Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
What Your Gastroenterologist Wants You to Know About Diet, Disease, and Digestive Health
What happens when a talented physician journeys from Pakistan's largest city to the heart of the American healthcare system? Dr. Sajid Zafar's remarkable path from Karachi to becoming a respected gastroenterologist in St. Louis reveals fascinating insights about medicine, migration, and the ever-evolving landscape of digestive health.
Dr. Zafar takes us behind the scenes of modern gastroenterology – a specialty that straddles the worlds of internal medicine and surgery. Performing between 1,500-2,000 procedures annually (likely more than any other medical specialty), gastroenterologists use scopes just millimeters wide to diagnose and treat conditions throughout the digestive system. From controlling bleeding and removing tumors to placing feeding tubes that once required major surgery, these minimally invasive techniques have revolutionized patient care. But the specialty also confronts difficult ethical dilemmas, particularly when families request interventions for elderly patients with advanced dementia.
The conversation takes an urgent turn when discussing the alarming rise in colorectal cancer among people under 50. This trend prompted the recent change in screening guidelines, lowering the recommended age for first colonoscopy from 50 to 45. Dr. Zafar emphasizes that family history dramatically impacts risk – if your parent or sibling had colon cancer before 60, you need screening at 40, or ten years before their diagnosis age. Unlike many aggressive cancers, colorectal cancer caught early has excellent survival rates, making proper screening potentially life-saving.
Perhaps most valuable is Dr. Zafar's wisdom about diet and digestive health. Following a primarily plant-based eating pattern himself (only 20% meat), he explains why whole fruits beat juices, how high-glycemic foods trigger problematic insulin responses, and why our sedentary modern lifestyles require more careful food choices than our physically active ancestors needed. Want to learn how simple dietary changes could transform your health? This episode delivers practical knowledge directly from a gastroenterology expert who lives what he teaches.
Welcome to Doc Discussions. I'm Dr Jason Edwards and this is, in my opinion, the world's best medical podcast. We're here to have discussions with physicians, to discover who they are and what they do, and I'm joined with my good friend, dr Sajid Zuffer today. Sajid is a gastroenterologist.
Speaker 2:Thank you.
Speaker 1:How are you doing, sir? Good, how are you? Yeah, I'm doing well, good, good. And so're from Pakistan. Originally correct, that is correct. And you went to school at Dow Medical College, which is in Karachi. Is that correct? And?
Speaker 2:then are you from Karachi originally? Originally from Karachi. And that's like the Miami of Pakistan, right it is the biggest city, it is on the ocean and it is the most hustling, bustling, most populated city more than 20 million people. Now, how about that? Yeah, so it's one of the top I would say top 10 biggest cities in the world.
Speaker 1:Yeah, and I've heard of Dow Medical School. It's a very nice medical school. Yeah, it is one of those founded in 1945. Okay, and then, how did you make your way to St Louis?
Speaker 2:40, about 45, okay, and then how did you make your way to st louis? So after I finished my medical school, um, I applied for residency from pakistan. Okay, and in those days you can apply by mail. There was no email or anything. This is 1991, okay, when applied. And you would get interviews in the mails. So SLU was one of the places who invited me for interview. So I took a flight and I had other interviews also, yeah, and about 15 or 20 interviews back then, which was a lot of interviews. That's a lot of flights, and it was good times. And so the embassy in Karachi, they would ask for why you want to go there and you would say well, you know, I'm going there for an interview. And in those days I think there was somewhat shortage of physicians in internal medicine, so they were quite lenient in giving interviews. They would check your scores.
Speaker 1:Yeah.
Speaker 2:And if you graduate of a medical school in Pakistan. And so we got interviews, got here and did a bunch of interviews. The reason I ended up in St Louis was one of my wife's uncle. He did his undergrad in St Louis, okay, so there was some familiarity with this town.
Speaker 1:Yeah.
Speaker 2:And when I interviewed, the interview went well. I liked the program and when you go through the match orders, I matched other places also and St Louis U was my first choice and the rest is history.
Speaker 1:The rest is history, as they say.
Speaker 2:So I did my residency here until 95. Okay, and then I worked primary care, oh really, in a small mountainous community in the Appalachia. Now, what city was this? It's called Bryson City North.
Speaker 1:Carolina? How about that? So that must be western North Carolina.
Speaker 2:Western North Carolina about an hour west of Asheville. Is it near Boone? Boone was not too far, yeah, so Knoxville was about an hour also.
