The Cortisol-Blood Sugar Connection: The Hidden Driver of Energy, Weight & Stress

Welcome back, Synergy listeners. Today's conversation is one that connects so many dots, and once you hear it, you just can't unhear it. We're about to talk about cortisol and blood sugar and how they're so related. These two systems most people think are completely separate, but in reality, they're deeply intertwined and they're quietly influencing everything from your energy to your weight to your sleep and to your mood. So if you've ever felt like you're doing all the right things, you're eating well, you're trying to manage your stress, but you still feel tired, maybe a little wired or stuck, this might just be the missing piece. And today we're so excited we get to have Dr. Jay on the podcast. She's an endocrinologist. She specializes in helping people understand the deeper physiology behind the patterns that drive dysregulation and stress and blood sugar. So this is one of those conversations that I can say will truly change how you look, not just at your body, but maybe even your whole life. So Lori Esarey MS, as I was preparing for this podcast, it got me thinking, you know, hearing your story about blood sugar dysregulation at such an early age and knowing how far we've come with technology, with all the tools that we have from Oura Ring to continuous glucose monitoring to podcasting and to resources. You know, are there things when you look back that you wish you had had in those early days as you were navigating this as a patient?

Gosh, Kelly, what a loaded question, because truly, yes. I mean, we have access to so many things now that were not even a consideration at that time. I mean, we had the ability to check our blood sugars through manual, right, using an Accu-Chek or something like that. But the on— you know, the onset of having continuous glucose monitoring and other wearable devices if I looked in the rearview mirror and, and really looked at one of the one things that I think would have been most powerful, would have been that to know specifically not just what you're waking up with in respect to your blood sugar, but specifically what's happening throughout the day. Because it's not one factor, and that's what we're going to talk about today. It is a ton of different factors that really regulate that system. And I would say number two, I look in the rearview mirror and I am so thankful for what I went through because I truly believe I wouldn't be where I was and I wouldn't have the practice that I had today if I hadn't gone through that, because it forced me to look at health through a completely different lens, very different than traditional medicine. And knowledge is power. And when applying it, life can change. So that's the take-home message today, is there— there's hope. You know, people don't have to live, you know, tired, brain fogged, walking around feeling sad. I'm going to differentiate depression versus sadness. They don't have to feel that way. And there's likely a relationship the blood sugar.

I love it. So let's talk a few minutes about the difference between Accu-Chek, like checking your finger stick, and being able to wear a continuous glucose monitor. Because I do have patients still today that'll say, oh, I'm checking my blood sugar, and I'm like, ah, there's so much more insight that we can gain from that continuous glucose monitor because we can see point in time, we can see the fluctuations that happen. It's really those changes in blood sugar, more than a 30-point dip or rise in blood sugar that really affect vascular health and stress response that may be driving everything that I think can be missed when you're just doing fingerstick glucose monitoring. What would you say to that?

I 100% agree. Like, yes, we wake up in the morning and we get up and we have that cortisol awakening response, right? So if we're just checking our fingerstick, right, we're just checking our fingerstick, we're going to get the point in time to which we checked it, which if that was just upon arising, maybe it's a little bit lower. But what happens in 30 minutes? What happens in an hour? What happens an hour later from that? And so you're exactly right. If you really want to connect the dots, having a continuous glucose monitor is golden. And to your point, variability is key, right? So we look at that differential, that roller coaster that we talk about all the time, because as blood sugar goes up, we have— that's an inflammatory response, right? So it goes up, body produces what? Insulin. Insulin is pro-inflammatory. We need it, right? And then blood sugar goes down. And if we do the typical American diet, right, eating more of the standard American processed glucose, sugar foods, that's probably going to stay up, right? But what if we have a day where we don't get a chance to eat and there's a delay in that? And then you compound that by not sleeping the night before, and then you compound that with you know, having a really high-intensity workout, like all the things, all the things. Having that continuous glucose monitor is honestly golden. And I'm not going to minimize that a good start may be finger sticks.

Sure.

Because some people are definitely opposed to wearing the continuous glucose monitor. It's a great place to start. But if you really want to dig deeper, the CGM is the way to go.

