working with our GI doctors in Central Valley and I’ve discussed these three steps and they love the message. And I’m hoping that they’re going to provide some feedback, because I usually recommend those three steps whenever I do read the fatty liver on imaging itself.

Casey Means (00:40:52):

Amazing. I’d like to circle back to what you were talking about with cancer. So first, you mentioned that rectal and breast cancer, you’re starting to see more and more in a younger population. What is the link between insulin resistance, fatty liver disease, and cancer? And why do you think we’re seeing more of these particular types of cancers in younger people?

Swaranjit Singh Bhasin (00:41:18):

Really the sad part of my job is whenever I have to diagnose someone in their 20s or 30s with breast cancer or rectal cancer because these patients will never go through the screening process. The screening process for mammography starts at 40, and then for colon cancer, it starts at 45. So these folks would never have had a screening examination. And this is where insulin resistance, I’ve seen a lot of data that insulin resistance is linked to these early cancers. We really need to call out this problem in order to help tackle this.

(00:42:04):

There’s a test in radiology. It’s called CT/PET imaging. So what we do is we take glucose and radio label it and then inject it in cancer patients. And where does that radioactive glucose go? It goes to where the cancer is. So this shows that cancer really loves sugar. If you’re insulin resistant, you’re going to have more glucose circulating in your body, and this will promote cancer cells. It will really help it grow. And this is why we’re seeing insulin resistant patients getting more cancers at younger age.

(00:42:48):

I’ve actually reached out to our regional oncology team. And the thing about metabolic health is these things permeate all different specialties of medicine, so cardiologist, endocrinologist, oncologist, surgeons, Everyone can really get behind the metabolic health message. And this is where I’m reaching out to our regional cancer teams, how can we integrate this into our protocols where when someone is diagnosed with cancer, we’re giving them the optimal diet that can really help augment their cancer treatment and at the same time also prevent cancer recurrence in the future?

(00:43:37):

And again, this is where I’ve seen a lot of positive things with ketogenic diet. We really need to unvilify ketogenic diets in healthcare. We need to get the message out that this is the way to really help our members. I know there’s a lot of ongoing studies studying ketogenic diets with cancer, so I think we’re going to be seeing a lot more data coming out soon, so I’m really excited about that, but we should not wait for that to come out before implementing.

(00:44:09):

So I’m getting the conversation going in our organization that let’s get this optimal diet to our patients ahead of time for prevention and also to augment treatment and prevent for future recurrences.

Casey Means (00:44:27):

If you’re open to sharing a little bit about what the reception has been with the doctors that you are sharing this information with. I mean, the first thing that, of course, comes to mind is why in the world would this not just automatically be the focus of Kaiser? Kaiser serves, I think, over 12 million members. Metabolic disease is basically decimating the American population and much of the global population.

(00:44:55):

Why is it that you are this person who’s sounding the alarm as opposed to this just being the way we practice medicine? And especially in large systems like Kaiser where you would actually imagine, I think, that in a more HMO system that you’d really be wanting to get to the root cause of things because of the way the financial system works. I’m sure you’ve thought a lot about the systems issue level of this.

(00:45:28):

Why are you sounding the alarm and probably others like you within the organization as opposed to just this just being the central way that we look at health and that we’re promoting? And what has been the reception been when you’ve really started bringing this up and giving lectures on this to other doctors in other departments?

Swaranjit Singh Bhasin (00:45:47):

The message is really, really well received. I’ve done five CME events at different Kaisers, and the feedback has been overwhelmingly positive. And this is where it’s hard. We don’t learn metabolic health and nutrition in medical school, so all of us actually have to learn this on our own. And I think it’s very tough. When you’ve been in practice for 10 to 15 years or 20 years, it’s very hard for you to change your practice itself. And primary care doctors do not have that much time when they’re seeing patients and members.

(00:46:29):

So what I’ve done is I’m trying to make the process very easy, so they would have a very easy way of explaining it to patients how to reverse disease. I did another presentation in the community out in Central Valley, and I just did a simple presentation for the three simple steps. Very well received because it’s a simple message that can be implemented by anyone. And once you hear it, you can actually pass it on to any of your friends and colleagues. And that’s where I tell everyone that gets a message, I want you to at least tell 10 other people this three simple steps.

(00:47:06):

Please share with others because we need to exponentially grow this. And again, I had another event, it was last week in our regional team in Oakland, and that was the most enthusiastic reception that I’ve had. They really loved the message that they got. They all decided that they’re going to go ahead and check the triglyceride to HDL ratio, and they’re going to have me come back for their next quarterly meeting. And they’re actually going to give me some feedback how they’re doing on their metabolic health.

