The burgeoning CBD oil scene has made finding a product easier than ever, but it’s also made choosing a product harder. If you recall my post from years ago on decision fatigue, you’ll know what I’m talking about: the paralysis of too many choices…. I know my readership, and I know you’re the type of people who will wonder about optimizing their CBD ingestion. This stuff isn’t cheap, and it’s perfectly rational to want to get your money’s worth.

While the compound itself—cannabidiol, or CBD—doesn’t change from product to product, the way it’s administered does.

(Just a reminder that we’re talking here about CBD oil, a.k.a. “hemp extract,” a legal form of cannabis with extremely low levels of psychoactive THC: there’s no “high” with CBD oil, but CBD oil does contain cannabidiol, a component with big physiological impacts for health. Read more on those impacts here. Likewise, “hemp oil” is different from CBD oil; hemp oil isn’t made from the full plant and doesn’t contain substantive CBD content. For the purpose of this article, I’m covering CBD oil only.)

Let’s look at the forms of available CBD oil….

There are oral CBD oil supplements—gummies, capsules, infused teas, chocolates. Things you eat and drink and digest.

There are sublingual CBD oil supplements—sprays, tinctures, lozenges. Things you swish and swirl around your mouth.

There are topical CBD—creams, lotions, and balms.

There are patches—things you rub and attach to your skin.

There is high-CBD cannabis and CBD-only vape juice. Things you can vaporize and inhale.

But how do you choose? What are the differences between the various routes of administration?

What To Consider When Choosing A CBD Product

Speed of absorption. How quickly do you want the CBD to take effect?

Intensity. How powerful do you want your CBD “experience” to be?

Duration. How long do you want it to last?

Effects. Where do you want it to take effect?

CBD Product Choices: The Rundown

Oral

Oral CBD is the most common method of administration. It’s simple, easy, and intuitive. Everyone swallows pills, eats food, and drinks fluids. There’s almost no way to mess it up (choking aside).

Oral CBD is readily absorbed. Like most everything else that travels through the digestive system, it goes to the liver to be metabolized and converted into different metabolites. The liver is so central to oral CBD that people with poor liver function actually end up with higher serum CBD after taking it orally, since their livers aren’t as good at metabolizing it into different compounds. This liver route also means it takes longer for oral CBD to take effect, but it lasts longer.

Taking an acute oral dose every once in awhile is less effective than consistent dosing because of the liver’s tendency to regulate its bioavailability. When you take it on a regular basis, CBD—being fat soluble like other cannabinoids—gathers in your adipose tissue where your endocannabinoid system can theoretically utilize it on an ongoing basis.

  • Speed: Slow
  • Intensity: Low to moderate (depending on dosage)
  • Duration: Long
  • Effects: Systemic

Sublingual

Sublingual CBD goes under the tongue for absorption via the mucosal membranes in the mouth, which are highly permeable. From there, it bypasses the portal vein—the passage that leads from the digestive tract to the liver—and heads straight for the blood. And then whatever’s left over and not absorbed sublingually gets swallowed and makes it into the digestive tract, so nothing’s wasted.

You have several sublingual options….

Tinctures: Little dropper bottles.

Sprays: AKA oromucosal spray; think CBD-infused Binaca (anyone remember Binaca?).

Lozenges: CBD lozenges that slowly dissolve in your mouth and enter through the mucosa.

The longer you let the CBD sit in your mouth, the more you’ll absorb. 60-90 seconds appears to be the most commonly recommended period of time.

  • Speed: Fast
  • Intensity: Low to high (depending on dosage)
  • Duration: Moderate
  • Effects: Systemic

Inhaled

The original way to get CBD, inhaling CBD, is the fastest-acting and the most intense (with intensity meaning “effectiveness,” not “this will get you messed up, man,” since CBD is not psychoactive). The vapor or smoke enters the lungs, whose alveoli act as a direct conduit to the bloodstream. Inhalation is also the most legally precarious (depending on where you live) because many inhalation CBD products also contain THC, which remains illegal in most places.

You can smoke cannabis bred to be very high in CBD and low in THC, but there will always be some THC present. You couldn’t exactly call this non-psychoactive (or legal in most places) either due to the THC.

There’s also CBD-only vape juice/E-liquid that you can vaporize and inhale.

It’s certainly effective, though if you’re going for efficiency it’s not “optimal.” Your lungs can’t absorb all the CBD in the smoke or vapor; a significant portion is exhaled and lost to the atmosphere. Plus, there’s the whole fact that filling your lungs with smoke is a major stressor. Vapor might be safer, but I’m skeptical.

  • Speed: Fast
  • Intensity: Low to high (depending on dosage)
  • Duration: Shorter
  • Effects: Systemic

Topical

Like other cannabinoids, the CBD molecule is highly hydrophobic and thus cannot pass through the aqueous layer of the skin to reach general circulation. However, if you lather enough of it on to an isolated patch of injured rat skin, it can interact with peripheral cannabinoid receptors that reduce pain and inflammation at a local level. This hasn’t been confirmed in live humans, but anecdotal reports are positive.

  • Speed: Fast
  • Intensity: Unknown
  • Duration: Unknown
  • Effects: Local

Which One Should You Choose?

I don’t have a dog in this fight. I don’t use CBD myself (though I’m not opposed to it and am open to incorporating it in the future if it proves to be uniquely helpful). As a result, I don’t have any strong personally motivated opinion about specific products. What I can give is my objective take on the available evidence, which is fairly light and preliminary:

The best-studied CBD administration methods are oral and sublingual. The majority of human studies have utilized those two routes. There are quite a few positive studies on smoked or inhaled CBD, too, but those often include THC and fail to isolate CBD. If you’re only interested in CBD and not in THC (or it’s illegal where you live), those studies probably don’t apply to you.

In the large set of case studies that found CBD helped patients improve their sleep, the subjects took CBD capsules.

In a study on CBD and pain, the subjects used an oromucosal spray.

In epilepsy patients, oral CBD capsules were incredibly effective.

For general use, whether it’s for anxiety, inflammation, pain, or “general wellness,” oral and/or sublingual use seems to be the real ticket. You know how much you’re consuming. You get a long lasting, fairly fast-acting duration of action. You get the quick absorption into the bloodstream of inhaled CBD without losing any due to exhalation. And if you don’t absorb it all through your oral mucous membranes, you’ll simply swallow and digest the rest. Nothing is lost.

What about you, folks? I know there are some experienced CBD users out there reading this. What’s your favorite method of administration, and why?

Take care everyone.

whole30kit_640x80

References:

Taylor L, Crockett J, Tayo B, Morrison G. A Phase 1, Open-Label, Parallel-Group, Single-Dose Trial of the Pharmacokinetics and Safety of Cannabidiol (CBD) in Subjects With Mild to Severe Hepatic Impairment. J Clin Pharmacol. 2019;

Lattanzi S, Brigo F, Trinka E, et al. Efficacy and Safety of Cannabidiol in Epilepsy: A Systematic Review and Meta-Analysis. Drugs. 2018;78(17):1791-1804.

Richardson JD, Kilo S, Hargreaves KM. Cannabinoids reduce hyperalgesia and inflammation via interaction with peripheral CB1 receptors. Pain. 1998;75(1):111-9.

The post CBD Oil: How Should You Take It? appeared first on Mark’s Daily Apple.

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The burgeoning CBD hemp oil scene has made finding a product easier than ever, but it’s also made choosing a product harder. If you recall my post from years ago on decision fatigue, you’ll know what I’m talking about: the paralysis of too many choices…. I know my readership, and I know you’re the type of people who will wonder about optimizing their CBD ingestion. This stuff isn’t cheap, and it’s perfectly rational to want to get your money’s worth.

While the compound itself—cannabidiol, or CBD—doesn’t change from product to product, the way it’s administered does.

(Just a reminder that we’re talking here about CBD oil or “hemp extract,” a legal form of cannabis with extremely low levels of psychoactive THC: there’s no “high” with CBD hemp oil, but CBD hemp oil does contain cannabidiol, a component with big physiological impacts for health. Read more on those impacts here.)

Let’s look at the forms of available CBD oil….

There are oral CBD oil supplements—gummies, capsules, infused teas, chocolates. Things you eat and drink and digest.

There are sublingual CBD oil supplements—sprays, tinctures, lozenges. Things you swish and swirl around your mouth.

There are topical CBD—creams, lotions, and balms.

There are patches—things you rub and attach to your skin.

There is high-CBD cannabis and CBD-only vape juice. Things you can vaporize and inhale.

But how do you choose? What are the differences between the various routes of administration?

What To Consider When Choosing A CBD Product

Speed of absorption. How quickly do you want the CBD to take effect?

Intensity. How powerful do you want your CBD “experience” to be?

Duration. How long do you want it to last?

Effects. Where do you want it to take effect?

CBD Product Choices: The Rundown

Oral

Oral CBD is the most common method of administration. It’s simple, easy, and intuitive. Everyone swallows pills, eats food, and drinks fluids. There’s almost no way to mess it up (choking aside).

Oral CBD is readily absorbed. Like most everything else that travels through the digestive system, it goes to the liver to be metabolized and converted into different metabolites. The liver is so central to oral CBD that people with poor liver function actually end up with higher serum CBD after taking it orally, since their livers aren’t as good at metabolizing it into different compounds. This liver route also means it takes longer for oral CBD to take effect, but it lasts longer.

Taking an acute oral dose every once in awhile is less effective than consistent dosing because of the liver’s tendency to regulate its bioavailability. When you take it on a regular basis, CBD—being fat soluble like other cannabinoids—gathers in your adipose tissue where your endocannabinoid system can theoretically utilize it on an ongoing basis.

  • Speed: Slow
  • Intensity: Low to moderate (depending on dosage)
  • Duration: Long
  • Effects: Systemic

Sublingual

Sublingual CBD goes under the tongue for absorption via the mucosal membranes in the mouth, which are highly permeable. From there, it bypasses the portal vein—the passage that leads from the digestive tract to the liver—and heads straight for the blood. And then whatever’s left over and not absorbed sublingually gets swallowed and makes it into the digestive tract, so nothing’s wasted.

