The ZRT Laboratory Blog

Supporting Teens with ADHD: Navigating Hormonal Changes During Puberty

Wed, 04 Dec 2024 15:28:08 -0800

Developing bodies, mood swings, new social dynamics, and increasing schoolwork make puberty a tough time for many young people. For the approximately 5% of children worldwide with the neurodevelopmental condition, Attention Deficit Hyperactivity Disorder (ADHD), these hurdles can feel even more overwhelming.

The significant hormonal changes of puberty can drastically affect the presentation and management of ADHD symptoms. This blog post explores the connection between ADHD and puberty. It offers support for parents and providers as they help teens during these challenging years.

“But Don’t Most Kids Outgrow ADHD?”

Until recently experts believed that about half of children with ADHD would 'outgrow' the disorder. In a 16-year study published in 2021, nearly 10% of young people with ADHD showed stable remission. Most participants experienced fluctuating periods of remission and then saw their symptoms return into young adulthood and beyond. (1)

The Hormonal Changes of Puberty

Puberty is a period of rapid growth and development. It typically occurs between ages 8 and 14 for females and 9 and 16 for males. During this time, the body goes through significant changes driven by increased production of sex hormones. In both males and females, testosterone levels rise, while females also experience changes in estrogen and progesterone levels as they start ovulating and menstruating in a monthly cycle.

Effects of Sex Hormones on the Brain

During puberty, the rise in sex hormones affects more than just secondary sex characteristics such as breasts and facial hair. These hormones also change the brain, both in how it's structured and how it functions. They influence the way brain circuits work and how neurotransmitters are processed. (2)

This process begins long before puberty. Experts believe that higher testosterone levels in boys before and shortly after birth can permanently affect brain development. This is especially true for dopaminergic circuits that control thinking, movement, and the brain's "pleasure and reward" signaling functions.

This early exposure to testosterone can increase the risk of developing inattention and behavioral disorders, making boys more likely to show hyperactive and impulsive behaviors. This leads to a higher rate of ADHD diagnoses and treatments for boys. (2)

As puberty begins, changes in sex hormones activate brain circuits that were affected earlier in development. For example, the effects of estradiol during puberty may change serotonergic pathways. This can put girls at a higher risk for internalizing and mood disorders. (2)

Symptoms of ADHD During Puberty

A recent 8-year study looked at how aging and puberty affect ADHD symptoms. It found the following:

Hyperactivity and impulsivity appeared to decrease as young people got older
Impairment from ADHD and depressive symptoms appeared to increase as puberty progressed
Inattention did not change

These findings may help explain why ADHD in teens has often been overlooked. As they grow, symptoms become less obvious to others. (2)

Additionally, teens may start to assert their independence by refusing ADHD medications or treatments that they previously accepted during elementary school. Some may seek peer acceptance, sometimes with others who struggle socially or academically. They may also experiment with risky behaviors, which some researchers link to pubertal testosterone levels. (3, 4)

ADHD and the Menstrual Cycle

Research shows that hormonal changes during the menstrual cycle can make ADHD symptoms worse for girls. Estrogen tends to increase levels of dopamine and norepinephrine, two important brain chemicals that affect focus and attention. Estrogen does this partly by slowing down enzymes (MAO and COMT) that break down these chemicals.

When estrogen levels are higher, like during the late follicular phase and peak luteal phase of the cycle, girls may find it easier to focus and stay organized. However, when estrogen drops or is low, such as at the end of the luteal phase or during the period, ADHD symptoms often get worse. This can make emotional regulation and attention more difficult.

These hormonal shifts can affect school performance and relationships, which are especially important during adolescence. This highlights the need for strategies and interventions that support girls with ADHD during these challenging times. (5, 6)

Teens, ADHD and Mood Disorders

Puberty is a sensitive development period in general, with teens becoming particularly vulnerable to emotional and behavioral dysregulation and psychiatric conditions. Depressive disorder, which has typical onset during adolescence, impacts about 13% of the US population. (3)

Youth with ADHD may be especially susceptible to depression as hormonal changes affect brain networks that control thinking, decision-making, and feelings of reward. These changes can make it more difficult to stay organized, do well in school, and stay motivated. (3)

Implications for Treatment and Support

Understanding the relationship between ADHD and puberty is essential for developing effective treatment strategies. Healthcare providers should consider the impact of hormonal changes on ADHD symptoms and adjust treatment plans accordingly. For example, small preliminary studies suggest that increasing stimulant medication doses before a woman's period may help improve worsening ADHD and mood symptoms during that time. (7)

Many women with ADHD also report that "cycle synching" is helpful. This means tracking their menstrual cycles and planning demanding tasks for times when their energy, focus, and mood are at their best. (8)

Primary care providers and mental health professionals should work together to provide comprehensive care for children with ADHD, ensuring that both neurodevelopmental and hormonal factors are addressed.

For parents, this may be the time to:

Seek out a therapist or peer support group to incorporate more behavioral therapies alongside medication adjustments.
Enlist educational support such as tutors or an organizational/executive function coach.
Be on the lookout for new, lasting or worsening mood changes.
Use visual cues and reminders at home and on devices. These can help with routines such as self-care, hygiene, homework, activities, and chores.
Discover and focus on your teen’s unique talents, interests and strengths. (9)

Conclusion

The relationship between ADHD and puberty is complex and influenced by normal hormonal changes, gender differences, and comorbid conditions such as depression. In addition to the suggestions above, utilizing convenient at-home hormone and neurotransmitter testing can help provide meaningful insights into the unique challenges faced by adolescents with ADHD during puberty. Armed with this information, healthcare providers can develop more effective, personalized treatment plans to support their teen patients through this critical developmental stage.

References:

1. Sibley, Margaret H., Ph.D., Arnold, L. Eugene, M.D., Swanson, James M., Ph.D., Hechtman, Lily T., Ph.D., Kennedy, Traci M., Ph.D., Owens, Elizabeth, Ph.D., Molina, Brooke S.G., Ph.D. (2021). Variable Patterns of Remission from ADHD in the Multimodal Treatment Study of ADHD. The American Journal of Psychiatry, Vol 179, No. 2. https://psychiatryonline.org/doi/10.1176/appi.ajp.2021.21010032.

2. Eng, Ashley G., Phan, Jenny M., Shitcliff, Elizabeth A., Eisenlohr-Moul, Tory A., Goh, Patrick K., Martel, Michelle M. (2023). Aging and Pubertal Development Differentially Predict Symptoms of ADHD, Depression, and Impairment in Children and Adolescents: An Eight-Year Longitudinal Study. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC10198896/#R6.

