Dr Marvin Singh: That doesn't work for everybody because everybody's different, everybody is not you. If we want to understand what to do for you, makes sense to look at you. You don't, you don't say I think I have a problem with my car engine and the mechanic doesn't then say, okay, well, let me look at all the cars in the lot and figure out what to do with your car. They don't say that. They say, let me look under the hood, let's see what's going on. So if you want to know what's under the hood, you got to lift the hood and take a look.
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests where we discuss the multiple determinants of what allows you to lead your best life.
Dr Rupy: Precision medicine, it is a hot topic right now with a ton of direct-to-consumer tools including stool tests, food sensitivity tests, genomic tests. And I think with all this rich information that we have out there, it can be quite overwhelming. So I wanted to talk to someone who comes from a traditional medical background and has really embraced the new technology and the science of precision medicine with a more sort of measured approach, a holistic approach. Dr Marvin Singh is the founder of Precisione Clinic and one of the only few integrative gastroenterologists in the United States. And we get into exactly what that means as well during the podcast. He's also currently a diplomat and a member of the board of the American Board of Integrative Medicine, having previously served as a faculty member at UCLA and Johns Hopkins University. He's also author of the brand new book Rescue Your Health and has co-edited the textbook of integrative gastroenterology. Today, we talk about a ton of stuff. To start off, we talk about how Marvin had some of the best training in the world but struggled to take care of patients and himself. So the approach that he took to looking at integrative medicine, the diploma that he did in University of Arizona and the approach to taking care of a patient if you had 60 minutes with them, which is a luxury that I'm aware many doctors who listen to this or medical students will be aware of is something that is very far removed from what we can actually do within the NHS. However, this is something that I wanted to talk about a lot more openly because I think we have to think about the solutions and actually what it takes to get someone to optimal health and treat patients as if they were athletes. What would it take for someone to be in optimal health so that they live the longest, healthiest, happiest life? We also talk about Marvin's specific approach to testing with specific regard to stool testing, metabolomic testing, which are the metabolites of the microbes that live within us, mitochondrial assessments, CT calcium scores, as well as visceral adipose tissue scans. This episode might get a bit technical in places, so I'm going to make sure that we do a follow-up with some questions and we do a bit of a deep dive into some of the things that we talked about, specifically mitochondria and why they're so important. And as every week, as I've started doing, we have a podcast recipe of the week. This is available on the newsletter, thedoctorskitchen.com/newsletter. You'll find this in your inboxes every single week, as well as on the app. You just need to search smashed potatoes with cashew pesto. The reason why I'm doing this one is because one of the ingredients that Marvin is a big fan of are greens, obviously, cruciferous vegetables, coriander, parsley, anything to do with greens. And this has got greens smothered all over it. It's absolutely delicious and super easy to make. Check out the show notes for links to Dr Marvin's books, as well as his website, as well as where you can find out more information about some of the topics that we discussed today as well. Without further ado, here is my conversation with Dr Marvin Singh.
Dr Rupy: Listen, I wanted to chat a bit about, to start off with, a bit about your training. You know, you're conventionally trained gastroenterologist. You worked, I believe at University of Scripps, is that correct?
Dr Marvin Singh: Well, I have, actually, yeah, so I trained at Scripps, so, but I'm actually on staff at one of the Scripps hospitals too. So, um, I guess where I started is where I'm at right now. I have three jobs right now, so we can talk about those, but um, my background's a little complicated, so sometimes that requires different sorts of settings to see different kinds of patients. So that's kind of where I'm at right now. But traditionally, I'm trained as a gastroenterologist. So I did my internal medicine residency at the University of Michigan in Ann Arbor, and then I went on to do my GI training at Scripps Clinic here in La Jolla, California. Um, then I travelled around a bit after that and kind of found my way back to San Diego and here I am. Right now I work as a gastroenterologist in a GI practice. I'm the director of integrative gastroenterology at the University of California in Irvine. I started a practice called Precision Clinic, which is my little baby where I do all the fun stuff in and that's probably some of the things we'll be talking about today. But that's where I do all these deeper precision medicine evaluations to help people optimise their health. So, different things for different people and different places right now.
Dr Rupy: Yeah, yeah, for sure. And and the term integrative gastroenterologist when you were at medical school, I'm assuming that was a pretty foreign concept or?
Dr Marvin Singh: I don't think I ever heard the word integrative medicine in medical school at all, period.
Dr Rupy: So where was the inflection point for you then? When was the the sort of decision to try something completely unknown to your training?
Dr Marvin Singh: After I had left the faculty at Johns Hopkins, it was one of my first jobs when I finished training, I kind of was left feeling that, you know, we can really take care of patients when they're sick and they're dying, they really need somebody to help them. But what about all the other people who keep coming to the doctor's office over and over again that they're not dying, but they're still sick, they still have problems. How come we can't really effectively take care of these people? Why do they remain sick? And at first, you know, being a doctor, I just blamed myself. I said, well, maybe I'm inadequate, maybe I don't know something, or maybe I didn't learn something good enough, maybe it's me. But then I realised that, you know, there's a lot of, there's a lot of components to this. You know, the way the healthcare system is designed in this country isn't ideal for prevention to help people understand where the root causes of their problems may be coming from and help them address that. Um, and I was kind of wondering what am I supposed to do with my life? And my my wife was actually more integratively inclined. So she says, here's this book, take a look at this. It's called Integrative Gastroenterology. And at first I said, what is this? This is just some junk that you found somewhere. But then I opened it up and um, I said, well, they're talking, they're, there are things that they're talking about for ulcerative colitis, for liver disease, for different kinds of GI conditions and um, you know, it's interesting, there's evidence, they're talking about the literature, so it's not like somebody just made it up. So I started reading into it a little bit more and um, then I, I said, then I, I called the, I talked to the people over at the University of Arizona and I talked to them about the fellowship program that Dr Weil started. And it sounded interesting and I just on a leap of blind faith, I said, okay, I don't know much about this, but maybe there's something to this. So I enrolled myself in the fellowship. And it's a two-year fellowship in integrative medicine, um, and so I learned a lot about integrative medicine and and how to relate that to GI disease and used a lot of this stuff myself in my own life. Um, and found that I was making transformations in my own health and my own life, my own well-being and I thought, man, this is, this stuff, this is, this is what I was looking for. And then the rest is history.
