Nov. 14, 2022

Indians—Is Rice really THAT bad for you? (Avantika Waring, S1, Ep 9)

Indians—Is Rice really THAT bad for you? (Avantika Waring, S1, Ep 9)

This is part II of our conversation with Dr. Avantika Waring.  Avantika is an Endocrinologist focusing on caring for people living with diabetes. She has worked with patients in various clinical settings for over 15 years and is currently the Chief Medical Officer at 9amHealth. Her clinical passion is the development of technology-enabled care delivery models that are equitable and culturally inclusive. She is originally from New Jersey but has lived on the west coast since 2009 and currently resides in Seattle, Washington. When she’s not at work, you can find her on the soccer sidelines watching her three kids, running and hiking the nearby trails, and skiing local mountains in the winter.

In part II, we dig deeper into several topics:

  • Important aspects of nutrition counseling: rice, lentils, ghee
  • The extremely uncertain science of glycemic index when it comes to rice
  • Not focusing on specific components of food but highlighting what people are eating and rebalancing rather than replacing food 
  • Beliefs around health
    • Decision-making with family
    • The importance of assertiveness when giving health recommendations, shared decision making health
    • The stigma around mental health, how to approach that

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  • Timespan: 56:09 Min
  • Transcription Type: Cleaned Verbatim
  • Speakers: 2 (Avantika Waring & Raj Sundar)


Avantika: I never tell anyone that they can't eat anything. And yes, ghee has a lot of calories, but any fat you use has a certain number of calories per gram. That doesn't change between fats, right? Although there are benefits of olive oil, there's a flavor that is imparted on ghee that is unparalleled, frankly. So, my approach is always like moderation and not a replacement. Because I think that if you are just replacing the ghee with another fat, that's not necessarily culturally appropriate.


Raj: Hey, everyone. I'm your host, Raj Sundar, a family physician and community organizer. Welcome to the healthcare for humans podcast. The show is dedicated to exploring the history and culture of Washington's diverse communities. So, clinicians are equipped with the right knowledge to care for all patients.

Welcome to part two of this series on the Indian community in Washington State. We'll be talking with Dr. Avantika today, an endocrinologist, a diabetic specialist, and the current Chief Medical Officer of 9 am Health, a virtual diabetes clinic. In our previous episode, in part one of this series, we talked with Dr. Amy Bot and reviewed the history of the Indian communities' immigration to Washington State. Today, we'll drill down on the topic that's important to know to care for the Indian community at a more granular level. We specifically focus on dietary recommendations for a large portion of this podcast. I'll say sometimes it's easier to talk about this than others. Remember when we spoke with the Ethiopian community with Rahel Schwartz?

We talked about our community's traditional food. But we focused on the changes made to the food after people arrived in America. For example, because teff was so expensive in the Ethiopian community, people substituted white flour for teff. So, in that episode, we talked about how you could replace white flour with whole wheat flour or bulgur for a more nutritious alternative. And that kind of conversation seemed culturally appropriate and respectful. But if you also remember, we've talked about rice in previous episodes. Rice in the setting of how it is so bad for you. Because it was often a replacement food for people's traditional food, it became an easy substitute for so many people because of its availability and price. And it's often led to higher levels of diabetes in many communities. And the conclusion from these conversations, which I learned is cool, too, is that rice is bad for you. Don't eat so much rice. This podcast's goal has always been not to advise anybody to avoid their traditional food. Because food is so much more in nutrition, it's your connection to family and your culture. It's what your mom made growing up. It's what you do when you get together for the holidays. And rice is my traditional food as an Indian. Yes, there's a way to approach the conversation around rice when you talk about it—decreasing the quantity of rice and not having so much rice with every meal. But I wanted to contend with the idea that rice is bad for you by itself. And to address how you counsel Indian patients about nutrition when living with diabetes and rice, Is there a traditional food? I'm unsure if we came up with a straightforward answer to this question. But I hope you learn as much as I did from this conversation. In addition, today, we'll be talking about other aspects of diet nutrition, including different protein sources, including lentils.

We also discuss not focusing on specific food components but highlighting what people eat and rebalancing rather than replacing certain foods. Then we talk about the highly uncertain signs of the glycemic index regarding rice. We end the episode talking about beliefs around health. Specifically, we talk about what it means to make decisions involving the whole family. The importance of assertiveness when giving health recommendations is sometimes in contrast to the shared decision-making model we use in health care. And lastly, the stigma around mental health and how to approach that conversation. Here's Dr. Avantika Waring. Welcome to the show Avantika.




Avantika: Thanks for having me. I'm excited to be here today.


Raj: Yeah, let's start by just talking about you. Tell me about yourself.


Avantika: So, I am an endocrinologist. My name is Avantika Waring. I am originally from the East Coast. I grew up in New Jersey, where there are a lot of Indian immigrants and many generations of Indian immigrants. But interestingly, I grew up in Talon, where there was essentially non so very unique experience, I think, compared to a lot of other people I met in college and later on who were from South Asian families that came from New Jersey but other parts of New Jersey where they had a larger community. So, I always think that because it shaped my relationship with my culture to a certain extent, I went to some of my training and education on the East Coast and then ended up meeting my husband, who is not Indian. He's white and Jewish and from California. And so, we moved to the West Coast. And I have been out here since now in Seattle. Since 2016, I have been the director of the diabetes program at Kaiser for the state of Washington for our region. And then, actually, just in May of this year, I left to take a new role as the Chief Medical Officer at a company called 9 am Health, which is an end-to-end virtual diabetes clinic for people living with type two diabetes. And it's just been an exciting transition for me using many of the same kinds of care management and population health skills and translating them to a more virtual format. So, I also have three kids who are talking about that. I'm sure that'll come up there. 12, nine, and six. And, yes, we have a lot of fun.


