The treatment usually prescribed by doctors, hormone therapy (HT), is controversial and not appropriate for some women. I won’t get into the HT debate here—Mark did a great job covering the pros and cons recently. Suffice it to say that HT isn’t the answer for everyone, and it’s not a panacea by any means.
Whether or not they choose to go the HT route, many women desire additional support during perimenopause and beyond. For the sake of keeping this post from becoming a novella, I’m going to focus on mind-body therapies today.
This is not meant to be an exhaustive list of nonhormonal options, nor is it meant to try to dissuade you from trying HT. That’s a decision you have to make for yourself with your doctor. The approaches below can be used alone or in combination with other modalities, including HT.
As with any medical-adjacent tools, if you are considering any of the options here, take the time to educate yourself, talk to your doctor, and find qualified practitioners to help you implement these practices.
A Note Regarding Research Evidence…
Because so many women are interested in complementary or alternative approaches, there’s a fair amount of research into nonhormonal treatments. There are also important limitations.
A lot of the randomized control trials—experiments that are best for establishing causal effects—are small. There is considerable variability in research design, so it’s difficult to generalize across studies.
Participants in these studies tend to be white and well-educated. Since there are cross-cultural differences in the experience of menopause, we shouldn’t assume that the findings apply to all women. Likewise, a lot of the research focuses on women with a history of breast cancer because HT is generally contraindicated in this population. While the results of these studies probably generalize to other women, it would be great to have more data.
Finally, vasomotor symptoms—hot flushes and night sweats—are studied more than other types of symptoms. Though they are the most common complaint, many women do not experience debilitating vasomotor symptoms. They might, however, experience mood fluctuations, depression, sexual issues, memory problems, and more. We know less about how these approaches might help those women.
Nevertheless, I’ll highlight some of the potentially fruitful avenues you might explore. When possible, I’ll focus on systematic reviews and meta-analyses. They pool the results of multiple smaller studies to help a more reliable picture emerge.
Cognitive Behavioral Therapy (CBT)
In CBT, individuals are encouraged to explore how their thoughts (cognitions) affect feelings, behaviors, and physical symptoms. With help, they change their thoughts or beliefs about a situation to help manage their responses and improve coping skills.
Although there isn’t a ton of research on CBT for menopause, available studies are very promising. Whether or not CBT reduces the actual number of hot flushes—and the data here are mixed—CBT should work by changing women’s perceptions of their hot flushes. Multiple studies do find that after CBT women view their hot flushes as interfering less with daily life. As expected, they are also less bothered by them.
Women who see themselves as having less control over their hot flushes also tend to experience more distress. Changing their perceived control could be an effective intervention for improving quality of life. Indeed, in one study, 95 women received either group-based or self-help CBT. After therapy they reported feeling greater control over hot flushes and having better coping skills compared to women in a no-CBT control condition. Further analyses showed that women’s beliefs about control and coping predicted how problematic they found their hot flushes to be. (Having more positive beliefs about how hot flushes affect sleep also helped.)
Women who participated in CBT also experienced fewer sleep issues and insomnia as well as fewer depressive symptoms and sexual concerns. They also noticed less impairment at work. Positive results were found with in-person therapy, self-help programs, and telephone-based therapy. When studies included a follow-up assessment, the beneficial effects of CBT persisted for at least six months.
Mindfulness, Meditation and Relaxation Training
A cross-sectional study of 1744 women found that women with higher scores on a mindfulness assessment tended to report less severe menopausal symptoms. For women with higher life stress, this association was especially strong. The idea here is that when women are able to be present-focused and observe their symptoms without judgment, they are protected against some of the distress, and possibly the physical symptoms, associated with menopause.
Although some of the women in that survey are probably mindful by nature—lucky them—mindfulness is also a skill that can be learned and cultivated. Among the many reasons to do so, mindfulness and meditation training can apparently lessen menopausal symptoms.
For example, researchers assigned 110 women to either an intensive eight-week mindfulness-based stress reduction program or a control group. The women who received mindfulness training reported having less bothersome hot flushes, better sleep quality, less anxiety and stress, and greater overall quality of life compared to the control group. When the researchers followed participants over the next 11 weeks, these results persisted or became even stronger.
A few other studies found that women who receive mindfulness or meditation training report fewer and less bothersome hot flushes, improved sleep, and better psychological functioning, though the results have not consistently endured over time. However, when looking at more general relaxation training and paced breathing techniques, effects are minimal, at least for hot flushes.
An ethnographic study of nine female yogi masters concluded that they tend to skate fairly easily through menopause. The authors concluded that menopausal women should be encouraged to practice yoga. Of course, in addition to yoga, these yogi masters’ lifestyles included “healthy food habits, adequate sleep, and the use of nature cure techniques (i.e., fasting, detoxification, selection of suitable food products, and living in well-ventilated houses) that facilitated the art of living in tune with nature.” This sounds pretty great, but can we give really yoga all the credit here?
Probably not. However, two recent meta-analyses did conclude that yoga offers small but significant relief from symptoms of all types: vasomotor, psychological (including depression), somatic (including fatigue and sleep disturbances), and urogenital. Women also report better overall well-being and quality of life after receiving yoga training.
In one study, a group of breast cancer survivors received twelve weeks of yoga and meditation instruction, and they were encouraged to practice daily at home. Compared to women in a control group (no instruction), they reported fewer symptoms and improved quality of life at the end of the twelve weeks and again when asked three months later. A later analysis found that many of the effects were mediated by improved self-esteem in the yoga group.
Note that most of the individual studies are small, and they employ different types of yoga practices. This might be considered a strength insofar as different practices have been shown to work, or a weakness in that it’s not clear if one approach is particularly effective.
Cross-cultural surveys find that women who are more active tend to have an easier time with menopause. For example, two large surveys of Swedish women found that women who exercised at least once per week reported less intrusive symptoms than women who never exercised, and women who exercised more than three hours per week were significantly less likely to experience severe symptoms than their less active counterparts. Sedentary women in this Finnish study experienced more vasomotor, psychological, and somatic/pain symptoms than women who were at least somewhat active.
While promising, experimental studies have not yielded such favorable results. When women were assigned to “physical activity” conditions (often walking), some studies report improvements, but others find no improvements or even worsening symptoms (perhaps depending on women’s baseline fitness). Multiple reviews have concluded that there is no systematic effect of exercise, particularly not for vasomotor symptoms.
Does that mean menopausal women shouldn’t exercise? Obviously no. It’s clear that being active—or at least not being sedentary—is important for overall health, and it probably helps menopausal women through the transition. However, there isn’t enough research to know what types of exercise are most effective and when. Do the types of movement you enjoy and that make your body feel good.
A recent review concluded that acupuncture is effective for reducing vasomotor symptoms, both frequency and severity, as well as for improving quality of life. However, the reviewers also found that acupuncture was not reliably better than sham acupuncture where needles are inserted at points other than the prescribed pressure points and at a shallower depth—a placebo condition.
A handful of studies have shown that clinical hypnosis can reduce hot flush frequency and distress among breast cancer patients. Another study of 187 women without breast cancer found that women who received hypnotherapy had fewer, less severe, and less bothersome hot flashes, as well as improved sleep. These results were evident at the end of the five-week treatment protocol, and they remained or got stronger in the six-week follow-up period.
The Experts Weigh In…
In 2015, the North American Menopause Society released a position statement on nonhormonal management of vasomotor symptoms. Of the approaches discussed here, the only ones NAMS recommended based on the strength of the available evidence were CBT and hypnosis. Mindfulness-based stress reduction earned a “recommend with caution,” which means, “We think it might work, but the evidence isn’t conclusive.”
The others—yoga, exercise, relaxation and paced breathing techniques, and acupuncture—were not recommended. This does not mean they are not worth trying! It simply means that based on their standards, the evidence was not strong enough for the committee to conclude that they are likely to be effective treatments for vasomotor symptoms specifically. This says nothing about other types of symptoms, nor about general well-being or quality of life.
Mind-Body Therapy Pros and Cons
So where does this leave us? Each of these therapies shows promise for alleviating at least some symptoms of menopause. Moreover, all these therapies have the potential to improve overall quality of life, sleep, stress, and general health. While reading these studies, I did wonder whether some of the women felt better simply because they were investing time and energy in taking care of themselves. If so, is that a problem? I don’t think so. They are low-risk interventions with a lot of potential upside.
That said, these aren’t quick solutions. The effective mindfulness/mediation trainings included six to eight weeks of classes and multiple hours per week. Women practiced yoga for two to four months during the study periods. Hypnotherapy was five weeks or longer. It’s not clear what the minimum time frame is for each of these therapies to be useful, but they’ll certainly involve a time commitment that might not be practical for all women. However, yoga, mindfulness/meditation, exercise, and even CBT can all be practiced at home once you know the proper technique.
As I said at the beginning, this is not an exhaustive list of nonhormonal therapies. There are also various supplements that might help, as well as lifestyle modifications that most of you Primal-savvy readers are probably already implementing: eating a variety of nutrient-dense foods, getting plenty of sunlight, practicing good sleep hygiene, and nurturing social connections.
Whatever you choose, be patient. Don’t just focus on one symptom; focus on the big picture. Pay attention to how you’re feeling more globally. Consider that while an intervention might not hit its desired mark, it might help you in ways you didn’t expect.
Have you used mind-body techniques (these or others)? What’s been your experience? Share your insights and questions below, and have a great week, everyone.
Atapattu PM. Vasomotor symptoms: What is the impact of physical exercise? J SAFOMS. 2105 Jan-Jun;3(1):15-19.
