P.2: World Health Day takes action on depression P4: Science Update with Ben Brown P5: The role of IgG in Food Intolerance with Nigel Abraham P9: Food in Season: Cocoa
OPEN EVENING : TUESDAY 21st march 6-8pm (P.13)
Dear readers, Welcome to the new-look newsletter. Easter is just around the corner so no doubt chocolate will be at the forefront of your minds, but fear not, we have some delicious and nutritious recipes for you to try as well everything you may want to know about the benefits of cocoa. Cocoa has also been shown to help with mood and brain function, which brings me on to World Health Day on April 7th which is throwing the spotlight on depression. Milada Fomina, a Year 4 BCNH student talks about the role nutritional therapy has in helping to manage the condition. Moving forward, we will also have a permanent section on 'testing' contributed by Cambridge Nutritional Sciences (CNS) and in this issue, they will be talking about food intolerance testing. I hope you enjoy this issue and I welcome any feedback. I wish you all a happy and healthy Easter! Joanne
WELCOME
March 2017 Newsletter
ISSUE HIGHLIGHTS
FACT FILE
FEATURE
WORLD HEALTH DAY - April 7th
Depression is one of the leading causes of disability and is estimated to affect more than 300 million people worldwide (WHO 2017). Globally depression is 1.7-fold more common in women than men and is more than twice as prevalent in young women as in men (14-25 years) (Albert 2015). Epidemiological data shows that depression not only leads to a functional and psychosocial impairment but also increases the risk of suicide, cardiovascular events and all-cause mortality (Lépine and Briley 2011), diabetes and obesity-related morbidity, Alzheimer’s disease and even cancer (Penninx et al 2013). The aetiology of depression is still poorly understood but is thought to involve the interplay of biological, environmental, genetic and psychological factors (Lopresti et al 2013). Emerging evidence suggests a role for nutritional therapy and its potential to modulate several biological factors implicated in depression (Sanhueza et al 2013). Omega-3 polyunsaturated fatty acids (PUFAs) are one of the most studied dietary substances thought to provide therapeutic effect in people with depression who are often found to be deficient in these essential fatty acids (Su 2015). The beneficial effect of omega-3 PUFAs is largely explained by their anti-inflammatory and immunomodulatory potential (Martins 2009).
This annual event held on April 7th marks the founding year of the organization and this year WHO will be taking action on depression, a preventable and treatable condition, which affects people of all ages. • Between 1990 and 2013, the number of people suffering from depression and/or anxiety increased by nearly 50%. • In humanitarian emergencies ongoing conflict as many as 1 in 5 people are affected by depression and anxiety. • Depression in women following childbirth can affect the development of newborns. • Depression costs the global economy more than US$ 1 trillion each year.
Depression By Milada Fomina, Year 4 BCNH Student Milada explores the impact nutrition has on depression, the theme for this year's World Health Day.
An increasing body of research suggests that modification of the overall dietary pattern rather than consumption of isolated nutrients may prove to be a better nutritional intervention in depression (Lai et al 2014). In particular, the Mediterranean diet characterised by abundant consumption of fruit, vegetables, legumes, wholegrains, olive oil, moderate consumption of fish, poultry and wine, has been associated with lower rates of mental disorders and suicide rates observed in Mediterranean countries (Sánchez-Villegas et al 2009). Interestingly, it has been observed that high to moderate adherence to this dietary pattern was associated with reduced risk of depression in non-Mediterranean countries as well (Psaltopoulou et al 2013). Although the role of nutrition in depression is a relatively new area of research, the evidence so far suggests that increased consumption of omega-3 PUFAs (abundant in oily fish), maintenance of adequate vitamin D status (through sensible sun exposure or supplementation in cases of deficiency), and adherence to the Mediterranean diet may all be beneficial in reducing the risk of mental health problems, including depression. (See P.14 for references)
Omega-3 polyunsaturated fatty acids (PUFAs) are one of the most studied dietary substances thought to provide therapeutic effect in people with depression who are often found to be deficient in these essential fatty acids (Su 2015). The beneficial effect of omega-3 PUFAs is largely explained by their anti-inflammatory and immunomodulatory potential (Martins 2009). Vitamin D is another nutrient that has been extensively studied in depression as a result of growing epidemiological evidence showing a correlation between low vitamin D levels and incidence of depression (Berk et al 2013). The potential role of vitamin D in depression may be supported by its ability to modulate the hypothalamic-pituitary- adrenal axis (Spedding 2014) and immuno- inflammatory pathways (Gowda et al 2015) dysregulation of which are implicated in the pathogenesis of depression.
