Welcome to Pushing The Limits. The show that helps you reach your full potential with your host
Lisa Tamati. Brought to you by lisatamati.com.

Lisa Tamati: Hi everyone and welcome to Pushing The Limits this week. Now, today, before we get underway, I just want to remind you. We have our eight-week long webinar series. This is once a week for an hour to an hour and a half that's going to be held from the first of September 2021. So if you're listening to this later on, we will be doing this on a regular basis. This is all about upgrading your life and improving your performance, your health, your mental well-being, your mental resilience, and toughness. You can learn an awful lot about your own biology. Stuff that you really should have known from the beginning. It's really all about upgrading your life and your potential. 

If you're interested in joining our little group for this, then please head on over to peakwellness.co.nz/boostcamp. That's boost with an S. BoostCamp. Come along and join us there. All sessions will be recorded. If you can't make it live on one or the other evening, that's no problem. You'll have lifetime access to this information as well and it's going to be a nice little community. It will be hosted live by me and Neil Wagstaff, my business partner who is a minefield of information as well. So I do hope that you will join us for that. 

Today's guest is a lovely lady. Now, I was contracted by her to do a speaking engagement, actually, up in Auckland to speak to a young group of gymnasts. We just got on like a house on fire because we both have similar outlooks on health prevention. She is Dr Katherine Sowden. She is a gynaecologist. She's a really highly respected professional and she currently leads the gynaecology services for Counties Manukau Health, Middlemore Hospital. Katherine has been a consultant gynaecologist at Counties Manukau Health since 2004. 

She's also the departmental lead for the non-tertiary gynecological oncology which is particularly interested in the management of premalignant gynecological conditions. She has also a private practice at the Auckland Women's Gynaecology which you can find online at aucklandwomensgynae.co.nz. She has a wide range of general gynaecology services and surgery. So she is a lady who has a lot of experience and today, we're going to be talking about women's health in particular and we're going to be talking about reproductive health. We're going to be talking what obesity does in regards to women's health. 

This one's really a bit of an eye-opener. It was certainly an eye-opener for me. Some of the statistics said... Dr Sowden actually shared with me. I was just like, 'Wow, that is damn scary’. So really one that you need to listen to. It's not irrelevant for the guys either because what happens with a woman when they're obese sort of also happens for men and with other implications. So make sure you tune in to this episode with Dr Katherine Sowden. 

Before we head over to the show, just want to remind you too of our longevity and anti-aging supplement, NMN. That's short for nicotinamide mononucleotide. You can check that all out on nmnbio.nz. I'll refer you to the podcast episodes that I did with founder Dr Elena Seranova who I have actually joined forces with in order to bring this down under because I wanted this desperately for my own family and now we have it. On that note, just an interesting side note, I've been on the NMN now for about nine months, I think it is, then had huge results for both my mother, my husband, and I. I've actually managed to even reverse menopause so that's pretty amazing. So make sure you check that out nmnbio.nz. Now, over to the show with Dr Katherine Sowden. 

Hi everyone, welcome to the show. Fantastic to have you here with me today. I have Dr Katherine Sowden with me who I met recently when I went to Auckland to speak to her gymnastics club. Well not yours personally but you sponsored me to come up there and talk to the young ladies here who are doing gymnastics which was fantastic. But you are also a gynaecologist and the clinical lead at the Auckland... Help me out here Katherine again.

Dr Katherine Sowden: Counties Manukau. Middlemore Hospital. 

Lisa: Middlemore Hospital and also have a private practice with a colleague Dr Lulu van Eeden that you run as well in gynaecology. So today's discussion is going to be all around women's health and what you see as some of the big problems that our society is facing with regards to women's health and all along that line. So Katherine, welcome to the show. Fantastic to have you here.

Katherine: Thank you, Lisa. Lovely to be here.

Lisa: Yeah, you go for it because we were already talking prior to this thing so let's get started.

Katherine: Well, I just like to talk about one of the issues facing us in women's health today. It's an issue around lifestyle and normalization of obesity. Essentially, we have an obesity epidemic and it's due to lack of physical activity, and poor food choices, and I guess a lack of understanding in the community about what is important with regards to health and movement and the importance it plays in your general well being. 

