Oily Fish, Fish Oil Supplements Linked to Lower Diabetes Risk

In the largest study of its kind to date, regularly eating oily fish such as salmon, sardines, lake trout and albacore tuna reduced the risk of type 2 diabetes.[1]

The observational study, which was published in Diabetes Care, analyzed the health and diet of nearly 400,000 middle aged and older UK residents across roughly 10 years.[2] The study found people who eat one or more servings weekly of oily fish have a 22% lower risk of type 2 diabetes compared with those who never eat oily fish. Even people who eat less than one serving of oily fish weekly have a 16% lower risk of type 2 diabetes. Non-oily fish, on the other hand, has no link to type 2 diabetes risk reduction, according to the study.  While the study may lead to future dietary guidelines for prevention of type 2 diabetes, clinical trials are needed before any formal recommendations are made.

Other Potential Benefits of Oily Fish

Fish oil contains high amounts of omega-3 fatty acids called eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).[3] Omega-3 acids support essential functions throughout the human body, from maintaining cell membranes to promoting hormone production.

Some research indicates omega-3 acids may reduce the risk of heart attack or stroke, according to the American Heart Association.[4] Other research suggests omega-3 acids can help reduce inflammation and even fight depression, according to studies published by the National Institutes of Health (NIH).[5][6]

Staying Safe with Fish

Oily fish is an attractive option for good health — not only for its rich omega-3 content and potential type 2 diabetes risk reduction, but also for its high amounts of protein, vitamin B12, vitamin D, iron, and numerous other nutrients. [5] However, it’s important to remember fish contain mercury. The Food and Drug Administration (FDA) provides detailed guidelines for safely eating fish, including which fish contain more mercury than others. As always, remember to talk with your doctor before making changes to your diet.

Though regularly eating oily fish was linked to the greatest type 2 diabetes risk reduction, the study found those who consistently took fish oil supplements had a 9% reduction in risk.[1] It’s important to remember not all fish oil supplements are equal. Make sure you choose high-quality, highly concentrated supplements  such as OmegaGenics EPA-DHA 1000 from Metagenics and follow the recommended dosage.

Sources:

  1. https://care.diabetesjournals.org/content/early/2021/01/05/dc20-2328
  2. https://www.medscape.com/viewarticle/945007
  3. https://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-and-cholesterol/types-of-fat/omega-3-fats/
  4. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/fish-and-omega-3-fatty-acids
  5. https://pubmed.ncbi.nlm.nih.gov/21784145/
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3976923/
  7. https://www.fda.gov/food/consumers/advice-about-eating-fish

Not Taking a Multivitamin? Here Are 5 Reasons to Reconsider

Modified from an Original Post by Metagenics Institute

You try to eat well to feel good and stay healthy. While it’s optimal to get your daily nutritional needs from the foods you eat, it’s just plain difficult. There is conflicting information out there on the benefits of supplements, but the Dietary Guidelines for Americans 2020-2025 say that supplements may be useful for providing the nutrients you may be lacking from diet alone.

Still on the fence? Consider these top five reasons to add a multivitamin to your daily regimen.

1. Healthy aging. As we get older, our bodies have a harder time absorbing nutrients from food. The National Institute on Aging notes that starting around age 50, people begin to require increased amounts of certain vitamins and minerals.1,2 In fact, according to a study published in the American Journal of Clinical Nutrition, researchers found that taking a daily multivitamin & mineral supplement may help improve micronutrient deficiencies associated with aging.3

2. Making up for eliminated food groups. While some people have to cut certain foods like nuts or gluten out of their diets due to allergies, many eliminate particular foods or food groups from their diet voluntarily. This can cause vitamin insufficiencies and deficiencies that would be helped with a multivitamin. Trying a paleo diet? You might risk a shortage of calcium or vitamin D by eliminating dairy or grains. Cutting back on red meat? A multivitamin will replace the iron and B12 you would normally get from diet.

3. Getting the RDAs you’re not getting from food. You’ve probably heard that the typical Western diet doesn’t include nearly enough fruits, vegetables, whole grains, legumes, or lean protein. Because of that, you don’t always reap the vitamin and mineral benefits that those foods naturally supply. Consequently, nationally US adults are routinely failing to meet their daily requirements for vitamin A, C, D, E, and K, as well as for calcium, magnesium and potassium from diet alone, and this is including fortified sources!4 Supplementing with a multivitamin is therefore a prudent way to strategically fill those gaps on a daily basis. After all, the goal should not simply be to avoid blatant vitamin deficiencies, like scurvy with vitamin C deficiency. Borderline vitamin and mineral insufficiencies are just as important to avoid and address. Even the most health-conscious eater will benefit from multivitamin support to achieve micronutrient sufficiency across the board.

4. Getting that extra energy to get through the day. In today’s “go-go-go” society, one of the top complaints is a general lack of energy. Instead of reaching for that third cup of coffee, remember that your cells require certain vitamins and minerals to power your busy life; especially if you’re not getting a full eight hours of sleep or eating a balanced diet, a multivitamin can help provide the nutrients you need to feel energetic throughout the day.5

5. Managing stress. Daily life stressing you out? You’re not alone. But vitamins and minerals play significant biochemical roles in supporting and preserving your brain’s cognitive processes, and studies have shown that a daily multivitamin—particularly one with high doses of B vitamins—can help to reduce stress and support a healthy mood.6

Ready to add a daily multivitamin to your diet? Be sure to check with your healthcare practitioner to see if he or she has personalized recommendations for you and to ensure that any medications you’re currently on won’t interfere with their effectiveness or the effectiveness of the multivitamin ingredients.

You can order multivitamins through Metagenics, our trusted supplier of nutraceuticals and supplements.

