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Menopause Expert: Belly Fat Grows During Menopause! Your Estrogen Levels Are Controlling You & This Hormone Is Quietly Killing Your Sex Life!
01:59:03
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- [00:01]
Dr. Sara Sal
3 to 75% of women do not get the treatment for perimenopause and menopause that they deserve. And women are asking, why is it that I can't manage stress the way I once did? Why do I have this belly fat that appeared out of nowhere and my usual techniques for how to deal with that aren't working. Why would I rather mop the floor than have sex with my husband? But there's more than 100 plus symptoms that women aren't aware of.
- [00:22]
Stephen Bartlett
But you believe many of the symptoms of menopause are avoidable?
- [00:25]
Dr. Sara Sal
Yes, and let's get into that. Dr. Sara Sal is the Harvard trained physician and hormone expert who's unlocking the science and simple tricks behind feeling your best. No matter your age, most people have imbalanced hormones. Think of them as text messages that your body sends to keep everything functioning optimally. But for example, out of the 40,000 people I've tested and treated, around 90% of them have a problem with their cortisol hormones.
- [00:49]
Stephen Bartlett
And if my body's making too much cortisol, what is the harm?
- [00:51]
Dr. Sara Sal
It's associated with more belly fat. We know that it shrinks the brain in women, but not men. It's associated with depression. But also, if you're someone who's making a lot of cortisol, you're going to make less testosterone, and that leads to a whole host of serious problems.
- [01:05]
Stephen Bartlett
And what about trauma? Does that impact your hormones?
- [01:08]
Dr. Sara Sal
Oh, yes. And one of the ways to measure trauma is the ACE test. It's a validated questionnaire, and they found that people who had one or higher ACE scores had a greater risk of 45 different chronic diseases. And my score is 6 out of 10. But those ACEs are living on in your body.
- [01:25]
Stephen Bartlett
And you went on a journey to heal yourself.
- [01:27]
Dr. Sara Sal
Yes, with lifestyle medicine, not a pharmaceutical.
- [01:30]
Stephen Bartlett
Tell me about that journey.
- [01:33]
Dr. Sarah Z
I find it incredibly fascinating that when we look at the back end of Spotify and Apple and our audio channels, the majority of people that watch this podcast haven't yet hit the follow button or the subscribe button. Wherever you're listening to this, I would like to make a deal with you. If you could do me a huge favor and hit that subscribe button, I will work tirelessly from now until forever to make the show better and better and better and better. I can't tell you how much it helps. When you hit that subscribe button, the show gets bigger, which means we can expand the production, bring in all the guests you want to see, and continue to do in this thing.
- [02:04]
Stephen Bartlett
We love.
- [02:04]
Dr. Sarah Z
If you could do me that small favor and hit the follow button wherever you're listening to this, that would mean the world to me. That is the only favor I will ever ask you. Thank you so much for your time. Dr. Sarah Z.
- [02:17]
Stephen Bartlett
What is it that you do for people?
- [02:20]
Dr. Sara Sal
I'm a physician, so I work in academic medicine. I do research for people, I teach, and I take care of patients. So that's the official BBC answer. And the unofficial answer is I'm a healer.
- [02:37]
Stephen Bartlett
And what does that mean, a healer? Because that's a broad term, so that could mean many things.
- [02:42]
Dr. Sara Sal
It means that my task is to connect to your innate healing capacity and to work with you to activate it.
- [02:53]
Stephen Bartlett
And who'd you do that for?
- [02:55]
Dr. Sara Sal
So I do it for professional athletes, executives, and everyday people.
- [03:04]
Stephen Bartlett
And when you say healing, if someone came to you and they said, how do you heal people? What would your answer be?
- [03:12]
Dr. Sara Sal
My answer is I don't heal people. That's. To me, that's a patriarchal way of thinking about it. What I do is I work with someone who's got the capacity to heal, and we work to be in the service of that. So it's not me providing something that they don't have already. It's more understanding what some of the obstacles might be to their own healing, understanding what would allow them to be the best version of themselves, to feel fully alive.
- [03:48]
Stephen Bartlett
And what was your training? So can you talk me through your sort of academic journey?
- [03:53]
Dr. Sara Sal
Sure. So my training is as a bioengineer. I did the Harvard MIT program, which is designed to train physician scientists. So the ethos of this particular program was to train the future researchers and academic physicians so that we could move the field forward. And all along, I was really interested in how do you bring the best of conventional medicine together with more ancient ways of thinking about the body, Things like Ayurveda from India or traditional Chinese medicine. How do we take these wisdom traditions and use that to inform mainstream medicine? So that's the type of care that I learned how to do. I became a surgeon. I did primary care after I finished a residency in obstetrics and gynecology. But I also realized pretty early on that I wanted to take care of men, too. So I've done that for about the past 15 years. And I would say that that training in bioengineering and a comfort with big data and with optimizing data sets to improve whatever the goal is, like performance or having the best conversations you can have on a podcast, that's what gets Me excited.
- [05:28]
Stephen Bartlett
How many people do you think you've treated or seen or worked with directly in your career?
- [05:34]
Dr. Sara Sal
Probably about 40,000.
- [05:38]
Stephen Bartlett
And if you had to try and summarize maybe the top three or five things that you're doing for them, what would you say?
- [05:46]
Dr. Sara Sal
Well, number one would be hormones. Hormones are the portal that most people start with me. It's a way of thinking about what drives what you're interested in. Most people have imbalanced hormones. I haven't detected that you do yet. But most people have an issue, say, with cortisol, either making too much of it or too little, or even both within the same day. And it affects energy, it affects mitochondria. So I would say the number one thing I help people with is their hormones, getting their hormones back into balance. Starting first with lifestyle medicine, not a pharmaceutical. So that includes breath work, which I think is one of the most underutilized tools that we have in health. Number two would be nutrition, but take it to the next level. Not what you might think of that a nutritionist would advise you, but what specifically is the ideal food plan for you for your goals? So whether you're a entrepreneur and podcaster and investor, or you're a professional basketball player, or you're a woman in perimenopause at age 42, what's the optimal nutrition for you? And we can measure that, and we can look at the interaction of your genetics together with what you're eating to see how we could personalize that. Number three, I would say, is prevention. And prevention has been a hard thing to sell. A lot of people just don't want to invest in prevention. And yet I take care of people who are in this continuum from a state of health often to a state of pre disease like prediabetes, as an example. And if they don't do something about it, they then move on to diabetes. So I like to intervene there as early as possible to reverse disease. Most of that is lifestyle. So those are the things that I tend to work with. I do a lot of metabolic health because it's so critical for the energy that you feel each day.
- [08:16]
Stephen Bartlett
You have a very diverse experience as a doctor slash healer. It feels like you've really had a lot of sort of reference points in your career that you've drawn upon. And ultimately you became the director of precision medicine at the Marcus Institute in Philadelphia.
- [08:36]
Dr. Sara Sal
That's correct.
- [08:37]
Stephen Bartlett
Precision medicine. That term, how does that differ from conventional medicine?
- [08:45]
Dr. Sara Sal
It's quite different. So conventional, mainstream, modern medicine, I believe, is broken. I feel like There are so many people who are failed by our current medical system, especially people with chronic disease, things like diabetes, autoimmune disease. So with mainstream medicine, generally, what happens is that you develop a condition, say high cholesterol, and you get treated with a pharmaceutical, say a statin. And what we know is that we have to treat about 100 to 200 people for one person to benefit. So that I would define as imprecision medicine. Whereas precision medicine is where we understand you as an individual. We look at your genomic blueprint, we look at your biomarkers, we look at your wearables data to determine N of 1 experiments where you serve as your own control and figure out what's going to be the most effective for you, depending on what your goals are.
- [09:50]
Stephen Bartlett
N of 1. You mean where that individual is the study, they are the experiment?
- [09:54]
Dr. Sara Sal
That's correct.
- [09:55]
Stephen Bartlett
You're not looking at broad sample sizes. What is wrong with conventional medicine? You use the term that it's broken. What is wrong about that approach?
- [10:04]
Dr. Sara Sal
There's a few things that are wrong. One is that it has become medicine for the average. And when you look at scientific evidence and you rank order it, what's considered the highest form of evidence is the randomized trial. But the randomized trial is mostly around using a pharmaceutical. So in the example I just gave, using a statin to help someone with their cholesterol, maybe help prevent a heart attack, the number one killer. The problem is we then, based on randomized trials, come up with medicine for the average. And it's not about optimal health. It's not even centered around health. It's centered around, okay, heart disease, number one killer. How do we help people prevent it? Oh, lifestyle medicine prevents 70% of it. Well, we're not going to do that because we can't make money off of it. There's no profit motive. So we're going to focus instead on these pharmaceuticals. Oh, GLP1s. That sounds like a good idea. Let's try that and solve problems with GLP1s. So to me, there's many layers to why the healthcare system is broken. But one key area is that 70% of the diseases we're facing right now are utterly preventable with lifestyle medicine. 70%.
- [11:34]
Stephen Bartlett
You used the word hormone balance earlier on and you said that that's the portal in which people often find you. I really don't know much about hormones, and it's not necessarily something that the average person thinks that they can do much about. I think because it's not easy to measure our hormones Is it?
- [11:50]
Dr. Sara Sal
Well, you can measure it in the blood. So it's not that hard to measure hormones. But I think there's a way that in mainstream medicine we're taught to tell people that their hormones vary too much and so it's not worth measuring.
- [12:06]
Stephen Bartlett
Yeah, that's what I've heard before.
- [12:08]
Dr. Sara Sal
It's what you've heard, but then if you're a woman who's 34 and you're trying to get pregnant and you're having trouble in that situation, we'll measure every single hormone. We'll look at thyroid, cortisol, testosterone, estrogen, progesterone, the control hormones like follicle stimulating hormone. And yet somehow in that situation, testing is more reliable, but it's not in this other situation. That doesn't make sense. That's double standard.
- [12:36]
Stephen Bartlett
Why did you choose this career? What is it about you, your childhood, your life that sent you down this road?
- [12:43]
Dr. Sara Sal
I would say it was growing up with a fair amount of trauma. And you know, what I've learned about trauma is it's less about what actually happened to you. It's the way that it became embedded in the system of your body. So for me, my parents got divorced when I was really young. I grew up in a way that I became a helper. And I realized that by being someone who was really looking out for others and tuning into their energy and helping them achieve their goals, that kept me really safe. And so there's a way that, that it was very resonant for me to discover medicine. And one of the things we know about people who go into medicine is that people tend to have a fair amount of trauma that leads to becoming a helper in this way.
- [13:42]
Stephen Bartlett
What was that trauma?
- [13:45]
Dr. Sara Sal
So there's a lot of different ways to measure trauma. One of the ways that I find helpful is something called the adverse childhood experiences. So ACE for short, I think I've got it here. Oh, do you? It's a questionnaire. So My score is 6 out of 10. So childhood, divorce. My parents got divorced when I was about a year old. That's one out of the six. Other things are abuse, neglect, emotional abuse, physical abuse, having a parent with a substance use disorder. So things that. It's not a complete list, but it's a validated questionnaire that was used in the 1990s and found among people who are middle aged. You're not quite yet middle aged. But for people who are middle aged 40 to 65, they found that people who had higher ACE scores 1 or higher, they then had a greater risk of 45 different chronic diseases.
