00:00:00
3 to 75% of women do not get the treatment for pmenopause and menopause that they deserve. And women are asking,
00:00:07
why is it that I can't manage stress the way I once did? Why do I have this belly fat that appeared out of nowhere and my
00:00:12
usual techniques for how to deal with that aren't working? Why would I rather mop the floor than have sex with my husband? But there's more than 100 plus
00:00:19
symptoms that women aren't aware of. But you believe many of the symptoms of menopause are avoidable. Yes. And let's
00:00:26
get into that. Dr. Sarasal is the Harvard trained physician and hormone expert who's unlocking the science and
00:00:32
simple tricks behind feeling your best no matter your age. Most people have imbalanced hormones. Think of them as
00:00:39
text messages that your body sends to keep everything functioning optimally. But for example, out of the 40,000 people I've tested and treated, around
00:00:46
90% of them have a problem with their cortisol hormones. And if my body's making too much cortisol, what is the harm? It's associated with more belly
00:00:52
fat. We know that it shrinks the brain in women but not men. It's associated with depression, but also if you're
00:00:58
someone who's making a lot of cortisol, you're going to make less testosterone, and that leads to a whole host of
00:01:04
serious problems. And what about trauma? Does that impact your hormones? Oh, yes. And one of the ways to measure trauma is
00:01:10
the ACE test. It's a validated questionnaire, and they found that people who had one or higher ACE scores
00:01:16
had a greater risk of 45 different chronic diseases. And my score is 6 out of 10. But those ACEs are living on in
00:01:23
your body. And you went on a journey to heal yourself. Yes. With lifestyle medicine, not a pharmaceutical. Tell me
00:01:30
about that journey. This has always blown my mind a little bit. 53% of you that listen to this show
00:01:37
regularly haven't yet subscribed to the show. So, could I ask you for a favor before we start? If you like the show
00:01:42
and you like what we do here and you want to support us, the free simple way that you can do just that is by hitting the subscribe button. And my commitment
00:01:48
to you is if you do that then I'll do everything in my power, me and my team, to make sure that this show is better for you every single week. We'll listen
00:01:55
to your feedback. We'll find the guests that you want me to speak to and we'll continue to do what we do. Thank you so
00:02:04
much. Dr. Sarah Zal, what is it that you do for people? I'm a
00:02:11
physician, so I work in academic medicine. I do research for people. I
00:02:16
teach and I take care of patients. So that's the official BBC answer. And the
00:02:23
unofficial answer is I'm a healer. And what does that mean, a healer? Because
00:02:28
that's a broad term. So that could mean many things. It means that my
00:02:35
task is to connect to your innate healing capacity and to work with you to
00:02:42
activate it. And who do you do that for? So I do it for professional athletes,
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executives and everyday people. And when you say
00:02:54
healing, if someone came to you and they said, "How do you heal people?" What would your answer be? My answer is I
00:03:02
don't heal people. That's uh to me that's a patriarchal way of
00:03:09
thinking about it. What I do is I work with someone who's
00:03:14
got the capacity to heal and we work to be in the service of that. So it's not
00:03:21
me providing something that they don't have already. It's more understanding
00:03:26
what some of the obstacles might be to their own healing. Understanding what
00:03:31
would allow them to be the best version of themselves to feel fully alive. And
00:03:37
what was your training? So can you talk me through your sort of academic journey?
00:03:43
Sure. So my training is as a bioengineer. I did the Harvard MIT
00:03:49
program which is designed to train physician scientists.
00:03:54
So the um ethos of this particular program was to train the future
00:04:03
researchers and um academic physicians so that we could move the
00:04:09
field forward. And all along I was really interested in how do you bring
00:04:16
the best of conventional medicine together with more ancient ways of
00:04:21
thinking about the body? things like aya from India or uh traditional Chinese
00:04:28
medicine. How do we take these wisdom traditions and use that to inform mainstream medicine? So that's the type
00:04:35
of care that I learned how to do. I became a surgeon. I did primary care after I
00:04:42
finished a residency in obstetrics and gynecology. But I also realized pretty early on that I wanted to take care of
00:04:49
men, too. So I've done that for about the past 15 years and I would say that
00:04:57
that training in bioengineering and a comfort with big data and with um
00:05:04
optimizing data sets to improve whatever the goal is like performance or having
00:05:10
the most the best conversations you can have on a podcast. That's what gets me excited.
00:05:18
How many people do you think you've treated or seen or worked with directly in your career? Probably about 40,000.
00:05:28
And and if you had to try and summarize maybe the top three or five things that you're doing for
00:05:33
them, what would you say? Well, number one would be hormones. Hormones are the portal that
00:05:40
most people start with me. Um, it's a way of thinking about what drives what you're interested
00:05:49
in. Most people have imbalanced hormones. I haven't detected that you do
00:05:54
yet, but most people have an issue, say, with cortisol, either making too much of
00:06:00
it or too little or even both within the same day. And it affects energy. It
00:06:05
affects mitochondria. So I would say the number one thing I
00:06:12
help people with is their hormones. Getting their hormones back into balance. Starting first with lifestyle
00:06:17
medicine, not a pharmaceutical. So that includes breath work, which I think is
00:06:22
one of the most underutilized tools that we have in health. Number two would
00:06:30
be nutrition, but taken to the next level. not what you might think of that
00:06:36
a nutritionist would advise you, but what specifically is the ideal food plan
00:06:42
for you for your goals. So whether you're a entrepreneur and podcaster, an
00:06:49
investor, or you're a professional basketball player, or you're a woman in
00:06:55
pmenopause at age 42, what's the optimal nutrition for you? And we can measure
00:07:01
that and we can look at the interaction of your genetics together with what you're
00:07:07
eating to see how we could personalize that. Number three I would say
00:07:18
is prevention. And prevention has been a
00:07:23
hard thing to sell. It's um you know a lot of people just don't want to invest
00:07:30
in prevention and yet I take care of people who are in this continuum from a
00:07:38
state of health often to a state of pre- disease like pre-diabetes as an example
00:07:44
and if they don't do something about it they then move on to diabetes. So I like
00:07:49
to intervene there as early as possible to reverse disease and most of that is
00:07:56
lifestyle. So those are the things that I tend to work with. I do a lot of metabolic health because it's so
00:08:03
critical for the energy that you feel each day. You have a very diverse
00:08:08
experience as a doctor/healer.
00:08:13
feels like you've really had a lot of sort of reference points in your career that you've drawn upon and ultimately
00:08:19
you became the director of precision medicine at the Marcus Institute in
00:08:24
Philadelphia. That's correct. Precision medicine, that term. How does that
00:08:30
differ from conventional medicine? It's quite different. So, conventional
00:08:37
mainstream modern medicine I believe is broken. I feel
00:08:43
like there are so many people who are failed by our current medical system, especially people with chronic disease,
00:08:49
things like diabetes, autoimmune disease. So
00:08:54
with mainstream medicine, generally what happens is that you develop a condition,
00:09:01
say a high cholesterol, and you get treated with a pharmaceutical, say a statin. And what we know is that we have
00:09:09
to treat about 100 to 200 people for one person to benefit. So that I would
00:09:15
define as imprecision medicine. Whereas precision medicine is where we
00:09:21
understand you as an individual. We look at your genomic blueprint. We look at your biomarkers. We look at your
00:09:28
wearables data to determine NF1 experiments where you serve as your own control and figure out
00:09:36
what's going to be the most effective for you depending on what your goals are. NF1 you mean where that individual
00:09:42
is the study, they are the experiment. That's correct. You're not looking at broad sample sizes. What is wrong with
00:09:47
conventional medicine? You use the term that it's broken. What is wrong about that approach?
00:09:53
There's a few things that are wrong. One is that it has become medicine for the
00:10:02
average. And when you look at scientific evidence and you rank order it, what's
00:10:09
considered the highest form of evidence is the randomized trial. But the randomized trial is mostly around using
00:10:16
a pharmaceutical. So, in the example I just gave, using a statin to help
00:10:22
someone with their cholesterol, maybe help prevent a heart attack, the number one
00:10:28
killer. The problem is we then based on randomized trials come up with medicine
00:10:35
for the average. And it's not about optimal health. It's not even
00:10:42
centered around health. It's centered around, okay, heart disease, number one
00:10:47
killer. How do we help people prevent it? Oh, lifestyle medicine prevents 70%
00:10:52
of it. Well, we're not going to do that because we can't make money off of it. There's no profit motive. So, we're
00:10:58
going to focus instead on these pharmaceuticals. Oh, GLP1s. That sounds like a good idea. Let's try that and
00:11:04
solve problems with GLP1s. So to me, there's many layers to why the
00:11:10
health care system is broken, but one key area is that 70% of the diseases
00:11:17
we're facing right now are utterly preventable with lifestyle medicine. 70%.
00:11:23
You used the word hormone balance earlier on. Um, and you said that that's the portal in which people often find
00:11:28
you. I really don't know much about hormones and it's not necessarily something that the average person thinks
00:11:35
that they can do much about I think because it's not easy to measure our hormones is it? Well, you can measure it
00:11:40
in the blood. So, it's it's not that hard to measure hormones but I think there's there's a way that in mainstream
00:11:48
medicine we're taught to tell people that their hormones vary too much and so
00:11:53
it's not worth measuring. Yeah, that's what I've heard before. It's what you've heard. But then if you're a woman who's
00:12:01
34 and you're trying to get pregnant and you're having trouble in that situation,
00:12:07
we'll measure every single hormone. We'll look at thyroid, cortisol, testosterone, estrogen, progesterone,
00:12:13
the control hormones like follical stimulating hormone. And yet somehow in that situation, testing
00:12:20
is more reliable, but it's not in this other situation. That doesn't make sense. That's double standard. Why did
00:12:26
you choose this career? What What is it about you, your childhood, your life
00:12:31
that sent you down this road? I would say it was growing up with a fair amount
00:12:37
of trauma. And you know the what I've learned about
00:12:42
trauma is it's less about what actually happened to you. It's the way that it became embedded in the system of your
00:12:48
body. So for me, my parents got divorced when I was really young. I grew up in a way that I became a helper. And I
00:12:55
realized that by being um someone who was really looking out
00:13:01
for others and tuning into their energy and helping them achieve their goals
00:13:08
that kept me really safe. And so there's a way that that it was very resonant for me to
00:13:15
discover medicine. And one of the things we know about people who go into medicine is
00:13:22
that people tend to have a fair amount of trauma that leads to becoming a
00:13:29
helper in this way. What was that trauma? So there's a lot of different ways to
00:13:36
measure trauma. One of the ways that I find helpful is something called the adverse childhood
00:13:41
experiences. So ACE for short. I think I've got it here. Oh, do you? It's a
00:13:47
questionnaire. So my score is six out of 10. So childhood divorce, my parents got
00:13:53
divorced when I was about a year old. That's one out of the six. Other things are abuse, neglect,
00:14:00
um emotional abuse, physical abuse, having a parent with a substance use disorder. So things that you know it's
00:14:08
not a complete list but it's a validated questionnaire that was used in the
00:14:14
1990s and found among people who are middle-aged you're not quite yet middle-aged but for people who are
00:14:20
middle-aged 40 to 65 they found that people who had higher A scores one or
00:14:26
higher they then had a greater risk of 45 different chronic diseases.
