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By Karen Miller-Lane, ND, L.Ac “ The fact is, everyone--both men and women-- naturally lose muscle and strength with age.  If you do nothing to stem that loss, you can expect to lose up to 8 percent of your strength each decade after your thirtieth birthday, and that decline accelerates after age 60.  So by the time you’re 55, you might be 20 percent weaker.  The years around menopause can make this worse, as estrogen is essential for muscle stem cell function and maintenance and is also the main driver of muscle mass and strength.”  STACY T. SIMS, MSC, PhD.  is a forward-thinking international exercise physiologist and nutrition scientist who aims to revolutionize exercise nutrition and performance for women. “Older muscle still responds to resistance training, proving again that it’s never too early or too late to start reaping the benefits of this crucial strategy for preventing muscle losses with age.  Show me a 90-year-old who says, “Gee, I wish I had less muscle mass” and I’ll show you a leprechaun at the end of a double rainbow riding a unicorn kissing a mermaid.” Peter Attia, MD. a Stanford/Johns Hopkins/NIH-trained physician focusing on the applied science of longevity, the extension of human life, and well-being In the following article, I hope to do four things to explain the importance of strength training for peri and postmenopausal women: Provide a definition of who we are speaking about when we use the term “peri” and postmenopausal women.” Clarify the mixed messages women have received regarding the importance of strength and, in particular, muscle mass, as we age.   Explain how strength training, along with other forms of exercise, can support the effects of normal declining sex hormones.   Lastly, I will offer some practical recommendations regarding how to include strength/resistance training in our lives now, and for the rest of our lives.  I want to make explicit how we can meet our expected life transitions and how mindful attention, action, and commitment to strength training (and of course, good nutrition, and sleep) is essential throughout our lives, but, specifically, in the second half of our lives.  I want to empower you through education, tools and embodied awareness to meet the next half of your life with strong and open arms. 1. What is Perimenopause and Menopause? Menopause is defined as the moment when women have not had a menstrual cycle for one year or 12 months.  If you do not have a cycle for seven months, and have one in month eight, you start counting anew.  Menopause is defined as 12 consecutive months without a menstrual cycle.  Perimenopause refers to the time before menopause which can be anywhere from five to 10 years prior to menopause. During this time, hormones are in flux.  We can feel like we’re in different bodies every 6 months and in a sense, hormonally, we are. These are moments in time similar to when a girl gets her first menstrual cycle.  A girl's first menstrual cycle and a woman's last menstrual cycle mark the beginning and end of a particular hormonal dance.  This hormonal dance impacts our heart health, bone health, muscle strength, metabolic health and so on.  Female bodies dance with estrogen and progesterone (along with numerous others) from our first menstrual cycle to declining levels of these two hormones after our last menstrual cycle.  These terms - menstrual cycle, PMS,  perimenopause and menopause - are ways in which medicine delineates and measures, but in no way do these terms reflect the nuanced, dynamic, whole and varied experience of each woman as she journeys through the moments and transitions of a life.  We are continually learning and understanding our hormonal dance. “ It’s never too late to begin incorporating some form of resistance training into one’s fitness routine, and evidence shows that even adults in their eighth and ninth decades of life gain muscle mass when they engage in resistance training.  Although the hypertrophic gains are modest in older adults, the relative strength gains can be enormous -- and may even be lifesaving, reducing the risk of falls and other aspects of frailty.  Of course, one will gain the greatest benefits from resistance exercises when they’re part of a lifelong program of fitness.” Brad Shoenfeld, Ph.D. He is a full professor in the Health Sciences Department at Lehman College in the Bronx, NY, and serves as the Graduate Director of the Human Performance and Fitness program. 2. The historical exclusion of women in medical studies and the impact this exclusion has had on our understanding of the importance of strength training for peri and menopausal women.     Before 1993 women were rarely included in formal medical studies in the United States. 1 The majority of studies on exercise, let alone strength or muscle mass were done only on men. As a result, conclusions from these male only studies regarding what might be “normal” were simply applied and ‘translated’ to female bodies. The assumptions on which the medical establishment has determined how to address cardiovascular health, how we build strength, and so on, have been historically based on male only data.  This is starting to change, albeit slowly.  Research that includes female bodies is starting to decipher how to support and enhance aging well in female bodies.  We are beginning to understand that what supports peri and postmenopausal women may be different from a lot of the information regarding strength and fitness that is currently considered mainstream but was, in fact, built on male only studies.  Myths surrounding muscle building for women: Socio-culturally in the U.S., being fit for men has meant building muscle and for women losing weight. Women have been steered toward cardio to lose weight.  We've had to contend with myths such as, “strength training causes women to ‘bulk up’” or  “women shouldn’t get too muscular”.  This emphasis on weight loss over strength training is misguided and wrong because strength and muscle mass are crucial to healthy aging.  Strength training, including lifting heavy weights with fewer repetitions translates to strength and power; strength and physical power can help provide overall body stability that can help prevent falls and not breaking a bone if we do fall. Furthermore, strength training does not have to mean “bulking up.”  Fortunately, we are now seeing spaces and places where a range of women's bodies are celebrated.  The 2024 Paris Olympics, for example, provided an opportunity to witness strong, powerful, amazing women in many shapes and sizes from gymnast Simone Biles to rugby player Ilona Mayer.  The message I want to reinforce is that strength training is about getting healthy and strong.  Strong means the ability to carry groceries, lift luggage, play with our grandchildren, catch ourselves when we fall–in other words, staying active and engaged.  Female bodies are different from male bodies.  We do not have the same hormones and females have different mass and a different ability to put on muscle than male bodies, especially in peri and postmenopause.  Let’s stop the not so old messages of being only one particular size or shape. Let’s think strong and allow ‘strong’ to show up in as many different shapes and forms as there are women in the world. “Overall, [we are] breaking the stigma that women need to prioritize long, endurance exercises and exclusively body weight work because they offer little benefits for body composition or lean mass during this time.  Instead, lifting heavy (whatever that means to you) will help most during this transitional period.” Dr. Stacy Sims 3. Female hormones, the dynamic experience of menopause and the need for strength exercises The subject of female hormones is a beautiful and complex field (how could it be anything else?!). In this section, I will offer a brief overview of how our hormones play a role in muscle strength, flexibility, injury and recovery.    Your hormones are signaling molecules that regulate your physiology and communicate with nearly every cell in the body.  Hormones guide your cells to do various things such as build or break down bone. Some hormones are altered due to changes in body composition, poor insulin sensitivity, and disrupted sleep. Other hormones, such as estrogen and progesterone decline with age.  This decline is normal although women have varied experiences.   Throughout peri and postmenopause there is a decline in estrogen and progesterone. This decline is not linear but dynamic.  Estrogen and progesterone are always in relationship with one another; levels of one can significantly influence the other. Estrogen and progesterone levels also fluctuate, and they can be irregular.     Estrogen is important for strong muscle contractions and for generating power and force. As a result, it helps drive the development of lean mass. Estrogen also promotes insulin sensitivity, helps manage body temperature through control mechanisms like blood flow to the skin and sweating, helps regulate nitric oxide, a compound in your body that works to expand your blood vessels for better flow, and is critical for maintaining both bone density and the strength of our bones. Estrogen helps to protect against heart disease and helps to keep your blood vessels healthy, limit inflammation, and control cholesterol levels.  2 Progesterone dances with estrogen in that it can stabilize connective tissue and support increased tension on tendons and ligaments.  Progesterone also produces a calming, anti-anxiety effect in the brain and may enhance memory function.  When progesterone levels are high we also have a greater pain tolerance. Finally, as with estrogen, progesterone decreases the rate of bone resorption and also reduces the loss of calcium in our urine thereby supporting bone health.  As you can see from just this very short overview, hormones are involved in numerous pathways to support women's health.   