The BIG SIGNS You Have PCOS & How To Overcome It With Your LIFESTYLE | Dr. Heather Huddleston

Inflammation may have some direct effect on ovarian dysfunction. This is a huge kind of controversy as well in the field.

About 5 to 10% of women who are of childbearing age have this and it's a really important cause of infertility. At Walter Willett at Harvard wrote a book called the Fertility Diet, which is a lot about this. It's also the most common hormonal disorder in premenopausal women, yet often the cause of it and treating it is not well understood by most doctors. So, Tell us a little bit how PCS has been the neglected stepchild of medicine and OBGYN and how we can correct that.

Yeah, I think it's a great question. I think it's a somewhat complicated disorder in the sense that it brings in a lot of different systems and a lot of different ramifications that cross a bunch of disciplines. I think the way medicine sort of is practiced in the United States these days is it's very siloed and there are sort of certain doctors that take care of one little specialty. And POTS has kind of fallen through the cracks in many ways of all of those specialties in my view. I mean, so POTS really brings in a hormonal component, it brings in a gynecologic and reproductive component, it brings in a metabolic component, and all of those things really weave together not only in the path of physiology, but also in the outcomes. And there's not really one specialty that really adequately covers those. OB-GYNs maybe know some of the reproductive piece, but they're not as always up to speed on that metabolic. Endocrinologists might know a little bit more about the metabolic piece, but they are a little nervous about what's going on with the reproductive side. So as a result, I think a lot of patients with PCOS sort of end up getting bounced around to different doctors, never really getting great explanations about what's going on with them and what are sort of some appropriate treatment pathways for them.

It's so true. And I think often doctors aren't great at diagnosing it. And maybe you can take us through what are the key symptoms that you would look for in a patient who came to see you with PCOS.

Yeah. So first of all, just to echo what you said, there's been some studies, international studies that have shown that the common average number of physicians or providers that people with PCOS see before getting a diagnosis is something like on average of four. So, oh wow. People are definitely wandering around trying to get someone to really help them. But there is an international kind of consensus at this point around the way that we diagnose PCOS and this has sort of been developed and sort of hammered out over the past 20 years. And it looks for three things and you really just need two of those things. So the first is irregular cycles or what we mean like long cycles going every 40 days or fewer than eight periods a year. the second component is hyperandrogenism. So either clinical hyperandrogenism, meaning hirsutism and.

Acne, or bioidentical hormone replacement therapy.

Hair growth, hair growth on your face. Yeah. Or a blood test is showing elevated androgens. And then the third component is features of polycystic ovaries on an ultrasound. And so those are the three components and you just need two. And so if I have someone coming to me looking to see if they, if the things that are going on with them sort of fit within the box of PCOS. Those are the three components that I'm.

Going to look at. Typically, when I was in medical school, I remember learning that, you know, this is typically overweight women, and that's not always the case. I actually have had many patients who are thin who have PCOS and struggle with acne and hair loss and irregular cycles. So, you know, can you kind of take us down the road of, you know, what is it besides the weight that can cause this? What are the causes? Obviously, part of it can be insulin resistance and diet and sugar and starch, but it's not the only thing. So what are the causes of PCOS?

Well, I think it's a little bit of a million dollar question. There's a lot of research trying to answer that question. It's also a very heterogeneous disorder, so I don't know if there's one thing that causes it for everybody. But I think we do know that a major underlying factor is the hyperandrogenism that is, you know, that there's elevated androgens. starting at puberty, and that that may then sort of underlie a lot of the phenomena that comes across with women. So one of the things we know is that there's an increase in visceral adiposity or sort of- Dr.

Belly fat.

Dr. Belly fat that happens that we know is more common in general with men, but this is what happens when you have elevated androgens in a woman, especially starting at puberty, they lay down fat in that area. And that in women causes a lot of inflammation that then can really be a setup for insulin resistance. So there may be sort of a pathway where you see hyper androgenism then in many people also leading to the insulin resistance. Then you start to get into a little bit of a vicious cycle because the insulin resistance in and of itself causes some weight gain, but it also can drive androgen production from the ovaries. So starting at puberty, a lot of these people get into a little bit of a vicious cycle. It's very hard, if not impossible, to get out of.

What starts the high levels of androgens or the male hormones, testosterone and others?

So it's a debated issue. I think that there's one component maybe that there's just an, if you look at some of the enzymes in the ovary and in the adrenal gland, there's just sort of an overactivity of those enzymes in the ovary and in the adrenal gland. So there's some thought that it's just an intrinsic overproduction of androgens. There's also, at least in some patients, we think just from the get-go, they have an increased LH secretion from their pituitary. This is a hormone that drives androgen production. from the ovary. And so they may be set up by that even sort of in utero to have increased LH secretion. So we don't really know, but we know that at puberty immediately these girls will often start to have much higher endrogen levels than their peers. And then that sort of lays the groundwork for a sequence of events to happen.

Yeah, you know, one of the things it's sort of read a lot about is the role of endocrine disruptors. in our health. And, Inoculon Shelters are environmental chemicals. Years ago, I read a book called Our Stolen Future by Theo Colborn. It was kind of like the silent spring of its time, where she mapped out the ways in which environmental chemicals affect all kinds of reproductive functions. And whether it's determining sex or determining risk of cancers or infertility in animals and human models, how do you think environmental toxins play a role in the uptick of what seems like this increasing phenomena of endocrine disorders in women.

I think it's hard to know how much they are causative in terms of PCOS. I think it's possible. I certainly think it's definitely possible that they may exacerbate certain elements of it by interfering with hormonal function. But PCOS has been around for a long time, as far as we can tell. It seems to be present at a pretty standard or set prevalence across many different countries and so in parts of the world, which somewhat argues against it being truly environmental. Now, I do think that certain environmental endocrine disruptors or just societal patterns, especially diet, can definitely exacerbate the way PCOS gets manifest. So if you look at PCOS patients in Europe, especially 10 or 20 years ago or in China, they tended to be much more lean than patients in the United States and have much less sort of inflammation and insulin resistance. And so there's certainly, if you have a PCOS phenotype and you put it in an environment where there is calorie excess or limited physical activity, you are gonna see potentially, at least in some patients, an exacerbation of the symptoms. But I don't know that in my view and from what I understand about this syndrome, I don't think it's actually caused by our lifestyle.

