#203 – Metabolic health strategies for women | Dr. Stephanie Estima & Dr. Lauren Kelley-Chew

The ketogenic diet, intermittent fasting, and other nutritional strategies for metabolic health are unique when it comes to the female body. Hormonal changes over the menstrual cycle trajectory matter. Dr. Stephanie Estima and Dr. Lauren Kelley-Chew discuss women’s metabolic health, how to time nutritional strategies with the menstrual cycle, and why strength-training is key.

Helpful links

Hello Betty: https://hellobetty.club

Dr. Stephanie Estima on Instagram: https://www.instagram.com/dr.stephanie.estima/

Dr. Lauren Kelley-Chew (00:00:06):

When we pull the goal down from like a 10 out of 10, 10 out of 10 up here is like losing 30 pounds, and a one out of 10 is like I’m going to lose one pound, that’s when we can start to layer and we can start to continue that forward momentum, because once you lose that one pound, you’re like, “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.”

Ben Grynol (00:00:35):

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 along the way we have conversations with thought leaders about research-backed information so you can take your health into your own hands. This is A Whole New Level. When the new year rolls around, we often have these thoughts in our head. We have these ideas about what we want to achieve. We set out these aspirational goals, and things feel pretty flat when they start to fall off. And so Stephanie Estima, podcaster and author, she sat down with Lauren Kelley-Chew, head of clinical product at Levels, and the two of them talked about this idea of goal-setting. And when it comes to achieving our goals, when it comes to things like this new year push that we often do, it’s not about being extreme. It’s about being consistent. It’s about making a pact with ourselves. This idea very much brought up in the book “Atomic Habits” by James Clear, the idea of casting votes for an identity of who we are and who we want to become, the way we see ourselves.

(00:01:49):

So we have to focus individually on what works for us. And in the episode, Lauren and Stephanie talked about many different facets of metabolic health: diet, sleep, exercise, and how these micro habits can lead to long-term change if we show up and do them consistently. Anyway, no need to wait. Here’s the conversation with Lauren and Stephanie.

Dr. Stephanie Estima (00:02:16):

Welcome to the show. So excited to have you here. I just finished listening to all of your 2022 best of recap episodes on your podcast, and they are really fantastic. I know you have many fans of your podcast and your work on the Levels team, so we’re all really excited internally to have you on, and I know our audience will learn so much from you.

Dr. Lauren Kelley-Chew (00:02:38):

I’m delighted to be here. Thank you for having me.

Dr. Stephanie Estima (00:02:41):

Let’s jump in. I think as we’re in the new year, a lot of people are thinking about the food they’re eating, the changes they want to make to their health. I know weight loss is on a lot of people’s minds this time of the year. I’m curious, from all of your experience, what are some of the biggest diet misconceptions that you see in your practice?

Dr. Lauren Kelley-Chew (00:02:59):

Yeah, good. When we think about diet misconceptions, I think it’s important to zoom out a little bit and talk about the big picture, because what often happens, the new year comes around, or there’s a wedding that you know that you’re going to be going to, or there’s a high school reunion or whatever it is, and we set these incredibly aggressive goals for ourselves when motivation is really high, right? So it’s like, “I’m going to get into that beautiful wedding dress,” or, “This is the year. 2023 is my year. This is the year when I learn French, lose weight, learn salsa,” whatever it is. And when our motivation is high, we can very much overshoot the target. So we might say, if it’s weight loss, “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,” and what ends up happening, of course, is over the course of that six weeks or 20 weeks or however the timeframe is, life happens, right?

(00:04:04):

The kids get sick, or you have a really big deadline, or you have to travel and you’re off of your schedule again. And so I think that 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, because by week… We’ve all heard the tropes of the gyms are really busy January 1st, then 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, and the reason for that is people go too hard, too fast. And the same is true in diet, right? So you might say, “I’m going to become a vegan this year. This is the year that I’m just going to cut out all meat,” or, “I’m going to do the ketogenic diet this year and no carbs shall pass these lips,” right? And we’re so black and white about it, right? We’re so strict and we adhere so fiercely.

(00:05:10):

We white knuckle, especially for women, and I know we’re going to talk a little bit about how women are different than men when we’re talking about application of diet, but we do it so aggressively that it’s so painful that you just give up. It’s like, “Well, if this is what it is to be keto, I’m having none of it. This is too painful,” et cetera. So I think that that’s the biggest misconception around diets in general, is that it has to be painful, and that you have to do it at 100% all the time in order for it to be effective.

Dr. Stephanie Estima (00:05:44):

I completely agree with that. And I guess what would be a recommendation for people who are listening to this who are saying, “Oh, actually that’s me. I’m guilty of that. I just did that a few days ago?” How do you take the initial goal and modify it to something that is more likely to sustain motivation?

