89 – The six lifestyle changes that support your hormones and health

0:00Today on the podcast I've got Dr Clare Nieland who is a GP and specialises in lifestyle medicine. Something that we should all be doing. We talk a lot about how to prevent diseases. Thinking about our lifestyle, how we move, what we eat, our mental health, how we sleep. All of that feeds in obviously with balancing hormones too. So it's a great conversation and I hope you'll come away wanting to improve your lifestyle from it. So Claire, it's great that you're here. You are, like me, a GP, lifestyle guru. And it's really confusing out there because there's lots of wellness, lots of lifestyle, longevity, health span, lifespan.

0:46Some of it, dare I say, is really commercial. And in my mind, a lot of it is common sense. But I've learned a lot just through my own personal journey, but also just being older, wiser. but a lot of lifestyle nutrition even exercise we didn't get taught at medical school and I don't think they still do now do they? Well it's becoming slightly more common so some universities are teaching lifestyle medicine some medical schools are which is great but I mean I think for me if I think back eight to ten years I was sort of introducing lifestyle medicine to my patients without really knowing what it was I didn't really know that it was a specialty in its own right and it wasn't until I went to a conference and I discovered the British Society of Lifestyle Medicine that I discovered it's actually a subspecialty in its own right and I joined BSLM and I've never looked back because I think I was at the point where what I was doing with my patients as a conventionally trained medic wasn't really working.

1:45You know we're taught to treat the end disease and actually we don't really look upstream to what's causing that and that's really where lifestyle medicine for me offers such um such hope to patients because we can really tackle the sort of underlying factors that are causing that end disease and um i'm not sure whether your listeners will know what lifestyle medicine is shall i just give a little explanation because it does mean different things and even to different doctors i think it means different things absolutely so lifestyle medicine is it's a rapidly growing specialty you can now do postgraduate qualifications in it which I have it's based on three fundamental principles so the first principle is a knowledge and understanding of the wider determinants of health and by that I mean things like environmental factors so do you have access to green space to get out in nature do you have access to good whole foods are you in employment for example and then it's the six pillars which I'll come back to in a sec and then it's the the thing that I think is the magic here is a knowledge and understanding of behaviour change so how we really work with patients on an individual basis to help nudge them closer to better lifestyle choices so those six pillars which is what lifestyle medicine is based on are physical activity nutrition sleep stress management avoidance of unhealthy substances and the one that often gets forgotten about social connection which is a great uh factor in longevity yeah and the seventh one it's got to be hormones i know i've heard you say that before and i do think you're absolutely right because actually if we don't think about it i think we're missing a trick so many of my patients and me as well find it impossible to do any of those six pillars if our hormones aren't balanced and i think people have been so scared of what hormones are but but even it's it's very obvious when you talk about it but it's not obvious and I think a lot of people who haven't been had training in lifestyle medicine they almost think if I start talking about it that's my whole 10 minute consultation gone whereas even as a GP I used to just say to people do you do any exercise and it's like a yes or no answer and then I'd find they'd come back to me and go do you know what I felt so embarrassed that question you asked me I've now started to go for a walk or go for a run yeah and I thought and I just thought ages ago wow I don't have to be taking a full history of how many minutes or what exercise and I don't know what we absolutely don't have to because sometimes it's just asking the right question at the right time and getting people to think about it and actually in NHS primary care now we've got lots of allied healthcare professionals that can pick that conversation up so for example we've got health coaches we've got social prescribers you know got clinical pharmacists so if we just ask the right question at the right time and you're right we don't have to spend the whole 10 minutes talking about it but it just gets people thinking and it opens the door to that conversation and the more I think about it the more I think there have been so many missed opportunities over time both in my own consultations and those of my colleagues and I almost think we're doing we're doing a disservice if we don't mention it because we know you know lifestyle medicine isn't evidence-based approach to prevent, treat and reverse chronic disease.

