 Take off this next session, Ancestral Health for Women. We have our two speakers, Sarah Ballantine and Stacey Toth. Some exciting news. Sarah Ballantine is, as of a few days ago, now a New York Times bestselling author. And Stacey Toth, also very cool. She just qualified for Strong Woman Nationals. That's very cool as well. So I will let them take it away. Stacey's going to, whoa, can you guys hear me? Oh, there we go. Stacey, do you want to interest the talk? Are you working yet? I've got to take a picture of everybody. All right. Pretend Stacey's saying something really awesome, everybody. Well, everything I say is awesome. So you guys can pretend that it's the end of our talk, and you're giving us this huge standing ovation. No, no, a huge standing ovation. Listen, it's going to be great. Everybody wants to stand. You know, my sitting is death. Come on, huge standing ovation. There you go. There we go. We got it. You're not corny at all. No, that's going on Instagram later. OK, so Sarah has done almost all of this. I'm just going to break it down into layman's speak for most of us, or maybe not most of us. Maybe most of you get it. I don't. So she's going to go into what the HPT and HPG accesses are and what our recommendations are because of those accesses within specifically women's bodies is what the talk is today. OK, so I think most of you are probably familiar with who we are. We both used to be unhealthy. We both found paleo. We both got healthy. I'm a scientist. And that's about it, right? Yep. OK, that's good. She does science. I do strong. It's not that I'm weak. It's not that I'm not smart. OK, so Sarah did this awesome little evaluation fixing of the primal man here to be a primal woman because every single diagram showing the evolution of man shows man and not woman. And today is about women's health. And similarly, almost all medical research studies are done on men. So what we're going to talk about is specific to women and what we found in that research. But typically, all of the research on this type of effects of hormones and all these sort of things are done on men. So we're just trying to remind you and bring home the message that we're looking at it from the perspective of women's health and how it affects women's hormones today. So there are many different hormone systems in the body. What we're really going to be talking about today are three different systems and how they're interlinked. So we're going to be talking about thyroid. We're going to be talking about adrenals. We're going to be talking about ovaries and how those things interact with each other and how those things interact with our environment. And by environment, specifically today, we're going to be talking about diet. So the hormone systems in the body are controlled by the brain. And specifically, they're controlled by the hypothalamus. So the hypothalamus is like hormone control in the brain. It actually receives signals from a different part of the brain called the hippocampus. The hippocampus is the part of the brain that takes information from the senses and kind of assembles it and figures out what's going on. It makes decisions. So let's say you're falling off a cliff. That's not a good thing to do, so don't go out and purposely fall off a cliff. But if that was a bad thing that happened to you, your hippocampus would be receiving these signals of, hey, there's no ground beneath me and I'm holding on by an arm and this is bad and I should do something. It sends signals to the hypothalamus, which then goes a how we're stressed, fight or flight response time. And the hypothalamus then sends a specific signal to the pituitary gland, which then sends a specific signal to the adrenal glands. Well, this works in not just the hypothalamic pituitary adrenal axis, which I'll talk more about in a second, but it works for all hormonal axes. There is a brain control and so there's a control of the hormones that really comes from the senses of our environment. So I talked a lot about the HPA axis yesterday to remind you this is the fight or flight response in the human body, but it also has very important normal roles in the human body. It's cortisol circadian rhythm hormone, it's a metabolism hormone and so it's not just fight or flight, it's also how this axis is activated and deactivated throughout the day. So the hypothalamus gets the signal from the hippocampus, it's time to be stressed. It releases a hormone called corticotropin releasing hormone or CRH, which sends the signal to the pituitary gland that we're doing stress response now. The pituitary gland releases another hormone called adrenocorticotropin hormone, or ACTH, which sends a signal to the adrenal glands. The adrenal glands then go, ah, okay, we're doing stress response now and they secrete all the things that adrenal glands secrete, including cortisol, including catecholamines like adrenaline. Now, what's really important about these axes is it's not just one way. So the brain needs some way of knowing that the target endocrine organ received the signal. So there's this negative feedback. So cortisol actually feeds back to both the pituitary gland and the hypothalamus and says, hey, we got the message, we know we're doing stress response now, we're on it. And this negative feedback is really, really important for controlling the system. So you don't just have, okay, wait, we're falling off a cliff and then forever after you're stressed out. So this is a really, really important system and it's