Dr. Lauren Kelley-Chew (00:06:00):

I love this stuff, because this is getting into the belief systems and the mindsets and the behavioral psychology piece of it. So I can say that from people that I have interviewed myself and that I have learned from, and then just my own journey… For all the people that are listening, I am that type A personality. I was the girl that was like, “I’m going to work out 365 times this year. That’s going to be me.” I was that girl as well, okay? 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. So from conversations that I’ve had with thought leaders, BJ Fogg comes to mind, Dr. Heather McKee, who I just recently had on my show as well, she’s a behavioral psychologist out of Ireland, 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, like, “I want to lose the 10 pounds,” or, “I want to be fluent in French…”

(00:07:09):

Some of those things sometimes are beyond your control, like we were saying before, kids, deadline, travel, you get sick, whatever it is, get in the way. But what we can and what we do have control over is the tiny little daily habits that we do every single day. So whereas we don’t necessarily have control over the outcome, we have control over our behaviors. So one of the ways to circumvent the big audacious hairy goal, it’s like, “I’m going to lose 30 pounds this year,” is, well, what does one pound look like? Can I just set a goal to lose one pound? Right? 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 on your plate, you eat 80% of what’s on your plate. That’s a much easier goal.

(00:08:02):

And so when we pull the goal down from like a 10 out of 10, 10 out of 10 up here is like losing 30 pounds, and a one out of 10 is like I’m going to lose one pound, that’s when we can start to layer and we can start to continue that forward momentum, because once you lose that one pound, you’re like, “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 kind of thing. I know that 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, right? And if you’re able to overcome that initial hump, let’s say, then anything above and beyond that is going to be bonus.

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So all the type A ladies and men that are listening, you get extra credit, right? So you’re like, “Oh, I already did this, and now here’s the A plus piece of it,” right? Rather than shooting so high that you need to recruit so much motivation, so many skills and assets, so much drive, it’s like, “Well, I’ve already gone for a 10 minute walk, so what else can I do now?”

Dr. Stephanie Estima (00:09:49):

And something I love that you talked about on your podcast was this idea of the confidence that comes from knowing that 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 this momentum. I think that really spoke to me. And like you, I also am a recovering perfectionist or aggressive goal setter where it feels like… In working in this line of work, it’s so easy to drop back into that where every book you read, every podcast, there’s like 1,000 possible ways you can modify your lifestyle, and it’s like-

(00:10:28):

And you’re like, “I’m going to do all of them.”

Dr. Lauren Kelley-Chew (00:10:29):

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, and there’s no way-

Dr. Stephanie Estima (00:10:35):

It’s like, I got to work. I got to get to work at some point. Yeah.

Dr. Lauren Kelley-Chew (00:10:38):

Exactly. We’re going to go deep into more of these topics, but just two common questions that I hear a lot that I think you can really help in clarifying for the audience. The first one is what is the role of calorie counting for all the people out there that 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?

Dr. Stephanie Estima (00:11:04):

I mean, like anything, any tool can be used for good, and it can be used for your detriment. So in the context of weight loss… And I should also just catch my own verbiage here. 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, right? So whenever we’re thinking about calorie counting, we want to be sensitive. I certainly am sensitive for my female clients and women that I’ve counseled, because like anything, it can vacillate from an appropriate normal use of it all the way up to disordered eating and disordered behaviors that feed into disordered eating and body dysmorphia and eating disorders. So I think that if you are someone who has a history of eating disorders, so anorexia, bulimia, anything like that, certainly you should be working with a professional counselor or someone who specializes in those eating disorders.

(00:12:17):

And you’ll also probably find that those professionals will typically shy away from things like calorie counting, because when we look at anorexia or we look at bulimia, a lot of times these are trauma responses in many cases, but it’s a play for control. And so you can see how if you’re trying to control something, you’re trying to control the food that you’re taking in, let’s say, that can become dysfunctional very quickly. So if you are someone who has an eating disorder or history of eating disorder, maybe you’re working with a professional, I would definitely leave it to the professional to advise you in terms of what you should be doing. But 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. And so I have run a diet for many years. It’s a female-centric ketogenic diet for women. It’s a metabolic intervention. We’ll talk about it, I’m sure, at some point today.

(00:13:31):

But it’s a temporary state. We’re not in keto forever. But in order for you to get into ketosis, you do need to, in some cases, aggressively, in other cases not so much, but with some people you need to really clamp down on your carbohydrate intake, and in order to do that, you need to have a sense of what your carbohydrate intake is. So for those women, I do recommend things like… What’s the one that my ladies like? Carb Manager. No affiliation, just 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’s many of them that I like. So anything that generally counts your calories, it 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 it also gives you a sense of what your nutrient timing or your behaviors are.

(00:14:32):

Again, 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, right? So usually dinner for most people 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, right? I read a stat, I think it was 45% of our calories for most North Americans come after 5:00 PM. So this is something to consider in terms of mirroring back to us when we are consuming our calories. So how much and when I think is also very important. And I’ll say that for me right now, I don’t have an app that I’m actively using, but when I was first starting out on my ketogenic journey and I had a whole 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.

(00:15:39):

And one of the things that you’ll hear me say over and over again, and I’ll probably say it a couple times in our conversation as well, is that the diet that you follow and the habits and the behaviors that you follow when you’re, let’s say, metabolically unhealthy, are not going to be the same behaviors and habits and diet that you follow once you’ve healed that metabolic derangement, or once you are healthier, which is the same reason why you’ll hear me say keto for women long-term is not a good idea. I don’t think that it’s a good idea. I think it’s a nice intervention, let’s say, if someone has a hormonal issue 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.

