The temporary quintupling of heart attack risk associated with cannabis smoking may be due to increased heart rate, blood pressure, and carbon monoxide levels.
Does “the dark side of cannabis”—both “synthetic and non-synthetic marijuana”—include stroke?
There have been case reports of artery damage due to the “vasoconstrictor effect of cannabis,” which has been well documented. One study found cannabis users had a hundred times greater odds of suffering from multifocal intracranial stenosis, where the arteries inside our brain clamp down at multiple points, as you can see below and at 0:39 in my video Does Marijuana Cause Strokes and Heart Attacks?, but that’s a rare condition. What about strokes?
“The paucity [lack] of high-level evidence regarding the adverse effects of marijuana usage on cerebrovascular [brain artery] health has permitted the false notion that recreational marijuana is safe.” So, researchers decided to put it to the test in a study of millions of cannabis users and found that “recreational marijuana use is independently associated with 17% increased likelihood of AIS hospitalization,” that is, being hospitalized with an acute ischemic stroke, but that may only be among those who use cannabis regularly, “weekly or more often.”
The reason we think it’s cause-and-effect is that the majority of recorded strokes were “during or shortly after marijuana exposure,” and there are even cases in which strokes recurred after re-exposure to marijuana. So, when you put all of that together, it makes a convincing case. Though, to be sure, you’d need to randomize people to use cannabis or a placebo.
It’s like the heart disease story. A similar “temporal” relationship has been found between marijuana use and the development of heart attacks and sudden cardiac death, meaning they seemed to occur while individuals were using cannabis or right after usage. “However, careful evaluation of the cardiovascular effects of marijuana inhalation is complicated by the fact that it is often used in combination with other drugs, such as alcohol or cocaine.” So, you can’t just ask heart attack victims if they were smoking pot at the time of a cardiac event and make the connection; you have to ask about other substance use, too. Within an hour of using cocaine, for example, the risk of having a heart attack goes up more than 20-fold.
That’s about four times more than after smoking pot. The hour after you smoke marijuana, your heart attack risk appears to nearly quintuple, but only for that hour. Then, your risk drops down to normal. So what does this mean? Even though heart disease is our number one killer, the risk of having a heart attack every hour is only about one in a million for any particular hour. So, even if you light up a joint, which may quintuple your risk, that would only bump up the risk to about 1 in 150,000 and only for that one hour. Even if you smoked every day, your annual risk might just go up by a few percentage points. But why the increased risk at all?
Well, we’ve known since the 1970s that within an hour of smoking a joint, our pulse rate goes up about 35 percent, as you can see below and at 3:20 in my video. Smoking a single joint also increases blood pressure, as well as carbon monoxide levels in the blood of angina patients, and it cuts their ability to exercise nearly in half. Now is that just because they’re breathing in smoke of any kind? No, smoking a placebo joint—that is, a marijuana joint from which the THC has been removed—only cuts down exercise capacity by about 9 percent. In contrast, after smoking an actual cannabis joint, the time the study participants could exercise before experiencing chest pain was cut by 48 percent. So, it does seem to be a specific drug effect. Is it as bad as tobacco? We found that out a year later.
“Smoking 1 marihuana [sic] cigarette decreased the exercise time until angina more than smoking 1 high-nicotine [tobacco] cigarette,” which only cut exercise capacity by 23 percent, compared to 50 percent after the joint. This may be because smoking marijuana seems to put more demand on the heart, so it’s no surprise that it was worse than tobacco.
It may also be carbon monoxide. Smoking marijuana leads to nearly five times more carbon monoxide in the bloodstream than smoking tobacco. This is in part because, compared to cigarette smokers, cannabis smokers inhale more deeply and then hold in the smoke for longer, allowing more carbon monoxide into their system. So, the increased heart rate and pressure, the “cardio acceleration,” may account for the accelerated chest pain in heart disease patients.
Does cannabis have any chronic effects on the arteries? Users do seem to have relatively stiffer arteries for their age, suggesting “an acceleration of the aging process.” We are only as old as our arteries.
Even second-hand marijuana smoke may be harmful, according to a recent study in the Journal of the American Heart Associationentitled, “One Minute of Marijuana Secondhand Smoke Impairs Vascular Endothelial Function,” meaning artery function. So, there was a call to protect “vulnerable populations, including elderly and disabled [multi-unit housing] MUH residents, pregnant women, and children.” But, that one minute of exposure to second-hand marijuana smoke was in rats, so it’s not clear how applicable this is to us beyond, perhaps, not smoking around your pets.
I have a slew of other videos on cannabis if you’re interested. Check out the related videos below.
I first released these videos in a webinar, and you can find them all in a digital download here.
Having post-traumatic stress disorder (PTSD) can affect people in the workplace, but there are coping strategies that can help, according to Harvard T.H. Chan School of Public Health’s Karestan Koenen.
In a Dec. 12 Forbes article, Koenen, professor of psychiatric epidemiology, said that having PTSD at work can lead people to re-experience trauma, become avoidant, and experience emotional dysregulation. “Avoidance can look like poor performance or not caring if it leads to missing meetings or obligations,” she said. “Emotion dysregulation can show up exactly how it sounds—losing your temper at work or exploding at a colleague over something small.”
She recommended several grounding, distraction, and relaxation techniques. Grounding can include feeling your feet on the floor or holding something with a comforting texture. She added, “Have a go-to video or music or something to distract your mind while the flashback runs its course. Really mastering breathing techniques that induce relaxation by practicing them every day (twice a day) is helpful.”
Home / News / Harvard Chan School faculty recognized among world’s most influential researchers
Harvard T.H. Chan School of Public Health’s Kresge building / Photo: Anna Webster
More than 30 faculty members or researchers affiliated with Harvard T.H. Chan School of Public Health were named to Clarivate Analytic’s 2024 list of Highly Cited Researchers. The annual list includes researchers from around the world whose papers have been cited most often by their peers—in the top 1% of citations for a chosen field or fields.
Worldwide, 6,886 researchers were named to the 2024 “highly cited” list. Those affiliated with Harvard Chan School are listed below. Thirteen Harvard Chan School faculty were identified as having exceptional performance across several fields. Their names are marked with an asterisk.
