Insulin Resistance – What it is and how we Combat it!

Insulin is a hormone produced by the pancreas that moves glucose from the bloodstream into the cells so it can be used to fuel the function of the cells and tissues of the body. In people with Type 1 diabetes, the pancreas is unable to make sufficient insulin to drive glucose into the tissues and thus they require injectable insulin to make up the difference.

Insulin resistance is when insulin is being produced by the pancreas, but it is not as effective in moving glucose into the cells and tissues. This results in higher blood glucose levels and an increased amount of glucose that is stored as fat particularly in our mid-section, which is called “truncal obesity”. Insulin resistance plays a role in the “metabolic syndrome”, which is a constellation of obesity, high blood pressure, high cholesterol and Type 2 Diabetes.

What Causes Insulin Resistance?

Risk factors for developing insulin resistance include:

  • Obesity
  • Inactive lifestyle
  • Diet high in processed carbohydrates
  • Smoking
  • Medical conditions such as non-alcoholic fatty liver and polycystic ovarian syndrome
  • Genetics/Family history
  • Medications such as steroids

How We Combat Insulin Resistance

  • Address the potential causes above with your doctor, fitness/nutrition coach.
  • Minimized processed carbohydrates (ie avoid “added suger” in the things we eat).
  • Reduce carbohydrate consumption to 30-40% of caloric intake (speak to your nutritionist).
  • Exercise! Skeletal muscles have a special metabolic pathway that is independent of insulin which helps to move glucose into muscle tissue (Glut4 pathway).
  • Pharmacotherapy – In more severe cases, there are a variety of prescription “insulin sensitizers” that can help with insulin resistance and Type 2 diabetes as an adjunct to the lifestyle modifications above. As always, check with your physician! ■

Carla DiGirolamo is Board Certified in Obstetrics and Gynecology and Reproductive Endocrinology and Infertility specializing in the care of women through all stages of life. She was named among the Top Doctors in the Boston area by Boston Magazine in 2019 and 2020. She is also a Crossfit Level 1 Trainer and member of Crossfit Physicians, Les Mills BodyCombat/BodyPump Instructor and Certified Precision Nutrition Level 1 Coach.

The Power Within at age 40 and Beyond

Shellie Edington, age 52; 2016 Crossfit Games Masters Champion – by Kevin Harrington

Over the last 30 years, the Fitness industry has evolved from the gym being mostly for “muscle heads” – and certainly not a place for a teenage girl – to a more inclusive environment – over all age groups and across genders. Today there are so many more fitness options to choose from, whether it be Zumba, Spin, Bar, Yoga or Crossfit, just to name a few, and today’s gym is most certainly a place for male and female high school and college athletes. But one of the fastest-growing demographics seeking to improve their physical fitness is the 40+ year-old woman.

This month I had the opportunity to take a course called “Menopause for Athletes” by Dr. Stacy Sims, exercise physiologist and nutrition scientist. I have spent 15 years of my career taking care of women in all phases of reproductive life, as well as becoming a Crossfit Trainer and Nutrition Coach. But this course was able to tie it all together.

Why is the 40+ woman special? Well, we have seen quite a bit of life, maybe raised children, solidified our careers, taken our “bumps” and celebrated some victories. As a result, we are wiser, more centered, care less about the “status quo” and are ready to conquer the next half of our lifetime! But in the midst of all this empowerment, our bodies are changing. But what I learned in this course and in my experience taking care of women, is that these changes are not the end of us; they are actually the beginning, and present new opportunity to embrace change and conquer it to make us better, stronger, faster and fitter!
So what is changing and how do we deal with it? Here are some tips!

Insulin Resistance

Insulin is a hormone secreted by the pancreas that helps move glucose (sugar) into our tissues. When insulin is not working properly, more glucose is stored as fat. From age 40 and beyond, our hormones are transitioning after a long reproductive life. As a result of greater hormonal fluctuations during this time, our bodies become more resistant to insulin. This is why we get that little “pooch” around our middles and feel more “squishy”. So what do we do?

  • Be mindful of refined sugar intake (a.k.a “added sugar”, sweets, breads, pasta) and reduce this intake.
  • Work those muscles!! Your muscles are one of the greatest utilizers of glucose in the body (next to the brain), so much so that they have a second metabolic pathway for moving glucose into the tissue – the Glut4 pathway – which is independent of insulin. The more you move and work your muscles, the Glut 4 pathway kick’s in and moves that glucose to a place that can use it rather than store it as fat, taking some of the load off of your insulin!
  • Focus carbohydrate intake around physical activity – within 1-2 hours before and within 1-2 hours after. During these periods, the body is either prepping for glucose utilization or recovering and thus using glucose, again, instead of storing it as fat. That does not mean restrict carbohydrate only to these times (that wouldn’t be healthy), just move some of your daily carbohydrate intake around activity, and have a little less during times of rest.

