Stress and Its Impact on the Common Stomach and Intestinal Conditions GERD (Gastroesophageal Reflux Disease), IBS (Irritable Bowel Syndrome), and IBD (Inflammatory Bowel Disease - Colitis and Crohn's Disease)

My recent lead author publication was just published in the March/April issue of Explore: The Journal of Science and Healing, entitled, “Perceived Stress in Patients with Common Gastrointestinal Disorders:  Associations with quality of life (QOL), symptoms and disease management.”  Explore 2017;13:124-8.

Here are the Important Study Findings:

1.     Perceived stress in people with GERD, IBS and IBD is higher than 84 % of the general population.

2.     The quality of life, both mental and physical, is at least one half to a full standard deviation below general population normative values.

3.     Perceived stress significantly correlated with average and worst pain in people with GERD and IBD – since these are indicators of disease management, stress may be an important marker of disease management in these conditions.  Note – there was not a correlation between perceived stress and pain in IBS, but I believe that this is due to the ability of stress to contribute to worse diarrhea in some people and worse constipation in others.

4.     While stress management should be included in the care of people with GERD, IBS and IBD, an integrative medicine or holistic approach, which also includes effective dietary guidelines and exercise, would be more important to study and include in GI care in order to get the best health outcomes.

Here is the Abstract:

ABSTRACT

Objective and Methods:  Research supports relationships between stress and gastrointestinal (GI) symptoms and disorders. This pilot study assesses relationships between perceived stress, quality of life (QOL) and self-reported pain ratings as an indicator of symptom management in patients who self-reported gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Results:  In the full sample (n=402) perceived stress positively correlated with depression (r=0.76, p<0.0001), fatigue (r=0.38, p< 0.0001), sleep disturbance (r=0.40, p<0.0001), average pain (r=0.26, p <0.0001) and worst pain (r=0.25, p< 0.0001).  Higher perceived stress also correlated with lower mental health-related QOL.  Similar correlations were found for the participants with GERD (n=188), IBS (n=132) and IBD (n=82).  Finally, there were significant correlations in the GERD cohort between perceived stress, and average pain (r=0.34, p<0.0001) and worst pain (r=0.29, p<0.0001), and in the IBD cohort between perceived stress, and average pain (r=0.32, p<0.0001) and worst pain (r=0.35, p<0.01).

Conclusions:  Perceived stress broadly correlated with QOL characteristics in patients with GERD, IBS, and IBD.  Perceived stress also appeared to be an indicator of symptom management (self-reported pain ratings) in GERD and IBD, but not IBS.  While future research using objective measures of stress and symptom/disease management is needed to confirm these associations, as well as to evaluate the ability of stress reduction interventions to improve perceived stress, QOL and disease management in these GI disorders, integrative medicine treatment programs may be most beneficial to study.

March, 2017 Blog: Challenges and Opportunities for Advancing the Field of Nutrition in Today's Healthcare Environment

Editor’s Note:  This has been a particularly busy time for me and so I did not get to post my March blog but here it is.  My planned topic for April’s blog was Nutritional and Holistic Stress Management in honor of April being Stress Awareness Month and I will post that it in June.  As for my May blog – this will be a discussion of my recent first author publication that was just published in the March/April issue of Explore: The Journal of Science and Healing, entitled, “Perceived Stress in Patients with Common Gastrointestinal Disorders:  Associations with quality of life (QOL), symptoms and disease management.”

Challenges and Opportunities for Advancing the Field of Nutrition in Today’s Healthcare Environment

Nutrition has always been pretty controversial and difficult to pin down given how complex a scientific discipline it is and given the competing models of care and approaches that are taken.  This may be best illustrated by the conventional medical model and its disease management system, in comparison to the integrative medicine model and its preventive and holistic approach to healthcare.  It is always difficult to change a model that is well entrenched but it is changing slowly.

It is generally accepted that conventional medicine is great for emergency and acute care, and does rather poorly with chronic disease care because it does not do a very good job with lifestyle characteristics such as nutrition, fitness and stress management, as well as sustainable behavioral change approaches.  Integrative or holistic medicine is an approach that includes the whole person and addresses physical, emotional and spiritual well-being.  Unfortunately, while there is research to support an evidence base for practice, the research is difficult to do and there is not the funding needed to more quickly support changes in care.  Much of the progress has also been supported by public demand and that is likely to continue.

