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How Sugar Influences Female Fertility with Georgia Marrion

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How Sugar Influences Female Fertility with Georgia Marrion

It's well established that sugar impacts metabolic health, but have you considered the impact to fertility?

Naturopath Georgia Marrion delights in untangling complex biochemical pathways and creating education for both her peers and patients, that helps digest complicated clinical and research data into usable chunks of wisdom. 

In today's episode, Georgia joins us to share her insights into how sugar might be an overlooked sniper in women's health, impacting hormonal and metabolic pathways leading to problems such as infertility, PMS and PCOS. Georgia takes us through how sugar can impact and crossover into multiple body systems and why it needs to be a discussion point for patients on a fertility journey. Georgia also shares how she tackles this in her practice from dietary guidance to key supplements and herbs she uses to support patients. 

Covered in this episode

[00:20] Welcoming Georgia Marrion
[00:39] Does sugar influence female reproductive health?
[01:48] The interconnectedness of sugar and reproductive health
[07:16] The thyroid and reproductive health
[09:16] Stress and stressors and women's wellbeing
[12:42] PCOS, perimenopause, sugar and insulin
[17:10] Which sugars is research showing to be an issue?
[22:13] Patient assessment tools
[36:22] The influence of the gut and microbiome 
[39:37] Patient assessment in the age of COVID-19 and virtual practice
[43:47] Steps to guide patient to mindful sugar consumption
[46:15] Partner inclusion in the path to wellness
[48:06] Expectations for clinical outcomes
[49:54] Hero supplemental and herbal interventions
[54:45] Insulin resistance: caveats and referrals 
[56:38] Thanks to Georgia and final remarks

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us on the line today is Georgia Marrion, who is a naturopath and nutritionist with over 15 years experience, and who specialises in women's health, particularly hormonal imbalances, fertility issues, and postpartum support. 

Now, today we'll be discussing how sugar impacts female reproductive issues. Welcome to FX Medicine, Georgia. How're you going?

Georgia: Thanks, Andrew. Thanks for having me. I'm great.

Andrew: Okay. So I guess we start right back at the beginning, how are sugar intake and female reproductive physiology and health connected? Short question.

Georgia: How long have we got, you know? My short answer to that question is it's actually pretty complex because you need to consider the different body systems and organs and tissues and their hormones that are involved in female physiology and reproductive and glucose metabolism. And you need to consider the bi-directional functional relationship between them. 

Then from there, you need to consider how sugar can be impacting them individually and how they're interconnected and how that can vary between one person and another, depending on their own makeup. So that's really where the complexity comes into it, I think.

Andrew: Okay. So, we're well versed in thinking about the liver's issues with dealing with the conversions of sugar and the pancreas involved in insulin release, but what other tissues, organs, and systems are involved? And let's talk a little bit about their interconnectiveness.

Georgia: Yeah. So here we're talking about, of course, your reproductive organs and tissues and the hormones, in particular oestrogen and progesterone, although it has an effect to a degree on all of them. Also your thyroid gland and your thyroid hormones, and then you're looking at largely your gastrointestinal tract and your liver. 

And then beyond that, it's the oxidative metabolic pathways in those various areas because they all function individually and synergistically to regulate both female physiology and to a certain degree, glucose metabolism. 

So, if you can imagine putting a picture in your head about this and drawing a line with each of these, it becomes a lot of arrows and a lot of lines, and I actually did that.

Andrew: You've not done that.

Georgia: I did do that because I was doing this and I’m like, "This is crowding my head." So with your sex steroid hormones, we know that they're involved in regulating your menstrual cycle, and essentially all things being in balance, providing a environment that promotes fertilisation, implantation, and should conception occur, embryonic development. 

But they also have a generally beneficial role in insulin action, your oestrogens and your progesterones and glucose homeostasis. So because oestrogen improves insulin sensitivity and it's involved in various processes to do with that as well as hepatic glucose metabolic processes. And that's a whole topic in itself, right? 

But then you add in your thyroid gland. So your thyroid hormones, they have direct effect on your oocyte and ovarian surface epithelium, your endometrium, and as well as your placental tissue. So, it's not surprising that your thyroid hormones, your T4 and your T3, they're involved in a lot of the molecular mechanisms that regulate things like endometrial thickness, and folliculogenesis, and ovulation, and fertility, and then embryonic development. 

But of course, the primary function of your thyroid gland is the regulation of energy metabolism. So, of course an excessive sugar intake is going to be involved in your thyroid gland. And then, so they're two big topics in themselves, but then you add in the gut and the liver, these are all quite large topics.

So just to really give a broad stroke, the gastrointestinal tract and the liver can also have a significant impact on reproductive health and function, because your liver is involved in your steroid hormone synthesis, as well as your metabolism of oestrogens, and your oestrogen metabolites via phase I and phase II and methylation pathways. 

Your liver is involved in the synthesis of your SHBG, which affects your oestrogen and testosterone levels and activity in the body. And then, the metabolism of your oestrogens is also occurring in your gut, but then your microbiome also produces a certain percentage of your peripheral T3, your bioactive T3. 

So, gastrointestinal tract and liver can have a significant impact on your female physiology, but they also have a significant impact on glucose metabolism. So, you can see where the complexity starts to come in.

Andrew: I'm thinking about patients and when we're talking about fertility issues, and we know that we are an overweight society, I get it. But many females who present for IVF are categorised to say your weight is the issue, and you need to lose weight before you'll get benefit, or that will be pushing a stone uphill until we lose weight. 

