Menopause hormone therapy (HT), also known as hormone replacement therapy or HRT, has many benefits for perimenopausal and menopausal women, including reducing hot flashes, night sweats, brain fog, and vaginal dryness, as well as improving mood, sleep, and long-term bone health.
However, there have been decades of controversy regarding this therapy. In the early 1990s, HT was very popular and in 1993, the National Institutes of Health launched the Women’s Health Initiative (WHI), a clinical trial to evaluate the impact of hormone therapy on the risk of chronic disease, particularly heart disease, stroke, cancers, and bone fractures. In this landmark study, more than 16,000 healthy postmenopausal US women with an intact uterus aged 50 to 79 (average age 63) were put on a protocol of estrogen and progesterone, and roughly 11,000 who had had a hysterectomy were placed on estrogen alone.
Enrollment proceeded from 1993 to 1998. In 2002 the combined group of the trial was stopped three years early, and in 2004 the estrogen-alone group was stopped one year early. The trials came to a halt when the risks of invasive breast cancer, blood clots, heart disease, and stroke exceeded the benefits for prevention of bone fractures and colon cancer. These outcomes instilled a general fear in the public and medical community that HT increases the risk of breast cancer and/or cardiovascular disease.
But, in May 2024, WHI researchers published their 20-year follow-up data that showed no increase in deaths from breast cancer or cardiovascular disease in the women in the trials. The follow-up report also showed a decrease in all-cause mortality when HT was started under age 60 or less than 10 years after the final menstrual period, illustrating that hormone therapy can be beneficial for many women.
Regarding breast cancer risk specifically, in the WHI trial, there were only eight cases of breast cancer per 10,000 women per year in the combined group and a decrease in breast cancer rates in women on estrogen-alone therapy. “Obesity, a sedentary lifestyle, and alcohol use pose much greater risks for breast cancer than HT,” says Karen Adams, MD, Stanford clinical professor of obstetrics and gynecology.
“There’s a lot of fear and misinformation around HT, and one of the biggest myths is that HT is a highly significant cause of breast cancer,” says Dr. Adams. “Today, only around three percent of women who are candidates for hormone therapy are actually taking it because they’re afraid.”
Dr. Adams is the founder and director of the Stanford Menopause & Healthy Aging program, a multidisciplinary team of women’s health experts that aims to educate providers in the use of HT since many medical schools stopped teaching the treatment after the WHI results. Since providers were not prescribing HT, an entire generation of women (now aged 65 to 80) did not receive or benefit from the therapy.
“It’s important that we get the message out there that we have learned how to individualize HT for each woman’s situation. Risks and benefits regarding hormone therapy are different for each person, and many women will gain significant benefits from hormone use, especially if they are under age 60,” says Dr. Adams.
Reducing Fears About Menopausal Hormone Therapy
In the last 20 years, results from follow-up studies of the original WHI trial and other studies have shown that HT is safer when specific guidelines are followed, such as making sure women start HT at the right age, and the treatment is administered in the proper form.
When Should I Start Hormone Therapy?
The first safety guideline is starting hormone therapy at the right age. Analyses of the WHI trial data found that heart attacks and strokes occurred primarily in women who started HT over the age of 65, meaning that age made a difference in how women responded to the hormones.
This finding has led to the current recommendation of starting HT within 10 years of menopausal onset. In other words, if a woman’s last period occurred at age 50, she should start treatment by 60.
“There is a window of greatest opportunity to start hormones. If you start within 10 years of your last period, you almost always get benefits. But, if you start after 10 years, or after the age of 60, possibly not,” says Dr. Adams.
Also, Dr. Adams shares that many women are starting HT in their 40s to relieve perimenopausal symptoms. Unpredictable hormone fluctuations can cause irregular periods during the years leading up to menopause, sometimes resulting in Perimenopausal Mood Instability or PMI.
“Everyone knows about PMS, but no one talks about PMI because the conditions that women have in midlife aren’t talked about enough … and PMI is like PMS on steroids,” says Dr. Adams. “Starting hormone therapy during perimenopause can be incredibly helpful to stabilize the ups and downs of hormone levels that can cause hot flashes, night sweats, and changes in mood.”
Dr. Adams explains that HT offers a lower level of hormones than birth control pills, so it does not prevent pregnancy. Therefore, many of her patients in perimenopause (where pregnancy is still possible) opt for birth control pills if they are sexually active to provide both symptom relief and contraception. But, if patients are using another mode of birth control, HT could be a good option to relieve perimenopausal symptoms.
What Forms of Hormone Therapy Should I Take?
The second safety guideline is knowing the best way to take the hormone. Research has shown that when estrogen is taken in pill form, the liver releases clotting factors, which can result in blood clots and other cardiovascular conditions. But, if estrogen is administered non-orally, such as through a skin patch or gel, the hormone is delivered directly into the blood stream without going through the digestive system, which takes the clotting risk back to baseline.
“This study is helpful for providers to understand whether HT is a good idea for a particular patient in that it divides people into low, moderate, and high risk for cardiovascular disease,” says Dr. Adams, referring to Figure 5 of the study. “If a patient is at high risk for cardiovascular disease, HT would not be recommended.”
Even though estrogen should be administered non-orally to prevent blood clotting, Dr. Adams recommends taking progesterone as a pill that is swallowed at night, since sleepiness is a convenient side effect. The purpose of progesterone is to protect the lining of the uterus. Estrogen typically thickens the uterine lining, which can cause irregular bleeding, and even pre-cancer or cancer of the lining. If a woman has had a hysterectomy, she does not have this risk and therefore she does not need to take progesterone.
Lastly, the WHI trial administered chemical forms of estrogen and progesterone, but Dr. Adams emphasizes the importance of taking bioidentical forms so that the body “recognizes” them. “The hormones we now use are bioidentical, meaning they are the same forms that were circulating in your body in your reproductive years,” she says. “They are much less inflammatory than the chemical forms that were studied in the WHI. Since inflammation increases our risk for all age-related diseases, less inflammation is always a good thing.”
What are the Benefits of Menopause Hormone Therapy?
At the Stanford Menopause & Healthy Aging clinic, HT is tailored to the patient’s needs and includes transdermal estrogen (via a patch) and micronized progesterone (via a pill) for those with a uterus. The primary use of hormone therapy is for management of menopausal symptoms, which can be distressing and can last for years.