Citations

  1. Department of Health and Human Services and U.S. Department of Agriculture. 2020–2025 Dietary Guidelines for Americans. 9th Edition. December 2020. Available at https://www.dietaryguidelines.gov
  2. National Institute on Aging. Dietary Supplements. Available at https://www.nia.nih.gov/health/dietary-supplements
  3. Xu Q, Parks CG. Multivitamin use and telomere length in women. Am J Clin Nutr. 2009; 89(6):1857–1863.
  4. Fulgoni VL, Keast DR. Foods, fortificants, and supplements: where do Americans get their nutrients? J Nutr. 2011;141(10):1847-1854.
  5. Bailey RL, Gahche JJ. Why US adults use dietary supplements. JAMA Intern Med. 2013; 173(5):355-361.
  6. Stough C, Simpson T, Lomas J, et al. Reducing occupational stress with a B-vitamin focused intervention: a randomized clinical trial: study protocol. Nutrition J.2014;13(1):122.
Woman With a Headache

COVID’s Lingering Symptoms

Two new studies are adding to a growing body of evidence suggesting COVID-19 causes chronic, debilitating symptoms long past infection and illness. There are now more than 50 symptoms tied to COVID in mild, moderate and severe cases. Fatigue, headaches, brain fog, hair loss, and loss of smell are the most common lingering effects while more worrying symptoms such as lung problems, chest pain, heart problems, sleep disorders and neurological issues have also been reported.

The first investigation is a large meta-analysis that included data from 15 studies in the US, Britain and Europe and involved nearly 48-thousand patients. It found eight out of 10 COVID-19 patients had lingering symptoms or signs 14 or more days after acute infection. At Houston Methodist Research Institute, one site where the data was collected, clinicians found fatigue was the most common symptom of both long and acute COVID-19, and remained present 100 days after onset.

The meta-analysis revealed that during follow up appointments, more than a third of patients had an abnormal chest x-ray or CT scan. Tests also showed elevated biomarkers for inflammation, such as D-dimer and C-reactive protein (CPR). Other symptoms included persistent cough, chest discomfort and pulmonary fibrosis, as well as cardiac arrhythmias, inflammation of the heart muscle (myocarditis), depression, anxiety and sleep issues.

Last month, the prestigious medical journal, The Lancet, reported findings from another study that followed hospitalized patients in Wuhan, China. It showed 76% of those patients were still struggling with the after-effects of COVID-19 six months later. The study cited fatigue and muscle weakness as the most common symptoms. However, some patients experience lasting impacts such as long-term cardiac damage, lung damage and kidney damage.

Because COVID-19 is a new disease, it’s not known how long many of the symptoms will last. Even patients with a mild case of COVID-19 report lasting symptoms for months after infection, such as breathlessness while walking. Adding further to the mystery, researchers are still trying to determine why some people experience these persistent problems — especially when the virus is no longer detected. In many cases, chest x-rays, scans and other tests mysteriously come back normal or negative.

There’s no specific diagnosis for post-COVID symptoms. The syndrome has been described as “long COVID” and those suffering with it as “long haulers.” While at first, some experts dismissed the idea of long haulers due to the lack of medical evidence and inconsistent test results, the medical community is now paying close attention. Dr. Anthony Komaroff, editor-in-chief of the Harvard Health Letter, believes post-COVID-19 symptoms can affect a wide range of people from young to old — those who were healthy, those who have been hospitalized, and those with mild cases. As he states, it’s not unthinkable that 50 million Americans could ultimately become infected. If just 5% of COVID patients develop lingering symptoms, post-COVID treatment will become even more critical.

The head of the National Institute of Allergy and Infectious Diseases, Dr. Anthony Fauci, has suggested “long COVID” resembles a condition called myalgic encephalomyelitis/chronic fatigue syndrome or ME/CFS. More commonly known as chronic fatigue syndrome, ME/CFS has symptoms including extreme fatigue, sleep dysfunction, and brain fog — similar to symptoms reported by long-COVID sufferers — and is known to develop following viral infection. A recent study at the Stanford University School of Medicine indicates inflammation is a powerful driver behind chronic fatigue syndrome. Similarly, some scientists believe inflammation could be an underlying factor in the lingering effects of COVID-19. More studies with standardized testing are needed to determine whether COVID-19 directly causes long-term symptoms or if these symptoms are caused by a preexisting disease or condition.

If you’ve had COVID and are still dealing with lingering symptoms that impact the quality of your life, contact your doctor or healthcare provider.

Sources:

Alopecia: Genes, Hormones, and More Causes of Hair Loss

By Bianca Garilli, ND

From Metagenics Institute

Hair loss, or alopecia, is a common complaint by patients, male and female alike. It can affect localized regions (like the temples and crown of the head seen in male-pattern baldness), the entire scalp, and sometimes can even extend to other areas of the body. Typical hair loss is approximately 50-100 hairs per day, but those suffering from more extensive hair loss frequently notice increased hair loss after brushing or styling their locks or even when cleaning the sinks and sweeping their floors.1 Hair loss can have a significant emotional and social impact on individuals. Understanding the underlying causes can be extremely helpful in creating an effective set of recommendations to mitigate hair loss.

Although hair loss or balding has a genetic component in many cases, there are also non-genetic, modifiable factors that may lead to hair loss. Let’s explore a few of the most common causes, including your genes, that underlie hair loss as well as targeted recommendations to reduce the loss.1,2 Woman getting a haircut.

Heredity (genetic): 

Many people are convinced that their hair loss is hereditary and runs in the family. For cases of male-pattern baldness or female-pattern baldness (both also known as “androgenetic alopecia”), this would be correct. This form of balding typically occurs gradually as the person ages, often following specific patterns such as a receding hairline in males and thinning of hair in specific areas or over the whole scalp in women.3

The genetics of hair loss is complex. For example, over 200 independent, novel genetic correlates of male pattern baldness were identified in a recent genome-wide association study (GWAS), with a majority of those being autosomal related, while others were found to be X chromosome variants.4 Another well-studied gene, the androgen receptor (AR) gene, is associated with hormonally-related balding and may contribute to androgenetic alopecia.5

Androgenetic alopecia is the most prevalent hair loss disorder globally.6 This hereditary baldness affects over 80 million people in the US alone, creating a demand for effective treatments.7 Hereditary balding may be caused in some part by excess androgens, when testosterone is converted into dihydrotestosterone (DHT) by 5-alpha reductase (5AR) at higher-than-normal rates.8 Approaches to slow the rate of balding include reducing DHT levels or giving 5AR inhibitors.8

Beyond the conventional medicine prescription approach, non-Rx options on the market are numerous, including: L-cystine, caffeine-based lotions and shampoos, capsaicin, marine protein supplements, melatonin, procyanidins (a phytonutrient class of anti-inflammatory flavonoids found mainly in plants, including apples, barley, cocoa, cinnamon, grapes, and tea), pumpkin seed and rosemary oils, saw palmetto, zinc, and various others.9

