31. Amy Shah, MD: Combating Burnout and Fatigue, Circadian Fasting, & Finding Balance

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Before I introduce this week's guests, a quick story time brought to you by LocumStory.com. Today we'll be reading One Job, Two Job. One Job, Two Jobs, Red Blood Blob, No Job. Elective Doc, Emergency Doc, Summon Overstock, Summon Out of Stock. This doc is too abused, this doc is utter used. This doc can't get sick, say, let's try a brand new trick. For all the docs about to cry, here's an idea you can try. Look into Locum Tennis Assignment, a really great option you might find it. Don't forget Locum's pays much better, and you can find assignments in any type of weather. With all this new info, track up in your thinker, go to financialresency.com, slash LocumStory, and use your mouse to thinker. It's here you'll find the unbiased answers you're after, so you can decide if Locum Tennis is your next chapter. Our guest today is Dr. Amy Shah. Dr. Shah is a double board certified physician and wellness expert specializing in food allergies, hormones, and gut health. She graduated Magna Cum Laude from Cornell University with a major in nutrition. She went on to complete her medical training at Albert Einstein College in New York, followed by a residency training at Harvard, and fellowship in allergy and immunology at Columbia University. To this day, Amy continues to employ her primary and advanced medical training in a busy practice, but she's well known for helping busy people transform their health using cutting edge nutritional and medical science. Amy's also known for the concept of circadian fasting, which she talks about at length in her book, I'm so effing tired. So in this episode, we talk a lot about why and how we are also tired. We learned about Amy's journey to burnout and what made her reflect and change her practices. Amy dispels some misnomers that are often used when describing fatigue and exhaustion. For my healthcare practice, Amy talks about trying to find balance between being anchored to the research in the conventional sense and also utilizing more novel and purchased health patients. We also discuss circadian biology and Amy gives some practical tips on ways we can do that immediately to enhance our quality of life. Now for those who follow Amy on Instagram, you know her name is Fasting MD, so of course we touch on Fasting quite a bit as well. For those who don't follow Amy, get on IG, Twitter, LinkedIn, and follow her. I promise it'll be worth your time. Now with that further delay, please enjoy this discussion with Dr. Amy Shah. All right, everyone, today we have an awesome guest with us, Dr. Amy Shah, Amy. How are you today? Thanks so much for having me. I'm great. Awesome. Well, I've been following you for a while now on Instagram. I forget how long have you been on Instagram for now? So officially, I've been on Instagram for years, maybe like four or five years, but I think I've really started posting and being more present about a year and a half ago. Okay, yeah, because your growth has been insane. I remember following you and you probably had about 13 or 14K, and now you're up to you know, 100,000 or more. So it's just been awesome to see your growth with everything educational, and that's exactly why we brought you on here is you just have so much knowledge. So can you tell us a little bit about your journey and kind of how you started off? What made you kind of want to go to medicine? My journey is one that so many of you, I'm sure you can relate to. I was burned out, I didn't know how to take care of myself. I was in a situation where I knew I wasn't feeling the way I should be feeling. My energy levels were so low, I had poor digestion, I was having all these food sensitivities, and I was looking up things like our patients do, like adrenal fatigue and hormone imbalance and, you know, gut health issues, and it's such a shame because I thought, why do I not know this knowledge, or why aren't we teaching other people this, the stuff that I'm coming across through my research, and I was in nutrition major undergrad. So I knew that there was like a foundation through food and gut health. So basically, I had this turning point when I had a really bad car accident in the middle, at the worst possible time in my life, I had a car accident. I was starting my own new practice, and I had all this pressure to make it work. And then I had my second set of boards coming up. As you know, every time you subspecialize, you have to take another set of boards, and I had my, an allergy and immunologies, like two boards combined into one. And so I had that board coming up, and I had two little kids, or I have two little kids still, but they were little then. And I was trying to be, you know, do it all. I really wanted to be a great doctor. I wanted to be a great mom. I wanted to, you know, feel good, look good. I want to figure out what my long-term career path was. And in the worst possible time, when I just was working on all of those things, I had this huge car accident. And for me, it was just a wake-up call. I felt like when I looked back at the events of the day, you know, it's always like that. You look back at the events, and you see what pace of life you're living, and the fact that I was never present. When I was out of meeting, I was thinking about going home, and when I was going home, I was thinking about what I should be doing for the next day. And when I was studying, I couldn't concentrate on any of those things. So that few weeks that I had to take off, because I was literally like, unable to go to work, and my car was in the shop. I had to make a plan of to change my life. It was like, it was not a choice anymore. So that's really what spurred me. That was when I started to write about wellness and health. I started to listen to podcasts like yours, and read some books, and start to formulate my own plans for myself and the people who are interested. So that's basically how I started. Yeah, and so when you talk about your car accident, I mean, I'm sure, like you said, we all have those moments where we're always thinking about the next day, right? We can't slow down. We're shoving food into our mouths. We're burning out essentially, right? And you wrote a book on it called, I'm so effing tired. Yeah. Take this through kind of the moments leading up to that car accident, maybe. What were your thoughts going up to that? Because I think we know burnout isn't just a single strike. It's something that builds up in us and then our cup overflows almost. Yeah. And I think that there are so many times in our lives that we experienced burnout, but I think the intensity for me was because I was now a mom, and the stakes were higher. It wasn't just like passing or feeling a med school exam or it was like, I wasn't going to be successful as a physician if I didn't get my hat together. I was going to fail as a mom. It's not like these responsibilities and mistakes were just so much higher. And I found that my old coping techniques, one, didn't work, and two, I almost didn't allow myself to do it because it almost, so things like going for an exercise or a nature walk or run felt to me like I was being selfish because I thought, oh my god, with all my free time in the evenings, after my kids go to bed, I should be studying, getting my practice materials ready for the next day, working on the finance part of my practice. I mean, you know, the messages to us are that to be successful in this world, you must work at all costs. And it's a badge of honor to be burned out and burning the candle at both ends, as we say. I mean, you know in training and in medical school and after, it is like you're proud to say that you overworked and that you didn't sleep and that you gave up all your hobbies and free time. And so that's what I did. I basically gave up everything I thought was