Benefits of Hormone Therapy:
- Reduction of hot flashes
- Reduction of night sweats
- Reduction of vaginal dryness that can cause painful sex
- Reduction of joint pain
- Reduction of brain fog
- Mood stabilization
- Sleep improvement
“Hormone therapy takes hot flashes and night sweats away in about three to four weeks. Regarding painful sex, the vagina gets more stretchy, moist, and flexible with estrogen,” says Dr. Adams. “HT also provides a small but measurable impact on lean body mass and can help to mitigate the ‘spare tire’ that women see in midlife.”
Long-term Benefits of Hormone Therapy:
- Reduced risk of osteoporosis and bone fracture
- Reduced risk of colorectal cancer
“Women take HT to not only relieve current menopause-related symptoms but also for improved long-term bone health. HT helps keep your bones strong and can potentially prevent osteoporosis,” says Dr. Adams. “Regarding heart health, we see a slowing of calcium deposition in the coronary arteries when HT is started under age 60, which may lead to a lowered risk for cardiovascular disease long-term.”
Benefits of Testosterone:
- Improved sex drive
“Testosterone is not part of a standard HT protocol since it’s not FDA approved for women. For that reason, insurance will not reimburse for it. The best data supports the use of testosterone in postmenopausal women with low sex drive. In those women we see small increases in desire, arousal, and orgasm, so some HT clinics do offer it for this purpose and follow a national guideline for administration,” says Dr. Adams. “Regarding improvements in muscle mass and energy, we don’t have enough data currently to conclude that testosterone mitigates the sarcopenia of aging or increases energy in women, but this may come in the future.”
Who Should Not Take Hormone Therapy?
Dr. Adams explains that people with the following conditions should not take hormone therapy:
- Women with a hormone-sensitive cancer, such as estrogen or progesterone positive breast cancer.
- People who have had a heart attack, stroke, or a blood clot in their leg, lung, or brain.
- People with gallstones, liver disease, gallbladder disease, or undiagnosed vaginal bleeding or pregnancy.
“It’s an exciting time to be a menopause specialist because there has been more attention being paid to menopause in recent years, which is great and long overdue,” says Dr. Adams.
“I want to send a message of hope. Once they figure out how to manage their menopausal symptoms, most women are happier than they’ve ever been in their lives. They are more confident, and their relationships tend to improve because they know themselves well. So, you just need to navigate these choppy waters of perimenopause to get to a time of life that is called ‘menopausal zest’. That is out there waiting for you, and it’s wonderful,” says Dr. Adams.
Learn more about Dr. Karen Adams’ recommendations for women’s healthy aging:
TED Talk: Sleep, Sex, and Menopausal Zest
SHE Talk: Taboos and Truths – A Frank Talk About Women’s Health
By Nicole Molumphy, BS and Sharon Brock, MEd, MS
Do you ever get those late-night cravings or feel like your hunger is never satiated? Research shows that consistent short sleep duration (less than 7 hours per night) can influence metabolic health, affect the function of appetite hormones, increase food cravings, and lead to a 38 percent increase in obesity in adults.
Consistent sleep deprivation can lead to altered functioning of the appetite hormones ghrelin and leptin. Ghrelin increases our appetite and is released by cells in the stomach lining. When your stomach is “growling,” that is the ghrelin hormone talking. Conversely, the hormone leptin, made by our fat cells, lowers our appetite. Studies have revealed that sleep deprivation can lead to increased ghrelin and decreased leptin, resulting in an overall experience of constantly being hungry.
“There are so many health conditions associated with poor sleep,” says Rob Oh, MD, Clinical Associate Professor (Affiliated) and family physician at the Veterans Affairs Health Care System in Palo Alto. “With chronic sleep deprivation, your metabolism becomes dysregulated, leading to cravings for processed foods. Also, you’re less likely to exercise, you feel more stressed, and you’re more likely to think poorly. The combination of these factors can lead to metabolic health problems like obesity and type 2 diabetes.”
Sleep Deprivation Increases Stress Hormones
Our cortisol levels are typically lowest near midnight and then increase towards waking hours, ultimately peaking around 9 a.m. Studies demonstrate that reoccurring poor sleep is associated with an altered cortisol secretion pattern.
For example, delaying your bedtime could lead to high cortisol levels in the middle of the day, rather than just in the morning. Sustained high levels of cortisol can lead to an increased amount of insulin in the blood, which promotes the accumulation of belly fat and has the potential to lead to prediabetes, type 2 diabetes, and other metabolic disorders. An increase in cortisol levels during the day may induce prolonged feelings of stress, increased food cravings, and further insomnia—promoting a recurrent, cyclical pattern.
“Inadequate sleep disrupts hormone levels, which dysregulates one’s metabolism and makes individuals hungrier,” says Dr. Oh. ” When we are hungrier, we eat more, which leads to weight gain and potentially metabolic disease.”
If that’s not bad enough, cravings for ultra-processed foods, sugars, and alcohol become more of a tease with sleep deprivation. A possible mechanism for this added hunger is an increased activation of the endocannabinoid system, which is found throughout the body and controls several biological systems, including sleep, mood, and appetite.
Sleep Deprivation and Increased Risk of Diabetes
Research shows that a lack of sleep may also result in insulin resistance, a driving factor in prediabetes and type 2 diabetes. Insulin is a hormone made by the pancreas that regulates blood glucose levels. Insulin resistance occurs when cells in the liver, fat, and muscles do not respond well to insulin, and in turn, glucose is not taken up into the blood.
The exact mechanism behind the causal relationship between insufficient sleep and insulin resistance is still being studied, however, some studies note that increased inflammatory markers, like C-reactive protein and hormone dysregulation, such as cortisol may be involved.
Currently, prediabetes affects one in three adults in the US. While many mechanisms contribute to the development of prediabetes and type 2 diabetes, some of the more prominent ones include impaired cellular insulin sensitivity, modified gut microbiota, and overly-sensitive sympathetic nervous system (fight-or-flight) activation. When the sympathetic nervous system is activated, it signals the liver to release more glucose into the bloodstream, leading to higher blood sugar levels.
What Can We Do About It?
