Welcome to the Hey Mami podcast!

Our guest today is Dr. Jaime Seeman, a board certified Obstetrician and Gynecologist practicing in Omaha, Nebraska. 

She has a Bachelor of Science degree in Nutrition, Exercise and Health Sciences. She then went on to graduate medical school and completed her OBGYN residency at The University of Nebraska Medical Center. 

Dr. Seeman is currently in private practice at Mid City OBGYN offering a full range of services in obstetrics, gynecology, robotic surgery and primary care.

She is a fellow in Integrative Medicine at The University of Arizona School of Medicine, and she is a board certified ketogenic nutrition specialist through The American Nutrition Association. 

Dr. Seeman has a passion for fitness, preventative medicine and ketogenic therapy — not only in her medical practice, but in her own life. She is married to her husband Ben, a police Sergeant, and has three young daughters. 

Dr. Seeman is also Mrs. Nebraska 2020 and appeared on NBC Titan games with Dwayne “The Rock” Johnson.

Or listen on Apple Podcasts | Spotify | Stitcher | TuneIn | YouTube

In today’s episode we will be discussing everything blood sugar.

Highlights:

• Dr. Seeman’s story
• How can a woman prepare to create healthy blood sugar within her body before she conceives?
• Does Dr. Seeman recommend a CGM (Continuous Glucose Monitor)?
• Thoughts on keto during pregnancy
• The association between subclinical hypothyroidism and insulin resistance, and/or risk factors for gestational diabetes
• What is PCOS (Polycystic Ovarian Syndrome)
• Thoughts on plant-based diets
• Carb-cycling
• Tips for exercising during pregnancy

Important Links

Find Dr. Seeman online here

Follow Dr. Seeman on Instagram | Facebook

Quotes

“The things I talk about my patients with, it’s the five pillars, and it’s nutrition, exercise, sleep, stress, and environment. And sometimes all of those things can contribute to insulin resistance.”

“If a woman was insulin resistant prior to pregnancy, then keeping carbs reduced through the pregnancy is going to be helpful. If she had great insulin sensitivity and she can tolerate more carbs, then it’s not necessarily advantageous to make her eat super low carbs.”

012: Blood Sugar, Insulin Resistance, Gestational Diabetes…Oh My! w/ Jaime Seeman, MD TRANSCRIPT

Alex:                      Welcome back to the Hey Mami Podcast. Today we’re going to be discussing everything blood sugar, with our fabulous guest, Dr. Jamie Seeman. Dr. Seeman is a board certified OB-GYN practicing in Omaha, Nebraska. Born and raised in Nebraska, she played collegiate softball for the Corn Huskers. She has a bachelor’s of science degree in nutrition, exercise, and health sciences. She then went on to graduate medical school, and completed her OB-GYN residency at the University of Nebraska Medical Center. She is currently in private practice at Mid-City OB-GYN, offering a full range of services in obstetrics gynecology, robotic surgery, and primary care.

Alex:                      She’s also a fellow in integrative medicine at the University of Arizona School of Medicine. She is board-certified in ketogenic nutrition through the American Nutrition Association. She has a passion for fitness, preventative medicine, and ketogenic therapy, and not only in her practice, but also in her personal life. She’s married to her husband, Ben, a police sergeant. Has three young daughters. Dr. Seeman is also Mrs. Nebraska 2020, and appeared on NBC Titan Games with Dwayne The Rock Johnson. Wow. That’s a lot. Welcome to our show. Thank you so much for being here.

Dr. Seeman:       Thanks for having me, Alex.

Alex:                      That’s amazing. Okay. Well, what Christine and I really want to start off doing, is we want to know why you do what you do, and what got you to where you’re at, because a lot of us in this world have a journey of our own, that brings us to practice medicine in a little bit more of a progressive way.

Dr. Seeman:       Yeah. A hundred percent. And my personal life is definitely reflected in the way that I practice medicine now. So I was a athlete growing up, so super active, free sport athlete in high school, went on to play collegiately. But because I was so active, I got away with eating really poorly. I grew up in the eighties and nineties where convenience food and Hamburger Helper was where it was at, but I don’t even know if there was hamburger in it.

Alex:                      I just remember the hand. Yeah.

Dr. Seeman:       Love my parents to death but I really didn’t eat that great growing up. I never really had any idea what nutrition was, or what I was putting in my body. But I went to college and I actually… Because I was on a pre-med track, I didn’t want to get a biology degree, because I thought, “If I don’t get into medical school, what the heck am I going to do with a biology degree?” So I really wanted an exercise science degree. Well, my college eliminated the program the first day I showed up, and I panicked. And then I thought, “Well…” They took some professors from that department and combined them with a nutrition department. So as luck would have it, I ended up getting a degree in nutrition and exercise science, it was a combined program. Which in the end ended up being a really great thing for going into medicine.

Dr. Seeman:       So I got this degree and I left the university, and got into medical school. And now here I was suddenly with this physical change of pace, right? Now I’m sedentary, I’m sitting in the library for long periods of time, taking tests on Saturdays. And I had really vowed to never lift a heavy weight again. So as a collegiate athlete, I was training very hard, lifting heavy weights, but always felt as a woman I could never express my femininity.

Dr. Seeman:       My feminine side was never being an athlete, there was just these societal pressures. And I really wanted to get rid of my muscles, because that was very masculine to me. So fast forward through medical school, I was in my fourth year of medical school, my husband and I decided to start a family. And here I was really struggling with my weight. And all I really thought I had to do was control calories. So I was really trying to count calories, I was doing some cardio exercises, but I got pregnant with my first daughter and I failed my glucose testing, which was this big slap in the face. And I never thought it had that much weight at the time, but I come from a family of normal BMI diabetics. So my dad’s a diabetic, normal BMI. My mom’s a diabetic, she has struggled with obesity in her lifetime.

Dr. Seeman:       But my dad’s parents, my grandparents at the time, normal BMI diabetics. So clearly I had some major genetic predisposition to insulin resistance. But I failed my glucose testing, and then after my baby was born, close to nine pounds, I had three nine pound babies. I was told I had hypothyroidism, and I had to go on levothyroxine. So I was on thyroid meds. And then all of my daughters, I have three daughters, are 23 months apart. So I had three pregnancies in less than three years. And I will be the first to admit, I tried to eat healthy, but when I say try, like I said, I was just like, “Oh, keep your calories in check, move your body, eat less, move a little more.”

Dr. Seeman:       But I was also in medical training, I was in residency. You guys know it’s [inaudible 00:04:56], it’s survival mode. So during my third pregnancy, in March of 2015 I actually had a horrible tragedy happen in my life. One of my best friends actually died in the middle of her pregnancy, we were very similar gestational ages. And after that pregnancy is when I ended up being told I had pre-diabetes. And here I was, I just felt like a complete fraud. Here I was, I had a nutrition degree, I had a medical degree, I had an amazing husband, three daughters. I mean, I felt like the whole world was right there in front of me, and I just felt like a complete fraud. How could I sit in clinic and tell my patients day in and day out how to be healthy, and here I was not living it my own life. My patients have excuses just like I had every excuse.

