[INTERVIEW]
Ronda Nelson: If you are a functional medicine or a wellness practitioner, stick with me, because you’re gonna want to hear this. Conventional medicine just did something that functional medicine should have done first. There are brand new guidelines that connect metabolic dysfunction, kidney disease, and cardiovascular risk into the same continuum, and this forces us to ask: are we really treating dysfunctional systems, or are we just isolating the symptoms into silos?
Let’s talk about it.
Well, welcome back. I’m glad you’re here. We are going to dive into a topic today that is a bit saucy, as I like to say. And you might be thinking, well, what are you talking about, what is this thing that we should have done a long time ago? Well, friend, when you hear about it, you’re gonna say, ah, dang, they beat us to it.
And yes, they actually did. But it’s okay, because we’re gonna draft off of what their recommendations are. So let me explain. This new guideline actually came from four very well-respected organizations in conventional medicine. It came from the American Heart Association. I mean, we could argue that their intention may or may not be always up and up, but nonetheless: the American Heart Association, the American College of Cardiology, the American Diabetes Association, and the American Society of Nephrology.
And what happened was they got together and they basically have formally made a statement, and they’ve said that kidneys, adipose tissue, the heart, cardiovascular system, and the metabolic systems cannot be managed independent of one another. Let me say that again. The cardiovascular system, the kidneys, fat, adipose tissue, and the overall metabolic system are essentially one big interconnected system.
And yes, I would say that we’ve kind of had that thinking, right, to some degree, in functional medicine, conceptually. We talk about wanting to get to the root cause, or we’re gonna try and connect all the pieces and get to the underlying cause. But here’s the thing. Have we really done that? Or, as I said when I opened, do we still put these symptoms into silos?
In other words, we look at metabolic dysfunction. Let’s get your glucose down, regulated, and maybe regulate some inflammation. Oh, you had a life screen, or what’s that called, the Lifeline screening? You had one of those, and you’ve got some arterial plaquing, carotid plaquing, then let’s put you on XYZ. We still separate those out, and I think we don’t need to do that, and I’m gonna show you why in this episode.
So I just went on a big deep dive. This episode might run a little bit longer, but hang with me. You’re going to want to hear it all the way to the end. We want to figure out what is the pattern. Why are these systems connected together? What is the pattern? What’s driving it? What’s behind it? What organ is showing signs of stress? And then I’m gonna give you the actual stages. I’m gonna give you what to look for, and I’m gonna talk to you about the blind spots that you might have as you’re starting to incorporate this way of thinking, or this new concept, into your clinical framework.
So let’s talk about it. It’s really just called CKM: cardiovascular, kidney, metabolic, okay? CKM. They’re referring to it as the CKM syndrome, and what this does is it’s basically talking about a multi-directional relationship between all of these different functions: between cardiovascular disease, and kidneys, and glucose and metabolic regulation, and then central, or excess, or dysfunctional adiposity.
Now, these factors don’t have to always coexist. You can have someone who’s just overweight, has a metabolic dysfunction, and that may never translate over into kidney or cardiovascular disease, and that can certainly happen. But CKM is not just one diagnosis. Don’t think, oh, everybody’s gonna fit in this box, because they’re not.
There are four very specific stages. Well, there’s actually five. Stage number one is stage zero. So let’s talk about that. That basically means they are at a healthy weight. There’s no excess adipose tissue. Their glucose is normal. They have no hypertension present. Lipids are normal. No cardiovascular issues, no plaquing, nothing. They’re good, they’re fine. All we’re doing is working to preserve their health, help them maintain it, and keep them out of the doctor’s office, right? That’s our job. That’s stage zero.
Now, the rest of the stages, stages one, two, three, and four, these are all going to be very specific in how you’re going to think about staging your patient, okay?
Stage one starts with excess adiposity, excess fat accumulation. So the patient is gonna be likely overweight, usually abdominal adiposity, and they may even be pre-diabetic, but they may not even have an elevated BMI, because you can have a skinny fat person. And now with these GLP drugs, we’re gonna start seeing more skinny fat people, where they have a lower amount of muscle. They look thin, they look fine, but their BMI might be a little higher. They may have more fat than muscle than they need to.