a very similar system in other axes in the body. Such as the hypothalamic pituitary thyroid axis. So notice, we start with the hypothalamus again. The hypothalamus receives signals. It sends a different stimulating hormone called thyroid releasing hormone to the pituitary gland, which then sends a different hormone. In this case, it's thyroid stimulating hormone to the thyroid gland, which then produces the prohormone T4, which is then converted into the active hormone T3 if everything's working properly. The hormones have their metabolic effects in the body and they also signal back to the brain and say we got the message that we're supposed to be making thyroid hormone right now, thank you very much. There's a similar axis again and you'll notice it starts with hypothalamus and pituitary gland. In this case, it ends with the gonads. We're talking about women's health today, so we're gonna be talking about ovaries, but this axis is comparable in men and women with some different hormone effects at the end. So the hypothalamus in this case produces gonadotrophin releasing hormone, which signals to the pituitary gland to produce luteinizing hormone and follicle stimulating hormone. These signal to the ovaries to produce estrogen and progesterone. Estrogen and progesterone though, here's a little bit of a difference with the HPG axis compared to the HPA and HPT axes. There is both negative feedback and positive feedback from estrogen and progesterone. And the details of exactly why this is and what other factors control whether we've got negative or positive feedback remain unknown. But we know that there's actually neurons in the hypothalamus that for some estrogen and progesterone turn them on and for some estrogen and progesterone turn them off. And so this becomes a much more complex system as soon as you add positive feedback in addition to negative feedback. And it's also very important to be well regulated. All the regulatory mechanisms still have been described, but it's important for it to be well regulated because this regulates of course the menstrual cycle. Now these axes don't exist in isolation. So we understand the hypothalamus is controlling hormones. It's sending signals to the pituitary gland. Pituitary gland is like middle management. It sends the signals down the road. But these axes are all intertwined. And so specifically, I mean it's no surprise that stress has a bunch of effects. Cortisol is going to suppress the production of estrogen and progesterone actually multiple ways. So it inhibits the formation of gonadotrophin releasing hormone and luteinizing hormone and follicle stimulating hormone while directly suppressing the production of estrogen and progesterone at the ovaries. What's a nice complicating factor is if your HPA axis is activated and you're producing a lot of cortisol, the body actually uses progesterone as the substrate. So it actually converts progesterone into cortisol. So not only do you get a inhibition of the production of estrogen and progesterone, you use up what progesterone you're forming and this is how we get estrogen dominance from stress. Cortisol also inhibits thyroid gland. It actually inhibits the conversion of T4 to T3 and supports the conversion from T4 to reverse T3 which is a competitive inhibitor for T3. So you get the double whammy of suppression of the thyroid there. Corticotrophin releasing hormone, as I talked yesterday, it's not just a one-way signal, it actually has direct effects in tissues. Yesterday I talked about gut health. One of the other things that it does is inhibit a thyroid stimulating hormone so it suppresses the thyroid again. And so what you'll see is, especially when we're talking about stress, it's not just what's happening with cortisol that is a problem in the human body. It's how these axes converge and how they interact. So a stress response affects the thyroid and suppresses the thyroid. It also affects the sex hormones and suppresses the production of estrogen and progesterone and the effects from those can further feedback to the HPA axis. So what Sarah's trying to say is that all of these things affect one another. That's all I've got. So we're gonna be reiterating this message but we've kind of broken down the individual items of each of these axes and what the major components that each is controlling so that you can think about it from the perspective of, okay, HPA controls cortisol and HPT controls thyroid. But ultimately what we're gonna talk about is that none of these things work in a vacuum. They're all working together. And so if one thing is out of whack, it's gonna throw everything out of whack. Okay, yeah, sorry, also. What we're gonna then kind of merge into is how the diet affects these things. So we've talked about overall how your body is working but ultimately what we're all here and interested in is how the foods that you're eating and that are nourishing your body, if they really are in fact nourishing your body in a way that produces something positive. So specifically the hormones controlled by HPA, HPG and HPT are specifically affected by blood sugar regulation. They impact, those changes, specifically if you change your diet, will impact your blood sugar regulation, your leptin and your insulin which we've just shown you has that big circular effect of affecting all of your hormones back in that reiterated circular motion. What did I miss? I don't know, go to the next slide. So to talk a little bit about insulin, one of the things that's