Hormonal Imbalances Can Ruin Your Life—Here’s How to Fix Them with Dr. Sara Gottfried

Hormones are a fundamental part of how every person’s body works. When they’re out of sync, people can suffer from all kinds of side effects. Hormonal imbalances will affect up to 85% of women at some point in their lifetime and can contribute to infertility, night sweats, sleeplessness, and irregular menstrual cycles, among other things. But the path to balanced hormones isn’t always straightforward. In this episode, Dhru Purohit interviewed Dr. Sara Gottfried about functional versus traditional medicine, the pros and cons of a ketogenic diet, and why metabolic flexibility can help balance your hormones.

18:15 – Correcting your hormones isn’t impossible

Imbalanced hormones drastically affect quality of life, but they can be corrected. It’s much easier to correct your hormone imbalance than it is to keep living with imbalanced hormones.

One piece of hope I want to give to folks is that this may sound like a complicated system, but the truth is correcting your hormone imbalances is so much easier than living with your hormones being out of balance. The way that you correct them is so much less work than the daily struggle when your hormones are not in balance. I think that’s really important to give people the wind at their back to pursue this and to understand, “What’s going on hormonally with your body?” Also, don’t outsource that to your healthcare professionals. I think it’s important for us to know what’s going hormonally individually.

35:31 – Metabolism is more than your weight

Metabolism is much more complex than just a number on the scale, which is why health data needs to be democratized.

Metabolism is not just your weight on the bathroom scale. It’s not just belly fat or how much fat mass you have. I think a lot of people think of it in that more narrow context. Metabolism is much bigger, broader, deeper than that. It is the aggregate of all of the biochemical pathways in your body, and that includes your hormones. So I like to start first with metabolism. I want to make it come alive for my patients. And the way that I do that is through precision medicine. So I really believe that we have to democratize data. We can’t take the annual test for fasting glucose and hemoglobin A1c, and have that just be owned by the clinicians that are taking care of the patient. I think it’s important that we use any means possible to really help people understand where they are on the continuum of health.

42:05 – Don’t sell yourself short

While genetics do play a role in our health, environment is also a major factor. Take control of the elements of your health you have power over.

If you look at the amount of time you spend, in a doctor’s office or a nutritionist office or on Zoom, since that’s what we do so much more now. We know that it’s probably less than 1% of your life, less than 1%. So you have this other 99% of your life where your health is unfolding before your eyes. And if you’re just outsourcing all of the metrics, the understanding of health to that 1%, you are really selling yourself short. So the point that you made about genomics and our idea with genomics, is that genomics may load the gun. I think Francis Collins said this or someone else. “Genomics load the gun, but it’s really environment that pulls the trigger.” And there is almost no condition that is 100% genetic. Environment plays a role in some way or another. The impact of that, the relative contribution, varies from condition to condition. But if you look at something like metabolic health, genomics probably plays somewhere around a 20 to 70% role. So you have this remainder that really is under your power to address.

59:18 – Stress doesn’t have to define you

You have agency over the choices you make in life, so it’s important to take control of factors like stress to get yourself healthier.

When you’re around people who lift you up, light you up, that has all of these benefits. There’s less data on that self-compassion in the way that you talk to yourself, but I imagine that also affects your genomics quite dramatically. We want to be having the best possible conversation with ourselves, especially when it comes to stress. This is one of those places where I think women often get the short end of the stick. Maybe they didn’t have a good stress response modeled for them by their parents. They end up having kids. They’re trying to balance work life and can really be struggling. It can lead to these hormone issues that I then pick up and measure, but I really want people to have the sense of agency that you can talk to yourself in a different way. You can change your perceived stress level, and you can become more resilient. All of that is within your power.

01:08:23 – Be careful about the diets you follow

Juicing, carb-cutting, and keto are some diet trends that, while popular, aren’t always best for long-term health.

A lot of us think that juice is healthy. We think it’s an efficient way to get… Maybe a green juice with celery and apple and spinach is so healthy for you, but we’re really designed to eat those foods together with the fiber. Juice is not the panacea that a lot of people think it is. I think that’s really essential to know. One of the things that I was doing back in my thirties was that I would do these juice fasts, and then I would refeed and I would gain all the weight back. It just wasn’t a helpful thing for me. It set me up for yo-yo dieting and really in some ways ruined my metabolic health. That’s number one. Number two I would say is villainizing carbs. I think we’ve gotten to a place where people hear about low carb diet, they hear about the ketogenic diet, and they think, “Oh my gosh, I just need to cut carbs out of my life. I don’t need carbs. I need protein. I need fat.” Maybe they go on a classic ketogenic diet. I think we have to be really careful about that, because the data looking at folks who follow a classic ketogenic diet, we know that there’s some significant changes that can occur to the gut microbes, to the microbes themselves, plus their DNA, which is known as the microbiome.

01:12:56 – Aim for metabolic flexibility

If you have metabolic flexibility, it means your body can use whatever form of energy you give it, whether that’s carbs, proteins, or fats. It’s the healthiest state for your body to be in.

The definition of metabolic flexibility is the ability to switch between burning carbs and burning fat, depending on what type of fuel is available. You can think of it like a hybrid car that can switch between electricity and gas, depending on the type of fuel that’s available. What happens is that a lot of folks become less metabolically flexible over time because they’re snacking all the time, or they’ve got too much stress, or maybe they’ve got some of those genetic variations that are associated with insulin resistance. They become metabolically inflexible, and they often get stuck in burning glucose, burning carbs.

01:14:35 – The benefits of a short-term ketogenic diet

While keto isn’t great for a long-term diet, if used for a short time it can help reset your hormones and increase your metabolic flexibility.

It’s not that I recommend that people go on a ketogenic diet and stay on a ketogenic diet for long periods of time. What I recommend is using a ketogenic diet as a therapeutic pulse. Typically four weeks, which is what I cover in my book, and then to start to bring more carbohydrates in while you’re tracking metabolic flexibility. You can track it as your ketones. You can use a breath meter like lumen. You can use a continuous glucose monitor. You can use glucose ketone index. There’s many different ways to track this, but what we’re looking for is that ease with which you can flip the switch between burning glucose and burning fat, depending on the type of fuel that’s available. It’s, it’s a powerful way to really see that metabolic flexibility as a human being, as an organism, the human species, has been probably a big part of what has allowed us to become the species that we are. Travel all around the world, be able to think of advanced technologies, be able to expand our brain size, because we had that flexibility as especially at times of major changes in the climate that could affect food sources and other aspects.

01:22:47 – The importance of open-mindedness

While large data sets can disclose overarching trends, it’s important to listen to what your body is telling you. Science requires everyone—patients and doctors alike—to be open-minded.

I was taught at Harvard Medical School that in the hierarchy of evidence, scientific evidence, there is observational studies, there’s expert opinion, anecdotal evidence, which is the lowest. Then there’s observational data, like the nurses health study. Then there’s randomized trials where you’re usually looking at just one intervention, like Metformin to prevent the progression of pre-diabetes to diabetes. And then above that is the n-of-1 experiment. Because instead of looking at populations, we’re looking at you, Dhru, and we’re designing a study to say, “Okay, what happens when you change your exercise in this way? What happens when we define your carb threshold? What then happens to your glucose and your metabolic flexibility?” So that n-of-1 experimentation, I think, is really the key here. And this idea of open-mindedness, I think we often forget this in medicine. Science requires us to be open-minded. Science requires us to change our mind. If there’s evidence that is not supporting what you’re doing and the guideline needs to change, we have to pay attention to that. And there are many times over the course of a career as a physician that you have to change your mind. And if you’re more close-minded, oh my gosh, I really fear for the patients of that particular physician. So I think that open-mindedness in many ways is part of the scientific process, and it’s the scientific method, and it’s essential to anyone who works in healthcare.

01:26:27 – Keto isn’t right for everybody

Dr. Gottfried found that a lot of her female patients really struggled with the ketogenic diet because it wasn’t working best for their bodies.

About seven or so years ago, I suddenly had all of these patients who came to me, who were struggling with the ketogenic diet. So they were early adopters. They were following different thought leaders. They were trying keto, they were doing the macronutrients, they were eating the fat bombs and the bacon, and they just weren’t getting the results that they were hoping for. Often they would do it, they’d do keto with a colleague from work, like a male colleague, and the male colleague would get all the benefits and they were struggling. These were mostly women. So I saw this sex difference. I saw that my male patients were doing a lot better on keto, they were becoming metabolically flexible, and the women were really struggling. And I called them my keto refugees because they were so frustrated and they felt like, “I’m doing everything right. What is wrong? Why is this not happening?” So, as I was struggling on my own with the ketogenic diet, I realized one of the first pieces that’s so important for women is to make sure that those detox pathways are open.

01:41:06 – Don’t suffer in private

Poor health often leads people to suffer in private. But you can achieve more when you reach out for help.

The thing that often gets people in the door is that they’re struggling with their weight and they’re suffering over it. There’s this private suffering, I think, that happens for both men and women. And I think women especially experience it because of some of those gender differences that we have in our culture. So, often it starts with a desire for weight loss. And what I hope is that we’re taking the middle path here, where it’s not just about losing fat, it’s about this much bigger picture of your metabolic health. So in terms of a teaser, I would say paying attention to your metabolic health is the best thing that you can do in terms of supporting those values that are important to you. So I think really owning your metabolic health, taking responsibility for it, that’s what this book is about. I take you by the hand to show you how to do it, some of the hormones that are involved.

Dr. Sara Gottfried (00:00:00):

The truth is correcting your hormone imbalances is so much easier than living with your hormones being out of balance.

Dhru Purohit (00:00:08):

Hi, everyone. Dhru Purohit here. Question for you. Do you have extra belly fat around your waist? Is your hair falling out what feels like earlier or in places that it shouldn’t be falling out? Do you have sleepless nights or breast tenderness? Or is your period irregular? Is your symptoms of PMS super strong? Well, if you you can relate to any of these questions or answer yes, these are signs that you might have a hormonal imbalance, and today’s guest, Dr. Sara Gottfried, has an important reminder for you. She says, “I can tell you without a doubt, you cannot achieve true health without achieving hormonal health and balance.” Today’s interview is about this topic. If you suspect that you have a hormonal imbalance, you want to pay attention. Stay tuned to fascinating conversation.

Dhru Purohit (00:00:56):

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Dhru Purohit (00:05:14):

Welcome to The Dhru Purohit Podcast. Each week, we explore the inner workings of the brain and the body with one of the brightest minds in wellness, medicine, and mindset. This week’s guest is Dr. Sara Gottfried. Dr. Gottfried is a board certified physician who graduated from Harvard and MIT. She practices evidence-based, integrated precision and functional medicine. She’s a Clinical Assistant Professor at the Department of Integrative Medicine and nutritional sciences at Thomas Jefferson University and a director of precision medicine at the Marcus Institute of Integrative Health.

