[Nina Fuller Shavel] (0:00 - 0:15)
There was a really well-publicised trial in the scientific literature, and this trial took people in their 60s, 70s, they gave them vitamin D, omega-3, and a very simple home strength programme. Combination of those three interventions cut cancer risk by 60%.

[Angela Foster] (0:15 - 0:28)
Dr. Nina, you are an Oxbridge-trained physician and scientist specialising in precision health and integrative medicine. What's happening in peri- and post-menopause that seems to increase our risk of certain types of cancer?

[Nina Fuller Shavel] (0:28 - 0:53)
We are getting combined levels of multiple different toxic exposures sustained really carefully over time and delivered to us from food to our cosmetics to even medication. Have you been exposed to endocrine-disrupting chemicals for decades? Have you been given HRT that doesn't really work for you?

Are you able to process the oestrogen that you get given? Do you have sufficient levels of testosterone? Do you think of everything, oestrogen, progesterone, testosterone, insulin?

[Angela Foster] (0:53 - 0:59)
What's your view in terms of testing? There's a lot of like full-body MRI, preventative testing.

[Nina Fuller Shavel] (0:59 - 1:04)
There's pros and cons to all of this, isn't there? For me, testing comes in two different flavours. One is that...

[Angela Foster] (1:04 - 1:11)
There was one message that you want to leave every woman with. What would you wish she understood about her health and longevity?

[Nina Fuller Shavel] (1:11 - 1:13)
That's a million-dollar question, isn't it really?

[Angela Foster] (1:13 - 1:31)
Dr. Nina, you are an Oxbridge-trained physician and scientist specialising in precision health and integrative medicine and one of the UK's leading voices in integrative oncology. Cancer rates are rising globally, including in younger people and in people who appear outwardly healthy. Why is this happening?

[Nina Fuller Shavel] (1:31 - 4:00)
That's a million-dollar question, isn't it really? I think if we're thinking about it very carefully, we know that the world has changed a huge amount in just over the last few decades. And so what we know is that cancer is a risk, really is composed of genetic risk and environmental factors.

And the interaction of the two together is what drives vast majority of cancer. So genetic risk has not changed very much, okay? We haven't suddenly got new genetics over the last few decades.

So the drivers are very much environmental and how those drivers interact with our genome. When we're thinking about the environment, we have to go around the circle of all the different systems and think about what we're doing and how it's affected. So from the gut microbiome, for example, we know that the heavy antibiotic use, the use of antacid medications in really young children has been really common.

The ultra-processed foods have changed our microbiome really quite significantly in the last few decades. And we know even in children, our rates in the UK are huge in terms of UPF consumption compared to some other parts of Europe. So when we're thinking about things like the gut microbiome, that's had multiple different hits, anything from medications to how we eat.

And of course, very importantly, what we don't eat, thinking about our fibre intake, our polyphenols, our colours, thinking about the fact that we're not always balancing our plate like we used to maybe in the 50s, as an example, right? The whole meat and two veg was a bit of a laugh, but actually the two veg was very, very important. Then we're looking at other things like environmental exposures.

And we know actually none of the chemicals that we have in combination swimming around in the soup, in our cosmetics, in our environment have not been tested on humans. So what we are now thinking is that the classic toxicology of saying you have to have one high level exposure to one toxin doesn't actually work anymore. So it's about the fact that we are getting combined levels of multiple different toxic exposures sustained really carefully over time and delivered to us in different venues, from food to our cosmetics, to even medications.

We have so many additives that we give in medications these days. All of that combination is actually partially what might be driving some of those risks. So it's really multifactorial.

I mean, I could go on and on and on and talking about other things that change our hormones, like endocrine disrupting chemicals. But I think it's important to realise our world has changed significantly. And we need to be thinking about what we can do to minimise our environmental risk factors so that we can try and minimise our long-term risks.

[Angela Foster] (4:01 - 4:22)
What I'm hearing from you there is the ultra-processed foods, right? We can minimise those and we can also increase our fruits and vegetables to help protect. But when we look at the microbiome, do we know with gut testing what we're looking for?

Are we looking for diversity? Is there... it seems like a very developing area.

What do we know about the gut microbiome?

[Nina Fuller Shavel] (4:22 - 7:46)
Well, that's a very good question. So I think one of the things that we need to think about is not one thing that we look at. So diversity is nice and that's important in terms of our overall body resilience.

But actually, there are different groups of bacteria that influence different parts of our metabolism and physiology. And we know even, for example, with obesity, obesity can be transplantable. You can actually transplant somebody's microbiome and you can actually engender obesity, at least in animals.

And there's been at least one case of that being done with a faecal microbiome transplant. So we know that our metabolism is influenced by certain groups of microbes. We also know that things like inflammation are influenced by another set of microbes and some of those things that produce like short-chain fatty acids like butyrate.

Then we know there's another set of microbes that increase your risk. So if you use a bacterium nucleatum as one example, an FN, specific strains of the bacterium can come from your mouth, settle in your gut and actually increase risk of colorectal cancer. Then we have another aspect of the gut microbiome that's to do with how we recycle our hormones.

So when we think about detoxifying our oestrogen, our oestrogen gets processed in the liver through the two-phase system and then it will get excreted into bile, nicely conjugated, nicely paired up in a way that gets it out of the body. And then when it gets delivered through the bile into the intestine, we have an opportunity there to recycle our own oestrogen. And that's a point again where some of these different species might actually may have an enzyme that recycles our estrogens back.

And that might increase our risk of hormone-driven conditions. So it's a very much a developing area. There isn't really one thing saying this is the healthy pattern because what's also healthy for you is not gonna be the same what's healthy for somebody who eats a Far Eastern Asian diet is not gonna be the same as somebody else with different genetics in different environment.

So it's about us being quite smart, very personalised about what we do. What kind of risk are we looking at? And how can we build a resilient microbiome that has the minimal number of risk factors, but is also strong and not recycling our oestrogen and is really adaptable to the changes.

And it's a living organ and it changes all the time with the exposures that we've got. So think about UPFs, they've changed our gut microbiome and of course our metabolism and obesity rates and everything else, hugely in the last few decades. So now we have children who are actually being brought up and they don't know where broccoli comes from or they haven't seen food grown and they think it comes from a supermarket in shiny little packets.

And their first exposures are flavours of UPFs not flavours of real fruit, vegetables and herbs and spices. And I think even that whole concept of children's food, children's menus did not used to exist. You ate what your parents ate, okay?

And actually that whole concept that children like bland food, they don't like herbs and spices, that's all been very much industrialised into us. This is not what we used to eat like in our 50s and 60s, 1950s and 60s. People used to eat what was given to them and they could eat curries and they could eat highly spiced foods and it would be absolutely fine.

So I think we need to be really critically thinking about what's been fed to us as information of what should and shouldn't happen and really critically appraise whether that's true or not. And that includes how we look after our gut microbiome or how we look after our skin, etc.

[Angela Foster] (7:47 - 8:35)
I think it's really difficult, isn't it? For many people, you know, because so many people are so busy and I remember when I was, you know, raising my own when they were very young and weaning them, I was very fortunate where I wasn't working so I have plenty of time to kind of introduce these vegetables and fruits slowly and puree them and introduce them to a wide variety of foods which I can honestly say has really, really positively impacted their palate and their long-term eating patterns. But I think that for many people, when they're busy, they may not have time to this.

