Your Guide to Simple Zone Meals
The secret to the Zone diet is reducing insulin resistance to achieve a better hormonal balance from your diet. This starts with having adequate protein at each meal. Protein is critical for success; you need a certain amount at each meal to induce satiety. That amount is approximately 30 grams of low-fat protein per meal. However, that amount of protein must still be balanced by the appropriate amount of carbohydrates to reduce insulin resistance. Then you add a dash of high-quality fat for flavor. The Ideal Balance of a Zone Meal A Zone meal should contain approximately 400 calories to help stabilize blood sugar. Those 400 calories should contain at least 30 grams of protein, less than 12 grams of fat, and about 40 grams of net carbohydrates (total carbohydrates minus fiber) primarily from low-glycemic choices. Carbohydrates choices should ideally be rich in fiber and high in polyphenols to achieve better hormonal balance in the blood. If you can go 4-5 hours without hunger after a meal, you know that meal had the optimal Zone balance. Your Guide to Making Zone Meals Here we will take you through simple ways to make Zone meals. Every Zone meal starts with adequate protein for superior appetite control. The better the quality of your choices, the faster you will reduce insulin resistance. Here are some general tips for a Zone meal. Start with Protein (approximately 30 grams per meal) Your goal is to get about 30 grams of high-quality protein at each meal. Add Carbohydrates If you are making classic Zone meals, you want to add sufficient low-glycemic carbohydrates (such as non-starchy vegetables) to balance the protein at a meal. Low glycemic means the carbohydrates from these sources enter the blood as glucose at a slower rate. Protein is more uniform in its density, whereas carbohydrates are not. Non-starchy vegetables have a low carbohydrate density, meaning you must consume many more of these carbohydrates to get the same amount of glucose entering the blood as in a much smaller portion of starchy vegetables or grains. Here is an estimate of the portion size of each type of carbohydrate to get about 40 grams of net carbohydrates per meal. Best carbohydrate choices for a Zone meal These carbohydrates enter the blood as glucose slowly and are the best to reduce insulin resistance. If you are using Zone PastaRx as your protein choice, you will only need to add 1 ½ to 2 cups of cooked vegetables to provide approximately 40 grams of carbohydrates at a meal to balance your protein intake. The best choices for non-starchy vegetables would be the ABCs (asparagus, artichokes, broccoli, cauliflower, and spinach), as they have a better protein-to-carbohydrate ratio than other vegetables. Less desirable carbohydrate choices These carbohydrates are less desirable as they enter the bloodstream as glucose at a faster rate and will not be as effective in reducing insulin resistance. However, if you want to use these carbohydrates to replace one quarter of the preferred carbohydrate choices for a Zone meal, here are the levels you can use (choose only one). You can also see that trying to balance your protein portion at a Zone meal using more than these fractions of fruits, whole grains or starchy vegetables will have a decreased effect on reducing insulin resistance because they rush into the blood as glucose at a much faster rate than preferred non-starchy vegetables. Poor carbohydrate choices include white carbohydrates (bread, pasta, rice, and potatoes) as they contain no polyphenols (that’s why they are white) and enter the blood quickly as pure glucose, thus increasing insulin resistance. Therefore, these carbohydrates should not be part of the diet for anyone with a higher level of insulin resistance. On the other hand, the use of Zone PastaRx as a rice or pasta replacement has been shown in clinical trials to reduce insulin resistance. Add Fat The last thing you add to your meal is fat. However, just enough for improved taste because too much fat provides excess calories that will slow down your rate of reducing insulin resistance. You only need one portion of fat per meal providing about 12 grams. Putting It Together A typical Zone meal should supply about 30 grams of protein, approximately 40 grams of carbohydrates, and about 12 grams of fat. This gives you a protein-adequate meal with moderate levels of low-glycemic carbohydrates and low amounts of healthy monounsaturated fat providing approximately 400 calories per meal. The result of that balance is a lack of hunger or mental fatigue for the next five hours because of better hormonal control of satiety and improved blood sugar levels. When To Eat Your Zone Meals Here is the basic science behind meal timing: Eat your first Zone meal within an hour after waking up. Consume three Zone meals of equal calories to control hunger throughout the day. Each Zone meal should contain about 30 grams of protein. Eat your protein first at every meal to maximize hunger suppression. Eat your last Zone meal before sunset or at least four hours before bed. Your metabolism is controlled by circadian rhythms determined by sunlight, meaning you want to spread your calorie intake evenly throughout the daylight hours. Your goal is to work with your metabolism to reduce insulin resistance, not against it.
