Butter, Epidemiology, and Great Teaching: Rod Jackson Part 2

Rod Jackson on Heart-Healthy Living, Teaching Epidemiology, and the GATE Frame

Adrian interviews Dr. Rod Jackson on the Building Bridges Podcast (Butler University Dr. Medical Science Bridge Program), focusing on cardiovascular prevention and his teaching approach. Jackson argues coronary heart disease is driven primarily by dietary saturated fat, largely from meat and dairy, and urges reducing saturated fat first, then avoiding smoking, eating largely unprocessed foods low in salt and refined sugar, and exercising (which he ranks lower than diet). He recommends regular cardiovascular risk assessment, especially for older adults, and notes safe, cheap blood-pressure and lipid-lowering drugs can substantially reduce risk and that lifestyle changes help even after disease develops. Jackson explains his engaging teaching style centers on connecting with students through relatable stories (like his evidence-based lunch) and using pictures to teach epidemiology via the “GATE frame,” which he calls the epidemiological paradigm, plus a “cross” to incorporate evidence, values, politics/cost, and individual circumstances in decisions.

00:00 Welcome Back and Recap

00:58 Heart Health Basics

01:30 Butter Cop and Saturated Fat

03:59 Prevention and Risk Meds

05:10 Never Too Late to Change

06:38 Teaching Style Secrets

11:00 Gate Frame Storytelling

13:46 Krebs Cycle Inspiration

15:03 Gate Frame Challenge

17:12 Decision Cross Explained

18:51 Final Thanks and Signoff

Links:
The GATE Framework for Epidemiologic studies: gateframe.pdf

Transcript

0:00

Welcome back. This is Adrian. This is the Building Bridges Podcast brought to you by the Butler University, Dr. Medical Science Bridge Program. And if you're just joining us, we're talking to. Doctor, professor Rod Jackson, who prefers to be called Rod. in part one, go back and listen. In part one we kind of talked about, his early life and how he got into epidemiologic research after training as a physician and how. His research with a huge portion of the New Zealand population really shaped guidelines and clinical decision making tools there specifically in the realm of, cardiovascular care. Rod has some takeaways from what he's learned about the different risk factors in cardiovascular disease, particularly around diet. And he's also an amazing educator and teacher. So in part two, we're going to learn more from Rod about those things, and we're jumping right in. Before we transition to teaching in a little bit, why you're so good at it, if you have any tips on it.

Adrian 1:07

yeah.

1:07

Before teaching, if you could summarize, like if someone came up to you, I mean you probably. No more than most humans on earth about how to keep your heart healthy. Do you have some kind of like summary statements? People must ask you this all the time, like, how should I keep my heart healthy? Do you have any summary statements on, do's and don'ts?

Adrian 1:28

Yeah.

rod 1:28

yeah. One of the things I'm known as by my students we'll discuss this later, is I'm known as the Butter Cop. New Zealanders are the world's biggest consumers of butter.

1:39

What? No, that can't be right. What about like France?

