#147 – What half of women in America will die of, and how to prevent it | Dr. Sara Gottfried & Dr. Casey Means

Why do women have a higher risk of metabolic dysfunction and cardiovascular disease than men, and how do women move forward as empowered patients with their clinicians? Levels Co-Founder and Chief Medical Officer Dr. Casey Means and Levels Advisor, physician, professor and author of four New York Times bestsellers Dr. Sara Gottfried sat down to talk about how metabolism and trauma play a role in cardiovascular disease and why women should care about metabolic health.

04:00 – Why women should care about metabolic health?

Women are more at risk for metabolic health conditions than men, and they need to take it seriously.

There’s a lot of reasons why women should care about metabolic health. I would say the first is, women are more vulnerable than men. So we’re going to get into the details of that today. But I think a lot of folks have this misunderstanding that men die more of cardio metabolic health, and it’s just not true. In some ways the men keep getting better, and those benefits are not equally applied. So that’s the first reason. The second reason is that what you measure improves. So I don’t want for women or men to outsource metabolic health to their physicians, to their healthcare professionals, because the more that you can take it on yourself, I think that’s what really makes the difference in terms of improvement and preventing some of those riskier, scarier diagnoses that we’re going to talk about today. Another reason is that when metabolic health declines, it’s mostly silent.

10:47 – Metabolism

When your metabolism is working for you, it’s not just about the number on the scale. It’s about your vitality and vibrancy, how you feel waking up in the morning and what you’re able to accomplish throughout the day.

So metabolism is the sum total of all of the biochemical reactions in your body. And the more that you can hold it that way you realize that aliveness, feeling like you wake up in the morning with just a sense of vitality and vibrancy. You love the work that you’re doing, that you’re animated by it. That depends on metabolism. It depends on these biochemical messages and signals in the body going from one part of the body to another, and having these signals work on your side. So when they start to falter, which is really the default in our country, you and I talk about this all the time, that 88% of Americans are metabolically unhealthy. So if the default is that you start to lose your metabolic health, you got to turn it around so that you can really access that vitality.

11:46 – A holistic take on metabolism

A holistic assessment and intervention are needed to improve metabolism.

I love that framing of this is not just some, really simplified version of metabolism is how quickly we burn calories. It’s literally the sum total of every single chemical reaction happening. And that is complex. And it takes a holistic framework to both assess what might be making metabolism go off the rails in a particular patient, and what interventions might need to be incorporated to improve the metabolism. I always think it’s funny when people talk about how just going low carb could fix metabolism. Because when you’re thinking about the metabolism as such a complex set of chemical reactions, just removing one macronutrient is never going to be the answer. It’s really about building a metabolically healthy body that can do all these things you talk about, the transport of hormones, the cell membrane integrity, all these things. And so I think reorienting people to that bigger picture framework of metabolism is so helpful because in the mainstream, we often just really simplify it.

22:21 – Blood pressure control

The recent SPRINT trial, which looked at blood pressure control, found that a lower blood pressure level conferred greater risk.

So if you look at, for instance, there was a recent trial looking at blood pressure control. This is the SPRINT trial. They found that blood pressure at a lower level conferred greater risk. So that led to some changes in the blood pressure parameters that we like to look at. And that increased risk was shown across the board in men and women. And it was significant in men. It was not significant in women. So that’s an example of some of the bias that comes through. And yet the guidelines apply blanket statements that should be used in both men and women. So those are a few of the reasons. And then there’s just really a lack of awareness about some of these biological underpinnings. So I mentioned that women have smaller coronary arteries, that they’re less likely to have obstructed disease. They’re more likely to have microvascular damage. And so the kind of diagnostic tests, like doing a angiogram, just doesn’t have the same sensitivity and specificity in women compared to men. There’s differences in the way that guidelines are used.

25:54 – Effects of trauma

Dr. Gottfried shared some effects that trauma cause in the neurological and endocrine system that will impact the metabolic health as well.

So trauma affects the immune system, the neurological system and the endocrine system. We think of the psycho immuno neuro endocrine system as the PINE network. So if you just start with trauma, the experience of adverse childhood experiences, ACEs are higher in women compared to men. So this is very well demonstrated that women experience more trauma than men, and it leads to this activation of the PINE network. So this activation of the immune, the neurological, endocrine system, as well as psychological changes that can then impact cardio metabolic health. So I think it’s important to start with that piece, that women have a higher risk of trauma.

36:20 – Becoming more metabolically unhealthy

As the rates for hospitalization from heart attack increase in women, it’s important to acknowledge the risk factors and pay attention to those clues to understand how to manage a healthy lifestyle.

When I was in my thirties I thought that menopause was this cliff that I would fall off of at 51, 52. And that I didn’t have to worry about it until then. And a lot of people have this perception that you don’t have to worry about high blood pressure or having a heart attack until after menopause. But the truth is, if you look at hospitalization for heart attack, the rates are declining in men. The rates in women, from 35 to 54, are increasing. Increasing, 35 to 54. Why is that? Because we are becoming more metabolically unhealthy. And as you said, there are all these clues. We just have to be able to put them together. And I can tell you, most physicians are not thinking along these lines.

45:17 – Seven clinical imbalances

Dr. Gottfried shared the seven clinical imbalances that can lead to different conditions, depending on the individual’s vulnerabilities, genetic vulnerabilities and how they interact with the environment.

So number one is your gastrointestinal system, your gut. Number two is your immune system and inflammatory tone. Number three is environmental inputs. Number four is energy production, and oxidative stress is part of that. Number five is detox vacation. Some of us are great at detox. A lot of us are not, including metabolic detox. Number six is neurotransmitters and hormones. Number seven is structural integrity. And then at the core of the matrix is mind, body, emotion and spirit, which I always like to ask about. But I think it’s important to realize that when you map the matrix on a patient, it gives you this much fuller picture of what’s going on, than sort of a standard history and physical that you and I were taught to do. And another myth that I think a lot of people have when it comes to cardio metabolic health, is that, ‘Well, I eat healthy and I exercise 150 minutes a week, moderately. So I don’t have to worry about my cardio metabolic health.’ And the truth is, once again, there’s this whole silent process that’s happening in more than 88% of us. And the sooner you intervene the better.

52:49 – What you measure improves

Measure and monitor basic biomarkers to help create foundational health in the body.

So start with measure, because it’s not me that says what you measure, improves. I think it was Lord Kelvin or someone like that, but you got to know what your baseline is. If you’re going to assess where you are with your cardio metabolic health, you got to measure it. You got to measure it. So you see where you start. And that could be something as simple as you know, for annual exam, with a primary care doctor, generally you get a comprehensive metabolic panel, you get a fasting glucose, you get what’s known as a hemoglobin A1C. So a three month summary, more or less of what’s happening with your glucose. It can give you a estimated average glucose, which I find very helpful.

01:02:06 – Dealing with trauma

Dr. Gottfried shared some steps on how to deal with trauma.

So with dealing with trauma, I think the first thing is to understand what happened. We know that trauma is modulated by having someone that you trust, that’s listening to you, that can hold you in your experience of trauma. And if you didn’t have that as a kid, then we can do that now. So trauma informed care, it’s not quite the same as just going to a therapist, any old therapist and talking about it. It has to be trauma informed care, because what works for trauma is a little bit different than what works for regular psychodynamic therapy. And what I see with a lot of my patients is that regular therapists who have less of an inclination toward trauma and how that shows up in the therapy relationship, often they reinforce trauma. They don’t resolve it.