- [14:43]
Stephen Bartlett
How important is it for us to understand our early upbringing and our trauma if we are to heal as adults? Because you said there that if you score high on this ACE score, this trauma score, this childhood trauma system sort of questionnaire, then as an adult, you're more likely to get a variety of different diseases. So do we need to heal our bodies in some way to avoid getting some of those diseases?
- [15:07]
Dr. Sara Sal
Yes, and that's the critical question. So if you know that you have an elevated ACE score, and there's a lot of people who have a score of zero, about 40% of men, about 30% of women. And what we know is that if you've got this greater risk for 45 different chronic conditions, there's a way that those aces are living on in your body, unless you're addressing them. And it's the living on in your body that we want to pay attention to. So for some people, it's their immune system, and it leads to more allergies, more histamine overload, more food intolerances, maybe autoimmunity, where their immune system is attacking their own tissues, maybe autoimmune disease. There are other people who have more nervous system dysregulation. Maybe they've got anxiety or depression or post traumatic stress disorder, mental health issues. And for other people, it could be more endocrine. They've got chronic cortisol problems, which is hormones. Yes.
- [16:20]
Stephen Bartlett
How did that manifest in your physical health?
- [16:23]
Dr. Sara Sal
So I didn't start to detect this until my 30s, but what I found was that I had depression. I had premenstrual syndrome. I had my first baby when I was 32 and I couldn't lose the baby weight. And as all of this was happening, and I'm a physician, I went to my doctor for help. And he suggested that I go on Prozac for the depression and the mood.
- [16:57]
Stephen Bartlett
Issues, which is an antidepressant pill, a.
- [16:59]
Dr. Sara Sal
Selective serotonin reuptake inhibitor that I go on the birth control pill because I sounded hormonal, and then I start exercising more and eating less. So that was his treatment. And that's typical mainstream medicine treatment. But I wasn't satisfied with that. I felt like that doesn't seem right. And I left his office and went to the lab, ordered my own hormone panel, and found that my cortisol was three times what it should have been. So there's the optimal range for cortisol in the blood. It's about 10 to 15 in the morning, 6 to 10 in the afternoon, and mine was 30. I also looked at my fasting glucose and insulin, and I had pre diabetes in my 30s. I had no idea. No one was checking for this. So I'm answering your question about how these aces showed up in my body. We know that adverse childhood experiences link to blood sugar problems and a greater risk of prediabetes and diabetes, which I had. We know that they link to chronic stress and cortisol problems, high perceived stress, whether the stress is there or not. It also led to, as I started using wearables, low heart rate variability, the time between each of my heartbeats. That's a measure of the sympathetic nervous system. Fight, flight, freeze, fawn versus the parasympathetic nervous system, which is where healing occurs.
- [18:32]
Stephen Bartlett
And you went on a journey to heal yourself.
- [18:34]
Dr. Sara Sal
Yes.
- [18:35]
Stephen Bartlett
Tell me about that journey.
- [18:39]
Dr. Sara Sal
So in my 30s, this is a huge epiphany for me because I realized that I wasn't trained. I wasn't educated. Even though I had an outstanding education, I wasn't trained to help with this. No one taught me about cortisol problems and how to manage that. I mean, I was taught about the extremes of Cushing's disease, which is really high cortisol levels, and Addison's disease, which JFK had. And it's when your adrenals in your back above your kidneys don't make cortisol. So I was taught about the extremes, but I wasn't taught about all the people who kind of live in the middle with problems with their cortisol. So this is when I started to take the scientific literature and apply it to my situation, because I wanted to feel better. I felt old before my time, and I had a lot of belly fat. And I was on this path of aging at an accelerated clip. So I did it to help myself. But then I also wanted to help my patients. And it felt like I needed to go deeper and understand what can we do to treat the trauma and also to treat the more proximal measurements that we're making, like with cortisol, with heart rate variability, with blood sugar.
- [20:06]
Stephen Bartlett
So what was step one for you?
- [20:09]
Dr. Sara Sal
Step one was awareness.
- [20:10]
Stephen Bartlett
Okay.
- [20:11]
Dr. Sara Sal
And I had no idea. These are not things that most doctors are checking for.
- [20:16]
Stephen Bartlett
It's pretty crazy that you're a doctor, but you don't know this part of health. I mean, how are you going to help anybody if you don't fully understand health from a more sort of holistic perspective?
- [20:29]
Dr. Sara Sal
That's a critical point. So I was taught at Harvard that if you have blood sugar problems. If you've got prediabetes and diabetes, the treatment is lifestyle. It's the most effective to change the food that you're eating, to increase your exercise, to manage your stress in a different way. And yet I wasn't taught how to help my patients do any of those things. I was taught how to prescribe a medication for it, like metformin or some other treatment, but I wasn't taught how to do lifestyle medicine. I had 30 minutes on nutrition. So, yes, it is pretty crazy.
- [21:09]
Stephen Bartlett
They gave you 30 minutes on nutrition?
- [21:11]
Dr. Sara Sal
Yes.
- [21:12]
Stephen Bartlett
During which training.
- [21:14]
Dr. Sara Sal
This is medical school. And I got about the same amount on perimenopause and menopause.
- [21:21]
Stephen Bartlett
Really? I mean, that explains a lot.
- [21:24]
Dr. Sara Sal
Yes, it does.
- [21:24]
Stephen Bartlett
About the medical system. So step one was awareness. What was step two?
- [21:29]
Dr. Sara Sal
Step two was what does the science tell us? And if we take what the science tells us, usually applied to a population, that then sets us up for step three, which is end of one experiments.
- [21:45]
Stephen Bartlett
Trying things on yourself and then measuring.
- [21:48]
Dr. Sara Sal
That's right.
- [21:49]
Stephen Bartlett
When we think of cortisol, which was the first sort of marker that you saw was elevated, we think of stress. So we think we get cortisol if we're stressed. So my brain, my very naive brain, said, well, you just need to be less stressed, Sarah, so you should just go on a holiday and then your cortisol will come down.
- [22:10]
Dr. Sara Sal
I used to think that too. And then I would come back from the holiday and I would still have cortisol problems. So stress is part of it. But cortisol is really interesting. These hormones that we're talking about, estrogen, progesterone, testosterone, cortisol, insulin. It's not a democracy. Like, they don't have equal footing. Cortisol is more like a dictator, especially if it's out of whack. So you need cortisol to live. Whereas you could live without testosterone, estrogen, progesterone, can't live without insulin. But cortisol is critical in terms of helping you with your immune system, helping you with your blood sugar and just managing the stress response. So it's not quite as simple as thinking your way out of a high cortisol or a low cortisol. And there are ways that your body can become stuck in a particular pattern of making too much cortisol or making not enough cortisol.
- [23:15]
Stephen Bartlett
And if my body's making too much cortisol and my levels are too high, what is the harm?
- [23:21]
Dr. Sara Sal
The harm is it's associated with depression. It's about 50% of people with high cortisol. 50% of people with depression have high cortisol. It's used by some psychiatrists as a suicide marker. It's associated with more belly fat. And so the fat receptors, the fat cells in your belly have increased receptors for cortisol. So it's a way of growing your belly fat. We know that it shrinks the brain in women, but not men. Starting in midlife, starting in your 40s. It's not an old age thing. And this has been shown a couple of different ways. There was a study from the University of Texas in San Antonio showing that women in their 40s with high cortisol have a shrinkage of total brain volume. And then Lisa Moscone at Cornell also just showed in a study looking at men and women that women with high cortisol also have shrinkage of their total brain volume. And they start to have a difficult time using glucose as fuel in their brain.
- [24:34]
Stephen Bartlett
Which is going to result in what kind of behaviors?
- [24:38]
Dr. Sara Sal
Well, it makes you tired, it gives you slow brain energy, and I can tell for the most part, you don't have that. But if you do have it, there's a way that you kind of. Your brain slows down, you feel foggy, you're not able to multitask and kind of keep up with everything.
- [24:56]
Stephen Bartlett
Is there a link between cortisol and trauma?
- [24:59]
Dr. Sara Sal
Oh, yes.
- [25:01]
Stephen Bartlett
What is that link?
- [25:02]
Dr. Sara Sal
So for people who experience toxic stress or trauma, what typically happens is cortisol goes up. That's part of the alarm, the body's stress response. What we know is that for people who've got more serious exposure to trauma and they have post traumatic stress disorder, those people have probably gone through a period of high cortisol, and now they can't keep up anymore, and they are in a low cortisol state.
- [25:34]
Stephen Bartlett
What are the things in the world at the moment that are messing up our hormones? Because the subject matter of hormones has become increasingly popular. And I know that there's hormones like cortisol, which we've talked about. Testosterone, estrogen, progesterone, insulin, glucose. What are the big things that are messing up our hormones at the moment? Because I want to make sure my hormones are in check. So I'm a guy. I'm sure that there's some of these hormones are more like. Things like estrogen have, I think, more pertinent to women.
- [26:05]
Dr. Sara Sal
But no, it's important for men, too.
- [26:07]
Stephen Bartlett
Oh, really?
- [26:08]
Dr. Sara Sal
So estrogen and progesterone are incredibly important for men, and it's involved in bone strength. Progesterone's involved in sleep in men. So the levels are lower in men and your testosterone's about 10 times higher. But in women, in and men, they're all important. So what's messing with our hormones? I would say toxin exposure. So there's endocrine disruptors. There's more than 700 known endocrine disruptors. Things like bisphenol A, like the plastic lining that you see in cans or in plastic containers, water containers. There's skincare products which women are exposed to more things like moisturizer and makeup and other things that contain endocrine disruptors like parabens. And there's flame retardants that we get exposed to. So there's a whole class of endocrine disruptors. And then it feels right now like we are more dysregulated than I've ever seen. And I'm not sure what the cause is. I don't know if it's the post pandemic experience or part of what we're experiencing in the United States with the change in leadership. It just feels like there's this hum of dysregulation that I haven't seen over my career. Are you noticing that?
- [27:49]
Stephen Bartlett
Are you seeing that in your patients?
- [27:51]
Dr. Sara Sal
I see it in my patients. I see it in their wearable data. I see it in heart rate variability. I see it in the cortisol levels that I'm measuring.
- [28:04]
Stephen Bartlett
You asked if I'm noticing that. I mean, the more digital the world has become, I think I've seen more dysregulation. And we're obviously moving further in that direction at rapid speed, especially with things like AI now and algorithms getting more smart and addictive. Yes, so I see that. Also there's just been a change in, I think the algorithms, the social media algorithms will compete with themselves to see who can hold you the most. And to do that, they have to kind of grab your attention. And the easiest ways to grab your attention is by showing you things that are probably dysregulating.
- [28:36]
Dr. Sara Sal
Yes, it's an attention economy. And the cost in that fight for attention is that often the nervous system becomes more dysregulated.
- [28:47]
Stephen Bartlett
So if you had to come into my life and you had to optimize my life to make sure that all my hormones were in check, you would get rid of plastics and toxins from my everyday life, my bathroom, et cetera.
- [29:02]
Dr. Sara Sal
I'd look at your skincare, I'd look at your cleaning products, I'd look at your air quality. I'd probably install A couple of air filters. If you don't have that, I'd want to know about your stress because you're someone who performs at such a high level. And I would assume that you found the right level of stress where it's not so little that you're not productive, but it's not to excess, to the point that there's a cost to it physiologically.
- [29:33]
Stephen Bartlett
Yeah. And then.