Goldstein KM, et al. Use of mindfulness, meditation and relaxation to treat vasomotor symptoms. Climacteric. 2017 Apr;20(2):178-182.
McMillan TL, Mark S. Complementary and alternative medicine and physical activity for menopausal symptoms. J Am Med Womens Assoc (1972). 2004 Fall;59(4):270-7.
Molefi-Youri W. Is there a role for mindfulness-based interventions (here defined as MBCT and MBSR) in facilitating optimal psychological adjustment in the menopause? Post Reprod Health. 2019 Sep;25(3):143-149
Moore TR, Franks RB, Fox C. Review of Efficacy of Complementary and Alternative Medicine Treatments for Menopausal Symptoms. J Midwifery Womens Health. 2017 May;62(3):286-297.
Sliwinski JR, Johnson AK, Elkins GR. Memory Decline in Peri- and Post-menopausal Women: The Potential of Mind-Body Medicine to Improve Cognitive Performance. Integr Med Insights. 2014;9:17–23.
van Driel CM, Stuursma A, Schroevers MJ, Mourits MJ, de Bock GH. Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis. BJOG. 2019;126(3):330–339.
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Inflammation gets a bad rap in the alternative health world: “Inflammation causes heart disease, cancer, and autoimmune disease! It’s at the root of depression.” These are all true—to some extent.
Name a disease, and inflammation is involved.
Crohn’s disease is inflammatory.
Major depression is inflammatory.
Heart disease is inflammatory.
Autoimmune diseases, which involve an inflammatory response directed at your own tissues, are inflammatory.
Arthritis is inflammatory.
Even obesity is inflammatory, with fat cells literally secreting inflammatory cytokines.
Yes, but the story is more complicated than that. Inflammation, after all, is a natural process developed through millions of years of evolution. It can’t be wholly negative. Just like our bodies didn’t evolve to manufacture cholesterol to give us heart disease, inflammation isn’t there to give us degenerative diseases.
So, Why Does Inflammation Happen?
When pain, injury, or illness hit, the first responder is the acute inflammatory response. In other words, it is brief, lasting several days or less. All sorts of things can cause an acute inflammatory response. Here are a few:
- Trauma (punch, kick, golf ball to the head)
- Infection by pathogens (bacterial, viral)
- Burn (sun, fire, seat belt buckle on a summer day)
- Chemical irritants
- Allergic reaction
Things happen pretty fast in an acute inflammatory response and involve several different players, including the vascular system (veins, arteries, capillaries and such), the immune system, and the cells local to the injury.
- First, something painful and unpleasant happens; choose one of the above injury options.
- Then, pattern recognition receptors (PRR) located at the injury site initiate the release of various inflammatory mediators, which in turn initiate vasodilation (or widening of the blood vessels). This allows increased blood flow to the injury site, which warms the site, turns it the familiar red, and carries plasma and leukocytes to the site of the injured tissue.
- The blood vessels become more permeable, thus allowing the plasma and leukocytes to flow through the vessel walls and into the injured tissue to do their work. Emigration of plasma into tissue also means fluid buildup, which means swelling.
- At the same time, the body releases an inflammatory mediator called bradykinin, which increases pain sensitivity at the site and discourages usage of the injured area. These sensations—heat, redness, swelling, pain, and a loss of function—are annoying and familiar, but they’re absolutely necessary for proper healing.
Why Is (Acute) Inflammation Essential?
Allow me to explain why the four primary symptoms of acute inflammation are necessary, despite being unpleasant:
- Increased blood flow warms the injury and turns it red, which can be irritating and unsightly, but it also carries the guys—leukocytes—that will be cleaning up the injury site, mopping up pathogens, and overseeing the inflammatory process.
- Swollen body parts don’t fit into gloves, are really sensitive, and don’t work as well as their slim counterparts, but a swollen finger is a finger that’s full of a plasma and leukocyte slurry and therefore on the road to recovery.
- Pain hurts, but if an injury doesn’t hurt and it’s serious, you’ll keep damaging it because you won’t know not to use it.
- Loss of function prevents you from using what could be one of your favorite body parts, but you don’t want to make it worse be re-injuring it. Besides, it’s only temporary.
What About Chronic Inflammation?
These symptoms both indicate and enable inflammation (and, thus, healing), but what’s the deal with inflammation being linked with all those chronic illnesses—like obesity, heart disease, and depression? How does something normal and helpful go haywire and become implicated in some of the most crushing, tragic diseases of our time?
When inflammation becomes chronic and systemic, when it ceases to be an acute response, when it becomes a constant low-level feature of your physiology that’s always on and always engaged, the big problems arise.
The inflammatory response is supposed to be short and to the point. And because a big part of inflammation is breaking the tissue down, targeting damaged tissue and invading pathogens, before building it back up, the inflammatory response has the potential to damage the body. That’s why it’s normally a tightly regulated system: because we don’t want it getting out of hand and targeting healthy tissue. But if it’s on all the time—if chronic inflammation sets in—regulation becomes a lot harder.
Acute vs. Chronic Inflammation
A perfect example of the acute inflammation versus chronic inflammation dichotomy is exercise.
A single hard workout raises inflammation. It’s a stressor, a damaging event imposed upon your body. See for yourself.
A hard run spikes C-reactive protein for up to two days.
During exercise, skeletal muscle releases the inflammatory cytokine IL-6, a marker of damage.
Volleyball practice elicits spikes in IL-6 in both male and female elite volleyball players.
Acute exercise spiked CRP in cardiovascular disease patients (but a four-month exercise program lowered it).
This table of inflammatory responses to strenuous endurance events shows some massive spikes in CRP, some up to 20-fold the baseline value.
Yet, study after study (epidemiological and clinical alike) shows that extended exercise programs generally reduce markers of inflammation (like C-reactive protein) over the long-term:
- In elderly Japanese women, a 12-week resistance training program reduced circulating levels of inflammatory markers compared to baseline; reductions in CRP were associated with increases in muscle thickness.
- American adults who engaged in frequent physical activity tended to have lower CRPs than adults who were more sedentary.
- In type 2 diabetics, (key term coming up) long-term high intensity resistance and aerobic training reduced inflammatory markers over the course of a year (independent of changes in body weight, meaning activity was the key factor).
- Endurance combined with resistance training reduced CRP in young, healthy women better than endurance training alone.
- In obese, post-menopausal women, a basic moderate cardio program lowered CRP without really affecting body weight either way over the course of a year.
There are many more out there, but the general gist is that regular exercise tends to lower markers of systemic inflammation while acute exercise increases markers of acute inflammation. And sometimes what’s acute can become chronic. How do we make sense of this? How do we avoid making those acute spikes a chronic, constant thing?
Identifying Chronic Inflammation: Objective Markers
First, we need to be able to identify chronic inflammation. What symptoms and biomarkers can we use to track our inflammation levels?
CRP, or C-Reactive Protein
CRP is a protein that binds with dead and dying cells and bacteria in order to clear them from the body. It can always be found (and measured) in the bloodstream, but levels spike when inflammation is at hand. During acute inflammation caused by infection, for example, CRP can spike by up to 50,000-fold. CRP spikes due to acute inflammation peak at around 48 hours and declines pretty quickly thereafter (post acute-phase inflammation CRP has a half life of 18 hours). Thus, if the incident causing the inflammation is resolved, CRP goes back to normal within a few days. If it persists, the infection/trauma/etc. probably persists as well.
Highly sensitive to many different kinds of stressors, CRP rises in response to essentially anything that causes inflammation. This makes it valuable for determining that inflammation is occurring, but it makes it difficult to determine why that inflammation is occurring—because it could be almost anything. But if you’re looking for confirmation that you are chronically, systemically inflamed, an elevated CRP (in absence of any acute infections, injuries, burns, or stressors) is a useful barometer.
“Normal” CRP levels are supposedly 10 mg/L. Absent infection or acute stressors, however, ideal CRP levels are well under 1 mg/L. You want to stay well below 1; you don’t want “normal.” Between 10-40 mg/L (and perhaps even 1-9 mg/L, too) indicates systemic inflammation (or pregnancy), while anything above that is associated with real acute stuff. Note that exercise can elevate CRP, so don’t get tested if you’ve worked out in the last couple days.
IL-6, or Interleukin-6
T cells (type of white blood cell that plays a huge role in the immune response) and macrophages (cells that engulf and digest—also known as phagocytosing—stray tissue and pathogens) both secrete IL-6 as part of the inflammatory response, so elevated IL-6 can indicate systemic inflammation.
Tissue Omega-3 Content
This is a direct measurement of the omega-3 content of your bodily tissue. It’s not widely available, but it is very useful. Remember that anti-inflammatory eicosanoids draw upon the omega-3 fats in your tissues and that inflammatory eicosanoids draw upon the omega-6 fats. People having a higher proportion of omega-6 fats will thus produce more inflammatory eicosanoids. Now, we absolutely need both inflammatory and anti-inflammatory eicosanoids for proper inflammatory responses, but people with high omega-6 tissue levels make way too many inflammatory eicosanoids. Studies indicate that people with the highest omega-3 tissue levels suffer fewer inflammatory diseases (like coronary heart disease).
Research (highlighted and explicated here by Chris Kresser) suggests that omega-3 tissue concentrations of around 60% are ideal, which is a level commonly seen in Japan—the seemingly paradoxical land of high blood pressure, heavy smoking, and low coronary heart disease rates.
This measures the EPA and DHA, the two important omega-3 fatty acids, as a percentage of total fatty acids present in your red blood cells. It doesn’t correlate exactly to tissue amounts, but it’s pretty good and a powerful predictor of cardiovascular disease risk. The omega-3 index doesn’t measure omega-6 content, but those with a low omega-3 index are probably sporting excessive omega-6 in their red blood cells.