00:14:32
How important is it for us to understand our early upbringing and our trauma if we are to heal as adults? Because you
00:14:38
said there that if you score high on this ACE score, this trauma score, this
00:14:43
childhood trauma system sort of questionnaire, then as an adult, you're more likely to get a variety of different diseases. So, do we need to
00:14:51
heal our bodies in some way to avoid getting some of those diseases? Yes. And
00:14:57
that's the critical question. So if you know that you have an elevated
00:15:02
A score and there's a lot of people who have a score of zero about 40% of men
00:15:08
about 30% of women and what we know is that if you've got this greater risk for 45 different
00:15:15
chronic conditions there's a way that those ACEs are living on in your
00:15:21
body unless you're addressing them. And it's the living on in your body that we
00:15:27
want to pay attention to. So for some people it's their immune system and it
00:15:32
leads to more allergies, more histamine overload, more um food intolerances,
00:15:41
maybe autoimmunity where their immune system is attacking their own tissues, maybe
00:15:47
autoimmune disease. There are other people who have more nervous system dysregulation. Maybe they've got anxiety
00:15:55
or depression or post-traumatic stress disorder, mental health issues. And for
00:16:01
other people, it could be more endocrine. They've got chronic cortisol problems, which is hormones. Yes.
00:16:09
How did that manifest in your physical health? So, I didn't start to detect this until my 30s. But what I found was
00:16:20
that I had depression. I had premenstrual
00:16:28
syndrome. I had my first baby when I was 32 and I couldn't lose the baby weight.
00:16:34
And as all of this was happening, and I'm a physician, I went to my doctor for
00:16:39
help. And he suggested that I go on Prozac for the depression and the mood
00:16:46
issues, which is an anti-depressant pill, a selective serotonin reuptake inhibitor, that I go on the birth
00:16:51
control pill because I sounded hormonal, and that I start exercising more and
00:16:56
eating less. So that was his treatment and that's typical mainstream medicine treatment. But I wasn't satisfied with
00:17:04
that. I felt like that doesn't seem right. And I left his office and went to
00:17:09
the lab, ordered my own hormone panel and found that my cortisol was three
00:17:14
times what it should have been. So there's the optimal range for cortisol in the blood. It's about 10 to 15 in the
00:17:22
morning, 6:00 to 10 in the afternoon. And mine was 30.
00:17:28
I also looked at my fasting glucose and insulin and I had pre-diabetes in my
00:17:35
30s. I had no idea. No one was checking for this. So, I'm answering your question about how these ACEs showed up
00:17:42
in my body. We know that adverse childhood experiences linked to blood
00:17:47
sugar problems and a greater risk of pre-diabetes and diabetes, which I had. We know that they linked to chronic
00:17:56
stress and cortisol problems, high perceived stress, whether the stress is there or
00:18:01
not. It also led to as I started using
00:18:06
wearables, low heart rate variability, the time between each of my heartbeats.
00:18:12
And that's a measure of the sympathetic nervous system, fight, flight, freeze, fawn, versus the parasympathetic nervous
00:18:18
system, which is where healing occurs. And you went on a journey to heal yourself. Yes. Tell me about that
00:18:25
journey. So in my
00:18:31
30s, this is a huge epiphany for me because I realized that I wasn't trained. I wasn't
00:18:38
educated, even though I had an outstanding education, I wasn't trained
00:18:43
to help with this. No one taught me about cortisol
00:18:48
problems and how to manage that. I mean, I was taught about the extremes of Cushing disease- which is really high
00:18:55
cortisol levels and Addison's disease, which JFK had, and it's when your
00:19:01
adrenals in your back above your kidneys don't make cortisol. So, I was taught about the extremes, but I wasn't taught
00:19:07
about all the people who kind of live in the middle with problems with their cortisol. So this is when I started to
00:19:15
take the scientific literature and apply it to my
00:19:21
situation because I wanted to feel better. I felt old before my time and I
00:19:27
had a lot of belly fat and I was on this path of aging at an accelerated clip. So
00:19:33
I did it to help myself but then I also wanted to help my patients and it felt like I needed to go deeper and
00:19:39
understand what can we do to treat the trauma and also to treat the more uh
00:19:47
proximal measurements that we're making like with cortisol with heart rate variability with blood sugar.
00:19:55
So what was step one for you? Step one was awareness. Okay. And I had
00:20:01
no idea. These are not things that most doctors are checking for. It's pretty crazy that you're a doctor, but you
00:20:08
don't know this part of health. I mean, how are you going to help anybody if you don't fully
00:20:15
understand health from a more sort of holistic perspective? That's a critical point. So, I was taught at Harvard that
00:20:24
if you have blood sugar problems, if you've got pre-diabetes and diabetes, the treatment is lifestyle.
00:20:31
It's the most effective to change the food that you're eating, to increase your exercise, to um manage your stress
00:20:40
in a different way. And yet, I wasn't taught how to help my patients do any of those things. I was taught how to
00:20:46
prescribe a medication for it like metformin or some other treatment but I
00:20:52
wasn't taught how to do lifestyle medicine. I had 30 minutes on nutrition. So yes, it is pretty crazy.
00:20:58
They gave you 30 minutes on nutrition. Yes. During which training? This is
00:21:04
medical school and I got about the same amount on pmenopause and menopause.
00:21:10
Really? I mean that explains a lot. Yes, it does about the medical system. So step one was awareness. What was step
00:21:17
two? Step two was what does the science tell
00:21:22
us? And if we take what the science tells us, usually applied to a population, that then sets us up for
00:21:30
step three, which is end of one experiments, trying things on yourself
00:21:36
and then measuring. That's right. When we think of cortisol, which was the first sort of marker that you saw was
00:21:44
elevated, we think of stress. So, we think we get cortisol if we're stressed. So, my brain, my my very naive brain
00:21:50
said, "Well, you just need to be less stressed, Sarah. So, you should just go on holiday
00:21:56
and then your cortisol will come down." I used to think that, too. And then I would come back from the holiday and I
00:22:02
would still have cortisol problems. So stress is part of it, but cortisol is
00:22:10
really interesting. These hormones that we're talking about, estrogen, progesterone,
00:22:15
testosterone, cortisol, insulin, it's not a democracy. Like they don't have
00:22:21
equal footing. Cortisol is more like a dictator, especially if it's out of whack. So you need cortisol to live.
00:22:29
Whereas you could live without testosterone, estrogen, progesterone. can't live without insulin. But cortisol
00:22:36
is critical in terms of helping you with your immune system, helping you with your blood sugar, and just managing the
00:22:44
stress response. So, it's not quite as simple as thinking your way out of a
00:22:50
high cortisol or a low cortisol. And there are ways that your body can become
00:22:56
stuck in a particular pattern of making too much cortisol or making not enough
00:23:03
cortisol. And if my body's making too much cortisol and my levels are too high, what is the what is the harm? The harm
00:23:12
is it's associated with depression. It's about 50% of people
00:23:18
with high cortisol. 50% of people with depression have high cortisol. It's used
00:23:24
by some psychiatrists as a suicide marker. It's associated with more belly
00:23:31
fat. And so the fat receptors, the fat cells in your belly have increased
00:23:38
receptors for cortisol. So it's a way of growing your belly fat. We know that it
00:23:44
shrinks the brain in women, but not men. starting in midlife, starting in your
00:23:50
40s. It's not an old age thing. And this has been shown a couple of different ways. There was a study from the
00:23:56
University of Texas in San Antonio showing that women in their 40s with
00:24:01
high cortisol have a shrinkage of total brain volume. And then Lisa Moscone at
00:24:07
Cornell also just showed in a study looking at men and women that women with high cortisol also have shrinkage of
00:24:14
their total brain volume. and they start to have a difficult time using glucose
00:24:20
as fuel in their brain, which is going to result in what kind of
00:24:26
behaviors? Well, it makes you tired. It gives you slow brain
00:24:31
energy. And I can tell for the most part you don't have that. But if you do have it, there's a way that you kind of your
00:24:38
brain slows down. You feel foggy. You're not able to multitask and kind of keep up keep up with everything. Is there a
00:24:45
link between cortisol and uh trauma? Oh yes. What is that link? So for people who
00:24:54
experience toxic stress or trauma, what typically happens is cortisol goes up.
00:25:01
That's part of the alarm. Yeah. The body's stress response. What we know is that for people who've got more serious
00:25:08
exposure to trauma and they have post-traumatic stress disorder, those people have probably
00:25:15
gone through a period of high cortisol and now they can't keep up anymore and they are in a low cortisol state.
00:25:23
What are the things in in the world at the moment that are messing up our hormones? because the subject matter of
00:25:29
hormones has become increasingly popular and I know that there's hormones like cortisol which we've talked about um
00:25:34
testosterone, estrogen, progesterone, um insulin, glucose. What are the what are
00:25:40
the big things that are like messing up our hormones at the moment if if I because I want to make sure my hormones
00:25:45
are in check. Um so I'm a guy. I'm sure that there's you know some of these
00:25:50
hormones are more like things like estrogen have I think more pertinent to women but No, it's important for men
00:25:56
too. Oh really? So estrogen and progesterone are incredibly important for men and it's, you know, it's
00:26:03
involved in uh bone strength. Progesterone is involved in
00:26:08
sleep in men. So the levels are lower in men and your testosterone is about 10
00:26:14
times higher. But in women and men, they're all
00:26:19
important. So what's messing with our hormones? I would say toxin
00:26:26
exposure. So there's endocrine disruptors. There's more than 700 known
00:26:31
endocrine disruptors. Things like bisphenol A um like the plastic lining
00:26:37
that you see in cans or in uh plastic containers, water containers. There's um
00:26:45
skin care products which women are exposed to more things like moisturizer and makeup and other things that contain
00:26:53
um endocrine disruptors like parabens and um there's flame retardants that we get
00:27:01
exposed to. So there's a whole class of endocrine disruptors and
00:27:07
then it feels right now like we are more disregulated than I've ever
00:27:13
seen. And I'm not sure what the cause is. I don't know if
00:27:19
it's the post-pandemic experience or part of what we're experiencing in the United States
00:27:26
with the change in leadership. It just feels like there's this hum of
00:27:32
dysregulation that I haven't seen over my career. Are you noticing that? Are you seeing
00:27:39
that in your patients? And I see it in my patients. I see it in their wearable
00:27:44
data. I see it in heart rate variability. I see it in the cortisol
00:27:50
levels that I'm measuring. You asked if I'm noticing that. I mean, the more digital the world has become, I
00:27:56
think I've seen more dysregulation, and we're obviously moving further in that direction at rapid speed, especially with things like AI now and
00:28:04
um algorithms getting more smart and addictive. Yes. So, I I see that. Also,
00:28:10
there's just been a change in I think the algorithms, the social media algorithms will compete with
00:28:15
themselves to to see who can hold you the most. And to do that, they have to kind of grab your attention. and the easiest ways to grab your attention is
00:28:21
by showing you things that are probably disregulating. Yes, it's an attention
00:28:27
economy and the cost in that fight for attention is that often the nervous
00:28:34
system becomes more disregulated. So, if you had to come into my life and
00:28:39
you had to optimize my life to make sure that all my hormones were in check, you would get rid of plastics and and toxins
00:28:47
from my everyday life, my bathroom, um, etc. I'd look at your skin care. I'd
00:28:53
look at your cleaning products. I'd look at your air quality. I'd probably install a couple
00:29:00
of air filters if you don't have that. I'd want to know about your stress because you're someone who performs at
00:29:08
such a high level and I would assume that you found the right level of stress
00:29:15
where it's not so little that you're not productive but it's not to excess to the point that there's a cost to it
00:29:21
physiologically. Yeah. And then and I'd want to look at your food. I'd want to know how much
00:29:28
protein you're consuming. Are you getting the right amount of carbohydrates? Seems like you are. Are
00:29:34
you utilizing those well? What's going on with the continuous glucose monitor? How are your nutrients? What's your
00:29:41
vitamin D? Things like that. You're a big fan of continuous glucose monitors, aren't you? I am. I think it gives
00:29:48
real-time feedback, immediate feedback on the food that you're eating. I've seen nothing else change behavior like a
00:29:55
continuous glucose monitor. And for anybody that doesn't know, it's the little patch you put on your arm and it
00:30:00
tells you your blood sugar levels in real time straight to your phone.