They may not have the budget, for example, to employ a nanny or a chef to do that. And I think that's commonly the pattern in modern life is that we're looking for what's quick and easy. Things like takeaways are on the increase.

How much do you think that's driving some of what we're seeing?

[Nina Fuller Shavel] (8:35 - 10:30)
I think it's a huge component, right? We are very time poor at the moment and I also think that we're also surrounded by easy ways of reducing labour, right? From that perspective, our mothers did not have that choice, actually, or not a lot of the choice.

Doesn't mean that ultra-processed food didn't exist at that point but they weren't continually surrounded by some of the advertising. Every time you walk into the supermarket, the first thing you get presented with a lot of the time is not unprocessed foods. And of course, then we have to balance demands of the fact that, you know, our children have a lot of demands at school now, even, and they are stressed out and we are stressed out and we have to manage that whole ecosystem.

I think it's not about being perfect. That's the point is actually if 80% of the time we're good to our body, our body has the resilience to cope with the 20, right? And that's what we are building.

You're building not a perfect ecosystem because always think if you have to be perfect to maintain your health, you're fragile. Actually, you need to be able to take the 20%, do whatever you want to do, have fun and not worry about it. And then actually really focus on the 80% that you do day in and day out.

So it's about finding time-saving ways. It's about using frozen fruit and vegetables. It's about adding little bits and pieces.

So a lot of the time when I talk to busy mums, I think about like just buy lots of frozen herbs because they never go off. They're not sitting like sad little parcels of parsley at the back of the fridge. And that means that you can incorporate a few things, whatever you're cooking, even if it is a UPF, whatever, but at least you can add something to it that has nutritional density and nutritional value.

So it's not about us beating ourselves up as mothers or as women, particularly who are supposed to have it all, whatever that myth is. We want to be able to make things easy, but we also want to do the best for our health and our children's health. So it's about finding easy, simple things we can implement using frozen foods, using dried herbs and spices, not aiming for perfect, but aiming for good enough and really just seeking to make incremental steps and changes.

[Angela Foster] (10:30 - 10:54)
I love that. I love that. That's something I do.

For example, I'll put rosemary in the freezer because let's face it, when you buy a whole pack, I mean, you're not going to use all of that. And it's so easy. I think when people realise that and you can just sprinkle a bit in straight from frozen, it's such a great tip.

I love easy hacks like that. Vitamin D is one of the most talked about nutrients in longevity and immune health. Why is it so important when it comes to cancer prevention?

[Nina Fuller Shavel] (10:54 - 12:52)
So interesting enough, there was a really well publicised trial in the scientific literature that never made it, I think, out to the public. And this trial actually took people in their 60s, 70s. And what they did was they did three simple interventions.

They gave them vitamin D, omega-3 and a very simple home strength programme. Combination of those three interventions cut cancer risk by 60%. Let that sink in.

60%, three simple things we could do. But interestingly enough, that's not being implemented out because it's almost too simple and there isn't a commercial drive behind it, unfortunately. So if I had to pick three interventions that are actually evidence-based, are proven by a randomised control trial that we can do, not just in later life, we can do them now, they would be the three things I would pick.

So I think vitamin D, it's important to also realise that what we've been told is sufficient is really not the case anymore. So the science is moving. We used to say anything below 25 was inadequate and maybe 50 is okay in terms of nanomoles per litre as a level.

And now we're really looking at 75 nanomoles per litre as your absolute bottom level that you need for bone protection, for healthy heart, for healthy long-term outcomes in terms of longevity overall. So I think it's essential that we have vitamin D. We test our levels.

We don't rely on one size fits all because all of us have different genetics in terms of how well we process it, how well we make it, how well we retain it and transport it. So I know some of my East Asian women need 8,000, 9,000 IU, some of them even more during pregnancy to be able to stay within that particular range. So find the level that's right for you.

Don't let anybody else tell you that 400 IU is actually sufficient. Vast majority of the time, I test my patients and I would say probably 90, 95% will be falling below 75 unless they've been supplementing.

[Angela Foster] (12:52 - 12:58)
Thank you. I mean, that study is quite incredible. So vitamin D, omega-3 and strength training.

[Nina Fuller Shavel] (12:59 - 13:31)
Yeah, strength training. Very simple home strength training programme, no equipment, just body weight strength training. That's what they've done.

And as I said, 60%. I personally think in the NHS, that should be something we should have a post on in every single GP surgery. We know the cancer rates are rising.

We know the system cannot cope to get people into treatment fast enough. So we should be doing that preventative work. They're cheap interventions.

They're not really expensive. It's much more expensive to treat cancer when it arises. So I think that's something that we need to take the vital trial and really, really go ahead with that.

[Angela Foster] (13:31 - 13:51)
I couldn't agree more. I mean, when you say that, when we look at it, I can see the omega-3s reducing inflammation, vitamin D supporting immunity. The strength training really interests me because we think about it in terms of bone health, for example, but also long-term muscle health and insulin sensitivity.

What's the mechanism of the strength training reducing cancer risk?

[Nina Fuller Shavel] (13:51 - 15:34)
Good question. I don't think we've fully answered that, but there's a lot of really interesting research. So I think the first thing's first, you're absolutely right.

Metabolic health and cardiometabolic risk is improved if we do that full stop. So we know part of the drive, massive drivers around the rising cancer rates is obesity and metabolic dysfunction. So metabolic syndrome is a problem for us in terms of that.

And that's also why we are seeing that young cancer rises because we're now having a lot more juvenile obesity. And you used to be, you used to call it adult onset diabetes, the type two diabetes. We can't call it that anymore because we have children that are very young presenting with type two diabetes.

So I think the cardiometabolic angle is absolutely something that we need to look at. There's also an interest in this myokines. So myokines are the signalling molecules that come out of your muscle and actually modulate your whole physiology.

So the way those myokines talk to our systems, including our immune system, is really, really important. And exercise long-term is also anti-inflammatory. And that's something we really need to be thinking about, unless you're doing excessive exercise, which can be pro-inflammatory.

If you're doing moderate exercise, that's right for you, then it's really, really important. And then even broader, thinking beyond cancer, as we know that we start having that sarcopenia drive, right, from really our mid-30s onwards, right, as well as losing our bone mineral density. So having that in the background not only is reducing our cancer risk, but maintaining our muscle mass and of course maintaining our bone mineral density.

So there's multiple different factors all at once. I think some anti-inflammatory drivers, excess also changes our gut microbiome, of course. Let's not forget that part.

And that's really, really crucial. So we know that if you do regular exercise, your gut microbiome looks quite different, even if you're eating a pretty similar dietary pattern.

[Angela Foster] (15:35 - 15:42)
So interesting. What role would you say does cardiovascular fitness play in prevention and long-term immune health?

[Nina Fuller Shavel] (15:42 - 18:48)
So according to the ASCO guidelines, we actually need both. And that's something that we have to do with everybody who's on cancer treatment. So you need to do your 150 minutes of moderate intensity aerobic exercise.

You need at least two strength training sessions per week for the full body. So it might end up being four if you're doing, for example, half the body at the time. So that's actually what should be recommended to everybody with an active cancer diagnosis during treatment.