How strength training supports declining sex hormones. Certain types of exercise, such as strength training (a type of exercise that uses resistance to build muscle strength, endurance, and size),  provide the neural stimulation you need to get your muscles contracting strongly to reproduce estrogen's positive effects.   Building true strength is a matter of increasing the maximum force your muscle can produce in a single contraction--how much you can lift or move in one action.  Exercises that challenge us stimulate satellite cells which regenerate muscle stem cells and replace the muscle and strength-building stimulus that we are losing as estrogen declines in the peri and menopausal years. Estrogen affects how your brain structures are connected, the way your brain cells communicate, and even the shape of your brain. 3   Hence, we want to approach exercise as not only good for muscle building but also as crucial to our overall brain health and function.   When we engage in strength training, we are using the central nervous system to create new neural pathways.  High intensity work, such as lifting heavier weights over time,  produces more brain derived neurotrophic factor (BDNF) thereby supporting and benefiting brain health.  4     Strength training stimulates a hormonal response to build lean mass, maintain and build our bones, and support other hormones such as serotonin and norepinephrine to support vasomotor symptoms such as hot flashes. Strength training is also good for our hearts.  It increases our vascular compliance (our blood vessels dilating and constricting more readily) giving us better blood pressure control and flow to skin and muscles.  Women who did strength training saw an even greater reduced risk of cardiovascular-related deaths – a 30% reduced risk, compared to 11% for men. 5 Strength training increases metabolic rate which means you burn more fat while you exercise.  Researchers have noted that “lean body mass seems to be the most important contributor to the observed changes in metabolism in women in the early stages after menopause”. 6  After six weeks of strength training and eventually lifting heavier weights, you begin to create changes to how the muscle utilizes carbohydrates for energy so we need less insulin, therefore better blood sugar control.   Building resistance (ie. strength) involves lifting heavier weights over time, which stimulates lean mass development and sends a signal to our body to decrease central and total body fat. Heavy resistance training is much more effective for changing body composition than endurance-based lifting or your typical cardiovascular exercise, especially in the years leading up to menopause and the years that follow. 6 7 Lifting heavy weights (properly!) stimulates your tendons and ligaments to increase their tension and give you overall stability and support your joints–such strength training is important for bone health. It improves bone mineral density which means stronger bones.   The bones need a compressive force on them to grow, and the compressive force comes typically when the muscles around them are contracting.  When the bone is put under load with strength training it sends a chemical signal to the osteoblasts and osteoclasts, which are the bone building and bone decaying cells respectively.  I refer you to this study by Belinda Beck at Griffith University in Australia called the LIFTMOR trial .  Here is a you tube video of her talking about the study. In summary, strength training, a certain type of high intensity interval training called sprint interval training, plyometrics, balance and mobility exercises support the outcomes that sex hormones once did in our early years, for the second half of our lives. Just adding back hormones will not prevent muscle loss. Engaging in these types of exercises - along with a good diet, and sleep -  support building healthy bones, heart health, mood and cognition, and muscle strength. My goal here is to provide accurate information that will enable you to make informed choices to meet this next life transition actively.  Now, let’s review how to begin. 4. How to begin–some practical recommendations Begin where you are.  Seriously.  If you have never lifted a weight before, strength training will initially mean supporting your own body weight. Start with a beginner’s yoga, pilates, or bone builder’s class.  If you have been lifting weights for some time, using the same amount of weight, with the same number of repetitions and the same movements, you are putting in work without any significant gains.  Our body adapts and needs regular stimulus to get stronger and mobile.  At least every 6 to 12 weeks we want to try new workouts or increase weight for example.  In addition, correct form is crucial.    Take a class from a trusted and respected instructor, work with a trainer, or watch a YouTube video of someone who can educate you on proper form. Otherwise, we risk injuring ourselves and stopping the process before we have a chance to make progress.  Slow and steady is the rule here.  Building muscle is a lifetime endeavor.  We also need to work with the body we have - past injuries and health concerns need to be thought through and discussed with your doctor, perhaps a trainer or physical therapist.  We need to listen to our body, which means there will be weeks when we may need to tone things down or ramp things up.  We want to be aware of changes to our schedule and how we can accommodate workouts in the face of these changes.  For example, on vacation, we can do some body weight exercises in our hotel room or family guest room and go for long walks if we don’t have access to equipment of the same routine.  My mantra is to stay mindful and consistent.  We are consistent when we are able to dance with change and meet it in innovative ways.   How do we sustain a healthy routine?  Try to establish the habit of doing something active every day.  This does not mean you need to do strength training daily.  Strength training 3 times a week builds and maintains muscle strength and power.  The rest of the week can include things like walking, cycling, yoga, stretching, zumba, swimming, dancing, yoga, pilates, tai chi, sprint interval training, and plyometrics to name a few.   If you have never lifted a weight before or been very active - start walking most days for 15 to 30 minutes.  Then, start including hill work.  Then, consider working with a trainer. Take a strength training class, bone builders, yoga, or pilates.  You can graduate to adding other bodyweight exercises.  I’ve included examples below.  Then begin lifting weights! Warm up exercises for seniors and beginners Bodyweight box squat Wall…push up Over 60 - 5 exercises  - scapular retractions; glute bridges; squats; heel lifts; grapevine For seniors  - wall push up; pull up; farmers carry; hip hinge; squat Core exercises for osteoporosis Complete Beginner strength training program example   When will I see the results? Be aware that the data on muscle protein turnover does not show increases in hypertrophy (building muscle) during the first six weeks of strength training (with weights).  During this time, muscle tissue is remodeled to become stronger, more resilient, and it starts protecting itself against damage.  The first six weeks is a time and cycle where muscle tissue is simply turned over.  After approximately 6 weeks, you will start seeing increases in building muscle and lean mass.  Keep going.  After 8 to 12 weeks we start to notice differences in our strength, energy and power. We can sometimes begin to measure the increased muscle mass in inches. Things to keep in mind when strength training Correct Form . Using correct form   is extremely important to prevent injuries in any activity but, particularly, when we are engaged in strength training.  We need to learn how to use our hips, knees, track our legs with our feet, and how to balance and create stability.  As we are building our practice - we need to consider increasing the frequency, then duration, and lastly intensity.  If we build intensity first, we are likely to injure ourselves.  Try to be mindful and consistent. Neuromuscular control.  In weight training, proper form not only ensures that we are building strength safely, but proper form means we are learning to control the weights we are using.  Our hand-eye coordination, coverall coordination, and balance increases with our strength.  A lack of neuromuscular control means that we are moving a weight we cannot control which inevitably leads to injury.  ( 8 min video on the basic concepts behind neuromuscular control ) Progressive overload .   This is a type of strength training that gradually increases the intensity of workouts to avoid a plateau in muscle mass and strength. If we are not continuing to challenge ourselves whether in the amount of weight we are moving, the duration, or intensity, then, we are no longer building muscle or strength.  In other words, if you have been doing the same strength training regimen for the past year without any changes you are not building strength or muscle. Again, this matters because as we get older, if we aren’t consistently training, we can lose 10–15% of our muscle mass and strength per decade.   And we need to realize that as we age our bodies have gotten into various patterns and certain muscles are overused and others are underused.  As we continue to build strength, mobility, and balance we may need to account for these imbalances with further support from a personal trainer or physical therapist to ensure that we do not injure ourselves.   Recovery . Recovery is another important element of any workout.  Conscious and healthy recovery is correlated with muscle growth and strength (if we are sore all the time we are probably training incorrectly or overtraining).  We need to give our bodies time to recover from a hard workout.  If we did a full body strength training workout then we need to give our body a day or two to recover, repair, and build muscle.  