really important to understand when we're talking about the effect of insulin on the HPA, HPG and HPT axes is that there's a happy medium. And then there's an effect when insulin is too low and there's an effect when insulin is too high. And then there's also an effect when you have insulin resistance which typically goes along with high insulin but not necessarily. And so insulin, this comes from a normal physiological mechanism to help us access stored energy in between meals and to help us know to store energy after feeding. But what happens is when you have insulin that is either too high or too low, you activate the HPA axis. And this comes from a normal mechanism but what happens is when we have really high insulin from chronic overeating, from high carbohydrate diets, especially high refined carbohydrate diets, we end up with chronically high insulin, we end up with insulin resistance, we also end up with chronic stimulation to the HPA axis as a direct result. It also suppresses the thyroid. So when insulin is either too high or too low, this suppresses the thyroid. Insulin resistance suppresses the thyroid. It also decreases the production of estrogen and progesterone when insulin is too high or too low. So too low is something that happens when our metabolisms are not particularly flexible. It also happens in a few cases that we're gonna talk about in a little bit more detail in a bit but it's something that can happen with very low carbohydrate diets. It can happen with prolonged fasting and it's really important to understand that while there may be benefits to these types of diet strategies that in women, we've got direct effects on some really important hormone systems that can have very detrimental effects to our health. Leptin is very similar in the sense that what we want is the proper levels and how levels go up and down with feeding, same as insulin, and we want leptin sensitivity in order to have proper regulation of the HPA, HPG, HPT axes. So when you have leptin that is either too high or too low or you have leptin resistance, and this is something that can be a direct result from overeating, being obese, chronically eating very high amounts of refined carbohydrates, but leptin also mediates the adaptation to fasting. So we actually also get leptin resistance as a result of chronically under eating. We can get leptin resistance from very low carbohydrate diets, for example, and it's the body's response to those types of changes in macronutrient ratios and total energy intake. So what happens when your leptin is not in the happy medium zone is again, you activate the HPA axis, you suppress the HPT axis, you're suppressing the thyroid, and you suppress the HPG axis, you suppress the production of estrogen and progesterone, and that has an impact on the human body, especially female body. So what Sarah's trying to say is all of these things affect one another. You good? Yeah, no, no, I got it. So some of the things that regulate insulin and leptin, I think Sarah talked a little bit about the example of carbohydrate. So it's not just whether you eat carbs or not, it's the amount of carbs that you eat, the quality of carbohydrates that you're eating, and whether you're eating them with other macronutrients or micronutrients is also gonna affect how your body handles them. It's gonna regulate all those axes that she's talking about and get your hormones in check if you're living in kind of that happy medium state. But if something is either too high or too low for what your body needs, it's gonna cause dysregulation in one part of what, say it with me now, all of those things work together. So some of the other things that can affect it are meal timing and size. I think we all have played with the idea of maybe eating six small meals a day versus three big meals a day. That's gonna impact it. We'll go into a little more detail about that. It's also the amount of adipose tissue that someone has coming into it, where you metabolically broken and obese or are you really lean and fit and you're an athlete. Sarah and I are really big proponents of lifestyle factors as well in terms of how it affects your health. And that's because the research supports that insulin and leptin are directly affected by that lifestyle factor, sleep, activity, stress. And then Sarah and I are also big nutrient geeks. We are self-proclaimed neutrophores. So we are highly encourage everybody to seek out the most nutrient dense foods that you can possibly eat, high source and good quality foods rich in micronutrients as well as the macronutrients that we're talking about today. So all of those things combined are gonna contribute to healthy, happy hormones. What we're trying to show you today is what we believe can help get you happy, healthy. I picked the wrong thing. There you go. Is that you? No, I think you already said all that. Awesome. Okay. I didn't even get a laugh. This is a tough crowd. Everybody should stand up and take a breath. All right. I know it's before lunch. That's the problem. It's before lunch. Low blood sugar. What does that do to people? Okay. So some of the other things that Sarah called all the rage in the paleo movement or we can say frequently talked about in the paleo movement are intermittent fasting. I think there was a big splash maybe a year and a half ago when it was discovered that there was a research paper out that showed that intermittent fasting specifically caused different reactions in women than men and it was then kind