considered free time or, you know, time I controlled and I put it all towards what I thought were my bigger priorities. And what happened is I ended up getting deeper and deeper into this burnout and the state of illness that, you know, a lot of us are living. And so that's kind of, it was getting to the point where I was really anxious all the time about, you know, what was going to happen next like. And my not only had to worry about the finances of the practice, but of, you know, the patient care, like, was I doing everything right? Because this was real world. Like this was, like I said, the stakes were just so much higher at that point. And I think that's what really culminated before the car accident. And of course, no one event can change everything. But when I look back at it, I was like, oh yeah, it just, that is when I really said, I need to make a big change and then it kind of snowball from there. Yeah, Tasha, you know, you talk about the badge of honor. I think about it. One of our previous guests, Max Shank, who talked about when most people in today's society look at these awards is the badge of honor and the certificate of suffering. They talk about, right? And we kind of wear that in our sleeve and busy is good, busy, busy. And he was talking about how he doesn't even like it. Other people are busy. And I feel the same way. I'm, you know, when people can just sit back and relax, I'm happy. Unfortunately, I might have picked a wrong profession for that. But, you know, the, the behavior that you've been modeling and what you've routinely talked about and things that I want to touch on, particularly the medicine and how we can help combat and some of the strategies. But it's not just unique to medicine, right? I mean, it's, it seems to be an epidemic and pretty much any specialty, any field. But I'm curious, you touched on a concept of adrenal fatigue. Say more about that. What does that mean? So adrenal fatigue, as it's described on the internet, is really inaccurate. We basically have an HPA axis, so hyperfilamic pituitary adrenal axis. And it's like a highway. And the way I describe it in my book is like, it starts in your brain. And then it starts off like a busy highway like you would find in any big city where there's exits and on ramps and off ramps. But there, if there's an accident anywhere in that system, you're going to get a slowdown in the entire system. And so what seems like it's coming from the adrieals can be coming from your brain, can be coming from your thyroid, can be coming from, you know, your ovaries for women, your testes for men. It's not a singular problem that you can supplement your way out of. And so that is something that I learned. Because I thought, we adrenal fatigue, we never learned about this. And then the more I realized that it was this concept that's mostly talked about in alternative medicine and functional medicine, they realize a real issue here is a hormonal imbalance that often stems from poor gut health, poor mind body connection. It's not necessarily because you have too little or too much a hormone. It's that these other regulators like your brain and your gut are off balance. And so it's causing this whole slowdown of the whole system. Yeah. And it kind of what you're discussing here is the kind of the dysregulation of the endocrine system, which, you know, in medical school, we'll be learning about that. We're always looking at the data, right? We're looking at the lab findings, you're talking about TSH, you're looking at growth hormone, things that you touched on. But often it's not rooted. Those things don't light up. For instance, I know you've talked about your story when you saw some physicians and the lab values came all clean. And people said, hey, you know, actually, tell us more about that. Like what happened there? And then, you know, how often have you seen that with your patients? When everything looks okay on paper, but the patient in front of you tells you, I'm so effing tired. What's up? All the time. Think about it. Our system, our entire medical system is based on, you know, catch me when I fall medicine or like pick me up after I've hurt myself. It is not meant to make you stronger like you as your sports medicine. You know, like it's about building up those muscles, building up that body so that you don't actually fall in the first place. It's not only about catching you when you're completely broken and on the ground. And so what happens when you check hormones and you check all these labs, we are equipped to see major deficiencies like, you know, if your cortisol is zero or, you know, you have true broken organs and hormones, you will find it under blood work. But often what we are dealing with with hormonal imbalances is subtle hormonal imbalances. Things are still within the realm of the huge normal, even though it's not normal for you. It looks like it's a normal range. And we just don't have the tools to pick up on the nuances. We really don't have the testing. I see people for food sensitivities and GI issues all the time and they ask me like, so why can't you just test me for the things I'm allergic to or that the, and you know, they're not talking about true food allergies. They're talking about GI sensitivities or, you know, food intolerances, which we don't have the ability to detect and same with hormonal imbalances. We just don't have the ability to check for that in the blood. No matter what everyone tells you, you know, people get confused because they check on the internet. They're like, well, I saw that you can get a test for this and you can get a test for that. And because there's so much competing information and misinformation on the internet, that they're like so many people I went to the smartest colleagues and I got the best testing available. And everything was within normal limits and it was embarrassing because I could've sworn that something was going to be way off. And that was, you know, they said to me, you know, you're getting older. You have a lot of stress in your life. This is, you know, common to feel this way. And so I kind of felt embarrassed and like defeated when I left because I thought, wow, I just wasted a lot of time and energy. And I feel like I was one of those doctors all don't want to be that patient. That's like annoying and getting blood testing for no reason. And I felt like that. And I knew in my mind that something was wrong, but I didn't, there's nothing that came up. So I basically had to do my own research and try to figure it out. And that's really what my journey has brought me to is that there is a difference between optimization and just living. Like what I was doing was living the default life, which is a fast fast track to burnout. And what I wanted to do is live a life where, you know, it was sustainable, was healthy, where I felt good. I started to really get interested in anti-inflammatory lifestyle and diet and, you know, the blue zones, the blue zones were around the world. These are areas that people live long, healthy lives over a hundred and are still functional. I mean, that's like the goal, right? So started to study what these, those people were doing. And what the research was saying about how to eat and how to live. And I slowly started changing things, things that are super easy. And that's why I talk about them. Actually, my Instagram handle is fasting MD because a few years ago, I started to talk about this. And people are like, oh yeah, we know about the anti-inflammatory food. We know, you know, you're not supposed to eat processed food. We know walking and exercise. But what is this other thing you're talking about? This whole, you know, intermittent fasting, circadian rhythms. What is that? And so I ended up educating people a lot on that topic and becoming kind of the expert in that area. And of course, now I want to change it back and I can't because