So remember that prediabetes, when we look at that, that’s like bordering on some dysfunctional adipose tissue, right? We get some diabetic type patient, we’re gonna start seeing some inflammation inside the fat cells, and we’re gonna start to see dysregulation in the metabolic system. So it happens before there’s pathology, even. We could just see it on a blood test. This is where we want to catch them, okay? So this is stage one, and I’m gonna get into the fixes in a little bit.
Stage two is, oh, we’re starting to move the needle up. Now we’re starting to see excess truncal or abdominal adipose tissue. Now we’re starting to get into hypertension. And you can probably think about a patient that you have that has this very thing. They’re hypertensive, they’ve got some elevated triglycerides, which is always the lie detector for fat, elevated triglycerides. They may have metabolic syndrome. You might be seeing now, like past prediabetes, they’re now into more of a diabetes state, and they could have moderate to high, maybe kidney disease.
There might be a little bit in there. This is where the CKM syndrome, or collection of symptoms, really becomes established, is in this stage two. The lifestyle, we have to address the lifestyle, that becomes foundational. Get the diet right, support blood sugar, and all the things. But the lifestyle changes and blood sugar support may not fix the problem, because now it’s starting to spread. We’re starting to move into other systems of the body. It’s no longer just a metabolic function with fat cells and a poor diet.
Stage three is where we start to see subclinical cardiovascular disease, or some kind of equivalent risk. There may be some coronary calcium, right? We may have some plaquing, some congestion in that coronary artery. There may be some other secondary coronary disease of some kind. They could have some signs of heart failure. They could have some dysregulated eGFR, cystatin C. There might be some other kidney signs that you’re looking at that may be indicating that there could be some more advanced disease here.
So when we get in here, we want to prevent this. When we get to stage three like this, this is a problem, right? We’ve got a problem. This is more than just a metabolic issue. The patient might, at this stage, even feel okay, even though they’ve got some arterial plaquing. They might be like, yeah, I’m fine. But the tests aren’t gonna lie. The numbers don’t lie. So don’t let the fact that they feel fine trick you into believing that there’s no problem. Primary prevention at this point doesn’t mean that they have low risk. It means that you’ve got to look at the blood tests or the labs, whatever you’ve got in front of you, and you’ll say, okay, what are the chances that there could be this cardiovascular, kidney, metabolic collection of symptoms, a syndrome, happening, and how quickly do I need to get on top of it?
So the last stage, which is stage four, this is when we have true cardiovascular disease. The patient has coronary heart disease. They’ve had strokes. They’re having TIAs. They’ve had some heart issues. They’ve got atrial fibrillation. They’ve got artery disease. You’re starting to see signs of kidney dysfunction, maybe swelling in the legs, poor sodium, electrolyte imbalance.
Look for, at this stage too, this is just my clinical experience, you’ll find that a lot of these patients are apprehensive or fearful. They’re usually worriers. That’s the emotion in Chinese medicine that goes along with the kidneys. This is when lifestyle, as with all the stages, lifestyle support is always very, very valuable, but it has to complement the other interventions that we’re doing to try and bring this system back in line and bring the cardiovascular, kidney, and metabolic markers back where they need to go.
You can even see this. They’re finding this now more and more in youth and younger children, this disease, and part of it, you know this, is because of our crappy diets, or the food that we feed our kids. There is a kind of calculator that you can use. It’s called the PREVENT calculator. I will link it in the show notes. It’s put out by the American Heart Association.
So now you know there’s four stages, and they’re pretty common sense, right? Stage zero, healthy person. And then we start with stage one all the way through stage four. When we get to stage four, we’ve got a problem.
So where are we gonna start? All right, well, number one, I want to make this really practical for you. We have to start with the adipose tissue, period. Remember that fat cells are an endocrine organ and an immune organ, and when we get too much adiposity, we’re gonna have inflammation, we’re gonna see oxidative stress, we’ve likely got some insulin resistance. There’s some increased fatty acids that get released. We’ve got all kinds of stuff happening just because there are these excess fat cells, and then the consequences are it starts to affect the liver. It starts to affect VLDL. Triglycerides start to go up. Glucose gets dysregulated, and we can end up with a fatty liver.
Now, we’ve always known this. This is just a bit of a side bit I wanted to throw in here for you. We’ve always talked about non-alcoholic fatty liver, right? NAFLD. The new terminology, you know they can’t leave things alone, like they changed PCOS, it’s fine, but for an old brain like mine, can you just keep it the same, please?