00:30:06
Sugar, is sugar the enemy? I don't think sugar is the enemy.
00:30:11
I think the enemy is the way that we eat it to access, the
00:30:16
way that we use it to change our emotional state. And we know people who have adverse
00:30:23
childhood experiences, they're more likely to have disordered eating. They're more likely to have problems
00:30:29
modulating the amount of sugar they consume. When you're treating patients,
00:30:34
do you focus heavily on their blood sugar levels? I do because I think it's
00:30:40
an important indicator of the way the biochemistry of the body, the metabolism
00:30:45
is working. It tells me about their mitochondria. It tells me about the way that they're producing
00:30:51
energy ATP by ATP. This compound, this um this measure of energy that you
00:31:00
produce inside of all of your cells, which is called ATP. ATP.
00:31:05
And that ATP then drives what? It drives our everything we do. ATP is fuel. So,
00:31:13
it allows you to feel like you're fully energized, especially when you wake up in the morning. And are there any
00:31:19
supplements that I should be taking if I'm trying to optimize my hormonal balance? Well, I'd have to look at your
00:31:25
total picture, but most of us inherit somewhere around 5 to
00:31:31
seven genomic um vulnerabilities and often we want to
00:31:37
work around those. So for instance, for me, my vitamin D receptor sucks. It just
00:31:44
doesn't work very well. So I have to take increased levels of vitamin D to keep the um kind of the baseline amount
00:31:52
of vitamin D in my system normal. So we would want to look for those. We'd look at your genomics to
00:31:59
see what's your relationship to B vitamins. With the stress that you
00:32:04
manage, do you have a a deficit with B vitamins? For a lot of men, it doesn't
00:32:09
show up until around age 40. So, this is a good time for you to do a baseline.
00:32:14
When you look at people's biomarkers and their blood samples, what are the things
00:32:20
that you like typically always see that are deficient? Because I'm sure there's things from a social level that we're
00:32:26
just all kind of getting wrong. Vitamin D is common. So, somewhere around 70 to 80% of people don't have
00:32:33
enough vitamin D. And one of the things that I think is so important to realize about vitamin D is that it's got 400
00:32:39
jobs in the body. One of them is keeping your boundary in your gut intact. So
00:32:47
keeping tight junctions working so that you don't have leaky gut. So vitamin D
00:32:53
is a common one. I had an executive that I took care of on Tuesday and he had a
00:32:58
fasting glucose of 102, which is in the pre-diabetes range.
00:33:05
No doctor has pointed this out to him before. He had uh his cholesterol was
00:33:11
starting to climb. His blood pressure was borderline, not high enough to require a medication,
00:33:19
but at the point where we want to turn that ship around before he needs a medication. He had a level of
00:33:26
inflammation in his body that was causing aches and pains
00:33:32
and um kind of like this silent condition
00:33:37
that um wasn't working well for him. So there's a couple ways to measure that.
00:33:44
For him, his homocyine was elevated. It was 14.7. And that's a that's one that's
00:33:49
really easy to measure in a basic panel. What we want with homoyine, which is um
00:33:55
heart specific inflammation, we want that to be 5 to 7. And when it's elevated, that tells us that often part
00:34:04
of the biochemistry in the body, your methylation is not working well. Methylation is just where you add a
00:34:10
carbon and three hydrogens to a molecule. And it's a way that we turn
00:34:16
uh genes on and off. And so in this person's case, he wasn't getting enough
00:34:22
B vitamins, methylated B vitamins. So we started him on a supplement to help him
00:34:27
with that. So that's a common one. His testosterone was good, so didn't have to address that. This guy was about 52.
00:34:37
Um, his cortisol was good. He was the chief financial officer of a company back east. Well, he had a number of
00:34:44
things on his genomics that we needed to pay attention to. What was interesting about this guy, Steve, is that he was an
00:34:53
athlete. He played football in high school and college. He had this identity
00:35:00
as an athlete, but when he came to see me at age 52, he was barely exercising.
00:35:07
He would lift weights maybe once a week. He would go swimming for about 30 minutes once a week. And so he wasn't
00:35:17
leveraging disposal of glucose the way that he could be, the way that he used to when he was in his 20s. So a big part
00:35:26
of understanding what made him tick was to reaffirm this identity as an athlete
00:35:32
and to use that to address this metabolic crisis that was starting to
00:35:38
happen in his body before it was too late cuz he's got too much glucose and he's
00:35:44
not doing enough with it. That's right. So his body is having to store it and getting inflamed.
00:35:50
and he said, "You know, listen, it's been the Christmas holidays. I had a lot of pound cake. I had some cocktails. You
00:35:58
know, maybe that's part of the problem." But we had measured his hemoglobin A1C,
00:36:04
which is a threemon summary of what's happening with your glucoses. And the
00:36:09
problem predated Christmas. So, we needed to get them into action around
00:36:15
exercise. Getting back to hormones, I really want to um close off on this
00:36:20
subject of cortisol because I know that that's such a important hormone. I've heard you say before that you believe
00:36:26
that uh cortisol is the most critical hormone to get into balance. You want to focus on cortisol really first and
00:36:33
foremost. So, someone like me, is there anything else I need to know to get my hor my cortisol levels in balance? And
00:36:41
also, what percentage of the population do you think have their cortisol out of whack?
00:36:47
H so we don't have data on the numerator or the
00:36:52
denominator and my patient population is
00:36:58
enriched with people who've got cortisol problems. So out of all of the people I
00:37:03
test, somewhere around 90% of them have a problem with their cortisol. And that
00:37:08
includes professional athletes because at least in the US like
00:37:13
basketball players, they travel a ton. They play backto-back games. They've got a
00:37:20
cortisol load, a stress load that is pretty high even for someone in their
00:37:26
20s or 30s who's used to high performance. So the number is high. If I
00:37:34
had to look at the general population, it would be a total speculation. I would say somewhere
00:37:41
around 30 to 50%. And what do you do about that? If you're an athlete and you've got
00:37:46
elevated cortisol levels, I think there's a number of different
00:37:52
things. There's the top down approach, which is cognitive kind of like what is
00:37:57
my prefrontal cortex? How can I leverage that to work with this? And then there's
00:38:02
more of a bottomup approach which is using your senses to create safety and
00:38:09
to change the cortisol signal kind of the alarm in the way that it goes off in the body. So breath work is really
00:38:16
important for that. Meditation um different forms of
00:38:21
movement dancing you know rhythmic movements walking hiking.
00:38:28
Running's a little tricky because um that can be a stress response and it can raise
00:38:33
cortisol. Um so I would say for a
00:38:38
professional athlete, what I usually recommend is um
00:38:45
meditation, regular meditation, and finding what's a really good fit for them. Because, you know, for some
00:38:52
people, mindfulness-based stress reduction is a good fit, but that doesn't fit for
00:38:58
everyone. Other people like resonance breathing, like a 5-second inhale, 7-second
00:39:04
exhale, six breaths per minute. Doing that for 10 to 20 minutes. That can really help to create balance between
00:39:11
the parasympathetic nervous system and the sympathetic nervous system. For some of my athletes, it's a
00:39:18
supplement. So if they've got high cortisol, one of the things I often do
00:39:23
is to give them cortisol manager, which is a supplement that includes ashwagandha and phosphatidal serereine.
00:39:31
And it's been shown to lower cortisol levels. So if they're traveling and they have to take a plane back to
00:39:37
Philadelphia after an away game, cortisol manager can help them manage
00:39:42
the cortisol. I found a supplement called I can't pronounce the name properly, but riol. Oh, rodeiola.
00:39:50
Rodeiola. Yes. Rodeiola is an adaptogen. So, it's a it's an herbal
00:39:56
therapy that's been shown to help with cortisol. Lowers cortisol. Yes. And I
00:40:01
was reading that it increases your focus potentially. Yes, it does. Do you prescribe that to athletes? I do. So,
00:40:08
generally what I try to do with most of my athletes is have them take a supplement either first thing in the
00:40:14
morning or before they go to bed. It's harder to do it during the day. And so I tend to start with cortisol manager
00:40:20
because I think it's got the best data, but rdea is also a good choice and I have prescribed that. Is it easy for
00:40:26
people to change in this regard to get them to make a set of different decisions? I think we're at a time of
00:40:32
year where a lot of people are thinking about changes and a lot of people are failing repetitively every year at the
00:40:39
changes they say they want to make. Is it easy to get someone to change? I
00:40:46
would say behavior change is the hardest thing that we do as humans. I think
00:40:51
there are ways that uh adverse childhood experiences tend to
00:40:57
set a pattern that's very hard to break. But I see people change their behavior
00:41:03
all the time. And I think part of it depends on what's the pain of staying the same.
00:41:11
if it's high enough to motivate you and to help you, you know, not take the shot
00:41:17
or two of tequila that has been your downfall in the past. If um you have
00:41:25
something that keeps you accountable and has like the Hawthorne effect, like a continuous glucose monitor, I think that
00:41:31
can also be very helpful as if someone was watching you because my patients
00:41:37
with their continuous glucose data, I am watching them. I'm scanning them.
00:41:43
But does doesn't that mean that in order to change, some people just need a bit more pain?
00:41:49
I would say people have a different level of pain that motivates change. Have you ever seen a situation? We were
00:41:56
talking about this a couple of couple of weeks ago where when you're trying to help someone, you actually end up propping them up and because you're
00:42:04
intervening to stop them experiencing the pain that they might otherwise, you end up harming them because you're
00:42:11
preventing them from going to that place where, you know, they call rock bottom
00:42:16
where self-motivated change would occur. It's a good question. I think there's
00:42:22
there's a fine line between motivating and also speaking
00:42:28
your truth about what you're willing to tolerate, say in your partner or a friend or family
00:42:34
member, and also enabling or [Music]
00:42:41
um being codependent. And so you have to try to
00:42:46
find that line. I mean, one of the things I found over my career, and it took me a while to learn this, is that
00:42:52
if someone has denial about what they're doing and how it's affecting their
00:42:58
relationships, their health, their ability to work, say, drinking too much,
00:43:03
having a sticky relationship with alcohol, it's not my job to break
00:43:08
through their denial. They have to do that. That's their work. Now, I can
00:43:15
say alcohol has no health benefits. Here's what it does. Here's what it does
00:43:20
to the female brain. Here's what it does to the male brain. Here's what it does to um break the boundary in your gut and
00:43:28
cause leaky gut. Here's all of the unoured effects of it. But it's not my
00:43:34
job to break through their denial. They have to do that. And that's very hard especially if you
00:43:40
have a family member or a a friend or a partner who is doing things that are
00:43:46
harming themselves. So what do you consider your job to be if you are a friend or a family member?
00:43:53
Your job is to determine what your boundaries are, what you're willing to tolerate to stay in relationship.
00:44:01
And that's, you know, that's where interventions play a role, where you
00:44:07
confront the person and say, "I'm really worried about you.
