Sara Gottfried, M.D.: Women, Food, and Hormones
Dr. Sara Gottfried is a Harvard educated doctor, scientist, researcher, mother, and seeker with 25 years of experience practicing precision, functional, and integrative medicine. Gottfried specializes in root cause analysis, as she firmly believes that the greatest health transformations unfold when you address the root cause of illness, not simply the signs. She is the author of three New York Times best selling books focused on healing our cells, and our souls.
Today we discuss her most recent book Women, Food, and Hormones. Yes, we talked about all of those things, but we also explored the culture of weight and wellness, and why the scale is not always a predictor of our health. She took us through the intricacies of our metabolic function, and we together questioned whether the “perfect” body we have in our head even matches the body that allows us to function at our best. As she explains: “I feel like women are stuck. They're stuck between diet culture, which I think many of us reject this idea that we're supposed to be thinner, obedient, smaller, take up less space and have these unrealistic standards for how we're supposed to look. And then we also have the fat acceptance movement. And what I like to do is to position myself in the middle where the focus is on metabolic health.” She walks us through her protocol for hormone balance, opening up detoxification pathways, and even gives us a script for talking to our doctors and regaining agency when it comes to our health. Gottfried implores us to remember that we are deserving of support at any age, and that righteous indignation when it comes to our health can move mountains.
EPISODE HIGHLIGHTS:
Discussion of Diet Culture & Body Positivity: Approx. 5:24
Metabolic Health: Approx. 9:40
Importance of Testosterone for Women: Approx. 19:31
Wearables: Approx. 23:48
The Ketogenic Diet for Women: Approx. 28:34
Detox: Approx. 38:43
Discussion of Courageous Conversations with Doctors: Approx. 49:54
MORE FROM SARA GOTTFRIED, M.D.:
TRANSCRIPT:
(Slightly edited for clarity.)
ELISE LOEHNEN:
Well, it's always lovely to see you and I feel so full circle, because you were one of the first people who I interviewed on The goop Podcast. It was so early days trying to find our footing and define that show. So it's nice to see you again—on the envy of your book launch!
SARA GOTTFRIED, M.D.:
Yeah. Yeah. We were in Brooklyn. And you were asking such good questions as always. I loved that conversation. And I want to hear about your new book. I don't know if there's time for me to hear about it!
ELISE:
Yes, of course. I have all the time in the world for you. It's interesting because, well, we could almost start there because the book that I'm working on is about women and the patriarchy and the ways in which we police ourselves and then each other, it's essentially about the invisible structures that keep us, or delimit, how we show up in the world and the ways in which we embrace those out of this idea of acceptance and safety and security. And then either…I think it's a projection on other women out of sometimes envy that we haven't really diagnosed or processed or fear like this person is sort of out of line. And I need to bring her back in. And the meta structure of the book is actually the seven deadly sins. And so I write a whole section of the book about gluttony, which feels obviously really relevant to our conversation today because I think that we are in such a strange, hard place as women, right.
Of this recognition that we are, that medicine is so far behind in terms of nutrition and our individual makeup. And the fact that all food obviously, and exercise affects each of us differently, the impact of the environment on our hormones. So women have known that this is a lie for a long time, much longer than I think everyone else, that calories in equals calories out. And if I'm just good in quotes, I should conform. And then it's sort of taking that whole thing and weighing it against this idea of like, what are we supposed to look like anyway? And what's healthy and natural. And our ideas of defining. We, you know, we live in such a fat-phobic culture and the standards that are established and that we see are not necessarily accessible attainable or healthy. So point is, I've been thinking a lot about this and your world as you help women navigate that very, very fine line between berating ourselves and actually making sure that, that we are healthy. So how do you think about that? I know it's like the nut of so much of your work.
SARA:
I so appreciate the frame that you just gave it because I feel like women are stuck. They're stuck between diet culture, which I think many of us reject this idea that we're supposed to be thinner, obedient, smaller, take up less space and have these unrealistic standards for how we're supposed to look. And then we also have the fat acceptance movement. And what I like do is to position myself in the middle where the focus is on metabolic health. And I think this is really important because it's not about, you know, some fad supplement or the latest crash diet. It's about how is your metabolism working? And if we could just talk about metabolism for a moment, I'm thinking metabolism here as much broader than most people think of it. It's not calories in calories out. That's a piece of it, but it's really the aggregate of all the biochemical reactions in your body.
