“How can I support my loved one’s recovery?” is a question often asked by many people. Do you or someone you know have a partner or loved one who recently received help for their struggle with substance use? That’s fantastic! However, that is only the first step in the process. Many people think when someone enters a treatment center, whether that be Detox, Rehab, IOP, or Outpatient that eventually their addiction will be ‘cured’, not realizing the lifelong effects of Addiction and subsequent recovery. Much like other ‘diseases’, Addiction is progressive & can be fatal if it is not treated and monitored. It impacts the person emotionally, physically, psychologically & mentally, and socially, so much so that it is often described as a ‘family disease’. In addition to the significant amount of work the substance user will have to put in to get & maintain sobriety, The ‘family disease’ implies that it affects everyone & their quality of life, requiring support & changes on the part of everyone in relation to the substance user.

Family members often find this frustrating because they have already been put out & impacted by their loved one’s using and now they have to make changes too?! Although it seems unfair, it is true if they want their partner & or loved one’s to have the best chance of prolonged abstinence. So, where are the family members supposed to begin? This brings me to the main question people ask, “How can I support my loved one’s recovery?”

Here are some ways to provide support: 

1. Learn about the disease of addiction, trauma, etc. There is a lot of ‘quit lit‘ (books, websites, youtube videos, etc)
2. Support their attendance at meetings & therapy and the time commitment they will have to make to their recovery process 
3. Consider attending your own support group (Alanon, Naranon, CODA) & therapy to process your own emotions associated with their recovery and to learn about codependency/enabling patterns
4. Inquire about their boundaries in social situations, ie: How do they feel about you drinking? Are they telling people about their recovery?
5. Discuss accountability & how you two will manage relapses if they happen
6. Ask how they want to celebrate recovery anniversaries & if they would like you to participate
7. Understand it is a lifelong process & that they will have cravings and triggers

If you’ve identified with anything you’ve read in this blog & would like additional support, please reach out for help today at 1-201-488-6678 or visiting specializedtherapy.com. We look forward to hearing from you! 

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Cycling as a form of exercise has been well-documented as an effective way to improve your physical and emotional health. Exercise contributes to many health benefits including improvements in sleep, heightened libido, stress relief, increased energy, weight loss, reductions in fatigue, and improved cardiovascular fitness and cholesterol. Exercise also has been shown to improve anxiety, depression, mood, self-esteem, and cognitive functioning. This because when an individual engages in regular exercise, blood circulation to the brain increases, and the hypothalamic-pituitary-adrenal (HPA) axis, which plays an integral in maintaining our body’s equilibrium and stress response, is able to regulate stress more effectively. Research also demonstrates that the benefits of exercise can be enhanced when combined with environmental stimulation, in other words – exercise in the great outdoors!

Cycling can be an extremely effective way to improve physical and mental health, as it is an accessible, low-impact, and fun way to engage your body and brain.

Benefits of Cycling on Mental Health

1. Cycling improves mood by increasing blood flow to the body, and thus the spread of endorphins and feel-good neurotransmitters, such as dopamine, norepinephrine, and serotonin.
2. Cycling helps improve self-esteem, depression, anxiety, and stress, due to the very nature of the exercise – It is reminiscent of nostalgic childhood experiences and provides environmental exposure and engagement with one’s surroundings.
3. Regular cycling has been shown to help promote better sleep quality and sleep efficiency through synchronizing circadian rhythms and reducing stress hormones that contribute to poor sleep quality, efficiency, and duration.
4. Cycling is good for our brain functioning and memory. The act of cycling contributes to the increased production of new brain cells responsible for memory and recall.
5. Cycling can offer an opportunity to engage in mindfulness. Cyclers can use a ride to concentrate on the rhythm of their breath, each movement of their legs, the wind on their face, and body to center themselves and increase positive thoughts and feelings.

Benefits of Cycling on the Brain

1. Similar to the way bike riding promotes muscle growth, it can also promote brain growth. As cycling promotes increased blood flow to the brain, this helps the brain and body pull in more oxygen and nutrients that can improve cycling performance and brain functioning.
2. Riding a bicycle leads to the production of proteins that help create 2-3x more brain cells than normal patterns of brain cell reproduction.
3. Taking a ride on a bike has also demonstrated efficacy in preventing natural cognitive decline as a result of aging.

30-60 minutes of steady riding, with approximately 75% of our maximum heart rate, 3-5 times a week, is recommended as the best cycling practice to reap the best rewards of this fun and rewarding exercise.

Specialized Therapy Associates offers a breadth of functional medicine and therapeutic services designed for health and wellness for individuals of all ages. For a free consultation with our intake coordinator who will match you to the best provider and service to fit your needs and goals, call 201-488-6678 or visit https://www.specializedtherapy.com/make-an-appointment/ to schedule an appointment.

References:

Leyland, L. A., Spencer, B., Beale, N., Jones, T., & van Reekum, C. M. (2019). The effect of

cycling on cognitive function and well-being in older adults. PloS one, 14(2), e0211779. https://doi.org/10.1371/journal.pone.0211779

MensLine Australia. (2020, May 19). Cycling – The Exercise for Positive Mental Health. https://mensline.org.au/mens-mental-health/cycling-positive-mental-health/#:~:text=Cycling%20for%20positive%20mental%20health&text=Cycling%20pumps%20blood%20around%20your,It%20promotes%20positive%20mental%20health.

Oja, P & Titze, Sylvia & Bauman, Adrian & De Geus, Bas & Krenn, Patricia & Reger-Nash, Bill & Kohlberger, T. (2011). Health benefits of cycling: A systematic review. Scandinavian journal of medicine & science in sports. 21. 496-509. 10.1111/j.1600-0838.2011.01299.x.

Sharma, A., Madaan, V., & Petty, F. D. (2006). Exercise for mental health. Primary care

companion to the Journal of clinical psychiatry, 8(2), 106. https://doi.org/10.4088/pcc.v08n0208a

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As COVID-19 cases increased around the United States toward the end of March 2020, governmental regulations issued stay-at-home orders, school closures, and caused many individuals to be laid off, furloughed, or to work from their homes. Although stay-at-home orders were intended to reduce the spread of COVID-19 and keep our communities safe from contracting COVID-19, home is not always a safe place for individuals to live, especially for adults and children who reside in homes where domestic and familial violence occurs. For these individuals, home environments are often a place where power and control predominate, and where significant others who perpetrate violence or abuse, can assert their power without intervening with others outside of the family unit. COVID-19 restrictions on movement and outside activity reduced access to escape, help-seeking behaviors, and mechanisms to cope for victim-survivors. Additionally, social norms and attitudes, with respect to family life and connectedness during the pandemic, likely contribute to increased challenges for victim-survivors to seek help, speak out, and/or leave due to increased feelings of shame, guilt, and embarrassment. As the pandemic and its restrictions continue, it is important to understand that positive conceptions of home and family life can contribute to increased marginalization and silence for individuals that live and have connections to a home life that is unsafe and may be fraught with violence.