01:11:21 – Food until the end

Food is the most important thing you can do for your body.

I would say maybe the final parting words are about coming back to your food. How food is, in my mind, the most important lever when it comes to metabolic health. A lot of people get lost in the details. And if you’re feeling overwhelmed, A, check your cortisol, and B, go back to your food. So really focus on eating in a way that fuels you the best. I think that continuous glucose monitoring is one of the best ways to discern that, but it doesn’t have to be at the cost of a CGM. You could just use a glucometer as a way of really understanding how you react to food. So I would say that’s the simplest message that I have. It’s a core part of this process and it’s the place to start. The most important place. And a lot of people think, ‘Oh, I figured out my food. I did that five years ago.’ But your body is so dynamic, that gene environment interaction keeps changing. So what was ideal for you five years ago might be different than what’s ideal for you today.

Dr Sara Gottfried: (00:00)

When I was in my thirties, I thought that menopause was this cliff that I would fall off of at 51, 52, and that I didn’t have to worry about it until then. And a lot of people have this perception that you don’t have to worry about high blood pressure or having a heart attack until after menopause. But the truth is, if you look at hospitalization for heart attack, the rates are declining in men. The rates in women, from 35 to 54, are increasing. Why is that? Because we are becoming more metabolically unhealthy. There are all these clues. We just have to be able to put them together.

Ben Grynol: (00:58)

I’m Ben Grynol. Part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health. And this is your front row seat to everything we do. This is a Whole New Level.

Dr Casey Means: (01:24)

Hello and welcome back to a Whole New Level. This is Dr. Casey Means co-founder and chief medical officer of Levels. I could not be more excited to welcome Dr. Sara Gottfried back on a Whole New Level. Last year, we had an amazing conversation about understanding predictive markers of metabolic dysfunction. And today we are going to be diving into a topic personal to both of us, and that is women’s health and metabolic health, and her recent research and publication on women and cardio metabolic disease. She just published a absolutely incredible paper about this topic called Women, Diet, Cardio Metabolic Health and Functional Medicine, that we will link in the show notes, and it really is a tour to force on understanding how women have differential risk for heart disease and much higher risk of heart disease than I think we really traditionally recognize in our traditional medical practice.

Dr Casey Means: (02:16)

So before I jump in, let me just share a little bit more about Dr. Gottfried and her amazing history. She is a physician scientist who graduated from Harvard medical school and MIT and completed her residency at UCSF. She also completed a two year fellowship in advanced cardio metabolic health at the Metabolic Medical Institute, and is the director of precision medicine at the Marcus Institute of Integrative Health at Thomas Jefferson University, where she’s on faculty. Over the past 20 years, she has seen more than 25,000 patients, and she specializes in identifying the underlying cause of her patient’s condition to achieve lasting health transformation, not just symptom management. So what we really love to talk about on a Whole New Level. For nearly every patient she designs an end of one trial to provide rapid information on whether the personalized plan is improving outcomes. So it’s really not a one size fits all methodology.

Dr Casey Means: (03:05)

It’s not disease centered. It’s a mission to transform healthcare, one patient at a time. She has four New York Times best selling books, including The Hormone Cure, The Hormone Reset Diet and Younger, her newest book, which is behind me, called Women, Food and Hormones is incredible. And if you’re curious to learn more about that book, we recorded a fabulous Whole New Level episode on it last year, that’s worth a listen. She also is the author of Brain Body Diet, one of my favorite books. These are all some of my favorite books, that it’s all profoundly influenced me. And I’m so excited for us to get to chat today. So before we get into your most recent research, I’d like to start big picture. Why should women especially care about their metabolic health? And I think this is important for both women listening, as well as many men listening, to understand and share with the women in their lives how important this topic is.

Dr Sara Gottfried: (04:00)

There’s a lot of reasons why women should care about metabolic health. I would say the first is, women are more vulnerable than men. So we’re going to get into the details of that today. But I think a lot of folks have this misunderstanding that men die more of cardio metabolic health, and it’s just not true. In some ways the men keep getting better and those benefits are not equally applied. So that’s the first reason. The second reason is that what you measure, improves. So I don’t want for women or men to outsource metabolic health to their physicians, to their healthcare professionals, because the more that you can take it on yourself, I think that’s what really makes the difference in terms of improvement and preventing some of those riskier, scarier diagnoses that we’re going to talk about today. Another reason is that when metabolic health declines, it’s mostly silent.

Dr Sara Gottfried: (05:06)

So you don’t know about it. You don’t know that under the hood, as your glucose is creeping up, insulin, maybe a decade before that, is starting to creep up. All of those things are happening and you may not be aware of it. You may notice a little more belly fat, but there’s this change that occurs, sometimes up to 10 to 15 years before you get a diagnosis or someone tells you, okay, your fast and glucose now puts you in the prediabetes category. So it’s mostly silent, which means that you’ve got to focus on it. And then there’s another piece that I think is important, especially for women, which is, many of these changes start around 35. So what’s up with that. What happens is that women have these really precipitous changes with their sex hormones. So the one in particular that seems to map the most to cardio metabolic health is estrogen.

Dr Sara Gottfried: (06:06)

And as estrogen starts to change as progesterone declines initially after 35, and then the balance between estrogen and progesterone changes, that’s where you notice this significant turn in terms of cardio metabolic health. And of course, insulin gets involved. And then the last thing I would say is that as you lose metabolic health, you lose aliveness. Out of all of these reasons, I would say that’s the one to care about the most, because I don’t know about you, I imagine you also want to be as alive as possible as you get older. Don’t let something that’s so preventable, rob you of that sense of delight and living your fullest life.

Dr Casey Means: (06:55)

Really, at the end of the day, what could be more important? Right? That spark inside of us and that sense of aliveness, I’d love for you to unpack, I think, two things. One is the term cardio metabolic health might be something that people don’t really understand. Why are we lumping cardio and metabolic together? How are these things related? And then the jump to, well, how does this relate to our spark and our sense of aliveness? Can you paint that picture, in your words, of how cardio and metabolic link together, and how that feeds into so many of the other aspects of our life and our health, as fundamental as our spark and our energy?

Dr Sara Gottfried: (07:38)

Well, first, when I first met you, we met at a functional medicine conference. And in functional medicine, what we really believe in is looking at root causes. So we know, for instance, that the system that you and I trained in, where there’s all of these silos of care. So if you’ve got a heart problem, you go to the cardiologist. If you’ve got a problem with your insulin, and you’ve got a diagnosis of diabetes, you go to the endocrinologist who does endocrinology and metabolism. So we know that these silos of care, gut issues go to the gastroenterologist, that they don’t work. Frankly, our healthcare system is broken, and in functional medicine, what we do is we look upstream. So we don’t use those silos of care. We look at these systemic imbalances that lead to problems such as heart disease when you’re in your sixties.

Dr Sara Gottfried: (08:39)

We also know that it’s not like it suddenly shows up, that you have a heart attack at age 65. This has been happening in the background, silently, for decades before that. And so the more that we can address years and years and years before the scary diagnosis, the better off we’re going to be, because that’s when we can really intervene and we can have the best chance of reversing some of these processes that are happening. So you asked about a definition for cardio metabolic health and these conditions that are in the paper. The reason I lump these two things together is because the root cause for cardiovascular disease and the root cause for metabolic disease are the same. So it doesn’t make sense, in my mind, to separate them. And in terms of what they are, these conditions, cardio metabolic conditions, are interrelated, interdependent conditions that affect things like the heart, the cardiovascular system, your blood vessels, as well as your metabolism.

