Ep. 476 AMA #12: Weight Loss Resistance, Muscle & Menopause

Welcome to my first solo AMA episode in quite some time! 

I recently submitted the second round of edits for my book. That excited me and inspired me to reach out on social media and invite questions from my listeners and community.

In my conversation today, I dive into weight loss resistance and reverse dieting, and I also share what I have been doing over the past year to build muscle. 

Join me for a transparent and candid conversation, interwoven with questions from listeners and social media followers, where I answer many of the questions that matter most to you.

IN THIS EPISODE, YOU WILL LEARN:

• Why the death of my father inspired me to back away from fasting and focus on strength training

• Changing my mindset to prioritize strength over thinness

• How the sex hormone shifts during perimenopause and menopause affect body composition

• The benefits of reverse dieting to improve metabolic health         

• Using strength training to counteract the effects of sarcopenia

• Chronic stress and its impact on cortisol levels and metabolic health

• inflammation levels and toxins from personal care products, food, and the environment

• Importance of prioritizing sleep 

• Connecting with hormone-savvy healthcare providers

• The best supplements for overall health

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“I now eat in a wide feeding window to accommodate three boluses of protein and lift heavy things twice a week with a trainer.”

-Cynthia Thurlow

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Connect with Cynthia Thurlow  

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• Submit your questions to support@cynthiathurlow.com

Transcript:

Cynthia Thurlow: [00:00:05] Hey. Hey. This is the first AMA solo episode that I have done in a very long time. And so many of you have asked, have requested to beg me to do one. And I just submitted my second round of edits for my book. It is May 29th. I am pretty darned excited. And I felt compelled to reach out to everyone on social media to get people's questions that they wanted to have answered about weight loss resistance, reverse dieting, what I've been doing for the past almost year to put on muscle. And it's going to be a transparent conversation that will also be interjected with questions from listeners and followers across social media. And so, let's dive right in.

[00:00:52] I think very transparently I shared last year that after my father's death it really had a huge impact on me. I physically very much like my father's side of the family, tend to be smaller built, smaller boned. One of the contributors to my father's death was sarcopenia and frailty and falls as I have shared previously. And it really had a huge impression on me. I think that, my relationship with my father was a difficult one, but he had been through many health crises before, but this one he didn't bounce back from. And so, I recall after he was buried that I really felt like one of the things I needed to prioritize was getting really serious about strength training. 

[00:01:43] And this is not to suggest that I have not been transparent or honest about how much I was strength training, but I really wanted to build muscle and in making that a goal for myself, it meant that I had to change some other things. And so that really speaks to the fact that I backed off on fasting and I've been doing that for almost 10 years. That doesn't mean that I don't occasionally fast. That does not mean that I am eating in a very compressed feeding window. In fact, it means that I am now eating in a wide feeding window to accommodate three boluses of protein. And we'll talk more about this and then lifting heavy things twice a week with a trainer. 

[00:02:23] And I'm happy to report that in the past nine months, I've gained three pounds of muscle and I have lost a pound of fat. Now, I would love if it was 3 pounds of muscle and 3 pounds of fat, but that hasn't been the case. And I think it'll be a constant work to fine tune and figure out what I need to be doing to build two more pounds of muscle and lose some body fat. With that being said, I would be remiss if I didn't say that it's a little bit of a mind screw when you step on the scale not just at your home, but at your doctor's office. And my internal medicine doc who's functionally integrative trained, Dr. Aaron Hartman, who I've shared very publicly, I work with. 

[00:03:06] We had a conversation and I said I would be lying to you if I said that when I looked at the scale, I was like, “wow,” I know I put on muscle because the scale has gone up, but I remind myself that it is a reflection of the fact that muscle weighs more than fat. And if you were to see me, I don't think you would think that I had put on 4 pounds of body weight. I think you probably would be surprised. So, I share this for transparency purposes. I share this because I'm human. I share this with the hopes that for any of you that are struggling with the same, stepping on the scale when you're really actively working to put on muscle, that you don't have that momentary blip in your brain because we've been so conditioned as women to be small and to be thin and to be skinny. And I'm here to tell you the things that keep you out of the nursing home, the things that keep you free from falls and free from the threat of falls is maintaining muscle mass and so, we have to prioritize that.

[00:04:09] And that's going to mean for some of you, that is going to be a little bit of a mindset shift. And again, very transparently, in 2019, when I left the hospital, I had lost 15 pounds. I was the thinnest I had been in my entire adult life. I was way too thin and it's because I lost all my muscle laying in a hospital bed, you can actually break down muscle and catabolize it pretty readily. It took a bit of time to put healthy weight back on. And over the past six years, with the transition into menopause, we know that we are at greater risk for accelerated muscle loss, shifts in sex hormones.

[00:04:46] Today, we'll talk about some of the things that are happening in our bodies that are a progression if we are not working against them in perimenopause and menopause. And so, I hope and I intend to have a transparent conversation with you all so that you will have a better sense of where I am on my journey and I can help support you on yours. Because there is no greater compliment for me is to read whether it is a podcast review, whether it is messages in our DMs, and I am generally the person reading the DM still at this point in time or emails that my team shares with me. It really brings me great joy to know that this is a wonderful platform and resource for you all.

[00:05:30] So, let's talk about why we develop weight loss resistance at this stage of life. Then I'll dive into some questions and I have a feeling this might turn into a two-part series because there are hundreds of questions that are sitting in front of me. So, obviously I won't be able to get to every single one in one shot and I want to try to keep this to an hour. So, first and foremost, as we are transitioning from the early stages of perimenopause into mid to late stages into menopause, a lot of what drives body composition changes or shifts in sex hormones without question. And so, with a decline in estrogen, we know that we are going to get increased fat storage. And these are the people that are saying to me, “I'm doing exactly the same workouts, I'm eating really healthy, I'm doing all the right things.”

[00:06:20] It is a hormonal situation. It is not a lack of effort. It is not a lack of information. The hormones are shifting in your body and hormones govern just about everything. So, number one, we know with this loss of estrogen, which generally is towards the latter part of perimenopause and menopause. We're going to get changes in fat deposition, especially visceral fat, which is the fat around our organs. So, when women say to me, I suddenly developed a menopot or a menopause belly or whatever vernacular you're using, that is a direct effect of changes in estrogen, it also can be worsened by shifts in testosterone. And we know not every woman in menopause has low testosterone. In fact, if you are someone that has PCOS or you're just part of that 25% of women in menopause that still have healthy testosterone levels, you are not part of this. 

