Dr. Rashmi Mullur is an integrative endocrinologist leading practices at UCLA and the VA in Los Angeles. She received her medical degree from University of Texas Southwestern Medical Center, and completed her internal medicine and chief residency at Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis. After this, she completed a fellowship in Endocrinology at the VA-Cedars Sinai Medical Center. A certified yoga instructor registered with the International Alliance for Yoga Therapists (IAYT), she is also a board-certified integrative medicine practitioner (American Board of Integrative Medicine), in addition to completing a research and medicine education fellowship. Dr. Mullur is also part of the David Geffen School of Medicine at UCLA curricular faculty, and chairs a course in endocrinology for first-year medical students, as well as leading the UCLA Health Integrative Medicine Collaborative as its education director. Her goal is to educate up-and-coming doctors in integrative medicine as they enter their training, with a focus on experiential learning. She has pioneered several clinical programs using integrative medicine techniques for the management of chronic disease, and she is recognized as a national leader on the use of integrative medicine for patients with diabetes. Given her background, the focus of her practice is in fully integrating Eastern and Western approaches to clinical care, using teachings from yoga, TCM, Ayurveda, and other modalities to truly connect mind and body in the treatment of endocrine disorders such as diabetes, thyroid disorders, stress management, and fatigue – often referring to acupuncturists, movement specialists, and other practitioners to complement her work. As a patient, Lauren can attest to the effectiveness of Dr. Mullur’s approach. One stunning fact: she takes a longitudinal history of each new patient, and has tailored her schedule to spend as much time with them as they need for appropriate treatment. So, basically: the needle in the proverbial healthcare haystack, and Lauren’s medical hero.
Listen in as Dr. Mullur shares…
- that she most often deals with patients who live with chronic stress and fatigue
- that she is a special needs parent, and that juggling work, life, and care-giving can be exhausting – so she has to find the space personally to deal with those challenges
- that her own experiences have given her a better understanding of what her patients are feeling, which has strengthened her empathy
- that while many of her patients live with disorders that aren’t validated by lab testing, that doesn’t mean they don’t require care
- an overview of the endocrine system, which is the focus of her work
- that she takes a longitudinal bio-psychosocial history of all her patients – and why that’s important
- her role: to bring her patients back to their own wellness
- that she started utilizing integrative medicine in her practice in 2011
- why “adrenal fatigue” isn’t an accurate diagnosis
- what makes a good doctor: curiosity
- an issue with the US healthcare system: that doctors are strapped for time with their patients
- that the VA in Los Angeles has been responsive to alternative and complementary approaches to medicine (such as yoga, Tai Chi, and acupuncture)
- how the VA has been advanced in its approach to helping veterans wean themselves from opioids, where addiction has become an issue
- how the VA has also led the charge with regard to telemedicine, and why she’s excited to be a part of its growing program
- the challenge of encouraging patients to find balance
- why she turns to her yoga training in her integrative approach to care
- that some patients have been ill for so long, they can’t hear what their bodies are trying to tell them
- that so much of suffering (from misunderstanding) – for both patients AND physicians – is based in ego
- that as a practitioner, she sees herself and patients in partnership over their care
- what’s shifting in medicine: doctors’ comfort with saying “I don’t know”
- that a lot of physicians deal with the same symptoms as patients: stress and fatigue associated with “burnout”
- the advantages and disadvantages of group intervention in medicine
- where physicians can improve in their approach to treating pain – in referring to PT, acupuncture, etc.
- the problem with hormone testing: that hormones are only a snapshot in time, and are constantly shifting – which makes the nuances harder to track
- that treating fatigue with hormones can often be like using a sledgehammer to knock on a door – it is often far too aggressive
- that Deepak Chopra is also AN ENDOCRINOLOGIST!!!! (This fact blew Lauren’s mind!)
- that we need to start speaking the language of energy medicine in traditional Western approaches to care – and that she thinks this will be the next advancement in medicine
- that she’s working on a book right now – all about coping with stress and fatigue (check here for updates!)
- the importance of patient empowerment – which goes beyond the concept of “patient-centric” care
- her role as an advocate in her children’s care – especially in the care of her special-needs son
- the power of social media to connect patients and caregivers
- how elimination diets should work: for a short period of time, with professional supervision, and with the plan to reintroduce “no” foods in the future
- that she sees a lot of orthorexia in her practice – especially among younger female patients with diabetes, who are also often at risk of micronutrient deficiencies
- why it’s important for patients to document their symptoms for their doctors
This episode is also sponsored by Embr Labs, creators of the Embr Wave.
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Lauren: All right guys, thank you so much for joining us today! I'm here with a guest who I have been wanting to have on the show for quite some time now … our esteemed guest, an integrative endocrinologist with both UCLA and the VA here in Los Angeles. Dr. Rashmi Mullur. Thank you so much for joining us!
Dr. Mullur: Thank you for hosting me. I really appreciate it.
Lauren: Oh my gosh, it's such a pleasure to have you here. So, I found you through Dr. Rothman, who's been on the show before. And starting to work with you really helped turn a lot of things around for me in terms of what I was dealing with. But I was wondering if you could talk to us a little about whether you have a personal connection to invisible illness aside from your work as a practitioner?
Dr. Mullur: Yeah, so in my work, I see patients with chronic stress and fatigue. And that tends to be the invisible illness that I'm dealing with most often. It's typically from a multitude of sources, in terms of patients’ etiologies for their chronic stress and fatigue. Personally, I have chronic stress and fatigue myself.
Lauren: You’re an MD … of course you do! (laughs)
Dr. Mullur: (laughs)
Besides just work, I’m a special needs parent.
And just juggling work and life and caregiving can be exhausting. Giving myself the space and time and emotional freedom to accept and deal with those challenges has offered me quite a bit of empathy, and a better understanding of what my patients who deal with chronic stress and fatigue are feeling. I think that's probably my strongest connection on a personal level to invisible illness.
Lauren: I think it's very clear working with you … I can say from my own experience, and we'll get into this … but the first time I saw you, you sat with me for over an hour. And this has continued in all of our appointments. So you're certainly able to accommodate a level of care that is not typical in every circumstance. And definitely the things that we discussed are so integrative, so it's really interesting to have someone like you with this medical expertise, as well as this psychological and meditative approach as well. Do you ever find that you have patients who are coming in to see you — aside from the chronic stress and fatigue, which you're obviously very familiar with — who are sort of borderline hypochondriacs, or you think might be attention-seeking? Or is it really that these patients are genuinely people who are dealing with invisible problems?
Dr. Mullur: I certainly haven't encountered anyone who I would characterize as a hypochondriac, by any means. Not every person I see has a diagnosable endocrine disorder or hormone imbalance that you could validate on lab testing. That does not mean they're not suffering from chronic stress and fatigue. And I think there are approaches and ways in which we can help those patients find their balance in terms of their own health and wellness, that don't rely on traditional approaches. Because sometimes the traditional approaches lead to people saying, “Oh, you don't have diagnosable condition X, based on your hormone testing. So it must all be in your head.” And that's the framework that I really try to avoid, and I'm trying to shift. But certainly hypochondria, dealing with patients who, you know, think they're ill and otherwise aren’t … if patients feel ill and stressed, that's enough for me. I don't really need to know the specifics of the causes, because it can be from anything.
Lauren: That’s really reassuring to hear, because I ask that question of every practitioner on the show … and every single one, including you, has said, “Hypochondria? No, don't really see it. It’s people with legitimate issues.” So that's very reassuring. You know, I realize also that there are probably people listening who don't necessarily know what an endocrinologist is, or what the endocrine system is. So maybe you could give us a little, quick background on what that is and how it all functions?
