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

Dr. Sara Szal 0:00 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.

Steven Bartlett 0:21 But you believe many of the symptoms of menopause are avoidable?

Dr. Sara Szal 0:25 Yes. And let's get into that. Dr. Sara Sahl is the Harvard-trained physician and hormone expert...

Steven Bartlett 0:30 Who's unlocking the science and simple tricks behind feeling your best, no matter your age.

Dr. Sara Szal 0:36 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.

Steven Bartlett 0:49 And if my body's making too much cortisol, what is the harm?

Dr. Sara Szal 0:51 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.

Steven Bartlett 1:05 And what about trauma? Does that impact your hormones?

Dr. Sara Szal 1:07 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.

Steven Bartlett 1:24 And you went on a journey to heal yourself?

Dr. Sara Szal 1:26 Yes, with lifestyle medicine, not a pharmaceutical.

Steven Bartlett 1:30 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.

Steven Bartlett 2:05 Dr. Sara Sahl. What is it that you do for people?

Dr. Sara Szal 2:10 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.

Steven Bartlett 2:26 And what does that mean, a healer? Because that's a broad term, so that could mean many things.

Dr. Sara Szal 2:32 It means that my task is to connect to your innate healing capacity and to work with you to activate it.

Steven Bartlett 2:43 And who do you do that for?

Dr. Sara Szal 2:44 So I do it for professional athletes, executives, and everyday people.

Steven Bartlett 2:54 And when you say healing, if someone came to you and they said, "How do you heal people?" What would your answer be?

Dr. Sara Szal 3:01 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.

Steven Bartlett 3:37 And what was

Steven Bartlett 3:38 your training? So can you talk me through your sort of academic journey?

Dr. Sara Szal 3:43 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.

Steven Bartlett 5:18 How many people do you think you've treated or seen or worked with directly in your career?

Dr. Sara Szal 5:23 Probably about 40,000.

Steven Bartlett 5:28 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?

Dr. Sara Szal 5:36 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.

Steven Bartlett 8:06 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.

Dr. Sara Szal 8:25 That's correct.

Steven Bartlett 8:26 Precision medicine, that term, how does that differ from conventional medicine?

Dr. Sara Szal 8:34 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.

Steven Bartlett 9:40 And everyone, you mean where that individual is the study, they are the experiment.

Dr. Sara Szal 9:43 That's correct.

Steven Bartlett 9:44 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?

Dr. Sara Szal 9:53 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%.

Steven Bartlett 11:23 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?

Dr. Sara Szal 11:39 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.

Steven Bartlett 11:55 Yeah, that's what I've heard before.

Dr. Sara Szal 11:57 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

Dr. Sara Szal 12:25 double standard.

Steven Bartlett 12:26 Why did you choose this career? What, what is it about you, your childhood, your life that sent you down this road?

Dr. Sara Szal 12:33 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.

Steven Bartlett 13:31 What was that trauma?

Dr. Sara Szal 13:34 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.

Steven Bartlett 13:44 I think I've got it here.

Dr. Sara Szal 13:45 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.

Steven Bartlett 14:32 How important is it for us to understand our early upbringing and our trauma if we are to heal as adults? Because you 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?

Dr. Sara Szal 14:56 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.

Steven Bartlett 16:06 Which is hormones.

Dr. Sara Szal 16:07 Yes.

Steven Bartlett 16:09 How did that manifest in your physical health?

Dr. Sara Szal 16:12 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.

Steven Bartlett 16:46 Which is an antidepressant pill.

Dr. Sara Szal 16:48 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.

Steven Bartlett 18:21 And you went on a journey to heal yourself?

Dr. Sara Szal 18:23 Yes.

Steven Bartlett 18:24 Tell me about that journey.

Dr. Sara Szal 18:28 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?

Steven Bartlett 19:55 So w- what was step one for you?

Dr. Sara Szal 19:58 Step one was awareness.

Steven Bartlett 20:00 Okay.

Dr. Sara Szal 20:00 And I had no idea. These are not things that most doctors are checking for.