So, how can we help deal with Domestic Violence?

What Friends, Family, and Significant Others can do to curb Domestic Violence:

Friends, family, and significant others can support others who are struggling with domestic violence by having conversations with victim-survivors. Though these conversations may be difficult, several tips can help support victim-survivors.

1. Acknowledge the situation is difficult and scary, and the violence or abuse is not their fault.
2. Let the person or family know that they are not alone and that there is help and support available to them.
3. Listen and be supportive. Telling victim-survivors what they should do or should not do will likely lead to further isolation and disempowerment. It is important that friends of victim-survivors make known that they support the individuals and their decisions.
4. Don’t be judgmental or harsh. Individuals have many reasons for why they stay in violent or abusive situations and/or leave and return to these situations. Perpetuating further shame or guilt to these individuals not only contributes to the shame and guilt they likely already feel, but can contribute to increased sensations of loneliness, isolation, and helplessness that their abusive situations already cause.
5. As much as we may want to “rescue” a person or family from violence, the only person that can save the person is themselves. Abuse and violence are about power and control, and we must do everything to empower these individuals to make helpful decisions for themselves.
6. Develop and collaborate on a safety plan with a person or family struggling with violence or abuse. A safety plan is an individualized, practical plan that can improve the person or family’s safety while experiencing an unsafe or abusive situation. This can be helping the person or family cope while remaining in the home, preparing the person or family to leave, or helping problem-solve after they leave. Safety plans include strategies to remain physically safe, emotionally safe, and sometimes involved with legal protections.
7. Help the person or family identify and build support from other family members, professionals, or people to increase the person or family’s recognition and access to safe people or places.
8. Suggest, identify, and collaborate with the person or family to find a local service provider, supportive professionals, or referral to a mental health care provider.

What Medical and Mental Health Professionals Do to Treat Domestic Violence:

1. Professionals should attend to and screen every patient for domestic violence at the beginning of visits while ensuring patient privacy by screening patients without the patient’s partner or children present, if possible.
2. Patient confidentiality should be reassured and sensitivities must be given to confirm if the patient can and has access to a private and safe place to talk.
3. Alternative methods of communication may need to be provided, and if possible, professionals should know how to provide comprehensive screening with yes/no questions. When applicable, professionals should provide nonverbal communication tools.
4. Referrals should be provided for patients who screen positive for intimate personal violence or domestic violence within their communities. Referrals to community resources can reduce psychological harm from IPV and offer support to victim-survivors. Additionally, barriers of access to resources provided should be assessed and problem-solving should be included to allow patients the opportunity to utilize the resources given.

Medical and Mental Health Professionals can search for local shelters at https://www.domesticshelters.org, search for resources by the state at https://www.womenshealth.gov/relationships-and-safety/get-help/state-resources, and find resources to use during the COVID-19 pandemic at https://www.futureswithoutviolence.org/get-updates-information-covid-19/.

If you need immediate help or need a discreet way to reach out for help regarding domestic violence, please visit The Domestic Violence Hotline   and call 800.799.SAFE (7233).

If you or someone you know is struggling with domestic violence or interpersonal violence, the trauma program at Specialized Therapy Associates can help. STA offers individual and group counseling by experienced, highly trained therapists to help individuals process trauma, reduce isolation and shame, and promote healing.

References:

1. Bradbury-Jones, C., & Isham, L. (2020). The pandemic paradox: The consequences of COVID-19 on domestic violence. Journal of clinical nursing, 29(13-14), 2047–2049. https://doi.org/10.1111/jocn.15296

2. Evans, M. L., Lindauer, M., & Farrell, M. E. (2020). A Pandemic within a Pandemic — Intimate Partner Violence during Covid-19.N Engl J Med, 383(24), 2302-2304. https://doi.org/1056/NEJMp2024046
3. Moreira, D. N., & Pinto da Costa, M. (2020). The impact of the Covid-19 pandemic in the precipitation of intimate partner violence. International journal of law and psychiatry, 71, 101606. https://doi.org/10.1016/j.ijlp.2020.101606
4. Naional Domestic Violence Hotline . (2021, January 4). Talking About Relationship Abuse. https://www.thehotline.org/resources/talking-about-relationship-abuse/.
5. Smith SG, Zhang X, Basile KC, et al.; Centers for Disease Control and Prevention; National Center for Injury Prevention and Control. National Intimate Partner and Sexual Violence Survey: 2015 data brief – updated release. November 2018. Accessed June 30, 2020.
6. Ver, C., Garcia, C., & Bickett, A. (2021, January 1). Intimate partner violence during the covid-19 pandemic. https://www.aafp.org/afp/2021/0101/p6.html.

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By Taylor Groff Functional Nutritionist

COVID-19 has caused an upheaval of life as we know it, with lasting implications that extend far beyond unwavering case numbers and death tolls. The impact of COVID-19 on physical and psychological well-being has proven to be a lasting one. So much so that the aftermath is now called “long-haul covid”.

Besides the mental anguish from social isolation, unparalleled uncertainty, and multiple layers of grief and loss, those suffering from long-haul covid may experience neurological and psychiatric symptoms even if they have no history of a mental health condition. Those with previous psychiatric diagnoses are at an elevated risk for worsening mental health due to increased inflammation, a physiologic manifestation that directly correlates with depression and anxiety (1).

Risk for Neurological and Psychological Symptoms: Long-haul COVID

The Lancet recently published a study of over 200,000 people diagnosed with COVID-19 and found 33% had long-term neurological or psychiatric diagnoses following infection, with 13% receiving their first such diagnosis. Neurological complications include intracranial hemorrhage, ischemic stroke, Parkinson’s disease, dementia, anxiety, and psychotic disorder, with anxiety disorder topping the charts at an incidence of 19% (2).

The constellation of long haul covid symptoms can range from heart palpitations to shortness of breath, brain fog, dizziness, insomnia, fatigue, fever, gastrointestinal discomfort, anxiety, depression, obsessive-compulsive tendencies, delirium, loss of appetite, headache, rashes, joint pain, persistent cough, hair loss, and more (3,5,6,8). There are also reports of reduced exercise and increased sedentary behavior due to concerns about overexertion causing relapse. These concerns stem from reports that suggest reduced lung capacity in hospitalized covid patients (8,9). One study found that lung damage from COVID-19 correlated with reduced pulmonary function until four months following infection (10).