Dr. Mullur: Great. Happy to. So …
An endocrinologist is someone who specializes in the treatment of patients with hormonal disorders.
Hormones being small chemical molecules secreted from a gland or one part of the body that then travel to another part of the body to exert its action. Glands that people are familiar with are the thyroid and adrenal gland, pituitary gland. Also, as an endocrinologist, I see patients who have diabetes — because the pancreas is both an endocrine and an exocrine gland, so the exocrine part of it means it's the digestive enzyme portion of it. And the endocrine portion is the insulin and glucagon that's secreted.
Lauren: Okay, so you're really dealing with glands that are all over the body; it’s not just a single system?
Dr. Mullur: Correct. And there's an interplay and crosstalk amongst the glands and among the hormones. So the complexity is something that I love. It's a source of great interest and academic curiosity. But also, it's a place where we just don't know all the answers.
Lauren: I was going to say, is it one of the most under-researched or least understood areas of medicine?
Dr. Mullur: I don't think it's under-researched in any way. But I do think that the approaches have been fairly dogmatic in terms of hormone testing. And I think we can make a couple of changes there. I think we are very quick to reflexively test hormones in patients looking for an answer. And that reflexiveness leads to some patients having abnormalities, or having no abnormalities; then we automatically characterize them as … you have a disease/you don't. But then some patients feel bad regardless. So you can be in the category that's diagnosed as having something beyond the appropriate treatment for that something — and not feel well. Or you could have been in the category that was told that they didn't have a hormone abnormality — and feel unheard. So I think both types lead to problems.
Lauren: Yeah, it’s much more nuanced in a lot of ways.
Dr. Mullur: Absolutely.
Lauren: So what tests do you first use to determine the various invisible illnesses that you're working with? And which of these conditions do you find to be most recurrent in your practice, as well?
Dr. Mullur: Most people who come to see me have some knowledge of the endocrine system or have been told that they have an endocrine problem. So I'm not usually doing the first round of testing. In many cases, I’m usually reviewing outside testing. And then if there's something on outside testing that needs followup or needs to be clarified, I will do appropriate testing based on what the patient brings in in terms of their prior workup. If I'm seeing a patient — and I often do in my VA practice where it's not a referral, but just a patient who's coming in for the first time without a diagnosed condition …
I’m very, very unlikely to order hormone testing as the first step. Because I usually find that asking detailed questions and a history, and taking the time to really hear a person's story, is more likely to get me to the answer.
Not necessarily solving their invisible illness of stress and fatigue. But at least it gets me on the right path towards working towards that goal. And it allows me a way to get to know my patient and also align our common goal, which is treatment and care. And it doesn't always involve testing.
Lauren: Again, I will say in my experience with you, the first time I sat down with you, you said, “Okay, so you were born … and?” And I was, like, do you really want me to go back that far? I don't even remember that! But we really did this huge, detailed history. And in doing that history, it even became clearer to me, things that have been going on for perhaps longer than I’d realized. And then we were able to dig deeper. So it's really fascinating.
Dr. Mullur: Yeah, and actually, that's what I love about my job. It's not necessarily figuring out the hormone mysteries — because frankly, there's a million reasons why hormone testing can be off, and we can maybe talk about that later if you want to. But truthfully, what I really enjoy is taking what I call a longitudinal bio-psychosocial history. So the bio-psychosocial history was first brought into medical training and medical history-taking by psychiatrists, who really felt that it's important to integrate the social history and the psychological wellness of a person with their chronic medical disease. Expert family practitioners do this as as they get to know their patients over time.
If you're seeing a patient for the first time as a consultant, you're often getting an editorialized view of what's happened.
So, what's nice about doing this and and what it allows, is that when I take this approach with my patients, I not only hear about them and their view of their lives and how they see themselves in the world — which matters when you're dealing with patients with chronic stress and fatigue. It matters how they view themselves, and how they view the stress and the burden that they feel has been thrust upon them or that they have taken on. But it also allows me to understand how they characterize their illness. And when it happened. The example I like to give people when I'm describing it is … let’s say you got diagnosed with diabetes when your parents got divorced, at age eight. That diagnosis and the way you deal with your diabetes and all of the stress and struggle that comes with learning how to be a diabetic patient … if you’re a kid at eight — is now, then, couched with this worldview of your parents splitting up and life being really, really hard — because divorce is hard. And if I see that person as an adult at age 28 … you know, 20 years later … and I say, “When were you diagnosed with diabetes?” And they say, “At age eight,” and then we just kind of move on … their distress, and specifically, their diabetes related to stress, hasn't always been addressed in that situation. And if they're doing fine, and they've coped, and they're doing great … then no big deal, and it's not an issue. But when you're seeing me for chronic stress and fatigue, it's important for me to know that, because our emotional view of our disease and our emotional view of how things got us off track and off our path is incredibly important to getting us back on track.
Lauren: Yeah, absolutely. And the key word that you use there is “integrate". It is this integrative approach. And the idea of root cause, as well. Which is a pretty radical approach, when it comes to the traditional Western medicine industry as we know it — because we're used to treating when there's a problem, rather than saying, “Okay, let's look at what's causing the problem” … maybe dealing with that stress, to actually fix a lot of the other symptoms. So, you have mentioned that a lot of people are coming to you and they've got stress and fatigue and invisible symptoms going on and they're not necessarily feeling heard. Do you think that you are taking this integrative approach not only to really get to the bottom of it, but also, in a way, to address patients’ feelings of being shuttled from specialist to specialist, and trying to find answers … and how stressful that can be on a patient?
Dr. Mullur: Yes, I definitely think that that is a part of it. Feeling unheard and feeling like your doctor’s thrown their hands up. I don't want to make it sound like I am the end-all be-all diagnostician. I'm not Dr. House! (laughs)
Lauren: Well, I think you are! You’re my Dr. House, so let’s just say that. You’re a version! (laughs)
Dr. Mullur: (laughs) But that being said …
I don't think I have magical answers. What I think I do well is help patients find their way or their path back to their own wellness.
I’ve been practicing integrative medicine since 2011. I started off doing integrative diabetes and using mind-body techniques to help patients with diabetes manage the stress from having diabetes. And from there, I had to deal with patients who had chronic fatigue and thyroid and adrenal issues, and those diagnoses that many endocrinologists don't know what to do with. For example, adrenal fatigue.
Lauren: Yeah, that's a big one. It's sort of become a buzzword in the wellness community, hasn’t it? I feel like adrenal fatigue got cool when Gwyneth Paltrow started talking about it; it’s that Goop thing! (laughs)
Dr. Mullur: And …
Adrenal fatigue is not a diagnosis that my colleagues accept, just due to the characterization of it and the description of it. And I can't disagree with them.
Because I think the way it is characterized online doesn't give credence to what the patients are feeling or actually what's physiologically even going on in the body. So the classic description online is ‘burnout and fatigue from a burnout of the adrenal glands from chronic stress.’
Lauren: And so it's actually stress — adrenals — fatigue, not adrenals — fatigue — stress?
Dr. Mullur: Right. And on top of this, the notion, or concept, that your adrenals will just burn out one day from chronic stress and fatigue …just isn't accurate. Absolutely there are diagnosable disorders that are endocrine disorders where you have either an over-function or under-function of the adrenal gland, specifically as it relates to the stress hormone cortisol. Which is what adrenal fatigue tends to talk about. But not only are there multiple other hormones secreted from the adrenal glands that never get discussed in adrenal fatigue, there are are also very few patients who truly have a hormone abnormality. That's one issue — the other hormones of the adrenal gland that don't ever really get discussed. And number two, there are so many patients with symptoms of adrenal fatigue that don't have a hormonal abnormality. And to blame it all on adrenal fatigue when … number one, it's not appropriately named, and number two, it doesn't characterize what's going on … It just doesn't help anyone.