Unfortunately, research finds that “weekend recovery sleep” is not enough to bring your metabolism back into balance after a lack of sufficient sleep throughout the week. Instead, Dr. Oh recommends taking a holistic approach and examining not only your sleep habits but also your nutritional choices and workout routines to support the restoration of metabolic health.
For those with pre-diabetes and type 2 diabetes, a diet focused on whole foods and low refined carbohydrates is critical for weight loss and glucose control.
Specifically, Dr. Oh recommends a low carbohydrate diet, such as consuming 75 to 100 grams of carbohydrates per day, to control and balance blood sugar levels. He also recommends quick, 20-minute, high intensity workouts for time-efficient and effective exercises that promote metabolic health. Regarding supplements, Dr. Oh recommends magnesium to promote muscle recovery and relaxation before bedtime.
“Optimal sleep is so intertwined with athletic and exercise performance, brain health, and metabolic health,” says Dr. Oh. “Sleep really is a keystone area where many of us can do better and hence reducing our risk for metabolic diseases and lengthening our healthspan.”
In recent years, a groundbreaking field known as Metabolic Psychiatry has emerged at the intersection of metabolic and brain health. Spearheaded by Shebani Sethi, MD, a Clinical Associate Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, this innovative field sheds light on the powerful connection between our metabolic health and mental well-being.
As rates of mental illnesses like Alzheimer’s, bipolar disorder, and schizophrenia rise alongside metabolic conditions such as obesity, diabetes, and cardiovascular disease, researchers are uncovering how these seemingly distinct issues may be intertwined. A Stanford study found that developing a metabolic disorder like insulin resistance can double your risk of depression, even if you’ve never experienced mental illness before. As such, emotional and metabolic disorders often occur together, with over forty percent of individuals with severe mental illnesses also experiencing metabolic syndrome.
It’s easy to see how mental illness could lead to conditions such as obesity or diabetes because someone struggling emotionally might be unable to eat well or exercise. However, it’s becoming increasingly apparent that metabolic disorders have a distinct role in the onset and progression of mental illnesses.
“Many psychiatric diseases have underpinnings in metabolic dysfunction,” explains Dr. Sethi. “We are seeing insulin and glucose handling differences in the brain in patients with psychiatric conditions.”
These metabolic issues in the brain are present even at the early stages of disease detection and progression. Dr. Sethi explains that patients diagnosed with a first episode of schizophrenia—before any treatment with medications—already show disrupted energy metabolism in the brain. Similarly, Alzheimer’s disease has been referred to as type III diabetes due to its strong link to disrupted insulin signaling in the brain.
Dr. Sethi has been a trailblazer in this area since 2015, founding the first academic Metabolic Psychiatry Clinic focused on treating patients with both mental health and metabolic disorders. Metabolic Psychiatry examines how improving metabolic health through nutritional interventions can significantly enhance brain health and mitigate the symptoms of severe psychiatric conditions.
How Metabolic Health Impacts Brain Health
Many psychiatric diseases are characterized by metabolic dysfunctions, which impair the brain’s ability to function properly. These dysfunctions occur when chemical processes are disrupted, hindering the body’s ability to produce and utilize energy efficiently.
A well-known example is insulin resistance, where the body’s cells don’t respond appropriately to insulin—the hormone that allows glucose to enter cells and be metabolized for energy. The brain, one of the most metabolically active organs, requires large amounts of energy to function. It is highly dependent on glucose due to its limited flexibility to use other energy sources. This dependence makes metabolic conditions like insulin resistance particularly harmful, as any disruption in glucose supply puts the brain at risk for cognitive decline and neuronal degeneration.
“If you don’t have optimal metabolic functioning in the brain, then you won’t process and create energy as efficiently as a healthy brain,” states Dr. Sethi. “The brain will have all this glucose around it, but you can’t actually use it properly. This is called cerebral glucose hypometabolism, and it’s very common in psychiatric and neurodegenerative diseases.”
Other metabolic abnormalities commonly seen in psychiatric conditions include oxidative stress, mitochondrial dysfunction, and neurotransmitter imbalances, which all have downstream effects on synapse connection and neuronal excitability.
“We don’t know for sure what the primary drivers for these metabolic dysfunctions are, but it is likely a combination of factors influencing one another,” says Dr. Sethi. “For example, insulin resistance is correlated with higher inflammation levels and oxidative stress in the brain, which in turn exacerbates mitochondrial and neurotransmitter dysfunction.”
Chronic inflammation disrupts brain activity and undermines the integrity of the brain’s protective mechanisms. The blood-brain barrier (BBB), a critical structure that protects the brain from harmful substances in the blood, becomes compromised. This “leaky” BBB allows inflammatory molecules, pathogens, and toxins to enter the brain from the bloodstream, exacerbating the inflammatory response within the brain and creating a self-perpetuating cycle of neuroinflammation. “We see significantly more inflammation in the brains of people with mental illness, especially in treatment-resistant patients, than in healthy people,” states Dr. Sethi.
How Nutrition Can Improve Brain Health
Dr. Sethi’s metabolic approach to brain health not only enhances our understanding of psychiatric conditions but also opens up new avenues for treatment, such as nutritional interventions. Studies have shown that nutritional interventions can impact the balance of neurotransmitters in the brain, which is crucial for regulating mood and behavior.
By targeting metabolic dysfunctions such as insulin resistance, oxidative stress, and improper energy utilization, nutritional interventions can help restore brain function and reduce inflammation. This comprehensive approach addresses the symptoms of psychiatric conditions while tackling their underlying causes, offering a more effective and holistic treatment strategy.
The Stanford Metabolic Psychiatry group, led by Dr. Sethi, is investigating whether dietary changes, such as adopting a ketogenic diet, can stabilize brain health. The ketogenic diet, which is high in fat and low in carbohydrates, encourages the brain to use fat and ketone bodies as primary fuels instead of glucose. This metabolic shift helps counteract issues related to glucose metabolism and insulin resistance. The diet adopted in the study focuses on consuming whole, unprocessed foods, including protein and non-starchy vegetables, without restricting fats.
“The ketogenic diet is a strong, powerful metabolic intervention. It can improve neurological and psychiatric conditions by making changes in the brain through these pathways,” says Dr. Sethi. “By providing ketones as an alternative energy source, the ketogenic diet reduces glucose dependency, which is beneficial in counteracting glucose hypometabolism.”