of generally accepted, maybe not as generally as we would like that the effects of intermittent fasting on women can be different long term specifically than they are on men. So when we talk about intermittent fasting and some of the information that Sarah's gonna share what we wanna kind of define and explain for you is that we're basing it on the assumption of what the research paper define, not paper, papers, who knows, studies, something. She's, I'm sure she's got links to wherever this stuff came from. That the fastest specific to 16 to 24 hour period. We realize a lot of people aren't likely fasting for 24 hours in kind of the paleo context but this is what we can tell you the medical research supports and that's what we're using. We can kind of suppose that a 10 hour fast a 12 hour fast, a 14 hour fast likely has the same effects, maybe not as quickly but I think the studies came from specifically families who did like Ramadan and people who are fasting for that amount of period of time. So in some cases people who fast paleo, it's all different, everybody does it differently. You can have some water, you can have some fat but specifically the frequency of what that means is that you're just not eating for a while. Including while you're asleep is usually. Definitely. Included in part of that. It's not 16 hours like starting when you wake up, it's 16 hours starting from the last time you ate. Yeah, and most commonly it's just people are skipping breakfast to simplify it. Okay, so Sarah did this awesome poll on just an informal poll. An informal poll. So obviously these aren't quantifiable research studies but from the group that we polled that was kind of unanimous and informal, there were five questions asked about intermittent fasting and I'm not gonna go through each of them and all the responses but what I will point out is that number one basically says I like intermittent fasting and then the rest say there's some part of intermittent fasting that doesn't work for me and I don't like it and so although right now you look at this and it looks like A says yeah, intermittent fasting is great, it's one third of the group that says that. Two thirds of all the people who answered the poll actually say that it didn't work for them in some capacity or another. So the question is why? We've got these clues from the interaction between the HPA and the HPT and the HPG axes but why does intermittent fasting work much more uniformly well for men than it does for women and why do we have basically responders and non-responders and I'm gonna read you a quote from this abstract. This is specifically in studies of Ramadan fasting so please keep that in mind, it's not people eating a strict paleo diet but it says however the chronobiological studies have shown that Ramadan fasting affects the circadian distribution of body temperature, cortisol, melatonin and glycemia, nocturnal sleep, daytime alertness and psychomotor performance were decreased. So this is the type of effect that is seen most typically in women from intermittent fasting especially regular intermittent fasting. It's okay. This is a study that was done in rats, I know everybody likes to discount animal studies but actually we can get a lot of really, really important insight especially into mechanisms. So okay why do women have this potentially quite negative health effect from fasting? So again I'm gonna read you a quote. Significant changes in body weight, blood glucose, estrous cyclicity and serum estradiol, testosterone and luteinizing hormone levels indicate the negative role of an intermittent fasting daily regimen on reproduction in these young animals. Leptin plays a mechanistic role in suppressing the hypothalamic, in this case a hypofysiole but it means the same thing, hypothalamic, pituitary, gonadal axis. So it's because as we already mentioned that leptin mediates the body's response to fasting and especially in the female body there is a direct interaction between leptin levels and sensitivity and the hypothalamic, pituitary, gonadal axis. So continuing from the same abstract, together these data suggest that intermittent fasting daily regimen negatively influences reproduction in young animals, yes in this case rats, due to its adverse effects on complete hypothalamus, hypophysical, gonadal axis and may explain underlying mechanisms to understand the clinical basis of nutritional infertility. So this comes from the rationale, the clinical analogy here is women who chronically under eat and chronically fast, as is typically seen in eating disorders like anorexia are infertile and it's because of the direct effects of fasting on the hypothalamic, pituitary, gonadal axis. So what's Sarah trying to say? There you go, it's all connected. I don't think they have any questions on this one. You wanna talk about ketosis? Okay. No, you're gonna do this one. You can tell we totally practice this a bunch, you want me to do it, okay. So like the previous one where we discussed intermittent fasting, the only other really dietary supported research that we could find, it's specific to nutritional ketosis. I think most of that research is done on epileptic patients, which is why the research is there to begin with or we can extrapolate from that a very low carb diet. So yeah, look, it's right there, nutritional starvation for epilepsy. I look at that. Ketosis is defined as under 30 grams of carbohydrate a day, a moderate amount of protein because we didn't really talk about it here but