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Menopause, which is a natural part of aging, brings with it an increased risk for various chronic diseases as well as a suite of unpleasant symptoms that most women will experience. Embracing these natural changes in the body and adapting dietary behaviors to manage the symptoms and reduce the disease risk can make this transition easier. As women commonly seek information about nutrients to consume (or not consume) to optimize their health during this time, it's important to share clear, evidence-based information about nutrition recommendations and other behaviors to adopt—and thus help prevent the spread of misinformation and promote safe and effective practices. How do women's bodies and their nutrient needs change during menopause? Perimenopause refers to the decade or so before the onset of menopause when menstrual periods start to become irregular (corresponding with declining estrogen production). It typically starts when women are in their 40s, and it is associated with many side effects related to nutrition (and the body's metabolism). Weight gain is often experienced; a reduced metabolic rate is often accompanied by symptoms such as fatigue and impaired sleep, which can reduce physical activity, elevate the hunger hormone ghrelin, decrease the satiety hormone leptin and lead to poor food choices. Hormonal changes can also increase visceral fat deposition (which releases pro-inflammatory molecules). Independent of a woman's initial weight, race or ethnicity, it's estimated that women gain an average of 1.5 pounds per year in their 40s and 50s. These factors all increase the risk of various chronic diseases, such as heart disease, diabetes and cancer. It's been estimated that more than 50% of women over 50 have low bone density, driven largely by hormonal changes but also often by inadequate micronutrient intake and inactivity. Certain medications—such as proton pump inhibitors taken for acid reflux disease, selective serotonin reuptake inhibitors for depression and some diabetes and breast cancer medications—can also reduce bone density. All these medications are taken more commonly by older adults. In addition, older adults have a higher prevalence of diabetes than other age groups, presenting yet another risk factor for osteoporosis (its risk is also elevated in patients with diabetes, independent of their medication regimen). Recent research suggesting important connections between the gut microbiota and estrogen levels indicates another pathway that affects the risk of developing these conditions. A recent paper by Ervin et al. referred to microbes in the gut that regulate hormone balance and estrogen metabolism during menopause as the "estrobolome." Further, when the gut microbiota ferment prebiotic soluble fiber, they produce short chain fatty acids that can help regulate the cells that control bone mass. We also know that they are intimately involved in the immune system and the inflammatory responses that drive the chronic diseases affecting older women. Of note, the median age of reaching menarche (or the age of first menstruation) in the US is decreasing, which may lead to earlier menopause; this is of particular concern because we know that women who experience premature menopause may be at higher risk for diabetes and heart disease. Some of the many overlapping factors that may lead to this earlier timing include genetics and modifiable risk factors like a high percentage of body fat and exposure to endocrine-disrupting chemicals that affect hormone production and function. Recommended behavior modifications to alleviate the symptoms of menopause In addition to the increased disease risks of age and the physiological changes associated with menopause, women commonly experience many unpleasant symptoms. Dietary behaviors can help to alleviate some of those symptoms. [Note that for younger women, these behaviors can help to manage symptoms during premenstrual syndrome (PMS), too.] For example, a recent randomized control trial (RCT) by Barnard et al. found that following a low-fat, plant-based diet that included soybeans (which are rich in phytonutrients including equol, which supports estrogen function) reduced the frequency of postmenopausal hot flashes by 84% (and their severity). Another RCT showed that a yoga-based intervention improved menopause-related quality of life. Other recommended behavior modifications are shown below. How can nutrition reduce the risk of disease after menopause? Following a balanced dietary pattern—such as the Mediterranean diet—consisting of whole foods rich in phytochemicals and fiber (and limiting processed foods like sodas and fried foods) can help prevent weight gain and stabilize blood sugar to prevent diabetes. Fiber will also promote satiety and limit overeating as well as help to lower LDL cholesterol. Following an active lifestyle by engaging in both aerobic activity and weight-bearing activity and getting plenty of high-quality sleep can promote good mental and physical health. Maintaining a healthy weight and stable blood glucose and insulin levels can also reduce the risk of cancer (especially breast cancer) during this period. It's particularly important to maintain bone density during this stage of life to prevent bone fractures, falls and osteoporosis. Key nutrients that support bone health and examples of common food sources include: Vitamin D: egg yolks, fatty fish, fortified milk Calcium: most dairy products, bony fish, leafy greens Magnesium: almonds, avocado, pumpkin seeds Phosphorus: dairy products, poultry and organ meats, tofu and soybeans Refer to this article from the Oregon State University's Linus Pauling Institute for more information about these and other micronutrient needs for older women. Prevent the loss of muscle mass through adequate protein intake. Individual needs may increase after menopause, up to 1–1.2 grams per kilogram of body weight per day (which equates to about 70 grams for a 150-pound woman). Eating a variety of protein foods will help to ensure the consumption of all the necessary amino acids. Leucine is particularly important for generating new skeletal muscle cells and is found in greater amounts in animal foods (though it's also found in legumes, nuts and seeds). Protein intake should also be spread evenly throughout the day to maximize anabolism (synthesis of new molecules, including for muscle tissue). Eating mindfully and intuitively can also help to prevent overeating and subsequent weight gain. Being aware of hunger signals and stopping when satiated can help to manage intake. Avoiding distractions like screens, chewing more slowly and preparing your own food can increase awareness of the ingredients and flavors in the food, leading to heightened enjoyment and satiety. As cognitive performance can also start to decline in women in this age group (partly due to elevated insulin and other factors related to hormonal changes), eating foods that fuel the brain (such as seafood rich in omega-3 fatty acids and zinc) is also important during this time. Refer to this article about the MIND Diet for more information. How should diet and lifestyle change after menopause? Eating a nutrient-dense diet, minimizing exposure to endocrine-disrupting chemicals and leading an active lifestyle across the life course can help minimize the risk of disease following menopause and alleviate menopausal symptoms. More specifically: Engage regularly in weight-bearing activity to maintain muscle mass and bone density. Be careful about portion sizes and excess snacking to avoid gaining weight. Use smaller plates, keep snacks out of sight at home and avoid being distracted by screens while eating. Make sure to eat foods rich in calcium, vitamin D and magnesium. If you're unsure of your serum vitamin D level, ask your doctor for a blood test. If necessary, consider a multivitamin supplement and/or a combination of vitamin D and magnesium (but check with your doctor or dietitian first if you take any medications to help prevent any negative interactions). The growing evidence about the connection between a healthy gut microbiome and the risk of the diseases mentioned in this post should encourage menopausal women to reduce that risk by consuming fermented foods and foods rich in fiber and phytochemicals and engaging in behaviors that foster healthy bacteria (such as avoiding unnecessary antibiotics). Resources Visit here for the full list of resources. Christina Badaracco, MPH, RD Christina is a registered dietitian and author who aims to improve access to healthy and sustainable food and educate Americans about the connections between food and health. She loves to experiment with healthy recipes in the kitchen and share her creations to inspire others to cook. Christina completed her dietetic internship at Massachusetts General Hospital and earned her Master of Public Health degree from the University of California, Berkeley. Previously, she graduated with a degree in Ecology and Evolutionary Biology from Princeton University, after conducting her thesis on sustainable agriculture and energy in Kenya. She has done clinical nutrition research at the National Institutes of Health, menu planning and nutrition education at the Oakland Unified School District and communications at the Environmental Protection Agency's Office of Water. She has also enjoyed contributing to children’s gardens, farmers markets and a number of organic farms. cbadarac@gmail.com www.linkedin.com/in/christina-badaracco/