However, it’s worth mentioning that long-haul symptoms following a respiratory tract infection are not exclusive to COVID-19. There is evidence for similar long-term symptoms following pneumonia (5). Like COVID-19, pneumonia risk, symptoms, and severity are related to age and pre-existing conditions like asthma, diabetes, obesity, and heart disease. Those with type 2 diabetes have a 25-75% higher risk of being hospitalized with pneumonia due to the harmful effects of hyperglycemia on the immune system and inflammation (11). Therefore, the combination of metabolic dysfunction increased risk for infection and inflammation is not exclusive or novel to COVID-19. However, neurological and psychological symptoms appear to be more common in patients diagnosed with COVID-19 than influenza or other respiratory tract infections (2).

How Long Will Long-haul COVID Last?

The truth is, we don’t know yet. The unpredictable nature and interindividual variability of long-haul covid symptoms come with many apprehensions. A new study based in the U.K. found that 1 in 20 people with COVID-19 is likely to suffer from ongoing symptoms that last eight weeks or more, and 1 in 50 people suffer from symptoms lasting 12 weeks or more (3). A study in the U.S. found that 35% of people have not returned to their baseline level of health 14-21 days after having a positive covid test (4). Moreover, females have higher reported anxiety and depression symptoms than men despite having lower inflammatory markers (1).

Additionally, there are reports of a 58% to 224% increase in the likelihood of diagnosis with a psychiatric illness two weeks to three months after a positive COVID-19 test with a drop to 5.8% three months post-diagnosis (12). The most common diagnosis was anxiety disorders at 13%, followed by mood disorders at 10%. Insomnia and dementia in adults 65 or older also came at a significantly higher risk.

Moreover, the likelihood of psychiatric illness diagnoses between two weeks and three months post-COVID-19 diagnosis was 18% for less severe cases and 40% for those requiring in-patient ICU treatment (12).

The Asymptomatic COVID-19 Long-haul

There’s a growing concern for people experiencing long-haul covid who aren’t aware of it because they’ve never had a positive covid test (5).  People who tested positive for COVID-19 with less severe sickness exhibit long haul symptoms after the 2-week quarantine period.  The unclear distinction proposes a new set of challenges for doctors to rightfully identify long-haul covid that manifest as physical and psychological symptoms, or if these symptoms are independent of covid that arose from living through such a chaotic time.

We’re here to help

In any case, psychotherapy, proper nutrition, adequate quality sleep, targeted nutrients, relaxation strategies, connection and support, and other interventions are available for those suffering from anxiety, depression, and trauma stemming from COVID-19. As with mental and physical health conditions in general, community, self-care, and healthy lifestyle habits in addition to proper medical treatment can make all the difference in developing resiliency and even post-traumatic growth. To learn more about how Specialized Therapy Associates and Fx Med Centers can support you, call 201-488-6678.

References:

1. Mario Gennaro Mazza, Rebecca De Lorenzo, Caterina Conte, Sara Poletti, Benedetta Vai, Irene Bollettini, Elisa Maria Teresa Melloni, Roberto Furlan, Fabio Ciceri, Patrizia Rovere-Querini, Francesco Benedetti. Anxiety and depression in COVID-19 survivors: Role of inflammatory and clinical predictors. Brain, Behavior, and Immunity. Volume 89 (2020): 594-600,
2. Taquet, M., Geddes, J., Husain, M., Luciano, S., Harrison, P. 2021. 6-month neurological and psychiatric outcomes in 236,379 survivors of COVID-19: a retrospective cohort study using electronic health records. The Lancet. https://doi.org/10.1016/S2215-0366(21)00084-5
3. Sudre, C.H., Murray, B., Varsavsky, T. et al.Attributes and predictors of long COVID. Nat Med (2021). https://doi.org/10.1038/s41591-021-01292-y
4. https://www.cdc.gov/mmwr/volumes/69/wr/mm6930e1.htm
5. https://jamanetwork.com/journals/jama/fullarticle/2771111
6. GreenhalghT, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute COVID-19 in primary care BMJ 2020; 370 :m3026 doi:10.1136/bmj.m3026
7. https://doi.org/10.1016/j.bbi.2020.07.037.
8. gov/citizen-scientists-take-challenge-long-haul-COVID-19
9. Bellan M, Soddu D, Balbo PE, et al. Respiratory and Psychophysical Sequelae Among Patients With COVID-19 Four Months After Hospital Discharge. JAMA Netw Open.2021;4(1):e2036142. doi:10.1001/jamanetworkopen.2020.36142
10. https://www.cdc.gov/dotw/pneumonia/index.html#:~:text=Certain%20people%20are%20more%20likely,and%20people%20who%20smoke%20cigarettes.
11. B. Kornum, M. Nørgaard, C. Dethlefsen, K.M. Due, R.W. Thomsen, A. Tjønneland, H.T. Sørensen, K. Overvad. European Respiratory Journal 2010 36: 1330-1336; DOI:10.1183/09031936.00184209.
12. Taquet, M., Luciano, S., Geddes, J.R., Harrison, P. (2020). Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62,354 COVID-19 cases in the USA. The Lancet Psychiatry. DOI:https://doi.org/10.1016/S2215-0366(20)30462-4.

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BPA: a chemical that plays a role in more than just plastic, but a hormone too!

By now, we’ve all heard about BPA, right? If not, you’re in the right place! In this article, you’ll learn about the history of BPA as a toxin, why it proposes a threat to you and your family’s health, and strategies on how to reduce your exposure.

BPA is an abbreviation for bisphenol A- a chemical used to make hard plastics that are used in many things, from plastic bottles to Tupperware containers to plastic toys to the lining of food and beverage cans. It’s even in thermal paper receipts! BPA permeates our industrialized world, food supply, and modern-day lifestyle.

BPA was first synthesized by chemists 130 years ago. It wasn’t until the 1930s that scientists discovered it had estrogen activity in the body (1). Upon this discovery, BPA was intended to be used as an estrogen replacement drug until a more potent synthetic hormone was invented (1). However, BPA didn’t go anywhere… it found its new role in the future of plastics (1). BPA was first used in the epoxy lining of cans, metal piping, adhesives for flooring and sealing teeth and eventually made its way into plastics in the late 1950s.