But what you're saying is that apart from just the weight, it could be the intake of sugar that is affecting their fertility, as well as those other components.

Georgia: Yeah. Well, it's certainly not going to be helping, and that's the thing, right?

Andrew: It might be the straw that breaks the camel's back.

Georgia: And that's the thing. I'm certainly not saying that sugar is the root of all evil in the whole world. And we all need glucose, we all need, you know, your brain needs it, your body needs it to be able to function, you know? So I'm not saying no one should have any sugar at all. That's not sensible nutrition advice.

Andrew: Don't say that to a nutritionist.

Georgia: No, that's it. But I mean, when you've got to consider, like what I was touching on before, when you're considering that environment that is within someone, and if someone is seeking assisted reproductive technology, obviously something's out of balance somewhere. 

So unfortunately for those people, they need to be looking at certain things a little bit closer, in a little bit more detail than someone that does not have issues with conceiving. And for some women, that might be sugar as a factor among several, depending on what's going on to bring them there.

Andrew: You were mentioning thyroid before. And I remember from the BioCeuticals Symposium 2020, Datis Kharrazian was talking all about thyroid. And you got the picture in your mind that the thyroid was the driver, the “cause,” of so many disorders. But you've always got to think about, “Well, okay, what caused the fibroid to become out of balance? Is it only genes or could it indeed be dietary intake, in part influenced by sugar?”

Georgia: So, if you look at, let’s say thyroid, we know that thyroid hormone dysregulation, it can affect reproductive health as Datis touched on. And anyone in this sort of area would be aware of that, because it can contribute. So, with your disorder, reproductive hormone profiles can lead to impaired ovarian and follicular growth and then also follicle steroid production. 

But then you add in… So that can happen anyway, whether someone's having excessive sugar or not, but then you add sugar in and that can make things worse because glucose metabolic processes and endogenous concentrations, it can affect things systemically and locally in the ovaries, you know?

So, in hypo- and hyper- animal models, it influenced ovarian GLUT expression, G-L-U-T expression, right? And then you've got your impaired thyroid function, which can contribute. We were talking before how obviously it's closely involved in energy metabolism and that can contribute to elevated glucose concentration in the ovaries, which can increase ovarian oxidative stress levels, and that can further impact on these processes. And that's just the thyroid.

Andrew: Yeah, yeah. And what about how females cope with the excessive stressors of the 21st century? I mean, being nowadays, not just breadwinners, but also the caregivers, the meal preparers, the home maintenance people, while guys sit there watching footy. Women do so much more. They have so much weight put onto them.

Georgia: And there's a lot of tabs open. I think as a female that I think - and this is generalising - it's just the way that male and female brains are different, generally speaking, is that females always have lots of tabs open and that's their normal. And not to say that's right, but that's how it is compared to the male way of thinking that tends to be a little bit more singular-focused, which is, probably not a bad way to be. And I see this a lot in clinic, how much a lot of female stress is, to a certain degree, from unnecessary high expectations that we hold of ourselves.

And whether those expectations come from internally or whether they come from our perceived people's external expectations of us, I guess this is another topic, but I think definitely stress, whatever is driving it and here we’re talking about sugar, but I'm yet to see a female clinic patient to do with any of these types of issues, to do with fertility or hormone imbalances, where stress is not playing a role, you know, to a degree in it.

Andrew: Yeah, well, that's right, but then you have to look back. When we're talking about sugar intake, it's not as simple as sugar intake because then we have to think about why.

Georgia: Why! Exactly. And that's always the thing. And this is why I think it was important, and this is why I was curious to look into this, because you see these patients all the time, where there's excessive sugar intake happening in various ways. 

But I think “Why is that happening?” and how is it that one person might be presenting in a certain way with certain reproductive imbalances or fertility issues, with say excess sugar intake being a factor compared to someone else on who it's presenting in a different way? And I think that's where you've got to be taking into account all these interconnections combined with someone's own individual makeup. Do you know?

But then it's interesting when you start looking at the impact of sugar on females, and we're talking about female reproductive health here, is largely the underlying mechanisms and it's not surprising really, but it's insulin resistance and oxidative stress and inflammation in the organs and tissues that we've been talking about. 

So, ultimately, the functional and structural effects in these areas can bring on hormone imbalances, to do with levels in signalling, and then that can progress to reproductive tissue and organ dysfunction whether you’re talking structurally and then going on to functional dysfunction. 

And then depending on the person and how long they've had it for and what else is going on, that can then go on to present with suboptimal reproductive function and outcomes. And then, there's a whole lot of mechanisms involved in leading to that. 

To pull back a little bit broader from that is that you need to consider, obviously the person in front of you. Naturally, that's what we do in this sort of area. I think a more accurate way to look at it is, do you have a premenopausal woman in front of you who doesn't have overt metabolic issues, or do you have a premenopausal woman who has PCOS-type that's diagnosed or presentation? 

And if it's PCOS, what subtype is she? Or is someone perimenopausal, and if they are, what stage are they, and how is perimenopause transitioning going for them? Because with those sort of people, say if you're talking about PCOS women or perimenopausal women, they've obviously got a particular hormonal profile going on.

So,sugar is one of the main drivers of insulin resistance. And when they're perimenopausal, their oestrogen is all over the shop for that period of time. And oestrogen, we spoke before about how generally speaking, it increases insulin sensitivity. So when your oestrogen levels are all over the shop, you can imagine the effect that's having on someone's insulin sensitivity. And then also, when there's issues with insulin sensitivity combined with the hormonal picture that's going on, there's a loss of muscle mass and an increase in your abdominal fat, which then also increases insulin resistance. And they also have a bit of testosterone dominance going on just for extra measure, extra fun and games, during menopause.