(00:16:39):

Most women will say, “Hey, 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 a whole host of other kind of symptoms. Thyroid also can go amuck. I’ve also seen thyroid in many, many women who do the ketogenic diet for too long can bonk as well.

Dr. Lauren Kelley-Chew (00:17:07):

Let’s actually dive more into the keto diet. And I want to start by saying I so, so appreciate your bringing awareness to the ways that male and female physiology is different, and that many of these interventions that have been so publicized really are based on studies in men, or maybe work in certain ways in men, and work differently in women. And I think it’s just now that that’s starting to be recognized. So I started keto probably about a year ago, and 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 (00:17:46):

You were licking a celery and putting that into Carb Manager. Yeah.

Dr. Lauren Kelley-Chew (00:17:48):

Exactly. And I had friends who were like, “This can’t possibly be right.” And I was like, “No, keto is right.” And like you described, I think in some ways it was helpful to me, but pretty quickly after a few months I started gaining weight and I never felt good. Can you talk a little bit about your approach to adopting keto for women?

Dr. Stephanie Estima (00:18:08):

Sure. Yeah. I think this is a very important topic, which is also often misrepresented, as you were saying, both in the literature and I would say in the online spaces where diet dogma and even just diet culture is discussed. And I’ll put every type of diet in this category. This is maybe a different question. This is just me pondering and thinking why do people get so crazy about diets? And I think that maybe it’s because, prior to 2023 and maybe in the last call it 30 to 40 years, less and less reliance on religion, right? So less and less people going to church, less and less people in these communal, let’s say, organizations, and so 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 or whatever it is. You’re adhering to something, because I think humans in innately want to belong somewhere to something. We want to belong in community.

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And I think for many years, the church and religious offerings fed that need, and now I think in modern society we aren’t as reliant, let’s say, on our pastors and our rabbis and whomever. And so we are trying to figure out a way to fit in somewhere. And so you’ll find that people will be like, “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. And you see this online. You see really, we’ll say, 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 path. 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, “I was not able to eat plants.”

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Well, there’s some people in the ketogenic and carnivore community that say, “Hey, plants are terrible for you. Plants are going to create oxalates, and plants want to kill you.” And so you hear that and you’re like, “Well, gosh, this person has a bestselling book,” or, “This person has so many followers, they must be right,” or, “They have a couple of impressive letters behind their name. They must be right.” And then I think that we can unintentionally guide people down the wrong path. So for a female-centric ketogenic diet, someone who might consider a female-centric ketogenic diet is the woman that I used to be, so someone who, let’s say, doesn’t have an optimal menstrual cycle. So I wrote about this in my book, but I’ll share with your audience. I used to hate my period. I used to literally feel like it was a curse, like, “This is what happens for being 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.

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I would have to stay the day in bed, severe cramping, lower back all the way down to my knees, couldn’t really function. All of my activities of daily living, I wasn’t able to participate in them, and didn’t think that it was anything to do with the way that I was eating. I didn’t think it had to do with any of my stress levels or some of my unprocessed stressors that I had experienced in my life. And I found the ketogenic diet just naturally through my own interest because my undergraduate degree is in neuroscience and psychology. I’ve always had this longstanding love affair with neuroscience, psychology, the brain. And 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. So keto was a very natural compliment to my already stated interest there. I first started reading about it I’d probably say like 20 maybe 15, 2016 is when I really got really interested in it.

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And I was reading about the history of it. Before there were seizure medications, the ketogenic diet was used to actually control grand mal, tonic-clonic seizures in children, and then of course the advent of medication negated the need for the diet. Insofar as how we might think about the ketogenic diet is restricting and clamping down on carbohydrates temporarily. And the carbohydrates that you do eat is a lot of plants, so that is maybe where I differ from other people. I know there’s more people that talk about this now, Dr. Sarah Godfried and myself. I think she’s an advisor at Levels, but her and I are very, very aligned on this idea that when you are going to do keto for a woman, that the carbohydrates that you’re consuming, if you’re building a plate, it should be colors of the rainbow. We should have a lot of green leafy vegetables like the spinach, the artichokes, the arugula, as you were saying, lots of greens, but then also the peppers and the eggplant and all different colors.

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And then when we are thinking about protein, again, the way that I structure a female-centric ketogenic diet for women is there is a moderate amount of protein. Classical keto would be a four to one where it was like 80% fat, and then maybe the last 20% was split between protein and almost no carbohydrates. I do like about 10% of the diet coming from carbohydrates, all of that, I like it to be vegetables, mostly vegetables, let’s say. Protein is about 20 to 25%. So visually, if you’re watching this, or if you’re not and you’re just listening, it’s just the inner part of the palm. If you look at your palm, it’s like, okay, that’s a serving size of protein. And then the fat is the fill, right? So if you’re looking at the plate and maybe you have some roasted brussel sprouts and you have some arugula, as you were saying, and then maybe there’s a filet mignon or a chicken breast or something like that. And then you can drizzle some olive oil on the top. That’s sort of the fill of it.

