Kathy Smith: Hi, I’m Kathy Smith, and welcome to On Health The Art of Living, where each week I bring you the latest information on how to live a healthy, more vibrant, more passion-driven life. I’m really excited because we have Dr. Sara Gottfried back today.
Now, she’s been on past episodes talking about how hormones impact every single system in your body. But in today’s episode, we’re going to take it one step further because, as she points out in her new book which is called Women, Food, and Hormones, food is the backbone of the hormones you make.
So, when it comes to your health and your metabolism, food is medicine.
In her newest book, Dr. Gottfried presents this groundbreaking new plan that helps women balance their hormones so they can lose excess weight and feel better. She also lays the groundwork of how to get your body to flip the switch from burning carbohydrates to burning fat.
So, let me just give you a little bit about Dr. Gottfried. The list goes on and on, but she’s a New York Times Bestselling Author, Harvard-educated women’s health expert. Over the past two decades, Sara has been and has seen over 25,000 patients. She specializes in identifying the root causes underlying the patients’ conditions and really helping them try to achieve true and lasting health transformations – not just this symptom management, which we hear so much about.
So, Sara, it’s always a pleasure to have you back. I’m excited about our discussion today. I love your book.
Dr. Gottfried: Thank you, Kathy. I’m always happy to be with you! We always have so much fun.
Kathy Smith: We do.
So, let’s just dive in. Your book is about the hormone balancing protocol, and it has three tenants. We talk about detoxification, you talk about nutritional ketosis and intermittent fasting. What I’d like to start with today is just dive into that second tenant, which is ketosis. Because there’s so much confusion about keto diets, and they’re so popular. Yet, there is controversy – good, bad. You have people that love keto. You have something you call “the keto refugees.”
So, why don’t we just start to unpack keto? Start from the beginning. What is a keto diet? Well, let’s start with what is ketosis, what are ketones, and why a keto diet? Now, a lot to cover. We can unpack it any way you want, but why don’t we just dive in.
[2:41] Dr. Gottfried: Well, I would say first, the way I think of nutritional ketosis is that your body has a choice. It can either burn carbohydrates or sugar, or it can burn fat. Your body is designed to go back and forth between the two; it’s not designed to stay in one place or another, such as burning carbs. So, with nutritional ketosis, you use your food to drive your metabolism, drive your body to burn fat.
So, you do that in a few different ways. One is that you limit how many carbohydrates you eat. So, I know you’ve talked about this in previous podcasts. If you limit your carbohydrates, it then allows you… You know, the body detects this. It says, “Oh, okay. We’ve got less glucose available. Let’s start burning fat.”
That process can be really fast in some people. It can take 24 to 48 hours, or it can be a slower process – especially for women, who can take a longer time to get into ketosis.
So, a big part of the book is about how to adapt the ketogenetic diet so that it’s better for women, and not sort of the one-size-fits-all that I think is what generates a lot of that controversy that you’ve been talking about.
Kathy Smith: Right. I know that, you know, you’ll have couples. The man will go on the keto diet. Eight pounds, my gosh! A week, two weeks, eight pounds! A woman goes on it, kind of feels uncomfortable, isn’t working for her, gets constipated, and feels like she wants to tear somebody’s head off. So, you have both sides of this.
So, let’s talk about the differences between not just men and women, but within the female category – because we’re directing this conversation mainly to females. I know within the female category, there are the body types. The long leans (like myself), you know, we’ve been on stage together so we like to talk about body types. You have your family history, your body type. But everybody who is listening to this has a certain body type. So, can we just address how keto impacts…? The difference between men and women, but also the difference between body types.
[5:14] Dr. Gottfried: Men and women first. You know, that story you just told of a couple that goes on keto was my story.
So, I went on keto with my husband. We did this before we got married. He dropped 20 pounds. I mean, he looked fantastic in his suit for the wedding, and I lost maybe two pounds over the month before our wedding. I was so frustrated! So, it got me to look at, “Okay, what’s the science of this? Why is it that women tend to struggle more than men do?”
So, one reason is testosterone. So, testosterone is such an important metabolic hormone. It determines your muscle mass. It determines mood and agency and confidence. It’s also known for its role in sex drive and libido. Men have more of it. Because they’ve got more testosterone, they’ve got more muscle mass. If you compare a pre-menopausal woman to a man, the man has about 50% more muscle mass and about somewhere around 10-15% less body fat compared to women. So, testosterone is a big part of that difference between men and women, but it means that men have this thing called the “testosterone advantage” so that they lose weight more easily. Frankly, regardless of what they do, but definitely on a ketogenic diet. They lose more fat; they lose more pounds. It happens much more rapidly than what you see in women.