Now non-alcoholic fatty liver is called MASLD. Can’t leave it alone. It now stands for metabolic dysfunction-associated steatotic liver disease. Basically, fatty liver. But now what they’re doing is they’re saying that it is linked metabolically. This fatty liver has a close association with metabolic dysfunction. Well, we already knew this, but this is where it kind of comes in: when we see that increased adipose tissue, we start to see triglycerides change. There’s gut dysfunction, and we’re gonna end up with MASLD rather than the NAFLD terminology.
Now, this is not a liver detox situation. Fatty liver is not detox. We don’t need phase one, phase two work. We do need it, but that’s not what this is for. We have to go after the metabolic side in order to clear and get that fatty deposition in the liver cleared up.
There are gonna be kidney markers you have to keep an eye on. Sometimes we just gloss over them. You can’t do that. So metabolic dysfunction, and if they’ve got hypertension, so hypertension, you’ve got to look at the kidneys. So metabolic hypertension, probably gonna have some kidney involvement. So kidney, you’re gonna look at eGFR, cystatin C, or even the urine. It’s called a UACR, and that is a urine albumin to creatinine ratio. It helps to give you information about kidney or vascular injury in the kidneys.
So okay, now why does this matter? Because the UACR can give us information about how they’re handling protein, basically, in the kidneys. So that is a marker that you’re gonna want to make sure that you order. We have to look at all aspects, depending on how they stage out.
Number one takeaway is address fat. You’ve got to address this, the adipose tissue. Get the inflammation down, get the fat down. And here’s the thing: if you have a patient and they’re just like, nope, not gonna do it, don’t want to diet, don’t want to do all of that, well, I can’t care about it more than you do. I really want to care about it with you. I want to help you. I want to see you live to hang out with your grandkids and have a great life. But they’ve got to get rid of the fat, especially when you see that kidney, renal involvement, and you see the cardiovascular involvement. It’s just essential. There’s no ifs, ands, or buts about it.
So now here’s what I want to give you: some blind spots to look for. This is what we have to guard against with our functional medicine training, right? You know I am functional medicine and I hate functional medicine all at the same time. You all know this, right?
I know that from a functional medicine perspective, it is still so easy to silo these symptoms. So our first blind spot is gonna be the protocol silo. Get one protocol for glucose, and then the lipids get another one, and then we’re gonna deal with the fatty liver with inositol and milk thistle, and we’re gonna give those things for fatty liver, and then we’re gonna give something for blood pressure, and oh yeah, we’d better give them something for their kidneys, and then maybe we throw in a little bit of food for the liver, take some bovine glandulars. It’s so easy to do. It’s just so easy to do. But don’t do it. Resist the urge. Look at what the organ is that’s under the most stress. And I would argue, if there is excess adipose tissue, you’ve got to get rid of that first. You can support the kidneys and support the cardiovascular system, but you’re not gonna get very far if their metabolism is all messed up.
Blind spot number two is making it all about insulin resistance and metabolic syndrome or glucose dysregulation as the explanation for everything. Well, if we just get your blood sugar under control, your cardiovascular situation’s gonna resolve, your kidneys are gonna improve, the dyslipidemia is gonna improve, all of it’s gonna get better. That’s not true either. It’s a piece of the puzzle, but it isn’t the entire puzzle.
Blind spot number three, this is when, I don’t do this, and so I always caution all of you listening, don’t do this. Do not go out and order a whole bunch of tests just because you can order like an NMR that’s gonna give you the HOMA-IR score. It’s gonna help you see particle size. You’re gonna see the lipids in there. That’s fine. I like that test. I’m all good with that. But more specifically, we need to go back to basics when we’re looking at patients that potentially have this CKM syndrome: cardiac, kidney, metabolic, cardiovascular, kidney, metabolic.
When was the last time you got a waist circumference? I mean, we’re talking basic here. Basic. Waist circumference. Get blood pressure. Take blood pressure in your office. Or ask them, take it in the morning when you first get up. Take it after a meal. That’s always telling. Don’t have them over-obsess about it, but you kind of want to just get a baseline. Order the right blood tests, but don’t order too many blood tests. We want to know: what is that waist circumference? What is their blood pressure? Because we can evaluate their BMI, and then that’s gonna give us some information about metabolic syndrome, where they are on the spectrum. So don’t forget about the basic tests. Fine to order the other ones, but don’t go crazy and forget about the basics.
