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- [00:00]
A
Hello, Everybody. It is Dr. Jamie, and welcome back to the Fit and Fabulous podcast. I could not be more excited about today's recording. I have been wanting to get this guest on here to talk about this topic for a little while and every time he posts something about this topic, I'm like, we gotta record this, we gotta do this. So please welcome Dr. Campbell. He is a professor and director of the Performance and Physique Enhancement Lab at the University of South Florida. Florida. Probably much warmer than Nebraska is today. He's authored three books on sports nutrition and author of over 200 scientific abstracts and manuscripts on topics that are related to sports nutrition, physique enhancement, and exercise performance. He's the past president of the International Society of Sports Nutrition. He also has this really awesome newsletter called Body by Science, and it summarizes all of this research, all of this review of research into one easy to read format. I've seen it myself. It's amazing. You guys can find them on instagram@billcampbellphd or bill campbellphd.com but the reason why I've invited Bill on today is to have a conversation about menopause. His research is starting to focus on optimizing physique through lifestyle. But he has conducted the first ever Women's Menopause Fitness Survey, and I've seen some of the results. The survey is about women's projections and reflections on menopause as they embrace a fitness lifestyle. He's created a free YouTube educational series series about menopause and fitness. It has lessons on exercise nutrition, hormone replacement therapy. I am so excited about what you're doing, Bill. Welcome to the Fit and Fabulous podcast.
- [01:35]
B
Well, thank you very much for having me. I'm excited to be here.
- [01:38]
A
Okay, so my listeners know who I am, but in case Dr. Campbell's listeners are on here, I'm an OB GYN. I have a background in exercise science and nutrition in my adult life. After being a collegiate athlete, got into bodybuilding and have competed in both women's physique and women's bodybuilding. So as a women's health practitioner, I look through a different lens, I suppose, when, when I talk about lifestyle with my patients. But what made you, Bill, you have this incredible, you know, list of credentials in sports and exercise nutrition. But what made you start to focus on menopause?
- [02:15]
B
Okay, so that's 100% was due to my wife's menopause transition. So if we were to back up five years from today and somebody were to tell me, hey, you're going to change your entire research program and focus on menopause. I would have said, there's no way it was so far removed from what I was thinking or my interest level. And essentially. So I'm a fat loss researcher, exercise physiologist by training. And I. My wife, very fit, lifts weights. And then when she got to her late 40s, she started to gain some weight. And in the past, I would always help to some extent, like, well, she's lucky, right? If she wants to lose weight. She's married to a fat loss researcher. So for the first time when, when I. This, I couldn't help this time, like everything that we used to do didn't help. And then. And let me also say not all women are going to gain weight. Not all women that go through menopause are going to have a hard time losing it. So I don't. It's not a doomsday scenario for everyone. But a lot of women will gain weight, especially in the midsection. And in my wife's case, she had a hard time losing it. Again, I was kind of, you know, I was being very stressed with, like, I can't help you. And her weight gain was not the most. She had larger problems with her menopause transition than just weight gain. But as a lot of women who embrace a fitness lifestyle can. Can empathize with, it was hard to gain weight when she hadn't gained weight in the past. I really didn't feel like she changed anything about her routine. Definitely had less energy, for sure. So that is why I'm like, I can't help you. This is a now a challenge to me. And then I started with her permission to start talking about this a little bit publicly. And let me tell you, the avalanche of responses from other women who say the same and continue to say the same thing. So I'm extremely.
- [04:26]
A
And I know exactly why. Because I have your wife in my clinic every single day. Every day. Single, every single day. I'm not kidding. There is a woman, she's in her late 40s or early 50s, and she is like, listen, doc, I'm working out. I'm going four days a week. I'm doing the same level of intensity. I'm lifting the weights, I'm eating the same diet, I am doing everything I used to do. And hey, you know, I haven't been perfect, but 10 years ago, I used to be able to, you know, manipulate it in this way. And I'd get the £10 off and I'd get back on track. Nothing is working. I'm so frustrated. I think I'm just going to quit doing it. And you know, they just feel so defeated because they feel like they really are doing the right thing. So you've shared a few things on social media about why this could be right. Maybe they're not really tracking adequately. Maybe their intensity of their workouts really isn't as intense as maybe they think it is. What was initially your theory when your wife is experiencing this? I mean, with your science brain, like what, I mean, what were you thinking? What questions were you asking?
- [05:37]
B
So at first I had no idea because it was new to me. Like all of my research or most of my research was in younger, metabolically healthy women. So mostly women in their 20s, maybe 30s. And every time we reduce calories, they would always lose, lose, lose fat. And I also want to say that I'm, I'm, was and probably still am one of the biggest advocates for the calories in, calories out. Like, there is nobody who beat that drum more than me as a fat loss scientist. And I'm not backing away from saying, hey, yes, you can.
- [06:11]
A
That still applies. It still applies, yeah.