And there's a bi-directional relationship between testosterone and insulin resistance, in terms of excessive testosterone can make insulin resistance worse. And so, it can go back and forth. 

So essentially, when those sort of women… Someone who is in that sort of picture, she's got this hormonal picture going on, but then sugar is making that worse. So I think it's more accurate, that her symptoms will be worse in terms of: she might have always experienced hot flushes, but if you add in the stress side of it, which can also make it worse, more severe, their periods are heavier than it might have otherwise been, their hot flushes are more severe and more frequent, and their energy fluctuations and mood fluctuations are perhaps more severe than otherwise.

And then, you can throw in, say, gut health, which we've spoken about. But everyone needs good gut health, particularly a perimenopausal women that has oestrogen levels fluctuating like she does. You need good gut health to be able to help metabolise those. 

So, I think it's more relevant to consider - if you are going to be grouping people into particular types - considering that as a broad starting point because their hormonal picture is going to be influencing how sugar is impacting them to a degree, if that makes sense.

Andrew: Yeah. Well, I mean, even further patient populations, pregnant women. We've discussed women requiring fertility management, but also right down to the period that they are in their cycle. I'm sure this is going to happen.

Georgia: That's absolutely right. Yeah.

Andrew: Yeah.

Georgia: Yes, for sure. And it depends on how someone... And that's why, to be fair, I did start saying it's a little bit complex, you know, that disclaimer at the start.

Andrew: Okay, I'll give you that.

Georgia: Yeah, so if someone is getting IVF, depending on the type of fertility assistance they're getting, what's led them to why they needed to, is it female factor? Is it male factor? If it's female factor, is it something that can be picked up and diagnosed, or is it something that's unexplained? Which is something that's, not to say it's not there, but it's not necessarily looked at in the same detail. 

So I think you've always got to be considering all these… I don't think there will be many women that whatever category you're looking at putting people in that we've been talking about, where excessive sugar intake is not having some sort of adverse effect. It just might be however it will present to them. And if it's something that is presenting in such a way that that's impacting their quality of life or whatever it is, their health, that they're trying to achieve.

Andrew: Yeah. Right. Well, you mentioned quantities. So let's talk about the different types of sugars and indeed the quantities, because we know that sugar is one of those generalised terms that there's an inference there, but we need to be careful about what we mean by sugar.

Georgia: Yeah, I think we do. And it's interesting when I was looking at the research on this, I was a bit surprised because I was expecting that it would always be fructose, your processed fructose. But the studies that were looking at and seeing effects here, it was different types of sugar that they were looking at those noticed effects. 

So some studies looked at dietary glycemic index in the glycemic load, so intake of breakfast cereals and white rice and potatoes, and found that they were associated with the higher risk of the ovulatory infertility versus your low GI foods, where there was a reduced risk. 

Whereas other studies were looking at the impact of actual table sugar and soft drink and chocolate and all the fun things in life to do with dysmenorrhea. One study was finding that it was more than four teaspoons a day that was associated with an increased incidence of dysmenorrhea, whereas a separate study found it was more than 12.

And, what I found interesting to do with the more than 12 teaspoons a day, so obviously that it's a pretty broad range. But what I found interesting was that the 12 teaspoons a day study, they classified moderate intake as 6 to 12 teaspoons, which is probably moderate in terms of what's actually happening, but moderate in terms of the impact on the body. Probably not so moderate in a lot of the populations we're talking about. 

And then, when we were looking at women who were going through ART, it was actually not very much at all. So they compared sugar-sweetened beverages versus artificial sweetened beverages - and obviously artificial sweetened beverages is a whole other discussion - but they were associated with lower quality and number of oocytes and top-quality embryos after stimulation and not...

Andrew: Wow.

Georgia: Yeah. So we're then talking about...

Andrew: Forgive me, that was the 6 to 12 level?

Georgia: This is a separate study where they looked at one cup or more a day of sugar-sweetened beverages versus no intake at all had lower quality and the lower clinical rate. Yeah. So this is the thing, obviously, there's other things going on as to if someone is getting ART, there are other factors going on as far as that things are out of balance and what have you. But as I said, if someone's going through that sort of process, it's not going to be helping.

Andrew: Well, maybe, I mean, you mentioned all the fun things in life, and obviously, if somebody got a high sugar intake, I mean, you were mentioning 12 teaspoons of sugar being the sort of ballpark range.

Georgia: No, that's what they studied. But the average U.S. woman, her normal intake, moderate intake is considered to be eight teaspoons. So that's about 41.5 grams a day.

Andrew: Okay. So, if let's say eight teaspoons is the moderate intake, the normal intake, I hate that word normal. That's really easily exceeded. 

Georgia: Absolutely.

Andrew: You get a little bit of stress. You get a woman seeing, as we're speaking about women, you get a woman who has two teaspoons of sugar in her coffee. And if she's having four coffees a day, that's already your normal intake. Then, you got chocolate in the evening, some ice cream and some flavouring on top of that.

Georgia: That is a glass of wine. And that's not taking into account the subvert sugar things that are inside your savoury foods or your tinned foods that, unless you were looking for it, wouldn’t realise that it's there. I think people are becoming more educated with that now. But I mean, your mind works in funny ways with the foods we count. That “this is the food we count.”

Andrew: Yeah. You think this is coffee, don’t you?