Steven Bartlett 20:05 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?

Dr. Sara Szal 20:19 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.

Steven Bartlett 20:58 They gave you 30 minutes on nutrition?

Dr. Sara Szal 21:01 Yes.

Steven Bartlett 21:02 During wh- which training?

Dr. Sara Szal 21:03 This is medical school, and I got about the same amount on perimenopause and menopause.

Steven Bartlett 21:10 Really? I mean, that explains a lot-

Dr. Sara Szal 21:13 Yes, it does.

Steven Bartlett 21:13 ... about the medical system. So step one was awareness. What was step two?

Dr. Sara Szal 21:18 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.

Steven Bartlett 21:34 Trying things on yourself and then measuring?

Dr. Sara Szal 21:37 That's right.

Steven Bartlett 21:38 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."

Dr. Sara Szal 21:59 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.

Steven Bartlett 23:05 And if my body's making too much cortisol and my levels are too high, what is the, what is the harm?

Dr. Sara Szal 23:10 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.

Steven Bartlett 24:23 Which is gonna result in what kind of behaviors?

Dr. Sara Szal 24:27 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.

Steven Bartlett 24:45 Is there a link between cortisol and, uh, trauma?

Dr. Sara Szal 24:48 Oh, yes.

Steven Bartlett 24:50 What is that link?

Dr. Sara Szal 24:52 So for people who experience toxic stress or trauma, what typically happens is cortisol goes up. That's part of the alarm-

Steven Bartlett 25:02 Yeah.

Dr. Sara Szal 25:02 ... 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.

Steven Bartlett 25:23 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.

Dr. Sara Szal 25:47 (laughs)

Steven Bartlett 25:48 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-

Dr. Sara Szal 25:55 No, it's important for men too.

Steven Bartlett 25:56 Oh, really?

Dr. Sara Szal 25:57 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.

Steven Bartlett 27:37 Mm-hmm.

Dr. Sara Szal 27:37 Are you noticing that?

Steven Bartlett 27:38 Are you seeing that in your patients and...

Dr. Sara Szal 27:40 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.

Steven Bartlett 27:53 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.

Dr. Sara Szal 28:07 Yes.

Steven Bartlett 28:08 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.

Dr. Sara Szal 28:25 Yes. It's an attention economy, and the cost in that fight for attention is that often the nervous system becomes more dysregulated.

Steven Bartlett 28:37 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?

Dr. Sara Szal 28:51 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.

Steven Bartlett 29:22 Yeah. And then...

Dr. Sara Szal 29:25 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.

Steven Bartlett 29:43 You're a big fan of continuous glucose monitors, aren't you?

Dr. Sara Szal 29:46 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.

Steven Bartlett 29:57 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?

Dr. Sara Szal 30:10 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.

Steven Bartlett 30:33 When you're treating patients, do you focus heavily on their blood sugar levels?

Dr. Sara Szal 30:39 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.

Steven Bartlett 31:02 Wh- which is called ATP?

Dr. Sara Szal 31:04 ATP.

Steven Bartlett 31:05 And that ATP then drives, well, it drives our, everything we do.

Dr. Sara Szal 31:11 ATP is fuel, so it allows you to feel like you're fully energized, especially when you wake up in the morning.

Steven Bartlett 31:18 And are there any supplements that I should be taking if I'm trying to optimize my hormonal balance?

Dr. Sara Szal 31:23 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.

Steven Bartlett 32:14 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.

Dr. Sara Szal 32:29 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.

Steven Bartlett 35:42 'Cause he's got too much glucose and he's not doing enough with it?

Dr. Sara Szal 35:45 That's right.

Steven Bartlett 35:46 So his body is having to store it and getting inflamed.

Dr. Sara Szal 35:50 And he said, you know, "Listen, it's been the Christmas holidays. I had a lot of pound cake. I had some cocktails. You 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.

Steven Bartlett 36:16 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?

Dr. Sara Szal 36:45 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%.

Steven Bartlett 37:44 And what do you do about that if you're an athlete and you've got elevated cortisol levels?

