Screen Time and Sleep—It’s Different for Adults

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By Mary Grace Descourouez, MS, NBC-HWC and Sharon Brock, MEd, MS

Many of us have heard that looking at our phones or iPads at night can keep us awake due to light exposure, however, research shows this may be true for children, but there is not sufficient evidence to support this claim for adults.

“Young children have a greater sensitivity to light because more light gets to the retina of a child than an adult,” says Jamie Zeitzer, PhD, Co-Director of the Stanford Center for Sleep and Circadian Sciences. “Since adults have more opacities in their eyes and smaller pupils than children, less light passes through adult eyes, so there’s less of an effect on melatonin production.”

Melatonin is a hormone that makes us feel sleepy and is released when the eyes perceive darkness. Conversely, when we see natural light in the morning, we feel more awake because light hitting our eyes stops the production of melatonin.

Given this logic, it would seem reasonable that looking at our screens (smart phones, computers, iPads, etc.) at night could delay melatonin production and inhibit our ability to fall asleep, but Dr. Zeitzer says this is not the case.

While darkness enables melatonin production, suppressing melatonin production works by the brain comparing the amount of light we receive during at night with how much we received during the day. It’s the shift from light to dark that cues the release of melatonin, which is why we start to feel sleepy after the sun goes down.

Since natural sunlight emits 10,000-100,000 lux of light and phone screens emit 25-50 lux under usual conditions at night, Dr. Zeitzer says the light from our screens doesn’t have much of an impact on the melatonin cueing process.

“There just isn’t that much light coming from your phone,” says Dr. Zeitzer. “As long as you go outside during the day and get exposed to the intensity of natural light then the amount of light from a screen in the evening most likely won’t halt the production of melatonin.”

If it’s Not Light, What Keeps us Up at Night?

Rather than light exposure, Dr. Zeitzer believes that what is keeping us awake is what we are watching on our screens. Millions of Americans stay awake at night scrolling on social media looking at page after page of emotionally activating content and writing posts that lead to likes, comments, and followers. Others stay up to play games on their phones or computers, all of which stimulate the dopamine reward system in the brain, which is the basis of addictive behaviors.

“In the past, when a television show ended, you turned off the TV and went to sleep because there was nothing else to do,” says Dr. Zeitzer. “But now you could watch Netflix, look at apps or play computer games all night because this entertainment has been commodified to engaged with it for as long as possible; it’s optimized to never stop playing and this is causing sleep deprivation.”

When watching screens before bed, Dr. Zeitzer recommends that we not only avoid content that could be distressing, but also content that could stir excitement within us.

“In order to fall asleep, we need to reduce stimuli exposure and calm our mind and body,” says Dr. Zeitzer. “Even if you’re watching something positive, if it stirs excitement, the brain will release dopamine, and over time we can develop a dopamine addiction, making staying awake playing games or on social media much more fun that going to sleep.”

Lastly, Dr. Zeitzer says that he can’t make a general statement that nighttime screen use negatively affects everyone’s sleep. For some, their addiction to games or apps could make falling asleep a challenge, while others may watch soothing nature videos on their phones to help them relax and fall asleep. Therefore, Dr. Zeitzer suggests that you take note of how screens are impacting your sleep health by asking yourself these questions:

  • Is the content of your screen time making you feel distressed or excited? If yes, then you should not look at screens for about an hour before bedtime to calm the mind and body and prepare for sleep.
  • Also, do you engage with screens throughout the night when you could be sleeping? If so, you may have a dopamine addiction that is making screen time activities more enjoyable than sleep.
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insomnia

How to Cure Insomnia

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By Sharon Brock, MEd, MS

Not getting enough restorative sleep is a rampant health concern across the US. It’s estimated that 50 to 70 million Americans suffer from sleep disorders, and 1 in 3 adults do not get the recommended 7 to 8 hours of sleep regularly.

Many of us have tried sleep hygiene techniques, such as keeping our bedroom dark, cool, and quiet and having a one-hour-before-bed evening routine, but still have trouble sleeping soundly on a consistent basis.

Stanford sleep specialist Fiona Barwick, PhD, DBSM shares that sleep hygiene is only one piece of the puzzle.  “If you have good sleep and maintain good sleep hygiene, then you’ll continue to get good sleep,” says Dr. Barwick, Stanford Clinical Associate Professor, Psychiatry and Behavioral Sciences – Sleep Medicine. “But if you have poor sleep, all the sleep hygiene in the world will not help because it’s not targeting what we typically see in patients with insomnia, which is anxious thinking and not building enough sleep drive.”

What Causes Insomnia?

Insomnia is defined as difficulty falling asleep, staying asleep, or waking up too early (greater than 30 minutes before the alarm) three times per week for at least three months. Many factors can cause insomnia, such as stressors related to one’s job, finances, health, family and friends, new onset health conditions, or feeling unsafe in one’s environment.

Dr. Barwick says her patients with insomnia often spend hours lying awake, ruminating about relationships and events in their lives, or simply worrying about how their inability to sleep will impact their performance the next day (especially true for perfectionists). To address these factors, Dr. Barwick teaches classes on cognitive behavioral therapy for insomnia (CBT-I) at Stanford University.

“It’s a vicious cycle. The anxiety we feel about not sleeping can prevent us from falling and staying asleep,” says Dr. Barwick. “With CBT-I, we address not only the physical requirements of sleep but also how we think and feel about sleep. CBT-I helps to shift our mindset about sleep.”

 

This table shows the difference between sleep hygiene and CBT-I:

How to Cure Insomnia with CBT-I Training

CBT-I employs a classical conditioning technique of having patients get out of bed when not sleeping so that they associate their bed with sleep and nothing else. Just as Pavlovian dogs salivated when they heard a bell, Dr. Barwick says we can teach our brains to see our bed as a cue to feeling sleepy and falling asleep rather than a place where we lie awake feeling anxious.

Along with bed re-association, another technique for improving sleep is sleep consolidation, or shortening the time spent in bed. At the outset of treatment, students of the CBT-I course are instructed to reduce the amount of time they spend in bed (their “sleep opportunity”) and get out of bed promptly when the alarm goes off (no hitting snooze!), regardless of how they slept. As wakefulness at night decreases and sleep quality improves, time in bed, or sleep opportunity, is gradually extended.

This disciplined approach of spending a shorter amount of time in bed for two to three weeks increases sleep drive and thus sleepiness, or the desire to sleep. By the end of treatment, patients are falling asleep more easily, waking up less at night, and returning to sleep more easily. They have also ensured that their bed is re-associated with sleep, rather than lying awake worrying, thus breaking the pattern of insomnia.

Along with bed re-association, CBT-I also offers cognitive strategies to calm anxious thoughts about sleep, relaxation techniques to reduce tension in the body, as well as emotional relaxation practices like mindfulness.

How Do I Fix My Sleep Problems?

Ironically, anxiety about sleep is often the cause of our sleep problems, making stress management an important part of restorative sleep. Dr. Barwick says that “our mindset about sleep is critical. We are worrying about a system that is not broken.” Instead of anxiety about sleep, Dr. Barwick encourages us to learn about the biological systems involved in sleep and optimize them with our behaviors.

The three biological systems that need to be in working order for sleep to occur are:

  • Circadian rhythm
  • Sleep drive
  • Stress management

“The way sleep works is, when your sleep drive is high, you understand your own circadian sleep-wake timing, and you allow yourself to relax, you should fall asleep and return to sleep easily,” says Dr. Barwick. “These biological systems of sleep are not broken; they are intact, but our worry about sleep can override their ability to function properly.”