You have several sublingual options….

Tinctures: Little dropper bottles.

Sprays: AKA oromucosal spray; think CBD-infused Binaca (anyone remember Binaca?).

Lozenges: CBD lozenges that slowly dissolve in your mouth and enter through the mucosa.

The longer you let the CBD sit in your mouth, the more you’ll absorb. 60-90 seconds appears to be the most commonly recommended period of time.

  • Speed: Fast
  • Intensity: Low to high (depending on dosage)
  • Duration: Moderate
  • Effects: Systemic

Inhaled

The original way to get CBD, inhaling CBD, is the fastest-acting and the most intense (with intensity meaning “effectiveness,” not “this will get you messed up, man,” since CBD is not psychoactive). The vapor or smoke enters the lungs, whose alveoli act as a direct conduit to the bloodstream. Inhalation is also the most legally precarious (depending on where you live) because many inhalation CBD products also contain THC, which remains illegal in most places.

You can smoke cannabis bred to be very high in CBD and low in THC, but there will always be some THC present. You couldn’t exactly call this non-psychoactive (or legal in most places) either due to the THC.

There’s also CBD-only vape juice/E-liquid that you can vaporize and inhale.

It’s certainly effective, though if you’re going for efficiency it’s not “optimal.” Your lungs can’t absorb all the CBD in the smoke or vapor; a significant portion is exhaled and lost to the atmosphere. Plus, there’s the whole fact that filling your lungs with smoke is a major stressor. Vapor might be safer, but I’m skeptical.

  • Speed: Fast
  • Intensity: Low to high (depending on dosage)
  • Duration: Shorter
  • Effects: Systemic

Topical

Like other cannabinoids, the CBD molecule is highly hydrophobic and thus cannot pass through the aqueous layer of the skin to reach general circulation. However, if you lather enough of it on to an isolated patch of injured rat skin, it can interact with peripheral cannabinoid receptors that reduce pain and inflammation at a local level. This hasn’t been confirmed in live humans, but anecdotal reports are positive.

  • Speed: Fast
  • Intensity: Unknown
  • Duration: Unknown
  • Effects: Local

Which One Should You Choose?

I don’t have a dog in this fight. I don’t use CBD myself (though I’m not opposed to it and am open to incorporating it in the future if it proves to be uniquely helpful). As a result, I don’t have any strong personally motivated opinion about specific products. What I can give is my objective take on the available evidence, which is fairly light and preliminary:

The best-studied CBD administration methods are oral and sublingual. The majority of human studies have utilized those two routes. There are quite a few positive studies on smoked or inhaled CBD, too, but those often include THC and fail to isolate CBD. If you’re only interested in CBD and not in THC (or it’s illegal where you live), those studies probably don’t apply to you.

In the large set of case studies that found CBD helped patients improve their sleep, the subjects took CBD capsules.

In a study on CBD and pain, the subjects used an oromucosal spray.

In epilepsy patients, oral CBD capsules were incredibly effective.

For general use, whether it’s for anxiety, inflammation, pain, or “general wellness,” oral and/or sublingual use seems to be the real ticket. You know how much you’re consuming. You get a long lasting, fairly fast-acting duration of action. You get the quick absorption into the bloodstream of inhaled CBD without losing any due to exhalation. And if you don’t absorb it all through your oral mucous membranes, you’ll simply swallow and digest the rest. Nothing is lost.

What about you, folks? I know there are some experienced CBD users out there reading this. What’s your favorite method of administration, and why?

Take care everyone.

cilantrolime_640x80

References:

Taylor L, Crockett J, Tayo B, Morrison G. A Phase 1, Open-Label, Parallel-Group, Single-Dose Trial of the Pharmacokinetics and Safety of Cannabidiol (CBD) in Subjects With Mild to Severe Hepatic Impairment. J Clin Pharmacol. 2019;

Lattanzi S, Brigo F, Trinka E, et al. Efficacy and Safety of Cannabidiol in Epilepsy: A Systematic Review and Meta-Analysis. Drugs. 2018;78(17):1791-1804.

Richardson JD, Kilo S, Hargreaves KM. Cannabinoids reduce hyperalgesia and inflammation via interaction with peripheral CB1 receptors. Pain. 1998;75(1):111-9.

The post CBD Hemp Oil: How Should You Take It? appeared first on Mark’s Daily Apple.

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I’m a believer in working hard AND playing hard. When we get stuck in patterns of overwork and overstress, we lose the important connection with our creative, intuitive, playful selves. Our work suffers and so does our happiness (which means everything else, like our relationships, will, too). Stuart Brown, one of the world’s leading experts on play, calls play a “profound biologic process.” What we all know (or used to know until modern living helped us forget) is that play is an essential component of our physical development and general well-being. From a personal standpoint, the older I get the more I recognize play as the linchpin for my own sense of vitality. As a result, I prioritize play—even above exercise. Fortunately, however, I’ve grown into a new relationship with fitness as a result of play. I gave up the slog of grueling training regimens decades ago now, but to this day I’m still living more deeply into a play-based fitness vision. Let me show you a bit of what that looks like for me….

You all have heard me talk about Ultimate—probably as long as Mark’s Daily Apple has been around. The fact is, it’s as thrilling for me today as it was twelve years ago. Nothing else quite combines the diversity of essential movement and the heart of play like Ultimate does. In a single hour, I’m getting regular sprinting, lateral movement, agility training, recovery phases, and mind-body coordination to skillfully throw, catch and move on the field. I love the intense challenge and fast pace of the game.

Ultimate plays very similarly to rugby or football. The field has two end zones, and a team scores by catching a pass in the defensive team’s end zone. The defending team performs a “pull” (think “kickoff” in football) to start the match (and after every subsequent point scored). The offense moves the disc by passing to teammates in any direction. Once a player catches the disc, he must come to a stop as quickly as possible. From this position, he can only move his non-pivot foot. A player has ten seconds to throw the disc after catching it.

The disc changes hands either by turnover or after a score. A turnover occurs when a pass is not completed, intercepted, dropped, blocked, held for longer than the allotted ten seconds, or thrown out of bounds. The defending team assumes control of the disc immediately following a turnover, from wherever the disc lands on the field. There is no stoppage of play (unless a foul, injury or bad weather occurs).

From a physical standpoint, you’re out there running, leaping, twisting, grabbing, throwing, and bumping into other players. You use practically every muscle in the body (if you’re not, you’re doing it wrong) and, rather than long protracted runs, you engage in short bursts of speed and activity punctuated by walking and brief jogging (almost like you’re on the hunt). Not only does it take keen, quick thinking, remarkable agility and throwing accuracy, and raw athleticism, but it also promotes good teamwork and sportsmanship. In fact, Ultimate has an official “Spirit of the Game” (SOTG), a sort of mission statement that stresses sportsmanship and honor. Highly competitive play is condoned, but not at the cost of general camaraderie. Everyone is out there to have a good time and get some great exercise.

Check it out.

Want more ideas for active play? Here you go.

And for more on the importance of play for a Primal Blueprint lifestyle, check out these resources.

Now you tell me: what’s your favorite way to play? How do you merge the Primal goals of mobility and fitness with everyday enjoyment? Thanks for stopping in today.

The post My Favorite Way To Play: Ultimate Frisbee Workout (with Video) appeared first on Mark’s Daily Apple.

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I know we missed Valentine’s Day, but I’ve always said love cannot be contained. Besides: People are always going on dates. People are always searching for new ways to break out of the regular mold, which is completely understandable. Dates are try-outs. You’re spending time with another person to determine how they fit into your life. Unconventional dates that branch out from “dinner, movie, drinks” into more adventurous, creative realms provide excellent feedback for making that determination.

Dates are also a way for established couples to keep things fresh and exciting, to keep the relationship moving. There’s no better way than to try something new.

As it happens, most work for friends, too.

Now, some of these dates are silly or out-of-left field. Some are more serious. And one is a Primal Costanza date—what not to do. But regardless, they are all worth exploring. And—as always—I’d love to hear what you’d add.

1) Watch a Movie and Fill In the Dialogue

You know that scene in Eternal Sunshine of the Spotless Mind where Jim Carrey and Kate Winslet are watching a drive-in movie without sound and filling in the dialogue themselves? Do the same thing, only make all the dialogue health and fitness-related. For example, The Empire Strikes Back would work great.

Just before Han is frozen in carbonite, Leia speaks. “I love cold therapy, so many benefits. I can send you the PubMed links.” Han replies. “I know.”

Vader gives Luke the bad news. “Luke, I am a vegan.” “Nooooooooo!”

Pick your favorite movie, and try it out yourselves. Drive-ins aren’t necessary (do they even still have those?); you could just put the T.V. on mute.

2) Couples’ Spa Day

A couple hundreds years ago, you didn’t really go to the doctor. You’d go to a spa. Spas were healing centers erected around natural springs of mineral-rich water. People would bathe in it (many were hot springs), drink it, and engage in other healthy pursuits. Many of today’s most popular bottled mineral waters come from springs that doubled as health spas back in earlier days.

The average person may think of a spa as a pleasure center, a superficial luxury. But getting a massage, soaking in hot mineral water, smearing yourself with mud and/or clay, exposing yourself to extreme temperatures in the sauna, steam room, and cold water pool? These are all objectively healthy and pleasurable experiences with measurable benefits.

Go for a hot soak, followed by a cold plunge. Do the mud bath thing. Get a deep tissue massage. Soak in the salty mineral-rich brine. And do it with your date, as your date.

3) Get Physical

No, not like that (necessarily). I’m talking about doing something physically demanding together, like a yoga session, a tough hike, a Tough Mudder, a Krav Maga class, or even a CrossFit workout.

