Dr Sam Manger – The Society of Lifestyle Medicine

Dr Sam Manger joins me to discuss lifestyle medicine, a practice that looks at the individual holistically. Sam covers a lot of territory in our chat, including how practitioners can incorporate lifestyle medicine into their practice. Sam is a medical practitioner, educator, communicator and President of the Australasian Society of Lifestyle Medicine.

Dr Sam Manger – The Society of Lifestyle Medicine Introduction

Now the purpose of this podcast, just to remind you, is to explore what the words holistic and stress actually means in our modern world. So today’s topic of Lifestyle Medicine covers such a range of those issues and is a phrase, Lifestyle Medicine. My guest today is Dr Sam Manger.

Sam is a medical practitioner, an educator, a communicator and also President of the Australasian Society of Lifestyle Medicine. We cover quite a bit of territory in this episode and it all ties together nicely with several themes we’ve covered in other episodes. I hope you enjoy this conversation I had with Dr Sam Manger.

Podcast Transcript

Dr Ron Ehrlich: Hello, and welcome to Unstress, I’m Dr Ron Ehrlich. Now the purpose of this podcast, just to remind you, is to explore what the words holistic and stress actually means in our modern world. So today’s topic of Lifestyle Medicine covers such a range of those issues and is a phrase, Lifestyle Medicine. My guest today is Dr Sam Manger.

Sam is a medical practitioner, an educator, a communicator and also President of the Australasian Society of Lifestyle Medicine. We cover quite a bit of territory in this episode and it all ties together nicely with several themes we’ve covered in other episodes. I hope you enjoy this conversation I had with Dr Sam Manger. Welcome to the show, Sam.

Dr Sam Manger: Hello Ron, thanks for having me.

Dr Ron Ehrlich: Sam, you are wearing many hats I know. One of those is the President of the Australasian Society of Lifestyle Medicine, I know you’re a practitioner, a teacher. I wondered if you, just actually give us a bit of a background about how your week unfolds and the sort of things that you’re involved with?

Dr Sam Manger: Yeah, as you say many hats. Two days a week I work in private practice two to three days, and then one day a week I work for Queensland Health running Lifestyle Medicine clinics in the mental health inpatient and outpatient. So we have about 1,500 people on our books.

And we’re trying to develop Lifestyle Medicine clinics to look after people holistically because the evidence is becoming pretty clear that you look after their body, then you also look after their mind, and we can talk about that a little bit later. It’s quite interesting research going on there and evidence.

And then, I spend roughly two days a week teaching for James Cook University, lecturing GP Registrars and in my region or around Queensland, and then that takes me around the place. So I’m going to Fiji, in a month to do a workshop with them on Behavior Change and Health Coaching for their GP training program, and that takes me around. And then I also have my podcast as well, the TV show, which keeps me pretty busy. And then a few other little endeavours which I’m building as time goes on.

Dr Ron Ehrlich: Yeah, well and there are only seven days in the week. Sam, I’m just trying to add all those, ones up. You’ve, have a very busy program there. Listen, lets, you know, the word Lifestyle Medicine. Can you explain what that means to our listener?

Dr Sam Manger: Yeah, sure. So Lifestyle Medicine basically means any lifestyle intervention that can be used as therapy. So, it’s anything that is not supplements, medications or surgery. And not that those don’t have their place, but it’s just not what Lifestyle Medicine is. And that includes nutrition, movement, mind, body interventions, sleep, connection with each other, connection with nature and behaviour change and health coaching techniques.

And then often we couple that with Apps and technology that’s coming up these days, that could be used, I.e in health coaching, so that’s the clinical aspect of Lifestyle Medicine. And then you’ve got the advocacy and public health aspect where we work with many universities and research institutions to start developing a very decent base of evidence for these interventions.

Nutrition and heart disease or mental health, for example, sleep therapy and Dementia. And then working with universities to try, and get this into the Core Curriculum or at least, at very least an elective placement for medical school placements and Dietitians and allied health and nurses.

Because it would be very common I’d say now at the moment, most weeks that I would get an Email from and a medical student or a GP Registrar who wants to do a placement in Lifestyle Medicine. And so now I’m through the organization, searching for members who want to take them on, and people who fellowed with our organizational certified.

And that’s great because people want to teach it and is starting to become a real career in it, which is refreshing. And likewise, I get most, almost most days now, but definitely most weeks, Emails from NGOs, and businesses, and organizations who want to open up lifestyle to be a part of their program, whether it be a corporate program or an NGO that works on mental health or post-traumatic stress disorder or something like that.

They want that as well to be a part of it, so they’re contacting us and looking for people to help them. So it’s a pretty broad range, but I suppose if you look at it, we’re trying to approach every level of the health system and society in a way.

Dr Ron Ehrlich: Before we dive into those kinds of things, I’d love to get your impression of where we’re at health-wise. Your assessment of our current state of health, how are we doing?

Dr Sam Manger: Oh! It’s a tricky one. Look, I think that it’s, we’re looking at, if you look at the stats, 50% of people have a chronic disease at the moment. 25% of people have two or more chronic diseases and 50% of people over the age of 65 are on five or more medications to manage those chronic diseases.

