The Impact of Exercise on Brain Health and Preservation

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By Carly Smith, BS, MPH(c) 

The foundation of longevity science exists in a balance of healthy physical, mental, and emotional aging. In the past, researchers have studied these aspects of health as independent subjects, but now scientists emphasize that every aspect of our health is intertwined. One of the major motivations behind the Stanford Lifestyle Medicine movement is to increase awareness of how total health is dependent upon the interactions between the pillars of our lives. 

Recently, members of the Stanford Lifestyle Medicine team collaborated to conduct a systematic review of existing research on “The Role of Physical Exercise in Cognitive Preservation.” The article, which was published in the American Journal of Lifestyle Medicine, responds to a call for more scientific investigations to focus on the prevention of cognitive disabilities associated with old age, such as dementia. 

“After conducting this review, a major takeaway is that we should be motivated beyond physical improvements to continue moving our bodies to promote long-term cognitive benefits,” says Matthew Kaufman, MD, lead author of the review article.

Exercise and the Brain

Both aerobic exercise and strength training are widely researched lifestyle interventions for quality health improvement.The US Department of Health and Human Services (USDHHS) recommends weekly exercise of at least ​​150 minutes of moderate-intensity aerobic exercise and two days of strength training for improving physical and mental health. 

There are multiple proposed mechanisms that define how regular physical activity combats cognitive decay. As you exercise, your heart increases the amount of blood that it pumps out to the rest of the body to compensate for the increased workload. This increase in cardiac output also increases cerebral blood flow, which is linked to heightened neural activity and reduced oxidative stress (or an improved ability to detoxify agents in the body). Another proposed mechanism is the increase in trophic factors (proteins that aid cell survival and growth), such as BDNF, VEGF, and IGF-1. These trophic factors support neuroplasticity (the structural reorganization of the brain to support learning) and angiogenesis (the growth of new blood vessels). Therefore, it is reasonable to promote exercise as a lifelong tool for optimizing brain health.

“It is important to understand the physiology of this relationship in order to maximize exercise regimens for prolonged cognitive benefits and goal setting,” says Dr. Kaufman, current Stanford Physical Medicine and Rehabilitation Resident.  

Key Takeaways from the Systematic Review

After reviewing over 1,600 total studies, 17 met the team’s final criteria for further analytical evaluation. To be included in the final review, studies must have been a randomized controlled trial published after 2000, excluded cognitive impairments more severe than moderate diagnoses, and included at least one physical activity intervention that lasted for 12 weeks or more and followed the USDHHS recommended guidelines. For this review, both aerobic exercise and strength training were included as exercise interventions. The final 17 studies selected for “qualitative synthesis” looked at the relationships of exercise and global cognition, exercise and memory, and exercise and executive function. 

The review team found the largest consensus in the research for improvements in memory for individuals with moderate, mild, or no cognitive impairments following the 12-week exercise interventions. For individuals with mild cognitive impairments, exercise was shown to improve cognition. Although weaker, there was also evidence found for relationships between regular exercise and improved global cognition and executive functioning. Some studies also found significant associations between improvements in physical and cognitive fitness and increases in regional brain volume or blood flow. 

However, included studies that analyzed the lasting effects of exercise following the study indicated a need for continued exercise. Improvements in memory and cognitive health were not always maintained once regular exercise stopped. This suggests the importance of exercise as a long-term principle of lifestyle medicine for adequate prevention of late-stage diseases. 

“Given that our review demonstrates that people did not see lasting benefits after stopping their exercise, the importance of routine exercise to continue reaping benefits is suggested,” says Dr. Kaufman. “It also strengthens our association that exercise interventions can, in fact, improve cognition.”

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How Joy is Linked to Gratitude and Well-being

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By Donovan Giang

This blog is part of our Gratitude & Reflection newsletter. If you like this content, sign up to receive our monthly newsletter!

With the holiday season upon us, the spirit of joy is in the air. From magazine advertisements of happy families having a delicious meal to hearing Christmas carols in department stores, we are constantly being fed the message that we should be joyful at this time of year. However, if we are not feeling joy, these messages can be a continual reminder of what we are missing, often making us feel worse.

Luckily, researchers such as Akivah Northern, DSci (c), MDiv member of the Stanford Lifestyle Medicine Gratitude and Reflection pillar, explore different ways to experience and cultivate joy in our lives. Northern is a chaplain, doctoral candidate at Loma Linda University and she received her Masters of Divinity from Yale University. Her dissertation research is a Stanford IRB approved study, exploring medical students’ joys and challenges as they were expressed during Reflection Rounds, a required course for medical students taking their core clinical clerkships at Stanford School of Medicine. Northern co-facilities Reflection Rounds with Bruce Feldstein, MD, BBC who brought Reflection Rounds to Stanford seven years ago.

