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Cardiometabolic Syndrome: Part 1 with Dr Bradley McEwen

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Cadiometabolic Syndrome: Part 1 with Dr Bradley McEwen

Collectively cardiometabolic syndrome(s) account for more deaths in Australia than any other single disease.

In today's podcast we're joined by Dr Bradley McEwen who, through his own research and clinical practice, is an expert in treating cardiometabolic disease with natural medicines, diet and lifestyle interventions. Today Brad takes us through the complexities of working with cardiometabolic disease; from assessment techniques to methylation, lipids and the myriad of hormonal disruptions like PCOS, and even the therapeutic potential of chocolate, Dr McEwen shares his insights into peeling back the layers and stepping patients through the process of healing and change. 

Covered in this episode

[00:49] Introducing Dr Bradley McEwen
[01:46] What is cardiometabolic syndrome?
[03:59] Methods of assessing body mass?
[09:58] The changing views of lipids
[14:53] The interplay of hormones, stress and energy
[22:39] Broken heart syndrome
[26:51] Blending the art and science of clinical practice
[30:43] Tracking results with mind maps and timelines
[38:02] Key foods for cardiometabolic health
[41:17] Prescribing "time out"
[42:38] The cardiometabolic 'top 10' 

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Dr. Bradley McEwen. He's a nutrition expert, naturopath, educator and lecturer, researcher and mentor with over 19 years of clinical experience. Brad received his Doctor of Philosophy in Medicine from the University of Sydney, a Master of Health Science (Human Nutrition) from Deakin University amongst other qualifications. 

Brad has numerous original research and review articles published in peer-reviewed journals, is also a peer reviewer for international journals. His special areas of interest include omega-3 polyunsaturated fatty acids, antioxidants, chronic disease prevention and public health. He also enjoys chocolate. 

Welcome to FX Medicine, Brad. How are you? 

Brad: I'm very well, Andrew. How are you?

Andrew: I'm great, thanks. I haven't had chocolate today. 

Brad: Whenever I'm home, you can pry it from my lips though.

Andrew: Is there a right time to eat chocolate for cardiometabolic protection? There's a question left for later on. But you've described cardiometabolic syndrome as a multifactorial, complex condition. And of course this sounds very serious. I guess we need to start off; what is cardiometabolic syndrome?

Brad: Well, cardiometabolic syndrome is what we classify as a multifactorial, complex condition. And that itself sounds quite complex. One thing to note that all aspects of chronic disease are on the rise worldwide, and being a chronic disease, it has a greater impact and influence on the body system. 

I want you to think that cardiometabolic syndrome is a cluster of different health conditions altogether, and these include abdominal obesity as measured by waist circumference, elevated blood pressure, high levels of triglycerides in the blood, low levels of HDLs, so the good cholesterol in the blood, and also elevated fasting blood glucose levels. 

Other aspects involved are, you know, insulin resistance, where the body is unable to metabolise insulin effectively into the cells, chronic inflammation, increased oxidative stress. It can be classified as a prothrombotic state which means you're at a higher risk of heart attack and stroke. And it is a major risk factor for cardiovascular disease and type 2 diabetes. 

It's also encompasses other body systems like the liver, so it could be nonalcoholic fatty liver disease, and particularly reproductive systems such as polycystic ovary syndrome or PCOS. Testosterone issues, erectile dysfunction in males, obstructive sleep apnoea, and thyroid dysfunction.

So it is quite a complex condition, and it pretty much covers all body systems. And this is one of my main specialties in clinical practice. I would also like to note that, out of the top 10 leading causes of death in Australia in 2016, quite a number of these, it’s around about six, can be directly related to cardiometabolic syndrome. And another three have links. 

Andrew: Yeah. 

Brad: So it's nearly half of all deaths in 2016 can be related to this health condition.

Andrew: Yeah, no matter what the diagnosis, it's related back to cardiometabolic issues.

Brad: That's correct.

Andrew: Yeah. So, just honing in on measurement a little bit. So we've got BMI – was the age-old thing – and you're talking about waist circumference. There was also this measurement of wrist circumference, and there was a ratio, is that right?

Brad: There is. I don't know much about that. It's a relatively new marker. So what you'll find is that BMI, as noted, is quite a long-term marker, and they're now actually breaking it…World Health Organisation is breaking it down into separate categories now into, not just obese and severely obese, but they're actually looking at Caucasian versus Asian background, European background, South American background. So, it's actually becoming quite complex with the BMI. 

So what they're looking at now is a lot of other markers such as wrist circumference. I've also read some literature on ankle circumference as well related to edema or fluid retention leading to cardiovascular risk.