Lauren: Medically, it’s not responsible, exactly, is it? Because that's not exactly what it is.
Dr. Mullur: It’s not exactly what it is; it’s not exactly what's going on. And for years as an integrative endocrinologist, I struggled with how to address these patients in a respectful and appropriate fashion, understanding that I am an endocrinologist, trained by traditional Western systems. But also I take an integrative approach to my patients. And finding a way to integrate those two aspects of my life took some doing; it took some research and homework. But I think turning to the neuropsychiatric literature and looking at the work that's been done in other fields that aren't necessarily endocrine, has helped me come up with some answers.
Lauren: It’s really interesting, especially because you're running these programs at UCLA and at the VA. You're definitely also in a position of influence to actually change the course of treatment for a number of patients, particularly with the people you're training.
Dr. Mullur: Absolutely. And certainly, I have had more endocrinologists come to me and tell me that they are interested in learning an integrative approach and want to discuss this. Specifically when it comes to fatigue, I tend to, again, not focus on the hormones … but try to get to the root cause of the stress and fatigue. We know for a fact that patients with trauma — whether it's the “Big T” trauma of violence and war and rape and tragedies like that — that certainly we recognize. But there's also what psychiatrists call “Little T” traumas, which are living with chronic disease, or being raised in a home as a child with adverse emotional childhood experiences … these play a huge role in how our bodies cope with stress. There are diagnosed brain changes on MRI images of patients who've been exposed to stress and trauma. And so that's where I turned to get some root cause answers. Because the hormonal testing just wasn't providing me with the information satisfactory for me, as a physician, to feel like I could very clearly say that my patient had something (a) wrong with them, or (b) not wrong with them. And then even if I said that to my patients, like I mentioned before, my patients sometimes didn't fit either category.
Lauren: It's really interesting because, what you were saying about being Dr. House … you really are digging through these mysteries!
Dr. Mullur: Again, I'm not Dr. House! (laughs)
Lauren: I know! But there is that discovery phase, right? Where you're really looking at so many more factors.
Dr. Mullur: I call it curiosity. I wrote an editorial piece for an endocrine practice journal, and …
I really think if we can keep our doctors curious about what they're seeing in patients and what patients are experiencing, then we can get to the bottom of it. But without that intellectual curiosity, if it doesn't fit one of our baskets, we just throw the whole thing away. And I never want a patient to feel thrown away.
Lauren: So, you've talked a lot about how your approach is a little bit different than the way that doctors are traditionally trained in this country to treat patients. So what are your thoughts about the US system — not only with the way that doctors are trained, but also with the way that we're expected to live our lives … in terms of work/life balance? This is sort of two different questions! So are we setting ourselves up to fail?
Dr. Mullur: That's a tough one. In terms of how doctors are trained, I will say we are making major progress in changing that. I have the privilege of sitting on a number of committees at the School of Medicine here in Los Angeles, the David Geffen School of Medicine. And we are training our leaders to be curious and empathic and humble, and advocates for our patients. And certainly in terms of training, we have our eye on the prize, in terms of creating that ideal physician who is able to best advocate for patients. In terms of training physicians to be able to approach a patient with invisible illness, that doesn't necessarily fit the standard boxes. So I think we're doing a good job in terms of training. In terms of the US healthcare system, I'm probably out of my league to talk about the challenges we face in trying to come up with a better model.
I do think the time limits that most primary care physicians and most physicians in large hospital systems face is unfortunate. It really doesn't lend itself well to providing that ideal patient-centered experience. Which is what we all strive for.
I think I have the privilege in my job at the VA to take the time I need with my veteran patients. I also think the VA has been incredibly insightful and prescient in thinking about the future of healthcare delivery. Not only were they first to integrate these otherwise complementary and alternative approaches … yoga and tai chi at the VA has been going on for years.
Lauren: I never would have known that! I think that’s so cool.
Dr. Mullur: It's really a privilege to be able to refer someone for yoga and tai chi, and know that my yoga and tai chi instructors are there to treat my patients and I don't have to send them to some studio somewhere else.
Lauren: And if anyone deserves it, it's disabled veterans.
Dr. Mullur: Absolutely. So not only have they been leading the way there, they've also been first to offer acupuncture, and deal with veterans in terms of offering alternatives for opioid usage and helping patients wean from opioid usage. Because so many of our veterans have suffered from the opioid epidemic. And, the other thing that I think has been wonderful being at the VA, is telemedicine. One of the other hats I wear is, I also supervise the telehealth program.
In terms of telemedicine, I think the way the VA is leading the nation is that by offering more telemedicine and telemedical approaches, we can meet the patients where they are, quite literally.
So I have the ability to do a telephone followup via old school telephone, or I can leverage the technology we have and use a smartphone linked to a tablet that has a view of their medical record. And I can do a full visit that way, and not have the patient have to drive in. And what's really interesting to me about that approach is that I get to see sometimes where the patients live, and how they're living. And so much of invisible illness is environmental, and your lived experience as a patient. When you come to my office, I see the version that you present and what you're able to present.
Lauren: Is it weird for you being in my house right now? (laughs)
Dr. Mullur: No, not at all! But it's a different experience. If you're seeing someone with chronic trauma, like I do so often at the VA … seeing them in their home and seeing what their lived experience is like just provides you with so much more insight. And it allows me to be so much more integrative and thoughtful in my approach.
Lauren: Yeah, and really to see whether people are setting themselves up for success or failure in their homes, right?
Dr. Mullur: Absolutely.
Lauren: And what do you think in terms of lifestyle, too …
Dr. Mullur: The second part of your question!
Lauren: You're talking about visiting these patients and seeing what their lives are like. But in terms of the way that we expect people to live now, and the hours people have to keep for work, and you know, all that kind of a balancing act?
Dr. Mullur: So I probably am the worst person to answer the question about work/life balance.
I don't know that I have any [work-life balance]. But that being said, I don't know that any of my patients have any. And I don't know that we live in a society that values that.
Lauren: That’s what I’m really getting at, yeah.
Dr. Mullur: And those changes need to be on a systemic level. I would love to tell my patients, “Oh, you just need a vacation.” “Oh, you just need a break from work.” Or, “You just need a day where you can unplug.”
Lauren: A day? Geez, just a day!
Dr. Mullur: There are so many of my patients, for whatever reason, [that] cannot unplug. And me included. There's no way you'll ever find me without my cell phone within arm's distance; I have a child with special needs who suffers from epilepsy! No one's going to tell me to take my phone away. And I think so many of my patients are in that same bind. They don't have the ability to unplug, for whatever reason. And so I think giving platitudes and non-specific advice just doesn't help anyone achieve their goals. So I think until the system changes and until we have the resources and help we need to change as a society and put our mental health and well being at the forefront of our care … until we really do that … I think what I try to do, is try to navigate with the patients in terms of small incremental changes that they can make. What is something you can do? What is something that sounds reasonable to you?
What would be most healing for you? I think the challenge is that most of my patients don't always know the answer to that question.
Lauren: So do you step in then with suggestions?
Dr. Mullur: So, I never try to tell a patient what they're thinking or feeling. I then actually turn to my yoga training.
Lauren: So you're trained as a yoga instructor?
Dr. Mullur: Yeah, I’m a yoga instructor.
Lauren: This makes so much sense! Things are coming together in my mind and in a whole new way. But when did you have time to train as a yoga instructor? That's a lot of work!
Dr. Mullur: Prior to children — when I was delusional about what I was going to do with my time! Because before you have children you think you have all the time in the world.
