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Inflammation is the body's natural, ancient, and protective response to injury and infection. But something's happened in our society and the way we live In the past 60 years, that's turned inflammation from the protective fire in a fireplace where it keeps us safe and warm to a force that's taken on a life of its own, a fire that for too many people is burning down the house Unchecked, chronic inflammation is in fact the mother of all root causes, the common denominator in most of the chronic symptoms and almost all the chronic diseases most Americans are facing. In fact, while COVID might not make it feel so infectious disease has increasingly taken a backseat to chronic diseases like diabetes and heart disease for several decades now. But inflammation simmers for a long time before it bubbles over into disease.
We get smaller signs and symptoms at first, things like period pain that we just write off as normal, chronic aches and pains, digestive problems, allergies and eczema, trouble losing weight, trouble sleeping. Western medicine leads us to believe that we have no control over our health destiny. And it's true we can't control it all. But we do know from robust studies that anywhere 80 to 95%, depending on who you ask of all chronic, modern western diseases are preventable. Even the big ones like diabetes, heart disease, and dementia that we assume are genetic, but they're much more avoidable than we've ever been led to believe. In fact, terms like brain- flammation and inflammaging are very real. And describe the impact on inflammation and describe the impact of inflammation on our daily health. And at the heart of preventing and even reversing most chronic diseases, particularly before they've gone too far, is cooling the fires of inflammation. This is something I talk about extensively in my books, The Adrenal Thyroid Revolution, a book about stress, overwhelm, inflammation and our health and in Hormone Intelligence where I hone in on the effects of inflammation on our hormonal health. It's also something I dive deeply into in my online practitioner course, the Women's Integrative and Functional Medicine Institute Practitioner Verification.
My guest today, Shilpa Ravella, MD, a gastroenterologist, is no stranger to the topic of inflammation. In fact, she's dedicated her debut book A Silent Fire: The Story of Inflammation, Diet and Disease to this hidden force at the heart of modern disease. Shilpa’s writing has also appeared in The Atlantic, New York magazine, the Wall Street Journal, Time, Slate, Discover, and USA Today, amongst many other places. And she's been featured as a guest expert on Good Morning America and NPR and more. Shilpa earned her BS in biology from MIT and an MD from the University of Pittsburgh. She's an Assistant Professor of Clinical Medicine at Columbia University Medical Center, and she splits her time between New York and Hawaii, a blue zone where she works in rural healthcare.
Through her writing, which synthesizes medical history, cutting-edge research, and innovative clinical practice, Shilpa illuminates how inflammation is an important basis for a unifying theory of disease. I'm delighted to have her on the show today for a chat about this powerful evolutionary and biological phenomenon, including what you can do to uncover whether you might have hidden inflammation, which – hint – most of us do, and how to get on a path to cooling those fires to prevent and reverse chronic disease.
Thank you so much for taking the time to tune in to your body, yourself, and this podcast! Please share the love by sending this to someone in your life who could benefit from the kinds of things we talk about in this space. Make sure to follow me on Instagram @dr.avivaromm to join the conversation. Follow Shilpa on Instagram @shilpa.ravella and visit her website at shilparavella.com.
Aviva: It's a pleasure to have you. So okay, let's start with the basics. For those who are listening, how do you explain inflammation to your patients?
Shilpa: Well, inflammation is actually an ancestral force that evolved to fight things like pathogens and poisons and traumas. If you think about stubbing your toe on a table, for example, you can see things like redness, heat, swelling, and pain. And these are the cardinal signs of inflammation in addition to loss of function. And those are a manifestation of what's going on inside of your body. The blood flow increases, blood vessels dilate fluid and protein leak out of the vessels, putting painful pressures on nerve endings. So that's inflammation in a nutshell, and it's meant to be a protective force, benevolent force and something that helps us.
Aviva: So how did you become interested in inflammation as something so fascinating that you decided to write a book about it? It wasn't something I learned about in medical training. I mean, I learned about inflammation, the four cardinal signs, how it manifests in sort of these obvious visible ways. But it was really my herbal training and my integrative approach that led me to Sapolsky's work in the late 1990s that really got me on inflammation and the stress response as these interconnected forces that are really these powerful influences in modern chronic disease. I'm guessing you didn't learn about this hidden inflammation in medical school.
Shilpa: I didn't, no, and at the same time, inflammation was everywhere in medical school, but more as a consequence of disease. It was just omnipresent. But as I went through my training and as I graduated to my attending years, I had a lot of patients coming in asking about inflammation as a cause of disease and also what they could do to prevent inflammation in their bodies to treat it. I really wanted to get behind what's the evidence here: Is inflammation actually a cause of disease as well as being a consequence? And I became very interested in the topic and also on a personal level, I had a friend who was diagnosed with a devastating autoimmune disorder. So those two forces, both my clinical practice and also the personal side really sort of made me obsessed with inflammation for a very long time. And I also became fascinated by the scientists in the story both past and present because this is a slow science and it took a very long time to really establish that inflammation is indeed not only a consequence of disease, but also a cause of disease.