Dr. Seeman:       I’m a busy mom, I had a police officer husband who was working nights and weekends, every excuse in the book. But the death of my friend really literally opened my eyes, to just the realization that our time on earth is limited. And why was I going to spend one more day being so tired and so miserable, if I had more control over it? So I set out on a very personal journey to fix my own health, and it started with a Whole30 and then paleo. And then I eventually settled on a very low carb ketogenic approach, and fixed my insulin resistance very quickly, lost about 27 pounds, got off of my thyroid medication. And it was like the lights came on. What started as really fixing my diet, all of a sudden I had so much more energy and I felt so much better that I started the business, and I went back to training, I went to fellowship to get an integrative medicine degree.

Dr. Seeman:       And literally everything changed in my life. And as you read my bio, fast forward from 2015 to 2020, I competed on Titan Games, I won Mrs. Nebraska. It’s amazing to me when you put the right things inside of your body, what you really get out of it. And what started, like I said, as nutrition, has changed the way that I parent, has changed the way I look at my marriage, and it’s a hundred percent changed the way I practice medicine. I really realized that it’s not that I was taught things that were false. I mean, everything that we learn in medical school is good information, but I think that information is always evolving, and we always have to be looking at the new things. And I think that alternative therapies are really underplayed in Western medicine. And I wholeheartedly believe that they have a huge role, and I’ve experienced that in my own clinical practice.

Dr. Seeman:       We know that giving people medications is like putting a bandaid on a bullet hole, there are so many things. 80%, 90% of the things that we encounter as clinicians, that could be fixed or improved with lifestyle interventions. So now that’s my mission. I know there’s a mom listening to this podcast right now that was in those shoes, tired at 8:00 PM, really subtle symptoms. That’s the thing, is if you went back and looked at a picture of me, you would have never known from the outside how metabolically I was unhealthy underneath.

Christine:             Yeah [crosstalk 00:07:59]

Alex:                      I think you’re talking to two moms right now.

Christine:             We’ve been through that same thing. And it is so true though, what you say, sometimes you look at somebody and they look okay, but there’s such a spectrum of disease and unwellness where it’s like the earlier you catch it, the easier it is to handle. Don’t wait until you’re 20 years down the line.

Alex:                      But we also live in a society where a lot of us live in this spectrum of unwellness, so it’s acceptable to just-

Christine:             Yeah. It goes back to what’s [crosstalk 00:08:31] isn’t necessarily normal, right? So it’s just a very being super fatigued or whatever is a common symptom, but it’s not normal.

Alex:                      So what I really want to know is from, I guess, a preconception prep perspective, how would a woman know that she has blood sugar issues? And how can she prepare to create healthy blood sugar within her body before she conceives? Because I think if we can get to the inflection point before pregnancy, then that makes a lot of potentials diminish. So yeah, how do you ask women or tell women, coach women, in the preconception period?

Dr. Seeman:       So I wish that more women came for preconception visits, because it’s not a super common visit that people come in for. A lot of times they call as soon as they get that positive pregnancy test. There was a lot of red flags that I wish I would’ve seen when I was trying to get pregnant with my first daughter. I had been on birth control for a number of years, and I was on it for irregular periods. Well, come to find out after I got off birth control that I likely had PCOS. I was the PCOS phenotype, right? An athlete, built muscle really easily, but had a really hard time losing fat, had some acne, I was oligomenorrhea, which means you’re skipping periods. And my doctor actually offered me Metformin and Clomid to try to get pregnant, it had been six, nine months, and we couldn’t get pregnant.

Dr. Seeman:       I ended up going on a very, very calorie restrictive diet, and ended up getting pregnant that month. But of course was not in the healthiest way. So when it comes to insulin resistance, it hides so easily, because by the time that we see insulin resistance clinically, a lot of times is by the time we check a hemoglobin A1C, right? Which is a three-month average of your blood sugars. But what happens before that happens, and you guys know but I’m explaining for our listeners, is that your body will just produce more and more and more insulin to make your blood sugars normal, until it stops getting that signal. And then eventually the blood sugars will start to rise. So for preconception visits, I recommend all patients to check a fasting insulin C-peptide and glucose. And we calculate their insulin resistance index, and we see, “How good are you at really handling glucose and carbohydrates in your diet?”

Dr. Seeman:       Because from a dietary perspective, I want patients to really have their nutrition in check, right? I don’t want micronutrient depletions. If they have insulin resistance, we can certainly fix it before pregnancy, because we know in pregnancy it’s going to get worse. Even if you’re insulin sensitive, it’s going to get worse because pregnancy is a physiologic insulin resistance state. So this is something that I really wish I would’ve known, I wish I would have checked. And then clearly next red flag, failed the glucose testing. Next red flag, developed hypothyroidism, right? I was on a five-year plan to type 2 diabetes. I mean, that’s the fact of it. So I think that when patients come in for preconception, we need to say, “What is this patient’s metabolic health right now?” And metabolic health, one is insulin resistance.

Dr. Seeman:       So looking at fasting glucose and fasting insulin levels, and then also looking at things like triglycerides, HGL, and other inflammation markers, so like homocysteine, high sensitivity, CRP, other signs and symptoms, right? But we can see things externally too, right? So if you’re dealing with acne or you’re dealing with other skin conditions, those are signs of inflammation. So we look at all those things, and the things I talk about my patients with, it’s the five pillars, and it’s nutrition, exercise, sleep, stress, and environment. And sometimes all of those things can contribute to insulin resistance. Here I was not sleeping well at night, not eating well, not moving well, not dealing with stress well. They all contribute.

Dr. Seeman:       You can’t just work on one of them, you have to work on all five of them eventually. So these are the things I wish people would think about before they get pregnant, because in pregnancy it’s harder to make drastic changes in the middle of pregnancy.

Alex:                      Yeah. I think what a lot of my patients often haven’t realized, but we put together so nicely in the integrative or alternative medicine world, is that everything affects everything, affects everything. There’s not just one separate system for each thing, like your reproductive system is not separate from everything else. So we spend a lot of time, I think, in society in large thinking that these individual pieces… If you can fix this individual thing, then everything will get fixed. But no, it’s the whole web. So yeah, thank you for explaining that. So something that I want to ask you about is, if you have someone that does have insulin resistance, even mild or maybe moderate insulin resistance. And they decide to go on a ketogenic style diet or just a low carb diet.

Alex:                      A couple of questions. Number one, do you recommend that they use a CGM? Well, I guess number one would be how do you even go about that? It can be overwhelming, and there’s a lot of keto myths or low carb myths that are out there, that people feel makes them nervous to make those changes. And then would you use testing CGM, or would you check blood sugar in the morning? Or what about carb cycling? There’s just so many questions that come when you tell someone, “Well, let’s think about doing a keto style diet.” Yeah.

Dr. Seeman:       Yeah. So when we look at… So to the note of the CGM first. So when somebody has insulin resistance, we look honestly at what they’re consuming, right? So standard American diet, 50% to 60% of carbohydrates, something that’s low carb or ketogenic, we’re talking less than 10% of calories from carbs. For most patients, we’re talking 25% to 30%, which is pretty restrictive for a lot of people. Another option we have is to do continuous glucose monitoring, and to actually figure out where that carbohydrates threshold is, right? Because certainly not all carbs are equal. For instance, if you eat a potato cold or hot, it’s going to have a different response, or if you eat it with protein, it’s going to have a different response. So that’s what I think is so valuable about continuous glucose monitoring.