Dr Sara Gottfried: (09:52)

And I think it’s important to realize that the kind of outcomes we’re talking about, having a heart attack, having coronary heart disease, having insulin resistance, developing prediabetes, or diabetes, having high blood pressure, all of these things are linked together. And often one of the common themes is insulin resistance, where your cells become numb to the insulin signal. So that’s why I like to group these together. And then your other question is about aliveness. I would say we got to bust a couple myths here. One myth is that your metabolism is how fast or slow you burn calories. And I think it’s important for all of our listeners to realize it’s so much broader than that. So metabolism is the sum total of all of the biochemical reactions in your body. And the more that you can hold it that way you realize that aliveness, feeling like you wake up in the morning with just a sense of vitality and vibrancy.

Dr Sara Gottfried: (11:06)

You love the work that you’re doing, that you’re animated by it. That depends on metabolism. It depends on these biochemical messages and signals in the body going from one part of the body to another, and having these signals work on your side. So when they start to falter, which is really the default in our country, you and I talk about this all the time, that 88% of Americans are metabolically unhealthy. So if the default is that you start to lose your metabolic health, you got to turn it around so that you can really access that vitality.

Dr Casey Means: (11:46)

I love that framing of this is not just some, really simplified version of metabolism is how quickly we burn calories. It’s literally the sum total of every single chemical reaction happening. And that is complex. And it takes a holistic framework to both assess what might be making metabolism go off the rails in a particular patient, and what interventions might need to be incorporated to improve the metabolism. I always think it’s funny when people talk about how just going low carb could fix metabolism. Because when you’re thinking about the metabolism as such a complex set of chemical reactions, just removing one macronutrient is never going to be the answer. It’s really about building a metabolically healthy body that can do all these things you talk about, the transport of hormones, the cell membrane integrity, all these things.

Dr Casey Means: (12:40)

And so I think reorienting people to that bigger picture framework of metabolism is so helpful. As in the mainstream, we often just really simplify it. And I think that really gets into something in your paper that is just so unique, which is that women, women, one, like you mentioned, are much more vulnerable, than we think, to cardio metabolic disease than is widely recognized, and even more so than men, and for unique reasons that are specific to being alive as a woman, as compared to a man. Can you walk us through a little bit of understanding what that increased risk is for women and what are some of the stats that women need to know about cardio metabolic health?

Dr Sara Gottfried: (13:28)

The stats are alarming. I would say, first of all, we know that in developed countries, half of women will die of mostly preventable cardio metabolic disease. Half, half. How is that possible? Especially since so much of it is preventable. Now, how does that translate into how often someone dies? A woman dies about every 80 seconds in the United States of cardio metabolic disease. Every 80 seconds. So we know that cardiovascular disease is the number one cause of death. But if you look at the top five, most of them are related to cardio metabolic health. So those are some of the stats that I find alarming. There’s a few others that I think are important that are related to this. You asked earlier about cardio metabolic disease. What is it that we’re talking about? So that includes coronary heart disease. It includes having a heart attack like the myocardial infarction.

Dr Sara Gottfried: (14:30)

It includes stroke, diabetes, insulin resistance. And when we look at some of the differential effects, like why are women more vulnerable? We’ll get into the root cause in a moment, we know that for women who have non insulin dependent diabetes, their risk of mortality is quite a bit higher than it is in men. And they start to show vulnerability at much lower glucoses. So for instance, if you look at a fasting glucose in a woman, a woman that has a level of about 110 milligrams per deciliter, she’s going to have vascular damage. Whereas for a man, it takes more like a level of a hundred and twenty five, a hundred and twenty six milligrams per deciliter, before we start to see that vascular damage. So there’s these differential effects. Another one is what’s known as type three diabetes, and that is Alzheimer’s disease. So two thirds of cases of people with Alzheimer’s disease are women.

Dr Sara Gottfried: (15:35)

We think that some of that risk is related to hormonal changes. And then another statistic that I think is important is that women suffer from autoimmune disease at a much higher rate than men. So in general, women have a much more responsive immune system. So that can work in your favor when you get pregnant, it can work in your favor in terms of response to vaccine, but it can also backfire. And that over responsiveness is a way to frame autoimmune disease. And some people even think that cardiovascular disease is an autoimmune disease. Now, one other stat I want to share that I think is so important. I’ve known all of my career about the increased risk that women have compared to men. We’ve known this for 30 years, but awareness is actually declining. So I’m going to get a little [inaudible 00:16:35] here because I think this is something that we can do something about, because we know, for instance, in 2009, when they asked women about the leading cause of death, about 65% of them said, oh, it’s cardiovascular disease.

Dr Sara Gottfried: (16:51)

But more recently, in 2019, a decade later, only 44% of women knew that cardiovascular disease was the leading cause of death. So even with the Go Red for Women campaign that we’ve had, even with all of this public awareness, awareness among women has declined. Now I know we can sometimes get overwhelmed with too many stats, but can I share just one more?

Dr Casey Means: (17:17)

Please. Yes.

Dr Sara Gottfried: (17:19)

So this also was so upsetting when I read it. It Came out a couple of years ago. We know that for a woman who’s having a heart attack, who goes to the emergency room, if she sees a female physician, her chance of survival is two to three times higher than if she sees a male physician. Now I’m not throwing male physicians under the bus. What this speaks to is the female specific awareness, especially that female physicians seem to have. It’s something that we’ve got to change with male physicians, and you might ask, well, what about if you’re a guy and you’re having a heart attack, the survival was the same, whether they saw a male physician or female physician. So that speaks to, not a sex difference, like smaller coronary arteries or this differential effect of glucose. It speaks to a gender difference, which is socially constructed.

Dr Casey Means: (18:23)

That is just absolutely harrowing. And one thing you talk about in the paper, that I think is really worth us chatting about today, because it could be very much life saving, is that women can present differently than men to the emergency room with symptoms of a heart attack. And I do wonder if part of these issues with women not being treated or picked up appropriately for these symptoms is because it’s honestly different, a different list than what we learned in medical school. It’s different symptoms for a heart attack. So could you run through what a woman might experience during a heart attack compared to the traditional signs and symptoms of left sided, chest pain and radiating arm pain to the neck and arm? How might a woman present?

Dr Sara Gottfried: (19:13)

Yeah, there’s a reason why women have different symptoms than men. So maybe we can get into the-

Dr Casey Means: (19:19)

Yeah, I’d love that.

Dr Sara Gottfried: (19:21)

But let’s start first with the symptoms because that’s potentially lifesaving. So with men, we all learned that a man who’s having a heart attack has the classic symptoms that you just described, an elephant is sitting on their chest, severe substernal chest pain right underneath the bones of the chest that radiates to the arm. So that’s what men experience, because they’re much more likely to have obstruction of their coronary arteries, and women are different, in the sense that they’re more likely to have erosion of a clot inside the coronary arteries. They’ve got smaller coronary arteries, they’ve got more microvascular damage. And so their symptoms are more subtle.

Dr Sara Gottfried: (20:11)

So instead of feeling like an elephant is standing on their chest, it feels more like I’ve got some neck pain, or I’ve got nausea, or I’ve got shortness breath, or I’m having trouble breathing. That’s the classic way that presents, nausea, vomiting. I had one patient who presented with syncope. She passed out. That was the only symptom she had of an acute myocardial infarction, a heart attack. So we’ve got to be aware of these subtle differences. For women, they’re much more atypical. They’re not the classic symptoms that we all learned as they are for men.