Now, another big difference is that women need carbohydrates. We need them for a lot of reasons. We need them to feed our good gut bugs, our microbiome. We need it to sleep well at night. We know that women have double the rates of insomnia compared to men. We need carbs to help us with mood. We need carbs to help us with thyroid functions. Women have seven to 10 times more thyroid issues compared to men. So, when it comes to carbs, we need a particular does that helps these hormones stay in balance, helps us avoid kind of a stress response to restricting carbs too much, but we don’t want so many that it leads to carbon tolerance and issues with insulin, which controls your blood sugar. Then, once insulin is out of whack, it just makes you store fat.
So, those are some of the differences between men and women, all of which we can work around. So, we’ll talk about how to work around them.
Then, you also mentioned the differences even within women. So, there are some women who have, as you were describing, I call you the celery type. I hope you don’t take offense with that.
[7:59] Kathy Smith: I heard that! I used to be called pencil, and in your book, it’s like celery. I’m going, okay!
Dr. Gottfried: Well, celery’s a really good vegetable. Yeah. So, you’re so tall and lean. You’ve had a stable body for so long. In the time that I’ve known you, in the time since I first started doing your videos – you know, decades ago – between the size that I am now, my body shape has changed quite a bit. I’ve had periods of time where I was a pear shape. So, I had more fat at my hips. I’ve also had some times where I was more of an apple shape, where I had more belly fat. So, what we know is that the celery types, almost whatever they do, they’re successful, because their weight is relatively stable, their metabolism is really high. The problem comes in with those of us who are the pear shape or the apple shape.
So, the apple shape are the ones that have more issues with insulin. We’ve got, you know, that visceral fat, which doesn’t just make it hard to zip up our jeans. It’s metabolically unhealthy for us. So, it leads to a higher risk of cardiovascular disease and dementia. All sorts of things that we want to avoid. 
Those people also have issues with detoxification. So, it’s just harder for them to get rid of some of those products that they make in their body that can slow down weight loss. 
So, what I find is that the people who are apple-shaped, they need to go into a deeper level of nutritional ketosis. They also need more detoxification to help them be successful with keto. 
So, all of this is laid out in the book. 
What I suggest for the pear-shaped folks – which is the shape that I am now – is that they can benefit from a lighter degree of ketosis. They can tolerate more carbohydrates when they’re on a ketogenetic diet, enough so that their sleep, and their thyroid, and their stress levels are good. But they also do well with intermittent fasting. 
So, intermittent fasting I think of as kind of a back door to ketosis because if you restrict your food for typically somewhere around 14 to 18 hours, if you don’t eat in that period, your DNA is designed to start to put you into ketosis. So, you run out of carbs to burn for fuel, and so you start burning fat. You burn the fat that, in my case, is on my hips and my butt – and that’s a good thing! We like that. 
[10:44] Kathy Smith: Yeah, it’s so true. You know, it’s interesting. It’s like this puzzle. In every podcast I have with you or Felice Gersh or, you know, Will Bulsiewicz or Zach Bush, you start to go down, and you start to see these terms that are being repeated over the years. People are starting to get a better understanding of them and starting to refine them.
So, the intermittent fasting, I know that I refined through the years from those 13-14 hours, as opposed to being 16 hours for men. So, now mine is more of a 13-hour, 14-hour. But then where I’ve really refined it is my snacking in between. So, I have a meal, but then a lot of us would have that meal, and then we thought where we have this feeding period, we could feed for a full eight hours or whatever. As opposed to you have your meal, you stop eating, you have another meal, you stop eating. So, mine turned a corner when I stopped snacking as much. So, that’s one thing I want to point out.
With the ketosis, what I think everybody that I talk to is trying to wrap their arms around is this idea of the proportions. So, let’s get into that for the Gottfried Protocol, which is your four-week plan. How much fat, how much protein, and how much carbs? I’m kind of asking these questions… I know I’m giving a few questions in a row, but I want you also to start thinking about my…
The most confusing thing for me is carbs and then net carbs. So, could you just explain a bit of that to all of us?
[12:34] Dr. Gottfried: Yes. So, net carbs are basically the total carbs that you eat plus the fiber.
So, as an example, if you have an avocado, and the serving that you have – a third of an avocado or a quarter – say that it has seven grams of total carbohydrates. But that serving also has three grams of fiber. So, the net carbs would be four grams. So, that’s an example of how to calculate net carbs.
I think it’s important for us to step back for a moment and talk about kind of the spectrum that we see of people who are eating a ketogenic diet.