Anything above 8% corresponds to a “low risk,” but levels of 12-15% are ideal and roughly correspond to the 60% tissue content mentioned by Chris’ article. Four percent and below is higher risk and can be viewed as a proxy for increased inflammation (or at least the risk of harmful systemic inflammation developing from normal inflammation).
Heart Rate Variability
Systemic Inflammatory Response Syndrome Score
There’s the systemic inflammatory response syndrome, which is incredibly serious and has four criteria. If you have two or more of them at once, congratulations: you qualify—and should probably see a health professional immediately. This isn’t relevant for low-grade systemic inflammation, like the kind associated with obesity or autoimmune disease.
- Body temperature less than 96.8 F (36 C) or greater than 100.4 F (38 C).
- Heart rate above 90 beats per minute.
- High respiratory rate, 20 breaths per minute or higher.
- White blood cell count fewer than 4000 cells/mm³ or greater than 12,000 cells/mm³.
Of these objective markers to test, I’d lean toward CRP, HRV, and one of the omega-3 tests. CRP is pretty comprehensive, HRV is a two-fer (inflammation and general stress/recovery), and, while omega-3 tissue or blood cell content doesn’t necessarily indicate the existence of systemic inflammation in your body, it does indicate the severity of the inflammatory response you can expect your body to have. Taken together, these tests will give you an idea of where you stand.
Identifying Inflammation: Subjective Markers
There are also subjective markers. They may be harmless artifacts, but they may indicate that something systemic is going on.
Flare-up of Autoimmune Conditions You Haven’t Heard From In Ages
Sore joints, dry, patchy, and/or red skin, and anything else that indicates a flare-up. For me, this is usually mild arthritis.
Acute inflammation is often characterized by swelling at the site of injury. The same effect seems to occur in states of systemic inflammation, although they aren’t localized, but rather generalized.
If you feel stressed, you’re probably inflamed. I’m talking about the kind that has you rubbing your temples, face palming, sighing every couple minutes, and pinching the space between your eyes very, very hard.
Persistent But Unexplained Nasal Congestion
Could be allergies, sure, but I’ve always noticed that when I’m under a lot of stress and generally in an inflamed state, my nose gets clogged. Certain foods will trigger this, too, and I think it can all be linked to a persistent but subtle state of inflammation.
If you fit the bill for the eight signs of overtraining listed in this post, you’re probably inflamed.
Ultimately, though? It comes down to the simple question you must ask yourself: How do you feel?
I mean, this seems like an obvious marker, but a lot of people ignore it in pursuit of numbers. If you feel run down, lethargic, unhappy, your workouts are suffering, you struggle to get out of bed, you’re putting on a little extra weight around the waist, sex isn’t as interesting, etc., etc., etc., you may be suffering from some manner of systemic, low-grade inflammation. Conversely, if you’re full of energy, generally pleased and/or content with life, killing it in the gym, bounding out of bed, lean as ever or on your way there, and your sex drive is powerful and age appropriate (or inappropriate), you’re probably not suffering from chronic inflammation.
Causes of Chronic Inflammation
We need to determine why inflammation is “on” all the time—and then take the steps to counter it. I’m going to fire off a few things that both induce inflammation and tend toward prevalence in developed countries. You let me know if anything sounds familiar to you.
- Toxic diets: High-sugar, high-processed carb, high-industrial fat, high-gluten, high-CAFO meat, low-nutrient food is a pretty accurate descriptor of the modern Western diet.
- Insufficient omega-3 intake: Omega-3 fats form the precursors for anti-inflammatory eicosanoids, which are an integral part of the inflammatory response. Poor omega-3 status means insufficient production of anti-inflammatory eicosanoids and a lopsided inflammatory response to normal stimuli.
- Excessive omega-6 intake: Omega-6 fats form the precursors for inflammatory eicosanoids, which are an integral part of the inflammatory response. High omega-6 status (especially when combined with poor omega-3 status) means excessive production of inflammatory eicosanoids and a lopsided inflammatory response to normal stimuli. The more omega-6 you eat, the more omega-3 you crowd out for anti-inflammatory eicasonoid formation.
- Lack of sleep: Poor sleep is linked to elevated inflammatory markers. Poor sleep is a chronic problem in developed nations. Either we go to bed too late, wake up too early, or we use too many electronics late at night and disrupt the quality of what little sleep we get. Or all three at once.
- Lack of movement: People lead sedentary lives, by and large, and a lack of activity is strongly linked to systemic, low-grade inflammation. People don’t have to walk to get places, they take escalators and elevators, they sit for hours on end, and they don’t have time for regular exercise.
- Poor recovery: Other people move too much, with too little rest and recovery. When I ran 100+ miles a week, I certainly wasn’t sedentary, but I was chronically inflamed. Overtraining is a form of chronic inflammation.
- Chronic stress: Modern life is stressful. Bills, work, commuting, politics, exercise that you hate – it all adds up and it doesn’t seem to let up or go away. And if it becomes too much for you to handle (I know it’s too much for me at times), your body will have a physiological, inflammatory response to emotional stress.
- Lack of down time: When you’re always on the computer, always checking your email/Facebook/smartphone, you are always “on.” You may think you’re relaxing because your body is stationary, but you’re not relaxing.
- Lack of nature time: We spend too much time contained in cubicles, cars, trains, and cities, away from trees, leaves, and soft earth. In a way, nature is home for us. Going home certainly has its measured benefits.
- Poor gut health: The gut houses the bulk of the human immune system. When it’s unhealthy, so is your inflammatory regulation. A healthy gut is also selectively permeable, allowing beneficial compounds passage into the body and keeping toxins out. An unhealthy gut often becomes leaky, allowing toxins into the body to stimulate an immune, inflammatory response.
- Poor acute stressor/chronic stress ratio: We respond far better to acute stressors than repeated, sustained stress – even if the latter is of a lower intensity.
See what I mean? Since we’re set up for acute stressors requiring an acute inflammatory response, all this other low-level, evolutionarily-discordant, superficially mild stuff set against a backdrop of misaligned fatty acid ratios and impaired gut health throws us off and sets us up for a lifetime of chronic inflammation.
Inflammation is a complex physiological process that can go wrong in a lot of ways. But luckily, sticking to the tried and true dietary and lifestyle measures will get you most of the way toward preventing inflammation from becoming chronic and untamed.
If you have any further questions about inflammation, fire away down below! Thanks for reading.
Eliakim A, Portal S, Zadik Z, et al. The effect of a volleyball practice on anabolic hormones and inflammatory markers in elite male and female adolescent players. J Strength Cond Res. 2009;23(5):1553-9.
Lara fernandes J, Serrano CV, Toledo F, et al. Acute and chronic effects of exercise on inflammatory markers and B-type natriuretic peptide in patients with coronary artery disease. Clin Res Cardiol. 2011;100(1):77-84.
Ford ES. Does exercise reduce inflammation? Physical activity and C-reactive protein among U.S. adults. Epidemiology. 2002;13(5):561-8.
Balducci S, Zanuso S, Nicolucci A, et al. Anti-inflammatory effect of exercise training in subjects with type 2 diabetes and the metabolic syndrome is dependent on exercise modalities and independent of weight loss. Nutr Metab Cardiovasc Dis. 2010;20(8):608-17.
Daray LA, Henagan TM, Zanovec M, et al. Endurance and resistance training lowers C-reactive protein in young, healthy females. Appl Physiol Nutr Metab. 2011;36(5):660-70.
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The ketogenic diet has exploded in popularity over the last few years. Hordes of people are using it to lose body fat, overcome metabolic diseases, improve their endurance performance, attain steady energy levels, make their brain work better, and control seizures. And increasing numbers of researchers and personal experimenters are even exploring the utility of ketogenic diets in preventing and/or treating cancer. After all, back in the early part of the 20th century, Warburg discovered an important characteristic of most cancer cells: they generate their energy by burning glucose. If a particular cancer loves glucose, what happens if you reduce its presence in your body and start burning fat and ketones instead?
It’s taken a while, but the research community is finally beginning to take a few swings at this and similar questions.
So, what do we know?
First, let’s just go through a few recent human studies and case studies.
Keto and Cancer Treatment
Women with endometrial or ovarian cancer improved energy levels, appetite, and physical function on a ketogenic diet.
A Bayesian approach to studying the effects of ketogenic diets in humans and animals with high grade glioma (a brain cancer) found an “overall survival-prolonging effect.”
In gliomas, an analysis of available case studies using ketogenic diets found increased overall or progression-free survival. These were not randomized controlled trials, however, so they say nothing definitive.
A recent review paper gives a good overview of the current state of ketogenic diet and cancer research, finding that:
- Ketosis targets tumor metabolism.
- Ketosis improves effectiveness of conventional therapies.
- Ketosis has favorable effects of anti-cancer gene expression.
One thing you might notice is that there are no studies showing that standalone ketogenic diets cure cancer. There aren’t very many randomized controlled trials in general.
What there are are studies showing that ketogenic diets are safe and potentially effective adjuvant treatments—treatments that supplement conventional cancer treatments. You don’t see keto “defeating” cancer alone. You see keto enhancing the effect of chemotherapy. You see keto enhancing the effect of radiation. You see keto protecting normal cells and increasing the vulnerability of cancer cells to conventional treatment.
That’s not to say that keto can’t beat cancer. Maybe it can. But the clinical research simply isn’t there to say one way or the other.