Intense physical exertion—performed together—increases bonding. You’re sweating, you’re touching, you’re working hard toward a goal. You’re a team. Make it a little dangerous and the juices really flow. For the same reason, going to see a scary movie helps couples get closer.

4) Go Dancing or Take Dance Lessons

Dance is the prelude to closer, more intimate physical contact. And it’s incredibly healthy learning to move with cohesion and fluidity and precision through constantly varying ranges of motion. Dancers are some of the most athletic folks around—think b-boys, ballet dancers, practitioners of modern dance. I’m not a follower of the show, but seriously just look at an episode of “So You Think You Can Dance” for plain evidence of their athleticism.

Go dance, or take dance lessons if you can’t dance yet. If the latter, don’t make this a one-off. Keep the lessons going. Build that skill together. Move together.

Dancing together in your living room to music on your smartphone is completely valid, too.

5) Cook the Farmer’s Market

This is a fun little date to try. Carrie and I used to do this at the Malibu farmer’s market every once in awhile.

Go to every stand, ask the farmer what’s best today, and then buy that item. If your market is huge, you don’t need to buy from every single stand. Try to stick to a dozen stands or so just to keep things manageable.

Be reasonable with the quantities. Otherwise it’ll add up fast. If, say, the farmer recommends the leeks, buy a couple leeks. If it’s cauliflower, buy a head. If it’s strawberries, buy a basket.

Go home and create a meal together using only the things you purchased from the market. Use things like oil/cooking fat, salt, pepper, and spices from home (unless you bought them at the market, in which case you get extra points). If your market doesn’t offer any meat, feel free to incorporate store-bought meat. But do your best to use only things from the market.

Prep and cook it together. There you go, that’s your date.

6) Ten-Mile Date

Walk ten miles, at least. It can be through the city, the suburbs, or the forest. You can stop at stores, cafes, museums along the way—it doesn’t have to be ten miles straight without stopping. But get those ten miles in however you can.

7) Roughhouse

Roughhousing is universal. It’s also great fun. You roughhouse. You wrestle, jostle, poke, prod, but you don’t (ever) hurt each other. You keep things light, engaged, dancing on the edge of intensity. I really like Rafe Kelley’s approach. Check out the one where he and his partner act like their wrists are glued together as they move around, roll, push, and pull. Or where they stand on a large log, clasp hands, and try to pull each other off balance. That stuff is really fun. I’d try any of the videos from that link.

Another is one-legged tug of war. You each stand on one leg, clasp the other’s hand, and attempt to pull the other off balance. If there’s a big weight or strength disparity, have the stronger person stay on one foot and the weaker person use both. Put pillows and other soft landing spaces around your perimeter.

If you’re a man and she’s a woman, there will probably be some strength disparities. Use your better judgement. Keep things fair and competitive and fun.

8) Picnic and a Hike

Think back to all the hikes you’ve done, all the wilderness areas you’ve explored. Were there any perfect picnic spots that jumped out at you? Maybe a dry pebbly shore next to a gurgling creek. Maybe a ring of redwoods. Maybe a grassy meadow. Maybe a beach that only locals know about. If nothing comes to mind, Google one.

Then pack a lunch and get moving.

9) Stand-Up Paddling

I’m extremely biased. Stand-up paddling is probably my favorite activity. It’s training, meditation, adventure, and a fantastic core and rear delt/lat workout all in one. I’ve seen dolphins, manatees, whales, and any number of marine life on my board. I’ve hit the flow state on my board. I’ve finally figured out meditation being on my board. I’ve woken up with some of the most intense DOMS after a long day on my board. My transverse abdominals and obliques have never been stronger. It’s an all-around great time—and it makes a great date. We’re no longer youngsters in love, but Carrie and I have had a lot of good times when I can get her out on a board.

Not everyone has access to a paddle-worthy body of water, although more than you’d think—rivers, lakes, and reservoirs all work with a paddle board, not just the ocean. If you can’t paddle, something similar like kayaking or even cross-country skiing will work well.

10) Lecture Your Date At Dinner

Make sure your date knows exactly how unhealthy everything he or she is putting in her mouth.

When he orders pasta, make a face.

When she fails to confirm that the salad dressing was made with extra virgin olive oil, pull the waiter aside and do it for her.

When he orders the fish, let him know the Monterey Bay rating.

If she gets anything deep-fried, tell her all about how restaurants reuse cooking oil, which (by the way) is most likely very high in unstable polyunsaturated fats.

This will ensure a second date.

That’s it for today, folks. If you try any of these date ideas, let me know how it goes. If you have any other ideas, write them in down below!

Take care.

collagenfuel_640x80

The post 10 Primal Date Ideas For Every Couple appeared first on Mark’s Daily Apple.

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Over the years, I’ve gotten a lot of questions from Mark’s Daily Apple readers about how I do my day. What do I eat each day? What are my favorite snacks? What do I do for exercise? How do I work out when I’m on the road? What supplements do I take (and how often)? Even what personal products I use… I feel like I’ve covered about everything there is, but then I’ll get something new. In this case, some readers over the last year have asked me about my bedtime. Do I have a routine? Just what do I do to get a good night sleep?

Quality sleep isn’t in any way optional for good health. In fact, it’s a Primal Blueprint Law. That means I consider the hour or two leading up to bedtime as important as my workout time.

Here’s my nightly ritual rundown. As you’ll see in the video, it takes advantage of the relaxing effect of heat along with the Grok Tip of finishing cold—a theme I continue with attention to the ambient temperature of my room. Check out how I wind down my day (and even what I’m reading before bed) below.

Thanks for stopping in today, everybody. Do you have a question for me to answer in a future video? Shoot me a line below. Otherwise, be sure to share your favorite tips for enjoying a great night sleep. Have a great week, everyone.

phc_webinar_640x80

The post My Evening Routine: How I Manufacture a Great Night Sleep appeared first on Mark’s Daily Apple.

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This is a surprisingly common question.

To get it out of the way: Yes, it does. Bone broth contains calories, and true fasts do not allow calorie consumption. You eat calories, you break the fast.

However, most people aren’t fasting to be able to brag about eating no calories for X number of days. They fast for shorter (often intermittent) periods of time for specific health benefits. It’s entirely possible that bone broth “breaks a fast” but allows many of the benefits we associate with fasting to occur.

As is the problem with so many of these specific requests, there aren’t any studies addressing the specific question. The scientific community hasn’t caught up to the current trends sweeping the alternative health community. But we can isolate the most common benefits of fasting and see how bone broth—and the components therein—interact.

Common Benefits of Fasting: Does Bone Broth Help or Hinder?

Ketosis

Fasting is a quick and easy (or simple) way to get into ketosis. You have little choice in the matter. Since you’re not eating anything, and your body requires energy, you break down body fat for energy. And because you’ve only got fat “coming in,” you’ll quickly start generating ketone bodies. If bone broth stops ketosis, it’s probably breaking the fast.

Bone broth doesn’t contain any digestible carbohydrates. Common additions like tomato paste and carrots might add a few tenths of a gram of carbohydrate to your cup of broth, but not enough to throw you out of ketosis.

Bone broth is quite high in protein, especially if you make it right or buy the right kind, but if it’s the only thing you’re consuming during your fast, the overall caloric load won’t be enough for the protein in broth to stop ketosis.

I can’t point to a paper. I know for a fact that I’ve consumed bone broth without affecting my ketones.

Fat Burning

Fat-burning is another important aspect of fasting. Since bone broth contains calories, you’ll probably burn slightly less fat drinking broth during a fast. But the calories come from protein, the macronutrient least associated with fat gain and most supportive of lean mass retention. And at any rate, your total calorie intake on a fasting+broth day will be under 100 calories—plenty low enough to promote fat loss.

Insulin Sensitivity

Over the long term, fasting is an effective way to improve insulin sensitivity and glucose tolerance. Most things that make you better at burning fat and expending, rather than storing, energy—like exercise, low-carb diets, weight loss in general—tend to improve insulin sensitivity over time. But the sometimes counterintuitive piece to all this is that in the short term, fasting can reduce insulin sensitivity. This is a physiological measure the body takes to preserve what little glucose remains for the brain. All the other tissues become insulin resistant so that the parts of the brain that can’t run on ketones and require glucose get enough of the latter to function.

There’s also the matter of sleep, fasting, and insulin sensitivity to consider. Some people report sleep disturbances during fasts, especially longer fasts. This is common. If the body perceives the fast as stressful, or if you aren’t quite adapted to burning fat, you may interpret the depleted liver glycogen as dangerous and be woken up to refuel in the middle of the night. Some people just have trouble sleeping on low-calorie intakes in general, and a fast is about as low as you can get. If that’s you, and your fasting is hurting your sleep, it’s most likely also impairing your insulin sensitivity because a bad night’s sleep is one of the most reliable ways to induce a state of insulin resistance. There’s some indication that total sleep deprivation creates transient type 2 diabetes.

That’s where bone broth comes in. A big mug of broth is one of my favorite ways to ensure a good night’s sleep. It’s a great source of glycine, an amino acid that has been shown in several studies to improve sleep quality and reduce the time it takes to fall asleep. It may “break” the fast by introducing calories, but a broken fast is preferable to bad sleep and the hit to insulin sensitivity that results from it.

Autophagy

Things fall apart. Cars, tools, buildings, toy trucks, civilizations. That’s entropy, which dictates that all things are constantly heading toward disorder. And people aren’t exempt. Our cells and tissues are subject to entropy, too, only we can resist it. One of the ways our bodies resist entropy is through a process of cellular pruning and cleanup called autophagy.  There’s always a bit of back and forth between autophagy and our cellular detritus, but it occurs most powerfully in periods of caloric restriction. Fasting enhances autophagy like nothing else because it’s a period of total caloric restriction.  If bone broth destroys autophagy, that’d be a big mark against drinking it during a fast.

Amino acids tend to be anti-autophagy signaling agents. When we eat protein, or even consume certain isolated amino acids, autophagy slows. Bone broth is pure protein. It’s almost nothing but amino acids. The key is: Which amino acids are in bone broth, and have they been shown to impede autophagy?