Yeah, I think if you're trying to connect the dots between stress, how you're working, or how you're moving your body, your sleep patterns, if you really want to dig into more than just food that you're putting in and how that's affecting your blood sugar, I think the continuous glucose monitor is the win.

Gosh, there's so many places I want to go, but it's a full conversation. Like, even with, um, PCOS and the change to being a full-on metabolic condition— like, who didn't know that, right? Like, we knew it. And it all goes back, it all goes back to insulin resistance. Like, it all goes back. It's almost mind-blowing to me. Like, I look in the rearview mirror and I, I just— I'm in awe— of what we saw clinically. We saw it clinically, but we just didn't have the research, right?

We didn't have the research to support what we were seeing clinically and what we were guiding. Even, I would say, 10 years ago, before continuous glucose monitors, we had already kind of picked up on the fact that if you had insulin resistance, um, you were more at risk for endometriosis, more at risk for polycystic ovarian syndrome, more at risk for poor pregnancy outcome. Like, the list was on and on and on when it relates to female health in general. Um, and we all know about visceral fat and what that does to inflammation and drivers of inflammation as we age. But I'm thinking about the young person where we're setting hormone regulation, preteen, teens, and that sets that whole cascade of what happens later on in life. Yeah.

And I think, you know, the conversation's always been about diabetes, not necessarily about insulin resistance, right? You know, so all of this was— all of the attention was paid to blood sugar or glucose levels.

And I think another thing I would say about continuous glucose monitoring and how it's been impactful is when we're working with patients, getting them re-regulated on insulin production, sometimes there can be a window where we work with their diet and we've really reduced this surge of insulin. So insulin levels start trending down, they're feeling better, they're functioning better, and then you do their lab work 12 weeks out from diet change and their A1C went up. And it's so confusing to them because they're like, I'm doing so good. And they're so used to looking at that hemoglobin A1C, which for our listeners, that's a measurement of glycation or stickiness of your red blood cell. Your red blood cell lives for 12 weeks, so it's a 12-week measurement of what's happened in regard to glucose management for that red blood cell exposure. And it's what we hang our hat on oftentimes when we're thinking about are they regulated or not. So sometimes we'll see it temporarily go up, and that's because there's still insulin resistance at cellular level. We haven't really implemented exercise, and we haven't implemented things that are going to activate insulin receptors, but we've decreased insulin production. So sometimes that can be really upsetting for patients to see their numbers, and they don't understand why things actually shifted in a negative direction on paper.

Yeah, you're so right. I remember when hemoglobin A1C came out, you know, and I was working in primary care at the time, and I remember people would come in and we were just looking at their glucose, and we would look at their A1C, and they're like, oh my gosh, I've been so great, right? I've been behaving myself, and their fasting glucose would, would, you know, be down, but their A1Cs would be super high. And there was that period of time that we weren't diagnosing based on hemoglobin A1C. And the reality is we should not really be diagnosing on hemoglobin A1C. Again, that is just my opinion, right? That is just— and let's be clear here— but part of that reason is because that variability we always talk about, being too high or being too low all the time, um, either one of them can be bad— being too high all the time, being too low all the time— but really on that coaster, right, of variability creates, you know, a big issue. And, you know, I'm with you. When people come in, they do get frustrated, right? Because they're wanting to see a metric improve. And we want to say to them, but your metrics did, you know, your biomarkers are not an A to an F grade. Your body is dynamic. It's dynamic. So we have to look at all of the numbers— fasting glucose, C-peptide, insulin, intact insulin levels. You know, is there disparity between your insulin and your glucose? You wake up in the morning and your glucose is 100, but you're, you know, maybe 100 or 120, but your intact insulin is like 2 or 3. You know, let's think about that. Is there disparity with that? Well, you would expect to have higher insulin for that level. There's a bigger picture. So we get to welcome Dr. Jay into the conversation. We are so excited to have you here today. Kelly and I get this unique opportunity to get to talk to an endocrinologist all about that relationship between cortisol and blood sugar. So, um, Dr. Jay, I got the unique, really cool opportunity to meet you at Mastermind, which is something that we get the opportunity to do, those of us who are really seeking to be pioneers in our field and ahead of, um, and really wanting to do great things for our communities and beyond our communities. And that's where I got a chance to meet you, and I just fell in love with you. I love your personality, I love all you do, and I love your passion. So can't wait to dig into this conversation with you today.

