Discover Why Your Metabolic Health Matters

Cynthia Thurlow, NP

Absolutely. I think you bring up such good points about how most of us are not making the connection that insulin resistance is at the basis of not just metabolic health disorders but also making us more susceptible to specific types of cancer, and in particular breast cancer. I, my whole background as a nurse practitioner was in medicine and cardiology, and we used to talk about heart disease, diabetes, and high blood pressure. But we were not making those connections between this drive for insulin resistance and how our population over the past 25 years has just gotten increasingly less metabolically healthy. That is giving rise to this constellation of largely preventable diagnoses. I want to emphasize largely that it does not, and perhaps not in every instance, but lifestyle diseases are making our population sicker and more chronically diseased.

Jennifer Simmons, MD

Yes. You started to touch on a phrase that I think is so important for people to understand. What is metabolic health? Because I know that very few Americans are metabolically healthy, and the vast majority of them do not know it. I would say that nearly everyone who comes to me with a diagnosis of breast cancer says I am healthy, but I have breast cancer. If those metabolic health statistics are correct; they are not healthy. Talk to us about what metabolic health is and how you know if you are metabolically healthy.

Cynthia Thurlow, NP

We know that pre-pandemic and in 2018, the USC School of Chapel Hill School of Public Health determined at that time that 88.2% of Americans were not metabolically healthy. That number seems staggering. Three years into the pandemic, we know that 92 to 93% of Americans are not metabolically healthy. How do we define metabolic health? Now we go back to the concept of metabolic syndrome. We are talking about waste circumference, we are talking about blood pressure, and we are talking about lipids, specifically triglycerides and HDL. We are talking about fasting glucose. 

To give everyone a construct, there are gender parameters. For example, waist circumference for women is greater than 35 inches, and for men, it is greater than 45 inches. When we are talking specifically about blood pressure, if your blood pressure, even with medication, is greater than 130 over 85, that is a concern. We recognize that triglycerides, meaning those that create the diagnostic criteria, are about 150. I tell everyone, your triglycerides should be under 75. A million years ago, when I was finishing up my nurse practitioner program, we were talking about blood sugars of 140. It is now under 100. There is good evidence to demonstrate a blood sugar between 90 and 99, which many of us celebrate and say, Good for you, that is good. No, it is not. We know that it increases your rate of developing diabetes by 30%. 

Understanding that these biomarkers—blood pressure, blood glucose, triglycerides, HDL, and waist circumference—are a good starting point to get a sense of where your metabolic health is failing you or where you have areas for improvement. I would add to that that fasting insulin is one of the first biomarkers that will be regulated in response to growing insulin resistance. Now, for some reason, this is considered to be an unusual test. It is very easy. It is covered by insurance. I remind people that ideally we want between 2 and 5 milligrams per deciliter, and I see women routinely who are weight loss resistant, and their numbers are 10, 15, and 20. I have seen numbers as high as 30 way before that blood glucose starts to look wildly abnormal. helping people understand that there are objective criteria for defining metabolic health. But I would also loop into that. 

When we are talking about metabolic health, we are talking about sleep quality, and we are talking about movement. We, as a society, do not value sleep. I say this as a generality: we do not value the concept of movement. Many of us are sedentary from the moment we get up in the morning to the moment we go to bed. Another thing that I tie into that is meal frequency. We have been conditioned to believe that we need to eat frequently to unquote stock our metabolism and that we need to be eating every 2 to 3 hours. That meal frequency point for me, Jenn, is one of the ones that sticks out the most and is making us sick as a society. There was a study done by Satchin Panda a few years ago, and it looked at meal frequency in an app. very easy and accessible for patients. The average person eats 6 to 10 times a day. Each time you eat, and I do not know if viewers understand that each time we eat in response to whether it is fat, protein, or carbohydrates, our body will well, glucose will go up in our bloodstream, and our body will secrete a certain amount of insulin to bring our blood sugar back down. Fat has the most negligible impact on blood sugar, followed by protein, followed by carbohydrates, which is probably not a surprise. But most of us are eating the wrong macros or eating too much carbohydrate; largely, the processed, hyper-palatable stuff that makes it irresistible to eat makes it hard to stop. 

We eat too little protein, and we are eating the wrong types of fat. I think that is the other piece of that. Along with chronic stress, I think the pandemic has demonstrated for us the net impact on metabolic health in terms of having chronically elevated cortisol levels. Our insulin will correspondingly go up in response to elevated blood sugar. At a lot of different levels, our modern-day lifestyles are setting up the perfect storm for poor metabolic health. After 25 years of working with patients, it seems to be getting worse and not better. As a clinician, it is something that I am passionate about, helping people understand that our lifestyle as medicine needs to come to the forefront.

