Whether its an experiment or doctor’s orders, going gluten-free is an adjustment. Removing gluten may mean eliminating not only some of your favorite foods, but possibly a good portion of your current diet. What foods will you eat in their place? How will you fill the gluten void?
Most likely, there’s no lack of “gluten-free” versions of your favorite foods on your grocer’s shelves. In fact, the number of gluten-free packaged foods is exploding to keep up with consumer demand. Going gluten-free may be as easy as buying and opening a different box—or bag or carton.
But are gluten-free packaged foods the answer? Possibly not. In fact, they may be the surprising reason behind many go-gluten-free resolutions. Here’s why.
There’s a better way. Don’t just swap out one package for another. Relying on gluten-free packaged foods can be taxing on your budget, blood pressure, waistline, and digestion. Rather, consider this an ideal time to shift your diet away from processed foods and toward more whole foods. Instead, give your diet a bona fide upgrade.
Financial Times, Going gluten free: one of 3 trends shaking up commodities https://www.ft.com/content/5348432e-1a13-11e7-bcac-6d03d067f81f, Accessed December 9, 2017.
By Noelle Patno, PhD
When you get “the runs,” you need to know what is actually causing the excess stool and how to control it. Diarrhea (“flow through” from the Greek), by definition, is frequent loose stools of small to moderate volume typically during waking hours, in the morning or after meals.1 Often there is a feeling of extreme urgency along with the sense of incomplete evacuation. If diarrhea is accompanied by blood or grease or is of large volume, this is cause for extra concern, and you should consult your doctor as soon as possible. Diarrhea may be due to multiple causes such as dysbiosis or alteration of the intestinal microbiota which lead to changes in the usual bacterial composition.
The ABCs and more of diarrhea causes
Chronic diarrhea is a decrease in fecal consistency lasting for four or more weeks, which requires further investigation by medical personnel. If you have any concerns related to diarrhea, you should discuss them with your healthcare practitioner.
By Bronwyn Storoschuk, ND
As human life expectancy continues to increase, there is also an increased risk for cognitive impairment over the course of a longer life.1 Brain health and cognitive performance have received a lot of recent attention by researchers in order to understand, and develop, strategies that will reduce the risk for cognitive decline.2 Furthermore, greater importance is being placed on “healthspan” versus “lifespan,” and there is an increased demand to find ways to optimize overall health, including brain health and cognitive performance.
In the past few years, more scientific interest on the influence of nutrition on brain health and function has emerged, especially as dietary fats have regained popularity among consumers.2 It has been well-documented that a ketogenic diet can have profound benefits on the brain and cognitive function; however, there is also evidence that suggests consuming a high-fat diet increases the risk of cognitive decline and may impair brain performance.2,3 To clear some of the confusion, it is important to differentiate between the different types of fats and the potential mechanisms that may explain impairment in cognitive function.
As far back as 1990, animal studies showed that diets high in saturated fats caused significant impairments in learning and memory.4 The results from subsequent human studies showed similar findings. Research showed that high-fat diets, containing mostly omega-6 fatty acids and saturated fats, were associated with worse performance on cognitive tasks.5 In addition, diets that contained mostly saturated fats and transfats have been associated with an increased risk of brain disorders.6 It has also been determined that high-fat diets with elevated amounts of saturated fats and cholesterol may impair intellectual function, along with increased risk for other health concerns.7 As most Americans follow a “Standard American Diet,” which contains high amounts of omega-6 fatty acids, saturated fats, and transfats and low omega-3 fatty acids, it is not surprising that rates of cognitive decline are increasing in the US.2,8
In the United States, the major sources of saturated fats come from:9
Although insulin is usually discussed in relation to carbohydrate intake, consumption of both saturated and trans fats have been studied to impair insulin sensitivity.12 In addition, data have shown diets high in saturated fats are associated with increased total body weight and abdominal obesity, which also contribute to insulin resistance.13 Overall, it has been found that cognitive performance declines as whole body insulin resistance increases.10
It is important to consider that the Standard American Diet is also comprised of large amounts of refined sugars and refined grains.2 Increased consumption of refined carbohydrates also leads to insulin resistance, the greatest effects of which are seen when high sugar intake is combined with excessive caloric intake—often found in conjunction with a high-fat diet.14 So although specific fats can induce insulin resistance, this combination is more detrimental and very common in the US population.2
It has been observed that a high-fat diet, primarily composed of increased intakes of saturated fats and omega-6 fats, raises the levels of free radicals in tissues and the brain.11,15 Free radicals, or reactive oxygen species (ROS), contribute to oxidative stress and lead to cellular damage.16 Chronically high levels of oxidative stress are known to lead to cognitive decline.16 Research has shown that high-fat diet-induced oxidative stress also leads to reduced levels of brain-derived neurotrophic factor (BDNF), which plays an important role in the survival, and growth, of brain cells and may explain some of the impairment in cognitive performance.2,17 Interestingly, data from preclinical studies indicate vitamin E, a potent antioxidant, is associated with better cognitive performance.18,19 While these findings still need to be confirmed in human studies, this information suggests that oxidative stress is involved in cognitive impairment and may be an outcome of a high-fat diet.2