Dr. Brad Jacobs is a recognized leader in Integrative Medicine, Lifestyle Medicine, and Corporate Health and Resiliency. He is board-certified in Internal Medicine and Integrative Medicine. Dr. Jacobs is the founder and director of BlueWave Medicine and former chair of the Academy of Integrative Health and Medicine. He regularly leads corporate seminars on resilience and well-being, and he has published peer-reviewed journal articles, medical textbook chapters, and books, including The Anti-Inflammation Cookbook and The American College of Physicians Evidence-Based Guide to Complementary and Alternative Medicine. He is the founding medical director of the UC-San Francisco Osher Center for Integrative Medicine and has served as an endowed professor, co-founder and SVP, Clinical Affairs, at Mytrus Inc., and senior medical director at Revolution Health Networks. He graduated from Stanford University School of Medicine, completed his residency at UCSF and received post-graduate training in acupuncture, herbal medicine, nutrition, fitness, stress management, yoga and martial arts. When not working, he enjoys spending time out in nature. He is a lover of surfing, skiing, and mountain and road biking. His daily regimen includes overnight fasting, yoga and meditation, aerobic or strength activity and quality time with friends and family. At the salon: Dr. Jacobs addressed the many facets of menopause. He discussed the early symptoms (which can appear 10 years before any hot flashes) and offered perspectives for and against hormone replacement therapy. And, finally, he shared how to age well with a thriving and flourishing mindset. Click here to view the salon video. Click here to view the salon powerpoint presentation. ​Contact Information: BlueWave Medicine BlueWaveMedicine.com office email: frontdesk@bluewavemedicine.com P 415-339-2692 Cavallo Point Lodge 601 Murray Circle Fort Baker/Sausalito CA 94965 Dr. Jacob’s books are available for purchase: The Anti-Inflammation Cookbook The American College of Physicians Evidence-Based Guide to Complementary and Alternative Medicine

Did you know that eating certain foods together can create a synergy that enhances the function of one or more of the nutrients in those foods? Different vitamins, minerals and antioxidants can affect the absorption, bioavailability and activity of one another. Your healthcare provider likely guides you regarding combinations of medications to take (or not take) together to maximize their effectiveness and minimize adverse side effects. Similarly, guidance about cooking and eating certain nutrients together is important to optimize their functions and potential health benefits. Six examples of such synergies and examples of relevant food combinations are described below. 1. Lycopene and olive oil Lycopene is a plant compound in the carotenoid family that gives many fruits and vegetables their red and pink colors. The top sources of lycopene include tomatoes, watermelon and guava. Because carotenoids are fat-soluble, eating them with a source of fat increases their absorption. Lycopene acts as an antioxidant in the body, preventing oxidative damage. Its consumption is associated with improved lipid profiles, protection against UV damage, reduced risk of stroke and other benefits. Olive oil is likely the best choice of fat to consume with lycopene, as evidence suggests that the combination leads to higher antioxidant activity. Many studies also suggest that cooking tomatoes (which can, of course, be done with olive oil) makes the lycopene more bioavailable. Examples of food combinations include: Tomato sauce (lycopene) cooked in olive oil Watermelon (lycopene), feta and mint in an olive oil-based dressing Sun-dried tomato (lycopene) pesto made with olive oil 2. Non-heme iron and vitamin C Iron is essential for many physiological functions, such as helping to produce red blood cells and oxygenate the blood, supporting immune responses and aiding cognitive function. Dietary iron exists in two forms: heme, found in some animal foods, and non-heme, found in animal and plant foods. Most of our intake comes from non-heme iron in fortified grains, legumes, leafy green vegetables and meats. Non-heme iron is less bioavailable than heme iron, but consuming a source of vitamin C (or ascorbic acid) with it can enhance absorption. Vitamin C modifies the non-heme iron molecule to increase absorption from the gastrointestinal tract and mobilization from storage forms in the body. To maximize this effect, it's best to consume it at the same time as the iron. Examples of food combinations include: Smoothie with spinach (iron) and pineapple (vitamin C) Stir-fry with bell peppers (vitamin C), tofu (iron), mushrooms, onions and brown rice Chickpeas (iron) with lemon (vitamin C) tahini dressing 3. Curcumin, piperine and fat A member of the ginger family, turmeric has been commonly eaten as a spice and used medicinally for millennia. It is generated from the plant's rhizome (or subterranean stem) and contains multiple health-promoting compounds, the most common of which is a polyphenol called curcumin. Both whole turmeric and isolated curcumin are known to have myriad health benefits, ranging from reducing inflammation to preventing cancer formation/progression to improving insulin sensitivity. Its low bioavailability has prompted researchers to investigate ways to enhance its absorption and utilization by the body; one method is to pair it with piperine, the compound in black pepper that imparts its pungency. Piperine has been shown to increase the absorption and activity of turmeric and curcumin by up to 2,000% (thereby substantially increasing its potential health benefits). Thankfully, these spices are commonly paired together in recipes. Also, like lycopene, curcumin is fat-soluble, so its absorption is enhanced when consumed with fat. Examples of food combinations include: Coconut (fat) curry (curcumin and piperine in spices) salmon (fat) and vegetables Golden (curcumin and piperine in spices) milk (fat in milk) Salad with lemon turmeric (curcumin) dressing (fat in olive oil) and black pepper (piperine) 4. Vitamin C and catechins Plants produce many types of secondary metabolites, which are compounds that are not necessary for metabolism but play a protective role in the plant. They also typically exhibit strong antioxidant activity when consumed by humans. Catechins are one such group; their proven benefits include protecting against tumor formation, promoting lipid metabolism, enhancing glucose sensitivity and more. While there are many different forms of catechins, the most well-known is epigallocatechin gallate (EGCG), found in green tea. They are also found in berries, chocolate, wine, stone fruit and beans. Studies have shown that combining different nutrients with foods that contain these catechins can enhance their absorption and stability after digestion; one of these nutrients is vitamin C (which also happens to be an antioxidant). Examples of food combinations include: Dark chocolate (catechins) with strawberries (vitamin C) Smoothie with cherries (catechins), oranges (vitamin C) and almond butter Sangria (catechins in wine, vitamin C in orange juice) with berries (catechins) 5. Fat-soluble vitamins with dietary fat Vitamins A, D, E and K are fat-soluble, meaning they are absorbed by the body together with fat. Some of the common food sources for these vitamins are as follows: Vitamin A: fatty fish, liver, dairy, fortified grains Vitamin D: fatty fish, egg yolks, fortified dairy Vitamin E: seeds, nuts, oils, avocado Vitamin K: leafy green vegetables (K1); liver and fermented foods (K2) Consuming fat-soluble vitamins with fat (or better yet, a full meal with adequate fat [i.e., at least 15 grams]) can help to maximize the absorption of both food- and supplement-based forms of these vitamins and their resulting blood concentrations. Examples of food combinations include: Green beans (vitamin K) sautéed in olive oil (vitamin E, fat) Thai salad with cucumbers (vitamin K) and peanut dressing (vitamin E, fat) Low- or full-fat (fat) yogurt made with fortified milk (vitamins A and D) 6. Mustard seed and cooked cruciferous vegetables Cruciferous vegetables are among the most nutrient-dense vegetables, providing rich sources of vitamin K, fiber, potassium, antioxidants and more. Common examples include broccoli, cauliflower, mustard greens, turnips and arugula. The well-studied glucosinolate metabolites found primarily in cruciferous vegetables have been shown to offer many benefits. An enzyme called myrosinase converts them into other compounds (e.g., sulforaphane and other isothiocyanates; see equation below) that benefit our bodies. Cooking, however, prevents this process. As noted in an earlier SOULFUL Insight about cruciferous vegetables, our gut bacteria can produce myrosinase, helping to maximize the conversion of glucosinolates. Also, it's been suggested that adding a source of myrosinase from an uncooked crucifer (such as mustard seeds or powder) can augment the myrosinase in a dish to increase the body's conversion of glucosinolates into beneficial metabolites. Examples of food combinations include: Aloo gobi, or Indian cauliflower (glucosinolates) and potatoes (myrosinase in mustard seeds) Broccoli (glucosinolates) cheddar soup (myrosinase in mustard powder) Sautéed, shredded Brussels sprouts (glucosinolates) with mustard seeds (myrosinase) and lemon Additional considerations Some nutrients should not be eaten together as some of their nutritional value is lost when they're combined. Examples include: Copper, iron and zinc can compete with one another for absorption (which is especially important to consider when taken in supplement form and at higher doses) Iron has also been shown to impair the activity of some antioxidants; they, in turn, can also impair iron absorption, so consider avoiding drinks like green tea and wine when consuming iron-rich foods (especially if you are anemic) Oxalic acid is a compound that can impair calcium's absorption; these two nutrients are commonly found together in foods like spinach and beans, so such foods can't be expected to provide great sources of calcium Finally, some media figures and nutritionists have recommended avoiding certain food combinations; examples include not consuming protein with carbohydrates and only eating fruit on an empty stomach. These recommendations are not grounded in evidence from clinical studies or decades of epidemiological research and don't reflect recommendations for overall healthy dietary patterns. Instead, consider the synergies described above and ways that you can incorporate more of those pairings into your meals each day. Resources Ahmad RS, Hussain MB, Sultan MT, et al. Biochemistry, Safety, Pharmacological Activities, and Clinical Applications of Turmeric: A Mechanistic Review. Evid Based Complement Alternat Med. 2020;7656919. hindawi.com/journals/ecam/2020/7656919/ Barba FJ, Nikmaram N, Roohinejad S, Khelfa A, Zhu Z, Koubaa M. Bioavailability of Glucosinolates and Their Breakdown Products: Impact of Processing. Front Nutr. 2016;3:24. ncbi.nlm.nih.gov/pmc/articles/PMC4985713/ Green RJ, Murphy AS, Schulz B, Watkins BA, Ferruzzi MG. Common tea formulations modulate in vitro digestive recovery of green tea catechins. Mol Nutr Food Res. 2007;51(9):1152-1162. pubmed.ncbi.nlm.nih.gov/17688297/ Lee A, Thurnham DI, Chopra M. Consumption of tomato products with olive oil but not sunflower oil increases the antioxidant activity of plasma. Free Radic Biol Med. 2000;29(10):1051-1055. pubmed.ncbi.nlm.nih.gov/11084294/ Shoba G, Joy D, Joseph T, Majeed M, Rajendran R, Srinivas PS. Influence of piperine on the pharmacokinetics of curcumin in animals and human volunteers. Planta Med. 1998;64(4):353-356. thieme-connect.com/products/ejournals/abstract/10.1055/s-2006-957450 Uwitonze AM, Razzaque MS. Role of Magnesium in Vitamin D Activation and Function. J Am Osteopath Assoc. 