Dr Casey Means: (20:52)

And why do you think we’re not learning differences in symptoms for women versus men? Because you’d imagine, why aren’t we learning both of these categories in medical school? What do you think some of the root causes are for why? Because this just feels like just the tip of the iceberg. I think there’s so many different conditions for which men and women might present differently and where we might only learn the male category. So what is leading to that?

Dr Sara Gottfried: (21:21)

There’s a confluence of factors. I would say first is the research bias. So women were not included in research routinely until the nineties. That’s shocking to me, but it’s true. So it was assumed that the experience of men and what was found in research studies also applied to women until pretty recently. The other issue is that patriarchal society, women’s lives are not valued to the same extent that men’s are. And so there’s less research money. There’s less of a interest in looking at sex and gender differences. So the funding often goes from this pharmaceutical companies to do randomized trials for the latest drug. Once that drug gets approved, it goes into guidelines. The guidelines don’t always consider some of these differential effects. So if you look at, for instance, there was a recent trial looking at blood pressure control.

Dr Sara Gottfried: (22:28)

This is sprint trial. They found that blood pressure at a lower level conferred greater risk. So that led to some changes in the blood pressure parameters that we like to look at. And that increased risk was shown across the board in men and women. And it was significant in men. It was not significant in women. So that’s an example of some of the bias that comes through. And yet the guidelines apply blanket statements that should be used in both men and women. So those are a few of the reasons. And then there’s just really a lack of awareness about some of these biological underpinnings. So I mentioned that women have smaller coronary arteries, that they’re less likely to have obstructed disease. They’re more likely to have microvascular damage. And so the kind of diagnostic tests, like doing a angiogram, just doesn’t have the same sensitivity and specificity in women compared to men. There’s differences in the way that guidelines are used.

Dr Sara Gottfried: (23:40)

So we know that women are less likely to receive guideline based treatment, even though we’ve already talked about some of the reasons why guideline based treatment might be limited. Another difference is that women have more abnormal coronary artery reactivity. So there can be these changes that you can see that may not be persistent, but this point about having a plaque in a coronary artery and having a obstruction, men are more likely, in general, to obstruct, women are more likely to erode, like erode a clot on top of a plaque. And so it’s that erosion that leads to these more subtle symptoms compared to men.

Dr Casey Means: (24:24)

That statement about angiography potentially being less sensitive in men than women because of the differential physiology is such a fascinating one, because I can’t think of many conditions that aren’t totally gender specific for which we actually diagnose people differently, through different diagnostic testing like that. That’s fascinating to think we might actually need to approach how you assess a patient differently, male versus female. I want to get back to that topic later in the episode, kind of understanding what your picture of an optimal biomarker and diagnostic assessment of a woman would be for cardio metabolic disease.

Dr Casey Means: (25:04)

But I think first I want to talk a little bit more about differential risk factors. Because I think this was such an important part of the paper of that women are having, in many ways, a different experience of life, culturally and biologically than men. And these things can feed deeply into our risk for disease. And you talk about some of the biologic and some of the cultural ones, and I’d love for you to unpack some of those biggies for people listening of what is happening in a woman’s life that can basically predispose us to higher risk for cardio metabolic disease.

Dr Sara Gottfried: (25:43)

Yeah, there’s a lot of them. My next book is about trauma and how trauma shows up for both men and women in ways that are not just psychological. So trauma affects the immune system, the neurological system and the endocrine system. We think of the psycho amino neuroendocrine system as the pine network. So if you just start with trauma, the experience of adverse childhood experiences, ACEs are higher in women compared to men. So this is very well demonstrated that women experience more trauma than men, and it leads to this activation of the pine network. So this activation of the immune, the neurological endocrine system, as well as psychological changes that can then impact cardio metabolic health. So I think it’s important to start with that piece, that women have a higher risk of trauma. Then you’ve got that overlay on top of this difference in physiology that we’ve talked about.

Dr Sara Gottfried: (26:50)

So a lower glucose threshold in terms of oxidative stress, and damage to blood vessels, risk of problems with vision, with retinopathy, problems with the retina, with the kidneys, with blood vessels in general, and then there’s also the hormonal network. So if we talk about hormones in detail, we know that we spoke before about how the change in estrogen that occurs in women over the age of 35 is really sudden and steep. And so, on average, women start to decline in their estrogen production around age 43. And that’s where some women have symptoms. They’ll have hot flashes, night sweats, maybe their PMS gets worse. Their periods get closer together. They might become heavier. They might be lighter. They might alternate, and they never really know what they’re going to have. They can also have some brain changes. They might have some memory issues. They might have more moodiness, like depression, anxiety. All of those relate to your risk of cardio metabolic disease.

Dr Sara Gottfried: (28:02)

So when I was first taught about hot flashes to night sweats, I was taught to medicate them away with hormone therapy in women who are good candidates. But now we know that those symptoms, hot flashes, night sweats are a biomarker of greater cardiovascular risk and potentially greater cardio metabolic risks. There’s less data about metabolism in those folks. It certainly changes the way that glucose is used in the brain. So we know that about 80% of women, starting in their forties, start to decline in their production of glucose metabolism. We can see this with what are known as pet scans, where you track what happens with glucose in the brain and women have this thing called cerebral hypo metabolism, where they just don’t use glucose the way they once did. It’s associated with many of these symptoms, and we think it might be an early sign of, or phenotype, genes interacting with the environment, an early phenotype of what develops later into Alzheimer’s disease.

Dr Sara Gottfried: (29:15)

So the way I describe that to patients is that it’s kind of like your brain slows down, slow brain energy. You’re not on top of your game like you used to be, you can’t multitask, you got to write things down more often. So those are really common symptoms, and women have double the rate of insomnia as men do. You know what’s amazing to me, when you look at the data on insomnia, there’s so much you can do in a woman who’s in the age group from 35 to 50 to help prevent falling down those hormonal stairs. One night a bad sleep is associated with changes in your insulin, changes in your cortisol. So you can imagine if you group together a string of months and then years of poor sleep, how that can decline your metabolic health.

Dr Sara Gottfried: (30:07)

So I’m a big fan of intervening and using hormone therapy in those folks, really, as soon as possible, I try herbal therapies first, but I have a low threshold for using hormones in those women. Another huge difference is stress. So we know that the way that women experience stress, they’ve got higher perceived stress compared to men. And the way that they experience stress can be translated into cardio metabolic function. And it’s much more sensitive and delicate than it is in men. Another issue is pregnancy. So I think of pregnancy as a stress test. It’s a stress test that I failed when I was in my thirties. So I did one of those glucola drinks, where you drink glucose, and then you measure your blood an hour later, the cutoff is 135 milligrams per deciliter for your glucose. I was 134, and I remember my OBGYN saying, oh, don’t worry about it, Sara, just stopped drinking juice.

Dr Sara Gottfried: (31:12)

Well, I wish I had a continuous glucose monitor at that time because I was showing early signs of insulin resistance. And no one was thinking about it. I’m a physician. I wasn’t thinking about it. So we want to be thinking of pregnancy as a stress test, because if you have problems with your blood pressure, whether that’s chronic high blood pressure or pregnancy induced hypertension or preeclampsia, if you have problems with gestational diabetes or a prediabetes story, like I did, if you have a small for gestational age baby, if you have problems with an abruption or there’s a number of other indicators that are known as atypical risk factors for cardio metabolic disease. I see so many patients who’ve had preeclampsia during their pregnancies. I always ask about what happened in pregnancy, because we know that preeclampsia doubles the risk of future heart disease, stroke, and diabetes.