Dr Rupy: Yeah, yeah, yeah. I wonder, I don't know if you mentioned that in the book, but can you elaborate a bit on your your personal sort of journey?
Dr Marvin Singh: Yeah, so, you know, um, I was more overweight at that time. I was having heartburn, um, difficulty, you know, sleeping for a long enough time. I think I was just overstressed, overworked, um, you know, just like a lot of us physicians are, you know, there's a lot of burnout, especially when you're running around doing a lot of things at the same time and being expected to to do 5,000 things at the same moment. Um, and once I started applying, you know, some basic concepts of nutrition and exercise and sleep and meditation, I found that like just my whole overall, you know, well-being, sense of well-being, I should say, improved and I started losing weight. I didn't have heartburn anymore. Um, I had elevated liver enzymes because I had fatty liver and those liver enzymes normalised. Um, so, you know, um, a lot of things changed and my perspective on life and health also changed at that time. So, um, so here I am.
Dr Rupy: I uh, I I I want to ask this question actually about how your colleagues, because like you said at the start, you you wear three different hats as it were, and you're you're likely going to be working with some colleagues that haven't been introduced to this world or might think of it in a negative light. Uh, what's the reaction that you get from some of those people when you talk about integrative gastroenterology?
Dr Marvin Singh: Well, I should say those three practices that we talked about, that that is where I ended up, but there was a lot of learning on how to end up there in the first place. So that's the path that I, so these are the obstacles that I that I faced. Um, when I was in the fellowship for integrative medicine and I was actively practicing GI. So it's not like I stopped working. I was actually working. So you work all day and then, you know, you you do a little bit of studying at night before you go to bed type of thing. Um, the hospital I was working for, um, the chief medical officer found out, I don't know, somehow, that I was doing this fellowship training and sent me a email and said, I don't know what this is, but um, I heard you're doing it and I, if you want to continue working here, you have to prove to me that this is actually going to be good for patient care. And I was a little taken aback because first of all, I was doing that on my own private time and it's an educational thing and it's through a university, you know, so it's not like, you know, you know, anything. But um, I put together a nice response. The folks over at the University of Arizona helped me with that and we we collated some articles and sent it back as a reply and I never heard back from him after that. So that was, so that was one part. So that was in the beginning. Um, and you know, as you go along, I think, I think times are changing now, you know, and largely probably because the people are demanding it because if if somebody doesn't get what they want in the doctor's office when they go there, they're just going to find somebody else. And to the point where they may even go to somebody who's not even a physician because they want it that much. So I think physicians are starting to come around to understanding that, um, you know, this is something good, you know, even if I personally don't know how to do it, I can at least understand that people want to do it and ensure that they're in the right hands when they want to do it. So things are changing, you know, obviously, we have a big university here, University of California in Irvine and they they have a integrative health institute. Um, so, you know, these kinds of things and there are other universities in the in this country that also have integrative medicine programs. And so I think this is rapidly growing area of medicine and I think people are starting to understand what it is, what benefits it has.
Dr Rupy: Yeah, you know, I agree. I think over here in the UK, we're we're a bit of a key change away from this being something that is acceptable. There are a couple of universities that do have integrated medicine programs, like Bristol Medical School, for example. Um, but outside of that, I'm not aware of many. So I guess a lot of the questions that I'm going to be asking you today about this area are going to be really responses to people that perhaps um might be openly critical of this sort of area of precision medicine. Um, but why don't we start off by why you wrote the book in the first place? Because um, it's really well done. I love how you've put it into different sections. You've gone through the different omics. It's a real lovely introduction into more specific investigations. But but tell us a bit what prompted you to write the book in the first place?
Dr Marvin Singh: You know, the idea, not necessarily for the book, but for the concepts that are talked about in the book, came um, I think even before I did the integrative medicine fellowship. As I was starting to think about um, different approaches to health, I remember sitting on the sofa in the basement with my wife and said, why couldn't we look at somebody's microbiome and their genetics, their sensitivities, their, you know, these kinds of components of their health and and tell somebody, well, this might be a better way for you to eat, this might be a better way for you to live. These are the things that you should do to make yourself healthy. And I think that was the initial spark. That was just like a random idea that came to my mind. And then, you know, over over years, you know, this developed into this concept of precisionomics. And I made that word up. So, you know, that's my word. I trademarked it even, so that's my word. And, you know, precisionomics basically means that we're taking all these omics, the microbiome, the genome, you know, all of these different components of health and environment and and using them towards making precise decisions for your health. So that's precisionomics. And um, then, you know, I eventually started a practice that that does that. So that's how I ended up doing that. It was just a really a random idea that um, really makes sense though, because you know, we're all so different. We're all individual, right? Even our microbiomes are only, you know, maybe up to 20% similar to each other. So how could you say that you should eat this way and everybody should eat this way because that's healthy. You know, what you're really saying is I eat that that way, that way is good for me, so everybody should eat that way. That's what a lot of people do as far as their experience and their recommendations. Um, you know, so, but that doesn't work for everybody because everybody's different, everybody is not you. If we want to understand what to do for you, it makes sense to look at you. You don't, you don't say I think I have a problem with my car engine and the mechanic doesn't then say, okay, well, let me look at all the cars in the lot and figure out what to do with your car. They don't say that. They say, let me look under the hood, let's see what's going on. So if you want to know what's under the hood, you got to lift the hood and take a look.