NEWS - NTEC accrEditation
A decline in mental function after lunch, known as the post-lunch dip, could be due to what you ate. Adding almonds to lunch helped. Post-lunch dip is common and mostly impacts memory and vigilance, but may also decrease mood and increase anxiety. The post-lunch dip has been associated with the nutritional composition of your midday meal, with fat and carbohydrate both playing a role. Conversely, some foods may enhance mental function and could offset the post-lunch decline. A research team from the Department of Nutrition Science, Purdue University, set out to see if a midday meal containing almonds which are low in carbohydrate, rich in healthy fats and known to improve cognitive function, would have a more favourable effect than a higher carbohydrate, lower fat, almond-free meal. Eating almonds at lunch reduced post-lunch declines in memory, but not attention performance. When compared with the high-carbohydrate, low-fat meal, almonds ameliorated declines in memory scores by 57.7 %. “Almond consumption at midday may be an effective means to maintain memory following the midday meal,” concluded the study authors. Beyond almonds, avoiding high-glycemic index carbohydrates, including some healthful fats such as extra virgin olive oil, and eating more phytonutrient-dense foods could do the trick. Reference: Dhillon J, Tan SY, Mattes RD. Effects of almond consumption on the post-lunch dip and long-term cognitive function in energy-restricted overweight and obese adults. Br J Nutr. 2017 Feb 10:1-8.
SCIENCE UPDATE
BCNH is delighted to have received confirmation that both our BSc (Hons) and Diploma qualifications in Nutritional Therapy have been successfully re-accredited by the Nutritional Therapy Education Council (NTEC) for a further 3 years. We would like to thank all students and staff who made themselves available to the NTEC accreditation panel at the time of the visit.
Post lunch dip? Almonds help By Benjamin Brown, ND - Naturopath, BCNH Lecturer, Science Writer and Speaker
There is a widespread erroneous belief that food allergy is exclusively associated with IgE antibody mediated mechanisms. However, according to more recent data, IgG-dependent hypersensitivity, characterised by a delayed immune response, also plays a very significant role in the pathogenesis of food reactions, often referred to as ‘food intolerance’. In addition, determination of serum IgG food antibodies opens new diagnostic pathways for patients who are hypersensitive to food components, which can be alleviated by food elimination diets based on the results of such testing. Gut permability Evidence suggests that the development of IgG-dependent intolerances are directly related to increased permeability of the intestinal barrier. In a healthy normal intestinal tract where homeostasis is preserved, this layer is tight and highly selective, so that only the desired nutrients enter the bloodstream from the intestinal lumen, while access of potentially damaging substances and pathogens is impeded. Studies have shown that damage to the tight junctions is the precipitating cause for the development of food specific IgG antibodies. Correctly functioning tight junctions between the intestinal cells ensure that the barrier shows the required selectivity.
The role of IgG in Food Intolerance
We are pleased to announce that Dr Nigel Abraham (Ph.D, MSc, London FIBMS), Group Scientific/Laboratory Director for Food Intolerance products and services at Cambridge Nutritional Sciences, will be a regular contributor to our Testing section in the BCNH newsletter moving forward. Nigel has more than 20 years’ experience as an assay development scientist. He trained originally in Pathology at St. George’s Hospital Medical School, London and went on to study Allergy and Immunology at University of Surrey. A specialist in allergy and intolerance, he has been involved in extensive research on mediators of allergic disease in Vienna and London and has published a number of scientific papers. Nigel is a Fellow of the Institute of Biomedical Science, a Member of the British Society for Ecological Medicine and a state registered Biomedical Scientist. As co-founder of Individual Wellbeing Diagnostic Laboratories in 1996, Nigel has been a pioneer of functional laboratory testing in the United Kingdom.