Jennifer Simmons, MD

Yes, I could not agree more, and there is a lot of unlearning that we need to do. As I was thinking about this interview today, there were so many myths that I wanted you to dispel. You started to touch on one of them, which is that we have been told for years that small, frequent meals are the way to go. Can you expand on what happens when you have small, frequent meals and why it is counterproductive for your metabolism and your health?

Cynthia Thurlow, NP

Yes, absolutely. When we are eating frequently, whether it is every 2 hours or every 3 hours, the average person is consuming a very low-protein, high-carbohydrate meal. What ends up happening is that each time you eat, your body is trying to process the food that you have consumed. In response, if you are eating a predominantly low-protein, high-carb meal, your glucose goes up, and in response, your insulin goes up. Insulin, unfortunately, gets a terrible rap. Everyone thinks insulin is bad and cortisol is bad. Insulin is a wonderful hormone when it is functioning optimally, but when our body is constantly deluged by food intake, we have higher blood sugars and higher insulin levels. When insulin levels remain elevated, our body cannot access stored fat as a fuel source.

Our body is just trying to process. It is almost like a gas tank. My dad loves to top off his gas tank when he gets a quarter of a tank down, and it is the same concept. We are never able to work through the reserves of stored energy that we have because our body is trying desperately to process this constant influx of food. The important thing to understand is that if you eat, let us say you eat breakfast at 8 a.m. If you have protein, some healthy fats, and maybe even a little bit of carbohydrate, your blood sugar is going to have a much more nominal response to that meal than if you sit down and have a big bowl of oatmeal, or if you eat cereal, granola, or any of these hyper-processed carbohydrate-laden meals without the buffer of having some protein to help buffer that blood sugar response. What I advocate for is less frequent meals and for some people, that might be that they eat three meals a day, or they may eat two. Because it allows our bodies in between those meals to to be able to not only start digesting the food, but also acclimate that blood sugar so that glucose is going to go down in response to the insulin being secreted, insulin will come back down and then we can in between meals if necessary, like if we are very physically active and our body needs to pull on some of these stored sources of your substrates, which is like stored glycogen or fatty acids or even ketones, our body can effectively do that, but most of us just never allow our bodies to be able to function optimally because we are just constantly topping off that tank. 

Think about it when you go on vacation. I know that when I go on vacation, I am normally not as conscientious about eating during the winter. I tell my kids I am surprised. I have days where I am like, I do not need that meal. I am going to do it; I am not. I am going to skip lunch. I will have breakfast with everyone. I will skip lunch; I will have dinner because my body’s just not acclimated to eating that large of a bolus of food at that frequency. It is something that can be super easy for people to do: just stop snacking like we do not. We should not need to snack. I even say that snacking with children is a sign that you are genuinely hungry in between meals; it is a sign that you put your macros together in the wrong format. Macros are protein, fat, and carbs, and I encourage people to eat more protein and eat different types of fat. Depending on how physically active you are and what life stage you are in, moderating the carbohydrate intake, which I know for many people can be very triggering, But I find that there is that satiety point. if you sit down and have a bowl of oatmeal, you might not be as satiated as you are when you have a piece of chicken or leftovers from the night before a piece of steak, or you sit down and have eggs and bacon or eggs.

Jennifer Simmons, MD

The other thing is that it is not driving. Oatmeal is driving that hunger hormone and those satiation centers differently than you are going to get from a protein source, or there are not a lot of people that are bingeing on chicken.

Cynthia Thurlow, NP

It is very hard to do that. Those stretch receptors in your stomach will remind you, like I tell people, that if I have six eggs, I am very full. There is no way I can put one more bit of food in my body or a very large steak. You are to your point; it is very satiating, especially if you have a fatty piece of meat or a fatty piece of fish with a sizable enough portion. It is going to stimulate that connection between leptin and ghrelin, like those satiety centers or mats, versus your point when you sit down and have a bowl of oatmeal. If you do not have a bowl of granola, you sit down and have a sugary drink. I am going to just call it a yogurt drink. There are plenty of those out there that have 40 grams of sugar in them. You wonder why you are hungry an hour later. It is because there is just way too much sugar for your body to process properly and hit those satiety centers. It is just very problematic.

Jennifer Simmons, MD

The other thing that comes along with a sugar bolus that I think most people do not recognize, and it is very important, especially for anyone anywhere along their breast cancer journey, is that it does affect your immune system, albeit transient. If you are giving yourself sugar bolus again and again during the day, that transient immunosuppression is meaningful. What essentially happens is that you can have all your systems on at once. If your immune system is on it is on because your digestive system is off, but if your digestive system is constantly on, then that is not a time for your immune system to be under surveillance. 