Hormones: 

Hormonal changes associated with various life stages including pregnancy, childbirth, and menopause or fluctuation in thyroid function and thyroid hormone levels can also lead to temporary and sometimes permanent hair loss. Partnering with a healthcare provider who practices personalized lifestyle medicine is key to balancing hormone levels through individualized lifestyle changes and sometimes targeted nutritional supplementation or medications, such as hormone replacement therapy (HRT).1

Medical conditions and medications: 

Medical conditions may also be the culprit for some individuals’ hair loss; these conditions may include infections such as ringworm, conditions with mental health underpinnings (e.g., trichotillomania, a disorder involving recurrent, irresistible urges to pull out body hair), and a relatively common condition called alopecia areata.1,7 The latter has a lifetime incidence of 2% globally and is an immune-mediated condition that creates smooth, round patches of hair loss on the scalp or body; characterized by unpredictability, spontaneous regrowth as well as possible relapse periods.6

Identifying and treating the root causes of the medical condition can lead to hair regrowth, so it is prudent to seek out clinician experts who know how to utilize a Functional Medicine lens. In some cases, medications used to treat other health issues can induce hair loss as a side effect; these might include medications used for the treatment of cancer, arthritis, depression, heart problems, gout, and high blood pressure.1

Stress: 

The physiologic effects of stress are not limited to specific organs like the brain or heart. No, stress impacts whole body health, including increasing the risk of hair loss through various mechanisms, one of those being the pro-inflammatory milieu (i.e., hormones, cytokines, etc.) of stress in the body.10 In recent years, the concept of a “brain-skin” connection has taken hold as a way to understand how stress may influence difficult-to-treat skin disorders such as psoriasis, atopic dermatitis, and urticaria, as well as its effect on hair loss.11

In particular, it is thought that, “neurohormones, neurotransmitters, and cytokines, released during a stress response may also significantly influence the hair cycle.”11 The growth of hair, the hair shaft production, and hair pigmentation, along with various other hair characteristics, may be impacted by the production of these stress-related molecules.12 If hair loss is considered to be stress-related (which may be a possible underlying factor in Telogen effluvium, alopecia areata, trichotillomania, and hormone-related hair loss), a wide range of mind-body, naturopathic, and Functional Medicine approaches may be useful.13

Nutritional deficits: 

In some situations, sudden weight loss or protein deficiency can lead to hair loss.2 Additionally, certain nutritional deficiencies can also exacerbate hair thinning and loss. These include: iron, niacin, fatty acids, selenium, and zinc; conversely, excess intake of vitamins E and A may increase risk of hair loss.2 Although biotin (vitamin B7) is anecdotally thought to be useful for combating hair loss, available published research indicates that biotin supplementation may only yield helpful hair effects if a gross biotin deficiency (relatively rare) or hair syndrome (e.g., uncombable hair syndrome) exist.14-15 Healthcare practitioners should use lab testing and physical exams to assess for nutritional insufficiencies or deficiencies, so a dietary plan and supplementation recommendations can be individualized and effective.

Beyond the above common reasons for hair loss, the following are also potential causes: radiation treatments, excessive hair styling, and certain types of hair treatments.

In summary, hair loss, although common, does not have to be permanent in all cases. Working with a Functional Medicine provider to determine the root causes of the hair loss is the first and best step in understanding the “why” of a patient’s hair concern and the “how” of the personalized treatment.

Citations

  1. Mayo Clinic. Hair Loss. https://www.mayoclinic.org/diseases-conditions/hair-loss/symptoms-causes/syc-20372926. Accessed January 11, 2019.
  2. Guo EL et al. Diet and hair loss: effects of nutrient deficiency and supplement use. Dermatol Pract Concept. 2017;7(1): 1–10.
  3. NIH. Androgenetic alopecia. https://ghr.nlm.nih.gov/condition/androgenetic-alopecia. Accessed January 14, 2019.
  4. Hagenaars S et al. Genetic predication of male pattern baldness. PLoS Genet 2017;13(2):e1006594.
  5. NIH Genetics Home Reference. AR gene. https://ghr.nlm.nih.gov/gene/AR. Accessed January 16, 2019.
  6. Villasante Fricke AC et al. Epidemiology and burden of alopecia areata: a systematic review. Clin Cosmet Investig Dermatol. 2015;8:397-403.
  7. American Academy of Dermatology. Hair loss. https://www.aad.org/public/diseases/hair-and-scalp-problems/hair-loss. Accessed January 14, 2019.
  8. US Pharmacists. Treatment options for androgenetic alopecia. https://www.uspharmacist.com/article/treatment-options-for-androgenetic-alopecia. Accessed January 14, 2019.
  9. Hosking AM et al. Complementary and alternative treatments for alopecia: a comprehensive review. Skin Appendage Disord. 2018. doi: 10.1159/00049203.5
  10. Hadshiew IM et al. Burden of hair loss: stress and the underestimated psychosocial impact of telogen effluvium and androgenetic alopecia. J Invest Dermatol. 2004;123(3):455-457.
  11. Botchkarev V. Stress and the hair follicle: exploring the connections. Am J Pathol. 2003;162(3):709–712.
  12. Paus R. Exploring the “brain-skin connection”: leads and lessons from the hair follicle. Curr Res Transl Med. 2016;64(4):207-214.
  13. Mayo Clinic. Stress management. https://www.mayoclinic.org/healthy-lifestyle/stress-management/expert-answers/stress-and-hair-loss/faq-20057820. Accessed January 16, 2019.
  14. Trüeb RM. Serum biotin levels in women complaining of hair loss. Int J Trichology. 2016;8(2):73-77.
  15. NIH. Biotin fact sheet for health professionals. https://ods.od.nih.gov/factsheets/Biotin-HealthProfessional/. Accessed January 16, 2019.