3. Silvery, Larry, M.D. (2020). Boys 2 Men: When ADHD and Puberty Collide: What parents of boys with ADHD should watch for as their sons pass through adolescence. ADDitude Magazine. https://www.additudemag.com/boys-2-men-when-adhd-and-puberty-collide/#:~:text=Fortunately,%20boys%20with%20attention%20deficit%20disorder%20(ADHD%20or%20ADD)%20don%E2%80%99t.

4. Laube, Corinna, Lorenz, Robert, van de Bos, Wouter. (2019). Pubertal testosterone correlates with adolescent impatience and dorsal striatal activity. National Library of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC7242510/.

5. Roberts, Bethan, Esienlohr-Moul, Tory A., Martel, Michelle M. (2018). Reproductive steroids and ADHD symptoms across the menstrual cycle. Science Direct. https://www.sciencedirect.com/science/article/abs/pii/S0306453017312635?via%3Dihub.

6. Eng, Ashley G., Nirjar, Urveesha, Elkins, Anjeli R., Sizemore, Yancey J., Monticello, Krystina N., Peterson, Madeline K., Miller, Sarah A., Barone, Jordan, Eisenlohr-Moal, Tory A., Martel, Michelle M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Science Direct. https://www.sciencedirect.com/science/article/abs/pii/S0018506X23001642#:~:text=Highlights%20%E2%80%A2%20Females%20with%20ADHD%20may%20experience%20both%20organizational%20and.

7. de Jong, M., Wynchank, D. S. M. R., van Andel, E., Beekman, A. T. F., Kooij, J. J. S. (2023). Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Frontiers in Psychiatry. https://pmc.ncbi.nlm.nih.gov/articles/PMC10751335/#:~:text=Preliminary%20findings%20postulate%20that%20changes%20in%20sex%20hormones%20during%20the.

8. Pesantez, Nathaly. (2024). Menstrual Cycle Phases and ADHD: Why Cycle Syncing is Essential. ADDitude Magazine. https://www.additudemag.com/menstrual-cycle-phases-cycle-syncing-adhd/#:~:text=Here,%20we%E2%80%99ll%20break%20down%20the%20phases%20of%20the%20menstrual%20cycle.

9. (2024). ADHD across the lifespan: What is looks like in children and teens. NIH MedlinePlus Magazine. https://magazine.medlineplus.gov/article/adhd-across-the-lifespan-what-it-looks-like-in-children-and-teens#:~:text=Puberty%20can%20exacerbate%20ADHD%20symptoms%2C%20making%20it%20harder,and%20explore%20different%20activities%20to%20discover%20their%20strengths.

The Science of Stress: The Time-Dependent Multimodal Effects of Stress Hormones on Memory and Learning

Mon, 24 Jun 2024 10:54:07 -0700

According to the American Institute of Stress, 55% of people in the United States experience daily stress. Stress is, technically defined as the body's nonspecific response to any demand – pleasant or unpleasant – but more commonly perceived as a state of physical, mental, or emotional strain or tension. Chronic stress is especially prevalent in the workplace, with 83% of employees reporting daily work-related stress (1). However, statistics show that stress among students is also significant, common, and increases proportionally to a student’s progress through the educational system.

Recent studies on academic pressure found that three-quarters of American high schoolers and half of middle schoolers described themselves as “often or always feeling stressed" by schoolwork (2). Meanwhile, at American colleges, over a third of students say they’ve considered withdrawing from their program for at least one term, and over half of those cite emotional stress as the primary reason (3).

And yet – not all stress is negative. Some stress is not only unavoidable but may actually be necessary to motivate and enable learning, retention and updating of information. Research has found that stress affects our memory through numerous mechanisms, each with different impacts. While the link between chronic excessive stress and cognitive decline in aging brains has been well established, the variable effects of different stress hormones on memory and learning in younger people have received far less attention to date.

This information may be key to helping learners of all ages understand and manage the impact of the type and timing of stress on their ability to be successful in meeting their educational and career goals. Within the medical community, understanding the hormone connections to learning and memory may help providers to better support patients experiencing elevated stress levels.

The Science of Stress

The two major stress systems have both been shown to be critical for the modulation of learning and memory processes. The autonomic nervous system (ANS) response is rapid and involves the release of catecholamines norepinephrine and epinephrine from the adrenal glands and the brainstem in a matter of seconds. This is how the sympathetic nervous system prepares the body and brain for a ‘fight or flight response,’ dilating the pupils and bronchi while constricting blood vessels and accelerating heart rate. The ANS also rapidly affects neural functioning in multiple brain regions including the amygdala, hippocampus, and pre-frontal cortex, with profound effects on attention, working memory and long-term memory.

The second stress response by the hypothalamic-pituitary-adrenal (HPA) axis is slower, effectively operating on a delay. In response to ANS signaling, the hypothalamus releases corticotropin-releasing hormone (CRH) which stimulates the anterior pituitary to secrete adrenocorticotropic hormone (ACTH), triggering the release of glucocorticoids from the cortex of the adrenal gland – primarily cortisol, a steroid hormone. Levels of cortisol peak about 20 to 30 minutes after the onset of the stressor and bind both glucocorticoid and mineralocorticoid receptors (MR) in the body and brain (4).

Glucocorticoid receptors (GR) are widespread throughout the brain, while MR is primarily expressed in regions associated with memory and emotion - specifically the amygdala, hippocampus and pre-frontal cortex. This allows cortisol to have two separate and opposite modes of action within the brain. Cortisol binding to the MR quickly increases neural excitability in the amygdala and hippocampus, while GR binding has a slower effect, developing over 60-90 minutes after the onset of the stressor, and causes changes to DNA translation and transcription to re-establish homeostasis and calm the neural excitability caused by the acute effects of stress.

This complex symphony of hormones explains why stress can have significant effects on memory that vary by timing of stressor, memory and the type of information being learned.

Fig. 1 The Stress Response System

Stress During and Around the Time of Learning Actually Enhances Memory

Moderate stress just before, during or just after encoding and consolidating new information may strengthen human memory formation.
The release of norepinephrine and cortisol activate the amygdala and hippocampus to enhance emotional processing, memory, and learning.
In particular, stress can lead to better memory for emotionally charged events or for information directly related to the stressor, through norepinephrine's activation of a brain network known as the salience network, which includes the amygdala.
This type of memory enhancement is norepinephrine-dependent and can be disrupted by the beta blocker propranolol, which is currently under study for prevention and treatment of Post-Traumatic Stress Disorder (5).
For example, showing an emotionally arousing, contextually related film before a lesson may enhance encoding and consolidation of pertinent information as a memory.