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And we have to think about fat being much more calorically dense than both carbohydrates and proteins. It clocks in at nine cals per gram compared to four for the carbohydrates and the protein piece. So very liberally drizzling olive oil can very quickly add up in terms of your caloric intake. So that is, let’s say, a basic formulation of a female-centric ketogenic diet. The way that I like to employ it is that you would do that macro split. We would figure out what your calories are, but you would do that macro split for at least one cycle, so about 28 or 29, let’s call it 29 and a half or so days, right? And then we’d reevaluate and see whether or not we need to repeat that, or we 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 to your menstrual cycle.

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If you’re in menopause, you can still cycle. You just don’t have to be like, “Am I in week one, or am I in week three?” It’s just on and off, right? It’s like one week keto, one week high protein, one week keto, one week higher protein and carbs. So that’s how I like to structure it, and then I overlay a couple of other things on top of that in terms of training and exercise as well with your cycle. But that’s how I think a proper ketogenic diet should be structured for women. Women are exquisitely, I’ll say, orders of magnitude more sensitive to our environment than men are. So we are very sensitive to changes in calories. So if we are calorically restricting for a long time, or 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.

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And so I think that the initial therapeutic intervention where we’re doing keto same, same every single day for a cycle, I don’t like that to be, unless if there’s a very extreme case of maybe there’s like a PCOS patient, or maybe she has Hashimoto’s, let’s say thyroiditis, and carbohydrates are actually aggravated. And there’s a whole reason why that is, and we can maybe get into it. I find 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. And so when we’re giving them a lot of carbohydrates, it can cause a lot of GI distress. So a temporary, double underlying highlighted temporary, elimination of carbohydrates, I found that to be well tolerated with someone with an autoimmune condition. But the goal always with someone with autoimmunity is actually to add those items back into the diet over time. So that’s how I typically structure a ketogenic diet for most women, trying to look through the lens of what’s the hormonal derangement here? Is it estrogen issues, androgen issues, thyroid issues, blood sugar regulation issues?

(00:28:16):

And then tweak it or nuance it for that person. And then once we’ve had that therapeutic intervention, then we move into the cycling, because I think protein is… Even just the word, I’m a word geek. If we break down the word, so protein comes from the Greek word protos and [inaudible 00:28:39], first nutrient is basically what it means. And that’s a shout out to all the Greek people that are listening. I hope my accent didn’t insult you too much, but that’s what it means. It means first, right? And every single cell in the body requires protein for a variety of different reasons, so protein is very important. And so is carbohydrates, especially for women. I’m cool with restricting carbs for a little bit of time, but what ends up happening is… As you were mentioning, you said you tried it and then you started gaining weight. Well, what happens is when you’re restricting the carbohydrate, you were like all you were eating… What did you say? It was arugula was the only thing you were having-

Dr. Lauren Kelley-Chew (00:29:18):

It was arugula with olive oil on it.

Dr. Stephanie Estima (00:29:20):

It’s like, okay, at some point you’re going to become nutrient deficient, if that’s all that you’re consuming. And you’re going to have, as I was mentioning before, some of those metabolic maladaptations, right? Your basal metabolic rate is going to drop. Your caloric expenditure is going to drop. So even if you’re doing the exact same workouts, maybe you’re a runner or you’re lifting weights or whatever you’re doing, you’re going to actually start burning less and less calories doing the same amount of work because your body’s trying to conserve energy, right? Your digestion is going to slow, all these different things that we don’t want to happen when you are overly restricting for a long period of time. So I hope that answers your question. I know I went on a couple of different tangents there.

Dr. Lauren Kelley-Chew (00:30:07):

It does, and it’s so helpful, and I wish that I had heard this exact conversation a year ago. And I think it’s such a reflection of how steeped I can get in terms of what you believe you’ve been told or have read is the healthy thing, because I remember being on keto and it got so restrictive. And there was part of me that was saying, “This can’t possibly be right,” and the other part was like, “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 everything says, so I just have to do it despite what my body’s telling me.” And like you said, I think I got increasingly malnourished despite gaining weight, and it took really a long time before I was finally like, “This is enough. This is not right for me. I can feel it, for sure.”

Dr. Stephanie Estima (00:30:51):

And many women get scared of the carbs. That’s the other piece too, right? You go on keto, let’s say you bring your carbohydrates down to whatever level, 10% of it or whatever it is, and then women will lose weight and they’ll be like, “Ugh, it was the carbs all along. That’s what it was.” And then we develop this disordered approach to carbohydrates. We think now we can’t have carbohydrates anymore because they’re not good for us, and if we have carbohydrates, well, that’s just the worst thing in the world, right? And of course, time and time again, I can tell you that I have a conversation with that woman almost every week now and we put some carbohydrates back in her diet and she’s like, “I don’t know what the hell we’re doing, but I’m losing weight.” And it’s like, yeah, because you need carbs because your thyroid is dying. I won’t get into the whole thyroid mechanics, but I will say that insulin, which is, we’ll say, the hormonal response to consuming glucose. Carbohydrates break down into glucose, and then insulin is released from the cells in the pancreas.

(00:32:00):

Insulin is a requirement to convert inactive hormones of thyroid T4 to the active hormone of thyroid, which is T3. So if you are constantly insulin deficient because you’re not having any glucose whatsoever, first, because glucose is so important, your body has its 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. Part of what active thyroid hormone does is when you’re eating, or even just not eating, any cell on the body we need to get the substrate, the glucose, or the amino acids, or the free fatty acids into the cell, the thyroid hormone. And when thyroid hormones and the thyroid gland is working in the way that it should, this is how we actually get substrate into the cell to create energy.