Aviva: Was there anything that you learned in your research that just either blew your mind or totally surprised you and that changed your own medical practice about inflammation, aside from the fact that you were now learning that it wasn't just a result, but a cause?
Shilpa: That's a great question, and I think one of the things that really blew my mind was learning about this 19th century pathologist, Rudolph Virchow and his ideas on inflammation. He was one of the first ones to really see inflammation on a cellular level to describe the microscopic changes behind what was overtly happening in our bodies. Virchow posited many, many years ago that inflammation was indeed a cause of heart disease. Now over a century later, over a century and a half later, we have randomized controlled trials to show that inflammation is indeed a risk factor. It is indeed a cause, an independent cause of heart disease.
Aviva: So yeah, we learn about something called Virchow’s Triad when we're in medical school and we learn that inflammation is a factor, but the way we learn it is really like, okay, yes, we know that inflammation is associated with heart disease and you can have increased inflammation in the vasculature, but there's really nothing done about it per se. We don't really talk about these underlying or as some people call “root causes” of inflammation in our lifestyle. So, let's talk about hidden inflammation, because when people think of inflammation, most of them do think about things like that acute injury, or they may read about inflammation on a wellness website and don't really know what that means. But there is an incredible amount of evidence now that does link chronic low-level inflammation as a cause of many diseases. Cardiovascular disease is one that is probably more obvious to us because we've all heard of that, but cancer, dementia, and even depression. So, let's talk about what hidden inflammation is.
Shilpa: Well, hidden inflammation is really the type of inflammation that today we are not typically accustomed to testing or treating for. And we know globally that we have this great benevolent inflammatory response. Our immune system can protect us against pathogens and poisons, but there's a price to be paid for that. And this is kind of the biological price of inflammation. And you see this with autoimmune disorders, for example, like rheumatoid arthritis or inflammatory bowel disease. But today we know that that price is just far more pervasive than ever imagined because the majority of us are walking around with this iteration of inflammation called hidden inflammation, and it's just swimming in our bodies. We may or may not know what's there. We don't typically go to a doctor's office and the doctor doesn't say, “Hey, let's test you for hidden inflammation and then let's treat it”. So, this type of inflammation has been found to either cause a variety of diseases or is associated with them. So, everything from heart disease and cancer, diabetes, obesity, neurogenerative disorders, depression, and this is really, really pervasive in the modern world today.
Aviva: One of the things that fascinates me about biology, and particularly evolutionary biology, is we have all these protective mechanisms, like you said, inflammation protects us against pathogens, infections, injuries, poisons. All these different phenomena that we may be exposed to in our environment. The stress response is another example of this, it's meant to be activated at acute times, when we need it. And then we have always this little low level of normal inflammation that gets triggered and it really, it's more like our immune response gets triggered when we get exposed to things all day long. But then there's this, what I call evolutionary mismatch. We have these responses that are meant to protect us, but there are factors that are happening in our daily lives that we're all being exposed to that prevent the off switch from getting kicked into place. We end up with these mechanisms that get stuck in the on position and inflammation is one of them. Can you talk about why you think that's happening and what's happening? How is that impacting us?
Shilpa: Sure. Well, we've evolved these bodies with robust immune responses, and it was to protect us against these ancient killers, but at the same time, we've really transformed our modern environments from the food we eat to the air we breathe to how we move and our social connections and so many other things. It's that evolutionary mismatch that is responsible for creating this low-level inflammatory state in the majority of humans today. And that can lead to various issues down the line, perhaps not suddenly, because this type of inflammation doesn't tell you that it's actually there in your body and may not cause problems ‘til years or even decades down the line. All of these lifestyle factors that are ongoing, a teenager's food habits may affect cancer in middle age. It's very insidious. It's a heterogeneous force and it operates pretty slowly and it's really due to this evolutionary mismatch that we have going on today.
Aviva: What are some of the signs you look for in your patients or explain to your patients that people can recognize as some of the more obvious hidden red flags, but maybe things that we're just sort of accustomed to living with in our modern culture that we ignore? In your own life, what would tell you that maybe you had some hidden inflammation that you would want to be aware of or concerned about or take a next step toward looking under the hood a little bit more?
Shilpa: Sure. I think it absolutely can vary by specialty as well. One of the first things in a primary care setting that I would look for is just the belly fat, because if you have that abdominal fat, that's a marker for the visceral fat, which is that deep fat that wraps around your inner abdominal organs and that type of fat is highly inflammatory and it's churning out inflammatory molecules at all hours of the day. So that's one thing that I think is a relatively easy thing to look for.
Aviva: This is really important because one, when we talk about fat and we talk about weight, I always want to differentiate between the medical and metabolic aspects of this and where we can run off into what's very common in medicine and our culture, which is fat shaming. What we're talking about here is very specifically called visceral abdominal fat or visceral abdominal tissue. And there is a way to measure this. There was a study that happened many years ago called the MacArthur Study on Aging. And one of the things that the MacArthur study on aging, and you might be familiar with this, looked at are markers of problematic aging that were due to underlying inflammation.