TESTING
Loosening of the tight junctions makes it possible for larger particles – not only nutrients but also toxins, allergens and microorganisms – to penetrate the barrier. The increased permeability of the intestinal barrier is often referred to as ‘leaky gut syndrome’. Inflammation When elements that originate from the intestinal lumen enter the bloodstream an immune response is triggered. While this response is necessary to eliminate potentially harmful substances and microorganisms, it is at the same time potentially undesirable with respect to harmless neutral food particles. Ingestion of food therefore leads to chronic activation of the immune system in which IgG antibodies are involved, leading to the development of immune complexes leading to chronic inflammation and mechanical damage to the surrounding tissues. The specific characteristics of IgG-dependent responses results in a delayed nature for such reactions, which is a considerable diagnostic obstacle, making it almost impossible for the patient to identify the factor causing the reaction. While IgE antibodies are responsible for acute, immediately developing allergic reactions, IgG-dependent reactions take much longer to develop.
Conditions in which food specific IgG antibodies have been demonstrated: • Irritable Bowel Syndrome • Inflammation, hypertension & arthritis • Migraine • Asthma / respiratory diseases • Crohn’s disease • Behaviour problems like schizophrenia and autism
Conditions in which specific IgG antibodies have been demonstrated:
Clinical manifestations Controversy surrounds food IgG testing and this relates to the role food IgG antibodies play in the pathogenesis and diagnosis of food intolerance and a number of chronic illnesses. However, elevated levels of IgG antibodies to food antigens have been observed substantially in diseases associated with increased intestinal barrier dysfunction. In addition, clinical studies to date have largely been supportive of a role for food IgG testing in certain illnesses. The clinical manifestations of chronic IgG-dependent reactions depend on the target tissue or organ to which the immune complexes, composed of IgG and the food antigens, are transported within the bloodstream. Diet The efficacy of a diet based on the measurement of IgG antibodies specific for food components has been demonstrated in a number of disease entities. Excellent results have been obtained in patients with migraine, type 2 diabetes mellitus, IBS, obesity and atopic dermatitis. A diet based on testing results has shown to be an alternative and safe treatment for patients with chronic conditions.
1. Which of the following are the major source of energy for the human body? a) Carbohydrates b) Fats c) Proteins
2. What is the calorie value of 1g of alcohol? a) 3.75 Kcal b) 4 Kcal c) 7 Kcal d) 9 Kcal
3. Which of the following foods have cholesterol-lowering effect? a) Oats b) Avocados c)) Potatoes d) Brown sugar
4. Nuts and seeds are good source of dietary fibre, polyunsaturated & monounsaturated fats? a) True b? False
I5. Individuals suffering from lactose intolerance cannot tolerate live yogurt. a) True b) False
6. Vegans are prone to deficiency of? a) B5 b) B6 c) B12 d) Folic acid
7. Which vitamin synthesised in the gut is involved in blood clotting? a) Folic acid b) B2 c) Vitamin K d) Vitamin D
8. Which of the following nutrients are vital for normal blood sugar regulation? a) Chromium b) Copper c) Calcium d) Magnesium
Answers on P.16
QUIZ
RECIPE
By Pilar Manzanaro (Dipl BCNH, BANT, CNHC) Easter is just around the corner, but do not fret because chocoholics can still indulge with a guilt-free fix of cocoa...
Cacao as we know it is made with the dried and fermented beans of the cocoa fruit. The cacao tree originates in Central America where it was consumed over 5,000 year ago. Cocoa is a natural food packed with nutrients and low in sugar – yes really! Especially raw cacao which has not been processed in heated conditions. However, cacao is used as an ingredient in chocolate and can be found in many foods loaded with sugar, unhealthy fats and additives. In these products, sugar and added fats tend to be the main ingredients. Nutella, for example, contains 57% sugar and most of the fat comes from palm oil not cocoa. Milky Way contains 65.3% sugar, that’s 10g per mini-bar which is more than half the recommended intake for children ages 4-6. In other words, a lot of the chocolate treats available are basically sugar with added fats and just a little cocoa. But let’s get back to cacao (a term typically used for nibs, powder or paste obtained without heating the beans of the cocoa pod) or cocoa. Up to 90% of flavonoids may be lost in cocoa processing (including fermentation of the beans, an avoidable step to reduce bitterness) so whenever possible buy organic and raw cacao which are more nutritious options (1).