And I think it’s about 60% of people over the age of 21, at least one medication. Medications cost roughly $20 billion a year and the health expenditure is about $160 billion a year, and whereas primary care only costs about 10 to 15 billion. So we actually spent less on GPs than we do our medications.

And the vast majority, that money goes to the hospital sector, because we are working on a downstream model. Meaning that we catch people when they’re sick and try, and fix it then when it’s, that’s good to do, it’s tertiary and secondary prevention. But ideally we need to now start looking at this primary prevention, or at very least when we catch people, let’s say with Diabetes, heart disease, we can use lifestyle FirstLine and then reverse it with that, not needing medication and actually truly reversing as opposed to just managing it.

So I think the health system, I have a lot of respect for it. I think, working in, I know that everyone has a good heart, they’re working hard. But the model is not built for the chronic disease issues we’re seeing now, and it just needs to evolve as it always has.

Dr Ron Ehrlich: Because I agree. I mean, I think one of the things that, because obviously I’m very involved with nutritional, environmental medicine and one of the things that, I think all practitioners that I know, and some are in that chronic management model, and others are in the integrative holistic space. One of the things that they both have in common is, they want the best outcomes for their patients.

Dr Sam Manger: Absolutely, yeah. I think, for the most part, I mean, there’s always exceptions to the rule, but for the most part, every doctor, nurses, allied health person I know regardless of their philosophy on health, of which there are many, on the spectrum of sort of conservatism to progressive, that they all do want the best for their patient.

They just have, might slightly different interpretation on how to get there. But, we’re now just reaching this challenge where simply the numbers aren’t in our favour anymore, and time is so pressured that even people like me who want to deliver much more holistic care, it’s very hard because, neither the financial model suits it nor the time model. It’s very hard to live good quality care in 12 minutes. So things need to change in that way.

Dr Ron Ehrlich: Well, I was going to say, “What are the barriers?” And I think it would be good to go into that. But you are involved in medical education at an undergraduate level, and I don’t know about when you went through medicine Sam, but I know when I went through university in dentistry, the nutritional aspect of what was causing all lifestyle aspect, that was causing so many of these diseases that we learnt so much about, it wasn’t being given a lot of time. Was that the case for you when you were going through?

Dr Sam Manger: Yeah, it was. I think it’s a tricky one. One of the things I often hear criticisms of doctors is that they don’t get taught in nutrition. And I think that is true to a degree, but I think there’s also, it’s more nuanced than that. So what is nutrition? I mean nutrition is Biochemistry essentially.

And so doctors get taught an enormous amount of Biochemistry. We know all about the citric acid cycles and all these sorts of things. The bit of information that we’re missing is, how to use that in a clinical space as therapy. Which diet is best for which condition, and how do I help people, or coach people to apply and change their lifestyle to do that?

That’s the bit that is missing to me. And so that needs, I do believe needs to be put in eventually into the core curriculum. The problem with medical school is that, and it’s not a problem, it’s just a sort of a fact of reality. Is that you have four years, you have to do pre-med at three years, you then do medicine at four years. There is an enormous amount to learn.

I mean, when I was doing medicine, you go to uni, you study all day, you get home, you study all night. That there is no, it’s not like any other, I did a science degree and that was pretty laid back, you just cram before the exams, but medicine was nothing like that. You study for the whole time for four years.

So it’s not like they’re not, it’s not included because they don’t have any to do, it’s just a competition thing. And you’ve got to finish medicine able to save a life of a person with a heart attack or with trauma, something like that. So that’s the priority and that’s what they teach.

And then, so the reality of getting this into Med school probably is not feasible in the short term. But what we’d like to do is, get it as an elective for people who want to do it more. But where we do need to get it in this, is in specialty training programs. So cardiologists, when they’re doing their cardiology training, should be learning about how to reverse heart disease with Lifestyle Medicine, but they’re not.

So, I don’t think there are many excuses for that. And GPs who are learning should be being taught lifestyle therapy as well. And they are a little bit, but not as much as, I think that they could be. But like I said, I don’t think that’s anyone’s intention, there is no malevolent there, they’re just, it’s just not in the system.

Dr Ron Ehrlich: I’ve often said that “If I had a choice of what I would go back and study rather than do a PhD, I would go back and study anatomy, physiology and Biochemistry.” Now, if I was taught by Biochemistry in unison with nutrition, it would have been fantastic, that would have gone well.

So that’s why I’m learning this cycle and that’s why eating X Y or Z is important, or anatomy and physiology and chronic pain management, that would have been fascinating too. But they were subjects that we kind of just had to get over before we got into the real stuff.

Dr Sam Manger: Yeah, I agree 100%. And it’s so interesting because now when I teach, I bring up, the citric acid cycle, or something like that, or electron chain transfer, or something like that. And I’m like, “So this is why you need B vitamins?” Because it’s involved in all these steps. And people are like, “Oh! I get it now, that’s why I need to eat Broccoli.”

So it’s like, you can actually start piecing it together in a much more meaningful sense as opposed to exactly as you said, “Just learning it for learning its sake.”

