Dr. Sara Szal: Cortisol Is The Dictator Behind Belly Fat

1. 0:00 – 2:05

   Intro

   1. SSDr. Sara Szal0:00

      73 to 75% of women do not get the treatment for perimenopause and menopause that they deserve. And women are asking, "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 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 symptoms that women aren't aware of.

   2. SBSteven Bartlett0:21

      But you believe many of the symptoms of menopause are avoidable?

   3. SSDr. Sara Szal0:25

      Yes. And let's get into that. Dr. Sara Sahl is the Harvard-trained physician and hormone expert...

   4. SBSteven Bartlett0:30

      Who's unlocking the science and simple tricks behind feeling your best, no matter your age.

   5. SSDr. Sara Szal0:36

      Most people have imbalanced hormones. Think of them as text messages that your body sends to keep everything functioning optimally. For example, out of the 40,000 people I've tested and treated, around 90% of them have a problem with their cortisol hormones.

   6. SBSteven Bartlett0:49

      And if my body's making too much cortisol, what is the harm?

   7. SSDr. Sara Szal0:51

      It's associated with more belly fat. We know that it shrinks the brain in women, but not men. It's associated with depression, but also if you're someone who's making a lot of cortisol, you're gonna make less testosterone, and that leads to a whole host of serious problems.

   8. SBSteven Bartlett1:05

      And what about trauma? Does that impact your hormones?

   9. SSDr. Sara Szal1:07

      Oh, yes. And one of the ways to measure trauma is the ACE test. It's a validated questionnaire, and they found that people who had one or higher ACE scores had a greater risk of 45 different chronic diseases. And my score is six out of ten. But those ACEs are living on in your body.

   10. SBSteven Bartlett1:24

       And you went on a journey to heal yourself?

   11. SSDr. Sara Szal1:26

       Yes, with lifestyle medicine, not a pharmaceutical.

   12. SBSteven Bartlett1:30

       Tell me about that journey. This has always blown my mind a little bit, 53% of you that listen to this show regularly haven't yet subscribed to this show. So could I ask you for a favor before we start? If you like this show and you like what we do here and you wanna support us, the free, simple way that you can do just that is by hitting the subscribe button. And my commitment 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 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 much.

2. 2:05 – 3:38

   What Do You Do?

   1. SBSteven Bartlett2:05

      Dr. Sara Sahl. What is it that you do for people?

   2. SSDr. Sara Szal2:10

      I'm a physician, so I work in academic medicine. I do research for people, I teach, and I take care of patients. So that's the official BBC answer, and the unofficial answer is, I'm a healer.

   3. SBSteven Bartlett2:26

      And what does that mean, a healer? Because that's a broad term, so that could mean many things.

   4. SSDr. Sara Szal2:32

      It means that my task is to connect to your innate healing capacity and to work with you to activate it.

   5. SBSteven Bartlett2:43

      And who do you do that for?

   6. SSDr. Sara Szal2:44

      So I do it for professional athletes, executives, and everyday people.

   7. SBSteven Bartlett2:54

      And when you say healing, if someone came to you and they said, "How do you heal people?" What would your answer be?

   8. SSDr. Sara Szal3:01

      My answer is, I don't heal people. That's, uh ... To me that's a patriarchal way of thinking about it. What I do is I work with someone who's got the capacity to heal, and we work to be in the service of that. So it's not me providing something that they don't have already. It's more understanding what some of the obstacles might be to their own healing, understanding what would allow them to be the best version of themselves, to feel fully alive.

   9. SBSteven Bartlett3:37

      And what was

3. 3:38 – 5:18

   Background and Training

   1. SBSteven Bartlett3:38

      your training? So can you talk me through your sort of academic journey?

   2. SSDr. Sara Szal3:43

      Sure. So my training is as a bioengineer. I did the Harvard MIT program, which is designed to train physician scientists. So the, um, ethos of this particular program was to train the future researchers and, um, academic physicians so that we could move the field forward. And all along, I was really interested in, how do you bring the best of conventional medicine together with more ancient ways of thinking about the body? Things like Ayurveda from India or, uh, traditional Chinese medicine. How do we take these wisdom traditions and use that to inform mainstream medicine? So that's the type of care that I learned how to do. I became a surgeon. I did primary care after I finished a residency in obstetrics and gynecology. But I also realized pretty early on that I wanted to take care of men too. So I've done that for about the past 15 years, and I would say that that training in bioengineering and a comfort with big data and with, um, optimizing datasets to improve whatever the goal is, like performance or having the most- the best conversations you can have on a podcast, that's what gets me excited.

4. 5:18 – 8:06

   Helping 40,000 People: What Sara Has Done

   1. SSDr. Sara Szal5:18

   2. SBSteven Bartlett5:18

      How many people do you think you've treated or seen or worked with directly in your career?

   3. SSDr. Sara Szal5:23

      Probably about 40,000.

   4. SBSteven Bartlett5:28

      And, and if you had to try and summarize maybe the top three or five things that you're doing for them, what would you say?

   5. SSDr. Sara Szal5:36

      Well, number one would be hormones. Hormones are the portal that most people start with me. Um, it's a way of thinking about what drives what you're interested in. Most people have imbalanced hormones. I haven't detected that you do yet, but most people have an issue, say, with cortisol, either making too much of it or too little or even both within the same day, and it affects energy. It affects mitochondria.So, I would say the number one thing I help people with is their hormones, getting their hormones back into balance, starting first with lifestyle medicine, not a pharmaceutical. So that includes breath work, which I think is one of the most underutilized tools that we have in health. Number two would be nutrition. But taken to the next level, not what you might think of that a nutritionist would advise you, but what specifically is the ideal food plan for you, for your goals? So whether you're a entrepreneur, and podcaster, an investor, or you're a professional basketball player, or you're a woman in perimenopause at age 42, what's the optimal nutrition for you? And we can measure that, and we can look at the interaction of your genetics together with what you're eating to see how we could personalize that. Number three, I would say, is prevention, and prevention has been a hard thing to sell. It's, um, you know, a lot of people just don't want to invest in prevention, and yet I take care of people who are in this continuum from a state of health often to a state of pre-disease, like pre-diabetes as an example, and if they don't do something about it, they then move on to diabetes. So I like to intervene there as early as possible to reverse disease, and most of that is lifestyle. So those are the things that I tend to work with. I do a lot of metabolic health because it's so critical for the energy that you feel each day.

5. 8:06 – 9:40

   What Is Precision Medicine?

   1. SSDr. Sara Szal8:06

   2. SBSteven Bartlett8:06

      You have a very diverse experience as a doctor/healer. It feels like you've really had a lot of sort of reference points in your career that you've drawn upon, and ultimately, you became the director of precision medicine at The Marcus Institute in Philadelphia.

   3. SSDr. Sara Szal8:25

      That's correct.

   4. SBSteven Bartlett8:26

      Precision medicine, that term, how does that differ from conventional medicine?

   5. SSDr. Sara Szal8:34

      It's quite different. So conventional, mainstream, modern medicine, I believe, is broken. I feel like there are so many people who are failed by our current medical system, especially people with chronic disease, things like diabetes, autoimmune disease. So with mainstream medicine, generally what happens is that you develop a condition, say high cholesterol, and you get treated with a pharmaceutical, say a statin, and what we know is that we have to treat about a 100 to 200 people for one person to benefit. So that, I would define as imprecision medicine, whereas precision medicine is where we understand you as an individual. We look at your genomic blueprint, we look at your biomarkers, we look at your wearables data to determine NF1 experiments where you serve as your own control and figure out what's gonna be the most effective for you, depending on what your goals are.

6. 9:40 – 12:25

   What’s Wrong with Conventional Medicine?

   1. SSDr. Sara Szal9:40

   2. SBSteven Bartlett9:40

      And everyone, you mean where that individual is the study, they are the experiment.

   3. SSDr. Sara Szal9:43

      That's correct.

   4. SBSteven Bartlett9:44

      You're not looking at broad sample sizes. What is wrong with conventional medicine? You use the term that it's broken. What is wrong about that approach?

   5. SSDr. Sara Szal9:53

      There's a few things that are wrong. One is that it has become medicine for the average, and when you look at scientific evidence and you rank order it, what's considered the highest form of evidence is the randomized trial, but the randomized trial is mostly around using a pharmaceutical. So in the example I just gave, using a statin to help someone with their cholesterol, maybe help prevent a heart attack, the number one killer. The problem is we then, based on randomized trials, come up with medicine for the average, and it's not about optimal health. It's not even centered around health. It's centered around, okay, heart disease is the number one killer. How do we help people prevent it? Oh, lifestyle medicine prevents 70% of it. Well, we're not gonna do that 'cause we can't make money off of it. There's no profit motive, so we're gonna focus instead on these pharmaceuticals. Oh, GLP-1s, that sounds like a good idea. Let's try that and solve problems with GLP-1s. So to me, there's many layers to why the healthcare system is broken, but one key area is that 70% of the diseases we're facing right now are utterly preventable with lifestyle medicine, 70%.

   6. SBSteven Bartlett11:23

      You used the word hormone balance earlier on, um, and you said that that's the portal in which people often f- find you. I really don't know much about hormones, and it's not necessarily something that the average person thinks that they can do much about, I think, uh, 'cause it's not easy to measure our hormones, is it?

   7. SSDr. Sara Szal11:39

      We can measure it 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 medicine we're taught to tell people that their hormones vary too much and so it's not worth measuring.

   8. SBSteven Bartlett11:55

      Yeah, that's what I've heard before.

   9. SSDr. Sara Szal11:57

      It's what you've heard, but then if you're a woman who's 34 and you're trying to get pregnant and you're having trouble, in that situation, we'll measure every single hormone. We'll look at thyroid cortisol, testosterone, estrogen, progesterone, the control hormones like follicle-stimulating hormone, and yet-Somehow in that situation, testing is more reliable, but it's not in this other situation. That doesn't make sense. That's

7. 12:25 – 14:32

   Why Sara Chose This Career

   1. SSDr. Sara Szal12:25

      double standard.

   2. SBSteven Bartlett12:26

      Why did you choose this career? What, what is it about you, your childhood, your life that sent you down this road?

   3. SSDr. Sara Szal12:33

      I would say it was growing up with a fair amount of trauma. And, you know, the, what I've learned about trauma is it's less about what actually happened to you, it's the way that it became embedded in the system of your 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 realized that by being, um, someone who was really looking out for others, and tuning into their energy, and helping them achieve their goals, that kept me really safe. And so there's a way that that ... It was very resonant for me to discover medicine. And one of the things we know about people who go into medicine is that people tend to have a fair amount of trauma that leads to becoming a helper in this way.

   4. SBSteven Bartlett13:31

      What was that trauma?

