--:-- Steven Bartlett: So in this part of the conversation, I want to talk about exercise, nutrition, fasting, lifestyle, sleep, environmental factors. And the first question is, why does muscle matter as a woman in particular?
--:-- Dr. Stacy Sims: Muscle matters because it helps your brain produce more neurons. And that's super important for brain health. As far as protection as we age, it's directly correlative to the amount of muscle that we have. And if you have something like PCOS or endometriosis, it's even more important for you because building muscle is going to fight insulin resistance and inflammation.
--:-- Steven Bartlett: I've got two questions to ask. Should women exercise differently across the menstrual cycle? And what is the reason why women hear what you guys say and they don't do it?
--:-- Dr. Mary Claire Haver: I'm so glad we're having this conversation. We're back with the leading voices in women's health. To unlock the specific insights, data, and tools needed to combat the growing challenges women face throughout their lives. For women, forever it was all about aesthetics. "I'm healthy. I'm thin." Because they are under the assumption through sociocultural ideas that a woman is coming to the gym to lose weight, not to get strong, not to gain muscle. But what we've ended up with is an epidemic of osteoporosis and frailty and really dementia. Where 40 to 50% of women will have low bone density, 70% of all hip fractures happen in women. And when you have that, 30% of the time, you have a chance of dying in one year.
--:-- Dr. Stacy Sims: Because most of it is based on male data. And I see a large number of women trying their hardest to be healthy, but what they are choosing to do is actually having a negative impact on their hormonal health. And it's not your fault. And this is where we have to educate. And it starts now.
--:-- Dr. Natalie Crawford: Which brings me to questions from the audience, like what's the best and healthiest way to lose weight? Is there a diet for fertility? Should women fast? Is there a link between environmental toxins and early menopause? We think so. But also, if you were to design perfect workout regimes for menopause and perimenopause, what would you...
--:-- Steven Bartlett: Oh, Stacey's clapping. Go ahead. This is part two of my conversation with four of the world's leading experts in women's health. And in this episode, we go even deeper into actionable, practical things you can do to improve your health. And by the way, if you're a man and you've been sent this episode by a girlfriend, a wife, a daughter, whoever it might be, I know you might not think this conversation is for you, but more than 50% of this planet are women. You have a tremendous advantage in your relationships, at work, and just being a human being going through life if you understand the majority of the population. And for so long, women's health, women's bodies, women's anatomy, their psychology and physiology has been a mystery because there hasn't been the same amount of scientific research done to understand them. So in this conversation, we're going to demystify all of that so that you can understand your wife, your partner, your daughter, your colleague, your mother, your grandmother even better.
--:-- So in this part of the conversation, I want to talk about exercise, nutrition, fasting, lifestyle, sleep, environmental factors, and all the things that we kind of alluded to when we were referencing hormones and menopause, but in a more actionable sense. And I guess the first question is similar to the first question in part one, which is why does it matter for us to have a conversation about women in this context versus fitness generally or nutrition generally?
--:-- Dr. Stacy Sims: Sport and exercise science in itself is a small subset of sports medicine and medical research, and most of the research has been done on men. So if we look inherently at most of the recommendations of exercise, recovery, nutrition, it's based on male data. And we established earlier that that's not generalizable. So when we really want to get into the nuances of how do we create an adaptive stress for women, we have to look at it differently. We have to look through the female lens, understand the female physiology and acutely how hormones can affect adaptations and how women respond to different environmental cues than men.
--:-- Dr. Natalie Crawford: Yeah, our hormones distinctly control a lot of our environment and our other cells that are not what we think of as our hormone cells work with our hormones. So if we think about the gut, we think about the liver, our immune system, a lot of this is so hormonally derived, but it's a two-way street, meaning your hormones influence what is happening in your gut, but your gut influences what is happening in your hormones. And because women have different hormones than men, as far as what's predominant and when they are, we have to come at this and approach it a different way.
--:-- Dr. Mary Claire Haver: There's so much to do with messaging that women receive as far as their health goes. And this, "be small at any cost," "get to that number on the scale." And I see it on social media that the conversation is changing. Hopefully, GLP-1s is tampering this a little bit. But "strong over skinny," "nutrition over calories," like we are trying to build bigger, stronger bodies and take up more space is the message that needs to happen. I mean, forever it was all about aesthetics. You have to look young, feel young, be young, anti all those things. And what we ended up with now is an epidemic of osteoporosis and frailty and really dementia.
--:-- Steven Bartlett: Should women exercise differently across the menstrual cycle?
--:-- Dr. Stacy Sims: So this is the nuance. And this is something if you'd asked me maybe five years ago, I would have said, "Sure, from a molecular level, we see that there are certain things that happen with estrogen being in isolation for the most part, and then when you have estrogen and progesterone, we see their metabolic shifts, we see their temperature shifts." But the caveat is we don't know if a woman ovulates or not. And I'm sure that Natalie can give some stats about the anovulatory incidences in most women. If we were to understand and know when a woman ovulates, in addition to how she feels across her cycle, then she can individually tailor her menstrual cycle to her training. But for a general plan, we can't do that.
--:-- Dr. Natalie Crawford: I think it's important that building muscle, using muscle, consistency is a huge part of effectiveness when it comes to exercise or to building strength. And so one fear we have when we say "do this in one phase of your cycle and do that in another phase" is that if 15% of patients are not ovulating or they have no idea when their follicular and luteal phases are, are they then doing overall less because they're waiting on this directive to tell them what to do? What is not untrue though, and how I frame this to patients, is that strength and resistance training should be the core of what you're doing regardless of the phase of the cycle you're in, regardless if you're pregnant, regardless if we're doing fertility treatments. Building muscle, using your muscle. Now what you do on other days is where you should allow yourself to say, "How do I feel this day? What do I need this day?" And be okay with giving yourself the grace that that may look different on your period, in your follicular phase, in your luteal phase. And saying doing something and moving your body is still ultimately, we're all going to agree, better than sitting on the couch.
--:-- Dr. Stacy Sims: Many women will say they have more energy in that late follicular phase. And so if you are looking at your workout structure, this is a day I want to try heavier weights or more reps. It can be smart to put that in a time where you have a higher chance of being successful. That's how I explain it. I'm like, if you have your own data and you know which days you feel really fantastic, that's where you want to put your higher intensity, your heavier lifting, because you know that you're going to hit those training metrics. What we don't want is for someone to go in to do a high intensity session on days they feel flat because then they won't hit the metrics that they need to get the stimulus we're after.
--:-- Steven Bartlett: Can you explain this to me like I'm a 10 year old in terms of where in the cycle typically women will have more energy and really be able to push themselves?
--:-- Dr. Stacy Sims: Right here, five to seven days before ovulation. Some women feel really great around ovulation. Some have a transient where they'll feel really awful in and around ovulation, and maybe 24 hours later they feel really fantastic. Most women are variable through the early luteal phase. So if we think about day 6 to 14, that's when we see women feel really robust and strong and feel like they can take on the world.
--:-- Steven Bartlett: Because estrogen is rising.
--:-- Dr. Stacy Sims: Yeah, exactly. And you see the physiologic changes, heart rate variability, resting heart rate. Your immune system is more prone to taking on virus and bacteria. It's not pro-inflammatory, so you have that working for you. Your core temperature is lower. You can access carbohydrate a lot easier, so you have more availability for fueling to hit high intensities. Then when we see with ovulation, like I said, some women feel really fantastic right around the time of ovulation because of the estrogen surge. Some have a transient where they don't feel so great. When that follicle ruptures and the egg is released, the granulosa cells that are surrounding it, which is what actually makes estrogen, get disrupted. And so some women feel that transient breakage and their estrogen drops before it reforms to become the corpus luteum and make again. So you have this high peak estrogen. And then some women are really sensitive to these hormonal changes and they feel that drop. So that ovulation day may not always be your very best feeling day, which makes women feel like it should be and like something's wrong with them.
--:-- Dr. Natalie Crawford: On a side note, we did a survey on women experiencing pain on ovulation because it's something that was never talked about.
--:-- Dr. Stacy Sims: Mittelschmerz.
--:-- Dr. Natalie Crawford: Yes, exactly. Mittelschmerz.
--:-- Dr. Stacy Sims: Mittelschmerz. We had... so you can feel the follicle rupturing, and that's called mittelschmerz. So it's German for "in the middle" because it tends to happen in the middle of your cycle when you ovulate.
--:-- Steven Bartlett: And it's painful?
--:-- Dr. Stacy Sims: It's a pain. It can be. It's like a cyst bursting inside your body. And then some women are down for the count because of it. So they don't plan any physical activity around that because they just can't, from a physical and mental standpoint, put themselves through anything. So that's why I'm saying like ovulation, some women feel bulletproof, other women who have this transient feeling of really flatness and pain. And then afterwards in the early luteal phase, so day 16 to about day 22, is variable. Some women will feel like on top of the world still. Other women will feel, "I can't quite hit high intensities." And then in general, these few days, about day 24 to 27, before those hormones actually drop, this is where you have your PMS, your premenstrual syndrome and cramping and fatigue. And a lot of women are like, not so great.
--:-- Dr. Natalie Crawford: That's when your progesterone drops.
--:-- Dr. Stacy Sims: When both of them drop.
--:-- Steven Bartlett: I just love how you guys explain it because what I see on social media is absolutes. "You must do this during follicular. You must do this at ovulation. You must." And I'm just like, really? And so I love how you're like, "Well, some women, it may affect them this way and others this. We generally tend to see X, Y, Z." So rather than like you absolutely have to do this at these different times.
--:-- Dr. Mary Claire Haver: I think learning to listen to your body and the signals that it's giving you across the stages of your life, that's really key to so many of the questions that we're talking about, because you want to understand your own response. And where many women are falling short is that they've been suppressing their cycles. They don't know about it and they were not taught all of these different changes that are perfectly normal. And so it's very hard to then hear a social media post that says "only do this in the follicular phase and don't ever do cardio in the luteal phase." And you get a lot of mixed messages when in fact there's no absolutes.
--:-- Steven Bartlett: No. And in terms of training, some people think moderate training is better for women, some people think high intensity training is better throughout the cycle and also considering what goals you might have in fertility. What would you say? Should I be doing high intensity interval training if I'm a woman, throughout the cycle and throughout my life?
--:-- Dr. Stacy Sims: So this is where we have to think about periodization first, lifestyle, but also how a person is feeling. We don't want people to do high intensity interval training every day because that's just not going to create an adaptive response. We have to think about the reason why we are exercising is to create a stress that the body is going to respond to. We don't get fitter during exercise. We get fitter from the stimulus of exercise and the recovery from it. So if someone is doing high interval training every day or five days a week, they're not ever going to get that subsequent recovery to be able to hit those high intensities and that stress that we want. We talk about high intensity during our reproductive years. You can pretty much get away with whatever you want to do during your reproductive years because you have the benefit of our hormones working for us. When we start getting into perimenopause and we start getting into menopause, this is where we have to really carefully look at volume versus intensity. That means if we're doing lots of stuff, or are we doing really purposeful high intensity versus low intensity? Because we're trying to create what we call a polarization of the training so that when we hit high intensities, we're actually hitting the intensities we need to create change. But on the other side of it, we want to hit really low intensity so that we can have recovery. It gets harder to recover as we get older, regardless if you're male or female. But in perimenopause, we don't have the benefit of estrogen supporting anti-inflammatory responses. So we have to be very cognizant that we need more recovery.
--:-- Dr. Vonda Wright: So I'll give you an example. So my office, my orthopedic office, is in a fabulous performance center. Outside my windows, I have floor-to-ceiling windows. There's a football field inside. That field is filled seven days a week with people taking a class called Ignite. Ignite has a lot of midlife women in it who are never exercising at low enough intensity to recover and never exercising at peak intensity to change their body. So what happens five or seven days a week, they're out doing moderate, mid-range intensity training, but they're not seeing body changes. They're not seeing recomposition. They're hurt every three weeks and in my office wondering why they're hurt because they're doing a lot of reps of medium intensity. So they're not really recovering and they're not intense enough to really change their physiology, but that's really common.
--:-- Dr. Mary Claire Haver: There are whole brands built around mid intensity.
--:-- Dr. Stacy Sims: And that falls into the whole sociocultural thing where we grew up that if you don't have a good sweat sesh and feel completely smashed when you leave, it wasn't a good workout. But that's a misconception.
--:-- Dr. Vonda Wright: Right. So they are smashed. They are dripping sweat, but it's not at peak heart rate ranges for short bursts of time, right?
--:-- Dr. Mary Claire Haver: So I know, look, it's very confusing because 20 years people have, as they've switched from only cardio, they're like, "Now we're going to do high intensity," which is fine. I'm not opposed to that word. It's just that how do you define that? What is high intensity? And so like you, because I've read your books, that we're exercising people at pretty low heart rate where they're about to flip from burning fat to carbohydrates because that's really metabolically healthy, but not so intense that people are going to get hurt. And I also prescribe really peak sprint interval training. And I did that myself in midlife to recompose my body, sprint interval training, because it's intense and lifting, right?
--:-- Steven Bartlett: Is the advice different for different women at different stages of life here? So if I'm before perimenopause...
--:-- Dr. Stacy Sims: You get away with most stuff.
--:-- Steven Bartlett: Assuming you have a regular menstrual cycle.
--:-- Dr. Natalie Crawford: Right. I think there's different time periods, which we've mentioned before, PCOS, hypothalamic amenorrhea, time periods where you're not making estrogen or making it reliably. You can get away with less. And so we want to protect a little bit of that. But when it comes to exercise, variety is the name of the game. You want to adapt so you shouldn't be doing the same thing every day. That doesn't mean you can't have a plan. There's seven days in a week. You don't have to move every single one, but you should pick these different activities based on your life, your schedule, what you want to accomplish. And it will vary in different phases of your life because your goals are going to be different. And so when it comes to exercise, we always have to think about what needs to happen. Are you somebody who is overweight and needs to lose weight? Are you somebody who's underweight and is trying to gain weight? Are you trying to get pregnant or going through fertility treatments or in menopause? So there's nuance to it, which always makes it hard, but there's not a "do this one exercise every single day." That's pretty much not the answer.
--:-- Steven Bartlett: So the most popular class for females right now, I just saw this statistic somewhere, is Pilates. And my daughter loves her Lagree and gets on that machine. But where does that fall in all of this?
--:-- Dr. Vonda Wright: I have a lot of Pilates...
--:-- Dr. Stacy Sims: There's a social aspect to it.
--:-- Dr. Vonda Wright: Pilates people hate you. Yeah, because we did this reel talking about how Pilates was not appropriate as strength training, especially as rehab. When we look at Pilates, it's a complement to true strength training. What I mean by true strength training is you're lifting a load that's heavy in multiple planes. With Pilates, it's really good for isometric control, core strength, balance, proprioception. But it isn't a stress that's going to create adequate muscle gain and strength of the bone, which is what we want from strength training. So just like yoga, Pilates has a place. It does definitely fit in the scheme of things, especially from the social aspect and the fact that it does give you control and proprioception, but it isn't the be-all end-all for strength.
--:-- Steven Bartlett: People that do Pilates frequently will be shouting, "But I'm saying it's so hard, it hurts so much."
--:-- Dr. Stacy Sims: And I know, well, I'm sure it's hard. The times I've done it, it's not easy. But the room... it doesn't set you up not to be frail. It is not building strength and power.
--:-- Dr. Mary Claire Haver: And I have women who have done so many Pilates, 1,500, it's like a badge they count their classes, 1,500 at the deficit of anything else. It's all that goes on. And I think that is another, you got to mix it up, number one. Number two, I say the same thing. So I'm not very popular in those crowds, but it's great for the standard that I ask people do of flexibility and joint range of motion so that you don't become really stiff and hunched over and shuffling like an old person. But it will never give you strength and power in the way to protect yourself from falling down.
--:-- Steven Bartlett: Because there's not enough weight?
--:-- Dr. Vonda Wright: For the most part, yes. And we also have to think about when you're doing strength training, you're creating a multi-directional force through the muscle and the tendons and the bones. With Pilates, especially if you're looking at the reformer, it's not multi-directional in the movements. Each movement is one plane. Up, down.
--:-- Dr. Stacy Sims: Yeah. You can be in different planes, but each motion isn't multi-planar. So if we think about what are we trying to get out of Pilates, we're getting neuromuscular control, we're getting core strength, we're getting some breath work, and all that is beneficial. But again, if we're trying to grow muscle and bone, take up space, be strong, it doesn't quite hit the points that we need to in order to create this new strength to bring us to that health span that women are looking for.
--:-- Steven Bartlett: So do it a couple of times a week.
--:-- Dr. Stacy Sims: Yeah.