Decline in Bone Density and Muscle Mass

Estrogen is the dominant female hormone during our reproductive life. When we are having regular menstrual cycles, the estrogen exposure helps to build and maintain our muscle mass and bone density. Once estrogen declines as it does in our 40’s and beyond 50, our bone density and muscle mass decline with it. So what do we do?

  • LHS – Lift Heavy Stuff! Resistance training is one of THE greatest things we can do to maintain our bone density! When the stimulus to build bone and muscle declines with less estrogen around, we can compensate for that stimulus with a new stimulus, and that is weight training.
  • Plyometrics – The key here is multi-directional: running, box jumps, jump rope, sports – incorporating a variety of plyometric exercises provides another stimulus for bone-building and maintenance.
  • Vitamin D and Calcium intake. They go hand in hand to build and maintain bone density. It is recommended that women in most age groups consume 1200mg of Calcium daily. Dietary sources are best but calcium carbonate or calcium citrate supplements are good too. Always check with your doctor. Vitamin D supplementation recommendations depend on sun exposure – here in New England, we all need it during the winter months! 1000-2000 IU per day is typically a safe range.
  • Protein intake. Always include a variety of sources including plant, animal, nuts, seeds, tofu, and dairy as tolerated. As we need to work a little harder to maintain our muscle mass as estrogen declines, we need to ensure that we have the building blocks to do that. There are some studies that suggest 2-2.3g of protein/kg body weight works well for maintaining muscle mass in the in active, exercising peri/post-menopausal woman.

Joint Laxity

Ever wonder how the little 70 year-old lady tears her rotator cuff carrying groceries? As we age, the absence of estrogen leads to more laxity in our tendons and ligaments (they have estrogen receptors too!). Coupled with declining muscle mass, this can lead to less stability within our joints and increase our risk of injury. The operative word here is “can” – because it doesn’t have to be this way! What can we do?

  • Core Stabilization Exercises: Focus a portion of exercise time on core stabilization work. Rotator cuff exercises (Crossover Symmetry is my fav!), planks, oblique twists, situ ups, back extensions – just to name a few; and LHS – “Lifting heavy stuff” requires tremendous core stability and is all the more reason to make it part of your exercise routine.
  • Yoga. Incorporating Yoga practice into your wellness routine builds and maintains core strength and stability, balance, body control and mindfulness; all strengths and skills that become critically important for our vitality as we age.

A Word About Stress

Stress reduction is important during our entire lives to remain healthy, happy, and to be good partners and parents to our children. But as we age, the negative impact of stress can become even more problematic for our health. Cortisol is a hormone that is secreted under times of stress – this could be physical stress or mental stress. We all experience stress in short bursts. This is healthy and our bodies are designed to adapt to this and recover to be stronger. But prolonged stress – and thus prolonged exposure to Cortisol due to overtraining or ongoing life stressors – can result in insulin resistance, an inability to recover, and suppression of our immune system. Our 40’s and beyond is a time of our lives where we become a little more insulin resistant and recovery/sleep become a little more challenging to achieve. So stress reduction is paramount to keeping us balanced, healthy and happy!
Our forties and beyond is a time to celebrate our accomplishments, our strength and our wisdom – and also our ever-changing physical selves! So ladies, join me in kicking 2020 to the curb and saying “Bring it, 2021!”

Carla DiGirolamo is Board Certified in Obstetrics and Gynecology and Reproductive Endocrinology and Infertility specializing in the care of women through all stages of life. She was named among the Top Doctors in the Boston area by Boston Magazine in 2019, 2020 and 2021. She is also a Crossfit Level 1 Trainer and member of Crossfit Health, Les Mills BodyCombat/BodyPump Instructor and Certified Precision Nutrition Level 1 Coach.

This is Not a Blueberry

The debate about “whole food” versus supplements is like the Clash of the Titans in the Nutrition world.  But when it comes down to which is better, I’ll take from the Precision Nutrition playbook and say “It depends..”. When it comes down to what is going to help any individual get healthier, there is no one-size-fits-all. 

So what exactly do we mean by “whole food”? It is food that is as close to its native form, straight out of the ground or right off the tree. These are your fresh fruits, vegetables, legumes, nuts, seeds, roots and herbs. These are typically foods that do not come in a package nor have they been processed to any great extent. The advantage of including whole foods in your nutrition plan is that their vitamins, minerals, cofactors and fiber are in their original architecture as nature intended. This is in contrast to juices, tablets, powders or capsules that have mirrored the nutrient profile of a particular fruit or vegetable and processed it with chemicals or mechanically into a powder or capsule.