They include: Rifat Atun*, Andrea Baccarelli*, David Bates*, Francesca Dominici*, Sarah Fortune*, Wendy Garrett, Edward Giovannucci, Christopher Golden*, William Hanage*, Miguel Hernan, Frank Hu, Curtis Huttenhower, Rafael Irizarry*, Ichiro Kawachi*, Karestan Koenen, Nancy Krieger, I-Min Lee, Marc Lipsitch*, Vasanti Malik*, Brendan Manning, JoAnn Manson, Vikram Patel, Alkes Price, Eric Rimm*, Shekhar Saxena, Meir Stampfer*, S.V. Subramanian, Elsie Sunderland, Tyler VanderWeele, Walter Willett, David Williams.
Krieger was featured in a Q&A on the site as one of seven researchers whose work contributes to societal impact. She said, “As someone whose scientific work for health justice is not part of the mainstream research that dominates the public health and medical literature, I find it encouraging, from the standpoint of health equity, that my work is cited frequently enough to merit my being named a Highly Cited Researcher. It is an affirmation that my work is of use to others.”
Discover the latest updates from the Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED) in our 2024 Annual Newsletter. This edition spotlights the inspiring work of youth advocates featured in the new documentary Generation Flex, the restoration of critical disordered eating questions into the CDC’s Youth Risk Behavior Surveillance System, and efforts to protect youth from harmful diet pills and muscle-building supplements. Through policy change, research, and youth-driven advocacy, STRIPED continues to push for meaningful progress in eating disorder prevention.
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What do randomized controlled trials of high-dose daily vitamin B12 supplementation show about its effects on cancer risk, death, and longevity?
In 2019, “Association of High Intakes of Vitamins B6 and B12 from Food and Supplements with Risk of Hip Fracture Among Postmenopausal Women in the [Harvard] Nurses’ Health Study” was published. Note, though, that only the combined high intake of vitamins B6 (≥35 mg/day) and B12 (≥20 mcg/day) was associated with an increased hip fracture risk. We know that treatment with high doses of vitamin B6 may increase hip fracture risk on its own. After a decade or so, those who had been taking high-dose (40 mg) B6 supplements had about a 40 percent higher hip fracture risk, but not those taking B12, as you can see below and at 0:35 in my video Do Vitamin B12 Supplements Cause Bone Fractures and Lung Cancer?.
That’s what the Harvard study found, too. High intake of vitamin B12 alone was not associated with increased risk. In fact, some observational studies suggest a slightly lower fracture risk at high B12 blood levels. What we care about most, though, are interventional studies, where people are randomized to B12 so we can see what happens, and when we look at those, we find there is no increased fracture risk among those given B12. In conclusion, based on randomized controlled trials, high doses of vitamin B12 have not been shown to be associated with the risk of fractures.
Okay, but what about this? In 2017, a study found that men taking vitamin B12 supplements appeared to have increased lung cancer risk. Now, the researchers didn’t find any such association in women, and the increased risk was mostly among men who smoked. Could it be that B12 was feeding budding tumors? It’s hard enough imagining a vitamin being carcinogenic on its own, especially if it somehow only affects men and not also women. “Replication of these findings in additional prospective studies with careful measurement of B vitamin supplement use is warranted.” And, indeed, when you put together all the observational studies, there is no significant correlation between lung cancer and levels of B12 in the blood, whether you’ve smoked or not. If anything, most studies seemed to trend towards higher B12 levels being protective, as you can see below and at 2:03 in my video.
Then, in 2018, a new study found an association between overall lung cancer risk and higher circulating levels of B12, again appearing to be more of a concern with smokers, as seen here and at 2:16 in my video.
Now, this was another observational study. Those with higher B12 levels were just observed to have higher cancer levels. Those of you who have been following my work know the drill: There are two potential issues that arise in observational studies that prevent us from ascribing cause-and-effect: confounding factors, also known as “lurker variables,” and reverse causation.
What might be a lurker variable in this case? What might be a third factor associated with both higher B12 levels and cancer that may be the true cause? Well, who has higher levels of B12 circulating in their blood? Those who eat a lot of meat and dairy, which are, in fact, “the most important contributors to serum vitamin B-12,” that is, B12 in our blood. And those who eat more meat do tend to have more lung cancer: “Dose-response analysis showed that consumption of red meat for 120 g per day might increase the risk of lung cancer by 35%, and consumption of processed meat for 50 g per day might increase the risk of lung cancer by 20%.” So, we’re generally talking about 35 percent more risk for every quarter-pound burger eaten each day and about 20 percent increased risk for every breakfast sausage link. It’s no wonder those with higher B12 levels in their blood could have more lung cancer. The B12 could just be a marker for meat intake.
And, if you remember, reverse causation is when X may not lead to Y, but, instead, Y may lead to X. So, instead of high B12 blood levels leading to cancer, maybe cancer leads to high blood levels of B12. And, indeed, nearly 75 percent of patients diagnosed with cancer exhibit elevated B12 levels. So, elevated B12 levels may simply be a marker for cancer. Besides taking extra B12, there are all sorts of reasons your levels can rise, such as liver problems, kidney problems, bone marrow problems, and cancer, as you can see below and at 3:50 in my video. So, high B12 levels may just be a marker of brewing, but not yet diagnosed, cancer.
What about observational studies specifically linking B12 supplement use to lung cancer, though? Those could also be reverse causation: “The consequence of being at risk for cancer is that patients will engage in healthier behaviors, including taking multivitamins (reverse causality). The well-established causes, such as smoking, chronic obstructive pulmonary disease, and previous cancers, are the real lung cancer risks.” So, we’re left with this “chicken or the egg causality dilemma,” which is why, ideally, we need randomized controlled trials to see if there’s any cause and effect.
This became even more urgent with genetic evidence suggesting that those born with higher lifelong levels may be at increased risk. Thankfully, as you can see below and at 4:47 in my video, we do have randomized controlled trials—more than a dozen randomized controlled trials randomizing thousands of people up to 2,000 micrograms of B12 every single day for years, in fact.
The findings? “Vitamin B supplementation does not have an effect on cancer incidence, death due to cancer, or total mortality.” And this includes specifically looking at lung cancer, as seen below and at 5:02 in my video. In fact, if anything, vitamin B supplements may actually lower the risk of the most dangerous form of skin cancer.
Formy other B12 updates, see related posts below. All of these videos can be found in one digital download: Latest Vitamin B12 Recommendations.
I’ve also explored vitamin B12’s role in stroke risk. See the related posts below.That series is available for digital download, too: Why Do Vegetarians Have Higher Stroke Risk?.