2018;118(3):181-189. degruyter.com/document/doi/10.7556/jaoa.2018.037/html Christina Badaracco, MPH, RD Christina is a registered dietitian and author who aims to improve access to healthy and sustainable food and educate Americans about the connections between food and health. She loves to experiment with healthy recipes in the kitchen and share her creations to inspire others to cook. Christina completed her dietetic internship at Massachusetts General Hospital and earned her Master of Public Health degree from the University of California, Berkeley. Previously, she graduated with a degree in Ecology and Evolutionary Biology from Princeton University, after conducting her thesis on sustainable agriculture and energy in Kenya. She has done clinical nutrition research at the National Institutes of Health, menu planning and nutrition education at the Oakland Unified School District and communications at the Environmental Protection Agency's Office of Water. She has also enjoyed contributing to children’s gardens, farmers markets and a number of organic farms. cbadarac@gmail.com www.linkedin.com/in/christina-badaracco/

Clia's style of teaching incorporates both yin and yang elements into an aligned vinyasa practice. She believes the benefits of yoga and meditation are immense, and she teaches in order to share them while also introducing more calm, clarity and connection to and among mind, body and spirit. Clia emphasizes that through our yoga and mindfulness practices, we can learn to be more present, with awareness and compassion, and to live our lives authentically. Clia’s education and experience include an MA and certification in Educational Therapy, additional certifications with Yoga Alliance and Transform Coaching Academy, Mindful Schools' mindfulness curriculum training and Shakti School. She teaches yoga privately and through PAMF (teen and prenatal yoga), hosts mindfulness workshops for all ages and stages and works one-on-one with clients as a transformational life coach and Ayurvedic Health Counselor. Clia's Contact Information: cliatierney.com Facebook LinkedIn AT THE SALON: Clia took us through a practice that included both physical asana and mindfulness practices. The sequence was appropriate for all levels of interest—from first-timers to experienced yogis. The theme was "renew and rejuvenate," with the intention to learn something new that can be practiced at home. Click here to see the salon video. Click here to view the passage, Two Feet In by Danielle Doby, Clia read during the salon.

What is Ayurveda? Ayurveda, commonly known as a sister science to yoga, is a 5,000-year-old holistic approach to health. The word "Ayurveda" is derived from two words in Sanskrit, "ayuh" meaning "life" or "longevity" and "veda" meaning "science" or "sacred knowledge." The word, therefore, roughly translates as "the science of longevity" or "the sacred knowledge of life." In more simple terms, Ayurveda is a system for living your best life—the healthiest version of YOU—by developing an awareness of how you feel and what you need physically, mentally, emotionally and spiritually. Ayurveda and the Seasons My personal interest in Ayurveda developed about a decade ago during my yoga teacher training. Since then, it has increasingly become a part of how I nourish myself, my family and my friends. I love Ayurveda's connection to the natural world and its attunement to both the seasonal and daily rhythms in our individual lives and in the world around us. Studying Ayurveda reminds me to spend time outside and pay attention and shift the way I spend my days depending on the changes in nature. Ayurveda explains that we can change our routines to better support our health when we pay attention to these rhythms. And our overall health benefits most when we have a consistent daily routine, even as the seasons change. By tuning in to the rhythms and cycles of nature, we can approach each day with habits that nourish us. For example, as we move from the warmth of summer into the coolness of fall, we can enjoy warm soups and stews with root vegetables, swap out raw greens and salads for steamed or baked vegetables, and warm and hydrate ourselves with herbal teas. As the weather cools and wind increases, we might shift from practicing power/intense vinyasa yoga to a slower yin style. Additionally, a grounding self-massage (abhyanga) using sesame oil before our shower or bath is excellent for improving lymphatic drainage to manage skin conditions, improve sleep and boost the immune system! As winter approaches, we continue nourishing ourselves with warm moist foods, and we add even more warmth with cozy hats and scarves or an extra pair of socks worn in bed. Ayurvedic Toolbox The vast toolbox of Ayurveda includes resources for creating daily and seasonal routines and rituals that make us feel our best. Ayurveda encourages creating awareness around our nourishment, our stressors and our lifestyle choices, and it asks, "What shifts can I make to feel better in my emotional and physical body?" Finding the answer may take some time in quiet reflection—through meditation or journaling—or it may be speaking to you loud and clear with a significant health challenge. In either case, Ayurveda provides a framework to increase our awareness of which tools to use and when to use them to heal. Ayurveda's tools are preventive, and many are both simple and manageable. We adjust and adapt tools to suit our individual constitutions, but all of us can use these tools to help us answer the questions "How do I feel?" and "What do I need?" In terms of nutrition, some of the more obvious tools include eating at consistent mealtimes, avoiding distractions like screens and phones, sitting down while eating, and remembering to pause, chew and breathe between bites. In addition, we can think of nutrition not only as food and drink but what we take in from our surroundings: the environment, our relationships, our habits. Ask yourself, How are these parts of my life feeding me? Is what I am taking in nourishing me or depleting me? If it is nourishing, then relax and enjoy! If not, ask yourself how things could be better. Improvements could include taking time to yourself to be outside or letting that next call go to voicemail while you enjoy a few deep breaths. Maybe you forgo that next not-so-critical social event to stay home and take a warm Epsom salt bath or snuggle on the sofa with your loved one (pets included!). Or perhaps you need to make a more significant and challenging change and may need additional support. How to use the Ayurvedic toolbox Establishing a consistent routine is one way I answer the question: What do I need to feel my best? The following is how I incorporate Ayurvedic principles at the beginning of my day (before breakfast): Wake up at the same time each day (6:30 am) Scrape my tongue Brush my teeth Wash and oil my face Drink warm water with lemon or sip herbal tea Meditate, stretch and journal Other tools in the Ayurvedic toolbox, no matter the time of day or season: Monitor screen time, especially at night Have a consistent bedtime and waking time every day Eat your largest meal at lunch Eat an early light dinner Eat seasonally (also organic, unprocessed, local) Avoid snacking Take good care of your liver Hydrate with warm water and herbal teas throughout the day Take a walk outside Pause periodically and take several deep breaths Meditate, journal and rest Exercise/move your body Lower stress If you are seeking to establish better habits, remember to keep them manageable and straightforward. Be present with what you are doing, how you are breathing, what you are feeling, your thoughts, sensations, senses, sounds, etc. Remember to regularly ask yourself, What do I need right now? Then actually take some time to listen! Ayurveda encourages slowing down and paying attention to what comes up for you, then reaching for your toolbox to shift toward better health. Resources About Abhyanga Self-Massage Banyan Botanicals - Ayurveda Basics Mohan, Siva. Ayurveda for Yoga Teachers and Students Clia Tierney, MA The owner of Asante Wellness Coaching, Clia Tierney helps women move past "stuck" into possibility. She coaches people to overcome obstacles and obtain clarity about their goals. Through the process, personal transformation takes place, resulting in greater well-being, life balance and fulfillment. Clia's professional background and life experiences as a teacher, educational therapist, yogi, wife, mother of teenagers, daughter and sister have fueled her passion for helping women of all ages identify and reduce their stress and struggle so that they can discover their purpose and confidently move forward. cstierney@gmail.com cliatierney.com Facebook Linkedin

