Menopause is defined as the cessation of menstruation (in women) and usually occurs between the ages of 45 and 55. Twelve to eighteen months without a menstrual period is a commonly accepted timing. Before menopause is the peri-menopausal phase when many of the symptoms begin to occur — continuing for up to three years before a woman is considered postmenopausal.
During the peri-menopausal phase, women ovulate irregularly (there can be months of increasing anovulation) (no ovum released), due either to reduced secretion of oestrogen or to the resistance of the remaining follicles to ovulatory stimulus.
About one-third of women experience severe symptoms, one-third exhibit moderate symptoms and the other third have very few symptoms at all. Correcting the hormonal imbalance associated with premenstrual syndrome before menopause can make a big difference to the severity of symptoms experienced during menopause itself.
The common symptoms women experience during menopause are (and they can vary from person to person):
- Main symptoms may be: hot flushes, dry skin, weight gain, vaginal dryness and urinary problems (incontinence), insomnia and mood changes, lack of energy.
- Secondary symptoms may be: aching joints, backaches, disturbed sleep patterns, palpitations, headaches, increasing facial hair, crawling feeling under the skin, reduced memory and concentration, changes in sexual desire.
- Lower levels of testosterone can be an issue and contribute to lowered energy, reduced libido and reduced cognitive function.
What is menopause?
Of the 300,000 to 400,000 eggs a woman is born with in her ovaries, only about 400 will mature during her reproductive lifetime. By the age of 50 not many active eggs are left. With menopause, the lack of active follicles (the cellular coating of the eggs) results in reduced production of oestrogen and progesterone. This drop triggers the pituitary gland in the brain to increase the secretion of follicle-stimulating hormone (FSH) and luteinising hormone (LH). Not having any active follicles to stimulate after menopause, these hormones trigger the ovaries and the adrenal glands to secrete increased amounts of androgens, which can then be converted to oestrogens in the fat cells of the hips and thighs, mainly. These levels are, however, much lower than that needed for reproduction but should be sufficient to maintain health.
Menopause is a normal physiological process — and possibly the only major physiological change we can choose to be conscious of. It is not a disease that has to be medicated — as it is frequently perceived in medicine. As 90 per cent of women reach the age of 60 in the Western world today, successfully managing the change can be a vital issue.
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In many cultures, women don’t experience adverse symptoms associated with menopause. For example, Asian women have less frequent and less severe hot flushes, suggesting that dietary and lifestyle practices can make a difference. Research shows that the reduction of symptoms is associated with their flavonoid-rich diet. It also suggests that botanicals with a high flavonoid content could be effective in managing menopausal symptoms.
While there are obvious dietary and environmental factors to consider, social and cultural factors contribute significantly to how women react to menopause. Unfortunately, in Western society, with its emphasis on youth and beauty, older women are often culturally devalued: look at our stories, fairy tales, even our languaging, with the negative depiction of the “crone”, the old “hag” etc. These terms used to mean “wise woman”, but not so today. Yet research has shown that the cultural view of menopause is also directly related to the degree of symptoms of menopause.
The medical approach
A decrease in the level of ovarian hormones during menopause is the main cause of the increase in both physiological and psychological changes that significantly impacts on the quality of life and health of older women. Current medical opinion primarily uses varying combinations of oestrogen and progesterone as hormone replacement therapy (HRT), but with the potential side effects of increased risk of breast cancer and cardiovascular disease, the question needs to be asked: is this really necessary?
Hormone replacement therapy
While medical HRT has assisted some women to manage menopausal symptoms and improve their quality of life during this time, long-term use is not recommended. A major research study — The Women’s Health Initiative — conducted a clinical trial using conjugated equine (from mare’s urine) oestrogens, treating 10,739 postmenopausal women aged 50 to 79. This trial was stopped early owing to lack of overall health benefits and increased risk of stroke. After one year of treatment, this study showed no significant improvements due to the hormone replacement in the areas of general health, physical functioning, pain, vitality, mental health, depressive symptoms, cognitive function and sexual satisfaction.
The Women’s Health Initiative also reported an increased risk of stroke with prescribed hormone therapy, with the mechanisms of risk potentially related to oestrogen’s pro-inflammatory and pro-thrombotic effects. However, the overall risk was considered uncertain, but further data from the same trial also provided strong evidence for an increased risk of cardiovascular disease with use of combined oestrogen plus progestogen in postmenopausal women.