rod 1:43

We eat more better Than French. New Zealand are the biggest exporters of butter in the world. We export more butter. We, well, we export more dairy products'cause I'm not sure if you know, but the climate is not that extreme. So grass grows all year round. We have a large dairy herd in New Zealand. And because there's not that many people, we are able to export it. So India is actually the biggest producer of dairy products, but, because of their huge population, they can chew it all. We're one of the top five producers, but we are the world's biggest exporters. And so, yeah, we have a lot of butter. And butter is so basically the course of coronary heart disease. The underlying cause is, diet, high saturated fat. Yeah. You basically cannot get coronary heart disease without bathing your arteries and saturated fat. And so that saturated fat comes from, meat and dairy products mainly. And yeah. If you wanna reduce your risk of coronary heart disease, reduce your saturated fat intake yeah. Once you've bathe your arteries and saturated fat, then a high blood pressure, a high blood glucose, those become important. Smoking become, they all become important on top of the diet, high in saturated fat. So step one, reduce your saturated fat consumption. Step two, don't smoke. Step three, focus on unprocessed foods that are low in salt and sugar, et cetera. And step four, regular exercise is good, but it's actually about number four. People often think that exercise is way up there. Exercise is good to do, but, we are what we eat. Primarily, we wanna eat. Low saturated fat, number one, low salt. And then low refined sugar et cetera. And the best way to do that is to eat largely unprocessed food that's low in saturated fat. largely plant-based, a bit of meat's. Okay. But if it's low fat, so if you cut the fat off meat. Yeah. We are big meat eaters as well in New Zealand. So trying to, you know, telling people they shouldn't eat meat turn them off. But you can get them to eat, it's not hard to transition to low saturated effect. Yeah. Mm-hmm. And then once that's prevention. Big picture, public health prevention, on a regular basis have your cardiovascular risk assessed. And, if it's too high for you, and it's very much a personal decision a combination of, cheap, safe accessible blood pressure loan drugs and lipid loan drug statins. So the combination can halve your risk within a few years. I mean, that's, so these are powerful drugs. These are powerful drugs. So, so the combination of prevention in terms of diet, what I've just been talking about mm-hmm. Diet and exercise. And then, certainly for people over 50, 60, 70, do have your cardiovascular risk assessed. And and if you know that, you know, if your risk of having an event is 10 over a hundred in the next five years you know, you can halve that to five out of a hundred if you take a couple of drugs that are, as we know, we've got decades of trial data on blood pressure lowering and lipid lowering, and these are powerful and very effective drugs.

5:10

Okay. Would it be safe to say that lifestyle is still effective there, even if you already have cardiovascular disease already?

rod 5:17

Oh, absolutely. Okay. So that's another good point. It's never too late to reduce your risk. I talked about diet and exercise. No smoking, everyone, everyone should do that their whole lives. I mean, that should be the focus. That should be number one. But on top of that, don't be scared of particularly once you're in your sixties and seventies of what are very safe and now very cheap. Simple medications. You know, as I said, they've been around for decades, statins over 25 years. You know, the common blood pressure, low drugs been around for the same time, if not longer. And they're cheap and safe and have very few side effects.

Adrian 5:58

I mean, I wish people were as afraid of butter as they are of statins.

rod 6:04

It's the butter, yeah. Yeah. Butter. Well, butter is for New Zealanders. Butter is the worst thing you could eat. It's the most poisonous food in New Zealand.

Adrian 6:12

Yeah.

rod 6:12

But there's a YouTube video that's called, I'm sorry, rod Jackson. That one of my, medical students actually put together, and he wrote a song because there's a song, I'm sorry, Ms. Jackson. It's a quite a famous song. He changed it to, I'm sorry, rod Jackson. You might wanna look at it. It talks about butter and yeah. But I'm numb for saying you can eat butter on your birthday.

Adrian 6:35

Just on your birthday. Good to know. I'll keep that in mind. I also wanna talk about your teaching style. Referring to the video, someone was inspired to make a YouTube video. Before I met you, I had watched the video, I used your materials in my class that I had found online, but then I got to be your student actually, and I was like, oh yeah, this is all. For real. It's not a show. He's just a really great educator and given that this is, teaching is my pun intended, bread and butter of what I do mostly. When you walk into the classroom and you're preparing something, how do you stay so engaging and enthusiastic and like happy and pleasant? You really do create a vibe that's just like, yeah, not scary. Welcoming. Yeah. This is hard stuff. And in a lot of other different situations, people do not look forward to learning about statistics and epidemiology. It can be really dry and boring and what's your approach? How do you keep it so interesting.