Now, we know that's not unfortunately happening in real life. There's even interesting trials where we are putting people on exercise bikes during their chemo. And that's because actually the reason we're doing this is number one, we are wanting to increase the perfusion of chemotherapy to the tumours.

And tumours can have very low oxygen areas in their centres. So in those areas, we don't really get good effects from chemotherapy or radiotherapy. So actually, if we are getting people to cycle or do anything else while they're having their chemotherapy infusion to increase the oxygenation, we're improving the way the chemotherapy works.

We're also reducing the deconditioning people experience by sitting around for hours and hours receiving those infusions. And then taking it back, I guess, to the prevention side, we know that that's crucial. Cardiovascular exercise is crucial in supporting the anti-inflammatory benefit alongside the strength training.

That's important. And from our perspective, again, the interaction is quite difficult to unpick because we're going to have some myocline influences, some gut microbiome influences from both sets of exercise. So it's tricky to say which bit is doing what.

But the crucial message is you have to do both. That's not an option. And then minimising our sedentary time is another thing that we really, really need to do.

So we can get into this habit where we're going, OK, well, I've gone for a run and I've done my strength training. Now I can sit for 10 hours in front of a computer. And it's really important that we're minimising the sedentary time.

It doesn't need to be long. It could be getting up and getting a cup of green tea or whatever it is you're doing. But we do need to be actually moving through the day as much as humanly possible.

So I've been known when I've been sitting through a really long conference, sit and bounce on my little balance ball. And you could always turn off your video as well. So I think it's about saying those exercise snacks, keeping mobile during the day, aerobic exercise, resistance training.

And then when we get older, I think it's really important to include balance. And that's the reason why we have so many of the healthy, you know, 80, 90 year olds and octogenarians in the Far East, because you do get that you're going in the park. You do do things that are communal exercises to do with balance.

And I think the other powerful bit of exercise that we do, we don't have to do it alone when we are struggling with motivation, when we need to get our social in and we are really, really busy. I always say, you know, instead of meeting up for coffee, go for a walk. The conversation flows a lot better.

You get into far more interesting topics than sitting down. You can hear each other, which is also a great benefit. And then you get your exercise and your social aspect in.

And I just do think that those little things that we can combine the two when we are so time poor, when we're already stressed out with how much we have to fit in. We can really get that benefit of all worlds, really.

[Angela Foster] (18:49 - 19:38)
If you're getting value from this show, the single best thing you can do to help us keep bringing you the highest calibre guests is to subscribe or follow wherever you listen or watch. It takes 10 seconds, but it genuinely makes a difference to the quality of the guests we bring you week after week. I love all of that.

I think walking for me is just such a great stress reliever, just as you were saying, just as transition points as well throughout my day. Anything that you kind of just feel like it's kind of getting into your nervous system, you can just offload it so easily with just five, 10 minutes outside or, you know, even if you're in an office building, just run up and down the stairs a few times and you'll feel lighter. You've got more blood flow, better concentration.

What about midlife? What's happening in peri and postmenopause that seems to increase our risk of certain types of cancer?

[Nina Fuller Shavel] (19:39 - 22:55)
So it's a very good question. I think when we think about breast cancer, there's this kind of myth of saying, well, because our oestrogen drops in menopause, surely we should get less breast cancer rather than more. And I'm like, it's your total exposure, OK?

And it's really complicated because the reason, of course, we're looking at vast majority of cancers being in the older population, even now with rising young cancer rates, we still have that heavy, you know, 50 plus tail of cancer. And the idea is that you had cumulative life exposures. So when we're thinking about breast cancer in particular, your long oestrogen exposure window.

So the earlier you start your periods and the later you enter menopause, that total cumulative exposure seems to matter in terms of overall trials. And of course, it's not just about oestrogen, it's about everything else. Have you been exposed to endocrine disrupting chemicals for decades, literally decades from that perspective?

Have you been given HRT that doesn't really work for you? That's another thing we have to consider. Are you being dosed at the two higher dose?

Are you able to process the oestrogen that you get given? Is it a sufficient oestrogen progesterone balance in the body? Do you have, you know, sufficient levels of testosterone?

So we think about hormonal environment, you know, we need to be thinking of everything, oestrogen, progesterone, testosterone, insulin. We become more insulin resistant, of course, in perimenopause and menopause, which is a huge drive of multiple things. That's when our cholesterol goes off track, our HB1C goes off track.

And of course, in terms of metabolic drivers, breast cancer does have a known metabolic driver in terms of body mass index, obesity, alcohol. Another thing that, of course, happens in perimenopause and menopause that's not physiological is the social stresses. You know, we have children in school, maybe, or we have other caring responsibilities, but potentially our parents are getting older and require more help.

We are balancing busy careers with busy home lives all over. So I think all of that then leads us to then potentially become maladaptive. We might be putting away half a bottle of wine quite easily with our partner, right?

And all of that then has an impact on cancer risk. So we know alcohol matters. We know that having things like your BMI go up significantly around perimenopause and menopause does matter as well.

So taking care of metabolic health or hormonal health, all of that really matters in terms of breast cancer risk. And then we have other problems as well. So thinking about other conditions that are very common in women, thyroid dysfunction often comes up during that time as well.

And a lot of the time that gets dismissed as menopause or perimenopause, and that's actually where autoimmune thyroiditis rates really peak. So there's a peak around pregnancy for thyroiditis, and there's definitely a peak around perimenopause. So that in itself also can cause problems for us metabolically again.

So I think it needs to be a really holistic view of it. And I'm really sad that the conversation around menopause or perimenopause seems to have gone down to HRT. And I'm like, that's such a complicated time in a woman's life.

It's not about... It's a very misogynistic way of treating menopause, I'm sorry to say. Chuck some hormones down at women and run away in the other direction.

That's really not the way we should treat menopause. It's a huge transitional period in a woman's life. And we need to look at it as a whole woman endeavour.

This isn't about just medicating ourselves out of it.

[Angela Foster] (22:55 - 23:44)
A hundred percent. I think people, I think women need to feel acknowledged as well, because I think that it kind of, my experience with it is that it really kind of calls you to look at what is and isn't in alignment in your life. And it's a much bigger thing than simply a prescription for menopause hormone therapy.

And all of the things that you're saying, I love in terms of nutrition, stress, resiliency, sleep, fitness, all of that are so important. Just to clarify then from what you were saying in relation to hormone, menopause hormone therapy, it sounds like from what you're saying is it needs to be discussed with your individual practitioner, but the dosage for you needs to be correct. Because I think there's a lot of social media content at the moment that's sort of very, very pro menopause hormone therapy and kind of pro quite high dosages of this.

Does this need to be better managed in women?

[Nina Fuller Shavel] (23:45 - 26:51)
I think so. And I think it's about, again, going back to the fact that what's right for human will be right for somebody else. So even simple things like patches, gels and sprays all get absorbed by different skins at different rates.

So maybe, you know, you, Angela, if I gave you 1.53, one Linzetto spray, 1.53 estradiol, you might go up to correct range straight away. Somebody else might be underdosed. Somebody else might be overdosed.

So it is really, really important. We don't do it on the NHS because we're not encouraged to do so. So it's all about symptom management.