Further research has indicated potential problems with hormone replacement and increased risk of breast cancer. In a study, 413 women taking these prescriptions were followed over a one- and two-year period. The results were disturbing, leading to the conclusion that use of oestrogen plus progestin (synthetic progestogen) for up to two years was associated with increases in breast (mammographic) density.
As a result of these trials, the prescription of hormone replacement was decreased significantly over subsequent years and women are looking at viable (but safer) alternatives.
Medicine & mood changes
While the changes in hormone levels during menopause generate many physical symptoms, oestrogen withdrawal specifically results in a decline in the release of neurotransmitters, primarily norepinephrine and serotonin (5-hydroxytryptamine or 5-HT), which can lead to a change in thermoregulation in the hypothalamus. This in turn, results in frequent sweating, hot flushes and night sweats, as well as increased depression and anxiety.
Knowing the neurotransmitters involved, increasing the amount of serotonin by activating specific 5-HT receptors, along with inhibiting serotonin re-uptake in synapses, are possible approaches in preventing the symptoms. In order to avoid hormone replacement treatments, some women have opted to choose selective serotonin reuptake inhibitors (SSRIs) to manage these menopausal discomforts. However, these also come with a number of undesirable side-effects, such as sexual dysfunction, nausea, weight gain, sleep disturbances and the risk of addiction.
Diets for menopausal women
While the food we consume on a daily basis is important at any age, the difference can be more marked when our health is under challenge — which can be exactly what menopause is for many women. There is substantial research indicating that a diet higher in vegetables assists in the protection from a broad range of chronic degenerative diseases. Therefore, concentrating on vegetables (including, but not restricted to, fennel, celery, parsley and alfalfa), fruit (particularly berries, apples and low-GI fruits), nuts and seeds, whole grains (not wheat) and soy ferments such as miso and tempeh will provide a high phyto-oestrogen intake.
Wild fish and seafood are excellent sources of protein and help to keep the thyroid functioning normally. The predominantly plant-based diets of some cultures may explain why their women rarely experience menopausal symptoms. High plant-based diets are also protective against osteoporosis, cardiovascular disease and risk of breast and colon cancer.
Phyto-oestrogens
Phyto-oestrogens are non-steroidal plant-derived compounds with diverse chemical structures possessing weak oestrogenic activity. Their constituents include coumestans, lignans and isoflavones. Phyto-oestrogens in foods and herbs are considered oestrogen-protective, as they assist in the liver metabolism of the more toxic forms of oestrogen, breaking them down to safer forms that can then “block” oestrogen receptor sites. These “safer” forms of oestrogen have activity that is considered beneficial without the side-effects of HRT.
Soy (Glycine max)
Soy products are a common source of phyto-oestrogens. Four major research studies have been published where the scientists examined diets enriched with soy, or soy protein, or 400mg standardised soy extract. The studies showed positive effects in the reduction in the incidence of hot flashes, reduction in vaginal dryness, and decrease in night sweats from all forms. Soy has also been shown to be protective for bones. Make sure the soy products you buy are non-GMO, however. The soy ferments (miso and tempeh) are even more beneficial for health.
Botanical regulation of menopause symptoms
Herbal medicines are most popular with women aged 40–50 years — the age group around peri-menopause and menopause — and this popularity is likely to increase as more women become wary of the risks of hormone replacement therapy and demand a good quality of life during menopause.
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As mentioned, there are several major factors to consider, including improving hormone balance and serotonin regulation. Important issues for the long term are the management of osteoporosis, and cardiovascular disease prevention. Before menopause, women are protected from cardiovascular disease due to the higher levels of hormones, but when postmenopausal the incidence reverts to the same as that of men.
Botanical medicines used to relieve symptoms of menopause have multiple activities, from hormonal balancing with the phyto-oestrogens, mood regulation by balancing serotonin, flavonoids reducing inflammation and providing cardiovascular protection, and components that improve musculoskeletal outcomes such as reduced osteoporosis.
Plants with either 5-HT ligands, or activity resulting in inhibition of serotonin re-uptake, potentially increase serotonin levels and include St John’s wort, black cohosh, kava, dong quai.