But one of the things that we deal with a lot at Counties Manakau Health is cancer of the lining of the womb which we call endometrial cancer. Also, the stages leading up to that. Women don't suddenly just get endometrial cancer. It's a slowly progressive disorder that starts with a normal endometrium when a woman is younger and over time, the endometrium changes and eventually, it turns into a cancer. 

Now, the leading cause of that is having too much estrogen and one of the leading causes of having too much estrogen is obesity. So what happens when you are overweight, your peripheral tissue or the fatty tissue leads to a production of more estrogen. So it's not just produced in your ovaries. You can get a conversion of substances in the fat to make estrogen so you end up in a hyper or too much estrogen state. What that does is it essentially tunes your ovaries off. 

This is why obesity is related to infertility because women don't have a normal ovulatory cycle and it also creates a lot of elaborate effects on the body and it overstimulates the lining of the womb. When your ovaries are turned off in this environment, you don't produce your normal hormonal environment so you don't produce progesterone which is part of a normal menstrual cycle which enables ovulation. So what happens with the constant stimulation of the endometrium, you get mutations occurring in that lining. Then over time, if you continue to get that hyper estrogenic environment, those mutations over time can turn into precancerous and cancerous changes. 

In a traditional teaching for us was this was a very slowly progressive disease and endometrial cancer was something that affected women over 40 or predominantly over 50. But what we're seeing in the population now which is really concerning and particularly in the Maori and Pacific population is we're seeing these changes younger and younger. We have women under 20 with endometrial cancer which, for many years ago, was unheard of. So obviously, the implications of that are huge because it's a cancer and the definitive treatment of cancer is a hysterectomy where you remove the womb. So this takes away a woman's choice for reproduction. 

The implications are enormous. They've become heavily involved in the medical system. We have to constantly follow up, constant intervention. Huge cost to them personally and huge cost to the health system. So it is a real worry and we know. Just to put it in perspective, if a woman has a normal BMI, her relative risk of endometrial cancer is one, okay? If her BMI is 30 to 35, the relative risk of having an endometrial cancer is 2.5. However, if her BMI is over 40, and we have a large number of women with a BMI over 40 in our society and it's kind of been normalized to a degree. The relative risk of getting an endometrial cancer is 7.1. 

So just for people listening to that, it means you are 7.1 times as likely to get an endometrial cancer than someone who has a normal BMI which is 18.5 to 25. So there is a hugely increased risk and a lot of these young women are obese from a very early age. You can imagine that high estrogen state for all of that time and what it's doing to the endometrium. That's why we see a lot of women in their 20s now and they certainly, even if they haven't got the cancer, that they've got the precancerous changes. When you see them and make this diagnosis, it is absolutely tragic. 

Lisa: Does this also affect breast cancers as well? Because there's another estrogenic. 

Katherine: Yeah. So we do know that there's also the obesity and the high estrogen states increase the risk of breast cancer as well. 

Lisa: Wow. I study genetics as you may well know. We're looking at the metabolites of the estrogens and which innate pathway, genetically speaking, a woman takes. Whether she's got more of the two hydroxy which is the more protective form of the estrogens or the four hydroxy. We have all three but what it predominantly does? Does that also play into the risk factor? So if we can identify a woman who may have that tendency to make the four hydroxy, I've just come off a call with a lady with that particular problem. Is that part of the equation as well? Because then, it's the more inflammatory, more quinones, and reactive oxygen species, and all of that sort of stuff? 

Katherine: Well, it may be, but we don't have any data around that and that would certainly be something that would be really useful to look at but we don't have the data to state that as effective at this point in time that I'm aware of. 

Lisa: Okay. Yeah, yeah. This is where it's interesting. Because I'm across so many different... Shallow knowledge of many different things it's quite interesting to see and connect the dots sometimes because one silo isn't here and another silo isn't there. Sometimes you get to see with those two dots connected.

Katherine: It may be so. Are you aware of any on there?

Lisa: So the four hydroxy definitely. I'm definitely aware of a lot of clinical data around. I can't off the top of my head bring them out. But around the endometrial and the breast cancers and the increased risk of that. Then, if we also look at, for example, hormone replacement therapy or the pill, the contraceptive pill and how that plays into it. So there's evolving data around that as well. 

Because if you've got the more inflammatory types of estrogens and then you add in the pill or later on in life, maybe the hormone replacement therapy, what risks... For example, with the lady that I was just speaking to has four hydroxy predominantly. That means for her, in combination with some of her other genetic factors in methylation detoxification, cop genes, all of those types of things. Not a great candidate for hormone replacement therapy because we're going to exponentially increase the risk if that makes sense. 