And when you look at it that way, we need metabolism on our side, we need metabolism to rock our mission. We need metabolism to execute on, say what the Dalai Lama once said about, you know, the world will be saved by Western women. We can argue that particular point, but I think we've got to really be thinking about: what is my metabolic health? How do I define it? How do I connect to it and own it and not outsource it to some doctor that I see once a year? So what is metabolic health? It has to do with glucose. It has to do with this, as you described, this personalized response to food and environment and lifestyle. It has to do with your fasting glucose in the morning. It has to do with, you know, whether sweet potatoes spike you up to the diabetic range, like they do to me. So I think positioning it, not as diet culture, not necessarily as body positivity, which has, I think an important message that goes along with it, but instead somewhere in the middle,
ELISE:
Well, I think body positivity, it's like as I am all for more inclusive structures. And I think as we sort of get at the root of these things, they're very, very important conversations. But body positivity in of itself is it's hard, right? To be like, you should feel good about your body and you should…when so many of us, it's such a complex relationship, particularly as we age and we start to feel like we're losing control because we are, and there's such a, a dance, at least this is how I feel personally as a 41-year-old woman. The things that I used to do don't really work anymore. And I find them to inherently that I spend more time. I sort of berate myself for the time that I spend even thinking about it, but then also I'm slightly alarmed. So I'm like, what is happening here? And should I be alarmed? Is this like a slow slide where I won't be able to recover? And so I think it ends up, there's a kind of no good way to go. And I think for a lot of people who just have a complex… and I don't know any women really, who don't have a complex relationship with their bodies, or haven't been disordered in some way, you know, we're all on that spectrum of permitting and restricting and, oh my God, I went wild last night and now I need to do penance. You know, now I need, now I need to be good that it's, it's really maddening. And then to go back to those like losing control, which is the focus of, you know, I think all of your work, but really Women, Food and Hormones is this like what's within my control. Like what is what's happening imperceptibly below the surface that might be working against me. It might be why I feel bad.
SARA:
Well…I so appreciate your honesty. A couple things. One is, I feel like I learned in my forties that control is an illusion. And maybe it's more about what's what's within my power. Like where, where is my power when it comes to supporting my metabolic health. How do I access it? What's going on under the hood? Because I think so often even really smart, sophisticated women will outsource that to their docs. There's also a piece of, I appreciate how you described body positivity. I mean, we all can get behind this greater inclusivity and to understand that shapes of all sizes are equal. I think that's really important. On the other hand, as a physician, your practices, you know, precision medicine, I really want for my patients to understand that the choices they make today at 41 at 31 at 51 affect your risk in the future of things like Alzheimer's disease.
You know, those things begin in the body decades before a scary diagnosis, breast cancer, you know, diabetes. So all of these things are under the hood. And I think the more that we democratize data so that people really have access to dense data sets if they want them. If they're nerdy like me. And really understand like how this machine is operating, I think that's really essential. And, and I like how you described, you know, kind of those values that we tend to put on food. You know, I went wild last night as you described. And I think it's so important for us to take a step back and to say, I have choice here. Like I have a choice to care about my metabolic health. I have a choice to care about maybe even fitting into the clothes in my closet. And I think what gets in some of this more polarized discourse is that we're made to feel bad or guilty about it. And that really, in some ways that's not any further, that's not advancing us any further than we were when we were stuck in the diet culture. So I think finding this middle ground is really important.
ELISE:
And you mentioned lifting the hood, which is one of my, one of my go-to phrases. I love that phrase, which I think, as women and this extends to men as well, but weight has always been shorthand, right? It's like, oh, if you're fat, you're unhealthy, whereas you could be skinny and have a lot of fat around your midsection. And you know, my husband has no weight problem. And yet he’s almost pre-diabetic and our scale confuses the two of us, which is mortifying. However, I would argue that I am definitely healthier than he is and all of my choices, but I think we we're, we're a visual society and we immediately go from, oh, you're thin, therefore you're healthy. And I like this, you know, the precision medicine, the metabolic function, looking for inflammation, because it's really actually about what's happening in the body.
Not necessarily how that's manifesting visibly, which I think is hard. It's like, it requires a bit of a retraining for us and moving away from like, oh, your BMI defines your health to actually, that's just like one very loose measurement that has shifted around over time. And we really need to understand, if you're at risk. So where do you start? When, when someone shows up in your office and the book is full of fascinating case studies, and I'm sure that there are some people where you're like, I don't know what to tell you. You might just you're, you're not sure where you need to be as maybe a little higher than you would like it to be, but you're actually like in perfect health versus, okay, there's something going on here. You feel tired, run down. You don't feel good to, to go out and do the work that you mentioned. So how do you like to start the work?
SARA:
Yeah, I start the work with the history. So, you know, I love to hear patients' narratives. That's really the greatest gift of being a physician is hearing a patient's story. And then understanding based on that patient's values, I see both men and women, but understanding based on those values, where do we begin? So it starts with the history it starts with, you know, I've got about a 20-page online form that I use with patients, and it goes through a list of metabolic questions. So asking things like, as you described with your husband, what's going on with your weight? You're right, that is the easy metric, although it often lies because we know that there's a lot of people who are so-called skinny-fat, and I'm going to be, I'm going to try to be careful about my language here. These are folks who are not metabolically healthy, even if they're in a normal body mass index.