For practical tips on how to optimize these three systems, read our blog, “Don’t Hit Snooze! And Other Practical Tips for Optimal Sleep.” 

What to Do When Lying Awake in the Night

If you’re lying awake in bed during the night, the first step is not to check the time. This can lead to anxious thoughts about how your lack of sleep will affect you the next day. It’s best not to look at the clock and trust that you’ll wake up and get out of bed with your alarm.

Secondly, take deep breaths and engage in mindfulness practices, such as feeling the softness of your pillow and appreciating the comfort of your mattress. Listening to gentle music or a guided meditation can also help relax the mind and body.

If these relaxation practices do not lull you back to sleep and you’ve been wide awake for over 30 minutes, Dr. Barwick suggests getting out of bed and doing a relaxing activity in another room until you feel sleepy again.

“It’s best to keep your bed for sleep, so if you can’t fall back asleep, be awake outside your bed in an enjoyable and relaxing way, such as reading a book in the living room,” says Dr. Barwick. “While reading, you build sleep drive and calm anxiety, so you’re more likely to fall asleep when you go back to bed.”

Another thing to remember is that your middle-of-the-night thinking comes from your emotional brain. During sleep, the rational part of your brain is offline, leaving your emotions to run unchecked. This can lead to bizarre dreams and even nightmares that could wake you up, especially if you’re going through stressful circumstances.

To address this, Dr. Barwick recommends reducing stress throughout the day, not just right before bed.

“People with anxiety are more reactive to stress and need to address sleep as a 24-hour endeavor,” says Dr. Barwick. “They need to put more effort into managing their stress response with exercise, deep breaths, and mindfulness throughout the day–not just before bed.”

Dr. Barwick explains that when we first go to sleep, our sleep drive is high enough to counter our stress level. But if we wake up 3-4 hours later, when sleep drive has diminished, it is harder to fall back asleep, especially if our emotional brain begins to ruminate from stress built up throughout the day. And since the rational part of the brain is offline, these negative thoughts can take over our consciousness.

Therefore, Dr. Barwick recommends journaling before bed to reframe life challenges and process difficult emotions. This way, if you wake up at night, you’ll be able to fall back asleep easily.

Along with journaling before bed, Dr. Barwick has a second recommendation for those experiencing anger that often leads to the rehearsal of mental arguments during the night.

“If you have resentment, I recommend you do loving-kindness meditation before bed. You can offer loving-kindness toward those whom your ego believes has ‘wronged’ you,” says Dr. Barwick. “This meditation can shift your emotional mindset from anger to ease, which will help you fall asleep.”

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How to Get More Benefits from 10,000 Steps per Day

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By Nicole Molumphy

Many of you are familiar with the 10,000-steps-a-day walking trend, but you may not know where it originated. The idea of walking 10,000 steps per day did not come from scientific research; rather, it came from a marketing campaign for a pedometer ahead of the 1964 Tokyo Olympics. Since the Japanese symbol for 10,000 looks somewhat similar to a person walking (see image below), the pedometer was named Manpo-kei or 10,000 steps meter, and the 10,000-step-a-day walking trend was born.

 

 

We know walking is good for us, but what do researchers have to say about this 10,000 number? Is this the right number of steps? What are the health benefits of reaching this number?

A 2023 research study showed 8,000 to be the sufficient number of steps to yield significant health benefits. In this study, participants who took 8,000 steps or more on one or two days during the week showed substantially lower cardiovascular and all-cause mortality risk.

Stanford Lifestyle Medicine Movement and Exercise pillar member Corey Rovzar, PhD, DPT, puts the 8 and 10 thousand numbers into perspective. “What is more important than hitting an exact number is that you’re moving more throughout the day,” says Dr. Rovzar. “If looking at a pedometer and trying to hit 8,000 steps will help you move more, then it’s a great tool, but rather than fixating on an exact step count, I recommend you think about your day and envision opportunities to move.”

Rather than walking all 8,000 steps in one go, which would take about 80 minutes at three miles per hour, Dr. Rovzar recommends walking the 8,000 steps throughout the day, such as in the morning and evening and after each meal. For example, you could split the 8,000 steps (80 minutes of walking) into four, 20-minute walks. If you stick to the 10,000-step goal (100 minutes of walking), that breaks down to five, 20-minute walks. This recommendation is good news for those who sit at a desk since taking several short walks during the workday is a perfect way to take a break. “It is important to note that all steps count! Even a few steps to the bathroom or to another room contributes to this overall count,” says Dr. Rovzar.

Ideas on How to Meet Your 10,000 Steps Goal:

  • Take the stairs instead of the elevator.
  • Walk more during errands by parking your car farther away from your destination or getting off the bus or train a stop early.
  • Walk more during your work day by taking a “walking meeting” or walking while on the phone.
  • Walking after each meal can help with digestion, blood sugar management, and cardiovascular health.
  • Walk every morning, evening, and during your lunch break. Even 10 to 15 minutes of walking can add up to 1,000 steps.
  • Catch up with a friend by going on a walk instead of meeting for coffee.
  • Use a step tracker to help you stay motivated and track your progress.

How to Get More Out of Your 10,000 Steps

If you’re already walking 8 to 10 thousand steps daily, you may be ready to take your walking to the next level. If so, Dr. Rovzar recommends adding modifiers to your walking routine to help you meet additional fitness goals, such as improving balance or building muscle.

Here are a few of Dr. Rovzar’s recommendations for intensifying your daily stroll and gaining more health benefits:

1) Cardiovascular (Endurance) Modifier:

Interval walking

Interval walking involves alternating fast and slow walking cycles. Researchers recommend five intervals of fast and slow phases, each lasting roughly three minutes. The effort expended should be 40 percent of your maximum effort for the slow phase and 70 percent for the fast phase.

2) Muscular Strength Modifiers:

Walk up and down hills or stairs multiple times

If you are looking for strength benefits, hills may become your new best friend. Walking hills or stairs not only has excellent aerobic benefits but also serves as a great form of strength training.

Add ankle and wrist weights or wear a weighted backpack

Another strength training modification is adding weight to your walk, either with ankle or wrist weights or by rucking. The term rucking originated during boot camp training and involves using weighted vests or backpacks while hiking or walking.

3) Balance Modifiers:

Take side steps

March (i.e., lift your knees as you walk)

Walk backwards

It is essential to perform balancing exercises as we age. Implementing side steps, marching, or walking backward are great ways to train your body to handle non-forward-facing movements, enhance joint mobility, and improve flexibility. Balance training is also an effective way to strengthen different muscle groups. For example, side steps engage your abductors, which are hip muscles involved in getting out of your car and transitioning out of bed in the morning.

4) Cognition Modifier:

Dual-task training

Cognition may also be enhanced with walking practices, like dual-task training. This practice involves performing a mental task while walking, such as talking to someone while walking, keeping step time to a metronome, or counting backward from 100. Combining the mental task with the physical action of walking forces the walker to increase concentration, which sharpens the mind and improves balance and stability.

Whole Body Health Benefits

In addition to the physical benefits walking offers, Dr. Rovzar says that walking improves mental clarity and well-being. Taking a step away from work and going on an outdoor walk can help you overcome mental roadblocks. Studies have found mental health benefits from walking outside in nature, including decreased cortisol levels, diastolic and systolic blood pressure, and pulse rate. While using a treadmill may be a great way to multitask and get in extra movement, there are considerable mental health benefits from taking a break outside, getting fresh air, and stopping to smell roses and pet dogs on your walk.

