Chronic stress

Dealing with
Chronic Stress:
A Holistic
Approach
G. Maggio, RN, NREMT-B

AKA How to Avoid T2DM and
other Chronic Non-Infectious
Disease
 The

modern, western lifestyle is strongly
correlated to the “diseases of civilization”
– T2DM, CVD, and other chronic noninfectious diseases. We can easily show
the causal mechanisms leading from
specific parts of this lifestyle to chronic
disease.
 Chronic stress is characteristic of the
modern, western lifestyle, and is a
significant contributor to chronic disease.

Normally, Hormones have an
Intricate Dance

But Chronic Stress Disrupts That
Dance…

Topics Covered
 Pathophysiology

of Stress: Acute and

Chronic
 Dealing with Chronic Stress: The
Foundation – Food, Sleep, Managing
Psychosocial Stressors, and Exercise.
 Dealing with Chronic Stress: Beyond the
Foundation
 Clinical Considerations and Discussion

Pathophysiology in 10 Minutes
or Less
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Acute stress is a response to a situation we
perceive as threatening or requiring
immediate action.
“Fight or Flight” – the sympathetic nervous
system is activated. The stressor stimulates the
hypothalamus to release arginine-vasopressin
(AVP) and corticotropin-releasing hormone
(CRH).
AVP reabsorption in the kidneys and
induces vasoconstriction, BP.

The HPA Axis
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Together, these two
hormones activate the
hypothalamic-pituitaryadrenal axis (HPA axis).
CRH travels to the
pituitary, which
releases corticotropin,
stimulating the adrenal
cortex to release
corticosteroids and
catecholamines.
Image Source: http://dujs.dartmouth.edu/fall2010/the-physiology-of-stress-cortisol-and-thehypothalamic-pituitary-adrenalaxis#.UnWmUpSife8

Cortisol: A Busy Hormone
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Cortisol blocks insulin by stimulating
gluconeogenesis; it also stimulates glycogen
production in the liver.
It prevents cells from losing sodium, and increases
potassium excretion, regulating ion balance.
It reduces inflammation by blocking interleukin
signals to T-Cells, and blocking histamines.
It inhibits CRH.
These functions – when things are running
smoothly – help us recover from acute stress, and
get going in the morning (when cortisol levels are
highest).

Cortisol in Chronic Stress
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In chronic stress, chronically elevated cortisol leads
to chronically elevated blood sugar through
increased gluconeogenesis and development of
insulin resistance.
The hippocampus has many corticosteroid
receptors. Chronic stress affects memory formation
and leads to premature aging of the
hippocampus.
The function of the immune system is impaired.
Circadian rhythms are disrupted – cortisol should
be low at night, and melatonin high.
Chronic stress leads to failure of inhibition of CRH.

Hans Selye’s General
Adaption Syndrome
 The

body tries to regain homeostasis, but,
with the stressor still present, can’t.
 First, the hyperarousal lessens.
 Eventually, the body reaches a state of
exhaustion as it can no longer cope (we
will talk about adrenal fatigue in just a
moment).

Other Effects of Chronic Stress
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Chronic stress depresses HPA function
(remember, it was working overtime!) – this
disrupts thyroid function (symptoms of
hypothyroid with no thyroid problem). It also
causes thyroid hormone resistance.
Release of IL-1, IL-6, and TNF causes systemic
inflammation and disrupts conversion of T4
into T3.
It encourages autoimmunity by weakening
immune barriers in the GI tract, lungs, and the
blood-brain barrier.

Adrenal Fatigue
 As

the adrenals are overworked, ability to
release corticosteroids and
catecholamines is reduced.
 Symptoms of this adrenal insufficiency
include dizziness, fatigue, low blood sugar
and the attendant carb-cravings and
weight gain, and depression.
 Also associated with autoimmune
disease.

The Road to T2DM


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We can now easily see how
chronic stress fits into this
diagram.
Research is showing that not
only does T2DM cause
inflammation, but that chronic
systemic inflammation is a
contributor to the disease
process.
Note: there is metabolically
healthy obesity, and nonobese people who get T2DM
tend to be hit harder (in fact,
obesity may be the body’s
way of trying to adapt!)

Image source: http://chriskresser.com/the-autoimmuneinflammatory-model-of-diabesity

Food!
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“Let food be thy medicine & thy medicine be
food” - Hippocrates
What we eat is the foundation of our health.
Our guidelines as clinicians are outdated, and
contradict the latest research.
Food can be anti-inflammatory or inflammatory; it
can lead to insulin resistance or it can help deal
with it.
The proper diet will help maintain blood glucose,
reduce cravings, and reduce rather than
exacerbate the symptoms of adrenal fatigue.