So, when keto first became popular, I would say it was with the Atkins diet. So, the first two weeks of the Atkins diet was, you know, the steak and the sour cream and not a lot of vegetables. So, that first two weeks was a ketogenic diet, but, you know, there aren’t many nutritionists that would agree that that is healthy for you long-term. What a lot of folks would label that is lazy keto. So, certainly, it’s effective to help people with burning fat and with losing weight, but there’s a cost to it. There’s a way that you’re not getting the phytonutrients. You’re not getting the 50,000 beneficial molecules that you get from plants.
So, there’s lazy keto – which is the bacon and the fat bombs and a lot of meat, a lot of fat, a lot of animal-based fat – and then there’s clean keto. Clean keto is what I’m talking about. It’s very vegetable dense. So, it includes all of those dark green leafies [sic] that we love. It includes at least five different colors of the rainbow in the vegetables that you’re consuming. It does limit fruit because that has a lot of carbohydrates. There are some fruits that are an exception, like avocados and olives.
But with the clean ketogenic diet, what you can do is you can still get into nutritional ketosis with much more emphasis on plant-based fats. So, the avocado oil, the avocado, the olives. I’m a big fan of avocado oil for cooking. You know, making sure that if you consume fish, that you’re getting that wild-caught fish that does not have too many endocrine disruptors in it. 
So, there’s that difference between lazy keto and clean keto. A lot of the research looking at keto initially started off looking at lazy keto. 
So, keto was first developed more than a hundred years ago by a neurologist to help reduce the inflammation in the brain of people with epilepsy. So, it was found that a ketogenic diet worked incredibly well. In fact, there are some people who are super-responders to it because they can go on a ketogenic diet, and they can actually get off of their anti-seizure medications. So, there’s definitely this effect on the brain. In some ways, ketones – which is what you produce from burning fat. Ketones are a preferred fuel source for the brain. So, maybe we can talk more about that in a moment.
But when it comes to the proportion, and is it net carbs, is it total carbs, how much fat did you say? Did you say 70%? What I advise is that you start with about 60-70% of your calories from fat. For women, especially, I think it’s important for that to mostly be plant-based and fish-based fat. Then, you layer on the protein. 
So, the ketogenic diet is high in fat, moderate in protein. So, you basically want to get enough protein so that it preserves your muscle mass. So, that typically is about 20% of your calories per day from protein. Then, the rest: net carbohydrates. So, this, again, can be differentiated. I recommend in general about 20-25 net carbohydrates per day. So, that’s somewhere around six to eight per meal. For the people that are the apple shape, those are the women who do better with restricting their carbs a little further temporarily. So, about 20 net grams of carbs per day. Whereas the pear-shaped can get away with a few more carbs – more like 25. 
[17:35] Kathy Smith: What if you’re more physically active? Would you add more carbs or not necessarily?
Dr. Gottfried: Yeah. So, there’s a lot of debate about this in the sports medicine world because there are some athletes and some people who are really active physically who just need carbohydrates for their best performance. So, there are some athletes who need additional carbohydrates, and you can adjust the dose of carbohydrates based on how active you are.
Now, there are some athletes who perform at a very high level on a ketogenic diet. But when you look at, you know, endurance athletes – people who run long-distance, the guys that are in the Tour de France, my basketball players that I take care of – what we know is that they can do a ketogenic diet like if they need that for medical reasons (maybe to help with a blood sugar problem), and then we tend to add carbs back about two weeks before a race or a performance. So, that’s a way to kind of split the difference in sports medicine.
Kathy Smith: So, we talked about brain function – the ketones and how it impacts brain function. I was also reading in your book how it affects mitochondria and aging. I want to kind of dive into this with a story that I mentioned to you right before we started talking, we went on air.
That is that my daughter Kate – and most listeners know that she is an Olympic athlete. Over Christmas – so, December 20th – she had gone to a wedding in Chicago, she got back. Even though she was vaccinated and boosted, she got Covid. Not only did she get Covid, but she also trained pretty hard while she had Covid because she thought it was going to be a two-day situation and she’d be through it. She became a long-hauler. A long-hauler, for people out there that don’t know, it means that you have symptoms and they don’t go away. They impact people differently.
Well, Kate got impacted with they’re thinking mitochondria. Heart was okay, but the whole how it manifested is that she had a hard time getting out of bed. She is third in the world right now. She’s ranked third in the world in the 800-meter. She would go for a five-minute walk and have to take a two-hour nap. It was just… Thinking that it was going to resolve itself in two weeks, three weeks. Two months later, you’re checking with all of the facilities around the country from Harvard and Yale and Stanford and all of the medical institutions who are doing studies on long-haulers. Fast forward. A few weeks ago… So, that was, let’s put it, in mid-April, I went to see her. We got on a ketogenic diet – a keto diet. Within about two days, symptoms started to resolve. Now, I’m not saying that she’s out there training at the highest intensity, but she is back training. Certain things like her heart rate went back down. She would go for a walk, and her heart rate would stay up at 180 beats per minute and not come back down.