- [06:14]
B
However, now I have to have almost like a menopause caveat where I think, or at least I'm open to the idea that some women, a small proportion of women that go through menopause, they. The traditional, or what used to work is not enough of a stimulus for causing fat loss when a few years ago it used to be. So it another way to say it is the calorie deficits that they need to employ to lose body fat are so low and unsustainable that, that it's just not healthy and, and more importantly, it's, or just as important, it's not sustainable. So I know I didn't answer your question yet. I'm just trying to give context around this. I'm not running away from, oh, calories don't matter, of course they do. But why, why does it, why do so many women claim that I'm doing the same thing and it's not working? And why do all of these women seem to be in their 40s and 50s, early 50s, late 40s, 40s. So all I'm doing as a scientist is, is listening to the culture around me in this sub population of women who embrace a fitness lifestyle and am starting to ask the appropriate scientific questions? So, so that's my thinking around this, what I originally thought. And again, at first I had no idea. Everything was new to me and my wife. We were completely reactive to this menopause Thing which was very frustrating. She suffered a lot more than she needed to. And my wife kind of defers to me for all of the health related components of her life and I defer to her on 99.9% of everything else in our lives. So she does everything I do. The one, I go to pubmed, I'm the one who, you know, well, hey, make sure you ask your doctor these three questions. So she's relying on me and I didn't have any answers. So one of the first things that started to come up was, well, what, what about this hormone therapy thing? And I was like, well, I know that that's, that can cause breast cancer. And I didn't know much. So I, I started with no knowledge and I jumped in try to, about most of what I read is research articles, but I read a few books early on as well. And just to now try to answer your question, what we do know with this weight gain, it happens the same exact time that estrogen, and I'm just going to use the word estradiol levels start to go down. So again is that causation is a correlation. Well, it's clearly correlated. So then I'm thinking, okay, if it's, and a lot of people will point to estradiol levels are, are getting lower and abdominal fat is increasing. So then I thought, okay, well this is pretty simple. This is a one plus one equals two. The women who take estrogen therapy, estradiol therapy, they're probably not going to gain this body fat or they'll be able to lose it. And I can't sit here today and say I don't think that's true for everyone. What I've learned both in conversations with women and by the way, as we have this conversation, I talk to through social media a lot. I'm a sponge for knowledge. I'm, I learned and I read all kinds of research on this. But I don't, I don't want to discount, I'm having conversations. So what I, let me start with the conversations and the anecdotal information. Women would tell me, oh, I started hormone therapy and it was great. I lost ten pounds. I, um, feel better, et cetera. Other women would say, hey man, I started hormone, you know, an estrogen patch or an estrogen pill. And man, I gained eight pounds in three weeks. And then other women are like, yeah, it didn't make any difference. So anecdotally what I'm learning is, boy, it's highly variable. I, I would think that estrogen would just solve all of this and then in the research, highly variable outcomes. Some studies show estrogen therapy helps with weight loss. Other research will show it actually can cause weight gain. Other research shows it will prevent the loss of body fat. So to answer your question, what was my theory? Initially it was all estrogen, estradiol and man, yeah, if it was just that easy. And now I'm left with, and this is my lab is literally, I was in meetings with my research team for the last few hours. We're designing a study to answer the question, well, well, just a document, does it exist? If it does, why? And we're not really answering the why. We're going to try to document yes or no first. But I wish it was estradiol because then there's a solution for that. But I don't know why it's so variable. So that's what I would love to know your thoughts. Do you know why?
- [11:21]
A
So for my listeners to understand what's happening, you know, we're suddenly seeing this shift at menopause. Well, what happens at menopause? Month over month, year over year. In perimenopause there is a average lower estradiol level month to month. And then finally once you make this menopausal transition, it's low and it's just steady state, low progesterone, same thing. Loss of progesterone. Testosterone does not fall off the cliff like estradiol does. But there is a slow age related decline over our midlife and through menopause. What we know estrogen does. So estrogen is, plays a very multifaceted approach with human metabolism. We have, we have known that and it's part of the reason why a lot of people shied away from studying women across the menstrual cycle. It's really hard. You have, there's, there's not much control when you have fluctuating day to day, week to week levels of estradiol. But we know that with, because of what estrogen does, we know that it does change energy balance, it changes glucose homeostasis. So it's not uncommon in a menopausal patient. The year she makes this transition, her A1C goes up, her fasting insulin and glucose go up. We start to see lipid metabolism changes. Her cholesterol panel all of a sudden is changing. We know that estradiol plays a role in human metabolism. So what's interesting for me, just like you, okay, well what about the HRT users? What, you know, that's probably the magic sauce. What I have found clinically when you say there's this like variability in how people respond is that I explain it to patients that it is like one, one of the puzzle pieces. And if you have a puzzle that has 10 pieces in it and you're making Mickey Mouse, it is an important piece of the puzzle, but it's not the whole picture. And I find that estrogen replacement works best in patients who are doing a lot of the right things. My kind of like mantra is these five pillars. Sleep, nutrition, exercise, stress mitigation, and kind of environment. So I do think that we're on the same page with who, who, who are these people that it works best in. How do you select for those people? Obviously it's always a choice to take hormone replacement in some patients. I actually had a couple followers message in. Can you please talk about the people who can't take it? Like what can we do? Right. These of course are breast cancer patients or, or there's some people that just have a risk of blood clot or whatever it is, they can't take it or choose not to take it. But when I've looked at the studies and you know this data better than I do, Bill, but you, you know, 2019 JAMA meta analysis on like 12 studies, over 4,500 patients, not much different in skeletal, lean, lean body mass gains. So it doesn't appear to like, you know, keep a bunch of muscle on patients. When you look at fat mass, you're right, it's all over the place. Some show they gain, some show they lose. Um, there is some favorability when we look at twin studies of people who took it and people that don't listen. I'm a fan of HRT for a variety of reasons that have nothing to do with body composition. There is less diabetes, less cardiovascular disease, less osteoporosis, less colon cancer in some studies, less breast cancer. And if you start HRT between 50 and 59, there's a 30% reduction in all cause mortality. So 30% less chance of dying of anything. So I'm a huge fan of that and the listeners know that, but let's go back to what you know and kind of segueing into this study. So if, Bill, if you're talking to somebody that's in their 20s, 30s, 40s, 50s, traditionally, you would have told all these women in all these different decades that the same principles apply if they want to improve their body composition. Because I think vast majority of people listening aren't bodybuilders. But because I've gone through a prep before I, I know that those same principles apply if I want to lose 10 pounds before vacation or you know, put on lean tissue. Would you, would you still say until we know more, until we kind of settle the science more, that the same principles still apply? For somebody that's listening, that's 30 versus 50?