Problems with the Western Diet
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The Western Diet is full of inflammatory foods – the
worst of which are refined flours, high fructose corn
syrup, and refined seed oils.
It also has a dramatic imbalance of Omega-6
(pro-inflammatory) to Omega-3 fatty acids (antiinflammatory). Both are necessary, but our ratio is
all wrong (15-16.7/1 as opposed to 2/1, which we
evolved on).
There are an excessive amount of carbohydrates,
particularly high Glycemic Index carbohydrates.
There is also an excess of energy dense, nutrient
poor food.

Signs it Might not be Real
Food…
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There are exceptions, but…
It has a lengthy list of ingredients, many of which you
can’t pronounce, or last saw in a chemistry class.
It doesn’t go bad, or takes months or years to go
bad.
It requires a “nutrition facts” label.
You have trouble identifying what animal or plant it
came from.
It has “low fat” or “low calorie” on the label; the fat
has most likely been replaced with refined sugars,
and the calories with artificial sweeteners (which
produce insulin spikes, among other things).

Fixing Your Diet
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Increase consumption of whole fruits and vegetables,
particularly vegetables. Fruits and vegetables are nutrient
powerhouses, giving us vitamins, minerals, and
phytochemicals that are antioxidants – we’re just
scratching the surface of all the things they do for us. They
are also far less calorie-dense than grains, give us more
fiber, and way more micronutrients.
Reduce or eliminate processed foods; reduce or eliminate
grains (particularly refined flour, but whole grains are often
not “whole”, and are still calorie dense and nutrient poor –
and many, many people have gluten intolerances, found
in several grains).
Eliminate refined seed oils; replace with extra virgin olive oil
for cold uses, and virgin coconut oil for high heat.

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Get protein from quality sources – unprocessed
meats and eggs (not cured meats, slim jims, and
“eggs” in a carton!). Cage-free eggs, pastured
meats, and wild caught oily fish are great if you
have access and can afford them. Leaner cuts
are better choices for conventional meats.
Low to moderate carbohydrates, and choose
carbohydrates from low glycemic index sources.
How many carbs you should eat is controversial,
and depends on activity level, insulin sensitivity,
and how you respond – in general, know your
body – food should make you feel good in the
short, moderate, AND long term.
Don’t let the perfect be the enemy of the good –
make the healthiest choices you can with what’s
available to you and what you can afford.
EAT YOUR VEGGIES!

How our Food has Changed
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Wild or pastured animals have lower omega-6
to omega-3 ratios than grain-fed, confined
animals.
Cage-free eggs have much greater amounts
of omega-3 fatty acids than conventional
eggs!
We treat animals horribly and make them
terribly unhealthy – we shouldn’t be surprised
when they aren’t as healthy for us.
Monocrop, industrial agriculture depleting soil
and leading to lower quality plant foods.

Don’t Fear Fat
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Fat has been much maligned, but, finally, we’re coming
around.
Fat does not make you fat. Insulin resistance and caloric
excess causes fat storage. Our bodies are not bomb
calorimeters – the hormonal environment, macronutrient
composition, and overall thermic effect of the food are all
important variables.
Fat doesn’t cause an insulin spike, and is very satiating.
Of course, not all fats are created equal – avoid refined
seed oils, due to free radicals produced by oxidation during
heat processing and poor omega-6/omega-3 ratios; and
trans fats should be completely eliminated from the diet
(but you knew that). And avoid an excess of omega-6s.

Coconut Oil: MCTs
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Coconut oil is an example of the changing view
on fats (including saturated fats).
Coconut oil is high in medium chain triglycerides
(MCTs), a saturated fat easily used for fuel. It also
leads to efficient energy use and can help restore
thyroid function. It raises HDLs and lowers LDLs.
It improves insulin sensitivity and glucose
tolerance, and lowers abdominal adiposity.
Get virgin coconut oil (the old “coconut oil is bad
for you” was about hydrogenated coconut oil –
don’t eat hydrogenated fats!)

