Metabolic health strategies for women with Dr. Stephanie Estima
The author and podcaster discusses women’s metabolic health, how to time nutritional strategies with your cycle, and why strength training is key.
Stephanie Estima, MD, podcaster and author, sat down with Lauren Kelley-Chew, head of clinical product at Levels, to talk about goal-setting, different facets of metabolic health—diet, sleep, exercise—and how micro habits can lead to long-term change if we show up and do them consistently.
When it comes to achieving our goals, it’s not about being extreme. It’s about being consistent. It’s about making a pact with ourselves.
Setting and Adjusting Achievable Goals
Dr. Lauren Kelley-Chew: I’m very excited to have you here. I know you have many fans of your podcast and your work on the Levels team. We’re all really excited to have you on. I know our audience will learn so much from you.
Dr. Stephanie Estima: I’m delighted to be here. Thank you for having me.
Dr. Lauren Kelley-Chew: When a new year comes around, a lot of people think about the food they’re eating and the changes they want to make to their health. Weight loss is on a lot of people’s minds. From your experience, what are some of the biggest diet misconceptions that you see in your practice?
Dr. Stephanie Estima: It’s important to zoom out a little bit and talk about the big picture. What often happens, as the new year comes around, or if there’s a wedding you’re going to, or a high school reunion or whatever it is, is we set these incredibly aggressive goals for ourselves when motivation is really high.
We might think, I’m going to fit into that beautiful wedding dress, or, This is the year. This is the year when I learn French, lose weight, learn salsa—whatever it is. When our motivation is high, we can very much overshoot the target.
We might say, “I can lose a pound a week for six weeks, and that’s six pounds,” or, “I can do it for 20 weeks, and that’s 20 pounds.” But over the course of those six weeks or 20 weeks or whichever time frame, life happens. The kids get sick, or you have a really big deadline, or you have to travel and you’re off of your schedule again.
One of the biggest misconceptions is actually setting too big of a goal from the outset, and then not being able to follow through on it. We’ve all heard how the gyms are really busy January 1st, and then by February 1st, they’re empty. And it’s true. Gyms are busier in the first month of the year, and then we start to see this steady decline back to the regulars by February or March. The reason for that is people go too hard, too fast.
The same is true with diet. You might say, “I’m going to become a vegan this year. This is the year I’m going to cut out all meat,” or, “I’m going to do the ketogenic diet this year and no carbs shall pass these lips.” We’re so black and white about it. We’re strict and we adhere fiercely.
We white-knuckle, especially women. We do it so aggressively that it’s so painful that you just give up. We think, “Well, if this is what it is to be keto, I’m having none of it. This is too painful.”
That’s the biggest misconception around diets in general: that it has to be painful, and that you have to do it at 100%, all of the time, in order for it to be effective.
Dr. Lauren Kelley-Chew: I completely agree with that. What would be a recommendation for people thinking with that mindset? How do you take the initial goal and modify it to something more likely to sustain motivation?
Dr. Stephanie Estima: I love this stuff, because this is getting into belief systems, mindsets, and behavioral psychology. I am that type-A personality. I was the girl who said, “I’m going to work out 365 times this year. That’s going to be me.” There’s no shame. I was totally her, and in many ways, I’m still that recovering perfectionist. I still catch myself overshooting and not prioritizing rest and all the things.
From conversations I’ve had with thought leaders—BJ Fogg comes to mind, as does Dr. Heather McKee, a behavioral psychologist from Ireland whom I recently had on my show—the through line, when you’re talking to behavioral psychologists, is that they talk about making a habit rather than focusing on the outcome.
Let’s say you want to lose 10 pounds, or become fluent in French. Some of those things are beyond your control. Like we were saying before, kids, deadlines, travel, sickness, whatever it is, get in the way. But what we do have control over are the tiny habits we do every single day. We don’t necessarily have control over the outcome; we have control over our behaviors.
One of the ways to circumvent the big audacious hairy goal of losing 30 pounds this year, for example, is to think, Well, what does one pound look like? Can I just set a goal to lose one pound? That’s not overwhelming. You don’t need a ton of motivation. You just need to take one less bite of the dessert. And when you’re looking at your plate, maybe instead of eating 100% of what’s there, you eat 80%. That’s a much easier goal.
When we pull the goal down from a 10-out-of-10—10 being losing 30 pounds, one being losing a single pound—that’s when we can start to layer and continue that forward momentum. Once you lose that one pound, you think, Oh, my gosh, that’s great. It’s been like two weeks and I’ve already done it. All right. Well, let’s do it again.
And it’s not that difficult: I just ate until I felt full. I didn’t just necessarily eat until the whole plate was gone. I know we’re early on in our conversation, but if that’s the big takeaway, that’s it. Bring the 10-out-of-10 goal down to a one-out-of-10. If working out every day is the 10-out-of-10, what’s the one-out-of-10? Maybe it’s working out once this week, and maybe it’s a walk. If you’re able to overcome that initial hump, then anything above and beyond that is going to be a bonus.