In 1958 the FDA passed the Federal Food, Drug, and Cosmetics Act in an attempt to regulate chemicals added to packaged foods. Since BPA was only thought to make its way into food and beverages through leaching of epoxy resin from the lining in cans and showed no indication of being harmful to humans, there was no regulation of BPA in our food supply until 1988.

In 1993 BPA’s estrogenic activity was brought back into the limelight. For the first time, it was proposed as a threat to human health as an endocrine disruptor, meaning it disrupts normal hormonal function, processing, and transmission in the body. Throughout the late 1990s and early 2000s plastic became a political battle with industry lobbyists trying their best to bury the evidence that BPA was, in fact, harmful to human health. By 2005 there were 115 studies on BPA exposure and 90% of them found dangerous health effects of BPA, especially in infants and children. Not surprisingly, the 10% of studies that didn’t find an effect were funded by the plastic industry (2). Major concerns were expressed regarding findings of impaired fetal prostate and mammary gland development, disruption of chromosome alignment in developing eggs, immune system impairment, as well as metabolic and neurological abnormalities (1,2).

Fast forward to 2008 and The Center for the Evaluation of Risks to Human Reproduction released a final report on BPA stating that “the possibility that bisphenol A may alter human development cannot be dismissed”, and that there is “some concern for the effects on the brain, behavior, and prostate gland in fetuses, infants, and children at current human exposure to BPA” (3). Following this report, six of the major baby bottle producers announced the removal of BPA from their products; and in 2012 the FDA finally banned the use of BPA in baby bottles, sippy cups, and epoxy resin in infant formula packaging (4).

However, this chemical is still present and allowed in teethers and children’s play toys. Despite the growing evidence that BPA is harmful in young children, the Toy Association still considers it safe and allows it to be in toys and game products (5).

Today, hundreds of research studies show a relationship between BPA and an increased risk for behavioral disorders like ADHD, anxiety, depression, and aggression in children (6,7).

What’s more, is that the BPA levels originally recognized as safe for human ingestion by the FDA may not be as safe as originally intended. BPA has shown to interact with and bind to thyroid hormone receptors and could play a role in autoimmune thyroid disease (8). Furthermore, BPA has shown to be an obesogenic toxin and is linked to diabetes, weight gain, heart disease, liver inflammation, cancer, and infertility. Disturbingly, a nationwide study found that 89% of individuals ages 6 years and older had detectable levels of BPA in their urine (9).

Here are some actions you can take to minimize your family’s and your own BPA exposure:

1. Only purchase baby toys, canned foods (soup, soda, sparkling water, beans, vegetable cans), and Tupperware containers that say “BPA-free” on the label.
2. Drink from a reusable stainless steel or glass water bottle instead of plastic ones (this is also better for the environment, so it’s a win-win).
3. Don’t microwave leftovers in plastic containers, BPA and other plasticizers (like phthalates) can leak into your food. Instead, transfer the contents to a glass or ceramic bowl or heat on a stovetop if possible.
4. Skip the receipt! This will do you and your cashier a favor for reducing toxic BPA (and its cousin BPS) exposure from thermal receipt paper. Simply touching receipts (also boarding passes, tickets) with your hands is enough to absorb it through the skin. Ask for an emailed or text receipt instead! If you need to handle a receipt, wash your hands with soap and water as soon as possible!

These are actions you can take to reduce your BPA exposure! If you have any questions on the impact this chemical has on you or your child’s health, click here and submit a question to our “Ask a Therapist” column and we can answer it in our next newsletter!

These are actions you can take to reduce your BPA exposure right now! If you have any questions on the impact this chemical has on you or your child’s health, click here and submit a question to our “Ask a Therapist” column and we can answer it in our next newsletter!

References:

1. Vogel SA. The politics of plastics: the making and unmaking of bisphenol a “safety”. Am J Public Health. 2009;99 Suppl 3(Suppl 3):S559-S566. doi:10.2105/AJPH.2008.159228
2. vom Saal FS, Hughes C. An extensive new literature concerning low-dose effects of bisphenol A shows the need for a new risk assessment. Environ Health Perspect. 2005;113(8):926-933. doi:10.1289/ehp.7713
3. Shelby MD. NTP-CERHR monograph on the potential human reproductive and developmental effects of bisphenol A. NTP CERHR MON. 2008;(22):.
4. https://www.fda.gov/food/food-additives-petitions/bisphenol-bpa-use-food-contact-application
5. https://www.toyassociation.org/PressRoom2/IndustryStatements/statement-on-bisphenol-a.aspx#:~:text=It%20has%20been%20specifically%20chosen,items%20has%20been%20phased%20out.
6. Li Y, Zhang H, Kuang H, et al. Relationship between bisphenol A exposure and attention-deficit/ hyperactivity disorder: A case-control study for primary school children in Guangzhou, China. Environ Pollut. 2018;235:141-149. doi:10.1016/j.envpol.2017.12.056
7. Ejaredar M, Lee Y, Roberts DJ, Sauve R, Dewey D. Bisphenol A exposure and children’s behavior: A systematic review. J Expo Sci Environ Epidemiol. 2017;27(2):175-183. doi:10.1038/jes.2016.8
8. Eschler DC, Hasham A, Tomer Y. Cutting edge: the etiology of autoimmune thyroid diseases. Clin Rev Allergy Immunol. 2011;41(2):190-197. doi:10.1007/s12016-010-8245-8
9. Lakind, J.S., and D.Q. Naiman. 2008. Bisphenol A (BPA) daily intakes in the United States: estimates from the 2003-2004 NHANES urinary BPA data. Journal of Exposure Science and Environmental Epidemiology 18 (6):608-15.

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Your child’s favorite breakfast cereal could contain toxic pesticides!

Did you know that oats, rice, and wheat are major but lesser-known, sources of toxic pesticides?

The USDA Dietary Guidelines for Americans recommends that at least half of our dietary intake of grains be from whole grains as a part of a healthy diet¹. However, less than 5% of Americans meet the recommended dietary intake for whole grains (≥ 3 oz/day)¹. Contrarily, over 95% of Americans meet the recommended dietary intake of refined grains (≤ 3 oz/day)¹ mostly in the form of packaged and processed foods (i.e., white bread, white rice, cereal, pasta, cookies, cakes, bagels, doughnuts, crackers, chips). Refined grains are stripped of their outer bran and germ layers during manufacturing- the parts of the grain that contain the majority of its nutrients (fiber, vitamins, and minerals)- leaving behind the nutrient-depleted endosperm. This process makes refined grains far less nutritious than whole grains.