Dr Ron Ehrlich: Yeah, and I, you used that word Sam holistic, which should cause, conjures up all sorts of things when people, they kind of think of crystals, and some kind of new age philosophy, but actually Lifestyle Medicine and holistic is kind of synonymous really, isn’t it?

Dr Sam Manger: Yeah, you’re right. It has a lot of connotations to it and as does lifestyle, sadly but that’s just the way it is. But so holistic, I mean in the terms of the whole person. And so what is that whole person? Where their biology, but they’re also psychology, and there’s a huge impact between the mind, the body, which is fascinating.

And then their environment, which they existed in. So the culture which they’re a part of, the everyday environment. And so when I talk about holistic I just mean, “Taking all of that into account when we’re talking about the person rather than just a minutia detail, like a blockage in their coronary artery or something like that.”

Dr Ron Ehrlich: So what, let’s go through some of these things that constitute Lifestyle Medicine, which we can talk about which, practitioners and patients should be learning about. Let’s go through a couple of them?

Dr Sam Manger: Sure, where do you want to start?

Dr Ron Ehrlich: Well, why don’t you pick somewhere, where would you start? Not necessarily in order of, is it in order of importance, if someone had to say to you, “What’s the most important aspect of Lifestyle Medicine, Sam?” What, how do you answer that?

Dr Sam Manger: Well, it has to be personalized, that’s the truth of it. So, because everyone’s lives and factors in their life are unique. So some people have a, not a bad diet but they’re incredibly stressed, and so you have to work at that level. And some people are sleeping very poorly, felt like they might have sleep apnea, or they may just have Insomnia or some other thing.

And so that’s gonna be one of the bigger things. So, to be honest, when I’m in my clinic, the first place I started, is not with advice, but with taking a good history. And, when I take a detailed history, it starts to become clear what areas need to be approached. And whether it be nutritional, sleep, or movement or wherever it is.

Dr Ron Ehrlich: Well, on a practical level, what sort of time are you allowing in your clinic for a new patient exam?

Dr Sam Manger: Well, most patients are booked in first appointments with me for half an hour, and that’s just the standard GP practice thing. And I can get some done then, usually, more of screening, get to know you kind of thing, and then I will often book them up. And it takes, it can take me two more 30-minute appointments before I’ve got to the depth that I feel I needed to get to. So at least an hour to an hour and a half, but sometimes that’ll be over a couple of weeks.

Dr Ron Ehrlich: And you mentioned the barriers for implementing this kind of approach, both financial and time. How do we overcome those? I mean, is it just a philosophical decision that a doctor has to make?

Dr Sam Manger:Yeah, I think, well, the MBS, which is the Medicare Benefits Schedule for GPs, at least is based on the time you spend with a patient. And per minute of time, you use to get a lot more money for spending, not much time with patients than you do more with more patients. So the incentive, it’s actually extremely hard to keep a GP practice afloat by seeing people for longer periods, and in bulk billing them which I bulk bill the vast majority of my patients.

And so, you’ve got this real conundrum where, if you need an actual viable business to pay your nurses and reception. You need to either charge a gap or you need to see people for a shorter amount of time and that’s just the nature of the [inaudible 00:14:53]. Now, the MBS is being reviewed and we’re hoping that that’s gonna change, but I can’t see it changing enormously anytime soon.

But with health care homes, which will come out in the next couple of years, may have an impact there, which is a different funding module four for primary care. So the way I go about it is, I just accept limits and I see people more frequently and for 15 to 30 minutes. And I sort of drip-feed out the intervention, which I actually find works anyway.

Because, when it comes to Behavior Change and Health Coaching, it’s, if I spend an hour with a patient, it’s often too much information for most people. So they can’t process it all, because it’s too much information for anyone really to hear all this sort of stuff and okay, you need to change this bit, this bit.

It’s much easier if I go, “Okay, well let’s just change one or two things this time and then I’ll catch up with you in two weeks, and we’ll change one or two things that next time.” And over, it can be a little bit slower I suppose or it seems, theoretically slower. But after three to six months, you’ve actually made an enormous number of changes and you’ve supported them the whole way, you’ve developed a very good relationship.

And I find that very I mean, that’s I think, why most people get into health, is the connection that you have with your patients. So that’s how I work my way around the system, but I also find that the more I do Lifestyle Medicine, the more efficient I become at it.

And so I can assess pretty quickly where I think the low hanging fruit is, or where I think the major issues are. And I also know, I’ve seen it many times, I know the evidence, so I can target my advice accordingly. So the more you do it, the quicker and the better you get at it.

Dr Ron Ehrlich: I mean, I like that because, we have this idea that, “Oh! No, I’ve got to set aside this hour, hour and a half because I’m wanting to be all things, to all people, all at once.” And that is a problem, but this kind of slower approach is realistically how one can incorporate it into practice, but it’s probably practically a better way of doing it with your patients?

Dr Sam Manger: Yeah, I mean, they don’t seem to mind. I mean, I will often make sure my first appointment is, I get a big scoping assessment and not just from a lifestyle point of view, but from a medical point of view, making sure there’s no red flags or nasties that they’re missing. And once they’ve ruled out, then we focus on the lifestyle areas.