People who do this chronically who are eating frequently and who are eating carbohydrate-rich diets that are converted to sugar. It does not matter if you are eating sugar, having honey, or eating wheat bread. That is all seen as the same thing in your body. It is seen as sugar. If you are doing this constantly, then your body is not able to respond to the other offenders. The truth is that we all make cancer cells. Every one of us, from young to old, and everyone in between, makes cancer cells. If your immune system is not intact because an intact immune system can defend against cancer, but if your immune system is not intact because you are on the wrong macros, you have a sugar-laden diet, or you are eating frequently, you are taking your immune system out of the picture.

Cynthia Thurlow, NP

The other thing that I would add is that I see a lot of women struggling with it because, maybe in their 20s and 30s, people drink socially. What I see for a lot of women in their 40s, 50s, and beyond is that alcohol impacts their sleep negatively. I think many people, in their minds, may feel like they are 18, but chronologically, they are no longer 18. So, the mommy drinking culture, I think, can certainly be an issue. It is interesting. I had a lovely clinician. It was on the podcast a few months ago, and she was saying, Do you know that if you drink alcohol and are on HRT, hormone replacement therapy will elevate your estrogen levels? I think she said 4 to 5 hours afterwards. All I could think of was, We talk about the interplay between different macros, but we also understand that alcohol may not be in our best interest. I do not know how you feel about it, but I started to speak out more openly. Just helping people understand this may not be serving you well. Like, examining your relationship and whether or not it is helping you or hurting you.

Jennifer Simmons, MD

Yes. The American Cancer Society says that there is no safe amount of alcohol for women. I tend to agree with what the American Cancer Society recommends because I probably hold people to a higher standard since their view of cancer care is so limited. As certainly anyone active in cancer, I think that there is no role for alcohol there. If you are far out, if you are in maintenance, if you have gotten everything else into balance, and you want to have an occasional drink, I think that is okay. But we need to take it in the context of where you are on your cancer journey. If you are early on or active in your cancer journey, it is very dangerous.

Cynthia Thurlow, NP

Yes, I can imagine.

Jennifer Simmons, MD

You touched on something. You used the B word, which is breakfast, and so I want to talk about several things there. I want to talk about it, I get questions all the time. What do you mean by having a savory breakfast? I want to talk about the statement that breakfast is the most important meal of the day and where that came from. I want to talk about what you mean by breakfast because I think most people think you mean a morning meal.

Cynthia Thurlow, NP

Yes. We know the concept of breakfast came from good old Kellogg’s. The processed food industry brought that to the forefront. They initially, unbelievably, have this construct of cornflakes because, well, how shall I say this? My understanding is that they wanted to discourage masturbation. So they thought that if they encouraged people to consume these processed cornflakes, it would be less likely that they would have this tendency. It gives you a sense of, like, the construct of their thought process. But when we are talking about the brain,

Jennifer Simmons, MD

I never heard of that before.

Cynthia Thurlow, NP

Yes. It is a real thing. It is a disturbingly real thing that that was the impetus for the creation of cornflakes. But we are talking about breaking our fast. The processed food industry has convinced us that it needs to be LEGOs, and LEGOs need to be eggs, bagels, muffins, and these hyper-processed, hyper-palatable foods that are going to skyrocket our blood sugar, increase our insulin, make us sleepy, and not be the best start to the day, along with a big glass of orange juice, which is unpleasant. But when we are talking about differentiating between a sweet breaking your fast versus a savory breaking your fast, a big distinction or a savory breaking your fast is going to be something that is going to stabilize your blood sugar. 

Again, focusing on protein, healthy fats, and, if that is appropriate, the types of carbs—I do not want anyone to take away that. You cannot have a piece of fruit. But, half a cup of berries is very different than having a bagel. Certainly, if you have bacon and eggs, sausage and eggs, or leftovers from the night before, breaking your fast can occur at any time. breaking your fast could be 10 a.m. It could be noon; it could be 2 p.m. It depends on you and your lifestyle. We know that based on research and not eating, the first 2 hours we wake up in the morning are very important. 

Jennifer Simmons, MD

What is happening there? What is the magic there? Because I know so many people who like waking up and going to the refrigerator.

Cynthia Thurlow, NP

Yes, well, we know that it is important for us in terms of this cortisol awakening response to get up, get moving, get some sunlight on a retina, remind our body, suppress the melatonin, and get the cortisol going. But we know that, in terms of a blood sugar response, in terms of glucose regulation, we are better with hydration, with water, like water’s great having bitter coffee or bitter tea. I know we are so sensitized to sweets when I say that people are like, what? They are like bitter-based compounds. These polyphenols are information for our body. It is a way of telling our bodies that it is time to boost fat oxidation, properly break down some fatty acids, and just get moving in the morning, which is far more effective. 

Looking at the research in terms of chronobiology and the circadian rhythm of cortisol distribution throughout the day, I understand that having a big food bolus in the morning is not going to benefit your cortisol awakening response. It is not going to benefit your energy levels or your cognition. I just remind people that hydration is great, movement is great, and light exposure is great. Those first two hours of the morning were protecting them. If you get up in the morning like my teenagers, they are starving, they are growing, and they are in this massive anabolic phase. The rest of us, hopefully, are not in a massive anabolic phase; we should be in a maintenance phase at this stage of our lives.

