If Everyone’s Got Anxiety, Does Anyone Have Anxiety? with Dr. Ellen Vora

24:56Yeah, even if you just think about it energetically, spiraling has this quality of like, you're like a cartoon where like the energy is spiraling up. And when we can come back into our body, whether it's through pushups, dance, music, going outside, splashing cold water in our face, doing a non-sleep deep relaxation exercise, full body scan, all of those things, we come back into our body and that does help bring the energy down and we don't spiral as much. And I think you're exactly right, social media plays a role. Character limits. We literally don't have space for nuance anymore. And we're now accustomed to communicating in character limits, if not even just emojis.

25:29So there's no more nuance. And that's contributed to the way we're hyperpolarized. And we no longer hold two things can be true. I want to come back to your whole argument around anxiety and really the role of inflammation and physicality in that anxiety in our society. Before we do that, I just want to ask you, because when I read that Times article in 2020, I did think these terms are so gendered. Like worry is a mental thing and it's really associated with women historically. Stress is like what men tell you. Men rarely say, oh, I'm worried. Dads do. But men usually are like, I'm stressed about my job.

26:06I'm not worried about losing my job. No, no, I'm not worried. I'm stressed about it. And then anxiety, I think, has had a more feminine connotation in our culture. That's right. Does either gender experience anxiety at higher volumes? So I think that's exactly right. And I think that this has so much to do also with like, what do we have permission to feel in a particular gender? And women have permission to be worried and to be anxious. Men have permission to be stressed and to be angry in ways that women don't. and and I think that um so yeah we latch on to the term that is still allowable and maintains our relationships and social standing um but I think that like a more conventionally minded psychiatrist would be saying but we're all feeling anxiety like that there isn't that much difference between a man and a woman in terms of they're feeling it it's just different what they're calling it so they might say well that guy he has anxiety he doesn't know it he's just drinking or he's just, you know, it's being expressed as anger.

27:04I'm like less interested even in the semantics of like, what are we calling it? I'm very interested in what is someone subjectively identifying with? Like if they're saying I'm stressed, let's work with that. They're saying I'm anxious, let's work with that. To me, those terms are very important for clinical research. Like we need standardization and whether or not someone meets criteria for a diagnosis is really important if we want to gatekeep interventions that have risk. Right. But most of what I'm doing, all of that is somewhat immaterial. And it's like, okay, you feel stressed, you feel anxious.

27:37I don't really care. It kind of points us in some directions. But ultimately, I'm going to roll up my sleeves and do the investigative work of like, what's out of balance here? Let's address that. imagine like a very nuanced world where we're maybe heading with AI where it's like, no, no, I'm not depressed. I have dysthymia. Oh, no, no, I'm not anxious. I have whatever. I have false things. I mean, I could imagine that this is where we're trending. Anyways, we'll take a quick break for our sponsored dumb question from Noom and we'll be right back to hear more about anxiety and how we can curb it.

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29:35So anxiety and the anatomy of anxiety. This begs the question of like, for me, what moves faster, our brain or our body when we're feeling something? Do you know the answer to that? Whoa. Okay. What moves faster? Like, where do we feel at first? Because as you're saying, like, you're, you know, mental health has always been like the neck up. Yeah. But I'm going to concretely answer that question to the best of my knowledge, but then I'm going to kind of philosophically deconstruct it a little bit. I love a little philosophical deconstruction after a mid-roll break. And so I think that reflexes are the body moving faster than the brain.

30:15A reflex is you take your hand away from the stove or even knocking the knee. That is going up your spinal cord and right back down without ever involving the cerebral cortex, without ever involving like, oh, should I take my hand away from the hot stove? It's happening in a way that's much faster than cogitation. and so sometimes the body moves faster sometimes I feel like my thoughts move too fast but I think that my philosophical deconstruction of that question is that like whenever I'm coming on to any any kind of speaking engagement it's like oh like her approach to mental health is that it's like the mind-body connection like that it's more physical anxiety is more physical than we think And usually how it's thought of is, oh, like the way some people's anxiety manifests as IBS.

31:05Some people's anxiety manifests as these physical symptoms, tension or something, or you're breathing differently. And that's all valid and something to explore and unpack. But I'm really actually interested in the other direction of traffic, which is that we're experiencing something we call anxiety, we subjectively feel as anxiety. But the root of it is physical imbalance. It's not that the anxiety has created physical symptoms. Also true. But the part where I'm like, where do we change someone's life? Where do we bring them relief? Is not in being like, let's fix your anxiety so that we can fix your IBS.

31:38That's hard to do. Let's heal your gut so that you're not anxious anymore at all. And so it's really starting with the physical body and understanding all the mechanisms for how physical imbalance generates states that we call mental health conditions. And so it's really just thinking, where is the physical body out of balance? Let's start right there. That makes a lot of sense to me. And that's very much how I read your book. It's like this idea of the neck up, the serotonin analysis, and then, you know, prescribing SSRIs to deal with what's the head. Well, I think I hear two things in what you're saying.