The Zone Diet versus the Mediterranean Diet
For the past six years, the Mediterranean diet has been voted the Best Diet in America as well as the best diet to manage diabetes. It’s remarkable since no one can define the Mediterranean diet. No one knows how many calories you should consume each day or how many grams of protein or fat should be consumed daily on the Mediterranean diet. There is also no distinction between low-glycemic or high-glycemic carbohydrates, protein-to-carbohydrate balance, etc. It certainly doesn’t give a strong feeling of robust science for the best diet in America as I pointed out in my book, The Mediterranean Zone (1). Furthermore, the initial results indicating the breakthrough of the Mediterranean diet published in 2013 had to be retracted and republished because of severe methodological problems in the study (2). Nonetheless, the lack of good science doesn’t prevent the Mediterranean diet from being consistently voted the top diet for general health and diabetes management for the past six years. A new study presents much more controlled research that can be used to compare the benefits of the Mediterranean diet to the Zone diet (3). The study was a direct head-on comparison to the Zone diet, so it was a “winner take all.” The study was conducted in a metabolic ward in an Italian hospital where all the food was provided to the subjects. The subjects also had significant insulin resistance (HOMA-IR > 4). Since the subjects were confined to the hospital, their dietary intake was tightly monitored. The control group received a calorie-restricted Mediterranean diet (500 calories less than needed to maintain their current weight) consisting of 55 percent carbohydrates, 20 percent protein, and 25 percent fat. The active group had the same level of calorie restriction but it was composed of 40 percent carbohydrates, 30 percent protein, and 30 percent fat. Although the authors cite this higher protein diet as a “high-protein Mediterranean diet,” it was identical to the Zone diet I described in 1995 (4). Furthermore, it was a crossover study since halfway through the study, the diets the subjects were consuming were switched after ten days to reduce any potential impact of individual metabolic characteristics of the subjects on the results. The Results The Zone diet demonstrated superior insulin resistance and hyperinsulinemia reductions compared to the Mediterranean diet. But there is more. The Zone diet also reduced the variability of blood glucose levels, indicating better hormonal stability between meals than the Mediterranean diet. This result was hardly new since Harvard investigators reported similar results after a single Zone meal compared to an isocaloric meal containing a higher level of carbohydrates and a lower level of protein in 1998 (5). In addition, the Zone diet is the primary dietary program used by the Joslin Diabetes Research Center at Harvard Medical School for treating type 2 diabetes. The reason is that the Zone diet is defined and, more importantly it works (6-9). So why don’t you hear more about the Zone diet in the medical research literature? I think the primary reason appears to be that the researchers wish to believe they came up with the idea of the macronutrient balance of the Zone diet all on their own, even though the Zone Diet was granted a U.S. patent for the treatment of hyperinsulinemia and insulin resistance in 2000 (10). Furthermore, since more than six million books on the Zone diet have been sold in the United States since the publication of The Zone in 1995, it is not that no one has ever heard of the Zone diet. Another problem is understanding the underlying metabolic problem that causes what is loosely termed “insulin resistance. “ It’s insulin resistance that causes weight gain and diabetes. However, insulin resistance can be best understood as a general term to describe the disruption of your metabolism. Furthermore, insulin resistance is associated with many other chronic disease conditions other than obesity and type 2 diabetes. These other chronic diseases include heart disease and Alzheimer’s. However, the most likely molecular cause of insulin resistance is the inhibition of the master regulator of metabolism known as AMPK (11). To optimally activate AMPK, you need a dietary triad consisting of the calorie-restricted Zone diet coupled with adequate intakes of omega-3 fatty acids and polyphenols. This is the Zone Nutritional System. Each of these nutritional interventions works synergistically with each other to increase AMPK activity. Any single intervention is good but using all three simultaneously is powerful. The molecular mechanisms of their interactions are complicated, but nutrition is always more complex than simple pharmacology. References Sears B. The Mediterranean Zone. Ballantine Books. New York, NY (2014) Estruch R et al. “Retraction and Republication: Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N Engl J Med 2013;368:1279-90 Retraction of Publication.” N Engl J Med. 378:2441-2442. doi: 10.1056/NEJMc1806491. (2018) Tettamanzi F et al. “A high-protein diet is more effective in improving insulin resistance and glycemic variability compared to a Mediterranean diet: A cross-over controlled inpatient dietary study. Nutrients 13:4380. doi: 10.3390/nu13124380. (2021) Sears B. The Zone. Regan Books. New York, NY (1995) Ludwig DS et al. “High glycemic index foods, overeating, and obesity.” Pediatrics 103:E26. doi: 10.1097/00008480-199908000-00005. (1999) Giusti J and Rizzott J. “Interpreting the Joslin Diabetes Center and Joslin Clinic clinical guideline for overweight and obese adults with type 2 diabetes.” Curr Diab Report 6:405-408. doi: 10.1007/s11892-006-0014-y. (2006) Hamdy O. “Diabetes weight management in clinical practice—the Why Wait model,” US Endocrinology 4:49–54. doi.org/10.17925/USE.2008.04.2.49. (2008) Hamdy O. and Carver C. “The Why WAIT program: improving clinical outcomes through weight management in type 2 diabetes.” Curr Diab Rep 8:413-420. doi: doi: 10.1007/s11892-008-0071-5. (2008) Hamdy O. et al. “Long-term effect of intensive lifestyle intervention on cardiovascular risk factors in patients with diabetes in real-world clinical practice: a 5-year longitudinal study.” BMJ Open Diabetes Res Care 5:e000259. doi: 10.1136/bmjdrc-2016-000259. (2017) Sears, B. “Method of and nutritional and pharmaceutical compositions for reduction of hyperinsulinemia.” U.S. Patent No. 6,140,304 (2000) Sears B and Saha A. “Dietary activation of AMP-activated protein kinase (AMPK) to treat insulin resistance.” Evolving Concepts in Insulin Resistance doi: http://dx.doi.org/10.5772/intechopen.103787. (2022)
Q&A with Dr. Sears: Anti-Inflammatory Diets
Learning more about anti-inflammatory diets and AMPK can be a bit confusing. Luckily, Dr. Sears is here to provide valuable insights and answer your questions about these topics. In this blog, you'll get access to his Q&A session and learn more about how to achieve a healthier lifestyle through an anti-inflammatory diet and the importance of AMPK. So, let's jump right in and find out how these can help you create a healthier version of yourself!Q. What is an anti-inflammatory diet?A. The best definition of an anti-inflammatory diet is one that reduces insulin resistance. Insulin resistance is a general term for a disrupted metabolism caused by inflammation. Insulin resistance can be quantified by a blood test known as HOMA-IR. If the levels of HOMA-IR are less than one, then whatever diet you follow is an anti-inflammatory diet. Less than 1 percent of Americans have a HOMA-IR level of less than one. Q. What are the benefits of following an anti-inflammatory diet? A. Although an anti-inflammatory is defined as one that reduces insulin resistance, the real benefit is the activation of AMPK, which is the master regulator of metabolism in each of your nearly 40 trillion cells. It is inhibition of AMPK that is the driving force for the development of obesity, diabetes, heart disease, Alzheimer's, and many other chronic diseases. If you have no insulin resistance (your HOMA-IR is less than one), that is your surrogate marker that AMPK is optimized and your likelihood of developing many chronic diseases is dramatically reduced. Q. How can chronic inflammation affect your health?A. Chronic inflammation decreases the activity of AMPK which controls your metabolism. It is the efficiency of your metabolism that is required to supply energy to the cell, reduce the excess production of inflammatory mediators, like eicosanoids and cytokines, and repair damaged tissue. Q. How can you activate AMPK?A. There are three distinct dietary pathways to activate AMPK. These would include omega-3 fatty acids and polyphenols that are usually deficient in American diets, and the Zone Diet which is a highly defined anti-inflammatory calorie-restricted diet designed to activate AMPK. Anyone of the three is good, but they are highly synergistic when they are all working together. (You may also like: Everything you need to know about the Zone Diet)Q. What foods are pro-inflammatory?A. It is excess calories and too much glucose that will increase inflammation and inhibit AMPK activity. Consuming too many omega-6 fatty acids (e.g., corn oil, safflower oil, soybean oil) and palmitic acid (e.g., palm oil, meat, butter) will also induce inflammation and reduce AMPK activity.Q. Can you share some quick tips on how to adapt an anti-inflammatory diet to your specific needs/preferences? A. You need to consume omega-3 fatty acids, polyphenols and follow the Zone Diet, and simultaneously reduce your intake of foods known to promote inflammation like omega-6 fats. There are hundreds of recipes and helpful tips at www.ZoneLiving.com. The decrease in your HOMA-IR levels will be the clinical indication of your success. The subjective markers are reductions in excess body fat and greater physical and mental energy. Do this for lifetime, and you get healthy aging. Q. How Easy Is It To Measure AMPK activity and HOMA-IR?A. Measuring AMPK activity is incredibly difficult since it never leaves the cell. Therefore, you need a tissue sample to measure its activity. Fortunately, it is very easy to measure HOMA-IR. All you need is your fasting glucose and insulin levels and you put them into a simple equation. If your HOMA-IR is less than one, then your future is bright. If your HOMA-IR is greater than 2, your future is bleak. The average HOMA-IR of non-diabetic Americans is 2.7. However, it’s future you can rapidly change by following an anti-inflammatory diet. Have more questions for Dr. Sears? Drop them in the comments below!