- [15:43]
B
Yeah. I would add a little nuance to this and this is just based on some preliminary research that we've done in my lab. So if I have 20, 30 year old, hey, let's do the traditional 25% caloric deficit optimal protein resistance training. And for almost all of them, at least in my experience, they're going to lose fat, they're going to retain their muscle. When we get into this again, I'll just say a sub population of women that are going through the menopause transition, so typically it's going to be late 40s, early 50s, and they, they have this, hey, it's not working. My suggestion or, or an option that I would want to have with them is, okay, there could be, you just need to be more aggressive. Now I've spent a lot of years railing against crash dieting and aggressive dieting because that, that does a host of negative things. Let's talk about them. When you diet aggressively for extended periods of time, you lose a lot of weight, you lose a lot of fat, but you lose a lot of lean mass when you do that. If you lose lean mass when you diet, as soon as your diet is over, you are significantly more likely to gain back body fat. And in many cases, depending on how aggressive you were, that body fat comes on not only rapidly but, but it comes back on more and more amount than what you had before you started your diet. So we call that fat overshoot. And that is due to a phenomenon known as hyperphagia. So hyperphagia is basically the term refers to uncontrollable hunger or a really strong desire to eat. And that is really tapered to lean mass changes. So my whole career has been built on kind of, you know, been like a bodybuilding perspective, helping people lose weight but maintain as much lean mass so that they have a greater likelihood of maintaining that fat loss. So there's the base. And now I'm going to sound like a hypocrite, but I, I'm actually not for the women that I've, that I've had come into my lab who have claimed weight loss resistance and this is not published yet. We did present some of this data at conference last year, but we didn't publish this study yet. We are Very aggressive with walking and low calorie. But now here's the key. The duration is very short. It is about. We have a four day protocol where they walk six hours a day and they're eating about 3 to 500 calories of mostly protein. So what does this do? Well, if the theory is that what used to work never is not working and which would be a normal caloric deficit, but I have to have my calories so low to make the, the, the fat loss needle move. What I'm essentially doing is leaning into that, but in such a way where the duration is so short that the body only responds in our data by losing fat and not losing any lean mass. In fact, most of the women we've had nine go through this protocol actually gained a little bit of lean mass. And these are all women that are fit and many of whom just dieting is not working, so they say. So there is something I would, that possibly would be a little different between somebody who says they're struggling, who's older, when I say older, 40s and 50s compared to your question, 20s and 30s. And one more thing, I am scared to death of publishing this data because I know what will happen. A lot of people will say, oh, four days was great, but let's do eight, let's do 12. And that's all of those harms are going to now be in play.
- [19:54]
A
Could you, Is this like they do this four days a month, four days every two weeks? Like what do you think the optimal ratio of rest recovery is?
- [20:06]
B
Yeah, so we've only, we've only investigated this as a one time four day period. And we brought them back 30 days later to make sure because everybody, you know, we, they did these four days and again it's, that's a very severe protocol. Like if you have a normal job,
- [20:25]
A
it's a lot of moving and not a lot of energy intake.
- [20:28]
B
Yeah. But on the energy side, because I, I obviously put myself through this and I'm a foodie. Like I, I think about food all the time. Like the GLP ones, like, that's me, like I'm constantly thinking of food, but surprisingly for myself and in most of the subjects that went through this, you're so busy walking that it really does suppress your hungry. Now I will say for myself, on the fourth day I was very hungry, but the, I was shocked at how little I thought about food during at least the first three days of this. And importantly, we put them through the protocol, then had them eat normal calories for three days and then we brought them back to make, you know, because their fluids are all messed up. So if you do body composition testing after four days of starvation, essentially and maybe some inflammation with all this walking, you're going to get wonky values. So we wanted to stabilized nutrition fluids, brought them back three days later and then we brought them back a month later because that's where we're going to see. Did we cause harm by. If they lost lean mass, did they now get this hunger drive and did they gain fat? And in every situation they all continue to maintain their fat loss, not lose any lean mass. And we did blood work. So it was, it was, I mean, there was no harm done at least within the 30 days and that's when, you know, we would see. So I'd like the health outcomes or the body composition outcomes without any adverse health effects. Now again, the key here is we were more aggressive, which I think it's probably what you need to do in menopause. Maybe stay away from the slow, long duration dieting, which again, for much of my career, I said that's the way to do it. I, I'm thinking that this should be an option and I want to, I want to say something else. My world and, and the women that I'm really trying to serve are those that embrace a fitness lifestyle. If, if I have a 50 year old come to me, I'll just use my wife. If my wife said, hey, I can't lose weight and she's not tracking her food and she's not lifting weights, I
- [22:42]
A
would say that's the starting point.
- [22:44]
B
Yes. Yeah, you're saying you can't, but how do you know if you're not? And again, I'm not saying everybody has to track, but if you're going to claim that nothing is working and you're not already, you know, I'll just say buttoned up, you're not tracking your food. You're not, you're not, you're not optimizing protein. You're not. I'm, I don't want to say I'm not going to believe you, but I'm. There's a lot. Or you're drinking a lot of wine.
- [23:10]
A
You got to have a baseline to start from. I mean, you could.
- [23:13]
B
Yes.
- [23:13]
A
So can you highlight for the listeners though, what does the data really show? With measuring and tracking,
- [23:23]
B
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- [23:33]
A
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- [23:37]
B
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- [23:42]
A
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- [23:51]
B
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- [23:56]
A
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- [24:04]
B
Oh, it's overwhelming. If you track just, just calories and body weight, significant, improve significantly positive outcomes for body composition.