32:10One, your head is part of your body. Yes. Like that's what you said at the very top. Your brain is actually part of your physical reality. So there's that. And two, it's also tied to everything else in your body, whether that's, you know, whether that's your gut, whether that's your exercise levels, everything. You know, that serotonin comes from somewhere, right? It's downstream. Right. And I think that when we're, like, looking at, like, can we nudge the serotonin behavior in the brain? Can we is even actually, we can nudge it. Does that bring us effective antidepressant effect? it looks like in severe depression yes to some degree in mild to moderate depression it's a little bit equivocal and basically that it doesn't seem to separate from placebo mark horowitz had a paper in molecular psychiatry in 2022 that was like there is actually no basis for the serotonin theory of depression which is very upsetting for anyone who's benefiting from their meds so i always want to follow that quickly by saying if you're benefiting from your meds you're benefiting from your meds, even if serotonin isn't the direct mechanism.

33:14And it's not even just to say the mechanism is only the placebo effect. It's to say we might not understand the mechanism, but if you're helped, great. Right. But not everyone will be helped. But not everyone will be helped. And we might do well to step back and say, should we start investigating other mechanisms? And so I think that, yes, the gut is involved in many mechanisms that impact the brain. And so it's more than serotonin. And nudging the serotonin is the most downstream place we can look. It's like we're looking at the very tip of the branch of the tree. Maybe we actually want to take better care of the soil that's surrounding the roots of the tree.

33:52Right. And the soil in this case is like your mother and your boyfriend. I'm kidding. The soil in this case is like your diet and your exes. It's all of it. It's holistic. Fantastic. Okay. So let's talk about the gut because I feel like the gut is so, I mean, everybody's talking about the gut, kimchi, et cetera. I feel like it's a little out of fashion. Like everybody was talking about the gut two years ago and like now everyone's talking about creatine and muscle. Like they've moved on from gut. But I feel like the gut is still important. And certainly when it comes to those Eastern modalities and so much of Ayurvedic medicine, 5 ,000 years of South Asian medicine is around this idea of like key, butter, your gut, your diet.

34:30And that not everybody should have the same thing. It depends on your physicality. So the gut has a – when we say gut reaction, does that mean anything to you? Yeah. What does it mean? It means that culturally, linguistically, we come up with all these terms that are a reflection of what's really happening there, what we're feeling, like long before we know the science. We do have a kind of knowing in our gut. It's interesting the way we're 10 to 1 gut microbes to our own cells. So like this is a very... There are 10 times more gut microbes than there are human cells. That's what we estimate. Oh, wow.

35:08Yeah. And I mean, I think that the centrality of the gut and its importance to our health, like our body hasn't moved on from that, even though social media has. Yeah. And it is central. It's out of fashion to be into your gut these days. I'm all for protein and muscle. That matters, too. It all matters. It all matters. And I think that with the gut, there are just certain mechanisms that are important to understand. which is that the gut is not only where we're manufacturing certain neurotransmitters like serotonin, like GABA. We don't usually talk about GABA. What's GABA? Gamma immunobutyric acid.

35:44It sounds like a band, like GABA. Yeah, right? And they just sing like lullabies. But GABA is our primary inhibitory neurotransmitter in the central nervous system. Translated to English, GABA is what makes us feel calm and we're going to be okay. And so GABA, I think it was an endangered species in modern life. It's also manufactured by certain microbes, interestingly, in the gut. And so when our gut is healthy, we're making neurotransmitters. We are training the immune system. The immune system does most of its basic training in the gut, and it's learning to differentiate between friend and foe based on this ecosystem of fungi and bacteria and even parasites and viruses that live in our gut.

36:27So when our gut flora has been decimated by antibiotics or just the lack of kimchi in our diet, then our immune system is lacking that basic training and it tends to not perform in such a calibrated way. And GABA, sorry, GABA is like a measurable thing? It's like a type of microbe? No, GABA is a neurotransmitter. It's a neurotransmitter. When we talk about serotonin, that's another neurotransmitter. Dopamine, those get a lot of, they're in the limelight, but GABA matters quite a lot and that's manufactured by gut bacteria in the gut. And neurotransmitters are things in your body that talk to your brain.

37:00Yeah, they're chemical messengers. They are the things that when two neurons, two brain cells, talk to each other, they can talk to each other in a few different ways, but one of the primary ways that they talk to each other is by spitting a neurotransmitter out from the end of one neuron to the next neuron. That's how they talk. And they can say, like, green light, red light. And red light sounds bad, but red light feels good. Like a brain that is full of excitatory signals and like go, go, go, that's kind of a state of agitation or even like muscle twitching. A calm system has a lot of inhibitory signals.

37:38It's a lot of what the way the brain functions well is not saying yes to something. It's actually appropriately saying no so that we can choose one path and do that with clarity and focus. And how are neurotransmitters different to hormones? hormones are happening in the bloodstream, circulating and communicating to organs all over the body. And there's overlap in all of this, but neurotransmitters are more associated with this is how our neurons in our brain are talking to each other, brain and spinal cord. Interesting. And you talk about the gut-body connection a lot in this book because you have seen many patients where their anxiety is actually a response to something that's happening in their gut.

38:20It's something that's happening, either antibiotics over prescription or diet. Yeah. Is that correct? Yeah. And I love that sentence that you'd said, where it's like, regardless of whether you're an endocrinologist and you're a psychiatrist are talking to each other, your gut and your brain are definitely talking to each other. And now it makes sense, because now I understand what neurotransmitters really are. So inflammation is like at the root of all of this. And you have this concept in your book. I have to look it up because I can't pronounce it. It's like the psychotime hypothesis of depression.