--:-- Steven Bartlett: Not seven days a week.
--:-- Dr. Stacy Sims: Correct.
--:-- Steven Bartlett: So if my partner, she's 33 years old, so she's not quite at perimenopause yet, if you were to design a perfect workout regime for her at that phase of her life, what would you... Oh, yeah, Stacy's clapping. Go ahead.
--:-- Dr. Stacy Sims: So if she has three days that she can go to the gym and has three one-hour sessions that she could have at the gym in a week over seven days, each one would start with mobilization. So using resistance bands or maybe you're doing a Pilates reformer warm-up, so you're getting through the range of motion.
--:-- Steven Bartlett: Why?
--:-- Dr. Stacy Sims: Just to open up the joint capsules, make sure you don't have any restrictions, so that you can get really good range of motion for the movements you're going to do next.
--:-- Steven Bartlett: Does that stuff actually work? I do wonder this. So many of my friends are getting injured at this age because they're my age and a bit older, because they walk into the gym and they start picking weights up.
--:-- Dr. Vonda Wright: Oh, yeah. No, I mean, I spend more time mobilizing, I think, than I do actually training now, just to keep range of motion going and keep the joint capsules open. And so that's using the heavy resistance bands to distend and distract all the joint capsules to increase range of motion. Stretching doesn't do that. Stretching will get to an end point of the muscle to allow you to have more flex in the muscle, but it's not actually stretching the joint capsule to give you range of motion. So when we talk about mobility work, we want to get into that full range of motion. So if you have a stiffening... as I was saying earlier about the guy in my... voodoo flossing or voodoo floss is a way where you're creating some blood flow restriction, then you go in a range of motion, and with blood flow restriction, you take the voodoo band off and the blood flow comes back and you go in the range of motion, get deeper in that range of motion. So it's all about accessing the tissues and making the tissues more viable for increased range of motion so that when you go do the lifting, when you go put on a heavier load, you have better control, better range of motion, and avoid the small little sticky points that cause injuries.
--:-- Steven Bartlett: Micro tears.
--:-- Dr. Vonda Wright: Yeah.
--:-- Steven Bartlett: Yeah.
--:-- Dr. Vonda Wright: So it's the micro tears that are going to lead to injury. And the micro tears come when I haven't warmed up properly.
--:-- Steven Bartlett: So here's why it's important. What would that look like for your shoulder?
--:-- Dr. Vonda Wright: I wish I had a rig so you could take one of those thick, big bands and wrap it around a rig or something and you can pull and distend so you're actually pulling the shoulder out in different ranges so you can rotate, roll, pull, extend, pull.
--:-- Steven Bartlett: What about this? So this is more trying to work the muscle.
--:-- Dr. Vonda Wright: Okay, and you have Pallof press as well where you're working rotation, but that's not getting into the joint. So you want to be... if you're distending, you're pulling back, you're not bending your elbow, you're actually pulling through the shoulder and distracting, and then the band is going to pull you forward to give you resistance to pull your shoulder joint out. And it's not painful, but you're just really getting into that full joint capsule. You can do that with the hips. You can do a banded pigeon stretch. There are just so many different ways of getting into the joint capsule, which not only gives you more range of motion and prevents injury, but it also gives you more of the flexibility that people think they get when they're stretching. The reason this is important as we age is because ligaments and tendons and the capsule, the inside skin of a joint, is made of collagen. And the covalent bonding, collagen is like if you envision strands of rope, the covalent bonding, meaning the bonding between those strands, becomes stronger as you age, and you become more and more stiff. Well, when we lose joint range of motion, we're injured more. It's why we start shuffling down the street, hunched over, shuffling instead of striding because we have full hip range of motion or full knee range of motion. And so, one reason to do this is to maintain full range of motion through all of our joints. We want full range of motion not only to avoid injury, but for instance, if your knee is stiff, whether it's an injury or because you just haven't maintained your motion, it will change something called your kinetic chain, meaning we really are from our big toe to through our spine connected. The big toes connected to the foot bone, the foot bone, because the way each of those body segments works activates the next body segment. So if you've got a glitch in the system because your knee doesn't move... or let's take this one, this is easier. Your ankles get stiff because we never worked on it. Your calves are tight, right? You're a jumper, you got tight calves. Your hip, your ankle doesn't flex. Well then, your shin bone or your tibia is not going to internally rotate. Well, without that, your knee's not going to bend as much and your femur, your thigh bone's not going to rotate. You must have the rotation of these bones to activate your glute. So if you're not activating your glute, your butt muscle, people are very hurt or they're not getting as strong or they start having lateral thigh pain. So everything works together and it starts with, among other things, the flexibility and range of motion exercises we're talking about right now, so that the body works like a chain.
--:-- Steven Bartlett: If I lose my range of motion because I never did all these things, can I get it back when I'm 50? So like, I'm 33 now. I'm like, damn, I've not been doing enough of this stuff.
--:-- Dr. Vonda Wright: Yeah. Yeah, you can. Unless you're having bone changes due to arthritis and it's blocked. Yes, you can.
--:-- Steven Bartlett: So I could theoretically start at 40?
--:-- Dr. Vonda Wright: Because if you think about your muscle and how it responds to picking up a weight and you aren't right, you're going to build the muscle. So if you're creating a force within the tendon and the ligament and the collagen as a repetitive force, a positive force, you're going to invoke change. So people's issues are malleable. So people that think they're stiff and they say, "I can't touch my toes," they can work on it, they can get it back. Here's another reason. So what happens in midlife, men and women actually, they remember what they used to do. And then they're like, "I'm going to start working out. And I'm going to start there." They're there. Yeah, this is when I get people who just show up on the basketball court after not having been there for quite some time. And they return to their memories of success. But because they haven't lengthened their tendons, their joints aren't moving quite so well. They rupture tendons because the load outstrips the ability of the tissue to be compliant.
--:-- Steven Bartlett: That makes sense. My friends have been getting injured and I think that's in part why, because they're trying to work out like they used to work out.
--:-- Dr. Vonda Wright: Yeah. And listen, they can return to really high level, but you can't stop. You can't start where you left off 20 years ago or 10 years ago. It takes a minute.
--:-- Dr. Stacy Sims: Two weeks for me.
--:-- Dr. Vonda Wright: It takes a minute. Yeah.
--:-- Steven Bartlett: So Mel's 33. Mobility work when she gets to the gym first and foremost on day one or every day?
--:-- Dr. Stacy Sims: Every day.
--:-- Steven Bartlett: Every day. So I'm assuming, and I could be wrong, that she already has a strength training history.
--:-- Dr. Stacy Sims: Yeah, she does.
--:-- Steven Bartlett: Okay, so we do the mobility work for about 10 minutes, really warm up well. Then we pick one compound movement we're going to work on. So it could be squats on the Monday. So we're going to work on loading in a squat pattern. So that's your knee forward, quad dominant type squat.
--:-- Steven Bartlett: Back squat, does it matter?
--:-- Dr. Stacy Sims: Back squat, front squat. You could do Bulgarian split squats. So we're adding load and we have a periodized program. So this is just a snippet of one day in a periodized program.
--:-- Steven Bartlett: What if she didn't have that strength training history?
--:-- Dr. Stacy Sims: Well, then we work on adding load through our... I want to see how she moves first. And we want to make sure that you're moving well before you add load. So this is where we work with lighter loads and more reps.
--:-- Steven Bartlett: What if she doesn't have you there? Yeah, that was my question. Like, what if you're not there? What can she do on her own?
--:-- Dr. Stacy Sims: Yeah. So this is still like, how do you squat? Where are your sticking points?
--:-- Dr. Stacy Sims: So you can assess, self-assess. If you've done your mobility, then you'll know like, oh, my hips are really tight. So I need to work on that. So let me do some air squats to see how I move. Then the next time you go in to do squats, maybe you're picking up two 10-pound dumbbells and you're holding them and doing air squats with your dumbbells. And eventually you're going to move to the barbell. So it's all about small progression under load to get to a point where you feel more confident to use a barbell back squat to get into more of those compound movements.
--:-- Steven Bartlett: Why don't people exercise? Specifically, if we just focus here on women, what is the reason why people hear what you guys say when you're talking about exercise and they don't do it? They don't start? It's hard. For what set of reasons make it hard?
--:-- Dr. Stacy Sims: Well, for women, it's set up in a gendered environment. I always use the example of a woman who is interested in strength training. If they go to a typical 24-hour fitness or another brand gym that's out there, they'll walk in and they'll say, yep, I want to join. And the membership person most often will say, great, here's the class schedule. This is where we have our spin classes. This is where we do our boot camp classes. They never direct them to the lifting platforms. They never look and say, hey, here are the ways to get strong. Because they are under the assumption through sociocultural ideas that a woman is coming to the gym to lose weight, not to get strong, not to gain muscle, not to recomposition.
--:-- Steven Bartlett: Right.
--:-- Dr. Stacy Sims: But if a man walks in, then it's always the, great, here's the lifting platforms. We have X amount of barbells. We have X amount of bumper plates. How much weight do you want to gain? Do you want to work with someone to help you build that mass?
--:-- Steven Bartlett: Vonda, why does it matter? Because there's a big social pressure on women to look a certain way. And it doesn't typically involve muscles, especially in the upper body.
--:-- Dr. Vonda Wright: No. So, we're still living under the times of be as small as you can. But small doesn't mean lean. There's a concept of skinny fat, which, you know, you can be as tiny as tiny, but you can have a body fat of 50%, which means you're neither strong, you're not metabolically healthy, you're just little, right? So there is also a misconception that lifting heavy is going to automatically turn you into a physique model or a bodybuilder shape. If that's your goal, that's probably going to take you five years or a decade. It's a lot of hard work for a long period of time with proper nutrition. So for a woman who wants to feel better, the goal is to build muscle to be lean, to recompose, not lose weight, right? I'm not really interested in somebody's weight. I'm interested in their body fat percentage and their lean muscle mass because it's what you're made of that matters, not the size of the shell.
--:-- Steven Bartlett: And why does muscle matter as I age as a woman in particular?
--:-- Dr. Vonda Wright: It matters for everyone, but for women, muscle matters because it's not just part of locomotion. It's not just part of moving you around. It is a metabolic organ. It is critical for glucose metabolism. It's critical for insulin sensitivity. It talks to the bone. Bone and muscle are endocrine organs, which cross-communicate all the time. So both bone and muscle have access to the brain, right? Muscle will produce a hormone called irisin, which has multiple functions in the body. The access between muscle and brain helps your brain produce more neurons, right? Bones' access to the brain has a role in satiety. Isn't that amazing?
--:-- Steven Bartlett: Which means not hungry anymore.
--:-- Dr. Vonda Wright: Why would you think these locomotive structures, if that's what you limit them to, would even have those functions? It's because we put organs in a box. So to answer your question, muscle in men and women, but women in particular for this conversation, we need as much muscle as possible to fight the insulin resistance that we get when estrogen walks out the door. We need muscle for glucose metabolism. We need muscle for the pure strength of it because we do not want to become frail and be one of the two-thirds of nursing home residents who are women because we can't do something as simple as get up out of a chair.
--:-- Steven Bartlett: But I could just get muscle when I'm 70.
--:-- Dr. Vonda Wright: You can, actually. It's a lot harder.
--:-- Steven Bartlett: So why does it matter for Mel to be thinking about it when she's 33?
--:-- Dr. Vonda Wright: Well, here's the great part for Mel is she still has all her estrogen. Estrogen has a profound effect on muscle protein synthesis. It is a significant anti-inflammatory. So high inflammation, chronic inflammation, if we've talked about it, decreases muscle synthesis, it decreases bone synthesis because inflammation with its high cytokine level, IL, tumor necrosis factor, those are all detrimental to these normal metabolic pathways. So the wonderful thing for Mel who is entering what I call the critical decade, which is 35 to 45 estimated, it's the prime time to set your physical activity standards and to build as much as you can while you still have all your estrogen.
--:-- Dr. Stacy Sims: In addition to the fact that for proper hormonal health, if you think about inflammation coming in and it's like static on a walkie talkie, the brain's trying to interpret your hormones. And when inflammation is coming in, it's making the signals really hard to hear. So we need to make sure that we're actively fighting that and building muscle is one great way because it's going to use up glucose and fight insulin resistance, which means it makes your cells more sensitive to when it sees glucose and able to use it better. If you have another thing that is pro-inflammatory, such as PCOS or endometriosis, it's even more important for you because your inflammatory burden by default of what's happening at a cellular level is higher. We now need to not just say, I need to not make it worse by being exposed to things. We have to say, I need a plan to fight this because my world is pro-inflammatory on a daily basis. What is my game plan to fight this? And building muscle. It's not just exercise is better than no exercise, but specifically building muscle because as everybody's saying, it has a metabolic function in your body, is going to help you the most.
--:-- Dr. Natalie Crawford: There's a term called geroprotective, geroprotection. So, gero is the term we use for aging. So, gerontology is the part of medicine that focuses on the elderly patients. And so, when we look in females and the organs that are the most geroprotective, it is the muscle and the ovary. And the ovaries go away. We have a shelf life in our ovaries. So then we're just really left with our muscle as far as protecting us in those elderly years as we age. And it's directly correlative to the amount of muscle that we have, because if you have a lot of muscle, you're going to have stronger bones.
--:-- Dr. Mary Claire Haver: And this is where the intensity part that Dr. Stacy is talking about seeing the Ignite class, and everyone's in that moderate intensity all the time. With moderate intensity, you don't have the post-exercise anti-inflammatory response. So if we're trying to build muscle and we're trying to dampen inflammation, if we're always doing this moderate intensity cardio, then we're not, one, going to be building the muscle we want, and two, we're going to have this baseline elevation of total body inflammation. So we need to mix it up and have that precedence on being muscle and building that muscle. One, to help with aesthetics. I mean, that's the byproduct of lifting weights. You tend to look better. But it's more than that. We see it improves brain health because of the neuroconnections and the neuroplasticity of the brain. Sleep, mood. All of those things. You get an incredible parasympathetic response when you've done a significant heavy lifting session or a sprint interval session, which you don't get with that moderate intensity cardiovascular work.
--:-- Steven Bartlett: Two questions to add to what you're about to say here. Is, am I right in thinking that at the end of that golden decade that you referenced, 45 years old, because you have changes in estrogen, one will expect to see a natural decline in muscle?
--:-- Dr. Vonda Wright: Yes.
--:-- Steven Bartlett: And an increased chance of osteoporosis, osteopenia, bone issues later in life. Do women, this is several questions, I apologize, but do women then also tend to have more frail bones in later life? And is that linked to the muscle loss?
--:-- Dr. Vonda Wright: So this is how it works. So both men and women build bone and peak about up to 25, sometimes 30. And then bone loss plateaus for a little while. Men continue to lose about 1% a year. So men do not arrive with hip fractures or devastating fractures until their 70s or 80s or older. Women also decline slowly until we lose our estrogen. And then the rate of decline, and I'll tell you why it happens for bone, doubles or triples, such that you will lose 15 to 20% of your bone density during your perimenopausal period just from loss of estrogen alone because estrogen plays many roles. I've already talked about estrogen being a huge anti-inflammatory. Bones are very sensitive to inflammatory chemicals in your body. Estrogen also directly affects the balance of the two main cells that subtract minerals from bone, the osteoclast, and the cell that builds the bone, the osteoblast. And in well-hormoned times, there is a balance. The body loves balance. We take what we need, we build it back. But because estrogen has such a profound effect on the osteoclast, the Pac-Man bone-eating cell, there's an unbalance and we take more bone than we're capable of building. We're still building bone, but the rate cannot keep up with this. So with the inflammation, with the direct effects on the osteoclast, women will lose bone density if they do nothing. Well, number one, they're going to lose bone density, but they must do something about it. The reason it's so critical for a 33-year-old is because you still have your estrogen. So let's learn how to lift heavy. Let's take advantage of the estrogen circulating. Let's learn to have a jumping practice and impact our bones, right? So the way our body tells our bones to build more is, there's another little cell called the osteocyte. It sits encased in bone, but it's connected to these other cells by little tunnels that contain fluid. When you jump, the biomechanical impulse of that fluid shifting in the little tunnels is translated into a biochemical stimulation that tells the bone, oh my God, she's jumping around. I need to build more bone. So we need that impact to stimulate the laying down of more bone.
--:-- Steven Bartlett: I was looking at this graph, which is what you were describing. Men and women aren't that far away in terms of bone mass. So this is showing the fact that because of the way testosterone interacts with a man's bones, he will peak at a higher bone mass than a woman will. So he's starting at a higher level. So I would want young women to do everything humanly possible to start at the highest possible level. But I see lots of 20-year-olds, 30-year-olds, really young women with poor bone density for a lot of reasons. And so I'm a big proponent for having bones measured early. Don't wait until you're old so you know where you're starting.