Georgia: I know that's not true. Yeah, that's it. Whereas if I drink it, well, then it totally doesn't count. And the subvert foods, all the savoury foods, all the sauces that sugar is in, on top of that, the things that we associate it with, that's where it can really add up. 

So, I think a lot of people, if you say to them, the average intake is say six to eight a day, “Oh, I wouldn't need that much." And then, you can look at it and go, "Oh, actually it's easier to have that much than you would think.” And then when you consider all the “healthy” foods that are out, like all your raw food desserts, there's a gravitation towards that...

Andrew: Nutri-bars.

Georgia: …"Oh, they must be better.” But sugar is still sugar, whether it's got organic kale all over it or not. So it's still going to have the same physiological effect on your body in certain quantities.

Andrew: Well, let's go into how you actually turn this around in a tick, but firstly, how do you assess these people? Like you've spoken about thyroid hormones, we've spoken about stress hormones, so cortisol there, we've spoken about the impact of how the body handles sugar. So you've got insulin and blood sugar levels. So what assessments do you take or make? How many labs do you do, and what do you find are the most useful?

Georgia: So, I think you always got to start with the diet, particularly when we're talking about sugar, right? Start with the most obvious spot in terms of what is their actual sugar intake and assessing that in whichever way that someone does it in their own clinics, in terms of, if it's a recall or food frequency questionnaire, or what have you. I usually do it over three days, if you can, during a week and then one day on a weekend. So, it depends the day of the week, because then their patterns tend to be a little different.

Andrew: You really wanna take out all the fun, don't you? Yeah.

Georgia: I really do. Fun police. Naturopath/Fun Police is our title. But with your sugar intake, the overt stuff that we all know, you don't need any nutrition degree to know about those ones. But then the subvert ones like consumption of drinks, counting drinks, like we spoke about, savoury processed foods, tinned foods, sauces, condiments, and that sort of thing. 

And also looking at really what's driving the high sugar intake, if they're having a lot, and also if it's changed. If it's changed, what’s happened around their change, say two years ago, is it sugar cravings? And then you can unpack that a little bit more. 

Or if we're looking at dietary stuff, are they having enough protein? It's easy to eat plenty of carbs throughout the day, but I mean, having enough protein and good fats, are they actually eating enough? Because there's a bit of a culture at the moment of cutting out whole food groups, but it's got to be replaced with something because your body's hormones are going to drive you to replace it. 

Are they eating enough at each meal? Is their portion control too strict and depending on what their physical activity levels are, are they eating enough to replace that? 

Is there a lack of energy and is that driving the sugar intake? Or is it stress, like we touched on before? Is that what's driving it? Generally, it's a combination of factors with a lot of women I see, a combination of stress and lack of energy, and sleep deprivation, and wearing many hats. So having many tabs open and that tends to go with what your body is biologically driving you to get more energy to respond to all of this input and stress. So that's the easiest thing to go for, right? 

So, that's probably the first place I'd be looking. And then looking at your glycemic index and glycemic load of the overall dietary pattern and especially in relation to their metabolic picture and what their physical activity is. How often are they training?Are they training? If they are, how often they're doing it and all those sort of things? 

And then you can look at particular levels of particular nutrients that can be affected by high sugar intake, such as vitamin C and vitamin D and magnesium and your calcium and chromium. So you could probably start there as far as your dietary assessment and looking at those types of things. 

Looking at your anthropometric measurements, what’s their waist circumference, what's their BMI? Obviously, it's a pretty blunt tool, but at least it's a place to record it in terms of if there's changes, but you need to be doing it along with all your other measurements.

Andrew: Yep. Do you do, by the way, a combination of BMI with hip to waist ratio, wrist assessments, that sort of thing, do you do anthropometric?

Georgia: I usually do BMI. Obviously have their weight and BMI and their waist circumference. So with this type of thing, because combined with the other information you're getting from them with your assessment, and when you're going into pathologies you can get a good picture with that, or at least where to go next. 

And you're not going to do all these pathologies with everybody. Some patients don't want to do any, some want to do a lot of them, but obviously you also always want to be - as you said before - giving them the most bang for their buck. So if it's relevant blood sugar parameters, obviously your fasting insulin, particularly. There's no point just taking glucose if you're not looking at your insulin with this type of presentation.

Your female sex steroid hormone panel, what's going on there? If it's relevant, their gut, like dysbiosis and intestinal permeability. Obviously you can get really good functional gut tests these days that measure a lot of different parameters. So, you get a really good overall picture. If it's relevant, liver, thyroid especially. And then you can look into, if it's relevant, look at oxidative stress parameters and inflammation and vitamin and mineral status. 

So, there are probably things that you'd be considering to see if it's worthwhile, depending on what they're presenting with and where you think things might be out of balance. That might be relevant in terms of changing your intervention or not. And then obviously you can look at their clinical presentation.

Andrew: Yeah, just a little bit about the earlier assessments. When you're talking about BMI, hip to waist ratio and some other anthropometric sorry, per metric? Anthropometric? Yes. Metric. Yes. assessments. 

What about things like bioimpedance and the various types of things out there? I mean, you can get $8 scales that, you know, apparently assess your lean body mass now. So, how sensitive do you find these? How useful do you find these sorts of pieces of equipment? Do you need to pay the thousands of dollars for the more sensitive, forgive me, I think it might be a 6-channel bioimpedance or can you get away with just simple measures, with a tape measure and a set of scales?