So that's what the guidelines are, which is understandable in terms of resources on the NHS, right? We cannot be testing everybody's estradiol serially. But certainly, if you're getting prescribed anything more than licenced dose, you do need to have blood levels to prove that you are staying within range.

And this is not the range of hormones that need to be for a 25-year-old. We need to be sensible about it. So I do not want to see 2,000 come up on a blood test.

So if you're thinking about, again, sense checking it, right? We don't want to be below 150. That's for postmenopausal type of level of estradiol.

We also don't want to be picking up at 2,000, 2,500. That's actually way above and beyond physiological range. So we need to be thinking about is the level right for you?

So do you get good symptom relief? And unfortunately, the other thing that I would highlight is that when you go to a clinic, you need to make sure they assess you as a person. So if you're a hammer, everything looks like a nail.

Every single symptom gets described as menopause or perimenopause. That is just not correct. Have you checked your thyroid?

Has your iron levels been checked? Have your vitamin D been optimised? Have we looked at other sources of some of your problems and issues in life?

So I think a lot of the time, I just urge people not to overmedicate on menopausal hormone therapy without checking all the other contributing factors. It's really important. We just don't focus on one thing.

And I do think that actually you yourself need to have an understanding of whether your dose is within licence range. If it's not within licence range, why is it not? And to have an idea of what your blood tests look like serially.

And then whatever hormone therapy we get given, particularly the oestrogen or the estradiol component, you do actually need to make sure you're processing it correctly down the normal liver pathways, because it is important. We know there's certain levels of metabolites if they go up in the bloodstream too high are associated with downstream breast cancer risk. So it's association, not causation, but it's still in the women I look after in the preventative setting.

I want to see those pathways. I want to see the levels. I want to see they're within normal range.

So it's making sure that things are right for you. And again, if you are reaching maximal doses of oestrogen and progesterone and everything else, and your symptoms are not controlled, the answer is very rarely more oestrogen. I can tell you that the answer is usually hiding in your gut, in your cortisol, in your insulin, in your thyroid, in any many different physiological systems that you have beyond the fact that you have sex hormones as a woman.

[Angela Foster] (26:51 - 27:46)
I'm so glad you said this. Actually, it's resonating a lot with me because when I tested my own, I did a really in-depth hormone panel recently, including things like growth hormone and just adrenal function and everything was fine. But I'd been experiencing just feeling like kind of feeling more puffy and bloated.

And actually what we've decided is that the oestrogen is probably a little bit high. It's also similarly, you were talking there about absorption rates. And what I found taking testosterone is I've got quite good veins is I've been absorbing it a little bit too easily.

So for me, actually halving that dose is better. And I just love what you're saying there because I think it is so personal and individualised and we need to pay more attention to that. I would encourage anyone listening or watching this to think about the symptoms that you're getting and not to ignore them because that for me was within, certainly the oestrogen and progesterone was within standard sort of prescribing limits.

But actually for me personally, it feels a little bit high.

[Nina Fuller Shavel] (27:46 - 29:06)
And I think that's the point. It's a little bit like the average shoe size for a male in the UK is nine. But would your husband fit into that or your partner or your dad?

It's a little bit like the average is designed to be the average. It's not there for you. When I look at thyroid hormone as well, I will not be looking at just the average.

I will be looking at the bottom 25% of the range in the top 25% because that's actually where people will start really exhibiting their individual preference. They will actually say, no, I need to run that little bit higher or that little bit lower from that perspective. So there are women who will get palpitations on thyroid replacement within, still within range, but within the top 25%, which case we need to back off.

We need to back off right straight towards 50% and then they feel best on that. So I think it's about, again, monitoring and when your other aspects of your life change and you have new symptom re-emergence, re-evaluating that continuously because nothing is static in our bodies in the world. So just because it worked for you in the past doesn't mean it's going to work for you now.

And certainly in perimenopause, you know, I end up changing prescriptions and support all the time. You know, it could be every three months. It could be every six months.

I might actually need to be changing something within somebody's support plan, whether it is prescribed or non-prescribed things. So it's really, really important that we're constantly dynamically assessing our needs and we're not sitting on them. We really are volunteering them to our health care providers.

[Angela Foster] (29:07 - 29:36)
Yeah, so important. You mentioned thyroid a few times there. Someone listening to this who is having, struggling with their thyroid.

One of the common things we see come up in that period to postmenopausal transition, as you said, is things like Hashimoto's. Some people will find that when they do a thyroid panel, their antibodies are raised, but their thyroid function looks normal. How do you treat the patient in that case?

Do you look to try and bring the antibodies down as a sign of impaired immune function? Or what's your approach with that, Dr. Nima?

[Nina Fuller Shavel] (29:37 - 34:22)
So it's a good question. I would say sometimes we actually have healthy people pop up antibodies and pop them back down. And that's just because something might have triggered the gut for whatever reason, the gut immune axis, particularly if you have any history, in terms of family history, might start pushing out some of those antibodies.

So again, people with celiac disease sometimes will have them in the background, but they're not actually actively having a thyroid problem yet. So I would view it as a longitudinal marker. So it's something we need to retest and we need to see which direction it's going.

And sometimes they will just disappear off itself. Within about six months, it will just go. But it's also not something I would rather leave.

So again, the conventional way, I would say, is very much let's leave them be until they present, they've fallen off the cliff and they've got hyperthyroidism. From my perspective as well, the ranges that we use, particularly from the TSH perspective and the fact that we do need to measure T4 and T3 together, really important. So the fact that we're over-reliant on TSH in conventional medical practise is actually not particularly correct.

So TSH can go up and down for multiple different reasons that have nothing to do with your thyroid. It's also, by the way, not a thyroid hormone at all for anybody who's not aware of it. It actually gets secreted from your brain, from the pituitary.

And then it goes off and talks to your thyroid. It goes, come on thyroid, make some thyroid hormone. So TSH is not a mark of thyroid function.

It's a mark of how loud is your pituitary shouting at your thyroid to make thyroid hormone. So because it's part of the brain and because it's a part of a really complex system, TSH responds to multiple different problems. So you get sick, you can get your TSH go off, but your T4 and T3 are not going to be affected.

For example, there are multiple things that will shift that needle. So if you're relying on TSH for your hormone assessment, we're missing the plot completely. So whenever I do this, I will normally do TSH, T4, T3, obviously free hormone as well.

So free T4, free T3, and then both thyroid antibodies. And we'll have a look at that. If we are finding again that we have a trend where the antibodies are going up and maybe we're seeing some trend for the thyroid to start becoming a little bit more impaired, maybe the T4 is trickling down a little bit, then I would like to intervene before we crash.

So that point is about looking what might be the drivers for that. And it could be multiple different things. A lot of the time we'll work with gut immune access.

So we will look at that as a potential contributor. We'll go back in the family history. We'll look at the thyroid disease family history, celiac disease family history, any other autoimmune diseases which can again coexist.

So unfortunately, autoimmune diseases can come in droves. So we always want to make sure if somebody else has type 1 diabetes or celiac and everything else, we are monitoring them for thyroid dysfunction actively and we're intervening. So gut immune access is one certainly one component that would normally look at toxic exposure.

So endocrine disrupting chemicals do affect the thyroid and do affect other things within our bodies. So we do look at that in particular. And there may be other things that we can do really easily and preemptively to try and get them back into range.