- [24:17]
A
How accurate is that for most people? Because I have some patients that come in like, oh, yeah, doc, I'm. I got my, I got my app right here. I'm. This is what I mean. I'm not losing weight.
- [24:27]
B
Yeah, that can be. Again, we talked about variability. That can be highly variable as well.
- [24:34]
A
Yeah.
- [24:34]
B
What I would do if I'm working with clients, I would say, hey, great, great, you're tracking. But if things aren't working, let's just. I'll you. Here's the example I use in my classes. Like, take a picture of what you just tracked and send it to me. So as an example, if they had a, a normal piece of lasagna and they say, yeah, I tracked and it's 250 calories, you're like, no, what you just ate based on the weight in this, the picture you sent me, that's closer to 800 calories. So there's a little test. So, yeah, so even then, even if you're tracking. But yeah, that's true. We, we have to make an assumption that you're tracking well and everything. A lot of people are like, well, I'm not going to count the dressing or.
- [25:22]
A
Yeah. One thing I always tried to share with followers when I was going through my own bodybuilding prep was, was like, I mean, you're weighing your food, you're measuring tablespoons. I mean, it's, it's a neurotic level of tracking when you're doing a bodybuilding competition. Because my calories were dropping like 45 calories each week. I mean, that's like one extra bite of food or like one less bite of food a day. I mean, that's like crazy. So I just want to highlight that for people that maybe you are counting and tracking and it's just not good information. So let's talk about another thing that comes up from menopausal women is they're like, I, I heard on a podcast I'm not supposed to do Orange theory because hit increases cortisol. And I heard you're not supposed to Be spiking your cortisol for menopausal women. So you did walking for this study. What kind of exercise do you think that menopausal women should be doing?
- [26:21]
B
Whatever they enjoy. I'm, I'm very. If you like a certain type of exercise, do that exercise. I, I would really hope and encourage people make resistance training the foundation of what you do. But if you hate that and you love pickleball or you, you love cycling, I'm not gonna. Any movement is good. So yeah, I'm, I don't like, I like people to lean into what they like to do, but I do highly encourage resistance exercise as ideally a foundational part or at least a, that it occupies some time of your, of your fitness program.
- [27:06]
A
Do you think there's a population of women that are doing too much cardio for too long or too much hit for too long and really creating a cortisol issue? You think it's even a thing?
- [27:17]
B
Yeah, I. So let me also say what we did in our study when they were doing these, these were all resistance trained women in this, what we call our rapid fat loss protocol. We said no lifting for these four days. Like this is, we want you to relax, try to walk outside. Now again, depending on if they lived in Florida. Careful, it. It, they lost no muscle even though we, we. Again, it's only four days of not lifting. But yeah, if I have, if, if I have women who are really high volume exercisers, I'm all for, hey. And they're coming to me saying nothing is working. And yes, you're tracking. Yes, I'm lifting, yes, I'm running, yes, I'm getting my steps in. Yes, I'm going to conditioning classes. To me, I'm like, okay, I'm just listening to you. And great for you. You're doing all of this movement, but you're also telling me that nothing, like whatever you're doing isn't working. If I get the sense that this, your volume of exercise is just so high, to me it makes sense that. Let's dial some of this back and let's see how your body responds. And in some cases it really helps. They, they bring, you know, they just cut everything in half. And that's a hard conversation for a lot of, a lot of the women that I talk to. But you already said nothing's working, so let's, let's try something else. Is that a cortisol issue? It could be. I, I do know that I don't see that in the research literature elevated cortisol that doesn't mean it's, it's not a real thing. But I, I, I do get the sense that it's. Well, here's exactly. So I'll have women say, hey, my cortisol is really high for whatever reason. And I'm like, oh, what were your values? Well, I didn't actually get it measured.
- [29:06]
A
Then the Internet told them they have a cortisol problem.
- [29:10]
B
Yeah. So that worries me. So somewhere they're getting a message that it's their cortisol. Maybe it is, maybe it isn't. It's not in the research literature and they're not really able to document it. When I ask that question.
- [29:22]
A
Yeah.
- [29:23]
B
What do you think? What are your thoughts on high volumes of exercise and cortisol?
- [29:28]
A
Well, I mean, we know like if you're doing like true high intensity interval training, like you shouldn't be able to do that for an hour. Like you're definitely not going at the intensity that you like think you are. Um, but I do, I mean, I think it's rare that somebody is over exercising like that. They're spending so many hours on the stairmill that like, that they're creating basically too much sympathetic, you know, like nervous system stimulation. I do think it's important. Like people need rest, people need recovery. Like we live these crazy jobs and careers and we're getting just stimulated all the time. So I do think sometimes people can get so neurotic about the diet and exercise portion that it's like, hey, how's your sleep? Maybe you need some meditation. Like, maybe you need some sauna sessions. Like I do think there's some women that can benefit from that, but I don't think it's a, you really are pumping so much cortisol out of your adrenals that it's inhibiting your results. I mean, I just don't, I just don't think that's a thing.
- [30:27]
B
And back to cortisol, it's. Cortisol release is a natural response to exercise. And when I was earlier in my career, I was really into over training and I was trying to look at all the research on what would predict over training. The only thing that jumped out to me was the body's failure to spike cortisol after intense exercise. So if the body didn't respond by releasing cortisol after high intensity exercise, that was a sign that that person was going to enter an over trained state. So it's something I've never forgotten.
- [31:04]
A
Yeah.
- [31:04]
B
Relative to cortisol.
- [31:06]
A
Let's talk about sleep. We know the data is very clear. People that have sleep deprivation gain weight, I can tell you right now, delivering babies at 2 o' clock in the morning the next day. My satiety is horrible, my, my hunger is up, my compliance is sometimes down. Thankfully, I usually have a night of recovery and I come back. But menopausal women, perimenopausal women, they're not sleeping well either. What role do you think that sleep plays in, in some of this?