In Dr. Sethi’s study among participants with schizophrenia consuming a ketogenic diet, there was a 32 percent reduction in Brief Psychiatric Rating Scale scores. There was also increased life satisfaction and enhanced sleep quality among participants.
The ketogenic diet can also have a positive influence on brain aging for everyone and has been experientially understood to help normalize the brain for centuries. Dating back to roughly 500 BC, fasting (which mimics the ketogenic diet) was used to treat epilepsy. Current research shows that the destabilization of brain networks might indicate early signs of reduced metabolism, which is linked to dementia. By increasing the use of ketones for energy, dietary interventions like the ketogenic diet can provide more energy to the brain and potentially protect against aging-related cognitive decline.
Dr. Sethi warns, however, that “the ketogenic diet is very specific and may not be suitable for everyone. It can be incredibly beneficial for people with insulin resistance, obesity, or diabetes, but it may not be feasible or appropriate for all individuals.”
Future studies will reveal further dietary interventions that benefit brain health. For example, Dr. Sethi and her team plan to conduct a randomized controlled trial with the ketogenic diet versus the Mediterranean diet in cases of serious mental illness. Whichever diet one chooses, Dr. Sethi recommends the reduction of sugar, ultra-processed foods, and refined carbohydrates to promote both metabolic and brain health.
“Our diet provides the precursors for neurotransmitters and other vital cellular structures in the brain, while also impacting inflammation levels. If we have deficiencies in our diet, we’re not going to be able to create the components and environment we need for optimal brain function and regulation of mood,” states Dr. Sethi.
By Maya Shetty, BS and Sharon Brock, MEd, MS
“Salud!” If you’ve ever raised a glass to your health, you’re not alone. For decades, many have believed that minimal alcohol consumption is potentially beneficial for your health. However, not every researcher would agree. A growing body of evidence reveals health concerns about alcohol use, making it crucial to understand the spectrum from harmless to harmful levels of consumption to keep your body healthy.
“Alcohol will impact everyone’s health differently,” says Douglas Noordsy, MD, Clinical Professor of Psychiatry at Stanford University School of Medicine and Assistant Director of Stanford Lifestyle Medicine. “Rather than a daily habit, drinking alcohol should be seen as an indulgence, something you have once in a while to celebrate.”
Experts have conflicting views regarding how much alcohol carries risks. Some believe that drinking in moderation is safe, while others believe that even light drinking can cause harm.
“While many believe light to moderate alcohol intake is safe and even healthy, this reality is far from true,” states Cindy Kin, MD, a colorectal surgeon and Associate Professor of Surgery at Stanford University. “In fact, no level of alcohol can be considered beneficial for our health.”
Isn’t One Glass of Red Wine Good for the Heart?
“Studies have gone back and forth, with some suggesting potential cardiovascular benefits of light drinking, while others point to increased risk of cancer and liver disease even when consumed at low intake levels. As a result, many are confused about headlines proclaiming alcohol as either good or bad for health,” says Dr. Noordsy.
The origin of this belief traces back to the 1980s, rooted in a concept known as The French Paradox–the observation that despite consuming a diet high in saturated fat, France had a low incidence of heart disease. Researchers of the era decided that this unexpected trend was attributed to the widespread consumption of wine in the region. This correlation led to extensive research into wine and the identification of polyphenols, thought to be responsible for wine’s apparent cardioprotective potential.
Since then, numerous observational studies have claimed that light to moderate wine intake has beneficial effects. “However, these studies overlooked some crucial factors,” says Dr. Kin. While early observations indicated poorer cardiovascular outcomes for non-drinkers than for moderate drinkers, researchers overlooked that many non-drinkers abstained due to existing health conditions that led to overall poorer health outcomes. Additionally, those self-identified as light drinkers were more likely to lead healthier lifestyles overall. This oversight has fostered a misleading impression that associates better cardiovascular outcomes with light drinking, falsely implicating alcohol as the causal factor. As a result, enjoying a glass or two of wine a day has become widely accepted as a healthy habit.
While red wine contains antioxidants like resveratrol, found in grape skins as well as in peanuts, dark chocolate, and blueberries, which might have heart-healthy benefits like reducing cholesterol and lowering blood pressure, the quantities are often misunderstood. To achieve the levels of resveratrol observed beneficial in mice studies, one would need to consume an impractical amount of red wine—somewhere between a hundred to a thousand glasses daily. Thus, while the idea of resveratrol’s benefits is enticing, the practical reality makes it an unrealistic source for therapeutic effects.
How Much Alcohol is Too Much?
Many people believe alcohol becomes a concern only when consumed excessively. “Excessive alcohol use” is defined as exceeding the US Dietary Guidelines’ recommendations, which advise males to limit themselves to two drinks per day and females to one drink per day, on average. Two-thirds of adult drinkers report drinking above this level at least once a month.
However, a growing body of recent research shows that even modest quantities of alcohol can be harmful to our health. Such consistent findings have prompted the World Health Organization to assert that “when it comes to alcohol consumption, there is no safe amount that does not affect health.”
The main issue with alcohol is that it enters the bloodstream and quickly spreads throughout the entire body (especially when consumed without food). Unlike most substances, alcohol is both water- and fat-soluble, allowing it to permeate nearly every cell and tissue, including the highly secure blood-brain barrier that protects our central nervous system.
While the liver does most of the alcohol metabolism, other organs also process alcohol, such as the kidneys and lungs. As our organs work to break it down into a usable fuel source, acetaldehyde is produced, which is toxic due to its ability to damage and kill cells indiscriminately. As acetaldehyde enters the brain, it causes a disruption in our neural circuitry that creates the sensation of “tipsiness” associated with alcohol. And, the more “tipsy” one feels, the greater the amount of toxic acetaldehyde in the blood.
Rather than following strict guidelines about how much to drink, Dr. Noordsy recommends that individuals take note of their personal perceptions of intoxication and pace themselves accordingly. He recommends using the feeling of being “tipsy” as the signal to slow down or stop drinking. “The ‘tipsy’ feeling is the indicator that blood alcohol levels have risen to the point that you’re starting to put your health at risk. And the more ‘tipsy’ you become, the higher the risk,” states Dr. Noordsy. “If you’re having alcohol with food, your blood alcohol level won’t be as high as compared to having drinks by themselves. So, if you’re enjoying a glass of wine as part of your meal, that’s a very different thing than drinking in a way that’s leading to the feeling of intoxication.”