Instagram is like blocked me from like, it's like, I literally have like I own Dr. Amy Shaw also. But I cannot for the life of me figure out how to contact Instagram because they won't let me change it. So I'm stuck. Well, it's not a bad handle to be stuck on. I don't think. But you know, it's interesting that you tell that anecdote about your experience when, you know, you kind of the labs are saying you're okay. I mean, I've been there and I think that, you know, sometimes just you kind of have to look in the mirror and say, well, you know, I'm a resident. I guess I'm supposed to be exhausted. Yeah. And I think that probably there's, you know, to an extent that that might be true, you know, this is a harder part of our lives. I mean, you've been there. We all have to kind of get through that. But I think that a lot of what you've just described is you talk about this as being subclinical, right? The things don't pop up is kind of what you're touching on. But something interesting, I thought of that. I think you mentioned on another show is that there is this drift between conventional medicine or conventional western medicine. And let's call it, again, alternative medicine. And for the listeners, I'm throwing heavy quotes on that alternative because, you know, Darshan, I don't see it that way, right? And I suspect you don't either from what we've followed your work. But where's that middle ground? Right? Where as physicians and our colleagues, we don't dismiss these advanced or even basic testing and appreciate them as data points in the context of the bigger clinical picture. But also don't go so far where we're ordering unnecessary testing that's burning the system or the patient and treating with things like supplements and just homeopathic concoctions, et cetera. This is such a difficult topic because right now, because of the pandemic, there's been a bigger divide. It's almost like you have to pick sides. And there's been this huge drift between physicians that are classically trained and alternative or whatever. You're like, you said, the heavy quotes, quote unquote, alternative world. So there's exactly what you said. There's a huge continuum. There's all different types of alternative practitioners. There's people like us, us three, who live in that middle ground. And you know, we might all be a little bit different in that middle ground. But we're not completely like, oh, if it's not evidence-based, it's trash. And we're not like, well, everything evidence-based is trash. So we're in the middle here. And we live in this kind of difficult place because we're trying to match the science to our practices. But we don't need it to be like verified for 10 years. It takes about eight to 10 years for any new studies to be incorporated into guidelines. And I think that's way too long with the amount of new research we have. We don't need to be waiting 10 years before we start doing intermittent fasting. When things like circadian rhythm management, these are all new ideas that should become normal practice in the next 10 years. But we don't need to wait that long. I think that's where we're all at. But there is a really big divide. It's really difficult because I have been on podcasts where we've had arguments kind of like, not necessarily arguments, but lots of disagreements off the air and on the air because there's some subjects like COVID is one of them, do you believe in COVID or do you believe that there should be conventional treatments? I mean, these are things that are unfortunately becoming a divide between the different types of practitioners we have in our world. So it is a crazy place. But I love that I have a special role, I think in this world because I can bring in my background, my specific background, like you guys can too, in informing, you know, my opinions are informed. They're not just random opinions. I try not to just throw in my opinion based on nothing but my experience. I try to see, hey, this is my experience. What does the data say about this? And try to stay in that ground as much as possible. Now, of course, I have opinions, I have experience, like just like you guys do, but it's a really, it's a difficult place to be in, I would say, at this time. A good, special, but difficult place. Yeah, I mean, I cannot thank you enough for saying that. I think it mirrors what Ultimation High have talked about throughout this podcast, even in our lessons learned episode. And we always talk about evidence-based isn't necessarily always data. I mean, yeah, that's part of it, but anecdote also plays a huge role, right? I mean, as we try to personalize medicine for the future, patients are starting to become more individualized, right? And looking for their own health, not necessarily treating for the masses. So, like you said, it medicines gray, and will never know something or everything about something, you know, there will still always be something more. And it's important for us to say skeptical, but also inquisitive, and delve into further research for everything, right? And, you know, I think about our ancestors, right, taking turmeric, right? I mean, it's been around forever. And the reason's been around forever is probably because it works. But now that we have data, people are starting to say, well, this data didn't, you know, really show anything, et cetera, et cetera. So, you know, I think, again, people have to look at both sides of the spectrum. So, I just want to thank you for saying that, you know? Yeah, just to further that point though, you know, I grew up, I actually, my parents are from India. I was born there. And we didn't come here until I was five years old. And I really shunned Ayurveda and, you know, Eastern medicine a lot because I went to, I felt like, oh, my Cornell nutrition training is so much better than, you know, what my grandmother and my mom was saying. And my, you know, my medical school training kind of negated some of the things that I had learned traditionally. And I just was like, those people don't know anything. There's that there are very, it wasn't until late, I think it was during my immunology fellowship that I was like, wait a second, a lot of the stuff is things that we talk about in Eastern medicine and things that my parents or my grandparents especially advise us to do. So, that's when it started to come back to me and definitely now I realized, wow, there was a lot of knowledge in those stages that we are just learning, makes sense now. Like, the crazy power of mixing turmeric with black pepper and oil and activating it, I mean, how would they know that thousands of years ago? It's insane, right? Like, so it's absolutely. Yeah, and Ultimash has a great quote. What is it? I have the right to, I preserve the right to change my mind. Well, it's not yours, but I reserve the quote. Yeah, I reserve the right to change my mind. Which is, which is how we all need to kind of be, right? Awesome. Wait a minute. I want it to get a little bit back into the science because you mentioned cortisol, right? And we know that cortisol kind of spikes in the morning, dips, and then, you know, it has its own kind of rhythm as well as almost all the hormones in our body do. So, what is so important about circadian biology or the ultramarital rhythm? Yeah, circadian rhythms. They control 80% of our genes. Okay, so 80% of genes work on a circadian pattern. We need the sun. We need darkness to inform this. That's the largest input that we have. So, our clocks are independently running, but they need to get these inputs through light. And then the secondary is like food and temperature. And they need to run properly. They need these. And you can break your clocks by chronically disregarding these things. So, light and darkness is not just for fun and, you know, mood boost, which obviously it is. It's also to give input to our brains so that it can send signals to all of ourselves