FOOD IN FOCUS - COCOA
Quinoa & Cocoa Granola Ingredients 200 g Rolled oats 200 g Quinoa flakes 40 g Pumpkin seeds 30 g Sunflower seeds 2 ½ tbsp Chia seeds 2 ½ tbsp Chopped hazelnuts ¾ tsp Ground cinnamon 2 tbsp Boiling Water 4 tbsp Maple Syrup 4 tbsp Coconut oil, melted 4 tbps Coconut shavings 3 tbsp Cocoa Nibs 3 tbsp Dried blueberries 5 min prep, 40 mins baking *Click here for instructions.
What is in cacao? Fat, protein and.... fibre! Nutritionally speaking, cacao contains 14% fat versus 31% in milk chocolate. Cocoa fat is 2/3 saturated which can increase LDL (bad) cholesterol (2) and 1/3 monounsaturated in the form of oleic acid (3) which has a positive effect on lipid levels. Cocoa also contains 20% protein with the rest being carbohydrates including a high fibre component of approximately 34%. A chocolate bar typically contains 3% fibre! Any micronutrients in cocoa? Yes, plenty of minerals So far, cacao appears to be quite a healthy food, right? Well, that’s not all, cacao also contains minerals including magnesium that helps muscle relaxation, copper, an important element in free-radical management, and to a lesser extent iron, to help transport oxygen throughout the body, and phosphorous to support growth (4).
Raw cocoa mousse with raspberries Ingredients (serves 6) 2 Avocados 2tbps Coconut Oil 1 Vanilla Pod 1tsp Finely Grated Ginger 3 tbsp Coconut water 3 tbsp Raw Cocoa Powder 1. Melt the coconut oil in a sauce pan over a gentle heat. 2. Slice the avocado in half length-wise and remove the stone. 3. Scoop the flesh out with a spoon and put in the bowl of a food processor. 4. Add the rest of the ingredients (except the raspberries) and the coconut oil 5. Blitz until smooth and creamy. 6. Spoon into individual ramekins or espresso cups and decorate with raspberries. 7. Refrigerate for 1-2 hours. 10 min prep, 1-2 hours refridgeration
FOOD IN FOCUS - COCoA
COCOA - the healthy way
Cocoa and antioxidants Cocoa contains flavonoids like those found in green tea and red wine and procyanidin also found in apples (5) to help us fight the harmful effects of free-radicals, which in large quantities can lead to oxidative stress and chronic disease. Note that dark chocolate is higher in flavonoids than milk chocolate (6) and that white chocolate has next to no antioxidants. Flavonoids in cocoa can also help increase insulin sensitivity (7) , which is on the rise and has been linked to metabolic syndrome, diabetes type 2 and PCOS among other conditions. Cocoa extract has been found to reduce inflammation due to its proanthocyanidins, powerful polyphenol antioxidants (8) but note that sugar is pro-inflammatory so cocoa is OK, milk chocolate bars, hot chocolate and chocolate ice-cream are, sadly, not. Cocoa can also help brain function and mood. Improvement in cognition induced by cocoa flavanols has been reflected in higher levels of brain-derived neurotrophic factor (BDNF) which also plays a role in depressive disorder (9, 10). Flavanols in cocoa can help brain function by playing a neuro-protective and neuro-modulatory role that supports neuronal function and brain connectivity, and via increasing blood-flow in the brain and sensory systems (11, 12). It is important to note that chocolate appears to improve mood, especially when eaten mindfully (13). (See P.15 for references)
TIPS
Be savvy when shopping this easter and read the labels because cocoa products tend to be much less healthy as they are loaded with sugars, unhealthy fats and additives. 1) Buy chocolate with a high cocoa content (at least 80%!) 2) Avoid anything filled with caramel, raisins or fruit pastes as they only add more sugar. Nuts and seeds, however, are a great addition to dark chocolate because they add healthy fats, protein and fibre so they slow down glucose absorption. 3) Opt for cocoa nibs - these are great as they have a lovely rich flavor and contain antioxidants without the sugar and can be added to yogurt, snacks and even to granola.
We are still enrolling for our intensive summer Science Foundation Course, which will commence on 6th May 2017. This crash course in chemistry, biochemistry and cytology consists of 4.5 weekends of lessons + 1 weekend of revision spread over 3 months. This intensive course will be run by Sephora Xuereb, an experienced science lecturer and it is designed for individuals who have missed the September enrolment and prefer classroom tuition. Students will cover the same course syllabus as students on the standard (4.5-month) SFC. As this is a crash course, students will require 15 hours a week of self-directed study (in addition to lecture attendance). For more information or to apply, contact Tom at admin@bcnh.co.uk.