Dr. Seeman:       And I just know in the next five to 10 years, we’re going to see it become more mainstream. There’s already companies now that are direct to consumer with CGMs. And I have found myself and my patients, that even just wearing one for 14 days, provides such an amazing amount of information. Not only how your blood sugars respond to food, but to exercise, to sleep, to stress. I mean, I love wearing my CGM. I walked into a delivery one time, and it was a very dramatic delivery. Baby’s heart rate was bad, I had to use forceps. And I came out and I had this huge blood sugar spike in the middle of the delivery.

Dr. Seeman:       But it’s cool for me to show that data to patients and say, “See, look, my body doesn’t know if I’m outrunning a bear, or if I’m trying to save a baby’s life, this is a normal response, right? We don’t get worried about this. But if we saw this response to eating some French fries or something like that, then that’s a bad deal, right?” So I think CGM data is amazing. Certainly you need somebody to help you interpret it. I don’t think the average patient knows how to interpret it or what numbers they’re looking for, so certainly need a good provider for that. But I think CGM is amazing, and I do use them in pregnancy as well. I think it’s also less invasive when a patient doesn’t have to poke their finger four times a day. And I think it’s more helpful too, because we see patients where they have high fastings, but the after the meal blood sugar, is called postprandials, are normal. And sometimes those are confusing. Why is this happening? Is it a done effect? Is it stress? Is it their last meal of the day?

Dr. Seeman:       So I’m a huge fan, hands down, of continuous glucose monitoring. Now, pregnancy, the concern with low-carb in pregnancy, a common question, because the patient comes in, they’ve got PCOS, you put them on a ketogenic diet, boom, they get pregnant the next month. It happens all the time. And now they want to know what to do with their diet. And women have been scared and fear-mongering into not limiting carbohydrates in pregnancy. So when we look at pregnancy and what a woman should really consume, first of all, we have to look individually at this patient, what was their metabolic health and insulin resistance coming into pregnancy? Because if a woman was insulin resistant prior to pregnancy, then keeping carbs reduced through the pregnancy is going to be helpful. If she had great insulin sensitivity and she can tolerate more carbs, then it’s not necessarily advantageous to make her eat super low carbs.

Dr. Seeman:       So I think it should be very individualized. Now, in the first trimester of pregnancy, this is a trimester that’s very, what we call, anabolic. So immediately the pancreas starts putting about 30% more insulin out. And we do see more blood sugar dysregulation, but an increase in insulin sensitivity. So in the first trimester is not where I get really concerned. Patients usually feel horrible, they have food aversions, they’re nauseous. I mean, it’s survival. If ketosis killed babies in the womb, not many of them would survive a first trimester. But then once we get into the second and the third trimester, it’s largely catabolic. So here’s where we have this physiologic insulin resistance that develops, and physiologic leptin resistance, and that helps maintain the maternal appetite.

Dr. Seeman:       And here’s where carbs do really start to matter a lot. So when we look at the standard American diet, if a woman was eating 50% to 60% of carbs, it would be mathematically impossible probably to get the micronutrients that she needs to grow a healthy pregnancy. A lot of those things come from nutrient dense animal foods like eggs and beef, things that are high in choline and vitamin D. So I get very concerned when patients are told to not eat less than that. Now, when we look at the Institute of Medicine recommendations, they say 175 carbs should be the lower threshold. And I think for some patients that’s fine. But I think for some insulin resistant patients, eating less than that is going to be more helpful. And I have some patients with gestational diabetes that do eat in the range of 30 to 50 carbs in pregnancy, just to control their blood sugar.

Dr. Seeman:       So the carb recommendations in pregnancy should be individualized to keep the blood sugars normal, because you can have normal blood sugars at the cost of a lot of insulin. And there are some trials, and we don’t have to dive super deep into them, but there are some trials that show it’s basically a linear relationship. The higher the blood sugar is, even the people that pass the glucose tests, there’s more adverse effects long-term, not only for the mom, but for the baby. So increased risk of obesity, type 2 diabetes, et cetera, in her baby, even if she passed the test but had normal blood sugars at the cost of a lot of insulin. So this is why it’s super important. So what I recommend is to individualize it. I prioritize for my patients protein, because protein is very satiating. You need more protein in pregnancy. It’s like the little Legos that build the baby, that’s how I describe it to my patients. And then we have to decide how much fat and how much carbs to eat, and that’s all based on the patient’s insulin sensitivity.

Alex:                      Yeah. I find that so true. And it speaks to me, because I was in that same spot. I was told to eat a lot more carbohydrate than I could tolerate. My blood sugar would go up if I ate that amount of carbs. So for me, it was a balance. I did finger stick blood sugar, fasting one to two hours after a meal, and maintained it really well. But I was a stickler about carbs, and having higher fat and higher protein was the helpful thing. But then also, I mean, how concerned are you if you see ketones on a urine spot, does that concern you at all?

Dr. Seeman:       Great question. So I think we should stop checking urinary ketones. So they don’t correlate with serum ketones. And the third trimester of pregnancy is actually, it’s very normal to see presence of beta hydroxybutyrate in the bloodstream, because like I said, the third trimester is very catabolic. And we see the presence of ketone bodies, we see the presence of fatty acids, we see the presence of glucose, all at the same time. And this is nature’s way of ensuring that there is a constant supply of fuel going to that baby. And we know by studies looking at umbilical cord blood, that the baby’s ketones are actually higher a lot of times than the moms. So babies are actually producing their own ketones as well in the third trimester. And then as soon as you clamp that umbilical cord, ketones are very useful in the first couple of days of life, to help support the rapid fetal brain growth that happens, the myelination of the brain. And [inaudible 00:21:10] babies are in and out of ketosis very regularly.

Dr. Seeman:       And then it isn’t until six months, but I always joke, we put them on the rice oatmeal and goldfish diet, that they’re permanently kicked out of ketosis for the rest of their life. So it’s normal to see ketones in a pregnant woman’s urine. I have to hit my head against my desk occasionally when patients get sent from the diabetes educators, and they’re freaking out because there’s ketones in your urine. Don’t even test them. And if there is real concern for something like diabetic ketoacidosis, then you should check serum BHB levels, otherwise I don’t even recommend checking them. It’s very normal for a pregnant woman to go in and out of ketosis.

Alex:                      And way more concerning to have a hyperglycemia or high blood sugar, than to have ketones in your urine.

Dr. Seeman:       Yeah, a hundred percent. When I go out and speak, I have a whole slide on the risks of hyperglycemia in pregnancy. And we’re talking the most common congenital birth defect in America, congenital heart disease, caused by hyperglycemia. I mean, high blood sugars in the first trimester can cause your baby to not form its brain in its head. I mean, this is serious, serious business. And then if you have a totally normally developed baby, hyperglycemia and hyper insulin anemia in pregnancy, is the most common reason for NICU admissions. Blood sugar dysregulation, electrolyte imbalances. So these are little things that people… People are missing these things. People don’t understand it’s because of the way they were eating in pregnancy. So I think it’s super important to limit carbs to your threshold in pregnancy.

Alex:                      So that raises the question, what are your opinions on testing when we do the glucose tolerance screening? And obviously that’s important. Pregnancy is just this thing that uncovers it. Something that was pre-existing, but we have the opportunity when we’re pregnant, to do some more in-depth testing than we normally do as individuals. But anyways, what are your thoughts on glucola, or do you know or use any alternatives to the glucola drink? Which is, for the listeners, that nasty orange drink that you have to drink?