Dietary Guidelines

There are good dietary models that are being promoted in general with the Mediterranean Diet being the best example and a good prototype for a healthy dietary plan.  Not only does it support a good dietary composition with vegetables, fruits, whole grains and beans, but it also effectively balances these foods with less animal products, and sugars and refined flour products, and it has an important philosophic approach suggesting a focus on fresh foods and unprocessed foods as much as possible.

What is not well supported is the importance of food intolerance or food allergy, and the importance blood sugar regulation and insulin resistance, which is described below.   These approaches will hopefully get more attention and research support in the near future.

Food intolerance and food allergy

The most common foods in this category is sugar, dairy and wheat and my work with clients and patients suggest that they need to be limited because they contribute to a variety of symptoms and problems such as stomach and intestinal symptoms, headaches, fatigue, as well as autoimmune disorders, allergies and other health issues.  It is also that these foods tend to be quick and easy to eat and can be addictive, which often decreases the amount of fresh vegetables and fruit in a diet.  This combination effect can have serious health consequences.  One of the best approaches to evaluate these health effects is to follow an elimination challenge diet that cuts out sugar, dairy and wheat, as well as many other potentially allergenic and intolerant foods for one to four weeks – foods are then added in one at a time to see if they produce reactions.

Hypoglycemia, abnormal glucose tolerance and insulin resistance

While this is well recognized to be important in healthcare, the problem is that there is not as much consideration of the fact that a higher protein, lower carbohydrate diet can be an important, healthy and practical approach for many people.  Again, this can get complicated because there are many approaches that can be considered and it should still be in the context of a fresh food and unprocessed diet.  When I worked at the Atkins Center for Complementary Medicine, I got a great training in these diets and saw how helpful they can be for weight, diabetes, cardiovascular disease and other disorders such as GI problems (GERD, IBS and IBD) and neuropsychological disorders (depression, anxiety and others) – it is again important to individualize the guidelines for each client or patient to insure that it is healthy and that people get the best results and outcomes.

Targeted Nutritional Supplements

This is the other important nutritional area where good progress still needs to made as a part of a more natural and preventive healthcare system.  Most of the public are open to and want to use more natural products but the entrenchment of the pharmaceutical industry in healthcare and the resistance of the healthcare system is making this difficult and slowing the progress down.  More and effective research would be helpful but again, this can be difficult research to do and not enough funding to make great progress.

The most common supplements that I recommend are a multivitamin and mineral, fish oil (omega 3 fatty acids), vitamin D, magnesium and calcium (these last three can also be combined in an osteoporosis or bone building formula).  Then there are specific and targeted supplements that can be useful for GI disorders (eg. a probiotic and digestive enzyme), heart function and heart related disorders (eg. coenzyme Q10 and hawthorne, in addition to fish oil and magnesium), and targeted supplements for a range of other health issues.

Moving Forward

Progress will continue to be slow with so much uncertainty in healthcare but this will continue to be most effectively promoted by integrative and holistic medicine, as well as the continued demand by the public.  Another big and important step will be the effective inclusion of prevention in medicine but it is hard to predict when that will really occur.

Nutritional Supplements and Healthy Hearts: What Nutritional Supplements are Most Important for Promoting Optimal Heart Health

Welcome to the February issue of the Health and Wellness Catalyst Blog

February is American Heart Month, highlighting the importance of heart health in the American population.  Heart disease is still the leading cause of death in the US for both men and women.  Also, the most common first symptom of heart disease is a fatal heart attack so it is important to work with your healthcare practitioners to effectively determine your heart disease risk and take steps to address the common and important heart disease risk factors BEFORE an attack occurs.

While it is important to consider the use of nutritional supplements for heart disease, it is also essential to put them in their proper perspective.  A healthy diet should always be the foundation of overall healthy nutrition, and this should be combined with healthy lifestyle approaches that include regular exercise and movement or physical fitness, and stress management or relaxation techniques.

Modifiable Heart Disease Risk Factors:  These can often be controlled through nutrition (diet and targeted nutritional supplementation) and lifestyle, especially if addressed at the time of diagnosis or even better preventatively - and they include:

High blood pressure                                                High Cholesterol           

Diabetes                                                            Lack of Exercise

Overweight/obesity                                                Smoking

Newer risk factors:   Inflammation (cardiac C-reactive protein),  Lp a  (can be tested)

Metabolic Syndrome:  Significantly raises risk – the core process is insulin resistance, which leads to obesity, high blood pressure, diabetes and cholesterol problems

Often overlapping risk factor:  Depression  (this most often significantly increases the risk and needs to be addressed)

Nutritional Supplements to consider:

Fish Oil and Omega 3 Fats:

Omega 3 fatty acids decrease triglycerides that increase cholesterol levels and have anti-inflammatory effects.  This is helpful because heart disease is now known to be an inflammatory process.  These oils can also help to decrease blood pressure and several studies show that they can decrease the risk of an initial heart attack and a second heart attack.  Finally, these oils help to prevent depression and maintain memory.