Andrew: Yeah. What about things like lean body mass? I remember years ago there was a sort of push towards looking at lean body mass measurement. I investigated this with a company, and they educated me on the different types of basically, the machines that they had, so that you had, like, I think it was a 12-channel lead that they used to use; you know, HIV wards to calculate lean body mass in those patients so that they could calculate effective drug dose. 

But then there was a two-channel machine, which was popularly used but not nearly as sensitive. Do you know where we're headed there? Have we left it behind, is it still appropriate? What's going on there?

Brad: These machines – some of them are classified as bioimpedance analysis machines…

Andrew: Yep, yep. 

Brad: Do measure quite a few points. And some of the ones you can get in…like, the retail environment do have two or four points of measurement. The more detailed machines have 12 points, 16 points, or minimum 8 points. And what they're doing, they're measuring electrical impedance throughout the body which then measures that fat mass, lean muscle mass, bone mineral density, fluid balance as well. And there's a lot of literature dating back decades showing that, when you have a good level of lean body mass, you have a lesser risk of chronic disease. Not just cardiovascular disease but chronic diseases such as liver disease, type 2 diabetes, osteoporosis as well. 

So, it is a good marker, and what I'd like to see in the future is a lot of these biomarkers made more readily available so people can actually track their symptoms. But also we can use them as a screening tool maybe when you've changed the front digit of your age or something like that, you can go and have the test done, it's a good time to do it as a memory tool. That'd be something I'd be going for, but I'm a long way from the next one so I'm happy to wait.

Andrew: So, what about the relevance of the 2, 4-track versus the 12-track. I remember there were some concerns about the sensitivity of the information that we were getting. Is that relevant or are we just using it since we're using it as a general screening tool that it's okay?

Brad: I think if we use it as a general screening tool, it's ok. If we just entirely rely on this device, that's where some of the faults could be. 

I'll give you an example. We've recently had the Commonwealth Games in Australia, and quite a few of those athletes if they were to use the waist circumference, BMI, and other traditional markers, they'd be classified as overweight or obese. But when we look at them, they're actually very fit, and healthy, and quite muscular with their lean muscle mass. This is where the bioimpedance would come in and actually analyse that and give us more detail. And so that grouping and fitting it all together, it makes a big difference.

And, one thing to note is the more channels, the better. It's more accurate. So the more accurate machines can measure the lean muscle mass density of the right arm or right forearm versus the left one. And there's a lot of research coming out of Melbourne, particularly Deakin University where they've done twin studies. Where they've looked at both twins having the same genetic material but one maybe exercising and eating well, the other one may not. And they can actually compare the bone mineral density, lean muscle mass against the same genetic markers or also genetic code. And that's quite interesting research. 

But it's also interesting in the person itself, because if you're a tennis player for example, you're pretty much using the same arm all the time so it's going to be a better, or a higher bone mineral density and muscle mass in one arm versus the other.

Andrew: There was one other point on these bioimpedance analyses machines that I have this dim, dark memory of. And that was one paper that I read. Oh, gosh, this has got to be a decade ago. It was looking at obese patients where it really didn't have any facility. It lost its sensitivity of picking up stuff because this patient was obese.

Brad: Sometimes it's very clear exactly what we're looking for, and other cases, depending on the machine itself, if it's a scale-type machine, these have a limited weight range. So if a person is obese and, let's just say, 120 kilos, the machine may have, say, 130 for this example. The machine may be able to read accurately up to 120 kilograms. So therefore anyone weighing more than that, it's not going to be accurate.

Andrew: Yeah. 

Brad: But the other channels, they actually lay down on a particular, let's just call it, table. And you get hooked up to all these electrodes like this is a 12, 16-channel that you're thinking of as well. You actually lay down and get hooked up to this machine similar to like, an ECG-type machine. And, it has a wider range of capacity and therefore there's no weight on the scales affecting the sensitivity or accuracy of the test. So I'm all for the utilisation of it. I think it's a good device to use in clinic.

Andrew: What about the function of lipids. You know, controversial of recent years because of the statin exposé that came out. And then we're looking at functional versus nonfunctional lipids regardless of what you term as healthy or dangerous lipids. In other words, there are good bad fats and bad good fats. But then I've spoken to Ross Walker and he says, "I don't really care. I care if it's causing disease." And it's like, "Oh, my God. Where do we go with this?" 

Where do you find the reasonable function of measuring lipids?

Brad: I'm in the same base as Dr. Ross Walker here. That anything that goes to the blood plays a role in the body. 

Andrew: Yep. 

Brad: Some people see it as the river of life so to say. So, anything that goes through it…and if the blood is really thick with lipids and other particles for example, it's slow, it's more sluggish. It leads to infiltrates and atherosclerosis. It's just jumping ahead in time there of course. 