- [31:37]
B
Well, they're. The only documented existence of true fat loss resistance is it comes from a sleep deprivation study. So I'll explain this and actually we just talked about this in my, in my research meeting today. They had middle aged males and females, mostly males, but a few females. They had them live in a metabolic ward, metabolic chamber, room, calorimeter, whatever you want to call it, for 14 days, two different times. So what is a, what is a metabolic chamber? It is a, it's a pretty small room that tells you precisely how many calories you're burning. And it does that through indirect calorimetry, which is basically measures your oxygen consumed and your carbon dioxide that you breathe out. It is the gold standard for measuring metabolism. So there is no better environment to test energy expenditure. They had these subjects for 14 days, all on a diet. So they reduced their calories by 33% one time. For 14 days they were allowed to sleep a normal night and they averaged seven and a half hours. A short time later they came back for another 14 days, same diet, reduced their calories, same amount, but this time they were sleep deprived by two hours. So it was 5.5 hours, all randomized, the same subjects. So the beauty of using the same subjects is you eliminate all genetic variability. Same genes, same metabolism, same same lifestyle. You will not find a better design sleep study than this. And what they found, when the subjects were sleep deprived, eating the same number of calories in a caloric deficit, they lost significantly less fat. They lost 2.5 times more fat. So I used to think, now I know you don't because you see this in the real world with, with patients and, and third shifts. But I'm like, yeah, sleep, I, yeah, it's important, but it never really, I never really cared about it. And then I've read that study and my position now is if you're at a point in life where you can't sleep, don't make that a diet phase. You are literally spinning your wheels. And that is you can't read that study and say that fat loss resistance is not real. That's A clear indication. So that that doesn't mean that menopausal women have it again, that. That, that hasn't been shown yet. But like you said, which out of all the humans in the world, which ones suffer from sleep deprivation the most? It would be women going through menopause. So it's not a far stretch to say, hey, if you're having sleep issues and you're trying to lose weight, that's a reason why it might not be working.
- [34:40]
A
Well, yeah, a hundred percent. So I've had so many different people on the podcast, and it really was not until my 40s that I realized sleep is like a skill. Like when you're a kid, you just like, lay down and go to sleep, and then suddenly in your 40s, and you're like, you got this, you know, you got red lights and you got a mask and you're taking, you know, magnesium and you got this chili pad on your bed. Like, I'm telling you, I know what these women are doing, and, like, they're trying a lot of things just to get a good night's sleep. I do think that it plays a role because I hear so many of them say they're having trouble sleeping, and then they're like, and I can't lose weight. And when people are, I think it's almost like this vicious toilet bowl that happens because they're not sleeping well. So then they're more hungry during the day, and then their joints are hurting because they're getting joint stiffness. So they're not mo. They're naturally just not moving as much. So even though they perceive it as like, I'm doing all the same things, there probably are some subtle changes. And it's not just estrogen and progesterone that go down when we don't sleep well. Testosterone changes, growth hormone, pulsatility changes. I mean, there's. There's more things that change, you know, with poor sleep and age related changes, too. So I'm, I'm with you. I think, I think that's a puzzle piece that if you're not sleeping well, you got to focus on that first. And sometimes it is a hormone issue. I mean, if you're waking up with night sweats 12 times a night, that's a problem. That's a problem.
- [36:12]
B
And on that note, just for whoever it may help, my wife's. She started on progesterone it immediately. I'll just say the word cured her sleep. Night sweats, hot flashes. It was, I would just say progesterone dramatically Improved my wife's quality of life.
- [36:33]
A
Yeah, the vast majority of my patients do really well with progesterone. There are a few patients that can't kind of quote unquote tolerate it. You want to take it at night, 30, 60 minutes before, before bedtime. I prefer micronized progesterone or prometrium is the trade name as opposed to a progestin. And that's because of the breast cancer risk. But it does, it's very good for sleep. And one of the metabolites of progesterone, allopregnanolone, increases GABA in the brain. So it's like, it's really calming to the brain. It helps people sleep. And even if you've had a hysterectomy, you can still take progesterone. You just don't have to take progesterone. You, if you're taking estrogen. But I use a lot of progesterone and perimenopause before I'm actually adding estrogen. Yeah, we don't have a lot of like, robust data to even support that. But that I will tell you anecdotally, progesterone and perimenopause, if you're not sleeping well, is, is a, is a great thing to try. Okay, I want to touch for just a couple of minutes on glps, you talked about this, like, extreme dieting, really extremely low calorie diet, aggressive weight loss, fast weight loss, and the rebound effect that happens with weight gain and satiety. We have seen that in the GLP data. But do you think that, that GLPs could play a role in weight loss resistance with menopause?
- [37:59]
B
Yeah. So the, the, the feedback that I get and the data that I have for the women in menopause who say that they have weight loss resistance. When, when those women start a GLP1 treatment, it's about an 80% of the time that they're saying, oh, this finally helped. This, this worked when other things wouldn't work. 20% of the time they were non responders to that. So, yeah, it's, it seems like it's very effective for, for these women.
- [38:34]
A
Yeah, I've seen that too, clinically. And you did an initial survey and you shared some, some results about women who are taking hrt. I'm just gonna go. We're not going to talk about GLPs. We could talk about the whole episode of that. But I do, I think there is some role for menopausal women. But you did a survey that compared to the average kind of women, only 5% were using HRT. But a fit women, 55% were using HRT. Why do you think that is?
- [39:00]
B
Yeah, and let me just, let me give one caveat to that. We, we cited other research for 5%. It's probably a little higher than 5, let's say 10 because a lot of women are getting compounded.