All the type-A ladies and men who are reading, you get extra credit. You think, “Oh, I already did this, and now here’s the A-plus piece of it.” Rather than shooting so high that you need to recruit a lot of motivation—so many skills and assets, so much drive—it’s, “I’ve already gone for a 10-minute walk, so what else can I do now?”
Dr. Lauren Kelley-Chew: I love how, on your podcast, you talked about the confidence that comes from knowing you can trust yourself to do the thing, even if it’s a small thing, and that over time, that belief and that confidence in yourself then creates momentum. That really spoke to me.
Like you, I also am a recovering perfectionist or aggressive goal setter. In this line of work, it’s easy to drop back into that. With every book you read, every podcast, there’s like 1,000 possible ways you can modify your lifestyle. And you think, I’m going to do all of them.
Dr. Stephanie Estima: Right. By the time the sun is in my eyes, and I haven’t eaten the carb, and I’ve gone to the sauna, it’s like there’s no other life.
Dr. Lauren Kelley-Chew: I mean, I’ve also got to work at some point.
Dr. Stephanie Estima: Exactly. One question I hear a lot is, What is the role of calorie counting for all the people who are really into MyFitneesPal, or really into that version or that tool of health management? What is your take on that? Is there utility in that? Is it helpful? Is it harmful? How does that play out?
Like anything, a tool can be used for good, and it can be used for your detriment. When we’re talking about weight loss, of course we’re talking about fat loss. We’re talking about reducing fat or total adiposity. We’re not talking about reducing muscle weight; we’re not talking about reducing bone weight or organ weight. Whenever we talk about weight loss, it’s about reducing total adiposity.
Whenever we’re thinking about calorie counting, we want to be sensitive. I certainly am sensitive for my female clients and women I’ve counseled, because like anything, it can vacillate from an appropriate, normal use all the way up to disordered eating and behaviors that feed into body dysmorphia and eating disorders. If you are someone who has a history of eating disorders—anorexia, bulimia, anything like that—certainly you should be working with a professional counselor or someone who specializes in those eating disorders.
You’ll also probably find that those professionals will typically shy away from things like calorie counting, because when we look at anorexia or bulimia, a lot of times these are trauma responses, a play for control. You can see how, if you’re trying to control something, you’re trying to control the food you’re taking in, let’s say, that can become dysfunctional very quickly. If you are someone who has an eating disorder or a history of an eating disorder, I would definitely leave it to the professional to advise you in terms of what you should be doing.
For those of us who don’t have a history of an eating disorder and are trying to lose weight, I do think that calorie counting can be useful, partly because, what I’ve found in terms of pattern recognition, is that most people have no idea what they’re taking in. I have run a diet for many years. It’s a female-centric ketogenic diet for women. It’s a metabolic intervention. But it’s a temporary state. We’re not in keto forever. In order for you to get into ketosis, you need to, in some cases, aggressively clamp down on your carbohydrate intake. In order to do that, you need to have a sense of what your carbohydrate intake is.
For those women, I recommend things like Carb Manager. I have no affiliation with them. It’s an app that everybody seems to really like. There’s a whole bunch of them. I’ve used Carbon Diet Coach in the past. I’ve used Carb Manager. There are many of them I like—anything that counts your calories, gives you a good ballpark of total calories, the macronutrients split, how many carbohydrates you’re taking in, how many fat calories you’re taking in, how many protein calories, and then also gives you a sense of what your nutrient timing or your behaviors are.
Coming back to that behavioral psychology piece, a lot of our calories, typically when we’re unaware and we’re not tracking, tend to come in the evening. For most people, dinner is the biggest meal of the day. It’s usually when we get to sit around with family, if there’s an opportunity to do that, and then of course there’s the after-dinner wine and snacking.
A significant amount of our calories, for most North Americans, comes after 5:00 PM. This is something to consider, in terms of mirroring back to us when we are consuming our calories. How much we eat, and when, is very important. I don’t have an app I’m actively using, but when I was first starting out on my ketogenic journey and had a host of hormonal issues and menstrual cycle issues and all the things, I was tracking, because I was trying to get a hold on what the problem was.
You’ll hear me say over and over again, and I’ll probably say it a couple times in our conversation, is that the diet you follow and the habits and behaviors you follow when you’re, let’s say, metabolically unhealthy, are not going to be the same behaviors and habits and diet you follow once you’ve healed that metabolic derangement, or once you are healthier.
This is the same reason you’ll hear me say keto for women long-term is not a good idea. I don’t think it’s a good idea. It’s a nice intervention if someone has a hormonal issue, let’s say, as I did—maybe they have blood sugar regulation problems, as I’ve had many women deal with over time. The ketogenic diet can be a very useful proxy to help attain an optimal fasting blood glucose level and some other parameters, but I don’t actually think that we should stay there, for a variety of reasons, one of which is that it actually stops working for most women.
