¶ Metabolic Dysfunction
Music . This is Wellness by Designs , and I'm your host , andrew Whitfield-Cook , and joining us today is Karen Squires , and she's a naturopath who holds a Master's in Human Nutrition and also a Grad Cert in Diabetes Education , and today we're going to be speaking about effective treatment of patients with metabolic dysfunction . Welcome to Wellness by Designs , karen .
How are you ? I'm good . Thank you for having me , karen it's my absolute pleasure .
Welcome to Wellness by Designs , Karen . How are you ? I'm good .
Thank you for having me , karen , it's my absolute pleasure . Just for everybody who's listening or watching in the pre-chat that Karen and I had , this lady's knowledge is extensive , so get ready . This is going to be fun . It's going to be really educational for you . So , karen , first of all , can we go back into history ?
Tell us a little bit about your career , because it doesn't come from naturopathy , does it ? No , it doesn't . Prior to becoming a naturopath , I was working as an executive assistant to a senior exec at a big Australian corporate which I loved .
I had always been interested in medicine in health and natural medicine as well , so I took a redundancy and I used the money to study naturopathy full-time and graduated in 2006 and been in full-time practice ever since .
Gotcha and you're down in Victoria , right .
I'm , yes , down in Victoria , in the beautiful high country of Victoria , up in the hills and the mountains .
Yep , okay , so let's talk about metabolic dysfunction . Let's dive right in . How big is this topic ? Like , how big an issue is this in Australia ? We've got more than one disorder here , correct ?
Yeah , that's right . It's a really big issue . In Australia . I concentrate mainly on metabolic dysfunction related to blood sugar dysregulation , so usually driven by insulin resistance . So in clinical it will cover things like metabolic syndrome , non-alcoholic fatty liver disease , pre-diabetes , type 2 diabetes .
The main driver , as I said , behind these is usually insulin resistance .
What's driving all of this , though , karen ?
The main drivers is our lifestyle , current lifestyle . So being sedentary or low levels of exercise , high caloric diets , being overweight or obese especially that visceral adiposity in particular that we get around the middle are the biggest drivers . 90% of what we're seeing in clinic are these modifiable drivers . There are non-modifiable drivers , such as aging .
So there are some things we can't do anything about , but most cases we actually can do something about them .
What about genetics ? We know about the you know in the olden days forgive me , it was the OB-OB gene . We know about genetic predispositions for diabetes , type 2 diabetes and even carbohydrate harvesting and obesity . How important are these in , a the patient presentation and B what you can control ?
There are genetic influences in obesity and chronic disease like type 2 diabetes , but given that most of it 90% is our lifestyle and modifiable , I concentrate on that before I get to genetics . It is something that I do like to look at , but it's not initially what I would start with , you know , given the presentation that I'll see in clinic .
So , for example , I can touch on a couple of the things that I see in clinics , such as metabolic syndrome , of the things that I see in clinics , such as metabolic syndrome . So this you know more than 35% of Australians have metabolic syndrome , which is a cluster of conditions that predisposes people to type 2 diabetes , stroke and heart disease .
I think it's really important for us , as clinicians , to ascertain whether our client has metabolic syndrome or not , because it contributes to the risk of cardiovascular disease , chronic kidney disease and type 2 diabetes . It type 2 diabetes is two to three times higher and some studies report up to five times higher than someone without metabolic syndrome .
And and the diagnostics for the syndrome are something that we as clinicians see daily . So , for example , an elevated waist circumference , elevated triglycerides or medicated , reduced HDL or medicated , elevated blood pressure or medicated , fasting blood glucose or medicated , and you only need three of these .
So I see many people with metabolic syndrome that don't necessarily come in with this , but you'll pick this up with or without their pathology results . So you know . Think about how many people we see in clinic , for example , with an elevated waist measurement on blood pressure medication and with reduced HDR . That's metabolic syndrome .
Yeah , yeah , yeah .
I think it's important for clinicians to pick up on that because it's been associated with so many other conditions like polycystic ovarian syndrome , sleep apnea , alzheimer's , some cancers as well . So , while it's a condition of its own , I think you can also view it as a bit of a canary in the coal mine , alerting you to other possible health issues .
So that's one of the metabolic dysfunctions that I like to pick up in clinic .