And one of the things they found was actually an increased waist circumference and that had to do with this higher level of visceral abdominal tissue. For women, one of the things that I do in my practice is for women who come in at a much higher BMI and BMI does not tell us everything, we know that, but past a certain point it can be indicative of inflammation. It's a kind of low hanging fruit that we can use to check for it. People who have a BMI over 25, women with an increased waist circumference over 35 inches, that is actually in and of itself a marker for higher risk inflammation, even without doing lab tests. It doesn't mean something bad is going to happen if you have it, but if you have it, it's a good indication to maybe look a little deeper at whether there's inflammation. I don't know if you use that marker in your practice, but I find it a great one. Even with telemedicine, my patients can just grab a tape measure, put it around their waist, and then we can talk about
Shilpa: That's a great idea. And I think just going back to this abdominal belly fat and feeling like you have to bring down that belly fat to zero, I think that is not necessarily the goal. It's more you change your diet, you change your lifestyle, and even in the absence of weight loss, you are actually having beneficial physiologic changes going on in terms of inflammation. So even if you don't lose that belly fat entirely, but are following adequate dietary and lifestyle factors, you can actually improve your inflammatory markers, improve the level of inflammation, decrease the number of immune cells that infiltrate your fat. There are lots and lots of things that folks can do.
Aviva: Okay, so that's one thing. What are some of the other things you look for?
Shilpa: In terms of clinical symptoms, I think honestly there's such a span of clinical symptoms, particularly with gastroenterology. Patients can come in with various inflammatory disorders, distinct disorders like celiac disease or inflammatory bowel disease, and the diagnoses for those disorders are based on clinical findings and imaging and endoscopic testing. And beyond that, you have diseases like IBS or dyspepsia, all of these other issues going on with patients. And some of these disorders too are tied to hidden inflammation. We don't test for inflammation in these settings, but patients come in with just a variety of symptoms, all kinds of GI symptoms from stomach aches and nausea and vomiting, diarrhea. For me, it's hard to find specificity with these symptoms. But we do know that with hidden inflammation, I don't test for it, particularly in my practice. I go by the clinical picture and then I will do endoscopic testing. But there are cardiology clinics that are testing for things like high sensitivity, C-reactive protein and see reactive protein. And C-reactive protein, for example, is a molecule that's made in response, it's made in the liver in response to areas of inflammation. And high sensitivity, C-reactive protein picks up just minute elevations in CRP, and that can be a marker for risk. And there are panels that folks check as well. As you had mentioned, also, do check a panel in your practice?
Aviva: I do. I do highly sensitive CRP in my practice, it's pretty low hanging fruit. I don't do it on every patient, but if patient fits the per bill of having high risk for inflammation or an inflammatory disease, then I want to get a measure because one, you can repeat tests and really measure improvement, but also it's an accessible test that most people's insurance will readily cover. And then I look for things like hemoglobin A one C, blood sugar. I look at how many hours are they sleeping, things that could contribute to inflammation, look at their diet, and then just a super core simple panel. But that highly sensitive CRP I think is a great low hanging fruit for people to ask their primary care provider to check for to just see if there's inflammation there.
Shilpa: I think it's an incredibly exciting field, and I'm very curious to see what's kind of coming down the pipeline. And there are folks talking about looking at inflammatory signatures, for example, that measure a panel of markers instead of just a few markers and are very disease specific or even just looking at inflammation in response to challenges as opposed to static inflammation, a snapshot of what's in the blood. I think it's an exciting area for sure.
Aviva: I think it's exciting that conventional medicine is taking a more global perspective, right? In the naturopathic world and the herbal world in the integrated medicine world, inflammation has been a part of the conversation for decades, but it's largely been ignored in conventional medicine. And starting to look at some of these under the hood causes rather than just saying, okay, someone got diagnosed with diabetes today, that's when their disease started. Let's look upstream and let's look upstream before the disease starts because we do have a sense of some of these markers, right? Waiting until someone's hemoglobin A1C is in the diabetic range or waiting until someone's highly sensitive, CRP is through the roof along with markers of diabetes. We don't have to wait that long.
So how can we get ahead of disease rather than just waiting for it to start? And let's go even more upstream than that because you and I share some things in common, which it's not just about testing, it's about some lifestyle factors that we can all use to prevent and even reverse inflammation. There's so much talk about anti-inflammatory diets and inflammation in the wellness world. So first, what are some of the common myths you see about an anti-inflammatory diet? And then what are the things that you feel are the most important components in an anti-inflammatory diet and the important things to avoid? So, myths and then realities.