The primary amino acids that make up the gelatin in bone broth are alanine, glycine, proline, hydroxyproline, and glutamine.

Let’s say you’re drinking a mug of strong, really gelatinous bone broth with 15 grams of gelatin protein. How do those amino acids break down?

So it’s a mixed bag. The most prominent amino acid in bone broth—glycine—seems to allow autophagy, but the less proinent amino acids may not. It’s unclear just how much of each amino acid it takes to affect autophagy either way. The absolute amounts found in bone broth are low enough that I’m not too concerned.

What Else To Know…

Okay, so while bone broth technically “breaks” the fast, it may preserve some of the most important benefits. Is there anything else related to bone broth and fasting that deserve mention?

If you’re the type to train in a fasted state and eat right after, you might consider incorporating some bone broth right before the workout. Just like my pre-workout collagen smoothie does, bone broth (plus a little vitamin C to aid the effect) right before a workout improves the adaptations of our connective tissue to the training by increasing collagen deposition in the tendons, ligaments, and cartilage. You’ve already done most of the fast honestly. What’s shaving off a half hour of fasting time by drinking some broth or collagen, especially if you stand to improve your connective tissue in the process? Ask any older athlete and they’ll say they wish they could.

Some spices and herbs that are often added to bone broth can have effects similar to fasting. Take curcumin, found in turmeric. Research shows that it’s an independent activator of mTOR, which in turn can activate autophagy. Ginger and green tea (what, you haven’t tried steeping green tea in bone broth?) are other ones to try. Bone broth with turmeric, green tea, and ginger might actually combine to form a decent autophagy-preserving drink during a fast. Only one way to find out!

That’s about it for bone broth and fasting. If you have any further questions, don’t hesitate to ask down below.

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References:

Xu X, Wang X, Wu H, et al. Glycine Relieves Intestinal Injury by Maintaining mTOR Signaling and Suppressing AMPK, TLR4, and NOD Signaling in Weaned Piglets after Lipopolysaccharide Challenge. Int J Mol Sci. 2018;19(7)

De urbina JJO, San-miguel B, Vidal-casariego A, et al. Effects Of Oral Glutamine on Inflammatory and Autophagy Responses in Cancer Patients Treated With Abdominal Radiotherapy: A Pilot Randomized Trial. Int J Med Sci. 2017;14(11):1065-1071.

Shaw G, Lee-barthel A, Ross ML, Wang B, Baar K. Vitamin C-enriched gelatin supplementation before intermittent activity augments collagen synthesis. Am J Clin Nutr. 2017;105(1):136-143.

Zhao G, Han X, Zheng S, et al. Curcumin induces autophagy, inhibits proliferation and invasion by downregulating AKT/mTOR signaling pathway in human melanoma cells. Oncol Rep. 2016;35(2):1065-74.

Hung JY, Hsu YL, Li CT, et al. 6-Shogaol, an active constituent of dietary ginger, induces autophagy by inhibiting the AKT/mTOR pathway in human non-small cell lung cancer A549 cells. J Agric Food Chem. 2009;57(20):9809-16.

Zhou J, Farah BL, Sinha RA, et al. Epigallocatechin-3-gallate (EGCG), a green tea polyphenol, stimulates hepatic autophagy and lipid clearance. PLoS ONE. 2014;9(1):e87161.

The post Does Bone Broth Break a Fast? appeared first on Mark’s Daily Apple.

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Fasted workouts are a controversial topic in the fitness world. To some, the idea of working out without “carbing up” or doing the pre-workout protein shake is unthinkable. Won’t my performance suffer? Won’t my muscles shrink? Won’t my body think I’m in the middle of some horrible famine and go into starvation mode?

To others, fasted workouts are sacred tools, the perfect antidote to modern decrepitude. When I train in a fasted state, I can will my adipocytes to release fatty acids and feel the heat as they burn, hear the barely audible *pop* of muscle satellite cells replicating and proliferating, and see visions of my future physique through my gaping third eye. 

Where does the truth lie? Let’s look….

To begin with, the evolutionary argument—the Grok logic—for fasted workouts is extremely appealing and intuitive.

Humans did not evolve with access to 24-7 fast food restaurants, grocery stores containing hundreds of millions of calories, and food supplies so ample that we often throw out half of it before we’re able to eat it. If paleolithic humans wanted to eat, they had to hunt or gather something—both of which require the expenditure of caloric energy—often on an empty stomach. In fact, these “workouts” for hunter-gatherers probably occurred more often than not in a fasted state.

This doesn’t mean that fasted workouts are ideal or optimal for health, performance, and fat loss. It does suggest that humans have the capacity for working out in a fasted state without falling apart or losing all the benefits normally associated with exercise. The question is if fasted workouts offer any special advantages.

Today, I’m going to dig into the literature to explore the most frequent questions and claims about fasted workouts and arrive as close to the truth as we can.

Are Fasted Workouts Good or Bad for Muscle Gain?

Let’s take a look.

One common argument is that since you’re not eating, which already “stresses” the muscles and deprives them of structural substrate, stressing the muscle with exercise causes it to “melt away.” This is overly simplistic, if attractive.

For one, that first bit is wrong. Reasonable durations of fasting don’t cause muscle loss. In fact, you can do a few days of fasting without incurring any significant muscle loss. The ketones generated during the fast have protein-sparing effects, and the fasting-induced spike in growth hormone also spares muscle from breakdown. There was even a study where blocking growth hormone with a GH blocker caused fasting people to lose 50% more muscle than fasters who didn’t get the blocker.

For two, strength training itself is a powerful signal to your body that your muscles are essential tissues vital to your survival. Your body generally tries to avoid burning through essential tissues. Lifting also increases growth hormone. Paired with the fasting-induced GH boost, your muscles will be in good standing.

Okay, so fasted workouts don’t appear to be bad for gains. Are they good?

Fasted training augments the anabolic response—the ability of muscles to take up protein and get bigger and stronger. A 2009 study found that, compared to athletes who lifted weights after breakfast, athletes who lifted weights in the morning before eating had an augmented anabolic response to a post-workout protein-and-carb shake.

Are Fasted Workouts Good for Fat Loss?

This one makes sense, doesn’t it? When you don’t have exogenous calories coming in, and you go for a run or walk or bike ride, your body should burn more body fat since it’s the only energy source available. But does it actually happen?

Well, short term studies find that fasted cardio increases fat oxidation in the body. People who go for a run in a fasted state have a lower respiratory quotient, an indication of greater fat burning versus glucose burning. One study found that a morning fasted cardio session increased 24-hour fat oxidation by 50% in young men.

An increase in 24-hour fat oxidation doesn’t say much about long term fat loss, however.

Another study followed a group of healthy women for four weeks, placing them on a morning fasted cardio routine. Three mornings a week, the subjects would perform 50 minutes of treadmill cardio at 70% of their max heart rate in a fasted state. Both the fasted group and the control group (who performed the same cardio, just not fasted) maintained a daily 500 calorie deficit. What happened?

There were no differences in fat loss between groups. Both groups lost weight and lost body fat, but fasted morning cardio did not accelerate the loss. A recent analysis of the available research came to the same conclusion: no difference in fat loss or weight loss between fasted workouts and fed workouts.

I’d like to see a similar four-week study done with men, who in my experience and from reading the fasting literature tend to have a more favorable response to extremes in caloric restriction.

This isn’t a perfect fasted workout study, but it’s better than nothing. A group of triathletes was placed on a “sleep-low” program: instead of eating a ton of carbs after their afternoon workouts, they ate none at all. They depleted their glycogen with the workout, ate a very low-carb dinner, and went to sleep. Then they woke up and did low-intensity cardio in a fasted state, which is the equivalent of a normal person going for a walk. The study was interested in performance, not fat loss, but the group who did their cardio in a glycogen-depleted, fasted state lost more fat than the control group.

An old bodybuilding classic for shedding fat is the fasted morning walk. Wake up, consume no calories, and go for a brisk 20-30 minute walk. In those who are already pretty lean but want to get very lean (like bodybuilders preparing for competition), fasted low-level cardio can be very effective. This is the hardest body comp transition—from lean to very lean. Lean is what the body “wants,” and going lower requires getting over the natural tendency to hold on to diminished body fat stores. A fasted walk, jog, or cycling session performed in the aerobic zone almost forces the body fat to release into circulation. Insulin is low. Sensitivity is high. The stage is perfect, in theory.

Are Fasted Workouts Good for Performance?

Yes and no.

To answer this question, we must note the distinction between training and competing. You might perform worse in a given workout if you’re fasting. You’ll probably perform better if you’ve eaten. But if you’ve consistently trained in a fasted state, the metabolic and muscle adaptations you’ll acquire will boost performance when you compete in a fed state. And that’s everything, isn’t it? While it’s fun to go hard in a workout, test your PR, and treat your training session like the world championship, the real reason we train is to adapt to the training and get better, fitter, and faster—whether for a legit competition or to simply get healthier. A fasted workout trains you to perform under difficult physiological conditions of low fuel availability, and that comes in handy. You probably wouldn’t enter a race or powerlifting match in a fasted state, but the fasted workouts you did in the months leading up to competition make you more likely to win.

The two are complementary. Train fasted, race fed.

Sprinting performance appears to suffer. In one study, sprinting athletes who had fasted had impaired speed and power thanks to less springiness. In another, fasted sprinting led to slower reaction times. Again—the question is, do the training adaptations you get from sprinting in a fasted state make up for the acute losses in performance?

Ramadan fasters (no food or drink during daylight hours) who engage in sprint training improve their soccer-specific endurance performance. They may suffer during the training, but they get good training effects.