So how often do patients come in seeing you for something totally distant to this , but something about your expertise tweaks and you go hang on for a tick . We need to be , as you say , being the canary in the coal mine . What are the things that you look at or notice that maybe other clinicians don't ?
I don't know that I notice anything more than other clinicians might . Perhaps they're focused on the presenting complaint which we often get on paperwork even before we see the client in clinic . So we can already tell a lot about the client before we see them . You know their age , what medication they might be on .
We may even be able to know what ethnicity they are , what family history , et cetera , so that already before we see the client in clinic can kind of , you know , just alert us .
They might be coming for a skin condition or a gut condition , but you know once they walk in the door if they're overweight they have that high waist measurement , certainly if they're bringing PATH results or if they're sent to you prior to an initial consultation , which happens often as well .
Certainly , seeing a trend in something like rising fasting blood glucose , even if it's not out of the range yet , should alert a practitioner into looking a little bit further .
Gotcha , gotcha . So let's go further into this patient presentation , because where I'm going to go here is outliers , and the reason I say this is when I'm going to go here is outliers . And the reason I say this is mature age couple , retired , quite wealthy , no stress , very positive attitude to life , healthy lifestyle , healthy eating habits .
The wife came in to see me not long ago and has been diagnosed with fatty liver . Out of the blue there was no indication that we could see and I have no idea at this stage why , you know . Let's talk about outliers Like what things tweak you to this sort of thing where you go something's weird ?
What things tweak you to this sort of thing where you go something's weird ?
Is it that rising glucose , as you say , it can be Also high insulin as well , so she wasn't overweight , normal weight , very healthy .
She was flawed . She was not an alcohol drinker . It was a very funny presentation and I wondered about medications passed or anything like that . I don't know .
Yeah , or something viral perhaps , or she could just be an outlier .
¶ Emerging Trends in Blood Sugar Monitoring
The nomenclature for non-alcoholic fatty liver disease just changed last year , so they've actually taken the alcoholic and the fatty out of the term because they found that that was not really reflective of what was going on and also a bit stigmatising .
So within that new nomenclature there is some little subcategories and one of those subcategories is someone who does not fit . So there could be a genetic influence there as well .
But if it's a diagnosis of fatty liver disease and if she has um had a you know a scan to to have a look at the extent of that , whether she's an outlier or not , you would still want to support healthy liver function . You know healthy detox pathways um , any inflammatory um .
You know nature of , of , of what she's got going on as well yeah , yeah , with the nomenclature like it used to be non-alcoholic fatty liver disease , I thought try and find a non-alcoholic person in australia , but anyway . So the nomenclature has changed and and I think it was um massiled . Is that right ? So metabolic associated it's metabolic dysfunction .
Yeah , what was it sorry associated ?
steatotic . Yeah sorry , it's metabolic dysfunction associated steatotic liver disease . So that's muscle d , and then there's mash as well yeah , non-alcoholic steatohepatosis , that's it , yeah , yeah . Okay , sorry you were going to say something , karen . It's still an issue in a person like an outlier . So what's driven that ? May be genetic . She's an outlier .
However , the liver fat is associated . You know it is very inflammatory . It's associated with impaired liver clearance of insulin . The liver is actually the main organ for liver clearance . So I would want to be wanting to keep an eye on blood sugar levels and insulin levels as well , given that she would have fatty liver .
Yeah , it's usually driven mainly by obesity , but yeah , you know , we are going to get those outliers occasionally .
Yeah . So what about assessments ? Let's go into them . You've spoken about fasting insulin , which is very rarely done by GPs . Do you just order it yourself ?
I do both . I will ask my patient whether they have a good open relationship with their GP and whether they feel comfortable in asking the GP to do that . Uh , if not , uh , I'll do it myself , but I you know , fasting blood glucose with insulin is really important to get those two together yeah , that's your homo ir right yeah , yeah , definitely .
so it'll give us a degree of insulin resistance . But also you can see people who , like your outlier , um , have a healthy weight , uh , have a healthy diet , have a healthy lifestyle , um , and have a normal-looking , fasting blood glucose , but their insulin levels might be off the scale , holding them there , okay , oh .
So the reason that that's important to know is that even in a normal glycemic environment , if the insulin is too high , it's still going to drive those dyslipidemias and cardiovascular problems .
Yeah , yeah . So other assessments . So we've got that HOMA-IR , the insulin resistance test . What about things like continuous glucose monitoring ? We're seeing that more and more used by healthy or otherwise healthy people not necessarily diagnosed diabetics and it's just amazing .