5:05And I almost feel like if we're not even thinking about it, then we're certainly not practicing good medicine, because it's a basis of good health. You know, it's the fundamentals. And I think coming back to hormones, you know, yes, women may need a little bit of hormonal support to start on that journey to better health. But if we're not having those conversations about lifestyle medicine, then maybe a woman will get so far with hormones but then she feels like she's reached the end of the road and absolutely not we need to help in all those six pillars yeah absolutely and in my mind it's the foundation of everything regardless of what else is going on and like you said at the start it is about preventing disease you know every health care system in whichever country you look at is having a crisis because there is too many chronic diseases as in chronic long term but they're related to inflammation yeah the source of everything is is inflammation and if we can reduce that and we know that lifestyle measures will reduce inflammation so therefore reduce diseases yeah absolutely and inflammation or meta inflammation or whatever you want to call it you know if we can use our lifestyle measures to reduce inflammation we're reducing our risk of long-term chronic lifestyle related diseases and you know living with perimenopause and menopause we're going through more than just hormonal changes.

6:27You know, we're seeing cardiovascular risk rise, Alzheimer's disease risk rise, other diseases like type 2 diabetes, because our blood sugar control, you know, becomes slightly difficult to manage. So we're seeing a rise in other lifestyle related diseases at this time. And therefore, it's a brilliant opportunity to open those conversations. And let's not forget, you know, a lot of this starts in our 30s and our forties it's not all about what we're doing no it's got to be done really early you know even thinking about other times of hormonal change so women with pmdd premenstrual dysphoric disorder they have a real decline of hormones in the second half of their cycle study came out last year showing those people have an increased incidence of inflammatory diseases again associated to the anti-inflammatory properties of our hormones but i feel strongly and i'm sure you do as well as as a doctor that I should be setting an example for my patients I feel like there's no point me talking about exercise and never doing it or telling people that they shouldn't smoke and then smoking I don't smoke by the way but you know but but I feel it's not ingrained in us enough I mean we do have to be some sort of role model for our patients do you think yes and no I think you can still be a good doctor and you're not saying it's a good doctor but I feel that we have some responsibility to help ourselves as well as educate others.

7:53Yes, because I think the other thing is lived experience. If you know how good exercise feels, you're more likely to recommend it to your patients. If you know how good your body feels when you've had a whole real food meal, nutrient dense meal, you know, no ultra processed food, and you're not having that mid afternoon slump, you're more likely to recommend it to your patients. So I think you've got you've absolutely, absolutely got a point. And I do I do you know, I walk the walk as well as talk the talk. But that's because for me, I need to turn up being the best version of myself that I can be.

8:26And I know the only way that I can do that is to prioritise my sleep, to eat well, to make sure I'm managing my stress, you know, all these things that we base lifestyle medicine on. I mean, I think just to come back to something you mentioned earlier about spending the whole 10 minutes talking about lifestyle medicine, sometimes I wonder what would the NHS look like if we have much more of a focus? on lifestyle and you know hopefully this is coming as we sort of look at the 10-year plan but there's by by no means enough focus on prevention but lifestyle medicine we can prevent we can reverse and we can treat chronic disease so you've only got to look at the work of david unwin who you know and you very kindly spoke at our conference the other week um but david unwin who's working with public health collaboration uses lifestyle to help reverse type 2 diabetes And I've been doing that in my practice and he's been a great mentor to me.

9:20And it's amazing to see the difference that makes. And when you can de-prescribe medication as a doctor, it feels great. It's amazing. But actually, you know, listening to him saying about how doctors are paid to prescribe, you know, with part of the QOF, the quality outcome frameworks, then disincentivises doctors to do lifestyle. it's so easy to just prescribe something if someone's got diabetes or raise blood pressure or raise cholesterol then it is and I used to I was I've never been a partner so my salary was the same regardless of what I did and I used to really frustrate my partners because I would be not rushing to prescribe and thinking about lifestyle and giving it time but I was very lucky because I knew my patients really well and I knew the ones that were more likely to engage with lifestyle than others and some of them you could almost have a bit of a joke and shame them into it when they saw their blood pressure going up with the amount of alcohol they were drinking and the number of fags that they were smoking and you could sort of call them out but it was a very I was very privileged because I worked in the same practice for 20 years so I really knew the patients like now I think it's hard if you don't have a relationship with a patient it could really undermine that whole confidence in your doctor if you're trying to call them out because it's difficult.

10:39A lot of people, these are addictive substances. Yeah, very much so. So many threads I could pick up on there. I mean, a couple of things. Look, I'm senior partner in my practice. I've been there 17 years and I practice lifestyle medicine. So it is very much not about the quaff points in our practice. And my doctors are all on board with this. It is about the person in front of us. It's about trying to help them to be healthier, be fitter, be strong fit resilient and not rely on medication and I think use the word shame there and I think that's a really important point because what we try and do is empower our patients help them understand maybe what those changes are that's going to lead to better health and then use behaviour change and I think obesity is a really good example you know as doctors we've been afraid to talk about obesity with our patients because of fat shaming because there's some implication that it's their fault.