   5. SSDr. Sara Szal13:34

      So there's a lot of different ways to measure trauma. One of the ways that I find helpful is something called the Adverse Childhood Experiences. So ACE for short.

   6. SBSteven Bartlett13:44

      I think I've got it here.

   7. SSDr. Sara Szal13:45

      Oh, do you? It's a questionnaire, so my score is six out of 10. So childhood divorce, my parents got divorced when I was about a year old, that's one out of the six. Other things are abuse, neglect, um, emotional abuse, physical abuse, having a parent with a substance use disorder. So things that, you know, it's not a complete list, but it's a validated questionnaire that was used in the 1990s and found among people who are middle-aged. You're not quite yet middle-aged. But for people who are middle-aged, 40 to 65, they found that people who had higher ACE scores, one or higher, they then had a greater risk of 45 different chronic diseases.

8. 14:32 – 16:06

   Importance of Healing from Past Trauma

   1. SBSteven Bartlett14:32

      How important is it for us to understand our early upbringing and our trauma if we are to heal as adults? Because you said there that if you score high on this ACE score, this trauma score, this 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 heal our bodies in some way to avoid getting some of those diseases?

   2. SSDr. Sara Szal14:56

      Yes, and that's the critical question. So if you know that you have an elevated ACE score, and there's a lot of people who have a score of zero, about 40% of men, about 30% of women, and what we know is that if you've got this greater risk for 45 different chronic conditions, there's a way that those ACEs are living on in your body unless you're addressing them. And it's the living on in your body that we wanna pay attention to. So for some people, it's their immune system, and it leads to more allergies, more histamine overload, more, um, food intolerances, maybe autoimmunity, where their immune system is attacking their own tissues, maybe autoimmune disease. There are other people who have more nervous system dysregulation. Maybe they've got an- anxiety or depression or post-traumatic stress disorder, mental health issues. And for other people it could be more endocrine. They've got chronic cortisol problems.

9. 16:06 – 20:05

   How Trauma Manifests into Health Conditions

   1. SSDr. Sara Szal16:06

   2. SBSteven Bartlett16:06

      Which is hormones.

   3. SSDr. Sara Szal16:07

      Yes.

   4. SBSteven Bartlett16:09

      How did that manifest in your physical health?

   5. SSDr. Sara Szal16:12

      So I didn't start to detect this until my 30s, but what I found was that I had depression, I had premenstrual syndrome. I had my first baby when I was 32 and I couldn't lose the baby weight. And as all of this was happening, and I'm a physician, I went to my doctor for help and he suggested that I go on Prozac for the depression and the mood issues.

   6. SBSteven Bartlett16:46

      Which is an antidepressant pill.

   7. SSDr. Sara Szal16:48

      A selective serotonin reuptake inhibitor. That I go on the birth control pill because I sounded hormonal, and that I start exercising more and eating less. So that was his treatment, and that's typical mainstream medicine treatment. But I wasn't satisfied with that. I felt like, "That doesn't seem right." And I left his office and went to the lab, ordered my own hormone panel, and found out my cortisol was three 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 morning, 6 to 10 in the afternoon. And mine was 30. I also looked at my fasting glucose and insulin, and I had pre-diabetes in my 30s. I had no idea. No one was checking for this. So I'm answering your question about how these ACEs showed up in my body. We know that Adverse Childhood Experiences link to blood sugar problems and a greater risk of pre-diabetes and diabetes, which I had. We know that they link to chronic stress and cortisol problems, high perceived stress, whether the stress is there or not. It also led to, as I started using wearables, low heart rate variability, the time between each of my heartbeats. And that's a measure of the sympathetic nervous system, fight, flight, freeze, fawn, versus the parasympathetic nervous system, which is where healing occurs.

   8. SBSteven Bartlett18:21

      And you went on a journey to heal yourself?

   9. SSDr. Sara Szal18:23

      Yes.

   10. SBSteven Bartlett18:24

       Tell me about that journey.

   11. SSDr. Sara Szal18:28

       So in my 30s, this was a huge epiphany for me, because I realized that I wasn't trained, I wasn't educated. Even though I had an outstanding education, I wasn't trained to help with this. No one taught me about cortisol problems and how to manage that. I mean, I was taught about the extremes of Cushing's Disease, whi- which is really high cortisol levels, and Addison's Disease, which JFK had, and it's when your adrenals, in your back above your kidneys, don't make cortisol. So I was taught about the extremes, but I wasn't taught about all the people who kinda live in the middle with problems with their cortisol. So this is when I started to take the scientific literature and apply it to my situation, because I wanted to feel better. I felt old before my time, and I had a lot of belly fat, and I was on this path of aging at an accelerated clip. So 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 understand what can we do to treat the trauma and also to treat the more, uh, proximal measurements that we're making, like with cortisol, with heart rate variability, with blood sugar?

   12. SBSteven Bartlett19:55

       So w- what was step one for you?

   13. SSDr. Sara Szal19:58

       Step one was awareness.

   14. SBSteven Bartlett20:00

       Okay.

   15. SSDr. Sara Szal20:00

       And I had no idea. These are not things that most doctors are checking for.

10. 20:05 – 21:34

    Lack of Nutrition and Lifestyle Education in Medical Courses

    1. SSDr. Sara Szal20:05

    2. SBSteven Bartlett20:05

       It's pretty crazy that you're a doctor but you don't know this part of health. I mean, how are you gonna help anybody if you don't really understand health from a more sort of holistic perspective?

    3. SSDr. Sara Szal20:19

       That's a critical point. So I was taught at Harvard that if you have blood sugar problems, if you've got pre-diabetes and diabetes, the treatment is lifestyle. It's the most effective to change y- the food that you're eating, to increase your exercise, to, um, manage your stress 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 prescribe a medication for it, like Metformin or some other treatment, but I wasn't taught how to do lifestyle medicine. I had 30 minutes on nutrition. So yes, it is pretty crazy.

    4. SBSteven Bartlett20:58

       They gave you 30 minutes on nutrition?

    5. SSDr. Sara Szal21:01

       Yes.

    6. SBSteven Bartlett21:02

       During wh- which training?

    7. SSDr. Sara Szal21:03

       This is medical school, and I got about the same amount on perimenopause and menopause.

    8. SBSteven Bartlett21:10

       Really? I mean, that explains a lot-

    9. SSDr. Sara Szal21:13

       Yes, it does.

    10. SBSteven Bartlett21:13

        ... about the medical system. So step one was awareness. What was step two?

    11. SSDr. Sara Szal21:18

        Step two was what does the science tell us? And if we take what the science tells us, usually applied to a population, that then sets us up for step three, which is N-of-1 experiments.

11. 21:34 – 24:45

    Cortisol and Stress

    1. SSDr. Sara Szal21:34

    2. SBSteven Bartlett21:34

       Trying things on yourself and then measuring?

    3. SSDr. Sara Szal21:37

       That's right.

    4. SBSteven Bartlett21:38

       When we think of cortisol, which was the first sort of marker that you saw was elevated, we think of stress. So we think we get cortisol if we're stressed, so my brain, my, my very naive brain said, "Well, you just need to be less stressed, Sarah. So you should just go on, go on a holiday, and then your cortisol will come down."

    5. SSDr. Sara Szal21:59

       I used to think that too, and then I would come back from the holiday, and I would still have cortisol problems. So stress is part of it, but cortisol is really interesting. These hormones that we're talking about, estrogen, progesterone, testosterone, cortisol, insulin, it's not a democracy. Like, they don't have equal footing. Cortisol is more like a dictator, especially if it's out of whack. So you need cortisol to live, whereas you could live without testosterone, estrogen, progesterone. Can't live without insulin, but cortisol is critical in terms of helping you with your immune system, helping you with your blood sugar, and just managing the stress response. So it's not quite as simple as thinking your way out of a high cortisol or a low cortisol, and there are ways that your body can become stuck in a particular pattern of making too much cortisol or making not enough cortisol.

    6. SBSteven Bartlett23:05

       And if my body's making too much cortisol and my levels are too high, what is the, what is the harm?

    7. SSDr. Sara Szal23:10

       The harm is it's associated with depression. It's, y- about 50% of people with high cortisol, 50% of people with depression have high cortisol. It's used by some psychiatrists as a suicide marker. It's associated with more belly fat, and so the fat receptors, the fat cells in your belly have increased receptors for cortisol, so it's a way of growing your belly fat. We know that it shrinks the brain in women but not men starting in midlife, starting in your 40s. It's not an old age thing. And this has been shown a couple of different ways. There was a study from the University of Texas in San Antonio showing that women in their 40s with high cortisol have a shrinkage of total brain volume, and then Lisa Mosconi at Cornell also just showed in a study looking at men and women that women with high cortisol also have shrinkage of their total brain volume and they start to have a, a difficult time using glucose as fuel in their brain.

    8. SBSteven Bartlett24:23

       Which is gonna result in what kind of behaviors?

    9. SSDr. Sara Szal24:27

       Well, it makes you tired. It gives you slow brain 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 brain slows down, you feel foggy, you're not able to multitask and kind of keep up, keep up with everything.

12. 24:45 – 25:23

    Is There a Link Between Cortisol and Trauma?

    1. SSDr. Sara Szal24:45

    2. SBSteven Bartlett24:45

       Is there a link between cortisol and, uh, trauma?

    3. SSDr. Sara Szal24:48

       Oh, yes.

    4. SBSteven Bartlett24:50

       What is that link?

    5. SSDr. Sara Szal24:52

       So for people who experience toxic stress or trauma, what typically happens is cortisol goes up. That's part of the alarm-

    6. SBSteven Bartlett25:02

       Yeah.

    7. SSDr. Sara Szal25:02

       ... the body's stress response. What we know is that for people who've got more serious exposure to trauma, and they have post-traumatic stress disorder, those people have probably gone through a period of high cortisol and now they can't keep up anymore, and they are in a low-cortisol state.

13. 25:23 – 28:36

    Daily Habits That Disrupt Hormones

    1. SBSteven Bartlett25:23

       What are the things in, in the world at the moment that are messing up our hormones? Because the subject matter of hormones has become increasingly popular, and I know that there's hormones like cortisol, which we've talked about, um, testosterone, estrogen, progesterone, um, insulin, glucose. What are the, what are the big things that are, like, messing up our hormones at the moment? If, if, if I... 'Cause I wanna make sure my hormones are in check.

    2. SSDr. Sara Szal25:47

       (laughs)

    3. SBSteven Bartlett25:48

       Um, so I'm a guy. I- I'm sure that there's, you know, some of these hormones are more, like, things like estrogen have, I think, more pattern to women, but-

    4. SSDr. Sara Szal25:55

       No, it's important for men too.

    5. SBSteven Bartlett25:56

       Oh, really?