And then there's also people who are overweight, even obese, who are metabolically healthy. Now the rate of having metabolic dysfunction as your weight increases is, you know, increased. But I think it's important to realize that body mass index or weight really doesn't tell us what's going on in terms of metabolic function. So I start with the history. I ask about specific hormones because hormones drive what we're interested in. And more often than not the patients who come to me have some sort of issue. So I see a lot of executives and professional athletes. You know, it depends on what their goals are, but I would say for most women who are say over 35 or over 40, they often are struggling with fatigue. Maybe they're not sleeping. Well, maybe they, you know, had a couple of kids and they can't lose the baby weight. Maybe they're just noticing that body fat is redistributing, which is something that happens in your forties.
But a lot of people don't know about. So this is insulin and estrogen, kind of working behind the scenes to create more belly fat, to take, you know, to deposit fat less in the subcutaneous tissues, especially at the breast, the hips and the buttocks, and to store them at the belly where it's more metabolically risky. So that's not just, you know, benign fat that makes it harder to zip up your jeans. It's the type of fat that is metabolically active and spewing these cocktails that create inflammation. Kind of like a frat party in the body. And that's not something that we want.
ELISE:
Right. Well, I feel like you just described me, which is it's interesting. And actually, one of the things that really made me a firm believer in functional medicine is that after I had my first child, when I was in my mid-thirties, I was really, I gained, I had a very inflammatory response to pregnancy and gained 60 pounds, 55, 60 pounds, regardless of what I did. And then I was, I was really struggling. And then I actually did the Clean Program and worked with Alejandro Junger M.D., and it was wild. It was like something just, it was a snap back suddenly where, you know, I just went, I went back to my wedding weight. It was a strange experience, which I have not been able to do after my second. And it is that redistributing and, and feeling as mentioned like, oh, I guess we're done.
I guess I'm no longer the same. And it's funny. Cause like you, you want to go back to the side of the pool and like touch and be like, okay, I recovered. I'm the same. And yet at the same, you're also so perceptibly changed by life, but you also don't want to reject that if that makes sense. Like I'm excited to get older. I think it's such a privilege. I don't mind wearing that on my face, but yeah, I also like, there's something strange. So I know, you know, we've talked in the past about leptin and insulin resistance and all of these other factors. I love that in this book, you also get into testosterone, which obviously is we think of as only being significant for men, but it's very significant for women, right?
SARA:
It is, you know, the, the most abundant hormone in the female body is testosterone. A lot of people think that it's estrogen, but if you look at your levels, if you get a hormone panel, testosterone is the most abundant. So yes, men have more, they have 10 to 20 times as much testosterone as women, but we're exquisitely sensitive to it. And it's one of those hormones that I don't think gets enough screen time. I think we need to emphasize it more for women because it's involved in confidence and agency. We know in a study that was done on MBA students that it's involved in risk taking, particularly financial risk. It's involved in, you know, some of the classic things that you might think of, such as muscle mass, getting a response to the exercises that you're doing. It's also involved in sex drive, but it is these functions related to vitality, particularly agency, that I think are so important for us as women.
And the decline with testosterone can be very subtle. So it tends to start to go down in your late twenties, depending on how much stress you have, how many refined carbohydrates you like. When I was 28, I was, eating a lot of refined carbs—that was during my medical training—and I accelerated the decline of my own testosterone. And then I realized, you know, as I started to look at these hormone panels, that there was so much I could do in terms of lifestyle, in terms of managing stress, in terms of the coffee that I was addicted to at the time, which lowers testosterone. There was so much I could do to meet my hormones in the middle. So that includes testosterone. It includes growth hormone. It includes estrogen, cortisol, all of these hormones that are involved in metabolism.
ELISE:
How do you, it's so interesting. I was thinking about, as you were speaking sort of the ways in which we accelerate the decline of certain things or spike certain things. Is there a version—and maybe as we do have access to this data and the metadata, and we really start to get a wider range and I know women are sort of woefully under-studied—but do we know with the, for a fact, what should be the rate of decline in testosterone? What, like, how do we determine? Because I think that we all have this struggle, right? Of like, what is my, is there a weight set point? They say there isn't, right? But I think we all intuitively feel that there's a place where our body is happy and we feel really good. How do you determine what's ideal? And is it just by referencing other labs that are often of sick people, right. Or people who are getting tested.