The holiday season is upon us—and when it comes to health and wellness at this time of year, we usually think of how to avoid the proverbial “five to seven pounds” of weight gain. While weight gain is worth keeping in mind, the holidays can have a more profound effect on the unseen aspects of our health. Did you know the holidays can take a high toll on our long-term brain health? To learn more, read on. Why are the holidays so hard on our brains? The brain is enormously complex, and its health is quite sensitive to lifestyle factors. In a sense, that’s good news. For instance, for those with a family history of neurodegenerative diseases (like Alzheimer’s or Parkinson’s), we need to bear in mind that our genes are not our destiny. We can make choices to change the fate of our brain health. The problem is that over the holidays, we often adopt behaviors that make our brains vulnerable to damage: We switch to a diet that favors excess sugar, more saturated fats, a higher carbohydrate load and high glycemic index foods. We are more sedentary and live more of our lives indoors, thanks to colder weather and earlier nightfall. We experience more stress as we entertain more guests, visit with family (especially where there is family conflict), manage depression and anxiety, and otherwise cope with the busiest time of year. We deprive ourselves of sleep. These disruptions can lead to long-lasting effects on the brain, including a greater risk of age-related brain disease and accelerated cognitive aging. Build the “Six Pillars of Brain Health” into your holidays Try adding the Six Pillars of Brain Health to your other numbered holiday traditions—like the 12 Days of Christmas or the Eight Days of Hanukkah. The Cleveland Clinic developed the Six Pillars framework to help us remember how to take care of our most important organ. Eat smart Diet is a powerful factor affecting brain health. Evidence points to the Mediterranean (MeDi) and MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diets as being excellent ways to eat to protect and strengthen your brain. Try to work MeDi and MIND foods into your holiday meals. Be sure to include: Colorful vegetables and fruits, particularly leafy greens and berries Extra virgin olive oil Coldwater fish Nuts and legumes Plentiful fiber Also, limit excess sweets, processed carbohydrates and saturated fats. In particular, beware of too many holiday cocktails. Alcohol consumption is reported to increase up to 100% during the holidays. Since these extra calories promote damaging inflammation and metabolic stress on the brain, limiting intake is a crucial strategy. Try the following: Use smaller plates to control portion sizes. Have a snack before leaving for social events to stave off the overconsumption of unhealthy “party” food and alcohol. Eat and drink mindfully: avoid distractions (e.g., TV or working while eating), focus on your senses—chewing, sipping, tasting, texture, smell—and your body’s cues of fullness. You’ll avoid overeating while enhancing your enjoyment of family favorites—a win-win. For more information, see these SOULFUL Insights on foods beneficial to the brain (here) and foods that are bad for the brain (here). And don’t pass up the post on alcohol (here). Sleep Sleep is essential for proper memory formation and waste removal from the brain. The holidays are particularly challenging to proper sleep thanks to additional social activities, work deadlines and late-night shopping (often online). We’ll inevitably lose some sleep, but we can minimize sleep disruptions with some simple approaches: If you must stay up late, you’re likely spending that time on a computer or your phone, which can interfere with your circadian rhythm. Turn down the lights and minimize blue light exposure by using the warm-colored “nighttime” settings on your device or wearing blue light-blocking glasses. Finish eating and drinking at least two hours before bedtime; this avoids disrupting the release of hormones that regulate sleep-wake cycles. Exercise—it’s an excellent, evidence-backed way to improve sleep. Move your body Endurance and resistance exercises cause the release of brain-derived neurotrophic factor (BDNF) and metabolites that stimulate neuroplasticity (the creation, adaptation and survival of brain cells and their connections). Unfortunately, the holidays make it tempting to indulge in TV specials and other sedentary behavior rather than exercise. Resolve to stay active. Here are some suggestions: Keep up with the exercise routine you already have; intentionally create a block on your calendar for exercise if you haven’t already. Look for opportunities to do small activities; they can add up. It can be as simple as walking a bit more each day, taking the stairs instead of the elevator, volunteering for yard work or shoveling snow. Participate in a holiday challenge like a “turkey trot” or a “Santa 5k.” Control medical conditions that affect brain health Type 2 diabetes can raise the risk of being diagnosed with Alzheimer’s disease by over 50%. Cardiovascular diseases such as atrial fibrillation and atherosclerosis can raise the risk of dementia and cognitive decline by almost 60%. During the holidays, try the following: Stay vigilant with your medications and health regimen, especially to manage diabetes or cardiovascular conditions. Schedule a regular checkup with your doctor; it will serve as a reminder to keep chronic conditions in check. Exercise your brain Cognitive stimulation and training are critical to preserving our brain’s ability to adapt to challenges and delay the onset of symptoms of neurodegenerative conditions. Scientists call this “cognitive reserve.” People build their cognitive reserve through curiosity and intellectual pursuits—and having a deeper reserve enables the brain to better compensate for damage and continue functioning well. The holidays present unique opportunities to build more reserves. Here are a few examples: Make or build gifts for others; projects like these require creativity, learning and planning. Take up old talents to entertain family and friends, like singing or storytelling. Engage in activities like reading, playing a musical instrument, attending cultural events and puzzles and games (e.g., crosswords or chess). The benefits of these kinds of activities are increasingly supported by clinical and epidemiological research. Stay connected to people Ultimately, the brain is meant to help us survive and thrive in the context of relationships with the people around us. These activities add purpose to our lives. People with an extensive and robust social network and more significant social activity enjoy a lower risk of dementia and cognitive decline. Take advantage of the holidays to: Meet new people (through volunteering, church attendance, work or other gatherings) and Reconnect with family and friends; even if you’re unable to meet in person, a simple text exchange can bring joy to a person’s day. Combining pillars is the key to success How can you be most efficient and effective at working the Six Pillars of Brain Health into your life during the holidays? By combining the pillars that are most important to you into single activities. Here are some examples of how to make good combinations: Organize a game night when your family is in town. It builds relationships, learning and strategy (not to mention the cognitive challenge of having to convince family members to play!). Commit to doing at least one charity or volunteer event. It’s a way to meet new people (relationships) and develop new skills, and it forces us to move. Make a brain-healthy recipe with your family and loved ones. Cooking together drives social connectedness, learning, planning, movement and, of course, brain-healthy eating. Combining the pillars is powerful. A groundbreaking randomized controlled trial with 1260 participants showed that a regimen of four pillars (diet, exercise, cognitive training and vascular risk monitoring) resulted in significantly better maintenance of cognitive function after two years. So, you can be confident that when you’re practicing the Six Pillars, you’re strengthening your brain and getting the most out of this holiday season! Resources The full list of resources can be accessed here. Edward Park, PhD Edward Park is the founder of NeuroReserve, a preventive health and nutrition company focused on healthy brain aging. Ed’s career spans more than 15 years in the fields of nutritional therapeutics, biopharmaceuticals and medical devices, where he directed R&D, testing and regulatory approval of products to treat people malnourished by cystic fibrosis, pancreatic cancer and preterm birth. Ed’s father’s history of neurodegenerative disease led him to brain health, where he realized the powerful role that nutrition and dietary patterns can play in reducing the risk of Alzheimer’s, Parkinson’s and other neurodegenerative conditions. This work inspired him to develop a new generation of nutritional products to strengthen long-term brain health and cognition. The NeuroReserve products are expert-designed, data analytics-driven and built on the best dietary evidence. Ed holds a PhD in chemical and biomolecular engineering from the Georgia Institute of Technology, where he was a National Defense Science and Engineering Graduate Fellow. He also holds an MS and an MBA from the Massachusetts Institute of Technology. As a special gift to SOULFUL Insights readers, NeuroReserve is offering a 15% discount on subscriptions and individual orders. Just use coupon SOULFOODSALON at checkout. Email: epark@neuroreserve.com Learn more about NeuroReserve here: neuroreserve.com Instagram @neuroreserve and Facebook @neuroreserve

Marti Wolfson is a health-supportive chef and integrative nutritionist. She has been a leader in the culinary nutrition space for 13 years, as a culinary teacher, nutrition consultant, speaker, and mentor. She bridges whole foods cooking, Functional Nutrition, and mindfulness practices for preventing and healing chronic illness. Marti has a unique ability to inspire clients to discover nutritious and delicious applications in the kitchen. ​ Her early days as a serious dancer and intrigue in human health, led her to pursue a range of studies, beginning with an Exercise Physiology and Dance degree from Skidmore College, advanced certifications in Pilates and Gyrotonic, culinary certification from the former Natural Gourmet Institute, and a Masters in Functional Nutrition. Her curiosity in the mind-body realm of human health has made her a compassionate, creative, and caring practitioner and teacher. ​ She has taught for the Natural Gourmet Institute, Center for Mind-Body Medicine, Maryland University of Integrative Health, NYU Prostate Cancer Retreat, and the Integrative and Functional Nutrition Academy. Marti works with people individually on various health conditions, and has online cooking classes for all levels. Cooking is Marti’s profession and her hobby, always dabbling and cooking for friends and family. She also loves hiking, cycling, doing Zumba with her 4 year old girl, and lounging around with her husband reading the paper when said 4 year old is asleep. ​ You can watch her 2014 TEDx talk: Intuition in the kitchen here. ​ Contact Information: martiwolfson.com mwculinarywellness@gmail.com Instagram: @mwinthekitchen ​ At the salon: Marti focused on simple recipes that are health supportive through the holiday flurry. They can be everyday dishes, ones for entertaining or even gifts. We discussed ingredients to support mind and mood, the immune system, and blood sugar. ​ Click here to find the recipes and a shopping/ingredient list for this salon. Please prepare the ingredients ahead of time so you are ready to dive into the cooking session with Marti! Click here to watch the salon video recording.