38:49Say it again. Cytokine hypothesis of depression. Yeah. And it relates also to inflammation. Yeah. And it's not the root of everyone's depression, but it's the root of some people's depression. Like what we've been talking about with serotonin, that's the monoamine hypothesis of depression. Serotonin, the type of neurotransmitter it is, is called monoamine. So we say monoamine hypothesis of depression, the one that says it's your serotonin. That is one of many possible narratives to make sense of depression. It's not even our most evidence-based one. It's just the one that happens to be the current consensus because our treatments are based on it.

39:21It's kind of derived from tuberculosis drugs that modulated serotonin and made some people feel less depressed. So we've been laser focused on serotonin for decades and to varying degrees of relief from people's depression. A competing hypothesis is the inflammatory slash cytokine hypothesis of depression. And it basically shows us that for some people, their depression correlates with the degree to which they have cytokines, these inflammatory molecules, coursing through their bloodstream. And it stands to reason, this one's interesting, because I always like an ancestral or evolutionary explanation for like, why would this create depression?

40:00So if you're on that proverbial savanna, and you made the mistake of drinking from the wrong pond, and you got a weird microbe, your body is thrown into a state of acute inflammation. what makes sense under those circumstances is to retreat to your cave you might be contagious you don't want to infect the rest of the tribe you want to go rest in the dark because those are the conditions under which your immune system has the best shot of keeping you alive resting in the dark resting in the dark having changes in your appetite socially isolating and that works for your body fighting off an infection that actually happens to look a little bit like what we would called depression.

40:36It's the sick response. You want to retreat. You want to be resting. You have low vitality. You have appetite changes. You're fatigued. You feel malaise. You don't want to socially interact. And so the theory is that a lot of people are in a state of chronic low-grade depression because they're in a state of chronic low-grade inflammation. And who among us is not in some degree of inflammation in modern life? Because the modern environment makes a broad assault against both inflammatory, provocative, pro-inflammatory insults, like foods that we're eating and exposures that we have, but also because our gut is so compromised that we're not properly calibrating our immune system.

41:13I love that you call it insults, like stuff that we do to ourselves, but it's an insult. What you put in your body, how you treat your body, whether you're on the phone all night and seeing that kind of blue light before bed. So if inflammation is the root of a lot of bad stuff in our body and our brains and our anxiety or depression, how do we know if we're inflamed or not? So there are blood tests and you're probably not getting those blood tests if you're just like walking into your primary care doc in a conventional setting. If you're seeing a functional medicine doctor, if you're seeing a naturopath, they may be testing for it.

41:43What are the specific things that you should be testing for? So some like starter ones are something called high sensitivity CRP or HSCRP. That's a good, that's a very good screener for inflammation. Sometimes you want to look at homocysteine levels. Sometimes you're going to do a much more involved panel looking at specific cytokines, but typically CRP is a really good place to start. Okay. And those are not the regular, like when you're going in our cholesterol or blood sugar, etc. Are those secondary measures? Like if we had an inflamed response, would we see that in the more traditional, conventional, you know, partialistic, dysfunctional medicine?

42:21So usually, and I thought of one other is the SED rate, which is ESR. And usually, the way a conventional doc is going to be checking for inflammation would only catch if you are in that moment acutely inflamed, like you might have high white blood cell count. And so this more subtle, low-grade background chronic inflammation is usually not going to get picked up by the complete blood count and basic metabolic profile that you're going to get with a conventional doc. I don't think we're good at naming our feelings. I have one more question in that, which is nowadays we're teaching kids color wheels for their feelings.

42:56I see this with my godkids. They're like, they feel blue or green. Green is good. Yellow, which is murky. Red is angry. And blue is down. Have you seen this color wheel? Yeah. I feel like that's actually kind of helpful. There's also this Finnish study that I sent you done 10 years ago where they looked at, I think thousands of people, they looked at people and they asked them to say what they were feeling and where they were feeling it in their body. I found that fascinating. To me, what's most fascinating about that is the universality of it. That it doesn't matter. It's not about like culturally learned phrases of like, I have a broken heart or, you know, like I got cold feet from this.

43:38It's that there's something universal about where we feel different emotions. I think the color wheels are great because we are in this emotion-phobic culture. We absolutely lack granularity in how we talk about our feelings. The work of Brene Brown in her Atlas of the Heart, she talked about how most people can only name like three emotions. I think it's like happy, sad, angry. How many emotions are there? I don't know. It's like 72 or something. And I think that Mark Brackett, his book Permission to Feel, is also a beautiful approach to this. And I think that the more granularity we have is really powerful, partly because, as we discussed, naming is very grounding and helpful.

44:12But also because we do confuse certain states. We have more of a tendency to say that something's negative when, in fact, it's not negative. It's just activated. So if you're about to—like, I was at school drop-off this morning talking to a family, and they're moving across the ocean. and this seven-year-old boy everyone was like are you excited are you excited and what he was struggling to try to articulate as a seven-year-old was i'm ambivalent like he's excited and scared and there's a lot to look forward to and there's a lot to mourn and that's just it so his response was just like but you can see in his eyes ambivalence and so of course because of course and so we need the granularity because when we're too simplified about it we're gonna bias negative and then we're going to move from that place.

45:05Right. And I think that actually causes some of our problems in relationships especially. It was interesting to read the study because it's like, oh, a lot of the negative emotions are happening in your chest up. They're like, you feel chest tightness and that could be you're sad, you're depressed. If you're angry, you feel it in your limbs, often in your arms, which is amazing. It's kind of like you see sometimes men get angry and they roll up their sleeves and there's a sense. And then the limbs are also where you feel love. like weakness in your limbs that can come from love or can come from sadness.