And I will say, “Okay, well today we’re gonna talk about, which one do you want to talk about?” I mean, again, personalizing, “Okay, I think this is probably the most important factor, which do you think is the most important factor?” And they’ll say, “Well, it’s my actual, my relationship with my husband is the biggest issue.”

I’m like, “Oh! All right, well then let’s sort that out first because that’s obviously of crucial importance to you.” So, it’s very much a partnership, Lifestyle Medicine is based on that sort of shared management.

Dr Ron Ehrlich: And patients’ response to this. I mean, people come in, I guess they come into you and they must, your reputation must inform them that something different may happen here. But people often come in with an expectation to a medical practice that isn’t kind of switched on to anything, other than what they’ve been exposed to throughout their entire life?

Dr Sam Manger: Yeah, I think, I certainly have experienced that. And that’s a really big topic, because, on the one hand patients, they do come in, and they’re very, they’re either seeking me because of that more holistic inverted commerce approach, or they just happen to stumble across me and then they realize that’s what I’m doing and they’re really pleased.

They say, “Well, no one’s ever talked to me about this before.” And they’re really, really happy about that. But again, it’s not, the problem with sort of speaking like that is, it’s almost insinuating that other doctors don’t do it, and I’m not insinuating that. I know a lot of other doctors who do this good work.

But there’s no doubt, a strong desire from patients to at least have this as an option. And not to be the only option to have other tools in the toolbox, but they’re very pleased when it’s raised as an option to go with.

Dr Ron Ehrlich:  I mean, you were talking also about you, your work with Queensland Health and the Mind-Body Connections. I wonder if you might just talk to us a little bit more about that? Because, the mental health, of course, is a huge and growing problem in our society. What are we seeing out there, what’s, what are we seeing in mental health issues?

Dr Sam Manger: Well, mental health is a real challenge. I mean, what the RSCGP had a report recently to the college of GPs showing that mental health was the most common presentation to general practice. And the World Health Organization’s have said, “Depression is the leading cause of morbidity worldwide now.”

So we’ve got a real challenge. And the good thing about Lifestyle Medicine in the context of that is, it works at two different angles, so it’s one solution for multiple problems. So if we take Depression, Anxiety but then the more severe mental illness like Schizophrenia and Bipolar.

So commonly what we see in Schizophrenia and Bipolar is that people actually die about 20 years younger than the average population because of metabolic disease, largely in COPD. So it’s not actually because of their illness, they’re dying. So we talk about, close the gap with Aboriginal health, which is obviously incredibly important and that’s about eight to 10 years between Aboriginal people and non-Aboriginal people.

But it’s about 20 years between those with severe mental illness and those without. And that’s because of the medication side effects, partly because the weight gain can be so significant on some of them, but also because of their lifestyles, that they often are smoking, they’re often not eating well, they’re not well supported, they can be homeless or itinerant.

And that they present all these challenges, not, of course, I’m not labelling everyone with these things, but there are pockets. And so Lifestyle Medicine treats that because your if they’re dying from heart disease, and COPD, and Liver failure

Dr Ron Ehrlich: COPD, just give us, I know it’s an acronym and I know it stands for, but go on?

Dr Sam Manger: Sorry, Emphysema folks smoking lung disease. If they’re dying from those things, well if you help them quit smoking and you get them to go on a good lifestyle and their heart disease reverses and their Fatty Liver Disease reverses, then you’ve now closed that gap.

But the really amazing stuff is the evidence now, in the last only, probably two or three years coming out. The impact of those lifestyle measures on their mental health themselves. So if you look at movement, is an easy one to talk about. We know pretty clearly now that, I don’t like the word exercise, but also we use physical activity.

But physical activity is as effective as Antidepressants and Psychotherapy in Depression. But also, it’s extremely effective in reducing psychotic symptoms in those with Schizophrenia. So we now have a single therapy that manages, improves a lot of mental illness. We now know that people with major Depression, like as in, severe major Depression, who go on a Mediterranean style diet, a third of those people will go into remission.

And this is from randomized controlled trials. So if you’ve got an intervention to let’s say, movement, physical activity improves a third of people, and you’ve got nutrition improves a third of people. That’s a lot of people with Depression that you were reversing without medication.

And then you’ve obviously got sleep, which is a huge one. And we know, for example, with sleep that people with Depression are four to 10 times, more people with sleep apnea, four to 10 times more likely to have Depression. And I think, off the top of my head, about 15 to 20 times more likely to have Anxiety.

And Insomnia is strongly linked to delusions in people with Schizophrenia, which is a type of psychotic symptom. And so we know clearly, sleep seems to be correlated with all these negative symptoms, we also know that it correlates with treatment. Resistance, meaning you give them medication but they’re not getting better get. And then we start to go, “What happens when we treat that sleep?” And trials and now starting to show you that when you eat, get people sleeping at good quality, seven to eight hours, at a reasonable time, then they, Depression improves, their treatment resistance results and things like that, and I’ve certainly seen that.