I'm excited too, Lori Esarey MS. It's mutual. I love it. You know, it's so much of what you do and talk is exactly what I do every day. And I can't wait to share more about this.

Yes.

Awesome. So tell us a little bit about your story. How did you— how did you, first of all, choose endocrinology and then how and what really prompted you to start looking at hormones differently and the endocrine system differently?

Yeah, yeah. You know, thank you for asking. And that's a journey that I cannot speak more about my personal life. When I was little, I had, you know, we used to live in a joint family in India and I had my uncle's family and our family, we lived together because I had lost my dad in a war. And you know, what do we do as families? We take care of each other. So my uncle's family and my family became one. So we were all living under one roof, and, um, his only son used to get sick all the time, you know, um, very easily get cough and cold. And we'll get sick at the same time as a kid, but we'll recover, and he would drag it, you know, it'll stay for a long time. And, um, that bothered me, and I didn't make much of it when I was a child, you know. I thought he's making excuses. You know, kids are mean, right? So I thought, hmm, maybe he doesn't want to go to school, you know, he wants to just be in the bed. And I didn't want to say that, but I was like, come on, stop being lazy, okay? But slowly over time, what we noticed was he did not get facial hair, he did not— his voice didn't change, and he stayed like a baby. So, um, I mean, in other words, he was not maturing, he was not getting his secondary sexual characteristics, things that are normal, right? So, um, that's when I was already in medical school, and he was 10 years younger to me. Um, so I told my uncle that we lived in a very small town in northern India called Pilani that was in Rajasthan state, and it's, it's, it's very well known for its education but not for medical care. So the medical care is very basic, but the education is excellent. So I told my uncle, I said, said, you may want to take him to the best hospital in Delhi or some bigger city so we can get him tested, because this is a pattern I'm seeing. So somewhere it made me realize that it's, it's something beyond. And I had no idea what infections and his growth— are they related by any means? I, you know, I never connected those dots. Um, but, you know, I was shocked, and I had never heard of a word called pituitary. Um, so after he got tested, they said Well, he has underdeveloped pituitary, and that's called panhypopituitarism. It's a fancy word just to say that pan is all of your gland, hypo is underactive. So whole gland is not functioning. Okay, so panhypopituitarism, that was introduction to pituitary in my life, and this first or second year of medical school. I mean, of course I had— I was doing my anatomy and I knew, you know, but it came really, really early. And that's what shocked me and made me in love with this hormones and gland system that I've been doing for the last 30 years now. Um, but that was introduction to how this tiny pea-sized gland which is sitting right behind our nose is, you know, under the brain inside, is connected to our thyroid and it's connected to our adrenals and connected to our sex steroids and, you know, ovaries and testicles. So I got fascinated with the idea this, this master gland, or we call it mother of all the glands, is controlling the whole body. And that was my start of the journey. So when I decided to do internal medicine, I had still not decided to do endocrinology, but the more I did medicine, the more I knew that my calling was to go dig more, dig more, you know, and help my brother. You know, that was my real reason to become an endocrinologist because he was 10 years younger to me. He was still living in India. I was in US and I'm like, he's not getting the best care. How can I be his anchor? How can I be his, you know, support in every way? Right.

So what helped you bridge the gap from traditional endocrinology into the functional integrative space?

Thank you for asking me that question, Kelly, because the more I practiced medicine, the more I realized how incomplete we are. Right. Sadly, we are so incomplete and we are so reactive where we want pill for every ill, and it does not work. It just does not work. And, and I try to put myself in that space when I am not well or whatever. I'm like, don't give me any prescriptions, I want to know what else could we do, you know? And same thing for my brother who decided to just, um, not take his medication sometimes. And in spite of me guiding him that, hey, you really need to make sure that you have of, you know, what is adrenal insufficiency, what is Addison's disease, and how it can be life-threatening if you don't take it. So his condition was opposite to what we see every day, which is hypercortisolism. He had hypocortisolism because his brain was not sending signals, right? So for him, taking the medicine was very important. But could he do more things? Absolutely, yes. He could eat better, he could sleep better, he could do things that could definitely help his gut health. Right, in spite of the need to take medicine. So that really guided me that we need to look outside the box. And same with my patients, you know, the patients would think that, oh, you take a pill and you're fixed. No, that's just piece of the puzzle.