But if it's more free-flowing with the right amount of lipids, coagulation factors, etc., it seems to be a more healthier blood. Allowing nutrients to go to the tissue, and to the cells, and for the detoxification process to occur and for it to be sent back to the lymphatics, through the system, as a normal process.

I think over the past we’ve focused too much…and this seems to be what happens every now and then particularly with topics of interest. We focus on something very tightly for a period of time, and then we realise, "Oh, it's not exactly what we thought it was." 

So if you look at some of the long-term studies like Framingham heart disease, the Lyon heart study, etc., these have been going since 1948 and they've got the original people plus their children, plus their children for example. And they've had blood collected at various timepoints like every 5 years, 10 years, etc. And they're able to now measure for new markers that weren’t around 5, 10, 20, 30, 40 years ago. So, for a long period of time, lipid's played a very major role because they were seen as biomarkers of cardiovascular risk. They were seen as pretty much the marker at some stage. But overtime technology's got better; we can look at more inflammatory markers, coagulation markers, transcription factors, all these different…you know, let's call them molecules for this example, play a much larger role as a complex entity rather than just as a single. 

However, if someone does have purely elevated cholesterol or lipid levels, that does have a fundamental role in the progression of a patient's cardiometabolic profile that may not have been the cause of it.

Andrew: I think what you mentioned right at the beginning there was a good old recap of Virchow's triad, that lamina flow issue. But I guess then it's up to what we do to upset that lamina flow. 

Brad: And that’s it. We all know the body is very reactive to the environment that it's in and also the environment we're in like if it's hot, cold, wet, or dry for example. And if the elements in the body are running perfectly, the body tends to run quite well. 

I want you to go back to this triad that you mentioned as well, which is what I was alluding to, which is great. If platelets are seen as a sentinel, they're floating around the body. They have a 7 to 10-day lifespan, so they don’t live long. They float around the body, the sentinel is looking for damage, looking for what's going on. But I want you to imagine that's what they’re like. Little satellites floating around. 

If there's any damage to the artery or the vascular system, it sets up a whole big reflex reaction to it. And then it lays down material, and therefore it sort of, heals and seals it, so to say. Well when the blood has a high level of lipids and other factors in there as well, this process can be amplified, leading to atherosclerosis, or a clot itself, or an occlusion in some cases where it's fully blocked. 

So the body has all these wonderful mechanisms in place where it's wanting to survive. It's wanting everything to be working properly. But sometimes it comes down to what we're doing to it, that's when there's a problem. And if we have a typical, Western diet, full of carby carbs, and chippy chips, and all the other wonderful Western foods, we're not actually helping the body system work effectively. 

But if we follow the more Mediterranean style diet of healthy fruit and vegetables, nuts and seeds, good quality proteins, etc., we're allowing the body to metabolise and absorb all the nutrients effectively leading to a better health within. Which then leads to better health outside. 

Andrew: Brad, you mentioned hormonal dysregulation previously. What's the link here between cardiometabolic syndrome and polycystic ovarian syndrome or PCOS? Can you expand on this? And also what about thyroid function?

Brad: Very good questions, because there are big links between the three of these actually. So, I want you to think hormones play a major role in our body as we know. And, in the case of PCOS or polycystic ovarian syndrome, there is a greater risk of insulin resistance. Because, remember, insulin is a hormone working in the body. And again this is where the body's not able to metabolise insulin effectively into the cells, leading to a resistant state. 

Glucose intolerance plays a major role as well. And this is all related to the stress response. There's a number of animal studies and human studies that have found that, when animals or humans are under stress, they have an increased level of glucose on the blood, lipids in the blood for example. And this is to give us that fight or flight response. So the body is ready to run away from a saber-toothed tiger, so to say, back in the old days. 

The world around us has changed but the body still remains the same, the way how it works. So the response to the stressor is the same and the body is what it was thousands of years ago. And it will increase, as I said, glucose and lipids in the body to get you to fight or flight. To get you out of the way in some cases. And with the modern-day stressors…I want you to imagine the past; our main stressors were physical. We'd be working on farms. As our grandparents told us, they walked 6 miles to school every day. 

Andrew: Yeah, oh that old chestnut.

Brad: We're not doing that. But there's a lot of things that you walked it off, you burnt off that stress. 

Andrew: Yeah. 

Brad: These days a lot of our stress is related to mental and emotional stress where it's held inside. It's more silent. We don't notice it. And it could be related to a work stress, a family stress, stress from friends. These are just classic, basic things. You can have an assignment due or presentation or something else like this, and this can cause a bit of a stress response. But most of the time, I'll say to you, the body gets over it, and the hormones, and everything, your transmitters, etc. go back to normal.