Georgia: Look, I think everyone uses different tools and strategies and assessments in clinical practice. I don't use bioimpedance personally, because I find it might be useful in some ways, but I think you can get a lot of information from the sort of questions you're asking in these types of measures that we're talking about. Like I said, the scales and being able to measure them and should you need to because you can look at someone and then you can look at their pathologies and I think you can get similar information. 

So, if you've got someone that's like, "the skinny fat person" that you talk about. To look at them they're lean, but then you take their pathologies - inflammation or blood glucose and what have you - and you can see that there's metabolic stuff going on. So, I think you can get the same information in other ways, depending on how someone likes to practice.

Andrew: And, looking at the labs, are there any labs that you tend to favour as standards, like fasting insulin, your thyroid assessments, antibodies, cortisol awakening response, for instance? That was something I found really interesting with Carrie Jones.

Georgia: I did, too. And to be honest, because I haven't used the cortisol awakening response before, but I think, yeah, I was really interested to see what she had observed clinically. So, it's on my list of clinical tests to add.

Andrew: My question, I guess, with that test is, if you're going to take the normal daily, what is it, four tests throughout the day via the pipette that's the standard way of doing it, versus the cortisol awakening response, which is the short peak in the morning that you're checking. And I think you do three tests there. I don't know, but I wonder, what if you just paid for that daily test, if it was cheaper, but just did it here. Wouldn't you be getting just as much useful information anyway? I don't know. I haven't looked into it.

Georgia: Yeah, and I think you just let the cat out of the bag for the pathology.

Andrew: That's your homework. But you know, we've spoken about thyroid. What about things like neurotransmitters? What about the effects of, let's say histamine or let's say GABA? Do you ever use any of the urinary marker assessments?

Georgia: No, but I found that interesting with Datis's talk at the Symposium. I would like to look further into those in certain women. So like with some women who are hyperthyroid or having subclinical thyroid issues where there are mood issues or anxiety and those sort of presentations going on. I think it would be worthwhile adding that in in certain cases to dig a bit further where there might be certain neurotransmitters having an impact on that, you know? I wonder about that. So that's not something I've used, but I would like to.

Andrew: And what about even simple stuff? Like blood sugar monitors are what, $80 now? I mean blood sugar levels...

Georgia: So, you still want to be getting insulin, yeah.

Andrew: Forgive me?

Georgia: So, you still want to be getting insulin. Like, you can have your plasma glucose, but you want to get insulin.

Andrew: That's right. So do you ever use BGL or do you just take a, like, a fast...?

Georgia: Well, if they're only going to get one test out of the two, you'd go for insulin. But ideally, you want to get the whole picture. So like, if you're going to get thyroid, you know a little bit from the TSH, but you're not really going to get enough information that's really actually helpful. So you want to get your full thyroid panel if you can do it. So, the same sort of thing with blood glucose.

Andrew: And, what about doing a two-hour or even a four-hour glucose tolerance test? Have you ever investigated these? And I mean, Dr Mark Houston used to favour the four hours and I just thought, “Good luck getting somebody to sit in a pathology lab for four hours while they're feeling like absolute rubbish.”

Georgia: Yes. I think for the most part it's probably realistic, it's relevant to do a blood glucose the two-hour one, to be honest. Because as you said, you'd love to have the patient where you can have all these pathologies and have the perfect… but that's not reality. So everyone's not going to do every test and to expect someone to do a four-hour test when it isn't going to change your intervention, is the main point. You're really only doing pathologies if it's actually changing how you would manage and how you would treat that person, rather than getting the information just for interest sake.

Andrew: What about access to these tests in Australia? Do you ever find pushback? Or do you just get the patient to pay privately?

Georgia: Sometimes. Yeah, sometimes there is and often it's a cost thing, but I think it comes down to how you're communicating with the patient. And it's obviously always up to them. It's very much a partnership situation in clinic in that I might know a lot about certain things, but then they're the expert on them. 

So it's about explaining what's the reasoning for the test and what we should get out of it and how that might change how we intervene or not. And then it's up to them whether they decide to go ahead with it. But obviously, as a clinician, everyone's had patients where they really find a particular test result useful, but then they decide not to go down that track and then, okay, well then you go from there. So sometimes there can be, but...

Andrew: And, do you find reticence to do these tests, particularly things like fasting insulin with GPs or do you just get the patient to pay privately?

Georgia: Often, I'll go privately depending on what it is that you're getting tested. So like, thyroid. If someone's thyroid is normal, but clinically they're not presenting as normal, getting them to get a full thyroid test can be tricky. So, I often find it's a little bit easier to go… and I explain both options to them. I always say to them, “Go see a doctor and this is an option to pay for.” And then, like anything, you present the evidence and the information and then it's up to them how they decide to proceed, is usually how I go about it.

Andrew: Yeah. I'm encouraged at least to see that GPs are more often screening for thyroid antibodies these days. Whereas before it was just this denial. It was a blanket “No.”

Georgia: Yeah. There's definitely more coming out, which is good because we've all seen in this sort of area, women who are presenting with subclinical hypothyroid issues and they're suffering. And something is out of balance when you look at them clinically. You don't have to take a thyroid test to know that. Something's out of balance, the thyroid imbalances can present in so many different ways. There can be the common symptoms and common clinical presentation, but it's so varied that you can't put people in the box of, “This TSH above here, well, you're perfectly normal,” when they're clearly not.

Andrew: Yeah. Perfectly normal, yes.

Georgia: Perfectly normal, even though you can't even stay awake at night and everything's changed for the last three years since you've had a child with your hormones. So, I'm glad that there's more information coming to do with that and TSH levels.