Dr. Lauren Kelley-Chew (00:33:09):

Yeah. It makes so much sense. And for people listening to this, let’s say they’re on a keto diet, these are women and now they’re realizing they do need to reintroduce carbs, when you start to cycle women back onto carbs and maybe going off and on from a lower carb to a 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? How much carb do you see as-

Dr. Stephanie Estima (00:33:33):

It’s like, are we going to Haagen-Dazs? Is this the question? Yeah.

Dr. Lauren Kelley-Chew (00:33:36):

Yeah, are we full on eating pasta again, or what is the situation?

Dr. Stephanie Estima (00:33:40):

Yeah, I think 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. So when we’re starting to reintroduce carbohydrates for a woman who’s been on the ketogenic diet, let’s say a overly restrictive ketogenic diet, for a long time, I usually like to start with complex carbohydrates, so things like yams and sweet potatoes and root vegetables, turnips, things like that. Squashes are really great as well. Squashes, actually, I just learned this, I didn’t know this, technically a fruit. All squashes are technically a fruit because they have seeds.

Dr. Lauren Kelley-Chew (00:34:26):

Wow. I did not know that.

Dr. Stephanie Estima (00:34:27):

I know, I didn’t know that. I thought they were vegetables. Yeah. So squashes are really great. So spaghetti squashes, butternut squashes, all these things. And of course you can’t eat those raw. Those have to be steamed or roasted, that kind of thing. Those are really great places to start. And taking a chapter from Dr. Casey Means in terms of nutrient timing, I think that it’s important that if you are… And I have rice and I have 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, right? So Dr. Means was on my show and she was talking about the value of nutrient timing, and we were talking about this as a function of the postprandial glucose curve.

(00:35:16):

And she was talking about this idea of fat and protein, if we consume fat and protein first and then the carbohydrate, because of the speed with which those foods exit and they can get spilled into the bloodstream, if you’re having the carbohydrate, the rice or the pasta or the squash or whatever it is last, you’re actually… If you’re concerned about your blood sugar, this is actually a really beautiful way to tamper down or pull down the amplitude of that post-meal blood glucose spike.

Dr. Lauren Kelley-Chew (00:35:48):

That makes sense. And how about protein? I think you’ve talked about how many women are under fueling on protein. What are the best sources of protein? I know 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 in the best sources?

Dr. Stephanie Estima (00:36:07):

Yeah, this is a good question. I think for me it depends on what the protein is being used for, right? So if we are thinking about it from a body recomposition perspective, so we’re thinking about it as I’m a woman who is in her forties or thirties or fifties or whatever, or a man, and I want to be putting on more muscle, which I hope… All my fingers are crossed in terms of that being a goal for everybody listening. If there are goals that you are setting for yourself over the long term, maintaining the muscle that you have or creating new muscles should be part of that. If it is for that specific purpose, collagen is not the answer. The answer is going to be in more animal-based proteins or foods that are rich in leucine. So 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, you may be vegan, let’s say, and I think that you can still get there.

(00:37:14):

You can still meet those minimum protein requirements for the purposes of creating new muscle, being a vegan or being a vegetarian. I just think it’s much harder. You really do need to do your due diligence to make sure that you’re getting the full compliment of essential amino acids when you’re consuming, let’s say, plant foods that have protein, like the legumes and the beans and that kind of thing, which are great sources. They are great plant sources of protein. You do have to be mindful that they also have carbohydrates. Beans have higher, let’s say, percentage of carbohydrates than an equivalent piece of chicken breast or lean ground beef or something like that. And you usually have to consume more. You have to usually consume a lot more. You mentioned powders, right? The animal-based powder would be whey, like a whey protein powder. Typically, when you’re looking at most whey, I mean there’s going to be some variability brand to brand, but most whey is one scoop is somewhere between 20 to 25 grams of protein, of which about 10% of that is leucine, so two to two and a half grams, let’s say, of leucine.

(00:38:38):

And that’s about the minimum requirement that we need to start that process of muscle building. So there’s a process in the body called muscle protein synthesis, fancy names just talking about what it’s doing, just create a new muscle proteins, and you need about 2.5 grams of that to start the process. For a equivalent, let’s say, vegetarian, or we’ll say vegan protein source, let’s say it’s a lot of protein powders that are vegetarian or vegan… They might be a rice protein, it might be soy, pea protein. I’m trying to think of some. Those are the big ones that I see. They have a much lower percentage of leucine. So in order to get that 2.5 minimum viable dose to start that MPS, that muscle protein synthesis, you’re going to be needing to take two scoops, sometimes three scoops of the protein. So you also have to consider the calories that you’re taking in as well. Usually what we find with vegetarians and vegans is that they have a hard time modulating their calories in order to get the amount of protein that they need. So animal proteins are by far my favorite.