Dr Rupy: Yeah, I think developing a culture of looking under the hood is something that we need to get used to over here because we utilise a lot of population studies, which are good at giving us a general steer as to what direction we should be going in. But like you pointed out, it's uh, it would be madness to apply the same analogy to a car and and wanting to know a bit more about our individual health, I think is something that a lot more people are getting used to these days. I guess to anchor our listeners that might be not used to this area of precision medicine, maybe we could talk about the concepts that you broadly talk about in the book from symptoms management to systems management and actually looking at the body and your physiology as as one interconnected system rather than all these individual silos of which we chase resolutions for individual symptoms.
Dr Marvin Singh: Right now, medicine is kind of more of a symptoms-based practice. Um, you know, you you gather the symptoms and if you don't know what the diagnosis is or what all these symptoms together might mean, then you just give a medicine for each symptom. Oh, you have nausea, take some Zofran. Oh, you have heartburn, take some Prilosec. Oh, you have abdominal pain, I don't know, just give you some narcotics. I mean, this is how, this is how a lot of doctors practice because, you know, the main concept is, well, patient comes in with a problem, I can fix that problem. I'll give you a medicine. But you're not really fixing the problem if you don't understand where the problem is coming from. You know, and and where that problem started from in the first place. And so that's I think really the difference is in is in looking at more of that root cause analysis and trying to figure out where the problem may have come from and addressing that or where a problem you're concerned about might come from and addressing that.
Dr Rupy: Yeah. And with all these um tools that are becoming increasingly available, uh direct to consumer, I wonder if we could talk before we drill down into some specific tests that are available now, maybe we could talk about the pros and cons of that becoming more accessible to the individual user because I certainly see on social media, um, particular people being targeted with certain tests and being, you know, shown them as a cure or a panacea really before they actually understand, okay, it's looking at the root cause rather than yet another label. Um, so maybe we could talk a bit more about the the pros and cons more broadly.
Dr Marvin Singh: These tests all together help you understand kind of what's going on. Um, I always tell people, you know, some people might come and say, well, I want to, let's just use make up an example. Somebody might come and say, well, I want to optimise my health and live long and I heard that the microbiome is really central to health and wellness and so I want to do a microbiome test. So I might say, okay, well, that's a good idea. You're right, the microbiome is central to health, but it's not the only thing that's part of health. It's important to understand that, you know, we're not just, you know, one isolated organ system. We are, as humans, we are multiple organ systems that interact with each other all the time on a nanosecond to nanosecond basis even. And so if you just look at one part, you're doing the same thing really that that we do in conventional medicine. Look at one set of symptoms and diagnosis and and make try to make a diagnosis so that you can figure out what other medicine to give somebody. You're kind of missing the point. So what I, you know, I usually try to encourage looking at different facets of your health. Because when you look at different facets of your health, then sometimes you get an understanding of a pattern or a theme or some underlying concept when you look at somebody's genetic results and then you see, you know, if there's issues in the microbiome or in their mitochondrial health or or whatever. And then you also have to look at what the person told you because that's also a test. I always say the best test that I can ever do is one that doesn't cost any money. It's the conversation. So the conversations I like to have are at least 60 to 90 minutes the first time I meet somebody because that never happens in the regular setting. I don't know how it is in the UK, but here in the United States, it's like,
Dr Rupy: Oh no, it definitely doesn't happen.
Dr Marvin Singh: It's like, you know, 15 minutes, 20 minutes if you're lucky, you know, you know, because that's just how it is, you know, it's not that the doctor wants that to be that way, that's just the environment in which we are forced to operate. And so, you know, you take all of these things together and then you try to make a plan because sometimes there are things that correlate, sometimes there are things that contradict and then you have to decide, you know, which one seems more important in your setting, this or this, you know, or what you told me and then you make a make a decision. So really it's that concept of looking at all of these different components together and kind of understanding the overall gestalt of this person. What is going on? What are the risks? What are the things that they are talking to me about? What are the things that I see? And how do I guide them with all of this knowledge and how do we move forward and what things do we follow up on and things like that. So it's really that kind of understanding and that understanding takes time, takes effort, you know, so, you know, what I do when somebody wants to do all these tests is I will spend hours studying these results. It's not, not like, oh, you got an ultrasound normal check, CBC normal check, metabolic check. Okay, all your tests were normal. Bye-bye, see you in three months. This is not how that, this is not how that works. It's you study the one result, you look for these patterns and things like that and then you try to make a conclusion based on that. So it does take a little bit of effort because the information is so voluminous. Um, but what's fantastic is that the information is there. The information is accessible. We can use it. Everything might not be perfect. We might have a lot to learn. We still do have a lot to learn. Um, but we have enough now, I think that we can use to to to help ourselves.
Dr Rupy: Yeah, absolutely. Well, that's a lovely way to to sort of um conceptualise this for the for the listener actually about what happens when you see a patient that comes in through the door. Um, just for context, working as a GP in the NHS, we get about eight minutes per patient.
Dr Marvin Singh: Eight minutes?
Dr Rupy: So, yeah, yeah, it's really, it's really bad. Um, and it and you know, that's that's piled in as well, like we have to
Dr Marvin Singh: It takes 10 minutes for the MA, it takes 10 minutes for the MA to put the patient in the room, so you have negative two minutes.
Dr Rupy: Yeah, it's uh, it's it's a tough world working in the NHS and it's getting worse and worse and actually a lot of my colleagues are um, trying to think of better ways in which to maximise the time. So group patient consults is something that is becoming quite fashionable here. I know, I know in the US it's probably started a few years ago. Um, but but but walking us through that patient that comes through the the door, they might say, I think I've got a food sensitivity or, you know, I've got brain fog or all these different things. Um, it sounds to me rather than honing on that one symptom, you're going to take a step back and you're going to ask a plethora of different questions around their different systems that allows you to get a more bespoke picture of that person in front of you. I wonder if you could broadly tell us about, you know, those different areas that you might inquire about to get that picture.