“We often strive to maximize our time working, but in reality, you might not be saving yourself time by omitting the breaks,” says Dr. Rovzar. “I recommend getting out of your work environment and going for an outdoor walk every couple of hours during the workday, even if it’s just five-minutes of movement to get your blood flowing.”

Practice of the Month:

Walk 5 Days per Week for 30 minutes with a Modifier

The US guideline for moderate physical activity is 150 minutes per week (which breaks down to five 30-minute brisk walks with a modifier per week). To ensure you’re improving muscle strength, balance, endurance, and cognition every week, Dr. Rovzar recommends assigning different modifiers to different days.

Sample Walking Routine (30 minutes per walk):

Monday: Walking up and down hills on Mondays (endurance)

Tuesday: Rucking (strength)

Wednesday: Incorporating intervals of side-stepping, marching, and walking backward (balance)

Thursday: Interval walking (endurance)

Friday: Adding ankle and wrist weights (strength) while counting backward from 100 with each step (cognition)

 

If a 30-minute walk seems too daunting, Dr. Rovzar suggests starting with 10 minutes of walking and incrementally working your way up to 30 minutes daily. “Much of this comes down to goal setting,” she says. “If you set too lofty of a goal, it becomes unachievable, but if you break your goal down to an amount that seems feasible and perhaps try it just for a week, it becomes more likely you will remain consistent in attaining it.”

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How to Build Your Own Centenarian Decathlon

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By Mary Grace Descourouez, MS, NBC-HWC

 

We all know about the Olympic Decathlon (ten track and field events held across two consecutive days), but have you heard about the Centenarian Decathlon?

Stanford alumni Peter Attia, MD, coined the term Centenarian Decathlon as the ten physical tasks you want to be able to do at age 100 (or in the final decade of life).

Everyone’s list is likely different, but the following is Dr. Attia’s personal list from his book Outlive. The list includes both common exercises as well as functional movements and lifestyle actions that most of us take for granted in middle age.

Dr. Peter Attia’s Centenarian Decathlon:

  1. Hike 1.5 miles on a hilly trail
  2. Get up off the floor using a maximum of one arm for support
  3. Pick up a 30-pound child from the floor
  4. Carry two five-pound bags of groceries for five block.
  5. Lift a 20-pound suitcase into the overhead compartment of a plane
  6. Balance on one leg for 30 seconds with eyes open. (Bonus: eyes closed for 15 seconds)
  7. Have sex
  8. Climb four flights of stairs in three minutes
  9. Open a jar
  10. Do thirty consecutive jump-rope skips

“There is a difference between lifespan and healthspan. Lifespan is the number of years you’re on this planet, but healthspan is the number of years that you’re healthy—being able to live independently and partake in activities you enjoy,” says Jonathan Bonnet, MD, MPH, and Clinical Associate (Affiliated) Professor at Stanford University School of Medicine. The Centenarian Decathlon requires a thoughtful analysis of what ‘health’ means for you as you age. Creating a personalized Centenarian Decathlon can serve as a powerful motivator and will help inform what types of exercises need to be done now in order to achieve those goals in the future.”

 Creating your own Centenarian Decathlon

Think about what you value in life. Is it being able to play with kids or grandkids? Traveling? Hiking? Sailing? Creating delicious meals in the kitchen? Identifying what is most important in your life will inform which activities will be on your personal Centenarian Decathlon.

“When creating your list of 10 functional activities, pair them with exercises that cultivate the type of abilities you would need to enjoy the activities you love,” says Dr. Bonnet. “For example, if you want to be able to play with a grandchild, being able to ‘lift 30 pounds from a squat position’ would be a valuable objective, as it would mimic picking up a small child from the floor.”

Here are examples of activities and values for a Centenarian Decathlon.

If you:

  • Enjoy bike rides with your spouse – Ride a bike for 1 hour.
  • Live in the snow and value being independent – Shovel snow off a driveway.
  • Enjoy playing golf with friends – Play 18 holes of golf.
  • Enjoy walking your dog – Walk 10,000 steps in a day.
  • Enjoy international travel – Lift a 20-pound suitcase into the overhead compartment. Climb 30 stairs without stopping.
  • Enjoy cooking – Lift a cast iron skillet with one hand. Carry two five-pound bags of groceries up four flights of stairs. Open a jar.
  • Enjoy being in nature – Hike up a steep hill for 10 minutes, operate a kayak, or whatever your favorite outdoor activity is.
  • Enjoy swimming in a pool – Tread water for 10 minutes. Get out of a pool without a ladder.
  • Enjoy dancing with your family in the kitchen – Perform 30 jumping jacks in one set for aerobic endurance.
  • Enjoy playing with children – Deadlift 30 pounds (to lift a young child from their crib or the floor). Get up off the floor using only one arm for support.

Lastly, it’s important to include activities that meet the following four fitness goals, which are important for healthy aging.

Fitness Goals Important for Healthy Aging:

1) Build muscle strength by doing activities such as:

  • Perform 10 push-ups in one set.
  • Perform 20 squats in one set.
  • Perform 10 bicep curls with 20-pound weights.

2) Cultivate stability, flexibility, mobility, and balance by doing activities such as:

  • Complete 30 minutes of Yoga or Pilates.
  • Walk up and down stairs with feet pointed perfectly forward (this is a sign of good ankle mobility).
  • Do a plank in perfect form for one minute (any core workout).

3) Increase maximal aerobic capacity (i.e., VO2 max or maximum oxygen consumption)

You can increase VO2 max with interval workouts where you give roughly 90 percent effort for a short amount of time (ideally 3-5 minutes), followed by a recovery period. Shorter intervals can be used initially to increase VO2 max, however, the duration of sessions should be increased for optimal results.

Examples include:

  • Perform 30 jumping jacks in 40 seconds, followed by 30-40 second recovery period (work up to repeating 6 times).
  • Perform 3 minutes of stair climbing, followed by a 3-minute recovery (work up to repeating five times).
  • Perform 4 minutes of interval running followed by a 4-minute recovery (work up to repeating)

4) Improve aerobic efficiency

You can improve aerobic efficiency with longer duration, steady state physical activity. These workouts are done at a much lower intensity, where you can hold a conversation, but not sing a song. The absolute intensity will vary depending on fitness, but could include activities, such as:

  • Walking 3-4 miles in 1 hour
  • Jogging for 30 minutes while maintaining a conversation
  • Riding a bike for 45 minutes at a 12-14 mph pace

“Each of these areas is important, though having a high VO2 max will generally allow one to do most things on a Decathlon list. If you can jog, that means you can hike. If you can hike, that means you can walk for three miles. If you can walk for three miles, you can likely go up a flight of stairs, and so on,” says Dr. Bonnet. “It’s not that VO2 max is magical by itself, it’s that it requires a certain amount of strength, stability, and aerobic efficiency to be able to attain a high VO2 max level.”

 

Now, take a moment to make YOUR list of 10 activities you’d like to do when you’re 100 (or in your final decade). Be sure to have a mix of strength, stability, VO2 max, and aerobic efficiency activities. Add a column to the right to note why this activity is valuable to you.

For example, at age 100, I want to:

  • Deadlift at least 50 pounds | in order to pick a suitcase up off the ground
  • Do a body weight step up | in order to be able to get up off the floor unassisted
  • Climb 4 flights of stairs in 3 minutes | in order to walk independently (e.g., hike up a hill, walk up a broken escalator at an airport, etc.) without requiring an elevator or ramp
  • Walk 2 miles in 1 hour | in order to walk my dog every evening

Continue until you’ve reached 10 activities.