(00:39:53):

Now, I know that there is a lot of problems with the way that animals in the conventional feedlots, and I am in full agreement with some of the ethical arguments that are brought up by vegans in terms of the way that animals live and the way that they’re killed and the living conditions. I am a big fan of regenerative agriculture, and I think that that is something that… Maybe 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. So I think that 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 really am into, collagen is actually great, right? There’s been several studies that have looked at three months of collagen supplementation having a statistically significant difference in terms of the amount of collagen in the skin, in the hair, and in the nails.

(00:41:09):

So we all want shiny hair and strong nails and that glowy skin, and collagen supplementation does seem to be a great… Oral supplementation of it. I’m not so sure about the creams that say, “Hey, we have collagen in the cream.” I’m not sure about that. But oral supplementation, the studies do clearly 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 nail. So from a 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, I’ll take one scoop of the collagen and then the other scoop will come, let’s say, from the whey protein or whatever the source is that you’re using.

Dr. Lauren Kelley-Chew (00:41:57):

That makes sense. So it’s a buffet of protein sources there for optimal… Okay, one more diet based question and then we’ll switch gears a little bit. Intermittent fasting for women and men, but I’m especially interested in it as a tool for women. I think my personal experience with intermittent fasting, and to be fair, I didn’t try it for very long, but it felt very stressful to me, not simply because I was outside the habit of what I normally eat, but really it felt stressful in my body. I’m curious how you approach that and if there’s signs that it is helpful for some women and maybe not for others.

Dr. Stephanie Estima (00:42:33):

Yeah. 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 in the same way that 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,” right? So fasting can also be overdone. Again, women, exquisitely sensitive to our internal and external environment. So fasting, in its pure form, there are many different types of fast, but a pure fast is where you’re not taking in any calories. Maybe you have a cup of black coffee or you’re drinking water, or there’s herbal teas. There’s no calories there. Doing that for 16 hours a day every single day, if you are a woman who’s in her reproductive years, I am not a fan of that. And I will say in the vein of openness and honesty and transparency, I used to do that, okay?

(00:43:42):

So I used to see all the guys online that I really looked up to, all the keto experts and medical doctors and all the people, and I was like, “Gosh, they’re doing a seven day fast. I should do a seven day fast,” not taking into account where I am in my cycle, that I’m not a man. As you were saying, it felt really, really stressful. And there was one time, I remember it was a couple years ago, I was moving homes and I had decided… Sometimes I’m like, “Where are the brains?” No brains that week. But I was like, “This would be a really great time to fast,” right? So not only am I taking boxes up and down, unpacking… Anyone who’s ever moved, it’s the most stressful thing, right? And then on top of that, I’m adding another stressor on it, which is I’m not giving myself any food. And there was a point, it was maybe five days into the fast, and I was like, “I think I’m going to pass out.”

(00:44:41):

I felt so lightheaded, and then I caught myself and I’m like, “What am I doing? Why don’t I just eat? Why can’t this be more of an intuitive thing?” So for someone who is very metabolically ill, and this is actually a large percentage, unfortunately, of the population where we might see things like obesity, pre-diabetes or diabetes, cardiovascular disease, any of these big lifestyle diseases… And then for women specifically, women who have androgen dominance, so there’s too me too much testosterone. One of the conditions that can happen from that is called PCOS, or polycystic ovarian syndrome, where we’re sometimes not having regular menstrual cycles. They’re anovulatory. They miss cycles so they don’t know where they are. Fasting can be a really, really great tool. It can also can be a really 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 that I like to fast for those women.

(00:45:51):

But the pure fasting… So it’s the PCOS women, anyone who is overweight, let’s say, who has a higher fasting blood glucose than what they would like. And I know that there’s different ranges. Some traditional doctors might say anything under a hundred milligrams per deciliter is normal. I actually a fasting blood glucose level somewhere like high seventies, low eighties is where I like to see people in the morning. But people who have blood sugar dysregulation, PCOS, which often has its roots in hyperinsulinemia as well, really respond beautifully to more of that pure fast, so where we are fasting for maybe 12 hours or 14 hours, even 16 hours, depending on the severity of the case, it might be 24 hours, something like that. But a five day fast is not something… And I wasn’t so metabolically unhealthy. I was just doing it because I was like, “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.

(00:46:55):

But I think for women where we’re seeing some of these hormonal derangement, like androgen dominance, let’s say, or blood sugar dysregulation, that kind of thing, fasting can be a really great tool. And I want it to be gentle. I don’t like long fasts. I used to really like them. And I’ve softened, let’s say, in my approach with fasting quite a bit with women. In that same vein, we are much more sensitive to our environment. So if you take away food to a body that is trying to develop and mature a follicle, you are going to impact ovulation, right? So 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. And 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. But I think that for women, we want to be much more gentle in our approach across the board.

(00:48:14):

So if you’re someone who’s fasting for 16 hours every single day without consideration for your cycle, maybe I would invite you, maybe I’m wrong, but I would invite you to just consider why you feel like that’s necessary, right? There’s certain times of the month as we go through the cycle where we are less hungry, which is typically in the first two weeks of the cycle, which is called 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 follicle can release an egg. So we typically are less hungry on bleed week and then the week before we ovulate, and then we’re hungrier after we ovulate. There’s a few reasons for that. One of them is under the influence of progesterone, which does have a stimulatory effect on appetite. We tend to be a little bit more inflamed. If you do have estrogen dominance, let’s say, you can be a little bit more inflamed. You can’t get your ring off, you feel like you’re holding water, tender breasts, that kind of thing.