Like , for instance , kira Sutherland uses them quite often in athletes and is amazed at the results . Yeah , so now , forgive me , I've forgotten his name , tim , I can't remember his name . He was a long-distance runner , south African . He got attacked by a dietician for him giving dietary advice .
He won that case some years ago Forgive me , sir , I can't remember your full name and he , even though being extremely fit , had type 2 diabetes , had type 2 diabetes . So it's not just that robust body people who have the type 2 diabetes or that insulin resistance I should say .
So how much further do you go in , like your intake form , to pick up on things that are alluding to glycemic malfunction ? Let's say , you know , lunchtime after lunchtime , tiredness , brain fog , that sort of thing . Do you look at these sort of weird vague symptoms to maybe pick up and look further ?
I do , once I have a client in clinic , go through what signs and symptoms that they might have . There's a lot that we can do in in clinic to pick up on on things like here .
I do use CGM continuous glucose monitors as well , not on every single person but it , you know , a fasting blood glucose is really just telling us how well our liver coped in the fasting state overnight .
You know , with the cgm we can really get greater insight than just fasting blood glucose , uh , an insight on in in how your body is actually responding to not just food but stress and exercise .
Uh , and most , most clients , I find , uh , using a cgm is extremely motivating for them , like they can actually see in real time , um , you know , the , the , the dietary and lifestyle choices that they're making .
And you know , tech like this is the future of health , I think , and there's several platforms out there now that are integrating other diagnostics , like Fitbits and Our Rings , and they're bringing it together with CGMs to get a really holistic view of a person's health .
And , you know , bringing it all together with sleep and heart rate and blood pressure and all of these kind of things with the CGM , and I think it really helps me and other practitioners who are using them to target interventions , you know , because we can start to see the trends .
You know we're not just seeing a fasting blood glucose and a fasting insulin , which are both important together , but that doesn't tell us what's happening during the day . So starting to see where the trends are , starting to see what glucose variability there is during the day , can really help us to assess what's going on .
And you know , at the moment these are only subsidised for certain people , so people are buying them off the internet . Otherwise , well , people , and I really think that will change , I think we'll see that change . Technology really is the future of health here .
Yeah , I must , just as a caveat or as a warning , I must say they're not infallible . I have seen probably the most common thing is that they fall off after about a week or so .
So particularly those people that might sweat during their work bricklayers , tradies , athletes they have to ensure that they've taped it on and continue to tape it on over the two-week period . The other thing is I have noticed in a few people they're doing fingerprint glucose monitoring as well and comparing it and it may not correlate exactly .
I've seen sometimes a bit of a variance . It's not massive but there is a variance .
And there should be a variance , because the continuous glucose monitor is monitoring interstitial fluid , which lags behind blood glucose by about five to ten minutes , so it will eventually catch up . It will eventually catch up . It'll be five to ten minutes behind .
So , um , if there is somebody with type 2 diabetes and the the glucose monitor is telling them that , uh , their blood sugar is currently high and there's a little arrow on the monitor that shows you if it's stabilising or if it's going higher , if they're quite concerned , they should do a blood sugar check , you know , like a glucometer , because that will give
them closer to what their real current blood sugar is , whether it is actually still going up .
Just as a last bit on pathology , Karen , what other pathology tests are of use ? They show a part of the picture .
Just on a standard pathology test , I obviously would . Still , you know , there will be the fasting blood glucose , hopefully fasting insulin , which we can use to work out insulin resistance . The HOMA-IR Important to have a look at EGFR to keep an eye on kidney function If somebody does have type 2 diabetes .
Chronic kidney disease is a , you know , a common complication of type 2 diabetes . Vitamin D even can be important . Beta cells , pancreatic beta cells , have vitamin D receptors . So I always make sure you know vitamin D is optimal . If you have a patient on metformin , for example , whether it's for PCOS or type 2 diabetes or pre-diabetes .
B12 is important to keep an eye on as well , because metformin inhibits the intestinal absorption of B12 . Looking at some inflammatory markers like CRP looking at some inflammatory markers like crp , hba1c , to let us know how the body has been dealing with its glucose load over the last couple of months .