45:36I thought that was such an interesting, to your point, like, I don't know, were you surprised by this? No, and like, unhappiness is the whole body. And like, I think there was something about fear, anxiety, like that your limbs go numb, you feel powerless. But I think two-way street is always a really interesting way to approach any of this. And a lot of those anger responses, they're just this hardwired stress response that we have. We're angry and deep down in our wiring, it's like you might need to fight somebody right now. So we get tense in all the ways that make us best able to run and fight.

46:08We get focused, our pupils dilate, we get tense in this area. We even like, err, like tense in our jaws, because that's part of how you show dominance. It's like that, you know, picture a dog growling. It's like, err. You're trying to actually ward off and insert dominance. So the other opponent decides to flee instead of fight you. And I think that what's always worth looking at is how does modern life get our body, just by happenstance, stuck in a state that tells our brain we're about to fight? Because when we're staring at the phone, when we are looking at the computer and our eyes are bulging, like a lot of this is part of a reciprocal communication between the body and the brain that says we're in a fight or flight situation.

46:53Sometimes it's not because we're not, we actually aren't. We just have jaw pain because we have a narrow palate and we're breathing through our mouth while we sleep. And, but it leaves us in a state of chronic stress. So you want to address it at that level and really figure out how can we not have TMJ so that we don't feel so anxious as a result. Where I think we can find relief in a pretty realistic, actionable way is preventing our body from getting tipped into a fight or flight response unnecessarily. That's my interest, because if you're genuinely in a threat, this is wonderful that we have a fight or flight response.

47:28If you are underslept because you're up doom scrolling, hungover, you had an extra cold brew coffee, you skipped breakfast, your blood sugar's crashing, you're in a fight or flight response, and it's kind of dumb. That's so much suffering, and it doesn't need to be happening. And I'm not saying like we should all lead perfectly virtuous lives, but there's small strategic shifts we can make that eliminate so much unnecessary fight or flight from our lives. You're basically saying like increase your tolerance so that not everything is activating your flight or flight response in some way. Sometimes it's increase your tolerance and sometimes it's...

48:03Or like raise your bar for what gets that out. Yeah, it is sometimes that, but it's sometimes not even... I mean, like some of these things are about changing the threshold for your body getting tipped into a fight or flight response. but sometimes it's really just don't have a blood sugar crash then no fight or flight response like keep your blood sugar stable but in your argument like the blood sugar actually like increase it like makes everything your body is triggered or triggered to have a primal fight or flight response exactly yeah sometimes i think like living in new york is like a great antidote to this because there's so many stimuli that you just kind of have to walk through new york like i still i've been here for six years and i still have this sensation like when people are like get the fuck out of the bike lane and i'm like oh i love living in new york i feel like in a movie you know like it's helping my anxiety yeah exactly in some way like it like raises my bar for everything because i'm like there's so much happening there is the beauty of the human body and how we acclimate to sensory information like if i go away and then come back to new york i'm like it's very loud here right but then a day and a half later i'm like it's normal yeah it is a little bit i think it is still a little subtly hard on our nervous system to be here is western medicine just trying to like perfect something that has existed for thousands of years or perfect or pharmaceuticalize something that's existed for so long?

49:17Well, is the suggestion there that anxiety is normal and we're trying to remove the bumps from the road of life? I don't know. I just feel like there's so much that we're recreating in the West that exists. Are we good at learning from what else is out there? No, we're not. But here's what I really think is that I think the human body is decently well-designed with the exceptions of the knee joint and menopause. It's decently good design. And so what happens is that we are living in a way that's so different. If you map human evolution, we were living in a way, I'm not saying it was easy. We didn't have hot showers and we had infant mortality and a lot of badness.

50:00But there was a certain set of inputs to our system for millennia. And then here we are, and the last sliver of time, we have Doritos and blue spectrum light after sunset. And so the springs are popping out of the machine. And it has to do with subtle aspects of modern life that we just didn't evolve to be okay with. Right. And so I think a lot of what Western medicine is doing is saying, like, there's all these problems. Let's patch it up. And sometimes I think the more elegant solution is to not have the problems in the first place by recognizing where are we giving the machine the wrong inputs?

50:37Yeah. And this is a question I have because I have heard this argument from many people that like light is really, electricity is really what fucked us. It's all, you know, Thomas Edison's. Right, right. And Franklin's fault or something. But the idea being that, you know, when we used to live and die by the sun or live and sleep by the sun. Yeah. Eat and sleep by the sun. Yeah. Our bodies were much more regulated. So how has technology kind of changed everything? Yeah. I mean, this whole system. has to have a 24-hour clock. And our internal clock, it's called the suprachiasmatic nucleus in the brain, how does it know when it's daytime and nighttime?

51:16It's not connected to a cell tower. That's not where it gets its information. It's connected to our eyeballs. And so the way it tells us... Our eyeballs, neurotransmitters. It actually is directly, like just neurons straight from our eyeballs are going to the suprachiasmatic nucleus and saying, hey, there's light hitting or there isn't light hitting. And so it's telling our brain whether it's daytime or nighttime. And that system was foolproof, and it helped us be awake during the day and tired at night. And I don't blame evolution for not anticipating this plot twist, which is that we were going to harness electricity and then invent the light bulb and eventually white lotus and nobody was going to sleep anymore.