If we overtrain, doing too much too soon, we will injure ourselves and not gain many of the benefits. If you have been lifting weights, here are some examples of at home you tube videos . Full body 30 minute with warm up and cool down. 20 minute full body work out Upper body workout Lower body workout Other recommendations to support strength training The following are included to provide a full picture of other aspects of strength and balance that are critical to aging well.  Experiment with the various options below and begin to sprinkle these in throughout the week. CORE EXERCISES Complete Core Strengthening   10 minute follow along Five minute standing Pilates Abs 12 minute standing abs with weights 10 minute abs no equipment PLYOMETRICS Whether you jump, hop, or bound, plyometrics gives your bones and muscles the extra stimulus that comes when you push off against gravity and land back down. It is those impacts—big or small—that generate important physiological changes. For one, they help build bone, which we lose during the menopause transition. Plyometrics also trigger epigenetic changes, or changes in your genes. When you do plyometrics, you wake up some otherwise very quiet genes inside your muscle cells that stimulate those cells to improve power and even the composition of the muscle itself in a way that improves the integrity of the muscle, its contractile strength, and its response and reaction time. They also improve your mitochondria function and insulin sensitivity—both of which are important for menopausal women.  If you are not used to doing these exercises, start slowly and if you are hesitant, working with a guide or organized group can help. SPRINT INTERVAL TRAINING (SIT) Sprint Interval Training is a form of HIIT (High intensity interval training). If you want to maintain your top end, you need to train your top end. That’s especially true during the menopause transition. The best type of high-intensity interval training for menopausal women is super short, sharp sprint-style intervals lasting about 30 seconds or less.  When you extend intervals past 60 seconds, you can get greater increases in the stress hormone cortisol and cortisol is good for a surge of energy. However, you don’t want those stress-hormone levels to stay elevated longer than necessary to get the job done, especially in menopause when cortisol can already be elevated. With 30 second sprint intervals, you still get the benefits–improved insulin sensitivity, stronger mitochondria, improved fat burning (especially visceral fat), and an ever-important boost of growth hormone after you finish! “ Tabatas ” are a simple way to add intensity to any exercise: After a warm-up, push as hard as possible for 20 seconds. Recover for 10 seconds. Repeat 6 to 8 times. Rest 5 minutes, and work up to repeating 2 to 3 more rounds.”  8 Here is another example of a sprint training interval that would be performed after a really good warm up or after your strength training workout: Do a dynamic warm up moving all joints in all directions. Then jog or fast walk for five to ten minutes.  Wear a stopwatch and time your sprints. Do your warm-up, sprint for 20 to 30 seconds and stop completely or walk. Rest (or walk ) for a duration twice as long as your sprint. For example, your rest would be 40 to 60 seconds. Sprint again after your rest and repeat for two to five intervals.  If you don’t want to sprint you could do this on a bike, rowing machine or on the road. If you can’t do more than 2 or 3, you are on the right track!  This should be hard.  You can always add it at the end of your strength training workout. There have been several studies on postmenopausal women showing the muscle-making powers of sprint interval training (SIT). In a 2019 study published in the journal Medicine & Science in Sports & Exercise,  researchers had a group of postmenopausal women ages 47 to 59 perform 20 minute bouts of SIT—alternating 8 seconds of sprinting on a stationary bike with 12 seconds of easy pedaling—three times a week for eight weeks. By the study’s end, the women lost fat, regained muscle mass, and also improved their aerobic fitness by 12 percent. 9 TOES/FEET/CALVES “ Toe strength is the biggest predictor of falling in people 65 years old and older.”   Courtney Conley an internationally renowned foot and gait specialist An often overlooked part of the body involved in building strength involves our toes and feet.  We want to include exercises to build toe/foot strength and calf strength. Courtney Conley, DC, is an internationally renowned foot and gait specialist.  As Courtney’s good friend Jay Dicharry always says, “ You can’t build a jet engine on a paper airplane.”  She emphasizes how we’re building all of our strength and focus on everything above the knee when in reality gait is shock absorption, it’s stance ability, it’s propulsion, and all of those things enable us to become efficient with movement. 10 Below are some exercise examples that include our feet and calves, a whole body approach to strength training.  Big toe banded exercises : 40 reps in each direction, if you can’t do the little toe, just focus on the big toe and then the 4 toes Banded toe spread Toe Yoga Training for the Anterior Fall Envelope : 20 reps. 3-5 second holds  Any type of calf raise: double leg standing , double leg seated   To specifically target the soleus, seated is better since the knee needs to be bent >60 degrees Do a single-leg calf raise using something as simple as a container of laundry detergent on your knee at home (a full detergent container weighs about 17 lbsThe aim is to feel fatigued after about 3 sets of 6-8 rep For a challenge, you can slow down the tempo and really squeeze at the top Active dorsiflexion ROM coupled with tibial rotation For general balance this works on activating the extensions of the toes and works on toe splay Do 20 reps then try to balance; ideally start with 10 seconds on each side, working up to 30 seconds. Closing thoughts Hopefully you have gotten a flavor of why strength training is part of a practice of aging well during perimenopause, menopause, and beyond.  My focus is on our quality of life. Growing older requires thinking about and experiencing ourselves as dynamic beings who are always changing and evolving.  We need to loosen the grip on the question, “How do I get back to where I was?” and, instead ask: What patterns will support how I want to live the rest of my life?   In order to step into the years that will follow with courage, grace and strength (literally!), we need to honor and welcome honoring where we are now and who we are now and build from this beautiful, dynamic place.  This approach will require different kinds of work and attention.  Just because we didn’t need to work out very much in our 20’s and 30’s doesn’t mean that there is something wrong if we have to in our 50’s, 60’s, and beyond. If we are already active, we may be noticing more aches, pains and injuries that have sidelined our ability to do the things we love with the same intensity that we once did.  Healthy aging requires different choices, and different kinds of work to stay strong, flexible, and mobile.  There is a lot of good life to live and,if we look around, we see numerous examples of people stepping up, embracing the work with humor, humility and grace, and aging well.   I know that I have included a lot of information in this post, but don’t let it overwhelm you.  Start simply.  Whatever that looks like for you.  Schedule it in.  Just begin.  Strength training doesn’t solve all our problems.  There is never one magic thing that changes our health outcomes.  Our health includes a constellation of practices that we engage with and stay   consistent with over time.   This is not a short term solution.  This is for life .  The choice to eat in a manner that will support a healthy body composition is not about the latest fad diet but what we are willing to do, consistently over time, along with other healthful practices that have lasting effects.  [See my article on protein.]  Our consumer culture would have us believe that the right fix takes just one, perfect purchase. But, by the time we are in our 50’s and beyond we have accrued enough life experience to recognize this is wrong and harmful.  We also start to recognize that we have to put more time and effort into our food choices, our sleep, exercise, and other lifestyle choices in order to stay healthy, fit, and have the quality of life we want for the next decades of our life.  Science is confirming what we know deep inside–we can get better with age with the conscious, mindful incorporation of consistent, life-affirming habits, in community.  “Faith is in taking the first step even when you don’t see the whole staircase” Martin Luther King, Jr. 1.   National Institutes of Health, NIH Inclusion Outreach Toolkit: How to Engage, Recruit, and Retain Women in Clinical Research 2. Centers for Disease Control and Prevention. Leading Causes of Death - Females - All races and origins - United States, 2018. 3. Barth C, Villringer A, Sacher J. Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods. Front Neurosci. 2015;9:37. doi:10.3389/fnins.2015.00037 4. Sarita Khemani, MD, https://longevity.stanford.edu/lifestyle/lifestyle-team/khemani-bio/ 5. https://www.nhlbi.nih.gov/news/2024/women-may-realize-health-benefits-regular-exercise-more-men#:~:text=Women%20who%20did%20strength%20training,compared%20to%2011%25%20for%20men . 6. Stacy T. Sims, Roar, New York: Rodale, 2024. 7. Ibid., pg. 90. 8. https://www.drstacysims.com/blog/how-to-power-your-way-through-menopause#:~:text=That's%20especially%20true%20during%20the,in%20the%20stress%20hormone%20cortisol 9. Boutcher YN, Boutcher SH, Yoo HY, Meerkin JD. The Effect of Sprint Interval Training on Body Composition of Postmenopausal Women. Med Sci Sports Exerc. 2019 Jul;51(7):1413-1419. doi: 10.1249/MSS.0000000000001919. PMID: 31210647. 10. https://peterattiamd.com/courtneyconley/   Peter Attia Podcast #296 - Foot health: preventing and treating common injuries, enhancing strength and mobility, picking footwear, and more | Courtney Conley, D.C., April 1, 2024.