So selenium and inositol is one of the combinations that we use that have been well trialled in terms of managing antibody levels and potentially even improving thyroid function. Obviously, all of this does need to be monitored because if you do end up going too high or too low, we might need to intervene from a medication perspective. But again, even sometimes mild cases of going slightly higher, we could manage with managing the gut immune access and using herbal medicines such as lemon balm or motherwort because that's under my purview as an integrative medicine physician herbalist to not have to go to really heavy medications that block the thyroid too much because otherwise we end up going up and down like this.

So we end up going, oh, I've gone hyper. And then now I've been given thyroid blockers and now I've crashed down and now I can't really do anything from there. And now I have to be resuscitated back into the midline.

So I'm a big fan of trying to modulate the physiology before it becomes truly pathological. And then if and when it does reach that point, then we intervene medically. But again, with the right dose for the right person at the right time as much as possible.

And there are patients I've looked after with pretty raging Hashimoto's thyroiditis that haven't had to go on to any kind of thyroid replacement at all. So we've been able to modulate and get the antibodies down with gut immune access work, replacing the vitamin D, all of the usual things that we do, testing, assessing and correcting the gut microbiome properly, looking at other immune factors that could be driving inflammation, so clinical inflammation. So when we're looking at that, again, as a whole woman, whole system problem, we can actually prevent people from progressing down to the point where so much of their thyroid destruction has led them to require thyroid hormone externally.

[Angela Foster] (34:24 - 34:34)
Super interesting. With inflammation, how much are you seeing that as a driver of metabolic problems, cancer and other kind of chronic diseases?

[Nina Fuller Shavel] (34:35 - 36:50)
So it's a bit of a chicken and egg situation, so they wind each other up, unfortunately. So if we, for example, have prediabetes or diabetes or starting to get these dysglycemia peaks, we actually know, of course, that excess blood sugar will cause more inflammation. So from that perspective, it's called an age-rage system, which I love.

I think actually does exactly what it says on the tin. So age stands for advanced glycation end products, and that's what happens when you have too much glucose floating around. It binds lots of things that shouldn't bind to, and it causes problems.

And then it does create rage. It creates rage in your immune system because it then upregulates your inflammation. So that's the reason why metabolic control is absolutely essential.

And I think inflammation, for me, it's a consequence of multiple systems going dysfunctional. It doesn't turn up out of nowhere. So I think it's a final pathway.

It's a highway that links multiple chronic diseases, including cancer, cardiovascular disease, et cetera, to the underlying root causes. So it could be things that, you know, come from the gut. It could be things that come from your metabolic status.

It could be other drivers of inflammation, you know, including infections, et cetera, that we need to be thinking about. But we do really need to be thinking about that as a key mark of health going forward, full stop. And actually, when I'm looking at my patient's highly sensitive CRP, and I do do the highly sensitive one because it's not very useful to me knowing it's below five.

When we're looking at long-term health and well-being, certainly my cardiology colleagues are very keen to keep people's CRP as low as possible. And we're aiming for HS CRP to be under one or as close to one as possible. And I can achieve that in patients, even with metastatic cancer sometimes.

And that's what I drive towards, because from my side, it's about sometimes, yes, sometimes the cancer will take this inflammation forward and will be so pro-inflammatory, it will drive that process. And until you can get the treatment that controls the cancer, you can't get under it. But a lot of the time we can.

We can lower those inflammatory markers actively. We also know if we can lower them proactively, we can improve immunotherapy's response, for example, in patients before they even hit immunotherapy. So I think inflammation needs to be, it's a superhighway that links all of those root causes to multiple chronic disease manifestations, something we really need to pay attention to.

[Angela Foster] (36:51 - 37:01)
Very much so. Which sort of brings me on actually to chronic stress, because we know that impacts hormones and longevity. What does that do to immune resilience and cancer risk?

[Nina Fuller Shavel] (37:02 - 43:27)
So chronic stress is an interesting one. So we know that if we go back to adverse childhood events, so ACEs, there have been this big, big ACEs study. When we start having stress as early on in childhood as they have done in that study, it actually links us to immune dysfunction, cardiometabolic consequences and increased risk of every single chronic disease under the sun, actually.

And we know now from research that some of that stress even gets programmed in utero. So actually, if the mother is really, really stressed during pregnancy, the baby comes out with an HPA access system that's pre-programmed epigenetically to be born into a stressful environment, which is appropriately adaptive, right? It would be anyway if we were living in overly short amounts of stress.

Unfortunately, it's maladaptive for us now because it's not very helpful to us. So we do know ACEs are very strongly linked to pretty much every chronic disease. Now, again, we can modify that.

I think that's one of the things that I would have loved to see in the ACEs study is saying, well, what about the people who tried to change that? What about the people who got therapy? What about the people who did certain things to modify their lifestyle risk factors, as an example?

Because going back to the ACEs study, so I would have loved to see some interventions within that setting. So could we actually, the people who have had these ACEs, but then had trauma treatment and have modified the lifestyle factors, affect their overall risk of chronic disease? And my feeling is from all of the other evidence that we have out there, I think that would have changed the outcome.

But we do need to do some research on that. What we know is, of course, in general, for us, particularly in midlife, cortisol becomes a problem for multiple different reasons. It could be sleepless nights, driving that overall load in terms of stresses.

Of course, perimenopause and menopausal hormone fluctuations in and of themselves can be a problem. So I think managing that proactively is really, really important. And again, it's not about sitting there going, OK, well, that's great.

I'm going to, you know, migrate to a desert island and think it's going to be great. That's not how we're going to be able to manage it. But what can we put in to our daily life from our circadian rhythms in terms of light exposures to the way that we use mind-body therapies, to the way that we think about how do we manage our previous predispositions and behaviours to try and make us as resilient as possible?

Because the point is not to live in a stress-free bubble. People often get asked this in the wellness industry. I get asked this all the time in podcasts, go, how do you keep balance?

I'm like, well, I don't all the time. That's the point. You do go through periods of life that are really stressful.

And that's when you draw on your resources, you draw on all of the things around you, from your social network to maybe your meditation, mindfulness practise, to your walking. Like you say, Angela, you know, in terms of being able to walk somewhere, to have some time to think and decompress and not have anybody calling you. All of those things, whether you've got whatever coping mechanism and mind-body practise you have, it's really important for us to have that.

And then we can lay other interventions on top of that. So it could be adaptogen, adaptogenic herbs, as an example. It could be other ways.

It could be certain ways of eating, of course, or balancing our blood sugar well is really important. And we can then layer some of the other interventions if what we're doing in our daily life is not enough. Now, again, in terms of stress and predisposition from the cancer perspective, the studies are quite conflicting.

So the ACEs study is quite strong. It does say, if you get an early in life, it will influence the cancer risk down the line. Midlife stress is quite interesting.

So anecdotally, I will have a lot of women come to me and say, literally two or three years after I've had my father pass away from a really traumatic illness, that's when I got my breast cancer. But the evidence isn't quite there. Some studies show a link and some studies don't.

So what I normally say to people is that we need to look at you. If for you, cortisol is a contributor. If for you, you've had a chronic fight or flight problem and we know that you can't sleep, you've been self-medicating with alcohol, you haven't been exercising, you have been eating well because you've been so stressed out of your mind.