SARA:
That's right. I mean, the problem with using the normal range, which is what mainstream medicine bases so much of care on, is that it includes a lot of folks who have say, thyroid dysfunction or who are highly stressed. And so to really understand your baseline, what I generally recommend is that you track your hormones over time. So there's a basic hormone panel that I wish every woman would order. I remember I've got two younger sisters and I remember my sisters asking me, you know, what should we do? What should we do to kind of sail through our forties, make it through this whole peri-menopausal thing. Cause they're quite a bit younger than me. And I said, you know, I want you to do a hormone panel. Like do it while you feel fantastic. Benchmark that. That's the best way to track yourself over time. So we know for instance, that testosterone declines about 1% per year. Starting in your late twenties, it's more accelerated more like 2% per year if you've got some of those conditions that I mentioned, like being highly stressed or having toxic stress, having certain lifestyle habits that tend to erode testosterone. So we can also track over time, which is where I really believe we're heading in medicine. Where instead of doing medicine for the average, we are moving toward medicine for the individual. And that includes collecting dense data sets. You know, like, you know, wearables using blood measurements, tracking your stool over time, looking at the microbiome so that you have a sense of what's your baseline. And then when you deviate from that baseline, how do we get you back to a state of homeostasis? And we can use N of one experiments. That's a fundamental tool in precision medicine to help you get back to that place of homeostasis.
ELISE:
How much. I mean, I know that you try everything and that you track everything. I, I see it. Is there, do you like Oura, Fitbit? Like, do you, or do you just do everything and then sort of aggregate what you see. And do you think that there's also, do you find that some patients can become obsessed with becoming scientists about themselves in a way that's not helpful?
SARA:
Well, there's always a risk of going overboard, right? I think the key is what are your goals? My goal when I started tracking so much was I wanted to deal with my pre-Diabetes. So you described, it sounded like maybe with your first pregnancy or maybe it was after your second, a level of inflammation that you had, where you gained a significant amount of weight. I did something very similar. So I gained about 60 pounds with both my kids. The first one was related to stress and eating too much. The second one, I was exercising and really careful about my food game, and gained the same amount. What was going on under the hood for me was insulin block where insulin was rising in my body. I was not aware of this. All I noticed was that I just had fat deposits in places I'd never seen before.
You know, like back fat, belly fat. And you know, some of that of course was related to the pregnancy, but my body went to an extreme place. You don't need 60 pounds to give birth to a six pound baby. So I was insulin resistant. I remember I did one of those glucose tests during pregnancies. I was around 27, 28 weeks. And my glucose tests was 134. The cutoff is 135. And I remember my doctor saying to me, well, cut out juice. Like that was her only advice. And here I was, you know, pregnancy is a stress test. It was an indication that I was already having problems with my metabolism, with my metabolic health. And that's often the first time that women are told about this. So pregnancy is such an important time in terms of really understanding what's going on.
In terms of what I do, I rotate to different wearables. Right now, I really like the Oura. I still use that. I also like the Garmin because they have some extra metrics that I find really helpful, especially for physical training. I use an Apple Watch because I think Apple is really at the leading edge with a lot of testing. I also use a continuous glucose monitor. I sound like a freak. I realize that. But what I find is that when I collect the right data and I use it to design these little experiments, like what food is Sara going to eat today to stabilize blood sugar, keep a mean glucose less than a 100, keep the standard deviation or the variability less than 15. That's what really works for me. So I realized it doesn't work for everyone. I also realized that there are some people who can become almost orthorexic in the face of so much data collection that, you know, they're, they're almost paralyzed and aren't sure where to turn. So in that case, I think we have to find the right dose. Like what's the right dose of wearables. What's the right dose of biomarkers to help pull you forward with the vision. You have yourself for yourself, for your health and your life, but not so much that it's messing with your head.
ELISE:
I think that makes a lot of sense. And we were messaging about, you know, one program that's, that's predicated on monitoring. I think it's, I haven't signed up yet, but I've been contemplating it. It does stool tests, continuous glucose monitoring. I would imagine that there's just going to be a glut of these coming to market as they're starting to aggregate, and they're doing it by aggregating, essentially doing what you're doing to yourself, but doing it on legions of people, right. To really understand how and I was reading, I think it was a, a group in Israel who were doing this at scale and they'd be like, oh, one person Wonder Bread, and they are like fine on all of the stuff that we have condemned in our diets. They have no bad effects. Meanwhile, another person is destroyed right by those similar foods. And that it's just, it's wild.
As you said, sweet potatoes, which we hearld as being sort of a wonder, food are not good for you, but that will start to have that insight into ourselves, right. Where it'll be like, wow, who knew blueberries do not work well with me versus, you know, so sort of stopping to demonize some foods that we've thought that we should never eat. And then similarly understanding the impact of, of other good foods. And, you know, similar Keto. Like, I love that you sort of go into Keto and then two week it, because we're also given these diets, it's like, this is just gonna work for everyone. And Keto made you fat, right? So you changed it. Is that accurate?
SARA:
So my husband and I went on a Ketogenic diet in 2016, he dropped about 20 pounds. He was feeling like, you know, he had Ketones throughout his body. He felt like he was hearing the angels singing, you know, like, and I was gaining weight. I was so frustrated. And I think many women go through this experience of trying the Ketogenic diet. Some women succeed. There's certain genetic variations, for instance, that are associated with being a super responder to Keto. And then some of us just don't. And what I found was that about 80% of the literature on the Ketogenic diet, especially for metabolic health, was in men. And it was just assumed that it applied to women. But I think women are, you know, we're different in many ways, in terms of sex differences, we've got some of those hormonal changes such as, you know, much higher estradiol levels or estrogen, lower testosterone levels, but still very important.