DIY Zone Friendly Taco Night
There is a reason Taco Tuesday is popular because what is not to love about a good taco and all the sides that come with it. This is one night you can minimize the calories of eating out and do it all yourself. Did you know Mexican cuisine is Zone friendly since it focuses on lean protein, lots of vegetables, salsas, and sauces? Even though the menu options go beyond tacos, one of the best things about making this part of your weekly routine is that it is great for picky eaters since there are so many options to choose from. Plus if you like to entertain, a DIY Taco night is colorful and flavorful, easy to make, and a crowd-pleaser especially if you have a lot of dietary considerations; low-carb, vegetarian, gluten-free, kid-friendly! HOW TO MAKE YOUR OWN TACO NIGHT Pick Your Protein Every Zone meal starts with lean protein so it makes sense this should be one of the focal points of your taco night, next to veggies of course. Grass-fed beef, grilled chicken, fish or Zone Orzo for a vegetarian option make for great choices. Don't forget to spice things up with cumin, chili powder, paprika, lime, or other seasonings of your choosing. Pick Your Carbs Veggies The ideal way to taco night would be to go with the taco salad. This is not the huge salad that sits inside a fried taco shell. This would be having your protein, veggies, and sides sitting on a bed of romaine or other greens. Whether you go with the taco salad or not, don't forget to add the veggies to your meal. Red onion, peppers, tomatoes, pico de galo, and lettuce make for great additions. Stachy Carbs: You can still enjoy tacos in a shell or wrap in the Zone but choose shells that have minimal ingredients (e.g. Trader Joes Taco Shells) and go for the small corn tortillas instead of the burrito size wraps. Just be mindful of the amount of starchy carbs. Two corn shells are a little over one Zone carbohydrate block and 2 small corn tortillas are about 2.5 carbs blocks in the Zone. Don't forget beans and Zone orzo also contribute to your carb allowance. Pick Your Fats Guacamole is the perfect complement to a taco or fresh avocado with a drizzle of olive oil dressing makes for a delicious salad. Just remember to keep your fats to primarily monounsaturated choices and if you want to use cheese or sour cream go for low-fat options and watch your portions. Make Your Own Taco Bar Have Your Pick- Taco Salad or Taco Shells Chopped Romaine/Greens or Corn Tortillas (Soft or Hard- be mindful of carbs) Stuff It Grass-Fed Beef, Grilled Chicken, Fish, Zone Orzo Top It Salsa, Guacamole, Lettuce, Pico de Galo, Red Onion, Peppers, Tomatoes, Low-fat Cheese, Low-Fat Sour Cream Side It Black beans, Tossed Salad, Zone Orzo You Might Also Like: Mexican Food Survival Guide Tell us if you like tacos as much as we do and what your favorite fixings are below.
Brain Boosting Foods
The foods we eat have a powerful impact on our cognitive performance. Everyone has those moments where it takes a bit longer to recall someone’s name, the location of our cell phone or car keys, or that feeling of being scattered and unfocused. There are various reasons this can happen, but as we age these moments become concerning that it could turn into something more. The good news is that our diet can be a powerful tool in helping to preserve and improve our memory and concentration. Imbalances in dietary fat intake, intake of inflammatory foods, or not getting enough fruits and vegetables all can increase the level of oxidative stress and inflammation in the body, thus impeding cognitive performance(1). Below are 7 brain boosting foods that have been clinically shown to improve cognitive health. See how your diet stacks up. Fatty Fish: Salmon, mackerel, sardines, and anchovies are fatty fish rich in omega-3 fatty acids, especially EPA and DHA. We know that omega-3s play a critical role in helping to reduce and resolve inflammation, stressing the importance of getting enough through the diet. Most of us don't get enough EPA and DHA. A recent study in the Journal Nutrients showed that a diet rich in omega-3 fatty acids, specifically DHA, may play a role in the development of Alzheimer’s disease, especially in those who carry the ApoE4 gene (2). In the study, those who had the highest blood levels of DHA were 49% less likely than those with the least amount to develop Alzheimer’s Disease. If you think your intake of fish is falling short, it might be time to consider supplementation. Berries: Berries are rich in polyphenols which are known for their antioxidant and anti-inflammatory benefits. The polyphenols in berries have been shown to help modulate signaling pathways involved in inflammation and cell survival. They offer protection to the brain by helping to prevent age-related neurodegenerative diseases while improving motor and cognitive functions (3). Leafy Greens: Did you know just one serving of leafy greens per day has been shown to slow age-related cognitive decline? Consumption of green leafy vegetables and foods rich in phylloquinone, lutein, nitrate, folate, α-tocopherol, and kaempferol may be responsible for these benefits (4). It doesn’t take much to reach one serving. It could be 1 cup of raw arugula or mesclun greens of ½ cup cooked of collards, kale, or spinach. Walnuts: Walnuts help reduce inflammation and oxidative stress. They do this by reducing free radical formation and boosting antioxidant defenses, minimizing lipid and protein damage in the brain (5). Extra Virgin Olive Oil: The Mediterranean Diet has long been praised for its health benefits especially when it comes to brain health. Extra Virgin Olive Oil is a main component of this eating plan to which many of its benefits come from its phenolic compounds. One of the primary phenolic compounds in EVOO has been shown to have a positive impact on delaying cognitive decline in older adults (6). It’s important when consuming olive oil to make sure you choose one that is minimally processed and less refined like Extra Virgin Olive Oil. This ensures it retains the highest level of phenols. Cocoa: Studies have shown that consumption of cocoa, especially cocoa flavanols, can help reduce insulin resistance, improve blood flow, cognition and reduce inflammation through its antioxidant and anti-inflammatory properties. Shortly after consumption, studies have shown cocoa can help increase cerebral blood flow and oxygenation. In young adults, continuous consumption has been shown to improve cognitive performance and increase levels of neurotrophins (7). Herbs and Spices: Herbs and spices have been used for centuries for their medicinal purposes. Since they are rich sources of polyphenols they are a great way to gain the most health benefits out of the foods you eat. There are numerous studies on the benefits of spices and brain health, but cinnamon in particular, which is a spice that is easy to incorporate into foods, has been shown to enhance memory and make poor learners into good learners (8). High levels of free radicals and oxidative stress play a critical role in cognitive performance and the onset of many neurological conditions. This is where the intake of anti-inflammatory foods rich in omega-3s and polyphenols plays an essential role in brain health. These foods help to scavenge and neutralize free radicals and restore balance to our cells. References: Spencer, S.J., Korosi, A., Layé, S. et al. Food for thought: how nutrition impacts cognition and emotion. npj Sci Food 1, 7 (2017). Sala-Vila A, Satizabal CL, Tintle N, Melo van Lent D, Vasan RS, Beiser AS, Seshadri S, Harris WS. Red Blood Cell DHA Is Inversely Associated with Risk of Incident Alzheimer’s Disease and All-Cause Dementia: Framingham Offspring Study. Nutrients. 