Dr. Seeman:       Yes. So the glucose test is the most widely studied test to identify patients with gestational diabetes. Now we know from a trial called the HAPO trial, the hyperglycemia adverse outcome trial, that essentially it’s this linear relationship, right? So you have to pick some point. Some doctors use 140, 135, 130. Here’s the issue, for somebody that is eating carbs throughout the pregnancy, it’s a decent test, right? It’s going to identify most, it is still going to miss some. If you carb load 24 to 48 hours prior the test, you can actually trick the test, right? Because you’re up-regulating insulin production from the pancreas. The issue for my low carb patients, who are low carb during pregnancy, is they’re not used to seeing a 50 gram glucose load. And they’re more likely to fail the test, right?

Dr. Seeman:       It doesn’t mean they have gestational diabetes, that means their body’s not used to tolerating that amount of carbohydrates. So for my patients, I already know what their diet is during the pregnancy. So I talked to them about either traditional glucose screening or doing glucose monitoring, so they can poke their finger or they can wear a continuous glucose monitor. And we test for at least a week. If they have a CGM, it’s great, because we can test for two weeks. At that 28 week mark, when that physiologic insulin resistance develops, and we see where their blood sugars are at.

Alex:                      Yeah. That’s such a great alternative, because I feel like, number one, that the test in and of itself and the product, it’s not really very good for you, it’s made of garbage.

Dr. Seeman:       Right. Dyes and-

Alex:                      Dyes and high-fructose corn syrup, I think.

Dr. Seeman:       [crosstalk 00:24:56] inflammatory response.

Alex:                      Yeah. So I love that. And in my last two pregnancies, that’s what I did as well, just followed the curve.

Christine:             Mine too. And I think it’s consistent with our diets. I mean, I was already… I wouldn’t say I was low carb, but I was lower carb. And my body doesn’t know what to do with 50 grams of glucola. I mean, it just doesn’t. I don’t ever eat that. So it’s not really a fair observation, and I actually wonder in retrospect, maybe it was just a false positive, I don’t know. But anyways.

Dr. Seeman:       Yeah. I mean, when you look at the obligatory use of glucose in pregnancy, I mean, we only have five grams of sugar circulating in our bloodstream at any given time. I honestly don’t think anybody needs more than 10 to 20 grams with each meal. I mean, even in insulin sensitive people, unless it’s pre or post workout, right? Unless it’s around a period of exercise. So to give people 50 grams just blows my mind.

Christine:             Yeah, it’s a lot. And just for listeners to wrap your head around this, if you look at some of the guidelines from the World Health Organization, for instance, they say people shouldn’t have really more than 25 grams of sugar a day from added sugars. So I think sometimes people don’t really understand how much is 20 grams in relationship to whatever, but there are certain foods that people are probably routinely eating, like flavored yogurts, or an Odwalla green smoothie, which has a crazy amount of sugar. There’s probably 40 grams of sugar in some of those products, which exceeds really what you should have in a whole day.

Dr. Seeman:       Right. Right. A bag of Skittles is 36 grams, and I’ve seen green smoothie, whatever it is, very clever marketing.

Alex:                      I know. You’re like, “It’s green.” But it’s also actually more sugar than Skittles. Yeah.

Dr. Seeman:       Even better.

Alex:                      They’re that really popular organic smoothie place here in Austin. And I have seen patients become pre-diabetic from their daily organic, healthy smoothie. And it’s like… It’s because it’s still a huge glucose load and fructose load. So yeah. Okay. So let’s see here. I want to know, Christine, we were going to ask Dr. Seeman about thyroids. So do you want to dig into that?

Christine:             Yeah. What I’m curious about is the association between subclinical hypothyroidism and insulin resistance, and/or risk factors for gestational diabetes. It’s my personal passion. And that I think a lot of people are underdiagnosed when it comes to hypothyroidism. And for the listeners, subclinical is basically this mild form of thyroid failure, where you have a higher than normal TSH, but a normal T4. But I feel like people are often untreated, even in reproductive health where the guidelines really suggest they should be treated. But how does that relate to blood sugar insulin resistance and gestational diabetes risk?

Dr. Seeman:       So insulin resistance and hypothyroidism are very much related. So for myself, failed my glucose testing, developed hypothyroidism postpartum. Pretty common trend in people with insulin resistance. It’s a little bit twofold. So when we look at hypothyroidism, right? There’s the two most common reasons, iodine deficiency and autoimmune thyroid condition, so Hashimoto’s being the most common. So first we could have just the inflammatory [maloo 00:28:26] of somebody with insulin resistance causing dysbiosis or problems with the gut microbiome. And that could predispose them to something like an autoimmune condition like Hashimoto’s. Insulin resistance also, these patients tend to be vitamin D deficient, magnesium deficient, and probably some of the other micronutrients that are super important for thyroid production.

Dr. Seeman:       So that’s why I start to see just this slow clinical picture of subclinical hypothyroidism. And these patients, it’s a better controversy, especially in pregnancy, whether to even screen for thyroid, and whether to treat subclinical hypothyroidism in pregnancy. So a lot of people have believed that, as long as the free T4, free T3 levels look okay, even if the TSH is rising, don’t treat until those look low. But I think we could be doing some harm there, especially in the first trimester of pregnancy, optimal thyroid levels. And when I say optimal, optimal is different than normal. Optimal levels are super important, because a baby doesn’t make its own thyroid hormones until later in the pregnancy. And a baby is completely dependent on T4 production, because it has to convert it into T3, once it crosses it can’t use that across the placenta.

Dr. Seeman:       So I think that there’s probably a lot that we don’t know. But for my patients with any suspicion of insulin resistance, I’ve screened for thyroid preconception and in pregnancy as well. And of course I always try to fix it at the root cause with diet and things like that. But if they need short-term thyroid replacement, especially for pregnancy, I think it’s important to do it. I personally found when I had hypothyroidism, that I felt the best when my TSH was close to one. I mean, when it would creep up into the three and four range even, I was very fatigued, I had constipation. My skin would change. So I felt better that way. And I think that when you look at the data and you look at the outcomes, I think we should treat most pregnant women to that level as well. I like my T3 to be somewhere in the three to 3.5 range, T4 above one.

Dr. Seeman:       So I think it’s definitely underplayed, and I think the role of nutrition in insulin resistance and subclinical hyperthyroidism, I mean, just like if we could catch the people with pre prediabetes, right? This is pre hypothyroidism. If we can catch that problem before it happens, instead of committing someone to just being on medication for the next 40 years. Because I find a lot of patients are on thyroid meds, and I’m like, “Well, what’s your plan to get off of them?” And they’re like, “Oh, I thought I was just supposed to be on them for the rest of my life.” And it’s like, “Well, let’s figure out why you’re on them.” And I think there’s definitely a link there.

Alex:                      Yeah, it’s interesting. So when you look at thyroid meds, and you screen your patients, what do you test for?

Dr. Seeman:       Yeah. So if a patient’s never been tested, I’m looking at TSH, and looking at their total and free T3 and T4, I do screen for reverse T3. And then I at least make sure they’ve been screened once for thyroid antibodies. And most patients who come in, they’re like, “Oh yeah, my doctor checked the TSH, said it was normal, said my thyroid function was fine.” Right? But a lot of times we’ll uncover other abnormalities in there, or I find people who’ve never been screened for antibodies. They don’t have any [crosstalk 00:31:53] why they have hypothyroidism.