Dhru Purohit (00:05:48):

Today, with Dr. Sara Gottfried, we’re talking all about hormonal balance, and if you feel exhausted or drained all the time, if you’re suffering infertility, night sweats, sleeplessness, irregular menstrual cycles. If you have breast tenderness, if you’ve been diagnosed with cysts or fibroids or endometriosis and breast cancer, these are all signs that you have a hormonal imbalance, and it’s worth it to start asking the questions as to why. Why are these things going on? How can you get to the root?

Dhru Purohit (00:06:23):

Today’s interview with Dr. Sara Gottfried is going to talk about all of those topics and more. She has three New York Times best-selling books, including The Hormone Cure, The Hormone Reset Diet, and Younger. Her upcoming book, which we’ll be diving into today, it’s called Women, Food, and Hormones. I think you’re going to enjoy it. It’s a fascinating conversation. Stay tuned.

Dhru Purohit (00:06:45):

Dr. Sara [crosstalk 00:06:46] Gottfried, welcome to The Dhru Purohit Podcast. It’s an honor to have you here.

Dr. Sara Gottfried (00:06:50):

Hey, Dhru. So happy to be here.

Dhru Purohit (00:06:52):

I’m a huge fan and I’m excited about the new book and let’s jump right in. Hormonal imbalances, they’ll impact by different estimates up to 85% of women at some point in time in their lifetime, but because, or rather I should say and, because hormonal imbalances are so ubiquitous, there is much of the population, not just women, but men, too, that have gotten used to it. It’s so common that everybody just thinks that it’s normal. I’d love to start off with a basic question, which is so important for setting the stage for this conversation. What are examples of hormonal imbalances? How are some of them things that people have gotten used to and they just think it’s a normal part of life?

Dr. Sara Gottfried (00:07:39):

Terrific question. I feel like I want to caution people. Don’t get used to it because there’s so many things that you can do to get these hormones back into balance, starting with your fork. What are some of the most common ones? I would say cortisol, insulin, estrogen dominance, or dysestrogenism, problems with testosterone, problems with growth hormone. These are some of the most common ones that I see. The way that you know you have these are basically with cortisol, the main stress cortisol, the main stress hormone, you know what? A lot of people describe is that they feel overly stressed.

Dr. Sara Gottfried (00:08:17):

Maybe they’ve got high perceived stress. High cortisol has all of these consequences in the body. High cortisol has all of these consequences in the body, including increased belly fat. Can make you feel wired and tired. It can also disrupt some of the other hormones. Another important piece here, Dhru, is that these hormones cross-talk, so you don’t get a hormonal imbalance in isolation. Often, you get sort of a pattern imbalances.

Dhru Purohit (00:08:43):

You have a quote, and I want to read this quote here with our audience because I think it’s a great one for my next question. You say, “I can tell you without a doubt, you cannot achieve true health without achieving hormonal health and balance.” Tell us what you mean by that quote and help us understand what the hell is going on that hormonal imbalances seem to be increasing year over year.

Dr. Sara Gottfried (00:09:15):

Yeah. You know what? What I see in my practice is that people will chase a certain goal, so that could be their weight, like a number on the scale. In my husband’s case, it’s how fast he can do a century. People chase different goals related to health, but I think what I find is that if your hormones are not in balance, if they’re not supporting what those goals are, you’re not really going to get there. We see people, for instance, who are at a normal weight and yet their hormones are out of balance. They’re those so-called… I don’t love this term, but skinny fat people.

Dr. Sara Gottfried (00:09:52):

You know, you can have a fasting glucose that’s relatively normal and yet have metabolic dysfunction because insulin is not working the way that it should be. Insulin is that hormone that opens up the door to the cell and lets glucose in. What happens with a lot of folks is that they have issues with insulin sometimes a decade, even 13 years before it shows up as a problem like type 2 diabetes. I think we have to pay attention to a number of different factors, and hormones drive what you’re interested in. That’s why I got so excited about hormones early my career. It’s why I think it’s so pivotal to one’s concept of health.

Dhru Purohit (00:10:38):

Before we go into your personal story, I want to tease out a little bit because I think hormone imbalance is starting to make its way out there a little bit more with the likes of individuals like yourself, incredible doctors, researchers putting the spotlight on it, but still, I think there’s a lot of people listening that are going through some signs or symptoms and they don’t understand that there’s a connect to hormonal imbalance. Let’s tease this out a little bit more. What are some other things, especially for women, which your new book is really focused in on, that are signs and symptoms that there are hormonal imbalances that are going on?

Dr. Sara Gottfried (00:11:19):

Well, there’s a long list of symptoms. It really depends on which hormone you’re talking about, but if we take a hormone such as thyroid, some of the symptoms that people can have include fatigue. You can have a hair loss, that’s both head hair, also eyelashes, eyebrows. Famously hypothyroidism, or low thyroid function, is associated with loss of the outer third of the eyebrows. You can also have constipation, so gut function is a really important part of this process.

Dr. Sara Gottfried (00:11:50):

Maybe we can talk a little bit later about… You know, I’m an engineer, so I think about the control system for hormones, and when we think about the control system for hormones, it involves the gut. It involves the brain talking to the adrenal glands, talking to the ovaries or testes in men, talking to the thyroid, but also talking to the gut. Constipation is one of those signs of low thyroid function. You can have rising cholesterol levels, dyslipidemia. You can also have cold intolerance.

Dr. Sara Gottfried (00:12:22):

Those are some classic symptoms of a thyroid that’s out of balance. That’s something that tends to affect women much more than men. Women are more vulnerable to hormone imbalances, so I think that’s part of why we especially need to be educated and empowered about it, but men experience a lot of these symptoms, too. They have issues with cortisol. Cortisol problems can lead to low testosterone, which I think has gotten a lot of press recently. Low testosterone in both men and women is also associated with loss of muscle mass, so the way that it can show up is that maybe you’re going to the gym or you’re doing home workouts during the pandemic and you’re just not seeing a response maybe to strength training to to other forms of exercise.

Dr. Sara Gottfried (00:13:07):

Another factor is sex drive, what’s happening with your libido. There’s a number of different hormones that are involved with that, testosterone being the most common, and then there’s mood issues, too. Estrogen, testosterone, cortisol, are all involved in depression, anxiety. I just had a patient last week who was having these really steep glucose excursions on her continuous glucose monitoring. Maybe we’ll talk more about this later, but one of the things that I found was that she would get panic attacks when her glucose was too low, so her insulin wasn’t working the way that it should be.

Dr. Sara Gottfried (00:13:46):

We want to be thinking about this full scope of symptoms, not just sex drive, not just hair loss, but this fuller scope. We know, for instance, that cortisol is a biomarker for depression and suicide, so about half of people with depression have high cortisol levels. Those are a few examples. I could go on. I’ve written a few books about it because I think it’s so common and, unfortunately, this is the part I think that’s very frustrating, I think that mainstream medicine fails people when it comes to hormone imbalances. We don’t look for them. We often don’t test them unless you’re trying to get pregnant and you’re having difficulty. The solutions that are often offered are things like, “Why don’t you take this birth control pill? Sounds like you might have a hormone issue. How about this birth control pill?” Or, “How about this selective serotonin reuptake inhibitor? It sounds like you might hae some hormone issues, maybe a little depression.” We have to be looking at the root cause. The root cause often maps to hormone imbalance.

Dhru Purohit (00:14:55):

It’s fascinating. You know, really the takeaway that I’m getting from that, and I think that the audience is getting from it as well, what you just covered, there are very few things that our hormones do not either intersect with or touch, and because of that, an imbalance that’s there, and many of the things that you read off, the signs and symptoms, many people have multiple aspects of them. You often find individuals who are struggling with extra belly fat and low sex drive and they notice that their hair is thinning, or somebody with super low energy, but then also is noticing one of the other areas that you brought up. It’s so integral, our hormones, that when they’re often imbalanced, there’s a whole host of things that we have names for to describe when our health stops working the way that it should.

Dr. Sara Gottfried (00:15:49):

Dhru, this is what I love so much about your podcast and the way that your mind works because you make some of these things that, I think, physicians often don’t understand is so foundational, you make them really explicit. The point that you’re making, that hormones are involved in so many functions in the body, is such an important part of this conversation. The way I think of it, I think analogies can sometimes be helpful when you’re talking about hormones and complex biochemistry, the way that I think of it is that your hormones are like the text message system of your body.

Dr. Sara Gottfried (00:16:25):

The way that your brain is telling your adrenal glands to make more cortisol, it’s a text message that gets sent through the bloodstream to your adrenal glands. The way that your hypothalamus and pituitary talks to your thyroid to like, “Okay, let’s pick up the clip here,” is again through these text messages. Unless you’re aware of these text messages and kind of how they’re originating, how they’re regulated, how food is such an important factor for them, how other lifestyle choices like sleep and exercise and your stress level, unless you understand some of these factors that are affecting those text messages, it’s going to be really confusing. Once you get sort of those text message idea, these things fall into place and it becomes much easier to say, “Okay, I’m mapping to this particular hormone balance. My metabolic hormones are a mess. Here is how I can fix it.”

Dhru Purohit (00:17:22):

It’s beautifully said, and I often think of it as imagine you’re getting mail and you live in a house, or email in this day and age and you have a notification that there’s a bill that’s coming due for your internet. You miss that bill because that message doesn’t get translated over, so you don’t pay your bill. Then, one day you’re just trying to function and on Zoom or doing an interview like we are here, and then your internet goes out and you’re wondering, “Why did my internet go out?” Or, “Why did the lights get turned off?” Or, “Why is the trash not getting taken out?” These messenger molecules are happening all the time, and if we don’t create the right environment for it, then the messages get lost in translation and a whole host of things end up happening. I’d love to come back to your personal story.

Dr. Sara Gottfried (00:18:10):

Can I say one quick thing about that?

Dhru Purohit (00:18:10):

Please, please, jump [crosstalk 00:18:11] in [crosstalk 00:18:11]-

Dr. Sara Gottfried (00:18:11):

So this… I really love this analogy, too, and I think one piece of hope I want to give to folks is that this may sound like a complicated system, but the truth is correcting your hormone imbalances is so much easier than living with your hormones being out of balance. The way that you correct them is so much less work than the daily struggle when your hormones are not in balance. I think that’s really important to give people kind of the wind at their back to pursue this and to understand, “What’s going on hormonally with your body?” Also, don’t outsource that to your healthcare professionals. I think it’s important for us to know what’s going hormonally individually.

Dhru Purohit (00:19:05):

Thank you for jumping in, and please jump in anytime because you have so much experience working directly with patients and seeing. I’ve seen so many people feel this sense of, “Okay, I know I have hormonal imbalance. I know I can relate to these things that Dr. Gottfried is talking about right now, but if my own doctor doesn’t understand it for the care that I’m getting right now, how the heck am I supposed to wrap my arms around it? There is hope, and your doctor is part of your team. They’re not in charge of you. They’re part of your team and you work in coordination with them, but you’re the CEO of your own health, and with the right information, you can navigate what direction this company, if you’re the CEO, the company is your body, what direction it wants to go in.