So yeah, we've got to dig into the weeds, probably off-camera, on all of that sort of correlation there. But what you're saying is that obesity is a major factor. Is this because the aromatase gene, the CYP19A1, this is the one that turns the testosterone into estrogens if you like. Then, expressed in fat tissue and that's why you get a lot more of it when you're...

Katherine: That's correct. Yeah. You get that conversion in the peripheral tissue of the androgens to estrogen. 

Lisa: Right. This is valid not just for women though, is it? Because if you just look around the population of young men who are struggling with obesity, they're also looking more feminized. Gynecomastia, and their love handles, all of those sorts of things. This is also playing a role with them and their hormone situation, their hormone household. So what can we do? Obviously, we need to lose weight but where do you think this is stemming from and why is there a tide of it now? Is it to do with... you were talking about the Pacific American populations. 

Genetically, from a genetic standpoint, we have a higher endomorph body type, higher problems with the MLS genes, the FTO genes which has ability to process fat. They also have a tendency to go after the higher energy, caloric, dense foods than other people and there's a whole lot of genetic predisposition factors there. We need to be doubly careful if we have that. It's like a background and then, there's the food industry. What does the food industry play in this?

Katherine: Well, it's huge because there's what they call obesogenic foods. It's everywhere, and it's easy, and it's available, and it's cheap. This is part of the problem and I think we've got... No government in New Zealand has the guts to say, 'Actually, this is not okay because we're creating a public health crisis.' One of the things that they do in some nations overseas is they remove the sales tax off fresh fruit and veggies. In France, for example, they don't put VAT on fruit, vegetables, or baguettes.

Lisa: The agricultural thing.

Katherine: But no one has actually been able to stand up and address this at the government level and I think that whatever political spectrum you're from, it's the same. I think it's unpalatable from a liberal point of view, however, I think it would be hugely beneficial. If you are a low-income family, how on earth can you afford to fill your trolley with healthy food when it costs three times as much as the cheap stuff? We tax cigarettes, we take alcohol. Why aren't we taxing some of this junk food? It is of no benefit to people whatsoever.

Lisa: It's costing the country money, let alone the personal tragic circumstances which are obviously the first and foremost but it's actually costing the health system. It's an avalanche that's coming. You and I know the statistics on this. There's an avalanche coming as these young people who are now still being able to cope at the moment come through being obese for 30-something years. We are looking down the barrel of a disaster. 

Katherine: It's not just cancer. It's things like diabetes. It's things like heart disease as you know. I think the current health system as it is with the increasing obesity and society is probably an unsustainable model. We need to do something and even if it is unpopular. So for example, taxing sugary food and drinks. It's got to be worthwhile. 

Lisa: We have to have these discussions around because when I go to the supermarket and I want to buy a bag of salad, it's costing me a fortune for a few leafy greens which should be the basis of my diet basically. Vegetables. It's much easier for me to go and buy a bag of french fries in the frozens department. They will cost me two or three and that will cost me six dollars for something that's not going to fill me up. 

The fruits in the salon are hugely expensive. So we have to do something about the basic foodstuffs that are healthy for us. If we also extrapolate that... I had a nutritionist on just a couple of weeks ago talking about preservatives and additives in our food which are an unmitigated disaster and some of the stuff. I was unaware even to the depth that she was explaining to me some of the lengths that they go to to make the food addictive. We are all getting addicted. So it's not even all our fault that we're obese. 

Katherine: No, it's not.

Lisa: This is the hard thing. If people go, 'Well, just take some personal responsibility'. Yes, but there are predispositions, there are genetic sort of factors, there's socioeconomic factors at play, there are cultural factors at play. Then, you've got the food industry that is intent on making you eat more of their foods and the chemicals that are in these foods. If we just take something like MSG or some of these things make you want to eat everything. You'll know if you have one chip, you cannot eat just one chip. You will eat the packet and I know that from myself so I try not to go near the chips aisle. Because if I start down that path, I know that I'm lost because I'm fighting against my biological, my ancient DNA in this new world with these chemicals that are going to... It's like being exposed to cocaine and sugar is as addictive as cocaine. So if you start down that path, you're in trouble. 