2022; 14(12):2408. Subash S, Essa MM, Al-Adawi S, Memon MA, Manivasagam T, Akbar M. Neuroprotective effects of berry fruits on neurodegenerative diseases. Neural Regen Res. 2014 Aug 15;9(16):1557-66. Morris MC, Wang Y, Barnes LL, Bennett DA, Dawson-Hughes B, Booth SL. Nutrients and bioactives in green leafy vegetables and cognitive decline: Prospective study. Neurology. 2018 Jan 16;90(3):e214-e222. Chauhan A, Chauhan V. Beneficial Effects of Walnuts on Cognition and Brain Health. Nutrients. 2020 Feb 20;12(2):550. Klimova B, Novotný M, Kuca K, Valis M. Effect Of An Extra-Virgin Olive Oil Intake On The Delay Of Cognitive Decline: Role Of Secoiridoid Oleuropein? Neuropsychiatr Dis Treat. 2019 Oct 29;15:3033-3040. Journal Martín MA, Goya L, de Pascual-Teresa S. Effect of Cocoa and Cocoa Products on Cognitive Performance in Young Adults. Nutrients. 2020;12(12):3691. Published 2020 Nov 30. doi:10.3390/nu12123691 Modi KK, Rangasamy SB, Dasarathi S, Roy A, Pahan K. Cinnamon Converts Poor Learning Mice to Good Learners: Implications for Memory Improvement. J Neuroimmune Pharmacol. 2016 Dec;11(4):693-707.
Dr. Sears Answers Your Questions On Protein and Protein Powder
The global market for protein supplements is anticipated to rise 8.5% by 2030. This increased demand is widely due health-conscious individuals, fitness go-ers, and millennials looking to add more balance to their diets. In this blog, Dr. Sears covers some basic questions on protein and then gets into protein powders and what you need to know. Q. How much protein do you need each day? A. It depends on your lean body mass and your level of physical activity. The reason you need protein is to maintain and repair damaged muscle tissue. If you are an active athlete, you will have more muscle mass, and your training will damage your existing muscle. Therefore, these individuals are going to need more protein. On the other hand, the average American male needs about 110 grams of protein per day, and the average American female requires about 90 grams per day. That amount of protein should be spread out throughout the day. This means you should eat no more protein at a meal than can fit on the palm of your hand. That’s about 3 ounces of protein for a female and 4 ounces for a male. Q. What are the primary nutritional differences between animal protein versus plant protein? A. Of the 20 amino acids in any protein source, only nine are essential. This designation is because essential amino acids can’t be synthesized by the body and must be supplied by the diet. Animal protein has a complete range of amino acids, whereas plant protein is usually deficient in some essential amino acids. Q. Does protein build muscle mass? A. To help with muscle growth, you need adequate protein in the diet and weight-bearing exercise.Simply consuming more protein doesn’t build muscle. Exercise causes muscle damage and this stimulates new muscle formation to replace the muscle that has been damaged. The higher the intensity of exercise, the more protein you need. Q. Does protein increase satiety? A. A benefit of adequate protein consumption is that it increases satiety. It does this by releasing hormones from the gut that go directly to the brain to stop hunger and by increasing the release of the hormone glucagon from the pancreas to stabilize blood sugar levels. This lack of appetite is why you want to consume adequate protein at every meal, especially breakfast. Q. Can you consume too much protein? A. The answer is yes. Of the nine essential amino acids, three are branched-chain amino acids. These amino acids are leucine, isoleucine, and valine, and these have the most significant effect on stimulating muscle development by activating the gene transcription factor called mTOR. High levels of mTOR are associated with insulin resistance, eventually leading to many chronic diseases such as diabetes and cancer. Q. Is there a connection between mTOR and AMPK? A. The more you activate mTOR, the more you inhibit your master regulator of metabolism known as AMPK. Low levels of AMPK activity ultimately cause insulin resistance. As a result, you want to keep your protein consumption in a zone; not too high but not too low. With this as a background, let’s talk about using protein powder to ensure you get enough protein to maintain your muscle mass but not too much to inhibit AMPK. Q. What are the benefits of using protein powder? A. Many of our meals, especially breakfast, can fall short on protein. If you are over the age of 50, you are likely not getting enough protein in your day. Protein is vital as we age since older adults are prone to losing muscle mass, resulting in loss of strength and function. Protein powder can help fill in the gaps when intake falls short. Isolated protein powder can also help balance out excess carbohydrate intake to provide a better hormonal response at meals generating stable blood sugar levels and hence greater satiety between meals. Q. Can protein powder help with weight management? A. It can as it helps to create satiety and minimize cravings. Q. How should protein powder be used? A. It should be used as an additive to carbohydrate-rich meals. For example, adding protein powder to oatmeal provides a superior meal compared to oatmeal alone, or adding protein power to a fruit smoothie will give excellent appetite suppression. Q. Can you use protein powder daily and is there a better time of day to use it? A. Yes, you can use protein powder daily as long as you don't exceed your daily protein requirements. Breakfast is probably the best meal to use it since that meal is most likely to contain excess carbohydrates relative to protein. Q. Who should use protein powder? A. Anyone who does not feel they are getting enough protein in a meal. Q. How do you know if it’s right for you or working? A. Your best indicator is the increasing lack of hunger after a meal. Q. Are there any negatives to using protein powder? The key with protein powder is making sure you do not consume too much relative to the rest of your meal. I generally tell people to aim for a total of 25 grams of protein at each meal and about 7-14 grams at each snack. This takes into account all of the sources of protein at each meal and a good gauge to know how much to consume. You do want to pay attention to the quality of the amino acids in the protein powder you choose. Some sources such as collagen are very poor in essential amino acids and therefore would not be recommended. Q. What type of protein powder is best, and what ingredients should you look for? A. I think dairy protein powders are best, but recommend looking for ones that are lactose-free. Plant-based protein sources such a soy or pea don't have the taste of dairy-based protein powders, but can be used for those who avoid dairy. All protein powders are superior to collagen protein which is highly deficient in essential amino acids. Have more questions for Dr. Sears? Drop them in the comments below!