Number four blind spot is treating their lifestyle and diet, and their medication, as competing. In other words, you’re over here doing diet, and then you’re trying to get them off of medication. I’m not saying don’t work with their prescribing doctor to see if you can minimize some of that, but sometimes those medications provide psychological safety. They provide mental safety for the patient. They’re not ready to do that, and we’re always advocating for optimizing their health. I love that, we need to do that. I want to do that. However, if we’re focused more on working with their doctor and making sure that there’s a plan to maybe get them off, don’t let that be the focus. Look at the adipose tissue if it’s there. Look at their lifestyle. Get the diet right. And then you can just assess, okay, well, maybe this is what’s going on.
And honestly, I don’t know very many providers that are evaluating it this way. In fact, my mom has this very condition, and every time she goes to the doctor, they’re looking at her kidneys. Her legs are swollen. She has massive amounts of inflammation. She’s overweight. She eats a lot of sugar and has her whole life. Days and weeks will go by, and all she’ll ever have is sugar, no protein, no nothing. And I’ve seen her health decline over the years, and it is absolutely a metabolic, kidney, cardiovascular situation. She has TIAs that render her unable to speak. She’s dizzy. She doesn’t feel good for hours. She has them at least once a week. And I know what’s happening, but she doesn’t really want my help, so I can’t help that. I love her. I just can’t help that. You’re going to find people who you can identify this in, but they’re just not open to having help. And it’s heartbreaking, but you have to just let that go. But you can’t go rushing in and take them off all their medication and just say, here, start eating beets and arugula, and you’ll be fine. That’s not gonna work either. I know, that was an oversimplification.
Blind spot number five: do not ignore the cardiovascular piece. I think sometimes we get a little squeamish about that, like, ugh, I don’t want to get into that because I don’t want to get sued, or I don’t want to get in trouble. You’re not gonna get into trouble. What we want to do is make sure that we have a good referral. So in your community, connect with a cardiac person, a cardiologist. Build that relationship and say, listen, I see a lot of these patients, and I would like to have someone to refer them to if I find this and I need some help. That’s a great referral, because if you find the right cardiologist, you’re gonna be able to get some cross-back referral, right? Hopefully that cardiologist will understand a little bit more about what you do, and for the cardiologist, they can send them to you for diet and lifestyle advice.
So find that right connection. This is just how you build a business around the clinical, and I’m a big advocate for that. You have to be good at what you do clinically, but you also have to have some business sense and business know-how to be able to know how to leverage what you do in order to get more people in the door. It’s the number one complaint I hear from practitioners: I need more people. I’m like, okay, well, first step first, go make a good referral relationship with a cardiologist.
Okay, so look for things like edema in the legs, exertional intolerance, where they get up and they can’t move, you know there’s a cardiovascular, cardiac something going on. Rapid weight changes, symptoms at night, they lay down, they can’t breathe, they get panicky, all that stuff. Just watch for those signs, because it’s real easy to say, well, I’m just gonna give you hawthorn for your heart, and that’ll be fine, and some adrenals because you have orthostatic hypertension. None of those are wrong, but you have to know when you need to refer out, so you have to match the patient with the right type of referral. If you feel like you’re the right one, awesome, you do that. But if you do need to refer out, make sure that you have someone that you can refer to.
So I would say, in closing, first you have to figure out what stage they’re in. Are they in stage one, where they just need a little bit of support, they’re pre-diabetic, and they just need some lifestyle, maybe get a little bit of that fat down? Or have they graduated into stage two or three? My mom is stage four plus. Actually, stage four has two sub-stages to it. My mom is in the second one. At the end of that, she’s all in.
Second thing we want to do is look at their trajectory. So I’m big about building a timeline. When you build a timeline, you say, okay, when you came in, your waist circumference is X, your blood pressure is X, your glucose and A1C is this, your triglycerides are here, your eGFR is here, your UACR: is it getting better or worse? That’s, remember, that’s protein measurement. Is your physical capacity increasing or decreasing? So there are some markers that you’re gonna want to track so that you know that you’re making progress, that the patient is making progress, and your protocols are making progress. We forget sometimes to take that ongoing snapshot of how the patient is doing. We don’t want to just get it one time and then go on about our happy little life, working with them and giving them supplements and lifestyle. We have to be able to measure that every single time. It’s a process and a trajectory. How do you know it’s working? If you see changes in BMI, changes in waist circumference, the hypertension is coming down, their glucose and A1C are regulating, that kind of thing. We’ve got to monitor that.