I'm not sure where I got this recipe, there are lots of great recipes online, but this one is both delicious and nutritious and turns out great every time! Hemp Hearts Tabbouleh 1/2 cup extra virgin olive oil 1/4 cup lemon juice 1/2 tsp sea salt 2 bunches of parsley - chopped (I sometimes add another bunch) 1 1/3 cup Hemp hearts 3 medium tomatoes - diced 8 green onions, finely diced 1 garlic clove - minced optional: 1/4 cup chopped fresh mint Mix olive oil, lemon juice and sea salt - whisk to combine Then add remaining ingredients, toss to coat and serve. It is best fresh. Based on 6 servings: calories:  293 fat: 32.6 carbs: 8.1 g fiber: 5.2 g protein: 13.1 g

By Karen Miller-Lane, ND, LAc “The challenges of studying nutrition and aging are one of the reasons I’ve become more flexible in my beliefs around diet for optimizing health with age. What is clear from reviewing the current evidence is that most people would benefit from increasing their protein intake with age. While there may be some exceptional circumstances, for many people, higher dietary protein would help maintain skeletal muscle, improve immune function, and reduce frailty – all of which translate to an increase in lifespan and healthspan.” Peter Attia, MD a Stanford/Johns Hopkins/NIH-trained physician focusing on the applied science of longevity and well-being How many of us understand what protein does and why it is important, let alone how our needs change as we age? Protein is one of the macronutrients, along with carbohydrates and fats that we hear alot about when it comes to supporting good health. Based on the research over the past 40 years we now understand that increasing protein and resistance training can contribute to thriving as we age and prevent a condition called sarcopenia. Sarcopenia is the loss of muscle mass and strength as we age; it can increase the risk of falls and fractures as well as contribute to frailty. The focus for this article is the importance of protein. I will leave the importance of resistance training for another article. However, protein and resistance training go hand in hand. But, for now, let’s explore what protein is, what it does, why it’s important, how much we may need, and explore examples of how to get enough protein daily. Proteins are essential for building new tissue and repairing old tissue. There are 20 amino acids that go into making a variety of proteins. Protein is made up of 20 amino acids. All of the 20 amino acids contribute to a wide array of cellular activity such as creating enzymes and hormones. We require approximately 300 grams of new protein per day. Of the 20 amino acids that are important for maintaining healthy muscle tissue and maintaining cellular activity, there are 9 essential ones that we need to get from our diet. Animal protein is considered a complete protein because it contains all of the 20 amino acids that we need. Plant based proteins are considered incomplete because they lack one or more of the essential amino acids. Proteins are much more than we realize. For example, insulin and our liver enzymes are made of proteins. Insulin is composed of 51 amino acids and myosin (a protein for muscle contraction) is made up of thousands of amino acids. Liver enzymes are replaced every hour whereas muscle proteins have a half life of 15 days. Amino acids, such as leucine, are also signaling molecules that directly stimulate muscle protein synthesis - building and maintaining muscle. For every new protein that’s getting made in the body about 6 or 7 amino acids are getting recycled. The body replaces every protein in it about four times per year. While we understand that young bodies have particular nutrition requirements, research is revealing that aging bodies have different nutrition and lifestyle requirements. According to Don Layman, a Professor of Food Science and Human Nutrition at the University of Urbana-Champaign, “aging increases the daily turnover of protein, meaning there is a greater need for protein intake simply to replace the tissue you already have.” For the past 40 years, Layman has investigated the role of dietary protein in muscle protein synthesis. He states, “We now know that protein efficiency goes down as we get older. If you give a 16 year old a certain amount of protein they will have a very good response. A 65 year old may have a 10% response or no response at all. As we get older, we can buffer that response with higher quality proteins and resistance exercise.” “Your overall health is determined on keeping the muscle healthy because it keeps everything else healthy.” Don Layman, Ph.D. When we get older, a higher level of certain amino acids such as leucine is required to stimulate maximum muscle stimulation and growth. Aging reduces the ability to breakdown and synthesize protein which reduces our ability to build muscle mass and strength. This is called anabolic resistance. The nutrition that allows you to easily build muscle in your 20s won’t be sufficient to keep building lean mass in your 50s and 60s. With the study of one of the essential amino acids leucine, Don Layman has found that if you give leucine to an older adult you can actually make the adult look just like a 16 year old in terms of muscle stimulation and growth. What we are learning is that while efficiency of synthesizing protein goes down, the capacity to respond does not. Resistance training and protein are a powerful signal for promoting protein synthesis, countering anabolic resistance, and maintaining muscle with age. The good news is it’s never too late to build muscle. We have the capacity to build and maintain muscle in our 60’s, 70’s and beyond. In order to do this we need to pay close attention to both the quantity and quality of our protein and incorporate consistent resistance training. Current thought in the field is that if you have a dietary protein requirement that’s about twice the minimum RDA of 0.8 gm per kg (2 x 0.8 = 1.6 gm per kg), you can get the 65 year old to respond the same as the 20 year old in terms of muscle protein. ” Don Layman, Ph.D. As we age, we have a greater need for protein simply to support cellular activity and the decreased ability to recycle our own protein. By increasing protein and focusing on high quality protein, we can maintain and build muscle and support the increasing need that comes with aging. The Recommended Daily Allowance (RDA) is a low water mark, it’s the minimum required to prevent disease. This may not reflect what is necessary to support optimal health. The difference as we age between 0.8 gms of protein per kg of body weight and 1.6 gms of protein per kg of body weight is the difference between living and thriving. Using the formula above which reflects a dietary protein requirement that’s about twice the minimum RDA, let’s provide an example of a ballpark range of protein requirement. Using 1.6 gms per kg, a 60 year old, 140 pound woman (140 divided by 2.205 = 63.502 kg x 1.6 (gm per kg) would need approximately 101 grams of protein daily. For a 200 pound male that would be around 145 grams of protein daily. A number of leading authorities in the field are suggesting that these may be on the low end depending on exercise and activity level. Some authorities recommend 2 gms per kg. Another consideration is how we look at the macronutrient protein. When we look at the macronutrients, protein, carbohydrate and fat amounts are often reflected in percentages such as ‘fat should be 20% of calories’. Based on current research, the amount of protein we get in a day should be an absolute number such as 100 gms NOT a % of calories such as ‘protein should reflect 30% of overall calories. Our need for protein is an absolute number and shouldn’t go down even if we are lowering overall calories. So if you are trying to lose weight, especially in our 40’s and beyond we need to be maintaining our absolute number of protein in grams. If I determine, for example, that I need to take in 1800 calories to lose weight and I need 101 grams of protein a day, I need to eat 101 grams of protein a day and work my other macronutrient calories of fat and carbohydrates around it. Consuming the necessary or ‘absolute number’ of protein is important because when people are trying to lose weight they don’t think about what they are losing. We don’t realize that we are losing lean muscle along with fat. So not only do we have an increased tendency to lose lean muscle, we exacerbate this when trying to lose weight. Muscle helps us to burn fat and excess calories and it is important for good metabolic health - how we break down and use energy. Research continues to support the fact that building and maintaining muscle mass is critical for remaining active and healthy as we age. As we age, there is a greater need for protein to just replace the tissue we already have. Also with age there is a blunted response to protein and therefore building muscle. Protein is essential to increasing muscle mass and we shouldn’t short change our consumption of protein when on any weight loss plan. This is also why it is important to understand that we need to get an absolute number of protein based on age and activity, not as a percentage of calories. When we look at protein there are two factors that go into a protein quality score: What’s the composition of those 9 essential amino acids? What’s its bioavailability? (how well do we digest it and absorb it) Not all protein is equal, getting 20 grams of protein in a meal doesn’t mean we are digesting and absorbing 20 grams of protein. Animal proteins contain all the 20 amino acids. They are complete proteins. With animal proteins and most isolated proteins such as whey, even soy protein isolates, the digestion and absorption is pretty close to 100%. Digestion and absorption for animal proteins is usually 95% or higher. Digestion and absorption for plant proteins is approximately 60-70% available because we can’t digest the fiber attached to the protein. Plant proteins are incomplete in that they do not have all of the 9 essential amino acids. If you are eating a plant based diet, the three important essential amino acids to make sure you get enough of are leucine, lysine, and methionine because they will be limiting in adults for protein synthesis - the ability to absorb and utilize the protein. Lysine is always limited in grains, methionine is limited in legumes, and methionine is low in all plant products. Protein synthesis is limited by the availability of the 9 essential amino acids. If our 20 grams of protein is limited by methionine or especially leucine, the body will only make protein until the methionine or leucine runs out. Don Layman explains that if you look at wheat protein on a cereal box and, for example, say it was wheat flour; and the cereal box says there’s 4 gms per serving of protein, there’s actually less than 2 grams that you can actually absorb. This is where quantity matters and if you are eating a plant based diet you should be aiming for 100 to 125 gms of protein per day to ensure an adequate amount of bioavailability. In our 50’s, 60’s and beyond, if you are only getting around 50 grams of protein a day, you may not be getting adequate amounts to support maintaining muscle and building new tissue, repairing old tissue, and the wide array of cellular activity that adequate protein provides. You may be asking how I can navigate and apply this information today? In general, determine how much protein you need based on the recommendation of 1.6 grams per kg especially if you are 50 years or older and consider 2 gms per kg if you are an athlete or quite active. Remember, protein quantity and quality become more significant as we age. I always recommend as close to a whole foods diet as you are able. This means the food you are eating and preparing is as close to how it came into the world - for example, an apple vs. an apple pie. Examples of meeting protein needs in a day: Breakfast options: 2 egg white/2 egg (4 egg) scramble (20 gms protein) - adding 1 oz of cheese increases this to 25 to 27 grams of protein. ¾ cup greek yogurt plain (add your own sweetener) with blueberries (17 gms protein) High Protein Overnight oats (approx. 