Your Mom Was Right – Eat Your Beets, They’re Good for Your Heart

By Bianca Garilli, ND

From Metagenics Institute

I have a patient who doesn’t like vegetables. In fact, this person is also not a fan of water (sans flavoring), exercise, nor high fiber foods such as legumes. This scenario is, in many ways, a perfect setup for a number of lifestyle-related chronic diseases, including hypertension. This patient has been on a cocktail of medications for many years but expressed to me that they’d like reduce the list. So, it was with great excitement that I recently shared emerging research on a natural, food-based approach for reducing blood pressure with this individual.

But, first, a little science background. Nitric oxide or NO, is an important signaling molecule in humans and is required for a large number of reactions and biochemical pathways in the body. NO can be made by the body (endogenously) through various, intricate enzymatic pathways and also through non-enzymatic pathways which require precursor nitrates and nitrites.1 One of the best sources of nitrates is the diet; beetroot and leafy greens such as arugula and spinach being some of the highest sources of dietary nitrates.1 After consumption, the dietary nitrate molecules are metabolized by oral bacteria into nitrites which are then endogenously transformed into the cardioprotective NO molecule.2-3

As noted above, NO plays a critical role in cardiovascular health. For example, low levels of NO in the body can lead to various pathologies, most notably endothelial dysfunction which contributes to hypertension and atherosclerosis; low NO has also been found to play a role in diabetes and hypercholesterolemia.1

In contrast, healthy levels of NO in the body support vascular tone, healthy blood flow, leukocyte adhesion, and platelet aggregation.Consuming food-based nitrates on a routine basis, then, would seem to be a logical next step for those desiring to prevent or treat NO deficiency-related disease processes. And, in fact, that logic is backed by science, which is the exciting new research I was hoping to share with the unnamed individual mentioned earlier.

A recent study published in Nutrition Reviews presents a systematic review and meta-analysis including 23 studies that measured blood pressure, endothelial function, arterial stiffness, platelet aggregation, and/or blood lipid outcomes in response to oral inorganic nitrate/nitrite intake.4 The analyses demonstrated that inorganic nitrate intake significantly reduced resting blood pressure, improved endothelial function (measured as flow-mediated dilatation), arterial stiffness, and platelet aggregation.4

Many of the studies in this review, utilized beets and beetroot juice as their sources for nitrates in their research. I don’t know about you, but my mother always made sure I ate my beets. These colorful root vegetables have leaves that are also edible and are classified in the Amaranthaceae family, the same family as quinoa, spinach, and lamb’s quarters (AKA wild spinach).5

One of the beetroot studies was a double-blind, placebo-controlled clinical trial that randomized 68 hypertensive individuals 18-85 years of age to one of two groups: 250 mL/day of beetroot juice or the “placebo”250 mL/day of nitrate-free beetroot juice for 4 weeks.6 Participants consumed their respective drinks daily for 4 weeks; this was preceded by a 2-week run-in period followed by a 2-week wash-out period. The trial found that daily supplementation with dietary nitrate from beetroot juice was associated with a reduction in blood pressure: systolic ↓7.7-8.1mmHg; diastolic ↓2.4-5.2mmHg.6 Additionally, endothelial function improved by approximately 20% and there was a reduction in arterial stiffness by 0.59m/s.6

These clinical trial findings are in agreement with a review and meta-analysis7 that analyzed results from multiple studies investigating the therapeutic benefits of beetroot juice supplementation on blood pressure. This review found an overall reduction in systolic and diastolic blood pressure of 3.55 mmHg and 1.32 mmHg, respectively, and these reductions were significantly greater in the beetroot juice supplemented groups vs. control groups.7 This same publication also noted greater improvements in blood pressure with higher (500 mL/day) vs. lower (70-140 mL/day) beetroot juice doses or with longer periods of consumption (≥2 weeks vs. <2 weeks).7

So, as in every good story, there is a moral. First and foremost – listen to your parents. Next, make your plate colorful and eat your vegetables, every day and lots of them. Finally, incorporate beets and other high-nitrate foods such as spinach and arugula into your healthful diet.

Citations

  1. Luiking YC et al. Regulation of nitric oxide production in health and disease. Curr Opin Clin Nutr Metab Care. 2010; 13(1): 97–104.
  2. Hobbs DA et al. Blood pressure-lowering effects of beetroot juice and novel beetroot-enriched bread products in normotensive male subjects. Br J Nutr. 2012;108(11):2066-74.
  3. Khatri J et al. It is rocket science – why dietary nitrate is hard to “beet”! Part I: twists and turns in the realization of the nitrate-nitrite-NO pathway. Br J Clin Pharmacol. 2017;83(1):129–139.
  4. Jackson JK et al. The role of inorganic nitrate and nitrite in cardiovascular disease risk factors: a systematic review and meta-analysis of human evidence. Nutr Rev. 2018;76(5):348-371.
  5. Encyclopedia Brittanica. Amaranthaceae. https://www.britannica.com/plant/Amaranthaceae. Accessed July 26, 2018.
  6. Vikas K et al. Dietary nitrate provides sustained blood pressure lowering in hypertensive patients: a randomized, phase 2, double-blind, placebo-controlled study. Hypertension. 2015;65(2):320–327.
  7. Bahadoran Z et al. The nitrate-independent blood pressure-lowering effect of beetroot juice: a systematic review and meta-analysis. Adv Nutr. 2017;8(6):830-838.

3 Reasons Lack of Sleep May Cause Weight Gain

From Metagenics Institute

If you’re trying to maintain a healthy weight, counting sheep may be as important as counting the carbs on your plate or weight repetitions at the gym. Because, while physical activity and a balanced diet are key factors, sleep may be the most overlooked aspect of your weight management plan.

Can you sleep your way to your dream body? Perhaps not. But if you are sleep deprived, more sleep may help you reach your weight goals. Here’s what you need to know about the sleep-weight connection.

Are you sleep deprived?

The National Sleep Foundation recommends seven to nine hours of sleep per night for adults 24-64, slightly more for younger adults and a bit less for those older.1 But due to electronic gadget lights, chronic stress, habitual caffeine, shift-work, and many other reasons, few folks get their target rack time. In fact, according to the Centers for Disease Control and Prevention (CDC), insufficient sleep is a public health problem2 with serious concerns for our productivity, safety, and health—including your waistline.