Black cohosh (Cimicifuga racemosa)
Black cohosh is a perennial plant native to eastern parts of North America. The dried rhizome is used for medicinal purposes with main active constituents including triterpenoids, flavonoids, phytosterols, tannins, and cimicifugin. Black cohosh has been shown to increase oestrogenic activity via direct binding of active constituents to oestrogen receptors. It is the most studied alternative to hormone replacement therapy, and one of the most effective as it not only relieves hot flushes and vaginal atrophy (a big problem for continuing sexual activity for many women) but also improves depression.
Dong quai (Angelica sinensis)
Dong quai is a perennial plant whose root is a popular remedy in traditional Chinese medicine. It is predominantly a female remedy that has been used to treat many female disorders, including menopause. It has good uterine tonic activity, improves liver function, relieves hot flushes and acts to stabilise blood vessels.
A recent study conducted on rats showed that dong quai root may inhibit bone turnover markers, thus potentially preventing bone loss. The mechanisms of action are through the pro-inflammatory cytokines as these are well-known regulators of bone metabolism. Dong quai was shown to be as effective as oestrogen replacement for the prevention of postmenopausal osteoporosis — with a strong safety record.
A Phase II clinical trial treating menopausal women with dong quai showed significant improvement in both physical and psychological scores, as well as reduced hot flushes, improved bone density and enhanced quality of life.
Red clover (Trifolium pratense)
Another major source of phyto-oestrogens is red clover, a herb frequently used to relieve menopausal symptoms and one that has multiple health effects. Red clover was traditionally valued as an antispasmodic and an anticancer treatment, not as an oestrogenic agent. Interestingly, red clover and soy share similar but distinct chemical profiles: both contain flavones such as genistein and daidzein, but red clover has significantly higher levels of these flavones and it’s these that are believed responsible for the oestrogen-like effects.
Red clover has been shown to reduce hot flushes in many women and also to improve bone mineral density; in addition, one study showed an improvement in lipid profiles (thus assisting in cardiovascular protection) by increasing the HDL (protective) fraction of blood lipids. Overall, studies showed no adverse side-effects.
Hops (Humulus lupulus)
Hops have been shown to be effective in reducing hot flushes, improving sleep time and reducing anxiety and depression — all symptoms being related to decreasing levels of oestrogen and rising levels of luteinising hormone (LH).
The potent phyto-oestrogen in hops (8-prenylnaringenin) is effectively absorbed in the human intestines, triggering measurably higher plasma oestrogen levels, with a concurrent lowering of LH levels. In one study, 67 women were treated for 12 weeks with a hops extract (compared with a placebo group) and the treated group showed significant improvement in their symptoms of hot flushes.
In another study, a gel containing hops extract was used as a vaginal application in women with vaginal atrophy. Although the study numbers were small, the women reported marked improvement in the symptoms after the first week of treatment.
Women taking hops have also shown an improvement in bone strength. Studies in rats showed that the effect on increasing bone mineral density was greater than that of both genistein (the active soy ferment compound) and resveratrol.
Sage (Salvia officinalis)
Sage is an old herbal remedy prescribed to reduce hot flushes in menopause, particularly night sweats, thereby allowing improved sleep. Sage has a role in improving memory and concentration and has been shown to have a positive effect on dopamine without adverse side-effects.
Liquorice (Glycyrrhiza glabra)
Liquorice contains phyto-oestrogen components. It has antidepressant properties, reduces hot flushes, improves adrenal cortisol and stress management and reduces cardiovascular risk with its antioxidant and lipid-lowering activities. Overall, liquorice has multiple activities in improving menopausal symptoms. One caution: be careful with long-term high doses as these may also reduce potassium levels.
Chaste tree (Vitex agnus-castus)
Chaste tree has profound effects on pituitary function and has been shown in menopause to have beneficial effects on LH and FSH secretion, thus relieving hot flushes and improving energy.
St John’s wort (Hypericum perforatum) & passionflower (Passiflora incarnata)
St John’s wort and passionflower showed significant improvement in menopausal symptoms, reducing hot flushes, insomnia, depression, anger, palpitations, headaches, vertigo, fatigue, muscle and joint pain, numbness — all these symptoms improving significantly from the third to the sixth week of the study. It was determined that these two herbs — prescribed either singly or together — are successful alternative treatments for menopausal women. Both these herbal medicines improved serotonin levels, enhancing the quality of life in the women in the study.