So, here’s an example of how this diet, how diet became her medicine. When I was with her… I’ll finish this story because it was so… When I mentioned it to her, she goes, “Mom, I kind of eat… I eat healthy,” is what she said.
I said, “Yeah, honey, but I notice that you’re just nibbling a lot through the course of the day. Not much. A bite of pancake, a little bit of this, a little taste of this, popping in some fruit or whatever. I would just give it a try.” It was mind-boggling.
So, maybe get into how it impacts other systems in our body, and why even if you’re not trying to lose weight it’s a powerful diet.
[21:36] Dr. Gottfried: Well, first, let me say that I’m so sorry that Kate has gone through this. I can imagine, as a mother, that has been to watch. I mean, she’s just at the peak of her career. So, my heart goes out to Kate. I love cheering her on in the races that she’s in. I haven’t taken care of her, so I don’t know the details.
But what we know is that there are a few different versions of long-haul syndrome. You know, there are some people who have issues with what’s known as the autonomic nervous system. So, that system that controls your heart rate and controls your blood pressure, and your breathing, that can sometimes be disrupted by Covid and by the long-haul syndrome. So, there may be some of that to what you’re describing with her heart rate.
Related to that is the neuroinflammation. So, this is the level of… I think of it almost like a frat party that happens inside your brain. It’s not a party that you want to be happening because it leads brain fog. It leads to a loss of executive functioning, of cognitive functioning. It leads to extreme fatigue, especially when the mitochondria are involved.
So, the mitochondria, they’re like the power stations in your cell. They basically help you feel fueled. It’s almost like when you plug in your cell phone and it’s fully charged, and you’re like, “Ah! I feel good again!” Similar sort of thing with your mitochondria. So, it’s this battery that just keeps you going in terms of energy. It allows you to feel like you’re full of energy.
So, what happens with some people with long-haul syndrome, it’s that they have this neuroinflammation. It’s almost like someone turned on this light, and they can’t get it to turn off again. Those are the people who often benefit from a ketogenic diet.
So, if we take a step back, what we know with a ketogenic diet is that there is something about the production of ketones. Burning more fat, burning less carbohydrates. Burning more fat, producing this chemical known as ketones. You can measure it with a finger stick – beta-hydroxy ketone. That is a preferred fuel for the brain.
So, there’s something about it that seems to reduce that frat party, that inflammation that’s happening in the brain. Whether that’s after Covid or it’s in someone with a seizure disorder, or even patients with dementia, with Alzheimer’s disease. A big part of the precision medicine protocol for patients with Alzheimer’s (or even early subjective cognitive impairment) is to try a ketogenic diet. You can also use it for patients with multiple sclerosis.
So, in some ways, regardless of your weight and your body fat situation, this benefit that happens in the brain is really profound.
I can tell you, I remember back when my husband and I first went on ketosis, my husband got into keto… He got into ketosis right away. It took me longer because I was a little more carbon tolerant. I took me about a week to really get into full ketosis. Then, it took me like another few months to really adapt to it. But my husband immediately got into ketosis. Her finger pricks were up to 1.0 millimoles per liter, which is ketosis. He was just like, “I have so much mental acuity.” Like, he had trouble sleeping because he was so energized. His mitochondria were so well-fed he could really focus. He could hyperfocus. He could just accomplish much more in a day.
So, that benefit that Kate is describing within 24 to 48 hours, that’s something that we see pretty routinely when you turn that light out on the neuroinflammation by using the ketogenetic diet.
[25:40] Kathy Smith: It’s so powerful. The experience, I love when my brain is lit up.
Dr. Gottfried: Yes.
Kathy Smith: So, let’s go through a day on the Gottfried Protocol, just so that people understand a couple of things. Like, maybe a breakfast, lunch and dinner of what you might eat during a day to stay within the parameters that you mentioned before with your macronutrients. Then, also, how will you be checking yourself? What are you recommending? How many times? How do you have to check yourself through the course of the day? Do you pee on a stick? You mentioned your husband pricks his finger, gets some blood. So, can you kind of go through a day in the life of the Gottfried Protocol food plan, and how you would know you’re in ketosis and stay in ketosis?
Dr. Gottfried: Sure. So, I’ll give you kind of the simple version, and then I’ll give you the more advanced version because there’s a range here.