Christine:             A hundred percent. Every single day. Yes. We see that so often. And I mean, your patients are so lucky to have an OB-GYN who knows all of that, and knows how to interpret it. And I think there are some doctors who are willing to look at that whole picture, but it’s not something they’re accustomed to looking at. So interpreting it is sometimes a little bit of a challenge. And I think that, yeah, there’s just a lot of people walking around who are undiagnosed, untreated, and don’t know what they’re dealing with.

Alex:                      Yeah. I think a lot of women with subclinical hypothyroidism suffer because they’re in that gray zone, and a lot of people are reluctant to do anything because it seems normal, but then they’re symptomatic.

Christine:             Yeah. And the guidelines really, I mean, at least in reproductive health, the guidelines support treatment under a TSH of 2.5. Outside of reproductive health, it’s a really hard zone where it’s like, we can treat if you’re trying to get pregnant, but postpartum, you’re stuck sometimes. And that’s a tricky place to be if you’re a mom of three and whatever. So awesome. Let’s transition a little bit and talk about PCOS. Because we mentioned that briefly earlier, and I think a lot of our listeners would really like to understand a little bit more about the underlying cause of PCOS. I think, like you mentioned earlier, PCOS is often just treated with a birth control pill, right? But what’s the root cause of it? Can you talk to us about what PCOS is, and what [crosstalk 00:33:30], especially when you’re a young woman, because I think a lot of that just gets overlooked.

Dr. Seeman:       Yeah, yeah. So it’s a horrible name for what it is. So many patients think if you were to ask, I think any patient they’re like, “Oh, that means you have cysts on your ovaries.” So every single day in my clinic, I have to dispel the fact that your ovaries make cysts. It’s very normal, makes a cyst every single month when it releases an egg. So the clinical diagnostic criteria, we’re looking for women that do have polycystic ovaries on ultrasound, they’re missing periods, or in the medical world we call that oligomenorrhea or amenorrhea, meaning no periods at all. And then they either have clinical or biochemical markers of hyperandrogenism. So we’re talking acne, dark hair growth, or elevated levels of DHA or testosterone. So it is definitely a spectrum of disease.

Dr. Seeman:       So we have patients that are skinny, from the outside you wouldn’t know if they have PCOS, but they definitely meet criteria, they’re skipping periods, their ovaries look very polycystic on ultrasound. All the way to patients who are obese, have almost a full beard, testosterone and DHT levels off the chart. So it’s definitely a spectrum. At the core of PCOS, what we know is that these patients have insulin resistance at the level of the ovary. They don’t always have peripheral insulin resistance, a lot of times they maintain good insulin sensitivity in the muscle, which is why somebody like me, it was very easy to gain muscle and be an athlete with PCOS. But at the level of the ovary, there’s insulin resistance, and this is driving that androgen production, that testosterone production from the ovary. So they start to develop this imbalance in LH and FSH, they stop ovulating, they’re missing periods, they’re making tons of estrogen, but not enough progesterone.

Dr. Seeman:       And they come into the clinic, and they’re like, “Doc, I’ve got this acne, and my periods are all over the place.” And we just say, “Okay, take this birth control pill.” Because it will fix their problems. I mean, it will increase their sex hormone binding globulin, which will bind up some of that testosterone. Sometimes it will make their acne better, especially if you use a certain specific progesterone like gestrinone. And then of course it will regulate their periods. You can’t see me, but I did air quotes. And then what happens is they come off of the birth control pills because they want to have a baby one day, and they’ve never fixed the real issue, and they’ve actually made it much worse. Because the birth control pill starts to drag on the thyroid, it contributes to their insulin resistance, because of the micronutrient depletion. So B vitamins, the insulin and magnesium.

Dr. Seeman:       So it’s a real issue. When you look at the studies on PCOS and the treatment options, of course things like oral contraceptives are there. We do see anti-androgen medications. But what we don’t see, there’s a few very small studies looking at nutritional interventions. Most of them will just say the patient should lose 10% of their body weight, right? And they’ll start ovulating again. Well, there’s a million ways to skin a cat. You can lose weight on lots of different diets, but certainly a ketogenic diet or low carb approach is what is going to be most therapeutic for these patients to help with their insulin resistance. And when we look at the studies on ketogenic therapies and PCOS, one of the participants in the trial actually got pregnant, thought she had infertility, got pregnant during the study.

Dr. Seeman:       But we see a huge improvement. They lowered their weight, they’ve lowered their triglycerides, they lower their fasting glucose and insulin levels, they start menstruating again. So this is such an important therapy for patients with PCOS. If they truly need birth control, that’s one thing. And I still don’t think birth control pills are necessarily the best thing for these patients, but if they need birth control, that’s one thing. But that is not the best treatment for PCOS. The best treatment for PCOS is good nutrition, stress reduction, exercise, focusing on sleep, and really trying to get the inflammation down. Because the insulin resistance creates such an inflammatory state in the body, and that’s why they get these bad skin conditions. Unfortunately, some of the hair growth issues with PCOS, dietary interventions a lot of times don’t improve those things for the patients with very bad hirsutism.

Dr. Seeman:       So sometimes we do have to look at anti-androgen therapy or laser therapy, or some of those other things from an aesthetic perspective, but dietary intervention for PCOS is for sure number one.

Alex:                      Right now I would say plant-based diets are very in vogue. So one of the challenges that I think Christine and I have both seen in our practices, is that some people are really unwilling to come off of a plant-based diet when they exhibit insulin resistance or PCOS. What are your recommendations in that case? And there’s also people who feel very averse to eating so much meat. So I don’t know if you can bust some myths here for us.

Dr. Seeman:       So my biggest fear with promotion of the “plant-based diet”, is that it is pushing people away from eating protein. And we are eating less protein now than we were 30 years ago, yet we’re seeing the rates of cardiovascular disease, diabetes, and cancer increase. And when we take away protein in the diet, we have to replace it with either fat or carbohydrates. So as people move into this plant-based approach, which I believe at its core was supposed to be more of a whole food based approach.

Alex:                      Right. Right, exactly.

Dr. Seeman:       I fear that it’s just going to give consumers more excuses to… I mean, if you walk through the grocery store, I mean, there’s plant-based butter, which is margarine, there’s plant-based… I mean, things that just have [crosstalk 00:39:31] and canola oil. Yeah. I mean, Beyond Meat has the same ingredients [inaudible 00:39:38]. I mean, that is my biggest fear. I have no issue if people have ethical moral reasons to be vegan or vegetarian or whatever it is, but this blanket statement of plant-based, I think is going to push most people in the wrong direction from a nutritional standpoint. When we look at what nutrients do we need, how I look at macronutrients is, with protein, it’s pretty hard to gain weight eating excessive amounts of protein. So I always have my patients prioritize protein in their diet.

Dr. Seeman:       And for women, like you mentioned, there are some people that they’re fearful of meat, they’ve been told red meat is bad. And we’re now starting to see this retraction, right? Saturated fat does not drive heart disease, it’s the sugar, flour and vegetable oils and the diet. So it does take a lot of reeducation with these patients, but I try to have them prioritize protein in their diet. And then when we look at fat, we talk about the fats that they’re supposed to be eating, right? Animal fats are fine, butter, olive oil, avocado oil, coconut oil, right? But we’re staying away from those industrial seed oils like canola and corn and all these things. And then I have no issue with plants. If your gut tolerates them, if you don’t have an auto-immune condition that’s exacerbated by them, fruits and vegetables and grains to your level of insulin sensitivity, is perfectly appropriate.