00:44:13
Here's what I'm witnessing. I really feel like you need to approach this in a different way. Are you willing?" But
00:44:20
it's a consenting process. You don't do it for them.
00:44:27
What's your experience? Well, I just I just have so many, you know, because these days I can help
00:44:32
people a much more than I could 10 years ago, whether it's financially or in other ways. And so, it's often tempting
00:44:39
when someone in my life is struggling in some way to just intervene with some kind of crutch. Yes. And I've actually
00:44:46
seen over the last like 15 years that the best things that I've ever done for some of my friends wasn't an
00:44:52
intervention. It wasn't paying for something for them or taking care of something for them. It was being honest
00:44:58
with them and then being there as they figured it out themselves. And often it was actually
00:45:04
removing my crutch which meant that they would fall a little bit and then climb
00:45:10
themselves out of the ditch to a very good life. So, I just always think about that that a lot of us through love or
00:45:17
through the fact that we can often end up propping people up in our lives and we're actually doing them a disservice because we're kind of inhibiting their
00:45:24
own natural growth journey. I agree with that. And I would I would also say that
00:45:30
what you just described is holding a mirror to someone in a way that is very
00:45:40
loving but also clear. It's a clean mirror and it's very different than just
00:45:48
loaning them the money. Yeah. And then being there for them as they stumble and struggle and try to make things
00:45:55
different. You you talked earlier on about the executive that you checked um recently. You said his testosterone
00:46:02
levels were intact. Yes. At what age should I be thinking about
00:46:08
my testosterone levels or should I be thinking about them all the time? cuz I kind of see it as something that I need to worry about when I'm when I get a
00:46:13
little bit older into my 40s and 50s. It tends not to decline until about age
00:46:19
40, but I would say do a baseline now. Okay, so a baseline biomarker assessment
00:46:24
would be worthwhile. And you know, one of the things we found during the pandemic was
00:46:31
that um the National Basketball Association was playing in a bubble.
00:46:36
They were playing in Florida and the players cut off from their families and
00:46:41
kind of stuck in Florida for a period of time. They had low testosterone levels
00:46:48
and these guys normally have pretty high testosterone levels. So, there can be specific situations
00:46:55
that can affect your testosterone level. What was it that was affecting those? Part of it was just
00:47:02
being in a hotel, in a bubble, unable to leave, cut off from their community,
00:47:08
their family, their friends, their usual ways of blowing off steam. I imagine
00:47:15
they're they didn't measure their cortisol, but I imagine it was probably higher than normal. And women have
00:47:20
testosterone, too, but you said, I think earlier, that men just have 10 times more testosterone. Men have more, but
00:47:27
it's the most abundant hormone in the female body. Women are exquisitly sensitive to it. It's the most abundant
00:47:34
hormone. Yes. Higher concentration than estrogen or progesterone. About 15 to 70
00:47:40
nanogs in a woman. That's what I read on WebMD. Yes, that's that's a pretty good
00:47:45
level. And in men, 300 a,000 nanogs. Yes. I like to see it somewhere around
00:47:52
500 to a,000. And what would be a sign that I had low testosterone if
00:47:58
I'm a man? Belly fat. Gynecomastia. What's that? That's when
00:48:05
you have breast development. Okay. mood changes, mood swings, uh irritability,
00:48:14
uh depression, cardiovascular changes,
00:48:19
erectile dysfunction, decreased libido. What about in a woman? So, if a woman
00:48:25
has low testosterone, what are the symptoms we see in a woman? They're similar. So, um both sexes have fatigue.
00:48:34
That's very common. Decreased libido. They might be working out at the gym and not seeing a response. They might have
00:48:41
some hair loss. And testosterone in women has a few unique features. Like one of the
00:48:48
things we've seen looking at MBA students, students who are getting a masters in business administration is
00:48:54
that the women with higher testosterone tend to be more comfortable with financial
00:49:00
risk. I believe it also tracks with confidence and agency. We have less hard
00:49:06
data on that. But those are some of the things that I see. It's a hormone of vitality in both men and women. So if a
00:49:12
woman is low testosterone, she might be less confident, have less motivation, less agency, less willing to take risks,
00:49:20
less sex drive. What if she has high tes testosterone levels? Too high. So high
00:49:25
testosterone tends to track with polycystic ovary syndrome. It's the most
00:49:31
common hormone imbalance that women have. It leads to infertility. Um it leads to increased
00:49:38
hair growth in places that you don't want it. So that can include like your chin and between your
00:49:44
breasts. It can lead to um insulin resistance in some but not
00:49:51
all but somewhere around 70% of people with PCOS have insulin resistance. So it leads to symptoms of
00:49:59
excess androgen, acne, heretism. It also is associated with problems with
00:50:06
the mitochondria. It's also linked to disregulated stress
00:50:13
response. That's something we see with people with PCOS. So, if I'm a man or a woman and I want to get my testosterone
00:50:19
levels in order and I don't want to inject myself with testosterone, are there natural ways, easy ways for me to
00:50:27
get my testosterone balanced? It depends on how off it is. First place
00:50:32
to start is your cortisol because cortisol has this
00:50:39
um interdependent relationship with other hormones. So if you're someone
00:50:44
who's making a lot of cortisol, you're going to make less testosterone. So someone who's got a high level of
00:50:50
stress, like I was talking about the NBA players in the bubble, maybe their stress was high and their cortisol was
00:50:57
high and that was why their testosterone was lower. So then if I'm a woman with polycystic
00:51:03
ovary syndrome and my testosterone is high, doesn't that mean I want to increase my
00:51:09
cortisol? No. In that situation, what we know is that food is
00:51:14
probably the most important factor with someone with PCOS. And inside of 7 days,
00:51:20
by eating a lower carbohydrate diet, you can change your testosterone level. So
00:51:25
you can lower it significantly within seven days. within seven days. So,
00:51:31
exercise. I'm currently eating like a ketogenic diet, so my carbohydrate level is extremely low. Does that mean my
00:51:38
testosterone levels are going to be low? Not necessarily, because you're not someone with PCOS. So, it's not quite
00:51:45
translatable across sex and gender. But for you, with a ketogenic diet, what we
00:51:52
typically see is that insulin levels are lower. So, it does seem to help with metabolic health.
00:51:59
It can cause some thyroid dysfunction. So, it's worth tracking thyroid. We know
00:52:04
that people on a ketogenic diet sometimes have increased inflammation.
00:52:10
There are some people who are super responders and they just do super well with ketogenic diet, but some people
00:52:15
have about a 10% change in their LDL, their so-called um bad lipoprotein. So,
00:52:24
if you stay on it for more than four weeks, I generally recommend that you look at some biomarkers.
00:52:30
Let's talk about estrogen then because I I was under the impression that um only
00:52:35
women had estrogen, but you're telling me that it's an important hormone for men as well. It is. Why is it so
00:52:40
important for for both sexes? What does it do? Well, I would say it's more important for women because it regulates
00:52:48
the entire female body. So we have estrogen receptors throughout
00:52:54
our body. Um when women there's two different life stages where estrogen is
00:53:01
low. The first is postpartum. So if you give birth to a baby, you go from skyhigh estrogen
00:53:07
levels down to almost nothing when you deliver your baby and you deliver your placenta. And so for a lot of women when
00:53:14
they're postpartum, maybe they've got mood issues, um they've got fatigue that is more than
00:53:22
just the sleep deprivation. This can be a preview of coming attractions in pmenopause and
00:53:29
menopause. So it's a window of opportunity that can tell you about the way estrogen works in your body. So for
00:53:36
the female body, estrogen has hundreds of jobs. It keeps her joints lubricated.
00:53:41
We know that frozen shoulder is a really common uh diagnosis in women who are in
00:53:47
pmenopause and menopause because the estrogen receptors just aren't getting the estrogen. They're not having
00:53:52
molecular sex between the estrogen and the estrogen receptor. So estrogen is really critical
00:53:59
in women. It regulates mood um breast development, development of
00:54:07
hips. It's a lubricant for your joints.
00:54:12
Um, it's also really critical for your skin. When estrogen goes down, you make
00:54:18
less collagen and that's why women notice that their skin ages. And in men,
00:54:24
it's a little bit different. The dynamic range is more narrow. And what we generally want with men is for you to
00:54:30
have enough estrogen to serve some of these bodily
00:54:36
functions like with keeping your bones strong um but not too much.
00:54:44
Does it have a role in weight distribution in my body? So where are
00:54:50
the fat stores and stuff? So in men I don't know. I don't know the answer to that. I'll have to look it up and get
00:54:56
back to you. But in women, yes, absolutely. So, one of the things that happens for women over the age of 40 is
00:55:04
that they typically become insulin resistant. Their cells become numb to
00:55:09
insulin. And what we know is that they gain about five pounds of fat and they
00:55:15
lose about 5 pounds of muscle every decade after age 40. So there's this
00:55:21
redistribution of fat to your point where they they deposit less at their
00:55:29
breasts in their hips and their buttocks and more at their abdomen. Does that happen in
00:55:36
men? I think there's some version of it in men, but I just would have to confirm that.
00:55:42
And is that inevitable? No, no, no. You have a choice.
00:55:49
So for women, I think what's important is to
00:55:55
understand what what are your estrogen levels that are associated with your best function. And that's why I think
00:56:02
baseline testing can be so helpful to know where your thyroid is right now, your cortisol, your testosterone,
00:56:08
um to know where you are with your metabolic health, so that when you're in your 40s, you can look back and say,
00:56:14
"Okay, I was in a state of optimization. I want to go back to something similar to
00:56:20
that. So for women, what I would say is right now 73 to 75% of women do not
00:56:29
get the treatment for pmenopause and menopause that they deserve. They're not
00:56:34
being offered for instance hormone therapy and that has to change. But
00:56:39
hormone therapy can help to reverse this so that you are more likely to
00:56:47
um not have some of these body composition changes as you get
00:56:52
older. And it's not just hormone therapy. I would say it's beyond hormone therapy. It's estrogen, progesterone,
00:56:58
testosterone, but it's also heavy weightlifting. It's cardiovascular
00:57:04
fitness. It's disposing of the glucose properly. eating the right foods,
00:57:10
disposing of the glucose properly. Yes. What do you mean by that? So, if you're, you know, like when I was in my 30s, my
00:57:18
fasting glucose was very high. It was in the pre-diabetes range. And so, I needed
00:57:24
to change the way that I was burning through glucose, like using
00:57:29
it with exercise. So disposing, it's like an input output
00:57:36
equation where you're inputting with your food and you're outputting with
00:57:41
your exercise and you want to get a good match between the two and muscle
00:57:46
resistance training, strength training is the optimal way to dispose of glucose, right? I think it's a critical
00:57:52
way. I mean, what we know with strength training is it builds muscle and so the more muscle mass that you have generally
00:57:59
the better your metabolism. This one change has transformed how my
00:58:05
team and I move, train, and think about our bodies. When Dr. Daniel Lieberman came on the diio, he explained how
00:58:11
modern shoes with their cushioning and support are making our feet weaker and less capable of doing what nature
00:58:16
intended them to do. We've lost the natural strength and mobility in our feet. And this is leading to issues like
00:58:22
back pain and knee pain. I'd already purchased a pair of Viva barefoot shoes.
00:58:27
So I showed them to Daniel Lieberman and he told me that they were exactly the type of shoe that would help me restore
00:58:33
natural foot movement and rebuild my strength. But I think it was planttoicitis that I had where suddenly my feet started hurting all the time.