rod 7:39

I think probably the most important thing with teaching is you have to connect with your audience. And it's specific audience. That's the most important thing, is connection. So for example my main teaching at the University of Auckland is I teach, currently it's 1400 students mainly 18 year olds. They've just come out from school, although they do have, they're all ages, but mainly 18, 19 year olds. And they have this career year, well, it's the first year at university where, they will apply at the end of the year for medicine, nursing, pharmacy, optometry, et cetera. So it is basically a cross section of the Future health sector. And I teach these mainly 18 year olds. So their first, I get them on their first day and, I teach them at 12 or one o'clock. I take my luncheon, so I say, so do you know what I'm gonna have for lunch or if I've already eaten it, I've taken a photograph. And I, when I introduce myself, I introduce myself as a cardiovascular disease epidemiologist. And my lunch is me practicing what I preach. It's an evidence-based. Lunch, it would be low in saturated fat and unprocessed. It's largely plant-based whole Foods. But that, for an 18-year-old, for someone who hasn't had anything to do with health or healthcare at all, that's makes a connection. That's what I eat. And the students, you know, they keep on asking me what'd you have for lunch, rod? You know? And the first thing is to make a connection and it's a way of breaking down barriers, i'm this professor, famous professor, but actually I eat lunch just like they do. It not only breaks down barriers, but I don't have any problem lecturing large audiences'cause I've done it for decades. But, you know, I'm always a little bit nervous beforehand. Everyone is a bit nervous beforehand, I still get a little bit nervous, but it actually relaxes me as well, and mm-hmm. And then i've connected. Yeah.'cause they think, God, what's he talking about his lunch for? But this is kind of potentially interesting and he says the butter is poison. Oh my god. You know, I talk about this. But I've connected to them. And I think that's really important to connect to your audience. I'm always watching them. And also I love what I do. I'm passionate now. Not everyone can be passionate about it, but it does help. It does help because if you are passionate and interested in that, people say, I want some of that, he enjoys it. It must be good That really helps. I don't, I mean, I don't try and pretend if it's something that I, I mean, if it's something that I can't I find boring. I try to think, how can I make this interesting? Because I don't think you ever want to teach something boring you know, I mean, epidemiology potentially is very dry. It's lots of numbers. I decided, and it's a bit like I did when I decided that hypertension was a wacky construct. Didn't make any sense. I just thought, you know, the two by two table of epidemiology, you know, students glaze over. It's boring. And so, you know, I decided I had to teach epidemiology in a different way. And I turned it into a picture, which is what the gate frame is. And a picture is a story. So that's another word that's important. Tell stories. People, you know, it's like the story of my lunch which is the story of my job and. The story of epidemiology is, I guess your students are gonna be looking at the gate frame. It's a triangle, a circle and a square. The square is the two by two table. Mm-hmm. But the triangle in the circle, and there's an arrow that fills out, that's the context. That's the whole story. Whereas the two by two table was just numbers. But, so I wanted to turn epidemiology into a story, into a picture. And, you know, I started. With three circles, believed it or not. And then I realized that the bottom circle was the two by two table, and then I had two circles in a square. And then students, why haven't got these two circles? What's the difference between them? And then I decided that top, that should be the triangle. That's almost like a funnel. And that's where everything comes in, you know? Life is a cohort study. You know, we are born, we go into this funnel and then we go, you know, the circle. We do some, you know, we're exposed to stuff or not exposed to stuff. And then the arrow is over time, as time passes, we get into the square, you get sick and you die. You know, so the square stuff. Life is a, is a big data epidemiological. Study. It's a cohort study that is what life is. And so yeah, the gate frame can be the cohort study of life or a particular study. And so, but again, this is all about making a connection. Telling a story. And the other, I mean, one thing I realized very early on is, I started, I mean the gate frame I started by teaching medical students in New Zealand. Medicine is a six year course, three years preclinical, and three years more clinical. I started developing the gate frame with fourth year medical students. So in their first clinical year. This was, a subset of about 1400 students. Only a couple of hundred the top students get into medicine. Despite. Medical students in general, being very smart. And also at school, they, most of them are done very well in mathematics. Mm-hmm. And, and science. Somehow when you go to medical school, someone waves a magic wand over you and you become enumerate. You lose your ability to think mathematically. and became very aware of that when I started trying to teach fourth year medical students. Numbers two by two tabs, they glazed over them. So I tried to get away from numbers and into pictures. And, and that's the gate frame. In your teaching cover the Creb cycle? Is that, does that ring a bell?