Where keto seems even more promising is in prevention of cancer.
Keto and Cancer Prevention
Diabetes is a disease of carbohydrate intolerance. It’s a disease in which carbohydrate consumption results in elevated blood sugar, exaggerated insulin response. The way most people with diabetes eat leads to chronically high levels of insulin and blood sugar. Yeah, yeah, I know about all the badass Primal eaters who are “technically” diabetic but keep their blood sugar pristine and insulin minimized by watching what they eat, exercising regularly, and just generally leading a healthy lifestyle—but those people aren’t a large enough a group to have an effect on the category known as (and studied as) “diabetics.” Most people with diabetes unfortunately keep eating the same junk that got them there.
What does research say about the cancer rate of most people with diabetes? It’s usually higher.
One of the most consistent risk factors for many types of cancer is having diabetes and experiencing all the metabolic fallout that entails—high fasting insulin, insulin resistance, elevated blood glucose. Cancers of the liver, pancreas, breast, endometrium, bladder, and kidney all have strong associations with type 2 diabetes. This should come as no surprise. Not only do many cancers thrive on glucose as fuel, the high insulin levels typical of people with diabetes and insulin resistance increase the availability of growth factors that promote cancer growth.
Meanwhile, therapies that are known to reduce the symptoms of diabetes—lower fasting insulin, increase insulin sensitivity, normalize blood sugar, etc—tend to lower the risk of cancer. A perfect example is metformin.
Metformin activates AMPK, the same autophagy pathway activated by exercise, fasting, polyphenol consumption, and reduced calorie intake. It lowers blood sugar, increases insulin sensitivity, and extends the lifespan of type 2 diabetics.
Metformin also seems to protect against cancer. It lowers hyperinsulinemia and may protect against insulin-related cancers (breast, colon, etc). Early treatment during adolescence, for example, protects rats against later tumor growth.
What does this have to do with ketogenic diets?
Ketogenic diets have many similar effects. They activate AMPK. They lower blood sugar. They’re great for fat and weight loss, which enhances insulin sensitivity. Recently, researchers have even used ketogenic diets to resolve type 2 diabetes.
Now, not all cancers are linked to diabetes. For example, diabetes doesn’t increase the risk of gastric cancer. That’s because it’s linked to bacterial infection, not elevated blood sugar. And that’s why taking metformin doesn’t reduce the risk of gastric cancer. This actually supports my hypothesis that, when diabetes does not increase the risk of a cancer, neither does metformin reduce it—like gastric cancer. Diabetes doesn’t increase it, so metformin doesn’t reduce it. That’s the mechanism in play.
Nor do all cancers burn glucose exclusively. Some thrive in a ketogenic environment.
There is a mutation called BRAF V600E in certain cancer cells that allows them to utilize ketone bodies to stimulate growth. About 50% of melanoma, 10% of colorectal cancer, 100% of hairy cell leukemia, and 5% of multiple myeloma cases exhibit the ketone-utilizing BRAF V600E mutation. Indeed, a cancer cell’s inability to break down and metabolize ketone bodies is the best predictor of whether a ketogenic diet can even help against a given cancer.
But if we’re talking prevention. If we accept that not developing diabetes—all else being equal— probably reduces the risk of getting cancer, then using ketosis to improve all the same symptoms linked to diabetes should also reduce the risk of getting cancer. And if it doesn’t reduce the risk, it probably won’t hurt. I mean, is there a doctor alive who claims that increasing insulin sensitivity, lowering hyperinsulinemia, and losing body fat will increase the risk of cancer?
A Few Takeaways To Consider
As I see it—and this is not medical advice—the most promising use of ketogenic diets in cancer are as follows.
Adjuvant therapy: Using ketosis to enhance the efficacy of conventional therapies like chemotherapy and radiation, increasing the susceptibility of cancer cells to treatment and increasing survival of healthy host cells.
Prevention: Using ketosis (whether intermittently or long term) to lower fasting blood glucose, reduce diabetes risk (or resolve extant diabetes), and improve your ability to burn fat and not rely on exogenous glucose so much should in theory reduce your risk of most cancers.
Whatever you do, if you’re an actual cancer patient, discuss this with your doctor. Make sure your particular variety of cancer isn’t partial to ketones. Make sure it’s one of the cancers that actually craves glucose. If you end up with a cancer that thrives on ketone bodies, and you go deep into perpetual ketosis, you could be making an enormous mistake.
But the bottom line is that, assuming you don’t already have one of the cancers known to utilize ketones, going into ketosis from time to time isn’t going to hurt—and it will probably help reduce the risk of cancer.
I’m going to close this post with an anecdote from one of my employees. His father passed away a dozen years ago from multiple myeloma, a type of white blood cell cancer. This was before he worked at Primal Nutrition; he was just getting involved in alternative forms of health and nutrition research. What struck him most, particularly in retrospect, was how his father’s appetite changed during his battle with cancer. He began craving candy—Reese’s peanut butter cups, Hershey’s kisses, Now-and-Laters, and all other kinds. As he says it, looking at his dad’s snack drawer was like looking at the archetypal bag of Halloween candy.
I don’t know if this is evidence of anything. Can cancer actually tap into your specific appetites? Can it change how you perceive and desire specific foods? Was his father actually being programmed by his cancer to over-consume sugar?
What I do know is that no one needs garbage candy. A few seconds of momentary gustatory pleasure, followed by regret and the incessant need to repeat—is it worth it? Is it worth the off chance that eating lots of sugar feeds and promotes cancer? Don’t do it, folks. I know my longtime readers are right there with me. I know you guys who’ve been here from the beginning are probably getting egged on Halloween because you’re giving out collagen packets and mini-kettlebells. But if you’re new to this site and way of eating in general—maybe a co-worker passed my info along to you, maybe you’re trying to make a big change in the way you eat and live—avoiding the obviously terrible-for-you stuff like candy and baked goods is the biggest change you can make. And not just for cancer.
So, do I want you to walk away from this post thinking that keto is a cancer cure? No. I’m a fan of ketosis, and I think almost everyone should spend time in that metabolic state, but I don’t consider it to be magical. The jury is definitely still out. Does ketosis look like a strong candidate for improving efficacy of various therapies in certain cancer patients? Yes. Can keto improve health markers shown to reduce a person’s risk of getting cancer in the first place? Yes.
The keys to good health are generally speaking pretty consistent.
- Maintain good insulin sensitivity.
- Avoid glucose intolerance.
- Get plenty of sleep.
- Consume hormetic stressors.
- Avoid obesity. Lose body fat.
- Exercise, or at least move every day.
- Dip into ketosis on a regular basis, either from ketogenic dieting, fasting, meal skipping, or (non-chronic) hard training—or all of the above.
There’s no guarantee against cancer, but I think the advice I just mentioned supports a good fighting chance.
Take care, everyone. Be well.
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The fitness world is booming these days. You can see it in the popularity of CrossFit boxes, obstacle course and endurance events, and record-breaking gym construction. It’s encouraging. Inspiring even. But there’s also a downside to the rising gym memberships and event registrations. There are still too many people dealing with recurring patterns of breakdown, burnout, illness and injury. More people are trying to do the right thing, but the flawed approaches they often gravitate to end up derailing them.
Nonetheless, there are changes afoot. It’s an evolution of thinking that’s slowly spreading its way through fitness circles. More forward-thinking coaches, trainers, and researchers are helping right the wrongs of the fitness boom with a general rejection of the “more is better” approach for one that respects the importance of balancing stress and rest, one that moves toward an intuitive approach to workout planning.
More people are implementing strategies to maximize workout return on investment and minimize the risk of injury and burnout that too often result from an indiscriminate approach. The endurance world, for example, is finally rejecting the narrowly focused, overly stressful chronic cardio approach of old in favor of emphasizing aerobic development at lower heart rates, avoiding chronic patterns, and becoming fat adapted instead of sugar addicted. Endurance athletes are embracing the importance of strength training and explosive sprinting just as strength/power athletes are doing more aerobic conditioning. The CrossFit movement itself is an ode to the health and longevity benefits and increased enjoyment that comes from achieving broader fitness competency.
What’s Wrong With HIIT?
I’ve talked recently about microworkouts and recovery-based workouts. Today, I want to delve in further and share a radical transformation in the way high intensity workouts are conducted that will generate fitness breakthroughs while simultaneously minimizing the risk of exhaustion. Specifically, I’m taking aim at the extremely popular workout pattern known as HIIT—High Intensity Interval Training. Sprinting is a part of the Primal Blueprint Fitness Pyramid, but I’ve been wary of the details around traditional HIIT practices because these workouts are quite often too stressful and exhausting to deliver the intended fitness boost they promise.
Yes, you have to challenge your body regularly with hard efforts to build fitness, but most of us do it the wrong way. When you complete a killer HIIT session at morning boot camp or spin class, at home on your Peloton bike, or with the Tuesday night track group, you get a tremendous sense of accomplishment and a flood of feel-good endorphin chemicals into your bloodstream. Unfortunately, the typical HIIT workout can also be depleting, exhausting, and stimulate an assortment of unnecessary cellular damage and inflammation.
It doesn’t have to be that way. Be redesigning your high intensity workouts, you can get leaner and fitter with higher quality, more explosive, less physically stressful workouts that are easier to recover from and thus can be performed more frequently. In short, a better approach involves transitioning from HIIT to HIRT, High Intensity Repeat Training. HIRT is an acronym coined by Dr. Craig Marker, psychologist, certified strength and conditioning coach, and CrossFit instructor from Florida.
Here’s a compare and contrast that can revolutionize your approach to intense workouts….