“We know that medical students are challenged, however less is spoken about their joys, which are equally as important,” says Northern. “Joy in medicine is an ancient aspiration that dates back to the fourth-century Hippocratic Oath, which is still taken by physicians today. Experiencing joy as a physician is part of the very foundation of medicine, so it is essential to cultivate it as medical students begin working with patients.”

So, how does one define joy? In Hebrew and Greek, joy has many meanings, such as delight, exaltation, rejoice, gladness, cheer, exuberance, and triumph. Northern shares that during challenging times, feelings of sorrow and grief are valid and a natural part of the human experience.

“There are times when life brings us situations when we have to lament, but we don’t have to stay there ,” she says. “There are so many different types of joy, such as received joy, divine joy, announcing joy, profit joy, fruit of the spirit joy, and jumping for joy, joy! So, even during hard times, we can choose to savor the myriad of joys and intentionally create reasons for joy.”

 Joy Linked to Gratitude

In exploring joy, researchers examined the relationship between joy and gratitude. This study consisted of self-report measures from university students. To measure joy, the researchers used scales developed within the study, such as the State Joy Scale and the Dispositional Joy Scale. To quantify gratitude, the researchers used scales of Dispositional Gratitude, a Gratitude Questionnaire, and a Gratitude, Resentment, and Appreciation Test. These self-report measures found that joy can increase gratitude and gratitude can increase joy, suggesting an “intriguing upward spiral” between the two.

“Research linking positive emotions like joy and gratitude to well-being is vital for patients as well as for  healthcare providers,” says Northern. “For example, preliminary results from my research showed that medical students’ expressed joy when they were grateful for teachers, peers, and for the profession of medicine, but especially for their patients”

Looking at her data, Northern found that in 30 expressions of joy by medical students, 17 were associated with gratitude. For example, one medical student expressed joy as gratitude for being “deeply honored” to have met and had “easy, comfortable conversations” with a patient, his spouse and family. Another student expressed joy as appreciation for the way his physician mentor engaged with a patient, describing the interaction as “beautiful and wonderful.” The student appreciated seeing the physician be present with the patient, admiring the quality of the physician’s presence and the “commonality” the physician and patient shared. A third medical student expressed that although she could not deliver medical care to a distraught patient with overwhelming life stressors, she still felt joy because “ultimately, just being a listening human was the number one therapy delivered that day.”  

“A surprising finding from the research was when medical students’ expressed joys and challenges simultaneously, they often had a breakthrough to a discovery or new joys and insights,” says Northern. “When we allow joys and challenges together, we become more resilient and emotionally buoyant, and often something new emerges from the experience.”  

Joy Linked to Well-being

In recent years, joy has become an object of study in the humanities and medicine. Joy, as a positive emotion, has consistently been suggested to be a key aspect of well-being in the field of positive psychology. Martin Seligman, the founder of this field, developed the PERMA+ Model. The “P” in PERMA+ stands for positive emotion (joy, gratitude, and optimism), the “E” for engagement, the “R” for relationships, the “M” for meaning, the “A” for accomplishments, and the “+” for other elements beyond these. 

In further research on joy as a positive emotion, researchers conducted a study to examine the pre-existing strategies individuals use to maintain high levels of positive emotion. To measure the strategies the participants (university students) used, the researchers applied an Emotion Regulation Profile to categorize participant reactions to hypothetical situations. One result from this study found that mindfulness (being present in the moment) was positively correlated with positive affect.

Another way positive emotions (including joy) increase well-being at the physiological level is by increasing one’s resilience. In this study, university students prepared a short speech, which served the purpose of stimulating a stress response. Using cardiovascular measures (to gauge the stress response), ambient mood and emotion measures, and psychological resilience measures, the researchers found that positive emotions hastened cardiovascular recovery (a lower amount of time needed to return to baseline cardiovascular measures, including heart rate and finger pulse data) after the experimental stressor. 

Another study examining the influence of positive emotions on physiological stress processes was the first to demonstrate that gratitude and thankfulness can buffer against the negative effects of acute stress on cardiovascular responses.

“Even in stressful times, joy can be a choice,” says Northern. “Even in a hard situation, we can look for joy. Even if we can’t see the joy currently, we can anticipate the joy that may come in the future from accepting the challenge, resolving it or reframing our understanding.. When we choose to approach challenges in the company of  joy and hope,  we are investing in our own well-being and our future.”