Health Concerns Linked to Alcohol Use
Recent data from the World Health Organization reveals that each year, alcohol contributes to three million deaths globally and accounts for 5.1 percent of the worldwide burden of disease and injury. Alcohol’s detrimental effects span more than 200 disease and injury conditions, encompassing everything from alcohol dependence and liver cirrhosis to a range of non-communicable diseases (such as heart disease, cancer, chronic respiratory disease, and diabetes) and mental health disorders.
Liver Disease
Acetaldehyde, a derivative of alcohol metabolism, inflicts significant harm on the body’s cells, especially within the liver. Given the liver’s primary role in detoxifying our bloodstream, it bears the brunt of the detrimental effects of alcohol metabolism. This continual strain can result in the buildup of fat, chronic inflammation, and potentially irreversible damage to the liver.
A study analyzing the livers of 3,649 participants discovered a concerning correlation: as daily alcohol intake increased, so did the accumulation of fat in the liver. Alarmingly, no identifiable threshold existed below which these harmful effects were absent, suggesting that even individuals who consume alcohol in minimal amounts are not immune to the accumulation of liver fat.
Fat accumulation hinders the liver’s vital metabolic functions, including blood sugar regulation, cholesterol processing, and nutrient absorption. It also increases the risk of inflammation around the liver, known as alcoholic hepatitis.
“The good news is that abstaining entirely from alcohol can reverse these changes, however, continuing to drink alcohol can lead to irreversible damage, scarring, liver dysfunction, and in advanced cases, liver failure,” states Dr. Kin. “This is especially concerning because fatty liver often presents no early symptoms, with individuals potentially unaware until it advances or results in serious complications.”
Another important consideration is that people who have non-alcoholic fatty liver disease, caused by obesity and other metabolic syndromes, have a much higher risk of developing alcoholic liver disease.
“This means that even small amounts of alcohol will cause the same level of alcohol-related liver disease (fibrosis, cirrhosis, etc.) as would larger amounts of alcohol consumed by someone without underlying fatty liver,” explains Dr. Kin. “Therefore, people who are already dealing with metabolic diseases should be extra cautious around alcohol because their livers are working extra hard already.”
Cancer
Alcohol is designated as a carcinogen by the International Agency for Research on Cancer due to its association with higher risk for many common cancers.
“Alcohol increases cancer risk specifically in areas it is in close contact with, such as the mouth, pharynx, and digestive tract. It also has carcinogenic effects throughout other parts of the body,” states Dr. Kin.
Underlying its harmful effects, chronic inflammation from alcohol consumption elevates cell turnover, heightening DNA mutation risks. Additionally, alcohol is believed to promote tumor growth while inhibiting tumor-suppressive molecules.
In 2017, the European Union reported nearly 23,000 cancer cases tied to light to moderate alcohol use, with half attributed to female breast cancers. Even at levels as low as three drinks per week on average, there is a slight but measurable increase in breast cancer risk. Notably, raising daily alcohol intake by just 10 grams—equivalent to what’s in a standard beer or wine—escalates the risk of breast cancer by 10 percent.
Cardiovascular Health
Despite popular belief, alcohol consumption, regardless of the amount, is linked to an increased risk of cardiovascular disease. A comprehensive study of 371,463 individuals found that as alcohol consumption increased, so did the risks of conditions like hypertension and coronary artery disease. Light alcohol intake (less than 8.4 drinks per week) led to a minimal but noticeable increase in cardiovascular risk. Researchers also found that when accounting for various lifestyle factors, the perceived protective benefits of modest alcohol intake against cardiovascular risks diminished significantly.
There are numerous reasons hypothesized for these detrimental effects, especially surrounding the metabolic effects of alcohol. “Alcohol offers no nutritional benefits; it’s essentially empty calories that are consumed on top of the calories required by your body. On top of this, alcohol interrupts the body’s regular metabolic functions. As the body prioritizes removing this toxic substance, it compromises processes like nutrient absorption and fat metabolism. This disruption promotes the storage of visceral fat, the harmful fat surrounding organs,” explains Dr. Kin. “This fat increases inflammation and poses significant risks, especially around the heart.”
Hormone Imbalance
Alcohol consumption raises estrogen levels in both males and females by increasing the activity of the enzyme responsible for converting androgens to estrogen. This accelerated conversion can lead to issues like gynecomastia (enlarged breasts in males), decreased libido, and increased fat accumulation. Additionally, consistent alcohol exposure can reduce testosterone levels over time, which is associated with reduced libido, fatigue, decreased bone density and muscle mass, and potential fertility issues in both males and females.
Additionally, regular alcohol consumption of more than 3.5 drinks per week for males and 2.6 drinks per week for females can cause chronic changes and reduced control of the hypothalamic-pituitary-adrenal axis. This disturbance may lead to an increase of the stress hormone cortisol released throughout the day.
Microbiome Issues
Alcohol also disrupts the gut microbiome by killing beneficial bacteria and other essential microbes. Additionally, alcohol’s pro-inflammatory properties trigger the release of inflammatory cytokines, causing gut inflammation and making the intestinal lining more permeable. This increased permeability can allow undigested food particles to enter the bloodstream. Over time, chronic alcohol consumption can further imbalance the gut microbiome, promoting bacterial overgrowth and dysbiosis. These disruptions can trigger immune responses, increasing susceptibility to food intolerances.
Brain Health
When alcohol is consumed, it enters the brain and suppresses neural networks involved in memory formation and storage. Through chronic consumption, this disruption can have permanent effects. A study involving over 36,000 middle-aged adults revealed that even moderate drinkers, consuming one to two drinks per day on average, displayed thinning of the neocortex and other brain regions, indicating neuron loss. This research also found that increased alcohol consumption correlates with diminished brain volume and reduced gray matter, which are the areas of the brain highly concentrated with neurons. As alcohol intake rose, so did the severity of these detrimental effects.
Fortunately, for most casual drinkers, abstaining from alcohol for two to six months can reverse damage to the prefrontal cortex and neural circuitry. However, chronic users may only experience partial recovery and might endure lasting effects.