That's what we need to correct. So whether I can, there's nothing, nobody's going to come with nice labels saying my cancer causes are one, two and three. It just doesn't work like that.

But we look at contributory factors and we have to correct them as much as possible. And as I said, it's not about being perfect. It's not about living in a bubble.

It's about what can be workably changed for you right now. And my other call for women is if you've had trauma in your life and if you do still suffer from PTSD-like symptoms, please get it treated by a proper trauma-trained professional. Because so many women are out there walking around with trauma, being told it's fine, whatever that is, is huge.

And then I see those women in my practise with cancer and then we start unpicking what's gone wrong. And not a single one of them has been offered anything beyond counselling. Now, counselling is fine.

It's a lovely support system, but it's not adequate to deal with trauma. We need to be able to provide people with the right level of intervention. If you turn up in A&E and you have an arterial bleed and you're spurting blood versus you stubbed your toe, guess who's going to get priority medical attention?

It's the same thing. Counselling is not appropriate for somebody who is having PTSD. And PTSD is very real in women.

It's very real in people who've nursed their other, maybe their other half through cancer or they've had other people who've had really significant, difficult events. We really need to look at not only the person who's going through a traumatic event, but also their whole ecosystem. Vicarious trauma, trauma that's been passed on to you through the situation is really important as well.

So intergenerational trauma, I mean, we could talk about it forever, but I do think it's really important to never suffer in silence. If you do think you're still getting some of those symptoms like intrusive thoughts, flashbacks, nightmares, you're avoiding certain things and triggers because you know that's going to generate a zero to 60 emotional response like that. We need to address it because that's a chronic loop of stress that never unplugs.

So trauma is a living thing that's happening to you right now at that point. And we need to be able to put it in the past as a memory rather than a living physiological mechanism at the moment. So it's my big passion point because I just see so many women with untreated trauma who've been told it's OK, it's just your anxiety or it's just your depression.

It's never just anything. It needs to be addressed properly.

[Angela Foster] (43:28 - 44:22)
And there are certain certain times of your life that that gets triggered, right? Often postpartum, for example, is a big triggering event. And I think people don't necessarily realise that it just gets written off as postpartum depression, which may obviously there is a hormonal component to this.

But past trauma can come up same in perimenopause, right? And I think it's so important because I think we think, oh, we can just sort of bury that. But actually it's in your body, it's in your physiology and it's having that impact.

I know when I spoke with Dr. Tommy Wood and we were talking about dementia prevention, one of the biggest risk factors was actually it wasn't the stress itself. It was feeling that you had stress, that you had no autonomy over. And I think, again, I'm sure that contributes to cancer risk if you if you don't have autonomy over your situation.

And so I love what you're saying there, because I think getting the right help. And also, I think in middle life, we do need to have some boundaries where we can actually take care of ourselves. I was like, it's so, so important rather than being last on the list.

[Nina Fuller Shavel] (44:22 - 44:28)
Absolutely. And actually, I loved it. I don't remember who said that, but I heard that someone said, no, it's a complete sentence.

[Angela Foster] (44:29 - 44:29)
Yeah.

[Nina Fuller Shavel] (44:29 - 46:14)
And I'm like, 100% right. It's just no, you don't need to explain yourself. You don't need to invent any other excuses.

In a way, I've become a lot better saying no. After my own breast cancer diagnosis, I was diagnosed at 33. I went through medically induced menopause and I was parenting a two and a half year old at the time.

And I said, it does teach you both perimenopause or any other big events in life will make those transitions. We do need to be very selective with what you let back in. In fact, some of the work I've done post-COVID with some of my patients, because we've all had all of our social bits and pieces shut down.

I had to think, you have to think very carefully what are you adding back in to your life? Do we really want to add that back in? Or is it just there because that's expected responsibility or expected something but actually doesn't serve you at all or your family at all in any way, shape or form.

So I always think about curating your actual list of things that you do is really important. Saying no, we just need to get better at it. And I was talking to one of my friends and somebody said to her, if it's not a hell yes, it's a no.

Because we've only got limited amounts of energy and we do need to, like you say, we cannot come last on the list. We do need to prioritise our needs because you cannot pull from an empty cup. And I know a lot of, for example, our guilt in midlife as women can come from, oh, well, I've got so many responsibilities.

There's so many, you know, people I'm taking care of. But I'm like, if you crash, the whole system's going to come down with you. Quite often, you are the linchpin.

You're keeping everything running. So if something happens to you, the whole system's going to come crashing down. We do not want that to happen.

We want to make sure that we're building resilience. And sometimes it does require saying no to things that would be nice to have. But actually, if they don't serve you, they shouldn't be on your list.

[Angela Foster] (46:14 - 46:52)
100%, I love that. And I think stress leaks out as well, right? Of the body.

You can actually, that's been shown and I know some of Dr. Tara Swartz, you know, content around this so important. And even when they've sort of studied people who've gone in and watched a really terrifying movie, I think, and then they exit the room and new people go in and they start to look at their physiology. When we say you could cut the air with a knife after an argument, actually, we are able to sense that.

And then that stress is coming into us. So if you're not managing your stress, whether that's you at work as a leader or you as a parent, unfortunately, it's having an impact. So that actually is another reason as well for us to look at our own stress, but it's also just better for us.

And I agree with you.

[Nina Fuller Shavel] (46:52 - 48:08)
Exactly. And actually coming back to that, Angel, that's the thing, it's like, why do we feel like we need a reason? That's so interesting for me.

But we've been taught, I think it's part of that cultural expectation. I'll give you one example. It's a funny example.

But yeah, my husband never apologised for going to the golf course. Not a sausage. I've never had him say, I'm so sorry, I'm going for golf on Sunday.

But me, I kind of, I've caught myself sometimes saying, I'm sorry, I have to do X. And I'm like, no, I am not sorry. I am doing this.

This is it. So I think it's important that we prioritise ourselves for our own sake, as well as for everybody else's sake. And that we actually make that a daily commitment.

And I often think about, we need to make some non-negotiables. It could be just two or three things that are non-negotiables. Okay, so for me, like when I'm not travelling, my sleep is my non-negotiable because I know that's a risk factor from the breast cancer perspective in terms of there's some shift work, contribution to that.

And I used to be a doctor in the NHS, so I did plenty of shift work. So for me, sleep is a non-negotiable unless I'm travelling. Even in that point, I make sure that I get enough when I come back.

You know, there's certain things that I will always do. My connection with family is really important. My connection with nature is really important.

Having a dog really helps, I have to say, when you really can't be bothered to get outside.

[Angela Foster] (48:08 - 48:08)
Yeah, 100%.

[Nina Fuller Shavel] (48:10 - 49:19)
My dogs keep me accountable. Very true. And you know, in things like nutrition and supplementation, certain things might drop off.

There might be certain things about, do I do every single week two whole body training sessions in terms of resistance training? Not always. It just sometimes does not make it on my list.

It doesn't mean it's dropped off my list, but there's a couple of things that I will say, these are my non-negotiables. It's been a really stressful week. I'm not going to beat myself up about it.

It's going to be okay. I will course correct when I've got a bit of a breathing space. So it's about also not beating ourselves up about giant to-do lists because we've got enough of those.

What are the two or three things I know will keep me sane? It could be sleep. It could be your nutrition.