11:35And I think if you can remove that blame and just talk open and honestly, you know, you've only got to walk around the supermarket and see what the food landscape looks like. It's very hard to buy healthy food. And I think if we can remove that sort of, you know, that shame that goes along with obesity, we can then start having really meaningful conversations. But the bigger picture is the food landscape and, you know, big food and big farmer and the people who make the policies. And I don't want it to become a political conversation, but I think there are bigger conversations out there. I think, you know, there is.

12:13Farmers change the landscape a lot over the last 50 years, really, hugely. When you look at the, I'm very interested in the history of medicine and you work out what goes wrong or what happens and you do see what's happening. It's like you said at the beginning, we're taught to treat disease as doctors, not to prevent it. whereas if we prevent we don't want to wait for that heart attack or wait for the stroke or wait for diabetes we should be intervening a lot earlier to avoid the medication avoid the disease but I feel you know a lot of my work is just empowering people with knowledge and that's where this conversation is so important because everybody listening to this needs to be thinking right am I really the best version of myself we can't just be leaning on our doctors and waiting to prescribe something I think you know maybe because I'm getting older I don't know but I'm so much more about you know I have to take responsibility for my health and partly lots of people know I have migraine and if I if I eat badly if I have a lie-in if I go to bed too late I'll get migraine so it's a it's a devil and a it's sort of it's a good and a bad thing having migraine because it rules my life and I don't know what it'd be like if I didn't because I probably would slip up I probably wouldn't bother doing yoga and I wouldn't meditate and I wouldn't do all those things but I have to but I do feel we have to as patients have responsibility yes I agree I mean I think just focusing on the migraine side of things you can now frame that in a really positive light that actually the benefit if you can use that word of having migraines is that you meditate you do yoga you avoid alcohol you eat healthy food yeah so frame it in a really positive light.

13:57But I think for patients, for individuals, look, being healthy suddenly feels really hard. I mean, you've only got to go on social media and see what people are putting on there to, you know, do this and you'll feel 10 years, you know, please, it's not about social media and lifestyle medicine keeps things really simple. And I think being healthy, it absolutely can be simple. You've just got to navigate your way through the rubbish that's out there. And I I think that that's where the British Society of Lifestyle Medicine comes in, training clinicians on the evidence base around lifestyle medicine so that it's not just, you know, sticking a finger up in the wind and guessing.

14:37It's using the evidence to support our patients. And I think from a patient's perspective, having that knowledge and understanding. Look, if any of your listeners think to themselves today, gosh, you know, I'd actually learn, like to learn a little bit more about this. what is it in my lifestyle that could impact my health moving forward, then brilliant, go and do some research, go and see your doctor and have that conversation. Because we know in menopause, well, actually, over the age of 40, our muscle bulk is decreasing, we're at risk of sarcopenia, our bones are thinning, we're at risk of osteoporosis, our risk of cardiovascular disease, etc, goes up, as we've already said.

15:16So yes, that's where the hormones come in. But it's also about where the strength training comes in and the protein comes in and you know managing our stress and our cortisol levels and you know there's so much more to it and it doesn't have to be difficult. Before we continue I'd like to tell you about Newsome Clinic the sponsor of this podcast. I founded Newsome Clinic to improve access to expert evidence-based hormone health for women. Our specialist clinicians support women with perimenopause, menopause, PMS, PMDD, postnatal depression, endometriosis, PCOS or PMOS and other hormone related condition.

16:01My clinic makes this podcast possible, allowing us to continue sharing free education and information to help women better understand their hormones and health. to learn more about newson clinic or book an appointment visit newsonhealth.co.uk this link is also in the show notes the real art of medicine is personalizing care it's really interesting and important that we look at the science but i'm very interested in how we personalize medicine and that includes lifestyle because you know you can't tell everybody to eat the same because they all have different metabolic responses to the same food or to exercise or whatever so and that's really important and somehow I think in medicine the personalization has has almost been lost a bit it's all quite guideline driven it's quite formulaic and that seems a shame doesn't it well yes and that's where lifestyle medicine really shines because it is about personalized care it's about the person in front of you so it's about meeting that person where they're at look if they can barely get up out of a chair there's no point in me telling them to start lifting weights you know actually for them maybe just going for a gentle walk is the first step to them doing some physical activity so like you said it comes back to knowing the person in front of you and really being interested in them you know what is it that they might like to do how would their life look better and then using the health coaching techniques to help them nudge them around that cycle of change.