- [29:35]
Dr. Sara Sal
And I'd want to look at your food. I'd want to know how much protein you're consuming. Are you getting the right amount of carbohydrates? Seems like you are. Are you utilizing those? Well, what's going on with the continuous glucose monitor? How are your nutrients? What's your vitamin D? Things like that?
- [29:54]
Stephen Bartlett
You're a big fan of continuous glucose monitors, aren't you?
- [29:56]
Dr. Sara Sal
I am. I think it gives real time feedback, immediate feedback on the food that you're eating. I've seen nothing else change behavior like a continuous glucose monitor.
- [30:07]
Stephen Bartlett
And for anybody that doesn't know, it's the little patch you put on your arm and it tells you your blood sugar levels in real time straight to your phone.
- [30:16]
Dr. Sarah Z
Sugar.
- [30:17]
Stephen Bartlett
Is sugar the enemy?
- [30:20]
Dr. Sara Sal
I don't think sugar's the enemy. I think the enemy is the way that we eat it to excess, the way that we use it to change our emotional state. And we know people who have adverse childhood experiences. They're more likely to have disordered eating. They're more likely to have problems modulating the amount of sugar they consume.
- [30:44]
Stephen Bartlett
When you're treating patients, do you focus heavily on their blood sugar levels?
- [30:49]
Dr. Sara Sal
I do, because I think it's an important indicator of the way the biochemistry of the body, the metabolism is working. It tells me about their mitochondria. It tells me about the way that they're producing energy. ATP by ATP, this compound, this measure of energy that you produce inside of.
- [31:12]
Stephen Bartlett
All of your cells, which is called ATP.
- [31:14]
Dr. Sara Sal
ATP.
- [31:16]
Stephen Bartlett
And that ATP then drives what? It drives everything we do.
- [31:22]
Dr. Sara Sal
ATP is fuel. So it allows you to feel like you're fully energized, especially when you wake up in the morning.
- [31:29]
Stephen Bartlett
And are there any supplements that I should be taking if I'm trying to optimize my hormonal balance?
- [31:34]
Dr. Sara Sal
Well, I'd have to look at your total picture. But most of us inherit somewhere around five to seven genomic vulnerabilities, and often we want to work around those. So, for instance, for me, my vitamin D receptor sucks. It just doesn't work very well. So I have to take increased levels of vitamin D to keep the kind of the baseline amount of vitamin D in my system, normal. So we would want to look for those. We'd look at your genomics to see what's your relationship to B vitamins. With the stress that you manage, do you have a deficit with B vitamins? For a lot of men, it doesn't show up until around age 40. So this is a good time for you to do a baseline.
- [32:25]
Stephen Bartlett
When you look at people's biomarkers and their blood samples, what are the things that you like, typically always see that are deficient? Because I'm sure there's things from a social level that we're just all kind of getting wrong.
- [32:39]
Dr. Sara Sal
Vitamin D is common, so somewhere around 70 to 80% of people don't have enough vitamin D. And one of the things that I think is so important to realize about vitamin D is that it's got 400 jobs in the body. One of them is keeping your boundary in your gut intact, so keeping tight junctions working so that you don't have leaky gut. So vitamin D is a common one. I had an executive that I took care of on Tuesday and he had a fasting glucose of 102, which is in the pre diabetes range. No doctor has pointed this out to him before. His cholesterol was starting to climb, his blood pressure was borderline, not high enough to require a medication. But at the point where we want to turn that chip around before he needs the medication, he had a level of inflammation in his body that was causing aches and pains and kind of like this silent condition that wasn't working well for him. So there's a couple ways to measure that for him. His homocysteine was elevated. It was 14.7. And that's one that's really easy to measure in a basic panel. What we want with homocysteine, which is heart specific inflammation, we want that to be five to seven when it's elevated. That tells us that often part of the biochemistry in the body, your methylation is not working well. Methylation is just where you add a carbon and three hydrogens to a molecule. It's a way that we turn genes on and off. And so in this person's case, he wasn't getting enough B vitamins, methylated B vitamins. So we started him on a supplement to help him with that. So that's a common one. His testosterone was good, so didn't have to address that. This guy was about 52. His cortisol was good. He was the chief financial officer of a company back east well, he had a number of things on his genomics that we needed to pay attention to. What was interesting about this guy, Steve, is that he was an athlete. He played football in high school and college. He had this identity as an athlete. But when he came to see me at age 52, he was barely exercising. He would lift weights maybe once a week. He would go swimming for about 30 minutes once a week. And so he wasn't leveraging disposal of glucose the way that he could be the way that he used to when he was in his 20s. So a big part of understanding what made him tick was to reaffirm this identity as an athlete and to use that to address this metabolic crisis that was starting to happen in his body before it was too late.
- [35:53]
Stephen Bartlett
Because he's got too much glucose and he's not doing enough with it.
- [35:56]
Dr. Sara Sal
That's right.
- [35:57]
Stephen Bartlett
So his body is having to store it and getting inflamed.
- [36:01]
Dr. Sara Sal
And he said, you know, listen, it's been the Christmas holidays. I had a lot of pound cake, I had some cocktails. You know, maybe that's part of the problem. But we had measured his hemoglobin A1C, which is the three month summary of what's happening with your glucoses. And the problem predated Christmas. So we needed to get him into action around exercise.
- [36:27]
Stephen Bartlett
Getting back to hormones, I really want to close off on this subject of cortisol because I know that that's such a important hormone. I've heard you say before that you believe that cortisol is the most critical hormone to get into balance. You want to focus on cortisol really, first and foremost. So someone like me, is there anything else I need to know to get my cortisol levels in balance? And also, what percentage of the population do you think have their cortisol out of whack?
- [36:59]
Dr. Sara Sal
So we don't have data on the numerator or the denominator. And my patient population is enriched with people who've got cortisol problems. So out of all of the people I test, somewhere around 90% of them have a problem with their cortisol. And that includes professional athletes because at least in the U.S. like basketball players, they travel a ton, they play back to back games, they've got a cortisol load, a stress load that is pretty high even for someone in their 20s or 30s who's used to high performance. So the number is high. If I had to look at the general population, it would be a total speculation. I would say somewhere around 30 to 50%.
- [37:55]
Stephen Bartlett
And what do you do about that if you're an athlete and you've got elevated cortisol levels?
- [38:00]
Dr. Sara Sal
I think there's a number of different things. There's the top down approach, which is cognitive, kind of like, what is my prefrontal cortex? How can I leverage that to work with this? And then there's more of a bottom up approach, which is using your senses to create safety and to change the cortisol signal, kind of the alarm in the way that it goes off in the body. So breath work is really important for that. Meditation, different forms of movement, dancing, rhythmic movements, walking, hiking, running is a little tricky because that can be a stress response and it can raise cortisol. So I would say for a professional athlete, what I usually recommend is meditation, regular meditation, and finding what's a really good fit for them. Because for some people, mindfulness based stress reduction is a good fit, but that doesn't fit for everyone. Other people like resonance breathing, like a five second inhale, seven second exhale, six breaths per minute. Doing that for 10 to 20 minutes. That can really help to create balance between the parasympathetic nervous system and the sympathetic nervous system. For some of my athletes, it's a supplement. So if they've got high cortisol, one of the things I often do is to give them Cortisol Manager, which is a supplement that includes ashwagandha and phosphatidylserine. And it's been shown to lower cortisol levels. So if they're traveling and they have to take a plane back to Philadelphia after an away game, Cortisol Manager can help them manage the cortisol.
- [39:54]
Stephen Bartlett
I found a supplement called, I can't pronounce the name properly, but rhodiohol.
- [39:59]
Dr. Sara Sal
Oh, rhodiola.
- [40:00]
Stephen Bartlett
Rhodiola, yes.
- [40:02]
Dr. Sara Sal
Rhodiola is an adaptogen. So it's an herbal therapy that's been shown to help with cortisol.
- [40:09]
Stephen Bartlett
Lowers cortisol.
- [40:10]
Dr. Sara Sal
Yes.
- [40:11]
Stephen Bartlett
And I was reading that it increases your focus. Potentially.
- [40:14]
Dr. Sara Sal
Yes, it does.
- [40:15]
Stephen Bartlett
Do you prescribe that to athletes?
- [40:18]
Dr. Sara Sal
I do. So generally what I try to do with most of my athletes is have them take a supplement either first thing in the morning or before they go to bed. It's harder to do it during the day, and so I tend to start with Cortisol Manager because I think it's got the best data. But rudiola is also a good choice and I have prescribed that.
- [40:36]
Stephen Bartlett
Is it easy for people to change in this regard, to get them to make a set of different decisions? I Think we're at a time of year where a lot of people are thinking about changes and a lot of people are failing repetitively every year at the changes they say they want to make. Is it easy to get someone to change?
- [40:57]
Dr. Sara Sal
I would say behavior change is the hardest thing that we do as humans. I think there are ways that adverse childhood experiences tend to set a pattern that's very hard to break. But I see people change their behavior all the time and I think part of it depends on what's the pain of staying the same. If it's high enough to motivate you and to help you not take the shot or two of tequila that has been your downfall in the past. If you have something that keeps you accountable and has the Hawthorne effect, like a continuous glucose monitor, I think that can also be very helpful. As if someone was watching you. Because my patients with their continuous glucose data, I am watching them, I'm scanning them.
- [41:54]
Stephen Bartlett
But doesn't that mean that in order to change, some people just need a bit more pain?
- [42:00]
Dr. Sara Sal
I would say people have a different level of pain that motivates change.
- [42:05]
Stephen Bartlett
Have you ever seen a situation, we were talking about this a couple of weeks ago, where when you're trying to help someone, you actually end up propping them up. And because you're intervening to stop them experiencing the pain that they might, otherwise you end up harming them because you're preventing them from going to that place where they call rock bottom, where self motivated change would occur.
- [42:30]
Dr. Sara Sal
It's a good question. I think there's a fine line between motivating and also speaking your truth about what you're willing to tolerate, say in your partner or a friend or family member, and also enabling or being codependent. And so you have to try to find that line. I mean, one of the things I found over my career, and it took me a while to learn this, is that if someone has denial about what they're doing and how it's affecting their relationships, their health, their ability to work, say drinking too much, having a sticky relationship with alcohol, it's not my job to break through their denial. They have to do that. That's their work. Now I can say alcohol has no health benefits. Here's what it does, here's what it does to the female brain, here's what it does to the male brain, here's what it does to break the boundary in your gut and cause leaky gut. Here's all of the untoward effects of it. But it's not my job to break through their Denial. They have to do that. And that's very hard, especially if you have a family member or a friend or a partner who is doing things that are harming themselves.
- [43:58]
Stephen Bartlett
So what do you consider your job to be? If you are a friend or a.
- [44:01]
Dr. Sara Sal
Family member, your job is to determine what your boundaries are, what you're willing to tolerate, to stay in relationship. And that's, you know, that's where interventions play a role, where you confront the person and say, I'm really worried about you. Here's what I'm witnessing. I really feel like you need to approach this in a different way. Are you willing? But it's a consenting process. You don't do it for them. What's your experience?
- [44:40]
Stephen Bartlett
Well, I just have so many, you know, because these days I can help people much more than I could 10 years ago, whether it's financially or in other ways. And so it's often tempting when someone in my life is struggling in some way to just intervene with some kind of crutch.
- [44:55]
Dr. Sara Sal
Yes.