CONSIDERING A CAREER CHANGE?
GET INVOLVED
We hope you enjoyed the new edition of the BCNH newsletter. We would love to hear your comments, suggestion and questions , which we aim to incorporate in future editions. Simply get in touch: joannej@bcnh.co.uk We look forward to hearing from you all! Breda & Joanne
OPEN EVENING
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Tuesday 21st March 2017 6-8pm UCL or online The best way to get a feel for what BCNH is all about is to come and visit us on our Open Evening. This will give you the chance to find out more about the academic and clinical work you will experience at BCNH, in addition to the career options that will be open to you as a graduate of our college. At the Open Evening, you will have the opportunity to learn more about the courses we offer, experience the UCL campus and facilities (where BCNH lectures and seminars take place) and also ask questions of staff members How to register your interest in attending the Open Evening? Please email admin@bcnh.co.uk in order to confirm your attendance and receive further information about the event. Please note that places are on a first come, first served basis. If you cannot attend the Open Evening, you can always book an interview / friendly chat with a member of our team via Skype or in person at our offices in NW3.
Depression Albert P R (2015) Why is depression more prevalent in women? Journal of Psychiatry & Neuroscience 40 (4) 219–221 doi: 10.1503/jpn.150205 Berk M Williams LJ Jacka FN O’Neil A Pasco JA Moylan S Allen NB Stuart AL Hayley AC Byrne ML Maes M (2013) So depression is an inflammatory disease, but where does the inflammation come from? BMC Medicine 11 200 doi: 10.1186/1741-7015-11-200 Gowda U Mutowo MP Smith BJ Wluka AE Renzaho AM (2015) Vitamin D supplementation to reduce depression in adults: Meta-analysis of randomized controlled trials Nutrition 31 (3) 421–429 doi:10.1016/j.nut.2014.06.017 Lai JS Hiles S Bisquera A Hure AJ McEvoy M Attia J (2014) A systematic review and meta-analysis of dietary patterns and depression in community-dwelling adults The American Journal of Clinical Nutrition 99 (1) 181-197 doi: 10.3945/ajcn.113.069880 Lépine J-P Briley M (2011) The increasing burden of depression Neuropsychiatric Disease and Treatment 7 (Suppl 1) 3-7 doi: 10.2147/NDT.S19617 Lopresti AL Hood SD Drummond PD (2013) A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise Journal of Affective Disorders 148 (1) 12-28 doi: 10.1016/j.jad.2013.01.014 Martins JG (2009) EPA but not DHA appears to be responsible for the efficacy of omega-3 long chain polyunsaturated fatty acid supplementation in depression: evidence from a meta-analysis of randomized controlled trials Journal of the American College of Nutrition 28 (5) 525-542 Penninx BW Milaneschi Y Lamers F Vogelzangs N (2013) Understanding the somatic consequences of depression: biological mechanisms and the role of depression symptom profile BMC Medicine 11 129 doi: 10.1186/1741-7015-11-129 Psaltopoulou T Sergentanis TN Panagiotakos DB Sergentanis IN Kosti R Scarmeas N (2013) Mediterranean diet, stroke, cognitive impairment, and depression: A meta-analysis Annals of Neurology 74 (4) 580-591 doi: 10.1002/ana.23944 Sánchez-Villegas A Delgado-Rodríguez M Alonso A Schlatter J Lahortiga F Serra Majem L Martínez-González MA (2009) Association of the Mediterranean dietary pattern with the incidence of depression: the Seguimiento Universidad de Navarra/University of Navarra follow-up (SUN) cohort Archives of General Psychiatry 66 (10) 1090-1098 doi:10.1001/archgenpsychiatry.2009.129 Sanhueza C Ryan L Foxcroft DR (2013) Diet and the risk of unipolar depression in adults: systematic review of cohort studies Journal of Human Nutrition and Dietetics 26 (1) 56-70 doi: 10.1111/j.1365-277X.2012.01283.x Spedding S (2014) Vitamin D and depression: a systematic review and meta-analysis comparing studies with and without biological flaws Nutrients 6 (4) 1501-1518 doi: 10.3390/nu6041501 Su KP (2015) Nutrition, psychoneuroimmunology and depression: the therapeutic implications of omega-3 fatty acids in interferon-α-induced depression BioMedicine 5 (4) 17-23 doi: 10.7603/s40681-015-0021-x World Health Organisation (2017) Depression Fact sheet February 2017 http://www.who.int/mediacentre/factsheets/fs369/en/ accessed 24/02/2017