51:51That's where we are, is that we have blue spectrum light, the light that resembles the daytime sky coming into our eyeballs long after sunset. Yeah. Whereas we evolved seeing fire and moonlight. And so our bodies are like, we have a lot of different drives for sleep. We have fatigue. We have sleep-dried. There's agenocene. There's all this going into it. But ultimately, it's saying, I sure am tired, but I can't argue with the sun being out. So that must mean it's daytime. We suppress our melatonin. We secrete cortisol. We feel awake, and then we don't sleep, and then that gets everything else out of balance.

52:25So just getting strategic about what kind of light is coming into our eyes during the day and at night goes a long way. Okay, and you suggest to have these blue light inhibiting glasses. Can we put them on? We can put them on. Let's model this. They're not very sexy, I will say. They're very sexy. You took the sexy ones for yourself and you gave me. No, no, it's fine. Those look extra metallurgy ready. These look very, this looks like I'm going to go into a sixth grade science experiment with a beaker or something. And I think like where we want to get strategic about light cues, it's first thing in the morning and it's after sunset.

52:59First thing in the morning, you just want to somehow, someway get actual sunshine into your actual eyeballs. Not through sunglasses, not through a car windshield, not through a window, the real thing. But that tells your body, this is morning. It's stamped that moment in time. And not only makes you feel awake during the day, but ticks in the background programming your brain to get tired at night. And then after sunset, that's the real secret sauce because that's what's most disparate from the conditions under which we evolve. So in the morning, get up and get outside. Not through a window, not through anything.

53:29Just like be outside. Even if it's just a couple minutes. It doesn't have to be the Andrew Huberman 20 minutes along the Pacific Coast, 30 if it's overcast. It can be a couple minutes. That makes a difference. Let your eyes show the brain, the sun. Even if there's no sun, even if it's a rainy day? Outdoor daylight, even on an overcast gray day, is so much brighter than anything indoors. Okay. And then at nighttime after sunset, if you don't have a date, put on these glasses. The solution is really to move off the grid and raise chickens and make sauerkraut and defenestrate your phone deep into the ocean.

53:58If that's not available to you in the next week or two, this is the harm reduction strategy. And how long do you have to wear these? What I do is I own two kinds. I own the less sexy kind of the sexy kind. Yeah, more and less sexy. And the more sexy are actually, they just look like glasses. I use the gooder ones. They're$25 and they just look like glasses, but they have blue blocking lenses. I put those on at sunset. I wear them. And then as it gets closer to bedtime, I switch to these. And that way, I am blocking blue spectrum light from getting into the eyes. Everyone's like, what if I just put night mode or night shift mode on my devices, flux on the computer?

54:33Those are all great. They're necessary, not sufficient. So it's wonderful to dim and orange-ify your screens. It's still going to be blue spectrum light. So blocking it is still helpful to produce melatonin as you get tired. What I've done is turn my phone into black and white. And that is amazing. It makes the phone so unsexy. I'm so uninterested in spending time with my phone on black and white. It's like next to raw dogging a flight. It's really hard to do, but I'm glad you do. Yeah. It tells you why the newspaper business is struggling. You're like, oh, this. They just need more glossy photos.

55:03It's not exciting. Exactly. Okay. So you're saying back in the day, there were no night owls in the year 100 BC. Oh, I think there absolutely were night owls. I think that we're all different chronotypes. Yeah. We all have a slightly different role in the community. And so someone had to be in a slightly later shift. Someone had to be on the earlier shift. But also, I think that those of us who feel like we are night owls, I'm one of these people. I am too. I'm like on 11 p.m. to 1 a.m. I love working. I love what happens to those hours. It turns out in my case, was I a night owl or was I exquisitely sensitive to the effects of light?

55:39When I wear these, I'm not a night owl anymore. Oh, gosh. Which is a great way that it got me through residency because you have to work an overnight shift, but you're in the fluorescent lights and LED lights of a hospital, which for my brain, it's like all systems go. I'm ready to go to the races. And so I think that some of us are more sensitive. And this is the design is our body has mechanisms for suppressing melatonin so that we can do the night shift mode so that we can... But you're saying if I put on these glasses, I will now know if I am or am not a night owl. It's a night owl test. You're giving your brain its fighting chance of secreting melatonin in response to the dark.

56:16and making you sleepy at like three hours after sunset. Also back in the day, our ancestors didn't eat so much. They didn't live as long, but they also didn't eat this many meals all the time. I find three meals a day is a little absurd, I have to say. I don't, I mean, I'm like, I'm a breakfast skipper. I'm also, you know, a 2 a.m. to 10 a.m. sleeper, which is a different vibe. But do we have to eat so much? I mean, many would say we should be eating less. I think that where we are right now is that we are eating so many refined carbohydrates, refined grains, added sugars, that we're on a blood sugar roller coaster.

56:57Yeah. And that doesn't feel good in every crash. We're a little, oh, we feel off. We feel, some of us, anxious. Some of us overwhelmed. Some of us lose focus. We get sleepy. But also, we then crave our next hit. So we're not eating in a very blood sugar stabilizing way. It also trains our body to not have a lot of metabolic flexibility. so it's the nature of our processed foods and even not just our ultra processed foods but even just our very refined diet like even pasta but like these are technically processed um that has us really riding a rapid up and down and a more blood sugar stabilizing diet of fatty cuts of meats and um berries and starchy tubers and full fat things like we're more likely to have stable blood sugar where we're then not dropped into basically drug withdrawal where we're then craving our next hit.