Most women will say, “I was feeling really great for three or four months, and then all of a sudden I started gaining weight, and I was miserable, and I couldn’t sleep, and my period, once fixed, is now back to where it was again,” or they experience a whole host of other symptoms. Thyroids also can go amuck. I’ve seen thyroid in many, many women who do the ketogenic diet for too long bonk as well.
Women and the Keto Diet
Dr. Lauren Kelley-Chew: Let’s dive more into the keto diet. I appreciate your bringing awareness to the ways that male and female physiology are different, and that many of these interventions that have been publicized really are based on studies in men, or maybe work in certain ways in men, and work differently in women. That’s just now starting to be recognized.
I started keto probably about a year ago. Like you were describing, for me, I really couldn’t make it work unless I basically cut out all carbs and even some vegetables. I was eating arugula, basically. It was really extreme for me to get there. There was olive oil on everything.
Dr. Stephanie Estima: You were licking a celery stalk and putting that into Carb Manager. Yeah.
Dr. Lauren Kelley-Chew: Exactly. I had friends who said, “This can’t possibly be right.” And I said, “No, keto is right.” Like you described, in some ways it was helpful to me, but pretty quickly, after a few months, I started gaining weight and I never felt well. Can you talk about your approach to adopting keto for women?
Dr. Stephanie Estima: This is a very important topic, which is also often misrepresented, as you were saying, both in the literature and in the online spaces where diet dogma and diet culture are discussed. I’ll put every type of diet in this category.
This is just me pondering and thinking, Why do people get so crazy about diets? I think that maybe it’s because, prior to 2023, and maybe in the last 30 to 40 years, there has been less and less reliance on religion. Less people are going to church, there are less people in these communal organizations. Diet becomes the replacement for Christianity, or whatever it was. Maybe if you went to church every Sunday, now you’re going to carnivore church, for instance. You’re adhering to something, because I think humans innately want to belong to something. We want to belong to a community.
For many years, the church and religious offerings fed that need. Now, in modern society, we aren’t as reliant, let’s say, on our pastors and our rabbis and whomever. We are trying to figure out a way to fit in somewhere. People will say, “Well, it’s going to be the way that I eat,” because it’s something that we have to do every single day. We have to interact with food in some capacity every single day. You see this online. You see set-in-their-ways people who talk about carnivore, people who talk about the ketogenic diet, people who talk about plant-based and veganism.
I went off on a little tangent. I’ll course-correct myself here, but I just wanted to bring that to light, because I think that sometimes, when we want to start a diet, we start looking at people online who talk about that diet.
You said you were unable to eat plants. Well, there are some people in the ketogenic and carnivore community who say, “Plants are terrible for you. Plants are going to create oxalates, and plants want to kill you.” You hear that and think, This person has a bestselling book, or, This person has so many followers, they must be right. Or you think, They have a couple of impressive letters behind their name. They must be right. We can unintentionally guide people down the wrong path.
Someone who might consider a female-centric ketogenic diet is the woman I used to be, someone who doesn’t have an optimal menstrual cycle. I wrote about this in my book. I used to hate my period. I used to literally feel like it was a curse. I thought, This is what happens when you’re a woman. Every month I was on very, very heavy painkillers. I had to take a day or two off of schooling at the time. I would be immobile.
I would have to spend the day in bed, with severe cramping in my lower back all the way to my knees. I couldn’t really function. I wasn’t able to participate in the activities of daily living, and didn’t think that it had anything to do with the way I was eating. I didn’t think it had to do with my stress levels or the unprocessed stressors I had experienced in my life.
I found the ketogenic diet naturally, through my own interest, because my undergraduate degree is in neuroscience and psychology. I’ve always had this love affair with neuroscience, psychology, and the brain. My professional training is as a chiropractor, so the musculoskeletal system is my jam. I want to know everything about the brain and the muscles and all the things. Keto was a very natural complement to my interest there. I first started reading about it in 2015. 2016 is when I really got interested in it.
I read about the history of keto. Before there were seizure medications, the ketogenic diet was used to control grand mal, tonic-clonic seizures in children, and then the advent of medication negated the need for the diet, insofar as how we might think the ketogenic diet restricts carbohydrates temporarily. And the carbohydrates you do eat are a lot of plants.
That is maybe where I differ from other people. There are more people who talk about this now, including Dr. Sara Gottfried. Her and I are very aligned on this idea that when you are doing keto for a woman, the carbohydrates she’s consuming should be the colors of the rainbow. We should have a lot of green leafy vegetables like spinach, artichokes, and arugula—as you were saying, lots of greens. But then we also should have the peppers and the eggplant and all the different colors.