REFERENCES
Cocoa (1) Mehrinfar R Frishman WH (2008) Flavanol rich cocoa A cardioprotective nutraceutical Cardiology Review 16 109-15 (2) Hu FB Manson JE Willett WC (2001) Types of dietary fat and risk of coronary heart disease: a critical review Journal of the American College of Nutrition 20 5-19 (3) American Dietetic Association (2000) Chocolate facts and fiction Nutrition fact sheet (4)) Ashton J Ashton S (2003) Why chocolate is a health food. In A Chocolate a Day: Keeps the Doctor Away 39-52 (5) Hammerstone JF Lazarus SA Schmitz HH (2000) Procyanidin content and variation in some commonly consumed foods. Journal of Nutrition 130(8S) 2086S-92S (6) Vinson JA Proch J Zubik L (1999) Phenol antioxidant quantity and quality in foods: cocoa, dark chocolate, and milk chocolate Journal of Agriculture and Food Chemistry 47 4821-4 (7) Grassi D Desideri G Necozione S Lippi C Casale R Properzi G Blumberg JB Ferri C (2008) Blood pressure is reduced and insulin sensitivity increased in glucose-intolerant, hypertensive subjects after 15 days of consuming high-polyphenol dark chocolate Journal of Nutrition 138(9) 1671-6 (8) Cádiz-Gurrea MdlA Borrás-Linares I Lozano-Sánchez J Joven J Fernández-Arroyo S Segura-Carretero A (2017) Cocoa and Grape Seed Byproducts as a Source of Antioxidant and Anti-Inflammatory Proanthocyanidins International Journal of Moleclar Science 18 (2) 376 (9)Neshatdoust S Saunders C Castle SM Vauzour D Williams C Butler L Lovegrove JA Spencer JP (2016) High-flavonoid intake induces cognitive improvements linked to changes in serum brain-derived neurotrophic factor: Two randomised, controlled trials Nutrition and Healthy Aging 4(1) 81-93 (10) Pase MP Scholey AB Pipingas A Kras M Nolidin K Gibbs A Wesnes K Stough C (2013) Cocoa polyphenols enhance positive mood states but not cognitive performance: a randomized, placebo-controlled trial Journal of Psychopharmacology 27(5) 451-8 (11) Sokolov AN Pavlova MA Klosterhalfen S Enck P (2013) Chocolate and the brain: neurobiological impact of cocoa flavanols on cognition and behavior Neuroscience and Biobehavioural Review 37(10) 2445-53 (12) Ristevska-Dimitrovska G Shishkov R Gerazova VP Vujovik V Stefanovski B Novotni A Marinov P Filov I (2013) Different serum BDNF levels in depression: results from BDNF studies in FYR Macedonia and Bulgaria. Psychiatria Danubina 25 (2) 123-7 (13) Meier BP Noll SW Molokwu OJ (2017) The sweet life: The effect of mindful chocolate consumption on mood Appetite 108:21-27
1.a) Carbohydrates Carbohydrates are broken down into sugar (glucose) which is the main fuel for energy. 2.a) 7Kcal Considering 1g of fat is 9 calories, alcohol is highly calorific. 3. a) Oats and b) Avocados Oats and avocados contain a type of fibre called β-sitosterol, which research shows help to lower cholesterol. 4.a) True 5.b) False Individuals suffering from lactose intolerance CAN tolerate live yoghurt as lactic acid bacteria convert lactose into lactic acid. 6. c) B12 B12 is found in animal foods only, hence vegans need to supplement this vitamin. 7.c) Vitamin K 8.a) Chromium and b) Magnesium Chromium helps insulin facilitate the transport and entry of glucose (blood sugar) inside cells of muscles and tissues, thus helping in the maintenance of stable blood glucose levels. Magnesium deficiency may result in decreased glucose uptake by cells, which may ultimately contribute to high blood sugar levels.
QUIZ ANSWERS