Kava (Piper methysticum)
Kava rhizome contains kava pyrones (also called kava lactones), which have anxiolytic (anti-anxiety) and sedative activity. Two double-blind, placebo-controlled, randomised clinical trials found significant improvement in nervous system function and psychosomatic (the mind/body) dysfunction in menopausal women who took a standardised 300mg kava extract daily for 2–3 months. Kava significantly improved symptoms of anxiety and insomnia (thereby increasing energy and wellbeing) in menopausal women.
Shatavari (Asparagus racemosus)
Shatavari root is regarded in Ayurvedic medicine as an aphrodisiac and a female reproductive tonic with rejuvenative actions for all ages. Shatavari is considered a remedy from the rasayana group, meaning it strengthens the health of all tissues of the body. Shatavari root contains steroidal saponins, which support a subtle oestrogen-modulating activity. Shatavari also reduces symptoms of anxiety.
It is an effective demulcent for dry and inflamed membranes of the lungs, stomach, kidney and sexual organs. Hence it may be of benefit for the treatment of vaginal dryness in menopause.
Ginseng (various)
There are several types of ginseng, including Panax ginseng (from Asia), Siberian ginseng (Eleutherococcus senticosus), American (Panax quinquefolius), and Indian (Withania somnifera). While they have differing therapeutic profiles for many conditions, all these ginsengs show activity in improving adrenal function (and therefore stress management). Healthy adrenal function is important in managing changes like menopause and in protection against immune dysfunction and chronic illness. The various ginsengs overall improve blood-sugar management, liver glutathione levels and hormonal balance, and have major antioxidant and anti-inflammatory effects. They provide neuroprotection (improve memory and concentration along with reduced anxiety and depression) and increase energy levels. Ginsenosides exert oestrogen-like actions without direct receptor binding.
Ginkgo biloba
Ginkgo biloba leaf is worth mentioning as it has positive effects on the vascular system and, by improving peripheral circulation, regulates high blood pressure, relieves cold hands and feet and improves the memory loss that frequently occurs with menopause. Ginkgo improves mental health in patients with cerebral vascular insufficiency. It not only increases blood flow to the brain but also enhances energy production within the brain by increasing glucose supply and improving the transmission of nerve signalling. Ginkgo must be taken for at least 12 weeks for noticeable improvement.
Hormones to consider supplementing
DHEA (dehydroepiandrosterone)
DHEA (an adrenal hormone) works at a different level from the supplements and plants that have hormonal activity. It’s one of the main precursors for the androgens, which in turn are converted to oestrogen, progesterone and testosterone. DHEA levels are lowered when a person is stressed (it is manufactured into cortisol preferentially under stressful conditions) and supplementing has been shown to increase oestrogen and testosterone levels in peri- and postmenopausal women, alleviating their symptoms and improving their general sense of wellbeing, energy and sexual function.
Melatonin
Melatonin is a major regulator of sleep, mood and the human circadian rhythms. Chronic insomnia is a common problem in menopausal women, triggered by a drop in melatonin levels. This is associated with hot flushing, particularly at night, restless leg syndrome and sleep disorders. At the same time, menopausal women with low melatonin are twice as likely to experience significant depressive symptoms. Research is showing that postmenopausal depression and insomnia are related to variations/reductions in melatonin secretion.
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Current research also indicates that melatonin regulates many aspects of physiology, including cardiovascular function, and the antioxidant enzymes related to ageing. Melatonin is considered a useful cardioprotective agent as it reduces the severity of essential hypertension, limits abnormal cardiac physiology and the reduction of heart damage from ischaemia, reduces cardiac hypertrophy and limits the frequency of heart failure — certainly in research on rats, at least.
Studies on humans support this research due to melatonin’s powerful antioxidant properties protecting the cardiovascular system.
Osteoporosis (& osteopenia)
Bone is a dynamic organ that undergoes turnover many times during a lifetime. This remodelling process involves cycles of resorption, followed by the formation of new bone to replace old bone and to strengthen bone in response to repeated physical stress. As we age, bone resorption begins to exceed bone formation, resulting in a yearly net bone loss (up to 1 per cent a year), leading to osteoporosis and increasing risk of fractures.