Dr. Sears Answers Your Weight Loss and Plant Based Questions
From Weight Loss to Plant Based, Dr. Sears is answering your questions. See some of the latest customer submitted questions and what Dr. Sears has to say in his latest blog. Q: What would you say are some of the most common dieting mistakes that make it harder to lose weight? A: The biggest mistake is not addressing the underlying cause of weight gain which is increased insulin resistance. Reducing insulin resistance requires a different dietary strategy than simply reducing calories. You have to activate the master regulator of metabolism which is AMPK. To do so cutting back on calories has to be supplemented with omega-3 fatty acids and polyphenols, both of which activate AMPK. The combination of the three dietary strategies is the best long-term way to reduce insulin resistance. Q: How do these habits make weight loss difficult or lead to weight gain? A: Getting adequate levels of omega-3 fatty acids will likely require supplementation. Getting adequate levels of polyphenols will require consuming far more non-starchy vegetables and fruits than most Americans currently do. Alternatively, one can use polyphenol extracts. Q: What tips can you offer for breaking these habits/creating healthier ones? A: Realize that reducing calories must be followed on a lifetime basis to be successful. Adding omega-3 fatty acids and polyphenols can increase dietary compliance by their activation of AMPK. This supplementation with omega-3 fatty acids and polyphenols will not only burn fat faster but also reduces insulin resistance which is the underlying cause of weight gain in the first place. Q: What are the best metabolism-boosting foods to put on your plate every day? How do these foods help boost your metabolic rate? How can this help aid weight loss? A: The cause of a slow metabolism is a condition known as insulin resistance. The molecular mechanism of insulin resistance is the inhibition of AMPK, which is the master regulator of metabolism in every cell. To speed up metabolism, you must activate AMPK. One class of nutrients that activates AMPK are polyphenols. These are found in low concentrations in fruits and vegetables. The more colorful the fruits (like berries) or vegetables (like artichokes) the more polyphenols. Unfortunately, you need to consume about 10 servings of such polyphenol-rich fruits or vegetables per day to get enough to activate AMPK. However, any AMPK-activating properties of polyphenols can be inhibited by consuming excess calories or glucose. So, to speed up your metabolism, you need to consume a calorie-restricted diet low in low in starches (bread, pasta, rice, and potatoes), and rich in fruits and vegetables. Q: More and more people are going plant-based for various reasons whether it’s health, animal welfare, trying to reduce the carbon footprint etc. A recent study showed that a diet rich in healthy plant-based foods may lower the risk of breast cancer but not if that diet is high in unhealthy foods, particularly juice and chips. What are your thoughts on plant-based diets and how they may impact cancer risk? A: A plant-based diet is lower in branched-chain amino acids. Branched chain amino acids can activate the gene transcription factor mTOR which promotes tumor growth, so moderating your intake of branch chain amino acids can help minimize cancer risk. As this study points out, it makes no sense to consume a plant-based diet rich in unhealthy foods. Foods rich in processed carbohydrates are high in glycemic carbohydrates which promote insulin secretion and can activate the IGF-1 pathway that also activates mTOR. Since cancer can be considered an inflammatory disease, you must follow an anti-inflammatory diet to have the maximum effect on reducing cancer development. Such a diet is calorie-restricted but rich in omega-3 fatty acids, and polyphenols all of which activate AMPK that inhibits mTOR in addition to optimizing immuno-metabolism to better eliminate cancer cells. Q: For vegetarians it’s a bit easier to find non-animal protein sources but for vegans trying to find adequate protein sources that are low-glycemic can be challenging. Which sources do you recommend? A: I think the better choices for vegans that are lower glycemic are tofu, tempeh, seitan and for those trying to minimize soy intake, supplementing with a pea protein powder. Also increasing intake of higher protein vegetables like asparagus, broccoli, Brussel sprouts, cauliflower, and mushrooms to name a few can aid fewer carbohydrates to your meal in addition to being great sources of fermentable fiber and polyphenols. Have more questions for Dr. Sears? Drop them in the comments below!