57:45You have in your book a hack that you talk about, which is taking a spoonful of almond butter every kind of like six to eight hours to regulate your body. Yeah. There were so many years when I was like, okay, patient, like let's overhaul your diet and have you eat in a blood sugar stabilizing way to treat your anxiety. And they were like, Dr. Vora, like you're nice, but no, like I'm not going to pack a bento box of organic strawberries and and bring that to work. And so I really started to meet people where they're at always. And you want to keep your blood sugar stable, but without a lot of effort.

58:16Something like almond butter, some people use coconut oil or ghee, clarified butter, things that are basically pure fat or fat and a little bit of protein are slow to be digested, slow to be released into the bloodstream and create a safety net of stable blood sugar. So I'd have patients who would have their panic attacks on their subway ride home in the evening that like that was their high risk time for panicking they'd have a jar of almond butter at their desk take a spoonful before they left the office panic attacks stopped wholesale are you on the take for like justin's almond butter no i probably should have been i do this thing which you are maybe going to think is weird which is i do a tablespoon of olive oil in the morning yeah because i think it's like good for joints sure and then i do in the afternoon i do the almond butter thing which i learned from you yeah and then in the evening I do honey.

59:01This is like absolute, like this is your secret to your success. Really? You think this is okay? I think it's good. I mean, I think here's the thing is that we don't know what the research says. We don't know. We don't care what Dr. Forrest says. If this is working for you and it's certainly not harmful, our body will tell us whether this is working or not. And our job is to listen to that. I feel like I had an A and now I have an A on a curve, but that's okay. We do have so many studies for everything nowadays. And I want you to help people understand, like, what is a good study? What is a bad study?

59:30How do I know what a study is? Like, everyone's talking about creatine right now and creatine in women's bodies. Like, how should we be digesting medical research, especially when so much research is actually funded? Yeah. Okay. I have, like, a PhD thesis on this question. Okay. I'll say it as quickly as I can. But basically, I think that the spirit of studies is a beautiful thing. Like we used to just argue by assertion and be like, I'm your doctor and you should put a leech on your body because I said so, because I think so. And then we're like, well, let's put it to the test. Let's see. Like what's the evidence?

1:00:10And there's beauty to that. We want to know the truth. We don't just want to like work through our biases. And then that system got bought. You know, they're industry interests that now systematically influence that system. So what gets studied in the first place, what gets published, what gets, like, if it was a negative finding, what never ends up in the journals in the first place, and then all the way down to what kind of financial relationships do the experts on the panels. All of that has industry interest influencing. So there's a place for it, and it's useful, and it's not perfect. And we did lose touch with two kind of anti-evidence things.

1:00:56One is anecdotal experience. We really poo-poo that. We say, like, that's just anecdotal. Like, it ends the argument. But anecdote is actually the base of the pyramid. We're at the very top, like a meta-analysis of several randomized clinical control trials. That's what we consider our gold standard. But the only reason we ever have a hypothesis in the first place is based on anecdote at the bottom of that pyramid. And what I find is that, one, we are getting even dustier at those wires of communication of listening to our bodies when we only outsource our knowledge to what has been studied. Like, should I take creatine or not?

1:01:35Like, the study told me I should. Like, we look back at that 10 years from now, maybe it's not reproducible anymore. How do you feel when you take it? Like, is your body saying yes or no? I think we want to get better at that. And I also find that there's a man-woman thing here because what gets studied and how we're measuring dosages and, like, whether there's parity in medical trials, like, it's always biased towards we're giving better information for a male body than for a female body, and we're being more dismissive of a female subjective anecdotal like, hey, I think this is happening in my body.

1:02:10And for years we said a woman would go on the pill and she'd be like, I think I'm crying every day. And we'd be like, there's no evidence for that. So we just sent her home. Even though there was a plethora of anecdote for that. There was so much anecdote, but it was hysterical women's anecdotes. And so then now we know indeed exogenous hormones influence mood. Because, of course, like if you've ever had PMS, you know that hormones influence mood. I mean, this is, I think, one of the craziest things because women are responsible for the vast majority of medical spend. They are the drivers of medical decision making and families and their own health, convincing their partners often to go get checked out.

1:02:47Keeping their partners, et cetera. Living longer. Exactly. And yet the medical community has done a pretty shit job of studying women. I had Tamsin Fidel on here. Love Tamsin. You know as well. And we talked about this study of menopause where they had linked the hormones in that case, hormone replacement therapy, to cancer, breast cancer. Once that story was out, even though there were countless studies saying that, hey, that earlier study was wrong, it's like you can't put the cat back in the bag when it comes to this. and now you know we're in this moment where okay for menopause women are being prescribed hrt again and uh noom which is my brand sponsor for this podcast like actually prescribes it yes like how this is where like the studies really like shake me but also the opposite reaction the reaction that like everything is false like the liar's dividend well if one thing is true if one thing is untrue then everything can be untrue is also really scary right because there has been that shift now where, okay, in say Europe, where there aren't the same capitalistic interests, there isn't, there's a lot more regulation.