I remind everyone to just consider: maybe if you do things differently, delay eating until you have gotten through at least the first hour, but preferentially 2 hours. If you get up at six, do not eat before 8 a.m. For a lot of people, they realize that they have these counter-regulatory hormones that suppress hunger in the morning. A lot of us are just not hungry. I am not a believer in eating for the sake of eating. If you are not hungry, do not force yourself to eat. But things like growth hormone and norepinephrine are designed to suppress hunger so that we get up and are productive. If you think about it, years ago, when people did not live in air-conditioned and heated homes, when people were probably living in circumstances where there were still predators, it was to their advantage to get them moving so they could seek shelter. They could look for breakfast before the advent of grocery stores and having available food. Uber Eats and all these other things make eating pretty easy. But that is likely where that stems from. However, the research certainly suggests that delaying eating in the morning is beneficial.

Jennifer Simmons, MD

We know from an evolutionary standpoint that we are designed to perform as well in a fasted state as we are in a fed state. It is not like you could come out of the cave in the morning and see the saber-tooth tiger and say, Can you just give me a minute because I have not had my breakfast yet? Maybe we are designed to perform optimally either way. I hear so many people say this because I include fasting in all of my protocols. I do believe that everyone is capable of fasting because, even when you think about it when a baby gets to be six weeks old, they are fasting through the night. They are sleeping through the night. Once they become neurologically mature enough, even a baby can get through an entire night without eating. But so many people say that they struggle with fasting. What do you think is going on there?

Cynthia Thurlow, NP

Well, I think there are a couple of things. First of all, I think it is a behavioral thing. We have been conditioned to go to the grocery store. We go get gas, we travel, and there is food everywhere. We are just inundated by cues in our environment that we are supposed to be eating all the time. I think some of it is psychological, but I also think that for the vast majority of us, we are not metabolically efficient. It may feel bad when you eat it at 8 a.m. to make it to 12 because you were not giving your body the proper fuel that it needs to go three or four hours without eating. Your body is not efficient at drawing upon stored energy. Let me be clear: if you are thin, you have plenty of stored energy and plenty of stored fat in your body. But if your body cannot access it, it is almost like a locked refrigerator. Your body cannot access the stored fuel. This explains a lot of the symptoms people experience. When they are not metabolically efficient, they will get angry, they may get shaky, they may get lightheaded, they may have energy drops, and they may get sleepy.  That is in response oftentimes, weight loss resistance. They are wondering, like, What am I doing wrong? I am doing everything with my doctor or my nurse practitioner. Or is she telling me to do so? I think that contributes. 

I know when I have someone who is eating a standard American diet and is not very physically active, we have to do things slowly because I think trying to convince someone who is eating six plus times a day to go from that to, I am going to tell you now, fast for 16 hours is terrifying. Because people do perceive that they are starving. I remind them that if we were not able to go longer periods without food, we would not be here from an evolutionary perspective. Especially women in particular. I think it comes down to a bit of mindset; some physiology goes on that can sometimes be uncomfortable for people. I always remind them, like, we are going to take it slowly. We do not go from crawling to sprinting. There is a continuum. But I think for a lot of people, it is that, and it is also these limiting beliefs that we tell ourselves that this is going to be uncomfortable, that it is going to be unpleasant. I am not going to like it. Find that reframe and find that reset for our attitude, if you will. It can be very, very important. It is like setting the tone for our patients. If we are encouraging and supportive, they are going to have greater success than if we just shove them out the door and tell them, Just go figure it out.

Jennifer Simmons, MD

Yes. For those grazers, for those people, the pandemic did not help with the whole grazing thing because most people were. But they are a stone’s throw away from their kitchen all the time. For those grazers, how do you start with them? Like, how do you create a roadmap for those?

Cynthia Thurlow, NP

Yes, I have a pretty step-by-step approach, and it starts with stopping snacking. The grazers struggle the most. Maybe if you are eating a couple of meals and then you are having a little snack in between. But I encourage them to understand; I want you to trust the process. I remind them, like, when you sit down, I need a meal, and I want you to eat no less than 30 grams of protein. Now that blows everyone’s minds because that might be what they eat the entire day. I just remind them that if you eat enough protein, you are going to be satiated. You will not be hungry in between your meals. We start by targeting the meals, making sure we have at least 30 grams of protein, and then discouraging snacking. Just saying that snacking is not serving you. Snacking contributes to this blood sugar dysregulation and elevated insulin levels. If I have a lab value, I just remind them that I am like, Your fasting insulin is 15. That is, it is 60% higher than I want it to be. We have work to do, so we are encouraging them that in between your meals, you can have plenty of water, electrolytes, and bitter tea. You can have decaffeinated bitter tea or black coffee, and that freaks everybody out. 