Speaker 1:That's a pretty area of the country, beautiful, very poor, beautiful.
Speaker 2:Very poor. There's no factories there, there's no industry there. I mean Smoky Mountain National Park. I mean I would say half or maybe more of the town was part of the Smoky Mountain National Park. I mean I would say half or maybe more of the town was part of the Smoky Mountain National Park, okay. So we spent three years there, okay. And then I decided I want to do fellowship and applied for gastroenterology and ended up at Columbia, missouri.
Speaker 1:Oh yeah, university of Missouri, columbia, sure and so.
Speaker 2:Missouri, missouri, columbia, sure. And so Missouri has become home. Yeah, and then in 2001, when I finished my fellowship, I came back to St Louis. St Luke's has been the home since then.
Speaker 1:Yeah, first and last job. Everybody knows you, you're. Mr St Luke's, you're a part of the fabric here for sure. Yeah, you know, I think that's one of the advantages of having good universities in cities and in states is it attracts highly talented people from across the globe to your city and sometimes they stay. And so, and also in my experience too, that the people who come from other countries and do their medical training here are typically kind of the cream of the crop because, that is true, they have their pick, and so.
Speaker 1:I know your scores must have been good yeah. Yeah, and and so now you're a gastroenterologist and do you do mostly procedures or do you see patients in the clinic and talk to them about their gastro?
Speaker 2:So both Okay, I mean procedure is a unique thing about gastroenterology because we really do a lot of procedures. Yeah, I think so. If you really calculate the number of procedures we do, I don't think so. There's any specialty which comes closer to us. Yeah, whether surgical specialty or medical subspecialty, because of just the very number of procedures we do, and I mean anywhere from 1,500 to 2,000 procedures a year performed by a busy gastroenterologist and some more.
Speaker 1:And that's colonoscopies, endoscopies, and that's when you go down the throat with the camera Right and colonoscopy the other end, and then ERCPs, yeah, other procedures in gastroenterologists.
Speaker 2:So not all gastroenterologists do all the procedures.
Speaker 2:Some specialize, some specialize, some only do that, some don't do that. So endoscopic ultrasound and anything, I mean I think we can pretty much get anywhere where the scope goes and we can do a lot of things. We've got a lot of toys and tools through the scope. We're talking about a few millimeter channels and then we just put probes through that and do everything cutting, stopping bleeding, removing tumors and polyps and doing a lot of injections, and so all through those probes we do everything and you and I have mutual patients patients who have gastro esophageal junction tumors or esophageal cancers.
Speaker 1:Putting feeding tubes, feeding tubes for people who are having difficulty swallowing for maybe a head and neck cancer, rectal cancer, and I would say GI probably interacts with a lot of different specialties.
Speaker 2:I feel sometimes GI should have been a surgical subspecialty. Yeah, it's somewhere in between. Right, we are somewhere in between. I mean, certainly internal medicine is our foundation. We all have to do internal medicine residency first before you become a gastroenterologist, just because in GI a lot of people don't know. I mean, we deal with liver, which is a big subspecialty of gastroenterology, and that's completely medical subspecialty. We deal with diseases of gallbladder and pancreas. We deal with diseases of gallbladder and pancreas. But a lot of bread and butter just requires a very close interaction with surgical subspecialties. If we diagnose something which we can't fix, a surgeon takes over and then we can do a lot of things minimally invasive as compared to surgery. A simple example is feeding tube placement, which used to be the forte of surgeons back in the days until we discovered percutaneous method.
Speaker 1:And that's really cool for people who have not seen it. It's a very simple procedure but it really saves you surgery. And so quickly describe it and you tell me where I'm wrong. A tube goes down the throat and it has a flashlight on the end and you shine it through the stomach and you can see it through the belly Right and then that's, and then you bring and that's become.
Speaker 2:That becomes my entrance point.
Speaker 1:From the outside in.
Speaker 2:Yeah, you need to have that good light reflection. Yeah, if you don't have a good light reflection, it mean you may be hitting another organ in between and of course there's been reports of liver in between or colon in between, yeah, so you need to have a good light reflection.
Speaker 1:And then it's a pretty slick procedure really, yeah, so you're feeding in, and then removal is also very easy.
Speaker 2:If you don't need it after that, just come to office. We just gently pull it out, and so it can be very helpful to the people. Who has a good indication Person with radiation esophagitis, head and neck cancer.