Andrew: Just tying into something you said way earlier, and that was about the microbiota, microbiome. And Datis was mentioning this as well, that there was a substantial amount of T4 to T3 conversion, which was enabled by your microbiota. Is that correct?

Georgia: Yeah, that's right. So, I think it's around about - and obviously, it will be varied by individuals - but they estimate it's around about 20 % for bioactive T3. Which is… obviously that's going to have a significant clinical effect on people. So, it goes by the enterohepatic circulation as well. So you can imagine what it does for gut health. Obviously, it's a fascinating area, which you can talk about for hours and hours, or we could talk about for hours and hours.

Andrew: And we're still only chipping away at the tip of the iceberg. Yeah.

Georgia: Well, this is right. Yeah, exactly, right. But if you even just take gut health and the impact of that on female reproductive health. Gut health is amazing in that it's also one of those areas that, with the right interventions you can really make a difference to people in terms of how they're feeling and what they're presenting clinically. And I think that's one of the amazing things about the gut.

Andrew: Yeah. Okay. So, when we're talking about sugars, we're talking about its influence on microbiota and carbohydrates certainly are going to favour the Firmicutes. Do you bother testing the gut microbiota at all? Do you just work on the diet and make sure that you've got your sugar intake to a minimum and dietary fibre up and adequate protein and all that sort of thing?

Georgia: Yeah. Well, when you're doing your gut tests, you're not usually just doing your microbiome. So, when it's in the context of everything else, I think it can be useful. As far as when you're getting your stool test, it's really only getting a teeny tiny snapshot of what's actually in the gut because that's just how testing is for it. 

But I do think when you're getting a lot of the parameters to do with gut, with your intestinal lining, and the parasites, and the absorption factors and inflammatory factors that they test for, I think it can give a really good overall picture when someone's presenting a certain way.

So, I think - not to say I test microbiome and do that for everybody because the test is not necessarily cheap - but I think in some ways, particularly if someone's presenting in certain ways, it can make your intervention more effective because as we know with gut symptoms, they can be caused by any number of things. And sometimes the fix is really quick and sometimes it's not. And when it's not, that's where having a test can be really helpful. Like, "Oh, there's actually a parasite that you've had for five years that's showing its little head now,” so to speak clinically, you know...

Andrew: Yeah. So to speak.

Georgia: So to speak.

Andrew: Well, let's go further into clinical interventions. I mean, we're talking about assessment in the age of COVID-19, and the changes in practice that we've seen over the last few months. Do you find that doing Skype interviews, for instance, is actually sometimes better because you can actually ask the patient to walk you to their pantry?

Georgia: It's fantastic. Oh, it's fantastic. And also because people tend to feel more comfortable because they're in their home environment. And to get, obviously it's useful from, "Okay, what supplements are you taking?" "I'm not sure. I can't remember." "Okay. Can you go get it for me and hold it up to the screen," sort of thing, if they hadn't taken a photo and sent it to you beforehand. 

But they're more comfortable and, especially because what I see with women largely is that, the tabs we spoke about before and all the things that they've had to do to get to your office. So it's another thing on their list of things to do. Whereas if you can do it via this way, for a lot of women it's one less thing, you know?

Andrew: Yeah

Georgia: So I think they are more useful in some ways in clinical assessment, because you getting people in their environment and they're comfortable and they're not feeling stressed. "Oh, my gosh, I've got so many things to do," that sort of thing. So yeah, I think it's good the rise of telehealth and people are more open to it these days.

Andrew: And efficacy of that changes. And more than that, adherence. How do you find that that works for you with helping to change these people's lives around?

Georgia: Well, I mean, whether you're seeing someone face-to-face or whether you're seeing someone via this, their motivation would be the same either way. 

Andrew: Right. 

Georgia: I think you've always got to meet someone where they're at. And obviously, that's partly to do with all the things we've spoken about in terms of where they're at with their symptoms, and their life, and all of that. But also meeting them where they're at as far as what their compliance is likely to be. 

That's something that I usually touch on pretty early in the piece as far as - like I said before - I know a lot of information about certain things, but I can't do it for you. I can provide you all the support and help and information, but at the end of the day, someone's got to have that motivation to make the changes that you're suggesting. So, I find their level of motivation is the same really, regardless of if you're seeing them face to face or in this type of modality.

Andrew: Do you ever enter into contracts with them? I remember Andrew Heyman, he would constantly challenge his patients to the point that they'd get angry with him and he'd say, "Okay, so on a scale of 1 to 10, how likely are you to do this? And on a scale of 1 to 10, how likely are you to do that, and that, and that, and that." And he just said, "I will keep doing it because I want to know your level of commitment. And I can gauge what I will get out of this, how effective my treatments are going to be or how I need to vary my treatments depending on what you're willing to change."

Georgia: Yeah, and I think every clinician does it in a different way. But I think there does need to be some communication one way or the other, whether it's that way or whether in a different way as far as, “Okay, well, this really is very much a team effort.” 

Because it doesn't do anyone any favours if people aren't going to follow what you suggest to them. And everyone's at different stages in their life and they might've been really motivated to start with, and then you'll find that they're really motivated and then come back, and then they drop off once they start to feel better. And then they come back when things have gone off, and that's just the nature of how it goes.

But I think all you can do is be communicating pretty clearly. It’s about educating people, as far as I can. I like to do that a lot with patients as far as, “Okay, they're presenting this way and that's because of XYZ.” So when people are empowered more with information, they're more likely to say, "Oh, okay. So, what I'm doing here is contributing to this and therefore..." But I find people, say, women who are having hormonal issues, or if they're trying to have a baby, they tend to be pretty motivated.