13:51

I personally do not. That's something that I think most pre-PA, pre-med, students would learn in undergrad bio. But yes, it rings a bell

rod 14:03

well, the reason I mentioned it, the reb cycle, it was a second year topic and it was boring as hell. And it's not actually very relevant in clinical medicine, which is why you don't use it. There would be a very small number of metabolic disease specialists who might have, you know, a handle on the Creb cycle and what it means. But at the time I knew it. I knew it well, even though it was boring as hell. And that's because it was in a picture. Crib. You drew it. So that was partly my inspiration for gate. I thought if something is boring and as irrelevant as the Kreb cycle, you know, you can learn that and you can get an idea of that. How can I turn epidemiology, which for most students is, boring. How can I turn that into a picture? Over time, I drew this picture, which, is the epidemiological paradigm. That picture describes epidemiology.

Adrian 15:04

Okay, so I've got one last question. It relates to the gate, critical appraisal tool. You threw out a challenge and said that if anyone can find a study that you cannot use the gate appraisal tool on an epidemiological study, you'd give them a hundred dollars.

rod 15:22

Yeah.$10,000. I said,

Adrian 15:24

Oh, 10,000.

rod 15:26

10,000.

Adrian 15:27

So since that time. Have you become$10,000 Lighter.

rod 15:34

10 years ago, a medical student happened to come up to me in the supermarket on a Sunday evening and said, excuse me, professor Jackson, but I think I know a study that's, doesn't fit the gate frame. Look as I just said before you asked that question, the gate frame is the epidemiological paradigm. So the the triangle is basically the recruitment people coming into the study. The circle is the denominator that you use. And so, well, the two, particularly if you have two groups, smokers and non-smokers. Yeah. They are the denominators the main denominators of an epidemiological study and the square, each of the squares is a numerator. Now the definition of epidemiology is actually numerator over denominator. Where denominator is a population, with particular exposures, and the numerator is sick people. I mean, that's epidemiology is the study of the frequency of disease and ill health and population. So it's, you know, turn that to mass. It's numerator over denominator over time. Mm-hmm. The gate frame, the circle, they're the denominators. The square are the numerators, the arrow is the time. So by definition, if you can't hang a study on the gate frame, it's not an epidemiological study. And so yeah, when someone comes and tells me about a study that doesn't fit the gate frame, I say it's not an epidemiological study. Because my$10,000 is, if you can find an epidemiological study that doesn't fit the gate frame, that's why I can offer$10,000.'cause it can't be done. Do you use the cross at the bottom of the gate frame ever? The cross is actually a, making a decision. And there's four components to the cross. There's the top one is the evidence, and then the left hand side is, values, et cetera. The right hand side is the politics and the and maybe the cost of data or the cost of doing an intervention. And then the bottom one is the individual personal circumstances for the patient. So this cross, but the reason that cross is there, because a student came up to me after some years of me using the gate frame and said, do you know that you've got a triangle, a circle and a square? If you had to cross, you've got all the kind of symbols in a in, in, in the PlayStation game. And I'd been thinking, the gate frame is the epidemiological paradigm. And it generates, you know, using the gate frame, you can decide whether an epidemiological study is any good or not. But the cross actually is the decision making. Component of which the evidence is just one of the quadrants. And so good decisions, are informed by good epidemiology, but it does have to go beyond the epidemiology and the benefit of the cross is that it actually heads off criticisms that you are only interested in the epidemiology decision making is much more complex. But the cross is actually acknowledging that there is more to a clinical decision than the evidence, than the epidemiology. It's an important part of it. It's essential, but there's more to it.

18:52

Rod, I really can't thank you enough. It has been a pleasure speaking with you today. I've learned so much from you. I really loved hearing your story from the beginning and how you got here, and then how you've just become such an influential teacher to, the students that are in your classroom every day, but also to people across the world like myself. Thank you for everything that you've given to all of us. I've had different requests or questions for you over the years, and you've always responded and you've always been pleasant and helpful and you're just a nice person. So I just really wanna thank you so much for giving us your time and all of your expertise. It's been great

rod 19:34

no, you're very welcome.

19:37

What an amazing researcher and educator. Just a nice guy that's gonna do it for us for this episode of Building Bridges. Very special thanks to our special guest, rod Jackson. But until next time, bye.