It’s like my thoughts were under a pile of garbage.
On a Friday night, as my husband and I tried to figure out where to eat, a typical conversation would go like this:
Me: Do you want to go to that restaurant?
Him: What restaurant?
Me: I can’t think of the name. We’ve eaten there before. It’s that place with the peanut shells on the floor? It’s next to… You know… It’s on that road where we used to take the dog to the vet. Do you know the one I’m talking about??
It was as if certain details got lost in a pile of sludge in the deep recesses of my brain. Then, hours later, the details would escape, and I’d shout into an empty room…
“Texas Roadhouse!”
Sludginess with proper nouns is typical for people who are middle-aged and beyond.
However, what seemed to be happening to me, increasingly in my late 40s and early 50s, felt far from typical.
Not only could I never seem to spit out the names of various restaurants or people or books or movies or so many other things, but my brain was also pooping out during the workday.
I’d sit in front of my computer screen, stare at a document, and will myself to do something constructive with my fingertips. Everything seemed hazy, like those first few moments in the morning when you’re awake enough to turn off the alarm but too sleepy to do basic math.
I had my good moments, usually in the morning, when I attempted to pack eight hours of writing into the two or three hours I possessed mental clarity.
On my worst days, however, I awoke with a haze I never managed to shake. Work was a non-starter. Nor did I have enough bandwidth to read, or do much of anything, really.
I sought medical advice.
Three healthcare professionals recommended antidepressants. I tried one, and felt even worse. I tried another. I tried yet another at a higher dose. Still, I felt like a zombie. Another professional gave me a sleeping pill. It left me feeling even more drugged.
Someone tested my thyroid. There was nothing wrong with it. Nor was I anemic. I tried supplements, mushroom coffee, and just about any product with the word “think” somewhere on its label.
Finally, after nearly two years of seeing a revolving door of doctors, I made an appointment with a gynecologist for my yearly exam. I mentioned vaginal dryness. That information triggered her to ask a string of questions that had nothing to do with my undercarriage. How was my sleep? Mood? Energy levels? Was I experiencing hot flashes? How about brain fog?
“Funny you should mention brain fog,” I said in my usual hazy monotone. “I feel like I’m barely alive.”
By the end of the visit, I understood that I’d likely never had depression.
What I “had” was menopause.
My gynecologist sent me home with prescriptions for estradiol and progesterone.
Within days, it was as if someone had flipped a switch.
I could think again. I could type words again. I could follow conversations. I could work past noon.
And, for the first time in years, I could sleep more than two hours without waking.
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Now, menopause isn’t a medical condition.
Nor is it a disease.
Instead, like puberty, it’s a life stage—a transitional moment to be precise.
Once you’ve gone 12 consecutive months without a period, you’ve reached menopause. And from that moment onwards, you’re officially “postmenopausal.”
As women approach this transitional moment, hormone levels fluctuate and fall, triggering dozens of symptoms. Weight gain and reduced sex drive get a lot of attention.
However, during and after menopause, roughly 40 percent of women report increased irritability, mood swings, anxiety, fatigue, and trouble concentrating, according to the American College of Obstetricians and Gynecologists.1 2 As the following image shows, it’s also one of the most vulnerable times in a woman’s life to develop depression,3 particularly if they’ve struggled in the past with it before.
Before starting hormones, I often found myself sobbing for no reason. Other times, the world’s stimuli felt too… stimulating.
Normal everyday sounds—like the buzz of traffic or people at the mall—literally hurt. I was jumpy and irritable and felt anxious about situations that had never bothered me in the past, such as driving over bridges or through construction.
It’s not completely clear what drives these cognitive and emotional symptoms.
Fluctuating hormone levels likely play a role, as do typical age-related changes in the brain.
In addition, during this stage of life, women often deal with several issues that siphon cognitive capacity faster than a thirsty vampire drains a carotid.
During their 40s and 50s, for example, many women have reached the peak of their careers, with responsibilities that follow them home and keep them up at night. They may also be parenting angst-filled teens, caring for aging parents, adjusting to an empty nest, questioning their marriage, or trying to wrap their bank account around the latest statement from the college bursar or hospital billing department.
However, one of the lesser-known and talked about triggers for cognitive discontent has nothing to do with aging or life stress and everything to do with that hallmark menopausal symptom: the hot flash.
Anatomy of a hot flash
Hot flashes, which happen during the day, and night sweats, which occur at night, fall under the category of vasomotor symptoms. (The word “vasomotor” refers to the constriction or dilation of blood vessels which, in turn, can influence everything from blood pressure to sweating.)
During a hot flash or night sweat, norepinephrine and cortisol levels rise. Blood vessels dilate in an attempt to shed heat. Blood pressure and heart rate increase.
Depending on the severity of the hot flash, your skin might redden as sensations of warmth spread through your face, neck, and chest.
You might sweat, experience heart palpitations, or feel anxious, tired, or faint.4
It’s not entirely clear why hot flashes crop up around menopause.
According to one theory, falling estrogen levels affect the hypothalamus, the area of the brain involved in temperature regulation. The brain’s internal thermostat gets wonky and occasionally thinks your body is too hot or cold (when it’s not).
How vasomotor symptoms change the brain
For many years, experts thought of vasomotor symptoms as mere inconveniences or sources of embarrassment.
(To be honest, so did I. During all of those fruitless visits to various healthcare professionals, it never occurred to me to mention them.)
However, an increasing body of research has revealed that hot flashes may do more than make us uncomfortable or force us to change our sheets in the middle of the night.
They may also affect our blood vessels and brains—and not for the better.5 For this reason, an increasing number of experts now consider vasomotor symptoms to be a treatable medical condition.6 7 8
Hot flashes and brain lesions
In one study, researchers asked 226 women to wear monitors that tracked when they were experiencing a hot flash. The women also underwent magnetic resonance imaging (MRI), filled out sleep diaries, and wore smartwatches that recorded how often they woke at night.9
As researchers looked at the brain images obtained from women who experienced the most hot flashes, they noticed an abundance of patchy areas called whole-brain white matter intensities.
These lesions were once thought of as a typical consequence of aging. However, neuroscientists now believe that the presence of whole-brain white matter intensities is predictive of future cognitive decline.
People with an abundance of these brain lesions are twice as likely to get diagnosed with dementia and three times as likely to have a future stroke.10
The blood vessel connection
It’s thought that the increased presence of whole-brain white matter intensities may stem, in part, from changes taking place in the blood vessels that feed the brain.