We also make more growth hormone until menopause. And then we have a pretty significant decline in growth hormone. So what we know is that women need to do Keto differently. And one of the pieces that I really found for myself was that I was generating all of these ketones and kind of this fat from the fat I was eating. And I had to detoxify it once I got that detoxification in place, which is a key part of hormone balance. When I got that into place and then did a Ketogenic diet, I was much more successful. The other problem with Keto that I think affects women more than men, is that we need carbohydrates. We need carbohydrates for good stress response, you know, not getting stuck and kind of that high toxic perceived stress state. We also need it for good thyroid function and we need it to, we need carbs to make serotonin, to help us sleep. We know that women have doubled the rate of insomnia. So what I found with developing this protocol first on myself, and then dozens of my patients is that if you have those three pillars, so detox, vacation, nutritional ketosis, following detoxification, followed by intermittent fasting, the intermittent fasting allows you to eat more carbs. So that allows us to find this balance with carbohydrates, where you get enough to feed those benevolent microbes in the gut and not so little that you get the stress response and the high reverse T3 and the difficulty with sleep.
ELISE:
Yeah. And I know you outline that all really clearly that there's a protocol for this revised Ketosis or the Gottfried protocol in, in Women, Food, and Hormones. And then is, this is the idea that people should do this in perpetuity? Because I, I tried Keto and then I kind of didn't lose weight, but I kind of lost fat. And then I rebounded and, and ended up above where I started. So how do you, how should we be thinking about this so that it can actually be a lifestyle and we're not sort of perpetually engaged in what feels kind of like a fight.
SARA:
It does feel like a battle. And I, my experience is the female body doesn't like battles unless it's something really worth fighting for. So I think that for women, especially a four-week pulse is the way to go with Keto. So I think of it as a therapeutic treatment, the most proven diet of all is the Mediterranean diet. Now I found with the Mediterranean diet that I gained weight, something about those whole grain breads and the grains, the fruits, it just was too much for my state of metabolic health. So what I advise is a four week pulse of the Ketogenic diet together with the detox and the intermittent fasting, and then a gradual transition to a lower carb Mediterranean diet. Now for people who have more weight to lose, what I advise is that you do these pulses and define your carb threshold. So what's the dose of carbs that really helps you stay in a state of hormonal balance.
And that's what I advise people do after the four weeks. So I talk people through this process, I call it a transition, where you increase your net carbs. That's total carbs, less fiber. You increase your net carbs by about five grams per day. Define your carb threshold, and then you can stay within that threshold if you want to continue to lose fat. So that's really designed to help with metabolic health and for people who go through an experience like you did, where you went on Keto, and then you came off of Keto and regained even more weight. We know that that's not healthy, right? So I think the language you used, which is how do we lifestyle this thing? Like how do we really build this into our day? So it's not, you know, villainizing carbs and it's not focused on the wrong thing. It's focused more on metabolic flexibility.
I think that's where the focus has to be. So metabolic flexibility is when you can toggle the switch back and forth between burning carbs and burning fat, and you want to be able to talk back and forth based on the type of fuel that's available, and what I found when I was going through Keto and I failed it twice with my husband starting in 2016, is that I was stuck in that carb burning mode where I just would store fat, store fat, store fat. And so I had to use a Ketogenic diet to reverse that, to reverse this metabolic dysfunction that I had. And it's one of the most effective ways to do it. You know, the other thing that we started with at the beginning talking about calories in calories out calorie restriction is a colossal failure. So we know 98% of the time, it just doesn't work for people.
We also know that it ruins your hormones. I mean, it does some of the same things as low carb does in terms of causing problems with reverse T3, your body just goes into a survival mode and metabolism can drop. So we don't want that. We want to stay metabolically flexible. And that's the benefit of a Ketogenic diet. The other benefit is satiety. I don't know if you had that experience when you were on Keto, but it was one of the only diets that has a biomarker that tells you how you're doing. So you can prick your finger and look at your ketones. You can look at it in your urine and your breath. And that tells you how well your body is making ketones. And those ketones really help you with getting your blood sugar down and with repairing the metabolism.
ELISE:
And it's funny that you say that because I think probably I didn't endure as long as I should have. And I think that the calorie deprivation for me over the years from being really stressed, and really busy, and certainly having those days where I'm like, I forgot to eat, or, you know, it's funny. I was talking to Will Cole, who was helping me sort of get set up for Keto. And we were looking at what I was eating and he was like, you are not eating enough. Like, what are you doing? So I think part of this is my body being like, let me live, you know, like, let me, let me live. And acknowledgement would say for myself, if I probably spent most of my life or most of the last 10 years holding myself at a weight below what was appropriate. So I think I also have probably unrealistic or unhealthy expectations. Cause he kept also saying to me, like, I think you will lose the weight that you need to lose, if you need to lose any weight.