Speaker 1:Yeah, sometimes the cancers get so big in the head and neck area that they can't swallow, and so that's a shortcut to get food in.
Speaker 2:Until they get stronger and tumor shrinks down and the radiation effects are gone.
Speaker 1:Yeah, and then we treat them with chemotherapy and radiation for the cancer up top. And you know, patients do so much better if they have a feeding tube in. Sometimes it's hard to convince them to get one, but it's so much easier on them.
Speaker 2:Now the bad part about the feeding tube part since we started this discussion is like today we got a consult for a 94 year old patient, okay, who has dementia, has no quality of life. There is no future for her to become ambulatory or active part or anything. Yeah, she is sort of checked and the family is insisting to have a feeding tube put in. Those are the dilemmas which become very difficult for us to handle sometimes, especially with the aging population.
Speaker 1:And with dementia you know you can pull the feeding tube out, and so there's some risk.
Speaker 2:There's more risk. I mean especially during any procedure or anybody who's octogenarian or above. It's just, risks are high and people don't understand, so it's difficult to sometime and we become the person in the middle of all of that.
Speaker 1:Yeah, and you have to navigate that very delicately.
Speaker 2:Very, very delicately, because it can make a lot of people unhappy.
Speaker 1:Yeah, so in the cancer world, one thing we've seen is that younger people below the age of 50 have had an increase in the incidence of rectal cancer and colon cancer. What do you think is causing that?
Speaker 2:Well, so we really don't know, the risk factor for colon cancer include obesity, increase in animal products, of course, family history. I think one of the reasons we may be discovering more is because we start screening at 45 years of age, now Sure. So once you start screening, you're going to discover more also. Yeah, years of age now, sure. So once you start screening, you're going to discover more also. Yeah, so there are a lot of factor. I don't think there's one factor which gives you the best answer for that, but it's a multiple factor. I mean, it is second most commonest cancer yeah in the world and so it is out there.
Speaker 2:we just have to be aware of it, be proactive in getting a screening done and all that and they've recently changed the guidelines from getting a colonoscopy at 50 down to age 45. Yeah, almost yeah, One and a half two years now and the main symptom-. That has increased our workload also, yeah, and so that's why majority of gastroenterologists are quite busy.
Speaker 1:Yeah, but you still have all your hair and most of it's not gray, and so, yeah, and so, and the main symptom patients have with colon or rectal cancer, what is that?
Speaker 2:Well, so once you start having symptoms, that is sort of late.
Speaker 1:Yeah. Still the outcome is pretty good and what's the first symptom people typically have? So I mean, somebody can have just rectal bleeding. Yeah, still, the outcome is pretty good and what's the first symptom people typically have.
Speaker 2:So I mean somebody can have just rectal bleeding. Yeah, so bleeding would be probably one of the most commonest thing.
Speaker 1:Yeah.
Speaker 2:If it comes to abdominal pain, then things have grown.
Speaker 1:Yeah.
Speaker 2:Things have grown that it's affecting you and causing pain, anemia, iron deficiency, anemia, weight loss, but rectal bleeding, I would say, or change in bowel habit.
Speaker 1:Yeah.
Speaker 2:More constipation, more diarrhea and things like that. Yeah, I think if people have family history, they need to be more proactive, and if somebody's father has a colon cancer at the age of, any first degree relative who has a colon cancer under the age of 60 is at high risk, and so those are the people who need to start their colonoscopy at the age of 40. Having said that, if a first-degree relative of a patient has a colon cancer at the age of 45, a first-degree then that person should have his first colonoscopy 10 years before that age.
Speaker 1:Yeah, and you start to worry about genetic diseases like hereditary Hereditary exactly Non-polyposis.
Speaker 2:H and PCC and so those are the thing. So I think it is one of the cancer we can really make a difference. Yeah, and a person can make a difference, because it's not like pancreatic cancer, it is not like cholangiocarcinoma or a brain tumor. This is where, even if you are a stage three cancer, your five-year survival is not as bad.
Speaker 1:Yeah, more likely than not, you will be cured, even if it's stage three.
Speaker 2:And plus with the new immunotherapy on horizon, I think so the whole cancer game for solid tumors. It's improving, it's improving and I'm hoping for more to come.
Speaker 1:Yeah, now I'm going to switch gears a little bit and talk about you personally. You know this is audio so people can't see, but you're, to me, a very healthy guy and you've got great hair too.