Stress Long Before Learning or in a Different Context Impairs Memory

In studies, encoding of new information was impaired when a stressor occurred more than 30 minutes before learning, or in a distinctly different context (for example, stress occurring at home versus in the classroom).
This may be attributable to the decrease in hippocampal neural excitability as a late effect (>1 hour) of cortisol exposure, which is theorized to protect the consolidation of the information learned during the stressful encounter, versus allowing new memories to form.
Chronic or excessive secretion of stress hormones can negatively impact long-term memory via structural and functional changes to the hippocampus, a brain region crucial for memory consolidation.

Cortisol Impairs Memory Retrieval

During memory retrieval, such as recall of information during an exam, high cortisol levels can hinder performance.
This effect was observed beginning 20 minutes after a stressor, when cortisol is at peak levels, and was even more prominent during the time when cortisol exerted its longer-acting genomic mode of action.
Cortisol-induced retrieval deficits were found to impact both adults and children aged 8-10, with broad significance for educational assessment of information learned.
Interestingly, context modulated this effect, so that recall was not impaired significantly by stress if the test information was relevant to the stressful situation, or if the learning and the test occurred in the same context.

Stress Hormones Impact Knowledge Updating, Cognitive Flexibility, and Goal-Directed Behavior

Reconsolidation theory suggests that consolidated memories return to a malleable state when they are reactivated. During reconsolidation, which takes place in the hippocampus and prefrontal cortex – key targets of stress hormones - memories may be weakened, strengthened, or altered.
While investigations are still underway, animal studies suggest that stress or cortisol exposure after memory reactivation impairs reconsolidation.
Misinformation studies in humans have also found that highly arousing information learned under stress results in more robust memories that are less susceptible to being updated. This may have negative implications for education, professional learning, and life experiences that require frequent updating of knowledge based on new information.
Under stress, cortisol’s action at the MR appears to shift human behavior toward habit, relying on more rigid striatal stimulus-response learning strategies rather than the cognitive hippocampal memory system. This system allows for the formation and recall of flexible memories and underpins goal-directed (action-outcome) behavior.

Balancing Stress Hormones is Essential for Cognitive Health

Optimal memory function requires a balance in stress hormone levels. Normal physiological responses to moderate acute stress can be beneficial for memory, but chronic stress and elevated cortisol levels are harmful.
Strategies like exercise, mindfulness, strong routines, emotional regulation, and adequate sleep can help regulate stress hormones and support memory and learning (4).

In summary, stress hormones can be a double-edged sword when it comes to memory and learning. In addition to the timing of stressors, individual perceptions of and responses to stress vary, and some people may be more resilient than others.

Fortunately, for anyone concerned about how stress may be impacting memory, attention or learning, saliva cortisol testing - considered the gold standard in cortisol assessment - is readily available from ZRT Laboratory. Alternatively, dried urine diurnal hormone testing may be used to assess cortisol and cortisone, as well as the catecholamines norepinephrine and epinephrine, which are needed in the right amounts at the right time of day to facilitate learning and memory formation. Either test involves collecting four non-invasive samples over the course of a single day to generate a four-point diurnal curve. This information allows health care providers to pinpoint any issues within the sympathetic nervous system and HPA axis that may be contributing to difficulties with attention, focus, memory, learning, and more. Utilizing convenient at-home stress hormone testing can help provide meaningful insights into a patient's health to support a path towards optimal memory, learning, and achievement of goals.

Figure 2. The effects of stress on memory depend on the specific memory process investigated and the temporal proximity between the stressful event and this memory process. While stress (indicated as red flash) long before encoding impairs memory formation, stress shortly before or after the presentation of new information generally enhances subsequent memory performance. In sharp contrast, stress before memory retrieval impairs the recall of information learned previously which may directly affect performance at exams. In education, knowledge needs to be frequently updated by new facts or concepts relating to prior knowledge. In addition to its effects on memory encoding and retrieval, stress appears to impair this integration of new information into existing knowledge structures (6).

Image credit: Vogel, Susan & Schwabe, Lars. "Learning and memory under stress: implications for the classroom." npj Science of Learning, Jun 29, 2016. npj Science of Learning.

References

Inositol Supplementation – Recent Research in Mood Disorders: Part 2

Tue, 02 Aug 2022 11:20:52 -0700

In part 1 of this blog post, we discussed the use of inositol for insulin resistance and related conditions. However, in the late 1990s and early 2000s researchers were largely focused on the effects of inositol on mood. A link between insulin resistance and depression has been established since, and may eventually provide one possible mechanism of action. (1)

A 2014 meta-analysis suggested that inositol may be beneficial in depression, particularly premenstrual dysphoric disorder. (2) Numerous smaller studies found inositol to be effective for a spectrum of disorders that usually respond to selective serotonin reuptake inhibitors (3), including panic (4) and obsessive-compulsive disorder [OCD] (5), as well as bulimia and binge eating (6). At dosages of 12 to 18g per day used in clinical trials, it was not necessarily the most practical therapy, but was nevertheless well-tolerated with mainly mild gastrointestinal (GI) side effects reported.

A more recent double-blind, controlled, crossover trial demonstrated that 18g of inositol had similar efficacy to 150 mg of fluvoxamine in patients with panic disorder and agoraphobia, reducing the number of panic attacks by four per week in the first month, with lower incidence of side effects such as nausea and tiredness. (7) As a natural component of the diet with few known side effects, inositol remains a viable therapy to consider for patients who are ambivalent about or intolerant of psychiatric medication for panic disorder, with larger studies needed to demonstrate long-term efficacy.

Dosing and Administration

The best way to determine the appropriateness of supplementing with inositol is to use lab testing in combination with clinical presentation.

Average dietary intake of inositol from beans, grains, nuts, and fresh produce in the US is estimated at around 1g per day. Because doses used in studies tend to be in the range of 4 to 18g per day, inositol as a supplement is often delivered in a powder form. Fortunately, this substance readily dissolves in water and has a slightly sweet taste – roughly half the sweetness of sucrose – allowing for flexibility in dosing and making it an easy addition to water, tea, or other beverages.

Adverse Effects and Contraindications

Across studies, adverse effects from inositol have been reported as mild, with no serious adverse events reported. As a sugar alcohol, inositol’s primary side effects are GI including gas, bloating and diarrhea, and may decrease over time or with gradual introduction.

However, it is important to note that any therapy that improves insulin sensitivity and glucose disposal may lower blood sugar, and should be used cautiously and under medical supervision especially in people taking other glucose-lowering medications. Close monitoring of blood sugar levels and medication dosages may be required to avoid hypoglycemia.

Test, Don’t Guess

The best way to determine the appropriateness of supplementing with inositol is to use lab testing in combination with clinical presentation. ZRT Laboratory offers minimally invasive testing in saliva and dried blood spot, including profiles that assess fasting insulin, cardiometabolic markers, and levels of sex hormones. Individuals with PCOS often benefit from the Fertility Profile or Wellness Metrics Profile. In addition, the NeuroAdvanced Profile offers dried urine testing and can help assess whether imbalances in neurotransmitters such as serotonin are contributing to symptoms of depression, anxiety, OCD, or panic disorder that may benefit from inositol or other interventions.