To Repeat Myself…
EAT

YOUR VEGGIES!!!
Image source:
http://uhaweb.h
artford.edu/MN
UNEZ/Veggies.jp
g

Some Tips on Eating Healthy
When Stressed
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Make the healthy option the easiest option – don’t keep
unhealthy options around when you’re stressed and have more
cravings.
Take the time to cook most of your food for the week in one
day – the goal is to have most of your meals for the week in the
fridge, and ready in five minutes or less. Chop and steam
veggies, so you can quick sauté them. It’s as easy to cook a
few pounds of meat in the oven as it is to cook one serving.
Stuff that simmers is your friend – get stuff done nearby while
multiple meals simmer away!
Frozen veggies are a good option – keep some on hand for
those “I’m out of fresh veggies, but don’t have time to shop”
days.
Some kitchen gadgets can save you a lot of time and/or effort
– e.g. crockpot, food processor.

Sleep
 Chronic

stress disrupts our sleep cycles.
 Acute sleep deprivation causes drastic
increases in cortisol, putting another
stressor on the body.
 Sleep loss reduces insulin sensitivity without
beta cell compensation.
 Sleep loss reduces leptin (hormone
responsible for satiety) and increases
ghrelin (increases appetite).

 Sleep

durations shorter than 7-8 hours are
associated with:
 CVD and diabetes risk factors
 Depression
 Accidents
 Learning and memory problems
 Excess mortality
 One study shows that 28.3% of US adults
sleep 6 or fewer hours.
 I would guess the percentage at YSN is
higher!

Fixing Sleep
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Practice good sleep hygiene – dark room, no
electronics, maintain a regular bedtime, and
so on.
Exercise!
Moderate caffeine consumption, and keep it
earlier in the day.
Acute sleep deprivation due to cramming
does more harm than good.
We’ll talk about supplements and herbs later.

Managing Psychosocial
Stressors
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Psychotherapy is beyond the scope of this presentation,
but is a good option, especially focused on reframing life
stress.
Get reality-checked by friends, family, and/or loved ones –
break out of those stress spirals!
Reappraising our physiological response to stress improves
performance, reduces cardiovascular and cognitive
symptoms, and moderates the relationship with depression.
Meditation and yoga – transcendental meditation found to
be effective in secondary prevention of CVD.
Find the things that center you that make you feel calm
afterwards (for me, that’s putting heavy weights over my
head, spending time in nature, making things, and Aikido –
your mileage may vary).

Exercise!
 In

a study of medical residents, the two
wellness behaviors most associated with
higher well-being were restful sleep and
exercise.
 Physical activity is associated with
decreased depression and anxiety.
 Exercise improves insulin sensitivity in both
normal and insulin resistant populations.

How to Exercise?
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While you can overdo it, we mainly see overtraining
(neuroendocrine derangement) in high-level athletes
or the “more is always better” crowd.
However, don’t get into the cycle of “I ate ___, now
I’ll run off the calories”. It doesn’t work, and it turns
exercise into a stressful punishment, rather than a
challenging and rewarding activity.
Exercise should be progressive – the body responds
to exercise by adapting to it, and requires a greater
stimulus to adapt further.
High Intensity Interval Training (HIIT) has benefits over
moderate intensity aerobic exercise, and is more
time efficient.

We can’t all be Sarah
Robles…
But we all should do progressive
resistance training as close to
functional, whole body
movements as our bodies allow.
Resistance training improves
insulin sensitivity over aerobic
exercise alone, further decreases
abdominal obesity, and muscle is
highly metabolically active tissue.
Plus, it reduces stress. And we’re
all going to lose muscle and
strength as we age – a higher
starting point will keep us
independent longer. Besides, it’s
fun!!!

Image source:
http://www.autostraddle.com/sarah-roblesraising-the-bar-for-lady-lifters-141756/

Beyond the Foundation:
Vitamin D
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We’re revising the minimum normal vitamin D
level from 30 nmol/L to 50; at that level, a
majority of the population is likely deficient.
We live in northerly latitudes, don’t get much
sunlight, and adipose tissue makes vitamin D
unavailable.
Very few foods are adequate sources of
vitamin D – oily fish is the best natural source.

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Vitamin D is the new hot micronutrient (and is
actually a hormone precursor).
Its vital importance in calcium absorption is wellknown.
Research is pointing toward a role in reducing
metabolic and oxidative stress and reducing risk of
cardiovascular disease.
Vitamin D deficiency increases parathyroid hormone,
worsening insulin resistance. In fact, vitamin D is
inversely related to insulin resistance, independent of
obesity, in a study of Korean adolescents.
Correction of vitamin D insufficiency in obese
children improved insulin sensitivity and glucose
metabolism.
Vitamin D may protect against stress-induced
deterioration of the brain and heart.
Vitamin D deficiency has also been associated with
fatigue, depression, poor concentration, and muscle
aches and pains.