[00:07:14] But I find that for most women, it is a combination of estrogen-- low estrogen, low testosterone, that can worsen these body composition changes. And so, we know that less testosterone is going to impact how we build and maintain muscle. It's also going to have an effect on metabolism. Progesterone doesn't have as much issue with the body composition changes. But obviously if progesterone levels are not optimal, we're going to have fluid retention issues. We can have poor sleep, which we know can worsen metabolic inflexibility and metabolic health, as well as more anxiety and depression. And when you're anxious and depressed, some of us eat and some of us don't eat. But I think all those things can definitely play a role. 

[00:07:58] We also know that estrogen is really intricately involved insulin sensitivity. And so that loss of insulin sensitivity, this is why people will sometimes be unable to eat the fun foods they ate in their 20s and 30s. I know for myself anything with flour is problematic. So, I try really hard not to keep gluten free brownies or cupcakes or cake or anything like that in my house because it is kryptonite. I can moderate dark chocolate. So, that loss of insulin sensitivity may impact the way you metabolize alcohol. It can impact the quality of carbohydrates you consume. It may impact a lot of carbohydrates. So, if you are already insulin resistant, you have to be conscientious about your carbohydrate intake.

[00:08:40] And so again, it goes back to if you're insulin resistant, if your fasting insulin is high, if you have low estrogen, low testosterone, it can worsen these body composition changes. This ties into the next thing which is really speaking to sarcopenia, this muscle loss with aging. It's not a question of if, but when it is going to happen if you're not working against it. And I think for a lot of people, I see a lot of women in-- and I'm going to pick on Pilates and I love Pilates, I like it for posterior chain work, flexibility, etc. But a lot of women assume that you just have to do Pilates and that's enough to build muscle. In many instances, it's great for flexibility of posterior chain work, which means the muscles on the back half of the body not as great at building and maintaining muscle unless you're working in a very intense regimen. So, I think that with age we lose muscle mass. Muscle mass begets insulin sensitivity. 

[00:09:40] The less muscle mass we have, the less calories we're going to burn at rest. And so, I just try to reemphasize like we want to be strong over skinny. I think this is a very important distinction to make. And it's one that again can be a little bit of a mindset shift, especially for people in my generation, I grew up in the 70s and 80s it was all about fat free, low fat, non-fat and we were conditioned to believe to be teeny tiny, skinny. And that was the ideal. And that's about the farthest from the truth. 

[00:10:07] Another thing that really contributes to changes in body composition is poor sleep. And I'm shocked at how many women really do not sleep well. And in some instances unsympathetic providers who don't properly counsel you on stress reduction modalities, don't talk about that loss of progesterone that's contributing to poor sleep. Don't talk about the role of hormone replacement therapy, talking about eating too close to bedtime, all the things that we know can contribute. And very transparently, this past year has probably been the most stressful year of my adult life. Between three family members deaths, my husband getting sick, writing a book and my youngest getting mono, it's been a lot.

[00:10:55] With that being said, I've had to be very proactive about managing stress. And I can also share very transparently that my functional medicine doc was shocked when he looked at my saliva cortisol results because they were actually pristine. And I think it has a lot to do with the things I do to manage my stress day to day, which I'm happy to share. Another thing that contributes to this is chronic inflammation. So, a little bit of inflammation is good. Chronic inflammation is not. We know with these sex hormone changes, changes in insulin sensitivity, loss of muscle mass, we can develop some degree of chronic inflammation. And in fact, chronic inflammation, chronic stress can lead to poor gut health. Obviously, my second book is really highlighting a lot of the microbiome changes that are happening at this stage of life that have systemic effects, meaning they affect every body system that you can imagine. And I can't wait to start sharing more content about the book, but right now I'm not going to. 

[00:11:53] We also know inflammation can come from toxins and this is not a trendy thing. But things in our personal care products, our environment, our food can all be inflammatory, especially if we're eating the most inflammatory foods. And so, this may be different for every person listening, but I find the big ones, gluten, grains, dairy, sugar, alcohol, can be really problematic in doing something as simple as a Whole30 for 30 days can be very insightful. Whole30 is not a forever thing. It is a temporary stopgap measure to get a sense of is there a food that could be problematic? For some people it's FODMAPs, for other people it's nightshades, things like potatoes, eggplant, tomatoes, peppers can be problematic. And so, the other thing that I think I would be remiss if I didn't address with this community is that many of you, including myself, have had many, many years of intermittent fasting.

[00:12:51] And when I started tracking my macros prior to really hitting the ground running with my trainer, I wasn't eating enough food. And it wasn't that I was purposely doing that. I think you just get to a point you're intermittent fasting of one meal a day, two meals a day maybe. And then when you actually start tracking macros, which we'll talk about today, all of a sudden you realize, like, “I was under nourishing my body for a long period of time, not with intent. I think this is where the intermittent fasting community can become problematic. I think it may be helpful for people to intermittent fast for a while. Maybe then they reverse diet and we'll talk about what reverse dieting is ebb and flow between both of those. 

[00:13:31] But I would imagine that a lot of women, especially the very active women like I am, are just in a position where it's no longer serving them to do that all the time. That doesn't mean that I don't intermittent fast one or two days a week or even a few days a week. Tomorrow, I will be traveling to speak at an event in Palm Beach. And you better believe I will be doing a little bit of fasting while I'm traveling until I get to my hotel and I can get a clean meal in the city I'm heading to. So, we know that if you're undereating or if you're overexercising, this is this red triad that they refer to. It's an athlete's triad where they undereat, they overexercise, they over restrict consumption of calories.

[00:14:15] We know it can elevate your cortisol. And so cortisol is not a bad hormone, but gets a bad rap. We know that it can potentially with that high cortisol lead to abdominal fat accumulation. So, we have 40x more cortisol receptors in our abdomen than we do in other parts of our body. It can also catabolize or break down muscle. And this is very important because how many of you have said, I really want to build muscle, but you're fasting 18, 20 hours a day and you just don't realize that what you're doing is you're inhibiting your ability to build muscle. You know, Dr. Stacy Sims, I did a great podcast with her and she's a big proponent of helping women understand that when you get up in the morning, you're still catabolic, you're still breaking down muscle in the presence of fasting.