It’s not just you

If you’re sleep deprived and find yourself battling the bulge, you’re in good company. Studies have found consistency in the sleep-weight connection; sleep deficiency is linked to weight gain. The largest study of its kind involved over 200 participants and simulated a sleep-restricted workweek. It compared the effects of restricting sleep to only four hours per night compared to unrestricted sleep, up to ten hours per night.3 After only five days, the sleep-restricted subjects had gained about 2 pounds. In contrast, the control group, allowed to sleep for up to 10 hours a night, gained virtually no weight.

If sleep restriction can cause you to gain two pounds in just five days, what can happen on the scale long-term?

A lot, according to women tracked for 16 years in The Nurses’ Health Study. Women reporting six hours of sleep per night were 12% more likely to gain at least 30 pounds during the study compared to the women who slept seven hours per night. But those women who were even more sleep deprived, reporting no more than five hours per night, were 28% more likely to gain at least 30 pounds during that same period!Apparently, with the sleep-weight connection, every hour counts.

How does less sleep = less svelte?

There are several underlying factors behind the sleep-weight connection. But a common thread is our own chemistry, which almost seems to revolt when restorative sleep is intentionally or unintentionally withheld. It’s you against them—and it’s not a fair fight.

Getting to know your hunger chemistry

There’s more than your sensation of fullness and stomach-brain communication involved. Rather, when it comes to hunger regulation and sleep, we have several chemical messengers at play. And when it gets complicated between you and the sandman, those messengers are not on your side. So get to know them:

  • Ghrelin: When ghrelin, known as the “hunger hormone,” is released from the stomach, it sends your brain a “feed me” signal. It signals not only when to eat, but also when to switch from burning calories to storing them as fat. Ghrelin naturally decreases after a meal and remains lower while you sleep, when caloric needs are less. But less sleep means more ghrelin.
  • Leptin: The opposite of ghrelin, leptin, is known as the “satiety hormone,” as it plays a crucial role in appetite and weight control. Released from fat cells, leptin crosses the blood-brain barrier and signals, ‘‘We’re good here. Put the fork down.” It also stimulates fat burning to create energy. Leptin levels naturally increase after a meal and remain elevated while you sleep, until you awaken and your metabolism increases. But less sleep means less leptin. Making things even trickier, sometimes leptin is secreted, but the brain’s not getting its signals. Think boy who cried wolf. This situation, known as “leptin resistance” can mean there is an underlying insulin resistance, a sign of disordered blood sugar metabolism, which puts you at risk for obesity and metabolic syndrome. While research on how to reverse leptin resistance is limited, animal studies show that an unbalanced diet can cause leptin resistance.5 So a dietary approach to reducing the underlying insulin resistance is a logical start.

As you can see, proper balance of ghrelin and leptin is very sleep-dependent. And for the caveman, perhaps these hormones were key to survival during the shorter, sleep-heavy but food-poor days of winter. They also played a part in the ability to capitalize on the longer, lighter sleep and more food-abundant days the rest of the year.

Today, our sleep-deprived bodies are prone to having too much ghrelin and not enough leptin. The result is that the body doesn’t feel satiated, thinks it’s hungry, and needs more calories—and squirrels away those calories for the long winter. In short, ghrelin and leptin kept the caveman alive, but they may be making you heavy.

  • Endocannabinoids: “It’s 1 AM, and I’m craving a salad,” said no one ever. If you’ve ever experienced sleepiness munchies, blame it on endocannabinoids. Sound vaguely familiar? Endocannanbinoids are the endogenous version of the cannabinoids in marijuana—our bodies can generate a very close facsimile of the previously illegal (in some states) substance. Endocannabinoids bind to the same receptors in the brain, fat cells, muscles, and elsewhere, causing a similar appetite-inducing effect as cannabis.6 Further, the endocannabinoid system interacts with your dopamine and opioid pathways, driving not just hunger, but according to some studies cravings for high-carb and high-fat.7 You want cookies. Now. Resistance is pretty much futile.

What to do?

That depends. There are two main reasons behind sleep deprivation. Either you have a sleep hygiene issue (trouble falling asleep or staying asleep), or you have a scheduling issue, in that your lifestyle is interfering with adequate sleep.

For sleep hygiene issues, the typical recommendations always merit consideration: limiting caffeine, avoiding blue light before bed, creating a cool and dark environment, etc. But, when you have a scheduling challenge, getting adequate sleep requires some lifestyle restructuring. It’s worth the time to re-engineer your schedule to slowly go to bed earlier or rise later to increase your sleep time. But in the meantime, can you catch up on sleep on the weekends?

Weekend catch-up sleep: is it a real thing?

Of course, you can get extra sleep on the weekend. But can it potentially reverse your Monday-Friday sleep deprivation? Perhaps. In a study of over 2,000 people participants, those who slept longer on the weekends, nearly two hours longer on average, had a significantly lower body mass index (BMI) than those who didn’t. Further, it appears that the sleep: BMI relationship was dose-dependent in that every extra hour of weekend catch-up sleep was associated with a significantly lower body mass.8 So catch-up sleep can indeed be a good strategy. That is, if your overall average sleep for the week puts you out of the red and into the black, as in you’ve paid back your sleep debt.

Sleep more. Weigh less. Not convinced? Sleep on it…

Citations

  1. National Sleep Foundation. National Sleep Foundation Recommends New Sleep Time. https://sleepfoundation.org/press-release/national-sleep-foundation-recommends-new-sleep-times. Accessed July 19, 2017.
  2. CDC. Insufficient sleep is a public health problem. https://www.cdc.gov/features/dssleep/index.html#References. Accessed July 19, 2017.
  3. Spaeth AM et al. Effects of experimental sleep restriction on weight gain, caloric intake, and meal timing in healthy adults. Sleep. 2013;36(7):981-990.
  4. Patel SR et al. Association between reduced sleep and weight gain in women. Am J Epidemiol. 2006;164(10):947-954.
  5. Vasselli JR et al. Dietary components in the development of leptin resistance. Adv Nutr. 2013;4(2): 164-175.
  6. Hanlon EC et al. Sleep restriction enhances the daily rhythm of circulating levels of endocannabinoid 2-arachidonoylglycerol. Sleep. 2016;39(3):653–664.
  7. De Luca MA et al. Cannabinoid facilitation of behavioral and biochemical hedonic taste responses. Neuropharmacology. 2011;63(1):161–8.
  8. Im HJ et al. Association between weekend catch-up sleep and lower body mass: population-based study. Sleep. 2017;40(7):zsx089.