But in people who have longer stress levels, longer impact of stress, this does affect areas of oestrogen, progesterone, testosterone. So, in males, it's like infertility or erectile dysfunction for example. In females, it's PCOS. And in males and females, it can actually relate to thyroid function as well. Because I want you to think that the thyroid is like the energetic balancer in the body. It affects various aspects of cardiometabolic syndrome. And, it's interesting to find that where I think of thyroid as energy. Those people that are feeling tired, it could be their thyroid; they could be right. But I want you to see the biochemistry in the background. The thyroid hormones are essential for the cellular energetic homeostasis, regulation of the body metabolic rate. 

So therefore if the thyroid is under or over functioning, that can alter our energetic pathways or energetics in total. So this influences body weight. If someone has hypothyroid or low thyroid health conditions, they have a typical increase in body weight. There's also been associations with low thyroid functioning with elevated blood pressure readings. Both systolic and diastolic. There's also relationships between thyroid hormone, lipid parameters, fasting glucose levels. And one of the main things it does, in the background, the thyroid hormone, it regulates insulin metabolism in the periphery. So not just your arms or legs like the rest of the body and metabolises glucose handling. So that way we can actually energize ourselves and our tissue more effectively. So, thyroid hormones play a very major role there.

It's very interesting that the body has an interesting way to adapt to energy. That it will throw itself out of balance; again, it's this fight or flight mechanism, where, in some cases, it might start let's just say eating up available nutrients for thyroid hormone production: tyrosine, selenium, zinc, copper, the B vitamins, etc. Which are also used to metabolise glucose levels and fatty acids in the body, not just the lipids. 

So, the body starts to utilise and, let's just say, take nutrients from other metabolic processes. And this again goes back to the person's diet. 

Andrew: Everything goes back to the diet. What I think is interesting though is that, back in my day, firstly polycystic ovarian syndrome was rare. Maybe we were underrecognising it, certainly. Also, lower thyroid function. Those two conditions were classically attributed to higher weight/body mass, the apple-shaped obesity with the classic PCOS body type. The hypothyroid patient was the person who had the sluggish metabolism and the myxedema, you know, that sort of textbook analogy if you like. But nowadays they just don't fit now, into the body types, so where should we be suspecting these issues.

Brad: These are very interesting points. Because if you look at the classic picture, you know low thyroid is seen as, “oh you're just tired or have chronic fatigue syndrome.” And, PCOS is overweight. But like you just said that, you could be underweight with thyroid issues. You could be underweight with PCOS. And this is because of individual variability, and this is why it's taken a very long time to have these classifications written up for these health conditions. It's estimated that around about 20% of the female population has PCOS.

Andrew: Wow, that’s huge. 

Brad: And that's quite a high number, so 1 in every 5. And if you think about whether it's a Western world…and they're also finding this all the way throughout Europe, and Asia, and even the African continents as well. So it's a widespread health condition. And I think only because it’s being recognised now with greater sort of, definition and characteristics,  we can actually see now that it's such a larger health issue. And some women have been suffering its effects for 10 years with multiple chronic health conditions and didn't know what it was. They now finally have an answer that we can work with. 

So, I've seen a broad range of patients with PCOS and thyroid disorders, and everyone's different. And that's one of the exciting things about what we do in natural medicine. Is everyone's different. So therefore we can actually take the notes, work out the specific case issues. And I could have, you know, 10 females in a row coming in with multiple health conditions, for example, and it may be 2 out of 10 sort of coming through. And that's quite a lot of patients coming through with PCOS, but they'll all present differently. 

So that's what I'm liking about there's more information in the news, magazines, newspapers, social media. There's so much more information on this health condition now that females are turning around and saying, "Oh, this could be it," and going in and they're consulting a healthcare practitioner and finding out what's best for their health and how they can work with us.

Andrew: Oh, yeah, such a huge issue now. I think the ATMS are holding their symposium this year because of that exact subject. I need to ask you a question and that is, when people have a major stress, usually a sad stress, like a death of a loved one, and they can die of a broken heart. What is it? 

Brad: Well, one thing I’d like to say, we've always heard of someone…they had died many die from a broken heart. So, there's loss of loved ones, a family member, a best friend; in some cases, their dog, or cat, or animal. Yeah, it's quite serious because we have a lot of love around it. 

Andrew: Oh absolutely. 

Brad: And so broken heart syndrome is real, you do hear about it. And, it wasn't only up until recently we found out more information about it.

World-leading research has been conducted at the University of Sydney which is…I don't want to use the word "fantastic" but it's good to have an actual understanding of what's happening. 

And what they've found in bereaved people who had lost someone in the last month or last 6 months, 12 months, for example, that they pretty much most of them compared to healthy controls, had increased heart rate, increased blood pressure, increased inflammation in the body, lots of thrombotic changes, increased platelets and coagulation levels. Higher cortisol levels because it's stress, higher stress markers, less sleep duration so they didn’t sleep, so their recovery stage is a lot less. And quite a number of them suffered from depression and anxiety. 