[00:15:01] And then if you're going to do a morning workout, you should have a small amount of protein 20 g of protein. And I've been doing that in my morning workouts. And again, I have not felt encumbered by having a small, whether it's a small piece of fruit with some protein, whether it's a small protein shake. Have not felt encumbered or felt like I couldn't get through my workouts, but definitely a different feeling than my afternoon workouts when I've already had two meals. I can definitely push myself a whole lot harder. So, something just to consider.

[00:15:30] And lastly, I would just say in terms of big themes, this disruption of the gut microbiome. So, we know as we are losing estrogen, it impacts immune function quite significant and substantially in the gut. And so, we know our gut bacteria are impacted by these sex hormones, in particular, estrogen impacts immune function, impacts insulin sensitivity, inflammation, nutrient absorption. And if you really look at the research, I've been knee deep in it. We know that something called dysbiosis, which is an imbalance of beneficial to nonbeneficial bacteria, is a harkening of the process that leads to leaky gut, developing food sensitivities, etc. 

[00:16:09] And so just to be keeping it on your radar, that our guts really do beget how we respond to being able to lose weight, as well as a myriad of other things, bone health, immune function, when we go into menopause or not. I know some of you are not yet there. So, let me start with the first question. So, in my free group, if you're not already part of this group, it's called “The Midlife Pause/Cynthia Thurlow” on Facebook Free Group, No drama. I don't tolerate any of it. And I, myself and Tessa, who is another team member, is another advanced practice nurse. We answer questions in there two days a week, so you can submit questions and then we just pull questions depending on where themes are.

[00:16:51] So one of the questions that was left for me today is how might a high FSH, this is follicular stimulating hormone, affect weight loss? She says, “An FSH over 70.” So, let's talk about what FSH is. Follicular stimulating hormone, it is a hormone in the hypothalamus, pituitary gland, that's communicating to the ovaries. So, we know based on study research, if you have two separate occasions where your follicular stimulating hormone is over 25, you very likely are in menopause or right there. There are some experts that feel like part of hormone replacement therapy should be normalizing that number. I think that is controversial. With that being said, an FSH of 70, if it was done on at least two occasions would be indicative of ovarian reserve decline. Excuse me, AKA menopause.

[00:17:49] And this is a question from Cheryl D. “I alluded to the beginning of conversation, the things that are changing in our bodies as we are navigating menopause.” And so, I would go back to some of the things that I was talking about sleep, stress, loss of muscle mass, changes in sex hormones, all of these things are going to make it harder to lose weight. Not impossible. We had to find that reframe, it's a little more tricky, usually requires a bit of diligence, but FSH in and of itself is really just indicative of these alterations in ovarian function, ovarian senescence, which is a fancy way of saying-- ovarian senescence is ovarian aging. Our ovaries are a pacemaker of aging in our bodies. But great question.

[00:18:37] This is a question from Amy Lynn R. “Best strategies for losing body fat that keeps creeping on. Specifically, for someone who already focuses on protein and works out three plus days per week.” I think it really goes back to basics. So, obviously basics apply to everyone and then there is nuance. So, number one, strength training. So, if you're working out and if you tell me you're doing Orangetheory Fitness or CrossFit three days a week, I would say you are better served by lifting weights two to three days a week and doing some degree of non-exercise induced thermogenesis. So, it's an acronym called NEAT. But just being physically active because a lot of people do their exercise and then they go and they sit on their bums all day long at work. I'm even guilty of this. 

[00:19:21] I'm sitting down as I'm recording this podcast. But I will be very active for the rest of my day because I've been seated for what now is like 30 minutes while we're recording. But we want to be active, park farther away when you go to the grocery store, take your dog for a walk more than once a day, if you need to get steps in and it’s super humid where you live, like it will be probably here in two weeks or it's raining outside or snowing, getting on a treadmill or getting on some type of apparatus at home or your gym is a good way to just get those steps in. I would say that, if you're getting your protein in, great, but how's your sleep? Are you managing your stress? 

[00:20:00] I feel like a lot of women are chronically stressed and they've just gotten so accustomed to never relaxing. To take a nap would be indulgent or sleeping in would be indulgent or saying no more often to social obligations would feel very indulgent. And I'm here to tell you that one of the most important things that you can do as a middle-aged woman is find your voice, create boundaries both professionally and personally. Stop saying yes to everything. I have a big thought process or methodology in my business. If it's not a hell yes, it's a hell no. So, if I don't immediately say “Yes, I want to do that, then I don't do it.” And I just politely say, “Thank you for that opportunity. I'm not interested this time.” 

[00:20:45] Same thing goes for things within our personal lives. Beyond what those things, I would say a really good stool test looking at inflammatory markers and we have PDFs that we can link up in the show notes for labs that we suggest and recommend. Just generalities and it goes without saying, targeted supplementation. A ton of questions about supplements, which we will get to, thinking really seriously about hormone replacement therapy, because those changes in sex hormones are going to impact body composition if you are not working against them. And what does that mean? That means even for me, having put on 3 pounds of muscle and lost a pound of body fat, and I jokingly said, “I wish it was equal, 3 pounds of muscle and 3 pounds of body fat,” that's just not the way it works. 

[00:21:35] I myself have been able to notice little subtle changes in my body, but it doesn't necessarily happen overnight and many of us are just not patient. I have moments of frustration for full transparency where I'm like, “I want this to happen faster.” I know because we've been conditioned by the diet industry that things should happen quickly, we should drop weight effortlessly. It should not be hard. I find for a lot of women also in this stage of life, they're just chronically inflamed. Whether it's dietary choices, things that they think are benign and innocuous. Like dairy is a really good example. I pulled dairy out of my life in 2018 and I got rid of the last 5 pounds of perimenopause weight that I just could not seem to get rid of. And it was just from occasional intake of dairy.