--:-- Dr. Mary Claire Haver: But that's not the standard recommendation.
--:-- Steven Bartlett: No, the standard recommendation is 65, which is way too long for that.
--:-- Dr. Mary Claire Haver: But because I do either a DEXA scan or a REMS ultrasound to look at bone quality on everybody, we can catch it earlier. And that's really important to get in front of it because it's estimated, research says, that in order to affect bone density if you're going to use estrogen for instance, you need to do it for 10 years.
--:-- Steven Bartlett: And why should people care about bone density? Everyone cares about muscles but very few people talk about bones. A fracture can't carry your muscle around if you have weak bones.
--:-- Dr. Vonda Wright: So without bone, muscle is just a heaping pile of steaming metabolic tissue sitting there, right? There would be no bicep to complement, right? Because it has to be connected to a bone. So they're important for locomotion and giving support to the muscle, but bone is an endocrine organ that secretes hormones that go to your brain to help build neurons, to your pancreas to be active in insulin release, to the muscle for glucose metabolism, in men to the testes to build testosterone. And that's only one of the many hormones that the bone produces. The bone is not only structural, not only hormonal, I've already talked about it being a storehouse, but it's an incubator in our pelvises where we build all of our blood cells. And so it has these multifunctions. But to Mary Claire's point, for women, 40 to 50% of women will have low bone density. And when you have that, 50% of the time you'll break a bone. So if we're looking around at this table, if we all have osteoporosis, which we don't, one in two of us will fracture. When that fracture is a hip fracture, which is very common, 70% of all hip fractures happen in women. And 30% of the time when you hit the floor and something breaks, you have a chance of dying in one year. This quick. Your life changes. 50% of the time, even if you survive, you will never return to pre-fall function, meaning you can't go home. And that puts your family in the situation of having to figure out 24-hour care. Or you move in with your eldest daughter. Or you go into a facility where you use your life savings until you have no more, and then you have to apply for Medicaid and the government will pay for it. These are terrible situations to get at something that we could have prevented had we started early enough.
--:-- Steven Bartlett: So you want to start early. So I have Mel. So Mel is going to be doing strength training not just for the muscle benefits but also because it's going to help us build strong healthy bones in that critical decade.
--:-- Dr. Stacy Sims: Yep. And then we finish it with some jump training.
--:-- Steven Bartlett: Jump training?
--:-- Dr. Stacy Sims: Yeah, plyometric type work. Or if we're looking at not having the robustness of doing straight plyos, then you can do banded assisted pogos, you can do low depth jumps. So you're getting some impact to the bone because, as Dr. Vonda was talking about, it's a multidirectional stress. People think, oh, I run. I'm going to have strong bones. But running doesn't do it. You need multidirectional stress. So if you think about it, when you land, your body has to move. The ground doesn't. So it's called the ground reaction force that comes up through the bone to create that strength. So that ideal situation in a workout for her would be some mobility, some heavy lifting. If we're doing plyo, that's also a sprint-type training, so you're getting a metabolic stress. So you're hitting all the major factors in one one-hour workout.
--:-- Steven Bartlett: I read that there was a study done with some Australian elderly ladies on bone growth. On lifting and bone growth?
--:-- Dr. Mary Claire Haver: Yes. Yeah, Lift More. The Lift More study by Dr. Beck.
--:-- Dr. Vonda Wright: Yes.
--:-- Dr. Mary Claire Haver: She was trying to dispel the myth, which I hear every day, that you've got osteoporosis, you can't lift weights.
--:-- Dr. Vonda Wright: Yes.
--:-- Dr. Mary Claire Haver: And so her study, because we're big proponents of teaching people to progressively lift heavier and heavier, and that scares people, but especially if you think you're going to break. So she did a study where the load was five reps, five sets under a supervised situation. So five reps means that it was heavy enough that at five reps they were near failure, right?
--:-- Dr. Vonda Wright: Right.
--:-- Dr. Mary Claire Haver: So these women, all osteoporotic, not only were capable of lifting heavy under supervision, none of them broke, and they built bone.
--:-- Dr. Vonda Wright: Yep.
--:-- Steven Bartlett: So that answers the question. Can you lift? Yes.
--:-- Dr. Vonda Wright: Yes, you can.
--:-- Dr. Stacy Sims: And the other thing that isn't really brought up into these conversations is when you hit perimenopause, not only is estrogen sort of the stimulus for satellite cell or building muscle cell, but it has a distinct influence on myosin. So myosin and actin are two contractile proteins. So if you think about a sliding filament or coming together, you have myosin and actin that bond together to then pull and move and pull and move. And that's how you have a muscle contraction. Estrogen is responsible for how tightly myosin bonds to actin. When we start to lose estrogen or we start to have variability in our estrogen, we get myosin dysfunction. So that means we're not going to get a very strong contraction. So we get weaker. And this is one of the very first things that people complain about to me. I don't have power. I don't have strength. My grip strength's gone. I don't know. But their body composition hasn't changed yet. So if we think about lifting heavier loads, it's a neuromuscular response. And that direct stimulus creates the adaptive change in myosin that now estrogen isn't responsible for. It's a different external stress that creates that change in myosin to go, yep, I have to grab onto actin and have a very strong contraction. So we see that this dysfunction happens first before we start seeing a change in our lean mass development. So if we are already in the habit of lifting heavier loads, then we can offshoot some of that myosin dysfunction that occurs with the estrogen change.
--:-- Dr. Mary Claire Haver: So when my patients come in and they are looking to prevent osteoporosis or they've gotten a diagnosis of low bone density, what can they do? I've discussed the Lift More trial. The new study just came out May of this year, 2025, and they looked at a very similar protocol used in Lift More. So there was a control group where they just did nothing. Then a group that did three days a week and they did resistance training and jump training. And then the third group did all the same exercises and added HRT. And depending if they had a uterus, they got estrogen or estrogen plus progestogen. And so, of course, as expected, the do nothing group lost bone. You gained bone as expected in the resistance group, but it seemed to be synergistic when we added hormone therapy and the resistance training together. They grew even more bone. They had even better results. So when my patients are like, I want to hedge my bets. My mother fell and fractured. She's broken her hip in a nursing home, whatever, and I'm trying to avoid this. We're hitting all the points. And the only medication of it, now we have other medicines that will help slow down resorption of bone, the bisphosphonates and stuff, but they can be hard to take and they have a lot of side effects. So to me, prevention is always better than cure, right? So I'm trying to get them early. I just ignore the guidelines that say you have to wait till 65 unless you have some chronic medical condition to get a bone density. I'm telling patients, you can find it for about $99 around, I work in Houston, and that is worth the investment for you to go get your baseline bone density. I don't know a single orthopedic surgeon, a single exercise physiologist or anybody who deals with osteoporosis who thinks 65 is a good idea. So if your listeners are like, oh, well, my insurance won't pay for it. I'm like, there are centers popping up now where you can go and get a DEXA scan and just pay out of pocket and get a great, you know, figure out where your starting base is.
--:-- Steven Bartlett: A DEXA scan is?
--:-- Dr. Mary Claire Haver: A bone scan to see your bone density is the easiest way to describe it.
--:-- Dr. Vonda Wright: And your muscle mass.
--:-- Dr. Mary Claire Haver: Yeah. They can do that as well.
--:-- Dr. Natalie Crawford: This conversation is really important, though, to extend besides just menopause or perimenopause, that there are women of reproductive age years who have profound periods of low estrogen who are also at risk for serious problems with their bone density both now and down the road. And so if you come to me and you say, oh, I haven't had a period for seven years, no big deal. Well, that is a big deal. And depending on the reason why, many of the causes will result that you had low estrogen and you were not ovulating and you have hit that graph you showed while you're building your bone. That person's on a different trajectory. And those women do need bone scans much earlier so that we can see where they are and see what treatment we need. But it's one of the biggest reasons bone health is one of the most acceptable medical reasons for why we should put younger women who have low estrogen time periods onto estrogen treatment because it can so profoundly change their bone health long term.
--:-- Dr. Stacy Sims: So in my niche of active women, we see there's a very, very high incidence of recreational active women and low energy availability, meaning they're not eating enough to support daily life as well as their training. So the subclinical aspect of not eating enough creates a myriad of issues that does create lower bone density, menstrual cycle dysfunction, greater inflammatory responses. So the end result would be hypothalamic amenorrhea. So their periods have stopped, which is that low estrogen standpoint. So keeping track of your period, making sure you're eating enough is one of the first stopgaps that we have in the athletic realm. We want you to eat enough. And if you're looking at bookending our calories on either end of the day, that's not appropriate. We have to look at how your circadian rhythm works, because the circadian rhythm, like we talked about in the first half, was about the pulses of our hormones. So if we're holding our calories on either end of the day, then there's this big space in the middle of the day where your body thinks it's under a starvation threat. So you start to have this downturn of all of our metabolic functions. We see after four days of low energy availability, there's a direct impact on thyroid function. So we have to be very cognizant that women who are saying, I haven't had a period in seven years, or my periods are really irregular, we have to bring it back to the energy function as well. So I know, unfortunately, we're still in this environment of aesthetics. And I'm always like, we need to eat. And if you eat in and around your training and fuel appropriately for what you're doing, it has a positive impact on body composition. You're not going to gain body fat, you're going to gain lean mass, you're going to gain bone, and you're going to see a decrease in body fat. But it's trusting the process that out in general sociocultural concepts is just not acceptable for so many women right now.
--:-- Steven Bartlett: And with that exercise regime I asked you to make for a woman that's pre-menopause, was there anything left off there? We had day one which is mobility, strength training. So if you were to do three days a week in the gym, that would be pretty similar except for the compound movement. What are we doing for each of those compound movements? A different muscle?
--:-- Dr. Stacy Sims: So it would be the knee forward squat motion one day, push-pull upper body next, and then posterior. So your hip thrusts, your deadlifts, that kind of stuff. Because women are quad dominant. To prevent injury, we really need to build the posterior chain. And this is your glutes, your hamstrings.
--:-- Steven Bartlett: Your deadlifts.
--:-- Dr. Stacy Sims: Yeah. So you're getting really strong around the knee joints, the hip joints. Because again, that feeds forward to better movement, movement economy, and prevention of a misstep for a hip fracture later down.
--:-- Steven Bartlett: What about cardio?
--:-- Dr. Stacy Sims: So that's where, like, if we're looking at those three days a week and we're finishing with plyos or some sprint work, then the other days just walking, low level intensity walking. Or maybe you have soul food, you want to go for a bike ride, you want to go for a run. If you're not training specifically for something, then those three strength training days are your key workouts. And then you can pepper in all the other things that you like to do.
--:-- Steven Bartlett: I hear a lot about VO2 max. So I thought, but we should all be driving our cardiovascular performance up to get a high VO2 max.
--:-- Dr. Stacy Sims: Well, that's where the intensity is.
--:-- Dr. Mary Claire Haver: I think it's, I mean, and correct me if I'm wrong, but my understanding after reading and watching everything is it doesn't take that much to build VO2 max. It's that high intensity that's a little bit uncomfortable where you're pushing at that max for about four minutes to build that VO2.
--:-- Dr. Stacy Sims: In the sports science world, it's always been the four by four, the Norwegian four by four. Four minutes on, four minutes off, four minutes on, four minutes off.
--:-- Steven Bartlett: But that's not three days a week.
--:-- Dr. Stacy Sims: No, not at all. Norwegian protocol is once a week.
--:-- Dr. Mary Claire Haver: Once a week at the most, right.
--:-- Dr. Stacy Sims: And the other sprints, just to give you, I tend to give my examples because it makes it more real. But when I'm doing sprint intervals, I do it the 30 seconds on and then complete recovery, meaning for 30 seconds, I'm taking my heart rate as high as I can get it. And then I'll completely recover, which takes me two to three minutes. I just happen to do it on a treadmill. But the reality is you can do it on anything. It's a heart rate function, not an apparatus function. So for me, on a treadmill, after I'm done warming up, you can't do it cold or you'll hurt something. After I'm done warming up, because I'm a really short person, I punch the treadmill up to 11 and I am just working so hard I don't fly off the back. But that gets my heart rate up really high, about 186. Everybody's top heart rate is different. And then I completely recover. And I do that four times. It doesn't take that long and you feel so good when you're done.
--:-- Dr. Mary Claire Haver: Yeah.
--:-- Steven Bartlett: So I can't run at the moment. This morning I did explosive kettlebell swings.
--:-- Dr. Stacy Sims: Why can't you run at the moment?
--:-- Steven Bartlett: Torn hamstring and meniscus. So I can't run at the moment. Running is in, run clubs have come in strong, it's back. Are you at all concerned with the fact that people are running all the time and doing resistance training less? Because running is cool now, it's how people date, it's, they're not going to nightclubs anymore.
--:-- Dr. Stacy Sims: It's like we said about Pilates. If all you do is running, then that is definitely not the best way to be. It's not the healthiest for your whole body. It's not that you're unhealthy, but we're really talking about how are we optimizing your body and your hormonal health for a variety of different goals.
--:-- Dr. Natalie Crawford: But also if we look very micro at running, 58% of runners have a luteal phase defect. That means that the second half of their menstrual cycle is not going to be able to last as long as we want it to, likely due to what Stacy was talking about earlier, this relative energy deficiency coming back to the brain. The brain signals it not as strong to keep that corpus luteum, what happens after the follicle, alive. And a lot of women say, I still have my period, so I'm okay. But if we're using our cycle as a vital sign, we can actually say the ratio of energy balance is not great. And it's often because we're doing it at sacrifice of other things. So if you're doing the strength training three times a week and you're running however you're spacing out your other days, that's such a healthy balance. It's hard that you're going to be in a bad position with that. And you'll actually improve your running more so than if you're to run every day or every other day.
--:-- Dr. Stacy Sims: Because if you're getting strong through full range of motion, then that feeds forward to better running economy. Then you can vary your pace without getting injured. But for people who are running every day and they're shuffling and they're getting stronger in their strong muscles and weaker in their weak muscles, then it perpetuates this and they're in my clinic.
--:-- Steven Bartlett: Yeah. People are very keen on doing marathons and half marathons at the moment. I've got a couple of friends that are doing a lot of marathons at the moment and they're very, very, very skinny.
--:-- Dr. Vonda Wright: Oh, welcome to my world of DEXAs.
--:-- Steven Bartlett: Is that healthy? I'm not even sure if that's the right question. One can judge from just looking, but being extremely skinny in that regard, being that sort of marathon runner physique.
--:-- Dr. Vonda Wright: There are some that are naturally predisposed to that, right? So naturally predisposed having really good running economy, running biomechanics, having a leaner body. And this is what we were talking about the Olympics earlier where you can see the ideal body type for that particular sport. And then there are those like me who build muscle naturally, it's pretty easy. So I'd never be a skinny little runner and my running economy is a little bit off because of where I build muscle versus not. So not everyone is meant to be a long-distance runner. And there are some that are meant to be long-distance runners. So if we're talking about your friends who are like super skinny, are they economically viable for being a long distance runner? Possibly, but we also have to...
--:-- Dr. Vonda Wright: Possibly. But we also have to look, are they male or female? What is their injury rate? What is their fueling? And then for me, I'd want to see the DEXA scans of the women that are just training long distance and super skinny. Because most of the time we see a higher visceral fat in and around the organs as we're talking about. Even though on the outside they look super lean, they have a really high percentage of visceral fat because of the inflammation, the low energy intake, and most likely estradiol suppression. And that's the skinny fat thing you talked about earlier.
--:-- Steven Bartlett: Is there an evolutionary lens on this? I always think about this when we're having these conversations, like what used to happen thousands of years ago? If we talk about the evolutionary biological theories—and there are a lot of sociologists that will counter what I'm getting ready to say, so I'll apologize in advance—when we look at original hunter-gatherer type communities, the male body was designed to go out to find the calories. The woman's body was designed to stay and take care of the offspring and make sure that home was set. If it was low calorie, the menstrual cycle would stop because you didn't want to reproduce in a time of low calories. Body fat would come on because there weren't a lot of calories.
--:-- Dr. Stacy Sims: So the equivocal in the time now is that I'm not eating enough or I'm burning more than I'm consuming.
--:-- Steven Bartlett: Exactly, so I'm in a calorie deficit in some way.