Vitamin D: More Important than Ever

Vitamin D has always been integral to a healthy diet, but recent evidence suggests it may have a critical role in fighting COVID-19. According to new research, people with low vitamin D levels upon hospital admission for COVID-19 have an almost quadrupled chance of dying.[1]

Vitamin D’s role in fighting COVID-19 is only beginning to be explored, but this vitamin already boasts a host of health benefits. It promotes healthy bone growth and can, according to medical research cited by Harvard University, even reduce cancer cell growth, help fight infections and reduce inflammation.[2]

Do You Get Enough Vitamin D?

So, how can you get enough vitamin D in your diet? Let’s explore options that provide good amounts of this important nutrient.

Fish contain more vitamin D than any other food type, according to the U.S. Food and Drug Administration (FDA).[3] That’s not all, though — fish also are a stellar source of protein, omega-3 fats and multiple minerals. Be careful, however, to follow FDA advisories about fish with high amounts of mercury.

Eggs are another source of vitamin D, according to the Centers for Disease Control and Prevention (CDC).[4] Although they contain less vitamin D than fish, egg yolks nonetheless have a small amount of vitamin D, according to the National Institutes of Health (NIH).[5] Eggs also are a good source of phosphorous, calcium and potassium.[5]

Although fish are among the few foods with a naturally high vitamin D content, other foods and drinks can be enhanced — or, fortified — to contain more vitamin D. Milk, for example, can be fortified with vitamin D. [4] For those avoiding animal products, fortified cereals and juices can provide a good alternative.

While food can provide varying amounts of vitamin D, it’s ultimately difficult to get enough from food alone. In fact, most people should take vitamin D supplements to get enough in their diet, according to Harvard University.[2] Supplements come in many shapes and sizes, so choose wisely!

So, do you get enough vitamin D in your diet? With the rise of COVID-19, it might be more important than ever. Consult with your doctor, maintain a healthy diet and experience the wonders of vitamin D for yourself!

You can order vitamin D through Metagenics, our trusted supplier of nutraceuticals and supplements.

Sources:

  1. https://academic.oup.com/ajcp/advance-article/doi/10.1093/ajcp/aqaa252/6000689
  2. https://www.hsph.harvard.edu/nutritionsource/vitamin-d/
  3. https://www.fda.gov/food/consumers/advice-about-eating-fish
  4. https://www.cdc.gov/nutrition/infantandtoddlernutrition/vitamins-minerals/vitamin-d.html
  5. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/
Pregnant Woman

COVID-19 and Pregnancy: What Do We Know?

by Michael Stanclift, ND

Sourced from Metagenics Institute


Introduction
Expectant mothers may find some reassurance in recent evidence suggesting COVID-19 infection during pregnancy doesn’t appear to pose the same dangers as related viral infections (e.g. SARS, MERS).1 Pregnant women contracting COVID-19 must still be cautious about their and their developing babies’ health, especially since treatment options are more limited during pregnancy; however, documented cases give us some insight into the short-term effects. As with all things related to COVID-19, the data is still emerging, and we must keep in mind that new information could further support or undermine what we know now. Data on pregnancy is limited by the number of cases and the time frame of the pandemic—meaning we will not know longer range effects or the validity of these findings for some time.

COVID-19-positive pregnant women mostly without symptoms
Doctors in a London hospital during its COVID-19 peak detected coronavirus (SARS-CoV-2) in 7% of pregnant women admitted for delivery; nearly all of them (89%) had no symptoms.2 During the pandemic peak in New York, the positive rate for SARS-CoV-2 in pregnant women was over twice as high as London (15%), with a similar number of them asymptomatic as well.2,3 The authors expressed concern that their findings support a trend of asymptomatic infection in healthcare facilities, suggesting poor infection control.2


What happens when a pregnant woman gets COVID-19
Unlike with infections such as influenza, pregnant women do not appear to be at increased susceptibility for COVID-19 infection, nor do they have more severe disease when they contract it.4 COVID-19 infection in pregnant women presents in much the same way as in nonpregnant patients—usually with a cough, fever, labored breathing, and low lymphocytes.Compared to infections caused by similar coronaviruses (SARS/MERS), the death rate in pregnant women with COVID-19 has yet to be determined; initial reports are very low, while SARS/MERS respectively have an 18% and 25% mortality rate in this population.1,5,6

Mother With Baby

  • 1st trimester: In other infections, developing a fever in the first trimester doesn’t contribute to birth defects, though it does increase the likelihood of inattention disorders in childhood.1 Because of the timeline of the pandemic, we don’t have data on COVID-19-related effects from young children born to mothers who had the infection, but experts hypothesize the same may hold true.1 Based on small numbers of COVID-19 cases, it doesn’t appear to increase the risk for miscarriage (spontaneous abortion) above the risk of the general population.1,7
  • 2nd/3rd trimester: Data from small numbers of cases show COVID-19 infection poses fetal risks, such as intrauterine growth restriction (9-10%) and preterm birth (39-43%), though the preterm birth information is somewhat conflicting.1,7,8
  • Early childhood: COVID-19 presents mostly as a mild respiratory illness in most children.1
  • Predicting severity of COVID-19 in pregnancy: Assessing and predicting mortality of COVID-19 in pregnant patients is more difficult than in nonpregnant patients, as the normal course of pregnancy skews measures used to predict the course of disease, such as D-dimer and sequential organ failure assessment (SOFA).1 This can make it a bit more difficult to predict when the severity of a case may increase and require higher levels of interventions.
  • Treatment of COVID-19 in pregnancy: Pregnant women who develop severe disease and require a ventilator need higher levels of oxygen to adequately provide for their growing fetus.1 Remdesivir, the most promising drug for the treatment of COVID-19, appears to be safe for use during pregnancy, as does chloroquine, though it may require higher doses in pregnant patients.1 An HIV antiviral being used, lopinavir-ritonavir, is safe in pregnancy, as demonstrated through public health data.1 Unfortunately, ribivarin, an antiviral drug, and baricitinib, a Janus kinase inhibitor being used for COVID-19, aren’t safe to use during pregnancy.1 Pregnant and breastfeeding women are excluded from current vaccine phase 1 and 2 clinical trials, though some OB/GYNs argue this is “both misguided and not justifiable and may have excluded them from potentially beneficial interventions.”9-11
  • Special considerations for pregnant healthcare workers: N95 masks can reduce oxygen uptake and are recommended against (as is frontline work) for pregnant women working in healthcare with growth-restricted fetuses.1
  • Vertical transmission (mother spreading the virus to baby): In theory, passing the infection from mother to baby while in utero is possible due to ACE2 (the receptor the virus uses to enter cells) expression on the placenta; however, no confirmed cases proving this have been recorded to date.1 A study published in JAMA found IgG and IgM antibodies against SARS-CoV-2 in newborn infants born to COVID-19-positive mothers.12 Since IgM does not cross the placenta, it suggests the infants were possibly exposed to the virus in utero; however, throat swabs and blood samples from the babies were negative for the virus.12 Measuring IgM antibodies has limitations with the possibility of false positives, so more evidence is needed to confirm the infection could be passed this way.13 In cases where a baby tested positive after being delivered by a COVID-19-infected mother, other causes of transmission could not be completely ruled out.Additionally, in COVID-19-positive mothers the virus does not seem to appear in amniotic fluid, umbilical cord blood, breast milk, or throat swabs from the infants.1
  • Delivery, breastfeeding, and skin-to-skin contact: Numerous reputable professional obstetrics societies declare vaginal delivery is safe for women with COVID-19, without risk of spreading the infection to the infant.1,8 Women with the infection may need to wear a facemask and avoid skin-to-skin contact with their new babies after delivery; however, all evidence suggests it is safe for the baby to drink breastmilk—which should bring some comfort to both.1