[00:22:20] So, it could very well be something that you are consuming sporadically, whether it's alcohol, whether it's treats, sweet things more often than not. I find when we start cleaning up our nutrition, we start seeing improvements. But that muscle mass loss is really something that I encourage everyone to focus in on. Get your labs checked, get some stool testing done, consideration to food sensitivity testing, and then getting very transparent about what you're using in your personal care products, food and environment. Because I just did a really great podcast with Aly Cohen and her book Toxins is a great resource. And she talks a lot about this toxin bucket is getting filled throughout our lifetime. By the time we get into middle age, all of a sudden, it's problematic. 

[00:23:09] So, really looking granularly at your personal circumstances and what you can change or improve upon, because I see a lot of female patients as an example, they have really stressful jobs, then they retire and they lose 20 pounds, or they're in a really toxic marriage and they finally get out of the toxic marriage and they suddenly have a lot less health problems, they're sleeping better. So, get really honest with yourself about what is working and what is not. I jokingly say that I have a complete inability to not say what I think. I was a reformed people pleaser for many, many years and at 53 years old, I can't not say what I think. 

[00:23:51] Whereas before I might have stifled my voice, now I feel an obligation to speak my truth, and I encourage each and every one of you to do the same. Okay, that was Amy's question. Now I'm going to jump to the hundreds of questions that are sitting here in front of me.

[00:24:06] This is a question from Emily. “I'm dealing with that lovely perimenopause weight gain. It's like I woke up one day and it packed all onto my midsection. I exercise regularly and eat a very well-balanced diet. I know some lifestyle modifications may be needed, but I'm so overwhelmed at where to start. Can you give some suggestions for the scenario?”

[00:24:24] So, just know that in perimenopause we have 20% to 30% greater fluctuations in estrogen at that time in our lives than we do at any other point. So, a lot of women including myself 10 years ago, I was on that slippery slope of what in the hell is going on with my body. I have changed nothing. Why are all these things not working? I think you start with basics. So, the basics for me are always sleep quality, managing stress. And we have to do more to manage stress in middle age than we did when we’re younger. This means that, you make that connection to nature, going to bed earlier, breathwork. And breath work can be really powerful. And I'm someone that fought meditation for a long time.

[00:25:10] I like breathwork, doing holotropic breathwork, breath therapy. I'm hoping to get Sachin Patel to come on and talk about how he guides people through that particular type of breath work, which I've done with him, which was incredibly powerful and for a lot of people with a history of trauma, can be very beneficial. But I think the sleep, the stress management. When you talk about a well-balanced diet, are your macros off? Are you eating too much healthy carbohydrate, like a lot of women think they can have a cup of rice with every meal, probably not. Those portions of carbohydrates, especially the grains or gluten, may need to be really curtailed. 

[00:25:54] In fact, when I'm working with patients, I will oftentimes say, I want you to measure out your portions. Maybe it's a quarter cup to a third of a cup of grains, if you tolerate them. Really looking at ancient grains like amaranth and teff, as opposed to rice and even quinoa, which I know a lot of people are very pro quinoa, but high carbs to get an adequate amount of protein in your diet. Some lentils, like I always say, combine animal and plant-based proteins would be mindful of portions because a lot of those plant-based proteins can be very carbohydrate dense. The other thing that I would say is, if you really like healthy fats, you like having a ribeye or you want that salmon steak or you want duck understanding that the saturated fats, although not bad per se, saturated fat like in the ribeye, fat is more calorically dense than protein or carbohydrates. 

[00:26:48] So, if you're trying to affect body composition, sometimes it means you have the leaner portions. You are having filet or flank steak, or you are having chicken breast, or you are having cod as opposed to those fattier fish and meat and chicken, excuse me, duck, that can make a big difference. And then it's really looking at labs. I think it's really, really helpful to get lab work done. Not just looking at sex hormones, but looking at inflammatory markers, fasting, insulin, glucose, A1c, high sensitivity, CRP, looking at thyroid, looking at leptin. There's a whole constellation, looking at targeted lipids beyond a lipid panel other than triglycerides and HDL, there's not a lot that I focus in on because we're really looking at some of those more advanced markers like ApoB and Lp (a), but really getting a sense of what's going on and then getting granular about how can we balance those hormones. 

[00:27:46] Do you need some oral progesterone two weeks out of your cycle to help balance this relative estrogen dominance because you have so much 20 to 30% more estrogen produced? It's like you have these wild fluctuations in perimenopause. I find for a lot of women that adding in some oral progesterone, please discuss with your licensed healthcare provider can be very, very helpful. Okay.

[00:28:11] This is a question from Denise. “I am 50 years old. Suddenly I'm 140 pounds. I'm 5’ 4” and I can't seem to lose my weight. What was effortless a year ago seems difficult now. I would like help, please. So, again, going back to some of those common themes that we've talked about sleep, stress, anti-inflammatory nutrition. When I talk about nutrition, we have to talk about meal frequency. Are you someone that's eating, snacking every two hours? We still have women in programs that tell us they're snacking every two hours. We know that the more frequently you are eating. So, if you're eating two to three meals a day, that is very different than six mini meals. That conditioning of understanding what is happening in your body when you are consuming food frequently that you are eliciting an insulin response, depending on what you're eating, could be higher or lower.

[00:29:01] Each time you do that, if your fasting insulin is up because you are in a fed state and you're eating with frequency and maybe you're eating too much carbohydrate and not enough protein, wrong types of fats that can be problematic and contribute to weight loss resistance. But more often than not, anyone that's submitting questions, there is some degree of hormonal imbalance, whether it's insulin, cortisol, thyroid, looking at our sex hormones, testosterone, estrogen, progesterone, those imbalances, and more often than not, it's a motley crew of imbalance. It is not just one hormone that's driving, it is multiple hormones driving it. And I find for a lot of people that once we figure out what they particularly need, some people need some food sensitivity testing because they're just not willing to pull things out of their diet.

[00:29:48] Some people need to get really honest about their alcohol intake. No judgment, but we know that alcohol does not serve us well. In particular in middle age, it can disrupt sleep, it disregulates glucose, insulin. Can contribute to food cravings. I always say, “You're not craving broccoli and chicken, you're probably going to crave junk.” So just to be mindful about that, I think can also be very helpful. 