Centenarian Decathlon is a Framework for Longevity

Now that you have your list, you need to make a plan regarding how you’re going to achieve the 10 goals listed on your personal Centenarian Decathlon. Since we naturally lose strength and aerobic capacity as we age, whatever it is we want to be able to do at age 100, we need to be doing much more now.

In his book, Dr. Attia writes: “Over the next thirty or forty years, your muscle strength will decline by about 8 to 17 per­cent per decade—accelerating as time goes on. So, if you want to pick up that thirty-pound grandkid or great-grandkid when you’re eighty, you’re going to have to be able to lift about fifty to fifty-five pounds now. Without hurting yourself. Can you do that?”

It’s time to ask ourselves, if we want to attain these 10 goals, what daily actions must we do now to get there?

Look at your list of 10 activities and add a column: What do I need to do now to be able to do this activity at age 100? Include the area of fitness and be sure all four areas are addressed at least once in your list of 10.

Note: a general rule of thumb that can be used to estimate approximate strength loss over 50 years is that the load at age 40 should be roughly 150 percent of what the intended goal is at 90 years old.

For example, at age 100, I want to:

  • Deadlift 30 pounds | in order to pick up a suitcase off the ground | so, now I need to deadlift 75 pounds (muscle strength)
  • Do a body weight step up | in order to be able to get up off the floor unassisted | so, now I need to do a step up holding dumbbells equal to 50 percent of my body weight (stability, balance, flexibility, mobility, muscle strength)
  • Climb 4 flights of stairs in 3 minutes | in order to walk independently (e.g., hike up a hill, walk up a broken escalator at an airport, etc.) without requiring an elevator or ramp | so, now I need to do climb 10 flights of stairs in 3 minutes (VO2 max)
  • Walk 2 miles in 1 hour | in order to walk my dog every evening | so, now I need to walk 5 miles in 1.5 hours two times per week (aerobic efficiency)

Continue until you’ve reached 10 activities.

Revisit this list every five years to update the column: Am I on track? What do I need to do now to be able to do this activity at age 100?

There you have it! Now you have a personalized framework for longevity and a specific pathway to win your very own Centenarian Decathlon. Be sure to take out this list on your 100th birthday and try out each activity!

“Having a personalized Centenarian Decathlon is valuable because it translates activities that matter most to you into tangible metrics that can be tracked over time,” says Dr. Bonnet. “While we may not be competing for a gold medal at the Olympics, the Centenarian Decathlon promises something better. A lifetime of being able to do the things we love with the people (and pets) that matter most.”

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How to Reduce Joint and Arthritis Pain with Lifestyle Medicine

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By Sean Nguyen and Corey Rovzar, PhD, DPT

Joint pain is common and can be a limiting factor in work, recreation, and overall quality of life. Osteoarthritis, caused by degeneration of the cartilage between joints, affects 32.5 million adults in the US, and nearly 600 million adults worldwide. It most often occurs in the joints we move and bear weight through the most like the hands, hips, and knees. Certain factors such as injury or overuse, age, weight, sedentary behavior, smoking, or gender (with women often experiencing higher rates of osteoarthritis) may increase the risk of developing osteoarthritis. Currently, there is no cure or reversal for the degenerative changes in osteoarthritis, making it the leading cause of permanent disability.

Without a cure for degenerative joint diseases, medical professionals often treat osteoarthritis with pain medications. While pain medication use may be helpful in the short-term, long-term use can lead to stomach, kidney, liver, or heart damage. While medications certainly have their place in the treatment of osteoarthritis, our goal is to investigate what more can be done by exploring lifestyle medicine approaches to improve joint health.

Adopting these lifestyle medicine strategies may help you manage your joint pain and enhance your overall daily quality of life, paving the way for smoother, more comfortable days ahead.

Nutrition Choices to Reduce Arthritis Pain

One of the most basic but often overlooked lifestyle changes we can make comes in what we choose to eat. Our dietary choices not only fuel our bodies but also fuel the health and function of our joints. Understanding how specific foods and nutrients impact joint health can empower us to make informed decisions that support our joint health.

The Western diet, a common dietary pattern in the US, is high in calorie-dense processed foods, unhealthy fats, and low in nutrients and fiber. High sugar intake has also been linked to arthritis pain. High-calorie diets that lead to weight gain can lead to increased joint degeneration, but simultaneously the Western diet can increase the inflammatory process of joints, which compounds their degeneration.

Specifically, the Western diet has been linked to a higher risk of both radiographic and symptomatic worsening of knee osteoarthritis when compared to a Mediterranean-like diet. In contrast, the Mediterranean diet, rich in legumes, fruits and vegetables, whole grains, and healthy fats is known for its joint health benefits. Switching diets may reduce pain and inflammation, boost mobility, and slow cartilage degeneration.

Supplements to Reduce Arthritis Pain

Omega-3

Beyond dietary choices, there is growing interest in the potential of nutritional supplements to further support joint health and mitigate osteoarthritis.

The future of osteoarthritis treatment may involve targeting inflammatory mediators, and one supplement shown to decrease inflammatory mediators is omega-3 fatty acids. Another study found that a specialized resolving mediator derived from omega-3 fatty acids, resolvin D1 (RvD1), yields promising therapeutic potential in joint inflammation. RvD1 is thought to protect chondrocytes from inflammatory damage and promote their proliferative and repair capabilities.

In studies involving human subjects, RvD1 has been shown to have a similar protective antioxidant effect on chondrocytes and lead to resolution of both acute and chronic joint inflammatory processes. By decreasing overall inflammation within the joint, RvD1 may preserve joint homeostasis and support long-term joint health.

For those with osteoarthritis, it is recommended to take 350-2400 mg of omega-3 supplementation per day for optimal relief of joint pain and improvement of joint function.

Omega-3 supplementation to increase RvD1 levels, combined with a low-inflammatory diet such as the Mediterranean diet, offer potential nutritional elements that could help lower systemic inflammation and promote optimal joint health. This diet and supplementation combination has potential impacts for those with osteoarthritis as well as joint pain related to rheumatoid arthritis.

Rheumatoid arthritis occurs when the immune system improperly creates inflammation and attacks the lining of joints, leading to pain and stiffness. A systematic review found that omega-3 fatty acids reduce rheumatoid arthritis activity by decreasing inflammation and oxidative stress, partly through gut microbiota benefits. Researchers advise combining the Mediterranean diet with at least twice a week consumption of oily fish (such as salmon) and/or two grams per day of omega-3 supplementation. To obtain recommendations specific to your needs, schedule a visit with a dietitian to optimize your dietary and supplementation needs.

Turmeric

Turmeric is another supplement commonly used to reduce joint pain. Turmeric is a medicinal herb that contains curcumin, which has been shown to reduce inflammation and pain at levels equivalent to pharmaceutical pain-relievers.

Numerous studies show that curcumin (which is found in turmeric) can be a great alternative for those intolerant to anti-inflammatory drugs. For example, this study showed that participants who took 1,500 mg per day of Curcuma domestica for four weeks experienced similar pain relief as those who took 1,200 mg of Ibuprofen, which sometimes has the side effect of abdominal discomfort. Another study showed 1,500 mg of curcumin per day offered equivalent pain relief to 100 mg of diclofenac, but with no side effects.