Dr. Seeman:       I think across the spectrum, we all agree that real whole foods, right? That either had a mother or were grown in the ground, are probably the most healthy. But when you have to choose what to eat, the reason that I like to prioritize protein for people is, as a woman ages and she gets later into her life into perimenopause and the menopause, having a decent amount of lean body mass is very protective to her metabolic health. And this is one thing that’s bent my platform a little bit in the last five years, is that women shouldn’t be afraid to have muscle. Because it is one thing, especially after menopause, that can protect us from metabolic disease, which is cancer and heart disease, the things that are going to make our lives miserable. And to maintain lean body mass, you need adequate protein. And as we age, we become less efficient at use of amino acids from dietary proteins.

Dr. Seeman:       So you actually need even more of it. So if you’re not used to eating it in your twenties and thirties, you’re definitely not going to get enough in your forties and fifties and sixties. So that’s why I really prioritize that with my patients. And the plant-based movement is, in my opinion, very politically based and definitely from another agenda. And we just have to keep fighting the good fight.

Alex:                      Yeah. And as far as protein macros go, how much do you recommend women eat? I know it depends on their level of exercise, but say just a normal woman who maybe works out three or four times a week for half an hour. What do you recommend in protein amount?

Dr. Seeman:       So I actually use a very high protein approach. So I have patients try to eat at least 0.8 grams per pound of body weight. Now, that’s a lot. So I’m a 165 pound person, so for me, my protein is going to be in the ballpark of 130, 140 grams a day. When we look at dietary use of protein in a meal, we’re talking 30 to 50 grams is probably necessary to maintain lean body mass and even building body mass. So that’s 30 to 53 times a day, that would at least get you to between 100 and 150 grams of protein a day. I find that when you force patients, a lot of them don’t hit that mark, right? But when you force patients to eat at that level, protein is so satiating and I think it helps their normal satiety mechanisms. Because if they’re not eating that much protein, it’s in place of either fat or carbs.

Dr. Seeman:       So I find that if you can try to challenge them a little bit to eat at that level of protein intake, that it helps with lean body mass maintenance and with weight maintenance. I find that when you have those normal satiety mechanisms, you don’t necessarily have to count and track all your calories and things like that.

Alex:                      Right. Yeah. Just point of reference for our listeners. I think in terms of getting 30 to 50 grams of protein per sitting, like a chicken breast has 40 grams of protein. What are other easy examples, like collagen peptides is one of my favorites. I think you’ll probably get around 20 grams of protein or two table spoons, or two scoops rather.

Dr. Seeman:       Yeah. So I always explain that a deck of playing cards is four ounces of protein, and that’s about 25 grams of protein. So if you need 30 to 40, you’re talking a deck and a half of playing cards, it’s really not that much. It sounds so scary and intimidating to people, but I’m like, “Listen, it’s not that much, it’s like a deck and a half of playing cards, or two decks of playing cards.” We calculate what they need visually. I think that visual representation is so important for people, because it just breaks it down into more manageable bite sized pieces. But yeah, it’s not that hard to get it, but you do have to think about it and prioritize it.

Alex:                      And this is the, I guess, riffing off of the CGM and identifying what your, I suppose, glucose or insulin, your tolerance for carbs are. What metrics are you using? What do you want people’s postprandials to be like? At what point after a meal… How do you categorize when people are meeting the right metric, if they’re using a continuous blood glucose monitor?

Dr. Seeman:       So normally we tell people we want fastings less than 95, and two hour postprandial less than 120. One hour postprandial, less than 140. I think that’s very liberal. And I have come to that conclusion based on watching people’s CGM data, and watching my own. Eating a whole food diet high in protein, I find that my blood sugar excursions are not at that level. I think that’s very liberal. And we have to ask ourselves, that’s at the cost of how much insulin? Because if you can keep your blood sugars normal at a lower cost of insulin, we’re talking less inflammation, better longevity, better immune function. So that’s the question I think we always have to be asking too. And I wish, and if I could wave my magic medical wand, in 2030 we have this amazing sensor on our arm that looks at insulin levels, glucose levels, and ketone levels all at the same time.

Dr. Seeman:       But I know that it’s actually very difficult, you can’t really track ketone levels in the interstitial fluid. So it will be hard. You’ll have to have a [inaudible 00:46:26] or something. But we always have to be looking at them, all in relation to each other. So for me, when we look at glycemic variability, what I really try to teach patients is, within two hours your blood sugar should be back to baseline. So if your fasting blood sugar wasn’t 95, I would like it to be back to 95 up to two hours, not at 120, at 95. And what I’ve noticed is that, and patients will notice this too, is that the more excursions they have, they get the up and then they get the down.

Dr. Seeman:       And when they start to see those counterregulatory responses, they start to notice these very subtle symptoms, “Oh my gosh, I was feeling very anxious as my blood sugar was trying to regulate and get back down.” Or, “I was feeling very tired.” And they start to notice those things that their body was telling them, that they didn’t realize how to do with their glycemic variability. So I just think that’s incredible information to have, but I personally think that most people could eat a diet where their blood sugar would be back to baseline after two hours.

Alex:                      Okay. That’s awesome. And then another question that often comes up, I guess, if we’re myth-busting, a lot of people express concern about doing keto and then suppressing thyroid, especially in women. What’s your thought on that? And then carb cycling, is that necessary?

Dr. Seeman:       Yeah. Yeah. So this is near and dear to me, because I was hypothyroidism. So yeah. Then you hear, “Oh, you need carbs free of thyroid.” So [inaudible 00:47:54] am I doing harm? So when we look at people who are on a ketogenic diet and thyroid function, there are researchers that have looked at this data, Dr. Jeff Bullock, out of the University of Ohio has probably published the most data on this. We definitely see a reduction in free T3 levels in patients who are low carb and ketogenic. But what we don’t see is the concomitant rise in TSH. So the free T3 goes down, but the TSH doesn’t go up. And the theory is that, just like we’re improving insulin sensitivity, we may be improving thyroid sensitivity, so improving T3 sensitivity at the cellular level. But I have been able to follow it in my patients, and I’ve seen this clinically.

Dr. Seeman:       Sometimes there is a reduction in free T3 levels. I mean, I’ve seen some patients get down to 2.1. But they’re not symptomatic, and then the TSH doesn’t rise. So this is an interesting subset of patients. Now, you brought up this idea of carb cycling. I think that just like there’s seasons on the earth, just like there’s… I think that cycling is always a good thing, and I find that naturally I go ketogenic and then paleo for a little bit, and then back to ketogenic, now that I’ve fixed my insulin sensitivity. And our bodies are an amazing piece of machinery and they’re so adaptive. So what I tell patients is, anytime you diet, anytime you restrict calories, you will see a reduction in thyroid function. That is the body’s protective mechanism. It is these nutrient sensing pathways are saying, “Okay, there’s less food in my environment.” Right? That’s the perception you’re eating less, there’s less food in the environment.

Dr. Seeman:       So it’s conserving the engine, it’s reducing thyroid function to conserve what stores we have. Now, in women, it’s always constantly saying, “Is this a good time to get pregnant?” So I tell patients, “If you’re low carbon ketogenic and you lose your period, that’s a sign that we’re not doing something right.” We probably need to add back carbs, and we maybe need to cycle them every 10 to 14 days. When we look at these thyroid changes, it’s about that 10 to 14 day mark where the thyroid starts making these adaptations. So a lot of times what I’ll help patients do is, after 10 to 14 days, have a day where you eat some more carbs and drop your fat, and then go back to your plan. For somebody that’s very insulin resistant though, I find that they can be low carb and ketogenic straight through, usually for many months.