And the nutritional part, what role does that play? Because I've had many patients with infertility who when we address the starch and sugar in their diet and treat the insulin resistance, they get better. And I mean, I had a breakfast relative who had, you know, obesity and pretty severe PCOS and hirsutism and acne. And, we radically changed her diet and she was able to get pregnant and have a baby. So, can you talk about the nutritional aspects of PCOS and how that plays a role and where it doesn't play a role?

Yeah, I mean, I think for sure there's evidence that in some people with PCOS, especially if there's evidence of insulin resistance or if there's evidence of glucose intolerance, you know, that they're clearly have entered a phase where they're not processing glucose well, that if you act to correct that through diet and through exercise and you reduce the degree of insulin resistance, you reduce the degree of adiposity, that in some of those patients they will ovulate more regularly, they will have more successful, more healthy pregnancies. So that is certainly something that I think I always talk to my patients about when I see them if I think that there's a window for that. There are patients, however, you know, especially when you look at some of the lean PCOS patients or patients who from the point of adolescence have never had regular cycles. You know, I think it's a lot to say, oh, just change your diet and you're going to start ovulating. I don't think that's always the case. So I think every patient's a little different and you need to really look at it. what I usually look at though is I want to say, how are we going to get you as healthy as possible for pregnancy? And maybe that will help you get pregnant. Maybe it won't, but I want to get you as healthy as you can for pregnancy and get your insulin resistance as much as possible under control. Yeah.

How about the microbiome? Because this is sort of the era of the microbiome. And before, nobody ever thought that the gut played a role in hormones or endocrine health or infertility, but now it's clear that it's sort of got its finger and everywhere. And, you know, we see studies, for example, on breast cancer, women who take antibiotics have high risk of breast cancer. We know that the microbiome plays a big role in hormone metabolism. So can you talk about what you're.

Learning about that and how that plays a role and how you approach that? Well, I think that there's definitely some really interesting research going on around microbiome and PCOS. And there's this idea that there may be a more sort of inflammatory microbiome that leads to more inflammation in the body. And we know that many patients with PCOS just have high rates of inflammation that is detectable. And if you look at blood markers or just even at the insulin resistance. So this isn't in many ways an inflammatory disorder. And so there is research going into how much of that might be driven by the microbiome. And that's a little outside my scope and maybe more your scope exactly how that may be the case. But I think it's, That's definitely a really interesting area for us to try to understand more, you know, how much that may be sort of setting people up to have PCOS sort of evolve at adolescence and really to exacerbate the metabolic phenotype.

Yeah, well, we said so super interesting about the inflammation because inflammation independent of its source seems to be a trigger for all kinds of things, obviously chronic disease in many ways, but for these hormonal disorders. So can you talk and maybe unpack a little bit more about the link between inflammation and endocrine disorders and in particular PCOS?

Well, I think for sure we know the inflammation may have some direct effect on ovarian dysfunction. So there are some studies showing that if you treat inflammation, you can improve sort of ovulation to some degree in the ovary. So there may be a direct effect of inflammation on the ovary. There's also a path where inflammation does drive up insulin resistance, and that's through sort of TNF alpha and other cytokines that are thought to interfere with insulin action. And we know that insulin resistance really drives androgen production from the ovary, at least in patients with PCOS. So there's definitely a metabolic sort of driver of the hyperandrogenism and hormonal dysfunction and anovulatory sort of status. that we do see. And then we also know that that inflammation in and of itself has really important downstream consequences, not only in terms of cardiovascular disease, but there's more and more of a thought around depression and cognition that may be impacted by inflammation. So I do think it's really an important piece of this disorder that we wanna try to get a handle on and try to treat.

It's so important. And it's so many cause of inflammation. It can be environmental toxins, it can be the microbiome, it can be inflammatory foods. I mean, there's so many factors that we know that are driving inflammation in our society that are just getting worse and worse. And so it might be not one thing, it may be so many different things. So can you talk about the difference between the patients you see with PCOS who would be the typical ones we learn about in medical school? They're overweight, they have acne, hair loss on their head, facial hair, irregular periods and fertility versus the ones who are thin and, you know, exercise and don't seem to have any weight issues. Can you kind of, is there a different subtype? Are these the same kind of condition? How are they different?

I mean, I think that they're, they're probably subtypes. I mean, I think that this is a, ketosis is, I think, a very heterogeneous disorder. It's really just a syndrome, right? It's a collection of things that kind of go together and sort of have somewhat of a shared pathophysiology, but it's not like, you know, if you think about something like hypothyroidism, which is very much, you know, it's like, your thyroid gland isn't functioning, you're going to have this, you fix this, it translates. PCOS is messier. And so, yeah, so the patient, there is a lean phenotype, we call it lean PCOS, and it's often quite different than the obese PCOS. Some of the things that may be similar is the lack of ovulation, the need for help with fertility care, so that may be a constant. The other thing that may be a constant is trouble with elevated androgens, so hair growth on the face, acne, that can still manifest in lean PCOS. But lean PCOS patients are lucky in that they're often not quite as much struggling with some of the metabolic features. Although in studies where they measure insulin resistance very closely and very carefully in research settings, in even lean PCOS, they are more insulin resistant than lean non-PCOS. So there is still an insulin resistance piece there, but it's sort of either genetically not as sort of exacerbated or maybe that that person has just a very healthy lifestyle and they're able to keep a lot of it at bay.

And what, you know, one of the one of the consequences for people, if they have PCOS, what should they be aware of? What should they know about? in terms of their own health and long-term risks?

I mean, it's, I think, a very multifaceted disorder. There's generally sort of five or six things that I go through with patients with PCOS. So the first is menstrual cycle control. So it's important for people to have somewhat regular menstrual cycles or to have at least some sort of progesterone in their system to prevent overgrowth of the lining. There's the management of their skin or cutaneous findings with PCOS. So how can they manage their hair growth? There's fertility concerns, there's metabolic concerns, especially things like future diabetes, future cardiovascular disease. And then there's a lot of mental health disorders that we see in PCOS. So there's a high rate of depression. Yep.