Moreover, high-fat diets, specifically the fats included in the Standard American Diet, commonly lack essential vitamins, minerals, and antioxidants, which may further limit the body’s ability to effectively combat the increased levels of oxidative stress resulting from this high-fat diet.20
Studies show high-fat diets composed primarily of saturated fats and omega-6 fatty acids have been associated with significantly increased levels of inflammation both systemically and in the brain.2 The brain is very sensitive to levels of inflammation, as inflammatory mediators can easily cross the blood-brain barrier.2 In one animal study, a diet comprised of 60% saturated fat showed significantly increased levels of inflammatory mediators, reduced levels of brain-derived neurotrophic factors, and highly reactive cells in the brain. As inflammatory mediators increased, significant impairment in cognitive performance was observed.21
Fats & cognition
It is clear that all fats are not created equally. For instance, a diet that is rich in omega-3 fatty acids has been found to support cognitive processes.11 Accordingly, diets high in omega-3 fatty acids are associated with enhanced memory and learning and may play a role in supporting healthy cognition.24-25 The most important omega-3 fatty acids for brain health are EPA and DHA.26 However, it can be challenging to get the appropriate intake of EPA and DHA by diet alone, especially when looking to enhance cognitive performance.26 Also, it is important to note that a low intake of total fat, less than 20% of caloric intake, has been studied to impair cognitive performance due to an inadequate intake of fat-soluble vitamins and essential fatty acids, all of which are necessary to support cognition and general health.10
Regardless of what diet is followed, when fat is consumed, it is very important to choose the right fats. Brain function is impacted by insulin resistance and is sensitive to oxidative stress and inflammation, all of which are increased on a high-fat diet.2 However, this does not mean that all types of fats are bad, as it is well-documented that omega-3 fatty acids support cognition, and fat, in general, is required for optimal brain health.24
This content is not intended as a substitute for professional medical advice, diagnosis, or treatment. Individuals should always consult with their healthcare professional for advice on medical issues.
Bronwyn Storoschuk, ND
Bronwyn Storoschuk, ND is a board-certified naturopathic doctor trained at the Canadian College of Naturopathic Medicine. Prior to attaining her ND, Dr. Storoschuk completed her Bachelor of Science (Honours) in Kinesiology at Queen’s University in Kingston, Ontario. She currently works in private practice in Toronto, Ontario. One of her practices is located within an integrative fertility clinic, where she provides naturopathic care to individuals undergoing assisted reproductive technology (ART). Dr. Storoschuk integrates evidence-based medicine with the understanding of the body’s natural physiology and innate healing wisdom. She is passionate about empowering women to take control of their hormonal health and has a clinical focus in hormone balance, reproductive health, and fertility.
Dr. Storoschuk is a paid consultant and guest writer for Metagenics.
An antioxidant introduction
In the world of antioxidants, coenzyme Q10, otherwise known as CoQ10, stands out as a key player in optimizing human health. It’s one of the most significant lipid antioxidants that helps prevent free radical generation and subsequent modification of proteins, lipids, and DNA.1 Naturally produced in the body,2CoQ10 is a fat-soluble enzyme,1 and the highest levels in humans are found in the heart, liver, kidneys, and pancreas.3
The history of CoQ10
CoQ10, a type of the coenzyme Q group, was first identified in 1940 and known under various names such as ubidecarenone, ubiquinone, ubiquinol, and vitamin Q10. In 1957, CoQ10 was isolated from mitochondria of the beef heart. Although there are several types of coenzyme Q, the most common type of coenzyme Q in human mitochondria is CoQ10. CoQ10 is also found in meat and fatty fish and in smaller quantities within whole grains, nuts, and vegetables.1
CoQ10 plays a significant role in mitochondrial oxidative phosphorylation and is critical for the production of adenosine triphosphate (ATP), which is necessary for energy transport throughout the body as well as supporting the cardiovascular system overall. 1,2
While the body naturally produces CoQ10, this ability to make CoQ10 peaks around 20 years of age and decreases with age.1 Some studies suggest certain health conditions may reduce CoQ10 levels in the body.1,4
CoQ10 has many well-researched benefits and plays an important role in many body functions:1
Use of CoQ10 should be taken with the knowledge and guidance of a healthcare practitioner to avoid any potential adverse interactions with existing medications.
1. Saini R. J Pharm Bioallied Sci. 2011;3(3):466–467.
2. Coenzyme Q10. Linus Pauling Institute: Micronutrient Information Center. Available at: https://lpi.oregonstate.edu/mic/dietary-factors/coenzyme-Q10. Accessed April 5, 2019.
3. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/coq10. Accessed April 25, 2019.
4. Garrido-Maraver J et al. Front Biosci (Landmark Ed). 2014;19:619-633.
Submitted by the Metagenics Marketing Team
Your body is built to fight off anything that may harm it, from infections to injuries to toxins in the air. And when your body is in danger, your immune system to triggered to respond.1 That response is called inflammation—i.e., your body’s way of protecting and healing itself.2 Eventually, you become healthy again. But what if you don’t?