Comparing HIIT and HIRT
The problem with a typical HIIT workout is that it’s too strenuous—too many repetitions of hard effort that (each) last too long, and with insufficient rest between hard efforts. This results in cumulative fatigue during the workout, a diminishing quality of performance over the course of the workout, increased cellular damage due to this cumulative fatigue, and extended recovery time afterward. These kinds of sufferfests are a great source of satisfaction and personal growth when you high five your fellow bootcamp classmates after an hour of power, or cross the finish line of a big event in which you’ve trained for months to prepare. But including them as a major and recurring element of your training program is a really bad idea. Unfortunately, the sufferfest mindset is incredibly common these days, perhaps suggesting that the ego has more influence that strategic planning or intuitive decision making.
A HIRT workout stops short of the exhaustive nature of HIIT. The essence of HIRT is to conduct maximum efforts, typically of shorter duration, with much longer recovery, and fewer total efforts than a HIIT session. The word “Repeat” in the acronym suggests that you maintain a consistent quality of effort on every repetition of hard work. This means not only the same performance standard, but also the same level of perceived exertion.
For example, say your workout entails running 100-meter sprints across a football field, and you hit 18 seconds for your first sprint. This is a nice controlled, explosive effort with excellent technique, and you assign a perceived exertion level of around 90 out of 100. Hence, you’ll want to do successive sprints in 18-19 seconds each, preserving explosiveness and excellent technique—delivering what you still discern to be 90 out of 100 on the effort scale. If you have to “dig deep” (the implicit objective, and badge of honor, with a HIIT session) just to arrive at 19 seconds on your fourth effort, that’s it, you’re done. If you notice a slight attrition in explosiveness or breaking form during the effort, you’re done. Typically, this might be a little twinge in the hamstrings or lower back, a tensing of the face or chest, or any other indicator that you have played your best cards of the day.
In Dr. Marker’s landmark article titled “HIIT versus HIRT” at www.BreakingMuscle.com, he explains that after HIIT sessions we bask in self-satisfaction of a job well-done, but disregard the health-destructive consequences of these sufferfests: “[Y]our subjective feeling of the effectiveness of a workout is not as important as what science tells us is important to building an impressive base of endurance and changing your body composition.” (That sound you hear is a slap to the face of highly motivated, goal oriented, Type-A fitness enthusiasts across the land. Don’t worry, I’ve been there, too….)
This admonition applies to everyone from elites to novices. Elite athletes are notorious for constantly pushing the envelope and frequently succumbing to injuries or periods of declining performances. Novices generally don’t concern themselves with training strategies, often leaving their fates in the hands of the bootcamp instructor. Without sufficient experience or reference points, they exercise themselves into exhaustion, believing that pain and suffering are part and parcel of the fitness experience.
The (too often) result? Ambitious, well-meaning enthusiasts burn themselves out and then are down for the count. The most dedicated keep going to their detriment, all the while accumulating fatigue, injuries and even pounds. Others simply stay away from the gym by invisible magnetic force. Alas, the subconscious is very good at avoiding sources of pain and suffering. Can we dump this suffering-and-attrition dynamic already?
Side note for those who love to read about sports: For inspiration, check out this article about the greatest marathon runner in the history of the planet, the amazing Kenyan Eulid Kipchoge. The article describes his training regimen as extremely devoted and incredibly impressive, yet he maintains a relaxed mindset, remains in control of his energy output, and never extends beyond his limits into exhaustion. Even the march to the unthinkable two-hour marathon (Kipchoge’s current world record stands at a mind-bending 2:01.39) comes from a sensible approach instead of an extreme one.
Marker explains that there’s an optimal duration for sprinting where you can obtain maximum benefits with minimal cellular destruction, and this is typically around 15-20 seconds. Try to maintain maximum effort for any longer than that and you’re not really sprinting anymore anyway, since it’s impossible to maintain maximum energy output.
Here’s why this works:
Look at what’s happening physiologically over the duration of a near-maximum intensity sprint of any kind (running, cycling, rowing, or kettlebell swings). During the first five seconds of your sprint, lactate starts to accumulate in the bloodstream. Lactate levels double between five to ten seconds, then double again from 10 seconds to 20 seconds—up to what Marker calls the highest acceptable level. As you increasingly feel the burn, lactate doubles again from 20 seconds to 30 seconds. It doubles again from 30 seconds to 60 seconds, causing cellular destruction, ammonia toxicity, and extended recovery time.
As Marker explains, “The amount of lactic acid produced up to 20 seconds [of sprinting] is still manageable, but the next doubling is over the top. Even a single 30-second sprint spikes ammonia levels almost five times! Why trash the body for no good reason? Rebuilding broken down cells is a costly and time-consuming process. And while it’s taking place, you feel tired and run down, with your ATP short of a full stack.”
You may be familiar with the Tabata concept of interval training, which entails a repeating pattern of work efforts lasting twice as long as rest intervals until you complete a Tabata set of a certain total duration. The original Tabata protocol, developed by Japanese physician and researcher Dr. Izumi Tabata and colleagues at the Japanese Institute of Fitness and Sport in Tokyo, calls for four minutes of a 20-second sprint, 10-second rest, 20-second sprint, 10-second rest pattern. In the original studies, Japanese Olympic speed skaters achieved massive boosts in VO2 Max in a short time with Tabata training. Unfortunately, the original Tabata concept has been widely misappropriated into workouts that honor the 2:1 work-to-rest ratio, but carry on for too long and generate cellular damage and exhaustion: multiple sets of kettlebell swings, pushups, box jumps, running sprints, cycling sprints, and so forth. Bottom line with sprint workouts: a little goes a long way, and too much can really mess you up.
How To Transition From HIIT To HIRT
To transition into a more effective, less stressful high intensity workout pattern, pick the sweet spot of 10-20 seconds for your explosive efforts. Take what Marker calls “luxurious” rest intervals to ensure that your cells have a chance to partially or fully regenerate ATP (takes around three minutes) and minimize the disassembling and deamination that occur when you ask your body to perform again and again with rapidly depleting cellular energy.
Finally, conduct between 4 and 10 sprints. You should be able to manage four shorts sprints even if you’re a novice. If you claim you can complete more than 10 and feel great, you’re better off going faster and doing fewer more explosively.
Keep in mind that a properly conducted HIRT workout is going to feel different than a HIIT sufferfest. It may require an adjustment in your mindset to feel confident and satisfied that you’re training with maximum efficiency and minimal suffering like a “real athlete.” If you’re a focused, driven, goal-oriented type, be vigilant about resisting the addictive allure of the endorphin rush that happens after a sufferfest. Remember, the blissful feeling of powerful pain-killing chemicals flooding your bloodstream is a fight or flight reaction to the extreme stress of the workout. Realize that the genetic purpose of the endorphin response is to help you continue to run for your life instead of lay down in exhaustion! If you abuse this delicate mechanism with a chronic pattern of extreme workouts, you’re going to pay a heavy price. Dr. Tommy Wood calls this overactivation of the fight or flight response, “liquidating your assets,” and I couldn’t agree more.
Several friends who have recently updated their approach to a HIRT protocol report feeling much better in the days following their most challenging sessions—more energy, less soreness and stiffness. That’s how it should be.
Combine the HIRT strategy with recovery-based workouts and walking. See how it goes for you, and let me know. Thanks for stopping in. Share your questions and thoughts below, too.
The post HIIT vs. HIRT: Reducing Workout Stress To Increase Fitness appeared first on Mark’s Daily Apple.
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In our previous menopause post, I mused on some perspectives of menopause that are positive and affirming for women. However, I don’t want to downplay the fact that many women experience menopause as a difficult, frustrating, and even disempowering time. (Again, I am using “menopause” to include the perimenopausal period.)
As I mentioned in the last post, some researchers estimate as many as 75% of women experience some type of “menopausal distress,” and we don’t talk about it enough. Today I want to examine some of the psychological and emotional facets of menopause. In the final post of this series, we’ll look at self-care techniques and non-hormonal therapies that seem to be the most beneficial.
What Research Suggests About Emotional Well-being During Menopause
Obviously menopause is a major life transition—significant biological changes wrapped up in a complex web of personal and sociocultural beliefs, fears, stressors, and stories. It can be a time of great apprehension, confusion, even despair for some women. Others pass right through menopause with hardly a bat of an eye. Still, others welcome and embrace it.
It’s extremely understandable why this would be a challenging time for women. Menopause can be a perfect storm of physical discomfort and cognitive symptoms (brain fog, forgetfulness), sleep deprivation (thanks to those night sweats and hot flashes), and emotional fluctuations. Besides how they feel, these symptoms can affect women’s personal relationships, ability to perform their jobs, and sense of self-worth and self-confidence.
For many women, menopause also coincides with the dual stressors of aging parents and raising teenagers or having a newly empty nest. Plus, menopause is an unmistakable marker of aging, which can evoke complicated feelings as well.
Overall, stress, depression, and anxiety seem to be fairly common during menopause. Recent Guidelines for the Evaluation and Treatment of Perimenopausal Depression commissioned by the Board of Trustees for The North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers describe perimenopause as a “window of vulnerability for the development of both depressive symptoms and a diagnosis of major depressive disorder.”
It’s difficult to know exactly how many women are affected. Studies of depression and anxiety are usually conducted on women whose symptoms are severe enough to seek help from their doctors. Researchers estimate that up to 40% of women will experience depression at some point during menopause; it’s unclear how prevalent anxiety might be.