So we’ve been running some projects, some research projects where I am at the moment, looking at sleep and doing sleep studies. And I’m amazed, how common severe sleep apnea is, and you as a dentist would obviously see this as a big thing. And it’s quite stunning, so these patients have been walking around severely sedate and thought to be the medication.

And then I started there and I said, “Okay, well maybe we should look at their sleep. Let’s get a sleep apnea study.” And they had severe, I’ve never seen a report like it. The specialist wrote, very severe sleep apnea, I never put them in that very before. And we gave them CPAP and then one person needed a Mandibular Splint. And as that does need some time, it actually works really well. And they just woke up, boom, next day, just like a new person and they, that no one could believe it. And so now this person wanted to start exercising, start eating well because they had the energy to do it. So we were well and truly on the path now to a better outcome.

And the whole, the different unit, I work at four different units, but the culture changes because now, this lifestyle is part of the treatment pathway. And that’s really lovely to see. I mean, there was a bit of resistance from the previous culture as it were. People didn’t think that lifestyle had its place, it was medication, psychotherapy that was it. But now you’re seeing the benefits to the patients, people are, “Okay, this is a, it just has to be part of the treatment now.” So that’s what I’m hoping to see unfold in the future, that it’s just an accepted part of therapy.

Dr Ron Ehrlich: Yeah, and it’s so simple. I mean, what’s so, almost unbelievable about it is that it’s actually remarkably simple to ask that question. It surprises me how often, when taking a history of a patient that is on antidepressants. And my next question is, have you ever explored your sleep pattern? And a lot has not.

So this is exciting to see this happening in practice because, it’s a huge, huge difference. If a practitioner is listening to this, and I know I do have a few practitioners that do listen to this, and they’re wanting to incorporate this into their practice. Well, how would you, what would you advise them, how would they get started on that journey?

Dr Sam Manger: Well, I think twofold. One is how you approach the patient, the second is resources. So how you approach the patient. My advice is not to go away and start reading about the latest or what you think the best diet is, whether as you think it’s Low-Carb, Keto or Whole Food, Plant-Based or Military Diet not to get sucked into that.

I would just take a really decent lifestyle history. To me, that’s where it starts. So nutrition, what do you want to know? You want to know what they have for breakfast, morning tea, lunch, afternoon tea, dinner, after dinner, before bed and overnight, because overnight snacking is a very common problem. And you will never know unless you ask. And then you want to know about drinks, coffee, milk, sugar, tea, added sugary drinks, in particular, is a major burden. And then a movement, when do you move, why do you move? Why is a big important question? How often do you do it, what do you like to do, and what did you use to like to do?

Sleep, when do you go to bed, how often do you wake up, do you wake up tired, do you snore, do you get headaches in the morning? Those sorts of questions. And the connection, how many people in your life would you consider that you would really connect with, that you could tell you really, you’re deep worries too?

And often it’s like, zero or one. And that’s not healthy, we’re tribal creatures and we need probably at least three or four. And so, if you take that history, the management becomes the kind of obvious, because you can have a person, I could go through any number of examples, but a patient the other day, I took a dietary history. And what typically happens in a console, is people say, “Do you eat well? Yep. Okay, good. That can’t be it then, can’t be the problem.” And like, that’s as deep as it gets, or they say, “Okay, well you know what? You’re eating too much junk food because you told me you’re eating junk food. So here’s a one-page handout on the healthy eating guide and I want you to go and do it.”

I mean, that is never going to work. So you need to personalize it, it could be that there, could be just, I had one patient the other day, who was having between 10 to 20 cokes a day, but they were eating really well other times. So, of course, the major issues that coke, but you have to ask them, why are you drinking that much?

We’ll probably save a Binge Eating Disorder or something like that. So it’s like, okay, then you need to treat that, that’s your management. You can’t give them a one-page handout because it’s gonna mean nothing to that person, it’s gonna be completely pointless. So it could be some people eating overnight because of their antidepressants. It could be that they’re eating one meal a day and it’s not a good meal, or it could be that they had in five meals or whatever. So you have to personalize it, and it goes the same as sleep, same with movement, same with connection, and nature time and those sorts of things. So I don’t try and get too hooked up in the advice.

I try and get people to be curious, be detectives. Also, because it’ll make the management more obvious, but the second thing is, it developed a relationship with your patients. Because, when people feel like they’re listened to because we’re all human when I feel like I’ve actually been heard and seen for all that I am, you now trust the person who’s doing that with you.

And when they then make a suggestion like, “Hey, maybe we need to really work on your coke intake, or maybe we need to work on that, all that bread that you’re having or whatever it is.” They’ll go, “Yeah, okay.” Because, they trust you now, they trust your opinion. And if you don’t spend time developing that and you haven’t listened and heard that person, then it’s, they’re going to be more resistant to it, because you are now an outsider.