Dhru Purohit (00:19:50):

That’s really the hope of this conversation in your book, so I’m excited to jump a little bit more into it. I want to start off with your personal journey. You know, you grew up in a very healthy and progressive family. You had examples of eating whole foods and positive examples in relationship to food and health, from what I understand, growing up. At what point in time did this understanding for hormonal balance, which you’ve written multiple books on, at what point in time did it become real? Did you start to fully understand it on your own personal level that this thing exists and is a problem for many people, including women like myself.

Dr. Sara Gottfried (00:20:35):

It’s a great question, because I would say I was always integrative. I was always looking beyond just a pill bottle to answer the question of, how do I create the best health? It wasn’t until I was in my 30s that I really feel like I got it when it comes to hormones, and what was happening for me, I think, is something that happens for many women especially but men, too. I was struggling in my mid-30s. I was working too hard. I was seeing patients in what I call fondly McMedicine, so I was seeing 30 to 40 patients a day and I was pretty frustrated with that because I felt like I went through, you know… I went through my medical training in my 20, and yet here I was in my 30s, not able to deliver the kind of care that I wanted to give.

Dr. Sara Gottfried (00:21:23):

There was this mismatch with the work that I was doing, which created stress. I had a couple of kids and I couldn’t lose the baby weight, so all the old tricks that got me to my goal weight, got me to fit into the clothes of my closet, they no longer worked. I remember driving home one day from work and sitting in my car in the driveway of my house, knowing that my two kids were inside the house with the nanny and I just was struggling to get out of that car and go open the front door. I just felt so exhausted and way too young to feel so tired. I was married, I was attracted to my husband, but my sex drive was almost zero. I just felt like, “Wow, this is no way to live. This is no way to live. I don’t want to live li;ke this for the rest of my life.”

Dr. Sara Gottfried (00:22:21):

I did what many people do, I went to my primary care provider and I said, “Here’s my list of woes. I’ve got PMS. I don’t want to have sex with my husband. I can’t lose this baby weight. I’m fatigued. I’m burned out at work. What do you suggest?” That’s where I got offered a birth control pill and also, at the time, Prozac. At first, I was kind of ashamed and put off. I remember he even wrote on a whiteboard, Dhru, he wrote on a whiteboard in his office, “Eat less plus exercise more equals weight loss.” He’s like, ” You know this. You learned this in medical school.”

Dr. Sara Gottfried (00:23:03):

That’s where I got angry because I realized that so many millions of people were being told this very same thing and it was wrong. Yes, calories matter, but hormones matter more, and so I had that righteous indignation that led to writing books and really looking at the ways that medicine fails us, both men and women. How can we work around it? How can I empower people to use lifestyle redesign to correct these most common hormone imbalances?

Dr. Sara Gottfried (00:23:39):

I left his office. I went to the lab. I ordered my own test. I science myself. I found that my cortisol as three times what it should have been. My estrogen was too high. Progesterone had left the building. Progesterone is like nature’s Xanax and I had almost none. My thyroid was not working properly, in part because my cortisol was so high. My testosterone was low. I was basically a hot mess, Dhru. That’s what really got my me to turn that corner and to say, “Okay, I got failed by the medical system. If I got failed by the medical system, if I got failed, so many other people are getting failed, too. We’ve got to do something about this.

Dhru Purohit (00:24:16):

You know, after that major awakening and part of your own hero’s journey, you went through something that a lot of people who might even be watching right now go through is once they understand that there’s a problem, the next question that comes up is why. As you started to ask yourself why, what came up for you as some of the core root issues that were playing into the imbalances for the hormones that you were running on yourself and getting the test results back from?

Dr. Sara Gottfried (00:24:51):

Yet another reason why I love talking to you, Dhru, because it’s all about root cause analysis. In addition to those hormones that I mentioned, one of the things I found, and this was at age 35 or so, my glucose was elevated. I had high insulin, so I checked my fasting glucose. I hadn’t checked it since maybe medical school. My fasting glucose was about 105 and I thought, “Wow, that’s weird? What’s going on? My doctor said, “Oh, this is fine. Don’t worry about.” My insulin was also elevated. It was like in the 20s and this was after fasting about 12 hours. I felt like there was something going on that was related to all these other hormone imbalances. What I found was that the primary drivers were my metabolic health, so that includes insulin, glucose. There’s so many different ways that we can assess this now, leptin, adiponectin, glucosamine, but it was also related to cortisol. It was related to the way I was interacting with my environment, especially work. That was dysfunctional, so I had too much stress, even though I started transcendental meditation in college. I grew up practicing yoga with my great-grandmother.

Dr. Sara Gottfried (00:26:12):

The dose of meditation, the dose of kind of managing my cortisol was not sufficient for my demands. That’s I would say kind of the root cause. It showed me that I was on this path of metabolic dysfunction that was totally flying below the radar of mainstream medicine. I’m not faulting mainstream medicine. I mean, I went through the same training as my primary care doctor. We were at Harvard Medical School. I was taught maybe 30 minutes of nutrition. It was considered kind of the lowest on the hierarchy scale. Immunology and kind of molecular biology was considered the highest in terms of that hierarchy.

Dr. Sara Gottfried (00:27:03):

I realized even as a physician, I’m going to have to teach this to myself. So that got me on this path of, listening to Jeff Bland and starting to read these books that are written for a lay audience, but they actually, books like Mark Hyman’s that teach us, so much about the physiology of the body and these root cause, root causes that we need to be paying attention to. So the short answer is my metabolic health was a total wreck and I needed to turn it around.

Dhru Purohit (00:27:32):

Well, we like the long answer here, so you can go long anytime you want to.

Dr. Sara Gottfried (00:27:34):

Okay. Good.

Dhru Purohit (00:27:37):

You talked about, two distinct categories that were there, that have interplay on each other. One was food and one was stress, and they can both have impacts on your metabolic health.

Dhru Purohit (00:27:49):

Let’s zoom out for a second and put your sort of, evolutionary hat on. And what is happening in our society, that is going on that has so significantly impacted those two categories. Food and the term of stress, which bundles a lot of different things inside of it.

Dhru Purohit (00:28:14):

So help our audience understand contextually what’s going on, that we are seeing year after year, these increases in hormonal imbalances and the severity in symptoms that you described at the beginning of the podcast.

Dr. Sara Gottfried (00:28:29):

Well, there’s so many, and I’ll probably leave out a few, but I’ll fit the high… I’ll hit the highlights that I think are the most important. The first is our food system is completely changed.

Dr. Sara Gottfried (00:28:43):

I mentioned my great grandmother earlier. She was born in 1900, so it’s really easy to do the math on her, she’s not no longer with us, but she died in her sleep with no chronic disease, very peacefully at 97, after coming to my wedding and dancing and flirting shamelessly with every man. That was at the ceremony.

Dr. Sara Gottfried (00:29:04):

So she’s a great model for me, but when she was growing up, apples were these small little tart green things. They weren’t these big, huge, hybrid, altered apples that are associated with higher fructose and kind of a change in the physiology that they create in the body. She was not eating processed foods. She was eating whole foods. We know that a whole foods diet, is the healthiest that we have.

Dr. Sara Gottfried (00:29:36):

If we look at the data, we know that a Mediterranean diet is the most proven in terms of health and she was eating a Mediterranean diet. It was altered a little bit because for instance, she found that alcohol didn’t agree with her, so she didn’t drink alcohol.

Dr. Sara Gottfried (00:29:51):

So our food system has completely changed. And in many ways, I think you and Mark have done such a stellar job talking about this, about how we have lost the small farmer. We’ve lost the number of fields that are organic, is so tiny.

Dr. Sara Gottfried (00:30:11):

We’re using glyphosate, which has all of these downstream consequences is one of the most important disruptors of the integrity of the gut lining. So food has completely changed and we also have more of it.

Dr. Sara Gottfried (00:30:23):

So we live in this time of abundance. I’m someone who struggled with disordered eating when I was in high school, in my twenties. And so, when you’re faced with this bountiful amount of food, it can be very tricky to make decisions about what to eat and what not to eat, especially if you’re the way that I was in my teenage years, where you use food for emotional reasons.

Dr. Sara Gottfried (00:30:53):

So we’ve seen this rise of eating disorders. We’ve seen, these changes in terms of the food system. We’ve seen the rise of pollutants, herbicides, pesticides, things like glyphosate.

Dr. Sara Gottfried (00:31:06):

And then in terms of stress, we know that stress is increasing. We also know from the annual survey, by the American Psychological Association, that women are more affected by stress than men. We know that during the pandemic, stress levels, numbers of depression, incidents of depression has dramatically increased in some reports, three X.

Dr. Sara Gottfried (00:31:29):

So I think we’re faced with a lot of environmental unknowns. Some people are able to manage that and have found, sort of the gifts of the pandemic. Other people are really strongly affected by it. I think there’s also economic forces here too, in terms of both the richer, getting richer, the poorer, getting poorer.

Dr. Sara Gottfried (00:31:52):

As well as racial trauma. I think trauma in some ways has either increased or our awareness of it and some of the downstream consequences has increased. We look at, for instance, the adverse childhood experiences study that was done at Kaiser 20 years ago.

Dr. Sara Gottfried (00:32:12):

We know that women experience more trauma than men. We know that trauma, in childhood is associated with more adverse effects later in life, whether that’s heart disease or alcoholism or even early mortality.

Dr. Sara Gottfried (00:32:25):

And as you can imagine, trauma is one of the most important disruptors of hormone imbalance, because when you’re growing up and these caretakers who are supposed to be looking out for your best interests, aren’t doing their job, you’re neglected, maybe there’s some abuse, maybe your parent went to prison, or your parents got divorced. Often that leads to dysregulation, of the control system of your hormones.

Dr. Sara Gottfried (00:32:54):

So here we’re talking mostly about the hypothalamic-pituitary-adrenal-axis and the release of cortisol. And we’re also talking about post-traumatic stress disorder. And even what I see more often in my practice, subthreshold post-traumatic stress disorder, which doesn’t meet criteria for PTSD, but it’s something that I see pretty commonly.

Dr. Sara Gottfried (00:33:18):

So I think trauma is a big piece here under the rubric of stress. There’s these gigantic changes in our food system. And then there’s also the way that this affects sleep. So you look at sleep, you look at sleep debt, how sleep debt is increasing, even with all the things we know about, how sleep is so important for your cortisol level the next day, your insulin level the next day. If you get to short sleep, which for most of us is less than seven to 8.5 hours, that leads to more carbohydrate cravings the next day.

Dr. Sara Gottfried (00:33:50):

So I think sleep is another really important piece. And once again, women are differentially affected. So women have about twice the rate of insomnia as men. I think some of that gets, kicked up postpartum, during pregnancy and also postpartum. And then it also, becomes an issue in perimenopause and menopause.

Dhru Purohit (00:34:11):

That’s a great lay of the land, and it’s a perfect segue into, our next chunk that I want to dive into. Your new book is called Women, Food, and Hormones.

Dhru Purohit (00:34:21):

And on top of everything that you shared here about the high level statistics of how women, are more impacted by especially stress in their lives. What is it that fundamentally you want, again, hormone imbalances, they impact men, they impact women, but there’s something that uniquely is there for women.