Related Resources

Blood Spot Testing

References

Inositol Supplementation – Recent Research in PCOS, Metabolic Syndrome and Mood Disorders: Part 1

Fri, 08 Jul 2022 09:58:47 -0700

We are living in an age of insulin resistance. Excessive intake of calories and refined carbohydrates, decreased physical activity, and chronic stress increase insulin secretion and decrease insulin sensitivity. This creates a vicious circle of requiring more and more insulin to shuttle glucose into cells. Years or possibly even decades before the elevations in blood glucose and hemoglobin A1C associated with type 2 diabetes, fasting insulin increases, and this high insulin is at the core of metabolic syndrome and polycystic ovary syndrome (PCOS). Recently published research suggests that insulin resistance also doubles the risk of major depressive disorder, which will be discussed in part two of this blog. (1)

In the quest to disrupt this cycle of increasing insulin resistance and prevent future disease and complications, some of our most powerful and fast-acting tools are insulin sensitizing agents, both natural and pharmaceutical such as metformin, thiazolidinediones, berberine, and inositol.

This post will focus on inositol, a carbocyclic sugar found in a wide range of mammalian tissues, with higher concentrations in the heart and brain. Although it was historically known as vitamin B8, inositol is now considered a sugar alcohol. Of the nine different isomers of inositol, the most abundant in the human body are myo-inositol and D-chiro-inositol. Because it can be synthesized from glucose by the kidneys and liver, inositol is not considered an essential nutrient.

Numerous clinical trials and meta-analyses have evaluated the effectiveness of inositol therapy for conditions including metabolic syndrome, polycystic ovary syndrome, and fertility.

Inositol acts as a second messenger - or intracellular signaling molecule - throughout the endocrine system and in the brain, relaying signals within the cell from an extracellular hormone such as insulin or from a neurotransmitter such as serotonin. Its ability to influence metabolism, hormone production and signaling, ovarian function, and neurotransmitter balance have sparked interest in the potential benefits of inositol as a nutritional supplement. Within the last few years alone, numerous clinical trials and meta-analyses have evaluated the effectiveness of inositol therapy for conditions including metabolic syndrome, PCOS, and fertility.

Inositol for PCOS – Does it Work?

The most frequent question providers and patients have about any nutritional supplement is, “Does it work?” Depending on the particular nutrient and indication, that research hasn’t always been done. But in the case of inositol for PCOS, a 2022 review of nine randomized controlled trials (RCTs) and 612 patients concluded that myo-inositol appeared to be equally effective to metformin in lowering total testosterone and increasing sex hormone-binding globulin, but myo-inositol was actually more effective in lowering triglyceride levels and had fewer side effects. (2)

An additional RCT published the same year also found similar effects of metformin and myo-inositol on body mass index (BMI), body composition, hormonal profile, metabolism of glucose and insulin, and levels of adiponectin, a hormone associated with increased fat burning. There were no significant differences between the two treatments in women with PCOS. (3)

What About Teens with PCOS?

A recent study focusing on lean teenagers with PCOS compared treatment with an oral contraceptive containing drosperinone/ethinyl estradiol with myo-inositol or a combination of the two. In this case, researchers found a differential benefit within two different age groups. For teens aged 13-16 years old, myo-inositol alone exhibited a significant decrease of weight and BMI, and an effective improvement in metabolic and hormonal parameters. This is helpful evidence for parents and providers of younger teens who may not desire or feel ready for hormonal contraceptives to manage PCOS symptoms.

In the older teenagers aged 17-19 years, myo-inositol treatment in combination with the oral contraceptive pill was found to be most effective for preventing increases in weight and BMI, and for improving the metabolic profile of the patients and the hormonal parameters analyzed. (4)

Could Inositol Improve Fertility in PCOS?

When it comes to fertility, the most comprehensive and controlled data collection occurs in the setting of assisted reproductive technology, specifically in vitro fertilization (IVF). Fortunately, we can extrapolate that the benefits found in such studies may extend to those seeking to become pregnant naturally as well.

While some studies have suggested that pretreatment with inositol may improve clinical pregnancy rates in women undergoing ovulation induction for intracytoplasmic sperm injection ICSI or IVF-embryo transfer [ET] (5), up until recently there has not been enough high-quality evidence of a benefit for sub-fertile women with PCOS undergoing IVF, when compared with standard of care (6). However, a new 2022 study suggests that 2g twice daily of myo-inositol is as beneficial as metformin 850mg twice daily in reducing the risk of ovarian hyperstimulation syndrome, and myo-inositol showed a significantly higher clinical pregnancy rate in PCOS women undergoing gonadotrophin-releasing hormone-antagonist cycles. (7)

Some reproductive endocrinologists have expressed concern that inositol may be inappropriate for women with non-classic PCOS or infertility who already have normal to low androgens, as these may be lowered further while using inositol. An adequate level of the androgens DHEA and testosterone are needed to maintain fertility as well as libido.

Metabolic Syndrome

The National Institutes of Health guidelines define metabolic syndrome as having three or more of the following traits: an increased waist circumference (greater than 35 inches for women and 40 inches for men); high triglyceride level; reduced high-density lipoprotein (HDL) cholesterol; increased blood pressure; and elevated fasting blood sugar. Metabolic syndrome is associated with greatly increased risk of developing diabetes, heart disease, and/or stroke.

Inositol has been researched for benefits on several of the diagnostic criteria for metabolic syndrome, including:

Lipid profiles: A large systematic review of RCTs found that inositol supplementation may result in an improvement in triglycerides, total- and low-density lipoprotein cholesterol levels, but did not affect HDL cholesterol levels among populations with metabolic diseases. (8)
Hypertension: Meta-analysis has indicated that supplementation with inositol significantly decreases both systolic and diastolic blood pressure in individuals with metabolic syndrome; this effect was most notable at a dose of 4000mg of inositol per day. (9)
Glucose homeostasis: In a separate analysis, inositol supplementation was observed to decrease blood glucose through improvement in insulin sensitivity independent of weight. (10)

Metabolic Syndrome in Menopausal Women

Menopause is associated with a redistribution of body weight and increased waist circumference, and after menopause women are at higher risk for cardiometabolic diseases including metabolic syndrome, type 2 diabetes, and cardiovascular disease.

In a study of 80 outpatient postmenopausal women affected by metabolic syndrome, women were randomly assigned to receive either myo-inositol 2g twice daily or placebo, in addition to a low-energy diet intervention. After 12 months of treatment, the myo-inositol group showed a significant improvement in serum glucose, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), triglycerides, total and HDL cholesterol, and blood pressure compared to the control group, although notably, BMI and waist circumference did not improve.