Shilpa: I think one of the biggest myths regarding an anti-inflammatory diet is that it's an exclusive diet and I've seen so many iterations of these diets and they exclude just various foods like gluten, all grains, beans, nightshade, vegetables. And I think one of the biggest things to keep in mind regarding inflammation in general and anti-inflammatory diets is that while you may have specific instances, specific disorders that require exclusion diets, the anti-inflammatory diet as a whole is for chronic inflammatory disorders. And when we are talking about chronic inflammatory disorders today, we're not just talking about rheumatoid arthritis and inflammatory bowel disease, we're talking about the majority of diseases that modern man suffers: heart disease, cancer, obesity, diabetes. This is really a diet that's meant for the whole population. And when you look at it in that context, and when you also look at the history and you talk about evolution and you look at all of the nutrition science data that we have to date, and also science on how food is affecting our microbiomes, we realize that the anti-inflammatory diet is incredibly inclusive.
It's a diet that is very high in whole plant foods, so largely or exclusively based in whole plant foods and all different types of plant foods. The diversity of the types of plants that you are eating is also a very important factor because we know that in some studies, they've showed that simply increasing the diversity of plants can actually lower inflammation in the body without making any changes in the quantity. The diversity and the quantity of plants I think are two of the biggest, biggest factors in designing an anti-inflammatory diet that is appropriate for the microbiome. And today what we're facing, when you look at the number of plants that we are actually consuming, we see that 95% of Americans today do not meet the recommended daily allowances for fiber intake. It's 25 grams for females and 38 for males. And only 5% of us are meeting this. And we know that fiber is one of the most anti-inflammatory nutrients that we can be eating. It manipulates all arms of the immune system. It's fermented by the gut microbiome creates wonderful short chain fatty acids that are immune modulating. I think just making that one simple change, filling your plate with the diversity of plant foods, that's kind of where we should be starting.
Aviva: I really try to talk to my patients and students about, we're talking about hidden inflammation, but some of the hidden sides of the wellness world. So when the whole anti-lectin movement started happening and people were shunning beans left and right, trying to explain to people, this is one person who cherry picked the literature to come up with a marketable platform, but all of the literature, all of the literature with extremely rare exception for a very limited number of people, show that eating legumes provides very important fiber for an anti-inflammatory diet, for gut health. Including legumes in your diet. Even just a couple of times a week has been shown without changing anything else to improve blood sugar balance, weight ranges, I mean it's pretty remarkable.
How do you address some of these wellness fads? As you said, it can be so restrictive, but so often, at least for me, I have patients coming in who are sure that that's the answer. And I also have patients who come in very reasonably who have IBS and when I say, okay, we need to increase your plant foods, but I can't because I get so reactive. Let's talk about some of these challenges. One, some of the fads, things like anti-lectin and how do you address that? And also for people who really are challenged when they increase plant-based foods in their diet.
Shilpa: Those are great, great topics. And I think when it comes to fads, I really do try to talk about dietary patterns and about the data behind excluding certain foods. If we don't have the data to exclude certain foods in the diet, then I talk to patients about the reasons for excluding those foods. For example, with celiac disease, we do know that we have to absolutely exclude gluten completely from the diet, but then there are instances like non-celiac wheat sensitivity, which is also tied to hidden inflammation, and in those cases, patients don't have to be as strict about gluten avoidance. I think there is a role for exclusion diets of all kinds. But when it comes to the general healthy person, I really do tend to talk about each individual food and have patients understand that when you're looking at a plant and you're picking portions of a plant like lectins, which are proteins that are found in a variety of plant foods like nightshade vegetables and grains and beans, and you're looking at studies where they have taken those portions of plants and given them in isolated excessive doses to animals, you really need to be looking at the big picture. You have to be looking at the forest. This plant evolved to fight predators. There's almost no food in this world from an evolutionary perspective that won't have some component that you can sort of point your finger at and say, “Hey, I don't want to eat that because of this, this, or that.” I think we have to look at this from an evolutionary context, from a historical context as well. What have our ancestors been eating? And this doesn't mean going back entirely to what our ancestors have been eating, depending on who your ancestors have been, but this means adapting to our current environment. I really talk about all of these things when I talk about excluding certain foods with patients.
And I think the bar to exclude any plant food should be very high. And sometimes there can be confusions about is there a sensitivity going on or an intolerance. Intolerances are due more to the lack of digestive enzymes, for example, like lactose intolerance, whereas the food sensitivity is related to immune issues. Is there underlying bacterial overgrowth or microscopic inflammation in the colon? Sometimes when some of these things are corrected, people respond better to a diverse diet. I think it takes some time to correct underlying issues. And then also if you're going from a zero percent plants to a hundred percent plants type of diet overnight, I think that's a very rough change for your body because your gut will tend to alter its secretions and its contractions over time in order to better process plants. And you need to build up the microbes in your gut that are able to process plants as well. Because as humans, we have a couple of dozen enzymes that can process those carbohydrates, but the microbes have tens of thousands. We really need to be building up that robust gut microbiome as well. I do talk to my patients about all of these different things and also just tell them not to give up hope because in some cases it can be a more protracted change.