Dr Sara Gottfried: (32:18)

It gives you a fourfold, increased risk, a future high blood pressure or hypertension. And we know that there’s this window of opportunity for these folks, basically until about age 50 to 55, where we want to turn this ship around. So pregnancy is such an important test of cardio metabolic function. Another factor that is important to consider is birth control pills. We know that, that increases cardiovascular disease. We know that it changes the way that you responded to stress. So the control system for your hormones, the hypothalamic pituitary adrenal axis becomes more rigid. So it just doesn’t roll with the punches quite the way it used to. We know that it affects the microbiome. So let’s talk about the gut just for a moment. There was a study from England showing that women receive somewhere more than 60% more antibiotic prescriptions than men.

Dr Sara Gottfried: (33:23)

And that certainly affects the microbiome, the diversity of the microbiome, which can set you up for a range of diseases, including diabetes, autoimmune disease. So we want to be thinking about that. We think the reason why women receive so many more antibiotics is because of our propensity for bladder infections. So we’ve got to be thinking about these sex based differences and also just the time course, the life course of a woman, and some of these differences in vulnerability that give us a window of opportunity to intervene.

Dr Casey Means: (34:02)

Oh man, those are so helpful to hear you list out. I’m hearing several different categories there, which is, one is psychosocial and really just cultural experiences that we might face as women at differential rates than men, that translate biochemically into increased metabolic risks. So that’s things like adverse childhood experiences, natural inclinations towards how stress is processed. I think also caregiver burden was mentioned in the article. Women face a higher rate of that. Then you’ve got hormonal, and not just at menopause, which I think some people do think like, oh, it’s really just menopause. That’s the thing we need to be thinking about for when women kind of go in a bad direction, metabolically, but it’s actually, I think, what I’m hearing you say, it’s even earlier, pregnancy, childbearing age, there’s a lot of clues there and also experiences that can happen during pregnancy that can increase our risk.

Dr Casey Means: (34:56)

Like if you have preeclampsia or gestational diabetes, your risk is higher from there on out for these conditions, post pregnancy. And then lastly things related to medication. So oral contraceptives, antibiotics, the insomnia one is fascinating. These are, I think, great for women to hear and understand because everything that’s an increased risk factor, a [inaudible 00:35:20] risk factor is also an opportunity for intervention and empowerment. And so what’s fascinating to me, listening to hearing you talk and reading the paper is just how much these things are often not brought into the conversation around both assessment and treatment. Certainly we take our standard social history and our medication history when we’re doing our history and physical for a patient, but it’s cursory at best. And it’s, I think, often not actually incorporated in the treatment plan. So I’d love to hear from you, knowing what you know, from your research and publications on this, how do we need to move forward as individual patients who are empowered and a medical community to rethink how we’re assessing patients, and how we’re building our plan for patients in terms of cardio metabolic disease.

Dr Sara Gottfried: (36:14)

I love that question. I want to emphasize a point that you made that I think is so crucial. When I was in my thirties I thought that menopause was this cliff that I would fall off of at 51, 52. And that I didn’t have to worry about it until then. And a lot of people have this perception that you don’t have to worry about high blood pressure or having a heart attack until after menopause. But the truth is, if you look at hospitalization for heart attack, the rates are declining in men. The rates in women, from 35 to 54, are increasing. Increasing, 35 to 54. Why is that? Because we are becoming more metabolically unhealthy. And as you said, there are all these clues. We just have to be able to put them together. And I can tell you, most physicians are not thinking along these lines.

Dr Sara Gottfried: (37:14)

They’re just thinking in terms of their guidelines, well, what’s her LDL? What’s her blood pressure today? They’re not thinking in terms of, oh, something was unmasked in that pregnancy. Oh, she’s struggling with insomnia. Oh, she’s got other atypical risk factors like endometriosis or migraine with aura. So this is where I think it’s important that we try to bring awareness, so that women can partner with their clinicians and really start to intervene as soon as possible. This is the work of precision medicine, where we’re thinking about, not just this lovely woman who’s in front of me, who’s telling me that she wants to lose 10 pounds, but we’re thinking about, okay, what’s going on with her genetics? How is that interacting with her environment? What kind of behaviors are modifying those changes, like what she does with food? And then how do we optimize that gene environment interface so that this woman can live as long and as well as she wants, so that she can have that aliveness that we talked about at the beginning? I think that’s so essential.

Dr Casey Means: (38:31)

Yeah, I think it’s so interesting how that statistic that you just said where women actually, even as early as 35, were starting to see hospitalizations go up, and what’s especially shocking to me is that this is in the face of trends with statin use, which are presumably this medication that is going to decrease LDL cholesterol and solve all our problems with heart disease. Statin use has gone up almost 80% between 2002 and now. There was a [inaudible 00:39:05] article on trends in statin use. And now we’re prescribing about 221 million statin prescriptions per year. And yet heart disease is still the number one killer in the United States. 700,000 people a year dying from it.

Dr Casey Means: (39:19)

Women starting to have more hospitalizations at an earlier age. So there’s sort of a approach outcome mismatch that I think we’re seeing here. And I think so much of what, of course, makes me obsessed with your work is that you approach things very differently, through a much more multifactorial lens. So can you describe how you assess a patient and build this comprehensive assessment, both from a biomarker perspective, but also the social perspective, and then how that feeds into your treatment plan and maybe talk to some of the outcomes that you’ve seen in some of your patients with that approach?

Dr Sara Gottfried: (40:02)

Love that question. And I’m so glad you led with statins. Statins change your risk of insulin resistance. And I’ll bring in… Remind me if I forget to do this. I’ll bring in one of my patients in terms of tracking his continuous glucose monitor and what happened when he started on a statin. But let’s go back to big picture, which is, how do you do this kind of assessment? What are you pulling together? And I’ve got a few different resources that I use here. So the first is, I learned the functional medicine approach. And so I’ve done all the courses that are offered at the Institute for Functional Medicine. I want to give them credit for some of the heuristics that I’m about to talk about. So they’ve got a way of retelling the patient’s story and putting it together to think about those upstream clinical imbalances that, I think, can be very helpful.

Dr Sara Gottfried: (41:02)

And there’s an example of this in the paper, if you want to see how this lays out. So the first is, we retell the patient story. So when I’m listening to a patient, I’m listening for a few specific things. I start first with what are known as the ATMs, antecedents, triggers and mediators. Antecedents are things like your genetics, your family history, your age, and what I’m listening for, especially, is a family history of cardio metabolic disease. So I had a few patients that I saw today who’ve got a strong family history of diabetes. So you can imagine those are the people I’m really, I’m all over their insulin and their glucose and their A1C and their uric acid. But that’s an example of antecedent. In terms of triggers, triggers are things that can influence the course of disease. What I’m listening for is, “I felt totally normal until I became pregnant.

Dr Sara Gottfried: (42:12)

And then in pregnancy, something happened. I just felt like afterwards I gained all this weight and I couldn’t lose it. My metabolism was changed.” And then I’ll say, okay, what else happened in pregnancy? “Oh, I was diagnosed. I had this problem with my glucose test and then I did the three hour test, but that was okay. So they told me not to worry about it.” And I’m like, ding, ding, ding. This is the sign of insulin resistance. And then of course, that woman never gets additional follow up postpartum. So she’s just left to go to the pediatrics services and she doesn’t get that metabolism checked again. Mediators are things that can modify your risk of disease. So that can be things like chronic stress. It can be things like sleep apnea, which is, whenever I see someone with a fair amount of visceral fat or their visceral fat is increasing over time.