Number three, you want to quantify it when you need to. If you’re looking at overall cardiovascular disease risk, use that PREVENT calculator, P-R-E-V-E-N-T. You can look it up online. It’s from the American Heart Association, and it’s just a little calculator. I think they actually have a way that you can put it on your website. If you’re a cardiovascular person and you see a lot of those types of patients, you can actually integrate it on your website. It’s best for adults aged, like, thirty to eighty. It’s not great for under thirty. It’s not great for kids. I wouldn’t use it for that. But I would use it for someone who’s a full-on adult.
And then I want you to be looking for those dominant drivers. That’s adiposity, glucose dysregulation, hypertension. They had a Lifeline screening, and they’ve got some arterial carotid plaquing. Sleep apnea is another one. We know sleep apnea is a huge indicator for inflammation, increases cardiovascular risk. Nicotine exposure is another one. Look at the nicotine exposure. See how much cardiovascular work they do, like, how much heavy breathing are they doing, out walking, walking up a hill, or on a treadmill, or jogging or something. And look at side effects of any medication that they’re taking.
I just recently had someone who emailed me and said, I don’t feel good, you gave me these new supplements. Funny, they always want to blame the supplements, right? You gave me these new supplements, and my mouth is dry, and I’m not breathing well at night. And I said, okay, well, I don’t know that any of these herbs that I had given her would be drying at all, but maybe you could look. Have you changed anything? Have you been on an antibiotic? Have you added a new medication, whether it’s prescription or over the counter? Are you doing anything different? Did you add a humidifier or a dehumidifier in your house? Did you get new air conditioning? Something like that.
Of course, you know what I’m gonna say. She comes back, and she had been taking an antihistamine or something, which dries out your mouth. She said, oh yeah, that’s one of the side effects, I realized it started with that. Okay, never mind, thanks.
So you have to ask those questions, because sometimes they aren’t always forthcoming about it. Look at the indicators, check medication, look for kidney disease. Don’t overlook those markers, because they really can, and inflammatory markers, I didn’t even talk about that, like eGFR, et cetera. You’ve got to look at that homocysteine, huge marker for this. Oh my gosh, that’s a huge one. And then we want to protect the organs that are showing damage. So if you know that there is kidney damage, please support that kidney. If you know that there’s difficulty with the kidney and protein regulation, please help support that whole process with whatever protocol that you do. Make sure that you’re supporting their eGFR, supporting the cardiovascular system. You would do that anyway.
And then I like to think about this as multi-glandular. If I could step back and take a five-thousand-foot perspective, like look down at the patient from a five-thousand-foot perspective, if I close my eyes and just look at the patient with a clean slate, what would I see? What would jump out at me? What intuitively would kind of show up for me that I might go, oh yeah, it just feels like I need to go there first? Just trust your intuition. Trust your intuition. You can’t fix everything all at once. It is a process. You cannot rebuild Rome in a day. You cannot fix everything at once. So that’s why you’ve got to trust your intuition. You have to trust what it is that you’re feeling, like, I think this is really a priority, because only you know that particular patient.
[CLOSING]
Ronda Nelson: So this is a new guideline, CKM. I want to put it on your radar. I have a resource for you that you can download. It’s called the CKM Checklist. You can download that. Go to rondanelson.com/ckmchecklist, and you can download it, and it just has a recap of what we just talked about here on the show.
You can save it, use it as a little bit of a checklist and a guide, and I want you to have something that you can look at, something that makes your brain go, oh yeah, this is the patient Ronda was talking about, that I need to go get that piece of paper. Put it in a sheet protector. Make several copies. Put them in all of your treatment rooms so you have it, because I want you to start thinking about this multi-system approach, rather than siloing the symptoms and classifying them as just blood sugar, just lipids, just kidney, just this, because the kidney, the cardiovascular, the metabolic adipose tissue, they all are gonna be working together.
So there you go. CKM checklist. Go grab it. I’d love to have you download that, and then let me know, if you ever have a patient or you have a question, you can always just email me: support@rondanelson.com. I always love to hear from you. But yeah, download that checklist and go get ’em. We are in this together, my friend. Take care. I’ll talk to you next week.
[END]