So this is quite a… I'm going to say to you a relatively new health condition that we've known since pretty much probably since the dawn of time. It is very serious, and it's very sad but also at the same time it shows you the connectivity people have with each other, as well as the animals, for example. 

So, yeah, it is real so to say. I've had people ask me that question, "Is broken heart syndrome real?" and the answer is yes and it has a massive impact on the body. And, my understanding is further research is being conducted at the University of Sydney, and now other universities around the world are looking into it as well. Because it's such a massive issue, the loss of a loved one of course.

Andrew: So I guess what the issue here is you mentioned inflammation. Are certain people predisposed to this if they're already inflamed or is it a genetic-type thing?

Brad: I'm going to say yes to both those. So, anyone that has inflammation…well, I should rephrase it. Everyone has inflammation but at certain levels. But when there's an elevation…

Andrew: Ahh, thankyou. 

Brad: …In inflammation of the body, it creates a bigger fire within so to say. And I think if you have multiple stressors leading up to a point. So let's just imagine they knew their partner was dying. And this person, let's just say, it was cancer, they've had a longer time knowing the endpoint is going to happen. This is building the body up over a long period of time, the stress markers. And then the person passes, which is a very emotional stress, and we've all lost someone. This is very major emotional stress on the body, and that can lead to those symptoms I mentioned earlier. 

But in some cases, you might actually have a huge, very strong stress. I knew of someone many, many years ago. They had a loss of a loved one. This person sort of went away on holidays and sort of didn't come back, so to say so, so they didn't actually get to say farewell to their family member. And that's very sad, so they had to go to that place and, you know, do the normal process, but their body's response was massive. They did have broken heart syndrome, and this person was in their early 40s. So, it's not like you have to be old and frail, 80, 90, 100-year-old kind of person. You could be, let's just say, 20s, 30s, and 40s for this, because it is such a huge impact on the body itself and the amount of change that it does is massive. 

Andrew: Yeah, huge. Brad, your main focus with lecturing is nutrition, and you say that nutrition and diet are the foundations for all health and healing, which seems obvious, but you're also a fan of the art of clinical prescribing, which I think is an interesting term. Can you effectively blend the art and the science?

Brad: The answer is yes. This is a great question. Because it's something I love, is the art of clinical prescribing. Because we can always look at the science and say like, we were just saying then, increased coagulation and platelet function, everything else like that. But it's a matter of blending it all together. 

So there is definitely an art. So I want you to think back to what I was saying earlier that everyone is different, everyone is unique. We have different family histories, so different genetics. Also gender and age plays a major role and health status. So, a lot of these things we take into play in our mind. The nutritional status, the overall diet, and deficiencies of the person. And then the art of it that comes with a lot more of the science as well. It's this synergy of the nutrients. It's the absorption, the metabolism, the assimilation, the excretion, the storage of these things. And how these interact within the body itself. And some of this has no scientific explanation as of yet. 

Also the emotional stress response, as we were just saying, how does this impact? And they've got some of the signs/markers of inflammation and oxidative stress, genetic polymorphisms like the MTHFR that we've been seeing the last, sort of 10, 20 years in clinical practice. And the biochemistry driving this all around. And this plays a very big role particularly with people taking medications or multiple medications. And the subsequent deficiencies like you mentioned statins earlier. For example, a common deficiency there is coenzyme Q10 because it's found in the same pathway. 

Another area to look at is previous response and adherence to treatment and how that went? Why did they continue treatment? Why did they stop treatment? Was there any breaks in it? So we're bringing the person back in, and it's like the overall factor behind or driving all this is the vital force. Now, I remember the first time I learned about vital force was from Star Wars, and I've told the story a number of times before. 

Andrew: Yep. 

Brad: So, yeah, you're in the Millennium Falcon and you've got Obi-Wan Kenobi talking about, you know, the force is all around us. It's in all living things. It's around us and everything else. And it sort of made me start thinking that there is a vital force. Because something's driving everyone, drive the Earth. We can go really deep with this kind of thing, and it's a matter of, you know, blending it all together. And a lot of it also is related to observation. 

I do a lot of face, tongue, nail diagnosis. You talk with the person. You sit down with them and go through their health status in detail for example. And you're piecing and putting everything together, and I think there is an art to the overall effect of what we do in clinical practice. And whether we're prescribing for an allergy, for example, like an acute case. Or a chronic, long-term health condition. And this patient may have seen you, let's just say, 10 times for health conditions or once. It's still an art to piecing and putting it all together. And that sort of where I use timelines and mind maps and sort of piecing it and putting it all together. Because there is a big art to actually sitting down and working out, "Okay, what's happening with this person in front of us? What has happened in the past? And if they continue on the same trail, do they continue the same way?" So if they keep eating a Western diet for example, would their health condition get worse? And of course we know that, yes.