Nutrition researchers have been studying optimal nutrient timing for many years. Their research has commonly focused on the timing around exercise and athletic activity to maximize performance and recovery. More recently, as lifestyle-related diseases have become more prevalent, people have become interested in caloric restriction and narrowing the window of eating through intermittent fasting to manage and prevent disease. And for those not looking to make such a drastic modification, recent evidence suggests that tweaking the timing of meals and redistributing macronutrient intake can promote long-term health. Athletics Athletes and fitness professionals have long aimed to time their food intake and hydration before and after workouts and athletic events to perform at their highest ability and recover quickly. Research and recommendations first focused on carbohydrate timing, aiming to replenish glucose stores through "carbohydrate loading" before endurance exercise and after intense exercise with high-carbohydrate post-exercise meals. In recent decades, protein consumption has become a primary focus. The period after exercise has been called the "anabolic window," referring to the 30–45 minutes of muscle cells’ increased sensitivity to taking in and metabolizing nutrients for building new molecules. However, a 2020 study showed that nutrient utilization post-exercise depends on the state of nourishment before exercise, suggesting that both pre- and post-exercise periods should be considered collectively to inform dietary guidance. Patterns of meal timing Among the general population, the timing of eating varies widely. For example, Europeans around the Mediterranean tend to eat dinner later. Americans more commonly skip breakfast (though traditional recommendations advise against it). Within the US, people from different cultures and with varied work schedules may eat at different times—either out of necessity or out of preference. Shift work may require people to eat fewer or later meals; refer to this article for more information about the connection between circadian rhythm, food intake and health. A pattern of eating later in the day and at night has been shown to increase biomarkers indicative of chronic disease (such as elevated insulin and fasting glucose). A 2018 study showed that later eating and consuming a higher percentage of calories in the evening were associated with increased cardiometabolic biomarkers, suggesting that eating earlier may be associated with lower disease risk. Also, a 2017 study showed that skipping breakfast is associated with increased odds of atherosclerosis, independent of cardiovascular risk factors. This also held true in a population of heart attack survivors, suggesting that adjusting meal timing may be important for secondary and primary prevention. But while we know that disrupting regular sleep-wake cycles affects weight and metabolism, it is unknown whether meal timing plays a causal role in metabolic dysregulation. A 2015 study evaluated the use of an app to correct the increasing tendency of Americans to eat most of their calories later in the day. The authors instructed participants not to eat so late and shift their meals to a more consistent schedule (i.e., with less variation between weekdays and weekends). They used the app to monitor daily temporal eating patterns (thus minimizing error due to misreporting) and found that the app was usable and these changes led to weight loss over three weeks. Together, these studies suggest the risks of eating too many of our daily calories later in the day and the potential benefits of shifting our eating earlier. Seemingly in contrast to this evidence, an extensive body of literature suggests many potential benefits of a pattern of intermittent fasting, which often involves restricting eating until later in the day. A key difference is its time-limited period of eating—sometimes as short as several hours over the course of the day—that leaves the body in a prolonged state of fasting, which can lead to metabolic benefits if followed very carefully and for an extended period. Timing of macronutrients We generally consume some of the three macronutrients—carbohydrates, fats and proteins—within each meal and snack. Depending on health conditions and dietary needs, these proportions may vary (with people on a keto diet consuming primarily fat, for example). Conventional recommendations for Americans who don’t have chronic conditions (e.g., type 2 diabetes) suggest following a "balanced plate" method, with roughly a quarter of each meal being a protein-rich food, another quarter being a whole grain and half being fruits and vegetables. Copyright © 2011, Harvard University. For more information about The Healthy Eating Plate, please see The Nutrition Source, Department of Nutrition, Harvard T.H. Chan School of Public Health and Harvard Health Publications. However, as with other national dietary recommendations, Americans don’t necessarily follow this method. Americans tend to overconsume protein at dinner—often including excessively large portions of meat that exceed 60% of their total daily needs. They also underconsume protein at breakfast, often consuming too much refined grain (e.g., pastries and cereal) and fewer than 15 grams of protein. However, we know it is preferable for metabolic health to balance protein throughout the day, having 20–30 grams per meal (depending on one's body size and unique medical needs). A recent cross-sectional study found that higher protein intake at breakfast or as snacks and less at dinner is associated with cardiometabolic health in adults, as measured through biomarkers such as systolic and diastolic blood pressure and insulin. Thus, Americans could benefit from reducing serving sizes of protein-rich foods in the evening and incorporating more protein-rich foods at breakfast time and in their snacks to balance intake throughout the day. Timing of specific foods There are, of course, also certain foods that are best avoided at certain times of the day. Most significant and familiar would be any source of caffeine—coffee and espresso contribute the most, but black, green and white tea, kombucha and yerba mate, and even chocolate contribute caffeine to the diet. Because they can potentially impair sleep, they should be avoided within at least several hours of bedtime. Further, foods that may exacerbate gastroesophageal reflux disease (GERD)—which may include spicy, acidic and high-fat foods as well as carbonated drinks—should be avoided before lying down for bed. Sugar and alcohol will also likely affect sleep quality. Finally, large meals may cause discomfort that would prevent sleep. It is preferable to avoid eating within a few hours of bedtime, when possible. If you are hungry enough to prevent quality sleep, choose magnesium-rich foods (such as nuts, seeds, bananas and toast) before bed to promote relaxation. Other sleep-promoting nutrients include melatonin (in tart cherries, goji berries, nuts, milk, etc.), vitamin D (in fortified milk, eggs and fatty fish), zinc (in oysters, beans, whole grains, etc.) and tryptophan (in turkey, oats, bananas, cheese, etc.). Also, consuming small portions of foods, including a balance of protein and complex carbohydrates, before bed may best help to promote sleep. Tips for timing your meals and macronutrients When possible, aim to distribute your sources of protein throughout the day—perhaps even consuming more in the first half of the day and reducing your serving of protein in the evening. Continue to aim for a balance of macronutrients at each eating occasion to ensure your body gets all of the macro- and micronutrients it needs. Ensure you aren’t too hungry (or full) right before exercise and that you replenish all macronutrients (as well as water and electrolytes) between bouts of exercise. Avoid eating too close to bedtime—particularly large servings of protein or foods that may impair sleep quality. For people with chronic metabolic conditions and/or taking medications that depend on meal timing, consult with your dietitian or primary care physician before making any modifications. Resources Allison KC, Goel N. Timing of eating in adults across the weight spectrum: Metabolic factors and potential circadian mechanisms. Physiol Behav. 2018. 1;192:158-166. pubmed.ncbi.nlm.nih.gov/29486170/ Arent SM, Cintineo HP, McFadden BA, Chandler AJ, Arent MA. Nutrient Timing: A Garage Door of Opportunity? Nutrients. 2020;12(7):1948. pubmed.ncbi.nlm.nih.gov/32629950/ Gill S, Panda S. A Smartphone App Reveals Erratic Diurnal Eating Patterns in Humans That Can Be Modulated for Health Benefits. Cell Metab. 2015;22(5):789-98. pubmed.ncbi.nlm.nih.gov/26411343/ Layman DK et al. Defining meal requirements for protein to optimize metabolic roles of amino acids. American Journal of Clinical Nutrition. 2015;101(6):1330S–1338S. academic.oup.com/ajcn/article/101/6/1330S/4564493 Makarem N, Sears DD, St-Onge MP, Zuraikat FM, Gallo LC, Talavera GA, Castaneda SF, Lai Y, Mi J, Aggarwal B. Habitual Nightly Fasting Duration, Eating Timing, and Eating Frequency are Associated with Cardiometabolic Risk in Women. Nutrients. 2020;12(10):3043. pubmed.ncbi.nlm.nih.gov/33020429/ Suni E. "The Best Foods to Help You Sleep." Sleep Foundation. Updated August 14, 2020. Accessed March 31, 2021. www.sleepfoundation.org/nutrition/food-and-drink-promote-good-nights-sleep Uzhova I et al. The Importance of Breakfast in Atherosclerosis Disease: Insights From the PESA Study. J Am Coll Cardiol. 2017;70(15):1833-1842. pubmed.ncbi.nlm.nih.gov/28982495/ Vieira Musse GN et al. Skipping breakfast concomitant with late-night dinner eating is associated with worse outcomes following ST-segment elevation myocardial infarction. European Journal of Preventive Cardiology. 2020;27(19):2311-2313. journals.sagepub.com/doi/10.1177/2047487319839546 Christina Badaracco, MPH, RD Christina is a registered dietitian and author who aims to improve access to healthy and sustainable food and educate Americans about the connections between food and health. She loves to experiment with healthy recipes in the kitchen and share her creations to inspire others to cook. Christina completed her dietetic internship at Massachusetts General Hospital and earned her Master of Public Health degree from the University of California, Berkeley. Previously, she graduated with a degree in Ecology and Evolutionary Biology from Princeton University, after conducting her thesis on sustainable agriculture and energy in Kenya. She has done clinical nutrition research at the National Institutes of Health, menu planning and nutrition education at the Oakland Unified School District and communications at the Environmental Protection Agency's Office of Water. She has also enjoyed contributing to children’s gardens, farmers markets and a number of organic farms. cbadarac@gmail.com www.linkedin.com/in/christina-badaracco/