Katherine: Absolutely. I think in addition to that, there's also been a normalisation of a high BMI. In a lot of areas of society, it's completely normal to be morbidly obese. I think part of that is a lack of education as to what the consequences of obesity are. I think we're very much in meets an ambulance at the bottom of the cliff. We actually need to put more resource into the community and to prevention. 

Lisa: I mean, forever in a day! It's unlimited resources and it's a system that's grown up over decades or hundreds of years actually. We need a complete paradigm shift to change that and to go into the prevention space and it doesn't show immediately. We were talking in the car when we were on the way to a talk. My dream to have the sort of a warrant of fitness one-stop shop where you come in once a year, get complete sets of bloods, your microbiome, your heart checked out, your diabetes, all of these risk factors. We can see if there's any cancers developing, we can see if you're heading towards diabetes, we can catch everything before you fall off the cliff. 

Imagine how much we would save the medical system but it's not set up that way for a number of reasons. The way it's developed is a disease control model rather than a different model. And then you've got pharmacological sort of pharmaceutical companies who have their own agenda and it's not always compatible. But that's my take, not preference, but that's my take. It's not always compatible with health because there's big money at play here and we need to at least be having discussions around this. 

This is why I was so excited to connect with you. Because you're in the system, you see the limitations and the problems, and we all agree there's problems. It's just how do we attack them and how do we change this paradigm and make it more preventative. Obviously, I'm in that space and trying to help people navigate and be preventative. Looking at their genetics, looking at their lifestyle, all that sort of stuff. But it's not sexy, it's not sexy when I tell somebody they need to maybe eat less of that, and more of the good stuff, and go for a run and get some sunshine on their eyes. All those sorts of things that are lifestyle interventions are really hard sells because people do like that 'Just give me a pill for that’. 

Katherine: It's not just ‘Give me a pill.’ It's ‘Give me an operation’. People come in and they are not interested in the other stuff. They want an operation because they perceive that it's going to fix the problem but operations don't always fix people's problems. You see, we can do operations that do amazing things, and really cure people of cancer, and improve the quality of life, but equally it shouldn't be the first option. I really believe we've got to look at prevention of these problems. We are very much focusing at the end of the pathway rather than the beginning. 

Lisa: Yeah, absolutely. You're someone who does operations. There are times when you need it.

Katherine: Definitely. I like doing operations. It's not always the right thing to do and a lot of them could be... Particularly in these women with these endometrial issues which is my area. A lot of it can be prevented. Not all of it, of course.

Lisa: Just interrupting the program briefly to let you know that we have a new patron program for the podcast. Now, if you enjoy Pushing the Limits if you get great value out of it, we would love you to come and join our patron membership program. We've been doing this now for five and a half years and we need your help to keep it on here. It's been a public service free for everybody and we want to keep it that way but to do that, we need like-minded souls who are on this mission with us to help us out. So if you're interested in becoming a patron for Pushing The Limits podcast, then check out everything on patron.lisatamati.com. That's patron.lisatamati.com. 

We have two patron levels to choose from. You can do it for as little as 7 dollars a month, New Zealand or 15 dollars a month if you really want to support us. So we are grateful if you do. There are so many membership benefits you're going to get if you join us. Everything from workbooks for all the podcasts, the strength guide for runners, the power divider, and future episodes, webinars that we're going to be holding, all of my documentaries, and much, much more. So check out all the details. patron.lisatamati.com and thanks very much for joining us. 

Lisa: On that point can I ask you? Because in my own life, I had fibroids. I've been on the pill for years. I don't know whether that contributed to it. I suspect that may have because I've otherwise got pretty good genetics when it comes to estrogen toxicity and so on. Adenomyosis. I was told when I had horrific bleeding, too much information for the public, but horrific bleeding, I'm talking about an entire year of mess of blood loss. 

So I was in and out of the hospital getting infusions. I had childbirth like pains as these fibroids tried to burst themselves out of my body and they were still stuck on the inside, it was falling into the cervix. Horrific. Like having a baby every week. I was in and out of hospital and I was told that if I did not have a hysterectomy, I would die. It was that bad as far as... and the anemia, I could hardly get my head off the pillow at certain times. 