So what’s the difference? If the nutrient profile is the same, then it must be just as good, right? Well, not exactly. How the body processes nutrients when the original architecture is intact, is very different from how the body processes a juice, powder, pill or tablet. For example, let’s consider an apple. Apples are considered a “low glycemic” fruit, meaning, the natural sugar that exists in the apple is slowly absorbed by the body, minimizing insulin rise due to the fibrous structure of the apple itself. If that apple is then processed into apple juice, the fiber is removed and it is now more quickly absorbed resulting in a more dramatic insulin spike. It has now lost its “low glycemic” properties because the fiber was lost in the processing. 

Another example is the loss of natural cofactors that exist in a food’s original form that cannot be replicated during processing into a pill, powder or tablet. An example of this is the absorption of iron from a kale salad versus taking an iron supplement. The body will see far more bioavailable iron from a kale salad with a squeeze of citrus. The citrus adds acidity to break down the fibrous scaffolding of the kale liberating the natural iron, then the vitamin C from the citrus and the greens promotes absorption of the iron. This simply cannot be replicated in pill form because the “whole” in “whole foods” is greater than the sum of its parts. 

But this certainly doesn’t mean that there is not a place for supplements. Supplements play a critical role in our health and well-being, particularly in cases of food intolerances, deficiencies, medical conditions such as pregnancy and dietary preferences. But what if you just don’t like kale? Supplements also play an important role as a transition into a healthier dietary alternative when you embark on a new nutrition program. When you are moving away from a Big Mac at lunchtime, the jump to the kale salad may be too much and you will be unlikely to adhere to it. Instead, a shake made with powdered greens is most certainly a step in the right direction to get the vitamins and minerals that are missing from the Big Mac. The shake also provides a healthier alternative that is more palatable than the kale salad that you dislike.

In the end, the “best” nutrition program is the one you can stick to. Fortunately, there exists a wide array of options, from the multitude of high-quality dietary supplements to the very foods that nature intended, to design a successful plan to achieve the healthiest version of yourself! ■

Carla DiGirolamo is Board Certified in Obstetrics and Gynecology and Reproductive Endocrinology and Infertility specializing in the care of women through all stages of life. She was named among the Top Doctors in the Boston area by Boston Magazine in 2019 and 2020. She is also a Crossfit Level 1 Trainer and member of Crossfit Physicians, Les Mills BodyCombat/BodyPump Instructor and Certified Precision Nutrition Level 1 Coach.

Finding Balance through Ayurveda

Unprecedented times call for unprecedented ways of managing disruptions to our environment and coping with uncertainty. Here we take a trip East to Ancient India where we explore an alternative medicine philosophy that focuses on balance and holistic well-being.

“Ayurveda” derives from Sanscrit roughly translated as “the science of longevity” or “the sacred knowledge of life” with roots dating back over 5000 years in the Vedic period of ancient India.  Ayurveda views “Health” as a “state in which the mind, soul, and senses interact harmoniously to experience a feeling of self, wellness, and even bliss.”

The pathway to good health in Ayurvedic philosophy views the universe as the interaction of “elements” (earth, fire, water, air and space) and opposing/balancing “qualities” (hot, cold, rough, smooth, etc.). Doshas are bodily humors that embody a combination of elements and qualities to create a functional entity—an energetic force of nature. There are 3 Doshas: Vata, Kapha and Pitta. All three Doshas are present in everyone, but in different ratios defining one’s constitution, which is present at the time of birth and vary through life and circumstance (To learn about your Dosha balance, take this quiz:  

Understanding  your constitution and when it is imbalanced lends insight into interventions that will help to move you back in  the direction of balance and well-being.

Addressing imbalance may be as simple as slowing down and having a cup of warm tea; reading a book; exercising in the morning rather than the evening, or adding new or different foods and spices to your daily menu. Sometimes simple modifications can go a long way to restore balance and well-being.  

Yoga, a practice related to Ayurveda through its roots in Vedic knowledge, is an integrative approach, harmonizing the body, senses, mind, and consciousness. Modern yoga uses physical poses and meditation to achieve balance and well-being and has grown in popularity across genders, age and athletes of all levels.

As the winter approaches and uncertainty about the future remains, staying mentally and physically healthy may require a different approach from what traditional medicine alone can provide. Looking to ancient India to explore alternative medicine philosophies that are still thriving today provides an exciting opportunity to get to know oneself in a completely different way.■

To learn more about Ayurvedic philosophy, check out this link:

Laursen, Marisa. “Ayurveda: A Brief History of an Ancient Healing Science.” California College of Ayurveda.