I structure a female-centric ketogenic diet for women to include a moderate amount of protein. Classical keto would be a 4:1 ratio, where 80% of calories come from fat, and then maybe the last 20% was split between protein and almost no carbohydrates. I like about 10% of the diet to come from carbohydrates—I like all of that to be vegetables. Protein makes up about 20 to 25%. The size of your palm is a good gauge for what the serving size of protein should be. And then the fat is the filler.
If you’re looking at your plate, maybe you have some roasted brussel sprouts and some arugula, and then maybe a filet mignon or a chicken breast or something like that. Then you can drizzle some olive oil on the top. That’s sort of the fill of it. That is a basic formulation of a female-centric ketogenic diet.
Fat is much more calorically dense than both carbohydrates and proteins. It clocks in at nine calories per gram, compared to four for the carbohydrates and the protein piece. Liberally drizzling olive oil can quickly add up, in terms of your caloric intake.
I like to do a macro split. We would figure out what your calories are, but you would do that macro split for at least one cycle, about 29 and a half days. Then we’d reevaluate and see whether or not we need to repeat that, or if we need to start moving into protein and carbohydrate cycling, which is where we start increasing protein and carbohydrates, if you’re a woman in your reproductive years, as it coincides with your menstrual cycle.
If you’re in menopause, you can still cycle. You just don’t have to calibrate according to which week you’re in: “Am I in week one or week three?” It’s just on and off. One week would be keto, one week high protein, one week keto, one week higher protein and carbs. That’s how I like to structure it.
Then I add a couple of other things on top of that in terms of training and exercise, also in sync with your cycle. That’s how I think a proper ketogenic diet should be structured for women. Women are orders of magnitude more sensitive to our environment than men. We are very sensitive to changes in calories. If you’re calorically restricting yourself for a long time, or if your body fat levels get too low, you’re going to lose your period, or your menstrual cycle is going to become irregular. You’re going to cause hormonal derangement. You’re going to cause metabolic derangement and maladaptations to it.
I don’t like to prescribe the initial therapeutic intervention of doing keto the same way during every single day of a cycle, unless there’s an extreme case of PCOS, or maybe Hashimoto’s or thyroiditis, and carbohydrates are actually aggravated. A lot of women with Hashi’s have a lot of gut dysbiosis. There’s a lot of hyperpermeability of the gut. The bacteria’s off. When we’re giving them a lot of carbohydrates, it can cause GI distress. A temporary, emphasis on temporary, elimination of carbohydrates is well tolerated with someone with an autoimmune condition. But the goal with someone with autoimmunity is always to add those items back into their diet over time.
When I structure a ketogenic diet for most women, I try to look through the lens of, What’s the hormonal derangement here? Is it estrogen issues, androgen issues, thyroid issues, blood sugar regulation issues? Then I tweak it for that person. Once we’ve had that therapeutic intervention, we move into cycling, and add in some protein.
I’m a word geek. Protein comes from the Greek word protos, which basically means “first nutrient.” Every single cell in the body requires protein for a variety of different reasons; protein is very important, and so are carbohydrates, especially for women. I’m cool with restricting carbs for a little bit of time, but at some point you’re going to become nutrient deficient. You’re going to develop some of those metabolic maladaptations. Your basal metabolic rate is going to drop. Your caloric expenditure is going to drop.
Even if you’re doing the exact same workouts—maybe you’re a runner or you’re lifting weights —you’re going to start burning less and less calories doing the same amount of work, because your body’s trying to conserve energy. Your digestion is going to slow. All these different things we don’t want to happen will happen when you are overly restricting for a long period of time.
Dr. Lauren Kelley-Chew: I wish I had heard this exact conversation a year ago. It’s such a reflection of how steeped I can get in terms of what I believe I’ve been told or have read is the healthy thing. I remember being on keto, and it got so restrictive. There was part of me that was saying, “This can’t possibly be right,” and the other part was saying, “I have to have this type of blood sugar curve, and this is the only way I can get it, and I believe this is right. This is what everythone says, so I just have to do it despite what my body’s telling me.”
Like you said, I got increasingly malnourished, despite gaining weight, and it took a long time before I finally said, “This is enough. This is not right for me.”
Dr. Stephanie Estima: And many women get scared of the carbs. That’s the other piece. You go on keto. Let’s say you bring your carbohydrates down to whatever level—10% or whatever it may be—and then women will lose weight and think, Ugh, it was the carbs all along. Then we develop this disordered approach to carbohydrates. We now think we can’t have carbohydrates anymore because they’re not good for us, and if we have carbohydrates, that’s just the worst thing in the world.
I have a conversation with that woman almost every week now. We put some carbohydrates back in her diet and she says, “I don’t know what the hell we’re doing, but I’m losing weight.” I think, of course you are, because you need carbs because your thyroid is dying. Insulin is the hormonal response to consuming glucose. Carbohydrates break down into glucose, and then insulin is released from the cells in the pancreas. Insulin is a requirement to convert inactive hormones of thyroid T4 to the active hormone of thyroid, which is T3.