Dr Marvin Singh: That's a great question. And part of that picture involves understanding their environment and who they are and where they came from. So, I'll just walk you I guess through how I take a history initially, I guess. Um, so, you know, I I initially to start the conversation, we'll start the history by asking one question first is, what are your goals for your health? How many patients you think actually get asked that question by a doctor?
Dr Rupy: I don't know. I don't know. You and your colleagues, what are your goals for your health? Why are you seeing me? What what do you want to gain from this interaction? Because that's important because we don't ask that, right? If we don't ask that, we don't know what's in their mind. If we don't know what's in their mind, we're just going to say, do you have abdominal pain? Do you have this? Do you have this? Okay, boom, boom, boom. But if the person says, yes, I have these symptoms, but the goal in my life is to lose weight or the goal in my life is to be happier, then you have to put that in the right context of their symptoms, otherwise you're missing the boat. So that's actually the first question I ask somebody. And then, you know, then I will take maybe more of a classical history to get an idea of like what are their symptoms? What are they feeling and things like that. And we may talk on that, I don't know, 15, 20 minutes or something like that. Give them plenty of time to to actually state what's on their mind. And then I'll transition to asking, I'll say, okay, now we're going to talk about some different kinds of things. Tell me about your life when you were a kid growing up. Um, were you born by vaginal delivery or C-section? Do you know if you were breastfed or bottle-fed? Were you sick a lot? Did you have ear infections? Did you have strep throat? Did you have mono? Were you hospitalised with pneumonia? Was your childhood happy? Um, was there any kind of abuse, any sort of trauma, any major, you know, traumatic event that you experienced or witnessed? And we start talking about those kinds of things. And we'll talk about what kind of diet you had as a kid. Tell me what breakfast, lunch and dinner might have been. What how was that as a youth and how is that now? So I can look at the comparison because this is interesting and important because you're really understanding where this person came from, what path and journey they took in life, what protoplasm they may have by understanding what kind of environment they grew up in and what kind of diet they started eating and what kind of diet they ate as they got older and where they're at now. It's not just important to look at where what you're doing now, it's important to look at where you came from too because that's how you got to where you're at now. And we'll talk about, you know, sleep habits and their stress and how are things with family and friends? Do you have good connections with them? Are you on good terms with people? Are there some, is there somebody that you had a falling out with that um, you really wish, you know, you didn't, you know, these kinds of things we talk about. Um, I feel that really gives me an a better understanding of who this person is in front of me. And that is maybe, if let's say it's an hour-long visit, that's maybe 40 minutes worth of the of the visit. After that, after understanding and hearing what they're saying, you know, I may make a suggestion, okay, well, you know, these are the things that you said, these are the things that you're experiencing. These are some of the investigations I might think might be useful for you. What do you think? What did you want to do? Did you want to do these? Did you want to do something else? Did you have other tests in mind? And then I may offer some suggestions for um, you know, certain things to do to try in the meantime to help with any symptoms or to, you know, help them whatever the situation is, understand, you know, what what they can do to get started because I always want to give people some recommendations on what to do. It's not just all about testing and wait for results. And, you know, and sometimes, often times, um, recommendations are, don't even have to be involved, you know, in in taking any medicine or supplements or anything. Sometimes you realise in talking to somebody that this person's main problem may be from years ago, from some, you know, the environment they grew up in. So sometimes I'll talk to people about, you know, the relationship you have with your mother, um, seemed to affect you growing up. Do you think that it affects you now? And they may, let's just say they say yes, you know, um, I feel blah, blah, blah, this is how it bothers me. So then I might talk to them about doing like a forgiveness ceremony, you know, where you don't even have to see your mother, you don't, or whoever it is, you don't have to talk to them about it, you don't have to read them the letter. You can just write the letter. Write the letter to your mother, let's just say it's the mother for for conversation's sake and and write the letter to your mother and, you know, you can be by yourself, you could be with your best friend, your significant other or or nobody. It's up to you, whatever you're comfortable with because the whole thing is to be comfortable doing this. And then light a candle, read the, read the letter out loud, um, and you can even burn the letter and blow the candle out and basically that's, it's one way of saying, I'm going to put these feelings and emotions on the table because I've been suppressing them all these years. They're in my mind, but I hadn't really made it real by writing it down. When it's written down and when it's spoken out loud, somehow it becomes more real. It's tangible. Otherwise, it's more of an abstract concept that, oh yeah, I know my mom used to do this to me. I hate it, I hate it, I hate it, I hate it. All that does is fester in you. When you bring it out, you say what's on your mind truthfully, how it affected you, how it impacted you, what it did to you, you make it real and then you just say, poof, it's gone because that was 30 years ago. You're now older now. Why is that thing from 30 years ago even bothering you? Get rid of it. And, you know, it sounds like a silly thing, a silly exercise. Man, it has been life-transforming for people. I have seen, you know, this, this over and over again. So, you know, so I may leave them with things like that, maybe a couple of things to try and then we move forward from there. That's maybe kind of how a first visit may go.
Dr Rupy: Yeah, no, I love that. I think even before you suggest supplements or an investigation, you've got this really rich picture of where your hunches might be as well. You know, this person's sleeping right, okay, is there a circadian rhythm imbalance that is negatively affecting their gut, which might be, you know, presenting with those symptoms? Is it something emotional? Is it something from their history? And because you've asked and spent the time to get that lovely timeline of of people's um health journey and and just, you know, life journey as well, um, you can make those sort of educated guesses as to where you can help them without actually having to see anyone. So asking yourself about your birth history, asking yourself about any trauma that was there.
Dr Marvin Singh: People remember things they didn't think they remembered.