17:36So I think there's a lot that can be done with the person in front of you, not using, I mean, look, what are guidelines? Guidelines are just that. They are not tram lines. They're guidelines that give us a bit of a framework around which we can build a really rich and nuanced conversation with our patients. And I think, you know, I'm a GP trainer and I'm passionate about training and they're really useful for younger GPs, you know, who are perhaps a little bit less experienced. But I think as you get older and wiser, you know, with age comes experience and wisdom. And I am very happy to use the guidelines as just that, as guidelines and have a really nuanced conversation with my patient in front of me.

18:20And if that means maybe stepping outside the guidelines, if I'm safe, then that's fine. And the thing about lifestyle medicine is I am not going to do any harm with lifestyle medicine, you know, and one of our overarching ethical principles is non-maleficence, isn't it? Do no harm. I'm not going to do any harm with lifestyle medicine. And I see so much benefit from it. Yeah, absolutely. And I do think this whole deprescribing is really important. You know, if you look at the Maudsley deprescribing guidance for gabapentin and progavalin highly addictive drugs like they are being prescribed so much when they came in and they were given a lot for depression and mood stabilizing i'd never got into that because i couldn't understand how they worked and now we're trying to you know whole books written about deprescribing but there's very little about lifestyle and very little about hormones as well the two things that really improve mental health and so we deprescribe a lot and it's like you say it's really rewarding but it's not just the mental health drugs blood pressure drugs diabetes drugs painkillers you know in my mind lifestyle and hormones go so closely together both of them I'm sure they're the similar drugs that you're deprescribing as well yeah absolutely one of the other things that we do in lifestyle medicine is something group consultations where we bring together people who have the same chronic disease and it's often things like type 2 diabetes or obesity or menopause is another really good one because I mean they get social connection but patients get the opportunity to share what's worked for them and share tips and advice and then as a clinician I will go in and do their one-to-one consultations But when I can stop prescribing something, the patient loves it.

20:14I love it. I've saved the drug budget a bit of money. You know, it's really, it just feels great. It's very powerful and it's almost counterintuitive because we're taught so much. This is a disease. This is the guideline. This is the treatment. Whereas we're sort of doing things differently. But actually to deprescribe when you don't have an alternative to offer can be really hard. You know, I think back in Shudder when I was a GP 15, 20 years ago, and it would always be the middle aged women that were addicted to the benzodiazepines and that no one wanted to prescribe for them. And these were women who then they'd started in middle age.

20:53They were 60, 70, and they were really struggling without them. So I would be the person that saw them, spent lots of time with them, try and reduce the amount to as much as possible. But I never once thought about hormones. I feel really bad because I know now, you know, once you give hormones, then they start to exercise, they're sleeping better. They know themselves they don't need those medication. So it's really easy. I was trying to explain to a psychiatrist recently how much easier it is to deprescribe when you've given them something else instead. Yeah, absolutely. And I think that's where lifestyle comes in as well, because actually what it does is it shows people that there's a different way.