Aviva: I agree. I really appreciate that. You talked about the kind of bidirectionality of food intolerances, if you will, where sometimes yes, there is an inherent lactase enzyme that somebody doesn't have and they really can't eat dairy products, but that often one has food sensitivities or intolerances partly due to the status of the gut lining. Something people often talk about as leaky gut or disruptions in the gut microbiome or digestive enzymes that prevent us from digesting those foods. So I really encourage my patients to not, unless they obviously have a true food allergy or true intolerance, to not assume it's the food, but to give it some time and see what we can do to work on some of these underlying challenges that they may have accumulated over time, whether it's from, and I think that this is a big contributing factor, the chronic overuse of antibiotics, but also chronic use of NSAIDs, other medications. We know that so many of the food additives, we know that even environmental toxins can alter our gut functioning and cause underlying inflammation.
For me, I have been truly, for lack of a better way to say it, just completely geeked out over the past decade watching conventional medicine finally go, yes, microbiome. It's really exciting. We need to study it more. It's impacting health. And I'm so interested to hear for you as a gastroenterologist, what are some of the most exciting and important findings about the gut and inflammation and the gut microbiome gets a lot of and well-deserved attention, but also what about the gut lining and its role in immunity and inflammation?
Shilpa: I think it's a very interesting topic and one that I've been fascinated by. And I think to start with, we do know now that we need these microbes just for our immune system to do its job. When you look at, for example, these animals that have grown up in sterile bubbles and they have no microbes on them, their immune systems are very jumpy and maladjusted, and they have a variety of deformities like shrunken brains and hearts and lungs. These microbes that we have inside of us that live in our gut, but also all over our bodies and on top of us and around us, they're so important for shaping a robust immune system. And that means one that reacts appropriately to things like pathogens, but also doesn't overreact to harmless issues like dust and other allergens. These microbes are important for shaping the immune system, and they're also shaped by the immune system. There's this bidirectionality going on there.
And we also know that it's very, very important from the minute we're born to be in contact with these microbes, so the quantity and quality of microbes that we are interacting with. So as a kid, we do need to be outside interacting with these microbes that we've evolved alongside – in contact with these microbes in mud when kids go hiking or they play at the beach and things like that because those are the microbes that are going to best shape their immune systems. The quantity and the quality of those interactions are incredibly important because your microbes are having conversations with your immune cells at all hours of the day. We are not static human beings, and we can't draw our boundaries as tightly as we used to think of ourselves. We have these microbes that are shaping us constantly and they're shaping our immune systems constantly.
Aviva: There's such fascinating research that surprised me when I was working on one of my books on the profound interactions, again in both directions, again, that bidirectionality talking about, because it's all connected right between the gut microbiome and circadian rhythm, how much of our circadian rhythm can disrupt the gut microbiome and even lead the gut microbiome to, if you will, I'm doing air quotes here, be jet-lagged, but also how disruptions in the gut microbiome can affect our sleep cycles, our liver function, other aspects that are circadian-primed.
Shilpa: Absolutely. There are so many associations now. I think it's a fascinating area of research how all of these lifestyle factors can affect our microbes, can affect our health, can affect inflammation as well as the cause of these various disorders.
Aviva: We've talked about increasing fiber, increasing plant foods in general, and the really significant importance of increasing plant diversity in our diet. We've talked about sleep and the bidirectionality of sleep and circadian rhythm. We've talked about time in nature, getting dirty. What do you think about the role of probiotics versus fermented foods because the data isn't really that strong and convincing yet that we should all be taking a probiotic, yet when we look at cultures around the world, the Blue Zones, as Dan Butner calls them, many cultures, if not most, have some form of lactofermented or naturally fermented foods in them, and those do seem to be really important for our health. I'd love to hear your take on all of that.
Shilpa: When it comes to probiotics, I think there are specific clinical situations for which they're indicated and that's what the evidence that we have.
Aviva: Yes, very specific diseases.
Shilpa: Exactly. So, inflammatory bowel disease, irritable bowel syndrome, antibiotic associated diarrhea perhaps. For the average healthy person, I typically do not recommend that they take a probiotic, but I am a huge fan of fermented foods because I think these foods are so wonderful for our gut microbes and they can be prebiotic and probiotic, meaning that they can be food for our gut germs, and they can also introduce new germs into the intestines. And when you look at fermented foods, like for example, a sourdough bread that's baked in the ancient tradition, some of these fermented foods have less gluten than the gluten-free breads that you find in the grocery store. You'll have a celiac disease patient go off to Europe and eat this ancient sourdough bread and feel just fine.
Aviva: There's actually a great study on that that came out just a few years ago, how people with celiac who eat sourdough bread, truly traditionally prepared may actually be able to eat sourdough bread made with wheat just fine.
Shilpa: Yeah, and it just goes back to this idea that preparation is so important when it comes to food as well. And this is something that all of the studies don't necessarily capture the nutrition science studies and even the microbiome studies because when you're looking at plants and how much of these plant foods you're eating, you also need to keep in mind that preparation is so important. You can ferment foods, you can soak them, you can eat them raw, you can eat them cooked. I mean, there's so many different factors, but fermentation is something that really does change the intrinsic architecture of the food, and it sort of decreases the anti-nutrients and it increases the nutritional quality of the food. It lowers the glucose so that sourdough bread will have less of a sugar spike in your body than the bread that you'll find at the typical grocery store. I think there are so many things that one can do even at home just to learn to prepare these fermented foods and it's not too time consuming as well.