“As alcohol consumption increases, so does one’s risk of cognitive decline and dementia,” states Dr. Noordsy.
Mental Health
As anxiety and depression continue to rise in the US, alcohol use also increases as individuals self-medicate to reduce stress. Also, the nightly glass of wine may cause more stress the following day since it impairs cognitive and physical performance, reducing one’s ability to cope. “During the pandemic, we observed a startling rise in cases of alcohol-induced hepatitis, indicating a growing reliance on alcohol as a coping mechanism,” says Dr. Kin.
One study, however, showed that light to moderate alcohol consumption may be beneficial to mental health by offering short-term relief by reducing stress signals in the brain. Although Dr. Noordsy acknowledges this study, he states that “learning to manage stress through physical exercise, mind-body and mindfulness practices can lead to safer and likely more effective mediation of impacts of stress than relying on alcohol use.”
Is There a Healthy Way to Consume Alcohol?
Given the extensive research on the detrimental health effects of alcohol, both Dr. Kin and Dr. Noordsy recommend abstaining from alcohol, or at least drinking very rarely, if one is experiencing or has a family history of liver disease, cancer, cardiovascular disease, hormone imbalances, gut microbiome issues, dementia, or mental health disorders, including addiction.
The precise amount of alcohol that is harmful is difficult for experts to confirm because it’s different for each person. Therefore, when it comes to alcohol and health, Dr. Noordsy recommends a balanced, personalized approach keeping in mind one’s individual risk factors and health goals.
“While heavy, regular consumption is linked to health problems, an occasional drink with meals may pose little risk for most adults,” says Dr. Noordsy. “However, individuals with personal or family histories of certain cancers or other conditions may need to be more careful with alcohol intake. We put thought into our nutrition and exercise habits, and we need to be just as thoughtful about the role that alcohol plays in our lives and make informed decisions regarding how much is the right amount for ourselves.”
Although less inclined to recommend light alcohol consumption, Dr. Kin acknowledges that it is an ingrained part of people’s social and cultural lives, similar to many other things that individuals consume that do not contribute to health. So, she encourages individuals to reframe their mindset around alcohol.
“Rather than viewing alcohol as a daily routine, consider it a treat reserved for special occasions or celebrations, much like enjoying a slice of birthday cake,” she says.
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So, you want to start meal prepping in 2024? Perhaps this is related to a larger goal to lose weight, eat cleaner, or meet your nutritional goals. To set yourself up for success, you have bought a container for each day of the week and started to plan your week-by-week meals. Maybe you’re planning to make the Sunday morning farmers market and subsequent wash, chop, and prep of your vegetables part of this new-you routine?
Once we begin to break down this resolution, we can see that it is composed of many smaller action steps, which many people may not have the time to do. Busy schedules often do not mix well with New Year’s resolutions that require a lot of time and effort.
Stanford Lifestyle Medicine’s head of the Healthful Nutrition pillar, Marily Oppezzo, PhD, MS shares that you only need to make a few adjustments to your meal prep plans to set you up for success!
“For the New Years’ resolutions, you can have your aspirational goal, but start with the side quests that lead up to that lofty goal in the end,” says Dr. Oppezzo. “Even if your first goal is to eat just one vegetable today, you are learning consistency and making progress. Incorporating one healthy habit a day based on your situation helps you feel successful and see that little accomplishments build up with time.”
3 Meal Prep Tips
“Realistically, not everyone has three hours every Sunday to dedicate to meal prep,” says Dr. Oppezzo, Registered Dietitian with 20+ years of experience in nutritional coaching. “If you have the time, that is great, but I encourage people to always have a back-up plan for when they don’t. Instead of ditching your resolution, rely on pre-cut vegetables, frozen vegetables, and bagged salads and add them wherever you can during the week.”
1. Frozen IS Fresh
Many of us succumb to the belief that frozen fruit and vegetables are not fresh, but oftentimes they are just as fresh, if not more, than those bought in the produce aisle or at the farmer’s market. You may prefer to buy fresh produce, but frozen produce is a great option when trying to make healthy meals in a pinch. Since these fruits and vegetables are frozen and preserved upon harvest, they will still maintain their day-one freshness once cooked.
2. Drawers of Doom
Dr. Oppezzo recommends avoiding the “drawer of doom”, or the drawer in the refrigerator that you toss all your veggies in. It is common to forget about these items once they are discarded into a drawer, especially during a busy morning or when you’re tired after a long day at the office. Instead, Dr. Oppezzo recommends keeping your healthy options on display so that they can help remind you of your nutrition goals. Throw your fruits and veggies into transparent containers and keep them within view on the shelf, rather than the drawer of doom. You can put all your less-than-healthy options in this drawer since you’ll grab for these items anyways.
3. You Know You
Perhaps the most important part of your meal-prep regimen is to be realistic with yourself. You know your schedule, abilities, and preferences the best. Your meal prep practices can adjust to match the time that you have available each week. If you have a free Sunday, you can spend more time preparing your meals for the busy week ahead. If you’re catching up on life on Sunday, perhaps you could opt for making a larger batch of quinoa or brown rice between activities to have on hand throughout the next few days. If you only have time for a quick trip to the grocery store on Sunday, shopping for convenient but still healthy options is just as good of an option if it helps you stick to your nutrition goals.
Dr. Oppezzo recommends grabbing a few microwavable grains and your preferred pre-cut, frozen produce to greatly cut down on cook time. Having these convenient staples can help keep healthy meals a viable option when spending an hour to cook a healthy meal is not realistic. The goal is to make meal prep easy, convenient, and consistent, rather than being overly repetitive or overly strict and giving up by the end of February.
“It is not so much about how psychologically committed you are, but more about what your life is like right now,” says Dr. Oppezzo. “Once you have mapped out your availability, you know how to best adjust your behaviors to keep with your resolutions using the time that you actually have.”
One of the hardest parts about exercising is finding the motivation to do it. Especially if you’re new to working out, motivation can be fleeting and dependent upon your daily mood or energy level. Even though we know that exercise greatly benefits our health, it may require weeks of effort and dedication before seeing significant results.