Dr Rupy: Totally, totally. It just, it takes being asked the question and asking the question yourself can also be a proxy for that, I've found anyway for for people. So before we get into the testing stuff, that's just an aside, I think people should be aware of and you've you've got some of those questions in your book. I want to talk about some of the testing now. So in terms of all the different tests that you you have, this is going to be a difficult question for you to answer. Which one do you, well, let's start with the gut actually. Let let's start with as as you're your GI, um, we we use the word microbiota test or microbial stool testing just kind of fancifully. You you hear it in the ether, you hear it through these DTC tests. What do we mean by a microbe stool test? What what actually is going on? What are you looking at as a as a physician?
Dr Marvin Singh: So, um, micro, well, first, I guess for those who may not even be familiar, the microbiome is is like an ecosystem of trillions of different microorganisms. They're majority are bacteria, there could also be viruses and fungi and yeast. We all get freaked out when we talk about yeast, but you know, they can be part of the normal environment, just like they can grow in your grass too. That doesn't mean, you know, all is lost because there was a mushroom in your backyard. Um, but um, you know, when we talk about microbiome or stool analysis, this is a kind of test where, you know, you take a sample of your stool, you send it off to the lab and the lab can sequence the DNA of the different microorganisms in the sample that you submit and then identify which bacteria or other organisms are there. Um, different tests can go, I guess, different depths as far as the analysis or the quality of the information you get out of them. I think this is probably one of the confusing points for people when they go to one practitioner and they get this test and they go to another practitioner and they get another test and then they're like, how many, how many of these tests can I do? You know, because are you not looking at the same thing? Actually, the intention may be the same, but you may not be looking at the same thing. That's correct. So, you know, you want to try to have a good test that can give you information and insight, as much information and insight as possible. Now, I will say that everything has limitations, you know, in medicine, no test is perfect. Um, everything has some sort of limitation. Um, one of the limitations in a stool analysis may be that, you know what, you're not submitting the entire stool, right? You are taking a sample by scraping the top or taking a little scoop of it and putting it in there. So the analysis that's being done is based on that sample. We always have to remember that. So it may not be perfect, you know, and but is it also practical to poop in a jug for 24 hours and submit that in the mail? That's also not really practical. People aren't going to do that just as human beings, it's gross. So until until we've figured out maybe a better way to collect a more thorough stool sample, you know, this is what we have. You know, and I tell people that, you know, my understanding is it took decades for people, the medical community even to accept the stethoscope as as a as a normal part of doctor's um, you know, armamentarium, things that the doctor could use to investigate a patient and listen to their heart. It took decades for that to be accepted. But now the stethoscope, you look silly if you're a doctor and you don't have a stethoscope around your neck. Are you really a doctor? You know, like, what are you? A dermatologist? You know, like, so, so, um, uh, you know, I I'm one that believes that use the tools that you have, understand the limitations, but use them in the right context with the proper understanding now because by the time you want to wait for the next best thing, that patient could be 100 years old in front of you that's 50 right now. They want to be healthy now. They don't want to wait till they're 100 and wait for the best test. They, we have the ability to do things. The sequencing methodology has rapidly advanced. Um, you know, it costs millions and millions of dollars to do this the first time and now you can get a stool sample, a stool test for like, you know, a couple 300 bucks or something like that. So, you know, that we have to put this in context, you know, and one day maybe it'll be 100 bucks, maybe it'll be 50 bucks, maybe it'll be covered by insurance, but that's going to take time because these things, you know, people, humans take time to grow to accept these things as part of our natural um, testing abilities. So, you know, I think it's okay to use these things. Science is always going to evolve. We want it to evolve. Um, if if if we said we don't need, you know, that we're good with what we have, then you're basically saying there's nothing else to learn. There's always something to learn. Science is never going to be dead. There's always going to be something that we have to learn in science. So we use what we have now and we look forward to learning more in the future. And I think understanding that is an important concept. I'm not one that'll come out and say, this is the test, this is the only test, this is the most important test of your life. This is the only test you should check. I'm like, this is the best test that I could see for now. Something else comes up, we'll look at that, you know, so I'm always looking at different kinds of tests. If some new test comes up or I hear that there's something that may be commercially available, I try to look into it and and try to include that also in my testing portfolio if if it's available.
Dr Rupy: Yeah, yeah. I think some of the pushback with microbe testing is I guess it has to be user dependent as well. So you might be looking at a selection of microbes that you would immediately think are pathogenic, but depending on the context of the patient, it might not be as as harmful. And I guess the other thing is the the flux of the microbiome and how it changes from day to day, let alone like from sample to sample can be can be massive as well. And so how much can we actually get from that? And I guess the other thing which I know you you do look at are the metabolites from the microbes themselves. So tell us a bit more about the metabolites because I think it that can potentially yield a bit more information that's attributable to the person.
Dr Marvin Singh: That's a great point and actually that's where I think the money is going to be at as far as understanding the microbiome moving forward. This is the area of microbiome science that I wish would most rapidly evolve. Um, and uh, you know, I think a prior, prior concepts were, well, let's do stool analysis and let's see if we can identify some bad bacteria and then figure out what to do about them. Um, now my, I may have started off with that similar sort of concept as well because that's how a lot of people actually still think that way. Although that's now, I think an old way of thinking. Um, it's not so important which bacteria are there. It's important what those bacteria are doing. Um, you know, just because, you know, you look like you could do something, doesn't mean you are actually doing it. So, you know, this is what we call the the metabolites are the the it part. It's what do these bacteria make? What are they producing? These are the chemicals that go to different parts of our body that create these end effects, these impacts on our health. And I think looking at the metabolome is really going to be, this is what we call the metabolome, is the collection of all of these different metabolites. That's where the most wealth of power is going to be in the future. You know, we can do, I mean, the science has the ability to do a whole metabolomic profile on somebody, but um, it's going to be volumes of information and I don't think anybody really knows what to do with that yet. So, you know, you know, focusing on perhaps some key functions where we may be able to guide people on, you know, like how are you digesting carbohydrates? How are you digesting proteins? How, you know, are you making enough butyrate? You know, things like that, you know, we can conceptualise. So some of the tests we do, you know, may focus on those pathways. But if you wanted your whole profile, you can get it done. It's just I don't know, there's not very many people who know what to do with it or anybody who knows what to do with it really because a lot of these chemicals and metabolites, we may not even really know what they actually do or how they interact or what's going on. Um, but I think that's the direction that the microbiome science and and um, health care around that is going to move. Is if we can understand, because that's where the interventions are going to come. So if we understand that, okay, well, you have this problem and we see that you're making a ton of this metabolite, then the question's going to be, okay, well, how do I stop that? How do I block that? What can I do to intervene? Because that's where the problem's coming from, so I need to stop that. Um, so these are where, you know, novel therapeutics may eventually come come out of. Or, you know, we know that this metabolite is really good for your heart health and we find that if people have this much percentage of it, I'm just making this up. If some if we find that somebody has this much percentage of it, it can reverse heart disease. What if we find a metabolite that can do that? Where does that metabolite come from? How do we give that metabolite? Can we give it to you as a supplement? You know, that's what a postbiotic is. So, you know, there's a whole arena of therapeutics that that is coming out called postbiotics. And these are basically metabolites essentially, these are products that the good bacteria make that we want that do healthy things for us. So we can take them as a supplement form.