This is Part Three of the three-part series on glucose and metabolic health. You can find Part One here and Part Two here. No matter who you are, eating a donut is likely to cause a pretty big spike in your blood sugar, but the magnitude of that spike will be different for each of us. Studies indicate that people with better metabolic health have better overall blood sugar control. By modifying your diet and lifestyle, you can reduce large blood sugar swings even without a Continuous Glucose Monitor (CGM). Focusing on the key concepts below, you can begin to reduce your blood sugar fluctuations. Later, if you choose to try a CGM-based technology, you can experiment with these concepts to make further refinements based on your own biology. Increase your intake of whole foods Use food's natural packaging to slow glucose release. Whole foods are foods that are still in their natural form. Fruits, vegetables, legumes (beans, lentils), nuts, seeds and whole grains are whole foods. These foods are still in the packaging nature provided, and they must be broken down during digestion to release glucose and other nutrients. Because this process takes time, the glucose gets released into your blood more slowly than when processed versions of the same food are digested. Whole food carbohydrates also contain many other nutrients that are good for you, including fiber, protein, healthy fats, vitamins, minerals and other beneficial compounds that can get stripped away in the processing before you eat them. Click here to grab the recipe. Reduce/eliminate processed foods The more processed a food is, the more of nature's packaging (and thus the nutrients and fiber) is removed. Processed foods will rapidly release sugar/glucose into the bloodstream and cause spikes in blood sugar—and potentially, an equally rapid drop once insulin is released. Highly processed foods include packaged treats, home-baked goods made with white flour, table and baking sugars, white rice flour—and all the products made from these ingredients. Even a little bit of processing can cause a significant change in glucose release. For example, an orange eaten whole has about 12 grams of sugar, surrounded by 5 grams of fiber that needs to be broken down to get to the sugar. By contrast, an 8-ounce glass of orange juice has 22 grams of sugar and less than ½ grams of fiber. The juice has almost twice the sugar, with almost no fiber to slow the glucose release. Pair carbohydrates with healthy fats, protein and high-fiber foods to slow the glucose release Eating whole foods or minimally processed carbohydrates will help slow the release of glucose into the blood. You can lower the impact still more by combining carbohydrate foods with good fats and proteins. Fats and proteins take more time to digest than carbohydrates and therefore help slow the sugar absorption of carbohydrates eaten in the same meal. For instance, if you pair whole-grain toast with avocado (a healthy form of fat), the fat will help slow the release of glucose into your blood. A rule to follow is not to eat your carbs by themselves. Eat carbohydrates last The order in which you eat the foods on your plate can change how a meal affects your glucose levels. Eat the foods that take a longer time to digest first to slow down the overall digestion of the meal. Start your meal with non-starchy vegetables, then move to proteins (such as beans, meat or nuts) and healthy fats (dairy, nuts, avocados, lean meats). Eat high-carbohydrate foods such as grains or starchy vegetables (potatoes, pasta, rice, tortillas, bread) last. Exercise Exercise signals your muscles that they need to take up glucose for energy. This signal does not require insulin, so if someone is insulin resistant or has a decreased ability to make insulin, this is an especially great tool. If you do light to moderate exercise directly after a meal, such as a brisk walk, your muscles will take up some of the glucose coming from your meal and reduce the impact on your blood glucose. Note: If you are using a CGM, you may notice that exercise, especially vigorous exercise, may increase your blood sugar as your body's way of keeping fuel available for your muscles, but this should not raise it to an unhealthy level like after a high-carbohydrate meal. An exercise-induced rise in blood sugar may be observed for even light to moderate exercise if the body is in a fasting state; this is a normal physiological response. Add more vinegar and cinnamon to your diet Regular cinnamon and vinegar intake have been shown to lower fasting glucose and HbA1c, and vinegar may directly lower post-meal glucose levels from high-carbohydrate meals. While the exact physiological processes are not fully understood, many studies in both human and animal models have shown that regular cinnamon consumption can lower fasting glucose levels and HbA1c. That said, the addition of cinnamon to a meal does not appear to have a direct effect on post-meal glucose levels. So, while you might not see the effect register on a CGM, adding cinnamon regularly to your diet can have a positive impact on your metabolic health. Like cinnamon, regular vinegar intake has been shown to lower fasting glucose and HbA1c, and it has also been shown to directly lower post-meal glucose rise when meals are high in carbohydrates. Some caution should be taken when adding vinegar to your diet because of its acidic nature. Vinegar lowers the PH of the mouth, which can both demineralize teeth and create an environment where bad bacteria can thrive. To counter this effect, vinegar should be diluted in water or followed by water to rinse the teeth. Lifestyle actions you can take today to improve your glucose response Eat whole foods Eat more fruits, vegetables, legumes (beans, lentils), nuts, seeds. Replace processed snacks with fruit, nuts, or veggies and dip. Swap refined grains for whole grains like brown rice, whole wheat or barley. Eliminate/reduce processed foods Eliminate/reduce processed foods like sugary drinks, fruit juices, packaged snacks, white breads, white rice and treats made with refined ingredients. When cooking at home, swap highly processed ingredients for whole foods or ones with lower processing, such as whole-grain flours or brown rice flour. Look for recipes that use applesauce or dates/date paste to add sweetness. Pair carbohydrates/save them for last Pair carbohydrates with good fats such as nuts, nut butters (low sugar) or proteins such as beans, bean spreads or lean meats. Pair carbohydrates with small amounts of dairy such as plain yogurt or low-processed cheeses. Eat fruits or vegetable snacks with hummus or nut butter. For example, you can pair peanut butter with an apple or a banana, hummus with carrots, peppers or celery, or guacamole or bean dip with chips. Add fruit to plain yogurt or slices of apple with cheese instead of crackers. When eating a full meal, eat your vegetables, proteins and fats first, followed by your grains or starches (bread, rice, barley, potatoes, tortillas). Exercise Take a brisk walk after meals. Try 10 minutes at first and then increase it by five minutes each day to see a bigger effect. Try 15–30 minutes of gentle yoga after meals. Make cinnamon and vinegar part of your regular routine Try adding ½-1 tsp of cinnamon to coffee, tea, oatmeal or other daily food. Use vinegar-based dressings on salads eaten before a meal. Take an ounce of vinegar in water before a meal with a moderate- to high-carbohydrate content. Resources Click here for the full list of resources. Jill Goldring, MNSP, MSIE Jill Goldring is a nutritionist, engineer, avid gardener, beekeeper and healthy food enthusiast. Nutrition is a second career for Jill after a successful Silicon Valley career managing high-tech projects. Jill is interested in the intersection of diet, glycemic response, microbiome and metabolic health outcomes. Her goal is to make positive changes to food systems and services that provide healthy food, nutrition education and nutrition technology to underserved communities. She is a volunteer with the Samaritan House San Mateo. She manages a pilot program that pairs nutrition education focused on glycemic response and CGM (continuous glucose monitor) technology for the free medical clinic's food pharmacy for diabetic patients. She has a Master's in Nutrition Science and Policy from Tufts University Friedman School of Nutrition Science and Policy, a BS in Industrial and Systems Engineering from USC and an MS in Industrial Engineering from Stanford University. guthappynutrition@gmail.com Instagram: @guthappynutrition