38 gms protein) see recipe below Lunch options: Salmon salad with 1 can of salmon on a bed of greens and veggies (38-40 gms protein) or in a whole grain wrap. Bean and Vegetable Enchilada Casserole (15 gms of protein) see recipe below Mid-Morning or Mid-afternoon snack options: Whey protein isolate or pea protein shake (20 to 25 grams of protein) 1 cup of edamame (17 grams of protein) Dinner options: 4-6 oz of chicken or turkey breast - used in a veggie stir fry (4 oz = 35 gms; 5 Oz = 44 gms; 6 oz = 52 gms) One pot lentils and Quinoa (19 gms protein) see recipe below Examples of protein servings: 4 oz cooked chicken = 35 grams of protein 4 oz cooked turkey breast = 34 grams of protein ¼ pound or 4 oz of hamburger patty = 28 grams of protein 3 oz of shrimp = 18 grams of protein 3 oz of salmon = 17 grams of protein 1 hard boiled egg = 6 grams of protein 1 ½ cups of cooked tofu = 30 grams of protein ½ cup cooked black, pinto, lentils = 7 to 10 grams of protein ½ cup cooked split peas = 8 grams of protein ½ cup quinoa = 4 grams of protein 3.5 oz of wild rice = 4 grams of protein The take home message is that our protein needs increase as we age. As we age, protein and resistance training supports getting stronger, staying active, having a healthy immune system, and improving our quality of life. What do you want to be doing in your 60’s, 70’s and beyond? Whatever it is, ensuring you get enough quality protein is essential to making that happen. Dietary protein: amount needed, ideal timing, quality, and more | Don Layman, Ph.D. [peterattiamd.com podcast #224] Recipes High Protein Overnight Oats: ½ cup milk of your choice (may want to add a bit more if too stiff) ½ cup greek yogurt, 2% Fage plain yogurt, or vegan yogurt ½ cup old fashioned oats 1 tsp maple syrup or other sweetener of your choice (optional) ½ tablespoon chia seeds 1 scoop protein powder - ex. Whey protein isolate or pea protein powder Berries and/or chopped nuts to top Mix all the ingredients except berries in a jar or sealable bowl the night before. Store in the fridge. Add berries and/or nuts before you eat. One Pot Creamy Spinach Lentils with Quinoa Since this one-pot meal has loads of dried herbs, the lentils soaked it all up and brought everything together. Super simple and super delicious! author: Alyssa https://www.simplyquinoa.com/one-pot-lentils-quinoa-with-spinach/ INGREDIENTS 2 tablespoons olive oil 1 large shallot chopped 1 cup chopped carrots 2 cups chopped mushrooms 2 - 3 garlic cloves minced 1/2 teaspoon red pepper flakes 1 teaspoon dried oregano 1/2 teaspoon dried thyme 1/2 teaspoon dried rosemary 2 bay leaves 1 cup green/brown lentils 2 cups vegetable broth 2 1/2 cups water divided 1 teaspoon miso paste optional* 1/2 cup red quinoa or variety of choice, uncooked 4 - 5 cups fresh spinach Salt + pepper to taste Olive oil fresh herbs and grated cashews* to garnish I INSTRUCTIONS Heat the oil over medium heat in a large Dutch oven or cast iron pot. Add shallots and carrots and cook until the carrots have started to soften, about 3 - 4 minutes. Add mushrooms and continue to cook until mushrooms are juicy and tender, another 5 minutes. Add garlic, red pepper flakes and herbs. Stir around until the whole mixture becomes fragrant, about 1 minute. Pour in lentils, broth, 2 cups of water and miso (if using). Bring the mixture to a boil, cover and reduce to simmer for 15 minutes. Remove the lid and add quinoa and remaining water. Stir to combine. Bring the mixture back to a boil, recover and reduce to simmer for another 15 minutes. Remove pot from the heat, uncover and add spinach, stirring gently to combine. Taste (carefully!) and season with salt and pepper. Serve with a drizzle of olive oil, fresh herbs and grated cashews. The miso adds a great umami flavor, but you can just use sea salt if you don't have miso. You can also totally use parmesan if you want! Makes 4 servings. NUTRITION Calories: 374kcal | Carbohydrates: 58g | Protein: 19g | Fat: 13g | Saturated Fat: 1g | Sodium: 457mg | Potassium: 1254mg | Fiber: 21g | Sugar: 6g | Vitamin A: 9205IU | Vitamin C: 15.5mg | Calcium: 100mg | Iron: 6.6mg Bean and Vegetable Enchilada Casserole A delicious vegetarian dish with Mexican flair. INGREDIENTS • 1 medium bell pepper, chopped • 1 large onion, chopped • 2 cloves garlic, minced • 1 Tbsp. olive or avocado oil • 1 can (14 oz.) black beans, drained and rinsed • 1 can (14 oz.) pinto beans, drained and rinsed • 1 package (16 oz.) frozen corn, thawed • 1 can (28 oz.) pureed or crushed tomatoes • 1 Tbsp. chili powder • 1/2 tsp. ground cumin • Dash of hot sauce, to taste • Salt and freshly ground pepper, to taste • 12 corn tortillas • 1 cup grated reduced-fat Jack cheese DIRECTIONS Preheat the oven to 350 degrees. In a large saucepan, heat oil over medium heat and saute bell pepper, onion and garlic for five minutes. Add beans, corn, tomatoes and seasonings, including salt and pepper, if desired. Reduce heat to low and simmer for 15 minutes. Assemble the casserole in a 9 x 13-inch baking dish. Cover bottom with one third of bean mixture. Layer six tortillas on top of beans. Repeat once more, ending with bean mixture on top. Sprinkle cheese on top and bake until hot and bubbly, about 30-40 minutes. Makes 8 servings. Per serving: 320 calories, 7 g total fat (2 g saturated fat), 53 g carbohydrates, 15 g protein, 11 g dietary fiber, 677 mg sodium. Recipe from the American Institute for Cancer Research.

November 7, 2023 There are three attached articles that I wanted to share to add perspective to how we dance with health and our health care system - today specifically bone health. The first two articles are from Teppo Jarvinen, a professor of Orthopaedics and Traumatology at the University of Helsinki and Helsinki University Hospital. The third is a study on how exercise effectively prevents falls and fractures. 1. Is boosting bone mass through pharmacotherapy really the best way to prevent fractures in the elderly? 2. Labelling people as 'High Risk': A tyranny of eminence 3. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials

What are the ten most important physical tasks you will want to be able to do for the rest of your life? Dr. Peter Attia, MD calls this the Centenarian decathlon. Here is a list of examples of physical tasks – what might you include? 1. Hike 1.5 miles on a hilly trail. 2. Get up off the floor under your own power, using a maximum of one arm for support. 3. Pick up a young child from the floor. 4. Carry two five-pound bags of groceries for five blocks. 5. Lift a twenty-pound suitcase into the overhead compartment of a plane. 6. Balance on one leg for thirty seconds, eyes open. (Bonus points: eyes closed, fifteen seconds.) 7. Have sex. 8. Climb four flights of stairs in three minutes. 9. Open a jar. 10. Do thirty consecutive jump-rope skips. “Exercise has the greatest power to determine how you will live out the rest of your life. From lengthening our lives by years, delaying the onset of chronic disease across the board, and both improving and extending our healthspan. Did you know that one of our most powerful tools for preventing cognitive decline is exercise? This is nothing new and there is more and more evidence supporting how essential exercise and movement is to our health.”[i] Below I provide some examples from different YouTube channels that show you how you can begin to move more, improve mobility, and build strength. I also highly recommend working with a physical therapist and /or trained fitness specialist to develop exercises and programs to meet your specific needs over time. The key is to begin. Small, simple, gentle movements, built with consistency over time into increased mobility, stability, and strength. Please remember that before you embark on any exercise or training program, especially if you have specific health concerns or issues, first talk with and get evaluated by your doctor. CARS (controlled articular rotations) part of a mobility program - Full explanation 10 min full mobility flow 1 of 5 videos explaining how to create a strength training regimen for beginners or even seasoned practitioners [i] Peter Attia, Outlive: The Science and Art of Longevity.

This is a beautiful passage from a generative book by James Hollis, PhD who is 83 years old and is a practicing Jungian analyst and author of numerous books. This passage is from his most recent book A Life of Meaning - Relocating Your Center Of Spiritual Gravity, Sounds True, pages 107-109, 2023. In the seventeenth century, Blaise Pascal, in his book Pensees (Thoughts), said even the king, king though he be, if he thinks of self will grow miserable and frightened. So the court has invented the Jester to distract the king and the court from reflecting on things that matter. Pascal labeled this distraction "divertissement," what we now call "diversion." Think about that in the light of contemporary culture with its twenty-four-hour seven-days-a-week wired-in experience of distraction. So much greater must be our estrangement from our own souls. So much greater must be our fear of that still, quiet voice that speaks within each of us. The ancients know this voice, and they talked about it. They chronicled it. They wrote scripture and mythologies about it. And then we forgot what they learned. The question is, can we return to that? This whole process of stepping into our depths can be intimidating. It can feel isolating, and still, we have to remember, this is our journey. This risk is what brings depth and dignity to our lives. Let's turn once again to a paragraph from Rainer Maria Rilke's fine Letters to a Young Poet. When the young poet is expressing his apprehensions about the difficulties of life and whether he'll be up to it or not, Rilke writes to him, "You must not be frightened if a sadness rises up before you larger than you've ever seen, if a restiveness like light and cloud shadows pass over your hand and over all you do, you must think that something is happening with you. That life has not forgotten you, that it holds you in its hand. It will not let you fall. Why do you want to shut out of your life any uneasiness? Any miseries or any depressions? For, after all, you do not know what work these conditions are doing for you." It's a lovely paragraph because it's a reminder that there's something in us, a life force that supports us, that holds us in its hand... ...Our own psyche keeps showing up, keeps knocking on the door, keeps summoning us back to the high calling of the journey. This is important because the soul also provides each of us the tools with which to navigate and constantly reminds us that we're charged from the beginning with accountability to what may be seeking its expression through us into the world. Our psyche is constantly summoning us, calling us back to the higher calling of that journey. Moreover, it gives us the tools with which to navigate, to find our way---the internal compass. It reminds us from time to time that we are charged from the beginning of the journey to its end with accountability to what is seeking its expression through us into the world, asking us only that we manage to be as courageous as possible, to show up as best we can, and to live that journey with as much integrity as we can muster.