 The

RDA for vitamin D is rather low (and
should be higher).
 A conservative, safe UL is 4,000 IU a day.
 1,000 and 2,000 IU vitamin D supplements
are cheap and readily available.
 Having your vitamin D level screened is
probably a good idea; make sure you
have a provider who is up to date on the
latest recommendations (most aren’t,
especially outside naturopathy and
functional/integrative medicine).

Fish Oil
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Fish oil is rich in omega-3 fatty acids, particularly
Docosahexaenoic acid (DHA) and Eicosapentaenoic acid
(EPA).
Flax is a good plant source of omega-3 fatty acids, but the
conversion of ALA to DHA and EPA is rate-limited, thus, it
doesn’t do much for DHA and EPA blood levels.
EPA reduced fasting blood glucose, HgA1C, and insulin
resistance in overweight T2DM patients.
There is a general association with improved insulin
sensitivity.
Studies have shown fish oil is effective in depression, and it is
likely the EPA.
Fish oil reduces basal cortisol levels.
2-4 grams a day, or 0.5-1.8g of EPA+DHA

Zinc, Magnesium, and
Melatonin to Improve Sleep
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In a study of residents of an Italian skilled nursing
facility (SNF), 5 mg of melatonin, 225 mg
magnesium, and 11.25 mg of zinc, administered
an hour before bedtime, significantly improved
ease of getting to sleep, quality of sleep,
hangover on awakening from sleep, and alertness
and behavioral integrity the following morning.
Quality of life was also improved.
The melatonin dose was very high; I suggest
experimenting with lower doses. I also am wary of
chronic melatonin supplementation and wonder if
it could affect circadian rhythms.

Acupuncture
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Found to improve memory and learning
impairments due to chronic mild stress.
Can improve sleep quality in patients with
insomnia.
Had beneficial effects on insulin, leptin,
ghrelin, and cholecystokinin (CCK) levels in
obese women.
Can improve hyperglycemia, hyperlipidemia,
altered sympathetic nervous system activity,
and insulin signal defect, contributors to insulin
resistance.

Herbs
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German Chamomile (Matricaria recutita) has
been shown to have mild to moderate
anxiolytic activity, at least in patients with
General Anxiety Disorder. It also has some
antidepressant effects in anxious, depressed
patients.
Chamomile improved day time functioning in
chronic primary insomnia, by improving sleep
latency, night time awakenings, the fatigue
severity scale.

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Lemon balm (Melissa officinalis), at a 1600mg dose
of dried leaf, increased calmness and improved
memory performance in healthy, young
participants.
Another study showed anxiolytic properties
combined with Valerian (Valeriana officinialis).
Skullcap (Scutellaria lateriflora) enhances mood
without decreasing cognitive performance.
Passionflower (Passiflora incarnata) improves
subjective sleep quality in healthy adults.
Passionflower is also used as an anxiolytic; two
studies showed a lack of difference in efficacy as
compared to benzodiazepines. One study showed
statistically insignificant (but warranting further
study) improvement in job performance (in
comparison), and another a statistically
insignificant lower incidence of drowsiness as
compared to a benzodiazepine.

 Cinnamon

(Cinnamomum sp.) – studies
have shown improvement in glucose,
insulin and insulin sensitivity, gastric
emptying, blood pressure, lean body
mass, lipids, and antioxidant status in
patients with T2DM, metabolic syndrome,
and PCOS. Cinnamon has been shown to
moderate postprandial blood glucose
levels in normal weight and obese adults,
lowering them up until the two hour mark,
with a higher level at two hours.

Adaptogens
 Adaptogens

are a class of herbs that help
the body adapt to and better deal with
stress.
 They are some of the more powerful herbs
in the herbal materia medica, and should
be used by knowledgeable practitioners.
 They don’t fit easily into the western
allopathic model, however, research
evidence is building.

Ginseng
 Ginseng

is a very important herb in
Traditional Chinese Medicine (TCM);
Panax ginseng and P. quinequefolius
(American Ginseng) are the two most
commonly used varieties; there are
differences within TCM (American ginseng
generates more yin), but they are similar.
 Siberian Ginseng (Eleutherococcus
senticocus) is in a different genus in the
same family.