Scrumptious Asparagus
Asparagus is loaded with essential vitamins and minerals. Even more important in my opinion, it’s rich in fermentable fiber. Eating a variety of non-starchy vegetables and fruits, specifically those known to be high in fermentable fiber, adds to the diversity of bacteria in the gut which gives many health benefits. You can read more about this in “The Resolution Zone” by Dr. Barry Sears. What we know: Asparagus is actually the shoot of a perennial flowering plant. In years past it was typically harvested in the spring but it’s now available fresh all year round. I was surprised to learn recently that one asparagus plant can produce shoots for approximately 20 years. I’ve included some tips here and a couple of easy delicious ways to enjoy asparagus. Both of these dishes can be put together in 10 minutes or less. Think of them as starting points rather than recipes. The asparagus is the star of the show here. Feel free to make these dishes your own by changing up the flavors and spices you add. There’s no right or wrong way. Have fun with it! Tips for fresh asparagus Store as you would cut flowers by trimming off the end and standing it up in a glass or jar containing about an inch of water. Cover the top with plastic and it will keep in the refrigerator for up to four days. Wash with a quick rinse under cold running water and pat dry with a towel. Before using remove the tougher woody part at the lower end of the stalk. Scrumptious Raw Asparagus Salad This one’s got a lot of crunch, a little heat, and a fresh bright flavor. I make it all on a large cutting board for easy cleanup. To turn it into a meal, add some lean protein on the side and a bowl of strawberries for dessert. Method: Bunch the raw asparagus shoots together on a large cutting board and chop on a slant. I prefer thin shoots cut into small bite-sized pieces. Sprinkle desired amounts of freshly ground black pepper, sea salt, red pepper flakes, and finely grated Parmesan onto the asparagus. Add some roughly chopped walnuts, toasted if you like. Zest some lemon with a Microplane (yellow skin only, not white) and add it on top. Squeeze fresh lemon juice on top of it all and drizzle with olive oil. Give it a quick toss lightly on the board with one hand. Using a spatula transfer it to a serving plate. Balsamic Asparagus, Feta, and Cherry Tomatoes with Zone Orzo This dish came together several years ago from what happened to be in my fridge at the time, and it’s a keeper. Have cooked Zone PastaRx Orzo on hand in the fridge for a quick meal anytime. Method: Place raw asparagus shoots on a cookie sheet covered with foil. Foil makes clean-up easy. Season with S&P and drizzle with olive oil. Place it under the broiler and watch closely. Remove when it begins to brown (about 4-5 minutes for narrow shoots). Flip the shoots over and put them back under the broiler for another minute or two taking care not to burn them. While the asparagus is under the broiler, heat some cooked Zone PastaRx Orzo on a dinner plate in the microwave. Place the asparagus, some halved cherry tomatoes, and some crumbled fat-free feta on top of the orzo. Drizzle with balsamic vinegar and olive oil. Serve immediately. Enjoy!
Seasonal Spices and Their Health Benefits
When we think about spices this time of year, we think of those that create warmth and provide comfort. Anise, allspice, cardamom, cinnamon, cloves, ginger, and nutmeg are popular spices in the fall and winter. They are interwoven into the season for the warmth they create but can be used year-round. Spices have been used for centuries for their medicinal purposes, and as flavoring agents and to preserve food. While including spices in your meals is a great way to enhance flavor, it significantly increases their healthfulness since they are a rich source of polyphenols and antioxidants. Here we break down each of these spices, tell a little about their health benefits and give you a few ideas on foods they pair well with. Anise: Anise comes in different varieties; seed, fennel, and star. It is known for its licorice flavor that comes from a compound call anethole. Anethole is found naturally in high concentrations in the oils of anise and is used in a variety of medicines and pharmaceuticals (1). Anise pairs well with fish and stews. Star anise is one of the main ingredients in Chinese 5 spice powder and Chinese cuisine (2). Allspice: Allspice is derived from the dried berries of the Caribbean tropical tree, Pimenta dioica. It is used in Central American cuisines (i.e. think jerk dishes in Jamaican cuisine) for seasoning meat and desserts. It is rich in polyphenols known for their anti-bacterial, anti-hypotensive, anti-neuralgic, and analgesic properties and studies in animals show some of the compounds it contains may offer protection against tumor growth (3,4). Cardamom (Green): Cardamom is a part of the same family as ginger and is made from the seeds of different plants. Studies have shown it plays a role in oxidative stress by enhancing anti-inflammatory enzymes. Its benefits are diverse in that it’s been linked to improvements in blood sugar and lipid markers (5), gastrointestinal health as well as a potential role in chemoprevention (6). It has a sweet and pungent taste and pairs well with chicken and lamb and is used in Indian and Middle Eastern cuisine. Cinnamon: Cinnamon comes from the inner bark of several trees. While it's popular for its role in many foods as a flavoring agent and condiment, it is well known in the literature for lowering blood sugar levels (6). Cinnamon pairs well with many spices, apples, cocoa, breakfast and brunch options and can be found in Indian, Mexican, Moroccan and Middle Eastern cuisine. Cloves: Cloves have one of the highest polyphenol counts clocking in at 16047.50 mg/100 g. It has antibacterial, antiviral, and antifungal properties which are largely attributed to its high polyphenols and unique oils. When it comes to food they pair well with baked ham and pork and work well with many other spices too. Ginger: Ginger is a root derived from the Ginger plant, a member of the turmeric family. It is thought to have originated in India. It is used in foods for its hot, fragrant spice but also is popular in medicine (1). Studies have shown its role in combating nausea, minimizing inflammation, managing blood lipids, aiding in tumor suppression and growth, and as anti-bacterial agent, too. Nutmeg: Nutmeg and mace are relatives in that they come from different parts of the same tree. They are derived from an evergreen tree indigenous to the Spice Islands in Indonesia (1). Nutmeg leans a bit sweeter in taste and while there are many foods it can be used with it pairs well with cheese/cheese dishes, cream, milk and spinach. This is one of the primary spices you’ll find in Eggnog during the holiday season (2). A little goes a long way when it comes to flavor. Favorite Fall and Winter Spices Did you know that your favorite seasonal spices can easily be made at home as they are just combinations of the spices above? Gingerbread Spice: Ginger, Cinnamon, Nutmeg, Cloves, and Allspice Pumpkin Pie Spice: Cinnamon, Ginger, Nutmeg, and Cloves Apple Pie Spice: Cinnamon, Ginger, Nutmeg, and Cardamom Why Dr. Sears Like Using Spices The best raw fruits (primarily berries) contain about 0.1 % of weight as polyphenols, raw vegetables about 0.2%. Dried spices are about 5% of their weight as polyphenols. This why they are so bitter. The ultimate benefit of polyphenosl is to activate AMPK which in turn inhibits Nuclear Factor Kappa B (NF-kB). This reduces cytokine formation. Most polyphenols are totally water-insoluble and therefore can't be absorbed. However, they can be metabolized by bacteria in the colon to smaller fragments