So how do we stay motivated? Stanford Lifestyle Medicine Assistant Director and Exercise Physiology expert, Anne Friedlander, PhD, recommends three ways to incorporate exercise into our daily routine and establish a habit of exercise that remains consistent in the long run.
Bundle Your Activities
Bundling your activities is a version of multitasking where you combine a pleasurable activity that provides instant gratification with an activity that involves delayed benefits, such as watching your favorite television show or listening to an audiobook on the treadmill. This type of multitasking, also known as “temptation bundling,” is a promising method to create and maintain an exercise habit. When your exercise is combined with a specific tv show, audiobook, or playlist each time, there is the incentive to exercise especially if you only allow yourself to partake in the engaging media while exercising. It creates an association between entertainment and physical activity, which allows you to benefit from exercise in the moment, rather than weeks or months later.
While this approach may bypass the mind-body connections that exercise can offer, temptation bundling is a great way to create a new exercise habit or get back into a routine. After you’re confident in your ability to maintain your exercise routine, you can let go of the television show and focus on optimizing your mind-body connection while exercising which can enhance the cognitive and mood benefits of exercise.
Research has been conducted on whether temptation bundling can improve motivation to exercise. In this study, researchers provided free audiobooks during workouts and measured the frequency in which people exercised. The results showed that not only were participants more likely to exercise compared to those not offered the audiobooks, they were more likely to keep up the habit after the study was over. The study also showed that the media needed to be enjoyable to the participants to increase incentive to exercise, meaning when the audiobook covered a topic that was particularly engaging for the participant, their motivation increased.
So, if you’re having trouble starting or maintaining an exercise program, listen to an interesting audiobook while out on a jog or watch your favorite television show while cycling indoors to get you moving towards your health goals.
“It is amazing how powerful temptation bundling can be if you find a good story or podcast and you only let yourself listen while doing your physical activity. You may actually look forward to your next workout!” says Dr. Friedlander. “Eventually physical activity may become its own reward, but in the meantime, lace up your shoes and queue up that mystery thriller.”
Find a Workout Buddy
Working out with a partner, friend, or family member creates a two-way street of accountability and makes you more likely to show up for your goals. While the presence of your workout partner nudges you to stay on your goal, your presence also motivates them to do the same. Skipping a solo workout may require very little thought or work, but skipping a partner workout requires more work and requires you to explain to the other person your reason for skipping. This process helps avoid the fleeting temptations that would deter you from exercising based on mood or energy levels.
Having someone to match your level of commitment also introduces a link between social connections and physical activity in the creation of a more healthy lifestyle. The pillars of our lives are interconnected, and strong habits often involve behaviors that embrace multiple aspects of our health.
A workout buddy can be more than someone that helps you stick to your program. They can also be someone to offer and receive encouragement and support, talk about goals,discuss overcoming obstacles, and form memories and relationships. By making the habit a more involved aspect of your social life, you open yourself to broader potential benefits.
“I am not a morning person, but I have a puppy who loves his playdates,” says Dr. Friedlander. “Every morning at 7 am I meet friends for a walk and puppy playtime. The group definitely helps me get out the door because I don’t want to disappoint either my human or puppy companions”.
Choose an Exercise You Enjoy Doing
Just because exercise is something that you should do, doesn’t mean that you cannot enjoy it. There is a certain level of discipline that is required to maintain an exercise routine over time, but you will be more motivated to stick to your routine if you like the type of exercise you are doing. If you enjoy team sports, you may enjoy achieving your exercise goals by joining a pickleball league, swim club, or soccer team. Alternatively, you may enjoy attending dance or yoga classes with friends or carving out a specific time in your schedule to lift weights at the gym. Even moderate-to-low intensity exercises, like going out for a walk every night after dinner, is beneficial for your health.
The best exercise for you is one that you know you will actually show up for time and time again. An added bonus is that you do not have to spend hours exercising to impact your health. The United States Department of Health and Human Services says that no matter the amount of exercise you are able to achieve, most efforts to overcome sedentary lifestyles have a positive impact on all-cause mortality. This means that even incorporating small bouts of moderate-to-vigorous exercises can increase your relative life expectancy. Thus, shifting your focus to do activities that you enjoy and will do daily or weekly may give yourself the best odds for success in the long-run.
“If you’re having trouble finding motivation, start small,” says Dr. Friedlander. “Following exercise guidelines is optimal, but doing any level of physical activity is better than nothing and can improve your health and mood, especially if kept consistent.”
The foundation of longevity science exists in a balance of healthy physical, mental, and emotional aging. In the past, researchers have studied these aspects of health as independent subjects, but now scientists emphasize that every aspect of our health is intertwined. One of the major motivations behind the Stanford Lifestyle Medicine movement is to increase awareness of how total health is dependent upon the interactions between the pillars of our lives.
Recently, members of the Stanford Lifestyle Medicine team collaborated to conduct a systematic review of existing research on “The Role of Physical Exercise in Cognitive Preservation.” The article, which was published in the American Journal of Lifestyle Medicine, responds to a call for more scientific investigations to focus on the prevention of cognitive disabilities associated with old age, such as dementia.
“After conducting this review, a major takeaway is that we should be motivated beyond physical improvements to continue moving our bodies to promote long-term cognitive benefits,” says Matthew Kaufman, MD, lead author of the review article.
Exercise and the Brain
Both aerobic exercise and strength training are widely researched lifestyle interventions for quality health improvement.The US Department of Health and Human Services (USDHHS) recommends weekly exercise of at least 150 minutes of moderate-intensity aerobic exercise and two days of strength training for improving physical and mental health.
There are multiple proposed mechanisms that define how regular physical activity combats cognitive decay. As you exercise, your heart increases the amount of blood that it pumps out to the rest of the body to compensate for the increased workload. This increase in cardiac output also increases cerebral blood flow, which is linked to heightened neural activity and reduced oxidative stress (or an improved ability to detoxify agents in the body). Another proposed mechanism is the increase in trophic factors (proteins that aid cell survival and growth), such as BDNF, VEGF, and IGF-1. These trophic factors support neuroplasticity (the structural reorganization of the brain to support learning) and angiogenesis (the growth of new blood vessels). Therefore, it is reasonable to promote exercise as a lifelong tool for optimizing brain health.