So, the simplest version is to start to get familiar with macronutrients and with what’s known as calculating your macros. So, I know you spoke to a previous guest about this who described it really beautifully. You can use an app like My Fitness Pal or something like that to determine maybe with some of your favorite meals, how many net carbs are in there? How much fat? How much protein? So that you can hit those macros, which are high fat, moderate protein, low carbohydrate.
So, what I do with each meal, I basically eat about two meals a day. I try to get somewhere around seven to 10 net grams of carbohydrates in each of those meals.
So, a typical breakfast for me, I love scrambles. So, I’ll make a scramble of vegetables. So, today what I had was red pepper, I had some broccolini (about a cup of it), I had some chopped spinach, I put some onion and garlic in there because those are great detoxifiers (they help to raise something called glutathione, which really helps your mitochondria; it’s an antioxidant in the body). So, I cut all of those up, mix them in some avocado oil, sauté them, and then I added a couple of pastured eggs. So, for me, that’s the perfect breakfast. Some people – depending on your body size – you might need another egg. For men, as an example. But that’s a really good meal for me. You can add, if you need to try to increase the amount of oil that you’re getting – because that’s often the difficult adjustment for people – you can add another tablespoon of MCT oil. 
What a lot of people do in ketosis – and I heard another guest of yours talk about this, too – is they start their day with coffee or green tea with some MCT oil or with some other fat to really help to produce ketones. MCT oil – medium-chain triglyceride oil – is great way to increase the amount of ketones that you make, especially for people who are first making that transition from eating mostly carbs to eating mostly fat. So, it can help to hasten that transition. It’s also associated with less hunger. 
I also recommend for people who are first starting to not have any alcohol. MCT oil can help you with cravings that you might have. You know, especially during the pandemic, you start to look at your watch around six and wonder when you’re going to have a glass of wine. So, the MCT oil around 2 p.m. can help you with that. So, that’s one meal. 
A second meal – which I made yesterday – was to use miracle noodles. So, I’m a big fan of miracle noodles. They’re made from sweet potato (Japanese sweet potato). They’re zero carbs, but they come shaped in different pastas. So, I miss pasta when I’m on a ketogenic diet. So, this is a great way to make an alternative. You could also spiralize vegetables. You know, you could do that with squash or with zucchini. You could make pasta out of vegetables. 
But I made a ragu yesterday that was so delicious. So, it had some chopped celery, onions, garlic. It’s a more [inaudible 30:03] on recipe that I learned when I was in college. I use some venison in it because I’m someone who tends to be low in iron. So, I made this low-carb ragu, and then I made this pasta. Put the ragu on top of miracle noodles (which are no carb), and then I added some additional vegetables on top of that. 
I always eat a big salad. So, I typically have that for dinner around five o’clock. I’m just a salad girl. I just love, you know, kind of… I feel like salads can cure you so far because you can really rotate the type of species that are in the salads. You can make all different kinds of salad dressings. You can use really healthy oils in your salad dressings. You can add some additional fats like nuts and seeds. You can add your favorite protein. 
So, I think, Kathy, in terms of templates, that’s my scramble template for breakfast, and that’s my kind of low-carb pasta with salad template for dinner.
[31:10] Kathy Smith: Yeah. I like this idea of having these templates that you can just… Different vegetables, different protein.  I just got introduced to walnut oil, which was very tasty. You can always make some salad dressings with that.
Plus, you have this secret weapon you have in the book, which is your soup. Which I’m looking forward to making. It’s just full of all of these vegetables. Right? It’s just really powerful…
Dr. Gottfried: That’s exactly right. I mean, yeah. The soup template is especially good for people who are first beginning because what I find a lot of people do, especially if you’re working at some workplace that’s not at your home. What I see a lot of people do is they have a small breakfast, and then maybe they have a small lunch. Then, they’re so hungry by the time dinner comes because they’re not yet in ketosis… When you make ketones, it is satisfying, so you’re not hungry. But while you’re in that transition from burning carbs to burning fat, you can get super hungry at dinner. That’s when people often will screw up. Like, that’s where they make the mistake of starting to eat more carbs because they’re just more readily available.
So, I’m a big fan of soups. We’ve got a lot of soup recipes in the book. I’ve got some cases of… Like, a woman who is of Southeast Asian descent, she added a bunch of soup recipes. You can basically take your favorite recipe and make it lower carb so that it fits within this template.
Kathy Smith: So, a couple of questions. One, I know because when I was asking people in my Facebook group what kind of questions did they want me to ask you, one thing that came up is what if you are vegan or completely plant-based? Is it possible to do a ketogenetic diet if you’re plant-based? 
[33:02] Dr. Gottfried: It absolutely is. 