Dr. Seeman:       But in patients who are close to a normal body weight, like if they’re just doing it because they want their brain to work better, or their mom died of Alzheimer’s and they have some reason for therapeutic ketosis, those are the patients we have to be a little bit more cautious and do a little bit more “cycling”. But to say that the thyroid needs carbs to function, I mean, there’s carbs and blueberries, there’s carbs and veggies. I even take care of some carnivore patients that are zero carbon, and not all of them develop hypothyroidism. So I think if you’re getting the right micronutrients and you’re getting enough calories, I usually don’t see any adverse effects on the thyroid.

Alex:                      Do you see when their free T3 goes down, that the reverse T3 is going up? Or I don’t know if you’re checking it every time.

Dr. Seeman:       No, it usually isn’t. It usually isn’t. I thought of that too, so I started checking at some of these patients, and it doesn’t. It’s literally just a free T3 reduction with no rise in TSH. And it’s very consistent with what Dr. Bullock has published in a lot of his studies too. And like I said, nobody’s really been able to explain the exact physiologic mechanism, but it’s thought that it’s probably an increase in thyroid sensitivity.

Alex:                      Yeah. The one thing that we can’t measure.

Christine:             Right.

Dr. Seeman:       Right, right. Yeah. Because most of the normal T3, T4, TSH values are in people eating standard American diet.

Alex:                      Right. So another question would be the keto flu, a lot of people are very afraid of going on keto, because they’ve heard of the keto flu and it makes you feel horrible. How long does it take to… How can you transition in a way where you can decrease that experience, and also about how long does it take to stabilize? Is it a couple of weeks? Is it a couple of months?

Dr. Seeman:       Yeah. So what happens if you go from eating 50% carbohydrates in your diet to eating less than 10% carbohydrates, as we see it, pretty rapid reduction in use of insulin, right? And as insulin levels plummet, insulin helps reabsorb sodium in the distal nephron of the kidney. So what happens is we start losing sodium in the kidney, we see this electrolyte imbalance that starts to happen, and we see essentially dehydration is what happens. And patients will notice this because there’s a rapid weight loss that happens, and most of it is a huge diuresis, a huge water loss from the body. But it comes with these symptoms of keto flu. And I tell patients, “This isn’t like the flu you picked up at the mall.” I mean, it’s really dehydration and electrolyte imbalance is what it is, but there are definitely ways to make this transition easier and with less side effects.

Dr. Seeman:       So first of all, electrolyte supplementation can be very helpful. People that eat low carb or ketogenic, their needs for sodium, potassium and magnesium are much higher, especially in the first couple of weeks. Eventually the body starts to regulate electrolytes, especially if you’re eating small amounts of carbs. But in the first couple of weeks, electrolyte supplementation is super important, because your body can get rid of extra sodium, potassium and magnesium, but it doesn’t have a store of it. It can’t go tap into it from anywhere. So I put patients on electrolyte supplementation right away from get-go. Exercise can be helpful, getting good sleep can be helpful, and using those electrolytes.

Dr. Seeman:       Now, another one that’s interesting is this exogenous ketones. So definitely over marketed and marketed for a lot of the wrong reasons. But exogenous ketone use can also be helpful in the first couple of weeks, because what it’s doing is it’s basically ingesting beta hydroxybutyrate, so BHB, the same ketone that your body makes. But what it does is it helps, on a cellular level, up-regulate your ketone transporters. So at the level of the mitochondria, it’s something called an MCT transporter that moves ketones in and out of the mitochondria. And as you’re switching from being a sugar burner to being a fat burner to being a ketone burner, you’re down-regulating glute transporters, and you’re up-regulating MCT transporters. You’re actually teaching your body how to efficiently and effectively use this new fuel source.

Dr. Seeman:       So exogenous ketones can be helpful, especially with appetite suppression, energy, and keto adaptation. Most of the symptoms will happen in the first couple of weeks, but the process of keto adaptation takes weeks to months. Dr. Bullock and a lot of his teams who have studied people, have noticed these physiologic adaptations, there’s no timeline. For you or me it might look a little bit different. And there continues to be changes in the cellular network. Ketone bodies actually act as self signaling molecules too. So there’s just these amazing things happening underneath, but you have to get patients through that first couple of weeks and that hump, or they do, they’re like, “I feel horrible. I’m going to go back to my whole diet.” [crosstalk 00:55:08] first couple of weeks, but once they get past that and they feel what it feels like to be in a state of ketosis, I always say, “I can smell colors.”

Dr. Seeman:       I mean, it this whole… My brain functions at a whole other level. And I don’t have to be there all the time, but I think that it’s the concept of dual fuel. It’s the concept of having your body be really good at fat oxidation, and just using glucose when it needs it for exercise and for burst type activities.

Alex:                      And have you found a magic number if you’re checking serum ketones in the morning, where people feel optimal? I know above one, but-

Dr. Seeman:       Yeah. So we consider nutritional ketosis to start at 0.5. So if patients are checking ketones, I say if you’re between 0.5 and 5.0, that’s a great place to be. Now, what’s interesting is that, the longer you are low carb or ketogenic, your ketone levels, you won’t register as higher ketone levels, because you’ve now up-regulated those transporters so well. Then you’re utilizing the BHB in the bloodstream so efficiently, that you don’t actually register high serum levels. So for me, I’m low carb ketogenic most of the time, it’s not uncommon for me to register around 0.3 most of the time. And it’s not that I’m doing anything wrong, it’s just that my body is so darn efficient now at using them.

Dr. Seeman:       And we always look at it in relation to glucose too, right? So we want to see that the glucose is normal, and as the glucose is coming down, the BHB is rising. That’s why I think it’d be so cool to have a dual monitor. And that’s why patients don’t get symptomatic either. When patients are in therapeutic ketosis, let’s say their ketones are 3.5, their blood sugar might even be in the sixties, but patients aren’t symptomatic because the ketones are being utilized for fuel.

Alex:                      Right. That’s fascinating. And then keto and sleep, do you find that it disrupts sleep for some people, or people need less sleep? Or do you find that people just sleep better or is it a range?

Dr. Seeman:       I mean, it’s definitely a range. And of course I see a female population, so my perimenopausal patients start to have pretty erratic sleep disturbances in that transition. From a hormonal perspective, I think is contributing. But in ketosis we actually see that patients need a little bit less sleep. And I found that myself, I used to need seven hours. And I track my sleep with an Oura ring. And I found that when I’m in ketosis, I usually only need about six and a half. And I don’t know, I think it may be because some of the efficiencies in the brain and things like that, maybe a possible slightly less need for REM, a little bit less. But I find that most patients need just a little bit less sleep, actually.

Alex:                      That’s super cool. Yeah, we’re big fans of the Oura ring. I think probably every interview, we bring up our rings. [crosstalk 00:58:06]

Dr. Seeman:       I don’t have mine on today, but it’s on the charger, but I love it. Yeah.

Alex:                      That’s super interesting data. Data’s always helpful.

Christine:             I know it.

Alex:                      Okay. Here’s another question. I know we probably need to wrap up soon, but if someone has been diagnosed with gestational diabetes, what can they do in the middle of their pregnancy?