Lauren: But also … a medical career. A full-time medical career … I don't even know how you have time for anything else, let alone yoga training.
Dr. Mullur: From the very minute I set foot in my first yoga class nearly 19 years ago now, it just felt right to me. Not everyone's going to have that experience with yoga, and that's fine. Most people view yoga as an exercise form and that's fine. I'm not trying to convince anyone that yoga is the end-all be-all of integrative approaches. But what I have found for me, is that using a yoga-based approach has allowed me the self-awareness and insight to let me know what my body needed.
So many of my patients just don't know what they need, because they haven't felt well in so long that they have forgotten that.
Lauren: Yeah. And you lose a sense of what it feels like to be in your body. You don't understand it anymore.
Dr. Mullur: And so much of healing, and so much of the integrative approach, is based on attention and awareness. I don't pretend to be the one that created the saying, and I would be at a loss to tell you who said this, but … “That to which we give attention, grows.” But if we're not aware, we can't give attention to. In my yoga-based training and in my practice, when I encounter a patient who really just doesn't know the next step, we pause and and I have them do some self-reflection exercises. Because I don't know your lived experience; only you do. And only you can can help decipher that. And I acknowledge the fact that sometimes I get a filtered view of the history; I get what people are willing to share. And over time, their ability to share and troubleshoot their own path becomes more clear. But I really view myself as a guide here. I'm not the person solving the problems.
Lauren: It sounds like there's a lot of removal of ego — not only for you as a practitioner, but also for the patients. The idea that if we remove a perception of how things should be, or that we have all the answers.
Dr. Mullur: …
So much of suffering for both patients and physicians is about that ego-based experience. ‘I'm going to go to the doctor; they're going to give me the answer.’ And the doctor saying, ‘Okay, well, you came to see me and I have all the answers.’ Both are falsehoods. It really should be a partnership.
And I view it as walking hand-in-hand with my patients. I don't know where the destination is all the time, because sometimes the patients don't know. But I'm willing to go on that journey with you. And I view you as a partner in your care. And ultimately, you're the person that's going to dictate what you do with your body. I'm not holding anyone’s hand and forcing them to take medicine. Because that's not my role.
Lauren: To me, that's revolutionary. You're making a face at me, like, ‘Oh, come on now.’ (laughs) But given some of the experiences that at least I have had, or that other patients that I know have had, there's a real mixed bag when it comes to practitioners. You don't know whether you're going to get the one who says they fixed you —even though you don't feel fixed. Or the one who was willing to sit with you and really figure it out. You really don't always know what you're gonna get. It’s like a box of chocolates. (laughs)
Dr. Mullur: True.
I think what helps, and what I try to teach my students, and what I think is shifting in medicine — is our comfort level with saying: “I don't know.”
Lauren: Being curious, too.
Dr. Mullur: Right. I think the first time we met, I think I said, “I don't know” to a lot of your questions.
Lauren: I don't recall that because I look at you and I'm like, she knows! She's shaking her head. (laughs), But yeah, I mean, I think there was a lot of … “Well, we don't have the answer” … even though you said, I don't know, you were, like, “But there are ways to maybe find out why.”
Dr. Mullur: Yeah, that's probably true.
Lauren: I think it was also going, “Okay. I don't know. But … here are ways that we can know”. But you also gave me the option of the different routes that we could take, and the knock-on effects of each option, as well. So I felt very informed in terms of my care. And that was also huge, because a lot of the time doctors are so pressed with the time they have with patients, it's like, “I gotta just give you the pill and move on to the next person." But being able to take the time and to figure out if it's actually the right approach …
Dr. Mullur: Right. And I think that that point is well made. Because again, I don't think I'm doing anything revolutionary, as much as I'm doing what I'm allowed to — because I have a great opportunity to take time with my patients. And I really feel for my colleagues who sometimes burn out themselves because they want to give that level of care, but they're always running behind on their clinic schedule because patients need their care. And then at the end of the day, they're an hour or two behind, and then they get caught up on their charts. And then what suffers is their own care and wellness. We do have this epidemic of physician burnout. And I think, again, it's kind of the same invisible illness that I see — which is stress and fatigue. That's most of what my colleagues and physicians who are suffering from burnout often feel. Which is this overwhelming sense of fatigue and stress because they don't feel like they're doing enough. But yet they're in a situation where they really can't do any more. And similarly, offering them platitudes of, ‘Well, here's a meditation camp that you can go to.’ And, ‘Why don't you do this five-minute breathing exercise between your patients’ … again, is similar to me telling my patients, “Well, try to meditate daily; you'll feel better." I think platitudes across the board just don't serve anyone.
Lauren: But it's really about asking what works for people. Because you and I arrived on meditation, and that actually works really well for me. So for me to be able to acknowledge that, to experience and try different pathways … we've talked about the Oprah / Deepak meditations a lot because we're both big fans. But I only tried them because you were, like, “I tried these ones recently, and I really like them!”
Dr. Mullur: And I think that's so important because I spoke from my experience. And so much of integrative medicine is experiential.
Lauren: But it's also so much more personal because of that too, right?
Dr. Mullur: I actually did a study with residents where I gave them a lecture on integrative approaches, and taught them about the benefits of acupuncture, the benefits of meditation and the benefits of yoga. We did a little pop quiz and then I actually followed their practices going forward. One group got the lecture, and the other group got an experiential session where they got to feel what acupressure and acupuncture felt like, and they got to practice some yoga and they got to practice some meditation. And surprise, surprise! The group that got the experiential learning was more likely to actually recommend patients for integrative approaches. And I think it makes sense. They say ‘physician heal thyself’, right? You have to come from a place where you can address this. And so many times, there's a lack of empathy because we're all so stressed out and so fatigued that it's easy to be, like,"Well, what do you want me to tell you? Because I'm stressed out, too. And your testing doesn't look like there's anything wrong with you.”
Lauren: And I think sometimes when patients come across that … sometimes it is just because the physician’s burned out and it's no fault of their own. It's just … that's sort of how the system's rigged against all of us sometimes in this sense, isn’t it? So, I'm going to skip around here a little bit, actually. Do you think that the inroads that you've made and that you're seeing are a lot to do with the fact that we're in hippie-dippie LA, and more of these boards are open to the idea of integrative medicine? The VA in Minnesota or somewhere else in the country … would it be a different story?
Dr. Mullur: Yes and no. I think a few years ago, absolutely … this kind of stuff was really only on the coasts and places like that, and yoga studios across the country were in the granola part of town, if you will. I don't think that's the case anymore.
I think we've really seen … as the opioid epidemic has continued, as patients understand the role of chronic stress and we talk about ACEs [adverse childhood experiences] and we talk about trauma, and we talk about wellness and well being … I think we're seeing across the country that people are looking for alternative options. And when I say ‘alternative’, I don't mean it to reject traditional care. I mean it as in a different approach.
Lauren: And a complementary one.
Dr. Mullur: Absolutely. Because I'm not opposed to medicine. I use standard medical formulations and prescribe medicines all the time. I think there are problems when patients reject traditional medicine and turn to supplements only, or Dr. Google, if you will. Because as great as the Internet is, I think the reason I don't mind doing a Google search sometimes with my patients when they have questions, is because I can filter out good and bad knowledge, and good and bad information.
Lauren: Well, that's huge, too, isn't it? In terms of systemic problems … fake news is part of the problem?
Dr. Mullur: Correct. Specifically, when it comes to adrenal fatigue, if you Google ‘adrenal fatigue’, you'll get more than 3 million hits. And most of it’s repetitive, most of it’s not necessarily accurate, most of it is just cut-and-paste from different other websites. It's really just a free-for-all in the wild west.