For some, inflammation can become chronic and persist; instead of becoming your ally, it becomes your worst nightmare.3 In fact, systemic inflammation is a known precursor to chronic illness.4,5
Unfortunately, chronic inflammation may be more common than you think. An otherwise healthy person can have a low to moderate amount of inflammation in his or her body and not even know it. The good news? There are plenty of foods you can eat that have been shown to help reduce chronic inflammation and can therefore promote overall health; there are also plenty of foods that have been linked to promoting inflammation which you can avoid. Keep these lists in mind at your next meal!
Leafy greensVegetables such as broccoli, spinach, and kale are packed with antioxidants that protect your body from foreign invaders.4,6
BerriesVarieties including blueberries, raspberries, cherries, and strawberries are high in protective compounds such as antioxidants and polyphenols.4,7
NutsHealthy snacks like almonds and walnuts have been associated with reduced markers of inflammation.4
AvocadoA superfood rich in monounsaturated fats as well as carotenoids and tocopherols, avocados can reduce your risk for chronic illness.9,10
Dark chocolateA delicious treat with plenty of antioxidants to fight off inflammation. It may even lead to healthier aging.1
Green teaSip on this ultrahealthy drink for its antioxidative, anti-inflammatory properties, particularly its high levels of epigallocatechin-3-gallate (EGCG). This substance inhibits proinflammatory cytokine production.12,13
Fatty fishOmega-3 fatty acids found in fatty fish (e.g., salmon) are metabolized into anti-inflammatory compounds called resolvins.4,14
Extra virgin olive oilThis kitchen staple is full of healthy monounsaturated fats and has been shown to reduce inflammatory markers.4
TurmericThis beloved spice contains curcumin, a powerful anti-inflammatory nutrient.8
CoffeeYour favorite morning beverage contains polyphenols and other anti-inflammatory compounds.
Note: Many of the foods on this list make the cut in one of the most well-researched diets in the world—the Mediterranean diet. Overall, the plant-based combination of healthy fats, carbs, and protein is shown to reduce key markers of inflammation.4,15-18
Saturated fatsFound in virtually all processed, packaged junk foods as well as things like shortening and lard, saturated fats can throw off immune cells and trigger inflammation. Common culprits include pizza, pasta, cheese, and red meat products.19
Refined carbsThese include white flour (breads, rolls, and crackers), white potatoes (French fries), and many breakfast cereals, which contain a high glycemic index.4,21
Processed meatsConsumption of processed red meats (burgers, hot dogs, and sausage) has been associated with increased levels of inflammatory markers.4,22
SugarForego anything that rhymes with gross (e.g. fructose, sucrose), as these can trigger the release of cytokines and lead to inflammation. 4,18
Omega-6 Fatty Acids
Found in corn, safflower, sunflower, peanuts, soy, vegetable oils, mayonaise and many commercial salad dressings, these fatty acids may inhibit the anti-inflammatory effects of healthy omega-3s. 20
With this information in mind, incorporating more of these plant-based foods and healthy fats into your diet while cutting out sugar and processed foods can be a powerful strategy in supporting your long-term health.
This information is for educational purposes only. This content is not intended as a substitute for professional medical advice, diagnosis, or treatment. Individuals should always consult with their healthcare professional for advice on medical issues.
Q&A: What Should I Look for in a Hemp Oil?
It seems like hemp products are everywhere you look. With so many options to choose from, it’s more important than ever to ask the right questions when seeking a hemp product.
Q. What is the composition of the product?
A. The Cannabis sativa plant contains more than 80 different phytocannabinoids, which are naturally occurring plant-based bioactive compounds that can support and influence the body’s endocannabinoid system (ECS). The ECS promotes biological balance in many cells and tissues throughout the body.
While certain phytocannabinoid compounds may be more well-known, research has indicated that several of the phytocannabinoids found in hemp may work together to produce synergistic effects on the body’s ECS. Terpenes, a group of compounds naturally present in all plants and spices including pepper, cloves, and cinnamon, are also thought to carry a wide array of health supportive properties. Terpenes work together with phytocannabinoids to enhance the overall benefit of hemp oil and support physiological health.This synergy is known in the research community as the entourage effect. Ultimately, healthcare practitioners can best advise on which compounds people might seek for their personal support needs.
Q. How much information does the manufacturer provide on the product?
A. This is where manufacturing transparency comes in. It’s vitally important to purchase any product from a trusted source. If you can access data from testing conducted on the product, it will provide added peace of mind.
Q. What extraction methods were applied?
A. Did you know there are multiple ways extracts can be obtained from plants? Conventional methods commonly using alcohol or solvents are generally more cost-effective and rapid from a manufacturing standpoint. Other more costly and time-consuming methods can include supercritical extraction. Supercritical extraction uses pressure to extract the desired compounds from a plant. The most well-known form of supercritical extraction utilizes carbon dioxide and is termed “supercritical CO2 extraction.” Unlike many conventional extraction methods, the supercritical CO2 extraction process is free of any harsh chemical solvents. CO2 extraction is also thought to be a more environmentally friendly method as compared to conventional methods.
Submitted by the Metagenics Marketing Team
BY RUTH KIRK-GARCIA | IMMUNE, INFLAMMATION | 0 COMMENT
Inflammation is the body’s initial response to cell damage and is designed to protect it from infection or further injury. Like day and night, the inflammatory process is a cycle defined by two halves – initiation and resolution.