 

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Optimism as a Means to a Longer Life

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By Jonanne Talebloo

This blog is part of our Gratitude & Reflection newsletter. If you like this content, sign up to receive our monthly newsletter!

We have all heard the saying “mind over matter” when it comes to athletics and physical challenges. But can this saying be applied to health, healing, aging, and longevity? Studies suggest that optimism may play a leading role in improving not only one’s emotional well-being but also physical health and increasing lifespan.

Optimism, defined as the tendency to be hopeful and expect positive outcomes, has been linked to improved mental health and well-being in that it uplifts one’s mood and outlook on life. Optimism alone may not be the silver bullet for health and happiness, but studies show that it is one of many factors that can positively influence health, longevity, and lifespan.

For example, research shows that optimism helps diminish stress and anxiety, which lowers the stress hormone cortisol. Elevated levels of cortisol and blood pressure have been linked to an increased risk of stroke, hypertension and heart attack. Chronic stress can have negative effects on almost all of our bodily systems, including the endocrine system, where stress can impair communication between the immune system and the hypothalamic-pituitary-adrenal (HPA) axis, and potentially lead to immune disorders.

Optimism also assists with healing. Akivah Northern is part of the Stanford Lifestyle Medicine Gratitude and Reflection Pillar and earning her doctoral degree in Religion and Health at Loma Linda University. She is a chaplain, which are professionals who listen and accompany patients and their families in life-threatening, physical, existential, moral, or spiritual distress. Northern is the founder of a soon-to-open healthcare center that incorporates lifestyle medicine, chaplaincy intervention, and the arts.

“Optimism is not just helpful, it is vital for those who are suffering,” says Northern. “As a chaplain, I engaged patients in optimism and hope, instilled a sense of the sacred, and offered explorations regarding ultimate meanings. These conversations served as calming, hope-filled, and relieving medicine for patients.”

Optimism and Longevity

Recent studies have explored the connection between optimism and longevity and how a person with a positive outlook has the potential to live a longer, healthier life. A recent study revealed that optimism (defined as “the global expectation that things will turn out well in the future” and measured by cortisol stress reactivity and questionnaires) was linked to decreased cortisol levels, which is an important factor regarding increased longevity. Another study found that higher levels of optimism (assessed using the Revised Optimism-Pessimism Scale) were linked to increasing lifespan by as much as 15 percent.

In a review article examining a variety of health and longevity benefits associated with optimism, researchers found a whole host of benefits. Highlights from the review were that greater optimism predicted greater career success, better social relations, and better health. The article also concluded that the positive effects of optimism appeared to reflect individuals with a greater engagement in pursuit of desired goals. Another large-scale study showed that the link between optimism and increased longevity was independent of ethnic origin and applied across many racial and ethnic groups.

In order to understand how optimism can make such dramatic impacts on our health and longevity, the neural underpinnings of optimism have also been studied. Research suggests optimism activates areas of the brain involved in mood regulation, attention allocation, emotional expression, language processing, and perception of oneself. Modulating these areas with our thoughts may improve psychological well-being by improving one’s perception of the world, themselves, and self-expression.  

“Optimism is the opposite of stress, worry and anxiety, which can increase inflammation and chronic illness in the body,” says Northern. “By leaning toward a calming and optimistic way of being, we are increasing not only our mental, emotional, and spiritual well-being, but also our physical health and longevity.”

Optimism can be Cultivated

Although optimism is defined as a trait ingrained in individuals, people can learn to develop optimism over time. Learned optimism can be cultivated through music, gatherings, and culture in community. This sense of community strengthened by optimism can promote individual well-being, contribute to advancements in public health, and even inspire social change on a global scale.

An example of cultivated optimism through culture and community is the fact that millions of Iranian women worldwide have learned to adopt an optimistic attitude in their fight for freedom and equality. Research also shows that optimism improves resilience, another essential characteristic for Iranian women. Optimism and resilience among the Iranian diaspora have been the foundation of a global community that continues to inspire change regarding women’s rights. 

Optimism can also be developed at the individual level by working with internal thoughts, such as breaking pessimistic thought patterns or cultivating the experience of gratitude by keeping a gratitude journal. Another way to work towards adopting an optimistic mindset is by challenging and re-writing negative self-talk. For example, this can mean changing phrases such as “I will never be able to do this.” to “This is a challenge I look forward to working towards overcoming.” Furthermore, one study notably found that optimism can be increased through a very simple intervention in which individuals imagined their best possible self for five minutes each day.