This is Part Two of the three-part series on glucose and metabolic health. You can find Part One here. Perhaps you have seen people wearing continuous glucose monitors (CGM), and you were interested to understand what they were. Or, you may have seen advertisements for products and services that claim to improve your metabolic health through the use of continuous glucose monitoring (CGM) technology. Current nutrition guidance and dietary requirements are published based on research averages, but none of us is average. Let's look at how glucose response is measured today and then explore the emerging research and technology that point to a future where a more individualized approach to improving glycemic response is possible. How is glucose response evaluated? Blood glucose is typically evaluated by measuring fasting blood glucose. Unfortunately, this method doesn't measure any post-meal glucose levels, even though most people spend most of the day in a post-meal state. For those with known or suspected disordered glucose control, HbA1c is also measured. HbA1c calculates how much sugar has accumulated on a hemoglobin (Hb) blood protein. Sugars are more likely to bind to the Hb when blood sugar levels are high. Based on the turnover rate of blood cells, HbA1c reflects average accumulation over three months. While both fasting blood glucose and HbA1c do correlate with likely long-term disease outcomes, they don't provide insight an individual can use to take action to improve their glucose response. The future of glucose control begins with continuous glucose monitoring-CGM technology. So, what is it? CGMs were originally introduced in the early 2000s to help people with type 1 diabetes. People with this autoimmune disease can no longer produce insulin. CGMs helped people better understand their glucose levels so they could administer insulin more accurately. The earliest versions were worn for only a few days and required that the data be shared with the physician before being released to patients. Current versions, which allow users to see their data in real-time, were approved for use in the US around 2015. At this time, studies and therapeutic usage of CGMs for prediabetics, type 2 diabetics and even outwardly healthy patients began to emerge. CGMs are wearable medical devices that continuously measure glucose levels, providing regular glucose data to the patient. The current devices are typically attached to the upper arm or lower abdomen and worn consistently for 10–14 days, depending on the device. They sample interstitial fluid, a clear fluid that surrounds the body's cells and is the conduit for nutrients like glucose between the blood and the cells. Glucose in the interstitial fluid reflects the levels in the blood, though the timing is slightly delayed. CGM technology opens a new window into discoveries for metabolic disorders because it provides frequent insight into what glucose levels do throughout the day under varying circumstances and for different people. It has the potential to help us understand how lifestyle choices such as nutritional and eating patterns, exercise, sleep and stress affect long-term metabolic health. Although the technology is relatively new, it has already begun to provide significant new insight. Key findings from emerging research Currently, glycemic response is predicted to be the same for all people and is based on the concepts of glycemic index and glycemic load, which are rooted in the carbohydrate content of foods. The glycemic index is a measure of how quickly a carbohydrate-containing food is digested and results in glucose in the bloodstream (based on a 50-gram serving of carbohydrates). Each food has its own glycemic index, and it is applied equally for everyone. Glycemic load takes the glycemic index and modifies it to reflect an appropriate serving size for a particular food. Emerging research using CGM technology has shown that the one-size-fits-all approach is not the best predictor of glucose response, and more individualized methods are possible. Some key early findings are discussed below. Individuals can have vastly different glycemic responses to the same foods or meals One study in Israel with 800 subjects found that, for the same meal of bread, the average rise in glucose level was 44 mg/dl (milligrams of glucose per deciliter of blood) but that it varied +/- 33 mg/dl—with the top 10% increasing more than 79 mg/dl and the lowest 10% rising less than 15 mg/dl. It also found highly interpersonal responses to different foods. For example, one person had almost no glucose rise in response to consuming a cookie but a roughly 15 mg/dl rise after eating a banana. A different person had almost no rise in response to a banana but an approximately 25mg/dl rise after eating a cookie, as seen in Figure 1 below. Carbohydrates tend to elicit a lower rise in glucose earlier in the day Recent studies have found that, for most people, having carbohydrates earlier in the day causes a lower rise in glucose than when the same meal occurs later in the day. A study conducted in the UK with 1,002 healthy adults found that when the same meal was eaten for lunch versus breakfast, it elicited an almost two-fold increase in glycemic response. Meal composition affects the glycemic response Meal composition refers to the make-up of a particular meal in terms of proteins, fats, carbohydrates and fiber. Studies have found that meals containing the same number of carbohydrates but different amounts of protein, fat and fiber may cause differing glycemic responses. One such study of 24 healthy adults used four standardized meals with 50g of carbohydrates to test the impact of different meal compositions. One meal, called meal 4, with lower fat, fiber and protein, had an average glucose rise of 54.8mg/dl, while another meal, meal 3, with higher protein, fiber and fat, had an average increase of just 20.2 mg/dl, as shown in graphs below. Although these meals demonstrate an overall standard pattern of glucose rise based on meal attributes, the individual rises varied over a wide range, as shown in the lighter lines above and below the average line. Models built using biometric data, including microbiome composition, have the potential to better predict individual glucose response to a meal than the traditional methods of using carbohydrate content alone (Note: Biometric data is any measurable biological information unique to an individual, from your height, weight or lipid levels to the makeup of your microbiome.) The two large-scale studies mentioned above in the UK and Israel created complex mathematical models to test if individual biometric factors such as microbiome, age, current glycemic biomarkers (e.g., HbA1c and fasting glucose) and meal context factors (e.g., meal composition, timing, exercise, sleep and previous meals) could predict an individual's response to future meals. Both studies found that their models' predictions correlated more accurately with actual glycemic response than models built on carbohydrate content alone. This research indicates that the one-size-fits-all nutritional guidelines and standard requirements are not predictive of individual glucose response, and it opens up the possibility that biometric-based personalized nutrition is on the way. How can you begin to understand your unique glycemic response? Try a CGM and experiment! For those with prediabetes or diabetes: CGMs will likely be covered by insurance with a doctor's prescription. CGMs such as Abbott's Freestyle Libre or Dexcom G6 come with phone-based applications that allow you to see your real-time response to foods and track trends. Experiment with the lifestyle modifications that will be discussed in next week's post in this series and see what works for you. For those without diabetes or those who want more structured assistance in learning from a CGM: In the last 18 months, various companies have begun offering unique phone-based applications that pair CGM technology and user-input food-intake data with other health data available—such as exercise, heart rate and sleep metrics—to provide the user with a more integrated understanding of their glycemic response. Some applications also include access to online dietitians. A few companies in this emerging market are Levels Health (in controlled release) and NutriSense. Other companies such as Zoe Global, DayTwo and January AI include predicted meal response tools based on machine learning models. Even if you don't use a CGM, you can improve your glucose response through diet and lifestyle modifications. Our final post in this series will provide concrete actions that you can take to help you achieve better glucose control. Resources Berry SE, Valdes AM, Drew DA, et al. Human postprandial responses to food and potential for precision nutrition. Nat Med 2020 266. 2020;26(6):964-973. doi:10.1038/s41591-020-0934-0 Freckmann G, Hagenlocher S, Baumstark A, et al. Continuous Glucose Profiles in Healthy Subjects under Everyday Life Conditions and after Different Meals. Journal of Diabetes Science and Technology. 2007;1(5):695-703. doi:10.1177/193229680700100513 Zeevi D, Korem T, Zmora N, et al. Personalized Nutrition by Prediction of Glycemic Responses Article Personalized Nutrition by Prediction of Glycemic Responses. Cell. 2015;163:1079-1094. doi:10.1016/j.cell.2015.11.001 Jill Goldring, MNSP, MSIE Jill Goldring is a nutritionist, engineer, avid gardener, beekeeper and healthy food enthusiast. Nutrition is a second career for Jill after a successful Silicon Valley career managing high-tech projects. Jill is interested in the intersection of diet, glycemic response, microbiome and metabolic health outcomes. Her goal is to make positive changes to food systems and services that provide healthy food, nutrition education and nutrition technology to underserved communities. She is a volunteer with the Samaritan House San Mateo. She manages a pilot program that pairs nutrition education focused on glycemic response and CGM (continuous glucose monitor) technology for the free medical clinic’s food pharmacy for diabetic patients. She has Master’s in Nutrition Science and Policy from Tufts University Friedman School of Nutrition Science and Policy, a BS in Industrial and Systems Engineering from USC and an MS in Industrial Engineering from Stanford University. guthappynutrition@gmail.com Instagram: @guthappynutrition