Magnesium:  

Magnesium is a calcium channel blocker, so it can help to control blood pressure, but it also helps with blood sugar regulation and insulin resistance, therefore helpful for weight, diabetes, hypertension and high cholesterol.  Other good effects that magnesium have are a calming effect on the nervous system, improves hormonal balance, alleviates constipation and helps with allergies and sensitivities.

CoEnzyme Q10:

Coenzyme Q10 helps with energy generation within cells, which is particularly helpful in heart cells and why evidence shows that it is beneficial for people who have the chronic heart condition, congestive heart failure.  Evidence also suggests that Co Q10 can be helpful for blood pressure, irregular heartbeats (arrythmias) and other heart disorders.  CoQ10 also is an anti-oxidant, protective of tissue damage.

Vitamin D:

Check your vitamin D level and make sure that it is normal – for many people it is low.  Vitamin D is important for blood sugar regulation, normal blood pressure and  depression.  Low levels also increase the risk of auto-immune diseases and specific types of cancer.  It also may be important to have higher levels of vitamin D although this is a current area of active research.

Hawthorn (this is an herbal product, Crataegus monogyna):

Some good research has shown that hawthorn can have several important effects for heart health, specifically high blood pressure, congestive heart failure, irregular heart beats (arrhythmias), and chest pain (angina).

Other supplements:

These could be included depending upon the diagnoses and circumstances but should be considered on an individual basis – arginine, carnitine, potassium, garlic, anti-oxidants (lipoic acid, vitamins C and E, and others), B complex vitamins (B6, B12 and folate) and possibly others.

Holistic approaches to prevent heart disease and stroke:

1.    It is very important to have your primary care practitioners involved with the selection of the best nutritional supplements to take, especially if they are open to integrative or holistic approaches to care

2.     Health diet and lifestyle – includes a Mediterranean or similar type of diet, exercise or physical fitness and stress management or relaxation techniques

References:

1.     Roth EM, Harris WS.  Fish oil for primary and secondary prevention of coronary heart disease.  Curr Atheroscler Rep 2010;12:66-72.

2.     DiNicolantonio JJ, Bhutani J, et al.  Coenzyme Q10 for the treatment of heart failure: a review of the literature.  Open Heart 2015;Epub Oct 19, 2015.

3.     Wang J, Xiong X, Feng B.  Effect of crataegus usage in cardiovascular disease prevention: an evidence-based approach.  Evid Based Complement Alternat Med 2013;Epub Dec 29, 2013.

Jump-Start or Re-Energize Your Health and Well-Being for 2017: 8 steps to getting your wellness program on track and feeling your best

Dr. Joel’s Health and Wellness Catalyst Blog for January – Happy New Year!

January is a great time to start fresh and make progress toward having an ongoing program of well-being for the year and feel your best.  Hopefully you had a wonderful Holiday and New Year that enables you to move forward with a sense of gratitude and purpose; or you can put a challenging year behind you and start fresh with renewed focus to make progress with accomplishing your plans and goals.

Here are 8 steps that can help you get started and on track – you can start with 1 step or take on 2-3 steps and build from there.  If you need assistance you can contact one of your practitioners that you work with (for example, a good nutritionist, counselor or primary care doctor) or start with someone new who can be helpful, such as a health coach, who can help you to put all this together and support you in many ways on your journey to sustained well-being:

1.     Know where you are beginning – check in with how you are feeling, get some blood work done, weigh yourself, and/or see your doctor to get your blood pressure taken or have any other assessments done that you may be concerned about and want to control better or address.  Having this clarity can help you to take specific actions that make the most sense.

2.     Set 1-4 goals that you are most motivated to accomplish – they should be important goals to you and be reasonable or attainable goals (3 month goals are usually best).  From the coaching framework that I find very effective, you would then make more modest goals, for example 2 week goals, that would help you to achieve your longer term goals – if you achieve the goals that would be great, but if not, be positive and see what you can learn about your challenges so that you can overcome them and do better with them over the long term.