(00:47:47):

I got one of my astute dieticians to join when we go back. That way we can answer questions. So bringing the different parties together, but this is where I think what we’ve done in our system, we cannot go with the same method because we’ve seen the diabetes and obesity rate has just… I usually show a map of the US over the years, a CDC map of diabetes and obesity rates, and it just gets darker purple where the disease is just getting worse and worse. So we really need to shift the paradigm where we’re preventing these things.

(00:48:29):

So I’m hoping for a big paradigm shift where we’re really empowering our members to take charge. In between their clinic visits, they can get healthy outside the medical system, not just when they get sick they come in and we help them. We’re trying to reverse the diseases, so we’re trying to keep them healthy outside. And this is where a lot of the dietary stuff really makes a big difference.

Casey Means (00:48:58):

Well, a couple other questions for you before we wrap up. I’m just so curious, having a seasoned radiologist on the line here, what are your thoughts on some of these trends that we’re seeing in the more direct to consumer wellness space of consumerized imaging studies?

(00:49:16):

So being able to go in and do a full body MRI with something like Prenuvo, just general take on whether this is positive. Should we be more proactive with getting body imaging for prevention, or are you concerned that these are going to bring up more incidental findings that we track down and cause more fear? Where do you fall on that?

Swaranjit Singh Bhasin (00:49:40):

Yeah, I’ve seen some of those examinations, the full body. I think these things are great, and I’m glad someone is working on them, because what the eventual goal would be to bring the cost down significantly over time. And with AI integration into medicine and radiology, we should be able to bring the cost down significantly and have less problematic callbacks. But at the same time, right now it is out of reach and expensive.

(00:50:15):

But this is where let’s empower our members to really prevent disease and also prevent cancers. And I would say in the near future, these things will probably most likely go mainstream and really help and tackle disease, but there’s a big almost a zero costs solution to preventing cancer that would really advocate for at this point.

Casey Means (00:50:50):

And what is that?

Swaranjit Singh Bhasin (00:50:50):

Dietary changes. You have to really watch what you eat. When you go out to the fast food, please be careful with the fries and the sodas. The liquid calories have to go is what I tell most of my patients. Let’s start cooking more at home. And I think the message of the seed and vegetable oils is actually getting across. I’ve seen recently that there’s a couple of nationwide food companies that have went… They’re advertising that they’re seed oil free. So I think the members and patients are starting to demand this.

(00:51:28):

And as consumers, when we start demanding these things, the food industry will change. So let’s be more vocal about it. And then this is where the last step, the intermittent fasting, very, very powerful. It’s a cost savings to you when you’re not eating a certain meal. You’re saving money and you’re improving your health. And this is where the stuff that I’ve learned that 24 hours fasting, you kick in autophagy where your body’s own cells will go around and clean up damaged cells. If we’re not giving our body a chance to do that, we’re actually not preventing disease and preventing the cancers.

(00:52:09):

And if you can go to 36 hours, the autophagy kicks in 300%. So I would encourage my patients, try to do a 24 to 36 hour fast once a year. I’ve done a couple of 24 hour fast. I’m working up towards a 36-hour fast, but this is where we should be writing more prescriptions for fasting. Let’s get the word out.

Casey Means (00:52:36):

I didn’t know that about the 300% increase in autophagy with a 36-hour fast. That’s amazing. My boyfriend and I actually have implemented… For a couple months now, we fast basically Sunday after dinner to Tuesday morning. So it’s a 36-hour fast, give or take a couple hours. It’s amazing how easy it gets just after a few weeks. Because you get to have dinner on Sunday, you go to bed, you wake up, you’re not that hungry.

(00:53:06):

What we’ve really realized is that the only actual hard part of the fast is about 2:00 to 6:00 PM on Monday, because it’s sort of like you’ve skipped breakfast and you’re hungry. And then once we’re both home from work and we’re chatting and it’s about four hours before bedtime, that’s actually you’re distracted, might take a walk or something, but 2:00 to 6:00 on Monday is very… It’s challenging because you want to eat. It’s middle of the day, you’re working. But if you can get through that, then you go to bed and you wake up and you eat again.

(00:53:39):

And it’s like, that wasn’t that bad. And actually during that 2:00 to 6:00 PM time, I’ll have some tea, I’ll have some water, zero calorie drinks and stuff, maybe some sparkling water. But as someone who loves to eat more than almost anything in the entire world, I’ve been astounded by how if you get in the habit and actually think about really break down what’s challenging about it, it’s actually just a very limited period of time that’s hard. And we feel amazing on Tuesdays. It really does feel like something’s been cleaned up a little bit.