Iron studies as well can be important um very high irons , a risk factor for type 2 diabetes . So there are some standard assessments on general pathology tests that can inform us also liver function , for example . All of these things can give us a little bit of a picture that we can put together with the client sitting in front of us .
Karen , can I ask , speaking about iron studies , can I ask about ferritin ? Do you see a high ferritin being a risk factor ? And b ? Do you see , during therapy , ferritin decreasing to a normal level if it's elevated ?
I I have done from In the studies . It can I don't want to say cause type 2 diabetes , but it has been associated with high iron environments . But ferritin can be that false positive for inflammation as well .
So if we start and type 2 diabetes is a very pro-oxidant and inflammatory condition so when we start to , you know , reduce some of that inflammation , we can see some ferritin , you know , can see that go down .
You're right , gotcha . Okay , and so to therapy . So now we've got so many things that we can talk about here . Where do you start ? Obviously , it's got to be dietary driven . How do you change a diet , though ? Because that's the probably the biggest hurdle you're ever going to encounter .
How do I change a diet ? Cgms do really help , as I said earlier , as a motivating factor .
¶ Nutritional Strategies for Metabolic Health
And , yes , diet and lifestyle is absolutely foundational to the treatment of metabolic dysfunction .
Look , it can be difficult with diet , but talking somebody through the benefits of increasing their fibre intake , increasing their vegetable intake , and talking to them about the diversity of food that they , you know , rather than taking things out , I tried to crowd more in so that we can , you know , diversify , especially the plant component of their diet , given that
a lot of metabolic dysfunction is driven by , you know , highly processed foods and things like that . So it's more about getting things in and talking to them about the different colours in the food . Actually , you know , we spoke about genetics earlier .
These colours in the food are very important signalling chemicals that turn on protective functions , you know , within the body yeah , yeah , sure , um , and so what about um supplements ?
you know , um , I was speaking earlier to someone about insulin resistance and metabolic um , we were talking about the importance of myo-inositol . Now , this was mainly in females they were talking about , but when you're talking about both males and females , do you have any like top five go-to supplements that you might choose ?
Nutritionals and herbals as well . So myo-inositol is really , really interesting , actually it's . You know , we do produce it in our bodies and we also get some in our diet . But uh , with somebody who already has type 2 diabetes there's an increased urinary loss . Plus there's also decreased um absorption or penetration into the cells . So kidneys and the retina .
I mentioned earlier about the complications of type 2 diabetes being nephropathy . So kidney disease and retinopathy . They're both depleted in type 2 diabetes in myo-inositol . So I did see a study that showed supplementation with that may help to prevent or delay development of those microcomplications .
It's particularly , I think of myo-inositol , particularly for insulin resistance . I think of myo-inositol particularly for insulin resistance . It's particularly good in slowing glucose absorption but it improves the muscle uptake , so it really improves that insulin sensitivity . So myo-inositol for insulin resistance .
For me , another one of my go-tos would be magnesium , especially for cardiovascular . You know , cardiovascular health , nervous system health and function , muscle function , energy production , all those things , uh , especially carbohydrate metabolism , blood sugar support . Yeah , magnesium is commonly deficient in people with type 2 diabetes . They have increased urinary losses .
They have increased urinary loss of magnesium . So it's often a requirement .
Yeah , what about the old things ? We used to use chromium and some of the lipotropic factors ? We're restricted in Australia to the good forms of chromium , as in the polynicotinate and the picolinate , to 50 micrograms per day dosing . How do you get around this ? What do you tend to use with chromium as a dose ?
this might not be included , andrew , but I've never actually really used chromium . I've only I've never used it as a single supplement . I've only ever used it as in combination . You know it might already be in something that I'm prescribing .
Gotcha . And what about herbs like berberine ?
Oh , herbs like berberine , definitely . Berberine is particularly a go-to of mine . It's fantastic for increasing insulin sensitivity . It's also been shown to have a positive impact on body weight . Also some of those um dyslipidemias like triglycerides , for example . It actually has an , even though it works different to metformin .
It has an insulizing , insulin sensitizing sorry action similar to metformin but , as I said , it's a different mechanism . So it can actually you be used alone or in conjunction with metformin . So , um , it's very safe there .
Um , berberine has actually been shown to be as effective as metformin in lowering fasting , blood glucose and HbA1c and some of those dyslipidemias that we see . So , yeah , berberine is definitely a go-to as well .