21:32it doesn't have to be all about medication um and showing them there's a different way that can achieve the same if not better outcomes you know we all know that if you if you eat ultra processed food and your body's inflamed your risk of mental health uh mental health problems is going to increase so actually how can we get you to exercise a little bit more what are those small steps that we need to take to make you make you do that and once people find that out for themselves it's very empowering so just on ultra processed foods yeah there might be people that don't know what that means okay can you it is so important yes it really is um i mean look you can use the standard nova classification but for me keep it simple if you're buying something and it's got more than five ingredients on the packet put it back essentially don't really buy anything out of of a packet if unless you really have to and look I totally get that people are living on a budget and not everybody has the means to buy expensive whole foods but you can still avoid ultra processed foods and eat well on a budget and actually where I work in Maidenhead our primary care network has done a piece of work with our community teaching people how to cook from scratch on a budget because you very easily can but I think we've we've sort of lost that kind of basic understanding somewhere along the line and we are led to believe that to eat um eat within a budget you have to eat rubbish or get the two for ones or you know and actually you really don't so I think there's something there about teaching children how to cook in schools making sure that our children our next generation are educated around what real food looks like and then um you know teaching people how to cook well on a budget using real food because it's the it's it's the it's the ultra processed foods that's driving a lot of inflammation it's driving our obesity epidemic it's driving type 2 diabetes fatty liver disease you know all the problems we've already spoken about because they cause a lot of inflammation don't they in the body and they're highly addictive as well it's it's a sweet spot yeah of fat and sugar that the very clever food processing companies uh you know know that they make us they're hyper palatable and they don't fill us up so one conversation i often have with my uh in our menopause consultations is about the importance of protein and using protein and fat fat is our friend you know good sources of fat are really important and we shouldn't be afraid of fat in our diet and you know the importance of getting enough protein so that we are feeling full and we can go and lift some weights if that's what we choose to do um you know and actually it helps us sleep better and sleep's the other thing you know sleep's our superpower and for women who are going through perimenopause and menopause and they're awake at three in the morning it's exhausting it's absolutely exhausting so what can we use from a a sleep hygiene perspective that's going to help you know yes hormones absolutely transform women's sleep but what can we do from a sleep hygiene point of view that means if they are still waking at three in the morning what measures can we put in place that mean they're not reaching for their phone and they're getting that dopamine hit so that's where lifestyle medicine comes in as well but you're right people learn from each other they learn good things but they also learn bad habits as well and it is throughout generations you can see that people are getting lazier they're not learning to cook and you know but it's really hard in some areas to even buy fruit and veg you know if that's what makes it so difficult yeah it's called a food desert and I mean you know you've only got to look up and down some of the streets in London where we are today and and and really appreciate how difficult it is for people to get their hands on good whole food yeah but it is about investing in the future but I think also unless you try changing your lifestyle you don't know how much better you feel because it's really easy to think this is as good as I get and I do worry sometimes about GLP-1s how people think that's just a quick fix but and obviously they do reduce some inflammation in the body but you still need the nutrients.

25:59Yeah absolutely I mean I bang on about this all the time because I find obesity medicine really fascinating and I've worked in that field and the landscape of the GLP-1s is changing very rapidly. We've got many more drugs not only available now but coming to fruition so there will be more drugs available and what we do in my clinic is we make a deal with the patient that actually if we're going to start a GLP-1 which probably is the right thing for some of my patients to have, then they work really closely with our health coaches on the nutrition and the physical activity. Because all that happens otherwise is you go from being an unhealthy person living with obesity to an unhealthy person who's a bit slimmer.

26:45Because what we really want to see is the metabolic changes. It's not just about the weight and moving people away from just the weight on the scale. And, you know, that's why I measure things. I quite like data. So, you know, that's why I'll measure lipids and HbA1c. And in my private clinic, both at the Windsor Wellness Clinic and Hook in London, where I work, we will measure markers of inflammation so that we can see the needle move. And that's not possible on the NHS within our budgets. But some of the simple tests like lipids, like HbA1c, like CRP, we can measure those and we can see the needle move.

27:20But it is about getting those lifestyle factors in place so that you still become, you're becoming healthier, not just slimmer. Yeah. And that's a problem. I think people are so fixated on how they look and forget that muscle is metabolically active. Absolutely. Bone is metabolically active. So that's where making sure that we're moving and exercising all the nutrients that we need, all those vitamins. Yeah, absolutely. If you're not eating, you can't get them from anywhere else. No, absolutely. And we do see problems with the GLP ones. You know, we've seen some deficiencies in nutrients that have caused real problems.

27:53but the other thing about that is the rise of the skinny culture and I think that is a really dangerous way to go and so I'm very much about promoting strong fit resilient women not skinny women because skinny is as unhealthy as obese and so actually we need to be promoting what fit and healthy looks like and that's where the role of sport comes in for young women you know getting young women into sport because it's about understanding how you need to fuel your body rather than you know what how you look yes and that is so important and I think that's where people are looking more into weights as opposed to doing high intensity workouts which can be really beneficial for anybody of any age as well and trying something new my my middle daughter's really into pilates she's traveling at the minute so she sent me a video of her this morning doing a Pilates class in Indonesia just to make me really jealous oh amazing but she does reformers she really enjoys it and it's great because she had sepsis of her pelvis a few many well a few years ago and it really stopped her exercising so she's had to find something that works for her but now it does it's great to see her really enjoy and want to build her body in a very positive way yeah yeah I think to find the right exercise and you must see it in your patients as well it's not always the first exercise so people that say i hate exercises often they hate that type that they've tried i i think i mean i i frame it i use the word physical activity because i think exercise traditionally can make people think oh no i don't want to do that get a bit sweaty and work hard physical activity or daily movement just movement absolutely you know just so 10 minutes walking around the block at a brisk pace after eating will help with your blood sugar control.