- [39:13]
A
We're talking about it.
- [39:14]
B
Yeah. And 55% was from my and my colleagues social media. That's how we recruited. So but nonetheless it was F. At least five times, five to 10 times higher than the normal population. So think that women who embrace a fitness lifestyle, they're already more open to supplementation. So maybe creatine, a protein supplement and probably even more so they're more in tune with their bodies and if their bodies aren't performing as well, they're going to want to know why. So that they are, you know, they're like finely tuned machines and if things aren't feeling right, I'll just like, I'll just say like my mom, who's not, who does, who did not live a fitness based lifestyle, I don't even know if she would know if things were off. She's not lifting weights to have this calibration. So I think it's the women who are, are used to performing at a certain level or recovering at a certain rate, it's not happening well. And then they're more likely to go to try to solve the problem.
- [40:22]
A
Yeah, yeah. I think it's great that most of the women using HRT are fitness gals because like I said earlier in the podcast, it's actually those patients that I think probably get the most benefit from it. And part of it in my science brain is that we know that loss of estrogen actually changes the mitochondria in various ways. And so these women, they're already doing things to support their mitochondrial health. And then it's just like, you know, one, it's like I tell what I always try to break this down in a way that my 10 year old can understand it. But it's like if you had like two car engines and this one, the oil's been changed, the timing belts have been going, undergoing maintenance versus this one that's never been serviced and then just try to pour premium gasoline into both of them, like they don't run the same way. So, so I like that that's what it showed because I do think that people have to do the basic things first. And then I think HRT is a, is a great Addition, But I also, I'll contradict myself sometimes when women aren't sleeping well and they're tired and they're fatigued and their joints hurt and they can't comply with their diet, whatever. Sometimes, sometimes, sometimes HRT can help them feel better and more motivated to start doing those things again. You know, maybe they did it and now they've just had trouble, you know, maintaining because they feel so crappy. So just something to consider. Okay. I want to talk about muscle. So estrogen's role in muscle. We have estrogen receptors in our muscles. When we lose estrogen, we start to lose satellite cell proliferation. We start to not turn over muscle proteins as well. I talked about the mitochondria. There's more oxidative stress in the muscle. So for a woman listening that she doesn't, she doesn't care about the extra 10 pounds of fat, but she's like, I want to gain muscle. And now I'm, you know, in menopause. Can, can women gain muscle at any point in their life? What does it look like pre and post menopause? What do you see in the data?
- [42:28]
B
Yeah, so what I see in the data is pre menopause, your body responds to resistant training better than when you're Perry or post menopause. So same workout program, your body is just more anabolic. Responds to the resistance exercise stimulus much better than when you're in menopause. Now the question could be maybe that's just aging and menopause doesn't have anything to do with it because anabolic resistance happens in men and women. I, I would. My personal thought of reading research, and I'm going to say once again, the best research is that estrogen is anabolic. So let me. The, the broad research would suggest that that's not estrogen therapy. Estradiol therapy is the one that, that I really focus on. That's kind of all over the place too, in terms that sometimes women will gain lean mass, sometimes they'll maintain their lean mass. But the, I guess I'll phrase it as the problem I have with all of this research, all of it, and I'll just, I want to just throw it away. It's always in women who have not embraced a fitness lifestyle. So once again, the women that I'm. That I want to serve, we don't have data on them. I'll share some research that, that I've read that that has informed my opinion on this. So I already said they respond better to resistance exercise before they're in menopause. Another, another research study gave early postmenopausal women an estradiol patch or a placebo patch. The women wearing the estradiol patch gained significantly more muscle compared to the placebo group, same exercise program. So when you compare, hey, women respond better when they're younger. And so when they have estrogen, estradiol, when, as women get older, when their estrogen levels are declining, they're not responding as well. But then we have a study where you increased estradiol and that it was a 0.1 milligram patch, they gained significantly more lean mass. So I'm using all of these data points to suggest as well as anecdotal, it's, it's anabolic and it helps. And the other, the other thing I want to say with this, all of this research that shows that women don't lose lean mass during menopause. And there's a lot of research, some of it's very well controlled. But that's ins, that's not in women who've spent 10, 15 years building it. What if we tested them? Do they lose more? I wouldn't be surprised if they do. And again, my conversations with women are that they do. So to summarize, estrogen, estradiol is anabolic.
- [45:25]
A
Yeah. Or at best anti catabolic. I mean even if you can just maintain, you know, what you have and not lose. But certainly, certainly the more muscle you can come into menopause with, your risk of sarcopenia, that it's same with bone mineral density. The higher you can start on that graph. Even if there's some sort of age related decline, despite whatever you're doing, you're at least starting at that higher point. So I always tell my perimenopausal gals, get it in order right now, get it while you can, and we'll support the hormones when we need to. But there was an interesting mouse, it's of course a rodent study, but basically saying that exercise could protect against a lot of the skeletal and mitochondrial changes independent of local estrogen synthesis. So I do think for the woman listening who cannot take estrogen, I still think they need to hear the message that these things matter. How much protein you're eating matters, how much you're training and the volume of training and the intensity of training, these things still matter despite whether you use estrogen or don't use estrogen. You agree, don't you Bill?
- [46:33]
B
Oh, yeah, it's the foundation. Yep, yep, yeah. What are the side effects of estrogen of a fitness lifestyle? They're all, they're, they're all positive.