--:-- Dr. Stacy Sims: Exactly, an energy deficit. So with the male body, and we see this, their brain and hypothalamus is not as sensitive to those nutrient deficits as much as a woman's body because we have menstrual cycle function. A man will lean up and get more cognitively focused in times of low calorie intake. So this is what we see with fasting data and we see with restrictive diets. And that was—we need to bring it back to that biological lens. Low calorie: I have to go find the calories. I have to be fit to go find the calories. Low calories: I need to not have to eat as much. So I need to store fat and I can't have a baby because we don't have enough calories. And then stress. When we add modern stress onto that, that's a comprehensive addition of cortisol and addition of inflammation. And that also perpetuates body fat.
--:-- Steven Bartlett: I mean, like stress 10 years ago would have been like a lion.
--:-- Dr. Stacy Sims: Oh yeah, a lion. It was episodic.
--:-- Steven Bartlett: Right. We had stress, and this is a natural stress response. We have to have them to survive.
--:-- Dr. Stacy Sims: Right. These were episodic stresses.
--:-- Steven Bartlett: Well, and your hormones would change for a very specific purpose that you would then go do. Your body would free up glucose from your liver. You're getting it ready in your bloodstream so you can go run from the lion.
--:-- Dr. Stacy Sims: Yeah.
--:-- Steven Bartlett: And then things would shift back to normal. And what's happening with chronic stress is you're getting all the hormone shifts because your body's really getting ready for the lion, except it's just that bad meeting you had. And then you're just sitting there longer and you're not using that glucose up.
--:-- Dr. Stacy Sims: Exactly.
--:-- Steven Bartlett: Exactly. Are women increasingly overtraining?
--:-- Dr. Stacy Sims: I think the problem in this country is not maybe in the women who are really intentional. Maybe there are some that are overexercising. But if we look at a population, nobody is exercising enough.
--:-- Dr. Mary Claire Haver: Exactly.
--:-- Dr. Stacy Sims: I mean, I would take—people ask me all the time, "Tell me the first thing people need to do." I'm like, "I'll take anything." I mean, I'll take getting off the couch with any method, whatever makes you happy. I'll say, "Get off the couch and do 10 air squats. Thank you. That's enough."
--:-- Dr. Mary Claire Haver: That's enough.
--:-- Dr. Stacy Sims: So in the crowd that's like, "I'm going to invest in my health every day," that is not the majority of people.
--:-- Steven Bartlett: Yeah, that's my bubble. And the people who listen to your show, though, might be a different demographic. We have to acknowledge, right, than the population of America. I mean, a lot of people who listen to your show, Steven, are interested in health and their body and achieving certain goals.
--:-- Dr. Natalie Crawford: And so certainly, you know, I have practiced fertility in North Carolina and in Austin, and I see a completely different patient population in Austin, Texas, which is a very fit area. Women are constantly overtraining. But to Stacy's point earlier about this evolutionary what happens, women go into this hypothalamic dysfunction even before it's what we call amenorrhea. Hypothalamic amenorrhea is essentially where the brain, where the hypothalamus is, shuts off, says "can't reproduce right now, XYZ reason." No FSH and LH are coming out, you're not ovulating, you're not making estrogen, you're not going to get pregnant. So you're more likely to survive.
--:-- Steven Bartlett: Yeah, so it's a survival mechanism.
--:-- Dr. Natalie Crawford: Pregnancy is dangerous in hunter-gatherers. But modern medicine acts like you're perfect or it's turned off. And the reality is there are all these shades of gray in between where these different chronic stressors and your insulin resistance and your inflammation and your overexercising and your underfueling come in and make it so the hypothalamus is not responding correctly. And what we're trying to do is get people to intervene there before it gets too bad. And I see a large number of women who do fall into that zone where they are trying their hardest to be healthy, but what they are choosing to do is actually having a negative impact on their hormonal health and how their brain is interpreting their hormones. And it's very rare to see that in a man. Meaning the number one reason why I will see low testosterone is purely because many men are taking testosterone or because of other exogenous factors like marijuana use. It is very rarely "my brain is not sending out the signals to cause my testicles to make testosterone."
--:-- Dr. Stacy Sims: I like to frame it where women are under-recovering, not over-training. So if we're under-recovery, then it makes it more acceptable to fuel. And I always want to bring it back to—because I come from high performance—I'm going to use those words where it's like, "You're not recovering enough. We want to focus on recovery on these days. We want to make sure that you're eating and fueling around." So it's never over-training. It's always under-recovery. The balance is wrong. They're not recovering.
--:-- Steven Bartlett: So what do you say to all the voices on social media that are just yelling at mostly women and telling them it's just a matter of willpower and you don't have the body composition you deserve?
--:-- Dr. Stacy Sims: Well, you swipe left and don't talk to those people.
--:-- Steven Bartlett: But that's me, right? I'm talking to the woman in Ohio who's feeling defeated and stumbles across someone screaming at her on the internet that her body composition that she's not happy with is her fault.
--:-- Dr. Stacy Sims: I hate that because it's a construct of society, right? Especially Western society. This is where we have to educate. It's not your fault. These are the things that have come into play and lined up to create this situation. But now we have tools to offer you to take one step out of that situation. And let's see how many more steps we can get you away from the situation to improve your health.
--:-- Steven Bartlett: And are the rules of exercise slightly different once you've entered perimenopause?
--:-- Dr. Stacy Sims: So this is where we really need to look at how we can use exercise and some environmental stress to create a really strong adaptive stress and a really strong recovery stress.
--:-- Steven Bartlett: Stacy, can you explain adaptive stress? Because I'm thinking of the 10 people who follow me who have no idea what adaptive stress is.
--:-- Dr. Stacy Sims: So if I go and I do some resistance training, some heavy lifting, I want to create a stress on my body that is going to then have a signaling cascade to repair the muscle in a stronger way than when I first went in.
--:-- Steven Bartlett: Because lifting the muscle damages the muscle?
--:-- Dr. Stacy Sims: Yes, and it creates a series of feedback mechanisms that make it repair stronger than when you first went in. So that's an adaptive stress. And we're looking at what levels of stress we can put—so it's a training stress—or what levels of stress we can use through exercise to really, really create an environment that improves our health. So if we talk about sprint interval training, the 30 seconds on and the two to three minute recovery, the reason why we want that super high end stress of our heart rate is it then creates eventual epigenetic change. So it's that environment that's going to create a change within the muscle that's going to allow that GLUT4 protein that I mentioned earlier to open up and have glucose come in, reducing insulin resistance. Also, with that really high heart rate, we're having a lot of stress on the muscle that's going to release some myokines, which are little hormone signals that then will go to the liver and say, "Wait a second, we don't need to store visceral fat. We need to create non-esterified fatty acids, which can then go into our skeletal muscle to be used in the mitochondria as fuel." So we want to have the stress that's strong enough to create these cascades of feedback mechanisms to improve our overall health. If we stay in that moderate intensity zone, we aren't creating a strong enough stress to create that signaling. What are we doing? We are exacerbating inflammation. We're exacerbating cortisol. Now, cortisol isn't the demon, but when we have an elevation of it, and especially in perimenopause, when we're sympathetically driven and we already have a higher level of baseline cortisol, if we are continuously in this moderate intensity zone, we never get a signal to allow that to drop. So if we're looking at polarizing, which is top, top end and low recovery end, then with the top end, we get the signal cascade of improving body comp, improving insulin sensitivity, as well as getting growth hormone and testosterone responses, which then feed back to drop cortisol.
--:-- Steven Bartlett: So am I right in thinking the solution, if I'm perimenopausal, is to do high intensity interval training for short periods of time?
--:-- Dr. Stacy Sims: So we look at the quality of the training, not the volume of the training. So if we're in our reproductive years, then yes, you can do the moderate intensity stuff because you have estrogen and some of our other hormone feedback signals that are going to drop cortisol. It's going to allow your body to recover and repair.
--:-- Steven Bartlett: And what makes quality training? What is quality training?
--:-- Dr. Stacy Sims: So this is your polar. So you have a very specific session that you're going to do. So for Vonda, it's your 30 seconds on as hard as possible, two to three minutes recovery. Do that four times at your session.
--:-- Steven Bartlett: Okay, I'm going to try and summarize this. See if this is a test. See if I understood all of this stuff. So if I do a lot of volume, but I play in that sort of medium intensity range, I'm basically just stressing out my body in all the worst ways.
--:-- Dr. Stacy Sims: Exactly.
--:-- Steven Bartlett: Like the inflammation. It's just not good for my body necessarily. If I don't do vigorous enough exercise, then that's also bad because nothing's going to break and therefore build. Nothing's going to adapt. Nothing's going to grow. If I do it for long periods of time—really anything for long periods of time—that's also stress. But the key thing to do is to do shorter, higher intensity exercise that will cause my body to adapt but won't put it into that inflamed stressful state. And you also have to pepper in some lower intensity work, so this is your flexibility, so that you have recovery, you're getting blood flow circulating, you're tapping into some mitochondrial work, so that you are still getting benefit of exercise but it's not in that moderate intensity. So that's what we mean by polarizing. So if we were to talk in like the zone talk that everyone talks about out there, right? We're looking at zones. So if we're talking about heart rate and the way that your body works, we have zone one, which is just sitting around.
--:-- Dr. Stacy Sims: We're in zone one.
--:-- Steven Bartlett: Zone two is the bro science kind of thing where you're like, "Let's work in this zone two area where we're working."
--:-- Dr. Stacy Sims: I was in zone two when you were talking about the menstrual cycle.
--:-- Steven Bartlett: Yeah, that's it. A little elevated. Your heart rate's elevated. You can still have a conversation. For women, it's good for recovery, stress release. For men, it's good to improve metabolic flexibility. When we're looking at zone three, four, that is the area you want to stay out of unless you are specifically training for something that requires you to be there. So that would be your half marathons, your endurance races, that kind of stuff.
--:-- Dr. Stacy Sims: Everyone wants to stay out of zone three, four.
--:-- Steven Bartlett: During training.
--:-- Dr. Stacy Sims: Oh, okay. Yeah.
--:-- Steven Bartlett: Fine. Because that's the medium range, right?
--:-- Dr. Stacy Sims: That's medium range.
--:-- Steven Bartlett: So you want to jump into zone five, hang around for five, six—
--:-- Dr. Stacy Sims: Yeah.
--:-- Steven Bartlett: A couple of minutes and then get out of there.
--:-- Dr. Stacy Sims: Yeah.
--:-- Steven Bartlett: But in a week, this is—
--:-- Dr. Stacy Sims: Yeah.
--:-- Steven Bartlett: It's clear. So two to four days a week, you should be lifting progressively to lift heavy, meaning heavier weights, fewer reps, right?
--:-- Dr. Vonda Wright: One compound lift a day plus the augmentive lifts that go behind it.
--:-- Steven Bartlett: Right.
--:-- Dr. Vonda Wright: So you're warming up first, then you're going to do one lift, and then you're going to do your jumping or your balance work. The other days of the week, you will do preferably low intensity doing anything. Walking briskly down the New York street could count as that. It's continuous motion. And then a couple days a week, add in your sprint intervals, your really high zone five, six high intensity. And then when you've got that, you can add in your 4x4 VO2 max on one of the other days.
--:-- Dr. Stacy Sims: Because it sounds like a lot, but when I work with non-pro athletes, I layer on behaviors.
--:-- Dr. Mary Claire Haver: Absolutely.
--:-- Dr. Stacy Sims: Because if I say all of this at once, nobody's going to do anything. I always describe it as we have these pillars, right? First, we have to nail sleep. Doesn't matter who you are. You have to. Because you cannot—it's non-negotiable.
--:-- Dr. Mary Claire Haver: Yeah, you cannot invoke any kind of metabolic or body composition change without adequate sleep.
--:-- Dr. Stacy Sims: Also, improve stress resilience. Then we look at nutrition and physical activity. The behaviors that go with both of those are somewhat independent. You have some people that are more motivated to do physical activity, and some people are more motivated to change nutritional habits. Most of the time, they're two different personalities. So we have to look at what comes next. And then we also have, which isn't lesser importance but often neglected, is the mindfulness in community. So this is being out in nature. It's connecting with friends. It might be going to a group exercise class. It might be just having coffee. But that is really, really important for parasympathetic and whole being life stress response.
--:-- Dr. Vonda Wright: Exactly. There's a new book out coming out called *Joy Span*. I don't know if you've spoken with her. She's a gerontologist and works with the very elderly. And she has a very specific—you know, what determines who's going to kill it in that last decade of life. And that community part, using your brain, having interactions with human beings, seems to be the key. And if you don't keep that going through your 40s, 50s, 60s, when you get to 70 and 80, you're not going to have a great end of your life.
--:-- Steven Bartlett: And what about the last phase then? So someone's post-menopausal, does their exercise recommendations change at all?
--:-- Dr. Vonda Wright: We like to start the habits early and continue them through. If you haven't started, it's not too late. As we're seeing with *Lift More* and some other of the older age resources coming out, it's never too late to start. We just have to be very careful how you start, to have support and phase you into these different exercise modalities.
--:-- Steven Bartlett: Is it the same exercises though? Meaning, you know, the three days a week, the mobility, the strength. I am firmly post-menopausal and I am doing all these things, but it's different. Different people always ask me, "What does heavy lifting mean?"
--:-- Dr. Mary Claire Haver: Right. It's relative.
--:-- Dr. Vonda Wright: It's relative. My heavy is not going to be Stacy's heavy. Or I should say it the other way: Stacy's very heavy is not going to be my heavy. In *Lift More*, the authors describe the one rep max. And so one rep max is like, safely, what is the heaviest you can do one rep? So for a bicep curl, what is the heaviest weight I can do one to fail? I'm going to fail after this one. And for me, that was about 20 pounds.
--:-- Steven Bartlett: With good form.
--:-- Dr. Vonda Wright: Exactly. Safely with good form. And so I could nail 20. And so then they took them down to about 70, 80 percent of that, which for me was about 15, 16 pounds. So that you can usually do about five reps before you hit failure. And that is what they consider lifting heavy. And that seemed to really resonate with my followers to understand what that meant.
--:-- Dr. Stacy Sims: And there are so many women that underestimate their strength. I see them and they gravitate towards the 10-pound dumbbells. It's like, "Put that away, go to the next one, do a couple of lifts with that. And then ideally I want you to put that away and pick up the next one because that is going to challenge you." Because women have been so conditioned to do 10 to 15 reps to get "toned" and not really put in the work they need to build muscle and to get the benefit out of strength training. And I'm always telling women, "You're underestimating yourself in so many facets. Don't cheat yourself with the strength training as well."
--:-- Dr. Mary Claire Haver: Because people have to remember what we're training for now. It's different. I had a woman recently say, "I was taught to do biceps curls five pounds 30 times." Well, after 30 times, not only are you bored, but you'll probably be at failure 30 times. That will build endurance. I am training to be as strong as possible. And when I have strength down, then I start playing with tempo so that I could replace some of the explosive muscle fibers that I'm going to lose over time.
--:-- Steven Bartlett: To your point, Vonda, I've just been writing my book in Cape Town, as I told you before we started recording. And one of the studies that I read about while I was writing the book was a study done by a guy called Hal Hirschfeld and his colleagues, where they put people in these MRI scanners and they asked them to think about a famous celebrity. And then they asked them to think about themselves today. And then they asked them to think about themselves in 10 years time. And in 10 years time, the same brain regions lit up as if they were thinking about the celebrity, which kind of led them to conclude that in our brain, we almost see our future selves as a bit of a stranger.
--:-- Dr. Mary Claire Haver: Yes, that's right.
--:-- Steven Bartlett: And so when we think about long-term planning, this is in part why a lot of this advice is often most effective when it's put in the context of like short-term performance or cognitive benefits, because we really do struggle to care about ourselves at 90. And I think we all kind of think we can just figure it out later.
--:-- Dr. Mary Claire Haver: I think what's different for women, especially in menopause, is because we're also taking care of our parents in so many ways. You know, we're in this like raising kids, going through our own hormonal upheaval, and then watching our mothers, our grandmothers, our aunts age. And the way society is set up, women become the caretakers of their parents, generally the oldest daughter. And I have to give full credit to my sister who lives in the same town as my mom and as a nurse. So she really is bearing the brunt of taking care of mama because I'm living this life. So thank you, Leah, if you're watching. It is such a tremendous stress, you know. And so our motivation, my sister and I, is like, "We don't want to do this to our daughters."
--:-- Dr. Vonda Wright: Yeah, exactly.