The Standard American Diet is heavily laden with processed foods made up of refined grains, sugar, salt, and fat. This combination of nutrient-poor, calorically dense ingredients may be why processed food consumption has been linked to the obesity epidemic² and an increased risk for other non-communicable diseases like diabetes, cancer, heart disease, and depression³.

Despite the USDA’s attempts to shift American plates to contain more whole grains, there is still nationwide overconsumption of refined grains. Why? Perhaps it’s due to the addicting nature of processed foods? Or that refined grains are cheaper and more accessible than whole grains? Or maybe it comes down to an education issue with less than half of low-income adults able to correctly identify whole grains from refined grains⁴.

In any case, processed food consumption keeps the demand for grains high. So high that the government pays farmers extra to grow wheat, corn, soy, rice, and oats in order to keep up with the demands of the market². As a result, monocropping, or only growing one crop at a time without rotation, has become a popular agricultural practice². Monocropping requires heavy pesticide application to kill any unwanted weeds or insects that may potentially contaminate crops, resulting in a streamlining of harvests².

Cue RoundUp, the most widely used pesticide in U.S. agriculture with 1.1 billion pounds applied annually⁵. The active component of Roundup, glyphosate, targets the shikimate pathway of weeds, insects, and fungi, the pathway responsible for their growth, abolishing them on the spot. Glyphosate is a water-soluble chemical that has made its way into our soil, food, air, and water supply. In 2015, the World Health Organization classified glyphosate as a neurotoxin, teratogen (a substance that may cause birth defects), and a “probable human carcinogen”⁶. Despite this, the EPA states glyphosate as having low toxicity for humans⁷ and U.S. regulators allow an acceptable daily intake of 1.75 mg/kg of body weight per day compared to the European Union which only allows 0.3 mg/kg of body weight per day⁸.

Glyphosate is sprayed directly on wheat and oats before harvesting to kill the crop and dry it out sooner than if the plant were to have died naturally⁹. In 2018, the Environmental Working Group tested more than a dozen brands of wheat and oat-based cereal products and found most samples exceeded the upper limit of “safe” glyphosate levels set by the EPA⁹. This is of special concern for 1- to 2-year-old children since they’re smaller and tend to consume oat and wheat-based cereal products often. The worst offenders were Quaker Old-Fashioned Oats (930 ppb), Quaker Oats Dinosaur Eggs (700 ppb), Cheerios Toasted Whole Grain Oat Cereal (497 ppb), and Lucky Charms (400 ppb)⁹.

Glyphosate has also been linked to disruption of the gut microbiome, autism, ADHD, birth defects, celiac disease, diabetes, depression, cancer, Parkinson’s, Alzheimer’s, dementia, obesity, and leaky gut¹⁰.  This proposes the question, is it the consumption of ultra-processed foods contributing to the exponential rise in chronic, non-communicable disease? Or is it the presence of glyphosate on our grains and in our food supply that we are encouraged to eat as a part of a healthy diet?

Regardless, to limit your and your children’s exposure to glyphosate opt for organic options and skip the non-organic packaged wheat, corn, soy, and oat-based cereal and processed food products! This way you can avoid toxic pesticides.

For more information on Toxic Pesticides, please visit us at Specialized Therapy Associates or call 201-488-6678 to book an appointment.

Tune into our next newsletter for part 3 of “Raising awareness: the dangerous truth behind the toxins present in our food supply”.

References:

1. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov.
2. Franck C, Grandi SM, Eisenberg MJ. Agricultural subsidies and the American obesity epidemic. Am J Prev Med. 2013;45(3):327-333. doi:10.1016/j.amepre.2013.04.010
3. Lane MM, Davis JA, Beattie S, et al. Ultraprocessed food and chronic non-communicable diseases: A systematic review and meta-analysis of 43 observational studies
   [published online ahead of print, 2020 Nov 9]. Obes Rev. 2020;10.1111/obr.13146. doi:10.1111/obr.13146
4. Molika Chea, Amy R Mobley, Factors Associated with Identification and Consumption of Whole-Grain Foods in a Low-Income Population, Current Developments in Nutrition, Volume 3, Issue 7, July 2019, nzz064, https://doi.org/10.1093/cdn/nzz064
5. Atwood, Donald, and Paisley-Jones, Claire. “Pesticides Industry Sales and Usage: 2008-2012 Market Estimates.” Environmental Protection Agency, 2017. Retrieved May 29, 2019, from https://www.epa.gov/sites/production/files/2017-01/documents/pesticides-industry-sales-usage-2016_0.pdf
6. https://www.who.int/foodsafety/faq/en/
7. https://www.fda.gov/food/pesticides/questions-and-answers-glyphosate#:~:text=Has%20the%20EPA%20established%20tolerances,from%200.1%20to%20310%20ppm.
8. https://oehha.ca.gov/media/dockets/8594/10069-dave_murphy_food_democracy_now/fdn_glyphosate_foodtesting_report_p2016_002a_0.pdf

9. https://www.ewg.org/childrenshealth/glyphosateincereal/#.W3Q-B9hKjEY
10. https://www.fs.usda.gov/nfs/11558/www/nepa/102900_FSPLT3_4047514.pdf

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Wellness is not any one thing or any specific area in our lives. It is a combination of many domains that make up who we are as a person. The United States Substance Abuse and Mental Health Services Administration (SAMHSA) recognizes eight domains of wellness that contribute to our personal wellness. These areas are Emotional, Spiritual, Intellectual, Physical, Environmental, Financial, Occupational, and Social. 

 These areas are interconnected and they influence each other. For example, untreated or poorly managed anxiety obviously impacts our emotional well-being but it very quickly can and does impact other areas as well. Perhaps it impacts our work performance due to poor concentration or missing shifts. Or it may look like isolating from friends and family. Maybe we avoid checking our credit card statement because it becomes too overwhelming or we become disconnected from our higher power. The good news is that when it comes to personal well-being and recovery, these interdependent domains can be used to strengthen one another. When we recognize that our emotional well-being is not being well managed, we can build on the other areas. Maybe we can concentrate on our physical health, change our environment, or work on art. 

Wellness is not any one of these areas but a combination of them all. In our own search for wellness, it is important to look at all domains to see how they can be used to strengthen and build on one another. Living  “life on life’s terms” means that the functioning in these areas will ebb and flow and finding optimal wellness is discovering how they all integrate within the self.

If you are interested in learning more or improving any of these areas of wellness, please contact us at 201-488-6678 or visit https://www.specializedtherapy.com/. We look forward to speaking with you!

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This week is National Eating Disorder Awareness Week! Did you know that eating disorders are among the deadliest mental illnesses second only to opioid overdose? 10,200 deaths each year are the direct result of an eating disorder (1).