29:44It doesn't have to be any more difficult than that. I mean, yes, it should be. We should be lifting weights three times a week, maybe a bit of cardiovascular exercise in there, and maybe a bit of HIIT training. But it doesn't have to be that. Just because that's what I do doesn't mean to say that that's what everyone has to do. It's finding something that works for you and that you enjoy. And if you can do it with other people, then you've got that social connection as well then even better and exercise will help us make better health choices with our food it'll help us sleep and it releases our happy hormones you know we feel better we get that dopamine hit and the other thing we haven't touched on at all which may be out of the scope of today's talk but is the gut microbiome and the importance of our you know of having good healthy gut bacteria to help with the hormones and our kind of state of mind as well and reduce inflammation yeah there's lots of other things it's but but they improve when we exercise as well which a lot of people don't realize they think it's all about taking probiotic or eating the right food but actually moving helps them as well doesn't it yeah absolutely and you don't have to take a probiotic I mean I do think the food landscape's changing and I do wonder about the quality of our food these days um but you know if you're eating a diverse range of you know 30 plants a week and that includes herbs and spices you know it hasn't got yeah absolutely it doesn't have to be 30 types of vegetables there are ways to to get that into your diet then you'll get and I say to my patients look just eat the rainbow every day you know it's let's keep things simple because it goes back to being health seeming so difficult again and it not needing to no I think making it as simple as possible makes it achievable as well and I think that's really important isn't it yeah Yeah, absolutely.

31:37And I think, you know, I would love to see lifestyle medicine become mainstream. You know, we are still working towards that. We're doing a lot of education for clinicians. I think patient empowerment is really important. I'd love to see the NHS have, you know, when somebody joins a practice, let's give them a lifestyle medicine questionnaire to fill out as opposed to just have you got heart disease, Alzheimer's, dementia, type 2 diabetes, which is what it is at the moment. Actually, how much are you moving? What's your alcohol intake like? Are you smoking? Do you sleep well? Yeah, we need to be thinking differently to keep healthy and prevent disease.

32:13So I'm really grateful you're coming today. So three take-home tips. People might be sitting there thinking, it's all very well, they're really healthy, they've done it. What can you do if you're just overwhelmed and you want to improve your lifestyle? So the first thing I think I would say is make well-being your own self-care at the top of the list because for women particularly those of us who are you know in in midlife we're the caregiver we're working we're trying to be all things to everybody if you don't look after yourself you can't look everyone else look after everyone else so move yourself from the bottom of the pack to the top of the pack and that self-care might just be five minutes of deep breathing before you go to bed at night it might be a little walk around the block to get some natural light exposure and some vitamin D.

33:04It doesn't have to be the big things that we've spoken about today. So put your self-care at the top of the list, because if you don't put your health as number one, nobody else will. And then it suffers. I think the second thing is have a think about what is one change that you could make today, one really simple change that you could introduce into your life and maybe it is let's try and cut out ultra processed food let's introduce more protein maybe it is yes I'm going to pick up some weights but just one change but make it sustainable make it so that it can become a habit that that sticks because they're the things that will last and will serve as well and I think the third thing would be, look, get involved.

33:50I mean, have a look at the British Society of Lifestyle Medicine website, see what it can offer if you're a clinician and you're interested, see what we do at BSLM. If you're not and you're a patient or, you know, if you're just a normal human being who's interested in lifestyle medicine, a lot of resources on the website. So get involved and know what you can do for yourself and then put that into action. fantastic thank you so much oh absolutely pleasure thank you for having me it's been great fun thank you so just a quick one it would be really great if you could follow or subscribe to this podcast this will really help me reach more people with evidence-based information about hormones and their future health and also means you never miss a future episode thank you