Lauren: And it’s so personal, too. Not one answer is going to fit every patient. I mean, that's true of so many things.
Dr. Mullur: I think it's incredibly true of integrative medicine.
The way I view integrative medicine is really a combination of both systemic and individual approaches.
I think doing integrative group approaches like group wellness, group education on integrative practices, yoga classes, tai chi; we do group acupuncture at the VA where we actually use auricular acupuncture …
Lauren: What is auricular acupuncture? Self-acupuncture?
Dr. Mullur: It's actually acupuncture in the ear. And so because we're doing auricular acupuncture, we can treat more patients in a group — which really allows us to deal with the veteran population, who are so in need of this care, but can't always access it. Acupuncture sessions, one on one, can take up to an hour. Whereas you can do auricular acupuncture and treat more patients in that time. And it's very complementary to standard acupuncture sessions. So it can boost access. I'm a big fan of of group interventions. That being said, when group interventions are introduced, they have to be introduced with some discussion of personal wellness and well being and self-reflection. Because I can tell you to go to yoga two times a week and to meditate every day. But you need a plan, an action plan for your life to get to your personal wellness. And that requires reflection. I'm happy to serve as a guide, but it requires individual approaches and reflection on what your needs are.
Lauren: Again, that removal of ego. We’ve come right back full circle. So, you brought up the opioid crisis a couple of times. Can you talk to us a bit about pain management, particularly in your experience working at the VA? I presume that's where it's come up the most. And this widely discussed over-use of opioids in the US, and this crisis that's evolved. And how you see it shifting more into, perhaps, root cause [approaches] to treat pain. Or being able to wean people off of these opioids if they don't need to be on them?
Dr. Mullur: Absolutely. So I can speak more to the weaning and the integrative approach. I kind of grew up in medicine at the same time that opioids were being developed by the pharmaceutical industry and being mass-marketed. During my training, I certainly started patients who were suffering from cancer pain or post-surgical pain on opiates. But it was never really part of my practice, and part of my training. I trained at an institution where we actually, even in a non-integrative clinic, started with an evaluation of what the cause was for pain. I don't think it really came from a place of doctors not being trained in how to approach pain. I think it came from pharmaceutical companies direct-marketing to patients.
Lauren: Yeah, in the number of investigative reports that have come up about the crisis itself, it really comes down to pharma messing it up for all of us.
Dr. Mullur: And really, telling patients that this is the only thing that can help you. And that's just selling a falsehood. The idea that there's only one approach is inaccurate to start with. So, in terms of the crisis and the etiology, I kind of tend to shift towards more of the pharmaceutical industry — rather than physicians not knowing how to address pain. Because I think we're really well trained in that, in terms of at least finding out what the cause may be. That being said, once we, for example, identify low back pain … which tends to be the number one thing that people complain about …
Lauren: We were just talking about mine!
Dr. Mullur: We don't necessarily do a good job of as physicians is, is referring to other interdisciplinary professionals who can help. We don't do a good job of referring to physical therapy; we don't do a good job of referring to chiropractors, or craniosacral therapists, or neuromuscular therapists, or acupuncturists. We’re doing a better job now. And that inter-professional interdisciplinary team is really what integrative medicine is about.
Lauren: Aside from the root cause thing, right?
Dr. Mullur: But I think when we do that, and we take a team-based approach and say, “Well, I can address the patient's health goals as a physician best when I have a team in place that can help me get there.”
Lauren: I think patients also realize that they need that, too. It's not just a doctor’s responsibility to refer you to all these various modalities. I took it upon myself as a responsibility to go, like, ‘Okay, I'm having acupuncture recommended. It's my job now to find the right acupuncturist … and having yoga recommended. It's my job now to find that practitioner who works best for me.’ So it really is a two-way street.
Dr. Mullur: Absolutely.
Lauren: You have to be an active participant in your care. You also mentioned something back earlier when we were talking about the accuracy of hormone testing. I wondered if you could dig into that a little bit for us, because I think there are a lot of us who are dealing with hormone imbalance issues and endocrine system issues, and are really confused about where to even begin.
Dr. Mullur: Absolutely. So, my mentor in endocrinology actually wrote a full book on thyroid hormone testing. It's a complex process. If you can dedicate a book to hormone testing on one hormone access, it just tells you what you're dealing with.
A hormone, as I mentioned, is a biochemical molecule that's secreted in one part of the body, that then travels and exerts its action in another part of the body.
And there's different types of hormones in terms of their chemical makeup. And because of that, some hormones get degraded in the stomach and you have to use them as an injection, if you're treating someone. Some hormones are bound to carrier proteins.
Lauren: Because most people, their understanding of hormones is: estrogen and testosterone.
Dr. Mullur: Right. And on top of that, the hormone then has to exert its action at that distant site, or the cell in question. And sometimes it binds to the outside of the cell; sometimes it is within the cell in terms of exerting its action. The analogy I like to use — and it's not a perfect one — but the one I like to use is: turning on the lights of a building.
So, when I do hormone testing, I know if there's power going to the building. And sometimes I can tell if the lights turn on and off. But I don't necessarily know if the lights on the 14th floor in the back corridor are on or not.
And I also don't know if they're on at your desk, wherever you're sitting in that building.
Lauren: Or where the light switch is, necessarily.
Dr. Mullur: Correct. And that's a crude example and it doesn't necessarily fit …
Lauren: But it makes sense visually to me, though.
Dr. Mullur: Hormone testing is just telling me if the access gland and the access hormone is intact. And certainly there are sometimes global deficiencies. And when there are global deficiencies, we can clearly diagnose them as an endocrine disorder. You have hypothyroidism; you have hyperthyroidism … you fit into a category. But there are times when you don't fit in that category, and it looks like the power going to the building is on, and when I do the testing, it comes back normal.
Lauren: But the patient who is the building is going, ‘The lights are not on.’ Or, ‘They’re flickering over here.’
Dr. Mullur: Right. And what I tell people is …
Hormones are a snapshot in time.
Lauren: That’s actually a really good point, too, because it is all time release stuff, isn't it? And that’s important to know, because your cortisol is a great example for that, right? Like, it's going to be completely different first thing in the morning than in the afternoon, after you’ve have lunch.
Dr. Mullur: And your endocrinologist is well aware of that, and knows when to appropriately test your cortisol. That being said, the nuances in the system, we don't necessarily know. So, for example, in adrenal fatigue, there are some models in certain populations, where patients with chronic fatigue have an abnormality in the binding protein that binds cortisol. It doesn't let go of the cortisol in time. So, of course, I mention that and people will say, “Well, should we be testing for the binding protein?” And what I would say is, probably not. Because the truth of the matter is, it's really unlikely that you're going to have a diagnosable binding protein abnormality that's just been described in small research papers. And frankly, the places that would do that testing would be … number one, not available in the US, and be exorbitantly expensive. And the treatment would essentially be the same.
Lauren: Interesting. So in a way some of the testing protocols … it doesn’t necessarily matter, because you know that you're still treating a chronic fatigue issue …
Dr. Mullur: And most of the time, I don't treat chronic fatigue with hormones. Most of my patients that I see who do not have a diagnosable endocrine disorder but continue to have chronic fatigue, we work on integrative approaches, and I continue to monitor their hormones and sometimes they use herbal supplements that have known activity on hormonal axes and glands. But I don't always recommend hormone treatment, because there are dangers with hormone treatment. And the analogy that I like to give there is …
Treating with a hormone for fatigue is similar to using a sledgehammer to knock on a door.