    6. SSDr. Sara Szal25:57

       So estrogen and progesterone are incredibly important for men. And it's, you know, it's involved in, uh, bone strength. Progesterone's involved in sleep in men. So the levels are lower in men, and your testosterone's about 10 times higher. But in women and men, they're all important. So what's messing with our hormones? I would say toxin exposure. So there's endocrine disruptors. There's more than 700 known endocrine disruptors. Things like bisphenol A, um, like the plastic lining that you see in cans or in, uh, plastic containers, water containers. There's, um, skincare products which women are exposed to more. Things like moisturizer and makeup and other things that contain, um, endocrine disruptors like parabens. And, um, there's flame retardants that we get exposed to. So there's a whole class of endocrine disruptors, and then it feels right now like we are more dysregulated than I've ever seen, and I'm not sure what the cause is. I don't know if it's the post-pandemic experience or part of what we're experiencing in the United States with the change in leadership. It just feels like there's this hum of dysregulation that I haven't seen over my career.

    7. SBSteven Bartlett27:37

       Mm-hmm.

    8. SSDr. Sara Szal27:37

       Are you noticing that?

    9. SBSteven Bartlett27:38

       Are you seeing that in your patients and...

    10. SSDr. Sara Szal27:40

        I see it in my patients. I see it in their wearable data. I see it in heart rate variability. I see it in the cortisol levels that I'm measuring.

    11. SBSteven Bartlett27:53

        You asked if I'm noticing that. I mean, the, the more digital the world has become, I 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, um, algorithms getting more smart and addictive.

    12. SSDr. Sara Szal28:07

        Yes.

    13. SBSteven Bartlett28:08

        So I- I g- I see that. Also, there's just been a change in... I think the algorithms, the social media algorithms will compete with themselves to s- 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 by showing you things that are probably dysregulating.

    14. SSDr. Sara Szal28:25

        Yes. It's an attention economy, and the cost in that fight for attention is that often the nervous system becomes more dysregulated.

14. 28:36 – 29:57

    What Can People Do to Optimise Their Health?

    1. SSDr. Sara Szal28:37

    2. SBSteven Bartlett28:37

       So if you had to come into my life and 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 from my everyday life, my bathroom, um, et cetera?

    3. SSDr. Sara Szal28:51

       I'd look at your skincare. I'd look at your cleaning products. I'd look at your air quality. I'd probably install a couple of air filters if you don't have that. I'd wanna know about your stress because you're someone who performs at such a high level, and I would assume that you found the right level of stress 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 physiologically.

    4. SBSteven Bartlett29:22

       Yeah. And then...

    5. SSDr. Sara Szal29:25

       And I'd wanna look at your food. I'd wanna know how much protein you're consuming. Are you getting the right amount of carbohydrates? Seems like you are. Are you utilizing those well? What's going on with the continuous glucose monitor? How are your nutrients? What's your vitamin D? Things like that.

    6. SBSteven Bartlett29:43

       You're a big fan of continuous glucose monitors, aren't you?

    7. SSDr. Sara Szal29:46

       I am. I think it gives real-time feedback, immediate feedback on the food that you're eating. I've seen nothing else change behavior like a continuous glucose monitor.

15. 29:57 – 31:18

    Is Sugar the Enemy?

    1. SSDr. Sara Szal29:57

    2. SBSteven Bartlett29:57

       And for anybody that doesn't know, it's the little patch you put on your arm, and it tells you your blood sugar levels in real time straight to your phone. Sugar... Is sugar the enemy?

    3. SSDr. Sara Szal30:10

       I don't think sugar's the enemy. I think the enemy is the way that we eat it to excess, the way that we use it to change our emotional state. And we know people who have adverse childhood experiences, they're more likely to have disordered eating. They're more likely to have problems modulating the amount of sugar they consume.

    4. SBSteven Bartlett30:33

       When you're treating patients, do you focus heavily on their blood sugar levels?

    5. SSDr. Sara Szal30:39

       I do, because I think it's an important indicator of the way the biochemistry of the body, the metabolism is working. It tells me about their mitochondria, it tells me about the way that they're producing energy, ATP by ATP. This compound, this, um, this measure of energy that you produce inside of all of your cells.

    6. SBSteven Bartlett31:02

       Wh- which is called ATP?

    7. SSDr. Sara Szal31:04

       ATP.

    8. SBSteven Bartlett31:05

       And that ATP then drives, well, it drives our, everything we do.

    9. SSDr. Sara Szal31:11

       ATP is fuel, so it allows you to feel like you're fully energized, especially when you wake up in the morning.

16. 31:18 – 32:14

    Supplements for Hormonal Balance

    1. SSDr. Sara Szal31:18

    2. SBSteven Bartlett31:18

       And are there any supplements that I should be taking if I'm trying to optimize my hormonal balance?

    3. SSDr. Sara Szal31:23

       Well, I'd have to look at your total picture, but most of us inherit somewhere around five to seven genomic, um, vulnerabilities, and often we wanna work around those. So for instance, for me, my vitamin D receptor sucks, it just doesn't work very well. So I have to take increased levels of vitamin D to keep the, um, kind of the baseline amount of vitamin D in my system normal. So we would wanna look for those. We'd look at your genomics to see w- what's your relationship to B vitamins? With the stress that you manage, do you have enou- a deficit with B vitamins? For a lot of men, it doesn't show up until around age 40, so this is a good time for you to do a baseline.

17. 32:14 – 36:16

    Common Nutritional Deficiencies

    1. SSDr. Sara Szal32:14

    2. SBSteven Bartlett32:14

       When you look at people's biomarkers and their blood samples, what are the things that you, like, typically always see that are deficient? Because I'm sure there's things from a social level that we're just all kind of getting wrong.

    3. SSDr. Sara Szal32:29

       Vitamin D is common, so somewhere around 70% to 80% of people don't have 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 jobs in the body. One of them is keeping your boundary in your gut intact, so keeping tight junctions working so that you don't have leaky gut. So vitamin D is a common one. I had an executive that I took care of on Tuesday, and he had a fasting glucose of 102, which is in the prediabetes range. No doctor has pointed this out to him before. He had, uh, his cholesterol was starting to climb. His blood pressure was borderline, not high enough to require a medication, but at the point where we wanna turn that ship around before he needs the medication. He had a level of inflammation in his body that was causing aches and pains, and, um, kind of like this silent condition that, um, wasn't working well for him. So, there's a couple ways to measure that. For him, his homocysteine was elevated, it was 14.7. And that's, uh, that's one that's really easy to measure in a basic panel. What we want with homocysteine, which is, um, heart-specific inflammation, we want that to be five to seven. And when it's elevated, that tells us that often part of the biochemistry in the body, your methylation is not working well. Methylation is just where you add a carbon and three hydrogens to a molecule, and it's a way that we turn, uh, genes on and off. And so in this person's case, he wasn't getting enough B vitamins, methylated B vitamins, so we started him on a supplement to help him with that. So that's a common one. His testosterone was good, so didn't have to address that. This guy was about 52. Um, his cortisol was good. He was a chief financial officer of a company back East. Well, he had a number of things on his genomics that we needed to pay attention to. What was interesting about this guy, Steve, is that he was an athlete. He played football in high school and college. He had this identity as an athlete, but when he came to see me at age 52, he was barely exercising. He would lift weights maybe once a week. He would go swimming for about 30 minutes once a week. And so he wasn't 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 of understanding what made him tick was to reaffirm this identity as an athlete, and to use that to address this metabolic crisis that was starting to happen in his body before it was too late.

    4. SBSteven Bartlett35:42

       'Cause he's got too much glucose and he's not doing enough with it?

    5. SSDr. Sara Szal35:45

       That's right.

    6. SBSteven Bartlett35:46

       So his body is having to store it and getting inflamed.

    7. SSDr. Sara Szal35:50

       And he said, you know, "Listen, it's been the Christmas holidays. I had a lot of pound cake. I had some cocktails. You know, maybe that's part of the problem." But we had measured his hemoglobin A1C, which is a three-month summary of what's happening with your glucoses, and the problem predated Christmas. So we needed to get him into action around exercise.

18. 36:16 – 40:25

    How to Regulate Cortisol Levels

    1. SSDr. Sara Szal36:16

    2. SBSteven Bartlett36:16

       Getting back to hormones, I really wanna, um, close off on this subject of cortisol, because I know that that's such a important h- hormone. I've heard you say before that you believe that, uh, cortisol is the most critical hormone to get into balance. You want to focus on cortisol really first and foremost. So someone like me, is there anything else I need to know to get my hormo- my cortisol levels in balance? And also...What percentage of the population do you think have their cortisol out of whack?

    3. SSDr. Sara Szal36:45

       Mm. So we don't have data on the numerator or the denominator, and my patient population is enriched with people who've got cortisol problems. So out of all of the people I test, somewhere around 90% of them have a problem with their cortisol, and that includes professional athletes because at least in the US like basketball players, they travel a ton. They play back-to-back games. They've got a cortisol load, a stress load that is pretty high even for someone in their 20s or 30s who's used to high performance, so the number is high. If I had to look at the general population, it would be a total speculation. I would say somewhere around 30 to 50%.

    4. SBSteven Bartlett37:44

       And what do you do about that if you're an athlete and you've got elevated cortisol levels?

    5. SSDr. Sara Szal37:49

       I think there's a number of different things. There's the top-down approach, which is cognitive, kind of like what is my prefrontal cortex? How can I leverage that to work with this? And then there's more of a bottom-up approach which is using your senses to create safety and to change the cortisol signal, kind of the alarm in the way that it goes off in the body. So breath work is really important for that. Meditation, um, different forms of movement, dancing, you know, rhythmic movements, walking, hiking. Running's a little tricky because, um, that can be a stress response and it can raise cortisol. Um, so I would say for a professional athlete, what I usually recommend is, um, meditation, regular meditation and finding what's a really good fit for them because, you know, for some people mindfulness based stress reduction is a good fit but that doesn't fit for everyone. Other people like resonance breathing, like a five second inhale, seven second exhale, six breaths per minute, doing that for 10 to 20 minutes. That can really help to create balance between the parasympathetic nervous system and the sympathetic nervous system. For some of my athletes, it's a supplement, so if they've got high cortisol, one of the things I often do is to give them Cortisol Manager, which is a supplement that includes ashwagandha and phosphatidylserine, and it's been shown to lower cortisol levels. So if they're traveling and they have to take a plane back to Philadelphia after an away game, Cortisol Manager can help them manage the cortisol.

    6. SBSteven Bartlett39:44

       I found a supplement called, I can't pronounce the name properly, but rhodiola?

    7. SSDr. Sara Szal39:48

       Oh, rhodiola?

    8. SBSteven Bartlett39:50

       Rhodiola.

    9. SSDr. Sara Szal39:50

       Yes. Rhodiola is an adaptogen, so it's, uh, it's an herbal therapy that's been shown to help with cortisol.