And do you think it's a cause or a consequence of it?

I mean, it's something I've been really interested in researching. One of the things we've shown in some of our work has been a very strong correlation between insulin resistance actually and depression. And even when you control for body weight and even when you control for androgens, even when you control for hirsutism. So, you know, I do think at least in some of these patients that insulin resistance in and of itself may be contributing to depression. That's something we see in the diabetes literature as well.

That's a frightening idea because when you look at the metabolic health of America, I think the new data came out from Tufts that 93.2% of Americans are metabolically unhealthy, meaning they have some degree of insulin resistance. And we also see this sort of epidemic of mental health disorders and depression. And I don't think people realize that, you know, sugar and starch and processed foods is driving not only weight issues, but also mental health issues.

Yeah, I think it's, to me, one of the more profound connections and profound concerns. And I think It's unfortunate because in some ways that depression can often make it harder to address the diet and the exercise. You know, if you're feeling depressed, you're not in the most ideal state to sort of make those important lifestyle changes. So I think it's important that we take into consideration what's happening in terms of a mental health milieu for patients with PCOS and take that into account when we kind of talk to them about treatment, because that's an important component, I think, that needs to be addressed if we want them to make those important lifestyle changes.

Yeah, for sure. So when you see someone with this problem, what's your general therapeutic approach? How do you treat these patients? What are the ways that we can help them have a regular cycle to their acne, their hair growth, their hair loss? And I think you mentioned something really important, which is that you want them to have progesterone, which is sort of the antidote to this overbuild up of estrogens that happens in these patients, and they don't ovulate every cycle. so they don't make progesterone, which is what you do when you ovulate. So can you talk about what are the kind of therapeutic approaches and how do we potentially use progesterone or other therapies like that?

I mean, so I think in terms of therapeutic approaches with PCOS, it's always hard because I think it to some degree depends on what is their goal, like what are they trying to achieve? You know, are they trying to get pregnant at this moment or not? But in terms of the menstrual, let's say it's someone who's like 22 and she's coming to me because she's only having three periods a year and when she does, that's very heavy bleeding. I want to address that because we know that when people go many, many, many cycles without ovulating, it means they don't get progesterone. And that means that estrogen is going to cause over time buildup of the uterine lining, which can lead to very heavy menstrual cycles, but it also is a risk factor for endometrial cancer over time. So it is important that patients with PCOS get some sort of progesterone exposure. And that can be in the form of oral contraceptives, it can be in the form of bioidentical progesterone being taken cyclically, it can be in the form of an IUD that releases progesterone. I mean, so there's a lot of ways to do it, but if I have a patient who's having three cycles a year or something like that, that's an important conversation that I'm gonna have is like, look, we need to figure out some way for you to have progesterone because it's not healthy for your uterus to not have that progesterone over time. So that's helpful.

And what else do you do to help with their, so besides bioidentical progesterone, what other kind of therapies support these patients?

In terms of their other symptoms or, yeah, how do you deal with hair.

Loss or how do you deal with the acne or how do you deal with the irregular cycles, what hormonal therapies.

Are used besides bioidentical progesterone? Yeah, mostly the yeah. So I think the irregular Cycles would be addressed through some sort of progesterone, but the hair loss or hair growth or acne, those skin findings are not, are most, are best addressed, quite honestly, by being on something like a birth control pill, because the, and you're going to suppress the sort of stimulation of the ovary that's driving up the androgens, and you're also going to increase sex hormone binding globulin, which is a protein from the liver that really soaks up that extra androgen. So that's honestly the best way to get benefit in terms of this, especially hirsutism and acne. And then sometimes we'll even use medications that will block androgen action like spironolactone. Now, I do have patients who don't want to go on those medications and feel like that's not fixing the underlying problem and it's just patching it or they don't want to be on the pill. for a variety of reasons. So that tool is not always, you know, the ideal tool for our patients, but it is certainly one that I would discuss.

And, and what role do you see as diet? Is it, is it a strong lever for changing these patients reproductive health and their Cycles and their symptoms? I mean, if you basically put people on a low starch sugar sort of diet that treats the insulin resistance, do you see big changes in their clinical picture?

I think in some for sure. And I think, you know, there haven't been great studies on this. There's been a few. I do think that if patients are able to maintain a very low carb diet, sort of a ketogenic diet.

They.

Will be able to really manage their insulin resistance. And that really takes away one of the sort of drivers or triggers or things that's really exacerbating their sort of phenotype or their symptoms. So if you are able to get the patient to sort of embrace that approach, I do think that you will see that often patients will see benefits. I think it's something that has to be monitored. I don't think all patients will suddenly start having regular cycles and their hair growth isn't going to suddenly go away. But some patients may have more cycles. some patients may be able to conceive that way on their own without fertility treatment, but others will not. So I think it's something that I try to discuss as an option, but I think I shy away from saying like, here's the way to fix this, because I think in all honesty it doesn't fix it for some patients. And that's really frustrating if they feel like they're sort of somehow failing.

Well, that sort of speaks to how little we know, right? Because in some patients it works, in some patients it doesn't, and you don't really know which one's which. Right? And it's really about personalizing care.

Yeah. So I think it's a challenge and I do think it's one, I mean, PCOS is definitely a disorder that just takes a lot of personalization because it's such a diverse heterogeneous disorder. The concerns and the goals are often very diverse. So I think no patient and no treatment plan, quite honestly, is exactly the same.

And, you know, years ago I read an article in the New England Journal of Medicine about D-chiro-inositol and PCOS, which is a derivative of B vitamin. It seemed very promising. It kind of seemed to fall off the radar. What is the role of that in or other supplements in the treatment of PCOS?