Dr Sara Gottfried: (43:10)

To me that is sleep apnea. And it’s so common. It’s not just people who are obese, and it’s really easy to test it at home now. You can do home testing for sleep apnea. Another example is people who have insulin problems. So I’m thinking about antecedents, triggers and mediators. Then I’m thinking about modifiable lifestyle factors. So that’s where I’m asking a patient about things like, what’s going on with your sleep? Do you track your sleep? What’s happening with deep sleep? With REM sleep? Do you have a lot of interruptions? Have you ever measured your oxygen saturation over the course of the night? What’s going on with your connections, your relationships to other people? What’s happening with stress? Are you at a place of U stress?Kind of a normal, healthy amount of stress or do you have too little or most of the time too much? What’s going on in terms of nutrition?

Dr Sara Gottfried: (44:14)

So that’s the thing I care about the most in some ways, because that’s where I like to start in terms of helping people. I take a pretty thorough nutritional history. Oh, and exercise. So exercise and movement. So those are the five categories, basically sleep, exercise, nutrition, stress, and resilience, and then relationships. And then this whole way of taking a patient’s history involves what are known as the seven clinical imbalances. And these are those upstream factors that can lead to different conditions, depending on the individual’s vulnerabilities, genetic vulnerabilities and how they interact with the environment. So the language that the Institute for Functional Medicine uses is a little different than the language that I like to use. Because I just find that patients can understand it better. What I like to… I always have one here at my desk because I use it on every single patient and I’ll just rattle through this.

Dr Sara Gottfried: (45:17)

So number one is your gastrointestinal system, your gut. Number two is your immune system and inflammatory tone. Number three is environmental inputs. Number four is energy production, and oxidative stress is part of that. Number five is detox vacation. Some of us are great at detox. A lot of us are not, including metabolic detox. Number six is neurotransmitters and hormones. Number seven is structural integrity. And then at the core of the matrix is mind, body, emotion and spirit, which I always like to ask about. But I think it’s important to realize that when you map the matrix on a patient, it gives you this much fuller picture of what’s going on, than sort of a standard history and physical that you and I were taught to do. And another myth that I think a lot of people have when it comes to cardio metabolic health, is that, well, I eat healthy and I exercise 150 minutes a week, moderately.

Dr Sara Gottfried: (46:23)

So I don’t have to worry about my cardio metabolic health. And the truth is, once again, there’s this whole silent process that’s happening in more than 88% of us. And the sooner you intervene the better. So I’ll give you a couple of examples. I take care of professional athletes. You would think pro athletes don’t have much to worry about. It seems like they won the genetic lottery. So you know that the map might be sort of empty. The matrix might be empty on them, but that’s not the case. Often they’ve got strong family history of cardiovascular disease. They’ve got family history of diabetes. And so I’m really interested in what’s going on in terms of their gut, how that’s talking to the immune system, what’s happening with their hormones, especially insulin and leptin and adiponectin. So the other thing that happens with pro athletes… I’m doing this systematic review in meta-analysis right now of CGM data.

Dr Sara Gottfried: (47:22)

We know that pro athletes often have much more high blood sugar, hyperglycemia than we originally thought. So another patient that comes to mind is a guy that was started on a statin. So he and I do quarterly blood draws. He really likes to do a quantified self time series. And so he does quarterly blood draws just to track things like his fasting insulin, his HOMA-IR. Hopefully you can explain this maybe in the show notes. We’re looking at glucose, we’re looking at insulin, we’re looking at the relationship between the two. We’re looking at a few other biomarkers that relate to this, like his lipids, and his doctor started him on a statin. And so that was an opportunity to see the before and after when he started on a statin. Now his LDL, the main thing that was being treated with a statin, improved, but at the expense of his glucose and insulin, his insulin went up six X. Nothing else changed.

Dr Sara Gottfried: (48:32)

So that’s an example of this deeper pheno typing, how you can get so much more information, and it may seem kind of overwhelming to go to this extent, but there’s a lot of doctors who offer this type of care. And I also want to emphasize that you can get back to the basics and hopefully we’ll talk about some of the basics when it comes to cardio metabolic health, because it’s not so much that you’ve got this really complex mapping of what’s going on with your entire body. Often the solutions end up being the same.

Dr Casey Means: (49:05)

Such a great overview. For many listening that might be the first overview they’ve heard of what really a functional medicine or precision medicine approach is, which is really, I think, in my opinion, and I know yours too, the way that all medicine should be practiced. Right? It’s looking at really the full, complete picture and how that picture feeds into the core physiology that actually leads to these symptoms and diseases that we label as separate things. But which are very connected by some of these core pathways that you talked about and listed. And I was laughing when you were talking about triggers in the ATMs, because you mentioned, oh, pregnancy was when someone might have felt like something totally went off the rails. And for me it’s like the day I started surgical residency, that was my trigger. I went from being in absolute perfect health, thriving, to a shell of myself. It just felt like all my thoughts went from color to black and white.

Dr Casey Means: (50:05)

I got acne, I got IBS, I got chronic neck pain, blah, blah, blah. And so fortunately I listened to a lot of your books as I was walking to the hospital on my headphones. I listened to Mark Hyman’s books. I listened to [inaudible 00:50:20] books. I feel like it’s the most guardian angel thing that ever happened to me, that somehow I got exposed to functional medicine. And so I’m in the hospital as a surgical resident, listening to all these books on call, on my [inaudible 00:50:32] and realized this trigger thing of, okay, so the day I started, what happened? Well, my sleep became erratic, my stress went through the roof. I started eating cafeteria food all the time. I basically stopped working out, and cool, so if I’m going to fix my body, I have to dial these things back or change them.

Dr Casey Means: (50:51)

And that’s exactly what ended up happening. And I completely restored my health. But I think the key thing that I think about when you’re talking is how the plan for each person might have different levers they have to sort of lean into more aggressively. For instance, now in my life, things are much more under control, but sleep is still an issue for me because I stay up really late. I work well late at night. So for me, the food is dialed in, the exercise dialed in, but sleep, I have got to lean into that lever. And so I think organizing it the way you talked about, where you’re looking at all the levers that could possibly be involved in a particular outcome, like weight or cardio metabolic disease, and then realize, well, what for you are the ones that we really need to lean into or pull?

Dr Casey Means: (51:40)

I think when patients understand that, they can basically be empowered themselves to figure this stuff out. Because it’s a lot for doctors, especially a doctor right now, who’s faced with huge challenges in terms of time and volume to get into all of this. This is the type of thing that I think I want people to hear this, you can learn this and you can actually advocate these things for yourself and lean into a lot of this, even if you don’t have access to a functional medicine doctor. Hopefully podcasts like this, reading books like yours and Mark Hyman’s and David [inaudible 00:52:17] and others. But what I’d love to hear, while it can be very beneficial to be quite personalized on these things and know where to lean in, like you said, there’s a lot of basic things that we can do that basically get us a lot of the way there. So I wonder if you could talk about, what are some of those things that everyone can focus on and implement to really help create foundational health in the body?

Dr Sara Gottfried: (52:44)

Absolutely. So the number one thing I think is to measure. So start with measure, because it’s not me that says what you measure, improves. I think it was Lord Kelvin or someone like that, but you got to know what your baseline is. If you’re going to assess where you are with your cardio metabolic health, you got to measure it. You got to measure it. So you see where you start. And that could be something as simple as you know, for annual exam, with a primary care doctor, generally you get a comprehensive metabolic panel, you get a fasting glucose, you get what’s known as a hemoglobin A1C. So a three month summary, more or less of what’s happening with your glucose. It can give you a estimated average glucose, which I find very helpful. You can look at some other markers of metabolic health, such as your waist circumference, your waist to hip ratio.