Andrew: So, when we're changing behaviours of intake, but you've got to be cognisant of the stressors that caused that intake to happen, which interventions do you find gives you a better bang for buck? 

Georgia: Yes, so that’s the thing.

Andrew: So like, I know this is a piece of string, I get it. But commonly, do you find that giving up the teaspoons of sugar because it's a measured dose is something that women are going to adhere to? Or do you find that reducing a dose, being a can of soft drink, is that the easiest thing that you can reduce their sugar intake? Or do you find that helping with food choices, enabling better food choices and cooking recipes is a way to go?

Georgia: I think it's both. Definitely both. 

Andrew: Okay.

Georgia: And depending on the person that it's in front of you and seeing, because it's human nature. If someone says “You can't have that,” all of a sudden, that's all you can focus on and that's all you want. 

So you need to be working it out, “Okay, so they might have 10 soft drinks a day. Okay. Well, let's look at reducing that over time and replacing that with something else that's a better choice.” And in the meantime, let's be looking at different strategies for, let's say you're having 10 cans of soft drink because it's an energy thing and that's how you're getting through your day, because you're getting four hours sleep a night and you've got so many demands on you. So let's look at reducing that and let's look at supporting your energy so you have more energy, so you don't have to have that quite as much.

And let's look at how your gut health or your thyroid or whatever is presenting for them is also contributing to that and doing that, whether it's obviously through diet and helping them out with that way. And then adding in supplements to help them through to bring that back in balance. It's always a multi-approach, really. 

There's no point in just giving someone magnesium if you're not changing everything else, or at least instead, small changes gradually, depending on how motivated they are and how much they've got going. Vecause you also don't want to be adding more stress. It's always that balance between wanting to help them enough that they feel changes, but not to the point where it's causing more stress.

Andrew: So, how often do you have to read the riot act to the partner?

Georgia: Well, yeah, it depends on the couple. I'm just going to leave it there.

Andrew: But, I mean, it's a really interesting thing. Lee and I have this argument all the time, and I'm a male, I mean, I love my barbecue. If I can barbecue, I'm in.

But you and I were speaking earlier about the, the old joke about the woman goes and organizes the children to be able to go out and do the shopping, prepare the food, cut the food up, put it into portions, season the food and the guy to put it on the barbecue, flips it once...

Georgia: "Honey, I've cooked."

Andrew: ...and goes, "Look what I've cooked."

Georgia: Yes, no that's assembling. That's not doing the barbecue.

Andrew: But do you find that that partner inclusion is actually an important step about going right back to alleviating the stressors, which can be that compounding thing on drivers of...

Georgia: Yeah, it can be. Depends on the dynamic of the relationship, because sometimes it can actually be the female that's holding on, and not wanting to give someone else to do something because they won't do it the same way. I do it as well. You know, females, we tend to be our own worst enemies in that way.

Andrew: Yeah, we need to talk, Georgia.

Georgia: Sometimes, it's okay. So, where the dynamic is that the female is doing everything and whether the husband's away or that there's a certain dynamic there, that's how it's evolved. So I think it depends on the picture of that. 

But for females, I think often it's more the other way where we're sort of reluctant to want to give certain things up because they won't do it the “right way," so to speak. So I think we've got to take responsibility for that too.

Andrew: Yeah. Okay. So, clinical outcomes, how quickly do you find that if you can intervene, let's say in the perfect sugar restriction, how quickly do you find a resolution to have a positive outcome? Like for instance, pregnancy.

Georgia: Okay. So I think pregnancy… I don't think you can put a timeframe on it because there's always… I mean, it depends on the person that you're seeing. If you're seeing someone that’s been trying to conceive for 18 months and there's a bit of, it's female factor infertility, but then there's male factor in there as well, obviously it's not fair to give someone a particular timeframe that “definitely by this stage, it's going to happen.” 

But I think anyone in this sort of area, you want someone to give you as a clinician, at least three months for the quality of the eggs and sperm. But you're wanting more than that, and that's just to get to your starting point of, "Okay, we're kind of at a bit of a baseline now," assuming that everything has been followed.

Whereas, if you've got someone that has menstrual issues or someone that's perimenopausal and that sort of thing, I think the interventions that we've been talking about can actually produce results quicker. So if you've got someone that has PMS types of issues and you take them off sugar, take them off dairy, or adding in some magnesium and B6 and things like that, they can see results pretty quickly. Whereas someone that might be experiencing different types of fertility issues, obviously they can take a longer time to unpack that. And also then, going in with the right interventions that will produce the results they want.

Andrew: Yeah. What about choosing the “hero?” I'm doing air quotation marks again, “hero supplements.” I know, I do it a lot. But what about the hero supplements? You've mentioned magnesium quite a lot of time. Myo-inositol is now freely available in Australia. That just wasn't available...

Georgia: I know, yes.

Andrew: ...let's say five years ago. Except, I think in one product. But then there's also the beauty of herbs. So let's talk about making up a prescription, you know, what's your...

Georgia: So, not everyone I see would have all of these, but if someone is presenting with some version of excessive sugar intake and depending on what particular system that's impacting on the most, you'd be looking at things like your magnesium for your nutrients. 

So, obviously your magnesium, you know, your B6, your myo-inositol that you mentioned, potentially looking at your lipoic acid, and your zinc, and your chromium. Those are the sort of things that would be in the mix commonly with them. 