My parents are South Indian. I'm South Indian, I grew up here, but in my family, a traditional food is a dosa and that is a fermented, lentil and grain patty. So easy to make. It just basically tastes like a crepe, and you can fill it with whatever you want. And that's kind of a staple in our house actually. And you can steam it as well and create a different type of food called an idli. And so, every culture, nearly every culture in the world has distinct fermented foods that they use. And I think it's great to be able to incorporate these types of foods into modern day cooking.
I do like probiotic vegetables as well, like sauerkraut and such, but you have to be careful because sometimes the versions you find in the grocery store are not necessarily probiotic and they may have a very high salt content, et cetera. It's great to be able to make these things in your home. I'm still learning as well how to create these different foods.
Aviva: Where do you come in when it comes to dairy? I'm so curious because from a research perspective, it lands all over the place. There are some studies that show that as many as 50% of people have some inflammatory response to dairy, whereas other people tolerate it just fine. I come in in my practice as not leaning into it as a primary main course food, but more as a compliment and a condiment for people who can tolerate it, particularly when it's a fermented form like yogurt. But I'm super curious what you think.
Shilpa: Yeah, I actually see a lot of lactose intolerance in my practice. I mean, so many patients come in with lactose intolerance as they get older, and I think I really tend to look at the dietary pattern. I don't see dairy as a food that's absolutely necessary in the diet. We have a great diet without dairy, and I actually counsel patients towards that type of a diet. But again, it's about the dietary pattern. And if you were eating for planetary health and for human health and you choose to incorporate small amounts of dairy, I usually steer patients towards the fermented forms of dairy. So fermented yogurts, for example, as opposed to other types of dairy foods. I think it does depend on not just the dairy, but the other things that they're eating in their diet as well.
Aviva: You mentioned a fascinating rat yoga study in your book that shows how exercise can be anti-inflammatory. And my colleague and friend Robynne Chutkan, who's also an integrative gastroenterologist basically just says, if you're not moving, neither are your bowels. Can you talk about the importance of exercise for immune health, inflammatory reduction and gut health as well?
Shilpa: Exercise is incredibly important for decreasing inflammation in the body. We have dozens of randomized controlled trials across age groups that show that exercise can dampen inflammatory markers in our blood. But then again, even the absence of weight loss, and this was something that just blew my mind. Exercise can decrease the number of immune cells that infiltrate your fat tissue. It has so many beneficial physiologic responses inside of your body, even if you do not lose that weight. And I think just incorporating some regular exercise into the day. You don't have to be at the gym for two hours a day, but you can incorporate exercise as folks in the Blue Zones do. You can try to make it a part of your daily activities. You can take the stairs at work, for example, and do things around the house and rely less on modern conveniences in some cases. I really counsel patients that it's not an all or nothing thing. Exercise can be something that you can do every single day as a part of your natural life.
Aviva: I really appreciate that you shared how beneficial it can be even without weight loss because there's such a big focus on weight loss, and particularly for women who enter into menopause and they're struggling with that five or eight or 10 pounds that they gained, they get really frustrated when they're exercising and exercising and not losing weight. They sometimes give up rather than seeing the more global benefits of strength and reduced inflammation. So, I'm really glad you shared that.
Shilpa: And I think conversely, you can be a thin person who has poor dietary and lifestyle habits and who does not exercise, and you can still have that visceral fat. I think the person who does have that belly fat, but who is exercising and following an appropriate diet is actually in better shape than the thin person who is not.
Aviva: So true. How have your colleagues responded to your book and your thoughts? I mean, I think it's not so out of the box as it was maybe 20 years ago, but still not the most conventional approach.
Shilpa: I think I've generally had great conversations with my colleagues about this, and I think this is something that has been in the alternative medicine circle for a very long time, for decades, and it's just coming into mainstream medicine. And I think because we do now have these large scale randomized controlled trials, particularly in cardiology, a lot of folks are seeing that, hey, this is a cause of disease and this is a deep biological link between distinct diseases and it really does compel us to think about treating diseases, not just piecemeal fashion based on each organ and specialty, but also treating the person as a whole and really delving to those root causes. I think that there has been a huge interest in lifestyle medicine, particularly from younger physicians and trainees, and I think the future is great for this field. I think the response in general has been that it's something that we should be offering our patients in addition to traditional medicine. At the same time, a diet and lifestyle does not replace traditional medicine entirely, but it is an adjunct, and it is a very, very important adjunct.
Aviva: Sometimes I think the fires that we're seeing on our beautiful planet are really a microcosm of her inflammation. And for me, environmental health, the health of the planet and ~40:42 the health of the choices I make for my own health are just entirely intertwined. And I wonder what you think about that, this concept of inflammation showing up in our planet in the ways that it is sort of microcosmically showing up in our bodies. And I wonder how you feel the changes we make for our own health can be beneficial to the planet.