It could be your daily walk when nobody's talking to you, turn your phone off, whatever it is. It could be your yoga practise or going to Pilates, whatever it is. But make that two or three lists.

Absolutely. That's my sanity list. Everything else is nice to have and I will do that when I can.

But those three things can never drop off. And I think if we prioritise it, it's like the air we breathe. It needs to be that essential.

I do find that we get that daily resilience. That means we can draw on our resources and then be able to replenish ourselves with the extra habits as and when.

[Angela Foster] (49:20 - 50:16)
A hundred percent. And I think also, like, don't delegate it to your wearable device because I think people do this a lot now, the algorithm. So they wake up and they're like, oh, I'm on a red recovery.

So therefore I can't go for a run when in reality, the red recovery is because you've got so much mental stress going on that one of the best things you can do is to go for a run, discharge it all. And I've seen that with, you know, some of my clients. It's like, we need to get to the bottom of what's driving that drop.

Because if it isn't physical stress, there's no reason you should be restricting it. If it's mental stress, we're probably going to discharge it. And actually just sitting and trying to force yourself to meditate for hours because you don't feel like you should go for the run isn't necessarily the right thing.

And then we just, you know, they go out, they go for a nice run or they do some exercise. And then we have a lovely rebound of their HRV the next day. And I think that's the thing is these wearables can't distinguish.

Is it mental? Is it physical? Is it environmental?

What's causing that? And I think that we mustn't kind of hand over everything, right? We need to check in with ourselves.

[Nina Fuller Shavel] (50:17 - 51:56)
Absolutely. I think that's sort of self-intuition. We call it interoception, right?

Being aware of your own internal environment. And I think that's really important. That's something, again, that I think we've been losing.

And actually children these days, again, are almost because they're so device driven and external driven. Some of them, at least, I'm finding that people don't check in with us. So when you ask somebody to think about how they're feeling, what something has made them feel, you can almost see they're really having to work very hard.

So for us, that interoception is absolutely crucial. You're right. Is it mental stress?

Is it physical stress? And actually, I find it quite interesting about the meditation side because, of course, naturally in yoga, we do not sit down for meditation first thing. What do we do?

Asana is used to prepare your body for meditation and your mind for meditation. So we do not do meditation first. We move first.

Then we are actually ready to sit down and do the mindfulness practise. So I always find this quite interesting how we are expected to just drop down and just drop into it. Sleep is the same, right?

We actually are expecting ourselves as adults sometimes during stressful times to just lie down and go to sleep. And then if we don't, something's wrong with us. And I'm like, think about what you've done for children or you've seen done for children, right?

We do the whole kit and caboodle. We give them a bath. We lower the lights.

We might give them a massage. We might read them a book. And that's what it takes to teach the nervous system to go to sleep, right?

To regulate itself and go to sleep. And yet for us, we just expect to just lie down and that's it, you're out. And sometimes we can be out.

That's great. But sometimes our nervous system needs the child-style wind down to say it's safe. It's OK.

We need to be able to come down and not just close the laptop and go to sleep.

[Angela Foster] (51:56 - 52:15)
Yeah, 100%. What's your view in terms of testing that people can do? There's a lot of like, you know, full-body MRI, preventative testing.

What are the kind of things that you think people should be looking at maybe on an annual basis to sort of over, sort of MOT their body, if you like?

[Nina Fuller Shavel] (52:15 - 58:01)
Good question. So there's pros and cons to all of this, isn't there? So the testing, for me, testing comes into two different flavours.

One is that we are looking at sort of diagnostic testing. And then the other, we're looking at screening, really. And those are quite different things.

And of course, in terms of your overall testing, think about doing your systems testing, things like, you know, if you've got gut problems or you've got other problems, that testing comes alongside in its own little bundle. For clinicians, I always say that if it doesn't change your plan, you shouldn't do the test. Because if you're doing the test for curiosity's sake or you are casting a very wide net, you should probably think clinically first before you run a boatload of tests on somebody.

So there are some clinics that will do the same five tests on cancer patients. And I'm like, that's not clinical thinking. You need to target your testing.

I think what you were talking about is much more around the kind of the MOT side. And here, the whole body MRI is interesting because of course, that's been up and coming. You know, it's been out in the US for ages.

There's a lot of these providers have turned up in the UK in the last couple of years. There's pros and cons to that. So MRI over-diagnoses everything.

So when we look at the body with an MRI, all of your normal anatomical variation, you and I, even though technically speaking in an anatomical textbook, we should be perfectly aligned. We're definitely not. I have some kinks.

You know, you have some kinks and it's absolutely fine, this normal variation. Problem is a full body MRI with no other information will show up a fatty lump on your kidney as something to worry about. Now, it's just like a lipoma under your skin.

It might be anything to worry about, but then you're putting the person through months and months of testing and all of the worry and all of the stress that goes with it for something that's anatomically normal for them. So let's not forget the MRI just looks at the body and goes, is there any lumps and bumps or something weird looking? Now, we don't know what that weird looking thing is.

It cannot peek inside the box and goes, that lump is cancer. That lump is not cancer. It cannot do that.

And that's why I'm a bit cautious with whole body MRIs. I will do them for a reason and I will caveat it very strongly with patients around actually what is the risk benefit and what's the anxiety generating, what might be the steps we might have to go through to actually figure out if something is abnormal or normal for them. So when I do use it, for example, patients who've had cancer before, I will quite often align them to some of their medical scans so we get a clean baseline.

So we can then assume that anything lumpy and bumpy on the MRI is normal because all of their pet CTs and some of the more complicated cancer markers are all normal. So when you have a useful baseline, it's useful. Sometimes it can cause a lot of worry and unnecessary investigation.

So I think it's about, again, talking to your clinician. I would not encourage anybody to go and do these tests by yourself. You need a physician who sits there and goes, what's suitable for you?

There are some, obviously, early multi-cancer detection tests out there. Obviously, Gallery has been trialled in the NHS and is actually, from what I understand, being pulled now in terms of the trial. There are some other platforms that are out there for early cancer detection.

We do do them in some patients. There's also genetic risk testing, which is very relevant. So we do two types of genetic testing in our clinic.

One is for the big high-risk genes for people with really high-risk family history because we know that in the UK, unfortunately, despite our amazing genomics programme, we have the most awful criteria for testing women for things like BRCA, as an example. We have the tightest criteria. You have to be, honestly, I don't know how many generations you have, but it's really, really tight.

Whereas in the US, anybody under 45, according to NCC and guidelines, should be genetically screened for all major genetic syndromes. We just cannot get it in the UK. So a lot of the time when women come to me and they've fallen through not being bad enough on the family history, effectively, to hit the NHS mark for testing, but we are a bit suspicious we will do the genetic testing for BRCA and some of the other high-risk genes to see and exclude the fact that they have that.

And we have actually picked up cases, particularly because I see a lot of patients for years where the NHS has been wrong about their BRCA status because they used one of their older tests before 2016, as an example, and it was falsely negative. And actually, when we retested, it was positive. So that opens up new treatment options to patients, but of course, makes it more complicated from the family side.