I mean, I think it's still on the radar in the sense that people are using it, people are trying to study it. I think that there's been sort of mixed results in the studies that are out there. I think we're somewhat hampered by the fact that people are taking it in different formulations and different ratios and different dosages, which makes it a little hard to figure out whether it's working. I will say anecdotally, I do have patients who seem to become more regular in their cycling when they're taking it, and they find it easier to take than other medications that might do that, like metformin. So, I think that there's potential there and I think there is a pretty good study being run right now that hopefully will give us some answers. So, I definitely think it's on the radar.

Yeah. And what about other supplements you ever prescribe? Other things to help with nutrition or with insulin resistance or any of the symptoms? Like for example, saw palmetto is something often used. It's a five alpha reductase inhibitor, which is like what you use for inhibiting androgen production for the prostate and for men, for example, like Proscar or finasteride.

I have had patients taking that. I'm curious to hear how much you see as a benefit. Do you see patients really come back and say it worked?

Yeah, it really depends on the individual. So someone's like, oh yeah, they notice their acne better or it's like spironolactone, it's similar similar effect to that, but it's an herbal formula. I mean, it's used for men's prostate, so it's a little weird to give it to women, but I said, well, don't worry about the name of the product that says prostate on it, but you didn't worry about the mechanism of action of the herb or, you know.

And I wonder about, you know, Omega-3s or vitamin D or. Yeah. So, I mean, I feel like vitamin D is really important. I definitely, we check vitamin D on all of our patients coming in. We definitely find many, many of our patients are deficient. so I do try to get patients to sort of really replete their levels of vitamin D. Beyond that though, I would just say we really just take a pretty common sense approach to the diet and trying to like work with, you know, where that patient is at that time. So like some people's diet is terrible and there's like a lot of room for improvement. Some people are already doing a lot of the right things and you're just tweaking it. I find one of the big things that's missing is exercise. And some of our studies have shown such significant benefits for patients who are able to sort of keep that as part of their life. You know, we've looked at sort of our patients who exercise and our patients who don't. And it's dramatic, I think, how much sort of metabolic benefit patients can get if they can be active on a daily basis.

Yeah, that's such a key thing. And so tell us about the mechanism of action. You know, you've done a lot of research on this, but how does this work?

I think there's the main mechanism of action and it's probably deeper than this, but we know that just by increasing muscle mass, you're going to sort of improve insulin signaling, you're going to improve glucose uptake, and so there just seems to be a direct correlation with insulin resistance and exercise that I think is profound. Some of my patients will come back after exercising and they'll say, I didn't really lose that much weight, and they'll be very frustrated about that. But if you look at their numbers, you'll see that they've, you know, their insulin levels have dropped, their glucose levels have dropped. And so sometimes for me, it's about really showing them like, you are healthier, you probably gained some muscle, and that's why it's not a different number on the scale. I think that's one thing. But I also think getting back to the depression piece, like there's a, you know, really often significant improvement in sort of self-acceptance and in mood. happens with exercise that then I think can translate into sort of more energy for all sorts of lifestyle improvements. And then that ultimately translates to insulin resistance improvements.

Yeah, for sure. So you've done a lot of research. What are you most excited about that you're working on in terms of the research on this and endocrinology in general and PCOS and fertility?

I mean, I think for me, you know, my biggest interest has been late has been around the mood. I've been interested in looking at cognition and how it's impacted in PCOS. And then another area that I've been really interested in doing more work in, and we have a small pilot study starting is on sleep. Because I think sleep is often very disrupted in people with PCOS. We know there's a high rate of sleep apnea, but even beyond that, other sleep disorders. And I also think sleep is like a really key thing that can help with insulin resistance. So I guess I'm really interested in a lot of these things around the edges of PCOS that we can sort of fix to sort of improve quality of life. I don't know that I feel like I'm going to necessarily cure PCOS or make it not ever be a thing, but I think we can do a lot to improve the experience of having it.

So would you say if you fix insulin resistance that PCOS gets resolved or are there other factors that keep it going forward. In other words, if you've got someone's insulin perfect and you've got their blood sugar normal and you've got their lipid profile normal through diet, lifestyle, whatever, would that kind of eliminate PCOS or is there still factors that are driving PCOS beyond and some resistance?

I think there's still factors driving it, at least in most, to the extent that it's truly a disorder of elevated androgens. you're not going to completely take that away by fixing the insulin resistance. You are going to minimize a lot of the symptoms. You're going to potentially make it a very manageable disorder by managing the insulin resistance. You're going to make it so it's not such a burden. But I don't know that you sort of can wave a wand and it's no longer there. I think that sort of intrinsic physiology that person was born with is still there. You're just sort of helping them manage it better.

Do you think it's partly genetic?

I mean, this is like a huge kind of controversy as well in the field. So like there was a lot of research that went on trying to look at, you know, these GWAS studies, looking at all of these genes. People had a lot of excitement about finding the PCOS genes. And ultimately they did not find very much. I mean, they found some genes that maybe explain like 10%. so, so, you know, there's some thought now that it may have to do with sort of a, you know, a basically like epigenetic phenomenon where maybe the maternal Androgen levels may be driving or causing sort of changes in the fetus in utero that then set the fetus up to sort of have a PCOS phenotype. And we know that that's sort true in animal models that you can induce PCOS by maternal androgens. So to what extent that explains it in humans, we don't know. Maybe there's this microbiome theory. So I don't know that we know. I think that there's probably multiple pieces, probably multiple genes and multiple environmental factors that maybe set it up initially. And then once it's in place, it kind of self perpetuates.

Yeah, and it's such a common problem like we talked about earlier. It's like five to 10% of women at some level. And I mean, that's a big chunk of the population. So you're probably very busy, my guess. You also created a platform, which is kind of exciting, or an advisor to a platform, which is an all-in-one virtual care platform for people with PCOS called Alara Health. How does that work and what does it provide and how do people get supported through this process because, you know, a lot of the stuff that has to be done is behavior change, lifestyle change, and it's not just taking a pill.