that, hey, yes, it's morning. Hey, yes, now it's evening. And we have special retinal receptors that go like, directly to the hypothalamus, to the circadian center that gives this input. And they can tell between sunrise and sunset and midday, all those light rays are programmed. It's insane how our body literally looks at that and determines what to do next. So, when you're sending your body, your brain signals a light in the morning. So, technically, you know, we should all be, if we didn't live in homes and didn't have blackout curtains, we'd all get that input naturally in the morning. But for most of us, or many of us, maybe most of us, we're not getting any light input in the morning. And windows actually block out at least 50, it's 50 times less effective through windows. Oh, look, it's my screens. There we go. The windows are block out, the circadian, this light by 50 times, so you really need natural light in the morning to go to your circadian centers and tell it that it's daytime. And then, again, at night, we're not supposed to be seeing bright blue light. We're not supposed to be intaking all the bright lights that we do through our computer, through our phones. And when we do, we're sending signals to our brain that it's not time to sleep, that there is a danger that, you know, dars is in danger. Don't let him fall asleep because there is some imminent danger. Somebody is chasing him or he's being hunted. And so that's why we can't fall asleep. And that's why our brain is on hyper alert and cannot go into the states of repair renewal. So circadian rhythms is not just about like getting nice fun nature timings, about really getting those inputs so your body can work correctly. And just like your brain, your GI tract needs a break from food in order to repair renew. I mean, we all know all about that through sleep, like the brain needs rest, the brain needs time to renew, solidify memories and complex processes, same thing with the gut. We need to have a break from food in order for our gut to repair and renew. And it works on a circadian pattern just like the rest of our body. Yeah. And, you know, I've definitely talked about Dr. Sushin Pandas work more than once. And I think that his book, the circadian code, which dars still has to read, is definitely one of my favorites because it kind of outlines everything that you're talking about. How every single organ is operating on its own clock, right? Earlier, you mentioned that getting light, obviously, first thing in the morning. I mean, we did a whole show with Rudy Nasib talk about that. We'll link that in the show notes. But what about folks who are maybe on the East Coast where we're still doing daylight saving, well, everywhere we're doing daylight saving time. It's going to be maybe one or two states. But maybe if we get up early, is that is your state, we don't do, is that really? Yeah. That's awesome. Well, what about, you know, what about if for people who get up early in the day and they don't have access, because I think that you've recommended it. And for most people, you know, within the first 30 minutes, 10 hour, you want to try to get as much sunlight as you can, right? Are there any recommendations that you'll make that they can get some of that light? Night shift workers and people who work in dark environments. Our bodies still need light input work. Not necessarily need, but we'll work optimally when you have light input before say 10 a.m. That's what I recommend. It's like get some light before 10 a.m. If you're at work already, maybe you walk outside for a few minutes, you really just need, I daily eight to 10 minutes, but even if you got one to two minutes of direct sunlight, you would feel so much better. So for night shift workers, I have this whole post where I go through some of the options for you. The real deal here is no matter what your work schedule is like, your body still works on a light dark schedule. Your GI still functions, your brain still functions on light and darkness. And so even if you're working all night, your body will never shift and switch because the minute it sees sunlight, it can tell a best daytime and it will turn on the daytime functions. So you're never going to switch your body cellular clocks or your brain's central circadian clock. So you have to work with it. For example, if you are finishing your night shift for people who work overnight, get some daylight when you're done and you come, you know, see some morning light. And even if you're going to go to sleep, eat your biggest meals during the light, light hours, because that's when your digestion is most likely to work well. For example, melatonin, two to three hours before bed. Not only binds to your brain receptors, but it also binds to your liver and your GI tract and tells your pancreas to shut down the production of insulin. And to tell your, you know, gall bladder, to tell all of your GI organs to stop producing the enzymes that it needs to digest to start to go into repair mode. So if you try to eat a huge meal at midnight, you're going to have reflux, you're going to have insulin resistance, you're going to feel really bloated the next day. I mean, this is just that's how our body works. And so it's really tough when you work crazy hours and I tell people if they have the option of resetting their circadian rhythms, like, you know, you have the option often as a night shift worker to get a few weeks of days or get a week or two of wash out or people who live in really, really dark places to buy one of those sun lamps from Amazon that you can keep in your office or places so that you can get some light. And even if you live on the East Coast, a cloudy day is very good still at helping you with these circadian rhythms. You don't need like a bright, bermuda sun, you know, you need just a little bit of daylight. I mean, that's interesting to me because, you know, obviously, in residency, as you remember, you probably don't do any nights shifts anymore, do you? No. Okay. All right, cool. But when we're like post-caller something and you haven't had a good night sleeping, I would always put my glasses on or whatever and just because I wanted to go and obviously say, hey, if the light, if I'm getting that response, kind of what you've already explained, then it's going to be more difficult for me to get that good quality sleep. I mean, we know that I think that the three best things they're going to help modulate the rhythm is you've already touched on light, right? Food is another one and then movement, exercise, that kind of stuff. But what you're suggesting is if somebody, let's say, clocks out at seven in the morning and if they're going to have their biggest meal, that sleep quality is probably going to be impaired. So how would you counsel, let's say a medical trainee who's doing that? Yeah. So here's everybody has different schedules. So the goal here is to get as much of your food intake during daylight hours as possible. So you could potentially sleep first wake up and then you have your biggest meal of the day before, as long as it's not late in the day, like it's not 8pm or later. Does that make sense? So maybe you sleep till four to five, four or five pm and then you wake up and you have your biggest meal, that would be ideal for someone who if you're getting adequate sleep. And then you could still have your circadian rhythm. And as you know, night shift work is an independent predictor mortality in people. Why? Because you know, you can only trick your body so much into thinking it's same time. So luckily for you, I hope that this is temporary. But for a lot of people, it's their jobs. They work. I mean, you live in a 24 seven world and a lot of people have the responsibility of working night shifts for long periods of time. So I suggest when I counsel I have a few people I work with that are doing this. I ask them if there's an option to