So, you know, I think initially with the lazy keto emphasis, a lot of people felt left out of that equation. They didn’t feel like if they were plant-based, vegan, or vegetarian, that they couldn’t do it, but you most certainly can. Because it comes down to those macronutrients. 
Now, I’ll be honest, I think it’s a little bit harder if you’re vegan to follow those macronutrients because so many of the protein sources end up being a little more carb-y when it comes to trying to hit those macros. 
So, it was important to me when I wrote this book that I included vegans, that I included people who were 100% vegetarian so that we could document that they were able to ketosis and stay in ketosis for four weeks. 
Now, the great thing about being plant-based is that if you’re eating a lot of vegetables already, that detoxification that’s the first part of the Gottfried Protocol, you kind of have it covered. I mean, maybe you might need to add some extra colors to make sure that you’ve got all the phytonutrients that you want to have for your metabolic health and your immune health, but you can absolutely do it. 
So, I’m an omnivore. I eat pretty much every
thing. But what I did for this book is I went 100% vegan keto for two weeks just to make sure that I could stay in ketosis. I found it was not difficult. 
Now, one of the crutches I used – I’ll throw another template in here – is that I used shakes when I was doing vegan keto. So, I found that to be very helpful. I used a vegan protein powder combined with MCT oil. I added some additional greens and steamed cauliflower, and then I would add some nuts and seeds to kind of get that richness and creaminess that I like in a shake. So, that can be, I think, a helpful swap or add-on to help you if you want to be vegan or 100% plant-based. 
[35:07] Kathy Smith: So, if you are… Let me see if I have this correct. That is if I am eating 35 grams of fiber, 40 grams of fiber, then I can basically be eating closer to 65 grams or 60 grams of carbohydrate? So, that gives me a little bit more wiggle room as a vegan.
Dr. Gottfried: It does. So, this is where the second part of your question comes in, which is tracking and seeing if this is working for you.
So, what a lot of people do when they go on a food plan like this is they measure their weight. Maybe they do it every day. That’s one of the worst measures we have of your metabolic health. So, what I prefer is that you check your ketones in the morning. So, you could just prick your finger once a day, look at your ketones, and look at your glucose. So, the two together give you a lot of information about your metabolic health. What we want is a fasting glucose of about 70 to 85 milligrams per deciliter. That’s what we know is the optimal range for people who do not have insulin resistance, who have normal metabolic health. Once you get above that, even though it’s not quite the criteria that we use for prediabetes in conventional medicine, but once your glucose is 86, 87, 90, 95, and then up in the prediabetes range – which is 100 to 125 – that shows that you have insulin resistance.
So, going back to your question. Dialing in the net carbohydrates, what I generally recommend is starting at around 20 to 25 net grams of carbs per day. For people who exercise more like you do – I’ve been with you to yoga and to the gym; I know how much you exercise – often you can get away with eating more carbs. People who are more stressed sometimes need more carbs. So, you have to eat a certain amount. I recommend starting at 20 grams of net carbs per day. Then, you test with a finger prick whether you’re in ketosis.
So, one other thing that happens that I think is important to mention is that when you’re transitioning from burning sugar, burning carbs, to burning fat, it’s almost like a hybrid car kind of going back and forth between the two. You can have this period of adjustment, which is known as keto flu. That’s where you can feel kind of headache-y, and have more cravings, and you can feel more tired. Might be harder to sleep. So, there’s ways to try to prevent keto flu. Things like taking that MCT oil that I mentioned. But, in terms of dialing it in, what I want to know is if you consume what you just described – like 35 grams of fiber, a total of 60 grams total carbs per day mostly from vegetables – then we would want to check your ketones the next day and every day to see if you’re in ketosis. For you, a very light level of ketosis I think would be appropriate.
[38:23] Kathy Smith: Right. I mean, I have to tell you, since I have switched into this metabolic flexibility – which you talk about in your book, which is the goal of all of this. Why don’t you just mention the benefits of metabolic flexibility so that people understand that it’s just not about weight loss, it’s about brain function, mitochondria, energy, aging – all of these other facets that keep me in a place where I love this kind of balancing act. That you can… If I’m traveling… I’m going to Greece in about two weeks for a wedding, and I obviously am going to be eating Greek salads and all kinds of yummy things. I mean, all of these oils and fish and whatever. Then, I’ll be in London for a birthday party, and my diet might change a little bit. I still stay within guidelines, but I can burn carbs. Or we might be walking around the city all day long, and we can’t stop to eat, and I don’t get into the hangry mode. Like, my body just switches over. Like, “Okay, burn some fat now!” Actually, the opposite is true for me in the sense, instead of getting hangry, I get more alert. I get more energized.