And once the storm is over you won’t remember how you made it through, how you managed to survive. You won’t even be sure, in fact, whether the storm is really over. But one thing is certain. When you come out of the storm you won’t be the same person who walked in. That’s what this storm’s all about. Haruki Murakami

Our understanding of health is a dynamic expression of pillars such as sleep, nutrition, movement, light, relationship, and the sacred as it dances with the cycles of a day, week, year, and life. Imagine health as an experience of movements over the phases of a life that can support and inform how we inhabit our bodies, ourselves, and our world. Please recognize that when I say there isn’t a problem in this video I am referring to a space where we can include a dynamic understanding of health. This never excludes that when there are health concerns, questions, or issues they are addressed promptly with your physician.

Karen Miller-Lane, ND, L.Ac Join me as we explore in more depth how the physiological sigh can support relaxation and reduce stress. Brief structured respiration practices enhance mood and reduce physiological arousal Balban, Melis Yilmaz et al. Cell Reports Medicine, Volume 4, Issue 1, 100895 https://doi.org/10.1016/j.xcrm.2022.100895

By Karen Miller-Lane, ND, L.Ac In Part One, I provided an overview of small intestinal bacterial overgrowth or SIBO. An important consideration to keep in mind is that SIBO may be an underdiagnosed cause of irritable bowel syndrome (IBS). Then, in Part Two, I reviewed the pathophysiology of SIBO in which the overgrowth of microorganisms in the small intestine can lead to GI symptoms such as bloating, gas, nausea, heartburn, stomach discomfort, diarrhea, and or constipation. Recall that factors such as stress or a GI infection, or when mechanisms that maintain gut health such as gastric acid, and digestive enzymes are impaired, they contribute to microbial overgrowth in the small intestine. These conditions and pre-existing conditions such as hypothyroid or celiac disease can lead to damage and inflammation of the gut mucosal barrier which then sets the stage for additional systemic conditions. [1] Small intestinal bacterial overgrowth: the chicken or the egg? In Part Three, we turn our attention to the consequences of a disrupted small bowel ecology that may affect other systems in the body. For example, when there is low stomach acid or a decrease in digestive enzymes, our natural GI protective mechanisms are compromised. This leads to dysbiosis, a state of microbial imbalance. In addition, changes in gut motility (the muscle contractions that mix and move food along the GI system), mucosal inflammation, decreased absorption of vitamins and minerals and fat-soluble vitamins (such as B12, iron, zinc, Vitamin D, A, and E) and increased intestinal permeability, all affect small bowel ecology. These factors can then set the stage for issues in other systems such as the skin, liver, and vascular systems. Many human and animal studies suggest that the intestinal microbiome’s influence extends beyond the gut and in fact contributes to the function, and dysfunction, of distant organ systems.[2] We discussed in Part Two that bacterial overgrowth in SIBO may be implicated in inflammation, intestinal permeability, and food sensitivities due to changes in the mucosal lining of the small intestine. In cases of disturbed intestinal barriers, intestinal bacteria as well as the metabolites of these microorganisms have been shown to accumulate in the skin and disrupt the balance of the skin.[3] This state of microbial imbalance may be implicated in acne vulgaris, atopic dermatitis or eczema, and psoriasis. Symptoms of SIBO have also been present with a variety of liver diseases perhaps due to intestinal permeability and inflammation. In liver disease there can also be increased intestinal permeability which occurs when the gut barrier is compromised and there is a translocation of bacteria, endotoxin, a toxin present inside a bacterial cell, and other inflammatory agents.[4] The bacterial translocation and inflammation involved in SIBO may contribute to conditions such as non-alcoholic fatty liver disease or NAFLD. Further investigation is needed before we can make any final conclusions. SIBO is also being investigated as a link to subclinical atherosclerosis. There is a protein (matrix Gla) involved in maintaining vascular health. Vitamin K2 is a prerequisite for matrix Gla’s activation and function. Vitamin K is present in two main forms (i) phylloquinone or vitamin K1 and (ii) menaquinone (MK) or vitamin K2. Vitamin K2 is involved in strengthening bone and, via the production of matrix Gla protein, preventing vascular calcification by repairing smooth muscle and endothelium. This means vitamin K2 is involved in preventing plaque formation in our arteries that leads to cardiovascular disease. Early studies show vitamin K2 may also enhance insulin sensitivity thereby supporting healthy blood sugar regulation. Intestinal bacteria are the main source of vitamin K2 in humans and bacterial dysbiosis is associated with altered K2 metabolism and impairing the protein (matrix Gla) required for maintaining vascular health. [5] Humans need gut bacteria in order to fulfill their vitamin K requirements because the dietary intake of vitamin K is often insufficient. SIBO, a condition characterized by gut bacteria imbalance, is also associated with impaired vitamin K metabolism. Therefore, SIBO and/or low vitamin K may hypothetically put someone at increased risk of atherosclerotic disease.[6] We still have a long way to go to understanding what constitutes the normal bacterial population of our gut – our gut microbiome - along with the challenges and limitations of testing. Our concept of SIBO will most likely change over time with further research and understanding. This is a normal part of scientific investigation. It means that, at times, it is appropriate to twist and pivot from what we think we know to be “true” to what is emerging as new insights and interconnections. Our challenge is to make these pivots consciously rather than reactively. At the moment, I believe SIBO is a useful and valid concept for understanding some of the mechanisms behind the varied symptoms of a form of irritable bowel disease. A diagnosis is always a thing in motion. A diagnosis is often a compilation of symptoms as we learn to understand what lies betwixt and between what we see, how we see, what we measure, and how we interpret. The diagnosis continues to be in flux, along with the tools we use and the way we come to know. This shared learning process between humans and our environment is all in service of a deeper integration of our understanding of how bodies and selves interact in the world. So, where does this leave us in the treatment of SIBO? The diagram below reminds us of where we began – exploring the factors that protect or go awry in the development of SIBO. [7] Treatments for SIBO have predominantly included antibiotic therapy. The above diagram points to the many considerations involved when treating SIBO. Some of the factors that I investigate and consider when treating SIBO include: proper digestion, healthy gut motility and healthy gut integrity. Some of the many questions that I ask include: · Is there an infection that needs to be treated? · Is there a pre-existing or underlying condition that is contributing to the disordered physiological processes? · What are the stressors that can be modulated? · Is there a gut imbalance or a predominance of certain gut bacteria that may be generating symptoms such as pronounced gas? · What foods aggravate the condition or is gut integrity the cause of food sensitivities? If so, could we experiment with changes in diet? · How do we calm an inappropriate immune response and inflammation? Are there nutrients that are being compromised and need to be replaced? · Are antibiotics and which antibiotics may be most effective? · Are there herbs or other nutrients that can soothe, and heal the gut, or reduce the bacterial imbalance? These questions and considerations are just some of what is involved in exploring SIBO in relationship with your doctor. The questions are built on a commitment to be curious and to pull back the lens sufficiently to be able to explore the intersection of our bodies, ourselves and our environment that manifest as our health. This process provides a dynamic, ever evolving understanding of how to listen, test, experiment, and treat conditions that are complex and that we are still trying to understand. There are some conditions and treatments that are more straightforward than others. As you can see, with SIBO, there are numerous moving parts as we continue to research and understand all of the factors and physiology involved. This again is why you are in relationship with your doctor to determine how to navigate this together with the best information and understanding possible in the moment. For example, there is research into certain herbs such as the Quebracho Colorado from Argentina. It is from the bark of a tree called the axe breaker and it is used to deal with fungus and the organism archaebacter which produces methane in SIBO. Peppermint leaf may be more appropriate than the oil due to the polyphenol content. M. balsameas a specific type of peppermint may be more useful in calming the stomach and small intestine than other forms of peppermint. There may be certain probiotics that may secrete a range of natural antibiotics that target common pathogenic organisms in SIBO such as Bacillus subtilis HU58 and herbs such as licorice flavonoids that protect gastric mucosa and balance H. Pylori levels. One of the unique challenges we face today is we are inundated with information that is limited and that does not include the full context. How we navigate what ails us is a dynamic process. A dance. Research is ever changing. SIBO is not just one thing - how it is expressed and treated is the art of medicine. Our symptoms may be complex and point in seemingly divergent directions. This is why the relationship between doctor and patient must not be merely transactional, but, rather, relational and grounded in a shared commitment to listen, learn, and explore what health means. [1] Menees S, Chey W. The gut microbiome and irritable bowel syndrome. F1000Res. 2018 Jul 9;7:F1000 Faculty Rev-1029. doi: 10.12688/f1000research.14592.1. PMID: 30026921; PMCID: PMC6039952. [2] Salem I, Ramser A, Isham N, Ghannoum MA. The Gut Microbiome as a Major Regulator of the Gut-Skin Axis. Front Microbiol. 2018 Jul 10;9:1459. doi: 10.3389/fmicb.2018.01459. PMID: 30042740; PMCID: PMC6048199. [3]Ibid. [4] Quigley EM. Gut bacteria in health and disease. Gastroenterol Hepatol (N Y). 2013 Sep;9(9):560-9. PMID: 24729765; PMCID: PMC3983973. [5] Rakel, D. Integrative Medicine. Elsevier Inc, 4th Edition, Chapter 33, 2018. [6] Ponziani FR, Pompili M, Di Stasio E, Zocco MA, Gasbarrini A, Flore R. Subclinical atherosclerosis is linked to small intestinal bacterial overgrowth via vitamin K2-dependent mechanisms. World J Gastroenterol. 2017 Feb 21;23(7):1241-1249. doi: 10.3748/wjg.v23.i7.1241. PMID: 28275304; PMCID: PMC5323449. [7] Bushyhead D, Quigley EMM. Small Intestinal Bacterial Overgrowth-Pathophysiology and Its Implications for Definition and Management. Gastroenterology. 2022 Sep;163(3):593-607. doi: 10.1053/j.gastro.2022.04.002. Epub 2022 Apr 7. PMID: 35398346.