A three-year study of 492 women supports that theory. It determined that women who experienced frequent hot flashes also tended to experience unhealthy changes in their blood vessels, such as an inability to dilate to accommodate increased blood flow.11
Other research has linked frequent hot flashes with increases in the following:
Thickening in the carotid arteries that supply blood to the brain, face, and neck12
Body fat
Total and LDL cholesterol
Insulin resistance13 14 15 16
The sleep connection
In addition to directly affecting the blood vessels, frequent hot flashes may also affect the brain by disturbing sleep.17
Interestingly, many women don’t necessarily know that hot flashes are disturbing their sleep.
They may instead—as I did—assume they have insomnia or sleep apnea.
That’s because night sweats aren’t always sweaty.
By the time a surge in cortisol and norepinephrine jolts a woman awake, the hotness of the flash may have dissipated. So, it can feel as if she’s repeatedly waking, over and over and over again, for no discernable reason.
These frequent awakenings may interfere with the brain’s ability to consolidate memories, metabolize toxins, and store all the names, dates, and facts one encounters daily.
It can also lead to lost connectivity in the hippocampus, a part of the brain that’s important for learning and memory.
Sleep loss also means the amygdala, a part of the brain involved in emotion, becomes more reactive, causing people to feel more easily stressed, anxious, irritable, frustrated, or enraged.18 19
All of these brain changes can set in after just days to a week of lost sleep. So, imagine what happens when you’ve been waking over and over again—for years.
Why it can be hard to get help
To diagnose depression, healthcare professionals use a tool called the Patient Health Questionnaire (PHQ-9) depression scale. If you check off four of the nine symptoms on the scale, you’re considered depressed.
However, four of the symptoms on the checklist also overlap with the symptoms of menopause-related sleep deprivation:
Little interest or pleasure in doing things
Trouble falling or staying asleep
Feeling tired or having little energy
Trouble concentrating on things, such as reading the newspaper or watching television
Check off those four items, and you might be diagnosed with depression, even if what’s really ailing you is the battle with sleep you’ve been waging since you turned 47.
A lack of menopause-specific training
Another problem: On surveys, 80 percent of medical residents admit they feel “barely comfortable” talking about menopause.20 In addition, few residency programs—including ob-gyn residency programs—offer training in it.21
Given the above, it’s no wonder so many healthcare professionals never think to ask about hot flashes or sleep disturbances when people like me show up complaining of fatigue, lack of gumption, and an inability to focus.
In addition, even when it’s clear that vasomotor symptoms are leading to cognitive and emotional symptoms, many healthcare professionals still shy away from prescribing menopausal hormone therapy (also called hormone replacement therapy, or HRT), often telling women that supplemental hormones are “not safe” or “too risky.”
These professionals are practicing what Michigan-based menopause-trained gynecologist Jerrold H. Weinberg, MD, calls “defensive medicine.”
“It’s one of the first reflexes doctors have when they recommend a treatment,” says Dr. Weinberg. “They worry they’re going to get sued.”
What the research actually says about hormone therapy
These worries are based on research done several decades ago that linked the use of certain types of hormones with a slightly increased risk of developing breast cancer or stroke.22
However, according to more recent research, that small increased risk seems to depend on several other factors, such as age, dose, the type of hormonal preparation, and the duration of hormone use.23 24
As long as you’re younger than 60 and have been postmenopausal for fewer than 10 years, many experts now say the benefits outweigh the risks for women with moderate to severe menopausal symptoms.25
It’s also counterbalanced by health benefits such as reduced risk of developing Alzheimer’s disease or osteoporosis, says Dr. Weinberg, who confirms the health benefits of menopause hormone therapy far outweigh the risks for most women.
Because some antidepressants can lift mood, improve sleep, and reduce hot flashes, some healthcare professionals turn to them instead of menopause hormone therapy. As with any medicine, antidepressants have their own list of side effects. However, for someone practicing defensive medicine, they often seem like a safer bet, says Dr. Weinberg.26 27 28
How to advocate for your health
If you or your client are on what seems like a never-ending quest to find a healthcare professional who understands menopause, use the following advice from Dr. Weinberg and Helen Kollias, PhD, an expert on physiology and molecular biology and science advisor at Precision Nutrition and Girls Gone Strong.
▶ Seek care from a menopause-trained health professional.
Usually, these professionals list this training and interest in their bio. For example, they might list “menopause” as an area of focus.
You can also search this database for practitioners who have earned a certification from the Menopause Society.
▶ Document your symptoms.
Write them down. That way, if you feel foggy or nervous during your appointment, you can lean on your notes.
This information can also help you judge whether MHT or another medicine is working. Based on your symptom data, you and your healthcare professional may decide to switch to a different medicine or change your dose.
Consider tracking:
How often you get hot flashes
The number of hours in a typical day you find yourself battling brain fog
How often you experience fatigue, anxiety, rage, or some other symptom
How often you wake up at night
▶ Be as specific as you can during your appointment.
Saying something like “I don’t sleep well,” is less likely to get you the right kind of help than saying, “During the past seven days, I’ve only gotten four uninterrupted hours once. I wake, on average, five times a night. On a typical night, my longest stretch of sleep is three hours.”
If you use a smartwatch, come ready to fire up your health app, so your healthcare professional can see the data.
▶ Talk about the pros and cons of treatment.
There’s a concept in medicine known as “shared decision-making.” Part of that process involves frank discussions about the benefits and risks of a given treatment. Then, patients and clinicians work together to make decisions based on those benefits and risks.
Many healthcare networks encourage clinicians to use shared decision-making, as it seems to reduce patient complaints as well as malpractice lawsuits.29 30
For this reason, shared decision-making can help shift a healthcare professional out of the “defensive medicine” mindset.
You might ask questions like:
“I’m interested in seeing if menopausal hormone therapy might be helpful. Could we discuss if I’m a good candidate?”
“I’ve read that menopausal hormone therapy could slightly increase my risk of breast cancer. Could you help me understand my personal breast cancer risk based on my family history, age, body weight, and lifestyle?”
“Osteoporosis runs in my family, as does dementia. I’ve heard that menopausal hormone therapy might help to reduce the risk for both, in addition to helping me sleep. Could you help me weigh the pros and cons?”