00:58:38
And after that I decided to start strengthening my own foot by using the Vivo Barefoots. And research from Liverpool University has backed this up.
00:58:44
They've shown that wearing Vivo Barefoot shoes for 6 months can increase foot strength by up to 60%.
00:58:51
Visit vivobarefoot.com/doac and use code dac20 for 20% off. That's a
00:59:01
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00:59:07
feet. What role is fiber playing in all of this? Because a lot of people are talking about fiber at the moment and saying that we're fiber deficient. Oh,
00:59:15
we are for sure. I mean, the average American gets somewhere around 14 grams of fiber a day. And we're meant to have
00:59:22
about 30 to 35 40 grams a day. Our paleolithic ancestors got even more than
00:59:28
that, 50 to 100 grams a day. So, we are not getting enough fiber. It's critical
00:59:34
for blood sugar stabilization. So, is protein intake. But getting fiber from
00:59:40
real food, you know, eating sufficient vegetables. We know from the microbiome
00:59:46
studies that you want about 25 to 35 different species of fruits and
00:59:53
vegetables in a week to be able to feed your microbiome.
00:59:58
And what role is the microbiome playing in my hormone function? It's playing a
01:00:03
huge role. So your microbiome is one of the control functions for estrogen
01:00:10
levels and maybe testosterone levels. So there's a birectional
01:00:16
relationship, Steve, where there are three bacteria in the
01:00:22
gut that can um take estrogen and make
01:00:28
it keep recirculating. So, you're meant to produce estrogen and
01:00:34
then use it and then either poop or pee it out. But what happens with some
01:00:39
people if they've got these bacteria is they keep recirculating the estrogen
01:00:45
like bad karma. And so those people tend to have higher estrogen levels. It tends
01:00:51
to be associated in men with this greater risk of um metabolic
01:00:56
dysfunction, prostate cancer and in women it's associated with more breast
01:01:01
cancer and endometrial cancer. And that a lot of that starts and is caused by the gut microbiome. Yes. And
01:01:08
the microbiome, their favorite food is fiber. So the way that you keep your
01:01:14
microbiome, your microbes happy and healthy is to feed them a fair amount of
01:01:20
fiber. What What kind of foods have high fiber? Is it like broccoli and stuff? Yes. So broccoli, Brussels sprouts,
01:01:29
cauliflower, cabbage, kabi. What do you
01:01:34
eat and like how do you live? So I'm a sensualist. So I love food. I love the
01:01:41
taste of food. I love the smell of food. I love the look of food. I had a history of disordered eating. I had anorexia as
01:01:48
a teenager and bulimia through my 20s and 30s. But now I have a more neutral
01:01:56
relationship with food. I have worn a continuous glucose monitor almost
01:02:01
continuously for the past seven years. And so I know a lot about the foods that serve me the best. So, usually for
01:02:09
breakfast, I love eggs. And so, I eat fresh eggs, usually scrambled
01:02:17
or um lightly boiled. I like to have that with greens
01:02:22
or some other leftover vegetable from the night before. I eat a lot of vegetables. I aim
01:02:29
for somewhere around a half pound to a pound a day. So that's divided between
01:02:35
um salads, the vegetables I have at dinner, um a smoothie. I put vegetables
01:02:42
in smoothies along with a protein powder. I eat a lot of cruciferous vegetables. I have sluggish detox
01:02:49
pathways. I know that genomically and I know it from my biomarker testing. What does that mean? Means
01:02:55
that maybe it's related to my sensitivity. I've got my I don't make
01:03:01
sufficient glutathione, which is um one of the ways that you detoxify. It's an antioxidant in your body. And
01:03:09
so I like to to close that gap by making
01:03:15
sure that I'm getting sufficient cruciferous vegetables. I eat a lot of broccoli sprouts. What do you
01:03:22
think of the keto diet? I'm a fan of the ketogenic diet because in your book there's this chapter called the keto
01:03:28
paradox. Yes. What are your thoughts on keto? Well, what I find with keto is that men tend
01:03:36
to do better on it than women. And what I found with women is that maybe related
01:03:42
to hormones and their sensitivity, they have more thyroid dysfunction. They have more menstrual irregularity. Somewhere
01:03:49
around 45% of women that are on a classic ketogenic diet. So women tend to
01:03:54
have more issues with the ketogenic diet takes them longer to get into ketosis than it does a man. Even if you the
01:04:02
average man if they fast for somewhere around 14 to 16 hours they start to
01:04:08
produce ketones and for women it takes longer takes more like 18 to 20 hours.
01:04:15
So probably that's related to fertility and evolutionarily there's some pressure
01:04:21
for us to not go into a ketogenic state, but it makes it harder for women to get
01:04:26
into ketosis and stay in ketosis. Is there a danger to women doing ketosis? Because you said me um their periods are
01:04:33
going to become irregular. Not necessarily. I think depending on how you do it, you know, a lot of the data
01:04:39
that we have on the ketogenic diet is in populations that don't apply to you or me because the bulk of the data that we
01:04:46
have is in people with seizure disorders. So, they're different. It's a different population and they're also on
01:04:54
a form of the ketogenic diet that is very strict. You know, no more than 10
01:05:01
to 20 grams of carbohydrates day. So, I think you can play with your
01:05:06
carbohydrates and find out what your carb threshold is so that you can remain in ketosis, get the benefits of all the
01:05:13
phytonutrients that you can get from vegetables and play both sides so that
01:05:20
you get the health benefits, you get the metabolic function improvement, you get
01:05:25
the uh lowering of insulin without some of the side effects. What are the side
01:05:31
effects? The main ones that I see are the thyroid dysfunction. Yeah.
01:05:36
Uh sometimes there's a a rise in cortisol in people who are really limiting their carbohydrates. And then
01:05:42
it can also affect serotonin so that people don't sleep as well on a ketogenic diet. Now, some people love
01:05:49
that. They go on a ketogenic diet and they're like, "Oh, I only need to sleep six or seven hours a night." But over
01:05:56
time, if you need more and it's the serotonin that is at the root of why
01:06:01
you're not sleeping as well, that can cause a problem. Is there anything else that the keto ketogenic diet might be
01:06:08
doing to my hormones, like my testosterone or my other hormones that is worth noting? Because I'm super, you
01:06:14
know, I'm wondering whether to stay on the ketogenic diet for a long period of time. I typically do it for a couple of
01:06:19
weeks a year, but I'm I'm wondering if this is something that I could do for like a year or maybe longer. So, I think
01:06:26
if you stay on it for more than a few weeks, you want to check your biomarkers and you just want to make sure that it
01:06:31
agrees with the intelligence of your body. So, do some molecular profiling and see if it's a good fit. Have you
01:06:38
seen people that stay on it for years and have biomarkers? Yes. Okay.
01:06:43
And I think what's important to understand is that exercise performance
01:06:50
some sometimes can be adversely affected by the ketogenic diet. And that might be
01:06:56
an interesting experiment for you to do like with your running and your 5K time. What a lot of athletes do is if they
01:07:05
want to experiment with a ketogenic diet, say they're a cyclist and they're trying to get their weight down so that
01:07:10
their um power is up, what what they tend to do before a race is they add
01:07:17
carbs back two weeks before the race so that they're they're filling their
01:07:22
glycogen stores. And so that that's another piece that you may want to be tracking is your exercise performance.
01:07:29
If I'm trying to lose weight, is there an optimal approach to take? Because the
01:07:34
ketogenic diet has been the fastest way I've I've ever discovered of losing weight quickly. But if you're a man or
01:07:40
woman trying to lose weight, specifically like that annoying weight, the belly fats, those kinds of things. If someone comes to you and says that,
01:07:46
what what do you say to them? What I like about the ketogenic diet for
01:07:52
weight loss, and I'm really careful about weight loss because it's problematic. It's problematic. And I
01:07:58
think body shaming is a big problem. And so I'm really careful about this. But when it comes to a ketogenic diet, what
01:08:04
I like about it is that ketones are really satisfying. So they increase your
01:08:11
satiety and I think it's much more effective than trying to limit your
01:08:18
calories and be in a calorie deficit. So, with a ketogenic diet, usually you
01:08:23
do a calorie deficit, but you're producing ketones, which are making you feel more satisfied, so you're not
01:08:29
standing in front of the refrigerator wondering when the next time is that you can eat. Mhm. And what about
01:08:37
fasting? You know, there's been a lot of talk about autophagy and doing these kind of long fasts to heal the body.
01:08:42
What's your perspective on that? I think there's a time and a place for fasting. I think these ways of activating some of
01:08:49
the benevolent um pathways in the body can be very good for you. So it can be
01:08:54
good for mitochondria. It can be good for uh your hormone balance. It can help
01:09:00
you with insulin as an example. So you asked about someone who was wanting to
01:09:05
lose weight and also wanting to address belly fat. I would say that's a situation where you really want to pay
01:09:10
attention to insulin. So fasting can get you that. So can a ketogenic diet. Often
01:09:17
we combine the two because you can induce ketosis faster by doing intermittent
01:09:25
fasting together with a ketogenic diet. Is the ketogenic diet like a form of
01:09:31
fasting? You could think of it that way. I mean I would I would say it allows you to fast
01:09:37
and it makes the behavior change easier. [Music]
01:09:42
Um, you know, the thing about fasting is there are some people who are really
01:09:48
good at it and it doesn't raise their cortisol. It doesn't induce a stress response. And then there are other
01:09:53
people who get very stressed with a ketogenic diet or with fasting. And so
01:09:59
part of it is is trying to get a sense of your own response to the food that you're eating
01:10:07
to see, okay, what suits me the best? How do I feel the best? Where is my
01:10:12
cognitive function at an optimal level? What helps me with brain fog? What helps me with allergies or whatever whatever
01:10:20
symptoms you're tracking? You know, one of the things we know with ketones, which are produced, you know, your body,
01:10:27
as you well know, is this. It's like a hybrid car that can flip between burning
01:10:35
gas, which is like glucose in this analogy, or electric, which in this
01:10:41
analogy is ketones. The thing about ketones is they're they not they're not just a satiety molecule that makes you
01:10:49
feel satisfied. They also have anti-inflammatory aspects inside of the
01:10:55
body. So, they're an important signaling pathway. There's a reason why your body produces ketones. Now, do you want to do
01:11:02
that for a year? We'd have to see. We'd have to look at your biomarkers. You know, the
01:11:08
the normal way that your genome developed was to flip in and out of
01:11:14
ketosis based on the food supply. And now that food is abundant, most people
01:11:20
are not going into ketosis. Been able but being able to switch back and forth can be very healthy for you. when people
01:11:27
come to you and they're asking questions about hormones these days, you must have seen in your career a shift in interest
01:11:33
um on the subject of hormones, but but also a certain a certain area of
01:11:39
hormonal health that people have a greater obsession with. Of all the sub the subjects we've
01:11:45
talked about today relating to hormones, what is it that people are most interested in right now?
01:11:52
I would say for women it's permenopause.
01:11:58
And for anyone that doesn't know what permenopause is, when does that begin and what is it? Typically begins between
01:12:05
35 and 45 for women. And it's the age at which your
01:12:11
ovaries start to run out of ripe eggs. And the mitochondria in your eggs are not working the way that they once did.
01:12:18
And so your ovaries are aging and that leads to changes in your hormone levels.