Dr. Sara Szal 37:49 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.

Steven Bartlett 39:44 I found a supplement called, I can't pronounce the name properly, but rhodiola?

Dr. Sara Szal 39:48 Oh, rhodiola?

Steven Bartlett 39:50 Rhodiola.

Dr. Sara Szal 39:50 Yes. Rhodiola is an adaptogen, so it's, uh, it's an herbal therapy that's been shown to help with cortisol.

Steven Bartlett 39:59 Lowest cortisol?

Dr. Sara Szal 40:00 Yes.

Steven Bartlett 40:01 And I was reading that it increases your focus potentially.

Dr. Sara Szal 40:03 Yes, it does.

Steven Bartlett 40:04 Do you s- prescribe that to athletes?

Dr. Sara Szal 40:07 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.

Steven Bartlett 40:26 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?

Dr. Sara Szal 40:46 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.

Steven Bartlett 41:42 Hmm. But does- doesn't that mean that in order to change some people just need a bit more pain?

Dr. Sara Szal 41:50 I would say people have a different level of pain that motivates change.

Steven Bartlett 41:54 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?

Dr. Sara Szal 42:20 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

Dr. Sara Szal 43:47 themselves.

Steven Bartlett 43:48 So what do you consider your job to be if you are a friend or a family member?

Dr. Sara Szal 43:53 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.

Steven Bartlett 44:26 Hmm.

Dr. Sara Szal 44:27 What's your experience?

Steven Bartlett 44:29 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.

Dr. Sara Szal 44:45 Yes.

Steven Bartlett 44:45 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.

Dr. Sara Szal 45:06 Mm-hmm.

Steven Bartlett 45:06 Which meant that they would fall a little bit.

Dr. Sara Szal 45:09 Yes.

Steven Bartlett 45:09 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.

Dr. Sara Szal 45:27 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.

Steven Bartlett 45:49 Yeah.

Dr. Sara Szal 45:50 And then being there for them as they stumble and struggle and try to make things different.

Steven Bartlett 45:56 You, you talked earlier about the executive that you checked, uh, recently. You said his testosterone levels were intact.

Dr. Sara Szal 46:03 Yes.

Steven Bartlett 46:05 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.

Dr. Sara Szal 46:16 It tends not to decline until about age 40, but I would say do a baseline now.

Steven Bartlett 46:22 Okay.

Dr. Sara Szal 46:22 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.

Steven Bartlett 46:58 What was it that was affecting those?

Dr. Sara Szal 46:59 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.

Steven Bartlett 47:19 And

Steven Bartlett 47:20 women have testosterone too, but you said, I think, earlier that men just have 10 times more testosterone.

Dr. Sara Szal 47:25 Men have more, but it's the most abundant hormone in the female body. Women are exquisitely sensitive to it.

Steven Bartlett 47:33 It's the most abundant hormone?

Dr. Sara Szal 47:34 Yes. Higher concentration than estrogen or progesterone.

Steven Bartlett 47:39 About 15 to 17 nanograms in a woman? That's what I read on WebMD.

Dr. Sara Szal 47:44 Yes, that's, that's a pretty good level.

Steven Bartlett 47:46 And in men, 300, uh, 1,000 nanograms?

Dr. Sara Szal 47:50 Yes. I like to see it somewhere around 500 to

Dr. Sara Szal 47:53 1,000.

Steven Bartlett 47:54 And what would be a sign that I had low testosterone if I'm a man?

Dr. Sara Szal 48:01 Belly fat.

Steven Bartlett 48:02 Mm-hmm.

Dr. Sara Szal 48:03 Gynecomastia.

Steven Bartlett 48:04 What's that?

Dr. Sara Szal 48:05 That's when you have breast development.

Steven Bartlett 48:07 Okay.

Dr. Sara Szal 48:08 Uh, mood changes, mood swings, uh, irritability, uh, depression, cardiovascular changes, erectile dysfunction, decreased libido.