Dr Sara Gottfried: (53:44)

On the blood testing side you can look at uric acid. I like uric acid a little bit lower in women than I do in men. I like it less than five in men, somewhere around five to 5.5. And so a lot of the really basic, inexpensive biomarkers can give you a lot of information. Checking your lipids also can be very helpful, but I can tell you, most conventional doctors are going to look at your LDL, they’re going to look at your HDL, look at your triglycerides, maybe your total cholesterol, and just make a quick, yes, no decision about whether you need a statin. They’re not going to be talking to you about how to change the way that you’re eating to affect that. So number one, measure, number two, eat in a way that supports your metabolic health. The way you do that is to understand how food impacts your metabolism. The typical patient that I take care of just assumes that things like eating an apple occasionally, having fruit on a daily basis, eating sweet potatoes, maybe other types of potatoes are really healthy for them.

Dr Sara Gottfried: (54:56)

And it’s often not until you get a continuous glucose monitor, or you get a glucometer, and you check your glucose after eating, that you know that there’s certain foods that really spike you. So I think dialing in your food is such an essential part. That’s number two. Number three, really getting the exercise that you need. I think in some ways, exercises is as close to a panacea as we have, when it comes to your metabolic health. You just got to keep moving. So that same patient I told you about, I feel like I should include some female patients, but that same patient who got started on a statin, one of the things he did during the pandemic is he started exercising three hours a day. So he loves to close all three rings on his apple watch. He’s really focused on walking five miles a day.

Dr Sara Gottfried: (55:46)

He does a period of time in the gym that he has at home. He’s got an elliptical, his wife likes Zumba. So you figure out what you love to do in terms of exercise. I love heavy weights, I like to do heavy weights two thirds of the time that I spend on exercise, about a third on cardio. I think that is associated with the best cardio metabolic health, but we all have to pick what we love the most. And then I would say the fourth thing is related to the mind. So mindset, purpose, meaning, love, connection, dealing with trauma so that your trauma isn’t dragging you around a few paces behind you. And instead you’re able to behave and act from a place that’s very connected and loving. Those are some of the keys that are really important.

Dr Sara Gottfried: (56:38)

I really appreciate this point you made about this trigger for you, when you started surgical residency. And of course you got me thinking about some of my patients and some of the triggers they have. And I remember I was talking to a friend of mine recently, we did residency together, and we were at UCSF and he and I calculated that between the two of us, we had about 2000 veggie burgers over the course of our residency. That is not a good thing to feed your cardio metabolic health. So veggie burgers sounds so healthy, but I can tell you, it was fried in industrial seed oil. It was some kind of weird combination of something that looked like a vegetable, but it was made into a patty. It had a bun that had gluten in it, that had refined carbohydrates. That was not a good thing for my cardio metabolic health. Maybe that’s what led to my problem with the blood sugar two years later when I got pregnant. So you got me thinking about my triggers as well.

Dr Casey Means: (57:43)

Well, those are such amazing foundational things that everyone can lean into to help their cardio metabolic health. You ended on mindset, meaning, purpose and figuring out your trauma that doesn’t drag you around for your whole life. A couple things come to mind. One is that there may be people listening who think, well, I’ve never had trauma. I haven’t had big T trauma, and I’ve had a pretty good life. And I think something I’ve learned over the years, working with patients, working with myself, is that trauma doesn’t have to be something that’s a super, overt, big T trauma type of thing, like a severe adverse event.

Dr Casey Means: (58:25)

Really everyone deals with trauma in some… Living is traumatic in a lot of ways. So I’d love to just hear maybe a little bit about your framework of how you think about trauma, how you talk to patients about trauma and how you counsel them on how to start making headway to unpacking that. Something I’ve come to believe is that foundationally, it’s almost like table stakes for us to get this piece dialed in for us to have the optimal health that we really want to. It’s up there with nutrition and it’s not an afterthought.

Dr Sara Gottfried: (59:00)

Such a good point. I would say almost all the patients that I screen for trauma, their first response is, “Oh, I didn’t have a traumatic childhood.” They want to move on. Let’s get to the recommendations and the supplements that you want me starting on. And I’ll say, well, hold on. Okay. So you grew up in Los Angeles, I’ll tell you about a typical patient. So I had a woman, last week, who was 50 at the time of the visit. And she had started having some problems with her blood sugar. So she had prediabetes and she was coming to see me to try to reverse this. And so I was asking her about adverse childhood experiences, and I had her fill out an ACE questionnaire, and her score, even though she said she didn’t have trauma, was about seven, which is very high.

Dr Sara Gottfried: (59:56)

So she’s got an increased risk of autoimmune disease, stroke, heart disease, all based just on her trauma. You put that together with a perimenopausal transition, so decreased estrogen, in her case. And I think that’s what led to this diagnosis of prediabetes. So as we start to work together, generally what I’m doing first is dealing with the biological issues. So we do [inaudible 01:00:25] experiments. And so we design some [inaudible 01:00:28] experiments to help her with her glucose. We got a continuous glucose monitor on her. We started doing some food experiments. I put her on a cardio metabolic food plan. And we’re noticing what happens to her mean glucose and her glucose variability, her time and range, as we do these [inaudible 01:00:48] experiments. So starting first with six to 12 weeks of the cardio metabolic food plan. Once we’ve got some trust established and she’s noticing that her mean interstitial glucose is starting to come down.

Dr Sara Gottfried: (01:01:02)

Her variability is starting to come down. It was about 25 when we first started working together. She was very spiky, had a mean glucose of about 110. So I’m trying to get her mean glucose less than a hundred initially, standard deviation, less than 15. So once we achieved that goal, I started to unwind what to do about trauma. So there’s a lot of ways to go about dealing with trauma. It’s hard to give just a few bullet points, but I’ll say that, understanding how trauma, small T trauma or big T trauma, as you described, how that gets biologically embedded, I think, is essential. And I think it’s one of our tasks, as human beings, to understand that there’s some people who have trauma and they develop psoriasis and irritable bowel syndrome. There’s other people who have trauma who develop prediabetes. There’s other people who have trauma and it leads to other issues related to that gene environment interaction.

Dr Sara Gottfried: (01:02:06)

So with dealing with trauma, I think the first thing is to understand what happened. We know that trauma is modulated by having someone that you trust, that’s listening to you, that can hold you in your experience of trauma. And if you didn’t have that as a kid, then we can do that now. So trauma informed care, it’s not quite the same as just going to a therapist, any old therapist and talking about it. It has to be trauma informed care, because what works for trauma is a little bit different than what works for regular psychodynamic therapy. And what I see with a lot of my patients is that regular therapists who have less of an inclination toward trauma and how that shows up in the therapy relationship, often they reinforce trauma. They don’t resolve it. So things like internal family systems, IFS, somatic experiencing [inaudible 01:03:08] therapy.

Dr Sara Gottfried: (01:03:08)

These are some specific forms of therapy that really help with resolving trauma, and with getting people to not just be inside their head and cognitively disassociate, but to be able to really experience their full body, which is part of this aliveness that we were talking about at the beginning. And then holotropic breathwork is another really interesting way of working with trauma, with creating an altered state with the breath and with carbon dioxide. And then there’s the whole field of psychedelic medicine, which I know we’re not talking about today, but it’s a really interesting area that probably provides the strongest, most durable effect at addressing trauma. And I’m not talking about taking MDMA and going to a rave. I’m talking about psychedelic assisted treatment, where you’ve got someone who’s really skilled, who’s working with you, to help you with resolving the trauma.