So, there is definitely an art to what we do.

Andrew: You and I have spoken previously about timelines and mind maps playing a major role in your prescribing. Can you explain this to our listeners, please?

Brad: Yeah, no worries. Timelines and mind maps is something I've been doing since the beginning of my career. I want you to imagine that timelines are used for the history of the patient to investigate the causes, correlations, and associations. And these are like, linear. So they could be from their teenage years. It could be from their 20s, 30s, 40s, etc. In some people, it may have been from birth because they've been never well since due to a traumatic birth process. So timelines we use for piecing and putting everything together.

Mind maps are very useful for putting all the pieces together both present, previous, long-term health conditions, in a more complex manner. So they're that little cloud on your page or in your mind, and you're mapping, you're building, and putting everything together. So, I want you to imagine that timelines and mind maps are seen as peeling back the layers. 

You have the person sitting in front of you, they're telling you their story, and their story could be cardiometabolic disease, PCOS, thyroid, and you're actually pulling and piecing everything together and peeling it back to find out what is the origin? What are the drivers of this person's health condition? And that's where this plays a major role. 

So you can actually use it to analyse even treatment responses and the time taken to heal. So they may have seen other health practitioners in the past so you can actually track to see how that worked. It's very good for tracking current treatment, suggesting progress based on the previous history, expected outcomes.

Andrew: And reassessment?

Brad: And reassessment, definitely. And that's what I was about to mention next. One of the best things about using timelines and mind maps is that could be useful for reassessment. 

So I tend to work in phases or stages, so to say. So, phase 1 is laying down the foundations. So you lay down the foundations and that could be just basic dietary changes at the first appointment for example. Then they come back where we view how they're going. If there's progress and everything is moving on quite fine, we move on to the next phase of healing. Let's just say there's been little progress or no progress in some cases. We review. We modify to suit the current health goals that the person now has. 

Because sometimes they'll get better in two weeks because it's such, let's just say, a basic health condition like a cold or flu kind of thing. And other things take much longer, and then that's where the phases work. So, it's a continual review, manage, review, manage, progress. And that's what I like about using timelines is they're not static. You can actually build upon something from the past and work forward onto the next. And, it's not like you can predict the future, but you can actually…say, the first person keeps tracking the way they are. Their energy levels today is 5 out of 10. It could actually be a 7 out of 10 in a number of weeks' time because 2 weeks ago they were 4. Now they're a 5. And if they keep doing it the way how they're going, it actually builds upon the foundations. And it's a very good tracking and review process. And as I said, I've used this from the beginning of my career and I find it very useful.

Andrew: I like the way that you always use these… I know that sometimes there's a subjective part to how people like getting better, how their progress is being seen,.But you always like to put it in a numbered format or some sort of definitive, objectified format so that you can say, "Well, before they were 2, now they're 4, 7." So you know not just "they're getting better" but you know how much better they're getting. Even if it might be of a subjective nature.

Brad: That's right. And sometimes patients forget. They might come back and say, "Oh, nothing's changed. I don’t feel any better," and you can say, "Well, how's your energy levels today?" And they can say, "It's a 7." You say, "Well, last time you said it was a 5. And the 2 weeks before, you said it was a 4." So, sometimes patients forget things that aren't there anymore, so they move on to the next thing. 

So, it's also a good thing for tracking but also to show the patient, like what you're saying, you can show them that they are improving. And a lot of the time I use this in something basic called Excel. 

Andrew: Yeah. 

Brad: I put it into Excel and use graphs and lines and all those kinds of things, because they can actually see it in a line graph and it makes it look much easier for them rather than just numbers. I use numbers and lines. 

Andrew: Well, what about compliance issues here, Brad? So, you know, there's no progress. Do you revisit your timelines and your mind maps and say, "Okay, I'm on the wrong focus here," and you have to really get them on board? For instance, Dr. Andrew Heyman. One of the great things he says is, "Patients get really frustrated with me saying, 'On a scale of 1 to 10, how likely are you to…' " And so he always gets them to basically opt into a contract and say, "What are you going to do here?" So what are your strategies? 

Brad: That's right. Well, my strategies are very similar. I use a 0 to 10 scale. Because that way 0 is no change, for example, or zero stress or zero energy as an example. 

So, I use it as a strategy for compliance. Because that way when you track it overtime, you can see, "Well, this person's energy levels or stress levels changed two months ago. What happened?" Oh, they missed their appointment. There was an extra stress. They were on a holiday. They had a work project due. They may be students studying, going into exams, or something else like that. 

Andrew: Yep. 