3.     With any specific concerns/problems, get good information and/or ask for help – for example, if you are not sure what an excellent exercise program would be for you, or if you have some aches/pains or chronic pain that create doubt about what is best to do without injuring yourself see a good physical therapist, osteopathic doctor or a good chiropractor who can work with you to manage your issues.

4.     Try a modified elimination diet or a really healthy diet for 1-4 weeks - we often forget how good we really feel when we are eating more healthfully or eating a clean diet (and doing some exercise, as well as finding some time to relax and practice relaxation techniques).  One such approach is to avoid or minimize sugar, refined flour products, dairy, wheat, alcohol and caffeine (or cut the caffeine intake in half).  These foods tend to cause the most problems (especially in combination) and could be minimized by including them once or twice per week – be sure to have other good food options to take their place.

5.     Get some support from family, friends, neighbors and/or work colleagues - this would be different from your work with practitioners, and could include taking a brisk walk with someone or meeting them at the gym to workout together or at the same time; or it could mean having lunch with a co-worker to share what is working and get support around more challenging issues; or it could be getting support from a family member or spouse to help with cooking/cleanup or getting time by having them watch a child while you exercise or have some time for yourself.

6.     Stay focused and organized – Logging food and/or exercise and/or tracking your progress can be an important part of your ongoing program.  Another could be keeping all of your health information and program records in a notebook, journal or file.  This way you have all of your information together and have a place to go when you need focus and need to do it more quickly.  It can also be helpful to journal several times per week to describe the good, the bad and the ugly – sometimes it is just helpful to get it out on paper but it can also be used to problem solve and/or get clear about what works best for you (even better is to talk about these with a practitioner or a friend).

7.     Try a new stress management technique and/or commit to staying  positive about yourself and your efforts – there are many approaches that you can select from or work with, and many people who present approaches that can be helpful - the important thing to remember is to see what resonates with you and what you are most interested in trying.  Some examples include breathing exercises, a yoga or tai chi class, meditation or guided imagery, and many others.  Consider also self-compassion or loving kindness meditations, or the book, Positivity, by Barbara Frederickson.

8.     Develop an excellent group of practitioners to work with – make sure that you like and trust them, and that they really do listen and try to help.  Sometimes it is the combination of practitioners that works best such as a solid primary care doctor and others who add other important parts.  Also, if you know what you need to do but have a hard time staying engaged, consider getting a good health coach who can help in many ways (helping you clarify your approaches, problem-solving/brainstorming, generally supporting you, and sharing experiences about approaches that have been helpful for different people with similar circumstances).

So good luck!  I have listed a number of approaches that can be helpful but the most important take home message is that you partner with your practitioner(s) to develop the individualized and effective program that is right for you.  And be persistent because there are answers and approaches out there that fit together like pieces of a puzzle and will work to have you feeling your best.

De-Stressing the Holiday Celebrations: How to enjoy and navigate the Thanksgiving to New Year's Holidays with the least stress

Dr. Joel’s Health and Wellness Catalyst Blog for November

While everyone’s challenges and stresses may differ during the holiday season, the approaches to having the most enjoyment and fun, and the least stress during this time can be priceless.  Between the work that is needed to prepare food and buy presents, and the challenges of potentially difficult family members (perhaps with opposing political views), lots of junk food calling out and/or the stress of ongoing work, home and/or other to do lists, we can often feel overwhelmed.  Drawing on lessons from past experiences and our current resources, as well as planning ahead can make all the difference.

What are your biggest challenges or stressors?

Identifying these at the beginning can be most important.  We also have strengths and weaknesses, enjoyable and torturesome tasks to do, and circumstances that push our buttons, so be present to these situations, and see if there are more effective or manageable ways to get them done.  Talk with family members or friends to make decisions that work best for you and your family, and develop a plan that hopefully finds the right balance.

Remember the true meaning of the Holidays?

Thanksgiving just finished – what a great holiday (definitely one of my favorites), and a chance to spend time with family and/or friends to reflect on all that we have to be truly thankful for and/or to be in action or think of others who may not have as much to be thankful for.  It is also a wonderful time to get some needed rest and relaxation, fun, and possibly plan for and prepare for the Holidays in December.  In addition to gratitude, consideration of loving kindness, service, mindfulness and peace for ourselves, our families and our communities, these all can provide the meaning and themes for this time of the year.