- [44:56]
Stephen Bartlett
And I've actually seen over the last, like, 15 years that the best things that I've ever done for some of my friends wasn't an intervention. It wasn't paying for something for them or taking care of something for them. It was being honest with them and then being there as they figured it out themselves. And often it was actually removing my crutch, which meant that they would fall a little bit and then climb themselves out of the ditch to a very good life. So I just always think about that, that a lot of us, through love or through the fact that we can often end up propping people up in our lives and we're actually doing them a disservice because we're kind of inhibiting their own natural growth journey.
- [45:37]
Dr. Sara Sal
I agree with that. And I would also say that what you just described is holding a mirror to someone in a way that is very loving but also clear. It's a clean mirror. And it's very different than just loaning them the money.
- [46:00]
Stephen Bartlett
Yeah.
- [46:00]
Dr. Sara Sal
And then being there for them as they stumble and struggle and try to make things different.
- [46:07]
Stephen Bartlett
You talked earlier about the executive that you checked recently. You said his testosterone levels were intact.
- [46:14]
Dr. Sara Sal
Yes.
- [46:15]
Stephen Bartlett
At what age should I be thinking about my testosterone levels or should I be thinking about them all the time? Because I kind of see it as something that I need to worry about when I get a little bit older, into my 40s and 50s, it tends.
- [46:28]
Dr. Sara Sal
Not to decline until about age 40. But I would say do a baseline now.
- [46:32]
Stephen Bartlett
Okay.
- [46:33]
Dr. Sara Sal
So a Baseline biomarker assessment would be worthwhile. And, you know, one of the things we found during the pandemic was that the National Basketball association was playing in a bubble. They were playing in Florida, and the players cut off from their families and kind of stuck in Florida for a period of time. They had low testosterone levels. And these guys normally have pretty high testosterone levels. So there can be specific situations that can affect your testosterone level.
- [47:08]
Stephen Bartlett
What was it that was affecting those?
- [47:10]
Dr. Sara Sal
Part of it was just being in a hotel, in a bubble, unable to leave, cut off from their community, their family, their friends, their usual ways of blowing off steam. I imagine they didn't measure their cortisol, but I imagine it was probably higher than normal.
- [47:30]
Stephen Bartlett
And women have testosterone, too. But you said, I think, earlier, that men just have 10 times more testosterone.
- [47:36]
Dr. Sara Sal
Men have more, but it's the most abundant hormone in the female body. Women are exquisitely sensitive to it.
- [47:43]
Stephen Bartlett
It's the most abundant hormone?
- [47:45]
Dr. Sara Sal
Yes. Higher concentration than estrogen or progesterone.
- [47:49]
Stephen Bartlett
About 15 to 17 nanograms in a woman. That's what I read on WebMD.
- [47:54]
Dr. Sara Sal
Yes, that's a pretty good level.
- [47:57]
Stephen Bartlett
And in men, 300 to 1,000 nanograms.
- [48:01]
Dr. Sara Sal
Yes. I like to see it somewhere around 500 to 1,000.
- [48:04]
Stephen Bartlett
And what would be a sign that I had low testosterone if I'm a man?
- [48:11]
Dr. Sara Sal
Belly fat, gynecomastia.
- [48:15]
Stephen Bartlett
What's that?
- [48:15]
Dr. Sara Sal
That's when you have breast development.
- [48:17]
Stephen Bartlett
Okay.
- [48:18]
Dr. Sara Sal
Mood changes, mood swings, irritability, depression, cardiovascular changes, erectile dysfunction, decreased libido.
- [48:34]
Stephen Bartlett
What about in a woman? So if a woman has low testosterone, what are the symptoms we see in a woman?
- [48:40]
Dr. Sara Sal
They're similar. So both sexes have fatigue. That's very common. Decreased libido. They might be working out at the gym and not seeing a response. They might have some hair loss. And testosterone in women has a few unique features. Like one of the things we've seen looking at MBA students, students who are getting a master's in business administration, is that the women with higher testosterone tend to be more comfortable with financial risk. I believe it also tracks with confidence and agency. We have less hard data on that, but those are some of the things that I see. It's a hormone of vitality in both men and women.
- [49:23]
Stephen Bartlett
So if a woman is low testosterone, she might be less confident, have less motivation, less agency, less willing to take.
- [49:30]
Dr. Sara Sal
Risks, less sex drive.
- [49:32]
Stephen Bartlett
What if she has high testosterone levels? Too high?
- [49:36]
Dr. Sara Sal
So high testosterone tends to track with polycystic ovary syndrome. It's the most common hormone imbalance that women have. It leads to infertility, it leads to increased hair growth in places that you don't want it. So that can include like your chin and between your breasts. It can lead to insulin resistance in some, but not all. But somewhere around 70% of people with PCOS have insulin resistance. So it leads to symptoms of excess androgen, acne, hirsutism. It also is associated with problems with the mitochondria. It's also linked to dysregulated stress response. That's something we see with people with pcos.
- [50:27]
Stephen Bartlett
So if I'm a man or a woman and I want to get my testosterone levels in order and I don't want to inject myself with testosterone, are there natural ways, easy ways for me to get my testosterone balanced?
- [50:40]
Dr. Sara Sal
It depends on how off it is. First place to start is your cortisol, because cortisol has this interdependent relationship with other hormones. So if you're someone who's making a lot of cortisol, you're going to make less testosterone. So someone who's got a high level of stress, like I was talking about the NBA players in the bubble, maybe their stress was high and their cortisol was high and that was why their testosterone was lower.
- [51:11]
Stephen Bartlett
So then if I'm a woman with polycystic ovary syndrome and my testosterone is high, doesn't that mean I want to increase my cortisol?
- [51:21]
Dr. Sara Sal
No. In that situation, what we know is that food is probably the most important factor with someone with pcos. And inside of seven days, by eating a lower carbohydrate diet, you can change your testosterone level. So you can lower it significantly within seven days. Within seven days, Exercise.
- [51:43]
Stephen Bartlett
I'm currently eating like a ketogenic diet, so my carbohydrate level is extremely low. Does that mean my testosterone levels are going to be low?
- [51:51]
Dr. Sara Sal
Not necessarily, because you're not someone with pcos. So it's not quite translatable across sex and gender. But for you with a ketogenic diet, what we typically see is that insulin levels are lower. So it does seem to help with metabolic health. It can cause some thyroid dysfunction. So it's worth tracking. Thyroid. We know that people on a ketogenic diet sometimes have increased inflammation. There are some people who are super responders and they just do super well with the ketogenic diet. But some people have about a 10% change in their LDL, their so called bad lipoprotein. So if you stay on it for more than four weeks, I generally recommend that you look at some biomarkers let's.
- [52:41]
Stephen Bartlett
Talk about estrogen then, because I was under the impression that only women had estrogen. But you're telling me that it's an important hormone for men as well.
- [52:49]
Dr. Sara Sal
It is.
- [52:50]
Stephen Bartlett
Why is it so important for estrogen for both sexes? What does it do?
- [52:54]
Dr. Sara Sal
Well, I would say it's more important for women because it regulates the entire female body. So we have estrogen receptors throughout our body. When women, there's two different life stages where estrogen is low. The first is postpartum. So if you give birth to a baby, you go from sky high estrogen levels down to almost nothing when you deliver your baby and you deliver your placenta. And so for a lot of women when they're postpartum, maybe they've got mood issues, they've got fatigue. That is more than just the sleep deprivation. This can be a preview of coming attractions in perimenopause and menopause. So it's a window of opportunity that can tell you about the way estrogen works in your body. So for the female body, estrogen has hundreds of jobs. It keeps her joints lubricated. We know that frozen shoulder is a really common diagnosis in women who are in perimenopause and menopause because the estrogen receptors just aren't getting the estrogen. They're not having molecular sex between the estrogen and estrogen receptor. Estrogen is really critical in women. It regulates mood, breast development, development of hips. It's a lubricant for your joints. It's also really critical for your skin. When estrogen goes down, you make less collagen. And that's why women notice that their skin ages. And in men, it's a little bit different. The dynamic range is more narrow. And what we generally want with men is for you to have enough estrogen to serve some of these bodily functions, like with keeping your bones strong, but not too much.
- [54:55]
Stephen Bartlett
Does it have a role in weight distribution? In my body. So where the fat stores and stuff?
- [55:02]
Dr. Sara Sal
So in men, I don't know. I don't know the answer to that. I'll have to look it up and get back to you. But in women, yes, absolutely. So one of the things that happens for women over the age of 40 is that they typically become insulin resistant. Their cells become numb to insulin. And what we know is that they gain about five pounds of fat and they lose about five pounds of muscle every decade after age 40. So there's this redistribution of fat to your point, where they deposit less at their breasts and their hips and their buttocks and more at their abdomen. Does that happen in men? I think there's some version of it in men, but I just would have to confirm that.
- [55:53]
Stephen Bartlett
And is that inevitable?
- [55:55]
Dr. Sara Sal
No, no, no. You have a choice. So for women, I think what's important is to understand what are your estrogen levels that are associated with your best function. And that's why I think baseline testing can be so helpful. To know where your thyroid is right now, your cortisol, your testosterone, to know where you are with your metabolic health, so that when you're in your 40s, you can look back and say, okay, I was in a state of optimization. I want to go back to something similar to that. So for women, what I would say is right now, 73 to 75% of women do not get the treatment for perimenopause and menopause that they deserve. They're not being offered, for instance, hormone therapy, and that has to change. But hormone therapy can help to reverse this so that you are more likely to not have some of these body composition changes as you get older. And it's not just hormone therapy. I would say it's beyond hormone therapy. It's estrogen, progesterone, testosterone, but it's also heavy weightlifting, it's cardiovascular fitness. It's disposing of the glucose properly, eating the right foods.
- [57:21]
Stephen Bartlett
Disposing of the glucose properly?
- [57:22]
Dr. Sara Sal
Yes.
- [57:23]
Stephen Bartlett
What do you mean by that?
- [57:24]
Dr. Sara Sal
So if you're, you know, like when I was in my 30s, my fasting glucose was very high. It was in the pre diabetes range. And so I needed to change the way that I was burning through glucose, like using it with exercise. So disposing, it's like an input output equation where you're inputting with your food and you're outputting with your exercise, and you want to get a good match.
- [57:54]
Stephen Bartlett
Between the two and muscle resistance training. Strength training is the optimal way to dispose of glucose, right?
- [58:02]
Dr. Sara Sal
I think it's a critical way. I mean, what we know is strength training is it builds muscle. And so the more muscle mass that you have, generally, the better your metabolism.
- [58:13]
Dr. Sarah Z
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- [58:35]
Stephen Bartlett
I'd already purchased a pair of Viva barefoot Shoes.
- [58:38]
Dr. Sarah Z
So I showed them to Daniel Lieberman and he told me that they were exactly the type of shoe that would help me restore natural foot movement and rebuild my strength. But I think it was plantar fasciitis that I had where suddenly my feet started hurting all the time.
- [58:49]
Stephen Bartlett
And after that, I decided to start.
- [58:50]
Dr. Sarah Z
Strengthening my own foot by using the vivobarefoots. And research from Liverpool University has backed this up. They've shown that wearing Vivobarefoot shoes for six months can increase foot strength by up to 60%. Visit Vivobarefoot.com DoAC and use COD DoAC20 for 20% off. That's Avivobarefoot.com DoAC use code DoAC20. A strong body starts with strong feet.