For those with osteoarthritis, it is recommended to take 1.5 grams (1,500 mg) per day of turmeric to reduce inflammation and offer joint pain relief. Also, taking piperine (black pepper) along with turmeric has been shown to potentially increase curcumin bioavailability, therefore increasing its efficacy. To obtain recommendations specific to your needs, schedule a visit with a dietitian to optimize your dietary and supplementation needs.

Sleep Factors to Reduce Arthritis Pain

Sleep variability and quality may be significant factors that can impact joint health. Research has shown that maintaining a regular sleep schedule is also important for quality sleep and reducing joint inflammation. Studies found that people who go to bed and wake up at regular times consistently reduce leukocyte platelet aggregates, a prominent mediator of joint inflammation that early research shows may contribute to multiple different types of inflammatory joint diseases.

Another important consideration is limiting sleep disturbances to improve sleep quality. Research suggests that joint inflammation, pain sensitivity, and rheumatoid arthritis disease progression may increase with consistent sleep disturbances. Poor sleep increases the production of proinflammatory marker NF-κB, which may further exacerbate symptoms of joint pain. For those who experience trouble sleeping, research has shown that established sleep interventions, such as cognitive behavioral therapy, may also be beneficial in reducing joint and back pain.

Lastly, lack of sleep impacts how people perceive pain, especially those with long-standing pain. However, it is important to note that restorative sleep can restore pain sensitivity back to normal. The amount of restorative sleep required to stabilize pain sensitivity depends on the duration of sleep deprivation, i.e. chronic sleep deprivation may require longer hours (more than 8 hours) of restorative sleep.

Movement to Reduce Arthritis Pain

While it may seem counterintuitive, movement can actually reduce joint pain, especially for those with osteoarthritis. Regular, low-impact physical activity helps maintain and improve the range of motion in affected joints by stimulating the production of synovial fluid, which lubricates the joints, reducing stiffness and pain.

To help understand this process, we can think of joints like hinges on a door. Over time, without regular use and maintenance, hinges can become stiff and creaky, making it difficult for the door to open and close smoothly. Like door hinges, joints in the body can become stiff and creaky when they aren’t moved or lubricated.

We can think of synovial fluid as WD-40 for joints. Just like we lubricate door hinges with WD-4 to reduce friction and allow the door to move freely, regular movement produces and circulates synovial fluid, which acts as a natural lubricant in the joint. This fluid reduces friction between our bones, nourishes the cartilage, and helps keep your joints flexible and pain-free.

Strengthening the muscles around the joints is another crucial benefit of exercise for joint pain relief. Strong muscles provide better support and stability to the joints, reducing the load and stress placed on them. This muscular support helps prevent further joint damage and alleviates pain by distributing the forces exerted on the joints more evenly. Additionally, exercise encourages the release of endorphins, the body’s natural painkillers, which can help reduce pain perception and improve mood.

While certain exercises may worsen lower body joint pain, such as those that increase loads on a joint (e.g., high-impact activities like running or jumping), there are many options to modify or perform different movements. For example, if you have knee or hip pain with a squat, try reducing the depth of your squat. By doing this, you are reducing the overall load on those joints. Low-impact activities such as walking, swimming, biking, yoga, and the elliptical can be excellent options for those with lower body joint pain as they tend to induce low loads through the knee and hip joints.

If performing lower body exercises isn’t working for you on a given day, this is a great time to work out other body parts like your core, chest, back, and arms. Even simple things like working on range of motion can go a long way in helping reduce pain.

So, just like applying WD-40 keeps door hinges functioning smoothly, incorporating regular, gentle movement into your daily routine keeps your joints well-lubricated and operating efficiently, reducing stiffness and discomfort.

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What are Exercise Snacks and Why are they Important?

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By Yasaman Nourkhalaj

We all enjoy a healthy snack like nuts and fruits or a less nutritious option like chips and sweets between our main meals, but have you ever heard of an exercise snack?

“Exercise snacks are short bouts of movements, anywhere from 30 seconds to five minutes, that don’t require going to the gym or any prep work. They are snacks, not meals,” says Marily Oppezzo, PhD, certified personal trainer and head of Stanford Lifestyle Medicine Healthful Nutrition pillar. “They can be anything that gets your heart rate up to a vigorous level–like jogging up the stairs at work or doing 20 jumping jacks–and you can accumulate vigorous activity multiple times throughout the day.” 

Exercise snacks are ideal for busy people. In our fast-paced lifestyle, it is challenging for many people to find the time to go to a gym and complete a formal workout. Exercise snacks offer an alternative way for busy folks to get their heart rate up and experience health benefits without changing their clothes or breaking a sweat.

Additionally, research shows that exercise snacks performed throughout the day may be more beneficial than a one-hour stint at the gym after sitting all day.

What Are Examples of Exercise Snacks?

If you have two minutes in your workday to get a snack from the refrigerator, you also have two minutes to do an exercise snack. Dr. Oppezzo explains, “Exercise snacks aren’t just a two-minute leisurely walk break. You’ll want the one-to-five-minute workout to elevate the heart rate to a point where it becomes hard to speak in complete sentences.”

Below are some examples of exercise snacks that Dr. Oppezzo recommends:

  • Instead of taking the elevator or walking up the stairs at work, jog up the flights.
  • Do 30 seconds of jumping jacks and 30 seconds of push-ups, repeating for two minutes while your food is warming up in the microwave.
  • Do one minute of burpees in the middle of your workday. If you cannot jump due to joint pain, here are instructions for walking-back burpees: put your hands on the back of a chair, step back, do a push-up, step forward, come to a squat and then reach for the sky. Repeat.
  • Do three minutes of the “Pet the Puppy” exercise. Instructions: stand up with feet hip-width distance, squat down, and pet an imaginary puppy; stand up, take a high knee step over the imaginary puppy with one leg followed by the other; squat down again and pet the puppy on the opposite side. Repeat petting and stepping (or jumping) over the puppy on the both sides.
  • High-knee march or jog in place, driving also with your arms, while your coffee is brewing.
  • Enjoy five minutes of Zumba on YouTube during your lunch break.

“With my clients, I’ve observed that becoming breathless with three or four exercise snacks throughout the day can sometimes be more stress-reducing than doing one longer workout and sitting the rest of the day,” says Dr. Oppezzo. “After raising your heart rate through exercise, your body has to kick into ‘calm down’ mode and exercise snacks give your body an opportunity to calm down multiple times throughout the day.”

Dr. Oppezzo is currently working on several exercise snack research studies. One is comparing breaks of walking and strength breaks throughout a sedentary day, and the other is helping identify the best ways to help people build exercise snacks as a habit.

Most people understand that many hours of sitting can be a health risk, but rather than focusing on total hours of sitting per day, Dr. Oppezzo recommends that we think about the number of hours we sit continuously without large muscle group movements. Therefore, she recommends a two-minute exercise snack every few hours of sitting. “We don’t know the optimal cadence of taking a break–every hour is easy to remember, but it’s not practical for many people,” says Dr. Oppezzo. “I would aim for taking a break every couple of hours, and try to make a few of your breaks heart-pumping exercise snacks.”

What Are the Benefits of Exercise Snacks?

Exercise snacks offer numerous health benefits, including improved cardiovascular health, muscular strength, and cognitive enhancement. This review article of several studies on exercise snacks showed significant benefits on cardiorespiratory fitness, including decreased total cholesterol, increased oxygen consumption, and overall cardiovascular function. A prospective cohort study, which follows and measures people over a long period of time without giving them a particular intervention, found that participants who self-reported three-to-four minute incidental (or non-intentional) short bursts of physical activity throughout the day had a 31 percent reduced risk in physical-activity related cancer incidence, especially in adults who did not regularly exercise.