“It is important to understand the physiology of this relationship in order to maximize exercise regimens for prolonged cognitive benefits and goal setting,” says Dr. Kaufman, current Stanford Physical Medicine and Rehabilitation Resident.
Key Takeaways from the Systematic Review
After reviewing over 1,600 total studies, 17 met the team’s final criteria for further analytical evaluation. To be included in the final review, studies must have been a randomized controlled trial published after 2000, excluded cognitive impairments more severe than moderate diagnoses, and included at least one physical activity intervention that lasted for 12 weeks or more and followed the USDHHS recommended guidelines. For this review, both aerobic exercise and strength training were included as exercise interventions. The final 17 studies selected for “qualitative synthesis” looked at the relationships of exercise and global cognition, exercise and memory, and exercise and executive function.
The review team found the largest consensus in the research for improvements in memory for individuals with moderate, mild, or no cognitive impairments following the 12-week exercise interventions. For individuals with mild cognitive impairments, exercise was shown to improve cognition. Although weaker, there was also evidence found for relationships between regular exercise and improved global cognition and executive functioning. Some studies also found significant associations between improvements in physical and cognitive fitness and increases in regional brain volume or blood flow.
However, included studies that analyzed the lasting effects of exercise following the study indicated a need for continued exercise. Improvements in memory and cognitive health were not always maintained once regular exercise stopped. This suggests the importance of exercise as a long-term principle of lifestyle medicine for adequate prevention of late-stage diseases.
“Given that our review demonstrates that people did not see lasting benefits after stopping their exercise, the importance of routine exercise to continue reaping benefits is suggested,” says Dr. Kaufman. “It also strengthens our association that exercise interventions can, in fact, improve cognition.”
By Jonanne Talebloo
This blog is part of our Gratitude & Reflection newsletter. If you like this content, sign up to receive our monthly newsletter!
We have all heard the saying “mind over matter” when it comes to athletics and physical challenges. But can this saying be applied to health, healing, aging, and longevity? Studies suggest that optimism may play a leading role in improving not only one’s emotional well-being but also physical health and increasing lifespan.
Optimism, defined as the tendency to be hopeful and expect positive outcomes, has been linked to improved mental health and well-being in that it uplifts one’s mood and outlook on life. Optimism alone may not be the silver bullet for health and happiness, but studies show that it is one of many factors that can positively influence health, longevity, and lifespan.
For example, research shows that optimism helps diminish stress and anxiety, which lowers the stress hormone cortisol. Elevated levels of cortisol and blood pressure have been linked to an increased risk of stroke, hypertension and heart attack. Chronic stress can have negative effects on almost all of our bodily systems, including the endocrine system, where stress can impair communication between the immune system and the hypothalamic-pituitary-adrenal (HPA) axis, and potentially lead to immune disorders.
Optimism also assists with healing. Akivah Northern is part of the Stanford Lifestyle Medicine Gratitude and Reflection Pillar and earning her doctoral degree in Religion and Health at Loma Linda University. She is a chaplain, which are professionals who listen and accompany patients and their families in life-threatening, physical, existential, moral, or spiritual distress. Northern is the founder of a soon-to-open healthcare center that incorporates lifestyle medicine, chaplaincy intervention, and the arts.
“Optimism is not just helpful, it is vital for those who are suffering,” says Northern. “As a chaplain, I engaged patients in optimism and hope, instilled a sense of the sacred, and offered explorations regarding ultimate meanings. These conversations served as calming, hope-filled, and relieving medicine for patients.”
Optimism and Longevity
Recent studies have explored the connection between optimism and longevity and how a person with a positive outlook has the potential to live a longer, healthier life. A recent study revealed that optimism (defined as “the global expectation that things will turn out well in the future” and measured by cortisol stress reactivity and questionnaires) was linked to decreased cortisol levels, which is an important factor regarding increased longevity. Another study found that higher levels of optimism (assessed using the Revised Optimism-Pessimism Scale) were linked to increasing lifespan by as much as 15 percent.
In a review article examining a variety of health and longevity benefits associated with optimism, researchers found a whole host of benefits. Highlights from the review were that greater optimism predicted greater career success, better social relations, and better health. The article also concluded that the positive effects of optimism appeared to reflect individuals with a greater engagement in pursuit of desired goals. Another large-scale study showed that the link between optimism and increased longevity was independent of ethnic origin and applied across many racial and ethnic groups.
In order to understand how optimism can make such dramatic impacts on our health and longevity, the neural underpinnings of optimism have also been studied. Research suggests optimism activates areas of the brain involved in mood regulation, attention allocation, emotional expression, language processing, and perception of oneself. Modulating these areas with our thoughts may improve psychological well-being by improving one’s perception of the world, themselves, and self-expression.
“Optimism is the opposite of stress, worry and anxiety, which can increase inflammation and chronic illness in the body,” says Northern. “By leaning toward a calming and optimistic way of being, we are increasing not only our mental, emotional, and spiritual well-being, but also our physical health and longevity.”
Optimism can be Cultivated
Although optimism is defined as a trait ingrained in individuals, people can learn to develop optimism over time. Learned optimism can be cultivated through music, gatherings, and culture in community. This sense of community strengthened by optimism can promote individual well-being, contribute to advancements in public health, and even inspire social change on a global scale.
An example of cultivated optimism through culture and community is the fact that millions of Iranian women worldwide have learned to adopt an optimistic attitude in their fight for freedom and equality. Research also shows that optimism improves resilience, another essential characteristic for Iranian women. Optimism and resilience among the Iranian diaspora have been the foundation of a global community that continues to inspire change regarding women’s rights.
Optimism can also be developed at the individual level by working with internal thoughts, such as breaking pessimistic thought patterns or cultivating the experience of gratitude by keeping a gratitude journal. Another way to work towards adopting an optimistic mindset is by challenging and re-writing negative self-talk. For example, this can mean changing phrases such as “I will never be able to do this.” to “This is a challenge I look forward to working towards overcoming.” Furthermore, one study notably found that optimism can be increased through a very simple intervention in which individuals imagined their best possible self for five minutes each day.
“Our internal dialogue is everything. What we tell ourselves, the language we use on the inside will come out on the outside,” says Northern. “So, we need to be intentional about being optimistic, generous, and forgiving—this will make such a difference not only for those around us, but for our own health and healing.”