Raj: So, let's get started. I was talking to you earlier about this. But in a previous episode, which was published right before this. We spoke to Dr. Bhatt about the history of immigration of the South Asian community, specifically the Indian community, to Washington. But we didn't go into diet and nutrition and some cultural nuances, like holidays. So, I think let's cover that first. And then, we'll get into the nuances of taking care of people from India and how to manage their health. So, food, where should we start, Avantika? I feel like I'm so familiar with this topic. And at the same time, I knew so little because I was researching this. There are 28 states in India and eight union territories. And what we think of Indian food in America is primarily Punjabi food. Like when you go to a restaurant, you look at chicken tikka masala, which people think is Indian food. But that's such a small sliver of actual Indian food. Tell me, what does Indian food mean to you?


Avantika: Yeah, so I am Punjabi. The dishes that you describe what I think they are the ones that resonate most with people seeking out Indian food, but they're not the things we eat at home. And many of the things we eat at home are very hard to find. I'd say now I'm seeing more restaurants where they're bringing out, they'll call it like a homestyle food or a street food or something. And then I find the dishes my mom used to make for us right, like Bangin Bertha, which is so delicious, so healthy, and very easy to make, but not something you would see often. So, any input for me, it's dal. It's lentils, that is the thing that we ate most. With every Indian meal, we had lentils. The most important thing to consider is everybody has a different experience. So, they're like going to Indian food will be something different. And I think for our family, a lot of that had to do with time, right? Like my mom worked. And so, what she could make for us might be different than what she ate growing up. There's like this Americanization of the Indian food that isn't making it taste like American food, but it just pairs down like what you're eating. And then the availability of the ingredients to like where we grew up. We didn't have an Indian store; we'd have to go an hour away to get the groceries. So, there's just a lot of ad-libbing, so we must remember this is the funniest one. I think they are yogurt with Kix cereal in it. Do you know what kix cereal is?


Raj: I think I remember it well.


Avantika: little sweet, but they're just tiny little corn puff balls. And there's some Indian crunchy thing that you put in Bay to make it like raita that, but we didn't have that crunchy thing available anywhere nearby. So, my mom would buy boxes of kick cereal and put them in our yogurt. And so, when I first had it at a place that wasn't my home, and it wasn't a little bit sweet, I was like, this is kind of weird. It's not sweet. And my mom was like this because it does not kick cereal. It's like the actual thing, which I don't even know the name of because we ate it so rarely.


Raj: Like this is made wrong. I've got the wrong thing


Avantika: And so, I think, what does it mean to me? Like skosh, it means all things to all people. And I think we could have a long conversation about the foods we've eaten growing up, and probably we've eaten some of the same things, but they were called something different and prepared in entirely different ways.


Raj: Yeah, I was always impressed. I grew up in Durham, North Carolina, but it is part of the immigrant experience as well as you're trying to blend what you grew up with to what you're learning in America. And I was always impressed with how my mom did that making a masala turkey. It's not like we ever eat a turkey in India, but that was the Thanksgiving dish. And I always thought that's what people ate at Thanksgiving. Like when I had a turkey. I'm like, Wow, it's so boiling. Let's set the context. A bit more about Indian food: I think people probably have a general sense of what it is. And I was looking up some stats. And part of the reason people believe that Indian food is flavorful. However, it's still prepared in Indian restaurants. Many dishes have seven or eight ingredients with a lot of spices that often don't overlap with each other compared to some American dishes so that it doesn't seem as bland because there's just a lot going on in each dish. And in the US, I was saying people typically think of Punjabi dishes as Indian dishes, mainly tomato onion based and red creamy. But each region I'll put up on the website has a different kind of Indian food; I'll bring in the experience I grew up in Chennai, Tamil Nadu, eating dosas and Idlys. Dosa is really hard to find. There's this one place that makes delicious dosa called Ahar; I want to be sponsored by them. So, I'm saying this out loud here. But you have to drive to Issaquah to get there. But really, it's not as common, right? Most people don't know what dosa is. And with Tamil Nadu and southern Indian food, there's more tamarind and lime juice. So, it's a little tangier than the creamy base that people think of. But breaking down the different kinds of Indian food, we'll just do it in a medical context right there. So, the carbs typically are rice, and there is also bread, Chapatis. These people may know paratha as people know that, but also dosas which I just mentioned, like a pancake made out of flour and gram. So, there are some protein components. The second is protein, which is often chicken and mutton, and legumes like lentils. I will do a deeper dive into that. And then the fat, which is different kinds of vegetable oil, often sesame oil, peanut oil, coconut oil, and ghee, clarified butter. Okay, let's do a deeper dive into the rice. Avantika, this is the problem; I've had a lot of episodes so far. And the thing is, rice has often been coined as bad for people because it takes over other people's native food. But I don't think people understand that so many kinds of rice exist. They not only taste different, but they also have different reactions in your body. How would you talk about rice?


Avantika: So, as you know, in prepping, I was like, Okay, let me look up the different kinds of rice because I think there are thoughts and theories that I have also held as accurate. Well, to know whether or not it is true, I wanted to take another look. And what I found is that there are a ton of different answers on the internet. Basically, it will feed you whatever you're looking for. So, we should probably just dig into the glycemic index a little bit further. So again, the glycemic index is a scale that goes some average numbers that might be in the 40s, 50s, or 60s, just to give people an idea of what kind of number to expect. But it tells you how quickly and dramatically a particular food that's got carbohydrates in it will turn into sugar and cause your blood sugars to rise. And that's not has nothing to do with diabetes. And this happens to all of us, right, we all are a sensor, and we ate a bagel. We would see that sugar would go up to some extent. So, there are probably hundreds or more types of Rice, and there are grain sizes, there's long grain, they're short grain, there's glutinous or sticky rice. And then there's a whole like brown rice, white rice, which has to do with whether it's polished. They remove the outer husk kind of similar probably to any grain; what I found on various websites, which I would say were all reputable, right? They were related to the health care system or hospital system. the ranges would go from 55 to 96. So, 35 is a pretty low glycemic index for a starch food 96 is high. And I feel like that doesn't tell us a whole lot. And so, I don't know, like, what was your take when you looked into this too? Is it I can advise about rice. I'm not sure that I feel like I can. And I'll just say that even though there is some association between glutinous sticky versions being higher and the long grain versions being lower, it's still not consistent. So brown rice and white rice, I saw different websites that have white rice and a lower glycemic index and certain brown Rice. And then, I went down this rabbit hole where there were other components of the rice like amylase and amylopectin. And the content of those different components changed the glycemic index of the rice, and I ended up just shutting all the windows down. I think people are not going to have a great answer for people to say this rice is good; this rice is bad. Don’t eat this rice.