Steven Bartlett 48:23 What about in a woman? So if a woman has low testosterone, what are the symptoms we see in a woman?

Dr. Sara Szal 48:29 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.

Steven Bartlett 49:12 So if a woman is low testosterone, she might be

Steven Bartlett 49:14 less confident, have less motivation, less agency?

Dr. Sara Szal 49:18 Less willing to take risks, less sex drive.

Steven Bartlett 49:21 Interesting. What if she has high test- testosterone levels? Too high.

Dr. Sara Szal 49:25 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.

Steven Bartlett 50:16 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?

Dr. Sara Szal 50:29 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.

Steven Bartlett 51:01 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?

Dr. Sara Szal 51:10 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.

Steven Bartlett 51:28 Within seven days?

Dr. Sara Szal 51:29 Within seven days.

Steven Bartlett 51:31 So if-

Dr. Sara Szal 51:31 Exercise.

Steven Bartlett 51:32 I'm e- currently eating like a ketogenic diet, so my carbohydrate level's extremely low.

Dr. Sara Szal 51:37 Mm-hmm.

Steven Bartlett 51:37 Does that mean my testosterone levels are gonna be low?

Dr. Sara Szal 51:41 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.

Steven Bartlett 52:30 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.

Dr. Sara Szal 52:38 It is.

Steven Bartlett 52:39 Why is it so important for, for both sexes? What does it do?

Dr. Sara Szal 52:44 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.

Steven Bartlett 54:44 Does it have a role in weight distribution in my body? So where the-

Dr. Sara Szal 54:50 Yeah.

Steven Bartlett 54:50 ... fat stores and stuff.

Dr. Sara Szal 54:52 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.

Steven Bartlett 55:42 And is that inevitable?

Dr. Sara Szal 55:45 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...

Steven Bartlett 57:10 Dis- disposing of the glucose pro- properly?

Dr. Sara Szal 57:12 Yes.

Steven Bartlett 57:12 What do you mean by that?

Dr. Sara Szal 57:13 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.

Steven Bartlett 57:45 And must resistance training, strength training is the optimal way to dispose of glucose, right?

Dr. Sara Szal 57:51 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.

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Steven Bartlett 59:09 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.

Dr. Sara Szal 59:15 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.

Steven Bartlett 59:58 And what

Steven Bartlett 59:59 role is the microbiome playing in my hormone function?

Dr. Sara Szal 1:00:03 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.

Steven Bartlett 1:01:04 And that- a lot of that stuff, and it's caused by the gut microbiome.

Dr. Sara Szal 1:01:07 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.

Steven Bartlett 1:01:20 What- what kind of foods have high fiber? Is it, like, broccoli and stuff?

Dr. Sara Szal 1:01:24 Yes. So broccoli, Brussels sprouts, cauliflower, cabbage, kohlrabi.

Steven Bartlett 1:01:33 What do you eat?

Dr. Sara Szal 1:01:34 (laughs)

Steven Bartlett 1:01:35 And like, how do you live?

Dr. Sara Szal 1:01:37 So I'm a sensualist.

Steven Bartlett 1:01:39 What does that mean?

Dr. Sara Szal 1:01:39 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.

Steven Bartlett 1:01:47 Mm-hmm.

Dr. Sara Szal 1:01:47 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.

Steven Bartlett 1:02:52 What does that mean?

Dr. Sara Szal 1:02:53 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.

Steven Bartlett 1:03:22 What do you think of the keto diet?

Dr. Sara Szal 1:03:24 I'm a fan of the ketogenic diet.

Steven Bartlett 1:03:26 Because in your book, there's this chapter called The Keto Paradox.

Dr. Sara Szal 1:03:29 Yes.

Steven Bartlett 1:03:31 What are your thoughts on keto?

Dr. Sara Szal 1:03:33 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.

Steven Bartlett 1:04:29 Is there a danger to women doing ketosis? Because you said me- um, their periods are gonna become irregular.

Dr. Sara Szal 1:04:34 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.

Steven Bartlett 1:05:30 What are the side effects?