SARA:
So that's a beautiful way to put it. I so appreciate that because, you know, I know this is part of that internal, that internalization that I think we've done with patriarchy, we've got these ideas about how we want to look in our clothes and that weight that we have in our mind may or may not be the metabolically healthy, appropriate weight for us. So in some ways, this kind of opens up this feeling of freedom, you know, to say, okay, Elise, what is, what is the weight? What is the muscle mass? What is the fat mass that really allows you to be the best author you can be that allows you to have, you know, the mental acuity to do these awesome podcasts that you record? What does that look like? And does that match, or does it not match with what you have in your head?
ELISE:
No, absolutely. And I think that that's work—and maybe through the data we can all, as we maybe culturally also start to shift away from using a scale as a metric of health or one of the only indicators of quote unquote, how we're doing, to be a little bit more tuned to how we're actually doing. That we'll shift that conversation. You brought up detox, which I think is worth talking about because obviously throughout the last 10 years, I've heard a lot of, you know, the, a lot of people are like detoxing is not a real thing. And, the body knows how to detox itself. So can you just talk a little bit about how we can help it along? And also, I mean, fat is alipophyllic right, like fat stores the toxins. And so when we start burning fat, we're excreting a lot of this stuff, too. So can you talk a little bit about how you would support the body before beginning something like Ketosis?
SARA:
Well, what we know with detoxification, it's true that, you know, mainstream medicine often criticizes the type of work that we do in functional and integrative medicine saying that, okay, the body detoxes on its own, you don't have to augment it. But the truth is when you look under the hood, most folks do not have open detox pathways, at least the patients who come to see me. So I see, you know, a lot of different folks from around the country who have one issue or another with detoxification. So that might be genetic. So there's, you know, dozens of different gene variations that are associated with the way that your liver takes a toxin, such as Bisphenol A and neutralizes it. So sometimes the body gets depleted, especially in some of the nutrients that support detoxification, things like n-acetyl-cysteine, which is a precursor to glutathione.
Glutathione is one of those molecules in the body that kind of mops up the toxins. It's almost like it's a master antioxidant. So you can think of it as a way of clearing out the rest in the body. Your liver goes through three different phases, phase one, phase two, phase three, to detoxify some of these toxins that we're exposed to. We're also exposed to more toxins than we ever have been before. So just counting on your body to do its best with this massive influx of toxins that it's exposed to. I find for most of my patients, that's not sufficient. Now the good thing is you don't have to do anything really complicated. A big part of detoxification is making sure that you're getting the right dose of cruciferous vegetables, broccoli, cauliflower, Brussels sprouts, radishes. Also making sure that you have sufficient allium vegetables, that's onions, garlics, and leeks.
We know that those are associated with raising glutathione levels. So you can use food as a way of detoxifying. You know, just hydrating sufficiently is also really important for detox vacation. So is sweating. So exercise, saunas, those are all really great for detoxification. Now, what I've found with Keto is that it's really important to be mopping up these toxins as you're losing fat. So you alluded to this because we all have a body burden of toxins in our body. That includes endocrine disruptors, as well as other toxins. You know, we're born pre-polluted unfortunately, with hundreds of different toxins. And so when you lose fat, which is really what I'm interested in, not so much losing weight, but losing fat. The toxins that are stored in your fat tissue get released into your bloodstream. So, you know, I went through this process in 2018 where I finally got Keto to work by coming up with these three pillars.
And I lost about 20 pounds of fat, mostly fat. When you're losing say the first 10 pounds, your body burden of toxins goes up. So you want to be able to mop those up so that they don't continue to foil your metabolic health. So that's a really important piece. There's a lot of different ways to do it. You want your gut working well, you want to be pooping every single morning. I see so many women who are not pooping every morning. I think that's essential for detoxification. That is phase three of this liver detox that we’re talking about. And with pooping, you know, the thing I think of is you want to have a bowel movement every morning. You don't want to have to trigger it with coffee. You want to have that bowel movement. You want to have a feeling like you have completely evacuated. And that's really important because another sex difference is that the intestines in women are about 10 feet longer than they are in bed, 10 feet longer.
ELISE:
Wow.
SARA:
And they're much more circuitous. So, you know, anyone who's gone through a colonoscopy, hopefully you haven't gone through this yet, at least, but most women have a pretty torturous colon compared to men. And it can be harder to have that bowel movement every morning. So having that in place, I think is an essential part of being successful with creating metabolic health.
ELISE:
Hmm. That is very validating. This explains a lot!