- [46:44]
A
I mean a little bit of your time, but I mean pay now or pay later. I mean you like I'm telling you, anybody that gets towards the end of their life and has some metabolic disease, cancer, diagnosis, like, I mean something will take all of us out. But I think we just like, we undervalue our health when we're young and we're so resilient and I, I think we perimenopause and menopause are a great time in your life to say like I'm in control of this and like this is worth my time and energy and effort because health is literally the only thing that can't be bought. And I, I gave a TED talk on women lifting weights and I have three little girls and I'm trying to set the standard that it's okay for women to have muscles. But I tell my patients all the time that resistance training is the only, only not if you want to like hate pharma and hate drugs. Weightlifting is the only non pharmacological intervention that has ever been to consistently shown to offset age related declines in skeletal muscle mass, strength and power. So they have never come out with some magic drug. GLP1s aren't great for your muscle mass, I'll tell you that. I mean unless we have some myostatin inhibitor that's coming, I mean but even then everything is going to have a tradeoff. So like weight. If you want a magic drug, weightlifting is the best magic that we have.
- [48:05]
B
Agreed.
- [48:06]
A
Yeah. I love it. I love it. Okay, so talk about creatine. Somebody sent in a question. Can you ask Bill about supplements that menopausal, that could be beneficial to menopausal women outside of hormone replacement therapy?
- [48:22]
B
Yeah, I'm. Creatine in my opinion is a, is a good supplement to take especially if you live a fitness lifestyle. It's the side effects are, there really aren't. I mean it is the most studied diet, sports, dietary supplement besides caffeine in the history of dietary supplement research. So we know it's safe, it's relatively inexpensive. It's not something if somebody hasn't taken it, you don't take it and you don't feel anything. So it's not like caffeine. But what we know that it does is it increases power production, it increases strength and lean mass. And now we're getting more recent research and I haven't read much of this literature yet, but I've, I, I'm aware enough that it's also being used to, to investigate brain function and what we know is you need higher levels so the sub, you need to supplement with more, about two to three times more to get potential brain benefits of, of creatine. So that, that's, I don't take many supplements. That's one that I take. It's one that I encourage my wife to take and she never listens to me.
- [49:28]
A
Yeah, it's about 20 grams of creatine in the studies on brain health. So it has to saturate the muscle first and then it spills over into the brain. So it's, you're right, it's instead of one scoop it's like four scoops. So it's, it's a lot of creatine. Um, from a dietary perspective, talk about fat, protein and carbs. Do you think that there is some sort of optimal ratio amount of these things when we become menopausal?
- [49:54]
B
No, the, the historic protein intake research would suggest, and again these are, these are gen, what I would call a general population person but protein intakes tend to be very low in middle aged women. So and I, we could spend a whole another session on, on this but just increasing protein when you do nothing else. No exercise. If you take a, a middle aged menopausal woman and this is the research I'm citing and if they're eating suboptimal protein and the only thing you do is increase their protein, they will gain lean mass and they will lose body fat. No exercise. So that's pretty powerful. And that's been shown in more than one study. That's, that's been shown multiple times. So me being an exercise scientist, former bodybuilder, liking that lifestyle, I, I always gravitate towards a protein anchored diet. So what you know, I, I always say hey, a good place to aim is 0.75 grams of protein per pound of body weight or ideal body weight. In terms of carbs and fat. I, again I, my one of my core values is simplicity. So do focus on protein and for carbs and fat just do whatever comes natural. Some people like more carbs. Great. Have more carbs. Some people like more fat. Awesome. In terms of body composition, outcomes, it doesn't matter. Protein moves the needle. Carbs generally you, you want enough of them that you can train with intensity, recover from your workouts. But I, I, I, I like just whatever you like to, whatever your dietary likes are just fill that in. Get that with your natural food selection. You don't have to stress about carbs and fat.
- [51:45]
A
Yeah, yeah, I My followers know I'm a proponent of, of the low carb ketogenic lifestyle just because of the massive amount of metabolic disease and diabetes and things that we see. But I agree, first control the amount of energy, get the protein as high as you can. We should have a whole nother podcast episode on this. But Robert Sykes, I don't know if you know who he is, Bill. He is a ketogenic bodybuilder trained traditional way for many years. He was my coach through both, both of my preps. But the first time that I ever did bodybuilding, I actually went into it more as kind of a, a student and a scientist more than anything because I took care of so many female competitors that became amenorrheic, lost their period, their thyroid was crap, they had no estrogen. Um, and I thought what if, what if you in. What if you maintained a higher percent of calories from fat as you dropped your body fat so low, um, and, and kept carbs lower? Would it preserve, you know, sex hormones? That was my kind of question. And this course was like an N1 experiment. But, but it did. And I had the ability to check labs of myself. This last show that I did like a week before the show, I clearly had an ovulation. I had an estradiol level of like 3:76, like one week before the show with like 13 to 14% body fat. So my coach and I have like a lot of theories around, around women and bodybuilding that there could be, there could be maybe a ser. A superior approach for sex hormone preservation. Um, and it, you know, time will tell. Time will tell. But. And then I saw meno. Hesel Henselman shared something this week about meta analysis on carbs that they're not superior at building muscle. So I think it's a, I think it's a fun debate because traditionally for so many years bodybuilding has been very low percentage of calories from, from fat.
- [53:34]
B
Yeah. And is that pretty much your lifestyle, a low carb lifestyle? That's. Or just.
- [53:38]
A
Yeah. So I, I was. After my third daughter was born, I was diagnosed with pre diabetes. So I started living a pretty low carb lifestyle, got back into weightlifting and I just, I just feel and function better eating a lot of fat and less carbs. Trust me, I love carbs. But, but I. Both of my bodybuilding preps were completely ketogenic and it, it was an interesting, fun experiment and I don't know, I think it, I think it's a great approach for women to consider, you know, from a, from A sex hormone standpoint. But we need a lot more people, we need a lot more subjects.
- [54:15]
B
Yeah, yeah. I get feedback from some women where when they've switched to a ketogenic diet or carnivore diet, that they're like, hey, this has been very helpful. So again, it's, I would always say, hey, if you're currently eating high carb and things aren't working for you, well, then let's consider a low carb approach.