Speaker 2:I have no hair, you have great hair.
Speaker 1:Life's not fair. But you've got, and so you, I would imagine your diet is pretty good.
Speaker 2:Is that accurate?
Speaker 1:Yeah, I mean, I'm sure you sin every now and then, right, right.
Speaker 2:You're pretty good, Regular five, six days a week. I mean we eat at home. It's not like we have to go out.
Speaker 1:Yeah.
Speaker 2:We cook at home and we eat at home, and so that's like everyday thing.
Speaker 1:Now, are you vegetarian? No, I'm not Okay. Do you eat some meat or a lot of meat? I eat majority of the meat, except for pork or ham. But like, what percentage of your diet is meat versus like fruits, vegetables, things like that?
Speaker 2:20%. You'd say 20%, 20%.
Speaker 1:It's not the staple of your diet. No, 20% and that's. I think that's more of kind of. My brother lives in japan and that's. You see that more in asia where meat is on the plate to kind of flavor the plate but it's not the main dish. Yeah, it's not like a steak yeah, and we didn't grew up eating just steak yeah, I grew up on a beef cattle farm, and so the steak was basically free, so every every meal was a steak.
Speaker 2:Yeah, we didn't have.
Speaker 1:We had grass-fed organic before.
Speaker 2:it was cool and then the other thing I personally, I mean, I eat steak, I eat beef, but beef is not what I grew up with. Yeah, I grew up with chicken and goat, okay, yeah.
Speaker 2:Chicken and goat meat, and it's still my favorite is goat meat now some people grew up in aero world, grew up on lamb, yeah, and so lamb becomes their thing. Beef was not something we ate a lot when we were growing up. Now in us, when you're eating steak, it's a beef steak, so sure, but it's still. We don't bring beef home to cook in our diets got you I mean, we eat it, but we don't bring it home on a frequent basis.
Speaker 1:I would say so, um, we also had, uh, goats and on our farm is that right? And um, we had one thing that I this I'm totally off subject here but we had this trailer that would the the flatbed trailer out in our field and it was like the tallest thing in the field and if you went and stood on the trailer the goat would come and try to push you off.
Speaker 2:And as a boy that's a lot of fun. You know wrestling with the goat up there. What was the purpose of goat on that farm? Were you guys eating? Yeah, yeah, yeah, for sure.
Speaker 1:Okay, so yeah, beef cattle and then some goats and chickens and the whole thing, but yeah, and so I think that's a healthier diet, like if you are going to have meat as a part of your diet. The data looks like you do better if you eat smaller portions of meat, exactly, and so and more plant-based. Yeah.
Speaker 2:I think so. Studies after studies are coming out now, yeah, regarding emphasis on plant-based diet. I think so. Studies after studies are coming out now regarding emphasis on plant-based diet, longevity data, for sure. I mean so it's more plant-based diet, I mean, if you can switch to become a vegetarian, which I am not certainly, yeah. On the other hand, I think so education is also important. I mean you see significant incidents of coronary artery disease and diabetes mellitus in countries like India, where there is a lot of vegetarian.
Speaker 1:But they eat a lot of ghee or what is fat lard.
Speaker 2:So they do eat ghee also. But again, at the end of the day, you need to know the glycemic value of certain, even fruits and vegetable. Which vegetable has a high glycemic index? If you consume most of those things, then your sugar is going to go up and sugar is going to store as carbohydrate and you're going to get fatty liver and you're going to get coronary artery disease and you're going to get diabetes.
Speaker 1:And so let's go a little bit into the physiology of that. And so you take in sugar and your glucose level goes up because you're ingesting sugar, and then your insulin level goes up and insulin is a very powerful uh like, probably more powerful than steroids at building muscle. But the problem with it is it indiscriminately puts um, uh, builds muscle, fat, uh, muscle and fat and so, which tends to be not healthy for you. So it's the insulin that can cause you trouble in a lot of this. And foods have a glycemic index that you can look it up glycemic index for an apple or a snickers bar but um, but they have something called the glycemic load too, which is, in my opinion, how quickly it goes.
Speaker 1:That that tells you how high does the insulin go, because the fiber and fruit will actually blunt the insulin effect and and so uh, uh. So an apple actually doesn't have that high of a glycemic load because there's so much fiber in it. And so I think for me, when I look at foods you know I've said I want to eat low glycemic foods I think almost the glycemic load kind of gives you a better real world view of what's good and what's bad, and so so it's not a you know and what's bad, and so so it's not a you know. For the listener out there, it's not a bad thing to google like glycemic load and get a list of foods.