containing phenolic structures that can be absorbed. This is why we recommend consuming various sources of polyphenols during the day; fruits, vegetables, spices and also maqui berry. The beauty of maqui berry polyphenols is they are directly absorbed by the body to have maximal impact on activation of AMPK. Tips For Incorporating into Your Foods We tend to be creatures of habit with our meal prep, but spices have a way of elevating the taste of anything we make to have it feel new and different. To avoid over-powering your dishes start adding a sprinkle or pinch first and then add small amounts as needed. Here are a few ways to add them into your day. Add them into your roasted vegetable mixes and stir-fries Rub on top of your meats for cooking or use them in your marinades Mix into yogurt and oatmeal Add into sour cream, plain yogurt and hummus for dipping vegetables and fruit Sprinkle them on top of your coffee grounds or into your tea before brewing Add into your sauces, soups, and stews Incorporate into salads and salad dressings You May Also Like: Herbs and Spice - What to Know References Rosa Vázquez-Fresno, Albert Remus R. Rosana, Tanvir Sajed, Tuviere Onookome-Okome, Noah A. Wishart, David S. Wishart. Herbs and Spices- Biomarkers of Intake Based on Human Intervention Studies – A Systematic Review. Genes Nutr. 2019; 14: 18 Page, K. Dornenburg, A. 2008. The Flavor Bible: The Essential Guide to Culinary Creativity, Based on the Wisdom of America's Most Imaginative Chefs Hardcover. Little Brown and Company. Lei Zhang, Bal L. Lokeshwar. Medicinal Properties of the Jamaican Pepper Plant Pimenta dioica and Allspice. Curr Drug Targets. Author manuscript; available in PMC 2014 Jan 14. Lei Zhang, Nagarajarao Shamaladevi, Guddadarangavvanahally K. Jayaprakasha, Bhimu S. Patil, Bal L. Lokeshwar. Polyphenol-rich extract of Pimenta dioica berries (Allspice) kills breast cancer cells by autophagy and delays growth of triple negative breast cancer in athymic mice. Oncotarget. 2015 Jun 30; 6(18): 16379–16395 Daneshi-Maskooni M, Keshavarz SA, Qorbani M, Mansouri S, Alavian SM, Badri-Fariman M, Jazayeri-Tehrani SA, Sotoudeh G. Green cardamom supplementation improves serum irisin, glucose indices, and lipid profiles in overweight or obese non-alcoholic fatty liver disease patients: a double-blind randomized placebo-controlled clinical trial. BMC Complement Altern Med. 2019 Mar 12;19(1):59. Ajaikumar B. Kunnumakkara, Varsha Rana, Dey Parama, Kishore Banik, Sosmitha Girisa, Sahu Henamayee, Krishan Kumar Thakur, Uma Dutta, Prachi Garodia, Subash C. Gupta, Bharat B. Aggarwal. COVID-19, cytokines, inflammation, and spices: How are they related? Life Sci. 2021 Nov 1; 284: 119201.
9 Tips To Avoid Premature Aging
While we know that aging is inevitable, no one wants to think of themselves as getting old. We want to hold on to our youthfulness as long as possible and to only get better with age. Rather than looking at age as overarching, we address the signs as they come whether it’s fine lines and wrinkles, a few more hairs in the sink, blood parameters creeping upward, or the annoying joint and body aches. Although we can’t turn back time, there are lifestyle choices that can lead to the betterment of our years and more successful aging. You won’t be shocked to learn a lot comes down to your diet. Here are 9 tips to help you avoid premature aging and to retain your youthfulness as long as possible. Restrict Calories: Studies show the best way to slow down aging is calorie restriction. You might be thinking this is easier said than done as it can be hard to restrict calories if you are always hungry and fatigued. This is why the Zone Diet maintains the appropriate balance of protein to carbohydrate at every meal and snack to control blood sugar and get to your next meal with minimal hunger. Curb The Sugar: Sugar is one of the hardest habits to kick but its intake is linked to premature aging. Collagen is a protein in our skin responsible for its strength and elasticity and it naturally declines as we age. A poor diet high in refined carbohydrates accelerates collagen decline. When excess sugar attaches to protein it results in the formation of Advanced Glycation End Products or AGE. This causes our skin to lose its elasticity making it more susceptible to sun damage, fine lines and sagging. Get Your Omega-3s: 90% of individuals fall short on their intake of omega-3s yet the anti-inflammatory benefits of their intake are well established. Omega-3s , specifically EPA and DHA, can activate a group of mediators called resolvins which play a vital role in our ability to combat inflammation and heal from injuries. Omega-3s also impact DNA. Telomeres are the “endcaps” on our DNA and a part of our cell that affects how we age. When they shorten they cause our cells to stop functioning resulting in premature aging. Omega-3s, like those found in OmegaRx 2, have been shown to help reduce this shortening which may help improve longevity. Eat Berries: If you want to keep your memory sharp, make berries your fruit of choice. Not only are they lower in sugar than other fruits, but their high polyphenol content can protect brain cells from inflammation and cell damage possibly helping to delay the onset of diseases that impact memory. Increase AMPK: Studies have shown that AMPK, a master switch of metabolism, naturally declines with age. Unfortunately, as our levels of AMPK drop our body composition begins to change and with that comes an increase in abdominal fat. The good news is that simple dietary changes can help minimize this trend by increasing our natural levels of AMPK. Polyphenols found in fruits and vegetables are one way to boost AMPK. Think Cocoa Flavonols: Cocoa is rich in a group of polyphenols called flavonols which have been shown to be protective in minimizing age related cognitive decline. In addition, studies show cocoa flavonols improve blood flow and when used during exercise can help reduce exercise-induced oxidative stress and even alter how the body uses carbohydrates and fats for fuel. Minimize Stress: Stress presents itself different in all of us, but at the cellular level it leads to inflammation and potential damage of our DNA. One of your best defenses comes from trying to minimize inflammation through the foods you eat. This is why the Zone Diet, omega-3s and polyphenols become one of your best defenses since they are based upon helping to control inflammation in the body. Dr. Sears also encourages the use of meditation to help reduce stress. Taking 5-10 minutes to focus on your breathing can help reduce stress making you feel calmer and mentally focused. Rest Up: Not getting enough sleep can literally take years off your life. Sleep deprivation has been linked to obesity, diabetes and heart disease. Even if you think you need less sleep with age it’s not true. Try to get at least 7 hours of sleep each night to give your body the rest it needs to rejuvenate. Hydrate: While the science isn’t quite there on water consumption reducing fine lines and wrinkles, what is clear is that with age comes greater risk for dehydration. As we age our ability to feel thirst declines making it even more important to hydrate regularly. Declines in muscle mass, kidney function, physical and cognitive function along with the use of more medications and reduced thirst put older adults at much greater risk of dehydration. Filling a large water bottle at the start of the day and putting it in a visible place is a good daily reminder to make sure you get what you need. You can see from these tips that many elements of the Zone play a key role in helping to slow down the aging process or premature aging. Tell us in the comments what about the Zone helps you feel and look your best.