As for strength training, there isn’t much solid scientific evidence that the fasted state improves or harms performance. One thing I’ve noticed—and have also heard from dozens of anecdotal reports—is that fasted workouts fill me with a special sort of energy. For lack of a better term, it feels more “Primal,” like you’re actually on the razor’s edge of desperation and performance, where your entire being is focused on lifting the weight, sprinting the hill, or spearing the deer that represents the difference between food for a week and total starvation. It’s pretty cool.

Some people report the opposite. Some people seriously lag if they haven’t eaten. They need something in their bellies to have a good workout. This is a subjective thing, and you’ll probably find that it changes from workout to workout. For example, strength workouts and low level aerobic activity (hiking, walking, paddling) go well for me on an empty stomach, while I prefer to have something light to eat before really intense Ultimate Frisbee matches. Figure out what works for yourself.

Implications for Certain Populations and Conditions…

Type 2 Diabetes

Fasted training improves several physiological markers that are especially relevant to people with type 2 diabetes. For one, it improves insulin sensitivity. The basic definition of type 2 diabetes is “extreme insulin resistance”; fasted workouts counter that insulin resistance. It also improves fat burning, another deficiency common in type 2 diabetes.

Keto Dieters

Keto dieters and fat-adapted folks on low-carb, high-fat programs seem to do better in the fasted state. If you’re already adept at burning your own body fat and training in a low-carbohydrate state, training in the lowest-carbohydrate state—a fasted one—isn’t a big leap.

Gender

As I’ve written before, women tend to react more poorly to intermittent fasting, especially fasts exceeding 14 hours. They are simply more sensitive to caloric restriction, seeing as how their biological “programming” prefers they have a steady source of calories in place for growing, feeding, and nursing babies. Whether you have kids or not, that’s what a significant portion of your DNA is geared toward.

That’s not to say fasted training doesn’t work for women. It just might not do anything special compared to fed training. For instance, this study found that whether overweight women did high intensity interval training in a fasted or fed state had no effect on the benefits. Both types of training worked equally well, improving body composition and the ability of the muscles to burn fat.

Other research finds that women can benefit from fasted training, though men may derive unique benefits. In another study, men and women performed fed and fasted endurance training. Both men and women saw better VO2max increases when fasted, but fasted men saw bigger boosts to muscle oxidative capacity. Fasting helped both in this case. It just helped men a little more.

How I Use Fasted Training

These days, most of my workouts are performed in the fasted state. Anything resembling lower level “cardio,” like walking, hiking, standup paddling, and bike rides are all done totally fasted.

Before heavy lifting or HIIT sessions, however, I’ll drink 20 grams of collagen peptides with some ketone salts and often creatine monohydrate. This isn’t to “fuel” me. The collagen provides the raw material my connective tissue (tendons, ligaments, cartilage) needs to adapt to the training stress, the creatine provides the substrate for quick ATP generation for short bursts, and—this is speculative, mostly—the ketones provide brain fuel to prevent “bonking” and act as an epigenetic signal for muscle preservation. This drink doesn’t contain many calories, nor does it provoke a huge insulin response. I’m technically breaking the fast, but I’m retaining most of the benefits.

I always continue the fast after my workouts. Going a few more hours without eating enhances the HGH response, which helps spare muscle burning and augments the adaptive responses. The ability to comfortably fast after a training session is a good sign that you’re fat-adapted. If I were trying to maintain some elite athletic schedule, I’d refill my glycogen stores, but I’m not chasing performance anymore. It just doesn’t make sense to burn through them and eat a bunch of carbs only to go do it again.

I don’t train in a fasted state for magical effects. I’m not expecting any miracles and neither should you. But I do think every healthy human should be able to complete a fasted workout without falling apart or losing more than a step.

I can. How about you? Ever try fasted workouts? How do you use fasting to augment your training?

Thanks for reading, everyone.

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References:

Deldicque L, De bock K, Maris M, et al. Increased p70s6k phosphorylation during intake of a protein-carbohydrate drink following resistance exercise in the fasted state. Eur J Appl Physiol. 2010;108(4):791-800.

Marquet LA, Brisswalter J, Louis J, et al. Enhanced Endurance Performance by Periodization of Carbohydrate Intake: “Sleep Low” Strategy. Med Sci Sports Exerc. 2016;48(4):663-72.

Iwayama K, Kurihara R, Nabekura Y, et al. Exercise Increases 24-h Fat Oxidation Only When It Is Performed Before Breakfast. EBioMedicine. 2015;2(12):2003-9.

Schoenfeld BJ, Aragon AA, Wilborn CD, Krieger JW, Sonmez GT. Body composition changes associated with fasted versus non-fasted aerobic exercise. J Int Soc Sports Nutr. 2014;11(1):54.

Aird TP, Davies RW, Carson BP. Effects of fasted vs fed-state exercise on performance and post-exercise metabolism: A systematic review and meta-analysis. Scand J Med Sci Sports. 2018;28(5):1476-1493.

Cherif A, Meeusen R, Farooq A, et al. Three Days of Intermittent Fasting: Repeated-Sprint Performance Decreased by Vertical-Stiffness Impairment. Int J Sports Physiol Perform. 2017;12(3):287-294.

Cherif A, Meeusen R, Farooq A, et al. Repeated Sprints in Fasted State Impair Reaction Time Performance. J Am Coll Nutr. 2017;36(3):210-217.

Aloui A, Driss T, Baklouti H, et al. Repeated-sprint training in the fasted state during Ramadan: morning or evening training?. J Sports Med Phys Fitness. 2018;58(7-8):990-997.

The post Fasted Workouts: When They’re More Effective (and How I Incorporate Them) appeared first on Mark’s Daily Apple.

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For many women, menopause can introduce new health challenges. In addition to the symptoms that perturb basic quality of life like hot flashes, headaches, night sweats, and irritability, menopause is also associated with higher risk for serious health concerns like osteoporosis, cognitive decline, and metabolic syndrome. This has made the standard treatment for menopause—hormone replacement therapy, or HRT—a multi-billion dollar business.

A few weeks ago, I explored the benefits and risks of HRT. It has its merits certainly, but it’s not for everyone. Today’s post is for those people. Say you’ve waded through the morass of HRT research and would prefer a different route. Or maybe you’ve actually tried conventional or bioidentical HRT and found it just didn’t work for you. Whatever the reason, you’re probably interested in using “natural” products if you can swing it and if it’ll actually help.

Are there herbal alternatives to HRT that actually work?

As a matter of fact, there are.

Black Cohosh

A medicinal herb native to North America, black cohosh was traditionally used to treat a wide variety of conditions, including rheumatism and other arthritic conditions, colds, fevers, constipation, hives, fatigue, and backache. They used it to help babies get to sleep and soothe kidney troubles. In the mid 20th century, it gained popularity in Europe as a treatment for women’s hormonal issues. Modern clinical research bears out its relevance for menopause:

It’s effective against hot flashes, reducing both severity and frequency.

It improves objective markers of sleep quality (the reduction in hot flashes certainly can’t hurt).

It improves insulin sensitivity, which often degrades during menopause.

It improves early post-menopausal symptoms across the board, leading to a 12.9 point reduction in the Green climacteric score (a basic measure of menopause symptom severity).

In one study, black cohosh was comparable to conventional HRT for reducing most menopausal symptoms and better at reducing anxiety, vaginal bleeding, and breast tenderness.

Here’s a great black cohosh product.

Maca

In its native Peru, maca root was traditionally used as a root vegetable (like a turnip or radish), as well as for its pharmacological properties as an aphrodisiac and subtle stimulant. Incan warriors reportedly used it as a preworkout booster before battles. Today, we know it as an adaptogen—a substance that helps your endocrine system adapt to stress, rather than force it in one direction or another.

A 2011 review of the admittedly limited evidence found that maca shows efficacy against menopause. More recently, maca displayed the ability to lower depression and blood pressure in menopausal women. And earlier, maca helped perimenopausal women resist weight gain and menopausal women regain their sexual function and reduce depression and anxiety.

What’s going on here? According to a 2005 study, maca actually lowers follicle-stimulating hormone and increases luteinizing hormone in postmenopausal women, thereby increasing estrogen and progesterone production.

Make sure you buy gelatinized (cooked) maca, as that’s what the studies use.

Red Clover

The red clover blossom is a rich source of isoflavones, estrogen-like compounds that interact with receptors in our bodies and relieve many symptoms of menopause.

Twelve weeks of red clover cuts the Menopause rating score in half (a good thing!).

Twelve weeks greatly reduces the intensity and frequency of hot flashes and night sweats. Including some probiotics has a similar effect.

Red clover also improves vaginal cellular structure and function while (again) improving menopause symptoms and reducing triglycerides.

More exciting, there’s reason to believe that red clover may reduce the risk of breast cancer and improve bone mineral density in menopausal women.

Here’s a potent red clover supplement.

And then there are those herbs and plants with more limited scopes.

Ginseng

Ginseng has limited application in menopause. It improves sexual function, and Korean red ginseng appears to help libido and reduce the total hot flash score, but neither type of ginseng reduces oxidative stress, improves endometrial thickness, or reduces hot flash frequency.

Here’s some Korean red ginseng. Here’s some concentrated ginseng.

Evening Primrose

It’s good for hot flashes, and that tends to improve other things like socializing and sex, but that’s about it.

Here’s some cold-pressed primrose oil.

St. John’s Wort

You might remember St. John’s Wort as an herbal treatment for such conditions as depression and anxiety, but it’s also quite effective against certain symptoms of menopause.

In one study, 3 months of daily St. John’s Wort supplementation helped perimenopausal women go from three hot flashes to one hot flash a day, get better sleep, and have a better quality of life. In another, it took 8 weeks of St. John’s Wort for both perimenopausal and postmenopausal women to reduce the frequency and severity of their hot flashes. Researchers also combined it with black cohosh to successfully treat hot flash-related moodiness.

This is a pretty good product.

Wild Yam

The yam has been used for hundreds of years for menopause treatment. These days, we know it contains estrogen mimetics known as phytosterols with clinical efficacy in menopausal women.

Try this one.