(00:49:21):

So in the second half of the cycle, fasting should be much gentler and much more different. 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. And I wanted to just come back before I forget, to my estrogen dominant ladies. If you are someone who suffers from PMS, as I did for many years, the tender breasts, the mood changes, sleep dysregulation, you’re hot, you’re cold, you’re hot you’re cold, your husband can’t do anything right, your children are driving you nuts, I do a different type of fast for these women. So I talk about this in my book, but I call it a caloric liquid fast. So we’ve been talking basically 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, call it, fast, where we are having things like the collagen, as we were talking about.

(00:50:18):

So 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. One of the hallmarks that a lot of women with estrogen dominance report is a lot of GI dysfunction. So a lot of gassiness, bloating, distension, let’s say, in that second half of the cycle. So consuming a lot of that bone broth, a minestrone, it can be a chicken soup, that kind of thing. So you’re still having some proteins and you’re getting a lot of the reparative proteins that we were talking about, like the collagens. When you break down collagen, we have the glycine and some of these other amino acids in there. Women who experience a lot of estrogen dominance, that’s how I really like them to fast, and it’s usually in the second half of their cycle where we might have a day of just bone broth. It might be just a day of minestrone or a day of chicken soup, that kind of thing where you’re still having protein and you’re having some calories.

(00:51:18):

So some fasting purists may say that’s not a real fast, and I’m fine with that. You’re still having some calories, but you’re giving yourself a bigger bolus, let’s say, of some of these proteins that are going to be reparative and healing to that inflammatory process that a lot of women can experience.

Dr. Lauren Kelley-Chew (00:51:37):

I really love that you refer to it as healing, because I think that’s the piece that often gets missed for people. Like I said, I’ve often been this person where it’s almost like I can set my mind to it and I will do whatever it is that 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 why is the question? And so I really love your approach to that. And 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. And for anyone listening to this, we’re almost out of time, so we probably won’t get to go too in depth on it in this conversation, but you have so many amazing episodes on your podcast that really get into the details of this, so I really encourage everyone to listen to those. They’re such amazing resources and tools.

(00:52:29):

Switching gears a little bit just before we run out of time here. In terms of exercise and strength training, growing up I was one of those people. I was a runner. I always equated working out hard and running with cardio, sweating, that it wasn’t really a workout and exercise unless I was pushing really hard. It’s really only more recently that I’ve gotten into strength training and I’ve recognized that as being really, really important. I think there’s so much confusion, though, from women and misunderstandings around strength training, whether it’s that they think they’ll get bulky or they’ll gain weight. What is your approach to strength training? What are some things that you feel like you often have to clarify with your clients? And 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 (00:53:16):

Oh, these are great questions. So the way that I actually paid for my professional schooling was I was a step instructor, so I’m totally dating myself, but if any of you remember the step, I was the step queen. I loved all the choreography and the three knee repeaters and all the things. Okay. So I think that cardio is important, so I’ll start off by saying that 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 do 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 just a little oxygen meter almost on the tip of the finger, it’s called an oximeter, and we’d be watching for oxygen saturation, because if there’s going to be any problems, you’re going to see it at the distal extremities, right? You’ll see it at the fingers of the toes or whatever.

(00:54:17):

And I remember there’s this one patient, he comes to my mind, and it was like 10 o’clock in the morning, we were doing a new patient and his oximeter was reading out at 96%. And it’s like, “You’re young, what is happening?” And so I redid it because I was like, “The machine’s drunk. There’s no way that this is right.” And redid it a couple times with the same readout. So cardiovascular training is important. I also think that as women we overdo it because we’ve been sold this idea that, especially in the context of weight loss, cardio’s going to burn calories. And it’s like, yeah, when you are a runner… I love that you said it 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, right? I don’t know. And 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?”

(00:55:20):

But there’s so many women that are listening to this that feel the same way, that if my heart rate doesn’t get up to 180 on the bike, on the Peloton, or on the whatever class, I’m at Orange Theory or whatever it is, and I’m not pushing myself, then it didn’t count. And I think that cardio, as I was mentioning, burns calories. But when you are doing the bike or you’re running, or you’re doing 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. So strength training for me is the foundational… If we think about a movement program, and if we think about it like a Maslow’s hierarchy of needs, what’s at the bottom? It’s strength training. If we’re thinking about movement practices, it’s a 100% strength training. Especially, this is true as we age, right?

(00:56:27):

One of the things that happens as we get older, naturally as a consequence of aging, is that if we’re not doing anything about it, we start to lose lean muscle mass, lean mass in general. So we start to see bones start to get thinner and more frail and more brittle. We will pair down the amount of muscle mass that we have. Everything gets smaller if we’re not doing anything about it, if we’re not activating those nerve growth factors, let’s say. So if someone only has three times a week for 45 minutes, I would actually say a 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 through the day.