“Our internal dialogue is everything. What we tell ourselves, the language we use on the inside will come out on the outside,” says Northern. “So, we need to be intentional about being optimistic, generous, and forgiving—this will make such a difference not only for those around us, but for our own health and healing.”

 

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Practice of the Month: Four Questions a Day

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By Carly Smith, BS, MPH(c) 

This blog is part of our Gratitude & Reflection newsletter. If you like this content, sign up to receive our monthly newsletter!

Spiritual practices do not have to take place in a church; therefore, every person lives with spirituality in some way. Individuals connect to their spirits and create meaning through various activities, including religious rituals, but also through music, art, or exercise. 

“Spirituality, broadly, is the way that we find purpose, connection, belonging, and dignity as human beings,” says Bruce Feldstein, MD, BCC, Stanford Lifestyle Medicine Head of Gratitude and Reflection. “People find it in various ways–it’s not important where you find it; what’s important is just to get started looking for it.” 

Dr. Feldstein is a board-certified chaplain at Stanford, where he directs Jewish Chaplaincy Services serving Stanford Medicine and an Adjunct Clinical Professor in the School of Medicine. He sees spirituality as the critical element missing from most lessons on healthy aging from elementary to medical school. His experiences as an Emergency Medicine Physician turned Clinical Chaplain inspired him to create the Spiritual Fitness ToolKit, which helps individuals cultivate well-being by exploring rituals for meaning, purpose, and connection.

 “A spiritual practice is as essential to cultivating well-being as physical fitness or nutrition. However, our ‘spiritual fitness’ is typically not discussed as concretely as these other aspects of health,” says Dr. Feldstein. 

Four Questions a Day Exercise

The Spiritual Fitness ToolKit opens with a reflection exercise titled “Four Questions a Day.” To develop habits of gratitude and reflection, Dr. Feldstein recommends spending ten minutes of quiet time at the end of the day to contemplate these four questions, one at a time. 

     The Four Questions:

1. What surprised me today?

2. What touched me today?

3. What inspired me today?

4. For what am I grateful?

Start by asking yourself the first question, What surprised me today? Reflect backward on your day until you come to the first thing that surprised you. Make a note of it in a little journal or on a file on your smartphone. It’s important to write it down. Then do the same with the other questions, one at a time. (This exercise is drawn from research on gratitude and from the teachings of Rachel Naomi Remen MD, originator of the Healer’s Art course.)

After a few weeks of practice, you may begin thinking about these questions throughout your day. Eventually, you may find yourself noticing moments of surprise, being touched, inspiration, and gratitude as they occur. This heightened awareness can allow you to see and respond to  situations in your life with “new eyes,” and bring elements of emotional well-being into your everyday experience.

“The Four Questions exercise could be essential in two ways for people getting started,” says Dr. Feldstein. “It can help develop a capacity for increased emotional awareness and encourage people to become reflective practitioners in action.”

Dr. Feldstein suggests committing to this practice for at least three weeks to develop a new habit, and for 90 days to create a new lifestyle. He also suggests engaging in the daily writing activity with a friend to promote connection and enjoyment.

Sharing Moments of Gratitude

An extension of the Four Questions practice is Sharing Moments of Gratitude, another valuable practice  in the Spiritual Fitness Toolkit .

Feeling gratitude within oneself is one part of the experience. When we feel grateful for something wonderful in our lives, we can share our appreciation of others by saying or doing something for someone else. Doing so expands the experience of gratitude to those around us.

Sharing gratitude can be done in many ways. Most simply, we can say, “I really appreciate what you just did. Thank you so much.” This is most powerful and the positive experience is mutual and immediate. We may also send a thank you note, or offer a small gift. 

One of Dr. Feldstein’s favorite practices is to produce small moments for gratitude at the end of each conversation, discussion, or meeting.

“I often ask my patients or people I am with ‘What can I wish for you today?’ I listen with openness, take in what they say, then respond genuinely with an open heart. This is a practice for offering a blessing. It is one that produces mutual gratitude,” says Dr. Feldstein. “It is a simple practice you can incorporate into any conversation or interaction and greatly encourages connection, healing, and finding peace.”

So, dear reader, what can the Stanford Lifestyle Medicine team wish for you today?

 

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Gratitude is Good Medicine

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By Sharon Brock, MEd, MS

This blog is part of the Gratitude & Reflection newsletter. If you like this content, sign up here to receive our monthly newsletter!