[00:30:14] Next question is from Lisa. “I'm a 60-year-old female, pear shaped, all extra weight in my belly. I need to lose a minimum of 20 pounds. I intermittent fast. I eat healthy, no sugar or processed food, exercise moderately, five days a week, including strength training and Pilates. It all sounds good, but I cannot lose weight, suggestion. So, in none of these questions do I know if anyone is on hormone replacement therapy. 

[00:30:37] That is never the first solution for most people. It is really lifestyle mediated. And it sounds like Lisa's doing a lot of the right things. Remember, we talked about at the beginning that these changes in sex hormones can change where we deposit fat in our body. So, when we're younger it can be subcutaneous, which is annoying. It can be on our arms, on our backside, it can be on the back of our bum. We don't like that. But yet that is what gives us curves as women. And then as we are making this perimenopause to menopause transition, what can happen is we suddenly have visceral fat deposition. And so, what Lisa's suggesting is she's got extra weight in her belly, which to me sounds more apple shaped than pear shaped. 

[00:31:20] I was reading what Lisa wrote, but that's the kind of fat that we want to avoid because that's fat around our major organs. And that is the fat that tends to be more inflammatory, tends to be the fat that leads to more insulin resistance fatty liver, things like that. The other thing that I would say is for everyone who's feeling they are weight loss resistant, getting readings from a bioimpedance scale. So, most of the time you would do this through a provider's office or you can do Bod Pod, you can look them up in your area. There are other companies that do body composition testing, but those are some of the major ones. And get a sense of like, what is your body composition? Do you have a good amount of muscle mass? Or is that your biggest issue is that you have more fat mass than muscle mass? And what we want is the reverse. We want more muscle mass to fat free mass.

[00:32:13] I don't expect anyone as a middle-aged woman to have a body fat of like 10% or 15%. That would actually be quite low. I would expect most women to be in the 20s, kind of ideally. But I I've worked with patients who've been 35% body fat and really working diligently to build muscle to alter that body composition. But I think it's very important when you step on a scale, most scales are not going to break down your body fat to your muscle mass. And that's what is most important because like I said when I stepped on the scale, and I technically am 4 pounds up on the scale, the bulk of that is muscle. In fact, it's probably all muscle and probably I was really well hydrated because it was towards the end of the day. 

[00:32:58] The other thing that I would say is when you go to weigh yourself, do it first thing in the morning after you empty your bladder. Don't do it at the end of your day when you're hydrated. You probably have restored some glycogen stores in your muscles, in your liver, maybe had some carbohydrates. So just finding a time each time you're testing this to do that. So, again, body composition is very important because just looking at the number on the scale does not give us the full picture. And I think that is very, very important. Just checking time to see where we are. Because like I said, I have so many questions. We could just talk for hours.

[00:33:35] This is a question from Katie. “I'm struggling with belt fat and back fat. I think I'm doing all the right things. I think sometimes the reason I'm unable to lose it is threefold. One, I wake up at a ridiculously early hour for work. Two, I have trouble maintaining intermittent fasting on my work days. And three, I don't get enough protein. I've never had this belly fat and it's very depressing. I'm at a loss.” Katie, very common. And I would say, I think there's two things here. Number one, you wake up very early, so I'm not sure how early that is. So that's number one. So, you may be not getting enough sleep, which could definitely be contributing. I'm less concerned about maintaining fasting on your work days and more concerned that you're not getting enough protein. I would say the two most important things that you've already told me in this question or statement is I'm not eating enough protein. 

[00:34:32] We need to fix that because protein's important for muscle-protein synthesis, satiety, etc., and then the sleep piece. So, if you're someone that does shift work, maybe you're getting up at 4 o’clock in the morning, we need to get you in bed earlier. And I know a lot of women will push back when I say that, but I'm like seven to eight hours needs to be the minimum. It does not mean that every single day of your life it has to be perfect. But over time you want those to be themes of where we are in time and space. So, I would say the two things from your statement that I think are the two things to work on right now, get more sleep and definitely be focused on protein. Maybe track your protein, maybe track your macros for a week, not forever. Because for a lot of people that would make them crazy. It would make me crazy, quite honestly. But I think for a lot of people, not eating enough protein is going to contribute to a lot of other issues. There's something called the protein leverage hypothesis, really speaking to what happens when we don't eat enough protein. 

[00:35:31] So, beginning the conversation, we were talking about high FSH that combined with low estrogen, those two variables for women in middle age are going to define this protein leverage hypothesis, which states that if you do not eat enough protein, your body is going to ensure you make up for it with carbohydrates and fat. Now, if this happens once a month, not a big deal. I even know when this happens for me. In fact, today's a really good example. I've been gone for most of the day and I just had a very large meal and I will have another meal before the end of the day because I want to try to get that protein in before the end of the day. So, getting creative with protein, planning ahead, meal prep, adding in a protein shake. 

[00:36:18] I am not going to sit in judgment of anyone who has a whey protein shake a few days a week. I mean, if you are working diligently to buffer your protein intake. And maybe you've been doing that very tight intermittent fasting window for a long time. A lot of women will oftentimes say, “I'm just not hungry for that other meal. Well, we need to work on that.” And we will get to the topic of reverse dieting during this particular podcast. But I want to remind everyone that track the macros. If you can't measure what you don't track. So, track just to get a sense of where you are, start increasing your portions of protein. So, maybe instead of 4 ounces, you go to 5 ounces of a protein. Maybe you're having a protein shake in between your two big meals.

[00:37:01] But there are ways to go about it, but you have to be diligent. When I started weight training last August, methodically with a professional who knows how to train middle-aged women, we talked about my goals, we talked about the things that are important to me. And she does not like fasting. She's been very honest about it and we've had very honest conversations. And I would be the first person to say I probably have on a regular day when I'm home and I can eat when I want to and stop when I want to eat. I'm having three boluses of protein a day. But I didn't start off that way. It was probably two meals and then I would have a protein shake. For those of you that are dairy intolerant, you can certainly use essential aminos.

[00:37:51] Dr. Don Layman, who's the expert in this area, talks about “If you can't get a 100 g of protein in a day, adding in some essential aminos is fine. That should not be long term.” I think as needed it's fine. But if every day you have to add in essential aminos because you can't buffer your protein intake, we need to renegotiate what you're doing. Maybe you're having 35 g in two meals of protein. So that's 70. And then you're having two scoops of protein in a shake and that's going to buffer you over to 100 g of protein. But we don't want that to be forever because I do think it's important to eat real food. I think it gives your body very important information and just to talk about what essential aminos are. So, protein breaks into amino acids. 