If you are constantly insulin deficient because you’re not having any glucose whatsoever, first, because glucose is so important, your body has the ability to create its own glucose through a process called gluconeogenesis. But you are going to now compromise thyroid function, which is an essential organ—it’s an essential endocrine organ for your metabolism.
The goal of your thyroid is to help get substrate. Active thyroid hormone gets substrate—glucose, or amino acids, or free fatty acids—to any cell in the body. When thyroid hormones and the thyroid gland are working the way they should, this is how we get substrate into the cell to create energy.
Feeding the Female Body, and Getting Enough Protein
Dr. Lauren Kelley-Chew: Let’s say a woman is on a keto diet, and now is realizing she needs to reintroduce carbs. When you start to cycle women back onto carbs and maybe going off and on from lower carb to higher carb, how high are the carbs? Are we talking about eating rice again? Or is it more just vegetables that are higher in carbs? Are we full on eating pasta again? What is the situation?
Dr. Stephanie Estima: For a lot of women who’ve been on the ketogenic diet for a long time, there is quite a bit of insulin resistance, because there has been no need for this insulin to be around. We actually become a bit insulin resistant. When we start to reintroduce carbohydrates for a woman who’s been on the ketogenic diet—let’s say an overly restrictive ketogenic diet—for a long time, I usually like to start with complex carbohydrates—things like yams, sweet potatoes, and root vegetables. Squashes are really great as well. Squashes, actually—I just learned this—are technically fruits because they have seeds.
Dr. Lauren Kelley-Chew: Wow. I did not know that.
Dr. Stephanie Estima: I didn’t know that. I thought they were vegetables. Squashes are really great: spaghetti squashes, butternut squashes, all these things. And of course, you can’t eat those raw. Those have to be steamed or roasted. Those are really great places to start.
I have rice and pasta now. I don’t have piles and piles of it, but I do have some on the side of my plate, but that’s usually the last thing that I eat. Dr. Casey Means was on my show, and she talked about the value of nutrient timing. We were talking about this as a function of the postprandial glucose curve.
She was talking about how, if we consume fat and protein first and then the carbohydrate, because of the speed with which these foods get spilled into the bloodstream, this is actually a beautiful way to decrease the amplitude of that post-meal blood glucose spike.
Dr. Lauren Kelley-Chew: That makes sense. How about protein? You’ve talked about how many women are under-fueling on protein. What are the best sources of protein? I have a lot of friends who are trying protein powders. People talk about collagen as being the miracle supplement. What is your approach to protein?
Dr. Stephanie Estima: For me it depends on what the protein is being used for. When we think about body recomposition, we’re thinking about putting on more muscle. If there are goals you are setting for yourself over the long term, maintaining the muscle that you have or creating new muscles should be part of that. For that specific purpose, collagen is not the answer. The answer is going to be more in animal-based proteins or foods that are rich in leucine. I am a big fan of animal proteins.
I understand that there are people who don’t like to eat animals for a variety of reasons. You may be vegetarian, or you may be vegan. I think you can still get there. You can still meet those minimum protein requirements for the purposes of creating new muscle. I just think it’s much harder. You really do need to do your due diligence to make sure you’re getting the full complement of essential amino acids when you’re consuming, let’s say, plant foods that have protein, like legumes and beans, which are great sources. They are great plant sources of protein. You do have to be mindful that they also have carbohydrates. Beans have a higher percentage of carbohydrates than an equivalent piece of chicken breast or lean ground beef or something like that. And you have to usually consume a lot more.
You mentioned powders. The animal-based powder would be whey, like a whey protein powder. Typically, when you’re looking at most whey, there’s going to be some variability brand to brand, but in one scoop, there’s somewhere between 20 to 25 grams of protein, of which about 10% is leucine—two to two and a half grams of leucine. That’s about the minimum requirement we need to start that process of muscle building. There’s a process in the body called muscle protein synthesis—creating new muscle proteins. You need about 2.5 grams of leucine to start the process.
A lot of protein powders that are vegetarian or vegan might be a rice protein, or a soy or pea protein. Those are the big ones I see. They have a much lower percentage of leucine. In order to get that 2.5 minimum viable dose to start that MPS, that muscle protein synthesis, you’re going to need to take two scoops—sometimes three—of the protein. You also have to consider the calories you’re taking in. Many vegetarians and vegans have a hard time modulating their calories in order to get the amount of protein they need. Animal proteins are by far my favorite.
There are a lot of problems with the way animals in the conventional feedlots are raised. I am in full agreement with some of the ethical arguments brought up by vegans, in terms of the way animals live and the way they’re killed. I am a big fan of regenerative agriculture. Maybe that’s a different conversation.
I eat a lot of animal protein. I understand and I’m grateful for the sacrifice that that animal has made in order to sustain my life. I recognize that that’s what’s happening. I think that is the best protein source, if we are thinking about it in the context of body composition.