By the end of the study, eight women (20%) in the myo-inositol group no longer met the diagnostic criteria for metabolic syndrome, while in the control group, only one woman no longer had the metabolic syndrome after 12 months of diet. (11) This study highlights some key takeaways for providers and patients about both the difficulty of losing weight after menopause, and the fact that insulin resistance and metabolic syndrome can be improved or reversed anyway.

In part two of this blog, we will be discussing inositol supplementation and recent research in mood disorders.

References

Phosphatidylserine – Protection from the Effects of Chronic Stress

Mon, 02 Nov 2020 11:22:49 -0800

If one were to create a word cloud of our clinical consulting calls in 2020, the word “phosphatidylserine” would likely float to the center in a large, bold, brightly colored font. After a year spent coping with a global pandemic, record high unemployment, social distancing, and remote learning for students, accompanied by not only an extreme wildfire season but also a contentious presidential election in the U.S., people are stressed – and it shows.

At ZRT we are seeing plenty of patients with abnormal salivary cortisol profiles, absent, blunted or exaggerated cortisol awakening responses, and symptoms typical of both high and low cortisol.

Stress management techniques

At times (looking at you, 2020…) stressors may exceed our coping strategies, and it may be harder than usual to implement our ideal lifestyle changes.

When we talk with practitioners about managing cortisol, we of course emphasize lifestyle interventions such as stress management, relaxation practices, social supports, optimal nutrition and meal timing to keep blood sugar stable, healthy bedtime routines and adequate sleep. Under normal circumstances, these may be adequate to help many patients reestablish a normal cortisol level and circadian rhythm.

At other times (looking at you, 2020…) stressors may exceed our coping strategies, and it may be harder than usual to implement our ideal lifestyle changes. Once established, some symptoms of high cortisol can become self-perpetuating, including sleep disruption and abdominal weight gain. Poor sleep raises cortisol, and high cortisol disrupts sleep. Cortisol leads to abdominal weight gain, and that very same abdominal fat inactivates cortisol to cortisone, to reactivate later within the tissue, leading to more weight gain. Eventually chronically high cortisol leads to receptor downregulation within the Hypothalamic-Pituitary-Adrenal (HPA) axis, so that less cortisol is made in response to the body’s demands, and people begin to feel fatigued or “burned out”; yet at bedtime, the worries and overwhelm kick in, and cortisol remains higher than it would normally be during sleep, when it should be at its lowest point in the 24-hour cycle.

We call this the “wired and tired” phase of adrenal dysfunction, and this is when we may reach for phosphatidylserine (PS) to help break this cycle. PS may help blunt the highest cortisol peaks during prolonged stress and reduce elevated cortisol levels at bedtime to allow adequate restorative sleep.

What is phosphatidylserine?

Phosphatidylserine is a glycerophospholipid, an important component of cell membranes that is particularly abundant in the brain and nervous system. PS ensures nerve cell membrane fluidity – so important to its structure, and therefore function – and plays an integral role in neurotransmitter metabolism, nerve signal transmission and effective glucose utilization by the brain.

Phosphatidylserine has been studied since the early 1990s for its ability to promote a healthy endocrine response to an acute stressor, blunting serum ACTH and cortisol elevations in response to either emotional stress [1] or physiological stress induced by exercise [2]. In the fitness world, PS is appreciated for supporting exercise tolerance and reducing exercise-induced physiological stress. PS is thought to promote a desirable hormonal status for athletes by blunting increases in cortisol levels, effectively lowering the cortisol/testosterone ratio to support tissue repair and lean muscle building [3].

Effects of PS supplementation

Chronic PS supplementation has been found to promote a less stressed, more relaxed state and a subjective improvement in mood [4,5]. Some studies have combined PS with other nutritional supports, namely phosphatidic acid or omega-3 fatty acids, to good effect [6,7]. In one of these, omega-3 administered in combination with PS were found to have stress-reducing effects exclusively in highly chronically stressed adult males who showed a blunted cortisol response to the Trier Social Stress Test (TSST), the gold standard for evaluating the neurobiology of acute stress.

Chronic phosphatidylserine supplementation has been found to promote a less stressed, more relaxed state and a subjective improvement in mood.

If you’re curious like I was as to how researchers ethically and reliably provoke a predictable stress response in human subjects, the answer is: they administer a public speaking task in front of a non-responsive audience, with a surprise mental math challenge thrown in – a scenario that may sound all too familiar to some of today’s online instructors and learners. In the study’s lowest responders, treatment with omega-3 plus PS for 12 weeks seemed to restore the cortisol response to this challenge, and the researchers concluded that those with high chronic stress and/or a dysfunctional response of the HPA axis may benefit from omega-3 plus PS supplementation [6].

A similar effect was found for a soy-based PS/phosphatic acid complex (PA) at a dose of 400 mg PS and 400 mg PA per day in normalizing ACTH and salivary and serum cortisol in chronically high-stressed males, but not in low-stressed subjects, and there was no significant effect at a dose of 200 mg PS and 200 mg PA [7].

Phosphatidylserine for PMS

Initial research may have focused on men because they generally have a higher HPA axis response to the TSST [8]. But what about women? As a matter of fact, the cortisol-lowering effect of PS was also observed in a recent study of 40 women aged 18-45 years with a diagnosis of PMS [9]. After a baseline cycle, they were assigned to take either PAS (containing 400 mg PS and 400 mg PA per day) or a placebo over the course of 3 menstrual cycles. PMS symptoms as assessed by the DRSP total score showed significantly better improvement with PAS intake as compared to placebo. PAS-treated women also reported a greater improvement in physical and depressive symptoms, less reduction in productivity and less interference with relationships compared to the placebo group.

In addition, the salivary cortisol percentage increase of the CAR was significantly less pronounced in the follicular phase of cycle 4 than in that of cycle 1 for subjects taking PAS. Serum cortisol levels of PAS-treated females slightly decreased between visit 1 and visit 5, while cortisol levels in the placebo group increased. This study provided further confirmation that a daily intake of PAS, containing 400 mg PS and 400 mg PA, can be considered as safe [9].

Phosphatidylserine for cognitive support

In addition to its effects on cortisol, PS is also one of the most well-researched ingredients for cognitive support and has been shown to support attention, memory, learning and mental flexibility. Since 2003, PS has been granted a qualified health claim by the FDA, related to cognitive dysfunction and dementia in the elderly. This status allows labels to state "consumption of phosphatidylserine may reduce the risk of dementia and cognitive dysfunction in the elderly," but it must appear along with the disclaimer "very limited and preliminary scientific research suggests that phosphatidylserine may reduce the risk of cognitive dysfunction in the elderly. FDA concludes that there is little scientific evidence supporting this claim."