do a one to two week wash out every week every month and to kind of change their shift of behavior a little bit. So they're eating very little overnight and most of their calories during the daylight hours. Awesome. Yeah. So what are the strategies you kind of talked about is fasting, right? And we talked a lot about how food is also plays a role in terms of our rhythm. But what about the elimination of food? How does fasting help us combat a lot of these ailments that you were talking about? As you know, digestion is a parasympathetic activity and when you're in danger or you're ill, your body will divert resources to deal with the problem at hand, right? So you really want to remember that fasting can really aid and repair renewal and dealing with GI issues. Like most of the people I talk to that end up doing some kind of circadian fasting are like, wow, my digestion is better. My gut health issues are improved. My energy levels are better. It's because they were living this very unnatural life, which we consider normal of eating until late into the evening, having your last wine or chocolate like right before you go to bed and literally waking up and rolling out of bed and having your first meal. I mean, Americans really don't even stop eating for more than eight hours during a 24 hour period. And so what ends up happening is that people get GI issues, they have fatigue, they have, it's like being jet lags the way you feel when you don't get enough sleep ever, it's the same issue when you're eating super late at night. And if you look at your glucose, people that have continuous glucose infusions, they basically can deal with this glucose until about eight o'clock at night. Around eight o'clock at night are insulin sensitivity goes way down. Our ability to take glucose into our cells goes way down and your blood sugar shoots up with the same infusion, the same infusion that was going 24 hours, you start to have impaired ability to process that around 8 p.m. So that just tells you that's, it's just pure science. It's not like, oh, I'm telling you the fast to lose weight, it is this process. And we know that insulin resistance and high blood sugars are the cause of pretty much every major of all the diseases of kind of metabolism today. Now, Amy, is there a minimum effect of dose that you tell your patients for how long they need to fast? It's funny, but even 12 hours is a difficult task for so many people. And it sounds easy, right? Oh, suck eating at seven, start eating at seven a.m. But you ask someone to do that and then they realize how much they actually snack and how much they actually need. And so Ruth Patterson, she's a cancer researcher, has a great studies on breast cancer survivors. And what she decided is that she was going to give breast cancer survivors really easy fasting instructions, like overnight fast 13 hours, like have an early or dinner that you're used to fast for 13 hours. And you know, nothing really much else besides that because she thought these people are stressed, they can't be doing 24 hours or even 16 hour fasting. And she found a 34% reduction in breast cancer recurrence in the group that was doing this circadian type overnight fasting. 13 hours, that's all you needed to make a difference in that cancer recurrence state. So if you can imagine that 13 hours gives you these kind of results. So what I have been asking people to do is just that is the most tolerable fast is a 13 hour or 14 or 15 when you get better at it. These are things that all of us can do busy people with crazy lives and very little time to prep and and I think a bit like exercise. Not everyone needs to be doing a marathon or a triathlon, right? That is what three day fasting is. That is what 24 hour fasting is. These are marathons and these are extra credit kind of great merit, but not for everyone. You know, everyone doesn't need to be doing these things, but everyone could be exercising for an hour a day or 45 minutes a day or 20 minutes a day. And that's what I think of as a circadian fast. It is something that's something you could easily do in your crazy life that doesn't require a huge shift in your lifestyle. Yeah, actually, it makes it easier, right? When you don't have to think about your next meal and you're you're already busy, it's just, sure, you just got to get over those hunger pains, but then, you know, after 30 minutes, one hour, drink some water, you're through it. So it is, it's really not that hard just like anything when you create a habit, you fire your neurons and neurons set fire together, wired together. And so when you create a habit and you keep doing it over and over again, it becomes old habit, then it becomes the default. Like for me, now it's a default and it took a lot, you know, we all have to talk about is it 60 days, 90 days, 120 days, but at some point it became default. And now a 13 hour fast is easy for me. If I wanted to more, it's still hard and I still have to work at it. But these are things like if you're having trouble, someone's trying this for the first time and they fail back off, if you couldn't do 16, do 15, 14, 13, 12 and start there and then get used to it and then go to the next level. I love that you're talking about individualizing it to the patient in front of you. And I think just going back to the circadian fasting thing, you know, one of my fears is all of us, I think, care can agree that we're talking about insulin sensitivity, right? For example, you mentioned later in the evening during the dark hours, we're going to be more insulin resistant. My fear is that a lot of times when, when, you know, patients hear this information, it's hard for them to digest, right? And they don't understand the art of medicine and they're like, oh man, but if I eat later in the day, I'm going to put it into places where it's not supposed to go and, you know, then they'll start skipping meals. And that kind of feeds into that cycle of high cortisol burned out. I mean, in your book, you talk about individuals exercising and just getting up to 4.30 and working it out six days a week and extra sessions because exercise is good for you. So with the same idea that, you know, fasting is good for you and maybe eating later in the day is not good for you. They might not do that. Like, for instance, let me give you my own case study, right? For me, if I'm working till 6.30, if I'm working from 6.30 am to 6.30 and then I can only get my training session and 60 90 minute training session and I get home at 8.39 o'clock, if that's really going to be my biggest meal of the day, not ideal, but we also know that exercise helps increase insulin sensitivity, right? So there's other ways to modulate that. And for me, you know, I kind of struggle with this for back and forth and I was like, comment, I really prefer to have a bigger meal on the day, but also I like to have my carbohydrates either pre-workout or post-workout, whatever might be. So I think that that's also important to keep in the back of my mind and that's why where the individualized approach comes. And I'm wondering if you have any thoughts that I'm sure you see people like that all the time. Yeah, all the time. I would, if you were my patient and you were trying to fast optimally, I would say exactly having your biggest protein content within an hour of your training session, but not necessarily having your biggest carbohydrate meal after your training session. So the timing of protein is pretty important if you're trying to build or keep lean muscle mass within that hour of your training session, but it doesn't necessarily have to be the largest meal of the day, might by default be the larger meal of the day, but I would say you could throw in another large meal at some point in your daytime practice, like maybe a lunch becomes a large meal as well. And so what you're doing is after your workout, you're getting that protein