So, my advice is to not get hooked in the current and carry strong current of nutritional debate and things like that, and more just get involved in the patient that is in front of you. As far as resources go, [crosstalk 00:29:22] Look, there’s plenty of good resources out there. I mean, obviously, The Society, Lifestyle Medicine and your college will have various resources and they can check them out on the Website. And there’s the Lifestyle Medicine textbook by professor Gary Yeager, is sort of like what I would call a [inaudible 00:29:37] is the key General Practitioner Textbook, and the Yeager book is the lifestyle one.

And then, there’s Repair, which is the American Lifestyle Medicine textbook. And then there’s Mechanic, which is the European one. And then there are various other formulations of that. And so that’s as a general thing, and then if you’ve got a specific area of interest, let’s say Behavior Change or Health Coaching, then you could look at Margaret Moore’s book, Health Psychology Coaching Manual. I think that’s a fantastic book. And then if there are other specific areas of interest, let’s say you want to figure out how to build rapport. There are some fantastic books by William Ury called, Getting Past No and Getting to Yes. So they’re two short books on how to, yet what exactly, it sounds like, Getting to Yes and Getting Past No.

So developing and diplomacy with your patient and shared management, and they’re fantastic short, concise books. So when you start taking history again coming, I sound like a broken record here, you actually then realize your own deficiencies. So you’ll go, actually, I just can never seem to get this person to agree with me or to actually do what I’m asking them to do.

So I must not be a very good salesperson, I must not be a very good coach. And I think that humility is really important because I go through it constantly, or you go, “Okay, actually this person just asked me about the best diet for reversing Diabetes or heart disease or whatever it is. I actually don’t know what that is.” So, I’m gonna go and do my reading in whichever area that is. But there are certainly good places to start, and those would be those resources that I just listed. And of course, PubMed is also, going back to the original studies themselves.

Dr Ron Ehrlich: It’s so interesting, the connection issue, isn’t it? Because that is, I mean, it’s proving to be so huge. I think, Harvard did a 75-year study and found relationships was the biggest predictor of health, wellness, longevity. But now as we are faced with so much technology, our connections are a bit odd. And I know that young people are suffering from mental health issues. This is a big challenge too, isn’t it, our relationship with technology?

Dr Sam Manger: Yeah, it is fascinating. So I think, I heard someone call it, Technopathy the other day..

Dr Ron Ehrlich: Technopathy, okay, that’s a new one. I’ll write that down.

Dr Sam Manger: So, technology’s an interesting one, right? It’s sort of like a car, you can use it to get somewhere or you can use it to kill someone. I mean that it’s inherently, it has its problems but it can also be used for good. And then sort of, you can look at it on both ways, so you’re absolutely right. Social media these days, in particular, Twitter and Instagram and Facebook, the constant classic, stereotypical things you hear about people posting their best life and everyone else feeling like they’re not living that and are insecure and unhappy about that.

And I think that’s definitely true, and also the trolling and bullying that goes on Online is obvious. But when you look at the number of people and the studies, look at the number of people that you would count as your clear and closest friends as I mentioned before, “Someone you could really confide in.” It’s gone from I think about 15 years ago. So social media really gets, Twitter was 2007 and Facebook a couple of years before that. But in the last sort of 20 years, it’s gone from I think 2.5 people to now 0.9. So we’ve got these massive networks of people, but no one we trust, and no one we really think understands us.

And that’s a horrible lonely position, and in fact, what we see when you actually ask people about loneliness, that is going up significantly. People are feeling much more isolated and lonely than they have before. And it’s, as you say, “Ironic, considering we’ve never been more technologically connected than we had before.” But it’s not real connections, it’s not sincere connection. And, that’s I think, it’s going to be a good thing, because I think humans are gonna rely on us as the human race will realize that. And I think we’re starting to already, you’re actually seeing Twitter use go down quite a bit now.

And Facebook’s starting to consolidate into groups, more than just general single posts, if you know what I mean? So they’re forming a community. So it’s a very interesting evolution of that. On the flip side, technology is interesting because let’s say, I don’t know if you’ve done many podcasts, or done much reading on the avatars and augmented reality and things like that.

So you’ve got avatars which are essentially fake people but are like, machine learning. Not artificial intelligence because we don’t have artificial intelligence, but they’re just sort of computer programs that can respond like, Siri in a way for your phone. And what they’re finding is actually, you have an avatar on the screen talking to a teenager. They actually trust that avatar and confide in that avatar more than they would their other therapists. So it’s a very interesting thing that, and that’s not obviously for all people but in certain people. And it’s interesting that we feel at the same time when it comes to technology, less judged unless we can drop our barriers.

It’s like talking to our dogs because we know they don’t respond back. We feel like we can give them everything we’ve got. And so, there are uses for technology, which I think are incredibly therapeutic and beneficial. And then there are ones that are incredibly negative and damaging, and so we will with time learn how to mature that relationship.

Dr Ron Ehrlich: Yeah, I kind of think with technology, we’re a bit like kids in a toy shop, we want everything, or we’re taking everything. But then we’re realizing that perhaps everything isn’t what we need, but we’ve kind of, I said, well if a practitioner was wanting to get started in Lifestyle Medicine, you’ve given us a good overview here. What about if somebody was listening to this and going, “Yeah, I think, lifestyle, I’ve got to look at my lifestyle.” Where, what would you be saying to them, where would they, what would you say to patients? I mean, I know personalized, I take that point, but what do you say to patients or people listening to this?