Phosphatidylserine is also one of the most well-researched ingredients for cognitive support and has been shown to support attention, memory, learning and mental flexibility.

A 2010 study in elderly Japanese subjects found that memory scores in PS treated groups were significantly increased, but only in subjects with low scores at baseline. This study specifically detected improvements in delayed verbal recall - a memory ability that begins to decline in the earliest stage of dementia [10]. As memory and cognitive function tend to be compromised in a setting of chronic stress and sleep deprivation, it’s a nice additional benefit to be aware of.

Doses of PS used in the above-mentioned studies have varied from 200 to 800 mg per day. Historically, PS was derived from bovine brain tissue, but that fell out of favor for obvious reasons related to prion disease transmission. These days, most PS supplements are derived from soy or sunflower lecithin or from cabbage.

Assessment of cortisol diurnal rhythms

In order to make the most appropriate recommendations for patients with suspected adrenal dysfunction, it is helpful to first assess cortisol diurnal rhythm. This can be done accurately and non-invasively by testing saliva and/or urine cortisol levels. ZRT Laboratory offers an Adrenal Stress profile that includes salivary cortisol upon waking, at noon, evening and at night before bed. CAR reveals a more detailed assessment of adrenal hormone and HPA axis dysfunction by measuring salivary cortisol upon awakening and at 2 additional timepoints in the first hour of the morning, followed by noon, evening, and night. ZRT’s Urine Metabolites Adrenal Profile provides insight into overnight levels of cortisol, cortisol excretion, and conversion to cortisone; this test is especially useful as a second step of testing patients with adrenal dysregulation symptoms whose salivary cortisol levels are normal.

Related Resources

The Role of Cortisol and Melatonin in the Synchronization of the Circadian Rhythm
Adrenal Stress Test Specialty
Urine Hormone Test Specialty

References

Practicing Gratitude for Ultimate Self-Care

Fri, 22 Nov 2019 13:49:58 -0800

In the U.S., the Thanksgiving holiday is upon us - a day traditionally set aside to gather, feast and give thanks. Aside from the holiday that reminds us to be thankful, gratitude in and of itself brings on powerful emotions of contentment, satisfaction, and resilience. There is an abundance of research on the benefits of spending even 5 minutes expressing, writing about, or meditating on gratitude on a regular basis. In fact, experts say expressions of gratitude can help fortify the foundation for our overall well-being and healthy relationships with others.

Gratitude is not only a feeling that arises following help from others, but also a habitual practice of appreciation and focus on the positive aspects of life. By intentionally shifting our attention, we can gradually change our perceptions, as what we focus on seems to expand.

In a holiday season rife with overindulgence, overspending and for some, social isolation or painful memories, gratitude helps bring perspective and balance. When we spend time practicing thankfulness to self and others, we generate hormones and neurotransmitters that help sustain positive emotions, protecting us from adversity and guiding healthier choices from a place of peace and strength.

In this post we will look at some of the demonstrated benefits of gratitude on health and well-being, and how to incorporate a gratitude practice into your self-care routine.

Gratitude May Help Reduce Stress and Depression

We can probably all agree that it is easiest to experience gratitude when things seem to be going smoothly. Yet the benefits may be greatest when we look for the positive in a stressful transition or health challenge. Two recent clinical trials demonstrated the benefits of a gratitude intervention for mental health during prenatal stress and chronic illness.

In a pilot randomized controlled trial conducted with 46 pregnant women, participants used an online mindfulness and gratitude intervention 4 times a week for 3 weeks. Measures of prenatal stress, salivary cortisol, gratitude, mindfulness, and satisfaction with life were completed at baseline, 1.5 weeks later, and 3 weeks later. Women who participated in the gratitude intervention demonstrated reduced prenatal stress in comparison to the control group, with significant reductions in waking and evening cortisol observed for intervention participants [1].

A separate study on the longitudinal associations of gratitude to psychological well-being in the context of two chronic illnesses (inflammatory bowel disease and arthritis) showed that gratitude uniquely predicted lower depression in these chronically ill populations [2].

A Gratitude Journal May Promote Physical Health, Well-being and Better Sleep

Keeping a gratitude journal resulted in participants reporting 16% fewer physical symptoms and 10% less physical pain.

According to the study Counting Blessings Versus Burdens [3], keeping a gratitude journal resulted in participants reporting 16% fewer physical symptoms, 10% less physical pain, 8% more sleep and 25% better sleep quality.

In a 2 week study of a gratitude intervention compared to a control of everyday events reporting, the gratitude group experienced increases in hedonic well-being, optimism and sleep quality, along with decreases in diastolic blood pressure. Improvements in subjective well-being were correlated with increased sleep quality and reductions in blood pressure, but there were no relationships with cortisol found in this study. This brief intervention suggests that subjective well-being may contribute to lower morbidity and mortality through healthier physiological function and restorative health behaviors [4].

More recent studies have shown that gratitude journaling may improve biomarkers related to heart failure morbidity, such as reduced inflammatory markers over time and increased parasympathetic heart rate variability (HRV) responses during the gratitude journaling task [5].

Practicing Gratitude Enables You to Take Better Care of Yourself

In the Counting Blessings Versus Burdens study [3], the gratitude journal group reported spending 19% more time exercising. Although that finding has yet to be replicated, a study of patients with post-acute coronary syndrome (ACS) did show that optimism and gratitude at 2 weeks post-ACS were associated with higher self-reported health behavior adherence and improved emotional well-being 6 months later [6].

Body Gratitude May Improve Your Body Image

Internalized weight bias and body dissatisfaction are associated with a number of negative psychological and physical health outcomes. A recent study examined the effectiveness of a body-focused gratitude intervention, delivered as a short writing exercise, as a strategy to reduce internalized weight bias and improve body image. Young adults were randomly assigned to either a body gratitude group or a control group. The gratitude group reported significantly lower weight bias internalization and significantly more favorable appearance evaluation, as well as greater body satisfaction when compared to the control condition. These effects were small and were not moderated by gender or BMI. These findings provide preliminary support for body-focused gratitude writing exercises as an effective individual-level strategy for reducing internalized weight bias and improving body image [7].

Gratitude May Help Expand Your Social Support

According to a recent headline, we are in the midst of a loneliness epidemic, and the health effects are as damaging as smoking 15 cigarettes per day.

According to a recent headline, we are in the midst of a loneliness epidemic, and the health effects are as damaging as smoking 15 cigarettes per day [8]. The good news is that studies suggest gratitude generates “social capital.” In other words, gratitude makes us nicer, more trusting, more social, and more appreciative. As a result, it helps us to make new friends, deepen existing relationships, and improve our marriages. It has been suggested that the positive effects of gratitude on physical health are significantly mediated by lower levels of perceived loneliness and stress. These findings are important, given the existing evidence that gratitude can be cultivated, and by buffering against stress and loneliness may improve somatic health symptoms [9].