Yeah, yeah. So I know you— yeah, it's part of it. I know you treat diabetes a lot. I can only imagine that you treat diabetes a lot. And I— and, and one of the things that, um, in both Kelly and I's experience, we have seen in treating a lot as well, right, more of the family practice and now integrative regenerative space is that oftentimes diabetes is just looked at as a glucose problem or an insulin problem. So today, can you help us start out by helping us understand how glucose and insulin and cortisol are related? How do you explain that to patients?

You know, that's a great question. And, and again, it's so important. And this brings me to that integrated part of of the equation that we just talked about, if we don't understand the cortisol piece of it, then we will always look for prescription for diabetes, and that's not what we should be doing. There's so much more we can do without we go into just the prescriptions. So I had the opportunity of writing a book recently, and it's coming out on July 1st, and that summarizes everything that you're asking. So I'm going to go back to the framework of that book so you can understand why am I speaking that in my book, and that includes 5 steps to reverse your diabetes. Okay. And, and yes, I get it. My colleagues frown at me when I say reversal because that's not the word we use these days. We say remission. In other words, once you get to diabetes, it's very hard to reverse and you can only do enough. But because you have cell— cellular memory and muscle memory and all those things, you can go back to where you started if you don't keep up with your lifestyle. Right? So the 5 steps that I have in my book, and that's where I'll answer your question, is number 1, precision mapping. Okay? We really need to know everybody's body, who's doing what. And in that case, I really, one of the steps that I do in precision mapping is to understand what's your cortisol level? What is your stress level? How much your sleep is affecting your cortisol? And, you know, or everyday life, how much is that affecting your cortisol? So precision mapping helps me understand where somebody is. And number 2 is lifestyle modification. Why do I want to do lifestyle? Because that drops your cortisol. Number 3 is hormone optimization. Number 4 is cardio metabolic optimization. And number 5 is lower the dose. And that's my thing, my philosophy, that I want you to stay on lowest dose of medication. Okay? So having said that and gone through the 5 steps, cortisol is literally named after what it does. Okay, it's a glucocorticoid, which means it's a hormone that controls glucose. So it's, it's in the name—

glucocorticoid.

And we need to just go back to our basics, right? Um, when the body is under stress, the cortisol tells the liver to make more sugar. And, and that is what we need to understand, that no matter what kind of diabetes you have Even if you have type 1 diabetes, everybody has liver, everybody has stress, okay? And everybody has adrenals, and you have 2 adrenals. So if you're stressed out, you're gonna tell, send signal with the stress to your adrenal gland, "I'm under stress." So it's constantly revving up and making too much cortisol. And that cortisol is going to our liver and telling the liver, "Come on, I'm under stress. Kick in some more cortisol. Give me some more." So it's a vicious cycle, okay? Sorry, the liver makes more sugar. Because it was supposed to be fight and flight for the times when we had, we were hunters and gatherers, right? You run and you're trying to save yourself and your cortisol, your liver is supposed to make sugar so you can run more, right? You can protect from animals and whatnot. In daily life, we don't have the, you know, fight or flight because of hunters and gatherers situation, but we have everyday stresses that are kicking our adrenals to make more cortisol, goes to the liver, liver is making more sugar. Yeah, so that is the connection that I want to tell you. Now, one is it dumps more in the bloodstream by making more, um, glucose. The other thing that the cortisol does is it also shuts down your body's capacity to utilize that glucose. So not only is it pumping in more, it's also cutting down on your capacity to utilize it. So it does not let you put that glucose into the muscles and the fat cells where they belong. So your blood sugars are rising. So the whole point is evolutionary is needed, was needed, but now we've changed it. Yes.