01:12:24
So a lot of people think of pmenopause is mostly being a hormonal situation. A change in estrogen, progesterone, maybe
01:12:32
testosterone. And what I think it's important to realize is it's much broader than that. It's your metabolic
01:12:38
system. It's the way that your brain is responding to glucose. It's your immune
01:12:44
system. It's a time when more women have the experience of autoimmunity and autoimmune
01:12:50
disease. So per menopause is this incredibly dynamic time. There's more
01:12:55
than 100 plus symptoms that women experience and it makes me crazy. I was just talking to my agent and my
01:13:02
publisher a couple weeks ago. They're both women in their early 40s and they
01:13:08
were having symptoms, you know, some of those hundred symptoms that are uh characteristic of pmenopause. They went
01:13:15
to their doctor and said, "I've got these mood swings. I'm having trouble sleeping. Having some night sweats. Is
01:13:22
this pmenopause?" And the doctor said, "No, you're too young." So, there's a
01:13:28
knowledge gap. There's a research gap and a knowledge gap and a huge treatment gap for women who are in
01:13:34
pmenopause. Most women are not getting the treatment that they need. So, what are they asking about?
01:13:41
out there asking about why do I feel so disregulated? Why
01:13:46
is it that I can't manage stress the way I once did? Why would I rather mop the
01:13:51
floor than have sex with my husband? Why is sex painful all of a sudden? Why do I
01:13:58
have this belly fat that appeared out of nowhere and my usual techniques for how to deal with that aren't working? Those
01:14:06
are some of the questions that they ask which map to your hormones. And what is the youngest you've ever seen someone
01:14:11
enter permenopause? Well, I see women who have premature ovarian
01:14:17
insufficiency, which is when you go through menopause before age
01:14:22
40. So, I've seen a fair amount of that. You know, probably 50 patients over the course of
01:14:29
my career. It's relatively rare. And then I see women who have early menopause, which is when they stop
01:14:35
having their periods or they have an FSH level of 25 to 30. And FA, what's FSH?
01:14:42
Follical stimulating hormone. It's one of the control hormones for your estrogen and progesterone in the body.
01:14:48
So if that occurs, they have their final menstrual period between 40 and 45.
01:14:54
That's considered early menopause. So there's this really dynamic time
01:14:59
where your hormones are wildly fluctuating, especially estrogen. Progesterone is declining and women have
01:15:07
this increase in the symptoms that they experience and no one is really tracking
01:15:14
it carefully. That's what needs to change. tracking it through their blood samples,
01:15:20
blood samples and connecting their symptoms to what is
01:15:25
happening in their ovaries, in their immune system, in their metabolic system and putting it together for them and
01:15:32
offering them options. You believe that many of the symptoms of menopause are
01:15:39
avoidable? Yes. Yes. And by that I mean using hormone therapy and using
01:15:46
lifestyle medicine as early as possible to manage that transition. Because when
01:15:51
a woman goes to a doctor now, that doctor might say, "Well, you're you're getting older. This is what happens." Or
01:15:57
they might just completely miss it. That's right. Or they might get started on a
01:16:02
birth control pill. That's used a lot for women who are in menopause. And I don't think that's the right solution.
01:16:09
What do you think of birth control pills? I think if they help you avoid
01:16:15
surgery, they can be beneficial, but I think they're way overused in our
01:16:21
culture. And most people who agree to a birth control pill don't receive full
01:16:26
informed consent. They're not told that it'll raise the inflammation in your
01:16:32
body by two to threefold. It increases your risk of autoimmune disease,
01:16:37
especially Crohn's disease. It makes your control system for your
01:16:42
hormones less flexible. It can rob you of testosterone. It can lower your free
01:16:50
testosterone. It can shrink your clitoris by up to 20%. I feel like if that was part of the informed consent,
01:16:57
very few people would sign up for it. But who is the birth control pill for
01:17:03
then? You know, I used to think that it was a feminist invention, that it was a way
01:17:08
of putting your fertility in your hands. And I went on the birth control pill
01:17:14
when I was 16. But I feel like there are some costs to it that um a lot of
01:17:23
teenagers and women in their 20s and 30s aren't aware of. And for me, I feel like
01:17:29
that awareness is really critical. So, who's it for? I would say it's a simple
01:17:34
entree into contraception, but I would much rather
01:17:39
people use things like an IUD or condoms or some other barrier method that
01:17:46
doesn't mess with their hormonal intelligence. How are you doing?
01:17:52
Oh, quite good. Quite good. I love that
01:17:58
question. I went through a divorce two years ago. And I feel like, you know, I
01:18:04
my I have two daughters. They both went off to college and were out of the house. And I realized
01:18:11
that my time with my now ex-husband had run its course and we
01:18:20
came together to create this beautiful family, but we were no longer a good fit for each other. So, a big part of my
01:18:27
spiritual work has been coming to terms with that and
01:18:34
um and really getting clear about okay for the second half of my life, what is
01:18:41
it that I want? What is my mission? How do I support that? How do I only give a whole
01:18:49
body yes to um the things that I say yes to?
01:18:56
How do I whole body? Yes. What does that mean? Whole body. Yes. So, this is something I learned
01:19:01
from one of my mentors, Diana Chapman. Um, she learned it from, I
01:19:07
believe, Katie Hendricks, who's a therapist. The idea
01:19:13
is that instead of saying yes to things that you're offered purely from a cognitive place,
01:19:20
that sounds like a good idea. Sounds like a good opportunity. Let me do it. Instead, you check up check in with your
01:19:26
whole body. You check in with your heart. You check in with your your gut. Does this really make a difference in
01:19:33
the world? Is this something that's going to make me jump out of bed in the morning? Is
01:19:39
this something that is worth the time and the effort? I'm a little older than you and
01:19:45
so I hold these opportunities a little bit differently than I did in the past.
01:19:51
How long were you married for? How long were you in a relationship with your partner? We were together for about 22
01:19:57
years and married for 20. How does one know that it's not right anymore after 20 odd years?
01:20:07
Well, I would love to riff on this with you. Okay. So I can tell you
01:20:12
that part of the challenge in my marriage was that
01:20:20
um we had difficulty talking about difficult topics. So highly charged
01:20:27
topics were tough for us to be able to navigate. When we had a conflict or a
01:20:33
fight, we didn't repair very well. There was a partial repair where you would
01:20:41
feel good enough to keep functioning and take care of the kids and do your householder stuff, but you didn't really
01:20:47
feel seen or like you cleaned up the pain that was
01:20:53
there. There was a way that I didn't feel fully understood or
01:20:59
seen. And not that I require that from my partner, but I I felt
01:21:05
like there was a misatunement. And I'm in a relationship
01:21:12
now where I have those things that I'm talking about. And it's someone that I
01:21:17
have known for 30 plus years. We were interns together at UCSF.
01:21:23
And I realize now that, you know, I came together with my
01:21:28
ex-husband and I really am so blessed by the life that we had and um the family
01:21:35
that we had, but we also had a trauma bond. There was
01:21:41
a way that his trauma kind of intersected with my trauma and we hung in there for a very long
01:21:49
time, probably longer than we should have. So, how do you
01:21:55
know? I don't know, Stephen. I just can tell you that there was a way
01:22:01
that our interactions was creating
01:22:08
disregulation in my body. And I'm not blaming him. I, you know, it's a two
01:22:14
there's two sides of the street. But there was a way that we just we didn't quite gel together.
01:22:22
And is that not something that can be prepared through communication and therapy or sitting down and I mean you
01:22:28
would hope so, but we spent about 10 years out of the 20 years of marriage in couples
01:22:34
therapy and it didn't really resolve some of these conflicts.
01:22:44
We got better at eye statements. We got better at saying what we were feeling and not blaming. We got better at
01:22:54
um going for a walk when we were talking about something difficult. But there was still a way
01:23:01
that I felt alone and lonely inside of the
01:23:07
relationship. And I decided I think a fair number of women decide this. I decided I was better off alone than to
01:23:14
continue in the marriage. When people hear that that weren't in your situation, they might think, okay, so
01:23:20
maybe he was preoccupied with something else or he was he worked away. When you
01:23:28
say the word lonely, these are the kind of things we think. We think of proximity. But you're saying it I'm
01:23:34
guessing it wasn't proximity. It wasn't proximity. I think it
01:23:39
was there was a way that we had a hard time expressing love and feeling and
01:23:47
receiving love. There was an obstacle and some of it was trauma. And
01:23:54
the good news is there's a lot you can do to resolve trauma.
01:24:01
But there was a way that I I got to the point where I couldn't
01:24:08
try any longer. I tried for a lot of years and I just couldn't keep trying.
01:24:15
When you look back, is there something that could have been done further
01:24:20
upstream to prevent you getting to this place in your view? Yeah, it's such a
01:24:27
it's a great question. You know, one of the things that I've seen that has helped to resolve trauma better than
01:24:33
anything else is psychedelic assisted
01:24:39
therapy. It's a way of looking at your story, a way of looking at the facts of your life with
01:24:46
um more objectivity and it's a way of resolving the way that trauma becomes embedded in
01:24:53
your system. And so I started doing psychedelic assisted therapy about five years ago
01:25:00
with the hope that it would help me with my marriage. And what I had hoped over time
01:25:07
is that I would do my part to resolve the trauma signature in my own body and
01:25:14
that maybe we would do psychedelic medicine together as a way of reconnecting to the love that we felt
01:25:21
for each other and you know kind of get the noise, turn down the volume on the
01:25:28
noise and we weren't able to do that. He wasn't willing to he wasn't willing. he
01:25:34
wasn't open to psychedelics and not everyone is. I'm not blaming him
01:25:40
for that. Um, and I think there's other ways to create healing states of consciousness. You know, breath work can
01:25:46
do it. Um, a near-death experience, peak experiences can do it, flow states,
01:25:52
there's lots of different ways to create these healing states of consciousness, but we weren't able to get into that
01:25:59
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01:27:01
that support your health. That's zoie.com with code Steven 10. One of the
01:27:06
things I've been told by one of the menopause experts that you mentioned earlier, Lisa, was that when women get
01:27:13
to menopausal a menopausal age, when they're in menopause, they often have
01:27:19
greater clarity in what they want in their life. That's what she said to me. and she said that she we see divorce
01:27:27
rates increase during this period of life. Is that true? It is true. It is
01:27:33
true. Yeah. The way it was explained to me by one of my mentors was that when
01:27:39
you're in your reproductive years, so premenopause, you've got a different
01:27:44
level of estrogen, progesterone, and testosterone every day. And it makes you accommodate, makes you kind of roll with
01:27:51
the punches. And it sets up this level of
01:27:56
flexibility that starts to disappear when you go through pmenopause and
01:28:01
menopause. And so the way my mentor described it was that the hormonal veil
01:28:08
is lifted and you start to speak your truth and not accommodate. You speak your truth maybe
01:28:16
for the first time about the state of your marriage, about the things that you're happy about, the things that you're not happy about, and it does lead
01:28:23
to an increased rate of divorce. What about your happiness levels? Does
01:28:29
it increase your happiness levels? I think it does. There's this really interesting study that um is called the
01:28:36
UBend, and it looks at psychological well-being for adults.
01:28:42
It's highest in your 20s and the very start of your 30s and then there's this
01:28:48
U shape where your psychological well-being goes down. I know you're 32, so I'm a little sorry to break the news
01:28:53
to you. And then it goes back up right around 50. So psychological well-being
01:28:59
goes up again. And when I first heard about this Ubend, I remember reading an
01:29:04
article in The Economist about it. It was so validating because it made me
01:29:10
feel like, oh, things are really hard. Makes sense to me that we see this through your 30s
01:29:18
and 40s and then it starts to have this uptick again. And I think there are ways to improve your psychological well-being
01:29:24
so that you're not stuck in the Ubend. But happiness, yes, I would say
01:29:30
happiness, psychological well-being is high again in your 50s.