    10. SBSteven Bartlett39:59

        Lowest cortisol?

    11. SSDr. Sara Szal40:00

        Yes.

    12. SBSteven Bartlett40:01

        And I was reading that it increases your focus potentially.

    13. SSDr. Sara Szal40:03

        Yes, it does.

    14. SBSteven Bartlett40:04

        Do you s- prescribe that to athletes?

    15. SSDr. Sara Szal40:07

        I do. So generally what I try to do with most of my athletes is have them take a supplement either first thing in the 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 because I think it's got the best data but rhodiola is also a good choice, and I have prescribed that.

19. 40:25 – 41:42

    Is It Easy to Get Someone to Change?

    1. SSDr. Sara Szal40:25

    2. SBSteven Bartlett40:26

       Is it easy for people to change in this regard, to get them to make a set of different decisions? I think we're at a time of year where a lot of people are thinking about changes and a lot of people are failing repetitively every year at the changes they say they wanna make. Is it easy to get someone to change?

    3. SSDr. Sara Szal40:46

       I would say behavior change is the hardest thing that we do as humans. I think there are ways that, uh, adverse childhood experiences tend to set a pattern that's very hard to break. But I see people change their behavior all the time and I think part of it depends on what's the pain of staying the same if it's high enough to motivate you and to help you, you know, not take the shot or two of tequila that has been your downfall in the past. If, um, you have something that keeps you accountable and has like the hawthorne effect like a continuous glucose monitor, I think that can also be very helpful as if someone was watching you, because my patients with their continuous glucose data, I am watching them. I'm scanning them.

20. 41:42 – 43:47

    Can Forcing Change Cause Harm?

    1. SSDr. Sara Szal41:42

    2. SBSteven Bartlett41:42

       Hmm. But does- doesn't that mean that in order to change some people just need a bit more pain?

    3. SSDr. Sara Szal41:50

       I would say people have a different level of pain that motivates change.

    4. SBSteven Bartlett41:54

       Have you ever seen a situation, uh, we were talking about this a couple of, a couple weeks ago where when you're trying to help someone, you actually end up propping them up and because you are intervening to stop them experiencing the pain that they might otherwise, you end up harming them because you're preventing them from going to that place where, you know, they call rock bottom where self-motivated change would occur?

    5. SSDr. Sara Szal42:20

       It's a good question. I think there's, there's a fine line between motivating and also speaking your truth about what you're willing to tolerate, say in your partner or friend or family member and also enabling or, um, being codependent.And so you have to try to 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 if someone has denial about what they're doing and how it's affecting their relationships, their health, their ability to work, say, drinking too much, having a sticky relationship with alcohol, it's not my job to break through their denial. They have to do that. That's their work. Now, I can say, "Alcohol has no health benefits. Here's what it does. Here's what it does 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 cause leaky gut, here's all of the untoward effects of it." But it's not my job to break through their denial. They have to do that. And that's very hard, especially if you have a family member or a, a friend or a partner who is doing things that are harming

21. 43:47 – 45:56

    How to Support Someone Breaking Bad Habits

    1. SSDr. Sara Szal43:47

       themselves.

    2. SBSteven Bartlett43:48

       So what do you consider your job to be if you are a friend or a family member?

    3. SSDr. Sara Szal43:53

       Your job is to determine what your boundaries are, what you're willing to tolerate to stay in relationship. And that's, you know, that's where interventions play a role, where you confront the person and say, "I'm really worried about you. Here's what I'm witnessing. I really feel like you need to approach this in a different way. Are you willing?" But it's a consenting process. You don't do it for them.

    4. SBSteven Bartlett44:26

       Hmm.

    5. SSDr. Sara Szal44:27

       What's your experience?

    6. SBSteven Bartlett44:29

       Well, I just, I just have so many, you know, 'cause these days, I can help people much more than I could 10 years ago, whether it's financially or in, in other ways. And so it's often tempting when someone in my life is struggling in some way to just intervene with some kind of crutch.

    7. SSDr. Sara Szal44:45

       Yes.

    8. SBSteven Bartlett44:45

       And I've actually seen over the last, like, 15 years that the best things that I've ever done for some of my friends wasn't an intervention, it wasn't paying for something for them or taking care of something for them, it was being honest with them and then being there as they figured it out themselves. And often, it was actually removing my crutch.

    9. SSDr. Sara Szal45:06

       Mm-hmm.

    10. SBSteven Bartlett45:06

        Which meant that they would fall a little bit.

    11. SSDr. Sara Szal45:09

        Yes.

    12. SBSteven Bartlett45:09

        And then climb 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 through m- 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 own natural growth journey.

    13. SSDr. Sara Szal45:27

        I agree with that, and I would, I would also say that what you just described is holding a mirror to someone in a way that is very loving but also clear. It's a clean mirror, and it's very different than just loaning them the money.

    14. SBSteven Bartlett45:49

        Yeah.

    15. SSDr. Sara Szal45:50

        And then being there for them as they stumble and struggle and try to make things different.

22. 45:56 – 47:20

    When Should Men Start Monitoring Testosterone?

    1. SSDr. Sara Szal45:56

    2. SBSteven Bartlett45:56

       You, you talked earlier about the executive that you checked, uh, recently. You said his testosterone levels were intact.

    3. SSDr. Sara Szal46:03

       Yes.

    4. SBSteven Bartlett46:05

       At what age should I be s- thinking about my testosterone levels, or should I be thinking about them all the time? 'Cause I kind of see it as something that I need to worry about when I'm, when I get a little bit older into my 40s and 50s.

    5. SSDr. Sara Szal46:16

       It tends not to decline until about age 40, but I would say do a baseline now.

    6. SBSteven Bartlett46:22

       Okay.

    7. SSDr. Sara Szal46:22

       So a baseline biomarker assessment would be worthwhile. And, you know, one of the things we found during the pandemic was that, um, the National Basketball Association was playing in a bubble. They were playing in Florida. And the players cut off from their families and kind of stuck in Florida for a period of time. They had low testosterone levels, and these guys normally have pretty high testosterone levels. So, there can be specific situations that can affect your testosterone level.

    8. SBSteven Bartlett46:58

       What was it that was affecting those?

    9. SSDr. Sara Szal46:59

       Part of it was just being in a hotel, in a bubble, unable to leave, cut off from their community, their family, their friends, their usual ways of blowing off steam. I imagine their, they didn't measure their cortisol, but I imagine it was probably higher than normal.

    10. SBSteven Bartlett47:19

        And

23. 47:20 – 47:53

    Testosterone in Women

    1. SBSteven Bartlett47:20

       women have testosterone too, but you said, I think, earlier that men just have 10 times more testosterone.

    2. SSDr. Sara Szal47:25

       Men have more, but it's the most abundant hormone in the female body. Women are exquisitely sensitive to it.

    3. SBSteven Bartlett47:33

       It's the most abundant hormone?

    4. SSDr. Sara Szal47:34

       Yes. Higher concentration than estrogen or progesterone.

    5. SBSteven Bartlett47:39

       About 15 to 17 nanograms in a woman? That's what I read on WebMD.

    6. SSDr. Sara Szal47:44

       Yes, that's, that's a pretty good level.

    7. SBSteven Bartlett47:46

       And in men, 300, uh, 1,000 nanograms?

    8. SSDr. Sara Szal47:50

       Yes. I like to see it somewhere around 500 to

24. 47:53 – 48:23

    Signs of Low Testosterone in Men

    1. SSDr. Sara Szal47:53

       1,000.

    2. SBSteven Bartlett47:54

       And what would be a sign that I had low testosterone if I'm a man?

    3. SSDr. Sara Szal48:01

       Belly fat.

    4. SBSteven Bartlett48:02

       Mm-hmm.

    5. SSDr. Sara Szal48:03

       Gynecomastia.

    6. SBSteven Bartlett48:04

       What's that?

    7. SSDr. Sara Szal48:05

       That's when you have breast development.

    8. SBSteven Bartlett48:07

       Okay.

    9. SSDr. Sara Szal48:08

       Uh, mood changes, mood swings, uh, irritability, uh, depression, cardiovascular changes, erectile dysfunction, decreased libido.

25. 48:23 – 49:14

    Symptoms of Low Testosterone in Women

    1. SSDr. Sara Szal48:23

    2. SBSteven Bartlett48:23

       What about in a woman? So if a woman has low testosterone, what are the symptoms we see in a woman?

    3. SSDr. Sara Szal48:29

       They're similar. So, um, both sexes have fatigue. That's very common. Decreased libido. They might be working out at the gym and not seeing a response. They might have some hair loss. And testosterone in women has a few unique features. Like one of the things we've seen looking at...... MBA students, students who are getting a Master's in Business Administration, is that the women with higher testosterone tend to be more comfortable with financial risk. I believe it also tracks with confidence and agency. We have less hard data on that, but those are some of the things that I see. It's a hormone of vitality in both men and women.

    4. SBSteven Bartlett49:12

       So if a woman is low testosterone, she might be

26. 49:14 – 50:16

    Symptoms of High Testosterone in Women

    1. SBSteven Bartlett49:14

       less confident, have less motivation, less agency?

    2. SSDr. Sara Szal49:18

       Less willing to take risks, less sex drive.

    3. SBSteven Bartlett49:21

       Interesting. What if she has high test- testosterone levels? Too high.

    4. SSDr. Sara Szal49:25

       So high testosterone tends to track with polycystic ovary syndrome. It's the most common hormone imbalance that women have. It leads to infertility, um, it leads to increased hair growth in places that you don't want it. So that can include like your chin, in between your breasts. It can lead to, um, insulin resistance in some but not all, but somewhere around 70% of people with PCOS have insulin resistance. So it leads to symptoms of excess androgen, acne, hirsutism. It also is associated with problems with the mitochondria. It's also linked to dysregulated stress response. That's something we see with people with PCOS.

27. 50:16 – 52:30

    How to Regulate Testosterone Levels

    1. SSDr. Sara Szal50:16

    2. SBSteven Bartlett50:16

       So if I'm a man or a woman and I wanna get my testosterone levels in order, and I don't wanna inject myself with testosterone, are there natural ways, easy ways for me to get my testosterone balanced?

    3. SSDr. Sara Szal50:29

       It depends on how off it is. First place to start is your cortisol, because cortisol has this, um, interdependent relationship with other hormones. So if you're someone who's making a lot of cortisol, you're gonna make less testosterone. So someone who's got a high level of stress, like I was talking about, the MBA players in the bubble, maybe their stress was high and their cortisol was high and that was why their testosterone was lower.

    4. SBSteven Bartlett51:01

       So then if I'm a woman with polycystic ovary syndrome and my testosterone is high, doesn't that mean I want to increase my cortisol?