“People think they have to go to the gym and kill themselves every day to get a health benefit. They think you need to ‘go big or go home,’ but the research shows that 60 seconds of vigorous movement still counts,” says Dr. Oppezzo. “We make exercise too complicated, but it doesn’t have to be. Rather than seeing exercise as an obligation or a chore, we can use exercise as a tool to manage stress and feel better. We can keep it simple with exercise snacks.”

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Stanford Lifestyle Psychiatry Clinic

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By Sharon Brock, MEd, MS

Top Recommendations for Brain Health as we age:

  1. Physical exercise – both aerobic and resistance training
  2. Healthful nutrition – fresh, fibrous whole foods
  3. Cognitive engagement – educational achievement and continued engagement in cognitively challenging and meaningful activities

The Stanford Lifestyle Psychiatry Clinic offers holistic psychiatric care, psychotherapy, nutritional counseling, medication management, mind-body practices, and health-and-wellness coaching. The clinic is different from other psychiatric facilities in that it offers lifestyle interventions (including exercise, nutrition, yoga, mindfulness, and sleep optimization) as primary modalities for mental health management, in addition to medication and psychotherapy.

“The clinic is for patients who prefer to take an active role in their healing by adding lifestyle practices to their treatment plan, rather than take the passive route of just taking medication,” says Douglas Noordsy, Founder and Director of the Stanford Lifestyle Psychiatry Clinic. “Patients should be interested and motivated to implement lifestyle practices in their daily life to acquire skills they can continue to use to take responsibility for their mental health.”

The clinic also offers rising mental health care professionals opportunities to train in lifestyle psychiatry and incorporate lifestyle interventions into medicine at Stanford and worldwide.

Focusing on Collaboration

Care in the Lifestyle Psychiatry clinic begins with a comprehensive assessment of past and current behaviors related to the patient’s health and well-being. The health provider identifies which behaviors may have contributed to the patient’s mental health symptoms and offers treatment options that may include medications, psychotherapy, and lifestyle interventions.

The provider then collaborates with the patient to review the potential advantages and disadvantages of a menu of lifestyle interventions. Together, the provider and patient create a treatment plan that sets manageable goals and promotes healthy behaviors. With ongoing sessions, the provider and patient continually revise the plan until the patient achieves the desired results.

“When working with patients, we offer a menu of lifestyle interventions, and they choose which option they would like to use,” says Dr. Noordsy. “With this shared decision-making approach, patients are more engaged and have a greater sense of ownership regarding their health. I’ve found that when lifestyle interventions are part of the treatment plan, patients feel more confident about managing their mental health and are likely to achieve better outcomes.”

Faculty at the clinic investigate various lifestyle practices to discern which are most effective for specific psychiatric conditions. For example, research shows that physical exercise results in increased brain activity by signaling neurons to form synapses (connections among brain cells). Also, brain imaging reveals that regular exercise causes critical areas of the brain to grow larger in volume. Increasing brain activity and volume is particularly supportive for those with schizophrenia and bipolar disorder.

“Neurotrophic factors released during exercise tell your brain, ‘It’s time to wake up; we are out of hibernation and into activity mode.’ This increased activity in the brain is especially beneficial for people with bipolar and schizophrenia who have impairment in the activity of certain parts of the brain as well as loss of brain volume,” says Dr. Noordsy. “Also, brain regions grow larger due to physical exercise, and a larger brain is healthier whether or not you have a brain disorder.”

Lifestyle Psychiatry and Depression

To treat depression, Dr. Noordsy explains that taking a standard antidepressant medicine could help decrease depression faster than a lifestyle intervention such as exercise but may not be effective over time. Also, patients often experience a flatness of emotion and sexual side effects from antidepressants.

Physical exercise is typically on the treatment plan for patients with depression because it releases neurotransmitters involved with mood and well-being, such as dopamine, norepinephrine, and serotonin. Although physical exercise may take longer to decrease symptoms of depression, this intervention has a more lasting effect. Additionally, exercise positively affects fatigue, cognitive function, heart health, and overall health.

“When lifestyle interventions are effective, patients often reduce the dose of their medication and sometimes come off of it entirely. This can be an ideal way to minimize medication side effects,” says Dr. Noordsy. “Ultimately, if a patient’s desired outcomes are a greater sense of well-being and greater ability to function in the world, then lifestyle interventions are the best way to get there.”

For some patients, their symptoms are so severe that they struggle to adopt lifestyle interventions such as regular exercise or optimal sleep without using medication.  In these cases, Dr. Noordsy prescribes an antidepressant to get them moving. Over time, as the amount of exercise, healthy nutrition, and mindfulness practice increase the patient may get to a point where symptoms are manageable and they can decrease medication dosage to minimize side effects.

Yoga and Mind-Body Practices in Psychiatric Care

Along with psychiatrists, the clinic’s team of providers includes a health-and-wellness coach and two psychologists trained in Stanford’s therapeutic yoga program, YogaX, which aims to bring yoga and mind-body practices into healthcare. With a full range of expertise, the clinic provides multidisciplinary care across the pillars of Lifestyle Medicine.

YogaX instructors are trained psychologists who promote the science and application of therapeutic yoga. YogaX offers yoga teacher training tailored to healthcare providers who want to bring yoga practices and philosophy to their patients. YogaX also provides free yoga and wellness classes for the public on its YouTube channel.

In the future, Dr. Noordsy will continue to train mental healthcare professionals in the value and application of lifestyle medicine in psychiatry. In this training, he emphasizes the importance of educating patients about the research behind the recommendations. For example, he believes that if patients know about the evidence-based mental health benefits behind the yoga intervention, they are more likely to engage in a regular yoga practice.

“I’d love to see the day where every psychiatrist offers lifestyle interventions as part of their treatment plan,” says Dr. Noordsy. “Whether it’s a weekly yoga group, eating salads for lunch, or taking daily walks in nature, seeing their psychiatrist for regular care is just one of many things the patient is doing for their well-being.”

***For more information or to schedule an appointment at the Stanford Lifestyle Psychiatry Clinic, please call (650) 498-9111.

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What Excessive Screen Time Does to the Adult Brain

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By Mary Grace Descourouez, MS, NBC-HWC

Binge-watching television, watching YouTube videos for hours, or scrolling on your phone every morning may seem harmless, but research shows that too much screen time may be detrimental to your health.

We know children’s brains are affected by spending too much time glued to their cell phones, however research shows that adult brains are also negatively impacted by excessive screen time, defined as more than two hours a day outside of work hours.

Too much screen time can impact our health in a myriad of ways, from eye strain and neck pain to social isolation and mental health, and in some cases, it may cause harm to our brains.

“The negative effects of screen time are insidious because you can’t see what’s happening in your brain as you’re staring at the screen,” says Maris Loeffler, MA, Family and Marriage Therapist, member of the Stanford Lifestyle Medicine Cognitive Enhancement pillar. “If you scrolled on your phone in bed for an hour just one morning, the negative impacts would be minimal. But if it becomes a habit, day after day, month after month, this behavior can take a toll.”

Since the eyes are directly connected to the brain, Loeffler encourages us to think about our eye health to ensure overall brain health. Rather than looking at our phones upon waking, Loeffler recommends starting each morning looking at the horizon or an object outside and far away.

To prevent eye strain throughout the workday, The American Academy of Ophthalmology recommends the 20-20-20 rule for adults who work on a computer. This rule suggests that individuals look at something 20 feet away for 20 seconds every 20 minutes of the day.

What is Happening in the Brain During Screen Time?