10 Foods To Add Protein Powder To
It’s hard to believe with how much we hear about protein that individuals still fall short on their needs. Dr. Sears recommends individuals consume at least 25 grams of protein at each meal. Did you know that adults 51 and older are more likely to fall short on their protein intake and have poorer diet quality? (1) In fact, those ages 51-60 are more likely to have poorer diets than their peers 60 and older. This poor diet quality is associated with decreased intake of micronutrients that play a key role in immunity and possible limitations in physical performance and decreased muscle mass due to poor protein intake. There are various reasons people fall short on their needs. Supplementing with protein powder can be an easy way to improve diet quality and get you closer to the guidelines of the Zone. Protein powder can make some foods that aren’t necessarily favorable in the Zone better choices by minimizing the impact of those foods on spiking blood sugar. This can also be helpful for kids or older adults who have a hard time meeting their needs or an easy way to sneak protein into food choices that aren’t the most ideal. 10 Foods You Can Add Protein Powder To: 1) Salad Dressings 2) Soups/Stews 3) Sauces 4) Yogurt 5) Oatmeal 6) Smoothies 7) Beverages 8) Baked Goods* 9) Mashed Potatoes* 10) Pancakes* *Although these starchy foods are not considered favorable in the Zone for those with poor diet quality or picky eaters, adding protein powder to these foods is a great way to sneak in some extra nutrition while adding more balance their to meals. Why Use Zone Protein Powder? Zone Protein Powder is an all-natural source of protein that’s flavor-neutral and designed to be added to soups, smoothies, yogurt, dressings, stews, and oatmeal to bring up the protein levels in your meals and snacks to match the Zone Diet guidelines. It is gluten free and sugar free. Fortified with 23 vitamins and minerals, our specialized protein blend of whey and milk protein dissolves quickly and is slowly absorbed by the body to keep you in the Zone without hunger when combined with a favorable balance of carbohydrates and monounsaturated fat. References: 1. Krok-Schoen JL, Archdeacon Price A, Luo M, Kelly OJ, Taylor CA. Low Dietary Protein Intakes and Associated Dietary Patterns and Functional Limitations in an Aging Population: A NHANES analysis. J Nutr Health Aging. 2019;23(4):338-347.
11 Meal Planning Tips
Meal planning is just like it sounds. It is taking the time to think ahead about your meals, plan out your menu, shop for the ingredients and do the prep work. The benefits are that planning ahead saves you time and money, is better for your health, and reduces stress. Studies show that individuals who frequently plan their meals have healthier diets and are less likely to be overweight or obese. If you tend to wing your meals or meal planning is not something you regularly do, here are some tips that can help you get started. 11 Tips To Get Started With Meal Planning 1. Start Simple: Pick just a few nights per week to start with. If Meatless Monday is already part of your routine or one weekend night is always take-out, stick with it and maybe add one or two more nights into your plan. 2. Survey Your Household: Start with meals everyone in your family enjoys. If you have picky eaters or lots of meal preferences adding in a taco night or a PastaRx night is a great way to make one meal that can be tailored many ways. 3. Check The Weekly Ads: We often have a routine to our eating but checking to see what is on sale for the week or using seasonal produce is a great way to add some variety to your meals and also save you money. 4. Look At Your Week Ahead: Looking at your schedule for the week can help guide what meals you choose and when. If you know certain nights are later than others make that night your easiest meal that involves minimal food prep or make that your leftover night. 5. Make Extra Food For Lunches And Dinners: Buying in bulk can save you money and making foods in bulk can save you time too. If chicken is on your menu make some extra that can be used in salads for lunches or dinners. Cook or prep extra vegetables the night before as an add on for a quick Zone Pasta meal or to go with another protein choice. 6. Breakfast For Dinner: This is an easy meal that can be healthy too! Veggie omelets, oatmeal, or even protein pancakes for kids with fruit are healthy and quick options. Zone cereal and Zone Shakes also come in handy as they are fast, convenient, and already Zone balanced. 7. Don’t Forget The Snacks: Make sure to have plenty of healthy snacks on hand. Keep fruit, cut-up veggies, cheese sticks, nuts, ZoneRx bars and shakes and other grab-and-go options on hand. Keep the non-perishable items visible on your counter, in your purse, gym bag, car, or office, as something to have when hunger sets in. 8. Don’t Try A New Recipe Unless You Have Time: Keep the tried-and-true recipes to the weeknight meals and save the new recipes for a weekend or a day when you have time. The first time you make a new recipe always takes longer than expected. Save yourself the stress and frustration and only do new recipes when time is on your side. 9. Don’t Throw Out Your Weekly Menu: Use your meal plan as a jumping off point for the following week. This will be a guide so you know what worked and what didn’t and to save you time. This is a great way to know which ingredients you are running low on, which meals you should you make more of and what you might tweak next time. 10. Plan Ahead: Meal planning takes time so designate in your calendar what day and time you plan to make your menu, what day you want to shop, and when to do you food prep. Just remember all this planning and prepping ahead will make your weeknights go so much smoother. 11. Be Flexible: Things come up during the week, plans get canceled, events get rained out and if you have to push something or move things around don’t stress it. You’ll actually feel more comfortable changing things up knowing you have everything you need on hand. The key with meal planning is to keep it simple. Even if you are using pre-packaged healthy foods to plan, that counts. Take it one meal or one day at a time and work your way up. As you get more accustomed to planning you will find you spend less time doing it and will reap the benefits that come from it; cost savings, weight control and improved health. References Hayes JF, et al. Greater Average Meal Planning Frequency Predicts Greater Weight Loss Outcomes in a Worksite-Based Behavioral Weight Loss Program. Ann Behav Med. 2021. PMID: 32301494 Ducrot P, Méjean C, Aroumougame V, Ibanez G, Allès B, Kesse-Guyot E, Hercberg S, Péneau S. Meal planning is associated with food variety, diet quality and body weight status in a large sample of French adults. Int J Behav Nutr Phys Act. 2017 Feb 2;14(1):12. doi: 10.1186/s12966-017-04617.
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