The final bit, I guess, is looking at polygenic risk scores, or PRSs, and that's really an up-and-coming area, and we do that a lot in preventative health. So anti-genes do things like breast cancer, prostate cancer risk screening, very simple tests, it's based on multiple different tiny gene variants called SNPs, but it's very well aligned in literature to then giving you a risk score. For breast cancer in particular, we can also take this polygenic risk score and we can plug it into really complicated risk model, like tyrocusic model, which has been popularised by recent sort of breast cancer diagnosis, and we can really quite precisely map out people's risk and risk range, and then design a personalised screening programme for them.

So it's not about one size fits all, it's not about everybody getting a whole body MRI and an early cancer detection test every year, that's not the way that this works. It should be your physician sitting down, looking through your family history, through your current risk factors and going, okay, what is the most important thing to you? Maybe it's driven by polygenic risk scores, maybe it's driven by something else, but it needs to be personalised.

I do think that we've gone past the publication screening programmes and we know right now the prostate cancer screening risk programme has shrunk as an example. So we just need to be very precise about are you high risk? Are you medium risk?

Are you low risk? And then according to that risk, we then design what's right for you. And then of course, if you get any new symptoms, if there's anything that worrying you, then we absolutely then change our minds and go down a different pathway.

[Angela Foster] (58:02 - 58:50)
And I think the patient's own psychology, as you say, is so important here, right? What they can take, because I know I went for a full body MRI and the gap between waiting was then a little bit anxiety inducing and then you will find things, right? I found like little tiny water filled cysts that mean nothing they've said, but you have to be able to accept that.

It's the same with testing your genes. I mean, I know like my mother has, sadly has Alzheimer's. When I test, I carry APOE4.

For me, that's quite empowering. I'm aware of the risk and I think I do limit things. So I don't drink alcohol and if I did, I would then moderate it as a result.

You know, I'm very on top of things like omega-3, all the different things, exercise, all these things. But I think for other people, they could, you know, see that and just think, oh my God, I feel really panicked. What if that's in my future?

And I think your own psychology plays a part in this as well, don't you?

[Nina Fuller Shavel] (58:50 - 1:01:26)
Well, 100%. And I think that when you talked about wearables, that's another thing, isn't it, right? I'm sure you find it with your clients that for some people, it's a really bad idea to have a wearable.

Yeah, it's anxiety-inducing for them, actually. And I'm like, then you're asking your wearable whether you've had a good night's sleep. And I'm like, that's the wrong way of doing it.

It might tell you that actually, you haven't been running your sleep to the right timeline for a little while, but we shouldn't be delegating that responsibility. And it can be anxiety-inducing for some people like CGMs, right? Continuous glucose monitors.

I would never recommend to somebody who's maybe on chemo and steroids because they're going to go sky high anyway. So what's the point of inducing anxiety? We know what's going to happen anyway, and we need to just be able to manage that.

So I think things like CGMs, wearables, whole body MRIs, we do need to consider how much mental load and how much is that going to really contribute to meaningful change? And that's a bit where we need to think about. And actually, things like whole body MRIs, we don't have a nice trial that's saying, actually, these whole body MRIs reduce diagnosis of late stage cancers by X percent.

We don't. And that's because not enough people have access to it at the moment. But that bit really needs to be proven.

So what we need is not just saying, oh, we're maybe picking up also really early stage cancer, we're never going to kill anybody. So if I actually biopsy the prostates of men in their 80s and 90s, vast majority of them will have some prostate cancer in situ. It's just not going anywhere, and it's never going to kill them.

So the key bit for us medically is to say, it's not just about saying we're going to diagnose you at an earlier stage, so that's more treatable, but we're also going to diagnose the cancer that is actually going to impact your life. We're not going to over-treat you and cause harm by over-screening you, which is another thing we need to consider. So financial toxicity, emotional toxicity, all need to be considered in the screening regimes and making sure we've got some evidence behind it.

That's really, really important. And when we don't have evidence, we need to be talking about it, like we don't have evidence, and you say, here are the pros and cons, right? Some of the newer things will not have long-term studies because we haven't actually had this technology around long enough to run a long-term study, but we need to continuously monitor.

And I just think it's such a... There are so many companies that build on this, like one-shot screening thing. And I'm like, that may be fine.

Like you said, if you are the sort of person who can take the anxiety and the waiting and who can framework that around this, and you're not going to be worried. And you're also prepared to have extensive investigations if there is something that may potentially be harmful or not. But if you're not that person, is it going to help you?

I'm not entirely sure it will.

[Angela Foster] (1:01:27 - 1:02:04)
Yeah, maybe not. I mean, it's like you were saying with the CGMs there, you can get obsessed for the two weeks or four weeks that you're using it, whereas really your things, fasting, insulin, HbA1c are more important because otherwise what happens is, like I remember doing this for a little bit and going, oh, like if I have a carrot juice or watermelon, it goes out of control. And it's like, yeah, but you could just as easily have something that's really high in fat and sugar.

And then it just stays in line. It doesn't mean it's healthy for you because it's an ultra processed food, but the fat's kind of moderating it. And when, you know, when did, when was watermelon ever really bad for you?

Do you know what I mean? And I think you can get a bit driven by that. Yeah, exactly.

[Nina Fuller Shavel] (1:02:04 - 1:02:15)
I think any single marker, isn't it, Angela? It's any single marker, right? You can become obsessed with like HIV is one single marker, right?

Or glucose is one single marker. It's like, take the bigger picture, right?

[Angela Foster] (1:02:15 - 1:02:27)
A hundred percent. And you've got to live a little. So what, what would you say if there was one message that you want to leave every woman with, what would you wish she understood about her health and longevity?

[Nina Fuller Shavel] (1:02:28 - 1:02:48)
That's too hard a question. I think take care of yourself and 80-20 would be, it's a combined message, but if you can take care of yourself well, 80% of the time, 20% of the time, have as much fun as humanly possible. Please don't add the cortisol or the guilt to any of this.

That would be my message.

[Angela Foster] (1:02:49 - 1:02:58)
I love it. What a great point to close on. Thank you so much, Dr. Lina. It's been absolutely fascinating speaking with you. Where can people connect with you and your work?

[Nina Fuller Shavel] (1:02:59 - 1:03:14)
So you can find us at the Synthesis Clinic website. So that's my private practise. And we also do charitable work at the NCIO, the National Centre for Integrative Oncology.

And I believe you will have some of those show note links in there. So yes, search us out there and please do support us.

[Angela Foster] (1:03:14 - 1:03:18)
Amazing. Thank you. We will link to all of that in the description.

Thanks again for coming on.

[Nina Fuller Shavel] (1:03:18 - 1:03:19)
Thank you so much.

Integrative oncologist Dr. Nina Fuller-Shavel joins me to explain why cancer rates are climbing in midlife women, even those who look healthy on paper.

WHAT YOU'LL LEARN

- Why cancer rates are rising even in midlife women who look and feel healthy

- The gut-estrogen connection: how your microbiome affects hormone-driven cancer risk

- The 3 simple interventions that cut cancer risk by 60% in a landmark trial

- How strength training lowers inflammation and disease risk

- Why lifetime estrogen exposure matters more than the estrogen drop in perimenopause

- Why standard HRT dosing gets it wrong, and what blood levels to actually ask for

- Why TSH alone can't tell the full thyroid story, and what a full panel should include

- How chronic stress and trauma quietly drive long-term disease risk