Dr Rupy: Yeah, yeah, just to anchor the listener. So postbiotics, I agree, is a really interesting subject matter. It's basically where you're just going further down the chain. So you have your prebiotics, which are your delicious fibres, inulin comes to mind and a whole bunch of other things that you find in specialised types of high-fibre foods, chicory, artichoke, garlic. You have your your probiotics, which are live microbes that are things like Saccharomyces boulardii or um, you'll have all the different types of lactobacilli, you find them in yoghurts, kefirs and and also in supplement form. And these postbiotics are essentially the metabolites of those microbes. So you're just taking them directly. And that's that's a really interesting area of research. I wonder if we could pull out some of, I know you said there's tons of metabolites that we could look at. Right now, there's specific ones that you look out for. You mentioned butyrate, for example.
Dr Marvin Singh: Well, you know, the testing for these things, uh, that's the thing. So, you know, um, testing for these particular metabolites may be tough. So you can maybe look in, you can consider using like urolithin A, for example, is a is a great metabolite. Urolithin A may come from pomegranates, right? Um, but we may not all produce urolithin A, depends on the bacterial composition in your microbiome, but it can help with mitochondrial health, um, and it can help with muscle building, muscle strength, exercise tolerance and things like that. Um, you know, so we can perhaps, if you were interested in mitochondrial health, we could do a mitochondrial analysis, we can look and see if there's dysbiosis in the microbiome and we could say, well, you mentioned that this is a priority of yours, a weakness of yours, we see that there are some issues here. Let's see if this, if this postbiotic might help with that. Other things like butyrate, which have been around for a little bit longer period of time, um, you know, we can, we can measure that, you know, we can look at butyrate pathways, we can look at how much DNA in the microbiome is there for the production of butyrate and get an idea of whether or not your microbiome is making enough and we can give a supplement for that. So, um, I would hope that testing would be available for a lot of these things as we move forward so that we can check, you know, and maybe they'll, you know, maybe one day, I'm giving somebody an idea, you know, but um, maybe somebody, you know, could create a panel of metabolites for particular diseases, you know, a Parkinson's panel, an Alzheimer's panel, a heart disease panel, and we can check metabolites along those lines. But the key thing is in understanding how many different metabolites are there, what do they do? Because if you just focus on one, like like we were talking again, you could still be missing the picture. An example of focusing on one and missing the picture, we can pick on MTHFR, the gene for for a little bit because people will say I have MTHFR, so I, you know, and they may even be a heterozygote, meaning they only have one copy of the gene, not like they even have the full-blown thing where they have two copies of the gene. But people will all the time say, I have one copy of the MTHFR gene, so um, I I take a ton of B vitamins because I don't methylate at all. That's not true. You know, that that can't be true because there are dozens of genes in our genome that work towards methylation. That's not the only one. That's the one that we sensationalised and marketed and made a whole thing about. So there are books written on it, but that's not the only way to methylate. The body is not that silly that it's only going to have one way. What if there was only one way to do one thing in the body? We may all be dead when we were born because, you know, if there's only one way that you can detoxify arsenic and you were exposed to arsenic, I guess you die, right? No, that's not how the body works. There are there are other pathways, other ways that things get accomplished. So, um, I think that's important to understand that there are a lot of things involved and um, this is a very exciting part of science.
Dr Rupy: Yeah, absolutely. I think that's a really good point for the listener to sort of sit with there that we have this idea that unless we are perfect in every pathway or we, you know, we're deficient in a certain amount, we have to make sure that we get that level up, otherwise we're all going to fall apart. You know, there are so many ways in which to to your point, we detoxify through our digestive system, through the liver, through our urine, through all these different areas. So, you know, we are very resilient um, human beings, but we just we do need a sort of a different approach when it comes to that systems based approach. You you mentioned um, mitochondria. I I I understand that the the gold standard way of assessing mitochondrial health is through a muscle biopsy, which is, you know, inappropriate for most people. What kind of things do you look at from the perspective of improving mitochondrial health as it is super important to a number of different issues that people suffer with?
Dr Marvin Singh: Yeah, so we don't obviously biopsy people's muscles to to do that. There there are other tests that are much less invasive that may not be as perfect as a muscle biopsy, but maybe good enough to give you an understanding of what could be going on. Um, I think, you know, knowing that it may not be the gold standard, but the gold standard is is more mutilating to your body. I think people understand that, okay, we can do this to at least get an idea of what's going on. You know, um, there are certain supplements that can be taken to help support mitochondrial function, the electron transport chain, like we mentioned, urolithin A is a postbiotic that can be um, good for mitochondrial regeneration and having good quality mitochondria. Um, this can help with your energy, your exercise tolerance, your your muscles and things like that. Um, you know, there are a lot of things that you can do lifestyle-wise that can also be good for your mitochondria. And what what I realised was very exciting, um, was that when we talk about what can I do for gut health? What can I do for my epigenetics? What can I do for my mental health? What can I do for any health? The same concepts always come back, always come back. And those are the concepts of lifestyle medicine because exercise, eating a whole foods plant-based diet with plenty of vegetables and and fruits there, having antioxidants, resting, sleeping properly, meditating, all of those things, guess what? They're good for mitochondrial health, they're good for gut health, they're good for your genetics, they're good for your heart, they're good for everything. So I always say that, you know, the body and health and disease seems so complicated, but by design, there are certain key things that are so simple that the body really responds to. And those are the lifestyle, those are the lifestyle measures.