[00:38:38] So, essential aminos are the amino acids that your body needs. There are certainly brands that I like. I think that you want to go with something that's clean and doesn't have a lot of ingredients. Most of the essential aminos, if they're flavored, they don't taste great. So, I use a capsule product by Kion and that's what I personally use. And that has worked well for me. But I have to take seven capsules to buffer that protein intake. So, it's not my favorite thing to do. So, I always caution people and say, “Try to get it from the real food. Try to give yourself grace.” But Katie, getting back to you, number one, get that sleep in. Number two, work on your protein intake. I think that will certainly help head things in the right direction. And again, prevailing theme, this is not an overnight fix. You have to be thinking about, this is a marathon, it is not a sprint race for weight loss.

[00:39:33] Okay, “Thoughts on rhodiola for perimenopause and weight loss.” This is a question from Wilma. So, for anyone that doesn't know, rhodiola is a wonderful adaptogenic herb that is beneficial for stress response. Most of the adaptogens buffer cortisol. Again, we know we become less stress resilient in perimenopause and menopause. I think it's wonderful for the right person. Rhodiola can be very nourishing, calming for evening time. Some women do really well with that at night. I haven't read anything that there's a direct connection between adaptogens and weight loss unless the connection is vis a vis reducing cortisol levels. 

[00:40:14] And let's talk about cortisol. So, cortisol is a hormone that gets a terrible rap and that should not be the case. I think it's important to highlight the fact that cortisol is a hormone that follows a predictable pattern throughout the day, ideally. So, highest in the morning, ebbs and flows throughout the day, lowest at night. And it runs in inverse relationship to melatonin, which is a sleep hormone but also a master antioxidant. And so, I always remind people that, cortisol just gets this really, really bad rap. Some of it I think is so undeserved. It's just really understanding the fact that with the loss of progesterone, with the increased demands on our adrenal glands, for a lot of individuals, they have to work harder at stress management.

[00:41:03] And it isn't just five minutes of meditation. It really needs to be a diligent practice, something that you are doing daily. Like for me personally, I like getting exposure to sunlight in the morning, walking out in nature with my dogs. Just part of my morning routine. I really crave it, I enjoy it. I like breath work. It's finding things that you like that you can consistently do. There is all sorts of gadgets that can be helpful, but I think the basics are very, very important. So, getting back to Wilma's question rhodiola is a wonderful adaptogenic herb. I think it can be helpful for sleep support. If we're talking about adaptogens and weight loss, I would imagine the mechanism is related to a reduction in cortisol over time.

[00:41:44] Okay, I got some very long questions. Let me try to find a shorter one. Super long. “Hello, Cynthia, I'm 68. In January of 2024, I started fasting and I've been doing some longer fasts. I cut out snacking and stopped eating processed foods. I added in kefir, homemade sauerkraut and only have mostly olive oil and butter. Reduce carbs and eat lots of ground veggies and some root veggies. I lost 20 pounds, which is great that I gained around my waist after menopause. I do not wish to lose any more weight. I basically continue with the same diet but only do one 24 to 32-hour fast per week. I eat plenty during the feasting, but then when I fast, I seem to lose weight. Around 18 to 21 hours of fasting I start showing a trace of ketones in my urine. 

[00:42:52] In between fasting I don't have ketones. How do I maintain without losing weight and should I- “Okay, so number one, if you're losing weight doing these long fasts, stop the long fasts. I would say you don't need to be doing if you're at a maintenance weight. I would say if you want to do one or two long fasts a month, I think that's fine. If you're building up ketones, it's because your body is mechanistically utilizing ketones as a fuel source. So, that's not per se a bad thing. How do I calculate the amount of protein-- So, she's asking “How do you calculate protein in particular types of protein?” You can go online. There's lots of online measurements that'll say 4 ounces of chicken equals 30 g of protein. You can just plug those in. There's lots of calculators. You don't need to stress about it. 

[00:43:46] If you use chronometer, you can plug it in there and they will do it for you. She's also asking about sourdough. There's a lot of questions all over the place. I'm just not a fan of bread. I think that it's not to suggest that when I go on vacation, I'm out of the United States. Will I have a gluten free piece of toast? Sure. But I think my patients and clients get their carbohydrates from whole food sources as opposed to a processed carbohydrate. And by that I mean something has been milled into a flour, it's been baked. I would rather you invest your efforts into having a piece of sweet potato or low glycemic fruit or if you tolerate like ancient grain, having some of that into your diet. I think you're going to get more benefits from that over time. 

[00:44:36] But I think overall, Carrie, the things that stand out to me stop the long fast, especially if you're losing weight and your desire is not to lose weight. Feel like you want to do one long fast a month just to support metabolic health, fine. But I would not do more than 20 to 22 hours and I wouldn't do it more than once a month. And I would monitor how you feel. Lastly, it's really easy to track protein. There are online calculators. You can also track it in chronometer. You can plug in exactly what you're eating. If it's 5 ounces of steak and it's 45 g of protein, you can just plug all those things in. So, don't let that be a stress source for you. I would just make sure that you are monitoring your protein intake because I think that is very important. 

[00:45:26] Okay, going on to the next questions. “I am struggling with 100 g of protein and weight loss. How to balance that?” This is from Marianne. Again, it really goes back to considering breaking your meals into two to three meals a day and then slowly increasing it. So, we know based on the science, you need at least 30 g of protein to trigger muscle-protein synthesis. Trigger this leucine threshold, which is a type of amino acid, very important for muscle. So, you need to determine what 30 g of protein looks like on your plate. That's number one. I'm not suggesting that anyone stuff themselves, I'm not suggesting anyone force themselves to eat. But when women start telling me they don't have the appetite for a second meal. That's a sign that we need to start reengineering what we're doing. 