Dhru Purohit (00:34:41):

So when you sit down with your patients, which I would say you see both men and women. But for the ones that are women, what do you want them to understand, about a lot of the solutions that are out there well-intentioned, well-meaning solutions that work for a lot of people? What do you want them to understand about those solutions in the context of their unique biology and hormones?

Dr. Sara Gottfried (00:35:06):

Yeah. There’s a lot that I want them to understand. And I think your… The subtext of your question is really great. Which is, how do we prioritize this? How do we, not overwhelm somebody? How do we really figure out, okay, here are the three things I want you to focus on initially.

Dr. Sara Gottfried (00:35:23):

So the way that I rank order, what to focus on, what to understand. I would say metabolism is first, because metabolism is not just your weight on the bathroom scale. It’s not just, belly fat or how much fat mass you have. I think a lot of people think of it in that more narrow context.

Dr. Sara Gottfried (00:35:44):

Metabolism is much bigger, broader, deeper, than that. It is the aggregate of all of the biochemical pathways in your body, and that includes your hormones. So I like to start first with metabolism. I want to make it come alive for my patients. And the way that I do that is through precision medicine.

Dr. Sara Gottfried (00:36:07):

So I really believe that we have to democratize data. We can’t take, the annual test for fasting glucose and hemoglobin A1c, and have that just be owned by the clinicians that are taking care of the patient. I think it’s important that we use any means possible, to really help people understand where they are on the continuum of health.

Dr. Sara Gottfried (00:36:33):

So I’ll start with blood testing. I’ll do some genomic testing to look at metabolism. I’ll look at particular biomarkers. I’ll look for micronutrient deficiencies so that we can really customize and personalize a food plan. But one of the things I love to do, is to really solicit from the patient.

Dr. Sara Gottfried (00:36:55):

What are your values? What is most important for you? And then how can I tie, what we’re learning about you, about your metabolism, about your metabolic health to those values? So I’ll give you an example.

Dr. Sara Gottfried (00:37:11):

For me, I want to live a long life. I’ve got a couple of daughters, I want to be if I could like my great-grandmother and dance at their weddings, to really see how they turn out to be part of their lives, to have that feeling of connection and love and intimacy. So that’s a really high value for me. And if I’m still able to dance reasonably, when I’m in my nineties, that would be really awesome.

Dhru Purohit (00:37:39):

You have the dance part, but don’t forget your grandmother was also flirting with the other men that was there. So you got to have both of those.

Dr. Sara Gottfried (00:37:45):

She was… Yeah we got to have both. For other people, my husband jokes that one of the reasons why he wants his health, is because he loves lemon ricotta pancakes, gluten free. And so he wants to eat as many of those as possible as he gets older. So we all have different values. And for some people it’s a particular mission. One of his missions is to reverse climate change.

Dhru Purohit (00:38:07):

Mm-hmm (affirmative).

Dr. Sara Gottfried (00:38:07):

So mission can pull us forward too, but then let’s connect it to metabolism, because that’s the way I think that you get the best buy-in. And when you can democratize the data. So that’s, with I share every single lab that I collect on a patient. We talk about it because this is owned by the patient. This is the patient’s physiology.

Dr. Sara Gottfried (00:38:32):

And there’s something incredibly enchanting, about looking at and understanding your own physiology. Instead of outsourcing it to somebody else, the way that more patriarchal medicine is practiced, but really understanding, okay when I eat sweet potatoes makes my glucose spike. When I am, in a fight with my husband, it raises my cortisol. And once again, it makes my glucose go up.

Dr. Sara Gottfried (00:38:59):

So understanding kind of those moment, by moment changes that can help in happen in your physiology, I think is very helpful. The last thing I’ll finish with, on this particular question is that I’m a bioengineer. So I think a lot about systems biology. And if you can bear with me for a nerd moment here.

Dhru Purohit (00:39:19):

Please.

Dr. Sara Gottfried (00:39:20):

One of the things I think about is, how do you define health? Because in medicine we’ve done a really lousy job, of defining health. We define it in a circular fashion as the absence of disease. And that really is not a gold standard that just centers our inquiry around disease.

Dr. Sara Gottfried (00:39:40):

So if you really look at health and you really understand what the drivers of health are, and I’m saying metabolism is one of the most important, it’s not the only one, but it’s, to me the most important.

Dr. Sara Gottfried (00:39:50):

And then you look at these transitions that can occur, along at continuum, from health to pre disease. So for instance, insulin resistance or pre- diabetes. And then another transition later, to maybe type two diabetes.

Dr. Sara Gottfried (00:40:06):

When you understand where you are on that line, it gives you this feeling of, oh my gosh, I can do something about this. And one of the cool things when it comes to metabolism, is that the most proven way to correct your metabolism, to reverse metabolic inflexibility or metabolic dysregulation, is through diet and lifestyle change.

Dr. Sara Gottfried (00:40:29):

So that’s been proven over and over again. Even though, our medical training system does not show physicians how to do this. So this is where I really invite our listeners to step into that place of not outsourcing the assessment of your metabolism to someone else.

Dr. Sara Gottfried (00:40:49):

Really understand it yourself, because it’s as important as your savings account. It’s as important as your retirement account. In many ways, it doesn’t matter how much you have in your 401k or defined benefits.

Dr. Sara Gottfried (00:41:02):

What matters is your metabolism, because that is such a key driver of health span. That period of time that you feel fantastic and you’re relatively disease free.

Dhru Purohit (00:41:12):

To me, it’s really a message I’m hearing from you, of empowerment. Because the law of responsibility says that, if it was your fault, and I don’t mean that in the sense of blame, but in the sense of control. If you had a part to play in it, if it was partly your fault in some way or another, then you can do something about it.

Dhru Purohit (00:41:35):

If it wasn’t your fault, if this is all genetics, if this is all somebody else is dealing, then we lose the power to change it. And so when we remember that it’s in our control, that’s a positive thing. That’s a beautiful thing because we can do something about it. Now I want to ask one question off of that.

Dr. Sara Gottfried (00:41:54):

Can I say one quick thing about that Dhru?

Dhru Purohit (00:41:55):

Oh, please jump in.

Dr. Sara Gottfried (00:41:56):

I love that point about responsibility. And what I hear you talking about is ownership. We… If you look at the amount of time you spend, in a doctor’s office or a nutritionist office or on zoom, since that’s what we do so much more now.

Dr. Sara Gottfried (00:42:16):

We know that it’s probably less than 1% of your life, less than 1%. So you have this other 99% of your life, where your health is unfolding before your eyes. And if you’re just outsourcing all of the metrics, kind of the understanding of health to that 1%, you are really selling yourself short.

Dhru Purohit (00:42:35):

Mm-hmm (affirmative).

Dr. Sara Gottfried (00:42:36):

So the point that you made about genomics and kind of the, our idea with genomics, is that genomics may load the gun. I think Francis Collins said this or someone else. “Genomics load the gun, but it’s really environment that pulls the trigger.”

Dr. Sara Gottfried (00:42:54):

And there is almost no condition that is 100% genetic. Environment plays a role in some way or another. The impact of that, kind of the relative contribution varies from condition to condition.

Dr. Sara Gottfried (00:43:08):

But if you look at something like metabolic health. Genomics probably plays somewhere around a 20 to 70% role. So you have this remainder, that really is under your power to address. So I’m sorry for cutting you off.

Dhru Purohit (00:43:25):

No.

Dr. Sara Gottfried (00:43:25):

I just wanted to fit that in.

Dhru Purohit (00:43:28):

I see cutting people off, in the context of friends and educate them, as a positive sign that people have things to say. So please cut me off. You have something really amazing to say, I want you to jump right in as you did.

Dr. Sara Gottfried (00:43:39):

And vice versa, cut me off anytime you want.

Dhru Purohit (00:43:45):

You want to know what’s changed the game entirely as far as it comes to my fitness performance and overall health? Sleep. I cannot say enough about getting good quality sleep and the importance of it, when it comes to taking my health to the next level and giving me a little bit of that superhuman ability that lets me run multiple companies, a podcast, and so much more.

Dhru Purohit (00:44:07):

Sleep is completely changed my life. But it’s not as simple, as just closing your eyes. The quality of your sleep is ultimately, what matters the most. And when it comes to quality and getting it. When my friends ask me about it, I tell them, about Whoop.

Dhru Purohit (00:44:22):

Whoop is a personalized, digital fitness tracker and health coaching platform that monitors your physiology 24/7. Whoop Sleep Coach, help me figure out my ideal bedtime and wake up time, based on my unique circadian rhythm.

Dhru Purohit (00:44:36):

Whoop’s, all new 4.0 system is engineered with haptic feedback that sends subtle vibrations to wake up, once I’ve hit my optimal recovery. It’s screenless, distraction free and 33% smaller too. So I totally forget that I’m even wearing it in the first place. Let me tell you a few more things about Whoop that makes it a game changer.

Dhru Purohit (00:44:59):

Whoop gives me a sleep score every morning, that’s based on my sleep performance. A measure of how the sleep I get, compares with the sleep my body actually needs. How does Whoop know how much sleep my body needs?

Dhru Purohit (00:45:11):

Because Whoop is smart as hell, and looks at the whole picture of everything my body actually goes through in a day. Another thing that I love about Whoop. Is Whoop monitors my heart rate variability, resting heart rate and respiratory rate and crunches those numbers into a recovery score, which tells me how hard I can push my body the next day. Whoop also calculates my daily exertion from workouts, travel and everyday stressors, which gives me a strain score. Now when my strain score is low on busy weeks, where I wasn’t that physically active, the strain coach gives me a simple nudge, which is very helpful. Telling me that I need to get my butt moving.

Dhru Purohit (00:45:48):

If you’re curious about Whoop. Right now, they’re offering my community 15% off their Whoop membership. Just go to join.whoop.com. That’s join.W-H- O-O-P.com and use the code Dhru 15 at checkout. That’s D-H-R-U 15 at checkout.

Dhru Purohit (00:46:08):

On the topic of empowerment. There has been more education and you’ve been a huge part of this. Around helping women and of course, men too. Right? The men that love them and are there to support them, but really helping women understand, that they are not just smaller men. In the context of their bodies. Yes. Women know, that they have a period every month, a monthly menstrual cycle, and yet hormones go a lot deep in that. Can you talk a little bit about the unique makeup, that is there for women that has to be kept into account when they’re looking to apply personalized medicine or personalized approach to their lifestyle?

Dr. Sara Gottfried (00:46:53):

Yeah. Another great question. So when it comes to your hormones, we’ll start with that in terms of some of the sex differences, the biological differences between men and women.

Dr. Sara Gottfried (00:47:05):

There’s also gender differences, which are the socially constructed differences between men and women, that are things like increased responsibility for child care and child rearing. And other things, household responsibilities.

Dr. Sara Gottfried (00:47:21):

But when it comes to sex differences, let’s start maybe with testosterone. So a lot of people think of testosterone as a male hormone, and it’s certainly, is a really important regulator, a primary regulator of the male body, but it’s also a primary regulator of the female body.

Dr. Sara Gottfried (00:47:40):

A lot of folks don’t realize that testosterone is the most abundant hormone, that women have. The most abundant hormone. So if you look at your level, if you get a hormone panel and you’re looking at your serum level of total testosterone, free testosterone, maybe progesterone, estradiol. What you’ll see is that the concentration is highest, for testosterone.