Have you ever wondered why you may eat the same foods as someone else, but they have tons of energy, and you don’t? Or why some days you have energy in the morning, but other days you have it at night? Or why, after lunch, you feel like you need a nap? Understanding how you uniquely respond to food and then learning how you can modify behavior to change how your body responds has the potential to give you the power to better shape your energy levels. With new research and technology, we are at the cusp of a revolution that will finally allow us to understand how we each respond to food. This is the first in a three-part series designed to help you understand how the body responds to food. We will expose you to emerging research and technology that is beginning to provide insight into our huge interindividual variability. We will look at key strategies that will help you improve and take more control of your health. What is metabolic health? Your metabolism is a series of chemical processes that break down the food you eat into the energy and nutrients your body needs to maintain the critical processes required for life. Metabolic health can be defined as how well your body functions in completing these processes. In medical practice, ideal metabolic health is typically measured as having optimal levels in all of the following measures: fasting blood glucose, triglycerides (fat in the blood), HDL (commonly known as “good cholesterol”), blood pressure, waist circumference and HbA1c (a measurement of blood glucose over three months). A recent study indicated that only 12.2% of American adults have optimal metabolic health. Metabolic health is affected by almost every aspect of daily life, but diet, sleep, physical activity and stress are the key modifiable contributors. How does your blood glucose response inform your metabolic health? Studies have indicated that disordered blood glucose levels are correlated with negative outcomes of other measures of metabolic health, including hypertension (high blood pressure), hypertriglyceridemia (high blood triglycerides) and low HDL levels. Given the interconnection of the various aspects of metabolic health and their outcomes, glucose levels offer a window into overall metabolic health. The basic biology of blood sugar control Most of your body’s mechanisms work to keep your bodily functions working within an optimal range, a state called homeostasis. Blood glucose contributes to homeostasis and is regulated to stay within a set range. Blood glucose levels are controlled by the pancreas using the hormones insulin and glucagon. When you eat something with carbohydrates, the carbohydrates are broken down during digestion into simple sugars including glucose, which is absorbed into your bloodstream, increasing your blood glucose level. The pancreas detects this increase and releases insulin into your blood. Receptors on muscle, liver and fat cells detect insulin and signal them to take up the glucose to either use as energy or store, reducing the amount of glucose in the blood. As a result, blood glucose levels will decrease over time following the meal. They can also decrease more rapidly with exercise. If blood glucose levels dip below the optimal threshold, glucagon, the partner hormone to insulin, is released. Glucagon triggers the liver to release glucose from storage and manufacture more, thereby either raising or maintaining blood glucose levels. The pancreas continually adjusts the insulin and glucagon levels to keep blood glucose in an optimal range. Glucose levels are often shown as milligrams of glucose per deciliter of blood written as mg/dl. Figure 1 illustrates how blood glucose levels might look over one day for a person with healthy glucose control eating healthy meals. In contrast, Figure 2 shows what unhealthy or disordered glucose control might look like over a similar one-day period. Consistent disordered glucose response is seen in the metabolic disorders of prediabetes and type 2 diabetes (T2D) but likely begins before these diagnoses are made. Spikes and crashes can occur for people without these disorders when eating high-carbohydrate, low-nutrient-density meals or foods. With prediabetes or TD2, often two interrelated problems occur: Problem 1: Insulin Resistance (IR): In IR, cells that detect insulin in the blood resist insulin’s signal to take up the glucose, so less glucose goes into the cells, leaving more glucose in the blood. This results in both increased baseline glucose levels and higher glucose in the blood after meals. Problem 2: Reduced Insulin Output: In this case, the body’s ability to make insulin is reduced. As with IR, with less insulin available to signal the cells to take up glucose, more remains in the blood—both after meals and between meals. These higher levels of glucose in the blood, known as hyperglycemia, can result in spikes after meals. It also likely means that extra glucose is already in the blood before the next meal, potentially causing an even bigger spike. Blood sugar crashes can also occur, leading to fatigue and sugar or carbohydrate cravings. In a person with diabetes, this crash can trigger more severe symptoms such as blurred vision, loss of consciousness and even coma. Insulin resistance and reduced insulin output are thought to be caused by a combination of complex factors involving the environment, lifestyle and genetics. The predominant lifestyle factors shown to have a high correlation with insulin resistance include lack of physical activity, sedentary lifestyles and unhealthy dietary patterns (including excessive caloric intake and diets high in processed foods). While the above illustrations show the contrast between a normal and disordered blood sugar, they depict clear cases of healthy versus disordered response. Most individuals vary along a spectrum of responses between these examples. Why is there concern over disordered blood sugar control? Chronic hyperglycemia, which refers to a pattern of frequent high blood sugar levels, has been linked to markers of chronic inflammation and favors the growth of existing tumor cells. Chronic inflammation can cause damage to both blood vessels and nerves throughout the body, and hyperglycemia supports the growth of energy-hungry tumor cells and increases cancer risk for many cancers. In addition, studies have shown that type 2 diabetes increases the risk for a wide variety of diseases, including: Cardiovascular diseases such as heart attacks and strokes. Chronic kidney disease that can result in the need for dialysis. Vision problems and blindness. Nerve damage, which starts as tingling, burning or numbness and which may lead to complete loss of feeling (neuropathy). Nerve damage that leads to irregular heartbeats. Reduced fertility. Increases in certain cancers including pancreatic, breast, endometrial, colorectal, liver and bladder. Diseases related to long-term brain health, including Alzheimer’s and dementia. A poor and disordered glycemic response can not only affect your long-term health, but it can also affect your daily life by causing food cravings, modifying energy levels and even disturbing sleep. Part 2 of this series will look at the emerging research and technology that has the potential to bring new understanding and solutions to improving glycemic control. Resources Click here for the full list of resources. Jill Goldring, MNSP, MSIE Jill Goldring is a nutritionist, engineer, avid gardener, beekeeper and healthy food enthusiast. Nutrition is a second career for Jill after a successful Silicon Valley career managing high-tech projects. Jill is interested in the intersection of diet, glycemic response, microbiome and metabolic health outcomes. Her goal is to make positive changes to food systems and services that provide healthy food, nutrition education and nutrition technology to underserved communities. She is a volunteer with the Samaritan House San Mateo. She manages a pilot program that pairs nutrition education focused on glycemic response and CGM (continuous glucose monitor) technology for the free medical clinic’s food pharmacy for diabetic patients. She has Master’s in Nutrition Science and Policy from Tufts University Friedman School of Nutrition Science and Policy, a BS in Industrial and Systems Engineering from USC and an MS in Industrial Engineering from Stanford University. guthappynutrition@gmail.com Instagram: @guthappynutrition

Robert H. Lustig, M.D., M.S.L. is Emeritus Professor of Pediatrics in the Division of Endocrinology, and Member of the Institute for Health Policy Studies at UCSF. Dr. Lustig is a neuroendocrinologist, with expertise in metabolism, obesity, and nutrition. He is one of the leaders of the current “anti-sugar” movement that is changing the food industry. Dr. Lustig graduated from MIT in 1976, and received his M.D. from Cornell University Medical College in 1980. He also received his Masters of Studies in Law (MSL) degree at University of California, Hastings College of the Law in 2013. He is the author of the popular books Fat Chance (2012), The Hacking of the American Mind (2017), and the just released book Metabolical: The Lure and the Lies of Processed Food, Nutrition, and Modern Medicine. His 90-minute lecture- Sugar: The Bitter Truth has been viewed over 14 million times on YouTube. He is the Chief Science Officer of the non-profit Eat REAL, he is on the Advisory Board of the Center for Humane Technology, Simplex Health, and Levels Health, and he is the Chief Medical Officer of BioLumen Technologies, Foogal, Perfact, and Kalin Health. ​ At the salon: Dr. Lustig delved into what is healthy in our food supply and what is not. He armed us with ways to avoid the unhealthy options. Click here to view Dr. Lustig's salon video. ​​ ​Contact Information: Website: robertlustig.com YouTube video- Sugar: The Bitter Truth ​ Click here to purchase Metabolical: The Lure and the Lies of Processed Food, Nutrition and Modern Medicine Click here to make a donation to EatReal.Org (Dr. Lustig is their Chief Science Officer)