Gratitude Can Enhance Your Financial Well-being

Gratitude has been shown to reduce economic impatience – that is, spending time feeling grateful for what you have helps you to save versus spend. In particular, individuals experiencing gratitude are more willing to choose delayed larger rewards over immediate smaller rewards, and display evidence of gratitude-induced changes in brain activity as measured by electroencephalogram [10].

Outward Expressions of Gratitude Improve Well-being for Both Parties

Expressing gratitude improves well-being for both expressers and recipients. However, expressers tend to systematically undervalue the positive impact of gratitude on recipients. Participants in 3 experiments wrote gratitude letters and then predicted how surprised, happy, and awkward recipients would feel. Compared to actual reports by the recipients, these predictions significantly underestimated how surprised recipients would be about why expressers were grateful, overestimated how awkward recipients would feel, and underestimated how positive recipients would feel. Underestimating the value of prosocial actions, such as expressing gratitude, may keep people from engaging more often in behavior that would maximize well-being for themselves and others [11].

Get Started with a Simple Gratitude Practice

A gratitude practice doesn’t need to take a lot of time to be effective. Writing a short list of 3 to 5 people, events, strengths or things you are grateful for, first thing in the morning or last thing at night, is enough to start or end your day in a peaceful and positive way. Collecting these in a dedicated journal allows you to look back over past days for inspiration.

If you aren’t feeling particularly grateful at first, that’s okay. Sit with your thoughts and dig a little deeper. If you are struggling with a problem, see if you can connect with gratitude for the resources you have at your disposal or a person you can count on to help you. If you are feeling a lack of abundance, begin by looking at what you do have and give thanks for that – even if that means just being thankful for the day.

If you have more time and are so inclined, consider a guided gratitude meditation to jump start your gratitude practice; there are plenty of options online, such as this 10-minute example. Writing a thank you letter to someone who has meant a lot to you is another way to practice gratitude; you can decide later whether to send the letter or not, but remember that expressing gratitude is good for both parties!

With time and practice, gratitude becomes habitual, and a lens through which we view the world. To kick start this season of gratitude, we at ZRT would like to thank the patients and health care providers who have helped us to grow and evolve over the past 21 years and 10 million tests. We wish you a holiday season full of peace, health and blessings to count.

Related Resources

References

[1] Matvienko-Sikar K, Dockray S. Effects of a novel positive psychological intervention on prenatal stress and well-being: A pilot randomised controlled trial. Women Birth. 2017;30:e111-e118.

[2] Sirois FM, Wood AM. Gratitude uniquely predicts lower depression in chronic illness populations: A longitudinal study of inflammatory bowel disease and arthritis. Health Psychol. 2017;36:122-132.

[3] Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. J Pers Soc Psychol. 2003;84:377-89.

[4] Jackowska M, et al. The impact of a brief gratitude intervention on subjective well-being, biology and sleep. J Health Psychol. 2016;21:2207-17.

[5] Redwine LS, et al. Pilot Randomized Study of a Gratitude Journaling Intervention on Heart Rate Variability and Inflammatory Biomarkers in Patients With Stage B Heart Failure. Psychosom Med. 2016;78:667-76.

[6] Millstein RA, et al. The effects of optimism and gratitude on adherence, functioning and mental health following an acute coronary syndrome. Gen Hosp Psychiatry. 2016;43:17-22.

[7] Dunaev J, et al. An attitude of gratitude: The effects of body-focused gratitude on weight bias internalization and body image. Body Image. 2018;25:9-13.

[8] Health Resources & Services Administration. The “Loneliness Epidemic”.

[9] O'Connell BH, Killeen-Byrt M. Psychosocial health mediates the gratitude-physical health link. Psychol Health Med. 2018;23:1145-1150.

[10] Patalano AL, et al. Gratitude intervention modulates P3 amplitude in a temporal discounting task. Int J Psychophysiol. 2018;133:202-210.

[11] Kumar A, Epley N. Undervaluing Gratitude: Expressers Misunderstand the Consequences of Showing Appreciation. Psychol Sci. 2018;29:1423-1435.

Ashwagandha: Ancient Medicine for Modern Adrenals

Fri, 11 Oct 2019 14:13:31 -0700

Over the past few years, dozens of Moon Milk recipes have appeared on various culinary and wellness blogs. These beautifully colorful and fragrant bedtime drinks are a trendy twist on the traditional Ayurvedic preparation of warm milk with an adaptogenic herb, usually Ashwagandha, given at bedtime to promote restorative sleep. Cow, coconut or nut milk may be used, and recipes often include other herbs to help promote sleep and alleviate stress, such as nutmeg, chamomile, skullcap or lavender. Variations range from a more traditional Golden Milk with turmeric and warming spices featured on Bon Appetit, to the beautifully fragrant Vanilla Rose Moon Milk, to the visually stunning Mermaid Latte made with blue matcha.

For over 3000 years, Ashwagandha has been used as a "Rasayana" or rejuvenator within Ayurvedic medicine, to promote youthful vigor, muscle strength and endurance

Moon Milk is just one way to take Ashwagandha (Withania somnifera), an Ayurvedic botanical medicine that is enjoying a renaissance for addressing the health issues that accompany chronic stress. For over 3000 years, Ashwagandha has been used as a "Rasayana" or rejuvenator within Ayurvedic medicine, to promote youthful vigor, muscle strength and endurance [1]. Similarly, in Western herbalism, Ashwagandha is valued as an adaptogen – an herbal modulator which can help restore hormone balance and healthy function in various body systems, but especially the adrenal glands, helping to promote stress resistance and energy throughout the day.

Ashwagandha has gained in popularity so much in recent years that, here in the Portland Metro area, we need not leave the urban growth boundary to find a farmer cultivating this herb in and around the city. In fact, it is one of the most frequently discussed botanicals among ZRT Laboratory’s Clinical Consultants on any given day, whether in the context of adrenal stress profiles, male and female hormone profiles, weight management or neurotransmitter testing.

Current clinical research largely supports the traditional uses of this plant in promoting a more “youthful” physiology in terms of stress resilience, hormone levels including cortisol, thyroid hormones, DHEA and testosterone, body composition, sexual function, memory and cognition. In this article, we will focus on recent randomized, double-blind, placebo-controlled studies supporting these stress-related health benefits of Ashwagandha:

Modulating Stress Response and Cortisol Levels

Stress is all too familiar to most of us as a state of mental or emotional strain or tension. The stress response is reflected in the body by an acutely elevated cortisol level which can be associated with agitation, irritability, anxiety, and sleep disturbances. Under ordinary circumstances, cortisol levels should return to the normal range within several hours following an acute stressor. However, if stressors persist, the brain and adrenal gland axis may become downregulated, and with significant enough hypothalamus-pituitary-adrenal (HPA) axis dysfunction cortisol levels may drop to normal and eventually low levels. Chronic stress over a prolonged period of time often leads to conditions such as weight gain in the waist, muscle and bone loss, depression, and immune suppression.