--:-- Dr. Mary Claire Haver: The other thing I want to bring in is the brain health component, right? We talk about Alzheimer's and dementia. And one of the reasons I really preface doing high-intensity work is the lactate production. Because we're finding more and more research coming out showing that part of the development of dementia and Alzheimer's in the plaque is a misstep in brain metabolism. So when we're looking at brain metabolism, the brain uses a lot of glucose, it also uses lactate. Now for women, we have less of the glycolytic or lactate producing fibers and we tend to lose those with age. Men are born with more, tend to hold on to them more. So it's not necessarily as big an issue for lactate production. Men need to spend more time in the low intensity being able to produce more of our fat burning capacity. But for women, doing that high intensity work and being able to produce lactate to then allow the heart and the brain to use that preferential fuel feeds forward to reducing the misstep in this brain metabolism component that occurs. And it's such a sex difference. We're seeing a change in glucose metabolism in and around perimenopause into menopause. So it's that lactate production that is kind of the offshoot of the high intensity work that's super important for brain health.
--:-- Dr. Stacy Sims: When you look at glucose metabolism in the brain, I'm talking specifically coming out of Arizona and from Lisa Moscone's work, and they looked at glucose utilization in the brain, especially the forebrain through the transition. It's wildly different based on what phase of perimenopause, menopause and postmenopause that they're in. And it's absolutely astounding. And they're seeing patterns that can give clues that may be the women who are headed towards the dementia route versus those who aren't.
--:-- Dr. Mary Claire Haver: And women are significantly more likely than men to develop dementia and Alzheimer's, largely because they have certain unique biological risk factors and also because they live longer.
--:-- Dr. Vonda Wright: And the sociocultural component. I keep bringing it up because I work—stress.
--:-- Dr. Mary Claire Haver: Yeah.
--:-- Dr. Vonda Wright: But also, if we're looking at women who are 80, 90 years old now, their upbringing to this point is completely different than ours. Meaning that the job availability and the brain stimulation they had when they were in their 30s, 40s, 50s is completely different than what we have now.
--:-- Steven Bartlett: Better or worse?
--:-- Dr. Vonda Wright: Worse. So they didn't have necessarily the opportunity to be scientists, lawyers, medical doctors. So they didn't have as much stimulation of brain and implications on that neuroplasticity. So we're seeing a higher episodic issue of dementia and Alzheimer's in older women now because they didn't have the same lay-down effect that we have now as 50-year-olds, 40, 50 year olds. And this is the stimulus we have for neuroplasticity.
--:-- Steven Bartlett: So okay, like you're laying down brain pathways and neural fibers. So neuroplastic—think about it like the bone—but you're creating pathways in your brain to make you less—easier but more resilient.
--:-- Dr. Vonda Wright: More resilient to dementia. But they're also going to have a stronger brain younger. Are they not going to have more stress if they're working? Maybe. Fascinating study, and this one shot me out of a cannon emotionally: if you choose to become a caretaker of a parent with dementia, you have a 60% increased risk. Now there's a genetic component, but when they took the genetics out of it, they feel like it's the stress of caregiving for that parent. You are signing your own death warrant because now you are increasing your risk of death.
--:-- Steven Bartlett: Because I'm right in thinking that women are still both caregiver and now in the corporate world?
--:-- Dr. Vonda Wright: Yes, that's right.
--:-- Steven Bartlett: So it's both.
--:-- Dr. Vonda Wright: Yeah, stress from both ends.
--:-- Dr. Stacy Sims: Lactate production for the win. But you have to have an active plan to combat this, right? So you're not going to live in a world that is stress-free if you're a woman in the world. You are likely to have a caretaking role in some fashion, even if you are chasing other dreams when it comes to professionally. Building good brain pathways is wonderful as a way to help start from a higher standpoint before you have brain loss. However, just like we've said on these other tangents, the brain is that too. We need to think about active ways we're going to combat what is happening in today's world naturally. And some of the factors are modern society that put us into this pro-inflammatory state. But we need to think about making lactate, what's important for us. And it really is a plan. This whole "I'm going to figure it out when I'm 90 and the problems in front of me" is too late for these medical problems.
--:-- Dr. Mary Claire Haver: And back to your point about neuroplasticity, we're not reading as much. We're on our phones.
--:-- Dr. Stacy Sims: Not in my house.
--:-- Dr. Mary Claire Haver: Yeah. And so as a culture, there is this worry that all this time on the phone and these dopamine hits, but not creating stories in your head and reading for pleasure at night. You know, a lot of women are on their phones now before bed rather than developing that neuroplasticity that we get from storytelling.
--:-- Steven Bartlett: I did something at 24 years old that has had a profound impact on my life. I set myself the challenge of posting every single day on my social media channels. And at the time I was doing it to grow my following, but it had this profound impact on my life and two remarkable things happened when I did that. I managed to learn faster because every single day I'm capturing what is happening to me and trying to distill it down into something that I can share with the world. But more remarkably, it led me to building a following of many millions of people. And that's the basis that I used to launch the Diary of a CEO. And that's why I want to tell you about our sponsor today, Adobe Express. They are the platform that I use to make all the posts across my LinkedIn and across my Instagram. It's a couple of clicks and you don't need to be an expert. And that is why I love using it because I'm not an expert in graphic design. It's accessible to use for all of us, even if we don't have the technical prowess to design great things. So if you want to start compounding both your reach and your knowledge like I did at 24 years old, then head to adobe.ly slash Steven and get started with Adobe Express. That's adobe.ly slash Steven.
--:-- Steven Bartlett: The next question that came in from the audience, we asked a thousand women to submit their questions. The next one is, what's the best and healthiest way for a woman to lose weight?
--:-- Dr. Mary Claire Haver: Lift weights.
--:-- Dr. Stacy Sims: Lift weights.
--:-- Dr. Mary Claire Haver: And eat.
--:-- Dr. Stacy Sims: And eat, yes, absolutely. And you could have a very slight calorie deficit towards the end of the evening.
--:-- Steven Bartlett: Running? As a way of burning calories?
--:-- Dr. Mary Claire Haver: The problem is people think that they can out-exercise a bad diet, and you can't. Composition of your diet matters immensely. And I hate calling it "lose weight." I now call it "recomposition." But let me put it in context. Yeah, go run. You're going to burn 100 calories a mile. Three Girl Scout cookies, three Thin Mints, U.S. favorites, is 180 calories.
--:-- Steven Bartlett: That's my fave.
--:-- Dr. Mary Claire Haver: So you have to run two miles to eat three cookies. Most of us, if you're going to eat cookies, don't eat three Thin Mints. You eat the whole sleeve, right?
--:-- Dr. Stacy Sims: To your point, it is impossible to out-eat—unless you are a high athlete who is burning a thousand calories. And even then, no. Because we look at diet composition and we see that endurance athletes who use a lot of high sugary type carbohydrate for like the gels and the sports stuff, they have interrupted their gut microbiome so much that they have—
--:-- Dr. Mary Claire Haver: Sugar alcohols.
--:-- Dr. Stacy Sims: Well, it's not even that. It's the phyla change. We're seeing a decrease in the diversity, even though they're exercising. And we see that exercise increases the diversity of the gut microbiome. It's what they're eating during the training with the heat and hypoxic stress.
--:-- Steven Bartlett: Wow.
--:-- Dr. Stacy Sims: That is creating the growth of the firmicutes phyla that's associated with obese outcomes.
--:-- Steven Bartlett: So that's a—it changes the gut.
--:-- Dr. Stacy Sims: The gut microbiome.
--:-- Steven Bartlett: Yeah.
--:-- Dr. Stacy Sims: If they are eating—so we have this misconception that if you're an elite athlete and you're burning all these calories, then you're just eating to fuel, right? But it's not. It's the quality of the diet. If we want to perform well, whatever performance means, if you're an Olympic athlete down to recreational person who just wants to accomplish a 5K, the composition of your diet is immensely important.
--:-- Steven Bartlett: What about a Zempec?
--:-- Steven Bartlett: Everybody seems to be on a Zempec, GLP-1s. I prescribe it. And our clinic is all perimenopause and menopause. And so we always start with, let's see how you do with lifestyle changes first. So we give that three to six months. When they come back, every time they come back, we're doing another body composition change. For probably 50% of the patients, lifestyle plus or minus HRT, their body composition changes. They're happy. They're much healthier. Everything's moving in the right direction. So now we're left with the people who are doing all the things. This isn't the typical story of people that start a Zenpec. They see it on Instagram. And then a week after, I'll be at their house and they'll tell me, oh, yeah, I'm on a Zenpec. And it's really, it's usually just someone sees it online, they hear it on a podcast and they're on it within a couple of days. The access is getting easier, the price is coming down, and there is for any medication there are risks, there are benefits, and there's ways that will promote health. And with any medication, you can not promote health if you give it.
--:-- Dr. Natalie Crawford: I mean, GLP-1s can be revolutionary for certain people. A lot of people are not training for a 5K, let alone anything else. And we know, if we go very simply, fat cells, right? They make a different type of estrogen. They're inflammatory. You have insulin resistance. And all of this sets you up at a deficit to say, I wanna get healthier. For women, we'll say you have PCOS, who already have a predisposition for insulin resistance. They have a harder time losing weight because now they're also storing visceral fat. We know they get on this cycle with hormonal change. Being on Ozempic allows them to lose weight and combat insulin resistance in a faster way than they've ever been able to do before. And especially when it comes to fertility and you're on a timeline, that can be really revolutionary. When you lose weight because that estrone decreases, many women with PCOS, if they were overweight, will start ovulating again because that suppression from the additional estrogen is gone and their inflammation markers go down, their insulin resistance decreases. So there's a subset of people who have found their life changed by them. And we never want to discredit that. Many people have a difficulty losing weight, chronic medical conditions, have been able to reverse them. And this has been a tool in the toolbox. Because about 70% of Americans would fit in that category of chronic health conditions, difficulty losing weight. 73% right now are overweight or obese. So should 73% of Americans be on GLP-1s? And it's higher in women. One common thing is having tools in the toolbox and being able to know when to use them, when to offer them. Just like when we have the HRT discussion, we don't want to see people, women for this discussion, not being offered a therapeutic option because or not choosing it out of fear.
--:-- Steven Bartlett: Well, when I hear that it's gonna help me lose weight and I've got two options, I can go out and lift all these weights, Stacy, and I can—which you know, one I don't—yeah, it's hard, isn't it? Go to the gym. I have to put my shoes on, all these things. Or I can take this injection and lose all your muscle and lose your bone and end up like the little floating figure in WALL-E movie that I've talked about before. Right. And that's my fear of just blanket people.
--:-- Dr. Mary Claire Haver: You're also, whether you mean to or not, giving the illusion that willpower is all you need to lose weight. Right. By what you said. Right. I can either do these hard things or I can choose this medication, which appears to be the easier way out. And two things can be true at once. People can work extremely hard. Maybe they don't understand exactly what they should be doing. And that's part of what we're trying to change the discussion on. But reversing some metabolic change even initially can make a big difference in their game plan. But you will lose body weight on these medications. And so you have to have somebody guiding the ship.
--:-- Dr. Stacy Sims: I think what we all don't love is the access without oversight, meaning nobody's helping you say, how are you not losing muscle? How are you doing this in a safe fashion? You can just text somebody on an app and suddenly get medication, have the medication shipped to your house.
--:-- Dr. Mary Claire Haver: In our clinic, it is an hour long. Now they're coming in to discuss the GLP-1 option. It is an hour long visit of risks, benefits, side effects, protein intake, resistance training, mandatory. We will follow your bone density. We will follow your bone mass. I mean, your muscle mass. We have these scanners. These are great. Available. And we're not going to get to a number on the scale and sacrifice your long-term health. And my patients are drinking the Kool-Aid. They're coming in. They've found, you know, they're coming to you for a reason. And so I'm a little bit unique in my clinic and that I have a social media following and people kind of watch a few things before they come see me. So they know my, they're not shocked by me giving this advice because I give it all day on social media. So if you give them the Zempek, but they still don't go to the gym, they still don't do anything else, then we'll stop giving it to them. They won't be healthy. And they know that we've talked to them about that. We've explained it on the front end that this is a tool in your toolkit because we can see their muscle mass. We won't renew the prescription if they've lost the muscle mass. So if you are losing weight and not lifting and eating enough protein on Ozempic or any way else, and you do a body composition, you may see total weight lost. You will see pounds of muscle loss. You may see body fat percentage loss. But if you do this correctly with enough protein in your diet and lifting weights, the amount of muscle loss will be very small versus amount of fat loss. So we know we're going to lose a little muscle, but you can't lose eight pounds of muscle.
--:-- Dr. Stacy Sims: Right.
--:-- Dr. Mary Claire Haver: Right. So we can tell. And I give them the hard numbers, like 10% is acceptable. We're going over that. We're getting into the danger zone. We're going to cut back on your dose. We're going to, you know, but they commit to the work on the front end.
--:-- Steven Bartlett: I think that's the important point is that these GLP-1 antagonists don't burn your fat. They stop you eating as much. They're satiety. Which is going to mess up, which is going to reduce everything. Because I was thinking about myself, I was thinking, well, I go to the gym every day. I'm going to keep going. So maybe if I had a little bit of a Zenpec or whatever it's called, then it would burn my fat. But actually, no, it just stops me eating, which is gonna reduce my muscle, my bone, right? Goodbye biceps.
--:-- Dr. Mary Claire Haver: Yeah.
--:-- Dr. Stacy Sims: That's the thing. It's like, I'll lose my subscribers.
--:-- Steven Bartlett: Yeah, exactly. Exactly. Yeah, okay, that makes sense. So to this person asking what's the best and healthiest way to lose weight, the response is stop eating the cookies and start lifting some weights on the 80/20 rule, right?
--:-- Dr. Mary Claire Haver: So 80% of the time you're on it, right? You're paying attention to a high quality diet, you are eating according to circadian rhythm, you are doing the strength training, you're getting the good sleep. And then 20% is life, where I'm going to stay up late, I'm going to have some wine or whiskey, I'm going to go out, I'm going to be on vacation. So you're not excluding all the fun things in life. If it comes to a point where you're like, I'm still not budging the needle, then maybe it's a 90-10 rule. 90% of the time you're on it, and 10% is the life factor.
--:-- Dr. Stacy Sims: There's these hard and fast rules I've been accused of giving. I don't give rules. I give optimization ideas. So it's not following strict 80-20 or 90-10. It's what fits in your life. And if you're really motivated on losing weight, the first thing I tell people to do is ditch alcohol.
--:-- Steven Bartlett: Everyone wants to lose the part on the belly.
--:-- Dr. Stacy Sims: Yeah, sure.
--:-- Steven Bartlett: Is there not like an exercise I can do just to burn the part on the belly?
--:-- Dr. Stacy Sims: No, there's no exercise.
--:-- Dr. Mary Claire Haver: So visceral fat's a little bit different. It's like a whole different organ.
--:-- Dr. Stacy Sims: So, when we talk about visceral fat, it has different drivers. We drive fat to the intra-abdominal cavity. It creates a different cytokine. Subcutaneous fat is a storage facility. It is when we overeat calories, we will drive fat under the skin. And it's kind of genetically determined. Females tend to gain about their hips and thighs. And actually that hip and thigh fat is protective for cardiovascular disease in premenopausal women, not in men, but in women. So, but when that fat shifts to the intra-abdominal cavity, it starts—that fat is much more metabolically active than the fat under our skin. And it creates these pro-inflammatory cytokines. And then you end up in this negative feedback cycle. Your liver starts becoming dysfunctional, insulin resistance increases, that drives more fat to the visceral cavity, increases inflammation, and it just goes on and on and on.
--:-- Steven Bartlett: So I'll get liposuction.
--:-- Dr. Mary Claire Haver: No, no, no.
--:-- Dr. Stacy Sims: You can lipo the viscera? That's inside. That really inside the abdominal cavity is what we're talking about, that visceral fat, which is the worst kind.
--:-- Steven Bartlett: But what about liposuction? Can I just suck it out?
--:-- Dr. Mary Claire Haver: People are doing all kinds with that fat. Under the skin. Under the skin you can. That's an aesthetic decision.
--:-- Steven Bartlett: But what about the stuff under the skin? Oh, shh. Liposuction it out? Is that a good idea or a bad idea?
--:-- Dr. Mary Claire Haver: No, it'll come back.
--:-- Steven Bartlett: All these things we're talking about, it sounds like a lot of instructions, and it is, actually. But when you layer them on, it becomes your lifestyle. It's not a diet. It's not an exercise program. It's just how I live. Which brings me to my next question from the audience, which is what is the best diet for a woman who is perimenopausal?
--:-- Dr. Mary Claire Haver: Plant forward. Plant heavy.
--:-- Dr. Stacy Sims: Yeah, because you're getting—so when I'm talking to patients, we talk about the quality of their nutrition. So is your pattern of eating—I hate to call it diet because it's a four-letter word now—but is the pattern that you're eating pro-inflammatory or anti-inflammatory?
--:-- Steven Bartlett: What's pro-inflammatory?