The initiation phase begins with a local dispatch of immune cells at the site of damage, which sounds the alarm, igniting inflammation within the surrounding tissue. Once the threat of infection or damage is neutralized, the resolution response is activated, calming the initial phase of inflammation and facilitating cellular repair and recovery.
The transition between initiation and resolution is required to complete the cycle of inflammation and to promote healing. However, for some people, this transition fails to occur, leading to a chronic, sustained inflammatory response. This keeps the body in the initiation phase where it cannot resolve inflammation; like a loud alarm system with a broken ‘deactivate’ button. The result? A state of unremitting inflammation that keeps the body in a cycle of tissue damage, preventing recovery.
However, for some people, this transition fails to occur, leading to a chronic, sustained inflammatory response. This keeps the body in the initiation phase where it cannot resolve inflammation; like a loud alarm system with a broken ‘deactivate’ button.
A Remedy for Resolution
If you or someone you know suffers from an inflammatory condition (such as arthritis), you will no doubt be aware of the frustration that comes from persistent symptoms, despite your efforts to find a solution. You may be doing all the right things, taking the right medications, taking steps to improve your diet, exercise and sleep, while proactively managing your stress. However, if the resolution of inflammation is impaired, you will continue to experience symptoms, as the inflammatory response cannot be ‘deactivated’. It’s no wonder that cutting-edge research in the field of inflammation resolution is turning heads, particularly in regards to a group of compounds called specialized pro-resolving mediators (SPMs).
Send in The SPMs
As their name suggests, SPMs trigger or ‘deactivate’ the resolution phase of inflammation in the body, which are produced from omega-3 fatty acids, (EPA) and docosahexaenoic acid (DHA). Like a half-time speech that inspires a triumphant victory, SPMs motivate the immune system to promote resolution. In the initiation phase, white blood cells are known as macrophages actively destroy problem microbes and clear the excess of immune cells released during inflammation. However, in the resolution phase, SPMs reprogram these macrophages, switching their game plan from offence to defense to help regenerate and repair damaged tissue. This results in resolution, relief and recovery.
So why, if the body can produce SPMs, does inflammation remain unresolved? Research tells us that the body’s ability to produce SPMs is lower in conditions involving chronic inflammation, meaning that in highly inflamed individuals, the ability to resolve inflammation is likely to be impaired. Some pharmacological anti-inflammatories (even some used to treat inflammation) may also prevent SPM activity, as they inhibit inflammation preventing the body’s ability to activate the resolution phase. This is why supplements providing SPMs are an exciting development for chronic inflammation sufferers; as restoring SPM levels goes beyond the effects of conventional treatments to actively promote resolution and full circle recovery.
This is why supplements providing SPMs are an exciting development for chronic inflammation sufferers; as restoring SPM levels goes beyond the effects of conventional treatments to actively promote resolution and full circle recovery
Viva la Resolution!
Heralding a new era of healing, SPMs offer a beacon of hope for those suffering from chronic inflammation, offering a new solution for achieving resolution! For more information on natural management of inflammation, read on by clicking here.However, if you are ready to experience the resolving effects of SPMs, contact a Practitioner near you today.
 Serhan CN, Hong S, Gronert K, Colgan SP, Devchand PR, Mirick G et al. Resolvins: a family of bioactive products of omega-3 fatty acid transformation circuits initiated by aspirin treatment that counter proinflammation signals. J Exp Med. 2002 Oct 21;196(8):1025-37.
 Hirahashi J. Omega-3 polyunsaturated fatty acids for the treatment of IgA nephropathy. J Clin Med. 2017 Jul;6(7):70. doi: 10.3390/jcm6070070.
 Spite M, Clària J, Serhan CN. Resolvins, specialized proresolving lipid mediators, and their potential roles in metabolic diseases. Cell Metab. 2014 Jan 7;19(1):21-36. doi: 10.1016/j.cmet.2013.10.006.
 Barden AE, Mas E, Croft KD, Phillips M, Mori TA. Specialized proresolving lipid mediators in humans with the metabolic syndrome after n-3 fatty acids and aspirin. Am J Clin Nutr. 2015 Dec;102(6):1357-64. doi: 10.3945/ajcn.115.116384.
 Chiang N, Serhan CN. Structural elucidation and physiologic functions of specialized pro-resolving mediators and their receptors. Mol Aspects Med. 2017 Dec;58:114-129. doi: 10.1016/j.mam.2017.03.005.
What we know for clinical practice and decision making
by Sara Gottfried, MD, and Kari Hamrick, PhD, RD
Polycystic ovary syndrome (PCOS) is a problem of hormone dysregulation that can lead to irregular menstrual cycles, high androgens, and its downstream sequelae such as acne and hirsutism, infertility, weight gain, and cardiovascular disease. As practitioners and their affected female patients anguish over the root cause and solutions, one part is very clear: up to 85% of women with PCOS are insufficient in vitamin D.1 For our patients with PCOS, correcting low serum vitamin D levels can be a helpful lever in improving hormonal, metabolic, inflammatory, and possibly cardiovascular outcomes.