I just want to remind you that you can add cinnamon, which will help with insulin sensitivity. You can add high-quality salt like Redmond’s, and that will change the flavor profile and make it a little less bitter, but it is not going to break it fast. Starting with those two things: no snacking and 30 grams of protein with each meal. I find that once they realize that they are not hungry, then we start pushing the protein labor up a bit. We will start with 40 grams and then remind them that we are ultimately working up to 100 grams a day. That is what we are working towards. I find that for people who are very quantitatively focused, they are like, okay, I am going to write these things down. I am going to measure out my protein. It gives them something to think about. Then they are like, Okay, if I can do 30 grams of protein three times a day and I feel good, I am sleeping well and my blood sugars are better, I am sure you probably use a glucometer and CGM with your patients.

Jennifer Simmons, MD

Yes, but I do want to talk to you about that because I do not. I do not know that that is universally happening. Can you talk about the continuous glucose monitors, who you are using them on, what you are looking for, and how people can optimize that technology?

Cynthia Thurlow, NP

Yes. Continuous glucose monitors are little monitors that are put into the interstitial fluid in your arm. It is not in a capillary bed; it is not in your venous system. Between that and if it does not fit your budget, looking at a glucometer, I want to know what your fasting blood sugar is when you wake up in the morning because that is very important information. Remember what I said earlier? If it is between 90 and 99, you have a 30% greater risk of developing diabetes. That is significant. If you wake up with blood sugar 78, you are in a good position.

Jennifer Simmons, MD

Yes. Do you want it somewhere between 70 to 90? Is that optimal where you are?

Cynthia Thurlow, NP

Yes, and it is interesting because I was looking at Robert Lustig; I am sure you are familiar with his work. Robert Lustig once was talking about how he likes to see in his mid-80s. He is a pediatric endocrinologist, but he gets very stringent. He is like, 90 is a dangerous zone. 90 to 99 is not out of the woods. Understanding where you are when you wake up in the morning, I do like people to know what your blood sugar is when you get hungry. Marty Kendall calls this the trigger point. I think this is important because it can help you distinguish between true intrinsic hunger and when am just bored, stressed, and looking for food. I think I am hungry, but I am not. The reason why this distinction is important is that if your blood sugar is, let us say, 78 when you are fasting, and 78 when you get hungry, it is between 78 and the high 80s. If you feel hungry and you check your blood sugar and your blood sugar is high, then it is not true intrinsic hunger. There is something else at play here. 

I like to monitor before the meal. When you get hungry, I like to look at your postprandial. After your meal, what are your numbers? I do not like to see a baseline blood sugar go up more than 25 points after a meal. Because if your blood sugar goes up by 40 or 50 points, it is not benign. That is a sign you likely have had too much carbohydrate, and a rough goal to look for is 30 grams of carbohydrate. That is not a lot. Most of my patients are perimenopausal women. We know this is a time when women become increasingly less insulin-sensitive. That is why we put that containment in. I say 30 grams of protein if you are going to have carbohydrates; no more than 30 grams of carbs, and make sure it is from things like beans, lentils, or other non-starchy vegetables. Do not load up with rice, pasta, or bread.

Jennifer Simmons, MD

That is heavily fiber-laden.

Cynthia Thurlow, NP

Yes. I like to monitor that, the postprandial. After the meal, I like to know, like, what is your average when you sleep? If you have a continuous glucose monitor, you can get those averages. If you are using a common, you have to stick to it each time. I would like to know what your response is to certain foods. For me personally, if I eat a plantain, it does not matter how I prepare it or what I eat with it. My blood sugar goes up to 150. Normally, I do not have that much glucose excretion. I would like to know what stress is due to your blood sugar. What is exercise due to your blood pressure? Blood sugar? What is the time? If you are still getting a menstrual cycle, what is your blood sugar like? 

We know that during the luteal phase, when we have more circulating progesterone, that tends to be when we are less insulin sensitive, versus the follicular phase, when we tend to be more insulin sensitive. Being able to see those variations and again, if you are in perimenopause, the 10 to 15 years preceding menopause or menopause, 12 months out of your menstrual cycle, you may not have as much wiggle room. It is an unfortunate fact, and there are lots of things that contribute to insulin resistance for women at that stage of life. But I like to know all the things. I always say I like my patients to keep a journal so that I can look at so I know what’s going on, or I use the FreeStyle Libre, so they will upload information for me that I can look at. But I think those kinds of metrics are helpful because many of us do not feel bad when our blood sugar is high; some of us get sweaty, and some of us get hot flashes, but not every patient gets symptomatic. That is where it can be so sneaky. That is why so many people are shocked. I have thin women in their 40s who are like, How could I be insulin resistant?