I want to go back to that whole stress conversation because I can think back to my mom in her perimenopausal phase when she would go to the doctor and she would be tired and wired, not sleeping well, gaining weight, all the things that we hear. And she would come back so angry because what she was told at that time was, oh, it's just stress. This is just stress. And it became such an offensive comment that I wanted to—

let's just stop it here. Yeah, you said something so powerful. Oh, it is just stress. So sad that as providers we stop there. Yes. And we need to take it to the next level. Oh, I would have reframed it and I said, oh my God, I'm sorry, this seems to be all stress-driven. So let's go back to what we can do to understand where the stress is coming. How can we help you?

Yes, I love it.

Does that make sense?

I love it. I love the pause. Yes, it's changing the conversation and giving space for the understanding that stress isn't just what's going on out here emotionally. But it's also what's going on physiologically, you know, our chemical stressors, our physical stressors. Blood sugar dysregulation is a physical stressor. So is anemia. So is having gut dysbiosis. You know, all these things that we don't even think about as stressors that are keeping that engine going every day, driving that, fueling that stress response that's causing a rise in glucose, a rise in insulin, fatigue, and that vicious cycle that we just can't seem to get out of.

And one of the most profound things that I was taught quite, I would say, I don't know, maybe 8 to 10 years ago, is truly the definition of stress. And I have found that extremely helpful too. I love what you said about pause, but reframing and redefining, because stress by definition is any demand for change. And what have we gone through in the past couple of years? I mean, change is the only constant. It's changed, right?

Wait a minute, you said gone through— what we're going through, and we're exponentially changing, right? And some of it's really good change, but it— to your point, it's a demand. It's a demand on the body.

Yes.

And when women understand that, when they understand that part of the stress that they're dealing with— and when we utilize that word— is inevitable. Stress is any demand for change. Good change, bad change. I think about having grandkids, you you know, getting married, you know, whatever it is, getting out of college, getting a new job, that's all stress too. And then the underlying metabolic stressors, you know, the environment and things that you spoke of too. But I love the pause. I love reframing it because it makes them less defensive, you know, in the equation and in the conversation.

Yeah. I want to take you back a little bit when I was talking about how, um, you know, how great it is, you know, running away from lion and being able to put that stress response and be able to utilize that extra glucose that comes out of the liver, right? All that was good. But if you have a person who has excessive cortisol from, let's say, tumor, okay, because there's adrenal tumors too that we treat as an endocrinologist. So I have lots of patients and I've seen in the last 30 years, it's not very common, but every year I have 2 to 4 patients who have Cushing syndrome or Cushing's disease. What does that mean? Cushing's disease is when you have excessive— those are interchangeable words, but Cushing's syndrome is what we need to understand more, um, because disease is a word that they give to if it's coming from pituitary. Um, so you could have excessive cortisol in your body from stress, like what we are primarily focusing on, but you could have excessive cortisol from abnormal functioning of the adrenal gland. So adrenal could be pumping in more because it's not capable of shutting you know, because the mother gland is not able to control it well. But that population is handful. It's not a lot, okay? But in the— in a year's time, when I see those 2 or 3 that I tease out of hundreds and hundreds of prediabetes and metabolic syndrome and whatnot, what we see is Cushing syndrome itself has tendency to give, um, diabetes in 47% of the cases. Okay, so literally 50% of people with Cushing's will have diabetes. Okay, yeah, so that just tells me that it is made to do that. If we can find the reason for your stress and work on that, that is most important. That's what we need to work on, right? But if unfortunately if somebody has a tumor or excessive cortisol that cannot be shut off by managing stress only, then we deal with it further. But that's very, very few and handful.

Yeah. So can we take a step back and talk about the non-diabetic, chronically stressed person and fasting glucose levels? So I want to know from an endocrinology standpoint, I think Lori and I have pretty similar ways of approaching this, but we use a lot of continuous glucose monitoring in our clinics and we want to— we have strived to help our patients reach optimization with the fasting glucose between 75 and 85. And our understanding is that every point above 85 for fasting glucose is a 6% increased risk for cardiovascular disease, right? So that's been kind of the standard. I was challenged recently by another provider saying that he did not want glucose below 80 fasting. And I was like, why? Why? I mean, why? Why below 80? So I didn't know if there was any research that I'm just not aware of or anything as an endocrinologist that you would speak to that.