- [59:19]
Stephen Bartlett
What role is fibre playing in all of this? Because a lot of people are talking about fiber at the moment and saying that we're fiber deficient.
- [59:25]
Dr. Sara Sal
Oh, we are, for sure. I mean, the average American gets somewhere around 14 grams of fiber a day, and we're meant to have about 30 to 35, 40 grams a day. Our Paleolithic ancestors got even more than that, 50 to 100 grams a day. So we are not getting enough fiber. It's critical for blood sugar stabilization. So is protein intake, but getting fiber from real food, you know, eating sufficient vegetables. We know from the microbiome studies that you want about 25 to 35 different species of fruits and vegetables in a week to be able to feed your microbiome.
- [60:09]
Stephen Bartlett
And what role is the microbiome playing in my hormone function?
- [60:13]
Dr. Sara Sal
It's playing a huge role. So your microbiome is one of the control functions for estrogen levels and maybe testosterone levels. So there's a bidirectional relationship, Steve, where there are three bacteria in the gut that can take estrogen and make it keep recirculating. So you're meant to produce estrogen and then use it and then either poop or pee it out. But what happens with some people if they've got these bacteria, it's is they keep recirculating the estrogen like bad karma. And so those people tend to have higher estrogen levels. It tends to be associated in men with this greater risk of metabolic dysfunction, prostate cancer. And in women, it's associated with more breast cancer and endometrial cancer.
- [61:15]
Stephen Bartlett
And that a lot of that starts in this course by the gut. Microbiome.
- [61:18]
Dr. Sara Sal
Yes. And the microbiome, their favorite food is fiber. So the way that you keep your microbiome, your microbes happy and healthy, is to feed them a Fair amount of fiber.
- [61:31]
Stephen Bartlett
What kind of foods have high fiber? Is it like broccoli and stuff?
- [61:35]
Dr. Sara Sal
Yes. So broccoli, Brussels sprouts, cauliflower, cabbage, kohlrabi.
- [61:44]
Stephen Bartlett
What do you eat and like, how do you live?
- [61:47]
Dr. Sara Sal
So I'm a sensualist. So I love food. I love the taste of food, I love the smell of food. I love the look of food. I had a history of disordered eating. I had anorexia as a teenager and bulimia through my 20s and 30s. But now I have a more neutral relationship with food. I have worn a continuous glucose monitor almost continuously for the past seven years. And so I know a lot about the foods that serve me the best. So usually for breakfast, I love eggs. And so I eat fresh eggs, usually scrambled or lightly boiled. I like to have that with greens or some other leftover vegetable from the night before. I eat a lot of vegetables. I aim for somewhere around a half pound to a pound a day. So that's divided between salads, the vegetables I have at dinner, a smoothie. I put vegetables in smoothies along with a protein powder. I eat a lot of cruciferous vegetables. I have sluggish detox pathways. I know that genomically and I know it from my biomarker testing.
- [63:03]
Stephen Bartlett
What does that mean?
- [63:04]
Dr. Sara Sal
Means that maybe it's related to my sensitivity. I don't make sufficient glutathione, which is one of the ways that you detoxify. It's an antioxidant in your body. And so I like to close that gap by making sure that I'm getting sufficient cruciferous vegetables. I ate a lot of broccoli sprouts.
- [63:33]
Stephen Bartlett
What do you think of the keto diet?
- [63:35]
Dr. Sara Sal
I'm a fan of the ketogenic diet.
- [63:37]
Stephen Bartlett
Because in your book there's this chapter called the keto Paradox.
- [63:40]
Dr. Sara Sal
Yes.
- [63:41]
Stephen Bartlett
What are your thoughts on keto?
- [63:44]
Dr. Sara Sal
Well, what I find with keto is that men tend to do better on it than women. And what I found with women is that maybe related to hormones and their sensitivity, they have more thyroid dysfunction. They have more menstrual irregularity. Somewhere around 45% of women that are on a classic ketogenic diet, women tend to have more issues with the ketogenic diet. Takes them longer to get into ketosis than it does a man. Even if you. The average man, if they fast for somewhere around 14 to 16 hours, they start to produce ketones. And for women it takes longer. It takes more like 18 to 20 hours. So probably that's related to fertility and evolutionarily there's some pressure for us to not go into a ketogenic state, but it makes it harder for women to get into ketosis and stay in ketosis.
- [64:39]
Stephen Bartlett
Is there a danger to women doing ketosis because you said their periods are going to become irregular?
- [64:45]
Dr. Sara Sal
Not necessarily. I think depending on how you do it. You know, a lot of the data that we have on the ketogenic diet is in populations that don't apply to you or me, because the bulk of the data that we have is in people with seizure disorders. So they're different. It's a different population. And they're also on a form of the ketogenic diet that is very strict. You know, no more than 10 to 20 grams of carbohydrates day. So I think you can play with your carbohydrates and find out what your carb threshold is so that you can remain in ketosis, get the benefits of all the phytonutrients that you can get from vegetables and play both sides so that you get the health benefits. You get the metabolic function improvement, you get the lowering of insulin without some of the side effects.
- [65:41]
Stephen Bartlett
What are the side effects?
- [65:42]
Dr. Sara Sal
The main ones that I see are the thyroid dysfunction.
- [65:45]
Stephen Bartlett
Yeah.
- [65:47]
Dr. Sara Sal
Sometimes there's a rise in cortisol in people who are really limiting their carbohydrates, and then it can also affect serotonin so that people don't sleep as well on a ketogenic diet. Now, some people love that they go on a ketogenic diet and they're like, oh, I only need to sleep six or seven hours a night. But over time, if you need more, and it's the serotonin that is at the root of why you're not sleeping as well, that can cause a problem.
- [66:15]
Stephen Bartlett
Is there anything else that the ketogenic diet might be doing to my hormones, like my testosterone or my other hormones? That is worth noting because I'm super. You know, I'm wondering whether to stay on the ketogenic diet for a long period of time. I typically do it for a couple of weeks, a year, but I'm. I'm wondering if this is something that I could do for, like, a year or maybe longer.
- [66:36]
Dr. Sara Sal
So I think if you stay on it for more than a few weeks, you want to check your biomarkers, and you just want to make sure that it agrees with the intelligence of your body. So do some molecular profiling and see if it's a good fit.
- [66:48]
Stephen Bartlett
Have you seen people that stay on it for years and have good biomarkers?
- [66:52]
Dr. Sara Sal
Yes.
- [66:52]
Stephen Bartlett
Okay.
- [66:54]
Dr. Sara Sal
And I think what's important to understand is that exercise performance sometimes can be adversely affected by the ketogenic diet. And that might be an interesting experiment for you to do, like with your running and your 5k time. What a lot of athletes do is if they want to experiment with a ketogenic diet, say they're a cyclist and they're trying to get their weight down so that their power is up. What they tend to do before a race is they add carbs back two weeks before the race so that they're filling their glycogen stores. So that's another piece that you may want to be tracking is your exercise performance.
- [67:40]
Stephen Bartlett
If I'm trying to lose weight, is there an optimal approach to take? Because the ketogenic diet has been the fastest way I've ever discovered of losing weight quickly. But if you're a man or woman trying to lose weight, specifically like that annoying weight, the belly fats, those kinds of things, someone comes to you and says that, what do you say to them?
- [68:00]
Dr. Sara Sal
What I like about the ketogenic diet for weight loss, and I'm really careful about weight loss because it's problematic. It's problematic. And I think body shaming is a big problem, and so I'm really careful about this. But when it comes to a ketogenic diet, what I like about it is that ketones are really satisfying, so they increase your satiety. And I think it's much more effective than trying to limit your calories and be in a calorie deficit. So with a ketogenic diet, usually you do a calorie deficit, but you're producing ketones which are making you feel more satisfied, so you're not standing in front of the refrigerator wondering when the next time is that you can eat.
- [68:44]
Stephen Bartlett
Mm. And what about fasting? You know, there's been a lot of talk about autophagy and doing these kind of long fasts to heal the body. What's your perspective on that?
- [68:55]
Dr. Sara Sal
I think there's a time and a place for fasting. I think these ways of activating some of the benevolent pathways in the body can be very good for you. So it can be good for mitochondria, it can be good for your hormone balance. It can help you with insulin as an example. So you asked about someone who was wanting to lose weight and also wanting to address belly fat. I would say that's a situation where you really want to pay attention to insulin. So fasting can get you that. So can a ketogenic diet. Often we combine the two because you can induce ketosis faster by doing intermittent fasting together with a ketogenic diet.
- [69:39]
Stephen Bartlett
Is the ketogenic diet like a form of fasting?
- [69:44]
Dr. Sara Sal
You could think of it that way. I mean, I would say it allows you to fast and it makes the behavior change easier. The thing about fasting is there are some people who are really good at it and it doesn't raise their cortisol, it doesn't induce the stress response. And then there are other people who get very stressed with a ketogenic diet or with fasting. And so part of it is trying to get a sense of your own response to the food that you're eating to see, okay, what suits me the best, how do I feel the best, where is my cognitive function at an optimal level, what helps me with brain fog, what helps me with allergies or whatever symptoms you're tracking. You know, one of the things we know with ketones which are produced, you know, your body, as you well know, is this, it's like a hybrid car that can flip between burning gas, which is like glucose in this analogy, or electric, which in this analogy is ketones. The thing about ketones is they're not just satiety molecule that makes you feel satisfied. They also have anti inflammatory aspects inside of the body. So they're an important signaling pathway. There's a reason why your body produces ketones. Now, do you want to do that for a year? We'd have to see, we'd have to look at your biomarkers. You know, the, the normal way that your genome developed was to flip in and out of ketosis based on the food supply. And now that food is abundant, most people are not going into ketosis. But being able to switch back and forth can be very healthy for you.
- [71:37]
Stephen Bartlett
When people come to you and they're asking questions about hormones these days, you must have seen in your career a shift in interest on the subject of hormones, but also a certain area of hormonal health that people have a greater obsession with. Of all the subjects we've talked about today relating to hormones, what is it that people are most interested in right now?
- [72:02]
Dr. Sara Sal
I would say for women it's perimenopause.
- [72:08]
Stephen Bartlett
And for anyone that doesn't know what perimenopause is, when does that begin and.
- [72:13]
Dr. Sara Sal
What is it typically begins between 35 and 45 for women. And it's the age at which your ovaries start to run out of ripe eggs and the mitochondria in your eggs are not working. The way that they once did. And so your ovaries are aging, and that leads to changes in your hormone levels. So a lot of people think of perimenopause as mostly being a hormonal situation. A change in estrogen, progesterone, maybe testosterone. And what I think is important to realize is it's much broader than that. It's your metabolic system, it's the way that your brain is responding to glucose. It's your immune system. It's a time when more women have the experience of autoimmunity and autoimmune disease. So perimenopause is this incredibly dynamic time. There's more than 100 plus symptoms that women experience, and it makes me crazy. I was just talking to my agent and my publisher a couple weeks ago. They're both women in their early 40s, and they were having symptoms, you know, some of those hundred symptoms that are characteristic of perimenopause. They went to their doctor and said, I've got these mood swings, I'm having trouble sleeping, having some night sweats. Is this perimenopause? And the doctor said, no, you're too young. So there's a knowledge gap. There's a research gap and a knowledge gap and a huge treatment gap for women who are in perimenopause. Most women are not getting the treatment that they need. So what are they asking about? They're asking about, why do I feel so dysregulated? Why is it that I can't manage stress the way I once did? Why? Why would I rather mop the floor than have sex with my husband? Why is sex painful all of a sudden? Why do I have this belly fat that appeared out of nowhere? And my usual techniques for how to deal with that aren't working. Those are some of the questions that they ask. Which map to your hormones?