protein affects insulin as well. So what we're really talking about is a very high fat intake and in a paleo diet we encourage good quality fats being the makeup of that high fat ketogenic diet. Very low carb would be kind of what we could extrapolate defined as less than 50 grams of carbohydrates a day. And a lot of paleo individual see results or it's proposed to produce the results of weight loss, improved energy, managing health conditions. Specifically there is good research to show that it does support epilepsy and extended life. So what we're gonna talk about is what we see in women in the research. Again, this poll that we did, this informal poll, has the results saying A, I've tried ketosis and I love it, I feel great. And then the rest of the results are I've tried it and it doesn't work for me in one way or another. And you can see that one third of the group says I tried it and I like it and two thirds of the group say it doesn't really work for me. Specifically, the difference between the intermittent fasting one and the ketosis one, interesting for me in the very least, was that there is a much larger margin here in D which is the significant negative effects that it had on someone's health. And there were a significant number of responses for that versus the other two that are kind of moderate responses. So you could be someone who falls in the one third it works well for me, but you could also be someone who falls into the almost one third, it really didn't work for me at all and it actually wrecked my health. And Sarah's gonna explain why. So really one of the limitations with research into ketogenic diets is that they're predominantly done in men. But what we do know is from a lot of the epileptic studies that there are effects on women that are reason for women to be at the very least extremely cautious when self-experimenting with a ketogenic diet. In particular, there's been three studies looking at epileptic adult men and women that then dissected some of the side effects of a ketogenic diet in women. What's really interesting about this is these were ketogenic diets with micronutrient supplements, very, very similar to what is typically recommended now for a variety of health benefits. But what is often experienced with women is effects to their sex hormones, which manifests as changes to the menstrual cycle. In one study, 21% of the women lost their periods completely. So it means that a ketogenic diet made them infertile, not permanently infertile. And they were able to, many of them regain fertility with the change back to a diet that contained carbohydrates. But that should be a really big red flag. In another study, every single woman, adult woman in the study on a ketogenic diet experienced menstrual irregularities. Every single woman had noticeable changes to their menstrual cycle. And in a third study, again looking at epileptic patients, 45% of the women had menstrual dysfunction and it was the most common side effect reported constipation being the second most highly reported side effect. There's been only one study that has looked at the effect of ketogenic diets on the thyroid that I was able to find. It was a short term study. So we can talk about adaptation to ketogenic diets over time and how that may change the effect. But what's really important to understand is at least in the short term study that a ketogenic diet caused a significant fall in the active hormone T3. It supported conversion of T4 to reverse T3. And that dramatically impacts of thyroid function and metabolism. So I wanna read- This is the problem with two people. So this is another study looking at ketogenic diets, again in animals and we can all obviously take it with a grain of salt. But this I think was really, really interesting because it really brings back the importance of diet and sexual function and sexual health in women. So they put these animals on a ketogenic diet and I'm gonna quote this cause it's quite amazing. A gestational ketogenic diet deleteriously affects maternal fertility and increases susceptibility to fetal ketoacidosis during lactation. So not only was there effect during pregnancy but also after the mice babies were born. What are mice babies called? Pups, I think they're called pups. Prenatal and early postnatal exposure to a ketogenic diet also results in significant alterations to neonatal brain structure and results in retarded physiological growth. So I don't think there's anybody out there who is recommending that a pregnant or lactating woman attempt a ketogenic diet. But this should be, if anybody is out there, if you hear of anybody suggesting this might be a good idea, while this is an animal study, it is a really big red flag saying that this may not only be dangerous to the mother but dangerous to the baby. Okay, so I know you've got this one. What I wanna kind of drive home in case you didn't actually get that they're all affecting each other is that what I hear very often from women who lose their period or have irregular menstruation is that, well, I'm gonna try and have a baby so it's not a big deal. But what we're trying to show you here is that it is a really big deal because that is a flag that you can see in your body right away that tells you that something isn't right. So if your menstruation becomes irregular, that means because all of this works together that all of this is becoming irregular and broken. So when we talk about infertility and irregular menstruation, if you are a woman or if you