Great question. So I'm going to again take a step back a little bit. Let's try to understand what is fasting glucose, what is driving it, right? And especially in this day and age, we have a lot of people on GLP-1 agonists. So we have to factor in everything else that goes on. In fact, I'm with a friend right now and she's on semaglutide— I'm sorry, tirzepatide. And we are both wearing the GLP-1 one, okay? She's visiting from France, and, and I said, let me give you a gift. While we travel for a week, we're going to put a CGM. So I've got mine, I was trying to look for that, and she's got hers, okay? And I am not diabetic, and I am not on GLP-1, so my fasting glucose is running in 85 to 95, and her fasting glucose is running close to 65, 55 to 65. So that really bothers me in a Okay, so I'm taking this liberty of sharing our story, but I wanted to answer your question in a way where you can relate to other people. Okay, so here I am, um, uh, under stress. Yeah, you can say that as a physician, but I'm not on GLP-1 and I am not diabetic. Okay, and she had her journey of of dealing with weight, and she's lost tremendous amount of weight, which is phenomenal. But now her glucose levels are running lower compared to me. Okay, why? Okay, what happens is our liver is supposed to make— in the morning, our cortisol level goes up. Okay, so there's something called circadian rhythm. So our body is supposed to tell in the morning, oh, it's time to wake up, take care of yourself. And, you know, it's going to send signals to adrenal gland, and adrenal gland is going to make cortisol, and cortisol is going to go to liver and make more sugar.

Okay.

In my case, it is what it is, like what you expect. But for her, because she lost a lot of weight, there's a phenomenon called nécidioblastosis. That's what we call it. So your body is making too much insulin all the time. Okay. Now that she's 30 pounds lighter, your beta cells don't get smaller. They are hypertrophied. They stay like that.

Interesting.

Okay.

Okay.

So I know I'm switching away from your question. No, that's okay.

This is great. This is really good.

This is very important because we have so many people who are losing all the weight with GLP-1 and all that. We need to be aware of this, right?

Yes.

Um, so what your body does is if you eat a little bit of, uh, carb, um, it's going to dump too much insulin. Okay, it's stored, it's making it, right? It's used to doing that. So that's what people need to understand. When they lose a lot of weight, they can lose the weight, they can look pretty, they can do everything else the way they want, but what you cannot do is shrink your beta cells. We're not there yet, we're not there yet. Um, so you do see people who have lost a lot of weight tend to get more tendency for hypoglycemia.

Okay, so tell me this, is there risk in having a blood sugar that low in the morning if they're asymptomatic? Say they're asymptomatic hypoglycemic, they feel fine. Is there a risk?

That's exactly the point. And thank you for bringing that up. If you're asymptomatic, I don't worry about it. Okay. And because she's wearing a CGM, because I know the pattern and I know she's not having— but we don't want to go into 50s.

Okay. Yeah, for sure.

It's time for her to eat, for sure. I don't like to get it less than 70 if I can. Okay. And my happy medium is 70 to 90. That's what I like. And I don't want to go more than 90 in the fasting state if I can.

Sure.

So for her, I've educated her about making sure every time she eats something, she has to have protein with that. It cannot just be pure carbs. Pure carbs are punishment to your adrenals because all it knows is to kick in more gluconeogenesis. Your liver makes more sugar. Because of the way your body's working. And that's going to, you know, if you look at the graph, CGM, that you're talking about, unfortunately I can't share that right here, but, um, but if you look at the graph, that's when you see sudden peak and sudden drop. And that's right, and that does not make you feel good when you have a sudden rise and a sudden drop. So we've really— again, Lori Esarey MS's question on, um, why integrative medicine— if you don't pay attention to what you're eating and putting in your mouth, and if you don't pay attention to your you cannot manage this situation. You know, we cannot just say, go on GLP-1. No, it's a lot more than that.