How to improve mental and emotional health during menopause: 9 lifestyle strategies
The lifestyle habits that improve mental and emotional health during menopause aren’t terribly different from the lifestyle habits that improve overall health—for any person, at any stage of life.
Other than avoiding caffeine, alcohol, and spicy or hot foods, there’s no special diet for people with vasomotor symptoms. (And by the way, tofu and other soy products don’t seem to help with vasomotor symptoms as much as once thought30—though they’re still nutritious.)
Strategy #1: Lean into fundamental health strategies.
Healthy behaviors don’t necessarily change during middle age.
Nutrition, physical activity, stress management, sleep, social connectedness, and a sense of purpose matter just as much during the menopausal transition as they do when we’re younger. However, these fundamentals are even more important to dial in as life progresses.
So consider:
Are you setting aside enough time for sleep and rest?
Are you physically active?
Are you eating a diet that’s mostly minimally processed and full of brightly colored produce, healthy fats, lean protein, fibrous vegetables, and legumes?
Do you regularly connect with other humans in ways that help you buffer stress and feel supported?
Do you find ways to experience awe, joy, curiosity, peace, and purpose?
If you answered “no” to some or all of those questions, consider why that is. What’s stopping you? How might you remove barriers or shore up support to make those fundamentals easier?
Strategy #2: Experiment with creatine.
In addition to helping to blunt age- and hormone-related losses in muscle and bone mass, creatine may also help bolster mood and brain function while reducing mental fatigue.
It also seems to counter some of the negative effects of sleep deprivation. 32 33 Research shows a daily dose of 5 to 7 grams of creatine monohydrate is effective.
Strategy #3: Get regular about light exposure.
In addition to helping you feel alert, sunlight helps to set the internal clock in your brain that makes you sleepy at night and spunky in the morning. Morning and late afternoon light exposure seem particularly potent.
In a study of 103 people, exposure to morning sunlight predicted better sleep quality the following night. When people spent time outdoors in the mornings, they fell asleep more quickly, slept longer, and experienced fewer awakenings the following evening.34
Sunlight may also improve mood and concentration.35
Strategy #4: Go easier at the gym.
If you’re already worn out, long, intense exercise sessions will likely make you feel worse.
For one, injuries crop up much more easily at middle age than during our 20s and 30s. In addition, it takes longer to recover between sessions.36
String too many overly zealous workouts too close together, and you’ll not only likely start to feel achy but also more irritable, tense, and tired.
However, much like a cold shower, short bursts of exercise may help you to feel alert during the day.
If you’re falling asleep at your desk, encourage yourself to take short movement breaks such as a 5- or 10-minute walk outdoors or a quick set of pushups or squats.
In addition, you may find gentle exercise—such as yoga or stretching—helps you relax before bed. Just don’t make it too intense, or you’ll trigger a release of adrenaline.
Whenever you exercise, tune into how your body feels, especially after a particularly bad night of sleep.
We’re not saying you should never exercise vigorously or try to beat your lifting PRs. However, depending on your sleep and recovery, you might want to pare things back, especially if you’ve traditionally hit the gym hard.
You can still do intense sessions—just balance them out with more moderate sessions, as well as proportionate recovery.
Depending on how you feel, you might decide to go all out, as usual.
However, you might also decide to do a zone 2 training session instead of an intense run. Or, if you’re resistance training, you might still do your planned session, but reduce the number of sets, reps, or volume lifted.
Strategy #5: Investigate Cognitive Behavior Therapy for Insomnia (CBT-I).
This research-based therapy for insomnia can help you develop skills and mental reframes that encourage sound sleep.
For example, a CBT-I therapist will help you develop the skill of getting up at the same time every day, regardless of how badly you slept (or didn’t sleep) the night before.
You may not have the energy (or desire) to do everything you did when you were younger. (When you were 36, your daily checklist defied time and space.)
As a result, you might benefit from looking critically at your current responsibilities to see which ones you can shrink or downsize. For several days, track how you spend your time and bandwidth. Then, analyze your data.
Ask yourself:
Is this how you truly want to spend your time and energy?
Does your current schedule allow you to rest, recover, and tend to your own needs? Or, do you spend nearly all of your time and energy caring for and providing for others?
What changes could you make to prioritize rest and recovery?
If you’re a coach, use the Wheel of Stress Assessment to help clients identify different dimensions of their life that might be draining their mental and emotional capacity. (When you know specifically where your stress is coming from, you have a better chance of resolving it.)
You might find you sleep better and experience fewer night sweats if you sleep in a cooler environment.
Try turning down the thermostat a couple of degrees, using a fan, or investing in an electric cooling mattress pad.
Strategy #8: Take frequent breaks.
When you feel the fog take over your brain, it’s not likely you’ll be doing “your best work” anyway.
So, for a block of time—say, 20 minutes—permit yourself to do nothing. You might:
Relax with a cold beverage
Cuddle with a pet
Gaze out a window
Sit outdoors while listening to the birds
Call a friend
If you need a quick “refresh,” you can also try a 5-minute mind-body scan.
Get your body into a comfortable position. For example, you might use the yoga “legs up the wall” pose or lie down and place a pillow under your knees.
Then, close your eyes and bring your attention to physical sensations in your body. Start at your head, and work your way down to your toes.
Don’t judge or rush to change anything. Just observe, like a scientist. You can also scan your mind, for example, by noticing thoughts.
When you’ve completed the scan, consider:
What are you feeling physically?
What are you feeling emotionally?
What are you thinking?
You don’t have to “do” anything with the information you uncover, just notice.
Strategy #9: Follow a diet that promotes healthy circulation.
The foods that protect the blood vessels around your heart can also protect the blood vessels in your brain.
For example, both the MIND and Mediterranean diets are associated with a reduced risk of Alzheimer’s disease and depression.37 38 These eating patterns are rich in vegetables, fruit, whole grains, olives, beans, fish, and other minimally-processed whole foods.
In addition, nitrate-rich foods like beets and dark, leafy greens may help to dilate blood vessels, temporarily improving memory by helping more blood to reach the brain.39 40
It’s frustrating when you feel like you can’t do it all.
Believe me. I know.
However, this stage of life presents a hidden opportunity, forcing you to re-evaluate what’s most important.
Before going on hormones, as my ability to type coherent words and phrases diminished, I was forced to ask an important question:
Do I really need to be doing this?
It was more of an existential question than a career-related one, and it allowed me to reassess how I wanted to spend my limited mental resources.