know a woman who has these problems, it is the utmost importance to figure out what is the driver behind that problem and how can you fix what the driver is so that the symptoms of the menstruation can change. All right, well, I just did. Don't touch it, Sarah. Yeah, so that's the next one. Okay, go nuts. I'm gonna go nuts, I'm gonna stand here. There you go. I'll stand here. Look pretty for everybody, Sarah. Okay, so what is the solution that we recommend? It's really dependent on who you are, what your activity level is, what your health is. We can't prescribe a result and a specific diet for everybody. I know that's what everybody wants to hear, but it really is about what you do and what your health is. So ultimately what you're looking to do is to keep your blood sugar regulated so that you can manage and regulate your insulin sensitivity, your leptin sensitivity. You want all that in checked. So moderate carbohydrate, what we're recommending and seeing in the research to support is 75 to 300 grams a day depending on your activity level, your health, your goals if you're a woman, could put you in that sweet spot to where you're gonna try to find your ideal health that would affect that overall circle. Sarah and I also highly recommend nutrient density. We both love the hashtag more vegetables than a vegetarian, not just because it's punny, because it is, but because vegetables are really important to health. There's science that indicates if you only eat a red meat diet you're more likely to have cancer, right? There you go, see, scientists not it. So if you are eating a lot of green vegetables specifically but vegetables entirely that actually regulates and helps your body recover from that and have health and longevity benefits. We would recommend that if you are eating meat that you would do so from pasture raised animals so that you're getting a higher nutrient density in the meat that you are eating. Specifically grass-fed beef if you're not aware has an extremely high amount of omega-3s and chicken no matter if it's pastured or not has a high amount of omega-6. So we support ruminant animals as being the majority of what it is that you consume. And seafood. And yeah, sorry, and bone broth and organ meats. We're kind of weird about that stuff. Okay, so adequate protein intake is really important. It's gonna help regulate that leptin and insulin but just in general eating protein specifically in the morning has been shown to have improved effects on weight loss for women. If that's what you're looking for, if not it's just still good to eat protein. So there you go, eat a high protein breakfast and that helps regulate those hormones. Regular spacing of your meals is one of those things that kind of we touched on earlier with the intermittent fasting. So if you're aiming for two to three larger meals per day maybe a snack versus one really big meal or skipping breakfast, you're gonna see regulation of hormones that will help it go up when it needs to go up and down when it needs to go down so that your body will stay level if you're eating the right macronutrients as well. And activity, specifically weight bearing activity, resistance training, not chronic cardio because that's where you're gonna see that HPA axis spike up in a way that you don't really want from a cortisol reaction. So weight bearing activity and strength training can really help with that regulation as well. And last but not least, sleep and stress management. I think they go hand in hand. I always feel better when I'm sleeping. I had a terrible day yesterday. I didn't sleep for 22 hours straight and I was quite stressed but I got some sleep tonight and I feel better. So if you can make the time to do that it will help your health, period. There's just no lack of research to support that. And figuring out ways to reduce the stress in your own life. So whether that be walking or yoga or whatever you find helps relax you. And I can let Sarah talk a little more about the self experimentation but ultimately what we would recommend is that if you are going to try to decrease or increase your carbohydrates if you've been doing something for a long time your body will do best to adapt with gradual changes. So not just jumping right into an intermittent fasting or not just jumping right into ketogenic but kind of five carbohydrates a day, reduce it down and see how you feel. And there might be a period where you hit 25 grams reduced makes you feel really great but 50 grams reduced makes you feel bad. And you would feel that in your own body if you did it gradually where that sweet spot might be. So when it comes to choosing carbohydrates with the goal of regulating leptin and insulin with the goal of then regulating the HPA axes the HPT axes and the HPG axes. Not all carbohydrates are created equal. Generally women respond better to slow burn carbohydrates. So these are the starchy vegetables just because that helps to regulate blood sugar very well. And that's not true across the board. Fruit is still typically a low to moderate glycemic load food but when you're experimenting with your carbohydrate intake with the goal of, well with any goal, with any health related goal but knowing that you need to regulate these important hormones, that is a really, really good place to start. It's also much easier to regulate your blood sugar when you're eating carbohydrates at the same time as you're eating other macronutrients, protein, fat, fiber. So when you are experimenting with carbohydrate