This study found that increased use of screens among adults may harm learning, memory, and mental health, as well as the potential to increase the risk of early neurodegeneration. The study shows that in adults aged 18 – 25, excessive screen time causes thinning of the cerebral cortex, the brain’s outermost layer responsible for processing memory and cognitive functions, such as decision-making and problem-solving.

Another study found that adults who watched television for five hours or more per day had an increased risk of developing brain-related disease like dementia, stroke, or Parkinson’s.

This study found that excessive screen time can hinder sleep, especially when looking at screens late at night. Light from the screen can delay melatonin release from the brain’s pineal gland, impacting the body’s natural circadian rhythm and causing difficulty sleeping.

Additional studies found that adults who engage in excessive screen time or have a diagnosed smartphone addiction had lower gray matter volume. Gray matter is brain tissue essential for daily human functioning and is responsible for everything from movement to memory to emotions. Gray matter volume naturally decreases as we age, so along with reducing screen time, engaging in activities that maintain our gray matter volume and promote brain health, such as exercise and movement, restorative sleep, social engagement, and stress management, is crucial.

“Passive screen time is like eating sugar but for your brain. It ‘tastes’ good, and you want it now, but you’re not actually feeding yourself. You’re not giving your brain any nutrition,” says Loeffler. “Instead, replace screen time with an intentional healthy habit that feeds your brain in a healthy way. Lifestyle medicine activities, like exercise, good sleep, social connection, and stress management, function like ‘nutrition’ for your brain and mental health.”

Specifically, Loeffler cautions us not to pick up the phone after the alarm goes off in the morning. She explains that looking at our email or social media on our phones while still in bed jolts the nervous system and can trigger the fight-or-flight response since we aren’t fully awake yet.

Also, if we look at our phones first thing every morning, we create a pattern and can set the flight-or-flight response as our default mode of operation. So, not only does this behavior set an anxiety-filled tone for the day, but we are also training our brains to be more hypervigilant in general.

“One of the biggest issues with picking up the phone right away in the morning is that when you have an object close to your face, it’s registered as a threat,” says Loeffler. “You wouldn’t want to wake up and look a bear in the face every morning. On a physiological level, it’s the same thing.”

Practice of the Month: No Screen Time for the First Hour of the Day

Stanford Lifestyle Medicine experts recommend no screen time for the first hour of the day to support cognitive enhancement. Instead, we suggest engaging in a lifestyle medicine activity upon waking to promote whole-body health:

  • Exercise
  • Call a friend or family member
  • Prepare a healthy breakfast
  • Meditate and count your blessings
  • Listen to music
  • Create a gratitude list
  • Read a book
  • Spend time outside and get morning light

“How do you want your day’s energy and mood to start?” says Loeffler. “Intentionally implementing a morning routine that reflects lifestyle medicine choices instead of screen time sets a positive tone for the day and supports brain health and cognitive enhancement.”

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Metabolic Psychiatry: Bridging Brain and Metabolic Health

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By Maya Shetty, BS

In recent years, a groundbreaking field known as Metabolic Psychiatry has emerged at the intersection of metabolic and brain health. Spearheaded by Shebani Sethi, MD, a Clinical Associate Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University, this innovative field sheds light on the powerful connection between our metabolic health and mental well-being.

As rates of mental illnesses like Alzheimer’s, bipolar disorder, and schizophrenia rise alongside metabolic conditions such as obesity, diabetes, and cardiovascular disease, researchers are uncovering how these seemingly distinct issues may be intertwined. A Stanford study found that developing a metabolic disorder like insulin resistance can double your risk of depression, even if you’ve never experienced mental illness before. As such, emotional and metabolic disorders often occur together, with over forty percent of individuals with severe mental illnesses also experiencing metabolic syndrome.

It’s easy to see how mental illness could lead to conditions such as obesity or diabetes because someone struggling emotionally might be unable to eat well or exercise. However, it’s becoming increasingly apparent that metabolic disorders have a distinct role in the onset and progression of mental illnesses.

“Many psychiatric diseases have underpinnings in metabolic dysfunction,” explains Dr. Sethi. “We are seeing insulin and glucose handling differences in the brain in patients with psychiatric conditions.”

These metabolic issues in the brain are present even at the early stages of disease detection and progression. Dr. Sethi explains that patients diagnosed with a first episode of schizophrenia—before any treatment with medications—already show disrupted energy metabolism in the brain. Similarly, Alzheimer’s disease has been referred to as type III diabetes due to its strong link to disrupted insulin signaling in the brain.

Dr. Sethi has been a trailblazer in this area since 2015, founding the first academic Metabolic Psychiatry Clinic focused on treating patients with both mental health and metabolic disorders. Metabolic Psychiatry examines how improving metabolic health through nutritional interventions can significantly enhance brain health and mitigate the symptoms of severe psychiatric conditions.

How Metabolic Health Impacts Brain Health

Many psychiatric diseases are characterized by metabolic dysfunctions, which impair the brain’s ability to function properly. These dysfunctions occur when chemical processes are disrupted, hindering the body’s ability to produce and utilize energy efficiently.

A well-known example is insulin resistance, where the body’s cells don’t respond appropriately to insulin—the hormone that allows glucose to enter cells and be metabolized for energy. The brain, one of the most metabolically active organs, requires large amounts of energy to function. It is highly dependent on glucose due to its limited flexibility to use other energy sources. This dependence makes metabolic conditions like insulin resistance particularly harmful, as any disruption in glucose supply puts the brain at risk for cognitive decline and neuronal degeneration.

“If you don’t have optimal metabolic functioning in the brain, then you won’t process and create energy as efficiently as a healthy brain,” states Dr. Sethi. “The brain will have all this glucose around it, but you can’t actually use it properly. This is called cerebral glucose hypometabolism, and it’s very common in psychiatric and neurodegenerative diseases.” 

Other metabolic abnormalities commonly seen in psychiatric conditions include oxidative stress, mitochondrial dysfunction, and neurotransmitter imbalances, which all have downstream effects on synapse connection and neuronal excitability.

“We don’t know for sure what the primary drivers for these metabolic dysfunctions are, but it is likely a combination of factors influencing one another,” says Dr. Sethi. “For example, insulin resistance is correlated with higher inflammation levels and oxidative stress in the brain, which in turn exacerbates mitochondrial and neurotransmitter dysfunction.”

Chronic inflammation disrupts brain activity and undermines the integrity of the brain’s protective mechanisms. The blood-brain barrier (BBB), a critical structure that protects the brain from harmful substances in the blood, becomes compromised. This “leaky” BBB allows inflammatory molecules, pathogens, and toxins to enter the brain from the bloodstream, exacerbating the inflammatory response within the brain and creating a self-perpetuating cycle of neuroinflammation. “We see significantly more inflammation in the brains of people with mental illness, especially in treatment-resistant patients, than in healthy people,” states Dr. Sethi.

How Nutrition Can Improve Brain Health

Dr. Sethi’s metabolic approach to brain health not only enhances our understanding of psychiatric conditions but also opens up new avenues for treatment, such as nutritional interventions. Studies have shown that nutritional interventions can impact the balance of neurotransmitters in the brain, which is crucial for regulating mood and behavior.

By targeting metabolic dysfunctions such as insulin resistance, oxidative stress, and improper energy utilization, nutritional interventions can help restore brain function and reduce inflammation. This comprehensive approach addresses the symptoms of psychiatric conditions while tackling their underlying causes, offering a more effective and holistic treatment strategy.