Jennifer Simmons, MD

Yes.

Cynthia Thurlow, NP

I am like, Well, there are a lot of things physiologically changing in our bodies, and so it makes it much easier. It happens much more easily, even if you are doing all the things.

Jennifer Simmons, MD

The truth is, the closer you come to menopause, the less insulin-sensitive you are going to be.

Cynthia Thurlow, NP

Yes. That is, I think, something that I certainly did not learn in school. I think that there is this lack of information about middle age, perimenopause, and menopausal years for women; there is not at all medical education; there is just no focus on it. I would say if clinicians are not prepared for their perimenopause journey, then you better believe the patients are not prepared for it either. I think that, to me, a CGM or a glucometer is one of the most valuable pieces of information. You have to be able to make better choices. I know I make better choices when I can look like, Okay, well, that dessert did not serve me. 

Jennifer Simmons, MD

Yes. We only learn by what we measure.

Cynthia Thurlow, NP

Correct?

Jennifer Simmons, MD

We only correct what we measure. Otherwise, it is a guessing game. As you said, so many people are completely unaware that they do not have metabolic flexibility, that they do not have good metabolic health, and that they do not have good insulin sensitivity. For so many people, they can be asymptomatic. It is not just people who are overweight; it is people who are seemingly of normal weight who are at the same time struggling. I think it is easy for all of us to make a connection when we are overweight. But I know that in my situation, I was not overweight. I was rocked to my core that I was not metabolically healthy because I just did not understand how it could be possible when I was not overweight. Here I am, five, six, wearing a size two. Like, how could I not be metabolically healthy?

Cynthia Thurlow, NP

But I can tell you what happens. That is the cruel irony is that we assume that if your body composition is X, then there is no way that you are insulin-resistant. I see so many; I see countless examples. I see little skinny women in the plotting studio I go to, and they will talk to me about what their fasting blood sugars are. I am like, You need to monitor that. Like, that is not how people celebrate; you are less than a hundred. No, you do not want to have a fasting glucose of 95. If that is your norm, if that is your average, then you have work to do, whether it is walking after meals, doing strength training, or intermittent fasting. I think a lot of people, just do not recognize that the habits that they were doing in their teens, 20s, and 30s are no longer serving them at this point.

Jennifer Simmons, MD

Yes. The other thing that we are not taking into account, which is so tied to metabolic health and insulin balance, is the effect that stress and cortisol have on this whole system. The truth is that if you think you are running away from a tiger, your body is less concerned about metabolic health because it is not necessarily worried about protecting your heart in the long run. If not, take it away from the tiger.

Cynthia Thurlow, NP

Yes. Unfortunately, in our modern-day lifestyles, which are so hedonistic, we have access to everything at any time of the day. Years ago, I was going to, well, I will probably date myself, but the TV went off at noon and there was no cable TV. You would wait; they were one static there.

Jennifer Simmons, MD

Static available.

Cynthia Thurlow, NP

Now my kids will talk about Uber Eats, which just makes me cringe, but I remind them that I am like, Guys, there is a reason why we should not have things so easily accessible. Whether it is the stress of being separated from loved ones during the pandemic, whether it is stress about your job or relationship, stress about money, or something as benign as maybe you are just stressed about, you are just an anxious person, to begin with. But that is chronic.

Jennifer Simmons, MD

Mean, there are these seemingly perfected lives that people are seeing on social media that are having a horrible impact on people who are just, trying to get by day to day, and even though we know, you and I live life in the public eye, and our lives are not perfect no matter how much our Instagram accounts look great. Like, no one’s life is perfect. But people have these seemingly perfect lives, and it is stressful for the observer.

Cynthia Thurlow, NP

I remind people all the time, like, if you follow someone on social media that makes you feel bad about yourself, unfollow them. That has been my general rule for a long time. When I get on social media, there are a lot of puppies and a lot of animals, and I like funny things because that is what brings me joy. But if I am following someone and maybe I have to follow them, just to be politically correct, I will mute them like I cannot see their stuff anymore. It does not bother me. But, from my perspective, life is too short to feel stressed when you get on social media or to feel less than I agree.

Jennifer Simmons, MD

I have unfollowed all of the haters and the posers and the these and the that. The people that tell me that, I am crazy and the diet does not matter and I am dangerous because I do not want people radiated, so and you have to and my feed is filled with dance videos and like, pictures of people petting whales? It has to be the things that bring you joy.

Cynthia Thurlow, NP

Yes, absolutely. I think of them as if I were a vet. For me, watching animals makes me think, This is great.

Jennifer Simmons, MD

It is so great. I love all the lab videos and golden videos, and the one putting the chicken in their mouth is so cute. 

I want to switch gears a little bit. I want to talk about the order of food consumption because there is a lot to talk about. You are putting your plate together. Does it matter in what order you eat your food?