    5. SSDr. Sara Szal51:10

       No. In that situation, what we know is that food is probably the most important factor with someone with PCOS. And inside of seven days, by eating a lower carbohydrate diet, you can change your testosterone level. So you can lower it significantly.

    6. SBSteven Bartlett51:28

       Within seven days?

    7. SSDr. Sara Szal51:29

       Within seven days.

    8. SBSteven Bartlett51:31

       So if-

    9. SSDr. Sara Szal51:31

       Exercise.

    10. SBSteven Bartlett51:32

        I'm e- currently eating like a ketogenic diet, so my carbohydrate level's extremely low.

    11. SSDr. Sara Szal51:37

        Mm-hmm.

    12. SBSteven Bartlett51:37

        Does that mean my testosterone levels are gonna be low?

    13. SSDr. Sara Szal51:41

        Not necessarily, because you're not someone with PCOS. So it's not quite translatable across sex and gender. But for you, with a ketogenic diet, what we typically see is that insulin levels are lower, so it does seem to help with metabolic health. It can cause some thyroid dysfunction, so it's worth tracking thyroid. We know that people on a ketogenic diet sometimes have increased inflammation. There's some people who are super responders and they just do super well with a ketogenic diet, but some people have about a 10% change in their LDL, their so-called, um, bad lipoprotein. So if you stay on it for more than four weeks, I generally recommend that you look at some biomarkers.

28. 52:30 – 59:09

    Why Estrogen Matters for Both Genders

    1. SSDr. Sara Szal52:30

    2. SBSteven Bartlett52:30

       Let's talk about estrogen then. 'Cause I, I was under the impression that, um, only women had estrogen, but you're telling me that it's an important hormone for men as well.

    3. SSDr. Sara Szal52:38

       It is.

    4. SBSteven Bartlett52:39

       Why is it so important for, for both sexes? What does it do?

    5. SSDr. Sara Szal52:44

       Well, I would say it's more important for women because it regulates the entire female body. So we have estrogen receptors throughout our body, um, when women... There's two different life stages where estrogen is low. The first is postpartum. So if you give birth to a baby, you go from sky high estrogen levels down to almost nothing when you deliver your baby and you deliver your placenta. And so for a lot of women when they're postpartum, maybe they've got mood issues, um, they've got fatigue that is more than just the sleep deprivation, this can be a preview of coming attractions in perimenopause and menopause. So it's a window of opportunity that can tell you about the way estrogen works in your body. So for the female body, estrogen has hundreds of jobs. It keeps your joints lubricated. We know that frozen shoulder is a really common, uh, diagnosis in women who are in perimenopause and menopause because the estrogen receptors just aren't getting the estrogen. They're not having molecular sex between the estrogen and the estrogen receptor. So estrogen is really critical in women. It regulates mood, um, breast development, development of hips. It's a lubricant for your joints, um, it's also really critical for your skin. When estrogen goes down, you make less collagen, and that's why women notice that their skin ages. And in men it's a little bit different. The dynamic range is more narrow, and what we generally want with men is for you to have enough estrogen to serve some of these bodily functions, like with keeping your bones strong, um, but not too much.

    6. SBSteven Bartlett54:44

       Does it have a role in weight distribution in my body? So where the-

    7. SSDr. Sara Szal54:50

       Yeah.

    8. SBSteven Bartlett54:50

       ... fat stores and stuff.

    9. SSDr. Sara Szal54:52

       So in men, I don't know. I don't know the answer to that. I, I'll have to look it up and get back to you.But in women, yes, absolutely. So one of the things that happens for women over the age of 40 is that they typically become insulin-resistant. Their cells become numb to insulin. And what we know is that they gain about five pounds of fat, and they lose about five pounds of muscle every decade after age 40. So there's this redistribution of fat, to your point, where they, they deposit less at their breasts and their hips and their buttocks, and more at their abdomen. Does that happen in men? I think there's some version of it in men, but I just would have to confirm that.

    10. SBSteven Bartlett55:42

        And is that inevitable?

    11. SSDr. Sara Szal55:45

        No. No. No, you have a choice. So for women, I think what's important is to understand what, what are your estrogen levels that are associated with your best function? And that's why I think baseline testing can be so helpful, to know where your thyroid is right now, your cortisol, your testosterone. Um, to know where you are with your metabolic health, so that when you're in your 40s, you can look back and say, "Okay, I was in a state of optimization. I wanna go back to something similar to that." So for women, what I would say is, right now, 73 to 75% of women do not get the treatment for perimenopause and menopause that they deserve. They're not being offered, for instance, hormone therapy, and that has to change. But hormone therapy can help to reverse this so that you are more likely to, um, not have some of these body composition changes as you get older. And it's not just hormone therapy. I would say it's beyond hormone therapy. It's estrogen, progesterone, testosterone, but it's also heavy weightlifting. It's cardiovascular fitness. It's disposing of the glucose properly, eating the right foods. So...

    12. SBSteven Bartlett57:10

        Dis- disposing of the glucose pro- properly?

    13. SSDr. Sara Szal57:12

        Yes.

    14. SBSteven Bartlett57:12

        What do you mean by that?

    15. SSDr. Sara Szal57:13

        So if you're, you know, like, when I was in my 30s, my fasting glucose was very high. It was in the pre-diabetes range. And so I needed to change the way that I was burning through glucose, like using it with exercise. So disposing, it's like an input-output equation, where you're inputting with your food, and you're outputting with your exercise. And you wanna get a good match between the two.

    16. SBSteven Bartlett57:45

        And must resistance training, strength training is the optimal way to dispose of glucose, right?

    17. SSDr. Sara Szal57:51

        I think it's a critical way. I mean, what we know is strength training as it builds muscle, and so the more muscle mass that you have, generally, the better your metabolism.

    18. SBSteven Bartlett58:02

        This one change has transformed how my team and I move, train, and think about our bodies. When Dr. Daniel Lieberman came on the Diary of a CEO, he explained how modern shoes, with their cushioning and support, are making our feet weaker and less capable of doing what nature intended them to do. We've lost the natural strength and mobility in our feet, and this is leading to issues like back pain and knee pain. I'd already purchased a pair of Vivobarefoot shoes, so I showed them to Daniel Lieberman, and he told me that they were exactly the type of shoe that would help me restore natural foot movement and rebuild my strength. But I think it was plantar fasciitis that I had, where suddenly my feet started hurting all the time. And after that, I decided to start strengthening my own foot by using the Vivobarefoots. And research from Liverpool University has backed this up. They've shown that wearing Vivobarefoot shoes for six months can increase foot strength by up to 60%. Visit vivobarefoot.com/doac and use code DOAC20 for 20% off. That's vivobarefoot.com/doac, use code DOAC20. A strong body starts with strong feet. What role

29. 59:09 – 59:59

    Importance of Fibre in the Diet

    1. SBSteven Bartlett59:09

       is fiber playing in all of this? 'Cause a lot of people are talking about fiber at the moment and saying that we're fiber deficient.

    2. SSDr. Sara Szal59:15

       Oh, we are, for sure. I mean, the average American gets somewhere around 14 grams of fiber a day, and we're meant to have about 30 to 35, 40 grams a day. Our Paleolithic ancestors got even more than that, 50 to 100 grams a day. So we are not getting enough fiber. It's critical for blood sugar stabilization, so is protein intake. But getting fiber from real food, you know, eating sufficient vegetables. We know from the microbiome studies that you want about 25 to 35 different species of fruits and vegetables in a week to be able to feed your microbiome.

    3. SBSteven Bartlett59:58

       And what

30. 59:59 – 1:01:20

    Role of the Microbiome in Hormone Regulation

    1. SBSteven Bartlett59:59

       role is the microbiome playing in my hormone function?

    2. SSDr. Sara Szal1:00:03

       It's playing a huge role. So your microbiome is one of the control functions for estrogen levels and maybe testosterone levels. So there's a bi-directional relationship, Steve, where there are three bacteria in the gut that can, um, take estrogen and make it keep recirculating. So you're meant to produce estrogen and then use it and then either poop or pee it out. But what happens with some people, if they've got these bacteria, is they keep recirculating the estrogen like bad karma. And so those people tend to have higher estrogen levels. It tends to be associated in men with this greater risk of, um, metabolic dysfunction, prostate cancer, and in women, it's associated with more breast cancer and endometrial cancer.

    3. SBSteven Bartlett1:01:04

       And that- a lot of that stuff, and it's caused by the gut microbiome.

    4. SSDr. Sara Szal1:01:07

       Yes. And the microbiome, their favorite food is fiber. So the way that you keep your microbiome, your microbes happy and healthy is to feed them a fair amount of fiber.

31. 1:01:20 – 1:01:33

    Fibre-Rich Foods

    1. SSDr. Sara Szal1:01:20

    2. SBSteven Bartlett1:01:20

       What- what kind of foods have high fiber? Is it, like, broccoli and stuff?

    3. SSDr. Sara Szal1:01:24

       Yes. So broccoli, Brussels sprouts, cauliflower, cabbage, kohlrabi.

32. 1:01:33 – 1:03:22

    Sara’s Preferred Diet

    1. SSDr. Sara Szal1:01:33

    2. SBSteven Bartlett1:01:33

       What do you eat?

    3. SSDr. Sara Szal1:01:34

       (laughs)

    4. SBSteven Bartlett1:01:35

       And like, how do you live?

    5. SSDr. Sara Szal1:01:37

       So I'm a sensualist.

    6. SBSteven Bartlett1:01:39

       What does that mean?

    7. SSDr. Sara Szal1:01:39

       So I love food. I love the taste of food, I love the smell of food, I love the look of food. I had a history of disordered eating.

    8. SBSteven Bartlett1:01:47

       Mm-hmm.

    9. SSDr. Sara Szal1:01:47

       I had anorexia as a teenager and bulimia through my 20s and 30s, but now I have a more neutral relationship with food. I have worn a continuous glucose monitor almost continuously for the past seven years, and so I know a lot about the foods that serve me the best. So usually for breakfast, I love eggs, and so I eat fresh eggs, usually scrambled or, um, lightly boiled. I like to have that with greens or some other leftover vegetable from the night before. I eat a lot of vegetables. I aim for somewhere around a half pound to a pound a day, so that's divided between, um, salads, the vegetables I have at dinner, um, a smoothie. I put vegetables in smoothies along with a protein powder. I eat a lot of cruciferous vegetables. I have sluggish detox pathways. I know that genomically and I know it from my biomarker testing.

    10. SBSteven Bartlett1:02:52

        What does that mean?

    11. SSDr. Sara Szal1:02:53

        It means that... Maybe it's related to my sensitivity. I've got my... I don't make sufficient glutathione, which is, um, one of the ways that you detoxify. It's an antioxidant in your body. And so I like to- to close that gap by making sure that I'm getting sufficient cruciferous vegetables. I eat a lot of broccoli sprouts.