It’s easy to assume that some women become depressed and anxious during menopause because their symptoms are so gnarly. To some degree, that narrative is probably true. Studies do find that women who experience more severe symptoms such as frequent hot flashes also exhibit more depression and anxiety. This makes sense—being physically uncomfortable and unable to get a good night’s sleep can certainly set the stage for poor psychological outcomes.
On the other hand, it’s likely that for some women, depression and anxiety exacerbate the physical and emotional symptoms. That is, depression and anxiety might be a lens that magnifies how bad menopausal symptoms feel, so these women report having more severe symptoms.
In any case, there’s more to it than “menopause is rough, and it makes women depressed and anxious.” One of the biggest risk factors for depression and anxiety during menopause is prior episodes of depression and anxiety. Women who are also experiencing other life stressors, including relationship stress and socioeconomic stress, are also more likely to become depressed.
In other words, women who are otherwise vulnerable are more likely to experience poor psychological well-being when hit with the additional stress of the menopausal transition.
Along these lines, one study compared depressed and non-depressed perimenopausal women on a variety of quality of life measures, including life enjoyment and satisfaction; ability to function in work, social situations, and relationships; and perceived social support. The researchers also assessed the severity of the women’s hot flashes. The depressed women scored lower than the non-depressed women on all quality of life measures. Severity of hot flashes had no effect for either group.
The authors concluded that future studies “need to distinguish between those women with [perimenstrual depression] and non-depressed women to avoid attribution of decreased [quality of life] to the menopause transition alone.” In other words, don’t blame the hot flashes for what the depression wrought.
This is an important point: We assume that menopause interferes with women’s well-being and quality of life because the symptoms stink (and they definitely do for a lot of women). However, the degree to which menopause actually impacts a woman’s quality of life might depend, at least in part, on whether she experiences concurrent depression or anxiety.
This is not to say that if you’re having a hard time dealing with your symptoms, you’re definitely also depressed. Rather, consider whether depression and anxiety are contributing so that you can address them directly.
Likewise, don’t assume that depression and anxiety will resolve on their own once the physical symptoms subside. Treating the physical symptoms is important, but for many women it might not be enough.
What We Need to Be Saying (To Each Other) About It
At the risk of stating the obvious, a lot of distress is surely rooted in the fact that women don’t feel like they can talk openly and honestly about their experience of menopause, perhaps especially the mental and emotional aspects.
In Becoming a Menopause Goddess, author Lynette Sheppard asserts that all of her friends experienced sadness, if not full-blown depression, during menopause. All of them. More than anything, she says, they needed to hear that it was normal, that there was nothing inherently wrong with them.
Instead, the stigma surrounding mental health struggles and the taboo nature of talking about menopause keep many women suffering in silence. Of course, it’s not like we talk freely about the physical symptoms, either. Sure, we can kvetch about hot flashes with our friends. How many women feel free to discuss brain fog and sleep deprivation with their bosses, even if they have very real consequences in the workplace?
I understand that “just talk about it” is neither easy nor sufficient—I’m not trying to be trite. It’s not like posting your hot flashes on social media will do anything to stop them. Nor can I promise that your boss will be super understanding if you march into his/her office and announce that you can’t finish your project on time because you simply can’t focus.
However, let’s think about what we can do to open up the channels of communication with our friends and partners at least to start. It’s no secret that social support can be an important factor in warding off depression during times of stress.
We Need A Multi-Pronged Approach
Besides talking about it, what else can women do to cope with physical, psychological, and emotional symptoms during menopause? Hormone therapy (HT) is the predominant approach that doctors prescribe (of course). I won’t cover the pros and cons, nor the safety questions, since Mark did so recently. Definitely check out that post if you are considering HT for yourself. Mark’s wife, Carrie, has also written about her experience with menopause symptoms in previous posts (1, 2).
I will point out that most symptoms aren’t clearly caused by the hormonal changes that characterize menopause. Vasomotor symptoms (hot flashes, night sweats) are the most strongly linked to hormonal changes, but other symptoms seem to be more related to psychosocial factors. Even vasomotor symptoms don’t map perfectly onto hormone fluctuations. Women with the biggest drops in estrogen won’t necessarily experience the most hot flushes, for example.
That doesn’t mean you shouldn’t try HT if you and your doctor decide it’s right for you. It clearly has benefits, including that it seems to help some women with depressive symptoms and anxiety. It’s not clear whether this is because it alleviates physical symptoms or because the depression and anxiety are directly caused, at least for some women, by hormone fluctuations.
However, it’s a mistake to assume that if we “fix” the hormones, or get rid of the hot flashes for example, the rest will fall into place.
Thinking about the quality of life study I mentioned above, it’s important not to get wrapped up in the story that hormones plummet, hot flashes and night sweats ensue, and then women become grouchy and depressed as a result.
In reality, the hormone stuff, the physical stuff, the emotional stuff, the sleep stuff, the relationship stuff, and more stuff all get thrown into the mix, each potentially feeding into and off of the others.
What we need is a multi-pronged approach. (I feel like there’s a pun here about protecting the flanks—I’ll keep working on that one.) Besides treating underlying hormone fluctuations with HT or herbal remedies, women and their doctors should also separately address specific physical and cognitive symptoms, general health, and psychological and emotional well-being.
The aforementioned Guidelines for the Evaluation and Treatment of Perimenopausal Depression, for example, offer this recommendation, “Proven therapeutic options for depression (antidepressants, cognitive behavioral therapy and other psychotherapies) should remain as front-line antidepressive treatments for major depressive episodes during perimenopause.” In other words, take care of the depression on its own.
For women who want to be holistic in their approach, and who perhaps want to avoid or minimize HT, there are a number of non-hormonal, complementary practices that have been shown to help. In the next post in this series, I’ll highlight some of the ones that show the most promise for relieving menopausal symptoms specifically, as well as for stress reduction, emotion regulation, and coping more generally.
Now I want to hear from you. Do you feel free to talk about your experience of menopause with the people in your life? Have you had positive or negative experiences when you have talked about it in the past?
Deeks AA. Psychological aspects of menopause management. Best Pract Res Clin Endocrinol Metab. 2003 Mar;17(1):17-31.
Schneider M, Brotherton P. Physiological, psychological and situational stresses in depression during the climacteric. Maturitas. 1979 Feb;1(3):153-8.
Zhou B, Sun X, Zhang M, Deng Y, Hu J. The symptomatology of climacteric syndrome: whether associated with the physical factors or psychological disorder in perimenopausal/postmenopausal patients with anxiety-depression disorder. Arch Gynecol Obstet. 2012;285(5):1345–1352.
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For my entire athletic career, I considered the gold standard of recovery to be sleeping, resting on the couch watching T.V., and generally being still and inactive. Come on, what could be more effective than couch potato mode to recover from the hormonal and inflammatory stresses of marathon training runs or long days of extreme swim-bike-run workouts? I’m kidding (mostly), but it’s not a total exaggeration. Our understanding of fitness recovery has grown exponentially since I was in the elite arena, and it’s exciting to see new and better approaches taking root that genuinely speed recovery and stave off burnout. I’m sharing two such techniques today. They’re simple, mostly free, and accessible to anyone with the most basic fitness opportunities and venues.
Note: Here’s the thing…. This is the stuff you should focus on before considering advanced techniques like exposure to cold or heat, Theragun treatments (although I happen to be a fan of this device), hyperbaric oxygen chambers, etc.
The first recovery technique is to move more instead of just sit around. That’s right, science is validating the idea that if you make a concerted effort to increase all forms of general everyday movement in the hours and days after strenuous workouts, you will help minimize the inflammation and oxidative stress caused by strenuous workouts.
Let’s call this strategy JFW—Just F—ing Walk.
Moving your body through space helps you burn fat better, which will maximize the fat reduction goals of your workouts. Walking also helps boost brain function. A 2017 UCLA study comparing MRI scans revealed that active older folks (over 60 and walking more than three kilometers per day) have faster brain processing speed, better working memory for quick decisions, and better memory consolidation than inactive folks. In his book, The Real Happy Pill: Power Up Your Brain By Moving Your Body, Swedish researcher Dr. Anders Hansen reports that just taking a daily walk can reduce your risk of dementia by 40 percent.
Walking and general movement of any kind improve lymphatic function for a huge recovery boost. The lymphatic system is a plumbing network running throughout your body that detoxifies every cell, tissue and organ through a separate operating system from the cardiovascular system. The lymphatic system operates through a pumping process instead of a beating heart. This means that you’re obligated to move your muscles and joints to turbocharge lymphatic detoxification and avoid the pooling of lymphatic fluid caused by chilling on the couch in the hours and days after heavy workouts. Even the old-time exercise apparatus of the mini-trampoline has come into vogue recently because bouncing around for even a few minutes has been shown to significantly boost lymphatic function.
To help your lymphatic system function optimally, be sure to hydrate adequately at all times. While my original Primal Blueprint presentation suggested that you simply honor your thirst to achieve good hydration, recent science suggests that successful hydration can be a little more complicated. Stacy Sims, Ph.D., a hydration expert who studied thermoregulation at Stanford and is currently a senior research fellow at University of Waikato in New Zealand, is doing some great work in this field. Check out this fantastic infographic. Her research suggests that the female menstrual cycle can influence hydration needs and strategies. Another breakthrough insight is that strenuous workouts have the potential to mute your thirst mechanism; you may become too hot and tired or distracted to notice that you’re actually getting dehydrated. For most minimally active folks, going by thirst might be just fine; the kidneys do an excellent job regulating fluid and sodium balance in the body.
If you are a novice fitness enthusiast, a high performing athlete, or routinely exercise in hot temperatures, a deliberate pre- and post-workout hydration is a strategy worth considering and implementing. Sprinkle some high quality natural mineral salt in each glass of fluid, which will help it become better absorbed in the tissues throughout your body.