Cynthia Thurlow, NP

Well, it is interesting. Glucose status certainly has caused me to think differently about food order. If you travel overseas and my mom’s Italian, you always have salads, and you always have fiber before you eat a meal. That was like a standard in my house, and when I interviewed her for the podcast, I was like, Thank you for breaking things down in such a way that it makes it very accessible for everyone. Causes me to think, but when I am thinking about meals, it is always protein-focused. Then, as an example, if I have a rib eye or a piece of salmon, I do not need more fat in my meal. I just added some healthy, usually non-starchy, vegetables. For me, protein is going to help you keep your blood sugar stable. It is going to help with satiety. I find that most of my patients make better food choices when they are protein-centric. If someone has terrible diabetes or is morbidly overweight, then we probably are not eating very much protein but more protein. I always say, like, giving someone the grace to understand that as they transition to a different nutritional paradigm, there are going to be some shifts.

 But I do think having what Glucose guys refer to as naked carbs, but carbs without anything else, you are going to get a much more exaggerated blood glucose response and insulin response if you have protein and fat or protein and carbohydrates, and so I always say protein is the consistent piece that I think is so helpful. A lot of what I am starting to see now is that people are advocating for having a starter salad, and that was always just part of growing up, not knowing that my mother was far smarter than I gave her credit for but knowing that fiber is going to also if you tolerate it, it is going to help with blood sugar stabilization and is the consistent piece.

Jennifer Simmons, MD

Yes. The only caveat I have to add is that, in the cancer population, we do have to be careful with the amount of protein. Now, that said, too little protein is also dangerous. This is one of those areas that needs a little Goldilocks. We do not want it too little, we do not want it too much. We just want it right. I want to talk about that because, when you look at it, where does fat fall in terms of the insulin response? I think the American Diabetes Association will have you believe, certainly their diet is the perfect diet if you want to get diabetes. They spend a lot of time saying; that is the problem. Can you talk a little bit about that, the insulin response, and what your feelings are about that?

Cynthia Thurlow, NP

Yes, I could not agree more with you that the FDA’s recommendations for diabetics are not helping their metabolic health. When I am thinking about healthy fats, it helps people understand that if we are looking at macros between fats, protein, and carbohydrates, fats have the most negligible impact on blood sugar. The healthy types of fats I am talking about avocado, I am talking about grass-fed butter, I am talking about olives, or olive oil. Those are good sources of healthy fats, depending on the individual. People do not tolerate heavier animal-based fats like duck, fat, lard, and tallow. There are exceptions for everyone, but I think some of the lighter, monounsaturated fats are, in many ways, much better tolerated. But they are going to keep your blood sugar stable. These are very different from the adulterated seed oils that are highly processed, exposed to chemical solvents, and highly inflammatory.

I think about the research that is coming out talking about the most consumed fat in the United States now being soybean oil, and it is because it proliferates in the processed food industry. But other examples are canola, sunflower, safflower, and cottonseed, and just understand that these oils damage our mitochondria. down at the cellular level, and I have read that they can damage the cellular membrane for up to two years. We have these cellular membranes that are phospholipid bilayers, and that is quite significant. From my perspective, when we are talking about healthy fats, we ought to be mindful that healthy fats are not to be confused with seed oils. Healthy fats are much more calorically dense than protein and carbohydrates. It is easy to overeat them. It is very easy to overeat nuts, seeds, avocados, and butter. 

Sometimes I have to caution my patients maybe this is the time to measure your portion. Whether it is a quarter cup of nuts or half an avocado, or you are having a tablespoon of olive oil, just being aware of those portions, especially for my population, tends to be weight loss resistant. I remind them that, even something healthy, too much of any one thing is not a good thing. You could put yourself in a position where your weight loss is resistant because you are just eating too much healthy fat. But I think being mindful of that is certainly very important. But I do have quite a few patients who love to push the envelope on healthy fats, in particular. They feel good eating a higher-fat diet.

Jennifer Simmons, MD

The last thing that, I will ask you: do you think that fasting changes according to age and decades of life? Do we become more in need of fasting? Do we become less in need of fasting? What is happening as women cycle through maturity?

Cynthia Thurlow, NP

Yes, that is a great question. I would say that my population of women who are 35 and under typically falls into two camps: lean, athletic women who do not need to fast frequently, versus my PCOS patients. polycystic ovarian syndrome patients who were patients who would benefit from some degree of fasting and can get away with a lot more because more often than not they are inflamed. Insulin resistance is at the basis of their disorder, and oxidative stress is at the basis of their disorder as women transition into perimenopause at ten or 15 years preceding menopause. 

This is when the lifestyle piece becomes hugely impactful. 