Dr Casey Means: (01:04:06)

That’s an amazing overview. And I hope it really inspires people to think about pursuing some of those roots and really normalizing how that examining some of these things can really be beneficial for almost everyone, because so much of achieving the true foundational health that we talk about has to do with behavior and choices, and so much of behavior and choices stems from mindset and sense of direction and purpose. And so it’s just all so interconnected, and I really appreciate and love the way that you talk about it. So we’ve had a lot of rough news in this conversation about the increased risk for women with cardio metabolic disease, but is there any good news where women are doing okay compared to their male counterparts in regards to metabolic health?

Dr Sara Gottfried: (01:05:02)

There’s a ton of good news. So women tend to live longer. We all know that. The latest data, women live until about age 80. Men, on average, live until about age 74. We’ve got longer telomeres, which are those caps on the chromosomes that seem to be a measure of biological age, as opposed to chronological age. We’ve got this more adaptive immune system, and there’s this greater dynamic range that women have. So there’s something known as the jogging female heart. I love this concept because if you just look at menstruation as an example, cardiac output can increase or decrease up to 20% just through the menstrual cycle. And then when you add on something like pregnancy, it can increase even more. So we sometimes see increases of cardiac output that go from 20 to 50% in pregnancies. So women have this built in dynamic range that is broader than what we see in men.

Dr Sara Gottfried: (01:06:06)

Now, another thing that I think is really interesting is that women are thought to be more social. So in general, when you look at connection, production of oxytocin, women fare better than men. In fact, Shelly Taylor at UCLA did this really interesting study in publication around how women don’t do best with fight flight freeze, in terms of the stress response. They do better with tend and befriend, tend and befriend. That’s the way that women respond best to stressful conditions. And it makes sense, because if you can imagine us on the Savannah and our male partners are off on the hunt, and we’re left in the village or the cave with an infant one hand and a toddler and the other, the protection of the people in our group is really what’s going to help keep us from having problems with predators and so forth.

Dr Sara Gottfried: (01:07:06)

But there’s this other idea that’s more modern, which is social genomics. And it’s this idea that, we think of ourselves as kind of these stable human beings, but the truth is our genetics and the way that our genes talk to our body, our epigenetics, it changes all the time, especially in response to other people. And this made me think of something that I’m going to call the Casey Means Effect, the Doctor Means Effect. So I learned from this guy at UCLA named George Slavich about social genomics. He’s really famous in the field for his work on social genomics and safety cues. And he talks about something in particular related to genetics and how genes are expressed, called the CTRA. And this stands for… Have you heard this before?

Dr Casey Means: (01:08:01)

I have not.

Dr Sara Gottfried: (01:08:02)

So it stands for Conserve Transcriptomic Response to Adversity. And the idea is that we’ve got this tendency, that’s in our genes, that when we’re exposed to adversity, we tend to increase inflammatory tone. So we increase pro-inflammatory cytokines, it helps us fight an infection, like if we get a bite from a predator. But the problem is this can backfire and it can lead to long term, if you’re exposed to adversity and distress, it can lead to other problems like depression or developing cardio metabolic disease. And so I’m really interested in this CTRA and how do we modulate it? And that’s where the Doctor Means Effect comes in. So there was this super interesting randomized trial, that was published in 2017, where they found that you could change the expression of your CTRA most effectively with acts of kindness for others.

Dr Sara Gottfried: (01:09:09)

And you, Dr. Means, are one of the kindest people that I know. And I feel like you figured this out way before George Slavich started to publish data on CTRA. And so one of the bits of good news is that, even if you’re someone who’s got a lot of inflammation or you’ve got cardio metabolic disease, maybe you have a diagnosis, or you’re like me and someone told you had prediabetes, you can start to change this. You can change the way that you interact with the environment. And one of the most effective ways is the way that you relate to other people and with doing acts of kindness, it’s one of the most effective ways to change that transcription of this particular set of genes.

Dr Casey Means: (01:09:57)

Oh my gosh. Well, first of all, thank you. That is one of the nicest compliments I’ve ever gotten. And I also just think that’s such an incredible… I think what I hear you saying is that by being kind and doing acts of kindness, you can literally change your gene expression and the way your genome is transcribed. That should be front page news.

Dr Sara Gottfried: (01:10:21)

It should be front page news. In this randomized trial, they looked at a few other things. They looked at self care and they looked at saving the world. I’ve got a husband who really cares about climate change. Those are not as effective as kindness towards others, the Casey Means Effect.

Dr Casey Means: (01:10:41)

I think it is very much also the Sara Gottfried Effect, and I appreciate that so much, and I’m so grateful for you. And thank you for sharing that beautiful piece of data, because I think it is extra motivating for everyone listening, that going that little extra mile to hopefully make other people’s days brighter can actually impact your own health by changing genetic pathways. That is absolutely mind blowing. Thank you so much for sharing that. So as we wrap up, is there anything big that we missed, that you want to make sure we touch on before we conclude?

Dr Sara Gottfried: (01:11:21)

I would say maybe the final parting words are about coming back to your food. How food is, in my mind, the most important lever when it comes to metabolic health. A lot of people get lost in the details. And if you’re feeling overwhelmed, A, check your cortisol, and B, go back to your food. So really focus on eating in a way that fuels you the best. I think that continuous glucose monitoring is one of the best ways to discern that, but it doesn’t have to be at the cost of a CGM.

Dr Sara Gottfried: (01:12:02)

You could just use a glucometer as a way of really understanding how you react to food. So I would say that’s the simplest message that I have. It’s a core part of this process and it’s the place to start. The most important place. And a lot of people think, oh, I figured out my food. I did that five years ago. But your body is so dynamic, that gene environment interaction keeps changing. So what was ideal for you five years ago might be different than what’s ideal for you today. So it’s an ongoing query that I really want to invite our listeners into.

Dr Casey Means: (01:12:46)

Yeah. It’s such a great point to end on. We’re basically shape shifters. We’re changing all the time. That gene environment interaction is changing all the time, and so our needs are changing all the time, even if we’re under more stress, chronically, for a short period of time. That may require us to increase our input of certain micronutrients to help regenerate our stress hormones or whatnot. It’s amazing. And now, for the first time, we have at least a little bit of visibility into that dynamicism. Right now, really just through continuous glucose monitors and some of the single time point measurements, if we’re getting our blood drawn more frequently and a little bit more in depth than our standard panels. But I think a great point that you brought up earlier is that even using our totally standard, yearly blood work, we can actually still learn a lot, our cholesterol panel, complete metabolic panel, et cetera.

Dr Casey Means: (01:13:40)

So, yeah. And I also think, just in terms of people feeling like, oh, I figured out my diet, my diet’s dialed in. I think I have yet to find a person, I think ever, who actually has it exactly perfect. And so I think there’s always room. There’s always room to keep going down that tunnel. And I would just plug your book, because I think this is really a great resource for helping people who think they figured out diet, but still aren’t getting the results they want, to learn more and to continue that journey. I know it really opened my eyes to new things as well. So I am so grateful for you and your work, this amazing paper that you published, your books, your speaking, thank you so much, Dr. Gottfried, for coming and chatting with our audience today.

Dr Sara Gottfried: (01:14:23)

My pleasure. So good to be with you, Casey.