Given that I was self-employed, I didn’t actually need to be working eight hours a day. That was a gift, wasn’t it?
Maybe I also didn’t need to cook dinner six nights out of seven. Maybe the recipes I chose could be simplified, too.
Finally, maybe saying “no” a lot more often and without regret would allow me to continue to say yes to the things that mattered most.
Things like visiting my aging parents.
And picking up the phone whenever my kid called from college.
Or meeting a friend for a meandering walk around town.
Thanks to the hormones and life tweaks, I now have energy again. I’m also clear-headed most of the time. However, I still tend to end my work day around 3 p.m.
Thurston RC, Chang Y, Buysse DJ, Hall MH, Matthews KA. Hot flashes and awakenings among midlife women. Sleep [Internet]. 2019 Sep 6 [cited 2024 Oct 31];42(9). Available from: https://pubmed.ncbi.nlm.nih.gov/31152182/
A new analysis of nearly 200,000 adults shows that those with a clean result on their first colonoscopy may not need another for longer — perhaps significantly longer — than the current recommendation of 10 years.
The result is a bit of good news about a cancer whose increasing rates in younger patients has worried experts, including the Harvard Chan School’s Mingyang Song, for several years. Colorectal cancer is the nation’s second-deadliest after lung cancer, killing an estimated 52,550 in 2023. While rates among older patients have been declining, younger patients — those 40 to 49 — have seen cases rise 15 percent between 2000 and 2026. Experts aren’t sure of the cause, but in 2021, the U.S. Preventive Services Task Force lowered the recommended age of first screening to 45 from 50. They also recommend that those with average risk get screened 10 years afterward.
Song, an associate professor of clinical epidemiology and nutrition at the Chan School, said that the increase in screenings has also increased appointment wait times.
“Especially with the lowered age, the clinic is overwhelmed,” said Song, also an associate professor at Harvard Medical School. “It was overwhelmed before, now it’s even worse.”
In the work, published last month in JAMA Oncology, Song and colleagues examined colorectal cancer screening results and colorectal cancer incidence among 195,453 participants in three long-running studies: the Nurses’ Health Study, Nurses’ Health Study II, and the Health Professionals Followup Study. They compared incidence between two groups: those who received negative results in their initial colorectal cancer screening — meaning no polyps or cancer — and those who had not yet been screened.
They found that the risk of developing colorectal cancer was significantly lower among those who had received a negative cancer screening than those who had not yet been screened. The research team, led by first author Markus Knudsen, a postdoctoral fellow in Song’s lab, then divided the negative screening result group according to lifestyle risk factors for colorectal cancer. The work was supported in part by the National Institutes of Health.
The results showed that it took 16 years for those with a negative screening result and an intermediate-risk lifestyle to have the same colorectal cancer incidence of the unscreened group at 10 years. Those with negative screening and a low-risk lifestyle — including a healthy diet and exercise — didn’t reach the 10-year cancer incidence of the unscreened group until 25 years from their negative screening.
The results, Song said, show that cancer screening should be individualized and discussed between patient and physician. While it is likely that additional evidence will be needed before national screening guidelines are changed, those with a negative screening result may be able to safely extend the screening interval beyond the recommended 10 years and, for those also living a low-risk lifestyle, perhaps as long as 20 years.
What this more tailored approach would do, Song said, is spare those who might get little benefit from a colonoscopy while focusing increasingly scarce resources where they’re most needed: on people who’ve never been screened — only about 70 percent of eligible U.S. adults have been screened — on disadvantaged groups with historically lower screen rates, and on those whose lifestyle or family history puts them at increased risk.
“What we have seen generally is that the more advantaged groups of individuals are more likely to receive colonoscopy, whereas those who are disadvantaged and who actually have a higher risk of developing colon cancer are less likely to receive colonoscopy,” Song said. “We’ve tried to correct this mismatch and improve colonoscopy delivery at the population scale.”
Acne can be triggered in one in ten people who get vitamin B12 injections.
“Acne is a disease unique to humans.” Why do we even get it? Well, think about the distribution of those greasy sebaceous glands. They’re “on the face, chest and back; these are exactly the same structures that pose the greatest obstruction during childbirth…Having extra lubrication at these sites would help make the baby more slippery for birth conferring a selective advantage to successful delivery.” Perhaps, but what triggers them to become inflamed into pimples later in life?
“In westernized societies, acne vulgaris is a nearly universal skin disease afflicting 79% to 95%” of teens. Not even a single case could be found in some populations where more “traditional” diets are eaten (i.e., minimally processed, high-carb, low-fat diets). “Nutrition counseling” has been suggested “as a first-line or adjunctive therapy…for individuals with mild to moderate acne.” It looks like high glycemic foods and dairy products are “exacerbating factors,” so we’re talking about sugar, soda, refined junky carbohydrates, white flour, breakfast cereal, and dairy products, like milk, cheese, yogurt, and whey, as well as saturated and trans fats, which are concentrated in meat, dairy, junk, and fast food. You can see a table detailing this below and at 1:21 in my video Do Vitamin B12 Supplements Cause Acne?.
“Acne patients should be encouraged to discontinue any whey protein supplements they might be taking,” for example. “The relationship between milk and acne severity may be explained by the presence in dairy of normal reproductive [sex] steroid hormones or the enhanced production of polypeptide [growth] hormones such as IGF-1…” What if you gave up dairy a month ago and there’s still no change? “It should be noted that changes in acne due to any pharmaceutical treatment or dietary changes are likely to take at least 10 to 12 weeks,” so you have to stick with it.
“Acne patients,” not surprisingly, “were more than twice as likely to have a non-vegan diet compared with controls,” but the difference did not reach statistical significance. Were the vegans eating a lot of vegan junk? Maybe, but what about the paper entitled, “Vitamin B-12 Induced Acne”? Mammalian herbivores, including nonhuman primates like gorillas, and our fellow great apes, get all the B12 they need by practicing coprophagy, the eating of feces, but my preference would be to take B12 supplements. And you don’t have to worry about getting too much because it’s been reported that “there are no reports of adverse effects associated with excess B12 intake”—but that’s not true. First described back in the 1950s, acne erupts in about one in ten people within days or even hours of getting an injection of vitamin B12, which then disappears rapidly when injection “treatment is discontinued.”