Take steps to manage the stress or plan for the framework of steps:

1.     Keep up with regular exercise – even if it is less than usual, do what you can and it will make a difference especially if you can do some others below

2.     Find the right balance that you need of healthy foods and other foods that are not as healthy but may be important for you to enjoy the holidays.  Set guidelines for holiday meals, parties, and foods that are kept at work or at home that might be tempting but also might cause you to feel tired, upset your stomach, give you a headache or just cause you to gain weight

3.     Continue your regular practice of relaxation techniques – mindfulness, meditation, prayer, breathing exercises and other approaches.  Again, even if you are not able to do as much as you usually do, whatever you can do will be helpful and help to balance the stress

4.     Ask for help – who can you go to if you need assistance to get things done

5.     Contact your go to people – who can you go see or call to talk about how you are feeling or the challenges or problems that you are dealing with

6.     Seek assistance or connect with your counselor, psychologist or social worker – this is why you have a practitioner as part of your healthcare team (or if it would be helpful, find someone), since this is also an opportunity to work through relationships or developmental issues that will tend to reappear until we fully address them, find completion and/or find peace with it/them

7.     If you are trying to lose weight, you may want to consider a different goal to maintain your weight during this time and start fresh again after the New Year to lose weight – not necessary for some but very important for others

Other Considerations

1.     Plan some of your favorite rituals to connect with the true meaning and joy of the holiday – this can be so many things from decorating for the holidays, to favorite or funny movies, to cultural activities, to sing-alongs, other musical performances and sporting events

2.     Take breaks or set aside time to do nothing or check in with how everything is going

Have a very Happy and Healthy Holiday Season!!

Managing the Winter Blues: Specific information and approaches to help control Seasonal Depression (Seasonal Affective Disorder - SAD) and the more mild and common form, winter blues

The Health and Wellness Catalyst:  October, 2016

This past year I have worked on a corporate wellness project for a healthcare system and it has been a revelation to me how common seasonal depression is, and how important it is to understand its influence on mood so that it can be managed effectively.   What I found was that about 20 percent of the participants that I worked with had this seasonal depression or winter blues, which I thought was surprisingly high – it also was important for me as their health coach to support them with information and/or approaches that would help them to address it.  In this way they could be more aware of their seasonal and yearly tendencies, and take specific steps to clarify, adjust and/or sustain their health and well-being goals.

I therefore went to one of the best resources:  Winter Blues: Everything you need to know to beat seasonal affective disorder, by Norman E. Rosenthal, MD, 4^th edition, Guilford Press, NY, 2013.  Dr. Rosenthal is a psychiatrist and one of the leading practitioners who has developed, researched and educated the public (and the healthcare field) about seasonal depression.  I also heard an interview with him (I think on Voices in the Family with Dan Gottlieb, PhD on NPR) and he is a truly caring physician who has made an important contribution to mental health and to those who see him as a health practitioner.

Anyway, Dr. Rosenthal states in his book that about 5 percent of the US population has SAD and another 14 percent have winter blues – which is about what I observed in my health coaching project.  Interestingly, some people start to feel the changes in the fall when days start to get shorter, while others commonly feel it starting in the coldest winter months of January and February.  SAD and winter blues can be felt by experiencing one or more of the following symptoms: feeling down or depressed, having difficulty focusing on work or in relationships, snacking more (especially on carbs and/or sugar), feeling more tired, sleeping more, difficulty waking up in the morning and many other possible symptoms.

What to do if you feel like you may have SAD or winter blues:

1.     Learn more about SAD and winter blues – look at information provided by reliable sources online or get Dr. Rosenthal’s book.  Also, discuss it with your primary care doctor and/or counselor or psychologist to help determine whether it is having an important effect and what steps should be considered.

2.     Look at your lifestyle to see how well you are doing with your nutrition (diet and targeted nutritional supplementation), exercise and fitness (are you consistent?), and your stress level and relaxation techniques (are you balancing the stress enough with exercise, relaxation/mindfulness/ meditation and time for yourself?)

3.     Light therapy – research suggests that it is very helpful for season depression and newer research suggests that it may also be helpful for non-seasonal or unipolar depression also.  Make sure you get a good light box that has been approved for SAD or winter blues and make sure you spend time each day in front of it to get the light that you need to feel better.

4.     Consider seeing a psychologist, social worker or counselor to get more specific assistance and support, and if necessary, consider if anti-depressant medication may be needed.

5.     Regular exercise is helpful for managing both stress and mild to moderate depression – is your program helpful? Are you following through with it? Do adjustments need to be made?