Yeah, exactly. A lot of times it's having a partner that you work with over time that can really sort of kind of take you step by step through the improvements you need to make. But yeah, so Alara is, you know, it's, I think it's very much similar to what we do in our multidisciplinary clinic, but it's, taking it to a virtual platform and making it available to people all over the country. And so, as we talked about, I think PCOS sort of falls through the cracks and there's not a lot of providers who really own this disorder. So I was really excited when I heard about Alara, as just something that could sort of bring, I think, an evidence-based approach to PCOS that incorporates things like nutrition and mental health support. and can do it sort of virtually and can do it over time in a way that really sort of partners with women and so and just improves access. You know, I think that there's a lot of people with PCOS out there that don't feel like they're getting the care they need.

So, oh, millions, clearly millions of people have this, right?

Exactly. And, you know, I mean, there's a few cities and a few cities and there's, you know, there's always going to be a few practitioners who really own it and understand it and want to talk about it, but many practitioners don't. And so this is a way, I think, to give access to more people to sort of feel like they have a home for their PCOS, feel like someone who understands PCOS can sort of walk them through the ways to improve their quality of life or achieve the goals that they want to achieve.

So if you were sort of, you know, this is really great because I think it offers a forum for people to get connected to other people who have this it offers guidance on how to do the things you need to do to kind of reset your system and move yourself down the path of health. From the perspective of, you know, an expert in this field, when you see a patient, you know, what sort of tell us, kind of take us through maybe a case before we close of what you see, maybe a few cases of how they presented, what were the different kind of findings and what were the approaches that you used and how did you sort of move them down the path to health?

Okay, I mean I think I've always found that partnering with patients and being able to sort of see them somewhat frequently has been a really big sort of helpful way to kind of help them make the improvements they want to make. I think an example might be, let's say a 22 year old that I originally saw who was came in didn't know why she wasn't having periods, didn't know why she had the excess of hair growth and acne and We did a workup, we identified PCOS, we did a lot of education around PCOS. At that time, it made sense for this patient to go on birth control pills to sort of manage a lot of the symptoms. And so she went on birth control pills for a few years. But then several years later came back, didn't want to be on birth control pills anymore, had gone off, had gained some weight, was thinking about starting a family soon. So at that point, you know, I ran some metabolic tests and found that she was insulin resistant. and wanted her to work on that before starting to try to conceive. And so at that point, we had her sort of work with a nutritionist or I worked with her and had her start exercising. That would be sort of the program I would want that patient on at that time to sort of optimize her health before getting ready to conceive. And then, you know, ideally, those things have been improved, and then it would be time to sort think about the different ways to help someone get pregnant. And, but as you said, some patients through the use of sort of diet, exercise, or other ways to improve insulin resistance may start ovulating on their own. And in those cases, they are very much capable of conceiving. PCOS is not a fertility diagnosis, it's just a disorder of ovulation. So many of those patients may be able to conceive on their own. But if not, you know, if they're not ovulating regularly enough despite doing all those right things, then, you know, there are other ways that we can help people get pregnant by, you know, boosting ovulation through medical therapy. For sure.

Amazing. You know, one of the things you've studied is want to touch on because it's not really common is measuring insulin. Now, I never learned to do it in medical school. I now almost never see insulin measured on any lab panels that patients come to with from other physicians. And it's something you measure, I've been measuring it for almost 30 years. And I'm curious about how do you diagnose insulin resistance? Because if you look at the data on our metabolic health, I mean, 90% of Americans are metabolic unhealthy. And that to some degree is a degree of insulin resistance. So, and yet it's the most common disorder in the world right now. And yet, most doctors don't know how to diagnose it. So how do you approach diagnosing someone with insulin resistance?

Yeah, I mean, we take a deep dive, I think, into people's metabolic health in ways that a lot of doctors maybe don't. I like to measure fasting insulin and fasting glucose, and the simplest way to diagnose insulin resistance there would be to calculate a home IR, which is a, you plug two numbers in basically to a formula and you can get a home IR. And if it's over over 2.1. There's some degree of insulin resistance. Even simpler though is just looking at the fasting insulin. I think you're in the double digits. You already know you're probably a little insulin resistant and many of our patients with PCOS are much higher than that. We also do a glucose tolerance test, which is another test I think a lot of doctors don't do, but I think it's also really helpful. A lot of patients with PCOS, their fasting glucose is going to be relatively normal, but if you give them that 75 grams of sugar, two hours later, their sugar is still really high. So that's another way of sort of, I mean, it's not quite specifically insulin resistance, but essentially it is because you're basically showing this patient is not able to dispose of glucose.

Do you measure insulin too on that test?

To be honest, I do. I mean, I think that's, it's almost more of like research kind of like, I don't know that we have like really validated measures or what's a firm cutoff there. But I will say in many of our patients with PCOS, we see very, very high two-hour numbers, sometimes like 300. And to me, I like to see that because it really tells me kind of what I'm working with and how sort of entrenched the grievance and resistance is.

Yeah, that's such an important observation. I had a patient once who was typical apple shape, very central obesity, very overweight. and I was shocked because her hemoglobin A1C, which your average blood sugar was normal, her fasting blood sugar was perfect in the 90s. And I said, well, let's just do a glucose tolerance test. And we measured insulin and we measured glucose, and it was shocking. Her blood sugar never budged. I mean, it went from, like, maybe 90 to 110. It was perfect at one and two hours, but her insulin, you know, was high fasting, like, probably 20 or 30, but it went up to, like, two or 300. And I was like, holy crap. You know, this person clearly, when you look at her, was insulin resistant, but her blood sugar and insulin and he was normal, which is what most doctors will check. So you'll miss so much if you don't look at the insulin also. So I think that's a real take home for people is ask your doctor to check your insulin at least fasting. And you said it double digits. Now, if you look at the reference range on insulin on most labs, it's like 15 or something or even more. That's not optimal. that's probably like less than five is good. Right. Five to 10 is maybe okay. Over 10, no way. So, I think it's just, we just have to kind of get better at diagnosing this as a medical profession because we're really bad at it and it's such a key driver of not just infertility and hormonal disorders, but obviously diabetes and heart disease and cancer and dementia. So, it's just really across the board, one of our biggest problems.