Going to the endocrine disrupting chemicals. I mean, it's pretty devastating to think about that burden. And I don't know if you've read The Obesogen Effect by Bruce Blumberg, but he talks about sort of his work looking at endocrine disruptors, looking at obesogens really. And then he talks about Dr. Skinner, I think is that the university of Washington as a PhD. And he did all these studies on mice with DDT, which was obviously rampant in the environment in the fifties and sixties. And when they look at it in mice, it causes birth defects in the first generation. And then in the second generation, it turns on obesity, which is wild to think about how these completely unregulated for the most part, particularly when they're environmental chemicals, could be affecting us in ways that aren't even part of our own lifetimes.
SARA:
That's, it's, it's a terrifying message, but I think it also points us in a particular direction to see how can we reduce exposure. And then also, how can we detoxify? So DDT is also associated with breast cancer in addition to being an obesogens for the most part of these obesogens work on your hormones. So it works on insulin. It works on leptin. It leads to things like increased appetite. It can also change the adipocyte stat. The part of the brain that manages your energy in and out and is associated with that set point that you mentioned earlier. You know, endocrine disruptors. I think the obesogens story is a really important one to track. There's also dementogens. So endocrine disruptors that rob you of IQ. So we want to be tracking these things. The other thing to realize is that, you know, there's other studies too, looking at these intergenerational effects where it's not just DDT, it's also things like stress.
So there was this really interesting study looking at a cold snap that occurred in Nova Scotia, where they had an ice storm and people were stuck in their homes, freezing cold weather for weeks at a time with no power, no heat. And what they found now, looking at this was in, I think, 1998, they've now looked at the children of women who were pregnant during that ice storm. And they found that the children who were part of that cohort, the babies of these women that were pregnant compared to control babies have much more of a problem with their metabolic health. So their immune system and their metabolic function was altered by that stress that occurred in utero. So yes, I agree with you endocrine disruptors. We got to keep our eyes on that. We also have to keep an eye on that intergenerational trauma and how much that can affect metabolism later on.
ELISE:
Yeah. That is, and it's so tough. These things are so tough to sort of imagine passing… that you're carrying them and then passing them onto your own children. And then there's, you know, the amazing research that's like, yes, stress is harmful, but it's really how you, but you can control it by your own minds. Like you can, you can see stress is like, oh, this is the challenge. This is exciting. And so you can sort of change the way that your body responds to stress, instead of, oh my God, this is happening to me. And I am going to go pull a blanket over my head and hide on the couch.
SARA:
Well this has so muc to do with agency, doesn't it, when it comes to stress. It’s so key because you know, it's impossible to have a stress free life. I tried, I, it just doesn't work. And so what we have to do is we have dance with it in a different way and that mindset that you're describing, I think that's key. It's so important to realize, okay, I've got to change the way that I'm dancing with stress. I mean, this is another place like talking about in utero stress. It's another place that women can take ourselves down, right? Like it's yet another thing that we can feel guilty about as mothers, and that's not the message that I want to share. The message I want to share is this is a call to action. It's a call to action to work with your stress in a whole new way to get curious about it. I love in your, when you're talking about your podcast, the trailer for your podcast, you talked about how you grew up with just this innate curiosity and also an outsider. And I feel like that is the mindset, you know, that kind of flexible mindset, growth mindset. That really makes a difference when it comes to hormonal balance.
ELISE:
So to satisfy our curiosity. What do you, you mentioned, do you like the Dutch Test, which I've done and I can't read, but I do in terms of things that people can, can widely access is getting a blood panel done with your doctor and then asking for the results enough? Are there good in your experience at home testing options? What do you, what do you recommend for people who can't see you, who want to work sort of from the book or on your site?
SARA:
If I was getting a hormone panel, I think that's really helpful for both men and women. So I have a list of some of the hormones that I think are the most important to check. Now, blood testing is the universal language of mainstream physicians. So that's what I tend to start with. So you can ask your physician to test you for thyroid function, test testosterone—free and total. Look at cortisol levels, look at growth hormone, which we measure as IGF 1. So you can do a hormone panel. You could even look at fasting insulin. You can look at post-prandial insulin like an hour after you eat. You can look at glucose. So this panel is a basic blood panel that I recommend. And for women who go to their doctor, I don't hear men getting told this. But for women who go to their doctor and say, can we run a hormone panel because I think I've got these issues and their doctor says, oh no, they fluctuate too much.
Here's what you say in response. Well, if I were trying to get pregnant, I think you would check every single one of those hormones. So why is it different if I'm 42 and trying to lose fat, then if I'm 32 and trying to get pregnant? So I think we have a double-standard that is designed to promote fertility, and we have to take that on, and we have to, you know, speak back to her doctors or find a more collaborative physician who is willing to order these tests. Now I also like to do some more advanced testing because that's the kind of work that I do. So I like to look at genomics. Genomics has a very strong role in terms of hormonal balance, especially when it comes to glucose and insulin, but other hormones as well, like testosterone.