Some common myths surrounding eating disorders are:

1. “People who have eating disorders must be underweight”. Eating disorders look different for everybody and present themselves in many different ways. Less than 6% of people with eating disorders are actually diagnosed as being underweight (2). Just because someone doesn’t look physically sick, doesn’t mean they aren’t suffering.
2. “Only women can have eating disorders”. Men can have eating disorders, too, and the number of cases has increased in recent years. From 1999 to 2009 the number of men hospitalized for eating disorder-related causes increased by 53% (4). Males account for 25% of individuals with anorexia or bulimia eating disorders. Gay men represent almost half of men with eating disorders and are more likely to fast, vomit, or take laxatives or diet pills to control their weight (5).
3. “Eating disorders are a choice”. Eating disorders are serious mental illnesses, not lifestyle choices.

Click here to fill out our Eating Disorder Self-Assessment checklist.

If you feel like you or someone you know is suffering from an eating disorder, we are here to help! Our staff offers a unique holistic and integrative approach to eating disorder treatment using psychological therapy and a functional medicine approach to regain health.

Call 201-448-6678 to make an appointment or click here to enter your information and learn more about how our team can help!

By Taylor Groff, MS Functional Nutritionist

References:

1. Deloitte Access Economics. The Social and Economic Cost of Eating Disorders in the United States of America: A Report for the Strategic Training Initiative for the Prevention of Eating Disorders and the Academy for Eating Disorders.June 2020. Available at: https://www.hsph.harvard.edu/striped/report-economic-costs-of-eating-disorders/.
2. Arcelus, Jon et al. “Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies.” Archives of general psychiatry68,7 (2011): 724-31. https://doi.org/10.1001/archgenpsychiatry.2011.74
3. Zhao, Y., Encinosa, W. Update on Hospitalizations for Eating Disorders, 1999 to 2009. HCUP Statistical Brief #120. September 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb120.pdf
4. Hudson, J., Hiripi, E., Pope, H., & Kessler, R. (2007) “The prevalence and correlates of eating disorders in the national comorbidity survey replication.” Biological Psychiatry, 61, 348–358.
5. Eating Disorders in LGBTQ+ Populations. (2018, February 21). Retrieved February 22, 2021, from https://www.nationaleatingdisorders.org/learn/general-information/lgbtq

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Due to the COVID pandemic, A lot of us are still working from home. This has both positive and negative attributes. Current clients report that it’s nice to reduce the commute time and the stress of traffic while others report that they miss the down-regulation & alone time to separate work from home life.  Some like being able to dress down more often while others struggle with being motivated without having the dress code and structure of a work setting. Lastly, many reports that it’s nice to not have the pressure to interact all day while others found work to be one of their primary forms of connection which they miss.  Needless to say, it’s a mixed experience for most individuals. Take a moment now to think about your work/life balance is affecting you. As a society, it’s clear We are struggling with finding the balance in this ‘new normal’, which leads me to one of the most important therapeutic questions in regards to this topic, Are we working from home or living at work?

This lack of boundaries between home & work is causing people to experience loss of identity, a significant increase in the amount of hours worked and loss of work/life balance, and significant amounts of anxiety & stress in addition to the multitude of other stressors we already experience on a daily basis.

So, What’s the first step towards healing? 

Fear & Anxiety are inevitable in times of crisis, as they naturally respond in a trauma situation (which a pandemic qualifies as trauma), however, now We are in collective grief. All parallel processing & struggle simultaneously. We also live in a time where overdoing is viewed as a status symbol & how busy we are is something we humble brag about.. but it’s important to remember. It’s not a contest and that our journey is ours.

The first is to recognize what your body is trying to tell you and listening to the stress & anxiety cues. Stress is our body’s way of responding to any sort of external threat of danger (whether real or imagined), which most of us would call the fight or flight response, and generally alleviates after the ‘stressors’ have passed. Anxiety, however, is our internal reaction to feeling ‘stressed’, which for most people starts with Anticipatory Anxiety; Anxious about being Anxious. It’s a pervasive feeling of not being safe emotionally & manifests in physical symptoms. Stress, however, is often categorized by Loneliness, Insecurity, Loss of Concentration & Memory, worried & panicked thinking, restless/keyed up and edgy, avoiding others, fatigue & difficulty sleeping, eating issues- over or under eating, teary/mood swings, obsessiveness with working & routine, compulsive behaviors/overdoing it, fear of silence/the quiet.

What can I do about my stressors relating to the work, COVID, Childcare situation and ultimately find balance? 

1. 1. Focus on what you can control
   2. Let go of comparing your COVID experience to others (‘Living their best life’, etc), although we may not have all caught COVID physically, we almost all caught it emotionally & it’s very challenging to carry the weight of collective grief around.
   3. Reduce catastrophizing & focus on what you can control and Stay in the moment
   4. ‘Thought Stopping’ by identifying irrational thinking
   5. Tolerating Distress & Ambiguity through Radical Acceptance

How can I take better care of myself during this time? 

Establish a self-care plan:

1. 1. Assess current ‘coping skills’ you’re using (ie: overeating, drinking, isolation, phone, etc.
      1. Community—essential to have a strong support system
      2. Eating
      3. Sleeping
      4. Exercising?
   2. Starting the day off right with a strong morning routine and following that throughout the day:
      1. Meditating (Visualizing things going well & you handling the day with ease), Reading, Journaling, Exercising, Praying—- Limiting social media & TV
      2. Midday mantras (“I will not scare myself by repetitively examining details over and over”), eating healthy and a wind-down routine at night time that is nourishing & not just binge renewing

If you or someone you know is struggling with the boundaries regarding living at work vs. working from home and is experiencing stress & anxiety as a result, please reach out to us today or visit our website or call 201-488-6678. We look forward to working with you!

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When we’re faced with unprecedented challenges, it causes us to lose motivation and retread back to our old ways, making it difficult to follow through on our resolutions year-round. A perfect example is this past year with the coronavirus pandemic, a challenge we’ve never faced before! As a collective, 2020 started off with the best of intentions, but unbeknownst to us- a global catastrophe stripped us from all inspiration and granted some of us permission to slip back into our old habits to find safety and comfortability during such an unprecedented time.

Nevertheless, New Year’s resolutions have the best of intentions, they’re a stimulus for growth, turning over a new leaf, leveling up to become a better version of ourselves. Despite naysayers that proclaim New Year’s resolutions are meant to be broken, there is evidence that shows resolutions have the potential to be a successful tool¹ as a new beginning, a chance to start over, an opportunity to embark on a new journey that supports overall physical and mental health and well-being.