Osteopenia is a lessening of calcium in the bones (the early stages of this process), whereas osteoporosis is the severe stage of bone fragility when sufferers are at increasing risk of fractures, especially in the hips (neck of femur) and spine. The conditions responsible for the diminishing strength of bones are multifactorial metabolic problems with a variety of dietary imbalances. Osteoporosis is considered an issue with abnormal calcium metabolism (a more complex issue than a simple calcium deficiency).
Reversing osteoporosis is therefore a complex metabolic issue: bone micro-architecture needs to be improved, osteoblast proliferation (bone rebuilding) needs to be increased and osteoclast (bone remodelling: breaking down) activity reduced.
Much is written about the role of calcium, but the source of calcium is critical. Calcium in foods is bound up with other micronutrients that regulate its metabolism, including magnesium, boron, zinc and silica (and phosphorus), and these are not always found in calcium supplements. If calcium replacement is needed, naturally sourced calcium may be a better option. Calcium hydroxyapatite is ground-up internal part of bone and contains all the nutrients needed in the correct proportions, so is potentially the best choice. Coral calcium and zeolite have shown promise in rat studies, so these are often considered good options.
Cod liver oil contains vitamin D, although a variety of supplements of this vitamin have been shown to increase blood levels when a person is low. Get your vitamin D checked, however, as there is an ideal level of vitamin D: 100 nmol/L, usually. Vitamin D is a critical nutrient but needs to be in the correct proportions. Cod liver oil also contains vitamin A and the anti-inflammatory omega-3 fatty acids.
Medically, bisphosphonates are prescribed for osteoporosis, but these can have adverse side-effects long term. There has been significant research looking at dietary and herbal alternatives that, over time, have been shown to be successful.
Dietary guidelines for menopausal management & bone density improvement
These dietary guidelines apply generally to improving health in older women.
Avoid wheat as bone density is lower in women with wheat sensitivity, gluten intolerance or coeliac disease. Coeliac disease is the most severe condition, and has a genetic component. One of the main issues with wheat intolerance or allergy is that ingestion of this common food triggers an inflammatory process along the lining of the gastrointestinal tract. Apart from the chronic inflammatory response and the subsequent immune challenge (a major trigger of inflammatory autoimmune diseases), this also results in poor absorption of many critical nutrients and therefore leads to multiple deficiencies — even with an otherwise good diet.
Diets to support bone structure (& health)
Diets high in vegetables and fruit (ideally more than nine serves a day) and adequate protein foods such as legumes and fish, showed better overall health, reduced menopausal symptoms and better bone structure due to high phytonutrient ingestion and an overall alkalising effect. The calcium and vitamin D levels (among other nutrients) were measurably higher in these diets.
High phytonutrients such as lycopene, phenolics, flavonoids, resveratrol and pectin derived from tomatoes, apples, grapes, berries and citrus fruits, and especially dried plums (prunes), are antioxidant and have a pronounced effect on improving bone. A diet high in these nutrients generates a higher bone mass, with higher trabecular bone volume and thickness and lower trabecular separation, thus indicating enhanced bone formation and suppression of bone resorption, resulting in greater bone strength.
These osteoprotective effects are mediated through the antioxidant and anti-inflammatory pathways and their downstream signalling mechanisms, leading to increased osteoblast mineralisation and increased inactivation of osteoclasts.
Onions and garlic have bone-protective properties, increasing bone thickness by inhibiting the resorption activity of the osteoclasts. Diets high in omega-3 fatty acids are protective for bone and also reduce the inflammatory activity associated with various forms of arthritis and cardiovascular disease.
Medications adversely affecting bone strength
Osteoporosis and its clinical consequences of increased fractures are well-known issues in chronic autoimmune diseases such as rheumatoid arthritis. In both male and female populations, the prevalence of reduced bone density is reported to be doubled in comparison to the general population. Patients are at increased risk of both spinal and hip fractures. Research evidence supports the view that bone loss is a disease related to both the increased inflammatory process and to glucocorticoid use independently.
To manage bone strength, the inflammatory process must be regulated, preferably by nutrients and herbal medicines, and both the bone nutrients and vitamin D should be supplemented.
Increased risk for bone fracture also occurs in chronic analgaesic users associated with the opioids, with one of the mechanisms being a direct action of opioids on osteoblasts.