Dr. Sara Szal 1:05:32 The main ones that I see are the thyroid dysfunction.

Steven Bartlett 1:05:34 Yeah.

Dr. Sara Szal 1:05:36 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.

Steven Bartlett 1:06:05 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.

Dr. Sara Szal 1:06:25 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.

Steven Bartlett 1:06:38 Have you seen people that stay on it for years and have good biomarkers?

Dr. Sara Szal 1:06:41 Yes. Yes.

Steven Bartlett 1:06:42 Okay.

Dr. Sara Szal 1:06:43 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.

Steven Bartlett 1:07:29 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?

Dr. Sara Szal 1:07:49 What I like about the ketogenic diet for weight loss... And I'm really careful about weight loss because-

Steven Bartlett 1:07:55 It's problematic.

Dr. Sara Szal 1:07:56 ... 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

Dr. Sara Szal 1:08:33 can eat.

Steven Bartlett 1:08:33 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?

Dr. Sara Szal 1:08:44 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.

Steven Bartlett 1:09:29 Is the ketogenic diet like a form of fasting?

Dr. Sara Szal 1:09:33 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

Dr. Sara Szal 1:11:26 you.

Steven Bartlett 1:11:27 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?

Dr. Sara Szal 1:11:52 I would say for women, it's perimenopause.

Steven Bartlett 1:11:58 And for anyone that doesn't know what perimenopause is, when does that begin, and what is it?

Dr. Sara Szal 1:12:03 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.

Steven Bartlett 1:14:09 And what is the youngest you've ever seen someone enter perimenopause?

Dr. Sara Szal 1:14:13 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.

Steven Bartlett 1:14:41 And FSH? What's FSH?

Dr. Sara Szal 1:14:42 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.

Steven Bartlett 1:15:18 Tracking it through their blood samples?

Dr. Sara Szal 1:15:20 Blood samples-

Steven Bartlett 1:15:21 Hormones.

Dr. Sara Szal 1:15:21 ... 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.

Steven Bartlett 1:15:34 You believe that many of the symptoms of menopause are avoidable?

Dr. Sara Szal 1:15:40 Yes. Yes, and by that I mean using hormone therapy and using lifestyle medicine as early as possible to manage that transition.

Steven Bartlett 1:15:50 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-

Dr. Sara Szal 1:15:57 That's right.

Steven Bartlett 1:15:57 ... completely miss it.

Dr. Sara Szal 1:15:58 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.

Steven Bartlett 1:16:09 What do you think of birth control pills?

Dr. Sara Szal 1:16:12 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.

Steven Bartlett 1:16:59 (laughs) But who is the birth control pill for, then?

Dr. Sara Szal 1:17:04 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.

Steven Bartlett 1:17:50 How are you doing?

Dr. Sara Szal 1:17:52 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

Dr. Sara Szal 1:18:28 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-

Steven Bartlett 1:18:57 Whole body yes. What does that mean?

Dr. Sara Szal 1:18:58 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.

Steven Bartlett 1:19:51 How long were you married for? How long were you in a relationship with your partner?

Dr. Sara Szal 1:19:55 We were together for about 22 years, and married for 20.

Steven Bartlett 1:20:00 How does

Steven Bartlett 1:20:01 one know that it's not right anymore after 20-odd years?

Dr. Sara Szal 1:20:07 Well, I would love to riff on this with you.

Steven Bartlett 1:20:09 Okay.

Dr. Sara Szal 1:20:10 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.

Steven Bartlett 1:22:22 And is that not something that can be repaired through communication and therapy or sitting down and ...

Dr. Sara Szal 1:22:27 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.

Steven Bartlett 1:23:17 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.

Dr. Sara Szal 1:23:36 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.

Steven Bartlett 1:24:15 When you look back, is there something that could have been done further upstream to prevent you getting to this place in your view?

Dr. Sara Szal 1:24:25 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.

Steven Bartlett 1:25:31 He wasn't willing to?

Dr. Sara Szal 1:25:32 He wasn't willing.