intake you can also experiment with the timing of your carbohydrate intake. So one of the really neat things is because there are some health benefits to very low carbohydrate diet, there are some health benefits to that higher fat intake and what happens in women's bodies especially is the negative impact is seen after a couple of days. So there's a couple of strategies that you can experiment with that may help actually avoid the negative impact while still allowing you to have some of the benefits of intermittent fasting or a ketogenic diet approach that is carb back loading where you stay very low carbohydrate through breakfast and lunch and in the evening you consume the majority of your days carbohydrates. Sometimes you consume those carbohydrates only on days that you are highly active and on days that you are less active you would maybe stay very low carbohydrate for the entire day. Carb cycling is very similar in the sense you have some days that are lower carb and some days that are higher carbohydrate. So if you'd like to avoid vaginal dryness, right? There they laugh. Vaginal dryness, that's what you wanted to hear about. Okay, if you don't want this stuff, what should you do? It all works together, right? Okay, any questions? That's like the most delayed applause ever. If you have a question, move to the mic so we can hear you please. I am just wondering how this fits into the ancestral health framework because it doesn't make sense to me that carb back loading, cycling, all this manipulation of carbohydrate, I mean, in the old days people didn't walk around with a glucose drip, right? So how did that work? So when you look at ancestral diets you look at 100 gatherer populations. A ketogenic diet is not actually a very typical example of what they were eating. So while they were typically sort of lowish to moderate carbohydrate, ketogenic diet was not necessarily seen certainly not for the extended long periods of time that many people are experimenting with this. One example though of where we do see these very high fat intake diets is in the Inuit. And the Inuit actually had sort of chronic infertility. So what would happen is seasonally, smaller animals would be available. They were eating the entire part of the animal and one of the things that the women were eating was the thyroid gland. There would then be a baby boom nine months later. So what was happening was that the very likely happening was the high fat low carbohydrate diet was suppressing their thyroid glands which was suppressing their sex hormone production. So they were actually infertile until they had a feed of thyroid gland which is basically everything that you need in order to make thyroid hormones. So it's kind of like a, it's a great little sort of hack if you are going to do this, you just find some good thyroid gland and you can help your body make those hormones. So I think that from an ancestral perspective, we can actually point to this type of direct impact on sex hormones happening in hunter-gatherer or hunter-gatherer sort of horticulturist populations. When you look at the majority of the populations that have been studied, they have much higher carbohydrate intake and then we don't see these types of effects on fertility. Great, thank you very much. It was a great talk. Thanks, Chris. Oh, are we going back? Sarah, that was amazing. Stacey, amazing. This is what... It was really all Sarah. You could have just left it at that. It's fine. This is what paleo women should be doing. I am a keto nutritionist and I have just a few things. I don't want any woman to think that vaginal dryness or infertility should stop her from doing a ketogenic diet if she has cancer. And I really do think the rules change for people who have cancer. And I want to bring up one thing you did say and I want everybody to really zero in on the Ramadan fasting studies were done with women who were not ketogenic. They were following standard diets. So the adaptation period is not... I mean, it's just four weeks. So a lot of these things that happen, the infertility, the losing your period, those things happen, I believe, as a result of the caloric restriction rather than the fact that they go ketogenic because I don't see these kinds of things in the people that I work with. So I think if it's a well-planned ketogenic diet, I really don't want women to be afraid to do it if they have cancer. Thank you. There's definitely health conditions in the medical literature in which a ketogenic diet has been shown to be an extremely powerful therapeutic tool. And I wouldn't want a woman to miss out on the opportunity to use such a powerful therapeutic tool for fear of these side effects. It's going to be a cost-benefit analysis for each woman. But I do want to point out that the epilepsy studies were in isocleric diets. So that was menstrual dysfunction without the calorie restriction. I have two questions, but I can say them really quickly. Oh, really? Pick your favorite. I'll ask the one about, as somebody who no longer has to worry about fertility, anything in your research about the effects on postmenopausal women of ketogenic or intermittent fastings? As far as I'm aware, it has not been studied. I did actually saw a study for the talk that I'm doing later this afternoon in postmenopausal women talking about the benefits of strength training for women postmenopausal in terms of hormone regulation and that sort of thing. So I can at least point to that, but not ketogenic specifically.