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P. ginseng has been shown to improve
working memory performance and calmness
in healthy young adults; decrease plasma
cortisol levels and help with fatigue; and
alleviate depression through peripheral antiinflammatory effects. It is thought to reduce
fatigue through significant antioxidant
properties.
P. ginseng is protective against acute
respiratory infection (ARI) and lessens the
duration and severity of ARI.
In patients with fibromyalgia, it reduced pain,
improved fatigue, and improved sleep as well
as amitriptyline; it improved anxiety, but not
as well as amitriptyline. It also reduced the
number of tender points and improved
patients’ quality of life.

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P. quinequefolius decreased blood glucose
and HgA1C in Type 1 and Type 2 diabetic
mice. Interestingly, it increased plasma insulin
and c-peptide in the Type 1 mice, while
decreasing them in the Type 2 mice. There
was an increase in islet area, possibly
indicative of β-cell regeneration.
It also prevented diabetic retinopathy and
cardiomyopathy in diabetic mice.
It has shown to be effective in glycemic
control in T2DM patients. Studies have
focused on patients with T2DM, but surmising,
via mechanism of action and traditional use,
that it would be helpful with insulin resistance
in general is probably reasonable.

Ashawagandha and Tulsi
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Ashawagandha (Withania somnifera) is an important
herb in Ayurvedic medicine.
It has been shown to safely and effectively promote
resistance to stress and improve quality of life.
It is used for memory, for neurodegenerative disease,
as an anxiolytic, to improve energy and
mitochondrial health, and as an anti-inflammatory
and anti-arthritic.
Studies are ongoing (mainly in India).
Tulsi (Ocimum sanctum), also known as Holy Basil, has
been demonstrated to have antioxidant properties in
rats; it is used as an adaptogen in Ayurvedic
medicine.

Rhodiola rosea
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Rhodiola rosea has been shown in vitro to
protect human cortical neurons against
glutamate and hydrogen peroxide-mediated
cell death through reduction of calcium
accumulation, via improving calcium
homeostasis.
Rhodiola improves endurance exercise
performance; it lowered heart rate during
warm ups and significantly reduced six mile
run times, likely due to decreasing the
perception of effort.

 It

has been most used in Eastern Europe,
where, in addition to its use in training and
exercise, it was also shown to improve
cognitive function and reduce mental
fatigue. Studies in Western Europe and
North America have indicated substantial
antioxidant properties.
 It lowered the level of c-reactive protein
and creatinine kinase after exhausting
exercise, demonstrating anti-inflammatory
and muscle protective properties.

Clinical Considerations
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Don’t let the perfect be the enemy of the
good for your patients, either.
Conversely, don’t make assumptions about
what patients are or are not capable of –
going for a harder, but still achievable lifestyle
change is probably worth it if they’re going to
see better results.
Work to improve access to quality, real foods
– can we get community health centers
having their own gardens and/or partnering
with local farmers?

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Know the physiology of bodily responses to food –
epidemiological studies are notorious for
confounding variables and being able to be read
any way you want to read them. Get skeptical if a
dietary recommendation conflicts with human
physiology or the anthropological record. And follow
the money!
Recognize that we have been giving conflicting and
ineffective dietary recommendations for years –
you’re going to have to win patients over, and
they’re going to need to see serious results. Diet is
one of those things where just jumping in is often
easier than incremental changes.
Food journals, even if they never show anyone else,
are really effective at getting people to realize
exactly what they’re eating – there’s a tendency to
do a lot of snacking on unhealthy foods on autopilot.
We really should be able to write a prescription for
cooking classes, and to make sure there’s a kitchen
that is in working order.

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Meditation is easy to do, requires no materials,
and is easy to teach the basics. Teach it.
Education on what stress responses mean in
the body can help in reappraising them.
Refer to psychotherapy when helpful – but try
to get the “house in order” before you reach
for the prescription pad for meds – why treat
the symptoms when you can treat the cause?
We can start slow and low volume in exercise
and get a benefit, but don’t underestimate
where patients can go – many of the studies
cited for HIIT and resistance training were of
patients with CVD or T2DM, generally older.

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Fit exercise recommendations with the
patient’s access to resources. Good gyms are
great, but if they can move, they can find a
way to progress from cardiovascular exercise
to HIIT; and there are a plethora of
calisthenic/gymnastic exercises, with great
variance in difficulty, to keep people busy
with resistance training.
Emphasize time management in regards to
working harder, not longer.
If you can refer a patient to physical therapy,
do so. Physical therapists not only know
rehab, they do exercise teaching. There are
good coaches and trainers out there, but
most personal trainers tend to be awful.