Thank you for sharing that, because we have so many people on GLP-1s now, or GLPs as a class. And we've got another next generation coming out soon that everyone's super excited about. And so it's a widespread situation. We're seeing it day in and day out. And so really having some ways of talking to patients and having them listening to this podcast and understanding better about what they should be paying attention to. And to your point, a lot of times when that appetite gets downregulated and they realize they can cheat a little bit and have the carbs and not gain weight back, the tendency is to go to those carbs, and they're not doing themselves a favor in the long run.

Yeah, I just wonder if that's why we're seeing some weight regain as well, right? So I am so intrigued by what you just said about the, the beta cells not shrinking, and I guess my question related to that, and maybe it's too early to tell, I'd love to know what you're seeing, is that is there a period of time in which the body learns to adapt to that? Like, does a larger beta cell always equate to this dysregulation, or can it be trained over time for this person?

Very good question. Yeah, because that comes in our daily practice, right? And we've got to do that. This is where the holistic care comes it, right? So you've got to make sure you pay attention to your sleep so you're not letting excessive cortisol run in your body. Okay. You want to make sure that you manage the amount of cortisol in your system and you do not eat pure carbs. I think those are the two things. If you can learn to equate those, that will go a long way. Mhm. You know, um, yeah, the only thing is, I— the answer for these patients I used to see this a lot more, um, when we did not have GLP-1, in category of people who were getting gastric bypass. Okay, so what happens is with the gastric bypass, the stomach is all smaller, and whatever way you have the surgery, and now you're losing weight, losing weight, and the pancreas is still gonna dump, right? So they— the first, second, and third treatment for them is Never have pure carbs. Always have carbs with protein. Okay? So pay attention to your choices. You really need to be careful. And that goes with everybody, with GLP-1, non-GLP-1, anybody who's losing excessive weight with whatever way, they got to pay attention to their choices, right? And that's not only to prevent hypoglycemia, but that's also to physiologically take care of yourself. And like Lori Esarey MS said, you stop the GLP-1 and then we have a tendency to regain the weight back. You know, I often talk to my patients about the good and the bad and the ugly of GLP-1s. Okay, so, so don't think anything that is out there that you can just put in your body is going to be all successful, right? Okay, but, but here's what I tell them, um, your weight is not doing any favor to you, you know. So there are some patients with— they come with skepticism, or they listen to too much of social media influencers, you know, where they— these people have no scientific background and all they talk about is GLP-1 with their limited knowledge, right? And, and what they talk about is, um, oh well, don't take GLP-1 because of the gut side effects of this and that and whatnot, you know, the other side of it. And, and that's when the conversation changes for me to talk to people. I said, hey, the weight leads to 13 kinds of cancers, right? The weight leads to so many other problems Don't worry about the rare side effects of GLP-1s. You can still benefit, okay? But we need to be wise and knowledgeable about what are we doing, what are our goals, where do we want to take you, where do we draw the line, okay? And that's what I mean by the good, the bad, and the ugly, okay?

That's right.

And by ugly, I mean GI side effects, the risk of weight regain, you know? Those are the two big ones that I have. But usually, Yeah, so I'm sorry, I'm diverting from your question.

No worries.

So, Dr. J—

Dr. J, there's so much to cover, and I know we're running out of time, but I wanted to get to the subset of patients because I know you see this too. I know Lori Esarey MS, but they at one time had really high stress, high cortisol, and then eventually their cortisol flatlines and they lose regulatory control over their immune system, which puts them at increased cancer risk, and they're fatigued, and they just can't get back to a regulated cortisol system. So I just would be curious to see from an endocrinology standpoint, how do you approach that patient in walking them back to recovery?

I think that's a very important question. And we see that these days. We see that because chronic stress will chronically increase your cortisol and you're blunting that circadian rhythm that we talked about earlier, right? So you don't have that peak in— and the trough throughout the day. You're normally supposed to peak in the morning around 7 or 8 o'clock, and then you're supposed to peak around 2 o'clock, and goes down during the rest of the day, and overnight it's supposed to stay low, right? And what you're saying is they've lost that tendency of the peaks and they're flat. We call that the cortisol clock, right?

Yes.