Raj: yeah, maybe the point is that it's more complicated than what we've been taught. We were taught that rice is horrible for you. Don't eat rice. And that's hard for somebody who's lived all their life with rice. And that's what home means to them to stop eating it altogether. The background of rice is complicated. And I don't even know if this is true; as you said, there are many conflicting resources. But there's this general sense that long grain is better than short grain because short grain is more sticky, and there's like arborio rice, which makes for risotto compared to basmati rice which is A rice that many Indians use. So there's a difference between long grain and short grain. And then in the long grain itself, that brown rice, wild rice, and basmati rice are maybe better for you than other kinds of rice. That is like a strong perhaps,


Avantika: I think the other thing I would point out is that one might be slightly better. But at the end of the day, they're all starch. And so, I, you know, my approach, I have never told a patient to switch the type of rice they were eating; that's not a thing I've ever done, maybe I should. I choose to help them balance the rice component of their meal. Because you don't have a lot of control over what you're getting, either. So, there are different types of long grain rice, there are all these various components, like no one's ability to go into the store and say how much amylase is in this bag of rice, and then it had the cooking time and pack it as well. And whether you've cooled it and reheated it is another thing you can go into. So, at the end of the day, if it's one component of your multicomponent dinner, I just don't know how much that one component matters. What probably matters more is thinking about the other things on your plate. And if this rice is part of your diet, why would anybody change that? It feels calm, and you also need to stop the curry. One thing that just occurred to me, too, is like growing up, we did eat a lot of rice. Still, it's a lot more rice than we would have traditionally been eating, I think, in our Punjabi household because traditionally, we would have chapatis, which are for anyone who's not familiar. It's like a flatbread made with very unprocessed whole wheat. But it's very labor intensive; you make the dough and have to roll one at a time. And traditionally, if you are a woman in the house, you are standing and making chapatis, not sitting with your family and eating. And so, we would have chapatis sometimes but not all that often. And I think for us and perhaps for many South Asian families who are now living in the States where a lot of women are working, or people are balancing in their families not to gender it but who's making the food and who's busy in the evening. it's pretty complicated to have that traditional form of starch with your meal, and putting the rice in the rice cooker is much simpler,


Raj: My dad often brings this up, which I don't know if it's true, but just a hypothesis. I'm from a small village in India. Technically, it's like 1000 people, and it's called Tamron Kot, which is close to Chennai. And I swear like nothing's changed there in thousand years. But part of what we realize even in that village is the prevalence of diabetes is increasing a lot compared to before. And the hypothesis my dad was saying just from knowing that community was at people's activity level decreased significantly. So even if we control for the amount of rice they're eating, they're like out in the field, doing a lot of manual work and labor compared to now where they're often sitting and not moving at all. And that may have helped balance out some of the caloric intakes, as you know that maybe we don't need to focus on just the rice itself. But what else is going along with the meal, and perhaps the activity level? After you eat a high-carb meal? Or if you're not active? You don't need that high-carb meal that you're taking.


Avantika: Yeah. Or do you need as many meals as you usually eat?


Raj: Yeah, exactly. And I want to highlight that Indians fold, wrap, scoop, dip for food, not just a fork and spoon. So, we need rice or chapati or something to eat all the rest of the food with, so it's hard to read anything without that main component. Okay, the second category is protein. I wanted to talk a little bit more about legumes. And I looked this up because I see it used interchangeably. Legumes, pulses, and lentils. So, legumes are the entire plant with fruits and sprouts. And pulses are the dry seeds found within legume pods, like dry beans, split peas, chickpeas, and lentils. And I want to focus on lentils because I think the overall knowledge of all the different varieties of lentils, as we said before, was limited here in America. And there's like hundreds of varieties. How would you talk about lentils?


Avantika: Yeah, they are a source of protein. They have carbohydrates. Basically, any food that comes from a plant has carbohydrates, right? So, they are unavoidable, but I think of them as a protein. And I encourage people to consume them, and they're super healthy, have a ton of fiber, and have a very low glycemic index. I have lived in the diabetes space. And so, most of my nutrition counseling has that in mind and what we're trained on and what you hear in the media is so much of this. Like, low carb, keto, paleo, like all these diets that reduce the number of carbohydrates but you know when you go out into practice. If you're working with, especially, I think, a South Asian population where people tend to be less meat-focused, not necessarily vegetarian, but some versions of vegetarian when they only meet with certain meals of the day. I remember stumbling and being like, Okay, so tell me what you can eat this got protein in it because I would say egg… you might say ah, we don't eat eggs. There's dairy. So, there's yogurt, but it's not so simple, right? You can just be like, well, have your Salmon and broccoli; the imagery of a healthy Western diet doesn't fit with eating. I wouldn't even call them preferences, but the eating requirements of many South Asians. So, I think there are two components to that. I would say that lentils are high in protein, and then the fiber content and the protein make the glycemic index low because it delays the conversion or the absorption of carbohydrates. So yes, there are carbs. If you look at the label, there's going to be 45 or 60 grams of carbs in a serving of whatever kind of lentil, chickpea, or thing you're eating. Still, it's not going to hit your blood sugar in the same way that a muffin with the same content would work with rice with the same content would; it's going to be slower. So, I encourage people to use those in their diet. And to your point, when you go to a Western, even a fancy grocery store here, you'll see a fair variety of lentils, but they're costly and come in small pouches for the most part. And so, it is a little bit different. If you're able to get to an Indian store, you can buy a huge bag of any kind of lentil you want, and it's affordable. And then you just have to figure out how to cook it. That's like the next step.