Yeah, I mean, I think we know that just even those high levels of insulin hyperinsulinemia, I mean, clearly is driving some of the problems in PCOS, but there's, you know, thoughts of how much that might drive cancer growth and things like that. And if you see that patients underneath the surface, it's almost like you're seeing how things are playing out. You see that their insulin are sky high two hours after glucose, which is, you know, happening to that person every single day when they have glucose so you're getting almost like this sort of underneath the hood look at what's going on in their physiology and you can see where that's gonna go. It's gonna not go well. And so that's, to me, that's often like a really great way to look at those numbers with a patient and explain that to them. And often it can be really motivating for patients when they see that to make the changes that they wanna make.

Yeah, that's great. I mean, there's so much new technology, the continuous glucose monitors that are emerging. I met somebody who's developing this company, which is like a Band-Aid that measures your blood sugar. It's sort of a new tech thing. I don't even know how it works. Some transdermal way to measure. So I think people are going to be getting more and more able to understand their health in real time. And, and, and I think the work you're doing is so important. So I really, I really appreciate what you're doing. And I think it's very hopeful because from listening to it, it's really clear that you can make a lot of progress with both the condition and the symptoms, both in improving fertility, regular Cycles, improving acne, hair loss. and things that really are distressing for women. So, I think it's a very hopeful conversation. It's great that you're looking at all the intersectionality of inflammation and the microbiome and environmental toxins and diet and all these things that often are kind of stepchildren of medicine but actually play a big role in all these disorders, whether we like it or not.

The hacks work in all of us. So, if me and my friend who both ate the cookie had both put some clothes on the cookie, let's say, you know, 10 almonds, both of our spikes would have been proportionately smaller than the naked cookie spike. So you have to keep that in mind. These principles work for all of us, but then if you have the opportunity to use a glucose monitor, you might discover much more personalized and in-depth, you know, preferences that your body has.

Yeah, you know, Jesse, I remember reading that Israeli study where they looked at the microbiome. and how that uniqueness of each of our ecological community that we live in.

Which is our gut, that lives in us.

Yeah.

How that actually is so determinant of what happens with our metabolism. And we know, we know from animal studies, if you take the poop out of a skinny mouse and you put it in a fat mouse, the fat mouse will get skinny.

Yeah.

Or in a diabetic, diabetic to not diabetic.

Yeah. If you take a healthy metabolically healthy person, which there's not that many of us around anymore, there's about only 12% of us in America that are metabolically healthy. But if you find a person, good luck, and you transplant their poop into a diabetic, their blood sugar gets better. And I remember, I remember a case, which I had years ago, I think I might have mentioned on the podcast once, of a gentleman who had type 2 diabetes. We really poorly controlled, sugars were well over 200 all the time. And we got 'em down to like 150, but we couldn't just get 'em all the way normal, even on a ketogenic diet. and one day he called me up and he said, Dr. Hyman, I'm having a lot of digestive symptoms. I'm bloated, I'm distended, I'm all these issues. And I said, okay, well, well, let's do some diagnostic workup, let's do all this stuff. But in the meantime, you know, while you're suffering, just try some charcoal to see if that can absorb some of these, these sort of bloating and the gas and the toxins, which, which can cause these symptoms. And he did. And then he called me back and says, Dr. Hyman, I don't know what happened, but my blood sugar went to normal. I don't even understand. But, and I did understand because the microbiome plays a huge role in our metabolic health and something called metabolic endotoxemia, which means that the toxins produced by bad bugs in the gut when we eat the wrong things get absorbed and they cause inflammation, the inflammation causes us to be insulin resistant and that makes us more diabetic. I mean, it's just a whole cascade of vicious cycle. And, and so simply by absorbing the metabolic toxins in his gut from bad bugs, We were able to actually correct his blood sugar. So it's quite fascinating. It's not as simple as we think. It's just, oh, just eat this or don't eat that or exercise or don't exercise. It's really, it's kind of a personalized story. And, and I think, there are universal principles, like you mentioned. I think, I just wanna loop back on something you said before as well, because you talked about these, these sort of toast that happens when proteins and sugars in your blood and you become toast and you're literally toast. I mean, yeah. It's actually, it's actually true. You're toasting your system and, and there's a, there's a phenomenon called advanced glycation end products. And we, we measure this when we measure our average blood sugar through hemoglobin A1C, which is just measuring the proteins in hemoglobin getting glommed onto by sugar and forming this like crusty creme brulee, like chicken skin. That kind of, that phenomena, it's called the Maillard reaction happens inside your body, not just when you're cooking. and, and that, that is one of the Hallmarks of Aging is the abnormal proteins that form in the body that gum everything up. And this happens in your brain. It's called type three diabetes. It happens in your heart, your organs. It really is the phenomena that leads to Rapid aging and, and death. And then what's even funnier is that these things are called ages, Advanced ligation end products, and they, they bind to receptors on your cell called rages. So the ages make you rage, literally, and turn on all the inflammatory downstream phenomena that we see as inflammaging. So it's such an important thing to understand and regulating your blood sugar is probably the single most important thing you can do. I remember being at Canyon Ranch years ago and there was a cardiologist that came from Harvard and he gave a lecture and he said, you know, if you could take a group of hundred year old people and you could find a group with clean arteries, they'd have one thing in common. What would that be? they're insulin sensitive, meaning they're very good at keeping their blood sugar even without a lot of insulin. That's the key to longevity and healthy aging. And not just that, but all these other conditions that you mentioned, from acne to infertility, to depression, to panic attacks, to fatigue, energy, insomnia. I mean, night, night sweats are even a common symptom. You know, men get night sweats, too. And often it's because they have these hypoglycemic spikes and they can wake up.

With soaked sheets, so.

Really important to get your sugar dialed in.