(00:54:14):

I don’t know how to explain it, but highly recommend if it’s safe for you. Fasting is not safe for everyone at all times. And so you actually mentioned this I think in your presentation, I’d be curious for you to just run through situations in which people should think a little bit more carefully about fasting and what populations should you just be a little bit weary about too much fasting.

Swaranjit Singh Bhasin (00:54:39):

Right. For pregnant patients or someone that’s trying to get pregnant, someone that’s breastfeeding should not be fasting. Anyone taking glucose lowering medication like they’re on insulin injections should not fast. And then also kids should not be fasting. What I usually recommend is doing the first two steps, try to give kids three good meals and try to eliminate snacking in between is key. And these are some of the ones that should not fast.

(00:55:13):

I think we have to break the message of… I think we’ve been ingrained by food marketing that if we go without a meal, we’re going to pass out or faint. It’s almost built in that, oh my god, you haven’t eaten for the whole day or you skipped breakfast. How can you do that? That’s the most important meal of the day. But this is where, again, the marketing really gets in the way.

(00:55:42):

I think we need to do a better job in healthcare marketing to really break through the big food marketing. They have a really big budget. They do a good job, and I know they’ve been winning, but we can do much better and get the message out of healthcare marketing.

Casey Means (00:56:00):

Definitely. Okay, final question for you. You are a parent and you are very focused on metabolic health and healthy diets. A lot of our Levels members are our parents, and one of the big struggles that people face is how do we inspire kids to eat metabolically healthy and to live a metabolically healthy life, especially in the face of a lot of uphill battles with childhood nutrition right now. So what are some of the tactics or tips that you have for inspiring healthy eating and healthy lifestyles in children?

Swaranjit Singh Bhasin (00:56:35):

For kids, we’re actually empty nesters this year, but ever since I’ve learned about all of this stuff, I’ve been telling our teenagers that what you want to do is, again, try to eat three good meals and try to cut out snacks is key. I think snacking is something that is really ingrained in our society and culture. It’s always available. If I go to the break room, there’s always snacks there. Your kids in college, they always have snacks available. I think we really need to get away from the snacking culture, and that can really make a big difference for kids’ health.

(00:57:21):

And again, let them know, large fries at fast food chain, 28 cigarettes. You got to imprint that in their head also. And this is where we can go to a place to get healthier alternative fries. I know a place in Modesto that makes their fries and beef tallow, so something healthier. We can get healthier fries. You can make it at home. So give alternatives. Do not fear the fat. Let the kids know. Butter should not be feared. Clarified butter should not be feared. I used to do that in the past. I used to tell my wife, easy on the gee, the clarified butter, but now I let her use it sparingly.

(00:58:07):

And yeah, these are the simple… The first two steps really build it for the kids. Avoid these really bad oils. They need the healthy fats, so have the healthy fats in their diet. And then the more we can cook at home, I think it really makes a big difference. And show them how to make simple meals with two, three ingredients. It doesn’t have to be complex the diet itself. And again, yeah, the message is all diets can be healthy. You choose a diet. We should all be free to choose the diet.

(00:58:44):

And this is something that I see in healthcare is we tend to focus on one thing or another. We tend to push just whole food, plant-based. We need to really get away from the messaging of what kind of diet, but empower our members with the simple principles that they can use and they’re not changing their… A lot of people have cultures and beliefs with the food that they eat. It’s very tied into who we are. So we should not really try to change that. Let’s just empower our members with a simple message of how they can really be healthy or whatever diet they choose.

Casey Means (00:59:24):

Amazing. Well, thank you so much for sharing, such a wealth of information. I have so much respect for you as a trailblazer, as someone who is doing things differently and going against the status quo treadmill that many of us are on in the healthcare system. And it’s just so inspiring. I know you’re inspiring countless other physicians.

(00:59:52):

I know that the people listening to this are going to take away a lot of really valuable messages. So if you would be open to just sharing about if people want to find out more about your work or resources that you have, is there anywhere online that is best for people to follow or connect with you or any resources you’d like to share with people who have listened?

Swaranjit Singh Bhasin (01:00:13):

Thanks again for having me and helping me get this healthcare marketing out for me. And this is where I’m just getting started. I haven’t really created any YouTube channel yet, but I have a few more podcasts lined up, and I’m hoping to really get the message out throughout the community, as well as in our system, in Kaiser too.

(01:00:37):

There’s a Yammer group that I started up in Kaiser Permanente. We have folks from all over the country. Kaiser gives care to millions across the nation, and we have folks that I’m trying to really empower throughout the region. And this is not just doctors, nurses, MAs, PAs, everyone should be involved in this simple message.