Raj: Yeah. And I want to say that this gets probably overwhelming for some people who've never thought about lentils. And maybe what I want to drive home is that it's important to speak your patients' language, not just the language like Hindi, Tamil, or whatever language you speak, but actually what foods they're eating. And it's a whole different feeling. If you start talking about lentils and dal, rather than begin by taking do you eat salmon? Or could you eat more salmon? And then to just have a general idea of what these things are? So you can at least ask the right questions to your patients. And you mentioned you ate a lot of dal growing up.


Avantika: Yeah, I love dal; all my kids love dal. It's the most impressive thing I've done as a parent.


Raj: It is a considerable accomplishment, right? Yeah, so there are different kinds of lentils. So, there's whole, and then there's splint and de-husked. So, if they're split or de-husked, they're easier to cook with because they don't have that coating, and that's often what dal is made of. Usually, I think you see lentils and American stores. They're the whole ones, not the split ones. But just remember that dal is an integral part of the diet, and maybe in some places, we can get people to focus more on rather than rice, not just talking about reducing rice. But think about how much dal you're eating. Could you rebalance that portion in your plate towards one rather than the other?


Avantika: Yeah, well, just thinking too about, like, we're talking about when you go to a restaurant and the dishes that you get, it tends to be like this tomato gravy that is perfect to be dumped on top of a pile of white rice. But that's not how we ate at home. We had dal, and then we always had some kind of vegetable like a subzi. We'd have the carbohydrate was more of an aside, but we didn't need it to soak up the volumes of creamy chicken tikka gravy. But you go, eat that, and associate that with Indian food. And it tastes delicious. Because when you put fat and sugar and salt in something, it's going to be good no matter what it is.


Raj: Yeah, that's a note in restaurants overall because it doesn't necessarily represent a home-cooked meal. So, I like to talk about how much you are eating out versus getting a home-cooked meal. And that's a huge difference. And part of the limitation is just people's time and energy, given the life we live these days. Okay, for fats, I think one component I want to focus on is ghee. It's not used often, but ghee and coconut oil are widely used in India. I don't know historically how much they were used. It's used a lot, especially in some Richard desserts and sweets. Tell me about your experience with gulab jamun.


Avantika: I love gulab jamun, and I am not a sweet person; every culture has its celebratory donut replacement. And it's like the Indians don't have a replacement. So, there are these. Well, I don't even know what they're made of. It's a batter, and you try these balls, and they're dark and delicious on the outside and almost creamy and light on the inside. And then you soak them in a straight-up. It's like sugar syrup. So, it is very, very sweet. It's delicious. And probably most of us did. I don't know; it should be like once a year on a holiday or celebration. But if you go out to an Indian restaurant and you get dessert, this is what you might be getting. They're donuts soaked in sugar syrup. That's what they are. Very high glycemic index. Yeah. I was going to put that out there.


Raj: Yeah, I think for me, what's salient about talking about ghee, which is clarified butter, and coconut oil is. Our patients have many sources of information from family back home or the internet, as you said. Still, things are constantly circulating about how good things are, like coconut oil has blank benefits that can regrow your hair and help you live longer. So sometimes, actually, we're just one source of information. So if I say ghee, which is clarified butter, has many calories, its gulab jamun has a high glycemic index. You need to have a good report for the patient for them to choose you over all these other sources of information they are getting.


Avantika: Interesting. I think I wonder if maybe my approach is pretty different. Because I never tell anyone that they can't eat anything, that's not guidance that I would ever give. And yes, he has a lot of calories, but any fat you use has a certain number of calories per gram or whatever; that doesn't change between dots, right? So, if my patient were cooking with ghee, I wouldn't necessarily find much value in telling them to replace it with olive oil. However, there are benefits of olive oil, and there's a flavor that is important in ghee that is unparalleled, frankly. So, my approach is always like moderation and not a replacement. Because I think that if you are just replacing the ghee with another fat, that's not necessarily culturally appropriate. You don't want the food to taste bad. And I don't want to deviate so far from making the process of making ghee like, it's such a cool thing, right? I don't know; I think this may not be your direction. But it would not be something that I would necessarily have a conversation about.


Raj: If I told my patient to change their ghee to oil, they'll probably walk out and be like, I thought my doctor was Indian. But he's telling me to do crazy things to make them use olive oil,


Avantika: to make my rice with quinoa or something. Yeah, I know. Yeah. And I think there's one other thing I'd probably just didn't touch upon here because we're not specifically talking about diabetes. Still, we, as South Asians, have a very different trajectory of type two diabetes disease than we see in a lot of other cultures. And we see there's this first phase, which we call insulin resistance, right? So that's where you can try to reverse diabetes, but cutting things out. But that works for some people, but for South Asians, it's been demonstrating the data. You kind of progress more quickly to needing insulin and being unable to manage with dietary interventions. And so sometimes I feel like when I try those other approaches, it's not successful, and then it leaves a patient feeling like they've failed somehow and haven't failed. It's just the way that our bodies are all imperfect. And that's just the way that their body may be imperfect. So that's part of the reason I've tried to get away from saying change this or eliminate this because, frankly, it's going to work for many of my patients. It's not going to get them off all their meds like maybe doing a keto diet would for somebody else. And I want to normalize that, right? I want them to realize that this is a part of life, and we manage through it. Of course, eating less of anything usually will help, right, so reducing the fat and the portion of the carbohydrate, yes, adding more lentils and less rice, that kind of balancing compromises can be made. But I haven't had a lot of conversations where I've said, well, replace your coconut oil or butter with another kind of fat because you need fat, it's healthy, in some quantities, and you need to prepare your food.