Cardiovascular disease prevention
Increasing the intake of foods high in antioxidant and anti-inflammatory components is vitally important, but oestrogen also plays a major physiological role in the cardiovascular system by protecting against heart disease. This is facilitated by its atheroprotective effect on plaque stabilisation and collateral vessel formation.
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Oestrogen has favourable effects on insulin, glucose and lipoprotein levels, but because the antioxidant effect of oestrogen is lost once women reach menopause, the incidence of atherosclerosis increases. This is associated with a higher level of oxidised LDL in the blood and higher levels of oxidation. This increasing oxidation makes postmenopausal women more susceptible to metabolic syndrome and insulin resistance, both of which (in a circular argument) are implicated as risk factors for cardiovascular disease.
Consumption of foods and herbs rich in antioxidants that also regulate blood sugar may therefore be helpful in enhancing the beneficial effects of other therapies for postmenopausal patients.
Fenugreek (Trigonella foenum-graecum)
Fenugreek is worth mentioning because it is high in flavonoids and polygalactomannans, giving it multiple roles in regulating insulin (fenugreek seeds regenerate β-cell activity in the pancreas) and regulating cholesterol metabolism by increasing the protective HDLs. It is anti-inflammatory and antioxidant, improves testosterone levels and reduces fatty liver. It also has reasonable levels of phyto-oestrogens.
Nutrients for cardiovascular protection
Two dietary vitamins, vitamins C (ascorbic acid) and E (α-tocopherol), can be used to reduce the incidence of disorders associated with an age-related decrease in oestrogen. Rich in their antioxidant capacity, these vitamins scavenge free radicals and neutralise oxidative stress. One study assessing the effect of these vitamins on postmenopausal women found higher levels of the various oxidative markers and lower levels of the antioxidant enzymes in those who did not supplement vitamins C and E in their diets. These vitamins are not only major antioxidants but they are also associated with a reduced risk of cardiovascular disease via their inhibition of cholesterol synthesis and LDL-cholesterol oxidation.
Both vitamins have also been shown to reduce the intensity and number of hot flushes by improving adrenal function, allowing increased hormonal production, specifically oestrogen, and supporting a greater antioxidant defence system in postmenopausal women. When considering vitamin C alone, its intake has been associated with a protective effect on bone. This can be seen through its suppressive action on osteoclast activity, which thereby prevents accelerated bone turnover and eventual bone loss.
A wee problem but a very inconvenient one: incontinence
Incontinence is increasingly common in older women and it continues to deteriorate with time. It can, however, be managed if caught early. Incontinence is caused by several factors: the hormonal diminution of oestrogens and progesterones, along with the long-term effects of damage from childbirth. This latter is more difficult to treat, but the former has possibilities and the treatments are along the lines of those already mentioned — with a couple of additional herbs.
The diet has to be one in which the bladder irritants are removed, the most common being wheat, but also refined sugar, caffeine and alcohol can exacerbate the problem. A diet high in flavonoids can strengthen the bladder. Incontinence also has its roots in neurological conditions such as anxiety. Insulin resistance and metabolic syndrome may contribute to this condition.
One useful herb is the Ayurvedic herb Cratavea nurvala (varuna) as it has multiple effects on improving the health of the urinary tract including the reduction of bladder irritability.
Exercise
There is an old adage that says “use it or lose it”. While this may have multiple applications, it is very true for maintaining both bone strength and good cardiovascular function. Overall, the research shows that average bone mineral density is higher in women who exercise regularly than in those who don’t exercise. Weight-bearing exercise is particularly useful. Regular exercise also improves balance and muscle strength, thereby reducing the incidence of falls in the elderly.
An interesting study showed that the ancient Chinese exercise regime tai chi chuan is particularly effective for elderly people as it maintains neuromuscular co-ordination, muscle strength and flexibility, is weight bearing and improves the function of the cardiovascular, respiratory and immune-endocrine systems.
Building long-term health
Menopausal women may suffer from a variety of symptoms, including hot flushes and night sweats, which can affect their quality of life. Although hormone therapy has been the treatment of choice for relieving these symptoms, it has been associated with increased breast cancer and cardiovascular risk, leading many women to search for natural, efficacious, and safer alternatives, such as botanical remedies and dietary supplements. Data from clinical trials indicate that foods and botanical medicines are useful to reduce menopausal symptoms, improve bone density and reduce the incidence of chronic disease, setting the foundation for long-term health.