I also look at the Dutch. So the dried urine test. The thing that you get with a Dutch test, that's different than a blood test is that it's more comprehensive. So I was talking earlier about detoxification and how so many of my patients just have these closed detox pathways or sluggish detox pathways. So a big part of the work at first is to open those pathways back up using primarily food as the tool. And one of those sets of metabolites that we want to be tracking is what happens to estrogen in the body? Does it convert to the benevolent type of estrogen, which is the two hydroxy estrogen, or does it convert to the more dangerous type of estrogen that's associated with DNA damage and potentially breast cancer? So the Dutch test gives us this additional comprehensive data about what your body is doing with the sex hormones, especially estrogen, progesterone, testosterone.
ELISE:
It makes so much sense. And what you said, just I'm still meditating on it, but it's so true. I think we have all had that. Those of us who have gotten pregnant and had children that way, the feeling of sort of attention and love and care as you're a vessel. And then the ways in which all of that attention immediately shifts to your baby. You are sort of relegated to the trash heap and told that your body will figure out how to get itself back in shape to have another baby. And then once you're past that age, it's really just like you're out to pasture. It's really true. It's it's, as soon as our procreate, it's very patriarchal, that the procreative function is the extent of our utility, and the moment when we need to be tended to at, at which point, we’re done.
SARA:
Yeah. It's not quite as bad as The Handmaid's Tale, but it's pretty close. I mean, if you look at the financial reimbursement, OB-GYNs get paid much more for taking care of pregnant women than they do taking care of perimenopausal women. So we know our healthcare system is broken, but that doesn't mean that once you're done as a vessel, that you want to take this sitting down. Like we have to fight this, you know, we need more women in medicine. We've got, we need better representation. We need to change the way that reimbursement is done so that women are listened to, they're heard, they're not dismissed, and are they're supported in the way that, I mean, I think so much about women over the age of 40 and the contributions we make. We are so deserving of support at any age. But I would say, especially as we get older, especially as we hit these moments in time of, you know, the, the glucose that goes up 10 points with each decade as you get older. With the cardiovascular risk, that shows up suddenly around age 50 to 55. No, it wasn't sudden! It was happening like all through your thirties and forties, and we need to be looking for it. So we really need to change the way that women's health is run in this country. I think that's such an important part of getting rid of these toxic tropes that we have from patriarchy.
ELISE:
Yeah. And thank you for giving us script, you know, to take into our doctor's office. Cause typically I think, you know, I, my dad's a doctor. I think that everyone intends to do well, but they're also sort of in their own ruts or ways of doing things. And so scripts are powerful. And I think it's powerful every time a woman who, and obviously there's a tendency to not be, not be a bother, not be that patient, not be, you know, labeled as that hyper, you know, hysterical, which obviously, as we know, comes from it's traced back to the uterus, like the, the, what it means to be a woman, right, is to be hysterical. But I think every time that one of us asks the question or pushes us back a little bit, or wants to go a little bit further, it opens the door for other women as well, and the standards of care start to change. So I think it's incumbent on all of us to be a little bit courageous and brave in how we advocate for our own health, because it, it radiates from there.
SARA:
I totally agree. I mean, I would add: Let's be angry. Like righteous indignation is what moves mountains and we need it. We need it right now. We need it for so many things. Women's health is the tip of the iceberg.
ELISE:
I love functional medicine as mentioned. My dad's a pulmonologist. My mom's a nurse. And I grew up working in their office, working at the hospital, delivering trays in the cafeteria, which was very glamorous in my hair net. So I, I sort of grew up in the healthcare system and have come to love its acute interventions, certainly. And also I think, you know, I really love and respect doctors. I think as Dr. Gottfried mentioned, our healthcare system is broken. Too often within the world of specialization, it's about treating symptoms rather than the root cause of disease. And I've had some pretty miraculous experiences over the years with Dr. Alejandro Junger, Dr. Will Cole, who I love, who sees patients in groups to make it more affordable. He does it remotely. He put my immunity back together after I was, after I experienced a really hard loss of my best friend, brother-in-law Peter, many years ago, I couldn't get, well, I was just getting these horrible viruses, just 10-day viruses, just taking me down again and again.
And he put me on a protocol and really built back my immunity. And so I think it's really loving medicine in my experience and highly, highly individual and personalized, which as Dr. Gottfried mentioned is certainly the way of the future. And I look forward to that. It's becoming rapidly more accessible and we all deserve to, I think be seen for more than just how we show up in the world and personalized medicine is certainly part of that. And another inroad against sweeping generalizations about how we apprise each other's well-being based on what we see with our eyes. She has so many great books. This last one is Women, Food and Hormones. And it's a plan. It has recipes and a protocol. And along with sort of all of the nitty-gritty details that you would need for taking on a project like this, and I'm curious how you all feel. I certainly struggle with, you know, wanting my body to be different and then judging myself for that desire, and then trying to understand how that fits in that context of how I'm actually supposed to be. So these are the things that I think about all the time. As always thank you for joining me and I will see you next week.