Vitamin D is known as the “sunshine vitamin” because sunlight can trigger cutaneous synthesis of vitamin D. Previously, I reviewed the role of vitamin D in the body and the prevalence of vitamin D deficiency and insufficiency across populations. Vitamin D is a steroid hormone precursor that has hundreds of roles in the body beyond bone health. Having been interested in vitamin D deficiency and the connection with health issues, especially those impacting women, I wanted to delve into the link between vitamin D and PCOS. I will review the current literature to help inform clinical practice and decision making for this unique patient group.
PCOS and women’s health
PCOS is the most common endocrine disorder among women during reproductive years, with an estimated prevalence of 4-18% from puberty to perimenopause.2,3 Prevalence varies based on ethnicity (i.e., in descending order: Black > Middle Eastern > Caucasian > Chinese).4 Clinical presentation may include insulin resistance, obesity, hirsutism (excess male pattern hair growth), and chronic low-grade inflammation.5,6 PCOS has been linked to serious health concerns, including increased risk of breast and endometrial cancers, infertility, heart disease, stroke, dysglycemia, insulin resistance, gestational diabetes, and preeclampsia.5,6
Women experiencing hormonal imbalance at any age may feel out of control and even disempowered. Women seeking help for PCOS deserve compassionate healthcare providers who are able to diagnose, understand the root causes of their symptoms, and provide evidence-based guidelines for measurable and effective health improvement.
Recently updated international PCOS guidelines have made diagnosis and care for patients more comprehensive, standardized, and evidence-based.7 In the summer of 2018, an international consortium of PCOS healthcare professionals, including 37 societies across 71 countries (spanning six continents), issued a guideline for the assessment and management of PCOS, with 31 evidence-based recommendations that help refine the therapeutic approach and increased the focus on the important role of education and lifestyle modification.7
I understand the desire to employ best practices with the most available research evidence in your clinic. But with patients coming and going all day, it is easy to become overwhelmed with journals piling up on your desk and not enough time in the day to do a targeted PubMed search, much less read all of the new hits. Along with key individuals clinical studies, the aforementioned international consensus guideline,7 as well as systematic reviews and meta-analyses, are a time-efficient way to help the clinician recognize patterns and synthesize evidence to identify answers or solutions to important research and clinical questions.8 Now, let’s explore the vitamin D-PCOS link further, from epidemiologic to intervention evidence.
THE VITAMIN D-PCOS LINK
Vitamin D status and PCOS
Systematic review of vitamin D research indicates that hypovitaminosis D (low serum 25-hydroxvitamin D [25(OH)D]) is common in women with PCOS.9 In a review of PCOS etiology, average serum 25(OH)D levels ranged 11–31 ng/mL, but the majority of patients (67%–85%) had values < 20 ng/mL,1 which is the cutoff for deficiency according to a vitamin D clinical practice guideline from the US Endocrine Society.10
Serum vitamin D status is inversely associated with PCOS symptoms and pathology, including obesity,11,12cardiovascular disease risk,13 and insulin resistance.2,11 In a clinical study investigating the impact of lifestyle intervention on health outcomes in women with overweight or obesity and PCOS, higher 25(OH)D concentrations were significantly associated with lower waist circumference and total cholesterol among participants of both cohorts.14
Taken together, these findings suggest that vitamin D status is an important therapeutic consideration for women with PCOS.
Vitamin D supplementation and PCOS
Vitamin D supplementation studies show promising results for the potential impact of this essential micronutrient in PCOS symptomology. A 2018 systematic review and meta-analysis examined 11 randomized controlled trials (RCTs) including > 600 patients with PCOS; as expected, vitamin D deficiency and insufficiency were observed to be prevalent in this patient group, and vitamin D supplementation significantly improved 25(OH)D status.15 Analyses considered factors like dose frequency and whether vitamin D supplementation was provided alone or as a co-supplement. Major findings include: continuous daily supplementation (i.e., as opposed to weekly bolus dosing) with vitamin D (< 4,000 IU/day) alone reduced homeostatic model assessment of insulin resistance (HOMA-IR). Vitamin D provided as a co-supplement (i.e., in combination with other micronutrients – vitamin K, calcium, zinc, or magnesium) also reduced HOMA-IR and also decreased fasting glucose concentrations.15 In other words, vitamin D supplementation yielded improvements in insulin sensitivity in women with PCOS.15
Biomarkers of oxidative stress and inflammation among women with PCOS have also been examined in RCTs with vitamin D intervention; overall, higher dose groups experienced improvements in oxidative stress and inflammation.16 For example, one 3-month study included in both meta-analyses15,16 investigated the impact of vitamin D supplementation with or without with metformin on metabolic profiles of insulin resistant, Iranian women with PCOS.17 This RCT randomized patients into three groups: “high dose” vitamin D (4,000 IU/d) + metformin, “low dose” vitamin D (1,000 IU/d) + metformin, or placebo + metformin. Following intervention, metabolic profiles were significantly improved in the high dose vitamin D group compared to the low dose and placebo groups.17
Specifically, the high dose vitamin D group experienced significantly lower total testosterone, lower prevalence of hirsutism, and lower high-sensitivity C-reactive protein (hs-CRP), a marker of inflammatory response.17 Additionally, significant elevations in total antioxidant capacity (showing improved free radical fighters) and sex hormone binding globulin (SHBG) were observed in the high dose vitamin D group, indicating improved body regulation of circulating hormones.17
Female-centric considerations for vitamin D status
There are many risk factors for vitamin D deficiency in women, which we have covered previously. One gender-based factor for some women, constructed by cultural and/or religious forces, may be partial or complete covering with clothing, and thus, limited exposure to sunlight and cutaneous synthesis of vitamin D.