At the time, we had no idea what the mechanism might be, and the problem remained unsolved until just a few years ago when we finally figured it out: Vitamin B12 modulates the gene expression of the skin bacteria that cause acne. Researchers swabbed the skin of ten people before and after being injected with vitamin B12. As you can see below and at 3:20 in my video, it turns out that the level of B12 on our skin is proportional to the level in our blood, so, after a B12 injection, the bacteria on our skin have to make less of their own B12. As a result, the acne bacteria could concentrate instead on using their cellular machinery to churn out more compounds to attack our face and “induce inflammation in acne.”
Indeed, as you can see here and at 3:53 in my video, without excess B12 on the skin (with B12 shown in green), the bacteria have to make most of it on their own at the expense of porphyrins (shown in red), which can trigger acne inflammation. When there is a lot of B12 floating around, the bacteria don’t have to waste resources and, instead, can focus on trying to pimple you up.
So, what do you do? We know that individuals on plant-based diets have to take supplemental B12, but we don’t have to get injections. Vitamin B12-related acne tends to occur only “in dosages in excess of 5 to 10 mg per week.” That’s 5,000 to 10,000 micrograms a week, which is well in excess of the 50 micrograms a day or, alternately, the 2,000-microgram single weekly dose that I recommend. The only time you should be taking 5,000 to 10,000 micrograms a week is if you are treating B12 deficiency. If you remember from my previous video, B12 deficiency is treated with 1,000 micrograms a day for a month or more, as shown below and at 4:35 in my video, and that could potentially trigger acne.
For example, a vegan woman who hadn’t been taking B12 developed a deficiency and had to be treated with such high doses of the vitamin that her face erupted in acne, as you can see at 4:49 in my video. All the more reason not to become B12-deficient in the first place. But, even if you do get B12 injections, the likelihood of it triggering acne may only be about one in ten.
For background and my updated recommendations, see my extended look at vitamin B12 in the related posts below. All of these videos can be found in one digital download. Check out Latest Vitamin B12 Recommendations.
I previously explored vitamin B12’s role in stroke risk, which you can also see in the related posts below. That series is available for digital download, too: Why Do Vegetarians Have Higher Stroke Risk?.
An entire issue of a cardiology journal dedicated to plant-based nutrition explores the role an evidence-based diet can play in the reversal of congestive heart failure.
It is a hopeful sign of the times when an entire issue of a cardiology journal is not just dedicated to nutrition, but to a plant-based diet in particular. Dr. Kim Williams, past president of the American College of Cardiology, starts his editorial with a quote attributed to the philosopher Arthur Schopenhauer: “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” He goes on to write that “the truth (i.e., evidence) for the benefits of plant-based nutrition continues to mount.” We’ve got the evidence. The problem is the “inertia, culture, habit, and widespread marketing of unhealthy foods. Our goal must be to get the data out to the medical community and the public where it can actually change lives—creating healthier and longer ones.” That’s essentially my life’s mission in four words: Get the data out. Based on what we already know in the existing medical literature, “plant-based nutrition…clearly represents the single most important yet underutilized opportunity to reverse the pending obesity and diabetes-induced epidemic of morbidity and mortality,” meaning disease and death.
As I discuss in my video How to Reverse Heart Failure with Diet, the issue featured your typical heart disease reversal cases, including a 77-year-old woman with such bad heart disease that she couldn’t walk more than half a block or go up a single flight of stairs. She had severe blockages in all three of her main arteries and was referred to open-heart surgery for a bypass. However, instead of surgery, “she chose to adopt a whole-food plant-based diet, which included all vegetables, fruits, whole grains, potatoes, beans, legumes and nuts.” Even though “she described her previous diet as a ‘healthy’ Western one,” within a single month of going plant-based, “her symptoms had nearly resolved”—and forgot about walking a block. “She was able to walk on a treadmill for up to 50 min without chest discomfort or dyspnea,” becoming out of breath. Her cholesterol dropped about a hundred points from around 220 mg/dL (5.7 mmol/L) down to 120 mg/dL (3.2 mmol/L), with an LDL under 60 mg/dL (1.5 mmol/L). Then, four to five months later, she must have started missing her “chicken, fish, low-fat dairy and other animal products” and “returned to her prior eating habits.” Within a few weeks, with no change in her medications or anything else, her chest pain returned and she went on to have her chest sawed in half after all. After the surgery, she continued to eat the same diet that had contributed to causing her disease in the first place, then went on to have further disease progression.
Another case featured in the journal has a happier ending. It started out similarly: A 60-year-old man with severe chest pain after walking just half a block decided to take control of his health destiny and switched to a whole food, plant-based diet. “He described his prior diet as a ‘healthy’ diet of skinless chicken, fish, and low-fat dairy with some vegetables, fruits, and nuts”—a diet that had been choking off his heart. Within a few weeks, he experienced the same amazing transformation—from not being able to exercise at all to walking a mile, then being able to jog more than four miles (6.4 km), completely asymptomatic, off all drugs, without any surgery, and off to live happily ever after.
Now, of course, case reports are just glorified anecdotes. What we need is a randomized controlled trial to prove that heart disease can be reversed with lifestyle changes alone. Guess what? There was one publishedthree decades ago, proving angiographic reversal of heart disease in 82 percent of the patients. Their arteries opened up without drugs and without surgery. So, these case reports are just to remind us that hundreds of thousands of individuals continue to needlessly die every year from what was proven to be a reversible condition decades ago.
The conventional use of case reports, though, is to present novel results in the hopes of inspiring trials to put them to the test. For example, consider this case report on a plant-based diet for congestive heart failure—not simply coronary artery disease. In this case, the heart muscle itself was so weakened that it couldn’t efficiently pump blood. It was only able to eject about 35 percent of the blood in the main heart chamber with every beat, whereas, normally, the heart can pump out at least 50 percent. And that’s exactly what the patient’s heart was able to do just six weeks after switching to a whole food, plant-based diet, which he chose to do instead of getting his chest cracked open. The researchers wrote: “To our knowledge, this is the first report of an improvement in heart failure symptoms and left ventricular ejection fraction following adoption of a plant-based diet.” It may be the first, but it isn’t the last.