01:29:37
I know that there's so many women that listen to this show. Um, and I get so many messages when we have conversations
01:29:42
about women's health, hormonal issues, menopause, because women for a long
01:29:48
period of time haven't feel like haven't felt like they've been heard and understood. Um, they often feel like
01:29:53
they're being gaslit a little bit maybe by their doctors or by some of the information out there. So, this is quite
01:29:59
atypical of me, but you know women better than I do, and you know what women are concerned about in all seasons
01:30:05
of their life, what they're worried about, what they're confused about. So, I want to just open the floor to you and
01:30:11
ask you based on all of the work that you've done. You know, you've done work on um women's hormones, diets,
01:30:19
lifestyle, sex drives, reclaiming their balance, sleep, healthy weight for both
01:30:24
men and women, but I'm asking specifically for women here. So with all of that in mind, what is the question
01:30:30
that I should be asking you? How do we do a better
01:30:37
job supporting women? How do we do a better job supporting women? Yes. How do we do it
01:30:43
systemically? How do we do it in terms of health care for women? But I would
01:30:50
say in particular for you with the platform that you
01:30:55
have, the women's health gap that we're facing right now, which has only gotten
01:31:01
worse over the 30 years of my career. I think to ask, how do we help women
01:31:08
rise? How do we make systemic changes so that we don't have this women's health
01:31:14
gap? Let's close the gap. How do we do that together? I have a question for you.
01:31:23
Can you guess what the question is? I have an idea. Go on then.
01:31:29
So, the women's health gap, I believe, is rooted in two things. Sex
01:31:35
differences, you know, having two X chromosomes versus XY in men. hormonal
01:31:41
differences, these life cycle cycle changes that women go through like
01:31:46
postpartum, pregnancy, pmenopause, menopause. But then there's also gender differences
01:31:54
which are socially constructed. And that includes women having more than their share of
01:32:00
emotional labor, women having more stress than men, experiencing more
01:32:06
stress, women having more trauma, so they have higher A scores than men. And
01:32:13
it's led to, if we just look at the statistics, double the rate of depression, double the rate of PTSD,
01:32:20
post-traumatic stress disorder, double the rate of insomnia, four times the rate of autoimmune disease, nine times
01:32:26
the rate of thyroid dysfunction. So there's sex differences that map to
01:32:32
those outcomes, but then there's these gender differences in the way that women don't
01:32:38
feel supported, the way that they feel conflicted in trying to create work life
01:32:44
balance, the way that they experience more stress. That's what we need to address.
01:32:51
We can't change the biology, but we can change the gender differences. we can
01:32:57
change the socially constructed differences that lead to it being a
01:33:03
health hazard to be female. Okay. So, tell me about that then. What is it about the socially constructed
01:33:10
narrative of what it is to be a man and a woman that is causing unfavorable outcomes for
01:33:16
women? There's a lot of things. So I would say what we know if you look
01:33:26
at the nervous system, we know that women tend to have more um imbalance
01:33:35
between the sympathetic nervous system and the parasympathetic nervous system. What's that? So the sympathetic nervous
01:33:40
system is fight, flight, freeze. The parasympathetic nervous system is
01:33:46
rest and digest, feed and breathe. So stay and play is relax, chill, play.
01:33:51
Relax, chill. That's where the healing happens. And we're not meant to hang out in one or the other. We're meant to have
01:33:58
this fluid balance between the two. Ideally, like a 50/50 split. And so
01:34:04
women tend to in dealing with our culture have more sympathetic
01:34:10
activation. And so finding ways to address that more stress, more stress.
01:34:17
So at least in the US, we do these annual stress reports and we find that
01:34:22
on average women have about 10% more stress than men.
01:34:27
Why is that just because they're more likely to report it or is there a
01:34:33
biological or evolutionary reason why they're more stressed? I don't think it's biological. I think it's related
01:34:42
to power imbalances. I think it's related to patriarchy. I think it's related to
01:34:50
power over. So for instance with these A scores, the trauma scores, the trauma
01:34:56
scores, we know that women experience more trauma than men, about 10% more,
01:35:01
similar to stress. And they also experience trauma at an earlier age
01:35:08
compared to men. They have much more sexual violence. They're 14 times more
01:35:13
likely to be raped than a man. So there are ways that our culture has allowed
01:35:19
women to be violated and that has to end. How do we
01:35:26
do that? I don't know. This is where we need to riff and figure out how do the
01:35:31
systems change so that there's a more equal distribution of power.
01:35:37
Are women more sensitive? So if you put a man and a
01:35:43
woman or a boy and a girl in the same stressful environment, would they have
01:35:48
different biological markers like biomarkers? Would you see higher levels of cortisol
01:35:55
in the woman or higher cortisol levels in the man? I don't know the answer to that. My sense is from the work of
01:36:03
Elaine Erin, who's done the work on this profile of high sensitivity, that it's about equal in men and women, but I
01:36:09
don't know that for sure. I'd have to fact check that. Do you see higher rates of autoimmune diseases in women or men?
01:36:17
Women. Forex. Forex. Yes. 400% more autoimmune
01:36:22
diseases and women. Yes. And what are these autoimmune diseases? What's an example of one? So, there's about 100
01:36:29
autoimmune diseases. It includes things like rheumatoid arthritis, multiple sclerosis, type 1 diabetes, Hashimoto's
01:36:37
thyroiditis, which is the leading cause of low thyroid function, uh
01:36:44
psoriasis, there's a long list. And why are women getting these autoimmune
01:36:49
diseases 400% more than men? We don't know. So the speculation is that it's
01:36:55
related to both biological differences, sex differences as well as gender
01:37:01
differences. So the biological differences include the difference in the levels of hormones, the X
01:37:10
chromosome. Women have more for instance vaccine response compared to men. our
01:37:15
immune system is more um reactive in some ways than the immune
01:37:23
system of men. But then there's also these gender differences, these socially constructed differences like women who
01:37:30
have a hard time saying no. Women who give until they drop, who overfunction, who are trained when they
01:37:37
go through their childhood to take care of others at the expense of
01:37:43
their own self-care. And so how these interact and lead to a
01:37:49
four-fold increased risk in women, we don't entirely know, but definitely we
01:37:55
see four times the rate in women. What's your view? There's a big debate that's always raging on about gender roles in
01:38:02
society and there's obviously been a big shift over the last couple of decades in I think actually in part caused by the
01:38:08
introduction of the contraceptive pill which has meant that women are working more I think in the western world and
01:38:14
these numbers might be wrong there's less babies being born men and women are having less sex with each other men are
01:38:20
killing themselves more often women are having coming into puberty earlier I believe or is it later it's
01:38:27
earlier and then having ch less children and significantly later. Funnily, I saw a
01:38:34
graph yesterday which showed the rise in breast cancer amongst women. And actually, I think it was actually no, it
01:38:40
was the rise in all cancers amongst women versus men. And the men graph was pretty flat, but there was this
01:38:46
significant rise in women getting more and more forms of cancer. And I was looking through some of the research as
01:38:53
to why that would happen. And one of them, one of the points of research said that because women are having children
01:39:00
later that this is in causing a rise in cancer.
01:39:05
Does that make sense? Well, that has been studied with for instance breast cancer. Okay. So, we know you know
01:39:12
there's a lot of different factors that can increase a woman's risk of breast cancer. One of them is the age at which
01:39:20
you have your first baby. And so the way that we think of this is that it's related to estrogen exposure. So women
01:39:27
who get pregnant and maybe they breastfeed for a year, that's often a
01:39:33
period of time like a year and 9 months where they're not exposed to as much
01:39:38
estrogen than they would be if they were menstruating during that time. And so having babies later seems to be
01:39:45
associated with a greater risk of breast cancer. The ideal age I was taught when I went through my training for having a
01:39:51
baby is 24. And I don't have a single friend who's had a baby in their 20s. Is there
01:39:58
something we're getting wrong with gender roles when you think about our biology and our hormones? I really love
01:40:03
the the questions. I mean, they're thought experiments. So, yes, I do think there's something we're getting wrong.
01:40:09
You had a guest recently who was talking about sex span. Oh, yeah. in the period of time that you're sexually active and
01:40:16
satisfied with sex. And I I do feel like we've got an epidemic of sexless
01:40:22
marriage. People who are not having as much sex, who don't realize how important pleasure is, especially for
01:40:28
the nervous system and for regulation. Orgasm is one of the most effective strategies for creating nervous system
01:40:36
regulation, for dropping into your parasympathetic nervous system, for dropping into your parasympathetic. And
01:40:41
what we know is that um you know with with gender roles and
01:40:48
with what's happened with work, we've lost some of the polarity
01:40:54
between um men and women. I mean, I imagine you also have listeners who are gay men or
01:41:03
uh lesbian couples. So, I want to be mindful of being inclusive here. But I think we've lost a lot of polarity.
01:41:11
And polarity exists in all kinds of relationships as well, doesn't it? To some degree, it does, but sometimes you
01:41:16
have to work at it. Sometimes you have to create the polarity. When you say polarity, if we're talking about
01:41:21
heterosexual relationships, what is the polarity that you think we've lost? I would say right now in my 50s, I'm
01:41:28
having the best sex of my life, the best orgasms of my life, and there's a lot of
01:41:34
polarity in my relationship. And I've learned that
01:41:39
um this is pretty controversial and edgy, so I'm I'm just gonna say it anyway. I feel like for women who
01:41:46
are professionals who work really hard, there are some ways that polarity can be
01:41:54
really helpful in the bedroom. And here I'm talking about um
01:42:00
gender roles and you know understanding sort of what what is satisfying for you
01:42:06
sexually and asking for it in your relationship. A lot of the professional
01:42:13
women that I know, they enjoy vanilla sex, but they
01:42:18
also like a weave of domination.
01:42:25
to be dominated or to dominate both. I mean, it's a personal preference, but I
01:42:31
think there's a way that it's a way of playing with power that I think can
01:42:39
be sexually very satisfying. What do you think? Do you
01:42:45
think it's important in sexual relationships to have polarity to have
01:42:51
um to have like the feminine and masculine attributes or do you think you both just
01:42:58
come to a sexual connection equals and that's how it should always be? I think
01:43:03
probably the answer is that everybody has their own favorite flavor of ice
01:43:09
cream. And I can only speak to my favorite flavor of ice cream, which is I
01:43:16
like I don't like vanilla Mhm. ice cream. It's not my favorite flavor. And
01:43:22
I think I do like to be more dominant. That turns me on. Mhm. And I like to
01:43:30
vary it cuz I'll get bored. Especially if you're in a long relationship, you got to [ __ ] find some way to spice it up. So, yes, you do. I'm buying all
01:43:37
kinds of stuff off the internet to try and, you know, keep it novel and new. Okay. Now, things are getting
01:43:43
interesting. Oh, really? Yes. Well, I honestly I've landed here in LA and before I even landed, I ordered loads of
01:43:48
stuff just to be at the house when I got here. Fantastic. It's probably because my team are
01:43:54
listening, but I [ __ ] No, but I do because I'm like I have I have to I like
01:44:00
try and plan sex to be interesting. Yes. Which is it's like a part-time job. It
01:44:05
is. What's the alternative? The alternative is it just fizzles out and gets boring and then it's the same. And
01:44:11
um but also I think I play with distance because of the way my schedule is. So I don't see my partner for a couple of
01:44:17
weeks and then we see each other and then we go away again. And so it kind of keeps it a little bit more novel and
01:44:22
stuff and interesting. I try and make sure that I stay attractive. Part of I told her I said part of the reason I go
01:44:28
to the gym every day is because we signed a contract. Mhm. Not a real
01:44:34
contract, but we signed a contract when we met each other that we'd stay attractive and that's intellectually attractive, that's physically attractive, it's whatever. So, so yeah,
01:44:41
I think a lot about it. That's fantastic. It's a good strategy. And I
01:44:47
appreciate how you are being very intentional about your sex life. Is this
01:44:54
in part why you knew the old relationship wasn't working? Yes. Just fizzled. It fizzled. And I'm a very
01:45:03
sexual person. Eroticism really matters to me.