intake, but not necessarily the huge carbohydrate or, you know, processed food intake. And as long as you are kind of timing your meal so that you're getting some, definitely some food during the day and some food after your workout. And maybe it's a compressed window, but you're getting that food. And then maybe at say you eat at 830 or 9, and then you get a gift yourself a good overnight fast, that would be how you could like optimize that. And maybe I don't know if you ever have a chance to do this, but doing one more workout, midi workout before you break your fast in the morning, that would be ideal, fasted workout. Yeah. And then just tinker with it, right? See how you respond to it. I mean, that's kind of what it is and get the feedback. And I imagine you do that all the time. I do the best results I ever get is like what you sometimes I have a chance to do later in the evening workout and to have a smaller meal after that late evening workout and start the fast and then do a quick mini fasted workout before you break your fast again. And you'll see like that, see because time your workouts around meals anyways has been known for many years to be optimal, right? You have the best absorption of protein and nutrient. And if you can do that kind of at, you know, take it like at the at night and then in the morning, do a mini one, you can get great results. Try it. On that note, are you doing some some form of intermittent fasting daily? So almost daily. Yeah. If circadian fasting is so short, you know, 13, 12 to 13 hours, sometimes I'll do just 12 hours if I had a late night meal or and I usually tell people that you can have one day where you are completely off off any kind of counting. You don't need to basically a day off from training, just like that, you know, a day off from your fasting and then be refreshed and ready to go again on a Sunday night, say. What are your other non-negotiable daily practices? I think one thing is morning light. I think that became a non-negotiable and again, it doesn't have to be bright sunlight. I happen to live in this crazy bright sunny place and it's I'm lucky but I was in LA for a few days less week and I realized it was like it just happened to be really gray in the mornings but just getting that nature time in the morning has become kind of a non-negotiable. It can be like, I tell people, it can be as simple as I don't park in the physician parking. We have like a special cover parking lot for private practice physicians in my building only and I don't park there because that is one covered indoor and two, it doesn't give me a chance to walk so I park at that very last spot and then I look like an idiot because I'm carrying like a thousand bags but I walk in the sun or in the daylight and I take the stairs, I have to do all the stuff to get to my office and like I said, in the first few weeks it was it was work. I had to think about it every time. I was like, oh shoot, no, I'm not parking there, I'm parking over there and walk it and then eventually became second nature and I don't even know, I don't can't even find my parking pass anymore to get into that garage. I love that. That's awesome. We talk about like supplement stacking but you're trying to pair things together and that's kind of what I do. Again, I'm a very much an auditory learner and so it's either audiobooks for me or podcast or whatever it is that I'm listening to and it's you know just putting my headphones on going for a walk first thing in the morning and you know I used to tell Darce one of my first things that I used to do is just get up and kind of do like this five minute flow thing that one of our previous guests max but now it's rather than get that sunlight outside and it's been super helpful and also that's allowed me to kind of delay that caffeine that I needed first thing in the morning. Yes. And you know because let that natural cortisol rise kind of kick in and and Dr. Huberman talks us about this at length about all the benefits of that so I'd love to come back to the concept of you know the beginning of this conversation we started with your journey and burnout and medicine and you know I mentioned a couple of times that it's it is challenging being a trainee right and you trained at some of the most prestigious institutions in the world and the East Coast and the East Coast lifestyles a little bit different as you know we're a little more fast-paced get out of there as soon as you can. It's the weather not so much but but otherwise yeah but you know this the concept of just fatigue and emotional exhaustion in healthcare which was even more amplified over this past year and a half two years with COVID and everything it seems to be so so normalized right and just talking about mental health and in the context of burnout and fatigue and I need a wellness day I mean that's just stigmatized right and more importantly trainees don't they don't want to burn their comrades but oftentimes depending on the culture of wherever they're practicing it's more like they don't want to seem like they're weak they they can't stick it out they can't handle it some of the things that you've talked about before. How do we help our colleagues as Josh and I are still trainees and or how do you when trainees rotate with you how do you help influence them or help them you know reformat their thinking that hey take that day you need that day and you know it's not going to be in the world you're not weak you're not incompetent or whatever it might be. Yeah unfortunately being our resident is very keen to being a South Asian okay so as a South Asian I grew up respect you have to respect that doesn't matter who that person is but you if they're older than you if they're more experienced than you then you have to respect them even if they're mean if they're abusive if they're if they're mean to you you're supposed to be eating kinder I mean that is that's the culture right so you cannot that culture is you don't have boundaries they are allowed to do whatever they want say whatever they want ask for whatever they want and you have no ability to say no and that's a problem right as we get older and as I've gotten older I've understood that it doesn't matter what their kind of ranking is in your life or in your culture or in the medical culture you are allowed to keep your own boundaries and that's easier said than done when you're in training you can't have a lot of boundaries you have but you have to have some non-negotiables if it's something that is going to impinge on your mental health you have to stand up you have to be like you know that person who looks weird or bad and say you know what I can't do that what you're asking me to do is going to impinge on my personal health and I can't do that and keeping strong boundaries and allowing residents to say that like just like in our culture like in a South Asian culture now we are learning that it's okay even if it's a senior person in your life you are allowed to say you are toxic or at least in your mind say that person's toxic I'm not going to spend time or give that person my energy the same way you have to allow residents to say if someone is crossing that boundary where you feel like you're going to be a danger to yourself or others or you're feeling like you're getting to the end of your line you are allowed to say hey I can't do that I need to take some time off and it has to be okay we have to normalize that and that's my advice for everyone I mean I for a long time even after I came out of training I was still in the mindset of I need to impress everyone I need to make everyone happy and when you're trying to make everyone happy inevitably you will end up unhappy and so you have to learn to have some health and mental health especially boundaries and this is why in medicine we have such high rates of suicide and depression and addiction because we never learned that