Before you go fill your Amazon cart with supplements and start chowing down on powders and pills, however, make sure you’re making the right move.

Talk to your doctor about the herbal alternatives mentioned today. Discuss and research potential interactions with medications and even supplements you’re already taking. Be sure to cite the relevant references.

Minimize the variables. Don’t start taking everything from this article. Start with one and evaluate.

Don’t underestimate the power of plants. Just because something is “herbal” or “botanical” doesn’t mean it’s completely benign at all doses.

That’s it for today, folks. Take care, and be sure to write in down below.

Have you ever used any herbs or botanicals to treat menopause symptoms? If so, what worked? What didn’t?

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References:

Mehrpooya M, Rabiee S, Larki-harchegani A, et al. A comparative study on the effect of “black cohosh” and “evening primrose oil” on menopausal hot flashes. J Educ Health Promot. 2018;7:36.

Jiang K, Jin Y, Huang L, et al. Black cohosh improves objective sleep in postmenopausal women with sleep disturbance. Climacteric. 2015;18(4):559-67.

Mohammad-alizadeh-charandabi S, Shahnazi M, Nahaee J, Bayatipayan S. Efficacy of black cohosh (Cimicifuga racemosa L.) in treating early symptoms of menopause: a randomized clinical trial. Chin Med. 2013;8(1):20.

Zheng TP, Sun AJ, Xue W, et al. Efficacy and safety of Cimicifuga foetida extract on menopausal syndrome in Chinese women. Chin Med J. 2013;126(11):2034-8.

Lee HW, Choi J, Lee Y, Kil KJ, Lee MS. Ginseng for managing menopausal woman’s health: A systematic review of double-blind, randomized, placebo-controlled trials. Medicine (Baltimore). 2016;95(38):e4914.

Lee MS, Shin BC, Yang EJ, Lim HJ, Ernst E. Maca (Lepidium meyenii) for treatment of menopausal symptoms: A systematic review. Maturitas. 2011;70(3):227-33.

Stojanovska L, Law C, Lai B, et al. Maca reduces blood pressure and depression, in a pilot study in postmenopausal women. Climacteric. 2015;18(1):69-78.

Brooks NA, Wilcox G, Walker KZ, Ashton JF, Cox MB, Stojanovska L. Beneficial effects of Lepidium meyenii (Maca) on psychological symptoms and measures of sexual dysfunction in postmenopausal women are not related to estrogen or androgen content. Menopause. 2008;15(6):1157-62.

Shakeri F, Taavoni S, Goushegir A, Haghani H. Effectiveness of red clover in alleviating menopausal symptoms: a 12-week randomized, controlled trial. Climacteric. 2015;18(4):568-73.

Lipovac M, Chedraui P, Gruenhut C, et al. The effect of red clover isoflavone supplementation over vasomotor and menopausal symptoms in postmenopausal women. Gynecol Endocrinol. 2012;28(3):203-7.

Hidalgo LA, Chedraui PA, Morocho N, Ross S, San miguel G. The effect of red clover isoflavones on menopausal symptoms, lipids and vaginal cytology in menopausal women: a randomized, double-blind, placebo-controlled study. Gynecol Endocrinol. 2005;21(5):257-64.

Lambert MNT, Thorup AC, Hansen ESS, Jeppesen PB. Combined Red Clover isoflavones and probiotics potently reduce menopausal vasomotor symptoms. PLoS ONE. 2017;12(6):e0176590.

Beck V, Rohr U, Jungbauer A. Phytoestrogens derived from red clover: an alternative to estrogen replacement therapy?. J Steroid Biochem Mol Biol. 2005;94(5):499-518.

Abdali K, Khajehei M, Tabatabaee HR. Effect of St John’s wort on severity, frequency, and duration of hot flashes in premenopausal, perimenopausal and postmenopausal women: a randomized, double-blind, placebo-controlled study. Menopause. 2010;17(2):326-31.

Briese V, Stammwitz U, Friede M, Henneicke-von zepelin HH. Black cohosh with or without St. John’s wort for symptom-specific climacteric treatment–results of a large-scale, controlled, observational study. Maturitas. 2007;57(4):405-14.

The post 7 Herbal Alternatives to HRT appeared first on Mark’s Daily Apple.

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Most people chalk urinary incontinence and excessive urgency up to age. We get old, stuff stops working, we wake up to wet sheets. Cue jokes about adult diapers and investing in “Depends” futures. It’s not entirely out of line. Aging matters. There’s just more to it. Like other aspects of “aging,” incontinence and unreasonable urgency don’t just “happen.” Aging may hasten or accompany the decline, but it’s by no means inevitable, unavoidable, or unmitigated.

There are surgical treatments available, many of which involve the implantation of balloons and slings and rings and hammocks. Those are beyond the scope of this post, which will focus on exercises and other less invasive interventions and preventive measures.

What’s the Deal With Urinary Incontinence?

The most well-known type is stress incontinence. When you do anything intense enough to create pressure, such as a sneeze, a particularly boisterous laugh, a trampoline session, a power clean, or a box jump, the pressure escapes through the weakest point of your body—your slack pelvic floor muscles which support and enable bladder function. The result is inadvertent leakage.

The most common type is urgency incontinence. That’s when you can control your bladder well enough, but you feel like you have to go more frequently than you’d like. This can disrupt sleep and place you in uncomfortable situations.

There’s also prostate-related urinary incontinence. If men have incontinence, it’s usually because of prostate issues or prostate surgery altering the normal flow and function of their urinary tract. Today’s post won’t deal with this explicitly, although many of the exercises I’ll discuss that help women treat incontinence can also help men treat prostate-related incontinence. For more info on this, revisit my post on prostate health from a few weeks back.

Both stress incontinence and urgency incontinence usually have the same cause: pelvic floor dysfunction. The pelvic floor acts as a taut, supple sling of muscle and connective tissue running between the pelvis and the sacrum that supports the pelvic apparatus, including organs, joints, sex organs, bladders, bowels, and various sphincters. We use it to control our urination, our bowel movements, even our sexual functions. It’s very important.

What Goes Wrong?

It gets weak and tight and pulls the sacrum inward (the tail gets pulled toward the front of the body), interfering with urination and urinary control.

What causes pelvic floor dysfunction?

Childbirth is one potential cause, but it’s not a foregone conclusion. Women who have vaginal deliveries are more likely to display more pelvic floor dysfunction than women who have cesareans, while a more recent study found that tool-assisted vaginal delivery and episiotomy were the biggest risk factors for vaginal delivery-associated incontinence, not vaginal delivery alone. Allowing passive descent in the second stage of labor, rather than active pushing from the get-go, might also reduce the association.

Muscular atrophy of the pelvic floor muscles. The pelvis is where the magic happens. It’s where we generate power, walk, run, procreate, dance, and move. To keep it happy, healthy, and strong, we have to move. And then keep moving. Through all the various ranges of space and time and possible permutations of limbs and joints. That’s what all our muscles expect from the environment. It’s what they need. When that doesn’t happen, they atrophy—just like the other muscles.

Who Develops Incontinence?

Stress incontinence is more common among women than men. And most women with stress incontinence are older, although childbirth can increase the incidence.

Signs of Poor Pelvic Floor Function

Besides urinary incontinence and urgency incontinence—which are pretty tough to miss—what are some warning signs of poor pelvic floor function?

Low-to-no glute activity when walking. According to expert Katy Bowman, the glutes play a crucial role in pelvic floor function and incontinence prevention.

Lack of lower back curvature. This suggests your pelvis is being pulled inward due to poor glute activity and/or overly tight pelvic floor musculature.

Muscle atrophy elsewhere. If the muscle’s disappearing from your arms and legs, what do you think is happening in other areas?

What Can You Do?

Work On Your Squat

If you can’t sit in a full squat, with shins fairly vertical and heels down on the ground, you need to work on your form.

I suggest reading this old post by Kelly Starrett describing optimal squat form. He focuses on performance and strength training, but the technique applies equally to basic bodyweight squatting for pelvic floor health.

One thing to emphasize: go as low as you can without reaching “butt wink” threshold. The butt wink is when the pelvis begins rotating backward underneath the body. If you’re butt winking all over the place, you’re shortchanging your glutes and preventing them from balancing out the pelvic floor situation. Stop short of the butt wink.

Squat a Lot

You don’t have to load up the bar, although that’s a great way to build glute strength. In fact, I’d refrain from heavy squatting if you’re currently suffering from urinary incontinence, as the stress placed on that region of the body during a heavy squat can make the problem worse and cause, well, leakage.

I’m mainly talking about everyday squatting: while playing with the kids, picking up dog poop, unloading the dishwasher, brushing your teeth, cleaning the house, gardening. If you can incorporate squatting while using the bathroom, perhaps with a Squatty Potty or similar product, that’s even better. Katy Bowman recommends women squat to pee in the shower as an integral part of her therapy for pelvic floor disorder.

Squat To Use the Toilet (or At Least Get Your Feet Up)

I wrote an entire post almost ten years ago exploring the virtues of squatting to poop. Not only does it improve symptoms in hemorrhoid sufferers, reduce straining, and alleviate constipation, but squatting to poop turns out to relieve a lot of excessive pressure on the pelvic floor musculature.

Not everyone’s going to hoist themselves up over the toilet standing on a stack of thick books, or go all out and build a Southeast Asian-style squat toilet in their bathroom, or even get the Squatty Potty. It’s probably the best way to do it—and it’s certainly the most evolutionarily concordant way to poop—but it’s not totally necessary. What matters most is getting those feet up and those knees above your hips. If you can achieve this by placing your feet on a stool (not that kind of stool) as you sit on the toilet, it should do the trick.

Take a Walk and Feel Yourself Up

Next time you walk, rest your palms on the upper swell of your butt cheeks. Every time you step through, you should feel your glutes contract. If they contract, awesome. You’re unconsciously using your glutes to propel yourself forward. If they don’t, you’ll have to train them to contract when you walk.