Then, I absolutely had to have a hysterectomy. You know I'm very stubborn and I said, 'No, I am not having a hysterectomy' because we were still trying to have a child at that point and we are actually going through IVF now. So I was not going to have a hysterectomy so I actually went after one specialist after the other and looked at what was happening. I had an MRI done and I worked out that there was one pedunculated fibroids that was the size of a grapefruit. 

It had actually fallen into the cervix and that was what was actually leaving the whole thing open and causing the most trouble. I asked for an operation just on that. I couldn't get it, and I couldn't get it, and eventually, you know I'm very persistent, I got it with a team and operation. I did not have to have a whole hysterectomy which is a very invasive and very psychologically and physically a major thing to go through. I managed to preserve my chance of having a baby. We're going through IVF now. 

Katherine: Fantastic. 

Lisa: Yeah, but only because I'm very bloody stubborn. I went through a year of hell though because I wasn't prepared to just go and get it worked out which was basically the answer. And in my case, I was lucky that I came across this but I tend to think that, and this is not backed up by any science. But from what I'm seeing is there's so many hysterectomies happening. Are we doing these too often in general? What's your take on that? Is it unnecessary?

Katherine: Certainly, a lot of hysterectomies are warranted but we're doing a lot for abnormal endometrium. We're doing them a lot for cancer and at that point, we have to do them. But the progression of the changes could be prevented at an earlier stage and we know this. For things like fibroids, I think your fibroids, Lisa, were probably bad luck. Some people get them in there's not a lot. I don't think that would have been driven by the pill. No. 

But I think we've always got to look at the patient as a whole person. The least invasive cure, the better. It's very easy just to jump in and do a hysterectomy and say, 'This will fix you.' Well, it won't fix your bleeding completely but then it wasn't actually what you needed at the time. The fact that you did discover there was another option is fantastic and I think we need to very much individualize here. Look at where the woman is at in their life, look at what they want and try and match the two together and I think, sometimes, we don't necessarily do that particularly well as a profession. Particularly in a system like the public system where you've never met the patient before they come in and you have to get to know them in a 20-minute time slot which is really difficult. 

Lisa: Yeah, I can imagine. 

Katherine: I can imagine people go away with the head spinning with all this information we give them and probably, sometimes do feel backed into a corner because it's too much and too short a timeframe. I guess that's one of the luxuries you have in a private practice as you do spend more time with these patients. But we have no option in public because we have this massive...

Lisa: Yeah, lack of resources. 

Katherine: A lack of resources. That's why the more people we can keep out of the hospital, the better because it means we can deliver quality personalized health care and come through.

Lisa: It also means that the more we go into our own research and go and try and understand what's happening to our bodies... There are pitfalls in that as we all know and it depends on your ability to research and...

Katherine: You can never know that the information out there is correct. 

Lisa: No, and you need to know where you're getting your sources from. Okay, I'm a researcher. I know what I'm looking at. Not everybody will know what they're looking at and nor should they have to. But the more you can educate yourself, the better. So that when you get that 20 minutes in the public system, you've got the questions to ask, you know what you're going in for. 

I do, sometimes, think we spend more time researching the car we want to buy or the trip that we want to take than we do about our own health because we've outsourced it. In our heads, we're told that the doctor will take care of it and you just go to them and they should know everything to do and that's just not reality. 

They have limited resources, and limited time, and limited ability to stay up with the latest stuff because how you do that on top of that and then that. You're only human. So that's where I see like this is where we can be proactive as people and go 'Okay, I'm going to research this. I'm going to look into that. I'm going to go and I'll have my questions ready and then I'll analyze and I might go and get a second opinion or I might go and make these...' Because these are major decisions.

Katherine: Huge, huge, huge decisions. People don't understand too, again, the safety of an operation. There's risks with every operation and those risks increase with obesity. So again, coming back to obesity. For example, we know that if you have a high BMI, you've got an increased risk of a wound infection, you've got an increased risk for bleeding, and increased risk of multiple complications. Including when you do a hysterectomy, you can damage organs, other organs inside the body like the bladder, the bowel, or the ureter that goes from the kidney to the bladder, and all of those things because the operation is much more difficult in an obese patient. 

The other thing, this is also the ability to be able to do surgery for the number of women on the waiting list is also impacted by obesity. Because for example, if you are a normal BMI woman, you should be able to do a hysterectomy in an hour. If a morbidly obese woman, sometimes these operations can take four or five hours. So you can imagine what it's doing to our ability to be able to operate and process the number of women we need to be able to process.