A few months ago, Stanford Chaplain Bruce Feldstein, MD, BCC, received a call to offer compassion and spiritual care for a woman in her 90s at Stanford Hospital. When Dr. Feldstein entered the hospital room, he saw her husband sitting at her bedside, holding her hand, and looking at his wife of 62 years with eyes of devotion and appreciation. Taking a seat, Dr. Feldstein was deeply touched and inspired by the love they shared between them and the immense gratitude the husband had for his wife. With reverence for the sacred moment, Dr. Feldstein whispered to the man, “Your gratitude and love is a kind of medicine that doesn’t come in an IV.”

Intuitively, we know gratitude is good for our health, and in recent years, researchers have proven this scientifically. Several studies have shown that gratitude practices are associated with a reduction in depression, anxiety, and an improvement in overall mental health. Studies also show that gratitude practices improve physical health, such as lowering blood pressure, improving sleep quality, and creating positive changes in brain activity.

This evidence that gratitude promotes mental and physical health begs the question, “How do we experience more gratitude in our lives?” Perhaps the first step is to have a deeper understanding of what gratitude is.

Gratitude is a Mood

So, what is gratitude, exactly? Although everyone has experienced gratitude to some degree, it isn’t easy to define. Some people have an overall attitude of gratitude, while others only feel thankful when they receive a gift or something good happens in their lives. Many people, however, are somewhere in the middle. They experience gratitude as a mood that comes and goes throughout the day.

It’s useful to be aware of our moods because they serve as metaphorical lenses that determine how we assess situations. For example, if a friend cancels dinner plans, a grateful person might appreciate the extra time in their evening to relax, whereas a person who chronically complains might think they don’t have any true friends. Even though the situation is the same, the responses are different due to the variance of their moods.

Dr. Feldstein notes how we can shift our mood toward gratitude by pausing and reflecting on what we are grateful for. Even with a busy schedule, we can weave in moments of reflection to experience more gratitude and enhance our mood.

“Reflection is an antidote to busyness. When we are busy, we typically don’t notice the wonderful things in our lives. We don’t stop to appreciate what is already there,” says Dr. Feldstein. “Some people say they don’t have time to stop and reflect, but it’s not about time. It’s about having a readiness to notice with appreciation and gratitude what is going on in the midst of our activity. It only takes a brief moment to stop and notice,  reflect, and appreciate the things we care about. Doing so contributes to a meaningful life and this can be cultivated.”

Gratitude is a Choice

Due to our biological need to survive, our default thoughts and emotions are often riddled with fear, defensiveness, and complaints. Without consciousness, our instincts prompt us to be on guard and defend ourselves from potential predators, which can be both physical and emotional. When we begin to spiral in these negative emotions, Dr. Feldstein recommends that we make a conscious choice to shift our focus from stressful circumstances to something good.

“Gratitude is a choice,” says Dr. Feldstein. “We don’t have control over what happens, but we do have choices related to how we see things, what we focus on, and ultimately how we respond.”

At any given moment, we can break the spiral of negative thinking by pausing and asking ourselves, “What am I grateful for right now?” By including moments for reflection multiple times a day, we can gradually shift our default thinking from negativity to gratefulness and other elements of well-being due to the neuroplasticity of the brain.

As a chaplain, Dr. Feldstein offers this understanding while accompanying patients in the hospital. “When a patient is going through a difficult time, I compassionately acknowledge their situation and then gently ask, ‘What sustains you?’ and ‘What is something you’re grateful for?'” he says. “This shifts their focus in the direction of well-being, and they begin to feel more at ease, which is a healing experience for both the patient and caregiver.”

Gratitude is Good Medicine

With enough practice in cultivating gratitude, we can start to embody the essence of gratitude while interacting with others. When we start saying “thank you” and “you’re welcome” more often, we feel more connected, and our relationships become stronger, sweeter, and more meaningful.

“Gratitude is not just something we have, it can also be something we are,” says Dr. Feldstein. “Rather than simply knowing the feeling of gratitude, I can be the expression of gratitude that I am inside and share it with others as a way of being. In doing so, we can be a healing force for ourselves, those around us, and the world.”

Dr. Feldstein shares that when healthcare workers pause during the day to prepare their attention and intention to allow for the emergence of presence, appreciation, and gratitude, they have more meaningful and healing connections with their patients.

“When we give and receive gratitude, we all feel better, we see more connection with other people, we see more possibilities in life. Whatever is happening with our physical bodies, gratitude allows us to be in a state of well-being,” says Dr. Feldstein. “So, when we [healthcare workers] are being grateful, it’s an expression of caring, which is enlivening for both the patient and ourselves, and that’s the promise of what medicine is all about.”

 

For more thoughts on gratitude, read What We Get Wrong About Gratitude written by Stanford Lifestyle Medicine team member, Barbara Waxman.

 

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