6.     Good nutrition is important - the foundation should be a natural, healthy diet, which could be a Mediterranean type diet or a lower/moderate carbohydrate diet.  Targeted supplements could be added also such as B complex, vitamin D, fish oil, magnesium, chromium and/or others.

7.     Meditation, mindfulness and stress management techniques such as yoga, tai chi, chi gong, and others can help – again do you have a good program? Are you following through? Are adjustments or new approaches needed?

8.     As with all symptoms or disorders, it is important to identify the most important and unique effects for you (for example, knowing when symptoms tend to start), what approaches are most important for you and getting support from the practitioners who are part of your healthcare team and/or family and friends who are part of your support network.   

As this discussion shows, there are many options for effectively managing SAD and winter blues, but half of the challenge is realizing that this may be a problem for you, and then the other half is to get into action by learning about it and finally getting any help that you need to manage it.

Know Your D Level: Although not a miracle nutrient, vitamin D is essential for helping to prevent many health problems including heart disease, cancer, depression and memory loss

Dr. Joel’s Health and Wellness Catalyst Blog:  September, 2016

Know Your D Level: Although not a miracle nutrient, vitamin D is extremely important for many health issues such as heart disease, cancer, depression and memory

The list of vitamin D related health issues seems to grow almost on a monthly basis – bone health, heart disease, blood sugar regulation and insulin resistance, depression, susceptibility to common cancers and auto-immune diseases, memory, pain, etc.  How can this be, you say – well, it turns out that vitamin D helps to regulate and is a co-factor for 10-20 % of all genetic activity, which is a huge amount and central to almost all of our bodily functions. 

**  Everyone should know what their blood level is and be taking it unless they have at least a level of 40 mg/dL.

A good example of the importance of vitamin D comes from a recent study looking at its important effect in memory and cognition.  What was most interesting to me was that not only was higher level of vitamin D at the beginning of the study associated with better memory or cognition level, but it was also associated with the amount of cognitive decline that occurred over time (lower vitamin D level was associated with greater change or worsening of cognitive measures over the four year period in which the participants were followed).

Research has tied vitamin D to variety of functions and influences within the brain that may be important for maintaining healthy functioning.  These include the vitamin D receptors found in many parts of the brain that affect brain activity and vitamin D’s promotion of anti-oxidant function which protects tissues from aging or ‘rust’ damage (very important for maintaining nerve cell function and overall nervous system activities).

Vitamin D and vitamin D blood levels are also important for the two leading causes of death in the United States – cancer and heart disease.  Benefits of higher levels of vitamin D have been shown in certain types of cancer - one study from Norway found that higher levels of vitamin D were associated with longer length of survival in breast, colon and lung cancer, as well as in lymphoma (Tretli S, et al, 2012).  With regard to heart disease, vitamin D level may be a marker of and/or contributor to high blood pressure, heart failure, stroke, peripheral vascular disease, irregular heart beat disorders and/or overall death or mortality – lower vitamin D levels increase risk.

I have also wondered why so many people are vitamin D deficient and I thought that it might relate to environmental chemicals (in addition to using so much sun screen and other influences – sun helps to make the active form of vitamin D) because many of these chemicals are hormone or endocrine disrupters and vitamin D is also a hormone.  A recent study has found a link between the intake of Bisphenol A - BPA (found in some food can linings and plastic water bottles) and phthalates (found in some plastics and cosmetics) and vitamin D blood levels (Johns LE et al, 2016).

It is therefore important to know your vitamin D level (25 hydroxy vitamin D),  take extra vitamin D if you need it (vitamin D3 – 1000 to 5000 IUs per day) and make sure that your overall nutrition and lifestyle program is effective for your health history and current health issues.

1. Wilson VK, et al.  Relationship between 25 hydroxyvitamin D and cognitive function in older adults: the Health ABC study J Am Geriatr Soc 2014;62:3839-53.

2.  Tretli S, et al.  Serum levels of 25 hydroyvitamin D and survival in Norwegian patients with cancer of the breast, colon, lung and lymphoma: a population based study.  Cancer Causes Control  2012;23:363-70.

3.  Lugg ST, et al.  Optimal vitamin D levels for cardiovascular disease protection.  Dis Markers  Sept 8, 2015; epublication.

4.  Johns LE, et al.  Relationships between urinary phthalate metabolite and bisphenol A concentrations and vitamin D levels in US adults: NHANES, 2005-2010.  J Clin Endocrinol Metab 2016 Sep 20 (epublication).