Lisa: Wow. I had no idea that there was... 

Katherine: People don't appreciate that fact. There are surgeons that need to take time off because they've got musculoskeletal injuries because these operations are so technically challenging. 

Lisa: Wow. See. I think they don’t understand...

Katherine: No, I don't think people understand that either. People have got no idea. If we have a morbidly obese patient, sometimes, they're the only patient on the operating list. So you've got all of these people waiting months, months, even up to over a year for an operation. This is another reason why the health system that's increasing obesity and the obesity epidemic is an unsustainable model. 

Lisa: Absolutely. so we really have to get on top of this basically. Because this is not just talking about women's health here. This is talking about cardiovascular health, diabetes, Alzheimer's, all of these things that impact... You know my husband's a firefighter and they've noticed he's been in there for 25 years, 20 years in the fire brigade and five in the Air Force. They're constantly now getting called by the ambulance to come to help with hugely morbidly obese people. The ambulance crews now have to have specially made beds. They need the firemen to come and actually... It will take six to eight people that had to take down bloody walls and houses to get people out. This is getting to the point where it's just tragic for the person and it's tragic for the system. 

The resources just alone in there, that you've got six firefighters coming in to help the ambulance staff, that means those firefighters are not available for other things, those ambulance people are not available for other things in order just to help someone get off the floor. This is the type of thing that you're seeing. This is where the food industry, I think, really has to take a really good look at what they're doing. 'Why are we allowing some of these things to be promoted?' Like we don't have tobacco sponsorship anymore for a reason. It's fine. We shouldn't have some other... and I don't want to pick on any one particular company but this is a discussion that needs to be in the public forum. How about we don't let certain things promote in their sport? 

Because those are what the young people are looking at. Their role models doing drinking, eating certain things thinking 'That's what I want to be so I'm going to go and do that'. Where you draw the line, God knows. I don't want to get into the weeds on that but hey, we need this conversation because it's going to. People are dying earlier. We're increasing our lifespan because of the knowledge, and the technology, and the medical, and all of that. But on the other side, we are actually dying earlier because of the diabetes, the Alzheimer's, the cancers. The connection between cancer and obesity, I don't think many people make.

Katherine: I don't think they appreciate it either. I just want to give you another figure about the endometrial cancer to put it in perspective. So there was a study at Middlemore in 2012. They looked at the age-standardized incidence of endometrial cancer in the Pacific Island women in the counties’ catchment area. So in 1996, the age-standardized incidence of endometrial cancer in the New Zealand population was 1.9 per 100,000. In 2012 in the New Zealand population as a whole, we'd gone up to 24.2 per 100,000. So that's increased by a factor of 20. But in the Pacific population and counties catchment, the age-standardized incidence was 46.06 per 100,000. So this is something that I feel really passionate about that we need to educate young Pacific Island women what is happening in their community. 

I think also Pacific Islander women are pretty stoical on the whole and they tend to normalize abnormal uterine bleeding. I think we need to be out there in schools, GPs. It's not normal to bleed so much that you have to wear nappies. You need to have it investigated. Even from a bottom of the cliff perspective, as I have said in the hospital, we can give them progesterone which they're not producing when they make themselves anovulatory with the hyper estrogenic state. They can reverse these changes when they're in the precancerous state. Even if they do nothing with the way, which is not the ideal solution, there's this ambulance at the bottom of the cliff, we can prevent them progressing to get endometrial cancer by giving them progesterone. I think early intervention is critical.

Lisa: Will it help also with their fertility and all that sort of stuff as well?

Katherine: Well, you're very unlikely to have a baby if you've got an abnormal endometrium so you need to normalize that. Because we struggle with the weight loss issue, we can give progesterone. We are normalizing some young women's endometriums and they are able, after a period of time, to stop that progesterone and try and get pregnant with some success. There have been some studies that have shown, even with early endometrial cancer, once you start treating the endometrium with progesterone, you can get pregnant. 

Ultimately though, and if they lose weight and change their lifestyle, as soon as they had the baby or stop taking their pregesterone over time, it's going to come back again. The only real way to get a definitive treatment of the abnormal endometrium is either remove the risk factor, which is lose weight, or in the end, they do need a hysterectomy. 

Lisa: Wow. Are you seeing across the board falling fertility rates? 

Katherine: Absolutely, on young obese women. 