Dr. Seeman:       Yeah. So I don’t send patients to diabetes education, I do my own education now. So what we do is we look at where they’re at in the diet, and we look at reducing dietary carbs too, to get them to a normal glycemic state. And then after the pregnancy, we know that patients that develop insulin resistance in pregnancy at the level of gestational diabetes are at a 50% more likely to go on to develop type 2 diabetes. So we look at postpartum, what can they do postpartum to prevent this from happening in future pregnancies, and to prevent them from going on to get type 2 diabetes. And it’s with carb management in their diet, getting some of their body weight off, trying to build lean body mass. And like we talked about those five pillars, it’s not just diet, it’s looking at their stress and their sleep, and all these other things that also contribute to insulin resistance.

Dr. Seeman:       But just so people know, it’s not a death sentence. I tell people, your genes are like a loaded gun, but the environment pulls the trigger. And that was certainly the case for me. I mean, family of diabetics. And I have tried to add more carbs in to see how much my body can tolerate now, and it’s the rest of my life. I’m never going to [crosstalk 00:59:53].

Alex:                      I’m in the same boat.

Dr. Seeman:       So I tried a vegetarian vegan experiments, where I was basically high carb, low fat. And no, it was a train wreck. And people were like, “Well, that’s because you don’t eat carbs.” But actually after about 48 or 72 hours, Benn Beckman, out of University of Utah, has done a lot of research with insulin. And even within a couple of days, the pancreas is quite adaptive at changing its excretion of insulin levels and things like that. And yeah, I wore a CGM for a while and it wasn’t pretty.

Alex:                      The first time I wore a CGM… I’ve been low carb keto for a while, but I ate a fig because I was starving and my son had a dried fig, and my blood sugar spiked up probably to 225.

Dr. Seeman:       I know, I’ve had that same experience.

Alex:                      It was horrifying. Dried fruit is… Yeah.

Dr. Seeman:       When I’m on my death bed, just bring me an entire bowl of dried mangoes.

Alex:                      Totally.

Dr. Seeman:       [inaudible 01:00:50].

Alex:                      I’ll be like, “I Can’t do it.” But yeah, I’m in the same boat. As much as I would love to eat lots and lots of carbs, my body just rejects them, or maybe likes them too much to my detriment.

Dr. Seeman:       It’s an unfortunate…

Alex:                      So as far as putting on lean body mass, and I guess in pregnancy that’s a little bit more challenging. But before someone gets pregnant, what can they do? And what can they do postpartum? Postpartum you feel like a train wreck for a while, right? And then you become a little bit more limited with kids, and then maybe you have more kids. I know we have a spectrum of listeners here, but I guess if you could talk to someone before their whole journey starts, what would you have them do in their routine, on the daily? And then if you’re talking to someone that maybe is six months, one year postpartum, what can they do?

Dr. Seeman:       So in pregnancy, you’re not going to be putting on lean body mass, because the second and third trimester are so catabolic. But what you can do, is eat a lot of protein to try to preserve your amino acid stores. So dietary protein is going to help protect that lean body mass. Now, you can exercise in pregnancy. So I tell people it’s like your brain has to tell your bicep that you still need it. So from an exercise perspective, yes, walking and cardiovascular exercise is good, and it’s good for maintaining blood sugar control, but resistance training can still be done in pregnancy, it can be done safely. And you actually don’t need heavy weights. So you can do isometric training, you can use resistance bands. These are things that can be done right in your living room.

Dr. Seeman:       And the same goes for postpartum. Now, of course postpartum you’re breastfeeding, you have a little baby, you have crazy sleep schedules, so you have to recover to some degree. But when you’re physically ready, adequate dietary protein and resistance training is going to help you, not only maintain that lean body mass, but at some point start to rebuild it, because pregnancy really depletes the body of a lot of things. And when we look at the studies, it can take up to three years to replete your body. And it’s crazy, right? Because nobody waits three years to have that second baby or that third baby or that fourth baby, but it can take up to three years to do that. So you have to give yourself time to recover and regain and to get back to where you were before pregnancy, but it absolutely can be done. But it does take a level of discipline, and postpartum is hard. Man, people painted as rainbows and butterflies and it is a hundred percent not.

Alex:                      There’s definitely some sweetness in there, but it’s a whole level of challenge that I think many of us don’t expect. Yeah. For sure. Christine, do you have any other questions?

Christine:             I don’t think so. You’ve been such a wealth of knowledge, and we appreciate it so much.

Dr. Seeman:       I appreciate [inaudible 01:03:55].

Christine:             And you are a super woman, I just want to point out. You have three kids, you went through OB-GYN training, which is a surgical residency with three babies, within, what did you say? 26 months? That’s insanity. [crosstalk 01:04:09]. You were a fourth year when you had your first-

Dr. Seeman:       Daughter. My oldest daughter was born right at the beginning of my fourth year of medical school, so I was pregnant for most of my third year clinical rotations. And then I had my second daughter as a second year resident. I had my third as a fourth year resident.

Christine:             That’s brutal [inaudible 01:04:28].

Dr. Seeman:       I had four weeks of maternity leave with each of them.

Christine:             Yeah, me too.

Alex:                      Yeah, I had my first during residency as well. Of course I developed preeclampsia on call.

Dr. Seeman:       [inaudible 01:04:44].

Alex:                      Yeah, I know. So anyhow. But tell us how our audience can find you. You have an awesome Instagram, you’ve got some cool programs. Tell everyone how they can find you, how they can potentially work with you.

Dr. Seeman:       Yeah. So I am on social media, both Facebook and Instagram, doctorfitandfabulous is my handle. I have a website, doctorfitandfabulous.com. I try to post podcasts and things that I’ve been on. I do have a monthly coaching group, so it is definitely a low carb high protein approach. And we just started our November challenge here. And this one is the best one yet, I’m making people take cold showers and-

Alex:                      That’s amazing.

Dr. Seeman:       … [inaudible 01:05:24], and it’s amazing. So it’s not just nutrition. But I have lots of fun. I have Mrs. America coming up in January, so I’m going to dial back on my coaching groups here through the new year, and then we’ll ramp them back up again. But I’m very active on social media. I don’t currently take telemedicine patients, but we’re working on setting that up. But I’m located in Omaha, Nebraska. So if you’re within the region, that’s where you can find me.

Alex:                      Oh, that’s wonderful.

Christine:             Awesome.

Alex:                      And we are really excited for Miss America.

Christine:             Yes. We hope you win.

Dr. Seeman:       We definitely need a doctor leading this nation and-

Alex:                      I will be watching. Watching what’s the official date?

Dr. Seeman:       It’s January 22nd through the 29th in Las Vegas.

Alex:                      Oh, wow.

Dr. Seeman:       [crosstalk 01:06:09] COVID doesn’t ruin it, but we’ll see.

Alex:                      Yeah. So by the time this airs, I think that we will have passed that, but we’ll be-

Dr. Seeman:       [crosstalk 01:06:18].

Alex:                      Yeah, exactly. We’re rooting for you.

Christine:             Yeah, we’re rooting for you.

Alex:                      Thank you so much for coming on the show, and we hope you’ll come back because I’m sure that we have, probably 10 different shows that we could do just picking your brain and your brilliance.

Dr. Seeman:       Absolutely. Thank you ladies so much.

Alex:                      Thank you.

Christine:             Thank you.