And then you go into your herbs. And again, it comes down to really where it's being driven from. So if it's sugar cravings, potentially things like St. John's wort and your herbal adaptogens. So with your stress/adrenal ones, combinations I use is things like ashwagandha and Codonopsis and eleuthero and Rhodiola. Or, withania, eleuthero, with Schisandra and passionflower and skullcap, I find those to be good. Obviously not altogether, there's sort of two different combinations I tend to use. 

Sleep support, I’ll tend to use things like passionflower, California poppy and skullcap and kava, if they can tolerate it. And hops with a magnesium powder at nighttime. I like that combination, that works really well. Usually, I tend to find a bit of both. 

And then obviously, if you've got PCOS, if it's appropriate for them, things like peony and Liquorice, that sort of stuff. So herbs, if you can get people to take them, especially the liquid ones, which is a discussion we usually have where I usually, quite upfront say, "Okay. They're not going to taste very nice, but they're amazing." And, you know, to be honest, when I say that most people are like, "Oh, I thought it was going to be much worse with the herbs.”

Andrew: I would say if you try and put a herb up, if you try and say, “It’s not that bad,” sure as heck, they're going to say it's worse. But if you say “They're absolutely disgusting,” more often than not they say “It wasn't as bad as what I thought,” as you say.

Georgia: Yeah, absolutely. Well, to be fair, I've never given anyone anti-parasitic herbs in liquid. I think that would be a bit mean, a bit nasty. But I find also if you tell people to have, say, a handful of walnuts or a handful of almonds after they have their herb mixture, that helps. Don't have a big glass of water because you're just prolonging the pain. 

Andrew: Yeah, yeah.

Georgia: And having some sort of nuts, sometimes milk can help as well. So have that handy afterwards. And remember, it's only about 2.5 millilitres to 5 millilitres, depending on the dose.

Andrew: Yeah. Always watered down. What about things like bitter melon and indeed Gymnema on its own to knock out the sugar?

Georgia: Yeah, definitely. If that's appropriate for them, I think that can be… like the Gymnema can be a bit of a band-aid. And that's one of the first things you learn in herb school. And trying it. And you think, "Oh, my gosh, that's quite amazing. Sugar really isn't that nice at all." 

Yeah, I think sometimes that can have its place, but I think I'm always more inclined to go… particularly with the people that I see, the sort of females we've been talking about, stress is usually playing a role to a certain degree. So, going down that track more so, and I usually go with the herbs and the nutrients that I mentioned before, I'll tend to go with those. So, I might add it to the mixture, but I wouldn't just do a sole blood glucose/sugar mixture. Do you know what I mean?

Andrew: And do you tend to combine a herbal fluid extract mixture with your nutrients in, whether it be tablet or powder form, to make up a...

Georgia: Yeah, I will. And I try not to give people too many different things, but yeah, that's usually what I would do, the most appropriate nutrient that you're talking about. And if they'll take the liquid herbs, having that as well, because the beauty of liquid herbs, you can modify them and add them and you can tweak them and really customise them for the person. 

But obviously, it's great now there's always a tablet version and capture version if someone's not interested in taking the liquid. So it's good that we've got so many options these days.

Andrew: Yeah. Just a quick word about caveats and responsibility of referral, I guess. When we're dealing with insulin resistance and we've got a whole population of undiagnosed diabetics. We know that. It's an estimated population, which I love that. 

But anyway, and you've got something as simple as a blood glucose level, which, if it's going to fluctuate throughout the day, okay, you may or may not have some insulin resistance. But if it's high, and you might have a type 2 diabetic, they're up in the 15s, 20s.

Georgia: Yeah, I would get them to see their GP and get a full assessment.

Andrew: Yeah, I actually wonder if the naturopathic profession could be the vanguard of helping to diagnose and to treat effectively this unrecognised population. Because nobody's looking at them.

Georgia: Well, I suspect it might be a little bit like thyroid was a few years ago when it was really...

Andrew: Good point.

Georgia: ...largely our profession, as far as that, we're the only ones and I'm talking broadly speaking, there are plenty of holistic GPs that were looking into it as well. But looking at these subclinical hypothyroid people that we've spoken about where their TSH is normal, but clinically they're presenting with thyroid and something is going on. 

So I suspect it's the same sort of thing with insulin now, is it's becoming more… there's more of an awareness now generally to do with insulin resistance and looking at that. And it's not just a magic number of one thing and you're under that and you're perfectly healthy, particularly when we look at, as Datis spoke about all the different impacts of insulin resistance on the body beyond just weight and diabetes. So, I suspect it might be the same for insulin and insulin resistance over the next few years.

Andrew: Now, time and time again, you've mentioned thyroid and we've also mentioned the impacts of stress on neurotransmitters. So, I'm just wondering, would you, I mean, it's a whole new podcast. There's so much more to cover. Would you be amenable to rejoining us on FX Medicine at a later date to discuss those topics?

Georgia: I'd love to. Yes. Absolutely.

Andrew: Excellent. I'd love it. But thank you so much for taking us through what you've seen in clinic and indeed, how you've been able to help these women. And in, I guess, not the least of which, the many tabs that your mind has. I can see you go like this. It's like an Indian head grip of different tabs.

Georgia: You can see my tabs.

Andrew: But I've also seen the diagram. So, it's interesting to see the cogs of your mind go, “But hang on, but hang on. But..."

Georgia: No.

Andrew: I look forward to getting another diagram from you and delving further into how we can help the issues of thyroid and neurotransmitter upset. So, thanks for joining us today on FX Medicine, Georgia.

Georgia: Thanks, Andrew. Thanks for having me.

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


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