Do this by going for a ten minute walk (minimum) every single day while feeling your glutes. Consciously contract them enough and feel yourself up enough and the resultant biofeedback will make glute activation a passive behavior, like breathing. Eventually you’ll start doing it without thinking. That’s the goal.

Do Kegels—Differently

The classic therapy for pelvic floor disorder is to train the pelvic floor muscles directly using kegels. This is the muscle you contract to stop yourself from peeing midstream. “Doing kegels” means contracting and releasing that muscle for sets and reps. A common recommendation is to hold for ten seconds, release for ten seconds, repeated throughout the day. Waiting in line? Kegels. Eating dinner? Do some kegels. Remember that man at the DMV last week who would randomly tense up and start sweating as you both waited for your number? He was probably doing kegels.

It’s definitely part of the story—studies show kegels work in men, women, and seniors—but it’s not enough.

Consider  Katy Bowman’s take on the subject. She thinks kegels by themselves make the problem worse by creating a tight but ultimately weakened pelvic floor muscle that pulls the sacrum further inward. Combine that with weak or underactive glutes that should be balancing the anterior pull on the sacrum but don’t and you end up with rising pelvic floor dysfunction and incontinence.  She recommends doing kegels while in the squat position to ensure that the glutes are engaged and all the other contributing muscles are in balance.

Do More Than Kegels

The bad news is that we don’t have controlled trials of Katy Bowman’s protocols with deep squats and frequent daily movement and going barefoot over varied surfaces and squat toilets. We mostly just have basic “pelvic floor exercises,” which usually just mean “kegels.” The good news is that even these suboptimal exercise therapies seem to work on anyone with incontinence, whether they’re just coming off a pregnancy, a 70th birthday, or a prostate procedure. Young, old, middle-aged, male, female—exercise works.

Actually, we do have one small study that suggests kegels will work much better if you balance them out with exercises that target the glutes and hips. In the study, women suffering from urinary incontinence were split into two treatment groups. One group did pelvic floor muscle exercises (kegels). The other group did pelvic floor muscle exercises, plus exercises to strengthen the hip adductors, the glute medius, and glute maximus. Both groups improved symptoms, but the group that did the combo exercises had better results.

For hip adduction, you can use that hip adduction machine where you straddle the chair with legs spread and bring your knees together against resistance. Another option is to use resistance bands. Attach one end of the band to a secure structure and the other to your ankle. Stand with legs spread, then bring the banded leg inward toward the unbanded leg; you should feel it in your inner thigh. Do this for both legs.

For glutes, you have many options. Glute bridges, hip thrusts, squats, deadlifts, lunges, resistance band glute kickbacks.

If you want to get deep into this subject and really learn the optimal exercises for pelvic floor dysfunction, I’d pick up a copy of Katy’s Down There For Women.

Get Strong and Stay Strong

One of the strongest predictors of urinary incontinence is physical frailty. The more frail—weak, fragile, prone to falling, unable to handle stairs, unsteady on one’s feet—the man or woman, the more likely they are to suffer from urinary incontinence. This mostly comes down to muscle atrophy; the frail tend to have low muscle mass all over, including the pelvic floor.

Studies show that strength training improves urinary control in both men coming off prostate procedures and women.

The best option is to never get frail in the first place. If you’re younger and in shape, keep training and moving. Don’t lose it. If you’re younger and trending frail, get training and moving. Don’t squander the time you have. It goes quickly. If you’re older and frail, you have to start today. Fixing this doesn’t happen overnight. Being frail makes it harder to do the things necessary to get strong, but that doesn’t absolve you of the responsibility.

The Bottom Line

None of this stuff is a guarantee against incontinence. Guarantees don’t really exist in life. But I’d definitely argue that anyone who employs all the tips and advice mentioned in today’s post will have a better shot at maintaining bladder control than their doppelganger in some parallel universe who never tries anything—the earlier the better.

If you have any experience with urinary incontinence, let us know in the comments down below. What worked? What didn’t? What worked for a while, then stopped?

Thanks for reading—and sharing here. Happy Halloween, everybody.

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References:

Bernstein IT. The pelvic floor muscles: muscle thickness in healthy and urinary-incontinent women measured by perineal ultrasonography with reference to the effect of pelvic floor training. Estrogen receptor studies. Neurourol Urodyn. 1997;16(4):237-75.

De araujo CC, Coelho SA, Stahlschmidt P, Juliato CRT. Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review. Int Urogynecol J. 2018;29(5):639-645.

Kokabi R, Yazdanpanah D. Effects of delivery mode and sociodemographic factors on postpartum stress urinary incontinency in primipara women: A prospective cohort study. J Chin Med Assoc. 2017;

Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol. 1996;88(3):470-8.

Dokuzlar O, Soysal P, Isik AT. Association between serum vitamin B12 level and frailty in older adults. North Clin Istanb. 2017;4(1):22-28.

The post Urinary Urgency and Incontinence: Why It’s Not Just Age appeared first on Mark’s Daily Apple.

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Many of you have asked about prostate health in a Primal context. Men are interested because they know men have a decent chance of getting prostate cancer. Women are interested because they’re worried about the men in their lives getting prostate cancer. Today, I’m going to delve deep into the topic, exploring the utility (or lack thereof) of standard testing, the common types of treatment and their potential efficacy, as well as preventive and unconventional ways of reducing your risk and mitigating the danger of prostate cancer.

Let’s go.

First, what does the prostate do, anyway? Most people only think about it in terms of prostate cancer.

It’s a gland about the size of a small apricot that manufactures a fluid called prostatic fluid that combines with sperm cells and other compounds to form semen. Prostatic fluid protects sperm against degradation, improves sperm motility, and preserves sperm genetic stability.

What Goes Wrong With the Prostate?

There are a few things that can happen.

Prostatitis

Inflammation of the prostate, usually chronic and non-bacterial. A history of prostatitis is a risk factor for prostate cancer.

Benign Prostatic Hyperplasia

Non-cancerous enlargement of the prostate. As men age, the prostate usually grows in size. This isn’t always cancer but can cause similar symptoms.

Prostate Cancer

What most of us are interested in when we talk about prostate health… After skin cancer, prostate cancer is the most common cancer among men and the sixth most common cause of cancer death among men worldwide. Yet, most men diagnosed with prostate cancer do not die from it; they die with it. The 5-year survival rate in the US is 98%.

That said, there is no monolithic “prostate cancer.” Like all other cancers, there are different grades and stages of prostate cancer. Each grade and stage has a different mortality risk:

  • Low-grade prostate cancer grows more slowly and is less likely to spread to other tissues.
  • High-grade prostate cancer grows more quickly and is more likely to spread to other tissues.
  • Local prostate cancer is confined to the prostate. The 5-year relative survival rate (survival compared to men without prostate cancer) for local prostate cancer is almost 100%.
  • Regional prostate cancer has spread to nearby tissues. The 5-year relative survival rate for regional prostate cancer is almost 100%.
  • Distant prostate cancer has spread to tissues throughout the body. The 5-year relative survival rate for distant prostate is 29%. Distant prostate cancer explains most of the prostate-related mortality.

What Are Symptoms of Prostate Cancer?

The primary symptom is problems with urination. When the prostate gland grows, it has the potential to obstruct the flow of urine out of the bladder, causing difficulty urinating, weak urine flow, painful urination, or frequent urination. This can also be caused by benign prostatic hyperplasia, a non-cancerous enlargement of the prostate.

What Causes Prostate Cancer?

A big chunk is genetic. People with “knockout” alleles for BRCA, which codes for tumor suppression, have an elevated risk of some forms of prostate cancer. That’s the same one that confers added risks for breast cancer.

Ethnicity matters, too. Men of Sub-Saharan African descent, whether African-Americans in the U.S. or Caribbean men in the U.K., have the highest risk in the world for prostate cancer—about 60% greater than other ethnic groups. White men have moderate risks; South Asian, East Asian, and Pacific Islander men have lower risks.

Testosterone has a confusing relationship with prostate cancer. Conventional wisdom tends to hold that testosterone stimulates prostate cancer growth, and there’s certainly some evidence of a relationship, but it’s not that simple.

In one study, men with low free testosterone levels were less likely to have low-grade (less risk of spreading) prostate cancer but more likely to have high-grade (higher risk of spreading) prostate cancer.

In another, testosterone deficiency predicted higher aggressiveness in localized prostate cancers.

In Chinese men, those who went into treatment with low testosterone were more likely to present with higher-grade localized prostate cancers.

Other studies have arrived at similar results, finding that “hypogonadism represents bad prognosis in prostate cancer.”

Many prostate cancer treatments involve testosterone deprivation, a hormonal reduction of testosterone synthesis. This can reduce symptoms and slow growth of prostate tumors during the metastatic phase, but prostate cancer tends to be highly plastic, with the ability to adapt to changing hormonal environments. These patients often see the cancer return in a form that doesn’t require testosterone to progress.

What About Testing?

If you have a prostate, should you get tested starting at age 40?

Not necessarily. The value of early testing hasn’t been established. Some researchers even question whether early testing is more harmful than ignoring it, and most of the research finds middling to nonexistent evidence in favor of broad testing for everyone. Early testing has a small effect on mortality from prostate cancer, but no effect on all-cause mortality.

PSA testing can also be inaccurate. PSA is prostate specific antigen, a protein produced by the prostate. It’s normal to have low levels of PSA present in the body, and while high levels of PSA are a good sign of prostate cancer—even years before it shows up in imaging or digital probes—they can also represent a false positive. Those two other common yet relatively benign prostate issues—benign hyperplasia and prostatitis—can also raise PSA levels well past the “cancer threshold.”

Other causes of high levels of PSA include:

  • Urinary tract infections
  • Recent sex or ejaculation
  • Recent, vigorous exercise
  • Certain medications.

In fact, if you have a PSA reading of 4 (the usual threshold), there’s still just a 30% chance it actually indicates cancer.

What About Treatment?