If we’re thinking about beauty, which I also am really into, collagen is actually great. We all want shiny hair and strong nails and glowy skin, and oral collagen supplementation does seem to be a great way of achieving that. I’m not so sure about the creams that say they have collagen. But with oral supplementation, studies show that after three months of continued supplementation, there is a statistically significant difference in terms of bumping up the amount of collagen in the skin, hair, and nails.
From an aesthetic point of view, you might say, “Yeah, I’ll put a scoop of collagen in my protein shake.” And then from a body composition point of view, you might opt for one scoop of the collagen and then the other scoop will come from the whey protein or whatever the source you’re using is.
On Fasting and the Importance of Listening to Your Body
Dr. Lauren Kelley-Chew: What are your thoughts on intermittent fasting for women and men? I’m especially interested in it as a tool for women. I didn’t try intermittent fasting for very long, but it felt very stressful to me, not simply because I was outside the habit of what I normally eat. It really felt stressful in my body. I’m curious how you approach IF, and if there are signs that it is helpful for some women and maybe not for others.
Dr. Stephanie Estima: You’re going to hear me say the same thing in a different way with everything: It’s a tool. You can pull some levers with fasting to have some really great changes in metabolism, and then it can be taken to the extreme. I’ve had women say to me, “I do cardio seven times a week and I’ve been doing keto for three years and I fast for 16 hours a day and I don’t know why I’m gaining weight in my belly.” Fasting can also be overdone.
Again, women are exquisitely sensitive to our internal and external environment. For a woman in her reproductive years, fasting—meaning you’re not consuming any calories—for 16 hours a day every single day: I am not a fan of that. In the vein of openness and honesty and transparency, I used to do that. I used to see all the guys online I really looked up to—all the keto experts and medical doctors—and I thought, Gosh, they’re doing a seven-day fast. I should do a seven-day fast.”
I didn’t take into account where I was in my cycle, or that I’m not a man. As you were saying, it felt really, really stressful. A couple years ago, I was moving homes and I had decided—no brains that week—that it would be a really great time to fast. Not only was I taking boxes up and down, unpacking—moving is the most stressful thing—but on top of that, I was adding another stressor: I was not giving myself any food.
About five days into the fast, I thought I was going to pass out. I felt so lightheaded, and then I caught myself and thought, What am I doing? Why don’t I just eat? Why can’t this be more of an intuitive thing? For someone who is very metabolically ill—and this is actually a large percentage, unfortunately, of the population—fasting can be a really great tool. It can also be a great tool for women who are estrogen dominant, as I was. But I’ll just put that off to the side for a moment, because there’s a different way I like for those women to fast.
I know that there are different recommended ranges for fasting glucose. Some traditional doctors might say anything under a hundred milligrams per deciliter is normal. I actually like a fasting blood glucose level somewhere in the high seventies, low eighties. But people who have blood sugar dysregulation, or PCOS, which often has its roots in hyperinsulinemia, respond beautifully to fasting, where you’re not consuming any calories for maybe 12 or 14 hours, even 16 hours. Depending on the severity of the case, it might be 24 hours.
I wasn’t so metabolically unhealthy, and a five-day fast was not something that was right for me at that time. I was just doing it because I thought, I want to keep up with the guys. If they can do it, I can do it. There was literally no reason for me to do it.
For women with more hormonal derangement, like androgen dominance, let’s say, or blood sugar dysregulation, fasting can be a really great tool. I want it to be gentle. I don’t like long fasts. I used to really like them. I’ve softened in my approach quite a bit. In that same vein, we are much more sensitive to our environment. If you take away food to a body that is trying to develop and mature a follicle, you are going to impact ovulation. We want to be very mindful of some of the physiological differences and the physiological demands that a woman has that are separate and unique and distinct from that of our male counterparts.
I’m raising three sons, so I love men and I want to raise three strong, beautiful men. They have their own set of problems, like decreasing testosterone. There’s an estrogenization that’s happening with men, and a testosteronization that’s happening with women. For women, we want to be much more gentle in our approach across the board.
If you’re someone who’s fasting for 16 hours every single day without consideration for your cycle, maybe I’m wrong, but I would invite you to just consider why you feel like that’s necessary. There are certain times of the month as we go through our cycle where we are less hungry, which is typically in the first two weeks—the follicular phase, which is all about the follicle. The whole point of the first half of that cycle is to develop one follicle so that it can release an egg.
We typically are less hungry on bleed week, and the week before we ovulate. Then we’re hungrier after we ovulate. There are a few reasons for that. Under the influence of progesterone, which has a stimulatory effect on appetite, we tend to be a bit more inflamed. If you have estrogen dominance, you can be a bit more inflamed. You can’t get your ring off, you feel like you’re holding water, tender breasts—that kind of thing.