Dr. Sara Gottfried (00:48:03):

So that means that women have less of it. So men have about 10 to 20X, the amount of women, but women are exquisitely sensitive to it. Exquisitely sensitive. So it’s involved in many of those things that we talked about already, such as sex drive, muscle mass, but it’s also involved in confidence, agency, vitality, mood.

Dr. Sara Gottfried (00:48:28):

In men, it’s associated with low levels of testosterone are associated with more anxiety and depression. That’s been less proven in women. But what we know is that, it’s really important to pay attention to these testosterone levels. So even though there’s a sex difference, don’t ignore, some of this metabolic hormones like testosterone.

Dr. Sara Gottfried (00:48:50):

Another key difference is maybe the reverse, which is estradiol, which is the most potent type of estrogen that women make. Men make it too. Women make much more of it. And the level of estradiol fluctuates considerably over a female life cycle.

Dr. Sara Gottfried (00:49:09):

So it increases at puberty. It goes through, kind of this maturing process with the control system. Sometimes periods are irregular, during that time. During pregnancy and postpartum, there’s really dramatic changes with estradiol.

Dr. Sara Gottfried (00:49:24):

And we know for instance that, postpartum, when you go from these sky high levels of estrogen, in this case, estriol together with progesterone, down to delivering your baby, delivering the placenta, and then having very low levels of these. It’s similar to perimenopause.

Dr. Sara Gottfried (00:49:42):

So that sudden change can really trigger mood issues for women. It can trigger postpartum depression, postpartum anxiety. It also can trigger, because these hormones are signaling molecules. It can trigger autoimmune attacks such as Hashimoto’s thyroiditis and all other autoimmune thyroid diseases.

Dr. Sara Gottfried (00:50:02):

And then in perimenopause and menopause there’s again, these dramatic changes with estradiol. Typically, in perimenopause, the first half it’s wildly fluctuating, which can trigger a lot of mood issues and again, anxiety, as well as estrogen has about 400 jobs in the body. So there’s a long list of symptoms. And so we really know that is a time of tremendous flux.

Dr. Sara Gottfried (00:50:26):

Another hormone that change, that’s quite different in terms of the sexes, is growth hormone. So women make more growth hormone until menopause, and then they make less growth hormone than men after menopause. So there’s this change that occurs right around, somewhere around 50 to 52.

Dr. Sara Gottfried (00:50:45):

The way that we secrete growth hormone is different. So women make it more continuously, whereas men pulse it more and it’ll back up for a second. What does growth hormone do? It’s a hormone just like its name, that’s involved in growth. So the growth and repair of cells, it’s when you’re a kid it’s involved in your height. So kind of your growth pattern, people who have short statures, sometimes have some issues with growth hormone like growth hormone insufficiency.

Dr. Sara Gottfried (00:51:16):

It’s also involved in modulating, things like belly fat and insulin, regulation. So it’s got its hands and a lot of different functions and levels can change, significantly for women after menopause. So these are a few examples of some of the sex differences, between men and women that I think are important to know about.

Dhru Purohit (00:51:38):

Powerful. And thank you for that review. I think a lot of that understanding is most helpful, especially when people are looking at how to personalize their approaches.

Dhru Purohit (00:51:48):

And since we’ve started talking about, solutions to get to the root causes of addressing hormonal imbalances, again, both for men, women, or any other gender that somebody identifies with but talking biologically, now comes the question of how do we begin?

Dhru Purohit (00:52:09):

You’ve already talked about metabolism. You talked about the power of continuous glucose monitors and how you use that to democratize medicine, as well as give patients access. And the analogy that I love about, continuous glucose monitors.

Dhru Purohit (00:52:21):

It’s like, imagine if you only were able to check your bank account once to twice a year. You would have no idea, are you on track for your budget? Are you not on track for your budget? Are things going well? Are they not going well? And I see glucose monitors operating in that, same way and I know you have some recommendations on that, which we’ll talk about in a little bit.

Dhru Purohit (00:52:40):

What are some other things, in the context of getting to the root causes of hormonal imbalances, that you want people to know are within their power to make a change and a difference on?

Dr. Sara Gottfried (00:52:53):

There’s a long list, once again. I think cortisol, is probably the low hanging fruit when it comes to the way that your physiology is behaving. And the reason why I say that next after talking about metabolism is because, cortisol is a priority hormone, meaning that you need it to live.

Dr. Sara Gottfried (00:53:18):

You can live without estradiol. You can live without testosterone. You can live without many hormones, but cortisol is essential to life. It’s involved in so many different things. It is involved in regulating glucose. It works together with insulin. It’s also involved in immune function. It’s part of your circadian rhythm.

Dr. Sara Gottfried (00:53:40):

So it’s got this really foundational role, in your health. And I think what’s interesting about cortisol is how much you can modulate it with mindset, with food. So reducing food stress, for instance not eating foods that you’re intolerant to. I happen to be intolerant to gluten and dairy. So it raises my cortisol if I get exposed to those foods. Cortisol I would say is really a low hanging fruit understanding where you are with perceived stress. I’ll give you an example of how you can test this. There’s a perceived stress scale that I think is very helpful that was published by Cohen. You can Google the perceived stress scale to take this really simple test, it takes about five minutes, and see where you are. Especially when you’re under a fair amount of stress and you’re not sure how resilient you are, I think measuring can be very helpful. Cortisol, I would say is one of those low hanging. I’ve had someone on a podcast before say, “Oh, it’s like Michael Cortisol Leone.” It’s a little bit of like the godfather in the body. That’s true because it’s such a high priority, it’s also so involved in this interdependence with other hormones that it’s good to know about. Once again, lifestyle factors can modulate cortisol so readily, whether that’s practicing yoga, which we know reduces cortisol, and by consequence, it also affects interleukin six and other biomarkers associated with inflammation. Meditation I think is a very powerful way to change to cortisol levels.

Dhru Purohit (00:55:24):

Can I jump in for a second?

Dr. Sara Gottfried (00:55:25):

Please. Please.

Dhru Purohit (00:55:26):

I saw a really great video that you made on Instagram not too long ago talking about also… Again, I love simple practical solutions that anybody can do, and it was about a breathing technique that was there. Would you mind sharing about that?

Dr. Sara Gottfried (00:55:39):

Of course. This is Buteyko Breathing. There’s a Ukrainian physician who developed this way of breathing, and it was so interesting to me when I first learned about it because I have a voice disorder, which you can probably hear. It’s just as a result of doing so much public speaking and not breathing properly for many decades. Buteyko Breathing is one of the recommendations that came from my voice therapist who said, “You seem like an over breather.”

Dr. Sara Gottfried (00:56:09):

What I was doing, Dhru, is what I think a lot of yogis do in that I’m a certified yoga teacher. I take these deep inhales. I extend the exhale, and that can create some inefficiencies in terms gas exchange. The work of Dr. Buteyko is to change your breathing pattern, to do this for about 20 minutes twice a day, to make you breathing more efficient. The way that I do it is I use an app, Breathing Zone, and it counts out the breath and kind of guide it’s me.

Dr. Sara Gottfried (00:56:44):

I just did my 20 minutes this morning before we got together. I start off with about five breaths per minute, and then I get down to about four breaths per minute. You get a little bit of air hunger, but you learn how to tolerate it. You learn how to tolerate especially the retention. I use this with my athletes. I work with an NBA team back East. I use it with people who struggle with cortisol issues. It’s a very efficient way of improving your breath pattern, and it’s been mostly studied in asthma.

Dr. Sara Gottfried (00:57:20):

It’s been shown to help quite a bit with asthmatics. It doesn’t have a ton of research behind it, but lack of proof is not proof against. This is one of those interventions that I think doesn’t require some complex randomized trial to show that it’s useful.

Dhru Purohit (00:57:35):

Ah, that’s great. Meditation, yoga, breathing, all simple things, even sometimes people practicing self-compassion and talking to themselves and letting themselves know. The research on self-compassion shows that our body doesn’t know the difference between us comforting ourselves and putting our hand on our chest. We had Dr. Chris Neff on the podcast who’s a leader in this space. She said your body doesn’t know. You calm your body down even at night, especially if somebody’s dealing with insomnia, other things that would affect their cortisol levels in the morning, or would throw off their hormones.

Dhru Purohit (00:58:12):

Telling yourself it’s all good, telling yourself that you’re there for yourself, telling yourself that it’s okay, you tried your hardest today and tomorrow’s another day, we’ll have another crack at the bat, those things are all key because they get to, as you mentioned earlier, these sub traumas that often don’t get diagnosed or addressed that we all as human beings are going through on a regular basis.

Dr. Sara Gottfried (00:58:38):

I love that, Dhru. Yeah, I would say trauma is part of the human condition. The question is, how do you respond to it, especially as an adult when we have more resources than we did as children. I love that you brought this up, because it makes me think of this concept of social genomics and how we’re not just these stable human beings that don’t change moment to moment, second by second. We change a lot. In response to me talking to you right now, my matrix is changing through social genomics.

Dr. Sara Gottfried (00:59:18):

When you’re around people who lift you up, light you up, that has all of these benefits. There’s less data on that self-compassion in the way that you talk to yourself, but I imagine that also affects your genomics quite dramatically. We want to be having the best possible conversation with ourselves, especially when it comes to stress. This is one of those places where I think women often get the short end of the stick. Maybe they didn’t have a good stress response modeled for them by their parents.

Dr. Sara Gottfried (00:59:54):

They end up having kids. They’re trying to balance work life and can really be struggling. It can lead to these hormone issues that I then pick up and measure, but I really want people to have the sense of agency that you can talk to yourself in a different way. You can change your perceived stress level, and you can book become more resilient. All of that is within your power.

Dhru Purohit (01:00:20):

It is in your power. Before we jump into your protocol that you’ve designed that really helps and walks people through all these aspects and puts it all together and some new things that we’ll get a chance to cover like intermittent fasting that we didn’t get a chance to go deep into, on a personal level, because there can be a targeted amount of stress that’s good for us, right?

Dhru Purohit (01:00:41):

Exercise, going in a really hot sauna, and even some of the life stresses that are out there, getting ready for a big public speaking event, or even your first speaking event, that can be stressful, but it builds courage. It builds resilience when we come out on other side and know that like we can handle a certain amount of what life throws at us.

Dhru Purohit (01:00:58):

Now, in the context of Dr. Gottfried being a human being and a mother and a wife and a physician today, as much as all the things that you practice and talk about, naturally I’m sure there’s days that are more stressful for you. What are your personal go-tos, or what have been things that have been a game changer in your journey to continue to help you bring in resilience in the face of the natural stresses that we all go through?

Dr. Sara Gottfried (01:01:30):

What a lovely question. I would say the biggest game changers for me were the way that I exercise. I’ve always been an exerciser, but I change the way that I exercised starting in my mid thirties. I exercise with friends. I think there’s something about being together with, in my case, a girlfriend. We’ve been exercising together every weekend for 16 years. I feel like that is probably the biggest game changer that I’ve seen in my life.