Let’s say you do have prostate cancer, confirmed by PSA and a biopsy (or two, or three, as needle biopsies often miss cancers). What next? Should you definitely treat it?

It’s unclear whether treatment improves survival outcomes. One study took men aged 50-69 with prostate cancer diagnosed via PSA testing, divided them among three treatment groups, and followed them for ten years. One group got active monitoring—they continued to test and monitor the status of the cancer. One group received radiotherapy—radiation therapy to destroy the tumor. And the last group had the cancer surgically removed.  After ten years, there was no difference among the groups for all-cause mortality, even though the active-monitoring group saw higher rates of prostate cancer-specific deaths (8 deaths—in a group of 535 men— vs 5 in the surgery group and 4 in the radiotherapy group), cancer progression, and metastasis.

In another study of men with localized prostate cancer, removing the prostate only improved all-cause mortality rates among men with very high PSAs (more than 10). In men with lower PSAs, “waiting and seeing” produced similar outcomes as surgery.

Prostate removal also carries many unwanted side effects, like incontinence and sexual dysfunction. No one wants prostate cancer, but it’s no small thing to have problems with urination and sex for the rest of your life. Those are major aspects of anyone’s quality of life.

Before you make any decisions, talk to your doctor about your options, the relative mortality risk of your particular cancer’s stage and grade, and how the treatments might affect your quality of life.

How Can You Reduce the Risk of Prostate Cancer?

1. Inflammation is definitely an issue.

For one, there’s the relationship between prostatitis, or inflammation of the prostate, and prostate cancer that I already mentioned above.

Two, there’s the string of evidence linking anti-inflammatory compounds to reductions in prostate cancer incidence. For example, aspirin cuts prostate cancer risk. Low-dose aspirin (under 100 mg) reduces both the incidence of regular old prostate cancer and the risk of metastatic prostate cancer. It’s also associated with longer survival in patients with prostate cancer; other non-steroidal anti-inflammatories are not.

Third, anti-inflammatory omega-3 fatty acids (found in seafood and fish oil) are generally linked to lower rates of prostatic inflammation and a less carcinogenic environment; omega-6 fatty acids can trigger disease progression. A 2001 study of over 6,000 Swedish men found that the folks eating the most fish had drastically lower rates of prostate cancer than those eating the least. Another study from New Zealand found that men with the highest DHA (an omega-3 found in fish) markers slashed their prostate cancer risk by 38% compared to the men with the lowest DHA levels.

2. The phytonutrients you consume make a difference.

A series of studies on phytonutrient intake and prostate cancer incidence in Sicilian men gives a nice glimpse into the potential relationships:

The more polyphenols they ate, the less prostate cancer they got.

The more phytoestrogens they ate, the more prostate cancer they got. Except for genistein, an isoflavone found in soy and fava beans, which was linked to lower rates of prostate cancer. The Sicilians are eating more fava than soy, I’d imagine.

How about coffee, the richest source of polyphenols in many people’s daily diets? It doesn’t appear to reduce the incidence of prostate cancer, but it does predict a lower rate of fatal prostate cancer.

3. Your circadian rhythm and your sleep are important.

Like everything else in life, tumor suppression follows a circadian pattern. Nighttime melatonin—which is suppressed if your sleep hygiene is bad and optimal if your sleep hygiene is great—inhibits the growth of prostate cancer cells and reduces their ability to utilize glucose. One way to enhance nighttime melatonin is by getting plenty of natural, blue light during the day; this actually makes nighttime melatonin more effective at prostate cancer inhibition. On the other hand, getting that blue light at night is a major risk factor for prostate cancer.

4. Get a handle on your fasting blood sugar and insulin.

In one study, having untreated diabetic-level fasting blood sugar was a strong risk factor for prostate cancer. Another study found that insulin-lowering metformin reduced the risk, while an anti-diabetic drug that raised insulin increased the risk of prostate cancer. Metformin actually lowers PSA levels, which, taken together with the previous study, indicates a causal effect.

5. Keep moving, keep playing, keep lifting.

This has a number of pro-prostate effects:

It keeps you insulin sensitive, so neither fasting insulin, nor fasting glucose get into the danger zone.

If you’re doing testosterone suppression treatment, exercise can maintain (and even increase) your muscle mass, improve your quality of life, and increase your bone mineral density.

Oh, and do some deadlifts. Men with prostate cancer who trained post-surgery had better control over their bodily functions, as long as they improved their hip extensor strength. If you don’t know, hip extension is the act of standing up straight, of moving from hip flexion (hip hinging, bending over) to standing tall. It involves hamstrings, glutes, and the entire posterior chain. Deadlifts are the best way to train that movement pattern.

The prostate cancer issue is frightening because it’s so common. Almost all of us probably know someone who has or had it, even unknowingly. But the good news is that most prostate cancers aren’t rapidly lethal. Many aren’t lethal at all. So whatever you do, don’t rush into serious treatments or procedures without discussing the full range of options in a frank, honest discussion with your doctor.

That’s it for today, folks. Thanks for reading. If you have any questions, comments, or concerns about prostate cancer, feel free to chime in down below. I’d love to hear from you.

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References:

Perletti G, Monti E, Magri V, et al. The association between prostatitis and prostate cancer. Systematic review and meta-analysis. Arch Ital Urol Androl. 2017;89(4):259-265.

Ilic D, Djulbegovic M, Jung JH, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis. BMJ. 2018;362:k3519.

Brawer MK, Chetner MP, Beatie J, Buchner DM, Vessella RL, Lange PH. Screening for prostatic carcinoma with prostate specific antigen. J Urol. 1992;147(3 Pt 2):841-5.

Castro E, Eeles R. The role of BRCA1 and BRCA2 in prostate cancer. Asian J Androl. 2012;14(3):409-14.

Watts EL, Appleby PN, Perez-cornago A, et al. Low Free Testosterone and Prostate Cancer Risk: A Collaborative Analysis of 20 Prospective Studies. Eur Urol. 2018;

Neuzillet Y, Raynaud JP, Dreyfus JF, et al. Aggressiveness of Localized Prostate Cancer: the Key Value of Testosterone Deficiency Evaluated by Both Total and Bioavailable Testosterone: AndroCan Study Results. Horm Cancer. 2018;

Dai B, Qu Y, Kong Y, et al. Low pretreatment serum total testosterone is associated with a high incidence of Gleason score 8-10 disease in prostatectomy specimens: data from ethnic Chinese patients with localized prostate cancer. BJU Int. 2012;110(11 Pt B):E667-72.

Teloken C, Da ros CT, Caraver F, Weber FA, Cavalheiro AP, Graziottin TM. Low serum testosterone levels are associated with positive surgical margins in radical retropubic prostatectomy: hypogonadism represents bad prognosis in prostate cancer. J Urol. 2005;174(6):2178-80.

Banerjee PP, Banerjee S, Brown TR, Zirkin BR. Androgen action in prostate function and disease. Am J Clin Exp Urol. 2018;6(2):62-77.

Zhou CK, Daugherty SE, Liao LM, et al. Do Aspirin and Other NSAIDs Confer a Survival Benefit in Men Diagnosed with Prostate Cancer? A Pooled Analysis of NIH-AARP and PLCO Cohorts. Cancer Prev Res (Phila). 2017;10(7):410-420.

Russo GI, Campisi D, Di mauro M, et al. Dietary Consumption of Phenolic Acids and Prostate Cancer: A Case-Control Study in Sicily, Southern Italy. Molecules. 2017;22(12)

Russo GI, Di mauro M, Regis F, et al. Association between dietary phytoestrogens intakes and prostate cancer risk in Sicily. Aging Male. 2018;21(1):48-54.

Discacciati A, Orsini N, Wolk A. Coffee consumption and risk of nonaggressive, aggressive and fatal prostate cancer–a dose-response meta-analysis. Ann Oncol. 2014;25(3):584-91.

Dauchy RT, Hoffman AE, Wren-dail MA, et al. Daytime Blue Light Enhances the Nighttime Circadian Melatonin Inhibition of Human Prostate Cancer Growth. Comp Med. 2015;65(6):473-85.

Kim KY, Lee E, Kim YJ, Kim J. The association between artificial light at night and prostate cancer in Gwangju City and South Jeolla Province of South Korea. Chronobiol Int. 2017;34(2):203-211.

Murtola TJ, Vihervuori VJ, Lahtela J, et al. Fasting blood glucose, glycaemic control and prostate cancer risk in the Finnish Randomized Study of Screening for Prostate Cancer. Br J Cancer. 2018;118(9):1248-1254.

Haring A, Murtola TJ, Talala K, Taari K, Tammela TL, Auvinen A. Antidiabetic drug use and prostate cancer risk in the Finnish Randomized Study of Screening for Prostate Cancer. Scand J Urol. 2017;51(1):5-12.

Park JS, Lee KS, Ham WS, Chung BH, Koo KC. Impact of metformin on serum prostate-specific antigen levels: Data from the national health and nutrition examination survey 2007 to 2008. Medicine (Baltimore). 2017;96(51):e9427.

Galvão DA, Taaffe DR, Spry N, Joseph D, Newton RU. Combined resistance and aerobic exercise program reverses muscle loss in men undergoing androgen suppression therapy for prostate cancer without bone metastases: a randomized controlled trial. J Clin Oncol. 2010;28(2):340-7.

Ying M, Zhao R, Jiang D, Gu S, Li M. Lifestyle interventions to alleviate side effects on prostate cancer patients receiving androgen deprivation therapy: a meta-analysis. Jpn J Clin Oncol. 2018;48(9):827-834.

Uth J, Fristrup B, Haahr RD, et al. Football training over 5 years is associated with preserved femoral bone mineral density in men with prostate cancer. Scand J Med Sci Sports. 2018;28 Suppl 1:61-73.

Park J, Yoon DH, Yoo S, et al. Effects of Progressive Resistance Training on Post-Surgery Incontinence in Men with Prostate Cancer. J Clin Med. 2018;7(9)

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