Normally cortisol will sharp so that we can wake up up, we can get that energy to take care of things, um, and hitting the lowest point of the evening, which allows us to sleep, right? And if you're not low, then what happens is at that point you're hungry all the time and you're eating all the time, and that's you— it's a vicious cycle that you're feeding out, feeding in. Um, so the flattening of the curve is what we worry about, and it goes back to what you need to do— go back to your habits. Making the right choices, sleeping on time, exercising, not exercising late in the evening, not triggering the stress response later in the evening by having caffeine or doing things that you should not be doing. So I really think making a routine and prioritizing and respecting your body and thinking about what you should be doing at certain times really helps you get it back. But there's certainly no switch that we can do.

That's right. Yeah, I love it. It. Yeah.

And I think one of the things that you had said in your framework too is that individual— individuality and that blueprint of investigation. I, I don't know that I said it exactly the way you said you did. You did.

Absolutely.

But beyond, you know, the lifestyle recommendations, those foundational pillars that we talk about that are so, so important that we cannot negate, there is that biochemical individuality of really understanding what what's driving that person to that place? Because I think, um, and you've likely seen it, I know Kelly and I have seen it so many times, that they're doing a lot of right things, a lot of right things, but they're not getting optimal results. And so when you think about that framework and, and digging into diagnostics, are there specific diagnostics that you come out of the gate with automatically?

Yeah, so that is a very critical point that you're making, Lori. Um, I do test everybody these, uh, general markers, and then I look at their hormones. Okay, so not only am I going to look at their cortisol, I'm also going to look at their thyroid. Okay, I'm going to look at their growth hormone. I'm going to look at their inflammation markers and try to understand if something else could be, you know, if they have some other situation that is increasing their stress in the body and that's increasing the inflammation, then your cortisol is not going to be just centered around that problem. You've got to work on that. And that's where we go back to root cause, right? So depending on somebody's presentation, you know, there could be some things that you do, you know, general in everyone. Otherwise, you just stay focused on what specific presentation somebody has, and you, you check their inflammation markers and try to understand where is the problem coming from so you can address that.

Yeah, for sure. Well, we could honestly stay in this conversation all day long. This is like, this is one of my favorite conversations Kelly knows this, like, I could stay in this conversation all day long. So we're going to have to have you back on. But as we come to a close today, I know that you have this heart to lower the dose. And so I would love if you could leave our listeners with a, just a pearl or a nugget of something that they can do that aligns with your passion of lowering that dose.

Wonderful question. I would definitely want to work with someone like you or someone like, um, Kelly and try to understand how's your body functioning, where are they in this stage of life, right, time in life. And one thing I missed earlier, and that is the most important thing, is if you're perimenopausal or menopausal, and the declining estrogen level or estradiol level will give you more risk of insulin So we need to understand what are your unique factors. You know, maybe I have so many friends who were doing excellent until recently, and now the change of the body's, you know, happening, and that's just stopping them from getting the results they're used to, right? So let's honor our bodies. Let's honor our needs. Let's honor our, you know, no matter if you're mom and daughter or sisters, you still are unique. You know, your blueprint is very unique. So let's work with someone who can really make you— help you understand your blueprint so we can work on that individually and make you feel the best. I love it.

I love it. So tell us, I'm so excited about your book coming out. What an accomplishment. I think that's gonna be a gift to the world. Yes. And hearing your framework, it's so important that people embrace that and understand it and, and feel empowered. How can people connect with you? How can they get your book? And then how can they connect with you if they want?

That's wonderful, Kelly. So I practice in Folsom, California, and I am available online or virtually and in person. And my website is rangymd.com. That's my first name— I'm sorry, last name— md.com. rangymd.com. And that will have all the information about the book, that will have all the information about how to contact me, and I'm happy to help one. Awesome.

Well, it's been such a pleasure not only to meet you at Mastermind. I believe everything happens for a reason. I too am extremely excited for you. I can't wait to read your book, and I would just encourage you to keep going, sister. Like, I am so proud. We've got to get that message out there, and together—

I'm so excited. Yes, yes. So many people, you know, we want to help so many people that We want to simplify to them, you know, not make it so difficult, but let's make it very simple.

Absolutely. Well, you enjoy the rest of your day and your time away.

Thank you so much, Lori Esarey MS, APRN-C.

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