Raj: So, the takeaway point is, really, maybe we don't need to focus on specific components other than maybe in your initial conversation, just getting an idea of what people are eating or whether there is room for changing the portions or the quantity or rebalancing a plate, but taking away food or replacing it? Not sure how high yield it is? Unless it's like I'm drinking a liter of coke, right? Like something so obvious.


Avantika: Yeah, most things that need to be replaced are not parts of the traditional South Asian diet. Those things are like the liter of Coca-Cola. There are, I think, some culturally specific foods that probably should be removed, but they're more like modern foods. Like, does your family eat tea with biscuits?


Raj: There's a lot of these packaged biscuits. So, biscuits mean there are cookies,



Avantika: They are cookies. Yeah. It's a cookie with another name. But yeah, so they're cookies. And then there's also the salty, crunchy snacks; then I know our family would. 


Raj: What do you call it there?


Avantika: Namkeen? Which just means salty thing?


Raj: We call it Mirko? Yeah, they're just fried or


Avantika: Chips. Yeah, I guess


Raj: Some form of it.


Avantika: Some things are more like, they're not traditional foods. They have a particular place. You have tea with your visitors, and then you want to serve them something, so we have cookies or something like that. I have encouraged people to cut back on that kind of thing. Because to me, those are all cookies and chips. You can cut it out, and they're packaged. My general rule for all of my patients is that the fewer things that come in packages that you consume, the better off you will be. It's pretty hard to eat unhealthy stuff if you prepare them yourself from scratch.


Raj: Yeah, yeah. Yeah. Okay. The other part of the diet is that many people are not as meat-focused. So, either they're completely vegetarian, which Indian community means no eggs. We'll be intentional about this. So, there's a cultural background to this Hindu culture of an Ahimsa, which is non-violence to other forms of animals, but, you know, at some point, people don't understand why they're doing it. It's what their families did. And that's what they continue doing. And there are a lot of other reasons people become vegetarians. But the point is that a lot of people are vegetarians. So, I think you've brought into the context of talking about me it's often not productive for them if you're trying to change their diet. But I think the other perspective that I wanted to bring out is that acknowledging people can be vegetarian to make sure that you are mindful of whether there could be any deficiencies or lack of something in their diet, given. They may have had a complete diet from their home country when they were Lacto-vegetarian, but they came to America and didn't have any time. And they're trying to juggle a job and cooking food. So, their diet has changed completely. They're still Lacto-vegetarian, but they're eating not as diverse of foods as we're eating. So potentially, they could become deficient in certain vitamins. I'm not sure if that ever comes to your counseling. Still, I found pediatrics in a review article because I think this is especially relevant for kids if you're trying to raise them as a vegetarian. But the main thing I found was ensuring you get adequate protein because sometimes that can be difficult. Again, not if you are doing a traditional diet with lentils, but also other micronutrients like vitamin B, 12, iron, and vitamin D. But there's also some risk of calcium deficiency, Omega 3, vitamin A, and selenium. I'll put this in the show notes. But does it ever come into your counseling at all, if you think about it, especially with diabetes and metformin,


Avantika: Metformin, which is, again, it's very common. Lee's medication for type two diabetes is associated with lower B 12 levels. So, we should advise people who follow a vegan diet typically will do some screening for B 12. If someone's on Metformin for a more extended period, it will get caught that way. People nowadays, I think, for most of the other nutrients, we all eat enriched products from the grocery store, so packaged bread and cereal and all these other things and have a lot of these other vitamins in them. I think iron is one that I do see a deficiency in. And I don't even know that that's specific to my vegetarian patients. Still, it just happens a lot, I would say, and people who are menstruating age throughout that portion of their life will see it honestly, vegetarian or not. Honestly, I don't see children. So maybe I don't have quite the same concern about protein deficiency and how that might affect growth. But I don't worry that much about protein because honestly, for health, my mom always used to say this to us growing up, there's a whole world of people who don't eat meat and are mostly fine. So, I think this obsession with having a certain amount of, like, some protein piece on your plate is a bit of a Western thing. Because there is protein in tons of vegetables that we eat, there's protein in lentils; there's protein in grains if it were good, grains going to be protein in it, and dairy products. And I know in the northern part of India, where I'm from, people do consume a lot of dairies, there's lassi, so like our yogurt drinks, and we put a lot of milk in the tea, sweet paneer, which is like a homemade, farmer's cheese. And so, I don't worry too much about the lack of protein, or frankly, even calcium, I think, at least my family members I've seen in the way we grew up. We probably drink and consume more milk than a lot of other people. So, I think, in that sense, it is pretty rich in some of those nutrients. But again, you're right. If you're coming in and you're feeding your kids noodles with butter because they're vegetarian and they're not getting a lot of other stuff, then certainly you want to screen for those possible things they might be missing.


Raj: Yeah. And maybe just be cognizant of it; that's not my go; recommendation to screen everybody or anybody.


Avantika: Yeah. That's more like a question you'd like to ask what do you eat? Rather than leading with what you should eat? Getting that baseline of understanding of what somebody does eat is helpful because I think often, we're likely to be surprised, right? We don't know what people are eating; we assume we know. But until you ask them,


Raj: exactly. Okay. Let's transition to culture. Again, we'll say this, India's very diverse, and what culture means to you is probably very different for me. We probably would be better off trying to be intentional about the diversity of India and making sure we allow people to express their diversity while understanding the common themes around what it means to be Indian. That could also mean a lot of different. So, for religions, we mentioned in the first episode of this series on India there's Hinduism, Buddhism, Jainism, and Sikhism. Hinduism is one of the major religions in India. I think it's certainly been true for me growing up in a Hindu household. Compared to other religions, sometimes Hinduism forms itself into a way of life or a philosophy. It is just like Hinduism was around you. It incorporates a lot of diversity and culture and rituals that make Hinduism in Southern India look different from Hinduism in northern India. But I wanted to start with that to talk about holidays because people may have a vague sense of holidays. But I think it's important to know a little bit more about them because it's probably important to the people you're saying or taking care of the famous holidays. How many people have heard of his Holi and Diwali celebrations?