Conclusion
Pregnant women are not more likely to get COVID-19, nor are they more likely to have a severe case based on the findings so far. While COVID-19 infection during pregnancy certainly presents possible risks to them and their babies, the emerging evidence is reassuring. In the absence of other modifying factors that increase risk and course of disease, pregnant women can reasonably expect that contracting COVID-19 while pregnant has the same risks as nonpregnant patients of similar makeup. Treatment options for pregnant women are mostly similar, with some limitations. There is no compelling evidence that pregnant women can spread the infection to their babies, other than normal transmission routes, namely respiratory droplets. Should their babies develop the infection, the course is generally mild in children.

The American College of Obstetricians and Gynecologists (ACOG) along with the Centers for Disease Control (CDC) has created guidelines based on the available research to date; however, there are still several unanswered questions, and additional information is needed to make better informed decisions.  Therefore, those clinicians with pregnant women under their care should routinely monitor any changes and updates to these recommendations.

Citations

  1. Dashraath P et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol. 2020. pii: S0002-9378(20)30343-4.
  2. Khalil A et al. SARS-CoV-2 in pregnancy: symptomatic pregnant women are only the tip of the iceberg. Am J Obstet Gynecol. pii: S0002-9378(20)30529-9.
  3. Coronavirus Resource Center. Johns Hopkins University and Medicine. https://coronavirus.jhu.edu/map.html. Accessed May 14, 2020.
  4. Blitz MJ et al. Intensive care unit admissions for pregnant and non-pregnant women with COVID-19. Am J Obstet Gynecol. 2020. pii: S0002-9378(20)30528-7.5.
  5. Karami P et al. Mortality of a pregnant patient diagnosed with COVID-19: A case report with clinical, radiological, and histopathological findings. Travel Med Infect Dis. 2020;101665.
  6. Hantoushzadeh S et al. Maternal death due to COVID-19 disease. Am J Obstet Gynecol. 2020;S0002-9378(20)30516-0.
  7. Yan J et al. Coronavirus disease 2019 (COVID-19) in pregnant women: A report based on 116 cases. Am J Obstet Gynecol. 2020;S0002-9378(20)30462-2.
  8. Della Gatta AN et al. COVID19 during pregnancy: a systematic review of reported cases. Am J Obstet Gynecol. 2020;S0002-9378(20)30438-5.
  9. Safety and immunogenicity study of 2019-nCoV vaccine (Mrna-1273) for prophylaxis of SARS-CoV-2 iInfection (COVID-19). ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT04283461?term=mrna-1273&draw=2&rank=1. Accessed May 13, 2020.
  10. Safety, tolerability and immunogenicity of INO-4800 for COVID-19 in healthy volunteers. ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/NCT04336410?term=ino-4800&draw=2&rank=1. Accessed May 13, 2020.
  11. Costantine MM et al. Protection by exclusion: Another missed opportunity to include pregnant women in research during the coronavirus disease 2019 (COVID-19) pandemic. Obstet Gynecol. 2020. [Epub ahead of print].
  12. Zeng H et al. Antibodies in infants born to mothers with COVID-19 pneumonia. JAMA. 2020;323(18):1848‐1849.
  13. Kimberlin DW et al. Can SARS-CoV-2 infection be acquired in utero?: Moredefinitive evidence is needed. JAMA. 2020. [Epub ahead of print].
3D Rendering of Coronavirus

The CDC’s New COVID-19 Guidelines: What You Should Know

COVID-19 is still a new disease, and we learn more every day about preventing it. The Centers for Disease Control and Prevention (CDC) released updated guidelines to help you avoid catching COVID-19.[1] Let’s explore some important takeaways.


How COVID Spreads

To better understand COVID-19 prevention, let’s first review how the disease spreads. According to the new CDC guidelines, COVID-19 spreads mostly through close contact — defined as being within 6 feet of an infected person.[2] At this close range, COVID-19 can spread from person to person through respiratory droplets — small bits of liquid expelled when we breathe, talk, sing, cough or sneeze. These droplets become known as particles if they dry quickly in the air.

Although respiratory droplets and particles usually spread through close contact, they also sometimes can stay airborne and infectious for minutes to hours after an infected person leaves a space. [2]

In addition to transmission through the air, COVID-19 occasionally spreads via contaminated surfaces and, rarely, from animals to humans. [2]

 

Staying SafeMan Wearing a Mask and Reading a Newspaper

In light of COVID-19’s transmission methods, let’s talk about preventing it.