Additionally, with the increased prevalence and public health awareness of skin cancer, more women are using sunscreen and limiting time in the sun. Because of less opportunity to receive vitamin D through the skin, clinicians should discuss the implications of low vitamin D status with their patients and promote practical ways to achieve and maintain healthy serum 25(OH)D levels– namely, vitamin D supplementation.
Genomic risk and PCOS
The actions of the active, hormone form of vitamin D [1,25(OH)2D] are mediated by the vitamin D receptor (VDR). And over 3% of the human genome is regulated by the VDR gene.18 That may not sound like a lot, but it translates into hundreds of protein-coding genes. With advances in genetic testing for various diseases, many patients may want to know if there is a genetic component to PCOS. One meta-analysis found that VDR Fokl and Taql polymorphisms were associated with an increased risk of PCOS in certain populations (e.g., Asians).18 Another meta-analysis found that VDR variants, Apal, Bsml, and Fokl, were associated with heightened risk of diseases related to insulin resistance, particularly in Caucasians with darker skin (i.e., from Saudi Arabia, India, Egypt, and Iran) and Asian populations.19
The good news is that even if the patient carries a VDR variant linked to PCOS, improving vitamin D status via lifestyle modifications (e.g., achieving healthy weight, incorporating sun exposure in moderation, and incorporating vitamin D sources in the diet) along with intervention via routine vitamin D supplementation has more impact on PCOS outcomes than genetic variations.
Dietary/nutrition considerations in PCOS
It is well recognized that lifestyle intervention is the cornerstone of treatment for patients with PCOS.20 First line PCOS treatment should include targeted lifestyle modifications that focus on weight management, including optimizing dietary approach and increasing physical activity. In fact, the good news is that a relatively low reduction in weight (~ 5 percent) can improve insulin resistance, hyperandrogenism, menstrual function, and fertility.20,21
Clinical consensus for dietary recommendations from the international consortium have focused on overall reduction in calorie intake and general healthy eating principles, with no one particular diet reported to have more favorable outcomes over another. Dietary guidelines and lifestyle recommendations are centered on achieving a healthy weight and managing metabolic and reproductive functions. The following recommendations have been shown via research to be successful nutritional management approaches for PCOS:21-24
More on the ketogenic diet for PCOS—initial data are promising, but not quite ready for prime time according to PCOS guidelines, though it is an active area of investigation. Other areas of active research include intermittent fasting and the fasting-mimicking diet.
Regardless of the dietary approach, “Weight loss should be targeted in all overweight women with PCOS through reducing caloric intake in the setting of adequate nutritional intake and healthy food choices irrespective of diet composition.”20
Improving vitamin D status in patients with PCOS
Individual nutrients of interest in PCOS research, such as vitamin D, were not specifically addressed in the 2018 international PCOS guidelines.6 However, because the growing body of research on vitamin D status and supplementation interventions in patients with PCOS is compelling, it is prudent for practitioners to partner with patients to assess their vitamin D status (via serum 25(OH)D concentration; sufficiency is defined as ≥ 30 ng/mL) and help them achieve and maintain vitamin D sufficiency through supplementation.10
Supplementation recommendations can be personalized based on periodic serum 25(OH)D measurements (e.g., it can take 3-4 months for 25(OH)D to reach a new steady state), and dosing depends on whether you are repleting a deficient state (6,000 IU/day or 50,000 IU/week for 8 weeks) or maintaining a 25(OH)D level in the normal range (at least 1,500-2,000 IU/day).10 However, it is important to remember that patients with overweight and obesity (common in PCOS) may need 2-3 times more vitamin D daily than their normal-weight counterparts.10
Optimal healthcare approach for patients with PCOS
A multidisciplinary, holistic, and personalized lifestyle medicine approach to care is the best practice for patients with PCOS. Collaboration and continuity of care with specialists across the PCOS spectrum has the greatest impact on outcomes and patient satisfaction.6,27
The evidence-based guidelines recommend lifestyle management as the first line therapy, with weight management being of utmost importance. Modest weight loss can net significant metabolic and hormonal improvements in patients with PCOS.20 Research indicates that weight management outcomes in women with PCOS are likely improved by the inclusion of the following factors: behavioral and psychological strategies, goal setting, self-monitoring, cognitive restructuring, problem solving, relapse prevention.28 Strategies that target improvements in motivation, social support, and psychological well-being are also key.28
Providing your patients with high-quality, multidisciplinary resources and referrals will improve their opportunity to receive support for the necessary lifestyle modifications.27 This may include consultations with fertility experts, endocrinologists, cardiologists, behavioral health specialists, registered dietitian nutritionists, or personal trainers, to name a few. Ask your patients what barriers to lifestyle management they may experience, and partner with them to champion key, gradual changes toward healing and wellness.