or we're never allowed that so that's something I learned the hard way and I would like highly advise to all of you to talk to your colleagues and then people under you and people over you and say hey guys you need to figure out how we can allow this for ourselves and our colleagues yeah I love that Amy you know what you just said kind of gave me all the feels I mean you know me being at 29 looking at how my parents raised me right and in our culture and looking at the trajectory of my career right now being a trainee and seeing how my childhood and the way I perceive the world has kind of shaped how I act right and I've learned that I'm a people pleaser at you know at the core it's very tough for me to say no and learning that over time and I mean you you've obviously gone through this right through Instagram you're getting asked by so many people hey can you just can you do that and you know I get that a little bit here and there and my first reaction is yes how can I make this happen right and I'm trying to change that mindset back to well free time is actually good time you know I don't need to fill up every single hour of my day with something right and taking that time for yourself that mental health that break learning to do meditation or mindfulness and taking that time for yourself and valuing yourself is just so so important so like like you said for everyone out there trying to you know change that mindset and be okay saying no um so thanks for that I do also want to get your advice um in terms of future doctors and trainees so I do a lot of pre-medicaching and a lot of the pre-meds say you know I kind of want to get into wellness I wanted to heal people I want to prevent ailments from happening and what obviously we often see as people go to medical school none of that is taught you get sucked in almost all you know quote-unquote brainwash I like to say by institutions in terms of hey this is how you train and then you go to residency and you never learn the wellness component of things so when you get out you have no idea how to even practice that what kind of advice would you give to pre-med or medical students you know in terms of learning the gray and you know keeping in mind that component wellness in medicine okay so whatever you're interested in medicine you should pursue whether it's wellness or some other part of medicine that is not taught to you so this is kind of a tangent but it really goes into this they recently found out that life satisfaction peaks at two to five hours of time that you control so that is not time where you're sitting on a couch but time that you control so if you're spending like you know if you're spending two hours a day learning something new that you are in control of no one assigned it to you it is not required there is no test that is satisfying that is going to grow you as a physician that's going to grow you as a person and that is what I recommend to anybody do take that time do the thing that you feel like could help your career help your personal health could help your mental health whatever it is if you can control some parts of your day I mean it sounds like a lot but that's what you need for life satisfaction so at some point in your in your career you need to find that time to really pursue something that you love and maybe that's just independent learning maybe learning under a coach or a mentor maybe it's going to do some kind of fellowship or extra training unfortunately in wellness we don't really have like a set fellowship or there's a bunch of like integrative medicine functional medicine and all kinds of new things popping up here and there lifestyle medicine obesity medicine but I felt like to get that life satisfaction I needed to do it on my own and I needed to learn on my own and I was lucky that I had the flexibility or I could make the flexibility to make that happen for myself and I highly recommend that people find what lights them up and do that for every day for a little while every single day I love that and I think that another part of it in terms of the wellness component it's gone are the days where the doctor tells the patient hey this is what it is and this is how we're going to go with the treatment plan and they're going to go I mean today it's about empowering the patients patients are empowered right first of all we have Google and so you can find anything the difficulty is filtering through the noise to get the actual signal right you test them that with all the dissension and everything that's going on it's either penge them on one end or the other end but one of the things that you've done a spectacular job you're an author you're a speaker you're lecturing and you're giving it put out so much great content and education how do you educate your patients on having the discussions with their physicians like for instance going back to the subclinical stuff like let's talk about thyroid or cortisol or whatever and pick a hormone we'll do thyroid just because it's so prevalent that they go into their physician today I'm not feeling right and you know I heard on medicine redefined podcasts that getting your these levels checked are important maybe some physicians who for lack of a better word I'll say aren't as open-minded or aren't into the wellness space they might say there's no clear indication for it at this point but patients don't really might not have a true deeper understanding of why that's important right and maybe they haven't taken your courses how do you educate the spaces to have this conversations and discussion with their physician to make the shared decision making because I feel like a lot of times when patients go and say I need this test and the physician's like whoa whoa whoa you don't need this test like you know what I mean how do you educate? Absolutely I think that's a big huge issue in medicine right now but here's the thing most of the things that we were talking about that we discussed today don't require a test they don't require any kind of equipment they don't require any kind of special supplements or anything really you can do most of the stuff that we just talked about without any of that now that being said there are we have changed leaps and bounds in the last five years you can order your own lab tests in most states across the US you can now go without a requisition to your lab and order tests and I think that's like a huge difference from when I graduated from med school you could not do you couldn't even get like allergy medicine over the counter I mean now you've really changed the entire system so that patients have a lot more autonomy and can get a lot of this testing on their own and so I have a lot of people who say oh I ordered my own labs or they use a site you know whether these sites that interpret interpret it for you or they work with their doctor and their doctor is you know willing to send a few extra labs so it's kind of a combination of any of those three but I agree with you that I think the problem is that in primary care a lot of physicians are taught that you're supposed to utilize the healthcare system very judiciously and not waste waste money and so then they end up not ordering tests some some of which are actually necessarily if you have a family history of diabetes and your people who have an A1C is okay you still should get a fasting morning insulin to see if that's elevated because that's an early sign of type 2 diabetes and all people with a heavy type 2 diabetes history should you know be considering or looking at that fasting insulin and that's something that's not included in your screening lab so it's either a discussion with your physician or then it's getting your own lab work quick follow up on that do you just as an early marker for just metabolic duration will you only check fasting insulin or will you do an OGTT to check post-prime dial insulin as well well