Brad: So, this is a good way to actually track compliance. And then you can actually turn around and say, "Okay, that person's health didn't go according to what we worked out a plan together because of these external influences." They may have left their supplements, for example, at work on the Friday and they didn't get back to it on the Monday. So it's two days' worth of a timepoint. And that could be enough for some people to actually make a difference in their health status. Missing supplements for two days. Or they've gone on holidays and left it behind. So this is a good way to track.

Andrew: Yeah, it could also make a difference in habit-forming. Because if you're… Like, I've done this even with medicine. You know, you forget a medicine for one day, two days, and then the habit of taking it is gone. 

Brad: And I'm glad you brought up medicine, because I forgot to mention that earlier. But these mind maps and timelines can be used in medicine as well. And for surgeries and any other health aspect. 

Let's just say if someone does have high blood pressure, they're on a medication for that, and their blood pressure's coming down over time as it hopefully should be with the medication, and diet, and lifestyle factors. We can then chart that more effectively. And when they go back to their GP for example, and get a review, the GP might change the dose of the medication or the frequency, etc. Or the medication itself might change. We can also track that along with what we do with vitamins, minerals, herbal medicines, and dietary changes, for example. And it comes back to that point that I mentioned earlier, synergy. That a lot of these things work together, and if you get the right match, this is again the art of it, if you get the right match, the person's health improves quite dramatically. And that's why I also love timelines because it's piecing and putting everything together.

Andrew: Getting back to therapy here, are there any specific foods that people should definitely be eating to reduce their risk of cardiometabolic syndrome? And I'm going to weave in your favourite food, chocolate. What about chocolate? 

Brad: One thing to remember is that diet has a very big impact on our health. And particularly for negative health as well. So, if you think about it…I'll go through this from the negative point of view first.

Andrew: Yeah. 

Brad: So then we can build upon that. If you maintain a purely Westernised diet and there's a lot of research on this, bread and processed meats, sweets, deserts, potatoes, the high-carbohydrate, high-glycemic foods, refined grains, high amounts of sugar and saturated fats, for example, even trans fats, you're at a higher risk of cardiometabolic syndrome and lots of chronic diseases. Some of these include now type 2 diabetes, insulin resistance, obesity, fatty liver disease, etc. 

But if you follow a diet that's more related to the Mediterranean diet or the Paleo or Paleolithic diet. And these are diets high in vegetables and green, leafy vegetables, fruits, vitamin C rich fruits and vegetables, potassium, fibre, tree nuts, particularly walnuts. In the olden days, like, in the past, it was more cacao bean itself rather than chocolate. It's been used for over a millennia. Polyunsaturated fatty acids such as omega-3. Even avocado has a lot of good research coming through now saying the health benefits of the good quality fats and nutrients in avocado. 

So I think if you look at the overall diet, I want you to think of it as laying down the foundations. And, this is what I tend to say, you know, my main focus on nutrition is sort of laying down the foundation, overall health and well-being. So if you put good quality foods in, you're more likely going to get good quality foods out. There's a very old saying that your body is a temple, and I do truly believe this. So, if you want the body to reach its full potential, you need a strong foundation. 

And these include, you know, high-quality foods; blueberries for example. These are very specific foods for good quality health. There's a lot of research coming out of Harvard…for example, Harvard University. Turmeric because it pretty much does everything, doesn't it? Turmeric. It's a favourite. You can have it as a spice every day and stir-fried, turmeric lattes, turmeric supplements. I have a lot of prescriptions where I just do turmeric with food for people, just have it every day. 

Andrew: Yeah, absolutely. 

Brad: Garlic and onions for their sulfur components for detoxification of the body. But also these nutrients are very high in zinc and selenium and other nutrients for antioxidant, anti-inflammatory immune status. 

Green tea, for example. Green tea is very good, because its antioxidant. But it's also fluid, increasing our fluids because a lot of us don't drink enough water or fluids during the day. Flaxseeds, chia seeds, nuts particularly walnuts. And again I'd like to emphasise having smashed avo on toast is okay. I just don't advise it every day.

Andrew: So you also prescribe time out to people. Can you tell us more about this?

Brad: Yes. Yeah, time out. It's quite interesting that we always need that time out. And if, you know, you go for a walk, find a hobby, go to the beach. We all need that time out from whatever we're doing. And whether it's work, or study, or any kind of intensity, we actually do need time out. 

And, I always say to people, "What do you love doing?" and they'll say to me, "I love reading a book," for example. I'll go, "How often do you do that?" And sometimes it makes people think that they actually aren't doing it as much as possible. 

Andrew: Yeah. 