Steven Bartlett 1:25:34 He wasn't open to psychedelics?

Dr. Sara Szal 1:25:38 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.

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Steven Bartlett 1:27:07 I've been told by one of the menopause experts that you mentioned earlier, Lisa-

Dr. Sara Szal 1:27:10 Mm-hmm.

Steven Bartlett 1:27:10 ... 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?

Dr. Sara Szal 1:27:31 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.

Steven Bartlett 1:28:28 What about your happiness levels? Does it increase your happiness levels?

Dr. Sara Szal 1:28:31 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-

Steven Bartlett 1:28:52 Yes.

Dr. Sara Szal 1:28:52 ... 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.

Steven Bartlett 1:29:37 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?

Dr. Sara Szal 1:30:32 (laughs) How do we do a better job supporting women?

Steven Bartlett 1:30:40 How do we do a better job supporting women?

Dr. Sara Szal 1:30:41 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?

Steven Bartlett 1:31:18 I have a question for you.

Dr. Sara Szal 1:31:19 (laughs)

Steven Bartlett 1:31:19 (laughs) Can you guess what the question is?

Dr. Sara Szal 1:31:25 I have an idea.

Steven Bartlett 1:31:26 Go on then.

Dr. Sara Szal 1:31:29 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.

Steven Bartlett 1:33:05 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?

Dr. Sara Szal 1:33:17 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.

Steven Bartlett 1:33:38 What's that?

Dr. Sara Szal 1:33:39 So the sympathetic nervous system is fight, flight, freeze. The parasympathetic nervous system is rest and digest, feed and breed-

Steven Bartlett 1:33:48 So para-

Dr. Sara Szal 1:33:49 ... stay and play.

Steven Bartlett 1:33:50 ... is relax, chill, play?

Dr. Sara Szal 1:33:51 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.

Steven Bartlett 1:34:14 More stress?

Dr. Sara Szal 1:34:15 More stress.

Steven Bartlett 1:34:16 Mm-hmm.

Dr. Sara Szal 1:34:17 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.

Steven Bartlett 1:34:27 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?

Dr. Sara Szal 1:34:38 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...

Steven Bartlett 1:34:55 The trauma scores.

Dr. Sara Szal 1:34:56 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?

Steven Bartlett 1:35:37 Are

Steven Bartlett 1:35:38 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?

Dr. Sara Szal 1:35:58 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.

Steven Bartlett 1:36:13 Do you see higher rates of autoimmune diseases in women or men?

Dr. Sara Szal 1:36:17 Women.

Steven Bartlett 1:36:19 And are all-

Dr. Sara Szal 1:36:19 4X.

Steven Bartlett 1:36:20 4X?

Dr. Sara Szal 1:36:20 Yes.

Steven Bartlett 1:36:21 400% more autoimmune diseases in women?

Dr. Sara Szal 1:36:23 Yes.

Steven Bartlett 1:36:25 And what are these autoimmune diseases? What's an example of one?

Dr. Sara Szal 1:36:28 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.

Steven Bartlett 1:36:47 And why are women getting these autoimmune diseases 400% more than men?

Dr. Sara Szal 1:36:52 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.

Steven Bartlett 1:37:57 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.

Dr. Sara Szal 1:38:22 Mm-hmm.

Steven Bartlett 1:38:23 Women are having, coming into puberty earlier, I believe-

Dr. Sara Szal 1:38:26 Mm-hmm. Yes.

Steven Bartlett 1:38:27 ... 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

Steven Bartlett 1:38:40 the rise in all cancers amongst women versus men. And the men graph was pretty flat.

Dr. Sara Szal 1:38:45 Mm-hmm.

Steven Bartlett 1:38:45 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.

Dr. Sara Szal 1:39:04 Mm-hmm.

Steven Bartlett 1:39:05 Does that make sense?

Dr. Sara Szal 1:39:06 Well, that has been studied with, for instance, breast cancer.

Steven Bartlett 1:39:10 Okay.

Dr. Sara Szal 1:39:11 So we know, you know, there's a lot of different factors