In the second half of our cycle, fasting should be much gentler. In the first half, you can afford a 24-hour fast if you want, or a 16-hour fast, but it shouldn’t be the same all the way through. If you are someone who suffers from PMS, as I did for many years—tender breasts, mood changes, sleep dysregulation, you’re hot, you’re cold, your husband can’t do anything right, your children are driving you nuts—I recommend a different type of fast. I talk about this in my book, but I call it a caloric-liquid fast. We’ve been talking about a non-caloric fast—the water, the coffee, the tea. That’s what I would refer to as a non-caloric liquid fast. A caloric-liquid fast would be a bone broth or a protein-sparing fast, where we are having things like collagen
You may be having bone broth, which is going to give you a lot of collagen; it’s going to give you a lot of glycine, which is really important. A lot of women with estrogen dominance report GI dysfunction—gassiness, bloating, distension—in that second half of the cycle. Consuming a lot of bone broth—in a minestrone, or in chicken soup—you’re still getting some proteins, and you’re getting a lot of the reparative proteins we were talking about, like collagen. When you break down collagen, you have the glycine and some of these other amino acids. For women who experience a lot of estrogen dominance, that’s how I like them to fast, and it’s usually in the second half of their cycle, where they might have a day of just bone broth, or minestrone or chicken soup, where you’re still getting protein and some calories.
Some fasting purists may say that’s not a real fast, and I’m fine with that. You’re still getting some calories, but you’re giving yourself a bigger bolus of some of these proteins that are going to be reparative and healing to that inflammatory process a lot of women can experience.
Dr. Lauren Kelley-Chew: I love that you refer to it as healing, because I think that’s the piece that often gets missed. Like I said, I will do whatever it is I’m supposed to do, but it doesn’t necessarily feel healing or restorative. I know I can do it—I’m going to do it—but the question is, Why?
I love your approach to that. Also, thank you for bringing up the menstrual cycle and the impact that has in terms of how we can optimize our health and how we can use different tools at different times. You have so many amazing episodes on your podcast that really get into the details of this. They’re such amazing resources and tools.
How Women Should Train
Dr. Lauren Kelley-Chew: Growing up, I was a runner. I always equated working out hard and running with cardio, sweating. I thought it wasn’t really a workout unless I was pushing really hard. It’s only more recently that I’ve gotten into strength training and I’ve recognized that as being really, really important. There’s so much confusion, though, from women, and misunderstandings around strength training, whether it’s that they think they’ll get bulky or that they’ll gain weight.
What is your approach to strength training? What are some things you feel like you often have to clarify with your clients? Can training actually replace cardio? If you only have enough time to do something three times a week, should it be strength training?
Dr. Stephanie Estima: These are great questions. I used to be a step instructor. That’s how I paid for my professional schooling. I’m totally dating myself, but I was the step queen. I loved all the choreography and the three-knee repeaters and all the things.
Cardio is important. Cardiovascular work is important. We do need to be thinking about training the cardiopulmonary system as we age, because if you’re not active enough—and a lot of people are not active enough—we see this exponential fall-off in terms of oxygenation capacity. I used to see this all the time in the clinic, where I would just pop on a little oxygen meter on the tip of a patient’s finger, and watch for oxygen saturation. If there’s going to be any problems, you’re going to see it at the distal extremities.
One patient comes to mind. It was around 10:00 in the morning. This patient’s oximeter read 96%. I thought, You’re young, what is happening? I redid it because I thought, The machine’s drunk. There’s no way that this is right. I redid it a couple times, with the same readout. Cardiovascular training is important.
Women overdo it because we’ve been sold this idea that, especially in the context of weight loss, cardio’s going to burn calories. I love that you said how exercise had to be hard. For me, it was like if there wasn’t a bucket nearby—if I wasn’t vomiting after the workout—then it didn’t count. Maybe you can think about, Gosh, what goes on inside that woman’s head for her to think that it has to be that extreme all the time?There are so many women that feel the same way—that if your heart rate doesn’t get up to 180 on the bike, on the Peloton, or in whatever class, and you’re not pushing yourself—then it didn’t count.
Cardio burns calories. But when you are on the bike or you’re running, or sprinting or whatever it is, your body is going to adapt to whatever stimulus you’re giving it. Unfortunately, if you’re going too hard for too long and too often, you will start to use muscle tissue as a source of energy if you’re not fueling yourself properly. If we think about a movement program like Maslow’s hierarchy of needs, what’s at the bottom? It’s strength training. If we’re thinking about movement practices, it’s 100% strength training. This is especially true as we age.
Naturally, as a consequence of aging, if we’re not doing anything about it, we start to lose lean muscle mass, and lean mass in general. Bones start to get thinner and frailer and more brittle. Everything gets smaller if we’re not doing anything about it, if we’re not activating those nerve growth factors. If someone only has three times a week for 45 minutes, I would actually say that 100% of that should be strength training, and then maybe we should be looking at other ways for them to get in low levels of activity throughout the day.