So, explain maybe just to wrap up a little bit here metabolic flexibility and why it’s so powerful. 
Dr. Gottfried: Well, the problem is, most Americans are not metabolically flexible. So, most Americans are metabolically unhealthy, and that’s 88% of Americans. So, only about 12% of us are in the category that you’re describing, where you’ve got metabolic flexibility, meaning that like a hybrid car that burns gas or uses a battery and electricity kind of as needed, you are like the hybrid car. So, you can flip back and forth. You could go to Greece and you could hike all day, and you could have your fresh fish and your Greek salad, and you could burn fat and actually find that you’ve got that increased mental acuity. Then, you could go to somewhere like London or to France – I think of that as the carb capital, or Italy. You could go there, and you could eat more carbs, but you could actually tolerate it without it hurting your metabolic health. 
Now, you mentioned hangry. That immediately takes me back to when I was in my 30s. I had a couple of kids. I had borderline glucose issues with both of my pregnancies. Not gestational diabetes, but like one point below the cutoff. What happened, then, for me, was that my glucose was borderline even after having kids. I would crave carbs all the time. I was one of those people who would have almonds and other things in my purse because I would get hypoglycemic, and I would just feel that hangry feeling of just being irritable and like, “I’ve got to stick something in my mouth.”
I thought the solution then – I mean, this was a while ago. 20 years ago. I thought the solution then was just to eat more, and to eat more continuously. But that does not really heal your metabolism. What heals your metabolism is to have this flexibility just like a hybrid car to burn gas or to burn electricity, kind of depending on what’s available.
So, I was stuck in that glucose-burning mode when I was in my 30s. No one told me about it. It wasn’t until I started testing myself that I realized, “Oh, I’ve got a fasting glucose of 105. That is prediabetes. My fasting insulin is elevated.” It was up in the 20s.
So, I got very determined to fix this because I knew I was heading in the direction of developing diabetes. I’ve got Alzheimer’s in my family; I felt like I was putting myself at an increased risk of that. So, I wanted to turn the ship around.
So, I got very focused on, “Okay, what could I eat to really improve my metabolic flexibility?”
There were two diets that were in the literature. The first was 100% plant-based. I tried that for a while, but I was hungry all the time on it, Kathy. I just found that I needed some animal protein. That was the best thing for me. Then, the second option was the ketogenic diet.
43:09 – So, I went on a ketogenic diet. I healed my metabolism. I reversed my prediabetes. I no longer ever feel hangry. I eat, you know, maybe after five hours. You know, my two meals a day, I’ll have my second meal five hours after my first one, but I could take it or leave it. Like, I’m not, like, white-knuckling like I used to be. 
So, when you have that metabolic flexibility, you’ve got this freedom. You’ve got kind of food freedom to choose the food that’s going to be the most nourishing for you. I think that is so powerful. 
[43:44] Kathy Smith: Right. That term freedom, that’s what resonates with me. 
The other thing is I just feel that 20 years ago when you were talking about when you were trying these diets, we had a certain amount of knowledge. The amount of information and the amount of technology right now to know what’s happening inside your body – and this is what I’m going to close with, and I’m going to give you one closing, and then we’ll wrap it up because I know you’re busy.
But what I am just feeling every single day, week, month is that we have the ability with a strip or a little tool that’s not very expensive to buy, to understand exactly what’s going on in our bodies. So, instead of comparing ourselves to this woman, or this woman, or that man, or does it work, or does it not work? It’s like, you will know if it’s working or not because you have this tool. You get up in the morning, you do this, and you know what’s happening inside the body. You know where your blood glucose levels are. You know these things that are very, very powerful when it comes to, once again, aging well, staying active, keeping your brain and your smarts and everything. It’s so easy. It is so affordable now. Those were not things that we were discussing 20 years ago.
So, this personalized medicine that can work for all of us, and that’s what I love about just everything you do. You bring it back. You simplify it. You explain it, you simplify it, but then you also want to make sure that you’re personalizing it for people, and helping them in the book of how do you personalize this program for whatever they’re going through in their life. I just think, you know, the future of medicine, future of health, future of weight loss is right here. It’s right here in this book. So, it’s powerful.
So, for me, I want everybody to know: women, food, and hormones – I’ve got my book. Dr. Sara Gottfried, I got my book on Amazon. As we close out, I’ll tell you everywhere you can get it.
But, Sarah, how would you like to leave us today?
[46:00] Dr. Gottfried: Well, you just wrapped up with a message of empowerment, which I think is so essential here because when I first tried keto 20 years ago, all we had were those urine strips that you could pee on and see if you were producing ketones. You could also tell from your breath. But those pee sticks don’t work very well because they show when you’re first in ketosis, but then as the body adapts, they don’t reflect what’s going on in your blood. They don’t reflect what’s going on in your brain.