I also really like turmeric as an anti-inflammatory helps that inflammatory cascade that you know it's a very inflammatory environment type 2 diabetes and turmeric works very well here , increasing insulin sensitivity . It also protects the microcirculation . Also protects the microcirculation so that chronic kidney disease , nephrology and the neuropathy that we see too .
That peripheral neuropathy .
Anything else that we need to discover ? I really like to use PEA , right . So this is interesting . I found PEA yeah , I really like to use PEA . It's anti-inflammatory but it's analgesic , so it's really good for that neuralgic pain and I have used it in peripheral neuropathy and had good responses .
Uh , with that , um , you know , peripheral neuropathy in type 2 diabetes is , um , it's the what's the word ? It's the highest indicator of mortality , uh , once somebody has that peripheral neuropathy and that nerve damage . So , uh , relieving some of that discomfort for people is is really important and it's so , pa pardon it's really painful for people .
It's really painful , it can affect their sleep as well , because it actually seems to be worse at night .
The thing that people don't realise with neuropathy in type 2 diabetes is , you know , we usually think of the peripheral neuropathy , so the hands and the feet and the toes , but it also has an autonomic effect where it can affect , um blood pressure control , which is one of the things that we're trying to to manage in um these metabolic , yeah , issues , uh also
temperature control and sensation , digestion , bladder function , sexual sexual function . So , people , it's not just hands and fingers and toes and , you know , as it advances , it is , you know , the highest cause of amputation . Right ?
gotcha In type 2 diabetes . What about lipoic acid ? How often do you employ it ? What dose do you go to ?
Do you know , andrew ? I didn't put anything for lipoic acid .
No , it's okay , but do you ever like forget about the notes ? Don't read off the notes , so do you use it in clinic ?
I use lipoic acid in clinic for kidney support .
Right , okay , and do you so ? Are you guided by EGFR with that ?
Yes , I am . Actually . I can't recall off the top of my head where that needs to be for that or what dosage I use . But I remember a particular client of mine recently that I looked up some some recent research on and it was definitely indicated for chronic kidney disease . Her EGFR , I think , was down to say 28 or 30 , something like that .
So it's quite low . She is very overweight . She doesn't have type 2 diabetes but she is very overweight and has quite a number of different disorders going on . But alpha-lipo acid has is definitely indicated for supporting healthy kidney function . That filtration rate karen .
What other nutraceuticals or nutrients do you tend to incorporate , like for instance we haven't discussed zinc ?
no , we haven't discussed zinc . I don't usually prescribe zinc separately . It's usually in a formulation . Perhaps it could already be in the magnesium or another combination that I'm using .
¶ Exercise and Nutrition in Diabetes Management
Zinc is really important in type 2 diabetes . It's really important for I mentioned earlier about clearance of insulin out of the body and there is an enzyme that's responsible for that . That is zinc dependent , so it's important to keep zinc levels good .
Other nutritionals that I would use would include omegas omega-3s obviously very anti-inflammatory and very good for modulating blood fats , which is important in type 2 diabetes . And we know that the DHA component is really important for eye health .
So most people with type 2 diabetes will actually get some degree of diabetic retinopathy once they've been diagnosed at some stage some degree . So that's really protective for that as well .
And you know , we know , that omega-3s improve you know that cell membrane fluidity just generally , and that helps all our cells communicate uh much more efficiently really important for cardiovascular health as well karen , forgive me , I never covered this off and I should have covered this off right at the beginning exercise .
We haven't even covered it . How do you get people to exercise ? What sort of exercises are most beneficial for them ?
uh , yeah , it's true , I'll see people in clinic that often aren't doing any exercise at all . So I'll start very simply . Start very simply . A lot of people , when they think exercise , they think that that means I've got to go out and walk for an hour or I've got to hit the gym or something like that .
But if it's somebody who hasn't exercised for a long time and they're quite sedentary , then I really want to make it part of their lifestyle . So I want them to adopt it easily . So , even if it's five minutes , it's about making it part of the routine , of of , you know , the new , the new lifestyle .
So , even if it's just five minutes and I'll just encourage people to do that they think it's not enough . But just any level of activity is beneficial . It will , you know , upregulate the glucose into the muscle cells . They'll start to feel a little bit better is beneficial . It will , you know , upregulate the glucose into the muscle cells .