Shilpa: Yes, absolutely. I think what we're doing in our kitchens, at our dinner tables and things, we are prescribing our patients in clinic in terms of diet and lifestyle, is all connected to the broader ecosystem at large. And when you look at ecological disasters like climate change, epidemics and pandemics, we know that food, how food is produced, how food is consumed, has a huge part in affecting these disasters. And one of the things that we can do to help avert these things is to follow a whole foods plant-based diet. Lots and lots of plant foods and even decreasing the amount of animal products in the diet, even if you don't go down to zero, if you just decrease it significantly, that can have huge implications for the health of the planet.
Aviva: Let's talk about that just a little bit more. There's been a huge push over the past decade toward a Paleo diet, which has a lot more meat. There's even a meat-based diet now, very animal food forward. What are your thoughts on that much food in the diet for health inflammation and also from a planetary perspective?
Shilpa: I think it just doesn't hit any of the things that we want it to hit because from a health perspective, we do know that the dietary pattern is what is most important. And if you're not getting enough of those whole plant foods, you're not getting enough fiber, which again is one of the most important anti-inflammatory nutrients that we have, then we may be able to see immediate changes in our bodies if you lose a couple of pounds on a keto diet for a while. But when we're talking about hidden inflammation and disease for us and chronic disorders, we're talking about the long-term. You may not see the results of what you're putting into your body immediately, but it may manifest five years down the line, 10 years down the line, a couple of decades down the line. We really need to be cognizant of what we're putting into our body and a meat-based diet or a diet that is comprised primarily of animal foods is not a diet that is sustainable for the planet and also not for your body. It's not the type of diet that will reduce your risk of chronic disorders and we have so many epidemiologic studies to back this up.
Aviva: And Shilpa so often people want to know what we do. So, if I may, do you include any animal products or meat in your diet?
Shilpa: I'm whole foods plant-based, so pretty much I do not. But at the same time, I have patients who have a variety of cultural preferences, and so I generally talk about the dietary pattern with patients, but I think you can be a hundred percent plant-based and be completely healthy. You can be 90% plant-based or even less. But I think it really depends on how many plants you are including into the diet.
Aviva: Do you include eggs or fish or dairy at all?
Shilpa: For myself I actually don't.
Aviva: What are your favorite sources of protein and how much do you emphasize protein in your diet?
Shilpa: You can get all the protein you need from plant sources, and I eat tons of beans, so lots and lots of legumes in my diet. And I also eat tofu as well. It's another great protein source. I think we have a tendency to think about vegan or vegetarian diets or plant-based diets or as not having enough protein. But we do know, for example, even just looking at the folks in the Blue Zones who are living ‘til a hundred protein deficiency is pretty difficult to develop and our protein requirements are relatively standard, and we end up, if we're focusing on a balanced diet, even one that is high in plant foods, we do end up getting adequate amounts of protein through those diets.
Aviva: I agree. I was pregnant with three children, completely vegan or vegetarian. My fourth, I started craving eggs and chicken, so I trusted my body. And I had also been breastfeeding straight through for two prior children. And I have a primarily plant-based diet. I eat a lot of legumes. I include nuts and seeds. I include small amounts of fish and eggs. And then occasionally and more recently I started adding in some organic sheep yogurt. Sometimes I just want something a little bit quicker, so I'll make a plant-based smoothie and add a little bit of, and the thing for me is I live in the country so I can also get it very locally sourced, which I think is important as well.
Shilpa: Nice. Absolutely.
Aviva: Agree. You can get all the protein you need, and we know it's better for the planet. We also know from a hormonal perspective; women have better estrogen who are much more plant-based in their diets. And again, like you, I don't make any judgments about people's diets. I'm here to educate my patients and meet women where they're at. And also, I do try to keep that bigger ecosystem in mind. What is sustainable?
So, if there were three takeaways on inflammation, if you could just tell people three things that you really want them to take away from this conversation, what would those be?
Shilpa: I hope that folks are starting to understand that inflammation is omnipresent and that it can actually be a cause of disease, a risk marker for disease. And it is tied to a variety of our modern chronic killers, heart disease, cancer, obesity, diabetes, neurodegenerative disorders, depression. I'll just list those over and over again. And two, I would definitely love for people to understand that they do have tools in their own kitchens even on how to live their life, to combat inflammation, to dampen it, to prevent it, and to reverse it in the body. And that is something that is just so powerful that we have the data supporting these practices. We have data to say that a particular type of diet and lifestyle can actually help to dampen inflammation, decrease your risk of chronic disorders so that you don't develop those chronic disorders in the future.
Obviously there are genetics that are involved in disease causation, so many other factors, but the part that you can control, you're able to control that part. And then the third thing too, which we just talked about, is just looking at the broader ecosystem at large. When you're eating a particular type of diet, you are eating for your own health and also your loved ones as well for their health. And also, you want to be around for them in the future. And you also want to preserve this planet for progeny, and you want to see this planet do well and you want to avert things like climate change, which is already ongoing as we know, and epidemics and pandemics. And I think there's a responsibility there, and there's an acknowledgement more and more from folks that what we're putting on our plates affects so many more people than ourselves and our own health.