Brad: So, it's quite interesting that, you know, we say we love doing these things, but we don't have the time to actually do them. So I say to people, "Set aside 10 minutes. Have a time out for you in this case. Read a book. Sit outside. Go for a walk. Meditate. Do some yoga or anything else for yourself and have that time out." And that could be once a day, two to five times a day. It doesn't matter how many times a day it is. It's because it's you wanting to do it and you feeling comfortable doing it. And that's the main point. 

Andrew: So some period of mindfulness, whatever that activity is.

Brad: That's right.

Andrew: What would be your top 10 for managing and treating cardiometabolic syndrome?

Brad: Always start with diet as the foundation. I'm looking at Mediterranean style diet, high fruits, vegetables, nuts, and seeds. And in recent years, there’s been a big push sort of in the media and in clinical practice for the paleo diet, the paleolithic diet. That plays a very big role as well. So I'm happy for people to subscribe to Mediterranean style diet. 

Omega-3, polyunsaturated fatty acids, antioxidant, anti-inflammatory, cell membrane, you know, cell signaling pathways. It does so much in the body that we're still learning about. And of course omega-3 could be taken all different ages; that's the exciting thing about omega-3. And I recommend, you know, several thousand milligrams per day of that. 

Magnesium, again antioxidant, vasodilator. It's a very useful nutrient. Particularly magnesium orotate in cardiometabolic disorders or disease or syndrome. It works very well. Again, vasodilator, blood coagulation. 

Blueberries play a very big role in my clinical practice, because it is such a good food that you can have any time. You can add it into your smoothie, into muesli, or just eat as they are. Packed full of nutrients and antioxidants. And again there's a lot of research coming out of Harvard University at the moment about the benefits of blueberries. 

Walnuts we've already sort of talked about. There's so much research with walnuts now. It's unbelievable what it does. 

Andrew: Yep, sterols.

Brad: It covers all the metabolic profiles including PCOS and thyroid disorder. But one thing I'd like to note about nuts, that I didn't mention earlier. There's always been concern about the fat content of nuts and that increases weight or waist circumference I should say. And there's a lot of research coming out the last 10 years now that shows that walnuts and other nuts actually reduce, you know, BMI as well as waist circumference. It's actually very good in cardiometabolic conditions. 

Add some spice to your life. Add some turmeric and cinnamon. Drink more water. Preferably filtered or purified. And again avoid sugar, trans fatty acids, artificial colours, flavours, sweeteners, preservatives, processed foods, refined foods, etc., etc. 

Number 9 would be my time out: mindfulness, stress management. Number 10 is increase physical activity. Go for a walk. Get outside. Go to the beach. Sit there and ponder, combining that with time out. 

As an extra bonus, because you asked 10, the bonus is chocolate. I do believe I have to get it in there.

Andrew: But particular chocolates.

Brad: High cacao chocolate. I don't want to mention any brands, but there's a lot of good brands in Australia and overseas, that are high-quality chocolate. Look for 60% and above. That's normally good. A lot of people get actually the 70% to 80% cacao. And also, mate, check the spelling. It should be C-A-C-A-O. If they change the letters around, it tends to have more sugar like cocoa versus cacao.

Andrew: Yeah, that's right. And the other part to that is ethically managed as well.

Brad: It's a very huge issue. I reckon in the next 20 years we're going to run out of vanilla and chocolate as in the cacao itself because of the amount of consumption of 7 billion people on the planet. So there's always word about that. So a lot of companies in Australia use sustainable forestry practices, etc. and they're looking after the environment, so I really support Australian companies in chocolates. 

And the extra bonus is of course having a bit of red wine every now and then. 

Andrew: Yay! 

Brad: Sitting back, relaxing, and having a bit of red wine, because again it's high quality and good for you with Mediterranean studies.

Andrew: Brad, thank you so much for taking us through. I mean this is not just a hour-odd podcast of course. This is a huge issue which requires true learning and true expertise to disseminate the many factors of this. But I thank you so much for taking us through some of the more important facets of cardiometabolic syndrome today. 

Brad: Thank you very much, Andrew. 

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. 

Additional Resources

Dr Bradley McEwen

Research explored in this podcast

Mahmood SS, Levy D, Vasan RS, et al. The Framingham Heart Study and the Epidemiology of Cardiovascular Diseases: A Historical Perspective. Lancet. 2014 Mar 15; 383(9921): 999–1008.

Kris-Etherton P, Eckel RH, Howard BV, et al. Lyon Diet Heart Study: Benefits of a Mediterranean-Style, National Cholesterol Education Program/American Heart Association Step I Dietary Pattern on Cardiovascular Disease. Circulation 2001 Apr 3;103:1823–1825

Kumar DR, Hanlin E, Glurich I, et al. Virchow’s Contribution to the Understanding of Thrombosis and Cellular Biology. Clin Med Res. 2010 Dec; 8(3-4): 168–172.


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