So that's one of the things that happens when we have a glucose spike. It's the toasting. And maybe I can mention something else that happens when our glucose levels spike. So every cell in your body needs energy to function. You know, your brain cells need energy to think, your eye cells to see, your toe cells to dance all night long. Like every cell in your body is really hungry for energy. and the most easy place they get this energy is through glucose that we eat. And so as you digest a meal and glucose goes into your bloodstream, it heads to your cells to be converted to energy. And the little organelles that do this work are mitochondria. They take glucose, turn it into ATP, which is energy. And so you might think, okay, well, if I need energy, then the more glucose I eat, the more energy I have, right? It must be correlation just like that. It turns out that's not the case. If you overwhelm your mitochondria with too much glucose, which is the case when a glucose spike happens, your mitochondria don't get excited. They actually shut down. They're like, whoa, can't deal with all this stuff. Don't know what to do. I'm stressing out. I can't work anymore. Your mitochondria shut down and they get stressed and they release these things called free radicals into your cells. And free radicals, they harm everything that they touch. So if they touch your DNA, they might harm it and create a mutation that could lead to cancer later on. If they touch a cell membrane, they can break the cell membrane and damage the integrity of the cell. So your body's response to these free radicals is inflammation. And that's one of the ways that glucose spikes increase inflammation. The problem is in this case, if it becomes chronic inflammation, it's not good. And that is another thing that creates a terrain for chronic diseases. I mean, Three out of five people are gonna die of an inflammation based disease.

I mean, so this, I don't know if it's three, it's probably a hundred percent, I think. Actually, sure. I mean, unless you get hit by a truck or fall off a, out of a train or something, I, I think most of the people die from inflammatory related conditions. Cause all, all aging itself leads to more inflammation through a whole series of mechanisms, including your blood sugar, including environmental toxins, including your microbiome, including latent infections. including our processed inflammatory diet, including chronic stress. I mean, all the things that we see around us all the time are all driving this inflammatory process. But sugar is, is sort of the king, queen, and prince of driving inflammation in your body. And so it's, it's, it's such an important thing. That's why I've, I've been talking about this for decades cuz, you know, as a doctor seeing patients and testing this stuff when no one else was looking at it, it was like, wow, people are messed up. I would do glucose tolerance tests, not on diabetics, but on almost everybody who came in as a screening test for their metabolic health. Because your blood sugar can be perfectly normal and you can still be a mess, right?

Yeah, absolutely.

And I think that's an important lesson. We've had Dr. Casey Means talk about this on the podcast, talking about how, you know, there's patients who literally have perfectly normal blood sugars, but their insulins.

Are so high that they're keeping their blood sugar normal and that causes a whole other cascade yeah, cuz I think insulin increases for 10 years before glucose, fasting glucose levels increase.

Yeah.

You know, I mean the last thing.

Yeah, I mean the last thing that happens is your, is your fasting glucose going up, right?

Yeah.

And then, and then the second thing.

That, you know, second to last thing is your fasting, your fasting glucose goes up, but then your, your insulin, I mean your glucose after you eat goes up. But that's again a late stage phenomena. Earlier stages are high insulin after two hours, then high insulin fasting and then So we're getting on the train so late in medicine, we need to think about how to go upstream to get to the cause.

Yeah, and for a long time we only thought diabetics should worry about this. Only if you have diabetes should you then think about managing your glucose levels. And by the way, to manage it, just eat better and exercise more. I mean, come on. We need to give people the hacks, Mark. We need everybody to be using this.

It's so easy. Yeah, they eat better and people have no clue what that means. The other thing I wanted to sort of jump into was hormones.

Mm-.

We talked about aging, we talked about heart disease, but one of the real problems with sugar is screwing up our hormones, both for men and women. And can you take us down how that works and what goes wrong and why it's so common to see such hormonal chaos in this country?

Absolutely. I think one of the conditions that is becoming more and more prevalent, especially in my community, I'm noticing that the numbers are increasing so much. is polycystic ovarian syndrome. And this is a condition where women stop getting their period, their ovaries become burdened with cysts, they start displaying masculine traits like hair on the chin, balding, et cetera. And this is something that often we're told to just medicate, oh, just take the pill and it'll fix it. It turns out, actually, that polycystic ovarian syndrome is a disease of too much insulin.

Yeah.

And we know, yeah, and the way it works is fascinating. So when your body has too much insulin in it, it's not as good as it was before at converting male hormones into female hormones. So you end up with people who have uteruses who have this excess of testosterone in their body. So their female hormones are just not working anymore.

Yeah. And you get, they grow beards.

Yes.

And they get acne.

You don't have your period anymore.

And they lose the hair on their head. So the women get bald. You ever see this kind of women with the big round middle and their hair is all thin and like looks.

Like they're going bald on top.

So many. Whiskers going.

It's heartbreaking. It's really from sugar. Mark. Yeah, because they don't know that the reason this is happening is because of too much insulin. And the reason there's too much insulin is because their glucose levels are out of whack. And so what's really empowering, I think, is when Women started playing the principles, the science backed stuff that I share, because they're able to get their period back within months. A few women even got pregnant, even though they had been told they were infertile. And this is so empowering because we have power. We have power. It starts in our plate. And this is really a message of hope. So anybody listening, like, this can really benefit you. And I hope you'll find a lot of relief in this information.

Yeah, it's not your DNA, it's your dinner.

I love that.

So here's the deal. In men, the opposite sort of thing happens. So what happens to men, right? What happens to men when they eat too much sugar and starch is they actually produce, because they produce way more fat cells, and the fat cells have a compound called aromatase, which converts testosterone into estrogen. so the men get man boobs and they get soft skin and they lose the hair on their bodies, so they become more like women. So basically men become more like women, women become more like men. It creates this massive chaos in the hormones. And I just want to reinforce what you're saying because you say glucose and most people, when they think of glucose, they think of sugar, but you should think of bread. or sugar or cornflakes in exactly the same way. In fact, bread is the gold standard for measuring glycemic index. And it's worse than sugar. The score for bread is 100. The score for sugar is 80. So actually you're better off having the sugar than the bread.

I would disagree, Marc, because in the sugar there's also fructose and all the things we talked about, you know, the aging, the inflammation, fructose does it at an even higher rate than glucose alone.

That's true.

I would argue that if you have a choice between something starchy and something sweet, I would go for the starchy thing. But better even have some vegetables first, then some protein and fat, and then have the starchy thing. And maybe you won't even want to.