Dr. Sara Gottfried (01:02:05):

That, again, is kind of one of these social genomics ideas, but there’s something about being together with your girlfriends that just really changes perceived stress. It’s one of the most helpful things that I found. When I was in that doctor’s office kind of shivering in one of those paper gowns and he was writing on the whiteboard, I was running about four to five miles four days a week, totally unaware that my chronic cardio was raising my cortisol levels even higher.

Dr. Sara Gottfried (01:02:39):

I realized when I saw this crazy high cortisol level, that was three times what it should have been, I realized, oh my gosh, I need more adaptive exercise. I need yoga. I need Pilates. I need to do more walks like walking meditations. I changed the way that I exercised. I started doing more HIIT training, because I still love kind of that power adrenaline, endorphin rush. But I really changed away from chronic cardio, which was driving up that cortisol level. Another thing that happened that I think is really important… It’s funny, this is such a game changer, and yet it’s such a simple thing.

Dr. Sara Gottfried (01:03:20):

I read the book by Gary Chapman, The 5 Love Language, and that’s one of those teeny little books that was… Seriously, it saved my marriage. It went from what happens with most people. I don’t know if you’ve talked about this book before, Dhru. Have you heard of it?

Dhru Purohit (01:03:40):

We haven’t talked about it, but I’m very familiar with it. I’ve done the quiz and everything.

Dr. Sara Gottfried (01:03:44):

Okay. What are your love languages?

Dhru Purohit (01:03:46):

Yeah. My love languages are quality time and physical touch.

Dr. Sara Gottfried (01:03:53):

Ah, yeah, that’s beautiful. Well, this is interesting because what happens in most couples is that one person, I’ll refer to myself first here, has two different love languages. For me, it’s acts of service and words of affirmation. We tend to marry somebody who’s got complete different love languages. My husband, for instance, is quality time and physical touch. The way that I would show him love the first five, 10 years of our marriage was I would do acts of service and I would give him words of affirmation.

Dr. Sara Gottfried (01:04:34):

He’s like, “I don’t really care about these.” I wasn’t showing him love in his own language. I think for me in terms of stress, kind of that day-to-day feeling of emotional currency with my husband and kind of getting rid of most of the conflict that we had was all about learning how to talk to him in his love length. Of course, he’s done the same. He’s realized, wow, when I balance the bank account, you see that as love. That’s so weird, but okay. That’s been a huge game changer. There’s many other things too.

Dr. Sara Gottfried (01:05:14):

I think for me, what I find really helpful is measurement. This is a particular bias that I have. I feel like… You know what Kelvin said? I think he said this. What you measure improves. Measuring my cortisol levels, doing that on a regular basis, not just an AM serum cortisol, but looking at my diurnal pattern, what happens over the course of the day with my cortisol, looking at my cortisol awakening response, looking at this once a year and kind of gauging how I’m doing, that has been really helpful for me. Measurement is really key.

Dhru Purohit (01:05:52):

Great reminders. And also, I think the big reminder within everything you shared, and thank you for being open about that and sharing about your marriage and your husband and a book that was really important to both of you, is that there’s so many pathways to creating balance for areas of your life that you don’t feel balanced. Food tends to get so much attention. In this day and age, also fasting gets a lot of attention. But sometimes take a step back and take a look at your life and see actually, do I need some support in my relationship?

Dhru Purohit (01:06:23):

Do me and my partner need maybe a third party like a therapist? I’m a big fan of The Gottman Institute and Gottman Therapy and their sort of approach. Do we need somebody to help us facilitate our communication to bring a deeper sense of intimacy? Do we need to work with a therapist to help with our relationship, with our son or daughter or child who’s struggling with something? It’s not always the next most important path for somebody is directly food.

Dhru Purohit (01:06:52):

Food is a low-hanging fruit and one that we all do a couple times a day at least. But it’s just another reminder that there’s so many aspects that could impact especially the context of stress. It’s important for people to find their own version of that so they can work on it.

Dr. Sara Gottfried (01:07:05):

Yeah, such a good point. I mean, I imagine we’re going to get to food next because it is such a huge game changer. I think many of the things that I thought were so healthy that I was eating… If I go back to my 35 year old self, the oatmeal for breakfast, the orange juice. I would do juice fast. A lot of the things that I was doing was creating excess stress in my body. Changing the way that I ate eight was probably the biggest game changer of all.

Dhru Purohit (01:07:38):

I’d love to talk about that. You just mentioned a few yourself. When you extrapolate that to our modern world and wellness has become a big business and there’s even people that are suffering from major hormonal imbalances that are pretty knowledgeable and consider themselves to be “healthy eaters.” What do you see, right? I want to so set this up for social media. I think this will be a great clip. Give us three top things that are mistakes, again, they could be well intentioned, that people have when it comes to their diet and how that impacts hormonal imbalance.

Dr. Sara Gottfried (01:08:18):

Love those two. I would say number one is juice. A lot of us think that juice is healthy. We think it’s an efficient way to get… Maybe a green juice with celery and apple and spinach is so healthy for you, but we’re really designed to eat those foods together with the fiber. Juice is not the panacea that a lot of people think it is. I think that’s really essential to know. One of the things that I was doing back in my thirties was that I would do these juice fast, and then I would refeed and I would gain all the weight back. It just wasn’t a helpful thing for me. It set me up for yo-yo dieting and really in some ways ruined my metabolic health. That’s number one. Number two I would say is villainizing carbs. I think we’ve gotten to a place where people hear about low carb diet, they hear about the ketogenic diet, and they think, “Oh my gosh, I just need to cut carbs out of my life. I don’t need carbs. I need protein. I need fat.” Maybe they go on a classic ketogenic diet.

Dr. Sara Gottfried (01:09:33):

I think we have to be really careful about that, because the data looking at folks who follow a classic ketogenic diet, we know that there’s some significant changes that can occur to the gut microbes, to the microbes themselves, plus their DNA, which is known as the microbiome. There can be a decrease in diversity, alpha diversity in particular. There can be a decrease in stool volume. We want to figure out, okay, it’s not that carbs are the villain. It’s actually metabolic inflexibility that’s the villain. That’s what we want to address.

Dr. Sara Gottfried (01:10:11):

Maybe we could talk a little bit about metabolic flexibility versus inflexibility. The third thing is… Oh, if I have to pick a third, I would say villainizing fat. I grew up with Dean Ornish. I remember reading his books in high school. When I went off to college and medical school, I would make these pasta dishes with tons of vegetables and zero oil. I remember in anatomy in medical school, so this is 1989, I was so disturbed and freaked out about working with a cadaver that I just couldn’t imagine eating meat. I stopped eating meat.

Dr. Sara Gottfried (01:11:04):

I was continuing with this low fat plan. And what I found was that my hormones just became a total mess. I remember my breast size went down by about two cups because my cholesterol, I remember measuring it right around then after I went on this vegan food plan with very little fat, what happened for me was that my total cholesterol went down to like 120. Cholesterol is the backbone of all the sex hormones that you make.

Dr. Sara Gottfried (01:11:33):

If you look at the sex hormone pathway, it goes from cholesterol to pregnenolone, the mother hormone of all of your sex hormones. It goes on to progesterone and cortisol and DHEA and testosterone and estrogen. Fat is not the villain. We went through that low fat phase, which I think did more harm than good, and we’re still recovering from it. Healthy fat is really important for you. It’s the way that you make a healthy balance of hormones. Those are the three that I think are the most important.

Dhru Purohit (01:12:06):

Those are three great ones, and I think we should abs go into metabolic flexibility because this is really the sophistication of the wellness movement, kind of the culmination. We’ll grow every year and we’ll learn more, but this is a term that a lot more people are getting familiar with because there’s been all sorts of diets that have steered us in one direction or another. And kind of like the Buddha used to say, the middle path is… There’s something to say about the middle path.

Dhru Purohit (01:12:33):

Talk to us about metabolic flexibility and how it’s understanding when we incorporate it into only our body, but our mindset can be a better way to navigate life and also a little bit more of an enjoyable way to navigate life.

Dr. Sara Gottfried (01:12:50):

It’s definitely more fun than I think the alternative, which is metabolic inflexibility. The definition of metabolic flexibility is the ability to switch between burning carbs and burning fat, depending on what type of fuel is available. You can think of it like a hybrid car that can switch between electricity and gas, depending on the type of fuel that’s available.

Dr. Sara Gottfried (01:13:14):

What happens is that a lot of folks become less metabolically flexible over time because they’re snacking all the time, or they’ve got too much stress, or maybe they’ve got some of those genetic variations that are associated with insulin resistance. They become metabolically and inflexible, and they often get stuck in burning glucose, burning carbs. That was my own story. When I first tried the ketogenic diet, I remember going on Atkins before I got married.

Dr. Sara Gottfried (01:13:44):

My husband lost about 20 pounds in a short amount of time, and I maybe lost two pounds. What I realized was that now I know in retrospect I was carbon tolerant and I was also metabolically inflexible. I then went a few years ago, in 2016, I tried the ketogenic diet a couple of times. I had a lot of patients who were coming to me on keto, and I wanted to learn more about it myself. I tried keto a couple of times and I just couldn’t get it to work. And part of what was the problem for me was that I was metabolically inflexible.

Dr. Sara Gottfried (01:14:19):

For instance, to get into ketosis, it would take me about 10 to 14 days just to start to make ketones because my body was so used to burning carbs. Metabolic flexibility is really the goal. It’s not that I recommend that people go on a ketogenic diet and stay on a ketogenic diet for long periods of time. What I recommend is using a ketogenic diet as a therapeutic pulse. Typically four weeks, which is what I cover in my book, and then to start to bring more carbohydrates in while you’re tracking metabolic flexibility.

Dr. Sara Gottfried (01:14:57):

You can track it as your ketones. You can use a breath meter like lumen. You can use a continuous glucose monitor. You can use glucose ketone index. There’s many different ways to track this, but what we’re looking for is that ease with which you can flip the switch between burning glucose and burning fat, depending on the type of fuel that’s available.

Dhru Purohit (01:15:22):

It’s, it’s a powerful way to really see that metabolic flexibility as a human being, as an organism, the human species, has been probably a big part of what has allowed us to become the species that we are. Travel all around the world, be able to think of advanced technologies, be able to expand our brain size, because we had that flexibility as especially at times of major changes in the climate that could affect food sources and other aspects.

Dhru Purohit (01:15:54):

It’s also great because diet sometimes can get so tribal and really between using these tools, as you mentioned, a continuous glucose monitor, using things like lumen or other breathometers that are there, you can really dial into what works well for you. On a personal anecdote, if I could add in, a few years ago when I started going to keto and a big part of keto in the more traditional sense is making sure you get a higher amount of saturated fat inside of your diet, the clean sources of saturated fat that are there, I noticed that…

Dhru Purohit (01:16:29):

My health journey originally started because I had really bad acne. I noticed that because I’ve dealt with so many gut issues from being on antibiotics as a child, that the saturated fat would trigger almost like an endotoxemia effect inside. I started getting a lot of flare up of almost acne-like symptoms. My face would be red all the time.