01:45:08
And to not have that be front and center felt like a death.
01:45:15
And you tried to revive, keep alive. Yes.
01:45:20
People can relate. I know this because I see much of the feedback I get on the
01:45:25
episodes where we talk about sex. People often are struggling with a dying, whimpering sex
01:45:34
life. Again, I ask you, is there anything that can be done?
01:45:40
Is it prevention? Is that is that the key here? Or is it about making sure you're
01:45:47
in a relationship with someone who's sexually open-minded? And I also I guess the third question
01:45:52
here would be was it ever good? So let me feel a way into answering your
01:45:58
questions. I feel like there's there's some sex differences too. Um biological differences
01:46:07
between what the male sexual response and the female sexual response and that needs to
01:46:14
be understood. I feel like when you have sexual dysfunction in a relationship,
01:46:20
it's a couple's issue. It's never one person or the other. It's it's a couple's issue that you want to address
01:46:26
as a couple. What we know is that men are a
01:46:31
little simpler. there tends to be desire
01:46:36
um you know uh this physiological change that occurs in terms of blood flow and
01:46:43
an erection and and then there's a um plateau phase and then orgasm
01:46:51
ejaculation we can talk about separating ejaculation from orgasm in a minute but
01:46:56
in women it's more complicated so that was the masters and Johnson way of thinking about the the sexual response.
01:47:03
Master St. Johnson Masterson and Johnson and now we know sorry Masterson Johnson
01:47:09
they were sexyologists that published this particular model. Yeah. And it wasn't until maybe 15 20 years ago that
01:47:17
Rosemary Basson at the University of British Columbia found that women have a different response. It's more circular
01:47:24
and it has to do with feeling
01:47:29
um emotionally connected in order to be
01:47:36
receptive to having sex with their partner. Whereas men in some ways do the
01:47:42
opposite. And I'm curious if this is true for you. They need to have sex in order to feel emotionally connected.
01:47:49
Women actually need the emotional connection first to be receptive to sexuality. And so this
01:47:57
leads to a lot of disconnect and it includes things like how many times in
01:48:03
the past week did you empty the dishwasher? There are things that create emotional connection that a lot of men
01:48:09
don't realize. And then for women, they often
01:48:14
don't feel um like they they the sexual
01:48:22
response will not happen unless they feel emotionally connected. And this was part of the
01:48:28
problem in my own marriage was that I didn't feel that emotional connection. I tried really
01:48:34
hard to establish that emotional connection, but I didn't have it.
01:48:41
I have it now. Is it related to the newness of my relationship? Maybe. And knowing that, knowing about
01:48:48
the emotional connection in some ways changes your
01:48:55
homework as a man. Do you know what makes your girlfriend feel emotionally
01:49:00
connected? Quality time. Deep questions. Yes.
01:49:07
Um, the conversation cards. Oh, yes. Tell me about that. Well, we sell these
01:49:14
conversation cards on this show. You can check in the uh description below if you want to buy them. But basically, at the
01:49:20
end of the conversations on this podcast, the guests write a question in this diary in front of me for the next
01:49:25
guest. And then these all become Yeah, thanks. These all become conversation
01:49:31
cards. Unlock deeper levels of connection. Open up to open up. Level
01:49:36
three is the the more deep questions. So Oh, I like it. Um this I'm probably a
01:49:41
level three person. You're a level three person, I would imagine. You strike me as a level three person. You really do.
01:49:48
But those kinds of things. So like deep um deep questions and spending time and then that's it. Can I see some of those
01:49:54
level threes? Yeah, here are all your level threes. What is the most important thing we haven't talked about that we
01:49:59
should have talked about? Is there anything else?
01:50:04
Sleep is something we didn't talk about when we think about the impact sleep has on our hormonal
01:50:10
balance. Is it important? My gosh. Sleep is as close to a panacea as we have.
01:50:16
When you say panacea, you mean like the holy grail? It is the holy grail. It is so critical for functioning. You know
01:50:23
what I see taking care of a lot of executives is that they think that they're the exception that they don't
01:50:29
need 78.5 hours of sleep every night. But only about 2% of the population has
01:50:35
the short sleep gene. The rest of us need to optimize our sleep to the best of our
01:50:43
ability. So what we know is that it affects your hormones inside of 24
01:50:49
hours. One bad night of sleep raises your insulin, raises your cortisol the
01:50:54
next day, makes you more hungry, makes you more likely to crave carbohydrates.
01:51:01
So, just like you can create a negative cycle, you can create a positive cycle by optimizing your sleep. I'm a big fan
01:51:08
of wearables because especially if you wake up in the morning and you don't feel flush with
01:51:15
sleep and fully restored and fully recovered, you want to understand the metrics. How much deep sleep did you
01:51:21
get? How much REM sleep? How many interruptions did you have? Did you
01:51:26
snore? What was your heart rate variability? was what was your respiratory rate? So, I feel like sleep
01:51:34
is one of those lifestyle factors that we need to optimize.
01:51:39
On my ketogenic diet, I noticed that my heart rate variability seems to go lower, which is scary. Do you see that a
01:51:47
lot when people do kind of these kind of more restrictive diets and they're in ketosis? There can be. I mean, I would
01:51:52
look at some of the other variables as well. And one of the things I really like is they eat sleep. Have you used
01:51:58
that at all? Yeah, I have. Um, the mattress. Did it help you with HRV?
01:52:05
I believe it did. Um, I I don't have the I had the results at the time, but I was
01:52:10
sleeping really really good on it. Um, I still use my Whoop, which hashtag ad. I still use my Whoop for um my HRV. Mhm.
01:52:18
What are the things that you aim at when someone comes to you with low HIV? A lot of people want to improve their HIV. We
01:52:24
kind of see it as this holy metric now. Sure. Well, I start with alcohol. So, we know alcohol makes your HV decline, not
01:52:32
just for one night, but somewhere around seven to nine nights. That's why I quit alcohol. Yes. My h it just killed my the
01:52:39
first time I put my whoop on and I saw the impact it had on my HRV. I thought I'm not doing that again. And that's
01:52:45
exactly the kind of behavior change that I get excited about. So when you see the metrics and you see the reflection of,
01:52:51
oh my gosh, my physiology is so much better off of alcohol and there's better
01:52:56
choices than alcohol, you want to make that swap and the behavior change
01:53:02
sticks. So I like I like grounding. So I find when I
01:53:08
get in the ocean, when I get in streams with bare feet, when I walk on the sand,
01:53:13
that improves my HRV. The country that seems to improve my HRV the most is
01:53:18
Costa Rica. There's something about the aliveness there. My HRV doubles to triples really. Micro doing mushrooms
01:53:25
also raises my HRV quite significantly.
01:53:30
We have a closing tradition on this podcast, like I said, where the last guest leaves a question for the next guest, not knowing who they're leaving
01:53:36
it for. And the question left for you is, what do you do every
01:53:41
day to make a better brain and better world?
01:53:48
M what I do every day when I'm home in Marin County is I
01:53:56
go outside when I wake up in the morning and I look at the I live on the ocean
01:54:03
and I look at the horizon like I trace my eyes along the
01:54:09
horizon and I just was looking at the data on morning sun because I didn't
01:54:15
quite believe it like It supposedly it helps you with your circadian rhythm. It helps you with sleeping better. It helps
01:54:23
you with melatonin production. It helps you with mood. It's got all of these benefits. And some
01:54:29
people say you only need five or 10 minutes of morning sun. That's sufficient. And so I started looking at
01:54:35
the data and you actually need more than that. like you start to see a benefit around 30 minutes, but you need um you
01:54:44
still keep improving some of these outcomes with longer like up to two and
01:54:50
a half hours. So the thing I do every day is I get morning
01:54:55
light and I trace the horizon and I look at nature and I remind myself that
01:55:02
nature is the best way to regulate. that helps my brain.
01:55:09
Sarah, thank you. Thank you so much for doing the work that you do. You're an incredibly intriguing person in many respects and you're clearly helping so
01:55:16
many people in so many wonderfully important ways. Um, I highly recommend everybody go and check out the books that I have in front of me. There's I
01:55:22
mean there's there's quite a few of them. I think there's six in total. I've got three here. The autoimmune cure,
01:55:28
healing the traumas and other triggers that have turned your body against you is the book that I'm going to um highly
01:55:34
recommend. I think this is the the new one and I've interviewed Paul Conte who writes the um recommendation for the the
01:55:40
book on back of this. I've also got another book here called The Hormone Cure which is all about reclaiming
01:55:46
balance, sleep and sex drive, maintaining a healthy weight, feeling focused, vital and energized naturally and one of the books that I was
01:55:52
referencing as we were going which is Women Food and Hormones a four-week plan to achieve hormonal balance lose weight
01:55:58
and feel like yourself again. If people want to know more from you, they want to hear you. You have a new podcast right?
01:56:04
Yes. Where do we go to listen to your podcast? My website is
01:56:09
sarahzalmd.com and the podcast is called Treated with Dr. Sarah. That's Sarah Zal
01:56:15
spelled S Z A L. That's right. And the podcast is called Treated with Dr.
01:56:22
Sarah. Thank you so much. Thank you so much, Stephen.
01:56:27
We launched these conversation cards and they sold out. And we launched them again and they sold out again. We launched them again and they sold out again because people love playing these
01:56:33
with colleagues at work, with friends at home, and also with family. And we've also got a big audience that use them as
01:56:39
journal prompts. Every single time a guest comes on the diary of a CEO, they leave a question for the next guest in
01:56:45
the diary. And I've sat here with some of the most incredible people in the world. And they've left all of these questions in the diary. And I've ranked
01:56:52
them from one to three in terms of the depth. One being a starter question. And
01:56:57
level three, if you look on the back here, this is a level three, becomes a much deeper question that builds even
01:57:03
more connection. If you turn the cards over and you scan that QR code, you can
01:57:09
see who answered the card and watch the video of them answering it in real time. So, if you would like to get your hands
01:57:15
on some of these conversation cards, go to the diary.com or look at the link in the description below. This has always
01:57:21
blown my mind a little bit. 53% of you that listen to this show regularly haven't yet subscribed to the show. So,
01:57:27
could I ask you for a favor? If you like the show and you like what we do here and you want to support us, the free simple way that you can do just that is
01:57:33
by hitting the subscribe button. And my commitment to you is if you do that, then I'll do everything in my power, me
01:57:38
and my team, to make sure that this show is better for you every single week. We'll listen to your feedback. We'll
01:57:43
find the guests that you want me to speak to and we'll continue to do what we do. Thank you so much.
01:57:50
[Music]
01:57:59
Oh, hey.
01:58:08
[Music]