Joel Jamieson, a noted trainer of world-champion MMA fighters in Washington (8WeeksOut.com—as in eight weeks out from a title bout), and developer of the Morpheus Recovery app, advocates a system called Rebound Training where specially designed workouts can actually speed recovery time in comparison with total rest. The idea that a Rebound Workout can boost recovery is validated through the tracking of Heart Rate Variability. Joel is a pioneer in Heart Rate Variability and has been tracking his fighters and other high performing athletes for decades. Yes, decades, as in dating back to the original hospital grade $30,000 units that required placement of a dozen electrodes on your skin.
The idea that a Rebound workout can beat couch time is an extraordinary revelation. Amazingly, when you drag your tired, stiff, sore body into the gym and do some foam rolling, deep breathing exercises, dynamic stretches, and even very brief explosive efforts, such as short sprints with long recovery on the bike, or “positive-only” deadlifts (lift the weight then drop it to the ground to prevent soreness caused by eccentric contractions), you can stimulate parasympathetic nervous system activity and actually accelerate recovery. The parasympathetic is known the “rest and digest” component of autonomic nervous system, and counterbalances the sympathetic “fight or flight” component.
You can learn more about Rebound Training and see a sample workout here. If you just want to dabble in the concept, know that increasing your walking and general movement in the hours and days after a challenging training session will help boost blood circulation and lymphatic function to speed recovery. I always find ways to walk more and spend more time at my stand-up desk in the 24 hours following a tough Ultimate Frisbee match or sprint workout.
Sample Restorative Workout
The next time you throw down a killer workout, trying heading to the gym the following day and creating a restorative experience.
Start by lying flat on the mat and completing 20 deep diaphragmatic breath cycles. When you’re in the prone position, you can hone good technique by placing your hand on your abdomen and making sure that the abdomen expands upon inhalation. First expand the abdomen, which enables the chest cavity to then expand outward and enable the full use of the diaphragm for a powerful breath. You notice this sequence better when laying down.
After 20 deep breaths, commence 10 minutes of foam rolling, dynamic stretches and flexibility drills.
Then, get a little sympathetic stimulation going with some bike sprints or positive only deadlifts as follows:
- Exercise bike: Warmup five minutes, then sprint for 10 seconds, followed by 60 seconds of easy pedaling. Repeat for five repetitions.
- Deadlift: With 70% of your one rep maximum weight, raise the bar three-quarters of the way to the top, then allow it to fall to the ground with minimal muscle engagement. Repeat five times.
The idea with these efforts is that you’ll trigger a brief stimulation of fight or flight sympathetic nervous system activity, but because the effort is so brief, you’ll prompt a compensatory parasympathetic reaction during the recovery period. The net effect of the session is to turbocharge parasympathetic for hours afterward to a greater extent than just chilling on the couch watching Netflix.
Thanks to the gentle nature of the session, you enjoy an increase in energy and alertness from getting the oxygen and blood flowing throughout the body—but without the cellular breakdown and glycogen depletion of a more strenuous workout. You should leave the gym feeling relaxed and a little looser than before the workout.
Implementing “Rebound”-style workouts, along with making a general effort to walk around more in the hours following your most challenging sessions aren’t just fun diversions; they’re part of putting recovery as the central element of your training program.
Speaking of HRV, Jamieson offers a breakthrough insight that has helped me further appreciate the value of tracking HRV over time, and also alleviate some confusion that arose during some data accumulation over the past several years. If you’re a fan of HRV, you know a high HRV on the familiar 1-100 scale is indicative of a strong and rested cardiovascular system. You have a greater variation in beat-to-beat intervals than a lower score, indicating a harmonious balance between fight or flight sympathetic nervous system function and rest and digest parasympathetic nervous system function. A low HRV indicates a more metronomic heartbeat, and sympathetic nervous system dominance over parasympathetic. These are reliable signs of overtraining or a general overstress condition in life, or a weak cardiovascular system in general.
By tracking HRV for several weeks, you can establish a healthy baseline, then gauge your level of stress and readiness to train based on daily HRV fluctuations. Low equals overstressed, high equals healthy. That’s all well and good, but here’s an important nuance I learned from Joel about HRV readings significantly higher than your baseline: An 86 seems better than the usual 72-75, but actually an abnormally high HRV could be an indication of parasympathetic dominance versus a sympathetic-parasympathetic balance. When your parasympathetic kicks into overdrive, it’s possibly because you trashed yourself way beyond healthy limits, and you’re struggling to return to a rested and stress-balanced state. This explained some strange outlier readings where I felt pretty cooked after coming off a jet travel binge or a series of extreme workouts in a tight time frame but delivered a rock star HRV reading.
As I’ve written about before, I’m not a fan of overdoing biofeedback devices. I’ve used them and still do occasionally when I’m attempting something new or just want to check in with some hard data, but too much tech can disconnect you with your intuition—what should always be front and center in your assessments. Dr. Kelly Starrett references scientific research indicating that the single most valuable and accurate metric for your state of recovery is “desire to train.” I wonder how this goes up against the blood lactate meters at the U.S. Olympic Training Center and any ring or watch data you can accumulate. I have confidence it would hold its own in most scenarios.
Thanks for stopping by today, everybody. How do you do recovery? What have you learned over the years in your own study and experience. Have a great end to the week.
The post Recovery Workouts: Two Simple But Powerful Ways to Speed Fitness Recovery appeared first on Mark’s Daily Apple.
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Last week, I linked to a story about a popular vegan blogger, author, and influencer who found herself going into menopause at the age of 37 despite doing “everything right.” She exercised, she ate raw, she avoided gluten and refined sugar, and, most importantly, she avoided all animal products. Now, this wasn’t a randomized controlled trial. This wasn’t even a case study. But it was a powerful anecdote from someone whose livelihood depended on her remaining a raw vegan. It wasn’t in her interest to make it up.
So, it got me wondering: How do diet and lifestyle influence the timing of menopause?
Now, before I begin, let’s just state the obvious: Menopause isn’t a problem to be avoided. It’s not something to be feared or maligned. It’s not “the end.” I wrote an entire series on menopause last year, and there will always be more to come on the subject because it’s an important time of life with its own questions and possibilities. While it’s a natural, evolutionarily-preserved part of being a woman, it also follows a natural cadence. Menopause at the right time in accordance with your genetics is normal, expected, and healthy. Menopause that occurs earlier than your genetics would direct suggests something is amiss. Sure enough, early or premature menopause—defined in most places as menopause before the age of 40—has a number of troubling links to poor health outcomes.
Early menopause is linked to:
- A shorter life and an increase in the risk of type 2 diabetes.
- Reduced physical function in later years.
- Lower cognitive function.
- Increased heart disease.
Not to mention that all the other things normally associated with menopause, like osteoporosis and changes in mood, also have the potential to occur, only earlier.
Okay, so early menopause can have some health consequences. Is veganism actually linked?
What Research Says About Diet and Menopause Timing
There was one study that found people who’d never been a vegetarian developed menopause at a later age, which is a roundabout way of saying that vegetarianism may increase the risk of early menopause.
Other lifestyle factors linked to later menopause included regular strenuous exercise, never smoking, midlife weight gain, and drinking alcohol. Strange mix of behaviors, both classically healthy and unhealthy.
But then another study in Han Chinese women found the opposite—that vegetarianism was associated with a lower risk of premature menopause.
Those are the only direct (if you can call it that) lines of evidence, and they conflict. No solid answers there. That said, there’s more indirect stuff pointing toward a link between exclusion of animal foods and earlier menopause:
- A high intake of vitamin D and calcium from dietary sources has been linked to a lower risk of premature menopause. Oddly enough, supplemental vitamin D and calcium were not linked to lower risks, suggesting that it’s the food—dairy primarily, but also bone-in small fatty fish like sardines—and not the nutrients alone. So a vegan might not be in the clear simply by supplementing with D and calcium.
- The amount of protein and carbs a woman eats throughout her life seems to predict the age at which menopause occurs. More protein, later menopause. More carbs, earlier menopause. Protein is harder and carbs are easier to come by on a plant-based diet—that’s for sure.
- Another fairly consistent finding is that polyunsaturated fat intake “accelerates” menopause. Women who eat the most PUFA tend to have menopause earlier. High PUFA intakes are pretty unavoidable when your diet is awash in seeds, nuts, and other plant-based fat sources.
Then there was a different connection in another study.
The Nurses Health Study found that women who ate the most plant protein were more likely to avoid premature menopause; animal protein intake had no effect. They even found beneficial links between specific foods and protection against early menopause, including dark bread, cold cereal, and pasta. Those are about as unPrimal as you can get.
How Can We Make Sense of Conflicting Research?
In addition to smoking (which we all know is trouble for almost all markers of health), one thing that keeps appearing in all these observational studies—and they’re all observational studies, unable to prove causation—is that underweight BMIs predict early menopause. In the Nurses Health Study, for example, BMIs under 18.5 were linked to a 30% greater risk of early menopause and BMIs between 25 and 29 were linked to a 30% lower risk. If that’s true, and if that’s actually a causal factor, then the most important thing a woman who wants to avoid early menopause can do is avoid being underweight. In that case, filling up on foods known to cause weight gain in susceptible people like bread, pasta, and cereal would be protective (at least for early menopause).
And that could really explain why the vegan blogger developed premature menopause. In her own words, she “had run out of fuel.”