(00:57:15):

So maybe when they go grocery shopping, they park at the end of the lot and then they have to walk a little bit further and then they make their way through the grocery store and walk all the way back, or maybe they don’t take the elevator, they take the stairs, or there’s a little app on their phone, every hour on the hour they get up for like a five minute or a 10 movement break. Something like that. Movement snack actually is the word that I love to use. So movement snacks. So strength training is important. And the other thing that I will also mention as we age is that the tissue actually becomes less and less receptive to stimulus. So if you’re not doing anything about, it’s almost as you age you have to do more to continue to maintain the signal and to maintain the tissue that you have, right? Building muscle’s actually very energetically expensive for the body to do, so it will get rid of it if there’s no need for it. So I think that when we are thinking about resistance training, I would say three times a week.

(00:58:13):

Well, if there’s no way that someone can do three times a week, I would say two times a week is the bare minimum. And if no one can do two times a week, I’d say, well, one time a week is the bare minimum. If someone only has three times a week, I would say in those 45 minutes you can actually design your weight training sessions to also give you a cardiovascular benefit, right? 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, right? Comes up 140, 150, sometimes 160, and then finishing the set, it comes back down, right? So you can absolutely derive a cardiovascular benefit from training, so it’s an efficient way, if you are very limited in time.

(00:59:03):

And then once you get into the rhythm of doing three times a week, then, if you are working with me, I’m going to try to find another 45 minute session somewhere for you to get to four, because three is good. Three is pretty good. I would say that that’s the minimum viable dose to maintain that mechanical signal that’s telling your body, “Hey, this tissue’s important. We need to protect it.” Four is better.

Dr. Lauren Kelley-Chew (00:59:27):

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 don’t think I ever realized, especially as a runner, my upper body was so weak my whole life. And unfortunately I think sometimes that’s actually glorified in women. That concept of being, I don’t know, just really thin in that way, and it really doesn’t feel good. This is my perspective.

Dr. Stephanie Estima (00:59:56):

I could not agree with you more. And I’m speaking to my own type A personality and probably the type As that are listening, if there’s one thing that I don’t like is not having control. I don’t like not being able to pick up… If I’m traveling, I want to be able to pick my… You know that little rotating thing when you’re waiting for your bags? I want to be able to grab my own bag. I don’t want to have to ask somebody, “Hey, can you help me grab my bag,” or what have you. So I think about it from that perspective. I love feeling strong. My goal this year, 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 stated goal. But 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 that you have for your body. Gosh, I’m so happy I could do this. I feel so happy and proud.

(01:01:08):

And I think when you can initiate that joy and that pridefulness around your body, I mean, that for me is what’s kept… I’ve been weight training for decades at this point now. I’ve competed in shows and stuff, but I feel like what’s kept… And I originally got into it because I wanted to look good. It’s like I want 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 that 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. So I think that there’s, for me anyway, some of the mental benefits of weight training, like the self-love, the self-acceptance, needing to modify the squat to the anatomy of my hips.

(01:02:09):

I have really long femurs, so I have to change the way that I squat in order in to squat low enough, or else I just hit a wall. If my feet are just all pointed forward, there’s a point where my hips are banging up, all my bones are hitting against each other, so I have to flare my feet out a little bit. So I’ve learned a lot about myself and my mechanics and what I’m capable of and how strong I can get. And I recently joined a gym, actually. I’ve just trained at home for many, many years. And it’s a really great feeling as a woman to going for the same weights as the guys are. I don’t know what it is about that, and maybe that’s just my ego, but yeah, I like that I’m doing the same as the guy beside me on the bench.

Dr. Lauren Kelley-Chew (01:02:54):

Mm-hmm. Oh, completely. And just, 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 was like 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, so I’m going to take inspiration from your goal.

Dr. Stephanie Estima (01:03:19):

I love that.

Dr. Lauren Kelley-Chew (01:03:19):

Thank you so much for coming on. Like I said, for everyone listening to this, there is so, so, so much information that you share on your podcast that I think is just so valuable. We didn’t even get to touch on so many things, for people listening, whether it’s menopause, a lot more into hormonal stuff, and specifics around ideas and tailoring for women. I mean, there’s just everything on there, mental health, sexual health. I really, really appreciate everything that you’re doing, all the conversations that you’re putting into the world.

Dr. Stephanie Estima (01:03:47):

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. I know my menopausal ladies, they’re always like, “What about me?”

Dr. Lauren Kelley-Chew (01:03:56):

I would love to have you back, and maybe just something even specifically on that topic, because there’s not nearly enough attention given, and the attention that is given is often negative, which is so, so behind the times. I think that’s the best language to put it. It’s ridiculous the way that we think about these different seasons in a woman’s life from the teenage years all the way through, so I would love to have you on and have a conversation about that. In the meantime, where can people find you?

Dr. Stephanie Estima (01:04:23):

The podcast, as you’ve mentioned. It’s called Better with Dr. Stephanie. So just as A Whole New Level, wherever you are listening to this show, you can find mine as well. I wrote a book about a lot of the concepts that we’re talking about, it’s called, “The Betty Body”, named after the Better show. So my Better fans often call themselves Bettys, and I was like, “Oh, that’s cute.” So we have, “The Betty Body”, balancing your hormones and thinking about diet and thinking about training and sleep and all of that. And then I’m pretty active on Instagram, so you can find me at Dr. first name, last name. So Dr. Stephanie Estima on Instagram. And I try to post there almost daily. Sometimes the day gets away from me, but I’m usually there several times a week.