Speaker 2:Yeah, yeah, I, I my.
Speaker 2:My wife gave me a watermelon juice the other day okay and she brought it in and she made it and it was beautiful, tasty and very good and beautiful color. Yeah, and I had it and it was. I said you know, this was a big sugar log, for sure, for sure. So her argument was well, there are some vitamins in it. Also, I said I think the advantage you are getting from the vitamin is much less than the sugar you're giving. So we had this discussion about these things. So a lot of people will say you know, fruits have more vitamins and all that. You get those two like orange juice. Now, orange juice is sugar. To me it is sugar.
Speaker 2:It is not indicated for people who have diabetes or anything, so you need to understand that. But yes, it has vitamin C in it. All citrus fruits have vitamin.
Speaker 1:C in it.
Speaker 2:All citrus fruit have vitamin C in it, but if you start drinking a glass of orange juice every day and your diabetes is not well controlled and you are overweight, then this is where the problem is and you have bad acid reflux at the top of it. Then you are in orange juice, not exactly health food, right, right, but I mean, we all grew up with the concept of eating cereals in the morning, which is nothing but sugar.
Speaker 1:We loved it.
Speaker 2:Yeah, we all loved it. I still like it.
Speaker 1:Yeah.
Speaker 2:But there are a bunch of sugars in it, for sure, I mean. But now I think so the awareness is coming on, but as a kid, hey, if I'm hungry let's go have some cereal, for sure, for sure, and you can find some that are healthier than others, but majority the one which we liked. Yeah, the Camping French.
Speaker 1:Yeah, for sure those were the sweeter ones. That's the best Kid approved.
Speaker 2:Kid approved. So I tell my patient who comes in and says struggling with the weight loss and everything, and especially with people who are pre-diabetic or diabetic, I tell them anything which looks good or tastes good has sugar in it.
Speaker 1:Yeah, and I think if you want something sweet, at least eat the whole fruit. You know your body was actually meant to take in the fruit that looks like it came off of a tree. You know you can take that in and the glycemic load's not that high because of the fiber. But when you crush, when you crush it in a press and take all the sugar and leave all the fiber, then not so good.
Speaker 1:No, then you got more sugar than anything else, yeah, and and sometimes the fructose can even be harder on the liver than the glucose, but I wouldn't intentionally try to uh. But so I think eating the whole fruit is is very reasonable, and having a smoothie or something like that that has some sweetness to it is is reasonable, just because the fiber not only blunts the insulin effect but also helps pull the cholesterol out of the blood, right and I think so.
Speaker 2:You can get away with anything, and our forefathers did got away with everything, but they worked very hard physically yeah I mean the kind of lifestyle we have now and we're going to be couch potato and do nothing and no exercise and no physical activity, then it's a problem. That's a great. You can drink a glass of grease, but if you have plowed all day in a field, then you know you'll burn it.
Speaker 1:If the furnace is hot enough, anything will burn, right?
Speaker 2:Yes, I mean you just have to burn it. If you're not burning it, then it's going to just keep on slowly accumulating, accumulating.
Speaker 1:Yeah, yeah, if you slightly sin, but every day it compounds just like your 401k Compounds just like your 401k, and so skeletal muscle.
Speaker 1:The nice thing about muscle is it there's a glute four transporter that takes. It's an insulin independent uptake of glucose, and so it's like a sink where it just takes the glucose out of the bloodstream. And so if you're working hard and working that muscle, you know it takes up the sugar well, and that's why you know, you know grandpa could eat a little bit more liberally than me and you yes sugar well, and that's why you know um you know grandpa could eat a little bit more liberally than me and you, yes, so, um, well, sajid, it's always good spending time with you.
Speaker 1:Um, and I think, um, you know, I, I know, you know, um, talking about the diet and trying to give people good and accurate information about the diet is one of the things that we can make our community healthier.
Speaker 2:Probably the, probably the thing absolutely yeah, yeah, and then you know decrease disease burden, cost-effective economic improvement and everything.
Speaker 1:Increase length of life, increase quality of life. Right, right, you know it doesn't really get, as far as health goes, more important than that in preventing disease. Yeah Well, buddy, thanks for sharing time with me, thank you for having me.