--:-- Dr. Stacy Sims: So meaning the things that you put in your body, are they likely to cause inflammation? And we know there are certain things that do that, like heavily ultra-processed foods in large amounts. Everybody can tolerate a little bit of everything. But if the majority of your diet—and for most Americans, the majority of their diet, 60% is ultra-processed foods—those are by and large pro-inflammatory.
--:-- Steven Bartlett: What about red meat?
--:-- Dr. Stacy Sims: Red meat in moderation and especially leaner ones seems to be a very reliable source of protein. As far as inflammation goes, it seems to be neutral in small amounts. High fat meats or processed meats, then you're flipping over into pro-inflammatory.
--:-- Dr. Natalie Crawford: Is there a diet for fertility? It's very much what we're saying right here. That plants have fiber that's going to feed your gut microbiome that's going to decrease inflammation. So fruits and vegetables, getting enough fiber is the number one change that most people need to make. From there, we want to decrease all your ultra-processed foods, healthy fats. Fat is the backbone of—cholesterol is the backbone of your steroid hormones. So if you want to make hormones, we've got to have some cholesterol, some healthy fats coming in to provide the backbone for that. That's essential. So things like olive oil, nuts, your avocados, seeds, these are going to provide some of those healthier fats that are easier to use for you. And when it comes to protein, there's a lot of different protein sources. We know that the data is so hard on nutrition because I can quote a study that says for every serving of plant protein that you take over animal protein, you have a higher chance of ovulating regularly. And that's true. A lot of that, though, is nuanced by the fact that people who eat plant-based sources of proteins tend to eat other plants in general and less ultra-processed foods than people who have the highest quartile of meat intake. If we go to a micro level, though, not all animal meat is created equal. Animal meat does not have fiber in it. So we know it's not feeding our gut microbiome. So if we want to talk about carnivore diet, things like that, it's definitely not microbiome friendly for you and not hormonally healthy. So we really want to have those whole foods, the fruits, vegetables, the healthy fats, the proteins that are going to be good sources. And just like we talked about other things, it's not all or nothing. Red meat every day is probably going to be inflammatory. Having it on the weekend is probably OK. And the way I describe this to patients is, let's imagine a scale where every decision you make can kind of tick up the inflammatory marker or bring it back down. If you are making active decisions that are more anti-inflammatory, you can tolerate the glass of champagne, the birthday cake, these little things that we know will cause inflammation in your body, but your body is meant to respond to inflammation and get back to normal. The problem is when it's constantly challenged, when 70% of the things that you eat cause this chronic inflammation inside of you, your body can no longer respond appropriately when it's challenged again.
--:-- Dr. Stacy Sims: Things that are pro-inflammatory tend to also disrupt the gut microbiome. It all makes sense when you think about it. And there's quite a few studies that are coming out in the four to five years before the one point in time called menopause. So in late perimenopause, that there's a significant decrease in gut microbiome diversity.
--:-- Steven Bartlett: Oh, Zoe did that work.
--:-- Dr. Stacy Sims: Yes.
--:-- Dr. Natalie Crawford: Yeah. And it's really interesting because of the second pass and the way that hormones are metabolized. When we have our natural cycle and we have an exposure of our sex hormones, the common cycle, then we have more diversity because the gut bugs help unwind, I guess. So we metabolize estrogen into inactive metabolites and then they get excreted in the feces. So it goes through the liver and then dumped into the bile.
--:-- Steven Bartlett: Does that mean that if my microbiome is likely to be less diverse as I age, I need to be thinking more about the diversity of your plant foods? And this is why it really—probiotics, etc.?
--:-- Dr. Natalie Crawford: Not over the counter.
--:-- Steven Bartlett: Okay.
--:-- Dr. Natalie Crawford: You first start with food.
--:-- Dr. Stacy Sims: Yes.
--:-- Dr. Natalie Crawford: Not a pill that you're trying to take, but actually the food that you're putting into your body is the best source of all the microbiome. The best nutrient for your gut microbiome is fiber.
--:-- Dr. Vonda Wright: What about protein, Vonda? The way I like to approach nutrition for people is first having people notice what they're eating and then from that, break it down into, well, how much of it is protein? How much is fat? How much is carbs? Without that kind of education, it's almost meaningless. So when we've done that and I'm making recommendations for protein, we will not build the muscle we need to build. We will not get stronger the way we're capable of getting stronger, A, if we're not eating enough, and B, if we're not taking enough protein. So the RDA recommendations of 0.8 grams per kilogram is survival doses of protein, like sitting on a chair like a mushroom. Preventing malnutrition is the goal of it.
--:-- Steven Bartlett: Yeah, of course you are.
--:-- Dr. Vonda Wright: It is not for active people. It is not for living your best life people.
--:-- Steven Bartlett: 0.8. The recommended daily intake. Is 0.8 grams per kilogram of lean body mass?
--:-- Dr. Vonda Wright: So it's low. It's very low. So the research supports, easily supports, let's use pounds, 0.86 grams per pound for lifting people. I recommend over a gram, a gram for ideal pound, because I'm presuming that the people I'm taking care of are going to start being active, that we're trying to build muscle, that we're not in starvation mode. So 0.8 grams per pound, I recommend one gram per ideal pound.
--:-- Dr. Stacy Sims: So there's some other research that's come out looking at skinny fat. So that's normal weight obesity. So not as we're talking. Normal BMI. Normal BMI, but internally high body fat. And what happens is they have low muscle mass. So they took a group of women, split them up. So you had a control group and then you had this intervention group and the only change they made—no exercise—and the only change they made was they brought the intervention group up to 1 gram of protein per kilogram. So that's just 0.8 per pound. And over the course of 12 weeks of eating that protein intake, this intervention group completely recomped their body. So their muscle quality came up, body fat went down. Control group, of course, nothing happened. So it just shows the importance of having that higher protein intake just to support basic muscle function.
--:-- Dr. Vonda Wright: And the frailty data out of the WHI, so the Women's Health Initiative, looked at multiple things, not just breast cancer and heart disease, but they followed these women even off of HRT for decades. And when they looked at frailty scores in the elderly and protein intake above 1.6 grams per kilogram had the lowest frailty scores just based on protein intake alone.
--:-- Steven Bartlett: Yep. What about fasting? I know so many people that are doing water fasts and juice fasts.
--:-- Dr. Mary Claire Haver: I've had an evolution with the way I think about fasting. When I first kind of stepped out of the box and what's happening in menopause and why was my body composition—I didn't know what to call it back then—but what was all this going on that was new and all my patients were having it as well. And these were my girlfriends. I worked in a small town with a big university and these are PhDs and we're running marathons. We're doing all this stuff and everyone's kind of complaining of the same thing. And so fasting seemed to be helpful. And my girlfriends were trying, we all kind of did this fasting thing and I was like super excited about it. Everybody felt better, blah, blah, blah. So fast forward, I'm learning more about hormones, body composition, protein intake, all of these needs. And suddenly as I'm counseling my patients, I'm realizing I can't meet my own protein goals if I'm trying to fast at the same time. And I quickly realized if we're looking at health span, if we're looking at body composition, there may not be a lot of room for fasting for these patients, or for my girlfriends. And it is really difficult for my patients to reach their nutrition goals. So never at the expense of meeting your basic nutrition goals and your calorie needs. And it is really, really hard to do while fasting. So you may get a short-term benefit with weight loss, but there really doesn't now. Stacy can get into the nitty-gritty of all this.
--:-- Dr. Stacy Sims: But the basic idea of fasting—if we want to use the term fasting, we have to look at it as are we talking about intermittent fasting or time restricted eating? So intermittent fasting is kind of like, you know, your water fast, your five day, two day, all that kind of crazy stuff, which for the most part men can get away with and have a positive impact on body composition, but women can't. If we want to talk about time restricted eating and working with our circadian rhythm, which is optimal, then you have breakfast or food within a half an hour of waking up. That helps dampen that ghrelin and cortisol response I talked about before, so that everything's coming down, your hormones are starting to work properly and your body's like, great, I'm ready to go. I can handle this. And then you're eating at regular intervals and I try to have people have protein and fiber at every eating interval so that they are maximizing protein and fiber intake. Then you have dinner and then you don't eat after dinner.
--:-- Steven Bartlett: What do you mean by every eating interval?
--:-- Dr. Stacy Sims: So breakfast, maybe you have a snack. If we're looking at training or exercise, if you're splitting your breakfast, then you're having some protein and carb before you're having the rest of your protein or more protein afterwards. And then you're having some protein and some fiber at lunch. So you're having maybe tempeh or tofu or salmon with salad or fruit and veg. So every time you're eating, you have a protein and fiber focus. So time restricted eating is within a 24-hour period, so you're looking at, I'm going to eat during the day when my body needs it, and I'm going to stop eating when I finish dinner. So I have about a two, maybe three hour break before I go to bed so that when I go to bed I'm not trying to digest food, my body can get into the parasympathetic responses it needs to to sleep well for reparation. And then again, at what time? When you wake up in the morning, it's typically about 12 hours of eating and 12 hours of not. So you're trying to follow that circadian rhythm and work with your hormones.
--:-- Dr. Natalie Crawford: It can also, when we do have that period of time—which maybe that sounds very intuitive, but a lot of people are eating at 10 p.m., they're snacking on food, then they're trying to go to bed, and then they're getting up. When you give your body a little bit longer, so at 12 hours time, is when your body will really efficiently be using up all your glucose, really dropping some of those insulin levels, but it's not so much that it's stressful. And we're using stress very generically here, but on a cellular level, long periods of fasting for women specifically can be very stressful to the body. And that's why if you think about Stacy's example of what happened in two fasting periods to a man and a woman, different things are going to happen to your body if it thinks it's being in starvation. So we don't want to put your body in a starved state. We're just trying to give it a time period without food so that it can start to process the energy that's available differently.
--:-- Steven Bartlett: Why not, though? What's going to happen? I understand from what we talked about earlier that my fertility, my cycle is going to change. But is that it?
--:-- Dr. Stacy Sims: Well, there's adaptive stress and then there's stress to the point of you're hurting yourself. You said that men can do longer fasts. They can do longer fasts and it can show to actually be something that might be advantageous for them for how their body is made. It might increase their focus and some other metrics. But for women, these longer periods are actually going to promote more visceral fat storage and become pro-inflammatory. And you said it a little casually, but disrupting your hypothalamus and shutting off your hormone system will cause a low estrogen state, and that's very problematic as we've talked about. So thinking about your body should not be in a starved state. So utilizing time restricted eating, meaning I'm going to eat within my circadian rhythm, the hours that there is sun outside—back to how your body is made to function—is working with your biology. If you're saying I'm going to not eat for three days because I'm doing this fasting period, for women, that's going to induce a stressful state where you're going to start to store more as visceral fat and cause more inflammation. And if we bring it into the people holding a fast till noon or after, you're phase shifting. So it's like you're having social jet lag, where if you're phase shifting your hormone responses, your appetite hormones, then you're not going to get into a good sleep because your body's like, it's not time to go to sleep. Your melatonin peak in women usually peaks around nine o'clock. So you start to get sleepy. That gets shifted to 11, 12. So you're not actually going to get good sleep because you now have reset your melatonin responses. So we want women to understand that time-restricted eating when you're not eating in the dark is really beneficial.
--:-- Dr. Mary Claire Haver: Easiest way to say it.
--:-- Dr. Stacy Sims: Easiest way to say it, yeah. You're fueling for your body during the day because that's when it needs the fuel. That's when we want to be able to create an environment that is supportive to hormone health, supportive to muscle growth, to brain health, to all the things, and reducing stress when we can control that stress. So when you start phase shifting and holding fast and creating this stress on a circadian level, knowing that there's a circadian response on every cell as well as a total body circadian rhythm, that if you shift that, then we start seeing a lot of metabolic dysfunction, poor sleep. And unfortunately, we see this in shift workers because that's what's happening. They're having circadian shift and they have significantly lower longevity. They live—I think I had 14 years less if you're working night shifts. I don't know. You have higher rates of infertility, higher rates of pregnancy loss. You're more metabolically unhealthy.
--:-- Dr. Natalie Crawford: Of course we're generalizing a group of people, and sometimes I think we've all had moments of time of life where shift work was part of what we had to do. But night shift work, most people are not getting enough sleep during the day and they're what we call flipping back and forth, right? Because you want to be on a daytime schedule on your off days and live your life, that you're constantly sacrificing what your body needs. And what I tell people is, you may, if you can get off of that, it will be a healthier life pattern. But in moments where it's not, you need to really prioritize trying to get enough sleep, making sure that you're taking care of yourself in the other time periods. It's because you're set up for a place that is going to cause hormone dysfunction and impact your metabolic health.
--:-- Dr. Vonda Wright: You believe the same, I believe. I advocate feeding ourselves for optimum health. To be any kind of active, you must feed yourself and stop eating three hours before bed.
--:-- Steven Bartlett: So what do you think of people that do these longer fasts? Do you think that they've just been given poor advice? Because I know I was talking about Mel earlier and I know she does frequently does three-day fasts.
--:-- Dr. Stacy Sims: Because I think people think they've heard this term autophagy.
--:-- Dr. Mary Claire Haver: Autophagy is the term. Take it, Stacy.
--:-- Dr. Stacy Sims: So this is the thing with autophagy. You get that with exercise. So the idea of autophagy is recycling some of the parts of cells that have broken down or somehow become dysfunctional. So your body's really good at cleaning that out. We see with exercise it invokes that autophagy. With fasting, it evokes that too, but not the severe fasting, like three-day fast, that kind of stuff. When we look at the telomere changes that people say with fasting, you get that with exercise.
--:-- Steven Bartlett: So telomere is points that we look on the DNA to see how you're aging. So we want longer telomere length because that means you are more stress resilient.
--:-- Dr. Stacy Sims: You get that with exercise because exercise is a big stress. It creates a change within, like we were talking about before, adaptive stress, epigenetic changes, which improves all of those markers that people are so adamant fasting does.
--:-- Steven Bartlett: What about fasting and then doing exercise? So fasted exercise?
--:-- Dr. Stacy Sims: For women, no. That's what she taught me. For men, I'm going to say no as well, because when we're looking at the fueling mechanics of exercise, muscle is a very metabolically active tissue. If your body is trying to fuel itself, it is going to break down the very first thing that's creating an energetic need, which is muscle.
--:-- Dr. Stacy Sims: We see in women, women lose muscle. You're going to break it down and use the amino acids as fuel. You can tap into blood glucose and some fat, but when you aren't bringing blood glucose up through eating first, it's really hard for your body to understand that this is what you want it to do. So it's like, okay, I need to conserve fat. I don't want to go through all the glucose that I have because I need it for brain health. So I'm going to start feeding more amino acids in to fuel what I'm doing.
--:-- Dr. Stacy Sims: For women, we already use more amino acid than men. So if we're looking at fasted training, then we're already increasing the amount of lean mass that our body's going to break down to use as fuel.
--:-- Steven Bartlett: I'm pretty sure it was you that told me there's this part of the brain that's kind of checking if there's energy in our blood, if there's glucose in our blood. That's part of our hypothalamus. And so the hypothalamus is this sensor that's kind of checking. And in a woman, again, correct me when I butcher this, but if it understands that there's no glucose in the blood, then it's going to go into that survival state, which is going to start to shut things down, which means growth of muscle isn't going to be possible. Because once upon a time, I guess that stress without the fuel would have been a threat, especially in the context of like my menstrual cycle and my reproductive health.
--:-- Dr. Stacy Sims: That's a good way of wrapping it up. Yeah, it's not that we don't have blood glucose, it's low blood glucose and no nutrients coming in that the hypothalamus is sensing. So we're looking at neuropeptide responses within the brain, within the hypothalamus, that controls appetite hormone, the way that your body is using fuel. So if we don't have stuff coming in, the hypothalamus is like, "Oh wait a second, what's going on?"
--:-- Steven Bartlett: Is it fair to say the woman's body is more... I was going to say stubborn, but that's slightly negative... less flexible than a man's?
--:-- Dr. Stacy Sims: More complex. Complex. It's complex and more stress resilient itself. It's very much stress resilient, so it's very defendable. It's trying to protect you. It really is looking at how, what is it going to do to keep your functions happening in balance.
--:-- Dr. Stacy Sims: But because women can get pregnant and pregnancy is not a health neutral state, it's a huge strain on the body. That is an extra layer. One of the things that sometimes decides, "I'm going to put this to the side because I'm going to protect you, keep you functioning. I want to work on all of our other body functions. We're going to shut off that side that's not sending out FSH and LH and making reproductive hormones." Because if we can't afford to keep you healthy, then we definitely can't afford to grow a baby and keep you healthy.