Karen Miller-Lane, ND, L.Ac My intent in providing these summaries is to strike a balance between what can be the overwhelming technicality of a research article in a professional medical journal and the oversimplification of important, albeit complex topics, in mainstream news sources. To be clear, there is technical information in these summaries because I believe that when we are able to access meaningful, scientific information, we are better able to make informed health decisions. However, hopefully, you will find these summaries clear enough to be meaningful and helpful. I look forward to having further conversations. As we discussed in Part One, SIBO is a common cause of irritable bowel syndrome or IBS. Symptoms of SIBO often include bloating, abdominal gas, flatulence, belching, heartburn, abdominal pain, constipation, diarrhea, or a mixture of the two. That said, there is often a varied presentation of SIBO. In other words, SIBO may look different depending on the individual's past medical history, underlying conditions, and present health concerns. In this article, we will look at the pathophysiology of SIBO which may shed light on its varied presentation and provide insight into how to approach its treatment. In SIBO, bacteria grow in our small intestine due to an infection, antibiotics, or stress for example. The small intestine should be relatively sterile, whereas the large intestine has a dense and varied microbiome. Along with stressors such as an infection or antibiotics, motility disorders account for a high percentage of SIBO cases. Motility is a term to describe the muscle contractions that mix and move food along the GI system. We have a migrating motor complex (MMC) which acts as a housekeeper in the gut. The MMC creates movements that clear the intestines at regular cycles between meals. It is also responsible for clearing bacteria from the small intestine to the large intestine and inhibiting bacteria from the large intestine entering the small intestine. Anything that impairs MMC function can be a risk factor for SIBO. The MMC is triggered by the fasting state, so MMC can be impaired if you aren’t allowing enough time (three to four hours) between meals. In a vicious cycle, the overgrowth of bacteria in SIBO can also exacerbate impairment of MMC function. Other risk factors for SIBO include decreased stomach acid, decreased digestive enzymes, and ileocecal valve dysfunction (IVD)--a condition that can occur when the valve that separates the small and large intestine ceases to function correctly. What follows describes a story in which factors affecting digestion, absorption, and the movements within the GI system cause imbalances and dysfunctions that create a landscape hospitable for SIBO. Stomach acid eliminates most of the bacteria that enters the body in our food. Digestive enzymes support efficient digestion of food thereby leaving less substrate for bacteria to ferment and the digestive enzymes also play a role in eliminating bacteria not meant for the small intestine. Bile acids break down fatty acids and are necessary in the absorption of fat-soluble vitamins. As detergents, they can alter bacterial membranes, reducing numbers. The ileocecal valve is a sphincter muscle located at the junction of where our small intestine and large intestine meet. If there is a dysfunction in the valve, then materials from the large intestine can back up into the small intestine. A healthy functioning GI system ensures appropriate digestion, absorption, and maintenance of a healthy gut ecology. Also, pre-existing conditions such as hypothyroid, diabetes, celiac disease, fibromyalgia, or lactose intolerance can lead to bacteria populating the small intestine and cause fermentation. The by-products of this fermentation, particularly of carbohydrates, are methane, hydrogen, or hydrogen sulfide, which account for the three types of SIBO. The hydrogen dominant type often causes diarrhea. The methane dominant often causes constipation. And the hydrogen sulfide results in diarrhea or constipation. Besides bacteria, the human microbiome consists of organisms called Archaea which are methanogens, meaning that the microbes belonging to this genus or category of organisms in the gut produce methane. The most prevalent species from this genus is Methanobrevibacter smithii. M. smithii is a methanogen, an organism that soaks up hydrogen and produces methane. Modern day antibiotics will not work on this organism. Methanobrevibacter smithii resides in the large intestine but is found in the small intestine of individuals with SIBO. Methane is relevant, not only because it generates significant gas, but because the methane works as a local paralytic. Methane slows everything down creating gut motility issues. This creates and exacerbates bacterial overgrowth. It’s worth pausing and recognizing that the space within our esophagus, stomach, small and large intestine is, in fact, the outside world. The mucosal barrier of our digestive system determines what enters our body, similar to our lungs and skin. Literally the space in the tube that extends from the mouth to the anus is the outside world. The mucosal barrier that lines our gastrointestinal tract is literally that, a barrier to the outside world. The reason I am pointing this out is because we often presume that everything that is inside us is our own inner world. Yet, our gut, is the space where the inside and outside world dance. The mucosal barrier of the GI system is there to determine which partners we are meant to dance with. Everything we eat and drink is of the “outside” world, yet, what we need to recognize is that the distinction between outside and inside is far more porous than we generally realize. Our GI system is both inside and outside–this relationship is central to our health. The increased bacterial overgrowth leads to inflammation within the lumen or cavity of the intestines. Within the lumen - or central cavity of this tube - are dendritic cells that reach up through the intestinal wall and sample the outside world – they are called B cells. B cells determine friend or foe (our dance partner). When bacterial overgrowth occurs the B cells trigger a larger immune response now comprising T cells, and memory cells. This initiates a further immune response. With SIBO there is an inappropriate immune response. This inappropriate immune response can generate chronic inflammation, intestinal permeability, and food sensitivities. The imbalance of microorganisms and bacteria in the small intestine generates an inappropriate immune response which causes changes to the mucosal lining of the small intestine. Here we find ourselves, once again, at the junction of where our body meets the outside world. When there are imbalances in the ecology of the outside world it affects the ecology of our internal world. This imbalance shows up as inflammation and malabsorption. As a result, inflammatory changes to the lamina propria and villous atrophy often occur in SIBO. The lamina propria is a type of connective tissue found under the thin layer of tissues covering the mucous membrane of the small intestine. Villi are the microscopic, finger-like tentacles that line the wall of your small intestine that absorb nutrients. Chronic inflammation, changes in bowel motility, and overgrowth cause the villi to atrophy and erode, leaving a virtually flat surface of the small intestine which causes malabsorption. This cycle can also cause malnutrition in other ways. The bacteria alter bile, which creates fat malabsorption (steatorrhea, fat-soluble vitamin deficiency). Along with a deficiency of fat-soluble vitamins there are also decreased levels of nutrients such as vitamin B12 and iron. The overgrowth of bacteria affects enzymes that are involved in digestion leading to carbohydrate malabsorption, fermentation, and gas. Thus, SIBO is involved in a cycle that provokes an inappropriate immune response within the mucosal lining of the intestines generating inflammation which can then initiate additional systemic symptoms which we will discuss in Part Three. Below is a diagram, by Dr. Allison Siebecker an advocate and educator in the understanding and treatment of SIBO. It provides an overview of the pathophysiology of SIBO that I have discussed above. The diagram provides a quick snapshot into the symptoms and conditions that can arise due to changes in the gut caused by SIBO. In the third and final article in this series, we will explore the effects that SIBO can have on other systems in the body and as a result other conditions that may be associated with SIBO such as rosacea or nonalcoholic fatty liver disease (NAFLD). In conclusion, we will look at approaches to addressing SIBO. For Further Reading: Pimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020 Feb;115(2):165-178. doi: 10.14309/ajg.0000000000000501. PMID: 32023228. Quigley EM. Gut bacteria in health and disease. Gastroenterol Hepatol (N Y). 2013 Sep;9(9):560-9. PMID: 24729765; PMCID: PMC3983973. Takakura W, Pimentel M. Frontiers | Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome – An Update (frontiersin.org); 2020 July. Volume 11. https://doi.org/10.3389/fpsyt.2020.00664