Research has shown that New Year’s resolutions that are restriction and avoidance-oriented are far less successful than those that are approach-oriented¹. This is probably why dieting, weight loss, and detox programs are unsuccessful and tend to lead to rebound weight gain and a disordered relationship with food, diet, and exercise.

Instead, focus on making SMART goals this year! SMART goals are specific, measurable, action-oriented, realistic, and time-lined. SMART goals are designed for success by making small, approachable short-term goals instead of BIG, overwhelming end-stage goals. Tackling one small goal at a time builds confidence which is foundational for success.

Having trouble knowing where to begin? Here are some SMART goals that benefit everybody!

Lower your sugar intake:

Sugar is a naturally occurring energy source found in carbohydrates derived from fruits, vegetables, and whole grains. However, the sugar in our food supply today is much different than what it was over a hundred years ago. Since the early 20^th century, sugar consumption has increased dramatically due to the industrialization of food which has allowed sugar to be easily added to processed foods and beverages in its highly caloric, refined form. Now, refined sugar is ubiquitous in our food supply and is found in almost every packaged and processed food (i.e., cookies, cakes, pretzels, pies, pastries, cupcakes, muffins, crackers, chips, white bread) and convenience food (take-out, fast food, convenience store/gas station food). It’s also added to canned foods, bread, cereals, yogurts, and seemingly healthy granola bars and juices.

It is no coincidence that with the increase in sugar consumption from low-quality, nutrient-poor ultra-processed foods has come with an accompanying increase in chronic diseases like type 2 diabetes, obesity, depression, anxiety, IBS, metabolic syndrome, cancer, Alzheimer’s, non-alcoholic fatty liver disease, high blood pressure, heart disease², and the list goes on…

Sugar comes in many forms and goes by many different names. Artificial sweeteners are no better for our long-term metabolic health as an alternative to refined sugars. In fact, these stand-in sugar substitutes have actually proven to cause more harm than good by negatively altering insulin sensitivity and raising the risk for other health conditions like cancer³.

Some helpful tips for lowering your sugar intake:

1. Increase consumption of high-quality fats

Examples- extra virgin olive oil, avocado, avocado oil, grass-fed organic animal products (meat, dairy), ghee, raw nuts, and seeds.

2. Increase consumption of high-quality protein

Examples- organic, pasture-raised, non-GMO poultry and grass-fed beef; organic, non-GMO plant-based proteins like tofu, tempeh.

3. Increase consumption of fiber in the form of fruits, vegetables, whole grains, sprouted beans and legumes

Examples- berries, apples, pears, cherries, broccoli, cauliflower, leafy green vegetables, onions, and garlic; oats, quinoa, brown rice, teff; sprouted lentils

4. Decrease alcohol consumption

Do it the SMART way:

Small- Start with one or more of the above interventions and once you feel comfortable and confident doing that, add another.

Measurable- Keep a journal and write down how you feel eating less refined sugar and drinking less alcohol. At first, it may be a challenge- and that’s to be expected! Write down everything you’re feeling. Refer back to the journal when experiencing difficulties staying on course, this will remind you of the progress you’ve made, how far you’ve come, and inspire you to keep going.

Attainable- Make a grocery list of whole foods before going shopping and stick to the items on the list! For whole foods recipe inspiration, click here to explore our Specialized Therapy Associates Pinterest board!

Realistic- You don’t have to cut out all sugar at once unless otherwise directed by your doctor. Instead, focus on cutting out one or two major sources of refined sugar in your diet- like soda, sweetened beverages, fast food, or go-to snacks like chips, pretzels, or desserts. Then, after you successfully do so, proceed to cut out more and more sources of refined sugar and carbohydrates in your diet.

Time-line- Give yourself a few days to adjust to cutting out the major culprits of refined sugar in your diet. After you’ve successfully done so, remove more sources of refined sugar. Aim for complete removal of refined sugar in your diet and elimination of highly processed foods in a timeline of 3 to 6 months.

Increase physical activity & movement

There is no question that physical activity plays a major role in the status of our metabolic health. The sedentary lifestyle of Americans in the 21^st century has come with innumerable health consequences. We know that physical activity helps with weight maintenance and weight loss, increases insulin sensitivity, lowers our risk for heart attack and stroke, cancer, diabetes, cognitive decline, polycystic ovary syndrome, depression, anxiety, osteopenia, sarcopenia, and osteoporosis⁴. To date, we know that physical activity is one of the most critical means of disease prevention, and yet, we still struggle with making time for it in our fast-moving lifestyle.

Exercise, by definition, is planned, structured, and intentional movement with the objective of achieving a fitness-oriented goal or maintaining physical fitness⁵. For some, exercise can be an incredible outlet for stress and boosting mood and energy levels. If that’s you, great! Aim for achieving 30 to 60 minutes of light to moderate-intensity exercise in the form of aerobic exercise (i.e., brisk walking, jogging, cycling, Pilates) or strength training (weightlifting, kettlebell squats, dumbbell training, etc.) every day.

For others, structured exercise can be a daunting, mundane, and dreaded task that we force ourselves into with the hope of gaining some sort of health benefit. If that sounds more like you, you’re not alone! Regimented exercise is not the only kind of movement we benefit from.

We also benefit from physical activity, a different form of exercise because it can be either structured or unstructured and typically consists of activities you enjoy while still reaping the metabolic health benefits. Structured physical activity may look like walking, riding your biking, hiking, swimming, dancing, yoga, or rollerblading. Examples of unstructured physical activity consists of activities that coincide with daily living such as playing with your children, cleaning the house, gardening, folding laundry, grocery shopping, washing dishes, walking your kids to school, taking the stairs⁵, etc. These types of unstructured physical activity and movement add up and result in increased calorie expenditure which may lead to weight loss over time.

Note: Please consult your physician or health care practitioner before starting any new exercise regimen to ensure it is appropriate for you.

Here are some helpful tips for increasing your physical activity:

1. Take the stairs instead of the elevator.
2. Go for walks on your lunch break or take time to stretch in between meetings.
3. Have a dance party in the morning while you’re getting ready for your day.
4. Stand up while folding laundry or doing desk work.
5. Clean daily- washing windows, vacuuming, mopping.
6. Do some form of pushups, squats, jumping jacks, or walking in place while watching TV.

Do it the SMART way:

Small- If you’re not an exercise buff, start incorporating small bits of movement a few times a week and work yourself up to incorporating movement into your daily routine.

Measurable- Write down the exercise or structured/unstructured physical activity you do and use a tracking app like myfitnesspal to look up how many calories you’re burning while doing so and log it in a journal.