1:03:53There isn't the same industry funding of academic trials. You know, they are saying similar science on certain things, including say, vaccinate your child for measles, mumps, rubella. This has been around for hundreds of years. And now we're seeing distrust in that. So how do you reconcile that as someone who's in the medical community and who understands who I think you know you in some ways skew a little woo woo yep yeah right like a lot yeah you like the honey I love it raw milk you have questions around birth control for everybody not around contraceptive but around birth control for everybody right but you also I don't think are part of the kind of like don't vaccinate your baby so so here's and I think that one just like sidebar around the menopause and birth control anecdotal issues is that we have societally a tolerance for female suffering and pain that I think is different for men.

1:04:44And there's intersecting layers of when you add to that, if this is a Black woman, we just have so much more tolerance for their pain. We allow it. And this is why we see maternal mortality and so much higher in Black women. And so it's like, there's ways that we don't take women suffering in pain and complaints seriously. And this is all kind of part of why I don't put all of my eggs in the basket of evidence, is that it's just not a perfect system, and we still need to listen to the subjective experience. And instead of saying, there's no evidence for that, we say, maybe. But how do you not throw out the baby with the bathwater?

1:05:29This is where we need to go back to teaching our kids to self-regulate, right? Because it's all about right now we don't tolerate nuance and gray area so we're like it's this or that yeah like you're in this cap or you're not you're maha or not never the two shall meet right and and and i think what's dangerous is that um you know with the pandemic response the systems of public health lost credibility by simplifying the message i'm not saying i envy that job i wouldn't want to have to think about like what's the right way to message this for our population we're figuring things out moment to moment.

1:06:01We're trying to save lives. Like, I don't envy that. But I think that sometimes we underestimate, sometimes we underestimate humans. And I think there was some balance that we missed in terms of, here's what we think is the right choice for each of us to make. Sometimes it's for our own well-being. Sometimes it's for the collective, which we don't really have that mindset as an American culture either. It's like, what's for the collective? But sometimes it's, there are risks. And I think in acknowledging that we maintain credibility. And by completely denying it, you lose credibility. And then someone turns and says, well, the whole system is untrustworthy.

1:06:38And then we're really in trouble. So we need to keep the credibility each step of the way. And sometimes it's admitting, we're not totally sure. We think this is the right choice. This has benefits and risks. We think the benefits outweigh the risks, but we're not invalidating the risks and your experiences. And I think that I have interviewed Dr. Fauci on this topic, and I think he himself has said, yeah, like, it would have been, I asked him, why didn't you say, I don't know more? Why didn't we say that at the time? And it's like, yeah, I wish I could have said that. There were certain politics that made that very hard to say.

1:07:11And clarity is the job in some ways of public health officials, because they're giving this kind of like brute force message to the world. But there wasn't listening. There wasn't listening about like, okay, let's at least be able to have conversation about lockdowns. Let's talk about the fact that women are seeing these weird changes in their cycle, you know, with respect to vaccine in certain cases. And acknowledge that this might be happening. Let's talk about different age populations and how they may or may not benefit from the vaccine X number of months out. I think the pandemic was such a moment of reckoning.

1:07:41And we did not just our public health officials, we as a society, the media, everybody, our politicians of the time, you know, just we're not good at handling that nuance. That's right. It comes back to the nine-year-old and the color wheel. Like, I do think that it's in our interest as a society to help all of us learn how can we hold two conflicting truths? How can we be with our ambivalence? How can we be in the messy, nuanced gray area of a situation? We're very black and white. We're very hyper-polarized. We're at each other. We're like, you're on that team. I'm on this team. And we won't even have a conversation.

1:08:19And I think that this is like at the root of so many of these problems. So if we find our calm in that moment, we have more idea labs then. We can say, hey, smart person who I respect who has a different opinion than I do. Like, help me understand your perspective. And I think I would love a world in which the public health messaging says, we don't think you're idiots. Let's talk about the real risks and benefits because it's complicated. And I think that's just it. Like all of my weird woo-woo views, to me, I'm at every step of the way thinking through the relative risks and benefits because every choice we have.

1:08:55Like Tylenol to like raw milk, it all has risks and benefits. And we get to decide. I think we get informed consent is really critical. And then I think we have a right to decide for ourselves. There's a collective angle here too. But like, given my situation, here's the right balance of risks and benefits for me. And I think we get too much into like, this is all good or this is all dangerous. But the communal stuff matters, which is to say, like, if you decide not to vaccinate your child against something that is hundreds of years of history and you're putting your child. Like, if you decide to stagger your vaccines in a way that they do it in, say, Denmark, that's a very different conversation.

1:09:33Right, right. You know, so I think there's a kind of nuance there. Yeah. Okay, last question before I ask you my final or my second to last question. What – are you worried about therapists being replaced by AI? Because everybody's using chat to be too. I think excited for it. I mean, I think it's confusing what happens when none of us has jobs anymore. Yeah. It's confusing to me why it's not like the Jetsons where Rosie was doing our dishes and our laundry, but we got to be artists. Like, why is it that it's making our art and we're still doing our dishes? But I think that, like, it's, I want, I want the alleviation of suffering.

1:10:07Like, that's my goal is viscerally I'm uncomfortable with humans suffering unnecessarily. And I have patients who are like, you know what's working for me right now is I get into my car, I drive home from work, and I have a conversation with ChatGPT and it's my new therapist. Hallelujah. Like, whatever is going to get you up that path. What do you think ChatGPT can do better than you as a therapist, and what can it do less well than you? So it can do almost everything better. I think it's smarter. I think it's more insightful. I think it has less discomfort with difficult confrontations. And currently, and this might change, what it can do worse is checking in on people, is follow-up.