Although vitamin D supplementation recommendations are not yet included in the latest international PCOS guidelines, the evidence to date indicates that assessment and treatment of vitamin D deficiency and insufficiency among PCOS patients is likely a critical piece of the PCOS management puzzle. Vitamin D supplementation is the most pragmatic, beneficial, and clinically necessary approach when serum 25(OH)D levels are low, a scenario that applies the majority of patients with PCOS.
Sara Gottfried, MD is a board-certified gynecologist and physician scientist. She graduated from Harvard Medical School and the Massachusetts Institute of Technology and completed residency at the University of California at San Francisco. Over the past two decades, Dr. Gottfried has seen more than 25,000 patients and specializes in identifying the underlying cause of her patients’ conditions to achieve true and lasting health transformations, not just symptom management.
Dr. Gottfried is the President of Metagenics Institute, which is dedicated to transforming healthcare by educating, inspiring, and mobilizing practitioners and patients to learn about and adopt personalized lifestyle medicine. Dr. Gottfried is a global keynote speaker who practices evidence-based integrative, precision, and Functional Medicine. She recently published a new book, Brain Body Diet, and has also authored three New York Times bestselling books: The Hormone Cure, The Hormone Reset Diet, and Younger.
Kari Hamrick, PhD, RD is a registered dietitian with over 25 years of experience in nutrition and wellness and is the founder of Navigate Nutrition and Wellness, a private practice nutrition counseling center located in Gig Harbor, WA. Dr. Hamrick earned her PhD in nutritional sciences from Texas Woman’s University and received Adult Weight and Lifestyle Management certification from the Commission on Dietetic Registration. Kari has special training and experience in Mindfulness Based Eating Awareness Training (MB-EAT), women’s health issues, and the nutritional management of heart disease, eating disorders, and digestive health. Dr. Hamrick is currently completing a medical communication fellowship at Metagenics. Dr. Hamrick’s passion is helping individuals meet their nutrition and health goals with respect, open communication, and a sense of humor. She is also a yoga and dance instructor and enjoys learning and performing aerial acrobatic arts.
by Ashley Jordan Ferira, PhD, RDN
The importance of vitamin D in diverse organ systems and biochemical processes is ever-growing with novel research findings. From calcium absorption to extraskeletal health processes such as immune function- vitamin D is essential.
The role of vitamin D in pain management is a newer area of investigation that has not been fully established. It is estimated that 25.3 million American adults experience pain every day, with nearly 40 million experiencing some form of extreme pain.1 Annual costs associated with treating pain and pain-related symptoms are estimated to be higher than cancer and diabetes combined, reaching upwards of $600 billion per year.2 The striking number of Americans experiencing pain, combined with the associated financial burdens, underscores the need for clinically efficacious pain management methods.
Chronic non-specific widespread pain (CWP) including fibromyalgia (FMS) is associated with diffuse pain, reduced pain threshold, multiple points of tenderness, disability, and decreased quality of life. To better understand if vitamin D supplementation can significantly impact (CWP) including fibromyalgia (FMS), researchers, performed a systematic review and meta-analysis, the results of which were published in Clinical Rheumatology.3
Researchers comprehensively assessed databases for pertinent vitamin D trials. The authors focused on randomized controlled clinical trials evaluating the effects of vitamin D on CWP and FMS; 4 clinical trials met the inclusion criteria. After pooling the data from over 270 patients, regression, sensitivity and heterogeneity analyses were evaluated. Visual Analog Scale (VAS) of pain intensity was a major outcome measure.
Pooled results revealed a significantly lower VAS of pain intensity in CWP patients who received vitamin D treatment vs. those who received a placebo control. The analysis concluded that vitamin D supplementation decreased pain scores and improved pain symptoms.
Why is this Clinically Relevant?
Link to abstract
The female-centric 411 on this essential nutrient
by Ashley Jordan Ferira, PhD, RDN
Vitamin D research and daily news headlines are ubiquitous. PubMed’s search engine contains over 81,400 articles pertaining to vitamin D.1 Information abounds on vitamin D, but the vetting and translation of that information into pragmatic recommendations is harder to find. Evidence-based takeaways and female-centric recommendations are crucial for healthcare practitioners (HCPs), their female patients and consumers alike. Women are busy, multi-tasking pros, so practical, personalized takeaways are always appreciated. In other words, women need the “411” on vitamin D. Merriam-Webster defines “411” as “relevant information” or the “skinny”.2 So for all of you busy women, here’s the skinny on vitamin D. Let’s explore common questions about this popular micronutrient.
Q: Is vitamin D more important for younger or older women?
A: All of the above. Vitamin D plays a critical role in women’s health across all life stages, from fertility/conception, to in utero, childhood, adolescence, adulthood, older adulthood, and even in palliative care. Vitamin D is converted by the liver and kidneys into its active hormone form: 1,25-dihydroxyvitamin D. This dynamic hormone binds nuclear receptors in many different organs in order to modulate gene expression related to many crucial health areas across the lifecycle, including bone, muscle, immune, cardiometabolic, brain, and pregnancy to name a few.3
Q: I am a grandmother. Are my vitamin D needs different than my daughter and granddaughter?
A: Yes, age-specific vitamin D recommendations exist. As an essential fat-soluble vitamin, women need to achieve adequate levels of vitamin D daily. Age-specific Recommended Dietary Allowances (RDA) from The Institute of Medicine (IOM),4 as well as newer clinical guidelines from The Endocrine Society,5 provide helpful clinical direction for daily vitamin D intake and/or supplementation goals.