Um , it'll , they'll start to feel a little bit better . There's , um , once again , a study I'm a bit of a nerd . I like reading studies um , that showed as little as three minutes a day of walking will show benefit . Will show benefit . It was as little as just three minutes on a lunch break of walking um .
And also very light bouts of resistance exercise , such as standing up from your desk and just doing a few squats , for example . Or you don't even have to leave your office room , you can go to up to the wall and just do some you know pushes against the wall .
That very light intensity exercise for somebody to start off with has been shown to be of benefit as far as glucose regulation goes . And then they can start to build on that .
And if they're wearing a CGM as well , you know , if they're wearing a CGM as well , you know if they're wearing a continuous glucose monitor as well , and they start to actually see that oh , I didn't think five minutes a day would make any difference .
And they can actually start to see that these choices it's not all dietary choices , it's lifestyle choices starts to have , you know , an impact and becomes very motivating for them to build on that .
Yeah , I couldn't agree with you more the number of times I've spoken to patients and it doesn't have to be this massive group hit therapy with everybody at the gym . It doesn't have to be that , it can be .
Simply , these people often are out of tune and so I don't want to be placing them into a situation where they're going to be over pressurizing their , over-exerting their system and putting themselves at health risk .
So I often talk about exactly what you said just doing a push-up quote unquote against the kitchen bench , or holding onto the kitchen bench and doing a squat as far as they can handle with their knees , simple things like that . I love what you've said about that exercise for three minutes a day because it's priming their system .
It's priming them for not just their system physically , but encouragingly . If you're talking about the continuous glucose monitoring , I love it .
And we want them to be successful . You know we don't want to make it hard . You know we want them to achieve the small goals because when they do that they feel motivated and they feel confident in tackling the next goal , whatever that might be . So you know , they may increase from walking for five minutes a day to 10 minutes a day .
And I often tell my clients as well don't go Dr Googling , don't listen to what your friend says or your mom says or whoever says . This is your own personal journey .
And if 10 minutes is working for you , then you just do 10 minutes and I just tell them that I want them to be successful , I want them to achieve that goal and then you know , as I said , they will have the confidence then to tackle the next one .
Beautifully said . Just a last point about red flags and potential medication interactions . What do we have to be aware of ?
I know that there's a lot of clinicians out there that are really concerned about prescribing nutritionals or herbal medicines with , you know , common anti-diabetic drugs .
But I haven't come across , I certainly haven't had the situation where I've personally experienced a negative interaction with any of my clients , and in fact a lot of the studies show , if we use metformin as an example , being one of the most common medications for metabolic dysfunction , in fact , some of our herbs , such as curcumin and nigella berberine , they've all
been shown to work very strongly synergistically with metformin . So yeah , you know , they work very well together . In fact , I think it was actually with berberine that it can be prescribed alongside metformin .
But as an example of how it can potentiate the effects of metformin , if it's prescribed two hours prior to somebody taking their metformin , the metformin will actually last a little bit longer than if they didn't take the berberine . So it increased the .
I can't remember the mechanism , but it increased the bioavailability of the metformin when it was dosed a couple of hours in advance . So , yeah , yeah , it's , you know , know , like ginkgo and metformin .
Um , I've looked at that because I use ginkgo for , uh , kidney support , the microcirculation there , and it's been shown to work together very well with metformin in in reducing fasting , blood glucose , bmi , waist circumference , so they work very well synergistically together . I've never had um an adverse uh combination effect . Um , in fact it's . It's it's often .
You know the pharmaceutical drugs that have the side effect . So , talking about metformin , 30 percent of people on metformin will have gut issues with it . So there'll be , nausea , diarrhea , yeah , even vomiting , um , in some people . So , uh , it's , it's a , it's a .
It's a safe environment to prescribe our herbs and they work very , very strongly synergistically with a lot of the diabetes medications .
¶ Covering Metabolic Health Essentials
Karen , thank you so much for taking us through this today . I know that we bit off way more than what we could chew . This is such a huge topic and we've only covered a small part of it . It's like a three podcast series , but thank you so much for taking us through your expertise today . I really appreciate it .
You're very welcome , thank you through your expertise today .
I really appreciate it .
You're very welcome , thank you and thank you everyone for joining us today . Remember you can catch up on this podcast . We'll put in the show notes as much information as we can , and all the other podcasts are on the Designs for Health website . I'm Andrew Whitfield-Cook . This is Wellness by Designs .