Keeping a distance of at least six feet from other people is heavily emphasized by the CDC’s prevention guidelines. [1] Social distancing demonstrably lessens the spread of COVID-19, according to research published by the CDC.[3]

Next up is wearing a mask. A growing body of evidence confirms mask-wearing slows the spread of COVID-19.[4] It’s important to choose the right kind of mask, though. The CDC recommends well-fitted masks with two or more layers of washable, breathable fabric.[5]

Washing your hands is crucial, too. Soap and water are preferred here, but hand sanitizer with at least 60 percent alcohol content can suffice.[1] You especially should wash your hands after leaving a public place and after blowing your nose, coughing or sneezing. These, however, are just a few of the instances where the CDC recommends washing your hands.

Speaking of disinfecting, it’s important to sanitize frequently-touched surfaces, such as tables, doorknobs, phones and keyboards every day.[1] After cleaning these surfaces of any dirt, apply a household disinfectant to finish the job.

It’s also important to avoid crowded or poorly-ventilated indoor spaces. COVID-19 droplets and particles more easily travel through the air — and even beyond six feet from infected people — in poorly ventilated spaces.[2]

 

What If I Get Sick?Thermometer

It’s key to stay home and isolate from others — except to get medical care — if you are sick with COVID-19 or suspect you might be.[6] You should stay in contact with your doctor and monitor your symptoms, including checking your temperature regularly. Symptoms of COVID-19 include fever, cough and more. Of course, you also should wear a mask when needed, cover your coughs and sneezes, and avoid sharing personal household items with others. You might also consider getting tested for COVID-19. The CDC offers more detailed guidance for what to do if you get sick.

 

A Developing Story

As doctors and scientists continue discovering more about COVID-19, it’s likely recommendations for preventing the disease will change further. Be sure to check the CDC website for the latest updates. You can also visit our COVID-19 page for useful information and resources.

 

Sources:

  1. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
  2. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html
  3. https://wwwnc.cdc.gov/eid/article/26/8/20-1093_article
  4. https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00818
  5. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html
  6. https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html
3 Reasons You Need Sleep (and 3 Ways to Get Enough)

3 Reasons You Need Sleep (and 3 Ways to Get Enough)

Sleep can become an afterthought in today’s busy world. Whether it’s working late, watching your favorite shows, or staying current on world events, there are tons of distractions to keep us awake. However, lack of sleep can have worse consequences than simply feeling sleepy. Here are three major reasons you need sleep… and three ways to get enough.

  1. Sleep Helps You ThinkSleep Helps You Think
    Have you ever stayed up late watching sports or preparing for a busy day? Sleep deprivation hurts our ability to reason and remember. Studies show sleeplessness can hurt both short-term and long-term memory. [1] Even decision making and reasoning are hampered by sleep deprivation. [1] So, getting quality sleep can help you be sharper and more productive.
  2. Sleeplessness is Linked to Mental Disorders
    Insomnia, a medical condition where people have difficulty sleeping, was found to precede 69 percent of depression cases in one study. [2] Even for children, data suggests poor sleep can signal the onset of depression. [3] What’s more, other research shows 24 to 36 percent of people with insomnia also suffer from anxiety disorders. [4]
  3. Drowsiness is Dangerous
    Did you know drowsy driving can be similar to drunk driving? One study found that sleep-deprived drivers drove as poorly as drunk drivers. [5] Sleep deprivation can be dangerous in the workplace, too. Research shows sleep-deprived workers are much likelier to have workplace accidents. [5] In fact, a study conducted in the Netherlands showed highly-fatigued workers were 70 percent likelier to have accidents than workers with low fatigue levels. Sleep loss can be dangerous for elderly people, too. For example, data indicates sleep-deprived older women are likelier to suffer falls than those with adequate sleep. [5]

It’s obvious we all need sleep. But what’s a healthy amount? The answer varies by age according to National Sleep Foundation recommendations. [6] Newborns require 14 to 17 hours of sleep, more than any other age group. Young adults need 7 to 9 hours, and older adults require 7 to 8 hours.

With that established, let’s talk about how to get enough sleep.

  1. Set a Schedule
    A regular sleep schedule is great for sleep at any age — it ensures you get enough sleep to power through life. A good sleep cycle not only means getting enough sleep, but also enables better sleep. One study found a regular sleep cycle resulted in better sleep and less trouble going to sleep. [7] Plus, the same study found people with a regular sleep cycle were less sleepy during the day. Other research even found irregular sleep patterns nearly doubled the risk of cardiovascular disease in older adults. [8]
  2. Put the Screens AwayPut the Screens Away
    The National Sleep Foundation recommends avoiding screens on electronic devices like phones, tablets and laptops for at least 30 minutes before bedtime. [9] These devices can emit blue light, which research shows suppresses our secretion of melatonin, a key hormone for falling asleep. [10] So, rather than racking up screen time just before bed, consider picking up a good book to let your melatonin get to work.
  3. Just Relax
    Speaking of reading a good book, it’s critical to wind down before bedtime. While reading is one option, studies show music can profoundly impact sleep. One study found music made people feel better rested and prolonged their REM sleep. [11] Another study of young adults found music can facilitate longer deep sleep. [12] If music isn’t your thing, then consider taking a warm bath or shower. A review of 13 different studies found a warm bath or shower one to two hours before bed helped people fall asleep significantly faster. [13]

So, make sleep a top priority, and enjoy the benefits to your health and wellness in waking life.

Sources:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656292/
2. https://www.sciencedirect.com/science/article/abs/pii/S0022395606001440
3. https://www.sciencedirect.com/science/article/abs/pii/S1087079214000392
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181635/
5. https://www.ncbi.nlm.nih.gov/books/NBK19958/
6. https://www.sciencedirect.com/science/article/abs/pii/S2352721815000157
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4143130/
8. https://www.nih.gov/news-events/news-releases/study-finds-irregular-sleep-patterns-double-risk-cardiovascular-disease-older-adults
9. https://www.sleepfoundation.org/articles/healthy-sleep-tips
10. https://pubmed.ncbi.nlm.nih.gov/30311830/
11. https://pubmed.ncbi.nlm.nih.gov/22494532/
12. https://pubmed.ncbi.nlm.nih.gov/23663079/
13. https://www.sciencedirect.com/science/article/abs/pii/S1087079218301552