What you need is someone to knock on the door and say, ‘Hey, I'm here to help.’ But when I treat with a hormone, I'm basically busting open your door, destroying it, and then impeding my ability to evaluate it in the future. Because what I really love to see for my patients who suffer from chronic illness, from fatigue and stress, is … let's say your hormones are “in the normal range”, but you feel ill. Let's get a sense of your baseline, and what it is. And let’s institute some integrative approaches, and see if you (a) feel better or not. And if you feel better, great. If you feel marginally better, great. But let's see what your hormone testing is in follow-up. Because, for example, the TSH has a normal range of 0.4 to three-and-a-half. It's a really wide normal range.
Lauren: It sounds like not much, but it's actually quite wide in the world of thyroids.
Dr. Mullur: Right. It's an order of magnitude of 10. People always ask me, “Well, my TSH came back normal. But I still feel fatigued.”
Lauren: But where was it in the range?
Dr. Mullur: Correct. And I don't know how to solve that problem globally, because those normal ranges were developed when these assays were developed — which was only 30-40 years ago.
Lauren: Which is in the world of medical science … even though that's fairly recent in our history … it’s a long time ago with regard to science.
Dr. Mullur: Yes and no. It's a long time ago in the terms of modern medical evidence, where there's a new journal article every week. It’s a really short amount of time when you think about traditional approaches to medicine. When I look at traditional approaches to medicine, I look to traditional Chinese medicine and I look to Ayurveda — which, in their integrative approaches, have these holistic approaches to chronic disease and fatigue, especially when it comes to stress and fatigue, that are not glandular-based. And they really focus on a person’s energy, how well they match their activity to their energy, where their sources of depletion are, what their sources of nutrition are. And the more I look to those systems, the more I think that integrating that approach is going to be what we need long-term.
Lauren: It’s interesting, because … I don't know if this is something that you want to talk about … but I'm thinking now about a discussion that we had a few appointments ago, where you were talking about where the glands are in the body and how these directly align with meridians that are considered energy centers.
Dr. Mullur: We were talking about the chakra system. Deepak Chopra, who is an endocrinologist, actually describes this really well …
Lauren: He’s an endocrinologist?!
Dr. Mullur: I know … mind blowing, right?
Lauren: Wait, what? I just know him as a great meditation guy. I had no idea. Yeah, totally mind blowing.
Dr. Mullur: Yeah. He describes these as energy maps, right? And so the traditional Chinese medicine map is of the meridian. They explain their disease along these meridians, and the disease occurs when there is a blockage of the vital life force, or the chi [also qi]. The Ayurvedic system, which is the traditional Indian form, often associated with yoga, but can be separated from the physical practice of yoga … the Ayurvedic system is energy maps based on the chakras. The chakras are described as these energy centers, and if you look online, you can find a million different chakra maps that link them to different endocrine glands. I will say that the chakra system is something that has been a thorn in my side for a number of years. Because I had trouble finding a way to acknowledge the value of that description and what I learned in my yoga training and my knowledge of Ayurvedic treatments with my training as a physician.
At UCLA, we have a Center for East West Medicine where we do traditional Chinese medicine approaches and acupuncture. I've had discussions with the leadership there; we agree that there has to be a reconciliation of these energy maps, if you will, with our approaches in Western medicine. And there can be room for both. And there can be room for both responsibly.
When I think about the chakras and and my view of them now, with my training and experience, I do think that viewing them as an energy map is probably the best approach. I think the fallacy lies in linking them directly with an endocrine gland. For example, the throat chakra … I've been in a million yoga classes where we'll do an inversion, specifically the Plow Pose, where you put your feet above your head in a certain position. I've had a million yoga instructors over the years tell me, “Well, this activates your throat chakra. So if you're having thyroid problems, this will help.” And every time it's said, I cringe on the inside. Because the idea that you could do a yoga pose to all of a sudden affect your hormonal function doesn't necessarily fit in my head.
Lauren: Well, it's not enough, is it, to move your body. There's a million other factors.
Dr. Mullur: Right. If it was that easy, I wouldn't have a job.
Lauren: Well, you’d be a full-time yoga instructor! (laughs)
Dr. Mullur: Right, that’s probably what I would do! So, breaking that fallacy, but still finding room for where these are connected. And I think if we talk about it in terms of energy, I think we can get to a lot better of an answer. I'm working on a book on this as as we speak.
Lauren: We’ll announce to everyone when it does come out.
Dr. Mullur: I'll keep you posted. The book’s working title is Coping with Chronic Stress and Fatigue. But one of the chapters will address my view of integrative endocrinology, taking into account these energy maps.
And if we talk about energy medicine, and we talk about integrative approaches for chronic stress and fatigue, what we are doing is changing people's energy. When you're fatigued, you have low energy. Or when you're stressed, your energy is getting displaced in all these different ways. So we really need to speak the language of energy medicine.
Most of my patients who start feeling like they're on the road to wellness, and the ones that start thriving, are the ones that take into account some energy-based approach — whether it's yoga, tai chi, reiki or healing touch, or traditional Chinese medicine, or some approach. It ends up being energy-focused and energy-based. I don't have the language to explain what the chi is in the body, or what the prana is in the body — other than to say it's the life force. But when we say that, and we think about something moving through our body, exerting changes … I’ve described over and over again that hormones are biochemical molecules secreted in one part of the body that exert their effect somewhere else. I cannot tell you that they're not involved. I don't have a full explanation of how they can all fit together. But I think working towards an energy-based view of integrative endocrinology, I think will be the next advancement.
Lauren: I think that's really exciting — because it's making it even more integrated, if you will.
Dr. Mullur: Yeah. I think the best kind of example I can give in terms of kind of what I'm working with and what I'm thinking about in that regard is, again, going back to adrenal fatigue. If you look at adrenal fatigue in terms of its chronic stress and trauma, and the integrative approaches — yoga, tai chi, acupuncture are really helpful — the patients who are suffering don't necessarily have a hormone problem in their adrenal gland, but their brain changes in terms of how they cope and respond to stress. And to use a lay terminology, the energy they spend on being stressed out makes them feel tired. And so if we use that same terminology to describe it in terms of the chakras and that weird part of integrative medicine that no one wants to talk about …
Lauren: The real woo-woo stuff …
Dr. Mullur: Right … You could reasonably say that that energy center is drawing away your vital energy in a blocked way — the same terminology that acupuncturists use when they’re treating a blockage of the chi. I think it's consistent, I think it makes sense. And when I think about it in terms of integrative endocrinology, if we can think about the energy that's used when people are stressed out … that gives people a way to reframe, and refocus, and retrain their bodies to better use that energy.
Lauren: And it sounds like … substituting the word “energy” with the word “hormones”, right? Like hormones and energy are maybe …
Dr. Mullur: Maybe more linked? I don't know if I can say the same thing yet.
Lauren: Oh, no, right. They don’t have the research, but anecdotally …
Dr. Mullur: I think they're very linked, and using that terminology, moving forward, might get us to more of the answers we're looking for. And my curiosity is developing along those lines, and that's where I'm spending my efforts. Because I have so many patients suffering, that that's where I feel like I could make the most difference.
Lauren: Yeah, I think it's really exciting. When you first told me about that, I remember being, like, oh my God … my mind exploded just like it did, when you told me that Deepak Chopra is also an endocrinologist! I think when you told me, I actually cried! Because all of a sudden, everything stacked up and it all made sense. So, we're talking about chronic stress and fatigue, and how all of these systems are interconnected. One of the things that we touched on, but we could probably dig into a little bit more, is … in what way do you think the health care system, as it is right now, is helping and working for patients? And in what ways do you think it could use the improvement? Is it the improvement and understanding of integrative medicine and going more in that direction — that's what we need to do? Is it spending more time with our patients, as physicians? Being more of an active participant in our health care as patients? It's all of that stuff, isn't it?