Dhru Purohit (01:16:52):

And then on top of that, as I would track my blood results on a pretty regular basis, getting blood work every month, I noticed again for myself personally, and a big part of this is genetics coming from a South Asian background, even though I was not worried about cholesterol, I was paying attention to my NMR particle size and I was noticing that my lipoprotein A was getting quite high up there.

Dhru Purohit (01:17:16):

I just saw that my body genetically for who knows what all the different reasons are was not as efficient as somebody else’s body at utilizing that saturated fat and putting it to work. Just another reminder of how you can try things, see the actual difference that it makes for you, get your blood work done, use things like continuous glucose monitors, and then you can personalize it to what makes sense for you.

Dhru Purohit (01:17:45):

Your, in cases sometimes biological sex, which you write a lot about inside of your book, your ethnic background, which plays a role into it, and your personal lifestyle choices and goals that are there. I think it’s the combination of all of that, just like you personalized it. We can all take a lesson from that and look at how we can personalize all these things. Broad strokes seem to work for a lot of people, but might need to be tweaked to work for us uniquely.

Dr. Sara Gottfried (01:18:11):

That was such a helpful illustration of how keto can increase inflammation in some people, especially the dose of saturated fat. I really appreciate how you shared that story with acne. Thank you so much. Your skin looks amazing, by the way, Dhru, I must say.

Dhru Purohit (01:18:27):

Oh, thank you.

Dr. Sara Gottfried (01:18:29):

I think this brings up some really important points, which include… When I put someone on a ketogenic diet or when people follow the four week pulse that’s in my book, what we know is that it’s pretty significantly changing hormone signaling pathways and there’s genomic drivers. For instance, part of the genetics that you inherited from your parents determine the way that you respond to saturated fat and the way that it affects the glucose and insulin pathways.

Dr. Sara Gottfried (01:19:04):

Sometimes knowing that information and be very helpful, or you can track some of these biomarkers, such as the NMR lipo fraction assessment that you were describing. We know for a lot of people that LDL goes up, if we just look at low density lipoprotein. LDL goes up in about 10%… Well, about one in four people that are on the ketogenic diet.

Dr. Sara Gottfried (01:19:28):

Sometimes it’s not clinically significant, but it’s something that we want to track and understand, especially if people are staying on it for a longer period of time, such as they do in the Virta Study, which enrolled type 2 diabetics and put them on a ketogenic diet. Overall, they had about a 10% increase in LDL. I think this individualization is so important. You said something else that I really liked, which is the tribalism that occurs around food. What I really hope that people hear from us and our conversation today is that I’m food agnostic.

Dr. Sara Gottfried (01:20:06):

I really believe that even though a lot of my friends are keto or they’re paleo or they’re vegan or vegetarian, I think it’s important to understand what works the best for you. I learned, for instance, in medical school, when I went vegan low fat, that was not a good for fit for me. I needed more fat. I needed more protein for my hormone balance. Being able to understand that feedback loop I think is such an essential part of this empowerment conversation we want to be having with our body, our health, our hormones.

Dhru Purohit (01:20:44):

What I also love about your journey, Dr. Gottfried, is that you’re trained at some of the best institutions out there, and you have this willingness and openness to try. Also, not just to try, but to be open to change your mind when something wasn’t working out, and you’ve shared a couple examples of how you tried something and it wasn’t working out, so you tried something different. I think that’s so important, especially for, I would say, the intellectual types that are listening here, that you might have a very advanced degree. Maybe it’s not in medicine, maybe it’s in engineering, maybe it’s a lawyer, maybe you think of yourself as just a very smart person. And there is nothing smarter than trial and error, and then pivoting after that. Even if you read every single book that’s out there in the world, you will never be as smart as trial and error, when it comes to your ability to figure out what works for you. And so I applaud you in openly sharing that and also having done that in your journey. Because our audience, myself, we get to benefit from all this wisdom that you’ve built up over the years.

Dr. Sara Gottfried (01:21:51):

Well, I think beginner’s mind is such an important part of health. Having that openness to change your mind. You raised something else that I just want to emphasize, and that is, I’m a big fan of trial and error. I’m an even bigger fan of trial and success. We design these experiments in the type of work that I do. So a lot of what I do in precision medicine is multiomic phenotyping. So we take someone like you, Dhru, we look at your genomics, especially nutrigenomics. We look at your biomarkers, like your micronutrients, your level of magnesium, CoQ10, glutathione, all those things. We look at your hormones, do a hormone panel. And then once we have that data and we know what your values are, and what’s most important to you in terms of your health, we can then design these n-of-1 experiments.

Dr. Sara Gottfried (01:22:46):

And I was taught at Harvard Medical School that in the hierarchy of evidence, scientific evidence, there is observational studies, there’s expert opinion, anecdotal evidence, which is the lowest. Then there’s observational data, like the nurses health study. Then there’s randomized trials where you’re usually looking at just one intervention, like Metformin to prevent the progression of pre-diabetes to diabetes. And then above that is the n-of-1 experiment. Because instead of looking at populations, we’re looking at you, Dhru, and we’re designing a study to say, “Okay, what happens when you change your exercise in this way? What happens when we define your carb threshold? What then happens to your glucose and your metabolic flexibility?”

Dr. Sara Gottfried (01:23:37):

So that n-of-1 experimentation, I think, is really the key here. And this idea of open-mindedness, I think we often forget this in medicine. Science requires us to be open-minded. Science requires us to change our mind. If there’s evidence that is not supporting what you’re doing and the guideline needs to change, we have to pay attention to that. And there are many times over the course of a career as a physician that you have to change your mind. And if you’re more close-minded, oh my gosh, I really fear for the patients of that particular physician. So I think that open-mindedness in many ways is part of the scientific process, and it’s the scientific method, and it’s essential to anyone who works in healthcare.

Dhru Purohit (01:24:28):

I think it’s such an important reminder, especially in this day and age where also the tendency now is, because we had one political party that maybe went in the opposite direction when it came to some of the science information. We’re seeing a little bit of the consensus science has now gone in the other direction, and consensus science cannot be the answer to every question. We still have to keep an open mind. We have to understand that sometimes the most crazy ideas that come out of the blue are an important part of the conversation. And that’s why we need to allow certain debates to take place and obviously encourage civility and true scientific discourse. But anyways, that’s for a different podcast and a different conversation. Let’s come back to the Gottfried Protocol, while we have a little bit of time here towards the end of our interview. What is it? Who is it designed for? And can you walk us through what are the key pillars that are part of it?

Dr. Sara Gottfried (01:25:31):

The key pillars start first with detoxification. Maybe I’ll give an overview and then we’ll circle back to why I designed it in this particular sequence. So step one is detoxification, opening up your detox pathways. That includes methylation, it includes cruciferous vegetables, it includes paying attention to antioxidants. The second part is the ketogenic diet. So really following a ketogenic diet in a particular way using net carbs. So I was told when I first started on keto not to use net carbs, but I think we have to, especially for women. And then the third part is to layer in intermittent fasting, but to do it in a particular way that doesn’t cause hormone imbalances like disrupted cortisol. So if I take a step back now, what I found, Dhru, was that about seven or so years ago, I suddenly had all of these patients who came to me, who were struggling with the ketogenic diet.

Dr. Sara Gottfried (01:26:37):

So they were early adopters. They were following different thought leaders. They were trying keto, they were doing the macronutrients, they were eating the fat bombs and the bacon, and they just weren’t getting the results that they were hoping for. Often they would do it, they’d do keto with a colleague from work, like a male colleague, and the male colleague would get all the benefits and they were struggling. These were mostly women. So I saw this sex difference. I saw that my male patients were doing a lot better on keto, they were becoming metabolically flexible, and the women were really struggling. And I called them my keto refugees because they were so frustrated and they felt like, “I’m doing everything right. What is wrong? Why is this not happening?” So, as I was struggling on my own with the ketogenic diet, I realized one of the first pieces that’s so important for women is to make sure that those detox pathways are open.

Dr. Sara Gottfried (01:27:32):

So I see a lot of women who struggle with constipation, who are not pooping every single morning with that feeling of utter relief, like you have evacuated completely, and you are ready to start your day. So we need that in place before you can really be successful on a ketogenic diet. You have to be eliminating. That is priority number one when it comes to many of these metabolic hormones, especially the estrogens, because the gut is so involved in estrogen balance, especially estradiol. So detox, getting that dialed in is so essential that I put it first, and also getting the vegetables that you need, the allium vegetables that raise glutathione, the dark green leafies that help you with the B vitamins that help you with methylation, really important to have that in place.

Dr. Sara Gottfried (01:28:23):

Then the ketogenic diet itself. Again, I said before that I use net carbs because I find that women who restrict total carbs too much, often end up having menstrual irregularity. We see that in up to 45% of people on classic keto. They often have thyroid issues because reverse T3 can be raised by restricting carbohydrates successively. And I also see that they have issues with cortisol, so too much food stress. So if you adapt the ketogenic diet, you focus on net carbs. I have people begin with 20 to 25 net carbs each day. I find that that is so much better in terms of keeping the gut component of the control system for your hormones really working. And then I like to layer in intermittent fasting. And the evidence right now, there’s a lot of different people giving conflicting information about intermittent fasting. My review of the literature is that 14 hours is probably the right number in terms of an overnight fast for women. That’s not associated with too much cortisol or other hormone disruption.

Dr. Sara Gottfried (01:29:34):

So this comes from UCSD, the work of Barbara Patterson. She’s done some work looking at breast cancer risk and a few other hormonal factors. And I think 14 hours is probably the best way to go. And I recommend that people ramp up slowly to intermittent fasting. I like to combine it with the well formulated ketogenic diet because it’s a back door to ketosis. So most people can get into ketosis after some period of an overnight fast, typically 14 to 18 hours. So that’s basically the protocol. And then when you come off the protocol it’s really important, almost like an elimination diet, to very gradually add those net carbs back in. So five grams of net carbs per day is what I recommend, where you’re tracking metabolic flexibility. So you’re looking at glucose, you’re looking at your weight, you’re looking at inflammatory fluid. You’re also looking, if you want to test a little further, you’re looking at glucose ketone index. So that’s a quick overview of the four-week protocol.

Dhru Purohit (01:30:42):

That’s great. And what are some signs, especially for somebody who comes from this background of pretty major hormonal imbalances, what are some of the leading indicators that they should notice during the program and especially afterwards that they’re headed in the right direction? What should they pay attention to?

Dr. Sara Gottfried (01:31:00):

Well, the first reaction is satiety, which is a very lovely reaction where you just don’t feel as hungry. If I take a step back, if you look at the literature on glucose and insulin, probably the most proven diet is a whole foods diet with no animal protein or fat. So this is very well proven to help with glucose control. My problem is when I eat that way, I actually gain weight. So it doesn’t work for me personally. And so I have to find a way to eat clean but to follow a ketogenic diet. The main issue when I eat a whole foods, plant-based, 100% plant-based diet is that I’m hungry. I’m really hungry. And so I end up eating excessive calories. So for me, the satiety that you get from producing ketones as a result of burning fat really helps me with creating that metabolic flexibility that I’m after.