Avantika: Those are the ones we celebrate. Yeah.



Raj: For Diwali, specifically, it's like the festival of light, and people say it's a victory of light over darkness. But holy or Diwali, people hear about a lot going into the diversity of Indian cultures. When I grew up in India, in Tamil Nadu, we celebrated Pungle. Now Avantika, do you know what Pungle is?


Avantika: I do not know what Pungle is. No, tell me.


Raj: This is funny because I think for me, Indian meant the things that I experienced growing up in Tamil Nadu and wasn't exposed to many other Indian communities. And it was funny in the first episode; it came out that I studied abroad in India to learn Hindi I studied abroad in a country that I came from because India was different than I had imagined or known it to be growing up. And Pongal is one of the major holidays we celebrate in Tamil Nadu, where we think of the son of mother nature and animals for the harvest. It's typically celebrated in January. We would make a special dish called pungle, rice boiled in milk. And we use jaggery, which is like raw cane sugar. It's one of the biggest holidays in Tamil Nadu, where people celebrate with food, but also new clothes,


Avantika: which is a common thing, actually, for most holidays you celebrate with new clothes. Yeah,


Raj: yeah. Yeah. And I think that brings us together, right, like food and clothing, that's always a good choice for an Indian holiday.


Avantika: Yeah, I think that Indians in America have their stuff that, like, we'll find someone grew up somewhere totally different. I was born in New Jersey to parents from India; there'll be a connection. There'll be some stuff that just happened with us, even though they are thousands of miles apart. A completely different friend, group, and community. When we finally did have a little bit of an Indian community where I grew up, we'd have these community center-like dances. The Donnie Ross. It's like a traditional dance where you have these sticks about 12 inches long, and you have two of them, and you do. It's like line dancing, actually hitting the sticks against your partner's sticks. It makes a beautiful noise, and it's really fun. It's also very easy to learn. So, kids can do it. People who grew up in New Jersey around all Caucasian peers can learn very quickly, like me. So, it's a really fun event.


Raj: Do you still do it?


Avantika: I haven't done it in years. But I talked about going a couple of years ago. But now it's hard because my parents have just moved here recently. So, I'm hoping to do some more of these things. Because I think without their motivation, it is pretty hard to get your act together and get your whole family out to socialize with people you wouldn't normally socialize with. That's it takes an extra step. But I am finding that it is more important as I get older because I want my kids to do it. They probably already know as much as I did growing up, but I wanted to go further.


Raj: Yeah, yeah, this is also a common theme. But I think especially salient with retaining community and trying and retaining that cultural identity.

So, let's move into beliefs around health. We talked about diabetes. How you incorporate some of the importance of family structures and involving the family and decision making and how you counsel and take care of patients.


Avantika: So, I think the family involvement for a routine visit with someone who's not from a South Asian background, I might just assume that I'm only communicating the information to the patient. But often, we'll see my patients from South Asia, particularly from Indian families, and they come with another family member to the visit very commonly and click with the email messaging. Sometimes another family member will be doing most of the email messaging back and forth with me. And I think when I started out seeing patients, I felt uncomfortable with that because you were trained in medical school and residency, that you have that permission, you could only communicate with the patient themselves. It's private health information. And it's very stressed that you're supposed to focus on your patient. But it doesn't work for some of these other cases. And I don't know if you've found the same thing; it tends to be more productive. So maybe, I'll say, " Oh, I'm happy to communicate with you as so, and so is the spouse or daughter. Many patients often will have a child who is also a physician who will want to talk on the phone about what's going on. And I appreciate that because I know how to like in our culture in our family and family, friends, it works people, they find it there's a doctor in the community, they trust that person to be like the go-between to give advice. So, I think being able to respectfully and flexibly engage with other parts of, I guess you would call it, the family care team which is really important. I think you're building trust with the patient; they'll feel better about it if you also speak to their friends now. SU [Not sure 40:00] was, and I don't know, a nephrologist in Albuquerque, right? It might seem random, but they trust that person to give good advice, and that person wants to talk to me. I'm pleased to engage in that as well. So, I think being open to the community caring for the patient, not just the patient themselves, is really helpful. And then I guess just with decision making, and I think that's something you maybe wanted to touch upon as well. I found there is not; I wouldn't call it deference, but a lot of trust and respect for the medical community and providers. So sometimes saying, like, do you want to try this? Or do you want to try this? Some studies say this is okay. But you can also try this because we do. I think we're moving more in medicine to letting patients have more choice and decision-making, which is good; it's not bad. But I've had conversations with outpatient patients where they're like, You're the doctor. What do you think I should do? I guess it comes back to that sense, especially because I am also a South Asian doctor. They probably are like, oh, it could be that I could be aunties niece, who's here in the visit with them. So, it's almost a slightly different relationship. And if I engage even in talking about the foods by using some traditional words to refer to things, I think it creates, like it's a different little doctor-patient relationship than I might have with some of my other patients.


Raj: Yeah, and I'll go with the first point that you made that it's a common phenomenon that another doctor is involved that they know personally because there are a lot of Indian doctors. We're going to talk about the reasons why it's with Dr. Bhatt. But still, this is going to be a situation you're going to be in. And it's best to incorporate that into your care plan rather than feeling challenged. If somebody's going to question you because everybody just wants the best for this family member they care about and want to understand.


Avantika: And sometimes that other doctor called to talk to you is also my generation. So, we'll see the scenario where it's like an older patient, renting from whatever Indian community, and then they have a son or daughter who will live elsewhere. And so, when I've talked to those other doctors, it's doesn't it's not like contentious or stressful. They're like, Yeah, my auntie told me to call you because another auntie wanted advice. And we're doing the thing of being the sound younger generation of the community to connect and help support our elders, which is another important concept in Indian communities and culture


Raj: Maybe we should define aunties that it's just maybe you're related.