Dr. Mullur: Yeah, of course; there's not one simple answer to get there.
Lauren: Why not? Can’t you just give us one answer? (laughs)
Dr. Mullur: In terms of what we can do better, from a healthcare standpoint, I think we can empower our patients more. I think patient empowerment is key. It's not just patient-centered. We can make things as shiny and pretty as we like them in the hospital … and have nice music in the elevator or nice music on the phone when you're waiting. But it's about patient empowerment and feeling like patients are the ones that are navigating the system.
We want it to work for [patients]. We want them to feel like they're making educated choices that prioritize their needs. And that's something that we can do better as a system. I think what we can do better as patients is become more self-aware.
I think we are so far removed from our bodies on a given day. Oftentimes, we're so attached to our electronics and our electronic monitoring systems — whether it's your Fitbit or whatever tracker you're using — that we don't know what we feel like. And if we don't know what we feel like, we can't advocate for what we need.
Lauren: Sometimes it's just unplugging, isn’t it? So, has your experience turned into advocacy on a larger scale, too? You're sitting on these boards, you're writing your book, you've got a lot of irons in the fire for sure.
Dr. Mullur: Yeah, I mean, I'm not the kind of patient advocate that's leading marches and speaking to Congress. But I think advocacy is: a patient at a time. That's how I view it.
Lauren: That’s really lovely.
Dr. Mullur: Because it's about personalized care. And the best advocates that I've seen for my son, who has chronic disease and a lot of health care usage, have viewed him as a person who needs help and needs care, and have understood his personal needs. So I view myself as a one-on-one advocate, if you will. Not necessarily advocate with a capital ‘A’, maybe advocate with a little ‘a’.
Lauren: Well, you're advocating for your son, absolutely.
Dr. Mullur: And advocating for my patients, one-on-one individually.
Lauren: And not just for your son, for all of your kids. It's not just the one! (laughs)
Dr. Mullur: Right! I have two others that are also equally important, that I love, yes! But I think that role of advocacy, which is not necessarily championed, but is so integral to what we do …
Lauren: Well, you’ve gotten to know my mom; she comes with me to my appointments. It’s the same thing with you and your kids.
Dr. Mullur: Correct. And I think that we have to recognize as physicians that we do have a role to play in that. Sure, there are social workers in clinics, and we can ask our back office staff to help with paperwork and this, that and the other. But taking the extra step, if needed, to make that call yourself or to fax that piece of paper yourself can expedite things. And certainly that ‘comma, MD’ behind my name offers me power and legitimacy in a way that my patients don't necessarily feel when they’re calling. So I recognize that; I know that. I use it for my patients. I use it when appropriate with my child, with medical needs! I think advocacy on an individual scale is where I really see myself, but I don't think that makes it any less important. I just think it is different.
Lauren: Yeah, absolutely. And I think you're really doing a service to patients in that you are also empowering us with information. Part of the reason that you're spending time with us and getting to know our case history is to also be able to go, “Okay, well, here are some things we can consider.” And going through all of that detail, I think with patients, enables us to think more deeply about the things that are going on in our body and to start to connect better as well. So, again, it's that two-way street of, we have to be open as patients to listening, to changing our point of view with regard to our health. But our physicians have to also be picking up where we sort of leave off. So you're always passing the baton back and forth, aren’t you?
Dr. Mullur: Yeah, we're partners in your care. And that's how it should be viewed.
Lauren: And what about keeping dialogue open in terms of invisible illness? Where do we go from here?
Dr. Mullur: I think the power of social media and the power of the connection that we are able to have through technology is huge these days.
For so many years, when I struggled as a new parent with a child with special needs, my only sources of comfort were online support groups.
And I thought to myself, if only I could find that one person that was just like me, who struggled with the same things I did, and whose kid had the same diagnosis that mine has. And I actually ended up finding not just one, but multiples of those people online. And certainly, we have developed a friendship over the years. But we've faced our challenges in different ways. And together. So I think in terms of keeping the dialogue open, I think that social media has its pluses and minuses, but this allows a way for patients to find their home. I would love for patients to feel like they felt at home in their bodies, but so many of them don't.
Lauren: And it's a journey to get there, too. But again, there isn't just one approach; there's a million different approaches. So here's a fun question: Should nobody be eating gluten; is it the devil? Also the same about dairy … are dairy and gluten devils??
Dr. Mullur: Boy! So, as someone who had tea and biscuits yesterday at 3pm … with whole milk and a cookie made of wheat flour and sugar … my answer is going to be, no. Because it was glorious to be able to have teatime with biscuits and a hot cup of Earl Grey, it was great.
Lauren: You’re describing my perfect teatime!
Dr. Mullur: Right? So no, not the devil. But I think people are sensitive to different ingredients, and you have to know yourself and know what you can tolerate. And it's not always everything in moderation, because some people are so sensitive that they can't tolerate it even in moderation. So I'm a huge advocate for patients who want to restrict or try elimination diets, with the understanding that an elimination diet is done for a short period of time to cool the inflammation off …
Lauren: And under supervision from a medical professional.
Dr. Mullur: Correct. And with the plan of reintroducing possibly non-aggravating foods, right? And I think so many people, whether it's elimination diets or AIP or FODMAP, they become so restrictive and they feel better. But you see them a few years later, and they’re, like, “Well, it's not working for me anymore.” And you’re, like, “Well, perhaps you restricted so much that you're not getting the micronutrients that you need.”
Lauren: And that's also related to just the psychology of food restriction in general, isn’t it?
Dr. Mullur: Yeah, I do see an overwhelming amount of orthorexia in my practice. Orthorexia is a term that's been coined recently, discussing patients who develop many, many rules around which they eat. It's not a psychiatric diagnosis; it’s not listed in the DSM, for example. But it is something that I see in patients, especially my younger women who want to be careful about what they put in their bodies because they view their bodies as a temple. And it comes from the greatest of intentions. But the amount of time they spend restricting … number one, takes away energy from other things they can be doing and contributes to their stress. And then, the amount of restriction they're doing puts them at risk for developing micronutrient deficiencies. And we shouldn't really be seeing that in this country. We have four to five grains in nutrition …
Lauren: But unfortunately, we also have packaged foods and preservatives.
Dr. Mullur: Exactly. And the fortified grains that we tend to see are basically cereals, and I'm not a huge advocate of cereals, since so many of my patients who have diabetes do poorly on cereals. So I don't want to make it sound like it's so easy.
Lauren: But it’s getting easier, though. Access is easier.
Dr. Mullur: But I think it's always a pendulum swing, and I think maybe the pendulum has swung a little too far in terms of the elimination and restriction, and maybe we can take a tailored approach. But I think part of the reason patients have gone so far the other way is that, especially when it comes to gluten testing, we tend to take a … “Well, you have celiac or you don’t.”
Lauren: We were talking about this before I hit record, yeah.
Dr. Mullur: And the thing about it is, we know now that there's gluten sensitivity that doesn't necessarily meet a diagnostic criteria for actual celiac that affects the lining of the gut. I don't pretend to be an integrative gastroenterologist; I work with colleagues of mine who are experts in this area, and I would defer to their expertise in terms of answering it. But I will say that I see so many of my patients who are gluten-sensitive and dairy-sensitive, despite not having a true allergy and/or celiac disease.
Lauren: And that may also be just because of the way in which these foods are processed, as well. Because if you were having milk from a cow, you might be all right. But by the time it gets to you in the supermarket, it's a totally different thing.
Dr. Mullur: Absolutely.