33. 1:03:22 – 1:05:30

    The Ketogenic Diet

    1. SSDr. Sara Szal1:03:22

    2. SBSteven Bartlett1:03:22

       What do you think of the keto diet?

    3. SSDr. Sara Szal1:03:24

       I'm a fan of the ketogenic diet.

    4. SBSteven Bartlett1:03:26

       Because in your book, there's this chapter called The Keto Paradox.

    5. SSDr. Sara Szal1:03:29

       Yes.

    6. SBSteven Bartlett1:03:31

       What are your thoughts on keto?

    7. SSDr. Sara Szal1:03:33

       Well, what I find with keto is that men t- tend to do better on it than women. And what I found with women is that, maybe related to hormones and their sensitivity, they have more thyroid dysfunction, they have more menstrual irregularity, somewhere around 45% of women that are on a classic ketogenic diet. So women tend to have more issues with the ketogenic diet. It takes them longer to get into ketosis than it does a man. Even if you... If the average man, if they fast for somewhere around 14 to 16 hours, they start to produce ketones, and for women, it takes longer. It takes more like 18 to 20 hours. So probably that's related to fertility and evolutionarily there's some pressure for us to not go into a ketogenic state, but it makes it harder for women to get into ketosis and stay in ketosis.

    8. SBSteven Bartlett1:04:29

       Is there a danger to women doing ketosis? Because you said me- um, their periods are gonna become irregular.

    9. SSDr. Sara Szal1:04:34

       Not necessarily. I think depending on how you do it. You know, a lot of the data 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 have is in people with seizure disorders. So they're different. It's a different population, and they're also on a form of the ketogenic diet that is very strict. You know, no more than 10 to 20 grams of carbohydrates a day. So I think you can play with your carbohydrates and find out what your carb threshold is so that you can remain in ketosis, get the benefits of all the phytonutrients that you can get from vegetables, and play both sides so that you get the health benefits, you get the metabolic function improvement, you get the, uh, lowering of insulin without some of the side effects.

34. 1:05:30 – 1:06:05

    Side Effects of the Keto Diet

    1. SSDr. Sara Szal1:05:30

    2. SBSteven Bartlett1:05:30

       What are the side effects?

    3. SSDr. Sara Szal1:05:32

       The main ones that I see are the thyroid dysfunction.

    4. SBSteven Bartlett1:05:34

       Yeah.

    5. SSDr. Sara Szal1:05:36

       Uh, sometimes there's a- a rise in cortisol in people who are really limiting their carbohydrates. And then it can also affect serotonin so that people don't sleep as well on a ketogenic diet. Now some people love that. They go on a ketogenic diet and they're like, "Woo, I only need to sleep six or seven hours a night." But over time, if you need more and it's the serotonin that is at the root of why you're not sleeping as well, that can cause a problem.

35. 1:06:05 – 1:07:29

    Can You Stay on Keto Long-Term?

    1. SSDr. Sara Szal1:06:05

    2. SBSteven Bartlett1:06:05

       Is there anything else that the keto- ketogenic diet might be doing to my hormones, like my test- testosterone or my other hormones, that is worth noting? Because I'm super, you 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 weeks a year, but I'm- I'm wondering if this is something that I could do for like a year or maybe longer.

    3. SSDr. Sara Szal1:06:25

       So I think if you stay on it for more than a few weeks, you wanna check your biomarkers and you just wanna make sure that it agrees with the intelligence of your body. So do some molecular profiling and see if it's a good fit.

    4. SBSteven Bartlett1:06:38

       Have you seen people that stay on it for years and have good biomarkers?

    5. SSDr. Sara Szal1:06:41

       Yes. Yes.

    6. SBSteven Bartlett1:06:42

       Okay.

    7. SSDr. Sara Szal1:06:43

       And I think what's important to understand is that exercise performance some k- sometimes can be adversely affected by the ketogenic diet, and that might be an interesting experiment for you to do, like with your running and your 5K time. What a lot of athletes do is...If they wanna experiment with a ketogenic diet, so they're a cyclist and they're trying to get their weight down so that their, um, power is up, what, what they tend to do before a race is they add carbs back two weeks before the race so that they're, they're filling their glycogen stores. And so that, that's another piece that you may wanna be tracking, is your exercise performance.

36. 1:07:29 – 1:08:33

    Strategies for Effective Weight Loss

    1. SSDr. Sara Szal1:07:29

    2. SBSteven Bartlett1:07:29

       If I'm trying to lose weight, is there an optimal approach to take? Because the ketogenic diet's been the fastest way I've, I've d- ever discovered of losing weight quickly. But if you're a man or 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, what, what do you say to them?

    3. SSDr. Sara Szal1:07:49

       What I like about the ketogenic diet for weight loss... And I'm really careful about weight loss because-

    4. SBSteven Bartlett1:07:55

       It's problematic.

    5. SSDr. Sara Szal1:07:56

       ... um, it's problematic. And I think body shaming is a big problem, and so I'm really careful about this. But when it comes to a ketogenic diet, what I like about it is that ketones are really satisfying. So they increase your satiety, and I think it's much more effective than trying to limit your calories and be in a calorie deficit. So with a ketogenic diet, usually you do a calorie deficit, but you're producing ketones, which are making you feel more satisfied. So you're not standing in front of the refrigerator wondering when the next time is that you

37. 1:08:33 – 1:11:26

    Fasting

    1. SSDr. Sara Szal1:08:33

       can eat.

    2. SBSteven Bartlett1:08:33

       Mm-hmm. And what about fasting? You know, there's been a lot of talk about autophagy and doing these kinda long fasts to heal the body. What's your perspective on that?

    3. SSDr. Sara Szal1:08:44

       I think there's a time and a place for fasting. I think these ways of activating some of the benevolent, um, pathways in the body can be very good for you. So it can be good for mitochondria. It can be good for, uh, your hormone balance. It can help you with insulin, as an example. So you asked about someone who was wanting to lose weight and also wanting to address belly fat. I would say that's a situation where you really wanna pay attention to insulin. So fasting can get you that. So can a ketogenic diet. Often we combine the two, because you can induce ketosis faster by doing intermittent fasting together with a ketogenic diet.

    4. SBSteven Bartlett1:09:29

       Is the ketogenic diet like a form of fasting?

    5. SSDr. Sara Szal1:09:33

       You could think of it that way. I mean, I would, I would say it allows you to fast, and it makes the behavior change easier. Um, you know, the thing about fasting is there are some people who are really good at it, and it doesn't raise their cortisol, it doesn't induce a stress response, and then there are other people who get very stressed with a ketogenic diet or with fasting. And so part of it is, is trying to get a sense of your own response to the food that you're eating to see, "Okay, what suits me the best? How do I feel the best? Where is my cognitive function at an optimal level? What helps me with brain fog? What helps me with allergies?" Or what other, whatever symptoms you're tracking. You know, one of the things we know with ketones, which are produced... You know, your body, as you well know, is this... It's like a hybrid car that can flip between burning gas, which is like glucose in this analogy, or electric, which in this analogy is ketones. The thing about ketones is they're, they're not, they're not just a satiety molecule that makes you feel satisfied. They also have anti-inflammatory aspects inside of the body. So they're an important signaling pathway. There's a reason why your body produces ketones. Now, do you wanna do that for a year? We'd have to see. We'd have to look at your biomarkers. You know, the, the normal way that your genome developed was to flip in and out of ketosis based on the food supply. And now that food is abundant, most people are not going into ketosis. Being able... But being able to switch back and forth can be very healthy for

38. 1:11:26 – 1:15:34

    What Is Perimenopause and When Does It Begin?

    1. SSDr. Sara Szal1:11:26

       you.

    2. SBSteven Bartlett1:11:27

       When people come to you and they're asking questions about hormones these days, you must have seen in your career a shift in interest, um, on the subject of hormones, but, but also a certain, a certain area of hormonal health that people have a greater obsession with. Of all the sub- the subjects we've talked about today relating to hormones, what is it that people are most interested in right now?

    3. SSDr. Sara Szal1:11:52

       I would say for women, it's perimenopause.

    4. SBSteven Bartlett1:11:58

       And for anyone that doesn't know what perimenopause is, when does that begin, and what is it?

    5. SSDr. Sara Szal1:12:03

       Typically begins between 35 and 45 for women, and it's the age at which your ovaries start to run out of ripe eggs and the mitochondria in your eggs are not working the way that they once did. And so your ovaries are aging, and that leads to changes in your hormone levels. So a lot of people think of perimenopause as mostly being a hormonal situation, a change in estrogen, progesterone, maybe testosterone. And what I think is important to realize is it's much broader than that. It's your metabolic system. It's the way that your brain is responding to glucose. It's your immune system. It's a time when more women have the experience of autoimmunity and autoimmune disease. So perimenopause is this incredibly dynamic time. There's more than 100-plus symptoms that women experience, and it makes me crazy. I was just talking to my agent and my publisher a couple weeks ago. They're both women in their early 40s, and they were having symptoms, you know, some of those 100 symptoms that-... are, uh, characteristic of perimenopause. They went to their doctor and said, "I've got these mood swings. I'm having trouble sleeping, having some night sweats. Is this perimenopause?" And the doctor said, "No. You're too young." So, there's a knowledge gap. There's a research gap and a knowledge gap and a huge treatment gap for women who are in perimenopause. Most women are not getting the treatment that they need. So, what are they asking about? They're asking about, "Why do I feel so dysregulated? Why is it that I can't manage stress the way I once did? Why would I rather mop the floor than have sex with my husband? Why is sex painful all of a sudden? Why do I have this belly fat that appeared out of nowhere, and my usual techniques for how to deal with that aren't working?" Those are some of the questions that they ask, which map to your hormones.

    6. SBSteven Bartlett1:14:09

       And what is the youngest you've ever seen someone enter perimenopause?

    7. SSDr. Sara Szal1:14:13

       Well, I see women who have premature ovarian insufficiency, which is when you go through menopause before age 40. So, I've seen a fair amount of that, you know, probably 50 patients over the course of my career. It's relatively rare. And then I see women who have early menopause, which is when they stop having their periods or they have an FSH level of 25 to 30.

    8. SBSteven Bartlett1:14:41

       And FSH? What's FSH?

    9. SSDr. Sara Szal1:14:42

       Follicle stimulating hormone. It's one of the control hormones for your estrogen and progesterone in the body. So, if that occurs, they have their final menstrual period between 40 and 45, that's considered early menopause. So, there's this really dynamic time where your hormones are wildly fluctuating, especially estrogen. Progesterone is declining, and women have this increase in the symptoms that they experience, and no one is really tracking it carefully. That's what needs to change.

    10. SBSteven Bartlett1:15:18

        Tracking it through their blood samples?

    11. SSDr. Sara Szal1:15:20

        Blood samples-

    12. SBSteven Bartlett1:15:21

        Hormones.