Attainable- If engaging in a structured exercise routine, start with light workouts 15-20 minutes a day, and gradually work your way up to longer time and intensity. If you’re trying to increase your daily movement, start with performing one of the abovementioned activities for 5-10 minutes when you have moments of downtime throughout the day.

Realistic- Don’t feel the need to make any drastic changes to your daily routine to incorporate rigorous exercise and physical activity. Start slow and gradually increase duration and intensity once your body adjusts. This will help avoid burnout.

Timeline- Aim for goals that are suitable for you and your lifestyle. There’s no rush to meet any fitness deadlines unless otherwise specified by a doctor, or yourself. Instead, focus on enjoying the movement you do incorporate into your routine to make sure its sustainable.

Note: Please consult your physician or health care practitioner before starting any new exercise regimen to ensure it is appropriate for you.

Be more mindful

Mindfulness is about paying attention in the present moment, on purpose, without judgment. Mindfulness means being able to bring direct, open-hearted awareness to what you are doing while you are doing it. Practicing mindfulness helps you tune into what is going on in your mind by bringing awareness to your thoughts and emotions as well as your body by paying attention to any internal or external physical sensations. Mindfulness can be practiced in a variety of ways- meditation, breathwork, walking in nature, exercise, physical activity and movement, cooking, eating, everyday tasks like laundry, cleaning, or even making your bed. There are countless moments throughout the day where one can practice mindfulness- ironically enough, you just have to pay attention to when those moments present themselves.

Mindfulness encourages curiosity and compassion for individuals and their environment. the evidence is clear that incorporating mindfulness into your lifestyle has a profound impact on our experience as human beings by tapping into a transcendental, restful state that beneficially alters our physiology thus improving quality of life. Practicing mindfulness has been linked to decreased anxiety, stress, depression, mood balance and regulation, emotional reactivity⁶ aging, improved immune function⁷, chronic pain management^8,9, and better sleep¹⁰

Tip for increasing mindfulness:

1. Go for a walk outside, pay attention to your surroundings. The way the air smells and feels on your skin, the sounds of the wildlife or cars passing by, the color of the foliage, how your feet make contact with the earth with every step.
2. Be present while eating by paying attention to the way food tastes, think about where it came from, the journey it took to make its way onto your plate, what senses its satisfying, the texture, smell, and sound it makes while chewing.
3. Practice mindful breathing. Take deep breaths and pay attention to how your belly rises and falls with each breath. Feel your chest expand with air and release entirely.

Mindfulness is a personal journey, there’s no right or wrong way of practicing it. Simply, try and pay attention to the routine motions of your life and practice gratitude for being alive rather than simply existing.

You can implement the abovementioned New Year’s resolutions by yourself, but research has shown that working in groups of people with the same or similar goals yields higher success rates and longer-lasting behavior change¹¹. Working in a group setting also provides a means of accountability and support when facing challenges to keep you on track with integrating new habits in order to reach your goals. Call 201-488-6678 to take advance of new groups Specialized Therapy Associated is offering this January!

Did you know we have a Board Certified Health and Wellness Coach on staff? If you would like personalized support and guidance on how to implement any of the above suggestions, please call Specialized Therapy Associates at 201-488-6678 to schedule your complimentary consultation. Our Health Coach, Anna Sandbank, LCSW, INHC, NBC-HWC will speak with you to learn more about your goals, and how she can support you to make them a reality in 2021.

By Taylor Groff, MS, Functional Nutritionist

About the Author:

Taylor Groff is a functional nutritionist that specializes in using evidence-based nutrition and food as medicine to treat the root cause of any illness- physical, emotional, and/or metabolic- that affects our ability to live a happy, healthy, and fulfilled life. Taylor helps move individuals into a state of optimal health by providing the tools and resources necessary to make informed health choices through teaching basic nutrition principles and providing personalized nutrition plans. Taylor focuses on the client as an individual with their own genetic uniqueness, health history, lifestyle, and cultural influences, and designs a food plan that is personal to them based on their health needs to ensure compliance for sustainable success.

Taylor has her M.S. in Human Nutrition and Functional Medicine from the University of Western States and her B.S. in Biological Sciences from Rowan University. She enjoys being outside in nature, going for hikes with her dog, and cooking healthy recipes. Taylor works alongside our Board Certified health coach, Anna Sandbank, designing personalized nutrition plans for clients.

References:

1. Oscarsson M, Carlbring P, Andersson G, Rozental A. A large-scale experiment on New Year’s resolutions: Approach-oriented goals are more successful than avoidance-oriented goals. PLoS One. 2020;15(12):e0234097. Published 2020 Dec 9. doi:10.1371/journal.pone.0234097
2. Stanhope KL. Sugar consumption, metabolic disease, and obesity: The state of the controversy. Crit Rev Clin Lab Sci. 2016;53(1):52-67. doi:10.3109/10408363.2015.1084990
3. Purohit V, Mishra S. The truth about artificial sweeteners – Are they good for diabetics?. Indian Heart J. 2018;70(1):197-199. doi:10.1016/j.ihj.2018.01.020
4. Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2012;2(2):1143-1211. doi:10.1002/cphy.c110025
5. Ceria-Ulep CD, Tse AM, Serafica RC. Defining exercise in contrast to physical activity. Issues Ment Health Nurs. 2011;32(7):476-478. doi:10.3109/01612840.2010.525692
6. Keng SL, Smoski MJ, Robins CJ. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev. 2011;31(6):1041-1056. doi:10.1016/j.cpr.2011.04.006
7. Black DS, Slavich GM. Mindfulness meditation and the immune system: a systematic review of randomized controlled trials. Ann N Y Acad Sci. 2016;1373(1):13-24. doi:10.1111/nyas.12998
8. Hilton L, Hempel S, Ewing BA, et al. Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Ann Behav Med. 2017;51(2):199-213. doi:10.1007/s12160-016-9844-2
9. Banth S, Ardebil MD. Effectiveness of mindfulness meditation on pain and quality of life of patients with chronic low back pain. Int J Yoga. 2015;8(2):128-133. doi:10.4103/0973-6131.158476
10. Black DS, O’Reilly GA, Olmstead R, Breen EC, Irwin MR. Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: a randomized clinical trial. JAMA Intern Med. 2015;175(4):494-501. doi:10.1001/jamainternmed.2014.8081
11. Paul-Ebhohimhen V, Avenell A. A systematic review of the effectiveness of group versus individual treatments for adult obesity. Obes Facts. 2009;2(1):17-24. doi:10.1159/000186144

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