--:-- Dr. Stacy Sims: If you are pregnant and go through times of severe stress, illness, injury, your body will eject what is in the womb through a miscarriage or early pregnancy loss or preterm labor because it is always going to try to protect you first.
--:-- Steven Bartlett: Mm-hmm.
--:-- Dr. Stacy Sims: So you're at high risk of a failed pregnancy.
--:-- Dr. Vonda Wright: I wonder if I could frame your question about Mel and the way I frame all the advice, whether it's research advice or internet advice, is you have to know what your goal is. What is Mel's goal or your goal? Because listen, they're exclusive.
--:-- Dr. Vonda Wright: Longevity. If longevity is your goal, like live longer at any cost, well, then there's a lot of research about severe calorie restriction and lifestyle and just lots of severe ways to live. Okay, if that's longevity is your goal, that's your goal.
--:-- Dr. Vonda Wright: If your goal is peak performance, like a pro athlete, that is a different kind of life and training and reps and peak performance at the pro level doesn't necessarily get you longevity. Pro athletes live less, at least contact athletes live less than people focused on longevity.
--:-- Dr. Vonda Wright: But the third bucket that most of us live in is healthspan and wellness. It's neither high performance, live less time, and it's neither austerity, live the longest possible. It is the middle ground. It's the homeostasis balance. And so when questions like that come up, the first question in my mind is, which bucket are you in? Are you in peak performance? You're going to do different kind of training, different kind of eating. We know you may have a decreased lifespan because of the stress you put on versus this. So what are we working for?
--:-- Steven Bartlett: I think a lot of the people that talk about these fasts often say to me, especially when they're referring to juice fasts, that it's kind of like cleaning out the system. You have... they say it's like cleaning out...
--:-- Dr. Stacy Sims: You don't need to clean out. That's not how you clean out your system. Taking the fiber out of those fruits and vegetables, taking away all the things that you need. Juice is 500 calories of pure glucose.
--:-- Steven Bartlett: What if it's vegetable juicing?
--:-- Dr. Stacy Sims: Why not just eat the vegetables and get the fiber for your gut? But you have a liver. Your liver is...
--:-- Dr. Mary Claire Haver: I think it's marketing. That's a marketing challenge. I think they're falling prey to marketing.
--:-- Steven Bartlett: Tell me what that means. And that's a big wellness trend. I know, but it's massive. Honestly, you would... Yeah, I know so many people, so many of my best friends... Going on detox wellness retreats?
--:-- Dr. Mary Claire Haver: Well, even when I ask them why they're doing a water fast, they say, "I'm just detoxing." Or when I ask them why they're grinding up this fruit and vegetable and, as you say, pulling out all the fiber from it.
--:-- Dr. Stacy Sims: It feels more attainable to say, "I'm doing this crazy thing for three days," than "I'm going to make a life switch to just live a more preventive, anti-inflammatory lifestyle."
--:-- Steven Bartlett: And in terms of supplements generally, do you know... again, not to bring Mel into this for the thousandth time today, but a couple of Christmases ago, I told her that she should be having creatine because all these people on my podcast told me it. And she said, "No, it's for bodybuilders."
--:-- Dr. Stacy Sims: Yeah, that's the old school thought. When we're thinking about creatine and how it got its chops in the supplement world, we're looking at muscle performance. And taking five grams four times a day with some carbohydrate to enhance muscle performance is how it started.
--:-- Dr. Stacy Sims: But when you start really disseminating down into the health aspects of creatine, creatine is used in every fast energetic of the body. So that means your brain, your heart, your gut, muscle, everything that requires energy from zero to 30 seconds, creatine is involved.
--:-- Dr. Stacy Sims: Women have about 70 to 80% of the stores of men. And when we start looking at all the different types of diets that are out there, lots of exclusionary food diets, then the intake of creatine is lower. What we're finding in the research from a health perspective is that it does so many positive things when you're able to saturate the tissues to bring it up with even a small dose of three to five grams a day. Our liver makes about three, but we don't necessarily eat enough to help supplement all of the tissues.
--:-- Steven Bartlett: How much would it take? Like 12 chicken breasts or something?
--:-- Dr. Stacy Sims: 22.
--:-- Steven Bartlett: 22 chicken breasts. A lot.
--:-- Dr. Stacy Sims: So when we look at the supplementation and being able to saturate all of our tissues thoroughly to support those fast energetics, we see things like better cognition, focus. We see a faster recovery from small brain trauma. Like a friend's daughter hit her head on the laundry door of the dryer and got a TBI or a small concussion from that. Started using creatine, came out of it a lot faster. I mean, there are things that help with brain metabolism.
--:-- Dr. Stacy Sims: We see women who have incidences with IBS or gut issues, and they're using creatine. It helps decrease the symptomology. We're seeing now studies coming out about fatigue. And this is where the 0.38 grams per kilogram of body weight, or the equivalent of 20 grams if you're 60 kilos, helps with fatigue and focus, especially if you're under a lot of high stress. Because if you're under a lot of high stress, your body's going through a lot of blood glucose trying to keep up with that stress. So creatine isn't just the bodybuilding set. There's so many different health benefits, and it keeps coming out with more and more research to show how beneficial creatine is.
--:-- Steven Bartlett: Could you give me the menopause supplement stack, if there is such a thing?
--:-- Dr. Mary Claire Haver: Okay. So in general, we're not going to cure menopause with supplements. Let me just say that straight up, okay? Most women are going to be deficient in fiber and most women are going to be deficient in vitamin D. And vitamin D is hugely important in multiple enzymatic processes in our body and it's really hard to get enough through our nutrition, even eating stacks of salmon a day, which is really high in vitamin D. So about 80% of my patients are not only just low in vitamin D, they're deficient. So that is one that we can supplement safely up to about 4,000 IUs, international units is how vitamin D is measured, a day without worries of becoming toxic or having too much vitamin D, which is possible. And so usually I'm having creatine, absolutely. It's like a go-to. And we're looking at her nutritional profile, we're looking at her fiber intake, and then we're adding in a fiber supplement if she needs it.
--:-- Steven Bartlett: Natalie, in terms of fertility, yes, the fertility supplement stack per se?
--:-- Dr. Natalie Crawford: First and foremost, we're going to say that if you are trying to get pregnant, which by asking fertility we're going to presume, we want to make sure you have folic acid on board. So folic acid is the essential component. One very important part in cell division, but it is essential for a baby when it comes to brain development and spinal cord development. We call these neural tube defects. And the reason why I'm bringing it up is that there is a lot of chatter about folic acid out there, but it is the only supplement, folic acid in its folic acid form, that has proven to prevent these neural tube defects, such as your baby being born without a brain.
--:-- Dr. Natalie Crawford: And interestingly, in today's world, a lot of foods are also fortified with folic acid. But these are some foods that are often processed and people are consuming less. So we are having less consumption of folic acid in our diet, therefore making it even more important that we are supplementing with folic acid.
--:-- Dr. Natalie Crawford: As Dr. Haver said, vitamin D. Vitamin D is essential for your entire body. But when it comes to hormone metabolism and fertility as well, we even see women who are going through IVF with donor eggs, and we know they're very good quality, have lower success rates if they have lower vitamin D levels. This is something that almost everybody is deficient in. We do test and then target treatment to try to get you to an optimal level.
--:-- Dr. Natalie Crawford: But also omega-3 fatty acids are really important in your entire body, but especially in your reproductive years if you might get pregnant. And I often recommend magnesium for most patients as well.
--:-- Dr. Natalie Crawford: And then from a fertility standpoint, if you have infertility, there are studies that show that coenzyme Q10 can be highly beneficial when it comes to egg quality. This is important in our mitochondrial health. And for the sake of the one question you asked, remember when we talked about eggs, we've got our genetic health, which is largely dependent on age. We have our metabolic health. The mitochondria from the egg controls all development for the embryo. And in fact, the cellular functions for an embryo, the first three days of life, solely come from the egg. The male genome doesn't even kick in until day three of embryo life. So the function of the egg to be able to divide and do normal cell functions is very important. And sometimes we see that reduced in infertility patients, and Coenzyme Q10 is an easy thing we can get over the counter. Doesn't appear to have any harmful side effects and has potential benefits in some subsets. So my infertility patients, I add that on.
--:-- Steven Bartlett: Vonda, all things aging, performance, strength, bone. What is the supplement stack for longevity?
--:-- Dr. Vonda Wright: Vitamin D. Magnesium is critically important for a variety of metabolic functions. Omega-3 for anti-inflammation. Creatine, I'm a big fan of.
--:-- Dr. Vonda Wright: If we move to looking at senescent cell load and inflammation... we haven't really talked about longevity, but senescent cells are those cells left over from normal function that are so damaged that they can't flip into programmed cell death. So they circulate around and produce noxious chemicals that can lead to a variety of disease. So we want to minimize those. And one way to do it is lifestyle. Another way is to use an herb called Visotin. So I add that on.
--:-- Dr. Vonda Wright: And then also, I do myself and check levels on my people of intracellular NAD+. NAD is a coenzyme in 300 metabolic reactions. It's an energetic pathway. Now, it's very popular right now. And the critical differentiator for me is that taking whole molecule NAD, such as in IVs, our body needs to make it. So for myself and for my people, I supplement with NMN, which is the immediate precursor of NAD+, so that my body can then turn it into NAD+, and it can work intracellularly. It can also be delivered two reactions out in the form of NR. These are in the B vitamin categories. So that in two reactions, your body makes NAD+. So the data does not show that you can IV NAD for efficacy because it works intracellularly. So you supplement its precursor.
--:-- Steven Bartlett: I've heard so many people talking about NMN recently.
--:-- Dr. Vonda Wright: Yes, that's right. That's what I'm talking about.
--:-- Steven Bartlett: Is there clinical evidence to show that it's effective?
--:-- Dr. Vonda Wright: So, you know, the lab that I work with, I happen to know the scientist and he has hundreds of thousands of data points checking before NAD plus levels, intracellularly supplementing and then after. And he can elevate those levels. And it's associated with longevity, like intrinsically associated with longevity.
--:-- Steven Bartlett: A lot of the bro science, I guess.
--:-- Dr. Vonda Wright: Well, it's intrinsically related to lots of normal metabolic function and energy in the body. Whether or not it makes you live longer, I don't have that data.
--:-- Steven Bartlett: Is it a tablet?
--:-- Dr. Vonda Wright: It is a powder, the way I take it.
--:-- Steven Bartlett: What about collagen? People talk a lot about collagen. It's in all the protein powders now.
--:-- Dr. Stacy Sims: I know, but it's not a protein as we think about it. Like you'll see all these "collagen protein." It doesn't count as dietary protein for muscle development.
--:-- Steven Bartlett: Does it work as a supplement?
--:-- Dr. Stacy Sims: It depends on what you're looking for.
--:-- Dr. Vonda Wright: Yeah, exactly. And Mike Ornsby out of University of Southern Florida, he has been doing quite a bit of research on collagen and joint pain and found that there is some efficacy in taking the type 2 collagen to reduce joint pain. It doesn't help with cartilage regeneration, it doesn't help with osteoarthritis, but it does dampen inflammation and joint pain. So again, it depends on what you want to use it for.
--:-- Steven Bartlett: In the first episode, we talked a little bit about environmental toxins. I wanted to, before we talk about sleep and close off, I wanted to just mention environmental toxins and the role they play. The term microplastics has been very, very popular of late. When we talk about environmental toxins, are we talking about microplastics in the air and maybe the water? What do we mean?
--:-- Dr. Natalie Crawford: Essentially, it's anything in our world that is impacting your body and how it functions. There's a few different types, right? So we have endocrine disrupting chemicals. These are actual toxins in the environment, in cosmetics, our kitchen, our food that change how our endocrine system works, our hormones. There's also things like microplastics, like you mentioned, which are actually going to deposit in our body and can cause fibrosis even in our ovaries, therefore changing how an organ's able to respond, even if it is given normal hormone signals. And then I also lump into this category behavioral toxins, right? Things like alcohol, marijuana, cigarettes, the choices that are toxic in our world as well. So "toxins" is kind of a large category.
--:-- Dr. Natalie Crawford: There are some toxins you can control. You can try to filter your water. You can learn what is in your water so that you can say, at the EWG, "This is my zip code, this is what's in my tap water. What type of filter might I need to try to have healthier drinking water in my home?" You can change what you're cooking with, not using non-stick cookware or Teflon. You can get rid of plastics, and especially when you're putting hot foods and beverages in, because the heat is allowing those toxins to leak into those things. And then as Dr. Haver said, our cosmetics, things that you use every single day that you put in and on your body are things that you're having a higher exposure to.
--:-- Dr. Natalie Crawford: And it's really important to decrease those because things like air quality you might not have as much control over based on where you live. And there are so many toxins in our world in general that it's unrealistic to say, "Let's avoid all of them." And because of this, we have that same mentality that we see with exercise sometimes: "Well, it's just too many, I can't avoid them all, so I will ignore this category," because it's easier to do nothing instead of making active decisions to start to live a less toxic life.
--:-- Steven Bartlett: So what changes have you made to remove pollutants and environmental toxins from your lives? Because we're in that fertility journey. I remember I came in one day and like all my shampoo and stuff had gone.
--:-- Dr. Natalie Crawford: Yeah. So you're starting to look through your products and getting rid of things that have endocrine disruptors in them.
--:-- Dr. Mary Claire Haver: You want to look... the kitchen is probably the greatest source of exposure for most people. So there's really no need to have any plastics in your kitchen. So getting rid of them. But many people don't think about when you do have processed foods, the wrapping, the container, anything that's coming packaged likely has toxins in it. When you order DoorDash and it comes and you have it in a container, that's often hot food in a container that is leaching chemicals into it. So a simple thing is take it out of that right away, even if you're not eating it. Put it into something glass or a different type of container so you can try to minimize that exposure.
--:-- Dr. Mary Claire Haver: Thinking about hot beverages, things that go in the microwave or the dishwasher especially. But then other things like thermal receipts. So getting receipts... thermal receipts have BPA in them.
--:-- Steven Bartlett: Thermal receipts?
--:-- Dr. Mary Claire Haver: Yeah, so the airline tickets or that thermal paper. So just the receipt from the grocery store when they say, "Steven, do you want your receipt?" You can just say no. Thank you. And then if you work with thermal paper, maybe you're a cashier and you touch it over and over, I highly recommend you wear gloves because your exposure to that thermal paper is so much higher that it can become problematic for you.
--:-- Steven Bartlett: Does it really make a difference if I take the receipt or not?
--:-- Dr. Natalie Crawford: You know, there's a lot of things where you can do that will say, "That person touched receipts all day and they still got pregnant or their sperm was great or they lived a long time." We can list a whole lot of negative behaviors or habits or exposures that one person might tolerate just fine. And for somebody else, the sum of all of these behaviors add up to be something that puts them in a place that is very pro-inflammatory, not healthy for the now or for the future.
--:-- Dr. Natalie Crawford: That to me is an easy decision. On the scale of decisions that are hard or that are easy, trying to change the things that you're exposed to in your world, you have to spend some time to learn about it. You might have to buy some new things, but over time those decisions are ultimately easier than how you eat or your exercise. Those take longer commitment. And especially if you're partnered, if you live with somebody, then the foods that you eat, your sleeping habits depend on them. You both have to be together on this.
--:-- Dr. Natalie Crawford: So sometimes I always say toxins are one place. I think you can do... you can look at your products. You can start to, when they run out, say, "Is this one healthy for me? Should I get something that's going to have less of an impact?" That one time of using very scented hand wash is no big deal. But when you wash your hands with that highly scented hand wash five times a day over and over, it is just an avenue of endocrine disruption that can add up to the litany of the other ones that you're experiencing. So we're all saying these little changes on one hand singularly probably do not matter much, but together they do.
--:-- Steven Bartlett: And there's a link between environmental toxins and menopause or early menopause?
--:-- Dr. Natalie Crawford: Early menopause. We think so. So, you know, you were born with a shelf life, a genetically predisposed shelf life on the ovary. Okay, and we don't know a lot of things to extend that shelf life because we have a certain number of eggs. But there are a lot of things we can do to speed that process up. So that's going to be smoking. Women who smoke cigarettes, or even looking at vaping now because it's a newer thing, but definitely tobacco consumption in the form of smoking, we see earlier menopause.
--:-- Dr. Natalie Crawford: Also stress. So there was this incredible study where they looked at women who were sexually abused, who then had children who were sexually abused, went through menopause, I think, nine years sooner. And it's the only study that looked at this, and it happened to be the stress they looked at was sexual abuse in the mother and the child. And so they went through menopause nine years sooner. So there is a component of emotional stress and long-term chronic emotional stress. Because it does cause chronic inflammation.