[00:46:20] And so now I'm going to introduce this concept of reverse dieting. This is something that I learned from friends of mine who do body composition work. Either they've been fitness competitors or they do personal training. And so, these are strategies that they use. So, I think number one, you have to track what you're doing to have a sense of where you need to go. So, if you were to get into chronometer, I have no affiliation with chronometer, I'm just using this as they have a free app. You can go in there and you can track your food. A lot of women are consuming 800, 900, 1000 calories a day. That is not sustainable, that is not healthy. A lot of you that are weight loss resistant or undereating, and perhaps it is completely benignly, you just have no idea. Maybe you've been fasting for 10 years or eight years or five years, and you've been eating in a caloric deficit for all that time.

[00:47:13] So, the thought process around reverse dieting is that you utilize it to slowly add back in, I would say ideally protein, maybe an additional 50 or 100 calories of protein a day, which is not a lot. And you slowly do that over time. But first you have to figure out what your baseline caloric intake is. And a lot of that goes into like what your needs are personally as your activity level. Again, that body composition. How much muscle mass do you have on your body? Are you predominantly body fat and not a lot of muscle? Because muscle is a much more metabolically active tissue, meaning you get to eat more food because you have more muscle mass on. And remember what I said earlier, muscle is not only a master metabolism supporter, but in a rested state, our muscles continue to burn calories even when we're not physically active. 

[00:48:10] And that's important. That's why I think about my teenagers as a good example. You know, they get up in the morning, they're ravenously hungry, and it's because their body's been catabolic overnight. They have a lot of muscle mass on their bodies and their bodies are like, “We are ready to refuel.” So, when we talk about reverse dieting, getting a baseline for body composition, tracking some macros and your caloric intake and then adding in, I call it refeeding, could be an additional 50 to 100 calories. That's not a lot of food right per day over time. And then you're balancing that with monitoring your weight. And this is not for the faint of heart. This is something-- if you are reverse dieting, it is going to take, 12 weeks to get back to consuming more food.

[00:48:56] Maybe the goal is to add in 250 more calories over time, but it is slowly adding those calories back in, generally just protein. It does not mean a pig out, it does not mean a cheat day, it does not mean you go and eat like a gallon of ice cream. It is high quality macronutrients that you are using and then diligently monitoring whether it's with a tape measure, whether it's getting on a bioimpedance scale, whether it's doing Bod Pod, measuring where you are at the beginning and then periodically throughout that process. This is what I had been doing. And again, it was a little bit overwhelming at first because I'm not someone that likes to track my macros. I don't like counting calories, I never have. But I did this as a due diligence effort over time. 

[00:49:42] And I think it was very valuable because I could see over time, okay, this is the amount of stress I'm putting my muscles under. This is my recovery, this is what I'm doing. And at the very beginning I was probably having two good-sized meals and then having a protein shake. And I, although being very dairy sensitive, I can get away with whey protein two days a week probably without any problems. And then I could get away with a beef protein isolate on another day if I needed another shake on another day with some essential aminos to round that protein profile out. So, there's a lot of different ways to go about doing it. Please don't overthink it, please don't feel like it's an all or nothing. I have to get it perfect. I really want the message to be that this is something that is sustainable. That's what we want.

[00:50:30] We don't want it to be arduous and hard because then it is very hard to sustain the effort. And ultimately, we really want to make sure that we are being conscientious over time. So again, reverse dieting for a lot of you that have not been eating enough food over time, and I would imagine it's more of you than I probably previously would have thought. It does not mean that there's anything wrong with intermittent fasting. It's just if you eat in a caloric deficit for too long a period of time, you can make it harder for your body to think it has enough fuel to be able to lose weight. Because we have to think about weight loss as we get healthy to lose weight. My friend Ben Azadi always says that “We get healthy to lose weight,” so we have to make changes in order to get in a position to lose weight. 

[00:51:14] So, to summarize some of the key themes we've been talking about today, number one, resistance training. But even before we do that, body composition analysis, bioimpedance readings, Bod Pod, etc., get a baseline, recheck it in six months, get granular. I always say, “Data is our friend. Data is not our friend.” I would say also in there is if you believe that you may be insulin resistant, even if you do it for the short term, either a glucometer or a continuous glucose monitor can be very, very helpful for seeing how your body responds to certain types of macros, how it responds to stress. I can tell you, during my last book launch, I stopped wearing a CGM, continuous glucose monitor because I would get excited every time I did press or every time, I did a podcast that my blood sugar would go up. 

[00:52:04] But it was more out of excitement. But I would watch these spikes all day long while I was getting interviewed. And so, you can see transient increases in blood sugar related to food intake, strenuous exercise, just stress, racing through an airport can be super stressful. Next is really getting serious about protein intake. Not, “Oh, I'm going to worry about this in six months.” You, you cannot measure what you do not track. So, if you have no idea where your protein intake is, you probably are not eating enough. I find a lot of women. Again, it's that little lady syndrome where you're like, “I just need to be teeny tiny. I'm going to eat as little as possible.” That is going to lead you to frailty, falls and issues, whether it's broken bones, head bleeds, etc., so we don't want that. 

[00:52:47] So, we want 1 g per pound of ideal body weight. I always say no less than a 100 g a day. If you track and you say, “Cynthia, I'm only eating 50 g of protein a day,” that is okay, we can change that. It's just we have to put the plan into motion and tracking your macros may be a really good first step. Other thing is how many of us think that we can sit down and eat a bunch of sweets or a bunch of potato chips or a bunch of tortilla chips. When we are plating meals, we have to think methodically. We want that protein. We want vegetables. You know what the carbohydrates to come from vegetables. I always say three vegetables to one piece of fruit. Most Americans have it completely the opposite. 

[00:53:28] They are consuming a lot more fruit than they need and not enough vegetables in your diet. So, find things that you like. I just had broccolini and chicken. That was my very late lunch because it was a very busy day. I love cabbage, I love squash. Finding things that you like and getting them prepped so that you have them available when you're going to sit down and have a meal. If you feel like you are struggling with meal prep, lots of grocery stores will now prep proteins or prep vegetables for you or there's lots of meal delivery services. Things that have clean proteins and clean vegetables. Just make it easy. There's no shame in doing that. In my house, I'm married to an engineer who likes things done in a certain way and he does the bulk of our meal prep. 

[00:54:11] I am so grateful for this because I jokingly tell him that if he wasn't doing it, [laughs] I would probably be the person in the grocery store that would be buying like, you know, prepared vegetables. Like not-- Anything that's been, well, maybe they haven't been cooked, but things that are already chopped up just make it easy. There's no shame in hitting the easy button.