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Know when to test things like thyroid hormone
levels, cortisol levels, and vitamin D, know why,
and know how to get them covered by insurance!
If not contraindicated, consider fish oil. Pretty
much everyone should have some degree of
vitamin D supplementation (we don’t get enough
from food, and don’t get enough sunlight).
Chris Kresser L.Ac has a great idea with
glucometers – have patients test fasting, before
lunch, and one, two, and three hours afterwards
to map response. Postprandial responses will
generally be abnormal before fasting and HgA1C
(see earlier discussion of adrenal fatigue).
Know your supplements and herbs. Try
magnesium/zinc/melatonin and gentle herbs
before going for the prescription pad for sleep
issues if you can. Teach sleep hygiene first.

 If

your further education doesn’t include a
study of herbalism, know who you can
refer patients to who is competent to
advise on adaptogens when appropriate.
 Know your local complementary and
alternative medicine practitioners – be
able to provide a variety of options, and
be able to direct patients to good
practitioners. For acupuncture in
particular, there are often community
acupuncture clinics that are very
reasonable.

 Keep

digging through the research, pay
attention to related fields (like nutrition
and exercise physiology), and look at the
research the skeptics and outsiders are
following – don’t fall for a consensus view
that is really just the loudest voices with
the most money.
 Don’t be afraid to be an innovator or to
buck the trends when you know the
science supports you – but realize you’re
going to need the research at your
fingertips to back you up, and you’re
going to need to draw attention to it.

Some Book Recommendations
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Written for laypeople, It Starts With Food by
Dallas and Melissa Hartwig (the folks behind
the Whole30) is the absolute best book on
nutrition, dietary change, and food’s effect
on health for a general audience that I have
ever read.
Diane Sanfilippo’s Practical Paleo: A
Customized Approach to Health and a
Whole-Foods Lifestyle is also excellent, and
has menus and food recommendations
designed for a variety of health conditions.

 Melissa

Joulwan’s Well Fed: Paleo Recipes
for People Who Love to Eat and Well Fed
2: More Paleo Recipes for People Who
Love to Eat are wonderful cookbooks full
of delicious recipes that work exactly as
described, and are made up of healthy,
whole foods. Also, she has enormous
amounts of advice in both books on
prepping and cooking food to keep you
in healthy food for the week when you
have a busy life.

References
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http://dujs.dartmouth.edu/fall-2010/thephysiology-of-stress-cortisol-and-thehypothalamic-pituitary-adrenalaxis#.UnT6RJSife9
http://faculty.weber.edu/molpin/healthclasse
s/1110/bookchapters/stressphysiologychapter
.htm
http://www.jblearning.com/samples/0763740
411/Ch%202_Seaward_Managing%20Stress_5
e.pdf

 http://chriskresser.com/5-ways-that-stress-

causes-hypothyroid-symptoms
 http://chriskresser.com/the-autoimmuneinflammatory-model-of-diabesity
 http://ods.od.nih.gov/factsheets/Vitamin
D-HealthProfessional/
 http://chriskresser.com/how-to-preventdiabetes-and-heart-disease-for-16

Peer-Reviewed Articles








http://www.dovepress.com/the-western-diet-andlifestyle-and-diseases-of-civilization-peer-reviewedarticle-RRCC
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC29
13796/?tool=pubmed
http://diabetes.diabetesjournals.org/content/54/s
uppl_2/S108.full
http://ajcn.nutrition.org/content/81/2/341.long
http://www.ncbi.nlm.nih.gov/pubmed/?term=Barr
%2C+S.%2C+Wright%2C+J.+Postprandial+Energy+E
xpenditure+in+Whole-Food+and+ProcessedFood+Meals%3A+Implications+for+Daily+Energy+E
xpenditure

 http://www.ncbi.nlm.nih.gov/pubmed/22

826636
075505
015695
911112
890471

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
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http://www.ncbi.nlm.nih.gov/pubmed/199316
17
36
89
http://www.ncbi.nlm.nih.gov/pmc/articles/P
MC2727237/
http://wjh.harvard.edu/~jamieson/JJ_JESP.pd
f
http://wjh.harvard.edu/~jamieson/JEP_reappr
aisal.pdf
43
http://circoutcomes.ahajournals.org/content/
5/6/750.full?sid=5bfb47bc-ce6d-4800-96932721f911c08c



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66
19
91
http://www.nature.com/icb/journal/v78/n5/fu
ll/icb200070a.html
20
12
18

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http://www.medsci.org/v04p0019.htm
http://www.medscape.com/viewarticle/464281_4
32898/
898/

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37
09
68
32
41
79
36
46

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15
31
79
90
49
75
60


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