Have the sugary thing at the end. Yeah, I think that's fair. But I also say if you're going to have starch, have starch that's in forms that are coming in a good package. So, for example, I have a Japanese purple sweet potato at night. I love that, which is starch, but it's got full of phytochemicals and fiber and vitamins and minerals, and I eat the skin. So it's, it's really actually a very healthy food and it's quite different than eating white bread, which is also a starch. So starch is and starch is and starch. It really depends on where it's coming from and how it's metabolized. Even oatmeal versus steel cut oats, profoundly different.

Absolutely. And this is so what I've been doing in my work is testing all these things on my own body and using a continuous glucose monitor, showing people the different spikes that happen. So I tested steel cut oats versus regular oatmeal and the steel cut has a smaller spike and same for bread. So white bread is far worse than something like sourdough, for example, which is worse than something like very dark pumpernickel bread that's all gooey and feels almost like a cake because it's so rich of fiber.

Yeah.

Germany. So, it's always a spectrum, right? You have to think within a category, there's different types of bread, different types of potatoes, different types of starch, and you can always make a choice to get better. And, you can always add some fiber.

To it and some vinegar and go for a walk after. So, basically, throw some Metamucil and some.

Vinegar on your food and you're good, right?

Pretty much, yeah. Sounds delicious. So, tell us some of the surprising things, Jesse, that you learned about your own , and in researching this about what you thought was okay to eat, but actually wasn't, or what you thought wasn't okay to eat, but actually maybe was okay.

Hmm. Well, as I mentioned, you know, I used to have donuts for breakfast, so I really got a cold shower in terms of nothing sweet first thing in the morning. Because first thing in the morning, when your body is completely fasted, your glucose levels will respond incredibly fast. to anything that you ingest. So I realized that if I wanted to eat something sweet, for example, a donut, I should never, ever, ever eat it on an empty stomach. I should always eat it after a meal.

Yeah.

Then in terms of other surprising things, I mean, oatmeal was a big one. Because they even say oatmeal is for diabetics. I mean, there's all this information that's very confusing. Yeah. Rice cakes. Oh, my God. Oatmeal's not a health food. No, it's not. Rice cakes. this is crazy.

Brown rice cakes. How could they be bad?

I tested brown rice versus white rice. Literally no difference.

Well, what if you put, like, nut butter on top?

Then it's perfect. That sounds really gross, but it probably works.

I love it. That's my favorite thing.

I get the rice cakes, and I put, like, on the rice cake. I thought you meant to put the.

Nut butter on actual rice, like warm rice. No, no, no, no, no, no, no, no. You get a rice cake. and you put on the, the nut butter and it's, it's kind of good. I don't know how. Yeah.

Then that works.

I think, I think so, so, so all the breakfast things are really in this country so geared toward extremely high levels of starch and sugar. And in fact, yeah, fruit juice is terrible. What, you know?

Right.

And, and I think people need to realize that the most important thing they need to do when they eat in the morning, eat plenty of protein, fat and fiber. Yes. Because those are the magic tricks. to actually keep your blood sugar normal, protein, fat and fiber. And you have to learn what foods have protein, fat and fiber. It's, it's a little bit of an education cuz, you know, as most people may not know, but it actually, it actually is the key to success. And you're, you're basically saying eat protein.

Fat and fiber before you eat any starch or sugar and that will mitigate all the results. Exactly.

Something else that was very surprising was oat milk creates a big glucose spike.

Because it's, no more oatmeal lattes, the oat milk lattes, no, no way, huh? People got really sad when I posted that test. I was like, I'm sorry, I know you guys love your oat milk, but it's just a big bowl of glucose. It's dessert. Have it as dessert. Don't have it first thing in the morning on an empty stomach. And then fruit was actually quite surprising to me, Mark, because I learned that fruit have been bred for centuries to be extra sweet and extra juicy and contain lots of glucose and fructose, so especially grapes.

Yeah, grapes are the worst.

You eat 20 grapes, super big glucose spikes. So I learned that anytime I have fruit, always put clothes on it. I'm French, so grapes and cheese. I actually just posted that test yesterday on my Instagram, glucose goddess, if anybody wants to see it. If you add cheese to the grapes, the glucose spike is smaller because you're adding this fat. But it's still there. It's still there. But it's still there. Yeah. So have it as dessert. Yeah, pineapple. Bananas, definitely always put some clothes on those. And I've really completely changed the way I ate Mark. I mean, now for breakfast, I have leftovers. This morning I have leftover green beans and cauliflower and two eggs.

I don't have to eat anymore.

So dinner for breakfast? Dinner for breakfast. Dinner for breakfast. I feel better than I ever have, and I'm older than I ever have. I feel so good. I don't have any cravings. I have energy throughout the day. I don't even drink coffee anymore. because I have so much energy just naturally. I mean, I sleep amazingly. It's, it's very powerful.

That's amazing. So you basically have learned how to hack. Now, what other foods you thought were, were bad for you that actually weren't so bad?

Well, there was this whole thing about fat is bad for you. You know, fat makes you fat, fat's not good. And I learned that actually that's not the case. You know, what drives heart disease the most is fructose. in your liver creating low density LDL. And that fat is actually your friend. And so I started putting way more avocado and avocado oils and olive oil and good fats like that, eating more fish. And that really helped stabilize my glucose levels. Other foods that I thought were bad that were actually good. I think it was mostly the other way around. It was lots of foods I thought were good that were actually bad. What about yourself? What did you just go fruit.

Yeah.

Fruit, right?

Yeah. I think fruit has, you have to be careful with fruit because it depends on the fruit. It depends on how, you know, sweet it is, how it was bread, the kind of fruit, you know, like when you, when you go kind of get a wild fruit, they're very sweet, but.

They'Re very, very small, you know?

And I think, you know. Oh, dried fruit is another big one. Oh, dried fruit's terrible. Yeah. Dried fruit's like candy. You know, it's just like candy. If you love that last video, you're gonna love the next one. Check it out here. What actually isn't a good diet? And I've written a lot about this. I wrote food, what the heck should I eat? The Pegan diet. There's no guessing what I think, but essentially it's whole real food. You know, I, I kind of used to do a lot of speaking in churches with the Daniel plan I did, and I say it's really easy.