Dr Rupy: This concept I actually made a statement out of and the statement is, if you give your body the ingredients it needs to do the job that it was meant to do, it will do the best that it can under your circumstances. If you think about that, that is exactly everything that I talk about. That's what integrative medicine is, that's what whole health is. It's basically saying that if you can identify where there are areas of weaknesses and try to offset those or correct those and give your body the things that it needs, the proper exercise, proper nutrition, proper sleep, stress reduction, all those things we're talking about, then it will do the best that it can under your circumstances, meaning your environment. That's that's the that's the part of the statement that acknowledges that environment plays a large role in your health. Um, and so I think I often say that and that often resonates with people. That's an important concept, I think.
Dr Rupy: Yeah, absolutely. I I totally agree. Um, I wanted to talk about two other investigations if I may. One of them pertaining to body composition. Um, I've heard a lot about DEXA. I haven't actually done a DEXA myself, but you talk about VAT. I wonder if you could uh, uh, talk to the listeners a bit more about why VAT is better and uh, and what sort of insights you gather from that.
Dr Marvin Singh: So think of VAT as like your internal BMI. You can tell somebody's BMI, right? It's just a calculation, you know, so it's based on weight and height. Um, but uh, if you are a better assessment of that is looking at how much fat is inside your body, you know, your visceral adipose tissue. Adipose means fat. By by looking at those levels, the correlation between risks for heart disease, stroke, cancer, metabolic syndrome, you know, liver disease, all those things, you get a better assessment. So some people can actually be skinny fat, for example. You know, how many people have you seen that, you know, are look like they're skinny, look like they're tall, look like they might, you know, oh, you're probably in good shape. But then they have a heart attack the next week. I've seen that happen all the time, you know. I've had people come in, you know, that look like they're in the best of health and and they say, yeah, I had a heart attack last month. Um, so, you know, and if you look at, you know, the data, there are people who can be skinny fat, which means that you may look skinny on the outside, but inside there's too much fat. So if you didn't do that kind of test, you wouldn't have that kind of understanding that, you know, you would be falsely led to believe that everything is okay just because of how you look on the outside when inside it's not. So I think that can be helpful to help people understand what their true risk may be for certain things.
Dr Rupy: Yeah, yeah. And and over DEXA, what what extra information can you get from VAT? Sorry if I missed that earlier.
Dr Marvin Singh: I think, I mean it's a rapid MRI. So, um, I think it's like eight minutes, I think, or less. I I did it myself a while back. Um, and um, it's it's just a very non-invasive, there's no contrast, it's very quick, there's no radiation, it's very easy to do. It can often be done together when you're doing whole body composition imaging as well. So whole body imaging if you're doing cancer screening by doing like whole body MRI, so they can usually couple it together. So it's a very convenient test to do um that gives you a good idea and calculations. They also look at muscles as well because some people are concerned about sarcopenia or their muscles getting weak. So you can get an idea of, you know, like are are your muscles uh where they should be for your age, for example. Um, and sometimes I use that information together, you know, some people may think because as you age, you have an increased risk for having muscle weakness, for having sarcopenia. So if you can identify that a little bit earlier, somebody may not even have a clue that, you know, oh, my my thighs are not as strong as they should be. They can start working on those things. And and how this ties in is, you know, if you did nutritional genetics panel or you had a, you know, whole genomics of some sort done where you get an understanding of um, what types of exercise this person might benefit from, then you can take that recommendation and take both, see this is how they interact. You can take the information from there and say, I say see this on your body composition scan and I see this in your genetics and maybe we should try to have your trainer work on this with you specifically, for example.
Dr Rupy: Yeah, yeah, that makes sense when you piece all these different investigations together and you can see how that would play out into a precision prescription uh of sorts. And and the other thing is CT calcium scoring. Now, this is something that we don't have as much access to over here unless you go via a cardiologist, but I imagine in the states you can get this directly through your primary health care physician. Is that is that correct?
Dr Marvin Singh: Yeah, I mean, we have free-standing radiology centres here that can do it even too. So it doesn't, you know, I mean, you have to have a doctor give you an order for it, but I think anybody can order it really.
Dr Rupy: Yeah. And how do you, how do you use those in your practice?
Dr Marvin Singh: So, you know, that's uh, it's one way of getting an assessment of what your risk you might have for heart disease. So, you know, um, it's it kind of goes along with a lot of the other assessments. You're obviously going to check somebody's cholesterol and, you know, lipid panel and, you know, haemoglobin A1C and all those other things because like I said, not just one thing is is good enough for risk assessment. But you can get an idea, you know, like if somebody's got a high calcium score in their heart, that they may be at risk for having um, you know, heart disease or a heart attack. Um, and they may not have an idea of whether or not that is the case or not. A lot of people have family history of heart disease or lipid imbalance and they're concerned, you know, what's my risk for having a heart attack? Because I don't want to have a heart attack like my dad did. And so this is one way of getting an idea of what your risk might be and so that we can make a program. So depending on, you know, how high your score is, uh, you know, maybe how intense the program may be because we want to try to reverse those changes. Sometimes it can be reassuring in a sense, you know, somebody may have this family history background, you do the test, you see their lipid panel is not too bad, their haemoglobin A1C is not too bad and their CT calcium score is zero. So now that person just feels a little bit of sigh of relaxation and they can focus on their health because that was maybe holding them back as a fear. So now they know that, okay, it's not so bad, but I don't want it to get bad either because, you know, there may be some genetics and other things in the background. So let me do things now that will keep it that way and make it better, even better.