The IOM RDAs4 are considered by many vitamin D researchers to be a conservative, minimum daily vitamin D intake estimate to support the bone health of a healthy population (i.e. prevent the manifestation of frank vitamin D deficiency as bone softening: rickets and osteomalacia):
Infants (0-1 year): 400 IU/day
Children & Adolescents (1-18 years): 600 IU/day
Adults (19-70 years): 600 IU/day
Older Adults (>70 years): 800 IU/day
The Endocrine Society’s clinical practice guidelines5 recommend higher daily vitamin D levels than the IOM, with a different end-goal: raising the serum biomarker for vitamin D status [serum 25-hydroxvitamin D: 25(OH)D] into the sufficient range (≥ 30 ng/ml) in the individual patient:
Infants (0-1 year): At least 1,000 IU/day
Children & Adolescents (1-18 years): At least 1,000 IU/day
Adults (19+ years): At least 1,500 – 2,000 IU/day
Q: I am a health-conscious woman who eats a nutritious, well-rounded diet. I should not need a vitamin D supplement, right?
A: Not so fast. Daily micronutrient needs can be met via diet alone for many vitamins and minerals. Vitamin D is one of the exceptions, which is why an alarming number of Americans (93%) are failing to consume the recommended levels from their diet alone.6-7 Very few foods are endogenous sources of animal-derived vitamin D3 (cholecalciferol) or plant-derived vitamin D2 (ergocalciferol). Some natural vitamin D sources include certain fatty fish (e.g. salmon, mackerel, sardines, cod, halibut, and tuna), fish liver oils, eggs (yolk) and certain species of UV-irradiated mushrooms.8 In the early 20th century, the US began fortifying dairy and cereals with vitamin D to help combat rickets, which was widespread. For example, one cup (8 fluid ounces) of fortified milk will contain approximately 100 IU of vitamin D.
Even though some food sources do exist, the amounts of these foods or beverages that an adult would need to consume daily in order to achieve healthy 25(OH)D levels (> 30 ng/ml) is quite unrealistic and even comical to consider. For example, you would need to toss back 20 glasses of milk daily or 50 eggs/day to achieve 2,000 IU of vitamin D! In contrast, daily vitamin D supplementation provides an easy and economical solution to consistently achieve 2,000 IU and any other specifically targeted levels.
Q: I enjoy the outdoors and get out in the sun daily, so I should be getting all of the vitamin D that I need, correct?
A: Vitamin D is a highly unique micronutrient due to its ability to be synthesized by our skin following sufficient ultraviolet (UV) B irradiation from the sun. Many factors can result in variable UV radiation exposure, including season, latitude, time of day, length of day, cloud cover, smog, skin’s melanin content, and sunscreen use. Furthermore, medical consensus advises limiting sun exposure due to its established carcinogenic effects. Interestingly, even when dietary and sun exposure are both considered, conservative estimates approximate that 1/3 of the US population still remains vitamin D insufficient or deficient.9
Q: What factors can increase my risk for being vitamin D deficient? Are there female-specific risk factors?
A: Although the cutoff levels for vitamin D sufficiency vs. deficiency are still debated amongst vitamin D researchers and clinicians, insufficiency is considered a 25(OH)D of 21-29 ng/ml, while deficiency is < 20 ng/ml.5 Therefore, hypovitaminosis D (insufficiency and deficiency, collectively) occurs when a patient’s serum 25(OH)D falls below 30 ng/ml. The goal is 30 ng/ml or higher.
Ideally, vitamin D intake recommendations4-5 and therapy are personalized by the HCP based on patient-specific information, such as baseline vitamin D status, vitamin D receptor single nucleotide polymorphisms and other pertinent risk factors.
Common risk factors for vitamin D deficiency to look out for include:
-> Older age
-> Regular sunscreen use
-> Winter season
-> Frequent TV viewing
-> Dairy product exclusion
-> Darker skin (more melanin)
-> Not using vitamin D supplements
-> Malabsorption disorders (e.g. bariatric surgery, IBD, cystic fibrosis)
-> Liver disease
-> Renal insufficiency
-> Certain drug classes: weight loss, fat substitutes, bile sequestrants, anti-convulsants, anti-retrovirals, anti-tuberculosis, anti-fungals, glucocorticoids
-> Lastly, additional female-specific risk factors to look out for include exclusive breastfeeding while mother is vitamin D insufficient (can result in infant being vitamin D deficient) and certain cultural clothing that covers significant amounts of skin surface area (e.g. hijab, niqab).
Ashley Jordan Ferira, PhD, RDN is Manager of Medical Affairs and the Metagenics Institute, where she specializes in nutrition and medical communications and education. Dr. Ferira’s previous industry and consulting experiences span nutrition product development, education, communications, and corporate wellness. Ashley completed her bachelor’s degree at the University of Pennsylvania and PhD in Foods & Nutrition at The University of Georgia, where she researched the role of vitamin D in pediatric cardiometabolic disease risk. Dr. Ferira is a Registered Dietitian Nutritionist (RDN) and has served in leadership roles across local and statewide dietetics, academic, industry, and nonprofit sectors.