- [74:20]
Stephen Bartlett
And what is the youngest you've ever seen someone enter perimenopause?
- [74:24]
Dr. Sara Sal
Well, I see women who have premature ovarian insufficiency, which is when you go through menopause before age 40. So I've seen a fair amount of that, you know, probably 50 patients over the course of my career. It's relatively rare. And then I see women who have early menopause, which is when they stop having their periods or they have an FSH level of 25. To 30.
- [74:52]
Stephen Bartlett
And FSH, what's fshing?
- [74:53]
Dr. Sara Sal
Follicle stimulating hormone. It's one of the control hormones for your estrogen and progesterone in the body. So if that occurs, they have their final menstrual period between 40 and 45, that's considered early menopause. So there's this really dynamic time where your hormones are wildly fluctuating, especially estrogen. Progesterone is declining, and women have this increase in the symptoms that they experience, and no one is really tracking it carefully. That's what needs to change.
- [75:29]
Stephen Bartlett
Tracking it through their blood samples.
- [75:31]
Dr. Sara Sal
Blood samples, and connecting their symptoms to what is happening in their ovaries, in their immune system, in their metabolic system, and putting it together for them and offering them options.
- [75:45]
Stephen Bartlett
You believe that many of the symptoms of menopause are avoidable?
- [75:50]
Dr. Sara Sal
Yes. Yes. And by that I mean using hormone therapy and using lifestyle medicine as early as possible to manage that transition.
- [76:01]
Stephen Bartlett
Because when a woman goes to a doctor now, that doctor might say, well, you're getting older. This is what happens. Or they might just completely miss it.
- [76:09]
Dr. Sara Sal
That's right. Or they might get started on a birth control pill that's used a lot for women who are in perimenopause. And I don't think that's the right solution.
- [76:20]
Stephen Bartlett
What do you think of birth control pills?
- [76:23]
Dr. Sara Sal
I think if they help you avoid surgery, they can be beneficial. But I think they're way overused in our culture. And most people who agree to a birth control pill don't receive full informed consent. They're not told that it'll raise the inflammation in your body by two to threefold. It increases your risk of autoimmune disease, especially Crohn's disease. It makes your control system for your hormones less flexible. It can rob you of testosterone. It can lower your free testosterone. It can shrink your clitoris by up to 20%. I feel like if that was part of the informed consent, very few people would sign up for it.
- [77:11]
Stephen Bartlett
But who is the birth control pill for then?
- [77:14]
Dr. Sara Sal
You know, I used to think that it was a feminist invention, that it was a way of putting your fertility in your hands. And I went on the birth control pill when I was 16, but I feel like there are some costs to it that a lot of teenagers and women in their 20s and 30s aren't aware of. And for me, I feel like that awareness is really critical. So who's it for? I would say it's a simple entree into contraception, but I would much rather people use things like an IUD or condoms or some other barrier method that doesn't mess with their hormonal intelligence.
- [78:01]
Stephen Bartlett
How are you doing?
- [78:03]
Dr. Sara Sal
Oh, quite good, Quite good. I love that question. I went through a divorce two years ago, and I feel like, you know, I have two daughters, they both went off to college and we're out of the house. And I realized that my time with my now ex husband had run its course and we came together to create this beautiful family, but we were no longer a good fit for each other. So a big part of my spiritual work has been coming to terms with that and really getting clear about, okay, for the second half of my life, what is it that I want? What is my mission? How do I support that? How do I only give a whole body yes to the things that I say yes to? How do I.
- [79:08]
Stephen Bartlett
Whole body yes.
- [79:09]
Dr. Sara Sal
What does that mean, whole body yes. So this is something I learned from one of my mentors, Diana Chapman. She learned it from, I believe, Katie Hendricks, who's a therapist. The idea is that instead of saying yes to things that you're offered purely from a cognitive place, that sounds like a good idea, sounds like a good opportunity, Let me do it instead. You check in with your whole body, you check in with your heart, you check in with your gut. Does this really make a difference in the world? Is this something that's going to make me jump out of bed in the morning? Is this something that is worth the time and the effort? I'm a little older than you, and so I hold these opportunities a little bit differently than I did in the past.
- [80:02]
Stephen Bartlett
How long were you married for? How long were you in a relationship with your partner?
- [80:06]
Dr. Sara Sal
We were together for about 22 years and married for 20.
- [80:11]
Stephen Bartlett
How does one know that it's not right anymore after 20 odd years?
- [80:18]
Dr. Sara Sal
Well, I would love to riff on this with you.
- [80:20]
Stephen Bartlett
Okay.
- [80:21]
Dr. Sara Sal
So I can tell you that part of the challenge in my marriage was that we had difficulty talking about difficult topics. So highly charged topics were tough for us to be able to navigate. When we had a conflict or a fight, we didn't repair very well. There was a partial repair where you would feel good enough to keep functioning and take care of the kids and do your householder stuff, but you didn't really feel seen or like you cleaned up the pain that was there. There was a way that I didn't feel fully understood or seen and not that I require that from my partner, but I felt like there was a misattunement and I'm in a relationship now where I have those things that I'm talking about and it's someone that I have known for 30 plus years. We were interns together at UCSF and I realize now that, you know, I came together with my ex husband and I really am so blessed by the life that we had and the family that we had. But we also had a trauma bond. There was a way that his trauma kind of intersected with my trauma. And we hung in there for a very long time, probably longer than we should have. So how do you know? I don't know, Stephen. I just can tell you that there was a way that our interactions was creating dysregulation in my body. And I'm not blaming him. You know, it's a two. There's two sides of the street. But there was a way that we just. We didn't quite gel together.
- [82:32]
Stephen Bartlett
And is that not something that can be prepared through communication and therapy or sitting down?
- [82:37]
Dr. Sara Sal
And, I mean, you would hope so, but we spent about 10 years out of the 20 years of marriage in couples therapy, and it didn't really resolve some of these conflicts. We got better at I statements. We got better at seeing what we were feeling and not blaming. We got better at going for a walk when we were talking about something difficult. But there was still a way that I felt alone and lonely inside of the relationship. And I decided. I think a fair number of women decide this. I decided I was better off alone than to continue in the marriage.
- [83:27]
Stephen Bartlett
When people hear that that weren't in your situation, they might think, okay, so maybe he was preoccupied with something else or he worked away. When you say the word lonely, these are the kind of things we think. We think of proximity, but you're saying it. I'm guessing it wasn't proximity.
- [83:47]
Dr. Sara Sal
It wasn't proximity. I think it was. There was a way that we had a hard time expressing love and feeling and receiving love. There was an obstacle, and some of it was trauma. And the good news is there's a lot you can do to resolve trauma. But there was a way that I. I got to the point where I couldn't try any longer. I tried for a lot of years, and I just couldn't keep trying.
- [84:25]
Stephen Bartlett
When you look back, is there something that could have been done further upstream to prevent you getting to this place, in your view?
- [84:36]
Dr. Sara Sal
Yeah, it's such a. It's a great question. You know, one of the things that I've seen that has helped to resolve trauma better than anything else is psychedelic assisted therapy. It's a way of looking at your story, a way of looking at the facts of your life with more objectivity, and it's a way of resolving the way that trauma becomes embedded in your system. And so I started doing psychedelic assisted therapy about five years ago. With the hope that it would help me with my marriage. And what I had hoped over time is that I would do my part to resolve the Traubman signature in my own body and that maybe we would do psychedelic medicine together as a way of reconnecting to the love that we felt for each other. And, you know, kind of get the noise, turn down the volume on the noise. And we weren't able to do that.
- [85:42]
Stephen Bartlett
He wasn't willing to.
- [85:43]
Dr. Sara Sal
He wasn't willing.
- [85:44]
Stephen Bartlett
He wasn't open to psychedelics.
- [85:48]
Dr. Sara Sal
And not everyone is. I'm not blaming him for that. And I think there's other ways to create healing states of consciousness. You know, breath work can do it. A near death experience, peak experiences can do it. Flow states, there's lots of different ways to create these healing states of consciousness. But we weren't able to get into that healing state together.
- [86:12]
Dr. Sarah Z
Just for a second. I want to talk about a company I've invested in and who sponsored this podcast called Zoe. Like me, many of you are big on tracking your fitness and your sleep. But how many of you understand how your body handles food? Metabolic fitness is all about understanding your metabolism's response to food. And we all react differently. So Zoe created a test to help you understand how your body responds. And it starts with their famous test cookies, which are identical test meals with the same sugar, fat and calorie content of the average meal, and therefore acts as a metabolic challenge. You also wear a continuous glucose monitor.
- [86:46]
Stephen Bartlett
That tests your blood sugar levels.
- [86:48]
Dr. Sarah Z
I've done this test and it left me wondering how my metabolic fitness compared to others like me. And my results revealed everything. So if you'd like to learn about your body's response to food, head over to Zoe.com to order your test kit now. And if you want a discount, use code BARTLETT10 at checkout for 10% off your membership as a Zoe member, you'll get an at home test kit and personalized nutrition program to help you make smarter food choices that support your health. That's Zoe.com with code Bartlett10.
- [87:17]
Stephen Bartlett
One of the things I've been told by one of the menopause experts that you mentioned earlier, Lisa, was that when women get to menopausal, a menopausal age, when they're in menopause, they often have greater clarity on what they want in their life. That's what she said to me. And she said that we see divorce rates increase during this period of life. Is that true in your sleep?
- [87:42]
Dr. Sara Sal
It is true. It is true. Yeah. The way it was Explained to me by one of my mentors was that when you're in your reproductive years, so pre menopause, you've got a different level of estrogen, progesterone and testosterone every day. And it makes you accommodate, makes you kind of roll with the punches and it sets up this level of flexibility that starts to disappear when you go through perimenopause and menopause. And so the way my mentor described it was that the hormonal veil is lifted and you start to speak your truth and not accommodate. You speak your truth maybe for the first time about the state of your marriage, about the things that you're happy about, the things that you're not happy about. And it does lead to an increased rate of divorce.
- [88:38]
Stephen Bartlett
What about your happiness levels? Does it increase your happiness levels?
- [88:42]
Dr. Sara Sal
I think it does. There's this really interesting study that is called the U bend. And it looks at psychological well being for adults. It's highest in your 20s and the very start of your 30s. And then there's this U shape where your psychological well being goes down. I know you're 32, so I'm a little sorry to break the news to you. And then it goes back up right around 50. So psychological well being goes up again. And when I first heard about this U bend, I remember reading an article in the Economist about was so validating because it made me feel like, oh, things are really hard and makes sense to me that we see this through your 30s and 40s and then it starts to have this uptick again. And I think there are ways to improve your psychological well being so that you're not stuck in the U bend. But happiness, yes, I would say happiness, psychological well being is high again in your 50s.