Maybe when they go grocery shopping, they park at the end of the lot and then they have to walk a little bit further. Or maybe they don’t take the elevator; they take the stairs. Or every hour on the hour they get up for a five- or 10-minute movement break. I refer to these brakes as “movement snacks.”
Strength training is important. As we age, the tissue actually becomes less and less receptive to stimulus. As you age, you have to do more to continue to maintain the signal and to maintain the tissue you have. Building muscle is actually very energetically expensive for the body, so it will get rid of it if there’s no need for it.
I would recommend doing resistance training three times a week. If there’s no way someone can do three times a week, I would say two times a week is the bare minimum. If someone only has three times a week, in each of those 45 minutes you can actually design your weight training sessions to also give you a cardiovascular benefit. If I’m wearing a heart monitor when I’m doing legs during the set, when my muscles are under tension and I have that mechanical load, my heart rate shoots right up to 140, 150—sometimes 160. As I’m finishing the set, it comes back down. You can absolutely derive a cardiovascular benefit from training. It’s an efficient way, if you are very limited with time.
Once you get into the rhythm of doing three times a week, if you are working with me, I’m going to try to find another 45-minute session somewhere for you to get to four. Three is pretty good. I would say that’s the minimum viable dose to maintain that mechanical signal that’s telling your body, “Hey, this tissue is important. We need to protect it.” Four is better.
Dr. Lauren Kelley-Chew: Strength training has definitely been an inspirational thing for me to try to incorporate, because in addition to the health benefits, which I think are undeniable at this point, I also just feel better when I feel strong. I never realized, especially as a runner, how weak my upper body has been my whole life. Unfortunately, I think sometimes that’s glorified in women—that concept of being really thin. It really doesn’t feel good.
Dr. Stephanie Estima: I could not agree with you more. I’m speaking to my own type-A personality, and probably to the type-As who are listening. If there’s one thing that I don’t like, it is not having control. If I’m traveling, I want to be able to grab my own bag. I think about it from that perspective. I love feeling strong.
I can punch out about seven pullups right now. I want to get to 12 by the end of the year. That’s my own personal goal. There’s nothing more satisfying than being able to pull up your own body weight. There’s that self-trust, there’s that love for yourself. There’s that reverence you have for your body. You feel so happy and proud.
I’ve been weight training for decades at this point. I’ve competed in shows and stuff. I originally got into it because I wanted to look good; I wanted to look good in a bikini. But what’s kept me here is some of the mental benefits around feeling strong, and learning about what I’m capable of. You want a personal development program? Build a body. Try to put on muscle, because there’s going to be days when you wake up and you’re not going to want to train and you have to do it anyway. It’s on your schedule. It’s set: This is what I have for the week.
There are mental benefits of weight training: self-love, self-acceptance, learning to modify. I have really long femurs, so I have to change the way I squat in order to squat low enough, or else I just hit a wall. If my feet are all pointed forward, my hips get banged up, and all my bones are hitting against each other. I have to flare my feet out a little bit. I’ve learned a lot about myself and my mechanics and what I’m capable of and how strong I can get.
I recently joined a gym, actually. I’ve just trained at home for many, many years. It’s a really great feeling to go for the same weights the guys are. I don’t know what it is about that, and maybe that’s just my ego, but I like that I’m doing the same thing as the guy beside me on the bench.
Dr. Lauren Kelley-Chew: Oh, completely. Like you said, to feel that you have your own power, that you have control over your body, that you have strength. My current goal is to do 20 clean, really good pushups, and I’m almost there. It’s not a huge goal. But it’s something where I thought, I should be able to do 20 pushups. In my opinion, every woman should be able to do that. And next up is pullups for me. I’m going to take inspiration from your goal.
Dr. Stephanie Estima: I love that.
Dr. Lauren Kelley-Chew: Thank you so much for coming on. Like I said, there is so much information that you share on your podcast that is so valuable. We didn’t even get to touch on many things, whether it’s menopause, more hormonal stuff, and specifics around ideas and tailoring for women. There’s just everything on there: mental health, sexual health. I really, really appreciate everything you’re doing—all the conversations you’re putting into the world.
Dr. Stephanie Estima: Oh, thank you so much, Lauren. I had such a great time. Happy to come back, if there’s a need or desire for it.
Dr. Lauren Kelley-Chew: In the meantime, where can people find you?
Dr. Stephanie Estima: The podcast, as you’ve mentioned, is called “Better with Dr. Stephanie.” I wrote a book about a lot of the concepts we talked about. It’s called, The Betty Body, named after the “Better” show. My “Better” fans often call themselves Bettys, and I was like, “Oh, that’s cute.”
The Betty Body goes into balancing your hormones and thinking about diet and training and sleep and all of that. And then I’m pretty active on Instagram. You can find me @dr.stephanie.estima. I try to post there almost daily. Sometimes the day gets away from me, but I’m usually there several times a week.