Lisa: Wow. This is a huge portion? Not just for the Pacific Islander, Maori population but everybody? Like on average, their BMIs is just going through the roof. 

Katherine: It's true. I've got some... Even Bacon's 2013, that was only 34% of the population was a healthy weight and a normal BMI. I suspect when more figures that are coming up from the Ministry of Health will show that over time, that's just going up exponentially. 

Lisa: Okay. So this is not just an aesthetics thing and this is not just you want to look good on the beach. 

Katherine: This is a public health crisis.

Lisa: You're ringing the alarm bells here and this is really, really good. I've studied a little bit on the metabolic approach to cancer so this is what we're talking about here basically, isn't it? The metabolic approach to cancer. Well, it's a bit more involved in that and I'm certainly no expert on that but it's basically, if you've got cancer, starving the cancer growth through not having high carb diets but having a more fats and protein-based diet. Does that play a role? Have you researched at all versus the genetic approach, the chemotherapy approach? Have you had a look at that sort of data at all? 

Katherine: I'm not aware of a lot of data on that. I certainly think it's an area that needs development and I think it's really important. At the moment, with the information that we've got, the oncologists do offer the chemotherapy approach or the radiotherapy approach, or we offer the surgical approach as the first line because that's what we're familiar with with data. But I'm not saying it's necessarily the be-all and end-all. 

I think, there's a lot more we can learn about that but I think often once you have that cancer, it's much more difficult to reverse a cancer. What's good is preventing it in the first instance and I think that's really where we've got a focus. Looking at the lifestyles to prevent these things occurring because they don't happen overnight. They are generally a slow progression that we're not aware of until we have a cancer. You have those pre-malignant states that slowly develop for a long time. 

Lisa: So I think what we're doing here is at least initiating the thought in people's heads that being obese is increasing your risk of cancer, endometrial cancers, and breast cancer. Are you aware that it's other cancers as well? Or is it just these ones?

Katherine: Oh, no. I think it is. There are other cancers. I don't have the data behind a lot of the other ones but off the top of my head, breast is not my specialist area, but I think from obesity, you are increasing your relative risk of breast cancer by approximately three times. I could be corrected by the breast surgeons on that. Usually, we know it plays a part because the estrogen results in a proliferation of breast tissue. The more you get that proliferation, the more every time you have cellular changes, you increase that risk of a mutation occurring. Then, of course, we do know that there are the genetic cancers like the BRCA which increases the risk of breast and ovary that certainly contributed in the Lynch Syndrome which is a genetic whether you have bowel and endometrial. 

There are those factors. So some people are at a genetically higher risk of getting a cancer and even if they have an absolutely pristine lifestyle with a perfect diet, some of them with the genetics will get cancer. Not all cancers are preventable but we can certainly, we know that there are, particularly with these estrogen-dependent cancers, we can significantly reduce the number of women with cancer by correcting their lifestyle. 

Lisa: Brilliant. If we just split the conversation just a little bit and go in the direction of general health for women's health, what would you like to see young women getting access to education around the whole reproductive cycle and how it all works? Because now when I went to school, we were told how to use pads and tampons. That was about that. Nobody told me how your estrogens go up, and this, and the follicular phase, and then the luteal phase. None of it was ever... If I talked to a lot of my girlfriends they still don't know the basics.

Katherine: The basic knowledge is very poor and I think we do need better education and a logical place to do that is at school and I don't think that that exists and I know my daughter's at school. What they got taught to her was very, very basic. They got taught nothing about, because it's also seen as politically incorrect to discuss obesity. But it's not politically incorrect. That's factual and it's a crisis. We need to stop pussyfooting around it and I think that young women needs to be given the facts about the reproduction that being overweight will increase the likelihood of being infertile. It will increase the risk of certain cancers. It will increase the risk of diabetes, and dementia, and heart disease, and all of these things. 

Lisa: Absolutely. I think this is not about not accepting different people in our society and not being inclusive. That’s not the issue, what we're talking about. This is straight. These are the facts on the medical side. This is not healthy to be this way. We need to give people the education and the support around changing the behaviours. We're not saying this is people's fault that they’re there. We all know is that the food industry and just the way our advertising is set up and that the food is on every street corner. 