Aviva: I love that. One of the simple things I have my patients do is a food journal, but not to police what they're eating, but to start to pay attention to how they feel when they eat certain foods. How do you feel, right when you're eating it? How do you feel a couple of hours later? It's something that we're just really not taught. It's amazing to me when my patients start to do that, how they become self-reflective on their food patterns, but also just are able to kind of auto-correct. “Oh, when I ate that for breakfast, I felt really tired two hours later, or I felt achy, or my nose was stuffy.” All the different things. And it's really fun. I also just think it's so easy to get, and of course we're scientists, we're writers, we're doctors, so we're looking through a certain lens, but it's easy to get clinical in the conversations.
For me, I just love being in my garden and my kitchen and making things up and experimenting with flavor and nourishing my family and nourishing my friends. It's like, yes, all of this is about disease prevention, but then we will look at the Blue Zones. There's so much more. I was in Italy and Paris this summer, and people have lengthy meals. They linger over meals and socialize and connect, and then they walk between meals or they're walking up pretty steep hills to get to a restaurant or get to the grocery store. You're combining joy and pleasure and food and movement and local agriculture into something that is, if you get into the habit and the lifestyle of it, really fun and really beautiful. And I sense that you feel the same way in your kitchen.
Shilpa: I love what you just said. Yeah, I absolutely love everything you just said right there. And I think that's one of the keys too, is that this is not a Draconian diet where you're excluding all kinds of foods and punishing yourself. It has to be pleasurable if it's going to be sustainable. And I think when you look at the traditional Mediterranean diet, for example, this was a very pleasurable diet and a very healthy one as well. And you look at all of these different cultures and all of these foods, and these are pleasurable diets that are rooted in ancient traditions. And pleasure has to be an important component of why you persist with this diet. Because without the pleasure, without the habits, it's hard to keep any sort of a diet up.
Aviva: There are so many food rules. And I'm guilty of this too, talking about eating within three hours of bedtime or not eating after seven o'clock for your circadian rhythm. And then I'm in Paris and we're at a restaurant at nine, and we don't leave until 1130 and people are still arriving at 11. And these are people who generally, I mean, of course I'm not checking for their hidden inflammation, but these are cultures that have classically and currently in general lower disease rates of these chronic diseases than we do, too. And I love how Dan Buettner talks about in Blue Zones, people in Greece or Italy who are eating wine and cheese and bread, and they're living well into their early hundreds, but they're not just living, they're thriving. They're still having sex and managing their own bank accounts and leading their own households. And so, it's not about restriction, it's about healthful choices, moderation, local food, well-prepared food, good ingredients, walking, socializing, all the things that go into…
Shilpa: Absolutely and beyond diet, all of these other things. And also stress levels, just reducing your stress levels because stress is, as we know, inflammatory and inflammation may be one mechanistic link between stress and the disorders that it leads to. I think all of those different things are so important.
Aviva: I have a question for before we go. I love to ask each of my guests, if you could tell your younger self anything, how old would she be and what would you tell her?
Shilpa: That's a great question. When it comes to food – I grew up in Indiana, in a small town in Indiana, and I grew up eating all kinds of different things, the traditional food my mother prepared at home, which was very healthy, and I also ate a lot of junk food. I had a lot of fast food. It was a culture at that time. And every time there was a half day of school, my friends and I would go out and get fast food. I had a lot of all the foods that I write about you shouldn't be eating. I ate a lot of those types of foods when I was a child. And we know that the food and lifestyle choices we make as teenagers or as kids can really affect potentially disease risk down the line.
I would tell my younger self if I could, to eat in a different way to eat more of the food that my mom prepared at home and to stay away from the ultra-processed foods because this was the nineties when all of these ultra-processed foods were having their heyday. It started even earlier than that in the 80s. But there's so much marketing that goes on, particularly towards children and teenagers when you look at all the foods that are marketed and when you're a kid, you think you're invincible and you're able to just take in all these foods and you feel fine afterwards. And so yes, I think I would tell my younger self to really focus on some of these health and wellness habits that I started to learn as I got older and as I got into my training,
Aviva: I love that you're able to look to your mom's food as a source of healthful nourishment. Shilpa, your book is beautiful. It's not a typical ‘how-to’ book. It really is a story of your journey. It's a story of the history of inflammation. and then there is of course your beautiful recommendations for bringing this into our everyday life. Thank you for writing such a gorgeous book and bringing more attention to inflammation. What are the best ways folks can find you?
Shilpa: I have a website, shilparavella.com, and that's probably one of the best ways. And it has contact information listed on there and some health tips and various categories as well.
Aviva: Well, thank you for this beautiful book. Thank you for this lovely conversation and being on the show. We'll put all the links for everyone to find you and your book, and I wish you just continued joy and enjoyment of this path that you're on.
Shilpa: Thank you so much, Aviva. This was a great conversation. Thank you so much for having me.