Dr. Sara Gottfried (01:32:08):

And of course it’s not about me. It’s about other people, when they follow a low carbohydrate, high fat food plan, moderate protein, they have this feeling of satiety that comes from the ketones that are produced, mostly beta hydroxybutyrate. So that’s one example, the feeling of being satisfied, not being hungry. I haven’t eaten yet today because my ketones are relatively high. I cycle in and out of ketosis as needed. Another benefit is there should be some weight loss. So, especially for people who are overweight or obese, we expect as you start to burn more fat, we expect that you’re going to have some fat loss. So technically it’s fat loss. I don’t want people to lose muscle. I want them to lose fat. And if you have fat to lose, that’s one of the benefits that you should see from this type of program.

Dr. Sara Gottfried (01:33:07):

Another one is relationship health. Since we talked about this earlier. I think this is a really key concept. I was filling out a functional medicine matrix, and under relationship and community, which is something we pay a lot of attention to at the Institute for Functional Medicine, I was thinking about how relationships are affected by someone becoming metabolically flexible. So when you’re metabolically flexible, your blood sugar is kind of where it should be and not spiking high after you have, I don’t know, an acai bowl and then crashing down low right afterwards. That’s the kind of situation where you are just a setup for a fight with the people that you love. And so I think another benefit is that you feel more even, your mood is better, you might find that anxiety is improved and that the quality of your relationships gets better. So those are a few examples. There’s a long list in the book, but those are the three that I’m thinking about right now.

Dhru Purohit (01:34:11):

Well, I can’t think of anybody that wouldn’t want those three things in their life. So those are three great ones. And if you can relate to that, highly recommended to pick up the book and to dive deeper into it. And then there’s a few other areas that we didn’t get a chance to dive into, which you do talk about in the book. You mentioned about fat loss, not muscle loss, especially as women and men and anybody gets older, muscle mass and maintaining that with targeted amounts of protein. And of course, some form of resistance training that we can incorporate in is a huge part of that. You do a deep dive into that inside of your book.

Dhru Purohit (01:34:51):

I do, before I let you go there, there are some tools. You’ve talked about ketose, you’ve talked about glucose monitoring. There’s a few tools that are out there that I think would be helpful to just share with our audience that trial and error, or as you said rather, trial and success is a really beautiful thing. And one way that we can increase the speed of trial and success is by getting data and information quicker. So I’d love for you to share some of your most used tools that you have, in addition to the blood work that you normally get done that have helped you to be successful on your journey, that maybe our audience can get a chance to check out.

Dr. Sara Gottfried (01:35:32):

First, I would say a glucose monitor. So we’ve been talking about continuous glucose monitors. When I first started to do this work and to look at my metabolic health, I bought one of those $25 glucose meters from Amazon. You can also get it from your local drug store. And it just involves pricking your finger, looking at your capillary blood, the way that a lot of diabetics do. But what we’re doing is we’re democratizing the data. So you don’t have to wait until you’re a type two diabetic or a type one diabetic to check a finger stick. You can do it now and assess your own metabolic health. So I find that very helpful. I’ve used tons of different meters over the years. I’ve been doing this for 15 or so years. Precision. I don’t use these as much. I use it as a backup with my continuous glucose monitor, but that is one way to go. I also use a Keto-Mojo, so I like Keto-Mojo. I hope I can mention brands.

Dhru Purohit (01:36:29):

Please, please.

Dr. Sara Gottfried (01:36:30):

So Keto-Mojo is one of my favorites because you can check both your glucose and you can also check your ketones, and it’ll calculate for you your GKI, your glucose ketone index. I find that very helpful, especially towards the end of the four weeks on this protocol, where you’re starting to add back more carbs and you’re looking at your response. I like a continuous glucose monitor. So I’ve got one right here. There’s a few different manufacturers. There’s Abbott, there’s Dexcom, there’s MetaMetrics. I use mostly the first two. I like the Dexcom because it gives you continuous data. I do research on pre-diabetes, so I love that data doesn’t get dropped. Although the Abbott allows me to look at my panel of patients, so I track their glucose on my phone, which I find very helpful. I can ping them and say, “Hey, what happened? Oh, it was your son’s birthday. Okay. All right. We can deal with that.”

Dr. Sara Gottfried (01:37:33):

So I find continuous glucose testing super helpful. And it’s more expensive than using a glucose meter, which as I said costs about $25, $30. Keto-Mojo is a little bit more expensive because we’re adding on ketones. Whereas the CGMs, now using them for people who don’t have diabetes, so using it for folks who have pre-diabetes, and we know that about two thirds or more of those people don’t know that they have pre-diabetes, what we know is that this is a little more expensive. Sometimes insurance pays for it. Sometimes it doesn’t. You have to get one with a prescription. So you can get that from your clinician. Or you can go to some of the direct to consumer groups that offer a telehealth platform to get CGMs. And there’s a long list of those, including NutriSense, Levels, January AI, ZOE. And I should disclose that I’m a research advisor to Levels, so I have a grant to Thomas Jefferson University to research early biomarkers of pre-diabetes.

Dhru Purohit (01:38:45):

Yeah, it’s great to see an explosion in this space. And it’s one of the reasons that I also got involved. I’m an investor to a bunch of different companies, but in the context of this, I invested in Levels. I met Casey, one of the founders, Dr. Casey Means, and she just really helped me understand where this is going in the future. So, great that you mentioned all those different ones, because I love seeing innovation in this space because you know good stuff is going to come out of it. And you know that the price is going to come down and make it more accessible. Just like Tesla did with electric cars, first one was super expensive, and they still are pretty expensive out there for the average person. But that technology is now being used by other companies to make electric cars more affordable. And I love that. Innovation is often such a huge part of helping us get healthier. And in this case it’s going in the right direction. So we’ll have links to those definitely in the show notes for the companies you mentioned, Keto-Mojo, your link with Levels and some of the other groups that you mentioned. I also want to give you a hats off as people are thinking about next steps after this interview. I love your social media, by the way. You do such a great job on your Instagram page, especially of breaking down a lot of these concepts that we talked about here in very simple, beautiful charts and videos that you also record there too. So be sure to follow Dr. Gottfried on Instagram as well. The book, it’s going to be out soon, September-

Dr. Sara Gottfried (01:40:11):

21st. Yeah.

Dhru Purohit (01:40:13):

… 21st. So congratulations on that. Women, Food and Hormones. If somebody’s listening here, and they know somebody who’s dealing with this, hormones can be a very … it can be a delicate conversation sometimes, to want to support the people in your life who are dealing with challenges. In addition to picking up the book for yourself, are there any other resources or content that you’ve put out there that could be a little bit of a teaser to get people excited about diving in and reading a book and then starting a plan? Or just anything that you’ve seen with patients? What gets them really invested into saying, ” This is important to me. And so I want to go deeper and read this and start a program that can impact my health”?

Dr. Sara Gottfried (01:41:06):

The thing that often gets people in the door is that they’re struggling with their weight and they’re suffering over it. There’s this private suffering, I think, that happens for both men and women. And I think women especially experience it because of some of those gender differences that we have in our culture. So, often it starts with a desire for weight loss. And what I hope is that we’re taking the middle path here, where it’s not just about losing fat, it’s about this much bigger picture of your metabolic health. So in terms of a teaser, I would say paying attention to your metabolic health is the best thing that you can do in terms of supporting those values that are important to you. So I think really owning your metabolic health, taking responsibility for it, that’s what this book is about. I take you by the hand to show you how to do it, some of the hormones that are involved.

Dr. Sara Gottfried (01:42:06):

You can skip the science section if you don’t want to get into the weeds. But I provide the kind of step-by-step sequence that I know is effective, because I did n-of-1 experiments with my patients, with the subjects that are in this book, the cases that are in this book. I had vegans and vegetarians and people who were on Paleo before, people on the carnivore diet who then followed this program, followed the tenets of this program and made it work for them. So I think that this is an accessible way to do a ketogenic diet. It’s also safe. I think it’s important to also talk about some of the contraindications to the ketogenic diet, which I’ve got a few sections in the book on that. I also have some social media posts about that. And if you’re ever unsure about whether it’s a good fit for you, you can always talk to your healthcare professional about that.

Dhru Purohit (01:43:00):

My favorite part of the book is the case studies because human beings, we learn through stories. We learn through seeing other people’s journeys. That’s how we’ve done it throughout history, up until a lot less recently, but we still are fundamentally wired to learn from stories. So I love that aspect of the book. So we talked about some of the devices that are out there. We talked about where and how to find the book. It’s the first link inside the show notes, so definitely check it out. Buy it. Buy a copy for someone in your life that you love and want to see their health get better in every context and have them feel better. And lastly, you also still, the practice still sees some patients, so people can check that out as well. Is that correct?

Dr. Sara Gottfried (01:43:40):

That’s right. Yeah. So I’m booked out for a while, but yes, my practice is still open.

Dhru Purohit (01:43:46):

Okay, great. Fantastic. Well, another link that we’ll add into it. Dr. Gottfried, I want to thank you for coming on our podcast and making the time for a deep dive on all these things that you’re just so knowledgeable about and have so many years of clinical experience, in addition to all the training and research that you’ve done on your own. And you are truly, truly a guiding light in this space of staying away from tribalism, providing education and practical science that can be applied right away.

Dhru Purohit (01:44:19):

And positive words of encouragement for people who feel like, “This is all so overwhelming,” you always provide the reminder of “All we have to do is take it step by step.” And it’s not, “Is it tough?” Because it is sometimes a little bit tough. It’s, “Is it worth it?” And when you’re suffering and you’re at the depths of your worst health, or you don’t feel good, anybody knows in that situation that it would be worth it. Some people would pay everything that they have to feel better. So thank you for being that voice and that reminder, because it’s very hopeful for people who are listening. So I really appreciate you and thank you for coming on the podcast.

Dr. Sara Gottfried (01:44:59):

Thank you so much, Dhru. I mean, you just spoke my love language there, which I so appreciate. You mentioned overwhelm. Let me say one quick thing about that.

Dhru Purohit (01:45:09):

Please do.

Dr. Sara Gottfried (01:45:10):

Overwhelm is a symptom of hormone imbalance. So if you find this information somewhat overwhelming, it’s not a moral feeling. It’s not that you’re doing anything wrong. It could be your hormones. So it’s another encouragement to check out your hormones. And I just want to say to you, Dhru, every time I talk to you, I met you many years ago, every time I talk to you, I just feel graced by your presence. I love the opportunity to spend quality time with you, even if it’s online. I just really love what you’re doing in the world and how you’re making it a better place, one podcast at a time, all the work that you do, just so impressed with your gifts and your achievements. Thank you.

Dhru Purohit (01:45:52):

Aww. Thank you. The gratitude means the world, and I really take it in and sit with it. So thank you for that. Dr. Gottfried, you are amazing. And I’m so happy that you came on to provide our audience with this education. So hope to have you back on soon, to have the next part of this conversation in whatever shape or form we want to take it. So thank you again for being here.

Dr. Sara Gottfried (01:46:18):

Thanks, Dhru.