- [54:33]
A
Well, I think it, what it naturally does. I, I do think it naturally increases the nutrient density of someone's diet. When you're suddenly focusing on, you know, protein and fat, you're eating, you know, more nutrient dense foods because there's a lot of very poor nutrient carb foods that processed food industry has saturated our entire life with. Okay, um, for the last bit of this, Bill, I want you to tell people about what is, what are you, what are you now studying? What are the questions you're asking? How can people become involved? Because I know you've shared, you know, some surveys and things like that on your social media.
- [55:11]
B
Yeah. So right now we're, my research team and I are planning a, are designing a weight loss resistance study in menopausal women. So this would be for women who embrace a fitness lifestyle. And we're going to define that as resistance training. That they have to be resistance training. But hopefully they're also doing some cardiovascular exercise as well. So specifically, again, a lot of people will claim I can't lose weight despite a caloric deficit. So we are unapologetically recruiting that population of fitness women. So if you think that you cannot lose weight through traditional dieting, we would love for you to be in our study. It's a virtual study. So you continue. You know, you have to, you don't have to come to Tampa, Florida to get testing. So you continue.
- [56:00]
A
We want to come to Tampa.
- [56:04]
B
You just, you continue your normal exercise routine, whatever that is, and we will put you on a diet. And we're comparing that to women who are premenopausal. It's a pretty simple design. We're just going to compare, hey, if you're given the same diet and you're not changing your exercise routine at all, do younger women lose weight at a faster rate? And again, this is in women who claim weight loss resistance that are in peri or early post menopause. So we're trying to match this with the data where this increase in body fat occurs. So the few years before menopause, the few years after menopause so if any of your listeners are interested, I'll give my email at the end. We're not officially recruiting yet but and we need younger women too and that, that, that's going to be our control group. So that's, that's the, what we're really focusing on. So I'm a little bit passionate about this because I know a lot of women who say this, what they're told from seemingly everybody. Well, you're lying about what you're eating. You're, you're skipping your workouts, which again probably 75% are. I'm, I'm listening to the women who do track everything, who do measure in way, who don't miss workouts and they're the ones saying this. So that, that's, that's who I want to test and my research will we if there is no difference? Well this is a study that will say hey, there is no difference. So and, and I also make this a point. I'm not out to try to disprove the energy balance equation. I'm an advocate of that. I'm not out, I'm not out trying to, to validate everybody's weight loss resistance. I'm just trying to further the conversation to get data. And regardless of our outcome, one study doesn't prove anything. So this is, at least there's somebody studying this for women who think there might be something that's different about their situation.
- [58:13]
A
Yeah. What are the data points? Are you tracking body composition? Dexa, what do you, what are the actual data points?
- [58:19]
B
Yeah, so that's, that's hard with a virtual study. So what we're doing, we're going to take up to three weeks to, to validate energy balance. So we're going to have them to eat normally, weigh themselves, what are your maintenance calories. Then we're going to give them an eight week caloric deficit. So I think it's 25%, 20 or 25% caloric deficit. Anchoring protein like 1.6 grams per kilogram. And we're having them use their own scales for these eight weeks so they weigh, weigh in every day, track their, their, their, their macros. So the main outcome is body weight. Now we do want and are asking everybody if you have access to a research grade body composition device like a dexa, like an inbody bod pod, something like that. We, we want you to get that data because then we can actually look at fat and lean mass. Yeah, I would love to be able to say hey, use this home scale that measures this I. There, there. I haven't have the confidence in them. So we have to use weight because that's. Well, one, it's easy. And two, I trust weight, but I would never do that in my own lab. Like, we would use our actual ultrasound in body bod pod, but when you do a virtual study, we have to use weight. And another limitation of our study is we're recruiting women who claim they are weight loss resistant. So I don't want them to be biased, but maybe they're already biased. But the reality is they have to follow the diet we're prescribing them or we withdraw them. And we trust that they will, just like we're trusting that the younger women do. So that's the, that's the main study. We're writing up all the studies on our menopause fitness survey as well.
- [60:12]
A
Okay, well, if any of my patients in Omaha are listening, I own a DEXA at Upgrade Performance Institute, so we can, we can, we can measure you. So I love. We. I love having that. I think it's a good, objective way not only to track, you know, obviously, you know, subcutaneous fat and lean body mass, but visceral fat. You know, there's some, like, fit women out there that I scan and they've got visceral fat or I do a coronary calcium scan. I'm like, you've got metabolic disease. You know, I think, you know, there's some women that think they might be healthier than they are sometimes. So.
- [60:46]
B
Yes. Oh, and real quick, let me give my email now. Yeah, this is my university email address, if you're interested. It's B. Campbell usf
- [61:01]
A
and we can put that in the show notes, too. The B. Campbell USF Edu. If you guys are interested in being in a weight loss resistance study studying menopausal women. And of course, we need some younger matched controls. Shoot, Bill. An email. And I'm, I'm. I'm waiting with baited breath to see what you find. And I think this is a good, you know, like, starting point. As you said on your social media, this will not settle the science, but I think that it's been a very understudied population and you came in into it, you know, on a very, for a very personal reason, which I think is how most scientists come into some of these, these conundrums. So, Bill, you're such a wealth of knowledge. Thank you. If you guys don't follow him At Bill Cable, PhD, he has a really amazing social media. He shares really, really, really useful tips and tricks and research. You can sign up for his newsletter, too. Bill, I really appreciate you coming on the podcast and giving us your time.
- [61:58]
B
Yeah, thank you very much for inviting me.
- [62:00]
A
All right, we'll talk soon.
- [62:01]
B
Bye.