As an adaptogen, Ashwagandha is well-known for reducing stress and anxiety in humans. This effect was supported by a 2014 systematic review of 5 human trials which concluded that treatment with Ashwagandha resulted in significantly greater score improvements (than placebo) in outcomes on various symptom scales of stress and anxiety [2].

In addition to improving subjective symptoms of stress and anxiety, Ashwagandha may help regulate cortisol levels.

In addition to improving subjective symptoms of stress and anxiety, Ashwagandha may help regulate cortisol levels. Clinically and anecdotally, we observe Ashwagandha and other adaptogens to modulate both high and low cortisol levels and support a normal diurnal cortisol curve, which is highest in the morning upon waking and falls throughout the day, reaching the lowest cortisol level around midnight. Most clinical research has focused on Ashwagandha’s effect on down-regulating high cortisol levels and less on helping the adrenals raise cortisol levels when low. In one study, 64 subjects with a history of chronic stress were randomized to receive either 300 mg of Ashwagandha root extract, or a placebo twice daily for 60 days. Not only did the treatment group exhibit significant reductions in scores on all the stress-assessment scales, but their serum cortisol levels were also substantially reduced to within normal ranges relative to the placebo group [3].

Supporting Restorative Sleep

In a small study exploring the safety and tolerability of Ashwagandha in healthy volunteers, a significant percentage reported improved sleep quality [4]. There is currently a prospective, randomized, double-blind placebo-controlled study underway to examine the effects of Ashwagandha on nonrestorative sleep, which is often both a result of stress and a direct cause of high cortisol levels as the body attempts to cope with chronic sleep deprivation or poor sleep quality [5].

It’s Not Just Cortisol; Anxiolytic Effects via GABA Modulation

A 2018 review article identifies Ashwagandha as one of only a handful of phytomedicines able to modulate the activity of the neurotransmitter GABA to exert an anxiolytic (calming) effect. This effect was first demonstrated in animal models of anxiety, and later observed in human clinical trials on male fertility, in which Ashwagandha demonstrated GABA-mimetic activity [6].

Managing Weight Gain Related to Chronic Stress

Weight gain associated with chronic stress is a growing health concern, with over 70% of the adult US population now in the overweight and obesity BMI categories. Because of Ashwagandha’s anxiolytic effects and ability to improve serum cortisol levels, researchers conducted a study to assess whether it could also reduce hunger and stress-eating behaviors. A total of 52 subjects under chronic stress received either 300 mg of Ashwagandha or placebo twice daily. Primary efficacy measures were Perceived Stress Scale and Food Cravings Questionnaire. Secondary efficacy measures were Oxford Happiness Questionnaire, Three-Factor Eating Questionnaire, serum cortisol, body weight, and body mass index. Each subject was assessed at the start and at 4 and 8 weeks. The treatment group showed significant improvements in both primary and secondary measures, suggesting that Ashwagandha root extract may be a useful adjunct to other strategies for body weight management in adults under chronic stress [7].

Small studies suggest Ashwagandha may also help improve upper and lower-body strength and support a favorable body composition, and is associated with significant increases in muscle mass and when used in conjunction with a resistance training program in young, recreationally active men over a period of 8 to 12 weeks [8]. A higher proportion of lean muscle mass in turn helps to maintain a healthy metabolic rate.

Dosing and Considerations

In the studies mentioned above, Ashwagandha was typically given in doses of 250 to 600 mg/day, in two divided doses. It can be taken as a tea, tincture, powdered herb, or in capsules, and is generally well-tolerated with few side effects. Although Ashwagandha itself can be given at any time of day and even assist with restorative sleep, it is often found in combination formulas with other adrenal adaptogen herbs, bovine adrenal glandular material, vitamins C and B5, and other nutrients that are best dosed in the morning and at lunchtime to avoid overstimulation near bedtime.

Ashwagandha is most effective when combined with lifestyle measures to support healthy adrenal function and continued production of cortisol, including adequate sleep, proper diet with adequate protein and vitamins B and C, and stress management practices such as yoga and meditation. Before incorporating herbs like Ashwagandha into your routine, it is best to determine where you are out of balance. ZRT’s adrenal stress, weight management, sleep balance, and neurotransmitter testing can help you and your doctor pinpoint your imbalances to ensure optimal clinical outcomes. Enjoying a cup of Moon Milk or Ashwagandha tea as a part of a relaxing bedtime ritual may be the perfect way to help release the stresses of the day and prepare for a restful night – and to do it all again tomorrow. Sweet dreams!

Moon Milk Recipes Too Beautiful Not to Try:

Related Resources

References

[1] Mirjalili MH, et al. Steroidal lactones from Withania somnifera, an ancient plant for novel medicine. Molecules. 2009;14(7):2373-93.

[2] Pratte MA, et al. An alternative treatment for anxiety: a systematic review of human trial results reported for the Ayurvedic herb ashwagandha (Withania somnifera). J Altern Complement Med. 2014;20(12):901-8.

[3] Chandrasekhar K, et al. A prospective, randomized double-blind, placebo-controlled study of safety and efficacy of a high-concentration full-spectrum extract of ashwagandha root in reducing stress and anxiety in adults. Indian J Psychol Med. 2012;34(3):255-62.

[4] Raut AA, et al. Exploratory study to evaluate tolerability, safety, and activity of Ashwagandha (Withania somnifera) in healthy volunteers. J Ayurveda Integr Med. 2012;3(3):111-4.

[5] Deshpande A, et al. Study protocol and rationale for a prospective, randomized, double-blind, placebo-controlled study to evaluate the effects of Ashwagandha (Withania somnifera) extract on nonrestorative sleep. Medicine (Baltimore). 2018;97(26):e11299.

[6] Savage K, et al. GABA-modulating phytomedicines for anxiety: A systematic review of preclinical and clinical evidence. Phytother Res. 2018;32(1):3-18.

[7] Choudhary D, et al. Body Weight Management in Adults Under Chronic Stress Through Treatment With Ashwagandha Root Extract: A Double-Blind, Randomized, Placebo-Controlled Trial. J Evid Based Complementary Altern Med. 2017;22(1):96-106.

[8] Wankhede S, et al. Examining the effect of Withania somnifera supplementation on muscle strength and recovery: a randomized controlled trial. J Int Soc Sports Nutr. 2015;12:43.