Lauren: So that's about being aware of sourcing, trying things out, trying the elimination diet, as you say, reintroducing … It's very interesting, because I talk about how I'm on AIP, but I'm also very flexible with it. I know that my body is less inflamed when I follow those rules, if you will. But I'm also not gonna waste stress and waste energy on every piece of minutia that’s related to what I'm putting in my body every single day. Because for the most part, I'm pretty on top of it, and I know if I have something that inflames me, I'll know pretty immediately and I can just eat more healing foods that will help me feel better. So it's a balancing act constantly, just like it is with your energies and your hormones and all that.
Dr. Mullur: Absolutely. And I see this most often … truthfully not with my patients who are struggling with AIP and celiac. I see it often with my diabetic patients.
Lauren: And that's got to be hard, too, because you're told “You can’t eat this” about a lot of stuff, right, if you’re diabetic.
Dr. Mullur: And diabetes is a chronic disease, and the stress that comes from that, where they feel like they need to restrict the amount or what they're eating, can take its toll. Especially for my Type 1 diabetics who take multiple injections a day and they have to count their carbs. They're on a fixed regimen, but all of a sudden, it's someone's birthday at work and you're like, ‘Well, I want a cupcake too, but I'm not allowed to have one.’ That's one aspect of it. And then we also have my Type 2 diabetics who are oftentimes overweight and obese, and sometimes they feel judged when they “don't eat properly”. And it contributes to fat shaming and this and that and the other, and I think …
As a general approach, we just need a little bit of kindness and compassion to ourselves. Food is essential as nutrients. But food is also comfort. Food is social connection. Food is family, food is joy.
Lauren: It is for me, at least! Not for everyone …
Dr. Mullur: And the thing is when that emotional connection gets out of whack, then we see emotional eating problems. But then, when we lose that emotional connection completely, then we see other problems. Again, it's about finding balance. Which sounds so simple, and yet is so challenging!
Lauren: But that’s why it's great to have a physician or team of physicians that you can work with, to find what works for you. Because I think a lot of us have sensitivities, and a lot of the sensitivities that we see, at least in this country, have to do with the way in which foods are processed. I think that's quite clear environmentally. And it's easy to remedy those problems if you live in a place with easy access to a good farmers' market and good farming practices that you can rely on. But not everyone has a local Whole Foods or a local farmers’ market.
Dr. Mullur: Right, and food deserts are a big issue in this country that disproportionately impact patients of color, who struggle.
Frankly, wellness shouldn't fall across racial lines, and it certainly does in this country.
And I would love to be part of that change, and really seeing that change happen. I think offering improved access to integrative approaches, whether it's group delivery or telemedicine delivery, can help deal with that aspect of it. In terms of food, it becomes a big deal. You can't reliably ask someone to go drive 30 miles to source a meal. That's not a reasonable expectation. So I try to meet my patients where they are. And if food changes aren't the step we can make right now, we'll work towards making incremental steps until we can.
Lauren: I think that's very reassuring. So, for people who are making these changes in their lifestyle, be it food or something else … again, the balance question … do we have to up-end our lives entirely? Even if you're a Type 2 diabetic, do you have to up-end your life entirely? Or can you take these incremental steps, or … cheat once in a while?
Dr. Mullur: So, sustainability to me is all about incremental steps, right. To use the example of diabetes … whenever you're first diagnosed with diabetes, one of the biggest challenges is reframing your life and your food and your eating as a diabetic now, and accepting the label. Even though we hate to label our patients, it is true. You are now forever watching your sugars, testing your sugars, watching your carbohydrate intake.
Lauren: There are a lot easier ways to do it now than there were 20 ago.
Dr. Mullur: Oh, absolutely. I mean, apps have made life so much easier.
Lauren: And even devices, like glucose monitors.
Dr. Mullur: Correct. And technology has made it incredibly accessible and actionable. Because we now have alerts that tell us if your sugars are going up or down, and so patients kind of know what they're facing.
Lauren: It’s just the cost of insulin that’s a problem!
Dr. Mullur: That’s another podcast! That's gonna be another episode. So, part of it is just accepting that new identity. And that acceptance is really key, because if you can accept that, then maybe you're not going to get so off track that you feel like your entire life path has been derailed by being diagnosed as diabetic, for example.
Lauren: You want to take it in your stride a bit more really, don’t you?
Dr. Mullur: Yeah, just offer yourself compassion and kindness.
Because we are not all going to live our lives without a disease touching us. In fact, most of us will live a life with disease that touches us in some way.
Lauren: Disease exists. There will always be stories …
Dr. Mullur: Correct. And so if you can accept it, and then make steps forward. And it's so easy when we're faced with change, to be avoidant of that change.
Lauren: Which is a stressor, that then makes our systems go even more haywire.
Dr. Mullur: Right. And so being accepting of the change and making incremental steps forward. When I see a Type 2 diabetic and we do a detailed history and we do a diet history, I'm not going to tell them, “All right, well, you need to be vegan, and you need to stop eating all carbs. And don't have any more juice for the rest of your life.” That's not usually what I'm saying. I usually tackle the things that are easy to tackle first. And part of me getting a diet history is not — what do you eat? But — what did you eat yesterday? And why did you eat it? Because oftentimes, no one wants to say they had the third slice of pizza that they didn't need to have, or even admit that they had pizza.
Lauren: Or they're not aware enough of their bodies to even know.
Dr. Mullur: Correct. So getting to why we make the food choices we make, getting to understand how we can make small changes that lead to larger impact, is going to be the step forward — whether it's diabetes or any chronic disease.
Lauren: I really like that. So, I'm ready to wrap it up with you. One last question: What are your Top Three Tips for someone who feels off, thinks they might have some kind of invisible or chronic illness coming into their lives or are already living with invisible illness? What would you suggest for these patients?
Dr. Mullur: I think it's a matter of being persistent.
Don't let someone else tell you how you feel. But you also have to document how you feel. Because feeling bad doesn't give me a lot of information.
“I feel bad” doesn't really tell me which ways you feel bad, how it impacts your life. Telling me more about, and documenting for your own reflection, the ways in which you feel bad, or things that have triggered you feeling bad … keeping a journal or a diary of your symptoms can be so useful, so you can reflect and start to notice patterns and trends. So being persistent, documenting, and then being open-minded. I know we talk a lot about physician open-mindedness. But I think, as patients also, being open-minded to a path that maybe you thought wasn't right for you. Like, “Well, I never want to do that because I heard so-and-so did that and they had a bad outcome, so I'm never going to take that medicine ever again." Or, “I don't want to see such-and-such specialist … ” because of whatever reason. Being open-minded to the meandering route to health and wellness.
Lauren: Because it's not always a straight shot, is it?
Dr. Mullur: It’s very rarely a straight shot. I don't know one person for for whom it's been a straight shot. Even people who are modicums of health have had their dips in their path before. Just being open-minded to changes, documenting what you've been through, and being persistent and honest in your feelings.
Lauren: Well, honestly, I think is a big one, too. Because it's also about removing the ego … and this is one of the big talking points of this episode, removal of ego! Dr. Mullur, is there anything else you'd like to add? Can you tell patients where they can find you if they want to? You know that everyone’s going to want to come and see you! I’d better make all my future appointments now!
Dr. Mullur: So, my practice is at UCLA. I also see veteran patients at the VA. So I'm available on the UCLA website. I do do quite a bit of speaking and educating, so anyone who's interested in that … I will be having a personal website for speaking and education topics. Because I think patient education is key, and physician education is key. And just letting the larger audience know that you're not unheard.
We see you; you're not invisible. We may not have all the answers, but we're determined to get there.
Lauren: Thank you so much, Dr. Mullur. It’s been such a pleasure having you on, and I cannot wait for people to hear your voice.
Dr. Mullur: Thank you.