    13. SSDr. Sara Szal1:15:21

        ... and connecting their symptoms to what is happening in their ovaries, in their immune system, in their metabolic system, and putting that together for them and offering them options.

39. 1:15:34 – 1:16:09

    Can Menopause Symptoms Be Avoided?

    1. SSDr. Sara Szal1:15:34

    2. SBSteven Bartlett1:15:34

       You believe that many of the symptoms of menopause are avoidable?

    3. SSDr. Sara Szal1:15:40

       Yes. Yes, and by that I mean using hormone therapy and using lifestyle medicine as early as possible to manage that transition.

    4. SBSteven Bartlett1:15:50

       Because when a woman goes to a doctor now, that doctor might say, "Well, you're- you're getting older. This is what happens," or they might just-

    5. SSDr. Sara Szal1:15:57

       That's right.

    6. SBSteven Bartlett1:15:57

       ... completely miss it.

    7. SSDr. Sara Szal1:15:58

       That's right. Or they might get started on a birth control pill. That's used a lot for women who are in perimenopause, and I don't think that's the right solution.

40. 1:16:09 – 1:16:59

    Birth Control

    1. SSDr. Sara Szal1:16:09

    2. SBSteven Bartlett1:16:09

       What do you think of birth control pills?

    3. SSDr. Sara Szal1:16:12

       I think if they help you avoid surgery, they can be beneficial. But I think they're way overused in our culture. And most people who agree to a birth control pill don't receive full informed consent. They're not told that it'll raise the inflammation in your body by two to threefold. It increases your risk of autoimmune disease, especially Crohn's Disease. It makes your control system for your hormones less flexible. It can rob you of testosterone. It can lower your free testosterone. It can shrink your clitoris by up to 20%. I feel like if that was part of the informed consent, very few people would sign up for it.

41. 1:16:59 – 1:17:50

    Who Is Birth Control For?

    1. SSDr. Sara Szal1:16:59

    2. SBSteven Bartlett1:16:59

       (laughs) But who is the birth control pill for, then?

    3. SSDr. Sara Szal1:17:04

       You know, I used to think that it was a feminist invention, that it was a way of putting your fertility in your hands. And I went on the birth control pill when I was 16, but I feel like there are some costs to it that, um, a lot of teenagers and women in their 20s and 30s aren't aware of. And for me, I feel like that awareness is really critical. So, who's it for? I would say it's a simple entree into contraception, but I would much rather people use things like an IUD or condoms or some other barrier method that doesn't mess with their hormonal intelligence.

42. 1:17:50 – 1:18:28

    How Is Sara Doing Today?

    1. SSDr. Sara Szal1:17:50

    2. SBSteven Bartlett1:17:50

       How are you doing?

    3. SSDr. Sara Szal1:17:52

       Oh, quite good. Quite good. I love that question. I went through a divorce two years ago, and I feel like... You know, I- my- I have two daughters. They both went off to college and were out of the house, and I realized that my time with my now ex-husband had run its course, and we came together to create this beautiful family, but we were no longer a good fit for each other. So, a big part of my spiritual

43. 1:18:28 – 1:18:57

    Sara’s Spiritual State

    1. SSDr. Sara Szal1:18:28

       work has been coming to terms with that, and, um, and really getting clear about, okay, for the second half of my life, what is it that I want? What is my mission? How do I support that? How do I only give a whole body yes to, um, the things that I say yes to? How do I-

44. 1:18:57 – 1:20:01

    Whole Body Yes

    1. SSDr. Sara Szal1:18:57

    2. SBSteven Bartlett1:18:57

       Whole body yes. What does that mean?

    3. SSDr. Sara Szal1:18:58

       Whole body yes. So this is something I learned from one of my mentors, Diana Chapman. Um, she learned it from, I believe, Katie Hendricks, who's a therapist. The idea is that instead of saying yes to things that you're offered...Purely from a cognitive place, that sounds like a good idea, sounds like a good oppor- opportunity, let me do it. Instead, you check up, check in with your whole body. You check in with your heart, you check in with your, your gut. "Does this really make a difference in the world? Is this something that's gonna make me jump out of bed in the morning? Is this something that is worth the time and the effort?" I'm a little older than you, and so I hold these opportunities a little bit differently than I did in the past.

    4. SBSteven Bartlett1:19:51

       How long were you married for? How long were you in a relationship with your partner?

    5. SSDr. Sara Szal1:19:55

       We were together for about 22 years, and married for 20.

    6. SBSteven Bartlett1:20:00

       How does

45. 1:20:01 – 1:24:15

    How to Know If a Marriage No Longer Works

    1. SBSteven Bartlett1:20:01

       one know that it's not right anymore after 20-odd years?

    2. SSDr. Sara Szal1:20:07

       Well, I would love to riff on this with you.

    3. SBSteven Bartlett1:20:09

       Okay.

    4. SSDr. Sara Szal1:20:10

       So, I can tell you that part of the challenge in my marriage was that, um, we had difficulty talking about difficult topics. So, highly charged topics were tough for us to be able to navigate. When we had a conflict or a fight, we didn't repair very well. There was a partial repair, where you would feel good enough to keep functioning and take care of the kids and do your householder stuff, but you didn't really feel seen or like you cleaned up the pain that was there. There was a way that I didn't feel fully understood or seen, and not that I require that from my partner, but I- I felt like there was a misattunement, and I'm in a relationship now where I have those things that I'm talking about, and it's someone that I have known for 30-plus years. We were interns together at UCSF, and I realize now that, you know, I came together with my ex-husband, and I really am so blessed by the life that we had and, um, the family that we had, but we also had a trauma bond. There was a way that his trauma kind of intersected with my trauma, and we hung in there for a very long time, probably longer than we should have. So, how do you know? I don't know, Steven. I just can tell you that there was a way that our interactions was creating dysregulation in my body. And I'm not blaming him. I, you know, it's a two, there's two sides to the street. But there was a way that we just, we didn't quite gel together.

    5. SBSteven Bartlett1:22:22

       And is that not something that can be repaired through communication and therapy or sitting down and ...

    6. SSDr. Sara Szal1:22:27

       I mean, you would hope so, but we spent about 10 years out of the 20 years of marriage in couples therapy, and it didn't really resolve some of these conflicts. We got better at "I" statements. We got better at saying what we were feeling and not blaming. We got better at, um, going for a walk when we were talking about something difficult. But there was still a way that I felt alone and lonely inside of the relationship. And I decided, I think a fair number of women decide this, I decided I was better off alone than to continue in the marriage.

    7. SBSteven Bartlett1:23:17

       When people hear that, that weren't in your situation, they might think, "Okay, so maybe he was preoccupied with something else, or he was, he worked away." When you say the word lonely, these are the kind of things we think. We think of proximity. But you're saying it, I'm guessing it wasn't proximity.

    8. SSDr. Sara Szal1:23:36

       It wasn't proximity. I think it was, there was a way that we had a hard time expressing love and feeling and receiving love. There was an obstacle, and some of it was trauma. And the good news is, there's a lot you can do to resolve trauma. But there was a way that I, I got to the point where I couldn't try any longer. I tried for a lot of years, and I just couldn't keep trying.

46. 1:24:15 – 1:27:07

    Sara’s Divorce: Could It Have Been Saved?

    1. SSDr. Sara Szal1:24:15

    2. SBSteven Bartlett1:24:15

       When you look back, is there something that could have been done further upstream to prevent you getting to this place in your view?

    3. SSDr. Sara Szal1:24:25

       Yeah, it's such a, it's a great question. You know, one of the things that I've seen that has helped to resolve trauma better than anything else is psychedelic-assisted therapy. It's a way of looking at your story, a way of looking at the facts of your life with, um, more objectivity, and it's a way of resolving the way that trauma becomes embedded in your system. And so, I started doing psychedelic-assisted therapy about five years ago with the hope that it would help me with my marriage, and what I had hoped over time is that I would do my part to resolve the trauma signature in my own body and that maybe we would do psychedelic medicine together as a way of reconnecting to the love that we felt for each other and, you know, kind of get the noise, turn down the volume on the noise.And we weren't able to do that.

    4. SBSteven Bartlett1:25:31

       He wasn't willing to?

    5. SSDr. Sara Szal1:25:32

       He wasn't willing.

    6. SBSteven Bartlett1:25:34

       He wasn't open to psychedelics?

    7. SSDr. Sara Szal1:25:38

       And not everyone is. I'm not blaming him for that, um, and I think there's other ways to create healing states of consciousness. You know, breath work can do it, um, a near-death experience, peak experiences can do it, flow states. There's lots of different ways to create these healing states of consciousness. But we weren't able to get into that healing state together.

    8. SBSteven Bartlett1:26:01

       Just for a second, I want to talk about a company I've invested in and who sponsors this podcast called ZOE. Like me, many of you are big on tracking your fitness and your sleep, but how many of you understand how your body handles food? Metabolic fitness is all about understanding your metabolism's response to food, and we all react differently. So ZOE created a test to help you understand how your body responds, and it starts with their famous test cookies, which are identical test meals with the same sugar, fat, and calorie content of the averaged meal, and therefore acts as a metabolic challenge. You also wear a continuous glucose monitor that tests your blood sugar levels. I've done this test, and it left me wondering how my metabolic fitness compared to others like me, and my results revealed everything. So if you'd like to learn about your body's response to food, head over to zoe.com to order your test kit now, and if you want a discount, use code STEVEN10 at checkout for 10% off your membership. As a ZOE member, you'll get an at-home test kit and personalized nutrition program to help you make smarter food choices that support your health. That's zoe.com with code STEVEN10. One of the things

47. 1:27:07 – 1:28:28

    Are Women in Menopause More Likely to Divorce?

    1. SBSteven Bartlett1:27:07

       I've been told by one of the menopause experts that you mentioned earlier, Lisa-

    2. SSDr. Sara Szal1:27:10

       Mm-hmm.

    3. SBSteven Bartlett1:27:10

       ... was that when women get to menopausal, a menopausal age, when they're in menopause, they often have greater clarity on what they want in their life. That's what she said to me, and she said that she, we see divorce rates increase during this period of life. Is that true in your experience?

    4. SSDr. Sara Szal1:27:31

       It is true. It is true. Yeah, the way it was explained to me by one of my mentors was that when you're in your reproductive years, so pre-menopause, you've got a different level of estrogen, progesterone, and testosterone every day. And it makes you accommodate, makes you kind of roll with the punches, and it sets up this level of flexibility that starts to disappear when you go through perimenopause and menopause. And so, the way my mentor described it was that the hormonal veil is lifted, and you start to speak your truth and not accommodate. You speak your truth maybe 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 to an increased rate of divorce.

48. 1:28:28 – 1:29:37

    Do Happiness Levels Rise in Your 50s?