A big downfall of many plant-based diets is that they starve you. They starve you of vital micronutrients you can really only get in animal foods, like B12, zinc, creatine, cholesterol, and others. They starve you of vital macronutrients, like protein and animal fat. And they starve you of calories. It’s hard to maintain your weight and physical robustness eating a diet of leaves, twigs, and seeds (unless you’re a gorilla). Oddly enough, I think vegans who eat grains and vegan “junk food” like fake burgers and weird nut cheeses are probably better off than the gluten-free ones who live off salads, simply because they’re getting more calories. It’s true that there are many ways to eat vegetarian and even vegan—and some are healthier than others (I’ve written about Primal recommendations for vegetarians and vegans in the past), but the more restrictive a person is with animal products, the trickier it will be to stay well-nourished.
If I had to make a bet, it’d be that any diet that provides sufficient nourishment in the form of micronutrients, macronutrients, and total calories will help stave off early menopause.
What about you? What’s your take on this? Has anyone out there experienced premature/early menopause that didn’t follow natural, familial patterns? What can you recall about the diet and lifestyle leading up to it?
Wang H, Chen H, Qin Y, et al. Risks associated with premature ovarian failure in Han Chinese women. Reprod Biomed Online. 2015;30(4):401-7.
Velez MP, Alvarado BE, Rosendaal N, et al. Age at natural menopause and physical functioning in postmenopausal women: the Canadian Longitudinal Study on Aging. Menopause. 2019;
Sujarwoto S, Tampubolon G. Premature natural menopause and cognitive function among older women in Indonesia. J Women Aging. 2019;:1-15.
Løkkegaard E, Jovanovic Z, Heitmann BL, Keiding N, Ottesen B, Pedersen AT. The association between early menopause and risk of ischaemic heart disease: influence of Hormone Therapy. Maturitas. 2006;53(2):226-33.
Purdue-smithe AC, Whitcomb BW, Szegda KL, et al. Vitamin D and calcium intake and risk of early menopause. Am J Clin Nutr. 2017;105(6):1493-1501.
Sapre S, Thakur R. Lifestyle and dietary factors determine age at natural menopause. J Midlife Health. 2014;5(1):3-5.
Boutot ME, Purdue-smithe A, Whitcomb BW, et al. Dietary Protein Intake and Early Menopause in the Nurses’ Health Study II. Am J Epidemiol. 2018;187(2):270-277.
Szegda KL, Whitcomb BW, Purdue-smithe AC, et al. Adult adiposity and risk of early menopause. Hum Reprod. 2017;32(12):2522-2531.
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When you stop to think about it, mushrooms are remarkable.
They’re closer to animals than plants on the tree of life.
They can break down plastic and petroleum.
The single largest organism on the planet is an underground honey fungus spanning almost 3 miles in the the state of Oregon.
They carry messages along their underground fungal networks using neurotransmitters that are very similar to the ones our brains use.
They’re a kind of “forest internet” which plants and trees use to communicate with each other.
And, as it turns out, they possess and confer some very impressive health and therapeutic effects. Several years ago, I highlighted the culinary varieties and explored their considerable health benefits. Go read that, then come back here because I’m going to talk about the different types of adaptogenic mushrooms today. These are the real heavy hitters, the ones that appear to supercharge immune systems, stimulate neuronal growth, improve memory and focus, pacify the anxious mind, increase the libido, and enhance sleep quality.
Let’s go through the most important adaptogenic mushrooms and the evidence for each. I’ll primarily stick to human studies, but may relay some animal studies if they seem relevant.
Reishi has been used in traditional Asian medicine for hundreds of years to treat diseases of the immune system. (Reishi is its Japanese name; in China, it’s called lingzhi and in Korea, it’s yeongji.) Other folk uses include all the regular stuff you expect—aches, pains, allergies, “qi”—but the majority of modern clinical evidence focuses on immunity, cancer, and inflammation.
But the interesting thing to remember is that inflammation figures into pretty much every modern ailment. Even conditions like depression and anxiety are often characterized by a surplus of systemic inflammation. If reishi can soothe the inflammation, it could very well help with all the other seemingly unrelated conditions, too.
- Reduced anxiety, depression, and fatigue and improved quality of life in breast cancer patients.
- Reduced insulin resistance.
- Reduced inflammatory markers and restored kidney function in kidney disease patients.
- Suppressed the growth of more adenomas (benign tumors with the potential to become malignant) in patients with existing colorectal adenomas.
- Boosted the immune systems of late-stage cancer patients.
Reishi is also said to be very good for sleep, though I wasn’t able to find a supporting human study.
Exercise caution if you have an autoimmune disease, as using reishi to”activate” the immune system that’s attacking you may—theoretically—increase the attack’s severity.
Reishi may also lower libido in high doses, as it inhibits the conversion of testosterone to dihydrotestosterone—albeit in rats. More rat research suggests that low doses of reishi could increase libido.
No human studies indicate this, but a rodent study found that giving reishi reduced time to exhaustion in a forced weighted swimming challenge (throw a rat in the water with a weight attached). They got tired faster.
Cordyceps is another mushroom used in traditional Chinese medicine to promote vitality and energy. For the men, that’s code for “better erections.” What does the evidence say?
It is broadly anti-inflammatory.
It’s an effective immuno-adaptogen: it boosts immunity when immune function is too low and dampens it when it’s over-activated. Autoimmune thyroiditis patients who took cordyceps saw dual-direction immunomodulation—too low got higher, too high got lower.
As for the “energy and vitality” claims, that appears to be true in mammals. We have evidence that rats, pigs, mice, and even yaks, goats, and sheep get boosts to testosterone status and sexual function when taking cordyceps, and that it improves brain function and cognition in small mammals, but nothing solid in humans. Still, the fact that it helps other mammals probably indicates utility for us.
Chaga is a mushroom with a long history of use in Northern Eurasia (Russia, Siberia) as well as a considerable body of animal evidence and isolated human cell evidence in support, but no real studies using actual live humans. That’s unfortunate, because chaga appears to be the real deal:
- Immunomodulation (mice).
- Increased endurance and improved lactate threshold during exercise (mice).
- Reduced cancer progression and spread (mice).
- Reduced DNA damage (human cells).
I hope we get some strong human studies in the near future. In the meantime, you can always run your own!
Lion’s Mane is a mushroom that looks like a pom-pom. Or a brain, which is fitting. Lion’s Mane’s main claim to fame is its purported ability to increase neurogenesis, reduce cognitive decline, and even regrow damaged nerves.
Studies in fact show that Lion’s Mane can:
- Reverse mild cognitive decline in the elderly (for as long as they continue to take the mushroom).
- Help nerve-damaged rats regenerate destroyed nerves and regain their ability to walk.
- Improve the Functional Index Measure in patients with dementia.
- Reduce anxiety and depression in women.
The majority of Lion’s Mane customers aren’t interested in reducing decline. They want a boost. They want increased focus, improved cognition, more and better neurons. Judging from the reversal of cognitive decline in the elderly and the flood of online anecdotes about improved focus and cognition, I suspect that there’s something there.
That said, another common side effect I’ve heard about from many of the same people lauding its cognitive effects is reduced libido. So keep an eye out for that one.
You know how I do things here. I can’t in good faith make definitive claims based on mouse studies that show this or that mushroom improving memory, blasting tumor cells, and increasing sexual virility. Still, I also can’t discount the hundreds (and in some cases, thousands) of years of traditional use of these mushrooms for many of the conditions, nor can I ignore (or write off as “placebo”) the thousands of experimenters out there online deriving major benefits from some of these mushrooms.
The only option, of course, is to try it for yourself, which I may do in the near future (and will write about my findings).
How to Choose a Mushroom Supplement
When you’re buying an adaptogenic mushroom extract, look for products that come from fruiting bodies (actual mushrooms) rather than mycelium (the “roots” of the mushrooms). Fruiting bodies tend to have more of the active constituents than mycelium. Fruiting body extracts will also be more expensive—mushrooms take longer to grow than mycelium—but the added potency makes up for it.
Look for products that list the beta-glucan content, not the polysaccharide content. Beta-glucans are the uniquely active constituents. All beta-glucans are polysaccharides, but not all polysaccharides are beta-glucans.
In the meantime, I’d love to hear your experiences with adaptogenic mushrooms. Have you tried them? How have they been useful for you (or not)? Thanks for stopping in, everybody.
Zhao H, Zhang Q, Zhao L, Huang X, Wang J, Kang X. Spore Powder of Ganoderma lucidum Improves Cancer-Related Fatigue in Breast Cancer Patients Undergoing Endocrine Therapy: A Pilot Clinical Trial. Evid Based Complement Alternat Med. 2012;2012:809614.
Futrakul N, Panichakul T, Butthep P, et al. Ganoderma lucidum suppresses endothelial cell cytotoxicity and proteinuria in persistent proteinuric focal segmental glomerulosclerosis (FSGS) nephrosis. Clin Hemorheol Microcirc. 2004;31(4):267-72.
Smiderle FR, Baggio CH, Borato DG, et al. Anti-inflammatory properties of the medicinal mushroom Cordyceps militaris might be related to its linear (1?3)-?-D-glucan. PLoS ONE. 2014;9(10):e110266.
Lin WH, Tsai MT, Chen YS, et al. Improvement of sperm production in subfertile boars by Cordyceps militaris supplement. Am J Chin Med. 2007;35(4):631-41.
Parcell AC, Smith JM, Schulthies SS, Myrer JW, Fellingham G. Cordyceps Sinensis (CordyMax Cs-4) supplementation does not improve endurance exercise performance. Int J Sport Nutr Exerc Metab. 2004;14(2):236-42.
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