[00:54:35] Next is prioritizing sleep. It's not sexy, right? I mean, someone asked me the other day “How early I go to bed on some nights.” Sometimes it's 8:30 I'm in bed. I now have one in college who is home for the summer and I have one that is driving, that is a junior rising senior. Generally, on the weekends my kids like to be at home. They like to have their friends here. 

[00:54:51] So, if they're home, I can go to bed early. My husband and I try to trade off, but oftentimes I'll stay up late with him on the weekends. But during the week I go to bed early because I need the sleep. I am going to be much more effective if I am getting my sleep. So, there's no shame in doing that. I know many of you have said, “Oh, my kids, they're not driving yet.” We have really early practices in the morning. Many of you have swim team kids. I used to be one of those parents. I get it. We used to have a kid that was swimming at 4:30 in the morning. It was brutal. My Husband and I would trade off on that. With that being said, go to bed earlier. 

[00:55:27] You don't need to do more emails. You do not need to catch up on organizing your pantry. Those things will be there. Go to bed. So important. If you're having trouble sleeping, talk to your healthcare provider. Is progesterone appropriate? Is estrogen appropriate? What are the other things I can add? Myo-inositol is always a favorite, adaptogenic herbs. Doing things like legs up the wall, having a routine before you get into bed. Really simple stuff. We do not need to overcomplicate this. Again, I can't say this enough. HRT, when I am doing intakes on patients and clients, I know who's on HRT because they are always sleeping better. They generally have better body composition because their hormones are better balanced. This is not to shame anyone because each one of us comes to the decision to do or utilize HRT on a different trajectory. 

[00:56:19] Two really great resources on this. There's a book called Estrogen Matters by Dr. Avrum Bluming and Carol Tavris. We will link this podcast in the show notes. I did a podcast with them. They are, I mean just revolutionary in helping to turn the tide on terrible data that was taken from the Women's Health Initiative that has perpetuated myths that hormones are going to cause cancers and other issues. And we've talked about the WHI multiple times on the podcast. I won't rehash it now. Another really great book is The XX Brain by Dr. Lisa Mosconi. That is a book when I read it, it changed everything for me. I had been on the fence about HRT, but that shoved me over the other side.

[00:57:05] I would say lastly is getting connected with hormone savvy providers. When I say this, I with great love. There are well meaning people out there all over the United States, outside the United States. It's getting connected to the right people for you. I tend to be more conservative. I think that you start off conservatively and then you adjust from there. I think that for a lot of people, if they're having terrible sleep, they're anxious, they're depressed, adding in progesterone and then dealing with the other lifestyle things can be life changing and then later adding in estrogen or testosterone if appropriate because they tend to be more excitatory whereas progesterone tends to be inhibitory. 

[00:57:44] Stay tuned for those of you that are saying “Oh my gosh, when I use progesterone, it gives me the opposite effect.” Did a really amazing podcast with Dr. Amy Killen that will be out on Saturday, which is May 31st. And we talk about different types of progesterone resistance. Really, really interesting research and science on this and how to address those things. So, do not stress if you are one of those. Tends to be anywhere from like 10% to 15% of the population. So, there’s like a spectrum of progesterone sensitivity, and there's all different ways to address it. And Dr. Killen does an amazing job talking about this. But when it comes to people that are out peddling pellets and telling you that's the only way to get your hormones, that is not the case. 

[00:58:28] And actually, I would caution people if they feel like that's the only option for them. Pellets tend to provide supraphysiologic dosing of hormone replacement therapy. I think most of us do best with more conservative measures. Do I think that there are colleagues and peers out there doing a great job with pellets? Yes, probably a few. But more often when people come to me and they're like, “I felt great the first time I had a pellet inserted and now I feel terrible, what do I do?” And this is not to pass judgment. I'm just saying, this is my gestalt. After working with thousands and thousands of patients that most women do best with a conservative, go slow approach to figure out what works best for them. And there's no one size fits all. I can tell you personally, I'm like, super sensitive to hormones. In fact, Aaron Hartman teases me gently about this. 

[00:59:20] I'm just grateful I have a provider who's willing to take things slowly for me personally, so that we can monitor for symptoms, make adjustments, etc. And then I would say lastly, “Test, don't guess.” This is a prevailing philosophy. Not just blood testing, stool testing, food sensitivity testing, saliva testing, all of these can make a huge difference. And make sure you work with someone who's looked at hundreds of tests. I cannot tell you how many people end up in our programs that have done a DUTCH as an example, with a provider who hasn't looked at more than 5, and the provider, God bless them, does not know how to interpret it. And they end up asking, “Could you please interpret this for this shared patient?” Of course. 

[00:59:59] But I've looked at hundreds and hundreds of DUTCH reports, hundreds of stool studies, if not thousands, lots of food sensitivity testing, nutrient testing like NutrEval by Genova that I think is a fantastic option looking at minerals, vitamins, fatty acids, all things that are really important because then you can fine tune everything for you as a bio-individual as opposed to saying these are the blanket statements for everyone. Then lastly, obviously supplements can be very important. I think creatine is a foundational supplement. I think things like vitamin D, magnesium, very important. If you need omega 3s, if you don't eat enough fish, if you aren't getting high quality fish, if you know that fatty acids, how important they are for cellular communication, cell membranes, etc., that can all be very helpful. 

[01:00:46] Sleep support like myo-inositol, thinking about signaling molecules like urolithin-A or Mitopure. If appropriate for you NAD. But it's not actually NAD. It's the precursor NMN. Really good podcast the I did with Dr. Andrew Salzman talking about Wonderfeel, which is one of these products that has NMM, which is that precursor, as well as botanicals to help with absorption. Really, really helpful. And interestingly enough after that podcast I had a lot of people sending messages saying “My biological age on my Oura Ring is improving. It's gone back half a year, one year,” which is really cool just from a supplement. 

[01:01:25] So, with that being said, this is the first of a series of AMAs. When you listen to this, I want you to let us know. You can send to support@cynthiathurlow.com. Let us know what you want us to talk more about. I did not get through all the questions. Obviously, we'd be here for a couple hours, but I appreciate each and every one of you and I can't wait to do my next AMA.

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