By Karen Miller-Lane, ND, L.Ac As a Naturopath one of the seven principles[i] of Naturopathic Medicine is Physician as teacher. Thus, I feel it is important to explain to my patients what the results of their blood work mean and how it applies to them. Blood work is generally ordered to help diagnose medical conditions, plan or evaluate treatments, and monitor diseases. That said, there isn’t always a test to diagnose a condition that you might be experiencing. Tests are also limited in their scope. For example, some of the measurements included in a lipid panel, may not, according to the latest research, adequately measure risk for cardiovascular disease.This lag time between what the research calls for and what happens in clinical practice can be decades. To explain why I believe the measurements on your lipid panel need to change, let me provide you with some general information about cholesterol that will provide the context to understand why a lipid panel is important in assessing your cardiovascular risk. Cholesterol is essential – you would die without it. Cholesterol is part of the cell membrane of every cell. It contributes to the fluidity of the cell membrane and this membrane affects the channels that allow things in and out of the cell. It’s essential to the creation of a cell and how our cells communicate. Cholesterol is also essential for the synthesis of steroid hormones like cortisol, testosterone, and estrogen. And it is necessary for the creation of bile acids, which is required to digest food. Along with cholesterol being essential, I want to highlight that the cholesterol in our bloodstream has little to do with the cholesterol in foods we eat. Most of the cholesterol that we eat is excreted. The cholesterol we are monitoring via blood work is made in our body and transported between cells through lipoproteins. Lipids are fatty compounds that perform a variety of functions in your body. A lipoprotein is part protein and part fatty compound which enables lipids to travel through our circulatory system. Now, unhealthy foods are unhealthy foods, and they can negatively impact our health, but foods that have decent amounts of cholesterol such as eggs and shrimp are not in and of themselves unhealthy foods because of the amount of cholesterol they contain. (Look to future blogs on this subject.) A lipid panel is a common blood test which looks at total cholesterol, LDL or low density lipids, HDL or high density lipids, Triglycerides, and non-HDL lipids to monitor and screen for your risk of cardiovascular disease. Your health care provider discusses your test results as they relate to your age, family history, and risk factors. Risk factors include high blood pressure, diabetes, or prediabetes, being overweight or obese, smoking, lack of exercise, diet of unhealthy foods, stress, or high total cholesterol. But here’s the rub, we know through clinical research that total cholesterol isn’t the best marker for predicting mortality or morbidity for cardiovascular disease [CVD]. To understand this contradiction between the research literature and the current practice let me further discuss lipoproteins, the types of lipoproteins and how to understand what those letters stand for in our bloodwork. Apolipoprotein B (ApoB) is the primary protein component of low-density lipoprotein (LDL). Apolipoprotein A1 (ApoA1) is the primary protein component of high-density lipoprotein (HDL). ApoB is the major protein in Very Low Density (VLDL), Intermediate Density (IDL) and Low Density Lipoproteins (LDL). ApoA-1 is the major protein in High Density Lipoprotein (HDL) particles. There is HDL cholesterol and LDL cholesterol, abbreviated LDL-C and HDL-C. There’s LDL-P and HDL-P, which is the particle member of LDL, which can be counted via electrophoresis or nuclear magnetic resonance [NMR]. The measurement of LDL-P is a better assessment of risk than LDL-C or total cholesterol and the current lipid panel only includes LDL-C. We can also count the number of these particles by measuring apoB. Peter Attia,MD who is both a practicing physician and a relentless researcher focusing on the applied science of longevity states: “The apoB concentration to me is the most important number you want to understand to predict from a biomarker standpoint your ASCVD (Atherosclerotic Cardiovascular Disease) risk, because it captures all of the atherogenic particles apoB gives you the total atherogenic burden of those lipoproteins… it’s the preferred metric by which we want to assess risk”‒ Peter Attia[ii] In other words, LDL-P is a better assessment of risk than LDL-C and apoB concentrations may be a better overall biomarker for evaluating cardiovascular disease risk because it captures all of the atherogenic particles. This is important because LDL can go into artery walls, become oxidized and then dump their oxidized sterol (waxy solid) contents into the subendothelial (part of the vessel wall) space. This elicits an immune response and other things that lead to atherosclerosis. In short, oxidized cholesterol is what builds up on the artery walls. We want to better evaluate cholesterol as a risk for atherosclerosis. ApoB and LDL-P are two things that far exceed LDL-C or total cholesterol at doing this. They are not included in the existing labs. To reiterate, health care practitioners currently get a lab report of 5 numbers: total cholesterol [C], triglycerides [TG], non-HDL-C, LDL-C, HDL-C. As I stated above, total cholesterol, LDL-C, and HDL-C may not be the best measures of CVD. The research has shown that the number of LDL particles is a more accurate index of risk than the LDL-C. The smaller the LDL particles the increase in CVD risk. However, we are still learning about the differences between HDL-C and HDL particles. Their relationship to our risk is much more complicated than previously assumed. For example, HDL may not confer the protection from CVD that we thought it did. Research is still investigating this very complex lipoprotein. The other metrics on your blood work may include VLDL-C , which is a cholesterol that’s in the very low density lipoprotein particles – think small particles. These particles come out of the liver and can promote the formation of plaque in the arteries. This is a risk factor. The literature also shows that non-HDL cholesterol is a better measure to understand risk than LDL-C. The higher the non-HDL the increase in risk. Triglycerides [TG] are on a lipid panel because people with high triglycerides are at increased risk of heart disease and have higher numbers of LDL particles and VLDL particles. For a long time, there has been a debate on whether serum TG constitutes an independent risk factor for CVD – and if so, at what levels. Currently, TG levels <150 mg/dL are usually described as “normal” or “optimal”. However, the latest research suggests the “optimal” value for TG to be around 50 mg/dL. Genetic studies are also pointing to the understanding that the risk factor of elevated TGs is more a reflection of elevations in apoB, in which case, measurement of apoB itself would provide the most accurate information about CVD risk. That said, TG are still an important marker for assessing the risk of CVD. It is also important to note that regarding the relationship of TG to CVD, there is a stronger association for women than men. These differences call for gender-specific guidelines for what constitutes “optimal” TG levels. I realize this is a lot to absorb, but stay with me for a little longer as we explore HDL. HDL is characterized by a different protein apoA-1, which is in a different family than ApoB. HDL metabolism is significantly more complex than LDL and there is much we have yet to learn. One of the questions being researched is if HDL confers protection against CVD. At present, we can’t assume anything if you have high HDL. I’m looking forward to what the research will show several years from now. One interesting side note is that observational data shows that apoA-1 is protective against neurological diseases. There are other blood work values to access CVD, but I will leave that for another post. The take home message is, first, to make sure that your labs include ApoB, which by the way, is not an expensive lab to run and, second, that non-HDL and triglycerides are important to consider as you are assessing your overall risk and how to treat or prevent cardiovascular disease. We have at least 30 years of research with ApoB and still most insurance companies will not cover the cost of including ApoB in a standard lipid panel. The research also shows it may be beneficial to include this testing at an earlier age, perhaps, starting in our mid to late 30’s to address and affect the course of atherosclerotic cardiovascular disease. The more we understand what is used to measure our health the better advocates we can be for ourselves. My hope is that we can use the research and available tests to support a better understanding of how to prevent disease and illness and support optimizing our health. [i] If you are interested in what the seven principles of Naturopathic Medicine are – click on Services in the heading of the website and click on Naturopathic Medicine. [ii] https://peterattiamd.com