Another case: A 54-year-old woman, obese and diagnosed with type 2 diabetes, presented with swelling ankles due to her heart failure. She switched from her regular diet of chicken and fish to whole plant foods. She started eating more healthfully, lost 50 pounds, and reversed her diabetes—meaning she had normal blood sugars on a normal diet without the use of diabetes medications. Her heart function normalized, too, going from an abysmal ejection fraction of just 25 percent up to normal, as you can see below and at 5:00 in my video. Since it wasn’t a randomized controlled trial, all we can say is that her improvements coincided with her adoption of a whole food, plant-based diet. But, “given the burden of heart failure [as a leading cause of death], its adverse prognosis,” meaning it usually worsens progressively, “and the overall evidence to date, a plant-based diet should be considered as part of a multifaceted approach to heart failure care.” We already know it can reverse coronary artery disease, so any heart failure benefits would just be a bonus.
Now, we just need good strategies for healthcare “practitioners to support patients in plant-based eating.” Shown below and at 5:42 in my videoare some excellent suggestions to pause and reflect on.
Doctors, for example, can “use the Plant Rx pads produced by the Plantrician Project” and prescribe a good website or two, like NutritionFacts.org, as seen below and at 5:50 in my video.
“While it is certainly true that many people would be resistant to fundamental dietary changes, it is equally true that millions of intelligent people motivated to preserve their health are now taking half-way measures that may provide only modest benefit—choosing leaner cuts of meat, using reduced-fat dairy products….Most of these people have neither the time nor the training to evaluate the biomedical literature themselves. Don’t they deserve honest, forthright advice when their lives are at stake? Those who wish to ignore this advice, or implement it only partially, are at liberty to do so.”
Do you want to go smoke cigarettes? Bungee jump? It’s your body, your choice. It’s up to each of us to make our own decisions as to what to eat and how to live, but we should make these choices consciously, educating ourselves about the predictable consequences of our actions.
Did I say reverse coronary heart disease? As in reverse the number one killer of men and women? I’ve got a lot of videos on the topic, and How Not to Die from Heart Disease is a good place to start.
Does walking with poles, also known as Nordic pole walking or “exerstriding,” beat out regular walking for depression, sleep quality, and weight loss?
Exercise recommendations for obesity have been referred to as “the mysterious case of the public health guideline that is (almost) entirely ignored.” Governmental, scientific, and professional organizations call for at least an hour of exercise a day for weight management, but “almost no obese adults meet this target.” As you can see below and at 0:32 in my video Are There Benefits of Pole Walking for Weight Loss?, surveys suggest American men and women watch television ten times more than they exercise.
For Americans with obesity, it may be even worse. Only 2 percent reach even 30 minutes a day, as you can see below and at 0:36 in my video, and the percentage exceeding an hour of exercise a day is expected to be close to zero.
Why don’t individuals with obesity exercise more? Why don’t we just ask them? When questioned, “obese adults typically describe exercise as being unpleasant, uncomfortable and unenjoyable.” How can we break this vicious cycle, where inactivity can lead to weight gain, which can lead to further inactivity and even more weight gain? The first thing to recognize is that “it is normal and natural to be physically lazy.”
“Nothing in Biology Makes Sense Except in the Light of Evolution” is the title of a famous essay written by a noted geneticist. Laziness is in our genes. We evolved to instinctually avoid unnecessary exertion to conserve energy for survival and reproduction. These days, there’s no shortage of available fuel, yet the hard-wired inertia remains. “The vast majority of people today behave just as their ancestors by exercising only when it is fun (as a form of play) or when necessary.” Just like dietary change for weight control, the only way exercise is going to work long-term is if it becomes “a stable, ideally lifelong, activity habit.” Exercise is only effective if it’s sustainable. So, we need “to restructure our environments to require more physical activity,” like using a treadmill desk, and figure out how to make exercise more enjoyable. It should just be a walk in the park—literally, perhaps!
Some wise advice from a 1925 medical journal entry: “The best prescription to be written for a walk is to take a dog…and a friend.” Listening to your favorite music might also help. Music has been described as “a legal method” for improving peak performance and, more importantly, enhancing the enjoyment of high-intensity interval training. As you can see below and at 2:37 in my video, listening to a preferred playlist during exercise can significantly reduce your “rate of perceived exertion,” which is how hard you feel your body is working. When severely obese youth got on a treadmill and were told to go until exhaustion, with or without music, those listening to their favorite tunes “ran significantly longer,” tending to go about 5 percent longer. This was chalked up to “attentional distraction”; the music may have helped them keep their mind off feelings of fatigue. If that’s the case, listening to a podcast or audiobook might have a similar effect.
One way to up your walking game is with walking poles. So-called Nordic walking, also known as exerstriding or Viking hiking, was originally developed in Scandinavia to maintain cross-country ski athletes’ training in the summer. It’s since gained in popularity worldwide as a general fitness activity. The augmented engagement of the upper body musculature may result in an 18 to 22 percent increased calorie expenditure over walking alone (depending, in part, on your pole handling technique). Does that translate into accelerated weight loss?
Before and after studies demonstrate weight loss with pole walking, compared to a sedentary control, but what about compared to regular walking? Of the four such studies I could locate, comparing thrice weekly 40- to 60-minute sessions of Nordic pole walking to regular walking, every single one found no significant difference in body fat measures after 8 weeks, 12 weeks, another at 12 weeks, or 13 weeks. You can see the last one below and at 4:16 in my video.
There are, however, other benefits over regular walking, such as increased upper body muscle bulk, improved muscular endurance, and increased strength, as seen below and at 4:20 in my video, though not as much as was seen with resistance-band training. But, as I was writing How Not to Diet, there wasn’t any evidence of a weight-loss-enhancing effect, which is why Nordic walking didn’t make the cut. Just as we were going to press, a study was published—the first to combine Nordic walking with diet, compared to the same dietary program with regular walking. And, once again, no significant difference was found in body weight or anything else. There was a hint that those in the pole group enjoyed it more, and, in the end, exercise only works if you do it, so that may be a benefit.
There may be other benefits, too. As you can see here and at 5:05 in my video, Nordic walking beat out regular walking in terms of reducing symptoms of depression and improving sleep quality.
Perhaps this should not be surprising, given the greater exercise intensity of pole walking, even approaching that of jogging at higher speeds, shown below and at 5:15 in my video. And that’s where I see the role of walking poles—to fill the intensity gap between people who are ready to graduate from walking but aren’t ready for more rigorous activities, such as running. The only potential downsides are the added expense and, “reminded of Monty Python’s famous ‘ministry of silly walks’ sketch…‘feeling fairly ridiculous’ when trying Nordic walking for the first time.”