--:-- Steven Bartlett: Yeah.
--:-- Dr. Natalie Crawford: And the ovaries are highly sensitive to chronic inflammation. We know that BPA exposure has shown that if you have a higher level of BPA exposure, you have lower ovarian reserve, meaning less eggs in your ovary, and will go into menopause earlier.
--:-- Steven Bartlett: And what is BPA?
--:-- Dr. Natalie Crawford: BPA is one of those environmental chemicals that we're exposed to largely through plastics, but it's also one that's in the thermal receipt paper that we're trying to avoid our exposure to. And that's where some of the data, even when it comes back to food, where soy, in taking soy products, can actually be very protective because it combats BPA. So how it works... when people say, "Oh, you shouldn't have tofu, you're a man, soy is so bad for you," that's actually false. And we found that people who had a greater exposure to soy products actually had the lowest level of BPA and improved reproductive performance because of that. So there's definitely correlation with these toxins in our world. And we might say, "Oh, is it linked to menopause? Maybe nobody's done that exact study," but it absolutely is. If you have lower eggs at an earlier time period, it's going to give you an earlier menopause. You know, the flip side of fertility is menopause, right?
--:-- Steven Bartlett: And lastly, I wanted to talk about sleep. Well, it's all of our favorites.
--:-- Dr. Vonda Wright: Yeah, and we're doing it a lot.
--:-- Steven Bartlett: So yeah. I wonder, I've heard you refer to sleep as the pillar of everything. And I say that because we think sleep is just passing out, like we're not conscious.
--:-- Dr. Vonda Wright: Well, that may be true from a from a, uh, our viewpoint, but it is the most regenerative period in our day. Actually, the brain is processing information, getting rid of toxins. The body is able to settle and, again, get rid of toxins. But many women in midlife have completely disrupted sleep because estrogen is critical.
--:-- Steven Bartlett: Most.
--:-- Dr. Mary Claire Haver: Yes, 80%. Very high. Estrogen is critical for sleep patterns. Many women wake up at 3:37 or thereabouts, either with a plummeting blood sugar, or that seems to be around the time in the middle of the night that the sleep disruption happens. So this broken up sleep, if you don't do it, then all the lifestyle things Stacey and the rest of us have been talking about are nearly impossible to do if you're under-recovered.
--:-- Dr. Vonda Wright: And so I have made, after nearly 11 years of not sleeping because of training and child, a religion almost. Like I am dedicated to this function. I do not eat three hours before I go to sleep. It's one of the primary reasons that I made the decision to stop drinking alcohol, because that completely disrupted my sleep. And I am more conscious of circadian rhythm than I've ever been in my life. Meaning I go to bed at the exact same time every night, except probably when I'm traveling, but at the exact same time every night. But more importantly, get up at the exact same time every day to start my circadian day and to start my adenosine usage so that by 9:30 at night, I'm ready to rest. It's that important.
--:-- Steven Bartlett: A Woman's Guide to Aging with Power, Unbreakable.
--:-- Dr. Vonda Wright: Yes, Unbreakable.
--:-- Steven Bartlett: And central to that is circadian rhythms and sleep, right?
--:-- Dr. Vonda Wright: It is, because the premise of this book is that women are already winning the longevity race, but we suffer longer. And we have this vision of women aging, which is usually a vision of frailty. But through the mindset changes, through the behavior such as sleep and lifting and considering hormones, we can age in a different way. So I'm trying to re-educate the world that a woman's destiny is not frailty. A woman can age powerfully, but not if we sit around and wait for time to make us its victim. We must be proactive. And sleep is one component of that.
--:-- Dr. Natalie Crawford: This should be the very first thing you do. Sleep sets the stage for your entire day. It's really that foundation of your health. If you are going to start the day in a sleep deficit, you're starting out stressed, inflamed, insulin resistant. There's going to be no behaviors you can do during the day that are going to overcome the deficit. And we know that women who get less sleep, they take longer to get pregnant. They have higher rates of infertility. We know that men who get less sleep have lower sperm parameters and lower testosterone levels. So if we are saying, "You, Steven, what's one thing you might be able to do?" Well, are you sleeping well? That's one of the first things you can start to do to say, "Am I getting seven to nine hours of good quality sleep?"
--:-- Dr. Natalie Crawford: That's not just time in bed because Mary Claire has her phone on her. That is actual sleeping time. And that makes a huge difference in trying to achieve hormonal health, which is really what we're all saying here is how do we get our body in the best, quote unquote, balance that we can, which means working with the different building blocks of our body in the most optimal way for as long as possible to be healthy. And even if we're not looking from a fertility standpoint, you can't invoke any kind of metabolic or body composition change without adequate sleep. So that's what I mean. When we're talking about the pillars and sleep being one of the first things we have to work on, you can't invoke any kind of change.
--:-- Dr. Mary Claire Haver: We're not talking about ambient induced sleep. No, no, no. Medication induced sleep doesn't count. This is not medication induced sleep. There's a huge percentage of patients out there who are addicted to these medications and it has become the only way that they can sleep.
--:-- Steven Bartlett: I've been really shocked at several of the women in my life that are between the ages of, I'm going to say 35, yeah, 35 and 45, who have like three to four hours sleep. And they appear to be perfectly fine.
--:-- Dr. Natalie Crawford: They are not. They are not. Their cells are not fine, Steven.
--:-- Steven Bartlett: No. Because obviously, because I do this a lot, I learn from all these scientists. But there's one particular, there's two particular women that I'm very close to that I actually work with in different capacities who showed me their WHOOP data and would often tell me, they would say, I get three hours, four hours sleep. And I thought there's no way because she did a 5K this morning at 6 a.m. So there's no way she's getting three to four hours sleep. So put a sleep tracker on her and she was getting three to four hours sleep. And her restorative sleep is like 45 minutes. But she's springing into the makeup chair next to me and she's got all the energy. I'm thinking, what the hell is going on?
--:-- Dr. Vonda Wright: Youth. I'm younger than her.
--:-- Steven Bartlett: Yeah.
--:-- Dr. Vonda Wright: I mean, when I was in training, I was getting three to five hours and getting up and operating and functioning. But I cannot do that now.
--:-- Dr. Stacy Sims: If I got three to four hours, I was good for the day. Because I was 20 years, 25 years younger. I think we all got through it.
--:-- Dr. Mary Claire Haver: I was telling some of my earlier phases. A breastfeeding mother is getting three to four hours. That is part of that.
--:-- Steven Bartlett: Wow, we're built. We can function, but age will take that resilience away from us.
--:-- Dr. Stacy Sims: Because perimenopause causes sleep fluctuations as well because of the change in hormones, right?
--:-- Dr. Natalie Crawford: Exactly.
--:-- Steven Bartlett: And are women just assuming that's normal and rolling with it or is it okay?
--:-- Dr. Mary Claire Haver: I think we have more public education about how important sleep is and the number of hours you need and the quality of the sleep. So I think years ago it was their normal and I'm just going to keep going. But now they're coming in saying this is a problem.
--:-- Dr. Natalie Crawford: Yep. I need help.
--:-- Dr. Stacy Sims: And I would be interested to see your glucose monitor when you first used it. Because that's how we can kind of navigate sleep too, is showing hypoglycemic effects for women who are exercising in perimenopause and not eating enough.
--:-- Steven Bartlett: Melatonin, is that a solution?
--:-- Dr. Natalie Crawford: No. It can be a tool in the toolkit. Most of the time, most people are taking too high a dose of melatonin which is actually doing more harm than good.
--:-- Steven Bartlett: What harm is it doing?
--:-- Dr. Natalie Crawford: Well, it's actually shutting off part of the brain to be able to help control their circadian rhythm. And then they're completely dependent upon it. And it's such an artificial induction, it's going to wear out of their system. So your melatonin is supposed to rise, help you go to sleep, and then it falls at a rate for when you're going to wake up so that when it's lower, you're going to wake up and your cortisol will naturally rise. Melatonin can be helpful in very low doses. Like 0.3. Most people are taking 5 to 10.
--:-- Dr. Mary Claire Haver: Yeah. Yeah.
--:-- Dr. Natalie Crawford: So I often recommend patients take maybe like a milligram, but you have to buy a children's melatonin very often for that dose because people are taking these huge amounts over the counter. You can just get so much. And so what you want to make sure is that if you're using it, you're going to take melatonin at a time where you're going to be able to go to sleep about 30 minutes afterward too. Because people are also using melatonin and then not allowing themselves the restful moment when it's trying to kick in, and then they're taking more or they're staying up later and they're suppressing their brain's ability to make their own melatonin.
--:-- Steven Bartlett: One of the questions we had from the audience was from a young girl that said, a young woman that said, "I'm 24 years old and I struggle so much to fall asleep. How can I fix my sleeping naturally if I have disturbed circadian rhythm and especially during my menstruation my sleeping pattern seems to get worse?"
--:-- Dr. Stacy Sims: This one would be interesting to see what her daily habits are. If we can kind of bring calorie intake and all those things back into the day so she's not phase shifting, and then use things like L-theanine, which is a non-protein amino acid that works on the GABA right, trying to bring parasympathetic activation back and calming them down.
--:-- Dr. Mary Claire Haver: And seeing what your sleep hygiene habits are. Is your phone out of your room? Do you have a cool bedroom? Do you have earplugs to block out some of the extraneous noises from what your partner is doing?
--:-- Dr. Natalie Crawford: Yeah. But sleep is really a lifestyle problem for most.
--:-- Dr. Mary Claire Haver: It is. But magnesium can be advantageous as well, especially if you're on your menstrual cycle and you're having menstrual related sleep issues.
--:-- Steven Bartlett: Why?
--:-- Dr. Mary Claire Haver: Well, many women run low in magnesium, especially when your hormones are very low, especially when your estrogen and progesterone are low. You're having contractility of your uterus when you're having menstrual cramps. Magnesium can help counter some of that and can also help you, if you're taking it at night, get into a more restful pattern.
--:-- Dr. Natalie Crawford: So I've been working with a sleep medicine specialist. And one of the things she points out, which I now discuss with my patients, is if women wake up in menopause from hot flashes, from night sweats, and then the relaxation we get from progesterone is gone, so we can add that back in. So say we've done all the things. We've given her a touch of melatonin. We've put her on hormones. She is still waking up at 3 in the morning consistently. She deserves a workup for sleep apnea because women disease differently than men. And men with sleep apnea, it's a very common presentation of snoring. They're waking up their partner, all these things. Women are much quieter about it. They still have the palate that falls back and the relaxation, and that's hormonally driven for a lot of women. And so they're becoming hypoxic in the middle of the night. That's one of those side effects of having sleep apnea is you stop breathing and your oxygen levels decline. You become hypoxic. But we are not recognizing it. And women, more than 50% of women are going undiagnosed and are living shorter lives, having more Alzheimer's because of this. So if I have a patient coming in and we've done everything and she is still consistently getting up, I'm sending her for a sleep apnea evaluation.
--:-- Dr. Mary Claire Haver: I've also been reading literature on CBT for insomnia that they've done with a lot of veterans and shift workers. And that seems really interesting.
--:-- Dr. Natalie Crawford: To help them fall back asleep.
--:-- Dr. Mary Claire Haver: Yeah, to break the pattern because your body and your brain learn that wake-up pattern. So if you can reset it, then that's very helpful as well.
--:-- Steven Bartlett: What is the most important thing we should have talked about that we didn't talk about, Dr. Wright?
--:-- Dr. Vonda Wright: I think we covered an amazing array of information. But what I want women to walk away from this is that there is hope for feeling like themselves again and that they are worth investigating to the ends of the earth to find the answers they need and not simply giving up the first time somebody says no to them or doesn't hear them when they say that they don't feel like themselves. They must continue to pursue it. And number three, that they are worth the work that it takes to age with power.
--:-- Steven Bartlett: Beautifully said.
--:-- Dr. Mary Claire Haver: Octavia, you really do need to be the CEO of your own healthcare. We have a medical system that was not built to serve the aging woman. After reproduction ends, we just become small men with breasts and uteruses, to quote Dr. Sims. And it's okay to educate yourself. It's okay to read the books. It's okay to go in educated with checklists. And you're going to probably have to do that and go find someone who's educated in the health of women after reproduction ends. And that could be your internist. It could be family medicine. But no one owns menopause. No specialty really owns it. And so you are going to have to quarterback a lot of this yourself until you find the right partner in this care. But it is worth it.
--:-- Steven Bartlett: Beautiful.
--:-- Dr. Natalie Crawford: I think when it comes to your health journey, nobody is really responsible for it except you. But there's this idea that we should wait until things are wrong to then go get them fixed. And what we are all trying to do across the spectrum of women's health and their lifespan is to say many of these things, if we start focusing on them much earlier and take a preventative approach, which is often against some of these recommendations about when you should screen or when you should do testing. But if we say, well, what is best for you as an individual? Focus on setting up a life that is going to help prevent some of these diseased outcomes. Start testing things earlier. You're going to be in a position of power to make the decisions that are right for you from a place of education and not be left making them out of fear or misinformation or not knowing. Because women will go through these stages. Time will make your fertility decisions for you if you do not. That's a fact. Your ovaries will stop functioning. You will go into menopause. So we need to both prepare for our reproductive years, optimize our fertility the best we can if that is a life goal for us, but also realize that it doesn't stop there. That you have to prepare for the next stage of the journey and what that's going to look like for you. But the steps to take care of yourself start well before if you're able to.
--:-- Dr. Stacy Sims: I look at the research and the health outcomes right now for women, and it is a very confusing space. So I always preface with the fact that I want women to be empowered. And how do you do that? You can't Google things and find out. So it's asking questions. It's sharing information. Most of all, taking up the space because you've earned it. I get so tired of the rhetoric that women should be small and demure and be like a delicate flower and things are happening to them that they can't control. I want the narrative to shift. I want people to say, "I own the space. I'm taking up the space." And it's my—I don't like to use the word "right" because it invokes a lot of angst—but it is your ability to understand your own body and advocate for yourself that's going to allow you to take up that space and get the answers that you want.
--:-- Dr. Mary Claire Haver: I've been advocating for so many women, myself included, and the pushback that you get from the medical society is real. It's not that they necessarily are trying to gaslight you, but it's just a product of the system. So you do have to push those boundaries. You do have to ask those hard questions. You do have to go in prepared to have that pushback. But take that space because everybody deserves a place at the table. And women's healthcare is being shunted in a way right now that is really unacceptable and we need to have a groundswell movement to push back.
--:-- Steven Bartlett: Thank you all so much. Thank you. Thank you. I really mean that. I'm thanking you on behalf of the many millions of people that are probably listening to this conversation. Because your conversations on this show have delivered more than 30 million downloads between you. So across YouTube and across audio, I was looking at the numbers and it's staggering. And you think about the impact of reaching potentially 30 million people just on this show in long form, and then their friends, and then their family, and then the advice that they give to everybody they know. And that domino effect is causing this wonderful ripple across the planet. And it's turning the lights on in different households and within families and amongst business owners like myself so that we can all cater to the plight, I guess, of women's health in a more effective way. Because, you know, even as a man, I've learned, oh God, so much from you four.
--:-- [The guests laugh softly]
--:-- Steven Bartlett: And the impact it's had on my life through improving how I show up for the women in my life, but also the way that I'm able to respond and support my partner, my sister, my mother in difficult times has been profound. And well done to all the men that have listened to this conversation and have gotten to this stage, because I know you often don't think it's a problem that you're going to deal with. But when 51% or 52% of the planet are women, it's going to be a huge part of your life, whether it's you having daughters or sisters or mothers. And through all of the work that you've done, I've been able to understand the women in my life better. And actually that's protected my relationships. And if it's protected my relationships, it's protecting me. And I've really noticed that. I've noticed how I've changed, especially through understanding the menstrual cycle, how I treat my partner. But it's you four. You four are like the Avengers of what you do. You're the very best in your industries. Thank you. I highly recommend everybody goes and checks out—I'm going to link all of your books below. Unbreakable, The Fertility Formula, The New Menopause. I believe you've got a new book on the way?
--:-- Dr. Mary Claire Haver: The New Perimenopause.
--:-- Steven Bartlett: The New Perimenopause. I'll link that as well if it's available for pre-order. And ROAR. But also just your content, you all make content, have Instagram pages and have websites. So all of that will be linked in the description below. And if you want to go deeper on these subjects that we've talked about today, then those are the doorways into a deeper understanding. I appreciate you all so, so much. Thank you.
--:-- [The guests respond in unison: "Thank you."]
--:-- Steven Bartlett: We've been talking for, what, nine hours now? And I'm sure it's helped a lot of people. Thank you.
--:-- [Applause and closing remarks fade out]