- [89:47]
Stephen Bartlett
I know that there's so many women that listen to this show and I get so many messages when we have conversations about women, women's health, hormonal issues, menopause. Because women for a long period of time haven't feel like. Haven't felt like they've been heard and understood. They often feel like they're being gaslit a little bit maybe by their doctors or by some of the information out there. So this is quite atypical of me. But you know women better than I do and you know what women are concerned about in all seasons of their life, what they're worried about, what they're confused about. So I want to just open the floor to you and ask you, based on all of the work that you've done, you know you've done work on women's hormones, diets, lifestyle, sex drives, reclaiming their balance, sleep, healthy weight for both men and women. But I'm asking specifically for women here. So with all of that in mind, what is the question that I should be asking you?
- [90:45]
Dr. Sara Sal
How do we do a better job supporting women?
- [90:50]
Stephen Bartlett
How do we do a better job supporting women?
- [90:52]
Dr. Sara Sal
Yes. How do we do it systemically? How do we do it in terms of healthcare for women? But I would say in particular for you, with the platform that you have, the women's health gap that we're facing right now, which has only gotten worse over the 30 years of my career, I think to ask, how do we help women rise? How do we make systemic changes so that we don't have this women's health gap? Let's close the gap. How do we do that together?
- [91:28]
Stephen Bartlett
I have a question for you. Can you guess what the question is?
- [91:35]
Dr. Sara Sal
I have an idea.
- [91:37]
Stephen Bartlett
Go on then.
- [91:40]
Dr. Sara Sal
So the women's health gap, I believe, is rooted in two things. Sex differences, you know, having two X chromosomes versus XY in men, hormonal differences, these life cycle changes that women go through, like postpartum pregnancy, perimenopause, menopause. But then there's also gender differences which are socially constructed. And that includes women having more than their share of emotional labor, women having more stress than men experiencing more stress, women having more trauma. So they have higher ACE scores than men. And it's led to, if we just look at the statistics, double the rate of depression, double the rate of ptsd, post traumatic stress disorder, double the rate of insomnia, four times the rate of autoimmune disease, nine times the rate of thyroid dysfunction. So there's sex differences that map to those outcomes. But then there's these gender differences in the way that women don't feel supported, the way that they feel conflicted in trying to create work life balance, the way that they experience more stress. That's what we need to address. We can't change the biology, but we can change the gender differences. We can change the socially constructed differences that lead to it being a health hazard to be female.
- [93:16]
Stephen Bartlett
Okay, so tell me about that then. What is it about the socially constructed narrative of what it is to be a man and a woman that is causing unfavorable outcomes for women?
- [93:28]
Dr. Sara Sal
There's a lot of things. So I would say what we know, if you look at the nervous system, we know that women tend to have more imbalance between the sympathetic nervous system and the parasympathetic nervous system.
- [93:49]
Stephen Bartlett
What's that?
- [93:49]
Dr. Sara Sal
So the sympathetic nervous system is fight, flight, freeze. The parasympathetic nervous system is rest and digest, feed and breed, play.
- [94:00]
Stephen Bartlett
And play is relax, chill, play, relax, chill.
- [94:03]
Dr. Sara Sal
That's where the healing happens. And we're not meant to hang out in one or the other. We're meant to have this fluid balance between the two, ideally like a 50, 50 split. And so women tend to, in dealing with our culture, have more sympathetic activation and so finding ways to address that.
- [94:25]
Stephen Bartlett
More stress.
- [94:26]
Dr. Sara Sal
More stress. So at least in the US we do these annual stress reports and we find that on average, women have about 10% more stress than men.
- [94:37]
Stephen Bartlett
Why is that? Just because they're more likely to report it, or is there a biological or evolutionary reason why they're more stressed?
- [94:48]
Dr. Sara Sal
I don't think it's biological. I think it's related to power imbalances. I think it's related to patriarchy. I think it's related to power over. So, for instance, with these ACE scores, the trauma scores, the trauma scores, we know that women experience more trauma than men, about 10% more, similar to stress. And they also experience trauma at an earlier age compared to men. They have much more sexual violence. They're 14 times more likely to be raped than a man. So there are ways that our culture has allowed women to be violated and that has to end. How do we do that? I don't know. This is where we need to riff and figure out. How do the systems change so that there's a more equal distribution of power?
- [95:48]
Stephen Bartlett
Are women more sensitive? So if you put a man and a woman or a boy and a girl in the same stressful environment, would they have different biological markers, like biomarkers? Would you see high levels of cortisol in the woman or higher cortisol levels in the man?
- [96:09]
Dr. Sara Sal
I don't know the answer to that. My sense is, from the work of Elaine Aaron, who's done the work on this profile of high sensitivity, that it's about equal in men and women. But I don't know that for sure. I'd have to fact check that.
- [96:23]
Stephen Bartlett
Do you see higher rates of autoimmune diseases in women or men?
- [96:28]
Dr. Sara Sal
Women 4x4x? Yes.
- [96:32]
Stephen Bartlett
400% more autoimmune diseases in women?
- [96:34]
Dr. Sara Sal
Yes.
- [96:35]
Stephen Bartlett
And what are these autoimmune diseases? What's an example of one?
- [96:39]
Dr. Sara Sal
So there's about 100 autoimmune diseases. It includes things like rheumatoid arthritis, multiple sclerosis, type 1 diabetes, Hashimoto's thyroiditis, which is the leading cause of low thyroid function, psoriasis there's a long list.
- [96:58]
Stephen Bartlett
And why are women getting these autoimmune diseases 400% more than men?
- [97:03]
Dr. Sara Sal
We don't know. So the speculation is that it's related to both biological differences, sex differences, as well as gender differences. So the biological differences include the difference in the levels of hormones, the X chromosome. Women have more, for instance, vaccine response compared to men. Our immune system is more reactive in some ways than the immune system of men. But then there's also these gender differences, these socially constructed differences, like women who have a hard time saying no, women who give until they drop, who over function, who are trained when they go through their childhood to take care of others at the expense of their own self care. And so how these interact and lead to a fourfold increased risk in women, we don't entirely know, but definitely we see four times the rate in women.
- [98:08]
Dr. Sarah Z
What's your view?
- [98:08]
Stephen Bartlett
There's a big debate that's always raging on about gender roles in society. And there's obviously been a big shift over the last couple of decades in I think actually in part caused by the introduction of the contraceptive pill, which has meant that women are working more, I think in the western world and these numbers might be wrong. There's less babies being born. Men and women are having less sex with each other. Men are killing themselves more often. Women are having coming into puberty earlier, I believe, or is it later and then having less children and significantly later, funnily. I saw a graph yesterday which showed the rise in breast cancer amongst women. And actually, I think it was actually, no, it was the rise in all cancers amongst women versus men. And the men graph was pretty flat. But there was this significant rise in women getting more and more forms of cancer. And I was looking through some of the research as to why that would happen. And one of them, one of the points of research said that because women are having children later that this isn't causing a rise in cancer.
- [99:14]
Dr. Sara Sal
Mm.
- [99:16]
Stephen Bartlett
Does that make sense?
- [99:17]
Dr. Sara Sal
Well, that has been studied with, for instance, breast cancer.
- [99:21]
Stephen Bartlett
Okay.
- [99:22]
Dr. Sara Sal
So we know, you know, there's a lot of different factors that can increase a woman's risk of breast cancer. One of them is the age at which you have your first baby. And so the way that we think of this is that it's related to estrogen exposure. So women who get pregnant and maybe they breastfeed for a year, that's often a period of time, like a year and nine months, where they're not exposed to as much estrogen than they would be if they were Menstruating during that time. And so having babies later seems to be associated with a greater risk of breast cancer. The ideal age I was taught when I went through my training for having a baby is 24. And I don't have a single friend who's had a baby in their 20s.
- [100:08]
Stephen Bartlett
Is there something we're getting wrong with gender roles? When you think about our biology and.
- [100:12]
Dr. Sara Sal
Our hormones, I really love the questions. I mean, they're thought experiments. So, yes, I do think there's something we're getting wrong. You had a guest recently who was talking about sex span.
- [100:23]
Stephen Bartlett
Oh, yeah.
- [100:23]
Dr. Sara Sal
And the period of time that you're sexually active and satisfied with sex. And I do feel like we've got an epidemic of sexless marriage. People who are not having as much sex, who don't realize how important pleasure is, especially for the nervous system and for regulation. Orgasm is one of the most effective strategies for creating nervous system regulation, for.
- [100:48]
Stephen Bartlett
Dropping into your parasympathetic nervous system, for.
- [100:50]
Dr. Sara Sal
Dropping into your parasympathetic. And what we know is that with gender roles and with what's happened with work, we've lost some of the polarity between men and women. I mean, I imagine you also have listeners who are gay men or lesbian couples. So I want to be mindful of being inclusive here, But I think we've lost a lot of polarity.
- [101:21]
Stephen Bartlett
And polarity exists in all kinds of relationships as well, doesn't it?
- [101:25]
Dr. Sara Sal
To some degree it does, but sometimes you have to work at it. Sometimes you have to create the polarity.
- [101:30]
Stephen Bartlett
When you say polarity, if we're talking about heterosexual relationships, what is the polarity that you think we've lost?
- [101:36]
Dr. Sara Sal
I would say right now, in my 50s, I'm having the best sex of my life, the best orgasms of my life, and there's a lot of polarity in my relationship. And I've learned that this is pretty controversial and edgy. So I'm just going to say it anyway. I feel like for women who are professionals, who work really hard, there are some ways that polarity can be really helpful in the bedroom. Here I'm talking about gender roles and understanding what is satisfying for you sexually and asking for it in your relationship. A lot of the professional women that I know, they enjoy vanilla sex, but they also like a weave of domination.
- [102:36]
Stephen Bartlett
To be dominated or to dominate both.
- [102:39]
Dr. Sara Sal
I mean, it's a personal preference, but I think there's a way that it's a way of playing with power that I think can be sexually very satisfying. What do you Think. Do you think it's important in sexual relationships to have polarity, to have to have like the feminine and masculine attributes? Or do you think you both just come to a sexual connection equals and that's how it should always be?
- [103:13]
Stephen Bartlett
I think probably the answer is that everybody has their own favorite flavor of ice cream. And I can only speak to my favorite flavor of ice cream, which is I like, I don't like vanilla ice cream. It's not my favorite flavor. And I think I do like to be more dominant. That turns me on. And I like to vary it because I'll get bored. Especially if you're in a long relationship, you got to fucking find some way to spice it up.
- [103:46]
Dr. Sara Sal
Yes, you do.
- [103:47]
Stephen Bartlett
I'm buying all kinds of stuff off the Internet to try and, you know, keep it novel and new.
- [103:52]
Dr. Sara Sal
Okay, now things are getting interesting. Yes.
- [103:55]
Stephen Bartlett
Well, I honestly, I landed here in la and before I even landed, I ordered loads of stuff just to be at the house when I got here.
- [104:01]
Dr. Sara Sal
Fantastic.
- [104:03]
Stephen Bartlett
It's funny because my team are listening, but I don't give a fuck. No, but I do, because I'm like, I have to. I like try and plan sex to be interesting.
- [104:12]
Dr. Sara Sal
Yes.
- [104:13]
Stephen Bartlett
Which is. It's like a part time job.
- [104:16]
Dr. Sara Sal
It is, because it's the alternative.
- [104:18]
Stephen Bartlett
The alternative is it just fizzles out and gets boring and then it's the same. And. But also I think I play with distance because of the way my schedule is. So I don't see my partner for a couple of weeks and then we see each other and then we go away again. And so it kind of keeps it a little bit more novel and stuff and interesting. I try and make sure that I stay attractive. I told her, I said part of the reason I go to the gym every day is because we signed a contract, not a real contract, but we signed the contract when we met each other. That weird. Stay attractive and that's intellectually attractive, that's physically attractive. It's whatever. So, yeah, think a lot about it.