1:10:47Because it's still directed by when someone's checking in with you. So someone could go into their chat GPT and be like, I'm having really low thoughts right now. Like I'm in trouble. And then chat is a very good therapist in that moment. And then later they can be like, what's the square root of 26? And chat could be like, I'll tell you the answer. Be like, are you okay, bro? And so, but they can't. It can't just say like spontaneously when not prompted, like, I'm still worried about you from that conversation we had yesterday. Are you okay? And chat currently can't do that. But once it can, it'll be better.

1:11:18It'll be much better. You're out of business. Okay. And that's okay because then I think what I'm actually really here to do at this point is, well, I'm even more of a writer right now than I am a therapist. Like, I still see patients. Yeah, you're working on your second block. But I want to spread ideas with the world. But I think that there's energy work that I am doing with patients that I still think actually we might be a ways off from AI to be good at energy work. Okay. There's also, energy work sounds very weird. Open a big can of woo-woo worms that we're not even going to open. Okay, so I'm like, what a fucking cliffhanger.

1:11:54Second episode with you. Okay. Then also the thing it can't do is it cannot, like, put its hand on your hand. It cannot, like, give you a hug. Yeah. That's the thing that Chachi P.T. currently can't do. We'll see what Johnny, Ive, and Sam have in store for us. But right now that's not the case. That's clearly coming. But you can't do that either, right? This is my last dumb question. Are you allowed to have your patient? Can I can't? Allowed? Not? Not? Like, there's so much boundary consideration. I am like 10 plus years in with so many of my patients. So like we have figured out what are the right boundaries.

1:12:24And sometimes like, and that's actually where a hug is all the more of a, of a potent healing offering as if we have a very distanced, very boundary relationship. And then someone's going through like a huge grief. That hug in that moment, I think is like a very profound intervention. And so it's kind of saying like, this is different. And it's like, let's, let's acknowledge that and bear witness to that. and like the human condition. There's also the privacy aspect in my perspective, which is like I'm more likely to trust one human than I am to trust one enterprise that has created an app that is connected to all my other phones that location trackers can like identify through third-party systems and trackers.

1:13:02So there's those things. So that should give you a little bit of pause. Professional ethics still count for something, but like you take an oath and there are boundaries to your profession and there's like conduct to it. And we don't have that with tech right now. Yeah, we don't. Last question I ask every guest. What is something that you have a dumb question about? What's something that you've kind of pondered and not been able to figure out or ask ChatGPT yet? I mean, my husband points out I'm dumb about everything other than the one thing I know deep, deep, deep. So it's like I'm all about functional mental health and then anything else, I'm useless.

1:13:31But I think that, like, one question that's always been on my mind and no one's ever been able to answer is like, so say you're trying to get from here to your destination and it's raining pretty significantly. if you walk or run like which one ends up getting you more wet because it feels like if you run you're less time in the rain but there's this way that you're like running into the rain and you feel this dramatically like getting wetter and so I'd love to know the answer to like what is the right strategy if you don't have an umbrella it's raining you need to get there how are you going to minimize getting soaked I love it what do you do you have a hypothesis I got what does your gut we We all instinctively run.

1:14:11Yeah. But I kind of love when we all instinctively do something and it turns out that was wrong. So I'd love to realize it turns out if you just... We all, if we're cold, we go like this. Right. And there's reason for that. But in certain ways, it makes us experience the cold worse. Because we get into the story of discomfort and non-acceptance. So it's like I try to relax my body in the cold now. And I'd be curious to know if I'm supposed to just walk slowly in the rain. Yeah. Okay. I love that. I will find out for you. Thank you so much, Ellen, for doing this. Really appreciate it. It's been a delight.

1:14:40So fun.

1:14:48That was a long conversation, but I just want to talk about three things that stuck with me. One was that quote from her book, which said that your gut and your brain are talking to each other, even if you're a gastroenterologist and your psychiatrist are not. I thought that was really well said and kind of goes to how we work as a body. I just learned so much from Ellen on that topic. The second was her point about why we're seeing more mental health issues in the United States than elsewhere. And I thought she really touched on something important, which is how can we be a country that's so wealthy, so innovative, so ahead of the curve, and yet in many ways so undernourished, so alone, so kind of divorced from the collective and our community?

1:15:26And what does that do to our health as a society? And that relates to the third point, which is how we got to this point of real divide and real divide around science and health, you know, and the role that the pandemic played in that. I think that there's a real opportunity for more open conversations where we hear questions and talk about, as Ellen said, the collective. You know, we acknowledge and have these conversations in a public space and we talk about what's best for our health as individuals and as a collective society to move forward. So I don't know, lots to think about there. And I would love to hear what you think.

1:16:00Please send me a note. I'm at naima raza101 at gmail.com. Or you can leave a comment or review wherever you're seeing this, on YouTube, on Spotify, on Apple, wherever you get your pods. That's it for this week on Smart Girl Dumb Questions. This episode was produced with Dana Balut, Noah Friedman, and Healy Cruz. Our theme music is by David Kahn. And I'm your host, Naima Raza. I'll see you next week. And in the meantime, I'm going to go get a scoop of almond butter or honey or something. Bye.

1:16:36I don't think I can be your friend, Isabella said. Rebecca's stomach flipped. This is the love story of real hinge couple Isabella and Rebecca, written and read by me, Temi Denton-Hurst. Listen to the free audiobook now.