Avantika: Everybody is an auntie.


Raj: Everybody that's Indian and older than you, and you kind of know,


Avantika: Yes, and, you know, I try to tell my kids to call it even non-Indian older people, auntie, uncle, and the other day, my 12-year-olds, but they're not Indian. Why am I calling them auntie? Give them like, it doesn't hurt. Still nice.


Raj: Yeah, exactly. And then the second point that you've made about, I would say, respect for authority. I don't want the takeaway message to be we need to go back to this paternalistic way of care that people are used to, and they want to be told what to do. But there is value in assertiveness. I think people doubt you when you're uncertain. And sometimes, I think, because even my training and how I've been trained here in America, admitting uncertainty is good. After all, you don't want to be so definite to do when you don't know. But when you're vocalizing uncertainty, I think it can come off in certain ways that you don't know what you're doing. So, the patient may lose trust in you, like, that person didn't know. He'd said I could do this or that. And I went to him to tell me what to do. So, I think just finding a way to be warm, respectful, and assertive is probably like art.


Avantika: Yeah. And I also think, as is true for all patients, patients will sometimes say, Okay, well, I see those two options; what do you think I should do? And this is not just patients and me. I've asked my doctor this because sometimes shared decision-making is stressful. I'm like, I make decisions all day, my everyday life. I'm here and want you to tell me what to do. So, responding then saying, Okay, what's to me what I think you should do, and this is what I'd like to try. And if it doesn't work, we can always change. But I think having a little bit more, like you said, a little bit of directedness is not always a bad thing. So


Raj: yeah, exactly. Okay, a few other things about beliefs around health and how to navigate that. I struggle with this because I think it's a common immigrant experience, too, about the stigma around mental health. It's probably underdiagnosed. And I also would bring up, like, some of the standardized instruments don't do justice in screening because many of those instruments, like PHQ, are tested on English-speaking patients and American culture. And interpreting that is different if you're Indian, especially if you don't speak English. So, I don't know how accurate that is. Do you find that true?


Avantika: Definitely. I think part of it like you said, is some of it is an immigrant experience. I can't speak to the conception of mental health in India now because I have not been there for a long time; I don't live there. Hopefully, things are open and changing. But there is a bit of this. And I think I grew up thinking this as well. So many things are bothersome in life, and you should just work hard. And these are minor problems. And it's not a big deal. And I think that's sort of grit and toughness, that as immigrants and kids of immigrants, we try and show up with every day. It doesn't do service to the fact that there may be things it's not, whether it's a big problem or a little problem; if it's a problem for you, it's still a problem. And it probably is huge about it. Because I also don't think I have excellent skills and can discuss this very well. Partially because of how I was raised, my parents listen to this; it's not because of anything they did wrong, so it's just you. There's a language like my husband is a psychiatrist, and his mom was a therapist. And so, the language on that side of my family is very different from the language we use. And my parents are extremely caring and always want their family and friends to take the best care of themselves. But we often don't have the words, as I think that's how I would say it.


Raj: Yeah, I don't know if that's universally true. Just reflecting, I think there was also a sense that we made it to America, and life's hard, but life was harder, and life is still very hard for people back home in many ways. So, we should be grateful. And then that undermines things that you're experienced. Sometimes you want to name depression, you want to get that diagnosis to go down this clinical pathway and algorithmic pathway that we're used to, but sometimes you don't need to like even acknowledge that things are complicated without trying to put a name to it.


Avantika: I wonder, too, have you seen a lot of somatic (bodily) concerns that seemed to be linked back? I have had a handful of especially older Indian patients who have a lot of physical symptoms; there is one after the next. And we work hard to try and figure them out. And it seems tied to mood. And, in a couple of those scenarios, what's been helpful is talking to the patient's child. Because they will say like, well, I think that they are depressed, or I think they're very anxious, but they don't believe they are having a problem with their kidney or with their hips or something like that. And that's a hard one. Because I never want to make light of someone's visible concerns. I always want to take that seriously. But it's helpful to consider whether that's the language they're using to describe how they feel that. Maybe it's not like I have depression, or I have depression with anxiety as we might now see on Tik Tok or something straightforward to say these words of the younger generation, which is great. But that's not how they're able to express their internal feelings.


Raj: Yeah, I've thought about this a lot, too, because it is a common phenomenon of somatization of mental health complaints, specifically depression and anxiety. And there's one way to approach this. You're trying to fight to change the patient's perspective, get them to acknowledge their depression, not like what they're feeling. And there's another way to reconsider that we in western medicine have separated the mind and body so much that we say depression, we have this sense of like mood. But, I mean, depression is often a physical symptom, too, like heaviness, right? I think we forget that a lot of the manifestation of depression is physical. And if we're able to, rather than try to change the perspective and just meet them in that bodily manifestation, if their family says, Yeah, I think they're depressed. Then you try to figure out why it is like social isolation. Did something happen? It's in reframing, you probably don't feel great, and your body feels terrible because of this.


Avantika: That's helpful. That's a great perspective. You're right because it's meeting them where they're at and fixing the problem they want to fix, not the problem that we think needs fixing. Okay.


Raj: Anything else about values you feel is important that you've come across? What's that movie that came out about closed awareness, this idea that you'll hide the seriousness of the illness for the patient who experiences that, so they don't suffer mentally? In western medicine and our current way of health care, we want to be direct and honest. But I think people's interpretation of some of that is like increasing the suffering when people are already suffering in some way.