Dr Sam Manger: Well, is general rules. When it comes to nutrition, you want to focus on real food, and that it means, no, or minimally processed food or highly refined foods. So that includes grains and oils. So you can have whole oils, so that’d be like, avocado oil, olive oil, flaxseed oil, all those sorts of things and no problems.

Lot’s to vegetables, can’t go wrong with that, nuts seeds, herbs and spices. If you’re gonna eat meat, some people do, some people don’t, then try, and make grass-fed and, or wild. And whole grains generally fine. Obviously, there are situations where some people don’t tolerate them, but, and so that’s … Essentially the Mediterranean diet, in a nutshell, is a good place to start.

And from that point, you may find that you need to go more in one direction or another based on your unique biology’s. There was an interesting trial in 2015, in, I think it was Tel Aviv in Israel, in The Journal Cell. And they looked at, I can’t remember how many people, but let’s just say, “It was a hundred people.” And gave them all exactly the same amount of carbohydrate, and saw there was a big spectrum of how people responded to that. For some people no blip in their sugar or insulin levels, some people significant. So we know that there are some people who respond more in a negative way to that, and some people who just tolerated, no problem at all.

And in fact, it seems to be very beneficial. So I don’t prescribe to a one size fits all approach. But I do think as a general rule, you can’t really go wrong with for visuals, nazis, herb spices, legumes, pulses, lentils, those sorts of things. The epic debate that’s going around now in the last couple of years about insulin theory of obesity and Low-Carb versus High-Carb and Low-Fat, I also think is painful, painful but interesting as well.

And we could talk about that, but we’re probably gonna run out of time. But it’s not as simple as people think, it’s not as simple as carbs equal insulin and everything does. I mean, there are certain carbs, for example, porridge has a lower insulinogenic response, then does steak. So it’s not as clear cut as just one food group versus another. And the movement, I would just encourage people to move for pleasure, not because someone’s telling them to do it, and not for a goal in mind. But just move because it feels good and it makes you happy to do it because when you start doing that, you’ll do more of it and it’s that simple.

So it, so ask yourself, “What do I enjoy doing, what do I fantasize about doing, or what did I used to enjoy doing?” And then just pick five minutes. Rock climbing, dancing, drumming, walking, swimming, I don’t care what it is, but just get out there and do something along those lines. Sleep, seven to eight hours, just do it. Like, there’s a lot I could say on sleep. We only do five cycles of sleep that are roughly nine 90 minutes each, hence 7.5 hours is where the recommendation comes from. And some smaller cycles, some longer cycles, but just get seven to eight hours.

There are very, very few people who can survive on these seven hours consistently. And you’re just lying to yourself, because the studies are very clear that, people who are sleep deprived have exceptionally poor insight into how sleep deprived they are and how much that impacts their cognitive abilities. So just because you think you’re doing fine, doesn’t mean you’re doing fine. Still, try, and get seven, eight hours. Despite all the stuff I do with my life, I still get seven to eight hours, I’ve prioritized that.

Dr Ron Ehrlich: Non-negotiable, non-negotiable life support system. It’s a recurring theme of this podcast. Go on, I love all this Sam, this music to our ears.

Dr Sam Manger: Good, stress is obvious that’s what you’re podcast and you’re all about that. And so that’s obvious, that you’ve got to try, and switch on the relaxation response as often as you can. And that can be, simply smelling a smell and being mindful to the experience on the side, or more classic things like progressive muscle relaxation or meditation.

There are plenty of ones that, they’re out there. And then connect, find people that you, there are certain conversations like the one we’re having now perhaps, but where you just lose, you lose the concept of time, and you just thoroughly enjoy it. You finish the conversation, you have more energy than when you started it. They are the kind of conversations we should be having more of.

So you need to find the people in life who gives you that feeling, and actually proactively, commit to putting in a bit of effort to catching up with them on a semi-regular basis once a week, or once a fortnight. Don’t hassle, but hopefully, they’re getting the same experience from you.

And so they’re the kind of relationships we need to foster. And then nature time again, it’s, the evidence is fascinating when you look at the impact of nature on our mental health, but also, on our very biology. I mean, there was a very interesting, repeated studies, showing that people who are in hospital, post-operative, in pain, who were able to view outdoors nature, or even view the sun, and the sky had about 20 to 30% fewer pain requirements, pain relief requirements, then those who didn’t.

So we know it’s actually deeply impacted our biology’s. So get out in nature, at least once a week, because we would evolve to be in it every day. So we should go and try, and mimic that. What situation did we evolve in, and try, and mimic that as much as we can? And then all the other stuff we talked about, go through, spend an hour going to your Facebook feeds and delete, block every single thing that makes you feel down except, maybe the occasional bit of news. And, if you want and then, actively sign up to things that make you feel better. Like you, we can control our environment’s probably more than most people would appreciate. And don’t be a victim, take power back.