- [104:54]
Dr. Sara Sal
That's fantastic. It's a good strategy. And I appreciate how you are being very intentional about your sex life.
- [105:04]
Stephen Bartlett
Is this in part why you knew the old relationship wasn't working? Yes, just fizzled.
- [105:10]
Dr. Sara Sal
It fizzled. And I'm a very sexual person. Eroticism really matters to me. And to not have that be front and center felt like a death.
- [105:25]
Stephen Bartlett
And you tried to revive Keep alive.
- [105:29]
Dr. Sara Sal
Yes.
- [105:30]
Stephen Bartlett
People can relate. I know this because I see much of the feedback I get on the episodes where we talk about sex. People often are Struggling with a dying, whimpering sex life. Again, I ask you, is there anything that can be done? Is it prevention? Is that the key here? Or is it about making sure you're in a relationship with someone who's sexually open minded? And I also, I guess the third question here would be was it ever good?
- [106:06]
Dr. Sara Sal
So let me feel away into answering your questions. I feel like there's some sex differences too, biological differences between what? The male sexual response and the female sexual response. And that needs to be understood. I feel like when you have sexual dysfunction in a relationship, it's a couple's issue. It's never one person or the other. It's a couple's issue that you want to address as a couple. What we know is that men are a little simpler. There tends to be desire, you know, this physiological change that occurs in terms of blood flow and an erection and. And then there's a plateau phase and then orgasm, ejaculation. We can talk about separating ejaculation from orgasm in a minute. But in women it's more complicated. So that was the Masterson Johnson way of thinking about the sexual response.
- [107:14]
Stephen Bartlett
Masters and Johnson.
- [107:15]
Dr. Sara Sal
Masterson Johnson. And now we know. Sorry, Masterson Johnson. They were sexologists that published this particular model. And it wasn't until maybe 15, 20 years ago that Rosemary Bazon at the University of British Columbia found that women have a different response. It's more circular. And it has to do with feeling emotionally connected in order to be receptive to having sex with their partner. Whereas men in some ways do the opposite. And I'm curious if this is true for you. They need to have sex in order to feel emotionally connected. Women actually need the emotional connection first to be receptive to sexuality. And so this leads to a lot of disconnect. And it includes things like how many times in the past week did you empty the dishwasher? There are things that create emotional connection that a lot of men don't realize. And then for women, they often don't feel like the sexual response will not happen unless they feel emotionally connected. And this was part of the problem in my own marriage, was that I didn't feel that emotional connection. I tried really hard to establish that emotional connection, but I didn't have it. I have it now. Is it related to the newness of my relationship? Maybe. And knowing that, knowing about the emotional connection in some ways changes your homework as a man. Do you know what makes your girlfriend feel emotionally connected?
- [109:12]
Stephen Bartlett
Quality time. Deep questions.
- [109:16]
Dr. Sara Sal
Yes.
- [109:19]
Stephen Bartlett
The conversation cards.
- [109:21]
Dr. Sara Sal
Oh, yes, tell me about that.
- [109:24]
Stephen Bartlett
Well, we sell These conversation cards on this show, you can check in the description below if you want to buy them. But basically, at the end of the conversations on this podcast, the guests write a question in this diary in front of me for the next guest, and then these will become. Yeah, thanks. These will become conversation cards. Unlock deeper levels of connection. Open up. To open up, level three is the more deep questions.
- [109:50]
Dr. Sara Sal
Oh, I like it. I'm probably a level three person.
- [109:54]
Stephen Bartlett
You're a level three person. I would imagine you strike me as a level three person. You really do, but those kinds of things. So, like deep questions and spending time and then that's it.
- [110:04]
Dr. Sara Sal
Can I see some of those level threes?
- [110:05]
Stephen Bartlett
Yeah. Here are all your level threes. What is the most important thing we haven't talked about that we should have talked about? Is there anything else? Sleep is something we didn't talk about. When we think about the impact sleep has on our hormonal balance, is it important?
- [110:23]
Dr. Sara Sal
Oh, my gosh. Sleep is as close to a panacea as we have.
- [110:27]
Stephen Bartlett
When you say panacea, you mean like the Holy Grail?
- [110:29]
Dr. Sara Sal
It is the holy grail. It is so critical for functioning. You know what I see taking care of a lot of executives is that they think that they're the exception, that they don't need 78.5 hours of sleep every night. But only about 2% of the population has the short sleep gene. The rest of us need to optimize our sleep to the best of our ability. So what we know is that it affects your hormones inside of 24 hours. One bad night of sleep raises your insulin, raises your cortisol. The next day makes you more hungry, makes you more likely to crave carbohydrates. So just like you can create a negative cycle, you can create a positive cycle by optimizing your sleep. I'm a big fan of wearables because especially if you wake up in the morning and you don't feel flush with sleep and fully restored and fully recovered, you want to understand the metrics. How much deep sleep did you get? How much REM sleep? How many interruptions did you have? Did you snore? What was your heart rate variability? What was your respiratory rate? So I feel like sleep is one of those lifestyle factors that we need to optimize.
- [111:50]
Stephen Bartlett
On my ketogenic diet, I noticed that my heart rate variability seems to go lower, which is scary. Do you see that a lot? When people do kind of these kind of more restrictive diets and they're in.
- [112:00]
Dr. Sara Sal
Ketosis, there can be, I Mean, I would look at some of the other variables as well, and one of the things I really like is the eight sleep. Have you used that at all?
- [112:10]
Stephen Bartlett
Yeah, I have the mattress.
- [112:13]
Dr. Sara Sal
Did it help you with hrv?
- [112:15]
Stephen Bartlett
I believe it did. I don't know. I had the results at the time, but I was sleeping really, really good on it. I still use my whoop, which hashtag add. I still use my whoop for my hrv. What are the things that you aim at when someone comes to you with low hrv? A lot of people want to improve their hrv. We kind of see it as this holy metric now.
- [112:37]
Dr. Sara Sal
Sure. Well, I start with alcohol. So we know alcohol makes your HRV decline not just for one night, but somewhere around seven to nine nights.
- [112:46]
Stephen Bartlett
That's why I quit alcohol.
- [112:48]
Dr. Sara Sal
Yes.
- [112:49]
Stephen Bartlett
It just killed my. The first time I put my whoop on and I saw the impact it had on my hrv, I thought, I'm not doing that again.
- [112:55]
Dr. Sara Sal
And that's exactly the kind of behavior change that I get excited about. So when you see the metrics and you see the reflection of, oh, my gosh, my physiology is so much better off of alcohol, and there's better choices than alcohol. You want to make that swap. And the behavior change sticks. So I like grounding. So I find when I get in the ocean, when I get in streams with bare feet, when I walk on the sand, that improves my hrv. The country that seems to improve my HRV the most is Costa Rica. There's something about the aliveness there. My HRV doubles to triples.
- [113:34]
Stephen Bartlett
Really?
- [113:34]
Dr. Sara Sal
Microdosing mushrooms also raises my HRV quite significantly.
- [113:41]
Stephen Bartlett
We have a closing tradition on this podcast, like I said, where the last guest leaves a question for the next guest, not knowing who they're leaving it for. And the question left for you is, what do you do every day to make a better brain and better world?
- [114:00]
Dr. Sara Sal
What I do every day when I'm home in Marin county is I go outside when I wake up in the morning and I look at the. I live on the ocean, and I look at the horizon like I trace my eyes along the horizon. And I just was looking at the data on morning sun because I didn't quite believe it. Like, it supposedly, it helps you with your circadian rhythm. It helps you with sleeping better. It helps you with melatonin production, it helps you with mood. It's got all of these benefits. And some people say you only need five or ten minutes of morning sun. That's sufficient. And so I started looking at the data and you actually need more than that. Like you start to see a benefit around 30 minutes, but you need, you still keep improving some of these outcomes with longer, like up to two and a half hours. So the thing I do every day is I get morning light and I trace the horizon and I look at nature and I remind myself that nature is the best way to regulate. That helps my brain.
- [115:20]
Stephen Bartlett
Sarah, thank you. Thank you so much for doing the work that you do. You're an incredibly intriguing person in many respects and you're clearly helping so many people in so many wonderfully important ways. These. I highly recommend everybody go and check out the books that I have in front of me. There's, I mean there's, there's quite a few of them. I think there's six in total. I've got three here. The Autoimmune cure, Healing the traumas and other triggers that have turned your body against you is the book that I'm gonna highly recommend. I think this is the, the new one. And I've interviewed Paul Conte, who writes the recommendation for the, the book on back of this. I've also got another book here called the Hormone Cure, which is all about reclaiming balance, sleep and sex drive, maintaining a healthy weight, feeling focused, vital and energized naturally. And one of the books that I was referencing as we were going, which is Woman, food and hormones, A four week plan to achieve hormonal balance, lose weight and feel like yourself again. If people want to know more from you, they want to hear you. You have a new podcast, right?
- [116:15]
Dr. Sara Sal
Yes.
- [116:15]
Stephen Bartlett
Where do you go to listen to your podcast?
- [116:17]
Dr. Sara Sal
My website is sarazall md.com and the podcast is called Treated with Dr. Sarah.
- [116:24]
Stephen Bartlett
That's Sarah Zahl, spelt S Z A L. That's right. And the podcast is called treated with Dr. Sarah. Thank you so much.
- [116:34]
Dr. Sara Sal
Thank you so much, Stephen.
- [116:37]
Dr. Sarah Z
We launched these conversation cards and they.
- [116:39]
Stephen Bartlett
Sold out and we launched them again.
- [116:40]
Dr. Sarah Z
And they sold out again. We launched them again and they sold out again because people love playing these with colleagues at work, with friends at home, and also with family. And we've also got a big audience that use them as journal prompts. Every single time a guest comes on the diary of a CEO, they leave a question for the next guest in the diary. And I've sat here with some of the most incredible people in the world and they've left all of these questions in the diary and I've ranked them from one to three in terms of the depth one being a starter question and level three. If you look on the back here, this is a level 3 becomes a much deeper question that builds even more connection. If you turn the cards over and you scan that QR code, you can see who answered the card and watch the video of them answering it in real time. So if you would like to get your hands on some of these conversation cards, go to thediary.com or look at the link in the description below. I find it incredibly fascinating that when we look at the back end of Spotify and Apple and our audio channels, the majority of people that watch this podcast haven't yet hit the Follow button or the subscribe button. Wherever you're listening to this, I would like to make a deal with you. If you could do me a huge favor and hit that subscribe button, I will work tirelessly from now until forever to make the show better and better and better and better. I can't tell you how much it helps. When you hit that subscribe button, the show gets bigger, which means we can expand the production, bring in all the guests you want to see, and continue to doing this thing we love. If you could do me that small favor and hit the Follow button wherever you're listening to this, that would mean the world to me. That is the only favor I will ever ask you. Thank you so much for your time.
- [118:36]
Stephen Bartlett
This episode is brought to you by Universal Pictures. From Universal Pictures in Blumhouse come a storm of terror. From the director of the Shallows the Woman in the Yard don't let her in. Where does she come from?
- [118:54]
Dr. Sara Sal
What does she want? When will she leave?
- [118:57]
Stephen Bartlett
Today's the day. The Woman in the Yard only in theaters March 28th.