    1. SBSteven Bartlett1:28:28

       What about your happiness levels? Does it increase your happiness levels?

    2. SSDr. Sara Szal1:28:31

       I think it does. There's this really interesting study that, um, is called the U-bend, and it looks at psychological wellbeing for adults. It's highest in your 20s and the very start of your 30s, and then there's this U-shape where your psychological wellbeing goes down. I know you're 32, so-

    3. SBSteven Bartlett1:28:52

       Yes.

    4. SSDr. Sara Szal1:28:52

       ... I'm real sorry to break the news to you. And then it goes back up right around 50, so psychological wellbeing goes up again. And when I first heard about this U-bend, I remember reading an article in The Economist about it, it was so validating 'cause it made me feel like, "Oh, things are really hard." It makes sense to me that we see this through your 30s and 40s and then it starts to have this uptick again. And I think there are ways to improve your psychological wellbeing so that you're not stuck in the U-bend, but happiness, yes, I would say happiness, psychological wellbeing is high again in your 50s.

49. 1:29:37 – 1:33:05

    Supporting Women Better

    1. SBSteven Bartlett1:29:37

       I know that there's so many women that listen to this show, um, and I get so many messages when we have conversations about women's health, hormonal issues, menopause, because women for a long period of time haven't feel like, haven't felt like they've been heard and understood. Um, they often feel like they're being gaslit a little bit maybe by their doctors or by some of the information out there. So, this is quite atypical of me, but you know women better than I do, and you know what women are concerned about in all seasons of their life, what they're worried about, what they're confused about. So I wanna just open the floor to you and ask you, based on all of the work that you've done, you know, you've done work on, um, women's hormones, diets, lifestyle, s- sex drives, reclaiming their balance, sleep, healthy weight, for both men and women, but I'm asking specifically for women here. So with all of that in mind, what is the question that I should be asking you?

    2. SSDr. Sara Szal1:30:32

       (laughs) How do we do a better job supporting women?

    3. SBSteven Bartlett1:30:40

       How do we do a better job supporting women?

    4. SSDr. Sara Szal1:30:41

       Yes. How do we do it systemically? How do we do it in terms of healthcare for women? But I would say, in particular for you, with the platform that you have, the women's health gap that we're facing right now, which has only gotten worse over the 30 years of my career, I think to ask, how do we help women rise? How do we make systemic changes so that we don't have this women's health gap? Let's close the gap. How do we do that together?

    5. SBSteven Bartlett1:31:18

       I have a question for you.

    6. SSDr. Sara Szal1:31:19

       (laughs)

    7. SBSteven Bartlett1:31:19

       (laughs) Can you guess what the question is?

    8. SSDr. Sara Szal1:31:25

       I have an idea.

    9. SBSteven Bartlett1:31:26

       Go on then.

    10. SSDr. Sara Szal1:31:29

        So the women's health gap, I believe is rooted in two things, sex differences, you know, having two X chromosomes versus XY in men, hormonal differences, these life cycle changes that women go through like postpartum, pregnancy, perimenopause, menopause. But then there's also gender differences, which are socially constructed, and that includes women having more than their share of emotional labor, women having more stress than men, experiencing more stress, women having more trauma, so they have higher ACE scores than men. And it's led to, if we just look at the statistics, double the rate of depression, double the rate of PTSD, post-traumatic stress disorder, double the rate of insomnia, four times the rate of autoimmune disease, nine times the rate of thyroid dysfunction. So there's sex differences that map to those outcomes, but then there's these gender differences in the way that women don't feel supported, the way that they feel conflicted in trying to create work/life balance, the way that they experience more stress. That's what we need to address. We can't change the biology, but we can change the gender differences. We can change the socially constructed differences that lead to it being a health hazard to be female.

50. 1:33:05 – 1:34:26

    Gender Roles and Their Impact on Women

    1. SSDr. Sara Szal1:33:05

    2. SBSteven Bartlett1:33:05

       Okay, so tell me about that then. What is it about the socially constructed narrative of what it is to be a man and a woman that is causing unfavorable outcomes for women?

    3. SSDr. Sara Szal1:33:17

       There's a lot of things. So I would say, what we know, if you look at the nervous system, we know that women tend to have more, um, imbalance b- between the sympathetic nervous system and the parasympathetic nervous system.

    4. SBSteven Bartlett1:33:38

       What's that?

    5. SSDr. Sara Szal1:33:39

       So the sympathetic nervous system is fight, flight, freeze. The parasympathetic nervous system is rest and digest, feed and breed-

    6. SBSteven Bartlett1:33:48

       So para-

    7. SSDr. Sara Szal1:33:49

       ... stay and play.

    8. SBSteven Bartlett1:33:50

       ... is relax, chill, play?

    9. SSDr. Sara Szal1:33:51

       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 this fluid balance between the two, ideally like a 50/50 split. And so women tend to, in dealing with our culture, have more sympathetic activation, and so finding ways to address that.

    10. SBSteven Bartlett1:34:14

        More stress?

    11. SSDr. Sara Szal1:34:15

        More stress.

    12. SBSteven Bartlett1:34:16

        Mm-hmm.

    13. SSDr. Sara Szal1:34:17

        So at least in the US, we do these annual stress reports, and we find that on average, women have about 10% more stress than men.

51. 1:34:26 – 1:35:38

    Why Are Women More Stressed Than Men?

    1. SBSteven Bartlett1:34:27

       Why? Is that just because they're more likely to report it or is there a biological or evolutionary reason why they're more stressed?

    2. SSDr. Sara Szal1:34:38

       I don't think it's biological. I think it's related to power imbalances. I think it's related to patriarchy. I think it's related to power over. So for instance, with these ACE scores...

    3. SBSteven Bartlett1:34:55

       The trauma scores.

    4. SSDr. Sara Szal1:34:56

       The trauma scores. We know that women experience more trauma than men, about 10% more, similar to stress. And they also experience trauma at an earlier age compared to men. They have much more sexual violence. They're 14 times more likely to be raped than a man. So there are ways that our culture has allowed women to be violated, and that has to end. How do we do that? I don't know. This is where we need to riff and figure out how do the systems change so that there's a more equal distribution of power?

    5. SBSteven Bartlett1:35:37

       Are

52. 1:35:38 – 1:36:13

    Are Women More Emotionally Sensitive Than Men?

    1. SBSteven Bartlett1:35:38

       women more sensitive? So if you put a, a man and a woman or a boy and a girl in the same stressful environment, would they have different biological markers, like biomarkers? Would you see high levels of cortisol in the woman or higher cortisol levels in the man?

    2. SSDr. Sara Szal1:35:58

       I don't know the answer to that. My sense is, from the work of Elaine Aron, who's done the work on this profile of high sensitivity, that it's about equal in men and women, but I don't know that for sure. I'd have to fact check that.

53. 1:36:13 – 1:38:40

    Why Women Are More Prone to Autoimmune Diseases

    1. SSDr. Sara Szal1:36:13

    2. SBSteven Bartlett1:36:13

       Do you see higher rates of autoimmune diseases in women or men?

    3. SSDr. Sara Szal1:36:17

       Women.

    4. SBSteven Bartlett1:36:19

       And are all-

    5. SSDr. Sara Szal1:36:19

       4X.

    6. SBSteven Bartlett1:36:20

       4X?

    7. SSDr. Sara Szal1:36:20

       Yes.

    8. SBSteven Bartlett1:36:21

       400% more autoimmune diseases in women?

    9. SSDr. Sara Szal1:36:23

       Yes.

    10. SBSteven Bartlett1:36:25

        And what are these autoimmune diseases? What's an example of one?

    11. SSDr. Sara Szal1:36:28

        So there's about 100 autoimmune diseases. It includes things like rheumatoid arthritis, multiple sclerosis, type 1 diabetes, Hashimoto's thyroiditis, which is the leading cause of low thyroid function, uh, psoriasis. There's a long list.

    12. SBSteven Bartlett1:36:47

        And why are women getting these autoimmune diseases 400% more than men?

    13. SSDr. Sara Szal1:36:52

        We don't know. So the speculation is that it's related to both biological differences, sex differences, as well as gender differences. So the biological differences include the difference in the levels of hormones, the X chromosome. Women have more, for instance, vaccine response compared to men. Our immune system is more, um, reactive in some ways than the immune system of men. But then there's also these gender differences, these socially constructed differences, like women who have a hard time saying no, women who give until they drop, who overfunction.... who are trained when they go through their childhood to take care of others at the expense of their own self-care. And so, how these interact and lead to a fourfold increased risk in women, we don't entirely know. But definitely we see four times the rate in women.

    14. SBSteven Bartlett1:37:57

        What's your view? There's a big debate that's always raging on about gender roles in society, and there's obviously been a big shift over the last couple of decades in, I think, actually in part caused by the introduction of the contraceptive pill, which has meant that women are working more, I think, in the Western world, and these numbers might be wrong. There's less babies being born. Men and women are having less sex with each other. Men are killing themselves more often.

    15. SSDr. Sara Szal1:38:22

        Mm-hmm.

    16. SBSteven Bartlett1:38:23

        Women are having, coming into puberty earlier, I believe-

    17. SSDr. Sara Szal1:38:26

        Mm-hmm. Yes.

    18. SBSteven Bartlett1:38:27

        ... or is it later? Oh, it's earlier. And then having ch- ch- less children and significantly later. Funnily enough, I saw a graph yesterday which showed the rise in breast cancer amongst women, and actually, I think it was actually... No, it was

54. 1:38:40 – 1:41:11

    Does Late Motherhood Raise Cancer Risk?

    1. SBSteven Bartlett1:38:40

       the rise in all cancers amongst women versus men. And the men graph was pretty flat.

    2. SSDr. Sara Szal1:38:45

       Mm-hmm.

    3. SBSteven Bartlett1:38:45

       But there was this significant rise in women getting more and more forms of cancer, and I was looking through some of the research as to why that would happen, and one of them, one of the points of research said that because women are having children later that this is then causing a rise in cancer.

    4. SSDr. Sara Szal1:39:04

       Mm-hmm.

    5. SBSteven Bartlett1:39:05

       Does that make sense?

    6. SSDr. Sara Szal1:39:06

       Well, that has been studied with, for instance, breast cancer.

    7. SBSteven Bartlett1:39:10

       Okay.

    8. SSDr. Sara Szal1:39:11

       So we know, you know, 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 you have your first baby. And so the way that we think of this is that it's related to estrogen exposure. So women who get pregnant and maybe they breastfeed for a year, that's often a period of time, like a year and nine months, where they're not exposed to as much estrogen than they would be if they were menstruating during that time. And so having babies later seems to be associated with a greater risk of breast cancer. The ideal age I was taught when I went through my training for having a baby is 24. And I don't have a single friend who's had a baby in their 20s.

Episode duration: 1:58:11