Dr Ron Ehrlich: Well, that’s just fantastic and I love the way we’ve kind of almost sandwiched, connect, just eat real food and connect with real people, and connect with nature. It’s kind of sandwiched all those other lifestyle things in between it. Listen, we’re just finishing up now because this has been fantastic, Sam.

You’ve given us so much information, so much to think about. Taking a step back from your role as a doctor, an educator, because we’re all on this health journey together. What do you think the biggest challenges for people today, on their health journey, through life in our modern world, what do you think that might be?

The Biggest Health Challenge

Dr Sam Manger: Well, I think that … Well, it depends on which level we’re gonna talk about. So at a cultural, systemic level, all these things are, I mean, disconnection from real food, from ourselves, from each other is becoming part of our culture. And that’s a real challenge to go against the tide of what people are being raised in.

So we have to raise awareness and encourage people to reconnect to those elements of life. So that’s a major challenge that I think we all face. From a point of view where people are kind of interested in health and they’re going down that path. It can be incredibly overwhelming, the amount of information out there and the amount of disagreeing opinions, especially in nutrition, and so that can be very confronting.

And I think that you have to develop a relationship with will probably a therapist you trust and go from there. And I, more along with the philosophy of rather than give a person a fish, teach him how to fish, that sort of philosophy. And so, I wouldn’t necessarily tell people what the right style of eating for them is, but rather I would encourage them to learn, of their own biases, learn what they may want to be true and question themselves.

And then whoever’s telling them, question them as well, don’t believe anything at face value. Learn the principles of what is, how did they come up with that opinion? What is the evidence and how do I look at the evidence myself so that I can make my own decision? Because I’ve read books on all kinds of things.

And I’ve been convinced at the end of that book that this is the way. And then I go and look at the studies with which that book was based on and I realize that they definitely interpreted misinterpret those studies to make themselves a book. And that’s really disappointing to me, and I’d say that I’ve seen that on every spectrum. I’ve seen that from Low-Carb advocates, I’ve seen that from Low-Fat advocates. And so you’d have to, in essence, just go, “Okay, I appreciate your opinion and your interpretation, I respect that, but I’m gonna go and do my own research and I’m gonna how to analyze data in its real sense.”

And that could be a big ask, but sadly, I think that we all need to be filters in a way. And then we need to develop a relationship with a Doctor, or a Health Coach, or a Dietician, or an Exercise Physiologist, or a Dentist. Someone we trust enough that we can then banter with and say, “Well, what do you think about this?” And hear their opinion and get another side of the story. And so we’re always going to need health professionals, but I would just encourage people to, as I said, “Learn the principles which underlie these things.”

Dr Ron Ehrlich: Sam, thank you so much for joining us today. It’s been terrific. I’m gonna have links to that, the ASL and Website. I think it’s a fabulous resource there, so thank you so much.

Dr Sam Manger: Thanks for having me, Ron.


Dr Ron Ehrlich: So there it is, quite a lot to think about. Interesting to hear Sam’s advice to practitioners wanting to incorporate more Lifestyle Medicine into their everyday practices. But three ideas stood out for me, the first one is, personalized. Whether that is the approach your medical practitioner is taking or not, it is definitely the way medicine in the future will be practised, personalized medicine.

It also means for you to personalize things. The advice you receive, where are your weaknesses, is it sleep, is it breathe, is it nourish, move or think? Focus on one at a time. Don’t overwhelm yourself, play the long game, it’s called life. Work out what is right for you, what do you enjoy doing, what stresses you out, how will I use sleeping? Another idea is the word real, and it’s a recurring theme. Just eat real food, very simple, uncomplicated, no controversy there. If it doesn’t come in a packet, if it’s not processed well, it’s probably good. Focus on fresh Whole Foods, vegetables, everyone agrees with that one.

A moderate amount of ethically grown proteins, another one and fats for that matter, healthy fats. The third idea that I thought stood out was a connection and summarized in that word, connection. It’s another one of those ideas we have referenced before, value the connections of real people in real time. It’s disturbing to think that 15 years ago when people were asked, how many people close to you could you rely on? The average was two and a half, 2.5, today it is 0.9 it’s hard to find 0.9 of a person. While we are more connected with the world, we are less connected with the people sitting right next to us, or our neighbours, or our community.

And this social isolation is a huge challenge to our physical, mental, and emotional well-being. Sam used the word Technopathy. Now, I hadn’t heard that before, but it’s a good one. While technology gives us access to so much information and does allow us to keep in touch with many people, it also has many problems and challenges. Well for one, the fact that WiFi radiation coming out of our phones and personal devices are now considered by the World Health Organization as a Class 2 Carcinogen. That means it is a possible cause of cancer, and it’s everywhere, so it is a real problem. But there is also the Psychosocial challenges connected with technology as well.

The fact that people are feeling more isolated, more lonely, Anxiety and Depression is a big problem, a bigger problem than ever before, I believe that’s no coincidence. Technopathy, Wow! Look, I’ll have links to the Australasian Society of Lifestyle Medicine Website, it’s a great Website. I hope you enjoyed today’s program. So until next time, this is Doctor Ron Ehrlich, be well.


This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.