Avantika: Yeah, I think it loops back to my release, in some way, to the idea that the family is very involved, right? So, I wouldn't necessarily always think about it as causing suffering for the patient and wanting to protect them. But it's more like a discussion they may wish to have with their family and not necessarily just with me, right? So having the franker part of the discussion only if this is okay with the patient and their family. And you've had that discussion beforehand, not just going in and making your own decisions about who wants to hear what but talking to the family members. A lot of times, it's the patient's child who's an adult child, having this conversation with them about prognosis, what might need to change, or what your really strong recommendation is. Then they act more confident and able to have that conversation with the patient themselves and have It absorbed, I think. I've never been in a situation with an Indian patient where there was something that I was told not to communicate to the patient in some way. But I communicated differently via family members or a group conversation where I spoke so and so's daughter or son. And then, they explain it in a way that may not be how I would have said it to the patient.


Raj: Yeah, I think that's good. Okay, two more questions. The next question is, what have you learned? It's all your experience providing clinical care to the Indian community.


Avantika: I think the two things that I would say have been most salient are what I mentioned. Number one, this idea of trying to control what people eat to make them get better. I have come a long way on that. This is my bro. Right? Because I've just found itself productive. I believe that I have made my patients feel judged to a certain extent, right? And I lost the ability to connect with them when I said, why don't you try doing this instead? And it's much more productive to say, Okay, what are the things you absolutely cannot give up?

Tell me what's important to you. So maybe it's because I have to have a samosa with my Chai. After all, my grandson comes over at that time of day. And that's the time we spend together, right? So why would I want to mess that up? That's just not it's not a productive approach. So, I feel like you look back at your ten years ago, 15 years ago, self, and you're like, oh, I can't believe I did that. But that's how we learn. You know. So, I think having more innocuous with my Indian patients, but in general, a more like a softer approach regarding nutrition and diet guidance. Because some of these things are far more deeply entrenched than just the macronutrients of what you're eating, it's a habit with insulin.

I have a very specific memory of a South Asian patient who has had like three breakfasts. Now, this was his routine; he did this. He went for a walk, had another breakfast, and we just dose insulin for every one of those tiny meals. And that's what he needed to be happy, and we were able to take good care of his body. So that's the outcome that is not the easiest thing for me. It's what's best for the patient. That's what we want. And then I think being open to this idea of family decision-making. Because honestly, when you're new in practice or busy, it can be annoying when you have to call like five other people before you make a decision. Or you're getting emails from so and so who work [Not sure 52:22] that like all this, like so. And so, who works at Harvard, and they want to talk to you and to feel like really insecure, well, they work at Harvard, and what if I'm doing the wrong thing? Still, I think I just, like, understand where that's coming from because my grandmother aged and my parents are a good help, but just reflecting on how I want to support them and how they would sometimes look to me to support them. It makes it so much more relatable. And then I'm like, Okay, I will talk to your family member in Harvard. No problem. They will hopefully teach me things that I don't know. And then we've created a sense of trust because the patient feels that it's not just me giving them the advice, but a community of people who care about them or provide them with advice on something.


Raj: Yeah, their sense of humility when you approach like that. Okay. And then the last question, a personal question. Have you ever had an experience with the health care system you like? That's something to aspire to, especially in how they care for your family member. You're the auntie in another relationship that they're calling for advice. When have you seen another doctor approach it in a way you wanted to mimic or aspire to?


Avantika: Yeah, actually, my grandmother passed away a little over a year ago, just in her 90s. Like she had, [Not Sure 53:33] this is another kind of common thing is when you're an Indian doctor, people want you to set them up with doctors that you know, so what I lived in California and my grandmother, I referred her to one of my partners in my practice, who is a wonderful person. I haven't spoken with her in a while. She's not Indian. But she just was so patient because my grandmother was a person who also had a lot of physical complaints that I think were somewhat related to isolation and depression. She lost her husband fairly young and was moved around with my parents but didn't settle into another Indian community. Like this physician, her name is Talia greaser. We love her. She was patient in taking everything seriously but not over-medicalizing it; that makes sense. So, I never felt my parents ever felt that it was a bother to bring my grandma and say, hey, now she's complaining that her left pinky is hurting. And you know, was this a family member, you're sort of like, okay, it's probably not a big deal, but she would take it very seriously, listen to have, like, so much compassion, but didn't send her 5000 tasks either. And so, I think just that ability to be patient when people communicate things differently is so valuable and something that I aspired to. I want to be able to do more and more, not just in my practice but also just with my family members and people older than our community in general and me. Because I think one of the things you see is as I get older, as we get older, you just to think, well, that's going to be me. And now it seems like it could be me, and I can see it. So just remember that compassion is going to be very much appreciated. And we'll come back to you, hopefully.


Raj: Yeah, we get paid to listen in many ways. And yeah, we fall short and continue to grow in that. But even more, being a good listener to your family, you know that. Yeah, keep reminding yourself.


Avantika: Yeah, I know. I know. It's important.


Raj: Thank you, Avantika. I think this was a great episode. We learned a lot.


Avantika: Yeah. Thank you so much.


Raj: Thanks again for joining me. It's me, Raj Sundar, in another episode of the health care for humans podcast. I hope you enjoyed this episode. As always, remember to check out our website, work, for show notes and a full transcript of the episode. Make sure you hit the subscribe button and tell a friend.


This podcast is intended for educational and entertainment purposes only. Views and opinions expressed in this podcast do not represent any of the participant's past, current, or future employers unless explicitly expressed, so always seek the advice of your physician or other qualified healthcare providers concerning your personal questions about medical conditions you may be experiencing. This Healthcare for Humans project is based on Duwamish land and makes a regular commitment to Real Rent Duwamish.

The transcript ends here.


Avantika WaringProfile Photo

Avantika Waring

Chief Medical Officer

Dr. Avantika Waring is an Endocrinologist focusing on caring for people living with diabetes. She has worked with patients in various clinical settings for over 15 years and is currently the Chief Medical Officer at 9amHealth. Her clinical passion is the development of technology-enabled care delivery models that are equitable and culturally inclusive. She is originally from New Jersey but has lived on the west coast since 2009 and currently resides in Seattle, Washington. When she’s not at work, you can find her on the soccer sidelines watching her three kids, running and hiking the nearby trails, and skiing local mountains in the winter.