So, that’s where these simple tools… Things like the blood ketone meter, checking your blood glucose in the morning with a little finger prick. That allows you to really personalize these diets because we know there’s not one-size-fits-all. We know that when it comes to metabolic flexibility, as an example, that what it takes for your body to be flexible is different than what it takes for my body to be flexible. But we can both do testing to see what is the best fit for us. That allows us to really personalize diet, sleep, lifestyle, connections. Like, all these things that are so important to our health.
Now, I want to close with one other point about this. You had asked about tracking, and what are some of the ways to do that. I mentioned the blood ketones once a day – some people do twice a day. You can even calculate your glucose ketone index. That’s something that I talk about in the book.
Another thing you can do is you could wear a continuous glucose monitor. So, I’m kind of obsessed about this. This is a more advanced strategy. You know I’m obsessed. I’ve got my little device right here that you can see. This has really helped me dial in what is the best diet for me. Because it’s not that I’m saying you should go on a ketogenic diet for the rest of your life. What I think is the most impactful for metabolic flexibility is to do four week of a ketogenic diet. Do it the way we’ve described, with detoxification first, nutritional ketosis, layering in intermittent fasting as a back door to ketosis. Do that for four weeks, and then you slowly start to add more carbs back. So, you go from 25 net grams of carbs per day to 30 the next day. Then, you go up to 35, and you figure out, “Okay, what’s the right dose for me?” This more advanced testing – and I’m not talking about for diabetes. I’m talking about for people who are non-diabetics. It can be really helpful to see, okay, what are the carbs that my body likes the best?
It turns out I do great with winter squash, but then I spike up to a diabetes level with sweet potato. I have problems with apples, but I can eat bananas. So, that allows me to really personalize, and gives me that freedom that I think we’re all after. It gives me that sense of empowerment that I’m not just like a victim trying to choose what to eat, and then suffering the consequences. Instead, I can architect what’s going to be the best diet for me.
So, that’s what I think is so empowering. You don’t have to have a glucose monitor to do that – a continuous glucose monitor – but we’ve got these tools that really allow us to determine, okay, what’s the best diet for me? Because it’s going to be a little different than the best diet for you.
[49:20] Kathy Smith: Can I just ask you: you showed us on your arm there… For the listeners, Sara held up her arm. It’s on the back of your arm. Is it taped there? How is it attached?
Dr. Gottfried: So, it’s a little device about the shape of a quarter. We’re going to have to get one for you, Kathy.
Kathy Smith: I’m going to get one. After today, I’m going to go… I mean, I already know that I’m going to do this. I’ve been traveling, I’m back. I’m going to have to… In the next hour, I’m going to have one. But where do you get them? It’s not implanted in your skin, is it?
Dr. Gottfried: So, it is implanted in your skin. There’s a little process. You can see it in on my social media. Every time I change it, every two weeks, I make a little video about it. But there’s no needle. There’s a little sensor that’s about the size of a hair – the diameter of a hair – that measures just under your skin what your glucose is 24/7. So, it allows you to know how you react to food. So, like, all the food that I just told you about that I ate today is shown on my little device here.
For those who can see the video…
Kathy Smith: Yeah, you can only see a white screen, but yeah. I see. That is…!
I know you’re a doctor, so you would do it anyway, but anybody can just put it under their skin, or you have to…? Yes? You can just buy it. You go to the store, you buy it, and I can slip it under my skin.
Dr. Gottfried: So, in the US, you have to have a prescription for it. So, you can ask your doctor for a prescription, but there are also a number of companies that are direct-to-consumer, that take care of that process for you. So, they have a telehealth questionnaire process.
Kathy Smith: Okay. It’s all in your book, too, right?
[51:01] Dr. Gottfried: It’s in my book. Yeah.
Kathy Smith: Okay. I will just buy… I’m going to go to that chapter, I’m going to read it. That is great. I mean, that is classic. I am definitely going to do it. I’m going to do it at least for a couple of months just to see. I bet it’s just mind-boggling how our bodies…
As you said, I can sort of feel… Like, I think I do well on bananas. When everybody used to say bananas are going to spike your blood sugar, etcetera, I’m thinking, “I actually do well on bananas.” I feel good on bananas.
So, anyway, Sara, it’s always a pleasure. We will talk again. I know, I know because I love you to death, and so does the audience. Thank you so much for being here.
Dr. Gottfried: Thanks, Kathy. So appreciate you.
Kathy Smith: Bye-bye now.
Dr. Gottfried: Bye.