Our ancient DNA, we've come from cavemen. I talk about this all the time. Our DNA hasn't kept up with the pace of change in our environment. Some things like electric light to the blue lights that we're getting exposed to at night time, to the food that's available 24/7 where it used to be you had to get up, go out, and hunt or gather, or do something in order to get breakfast. You were moving all day, outside in nature and when you start to adopt some of those lifestyle changes within the bounds of what's possible for you. 

But that means for me, if I'm stuck on the computer all day, I change between the standing desks and the sitting desks. In between I'm doing press-ups and sit-ups, and I'm going for a walk, so I'm getting sunshine in the early morning. All of these tiny little ritualized habits that I've developed in order to keep myself sane and to keep myself relatively healthy. To be proactive in that space. I think that's the discussion that we need to be having more. 

Katherine: Yeah, I think so. There's very little resource. The health system as it is, a vast amount of the health dollar is spent in the final years of someone's life and very little resource is put into patients in their early years, particularly in the community, because of the way our model has developed. Something you just touched on, Lisa, that's really important is also to keep you sane. 

Mental health is just a huge part of someone's wellbeing. The diet, and the exercise, and the movement is hugely important to that. Also, we've learned in the last few years that a large amount of serotonin is produced in the gut. Eating at a sort of an obesogenic horrible fast food diet, that affects your production of serotonin which, again, affects your mental health.

Lisa: With depression and all of it.

Katherine: If you're depressed, you're less likely to go and choose healthy food so it's a vicious cycle. We've also become very siloed in our health care model and it's really important to have GPs and people in the community is we need to look at people as a whole. If you look at one isolated area, like we do in hospitals and we're all sort of super specialized and one little thing, we're not good at actually looking at the whole person because we have such a short timeframe to see those patients. So this is a real important role of GPs and other people working in the community. 

Lisa: So this is where I see the greatest growth happening and the greatest development happening is with people like what I do and health coaches and people that are lifestyle coaches and things than actually...  because we just don't have enough doctors and we just don't have enough money in the system. This is a way that we can bring in allied health professionals, if you like, to actually give people the time of day and actually go through different testing regimes. Everyone has their specialty. I will go to my chiropractor, my naturopath, my herbalist, whatever area, and all of these things that these people can help in this conversation of being in that preventative space so that you don't even get to the hospitals, hopefully. That's my goal. To stay out of the hospital. 

Katherine: That should be everyone’s goal. Don’t go to the hospital unless you have to. 

Lisa: With the exercise and the hard parts of all of that. In a paper, 'I don't want to it's not pleasant. Why should I do it?' I tell you, as someone who's rehabilitated someone from a massive, massive aneurysm and stroke, that path back is horrific. Way more unpleasant than going to the gym, going for a walk, doing those preventative things, and eating nicely. Than trying to rehabilitate somewhere. 

Katherine: Yeah, absolutely. I'm sure you can speak to that from your own experience.

Lisa: Very, very, very much so. So I'm in that space. Katherine, Dr. Katherine Sowden, you've been absolutely wonderful today. Thank you for sharing your insights and being so candid and open and having these conversations. Because only when we actually get to talk to doctors, talk to medical professionals or people in public health and open up these conversations, can we get some good positive change and it's not a us-versus-them. I don't ever want to be in the us versus them space because it has to be a collaborative effort if we're going to improve the health of our nation and our world. Fantastic to have had you on the show today. Thanks.

Katherine: Oh, thank you very much for the opportunity to speak, Lisa. It’s been a pleasure to meet you and a pleasure to chat again today. I hope it can help raise awareness of the issues surrounding women's health and what we can do and it's been an absolute pleasure. Thank you.

Lisa: What about, Katherine, if someone wants to reach out to you, are they allowed to? How would they do that? Or even for your private practice, where would they find you? 

Katherine: So they can find me at www.aucklandwomensgynaecology.co.nz.

Lisa: Okay. www.aucklandwomensgynaecology.co.nz. I'll put that in the show notes. 

Katherine: I am at through Counties Manukau. It's a little bit more difficult to reach me that way. If people want to reach me through Auckland Women's Gynaecology, then I can point them in the right direction if they want to come through the public system. 

Lisa: Brilliant. Absolutely wonderful. Thank you so much for talking to us today, Katherine. 

Katherine: Pleasure. Thank you, Lisa. 

That's it this week for Pushing The Limits. Be sure to rate, review, and share with your friends, and head over and visit Lisa and her team at lisatamati.com.