ideally you would do both but it's much more difficult so say you're seeing a patient virtually or you're seeing patient that doesn't necessarily have access to an OGTT you can instruct them how to do it on their own or you know a lot of people are getting these the blood sugar continuous glucose monitors CGMs and that can be really helpful in looking at two-hour post-prandial and watching your blood sugar strap and you know there's lots of controversy about whether normal people that don't have type 2 diabetes should be using these but in conjunction with a qualified practitioner that can be really helpful. Gotcha. Cool well Amy this has been a super awesome fascinating, effing awesome conversation. You know I can't thank you enough for coming on you know I've been I've been following your work for a long time and I think the listeners will understand why now so thank you again. We do want to ask you though what's next for you so you already have one book down what's what's coming up the pipeline. Definitely I'm writing my next book. Awesome. That's coming up soon so more about that soon. I have a new like I have a free challenge that I just created. That's something I think you guys I think any doctor who has knowledge or is willing to do like it was so cool it basically every for 60 days every day you get like one step that if like to add to your your daily routine or to your meals or whatever and really step by step in 60 days you'll be optimizing your life instead of just you know living your life as it is and it was a lot of work to put together but in the end I feel so happy and satisfied because I'm able to like in conjunction with my book able to really impact people's lives and that just grows my own personal presence right like by giving away a lot of free content you are giving people so much value that they then want to buy your books or they then believe in what you're saying or they will spread the news so it's literally like so worth it. Absolutely. Wait, speaking of when I come back week so your book is called I'm so I think tired um who's that for is it for is it targeted towards healthcare folks is it everyday people? Everybody it's everybody and you know the thing I learned is that I think you guys are in the same position so I can say this what I learned is I felt like with this first book I really wanted to make sure that I covered on my basis like I wanted someone who is a lay person a functional medicine or non medical person to be able to read it and a medical person to be able to read it um and I was trying to be that people pleaser okay so I myself will tell you that I over like I over explain I oh I give tons of evidence because I was the person that I became the person that I've always been raised to be like make sure everyone's happy with you you know like don't make sure people don't say like oh where does she get that from the second book I'm being much more bold and much less um apologetic and I'm just gonna put it out there and so I can definitely tell you that I'm grown since writing that book and I'm writing in a dendum to um I'm so I'm tired to kind of reflect that that's exciting because I remember you mentioning on another another I think maybe it was the genius life podcast that one of the the feedback or comments that you got were that hey this is just the basics there's nothing uh you know groundbreaking in this um and the what I found so amusing about that is you know everybody is looking for that magic pill right we talk about that all the time so the more polarizing you can be the more likely it's to work right it's like oh man this is awesome but you're just kind of driving home the basics and for you know again 90 percent of the time maybe even more um that's what people need to focus on and that's what you're focused all about so I really love that I mean people people love to hear the lectins all these things you've been eating all your life are like silently killing you I mean these unfortunately you can say anything and um it will sell lots of books right but you you and I we all have a responsibility I mean the way that we were trained and uh to to do things that are actually true or at least you know backed by some kind of medical science and so it's a little less like you know take this pill and um everything will be better or do this crazy thing like put butter in your coffee like and now you're automatically like super charged or something so it it's a little harder and to be um saying things that people will think are is new and fresh but I really do think that some of this stuff it for me it is new and fresh and for most people you really look at your life it is definitely new and different and that's why I think the whole circadian fasting thing has taken off a little bit because it is kind of counterintuitive to what we've been doing for all these years right well we are going to link all that in the show notes and cannot wait for the new book that's um super exciting what's um should is there an expected timeline or is it super early yeah it's coming uh next year awesome so it seems so weird but 2021 is almost over that's crazy I know I was just thinking I'm like oh my god I have to I'm almost done but uh everything done by December and so I'll come out in 2022 stoked uh can't wait for that well I mean I want to thank you so much for doing everything you do for for being so generous with your time and just constantly educating and and put out the good word um as you mentioned earlier there is a lot of misinformation and unfortunately a lot of disinformation as well and I think one of my mentors came on here and said the only way to combat bad information to spread good information and you've done that over and over again so thank you so much for everything you do where can uh other than fasting it um fasting md on instagram which you can't get rid of uh so you're stuck with that so people get well we'll put that well but even amishah right that's the other one they can follow you may uh we're also gonna be fine on twitter I'm at amishahmd and facebook amishahmd and um my website is amymdwellness.com awesome cool we'll link it all on there uh last question we ask all our guests amy is how do we put the health back in health care wow you didn't cut me on this one or maybe I didn't read the like surprise uh surprise questions how do we put the health back in health care um but empowering patients to do things in their life that actually optimize their health instead of just things that can fix them when they're broken i like it absolutely well thanks again amy thank you thank you thanks guys so much i enjoyed it i hope you enjoyed our conversation with dr amishah now we discussed a few strategies that you may want to try to optimize your life but by no means was this an exhaustive or all inclusive list of things we can do if you enjoy this however i highly recommend you follow amy on social media and check out her website as well all of which will be linked at the show notes also for my doctors remember the story has changed visit financial residency.com slash locum story to see if a locum tendons assignment is right for you it's here you'll find the unbiased answers you're after so you can decide if locum tendons is your next chapter now before you sign off please remember this important disclaimer that everything in this podcast is for educational purposes only it does not constitute the practice of medicine nor should it be construed as medical advice no physician patient relationship is formed and anything discussed in this podcast does not represent the views of our employers we highly recommend that you seek the guidance of your personal physician regarding any specific health related issues however if you enjoy the show please be sure to subscribe review and share with anyone who you think will gain value from this and until next time thank you for listening