Dr Rupy: Yeah, yeah, yeah. I I I'm glad you you explained it like that because I think sometimes there can be a bit of false reassurance with a zero score in isolation without actually looking at all the other lifestyle factors that could be brewing up inflammation systemically. And if you pair that with a family history of cardiovascular disease, then that's that's a recipe for disaster. So, yeah, like having that calcium score in context, I think it's it's super important.
Dr Marvin Singh: And the body composition score too, right? So like if if you're like the VAT score we were talking about. So you could have a, let's say you have a CT calcium score of zero or something low, one or something. Um, but your VAT score is moderately high. You know, you say, okay, I'm glad there's not much calcium deposition going on there, but you have the protoplasm for something to happen because of that. So don't be falsely reassured by the scan on your heart. We have to work on this still in this way and then you make goals for care. Okay, our first goal is this, second goal is this and then you can, you know, that's what that's kind of what I like doing is coaching people along the way step-by-step, you know, and re-evaluating these things. I think we were talking about the theme about this a lot, but we haven't actually said it. In the book, um, I talk about the snow globe theme, right? So, you know, you have the snow globe, um, everybody knows what the snow globe is and when you shake it, all the snowflakes go flying around everywhere. So, um, I I I usually will say, okay, so what's the cause of my heart disease, right? Shake the snow globe. You see all the little snowflakes? It could be all these little things going on, not just one thing. So that's the whole idea of like, it's not just one thing that can cause your problem, not just one place you should look. You have to look in many different places because there are many different snowflakes in that snow globe. And if you eliminate one snowflake, all those other snowflakes, I don't know whether they collapse or whether they'll make a bigger, you know, a bigger snowstorm inside of that globe. What will happen? So we want to try to look at all these different components and see how we can manage them so that the storm settles.
Dr Rupy: Yeah, yeah, yeah. I think that's a, that's a really good analogy. I forgot to mention that in the book and I
Dr Marvin Singh: We're actually talking about it. I haven't actually, we haven't actually come out and said snow globe. So I thought, let's just say it, snow globe.
Dr Rupy: Yeah, yeah, snow globe. I got you. Um, I think just for the, whilst we wrap this up, just for the listener, I'm conscious that we've probably made it pretty overwhelming for a lot of people. They're probably thinking, man, I got to go, I got to get my gut tested, I got to have these genetic tests, I got to get, you know, uh, I I I've got to do a CT calcium score now. Like, so what if someone's in general good health or maybe they have a few symptoms, um, maybe they put it to, put it down to middle age. The majority of the listeners are between the ages of 30 and 55, you know, a split largely towards women, but we do have male listeners obviously as well. Um, what kind of things do you think should be part of a panel of investigations that are reasonably inexpensive that we should be looking at doing at least yearly if not more often?
Dr Marvin Singh: Yeah, that's a great question. And that was actually one of the points of my book too, um, because there are a lot of tests you can do. You can spend thousands of dollars in a minute if you want to, and some people want to. Um, but do you need to? It all really depends on what your priorities are, what you want to do, what you want to gain out of it. Like I say, you know, if you need a car, you can buy a Ferrari, you can buy a Ferrari, or you can buy a Honda. They both drive, they both get you to work. So, you know, and as you age, as things move along, your priorities in life, your priorities in health are also going to change. There's no race, there's no, you know, this is this is not a sprint we're on, this is a marathon, it's life, right? So, you know, um, it's okay to pace yourself, it's okay to focus on one thing, um, at a time because the key point when you're talking about precision medicine, preventive medicine is that whatever changes you talk about, whatever things you make suggestions for, you want them to be sustainable because you actually want them to work, right? And so that's my viewpoint. Like when you, when you go to a conventional doctor, they may say, you got to do this, you got to do this, you got to do this. And then when you come back and they say you didn't lose 20 pounds, you didn't change your diet. Well, okay, well then it sounds like you just got put in detention by the doctor. But that's not, and that just creates more frustration. So you make your list of things that you want to do, you make your priority list and then you can work down them. If you want to do 10 different tests, you don't have to do all 10 different tests right now if you're not able to or if that doesn't make it, if it's not feasible for you. Um, a lot of the tests that I chose as some of my top tests are the most affordable tests. Um, for the specific purpose of trying to help people understand, if I want to start, but I don't have thousands of dollars to do like whole body MRI and some of these other more fancier tests, what can I do to at least get started in looking at my health? Um, so that's where some of these top tests came from. And if you said, okay, well, I don't even have 200, 300 to do a nutritional genetics panel or a microbiome test, what can I do? Um, I would say, well, start with some of the basic lab tests. So that's why actually basic labs are are on my list of top five. You know, you can check your cholesterol, you can check your A1C, you can check insulin levels, you can check CRP, homocysteine, vitamin levels, all these things you can check and um, I don't know how it works in the UK, but here these are tests that should be easily covered by insurance. Um, so you may not even have to pay for them or you have a co-pay or whatever. So you can gain information by doing these kinds of tests, um, you know, on an annual basis and they can be insightful. You know, everybody has certain limitations and I always keep that in mind as well. So, you know, if you want to get started, you want to do something easy, at least do that. There's, there are a lot of people out there who've never had their cholesterol checked, never even had their blood pressure checked. I mean, these are some of the basics, you know, we still use these tests. Just because we have new science and technology doesn't mean that the old stuff is garbage. Don't check your lipid panel because it's garbage anymore. No, we still use those kinds of tests because they also show us a little bit about what's actually going on actively in your physiology, what your body is doing right now. Um, so they can be insightful. So that's a good place to start, just do some of the basic lab assessments.