Understanding that things like stress management help us become less resilient to stress as our ovaries produce less progesterone and our adrenal glands step in. It is like the backup quarterback: anti-inflammatory nutrition becomes more important, and strength training becomes more important. There are still women in their 40s and 50s who want to do CrossFit, starting to pick it up five days a week with no rest days. They wonder why they are struggling to manage that degree of workload on their bodies. Sleep becomes hugely important. If you are not sleeping, you are eating a garbage diet, you are overexercising, and you are not managing your stress, adding fasting is like adding gasoline to a fire. It is going to make it harder. 

But in the context, if all those things are dialed in, I think fasting, especially based on where a woman is in her menstrual cycle—again, the follicular phase is when women can get away with a bit of fasting, more intense exercise, etc. Menopause, is probably the easiest time for most women to fast because there is not as much hormonal fluctuation week to week, month to month, provided that caveat again, they are sleeping, they are eating an anti-inflammatory diet, they are exercising properly, and they are managing their stress. 

But I find a lot of women, and the presumption is made that it is getting harder to maintain my weight above 40. They are like, if a little bit of fasting is good, more is better. These are the women who are eating OMAD or one meal a day. There is a woman who works out six days a week with no rest days. They are not eating enough food, and their sleep quality is being eroded. It becomes this vicious cycle of trying to help them understand that fasting is a form of, for me, beneficial stress in the amount at the time. But if you are doing it when it is not at the right time, it can make it harder for your body to function optimally.

Jennifer Simmons, MD

Assuming that all those other pieces are dialed in, let us just summarize: What are the benefits of fasting? As long as you are protecting your sleep, you are not overstressing, you are not overexercising, and you are eating the right things, what benefits should people expect to get from fasting?

Cynthia Thurlow, NP

I think a lot of people come to fasting because they want to change their body composition or lose weight, but they stay for mental clarity. They stay for the energy that they feel. They stay because they have a reduction in inflammation. Maybe their joints no longer hurt. Maybe they can get up and be more physically active. All of a sudden, their blood pressure improves their other biophysical markers, improves their lipids, improves their triglycerides, goes down, their HDL gets up, goes up, and their LDL goes down. Potentially, their inflammatory markers like high-sensitivity therapy and homocysteine can oftentimes improve. They reduce their risk of neurocognitive disorders. I think about Parkinson’s as I think about Alzheimer’s in particular.

Then this autophagy, this waste and recycling process, which I know we have alluded to during our conversation, is one of the most important ones, understanding that it allows your body to go in and remove disease, disordered organelles, and mitochondria that have the potential to go on and create disease or precancerous cells. Understanding that the process of eating less often is so much more than the physicality. I think the other thing that I would tie into that is greater spiritual awareness. The longer that I have been fasting, the more I feel much more connected to nature, my relationships, etc. It allows you to eat spiritual fasting or fast from relationships, but I think it is also very helpful for people to understand that fasting is much more than body composition changes. It is the deep cellular improvements, down to the mitochondrial level, that confer a lot of benefits. certainly for your population of patients, something that I think would be hugely helpful to do in conjunction with treatment.

Jennifer Simmons, MD

Yes, absolutely. We know through the work of Valter Longo that fasting-mimicking and eating beyond a certain threshold are very beneficial throughout chemotherapy treatments because they protect normal tissues while making cancer cells quite vulnerable. 

We talked about a lot of great stuff today. We talked about metabolic health, metabolic syndrome, the risk factors, and what to look for. Everyone should know what their fasting insulin level is like. We talked about the importance of tying in those other lifestyle factors because fasting alone is somewhat of a stressor. You want to make sure that you have pulled the stressors out of the rest of your life. 

Dispelling the myths about small, frequent meals being beneficial. They are anything but. Breakfast is not the most important meal of the day. When you are breaking your fast, you want it to be with a savory meal to stabilize your blood sugar. A bowl of oatmeal and a glass of OJ is probably the worst choice that you could make. If you are not hungry, do not eat, and stop snacking. 

We talked about how to use your continuous glucose monitor and the benefits of doing that. Then we talked about the role of fat and how you should exercise, especially as you age. We finished with the benefits of fasting. This was a phenomenal talk. I thank you so much for your time and your brilliance. Everyone should read your book. Where can people find you?

Cynthia Thurlow, NP

Yes, it is probably easiest to go to my website. Thank you again for including me and your summit at www.cynthiathurlow.com. I am active on Instagram. I am a little snarky on Twitter. I do have a YouTube channel that I am aggressively trying to grow. I have a wonderful podcast called Everyday Wellness, which is absolutely, positively one of my favorite things I do in my business. I will be interviewing Dr. Jenn tomorrow for the podcast, and of course, on my website, you can also get my book, The Intermittent Fasting Transformation: The 45-day Program. You can check out all of that information on the website.

Jennifer Simmons, MD

Great. Thank you so much. It is Dr. Jenn. Bye for now.