Deep Health: What is It? … and How do we Achieve It?

While I was training for my nutrition coaching certification through Precision Nutrition, we learned about the concept of “Deep Health”. Traditionally we think about “Health” as our blood pressure,  cholesterol levels, regular exercise, eating a “healthy” diet. But “Deep Health” goes beyond this. It is our ability to thrive in multiple dimensions of our existence. The figure below shows 6 domains of the Human experience that comprise a “Whole person” approach to good health. You could be a fit, physically healthy marathon runner, but if you do not have a sense of purpose or live in a non- supportive environment, your Human experience could be quite challenged. These domains are not entirely separate-they are, in many ways, intertwined where improvement in one domain may also result in improvement in another domain.  Deep Health is achieved by findng balance among these elements that all play a critical role in our well-being.

In this age of COVID 19, many aspects of our lives that we may have taken for granted have been turned upside down and now require effort to balance. For me, it was going to the gym and seeing my friends. This was an every-day thing that just happened for me. Now, with gym closures and my support network dispersed, it has left a gaping hole in my “Relational” domain which was one of the strongest domains of my existence.

How do we achieve this balance? The first step is simple awareness. If we can take a step back and assess our life situation objectively in the context of these domains, we then take steps to change our situation. One strategy is to assign each domain a number on a scale of 1 to 10 with 1 being “poor” and 10 being “excellent”. This exercise will help to identify areas of your life that are doing well and those that need improvement. Once you have identified these areas, it can be overwhelming trying to navigate the obstacles. A very effective strategy for approaching a daunting problem is to take small steps. Taking steps that move the needle in the right direction motivates us to take more steps, and before we know it, we are making real progress. Once you identify what you would like to improve, take a “5-minute action” each day – one small step that takes 5 minutes – toward your goal of improving your existence in that domain. For me, a 5-minute action was doing an internet search to find a new Crossfit gym, or texting my friend, Kate to set up a video chat. Through many of these 5 minute actions, I have recovered my Relational domain by finding a new gym and reconnecting with friends. Now more than ever we need to take charge of our well-being. Sometimes in the throes of a situation it is difficult to see the forest for the trees. But with awareness and a promise to ourselves for better days ahead, we can chart a course toward achieving Deep Health and greater sense of well-being.

Bone Health Essentials – What Every Woman Should Know

Bone Health Essentials – What Every Woman Should Know

When we think about what it means to be “healthy” we think about our heart, lungs, exercise, how we eat …. but we rarely think about our bones – until we are older, when our doctor talks to us about osteoporosis (severe bone loss) or sadly, we have a fracture. But by then, the damage is done. Here we will talk about the essentials of what every women needs to about how sound bone health is the foundation of an active lifestyle and lifelong physical independence.

(image by Pure Yoga Texas)

Bone Basics

Bone is made up primarily of calcium, collagen (a structural protein) and phosphorus and functions to support and protect our body’s organs and tissues. It also serves as a reservoir for calcium as the cells that inhabit bone are continually storing and liberating calcium in the bloodstream in a process called “bone remodeling” through a balance of bone deposition and breakdown. For women, starting in our teens and into our early 30’s, the balance of bone deposition is greater than the rate of bone breakdown and, therefore, results in an increase in bone density or bone “strength”. Greater bone density reduces the risk of fractures.

Beyond our 30’s, and especially into menopause, bone density naturally declines. This decline results from a shift in the balance of calcium deposition/breakdown such that the rate of bone breakdown is greater than bone deposition. This is a function of changes in estrogen levels (a female reproductive hormone that declines precipitously in our 40’s and beyond menopause), nutritional status, physical activity, vitamin D production/absorption factors, just to name a few. However, if we are vigilant about our nutrition and the level and types of physical activity we engage in, we can significantly slow this decline allowing us to maintain greater bone density later into our lives.

5 Ways to Maximize your Bone Health

  • Adequate calcium and Vitamin D intake: Most women age 13-70+ require 1200mg of Calcium daily
  • Weight-bearing exercise
  • Eliminate tobacco use and excessive alcohol consumption. The CDC defines “heavy alcohol consumption” for women as more than 8 drinks per week or >4 drinks consumed on one occasion.
  • Speak to your doctor about Bone Density Testing at the time of menopause or at any age in the event of a fracture.
  • Consider dietary optimization or medication in the event that bone loss is severe. Speak to your doctor.

For more information about bone health:

Written by Carla M. DiGirolamo, MD, CFL1, PN1