The Stanford Metabolic Psychiatry group, led by Dr. Sethi, is investigating whether dietary changes, such as adopting a ketogenic diet, can stabilize brain health. The ketogenic diet, which is high in fat and low in carbohydrates, encourages the brain to use fat and ketone bodies as primary fuels instead of glucose. This metabolic shift helps counteract issues related to glucose metabolism and insulin resistance. The diet adopted in the study focuses on consuming whole, unprocessed foods, including protein and non-starchy vegetables, without restricting fats.

“The ketogenic diet is a strong, powerful metabolic intervention. It can improve neurological and psychiatric conditions by making changes in the brain through these pathways,” says Dr. Sethi. “By providing ketones as an alternative energy source, the ketogenic diet reduces glucose dependency, which is beneficial in counteracting glucose hypometabolism.”

In Dr. Sethi’s study among participants with schizophrenia consuming a ketogenic diet, there was a 32 percent reduction in Brief Psychiatric Rating Scale scores. There was also increased life satisfaction and enhanced sleep quality among participants.

The ketogenic diet can also have a positive influence on brain aging for everyone and has been experientially understood to help normalize the brain for centuries. Dating back to roughly 500 BC,  fasting (which mimics the ketogenic diet) was used to treat epilepsy. Current research shows that the destabilization of brain networks might indicate early signs of reduced metabolism, which is linked to dementia. By increasing the use of ketones for energy, dietary interventions like the ketogenic diet can provide more energy to the brain and potentially protect against aging-related cognitive decline.

Dr. Sethi warns, however, that “the ketogenic diet is very specific and may not be suitable for everyone. It can be incredibly beneficial for people with insulin resistance, obesity, or diabetes, but it may not be feasible or appropriate for all individuals.”

Future studies will reveal further dietary interventions that benefit brain health. For example, Dr. Sethi and her team plan to conduct a randomized controlled trial with the ketogenic diet versus the Mediterranean diet in cases of serious mental illness. Whichever diet one chooses, Dr. Sethi recommends the reduction of sugar, ultra-processed foods, and refined carbohydrates to promote both metabolic and brain health.

“Our diet provides the precursors for neurotransmitters and other vital cellular structures in the brain, while also impacting inflammation levels. If we have deficiencies in our diet, we’re not going to be able to create the components and environment we need for optimal brain function and regulation of mood,” states Dr. Sethi.

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Douglas Noordsy, MD, Bringing Lifestyle Interventions to Psychiatry

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By Sharon Brock, MEd, MS

Stanford psychiatrist Douglas Noordsy, MD, is a physician who literally walks his talk. For the last 40 years, he has woken up at 6 a.m., drank a glass of water, and gone for a run, often with his dog.

“Living a healthy lifestyle has always been an integral part of my life. I share lifestyle interventions [such as daily exercise] with my patients because these practices have worked for me,” says Dr. Noordsy, Head of the Stanford Lifestyle Medicine Cognitive Enhancement pillar.

As a practicing psychiatrist for more than 35 years, editor of the book Lifestyle Psychiatry, and founder of the Stanford Lifestyle Psychiatry Clinic, Dr. Noordsy has played an integral role in incorporating lifestyle medicine into traditional psychiatry care. Dr. Noordsy’s research interests at Stanford include medication and the impact of exercise and nutrition for individuals with schizophrenia and bipolar disorder. He is currently Director of the Lifestyle & Sports Psychiatry special initiative in the Department of Psychiatry.

“With lifestyle psychiatry, clinicians utilize three methods of care—psychotherapy, medication, and lifestyle interventions,” he says. “This three-pronged approach helps us to be more effective physicians, and patients have a better chance at achieving their best outcomes.”

Northeastern Roots

Doug Noordsy always knew he wanted to be a physician. Initially thinking he would go into primary care, he shadowed his family’s doctor as a high school student in Syracuse, New York. As an undergraduate, he took pre-med courses at St. Lawrence University, a small liberal arts college in upstate New York.

“In my junior year, I took the ‘Introduction to Psychology’ course and I fell in love with it,” he says. “I was particularly interested in those with significant disorders such as schizophrenia—I was intrigued by how they thought. So those early experiences drew me into psychiatry.”

In the 1980s, he attended medical school at Washington University in St. Louis, Missouri. During this time, neuroscience and psychopharmacology were becoming more advanced, which led to debate among mental healthcare professionals about the relative merits of pharmaceuticals over psychotherapy.

“We learned about psychotherapy and medication, but lifestyle medicine wasn’t on the table at that time,” says Dr. Noordsy. “There was discussion about the importance of social support, but we didn’t consider how other aspects of lifestyle affected mental health, such as exercise, nutrition, and mind-body practices.”

After completing his residency at Dartmouth-Hitchcock Medical Center in New Hampshire, he served as a Professor of Psychiatry at the Geisel School of Medicine for 25 years. At Dartmouth, he was also the Director of Psychosis Services and an Investigator in the Psychopharmacology Research Group.

“At Dartmouth, there was an emphasis on treating patients in a collaborative, recovery-oriented way rather than a paternalistic approach,” says Dr. Noordsy. “It was important in my early development to be trained in a model of care that was respectful of the wishes and preferences of the patient.”

Leading a Movement

Dr. Noordsy was ahead of his time regarding the connection between lifestyle medicine and mental health. As a medical school student, he managed his own mental health using lifestyle practices such as daily exercise, healthful nutrition, and quality sleep. He found benefit with these practices and shared them with his patients.

“At first, I was shy about sharing my experiences because they weren’t evidence-based at that time. It’s counter-academic to share things with patients from your own life that are not supported by clinical trials,” he says. “But over time, the evidence caught up.”

Indeed, over the last 15 years, research on lifestyle medicine has shifted the narrative from personal anecdotes to gaining attention and respect within the medical community. Specifically, Lifestyle Psychiatry has moved from something psychiatrists recommended softly to valid, evidence-based medicine.

In the fall of 2015, Dr. Noordsy came to Stanford to join the Department of Psychiatry & Behavioral Sciences, which was building a team for student-athletes. Many of the athletes wanted to minimize medication exposure, so he continued to recommend lifestyle interventions as options to support their mental health.

In 2019, Dr. Noordsy coined the term “Lifestyle Psychiatry” by publishing a book with that title. This book is a curation of research from around the world detailing the evidence on lifestyle practices in psychiatry. In 2020, he opened the Stanford Lifestyle Psychiatry Clinic. In 2024, the president of the American Psychiatric Association (APA) promoted lifestyle interventions as a core component of psychiatric treatment, bringing this approach into the mainstream.

In his 35-year career, Dr. Noordsy has been a member of the Schizophrenia International Research Society, the International Early Psychosis Association, the American College of Lifestyle Medicine, and a fellow of the APA. He received the Exemplary Psychiatrist Award from the National Alliance on Mental Illness in 2001 and the Excellence in Leadership Award from the Stanford Department of Psychiatry and Behavioral Sciences in 2018.

Although Dr. Noordsy is a nationally acclaimed psychiatrist, his most significant source of pride is his influence on how psychiatric care is delivered. For severe disorders, psychiatry has had a long history of authoritarian care in some settings. With lifestyle psychiatry, where patients choose from a menu of lifestyle practices as part of their treatment plan, the care model shifts from “the doctor knows all” to one where the psychiatrist collaborates with their patients, respects their wishes, and takes a whole-person approach.

“What I’m most proud of is being part of a movement toward empowering and engaging patients to participate in their own health and well-being, rather than just be compliant to their doctor’s instructions,” says Dr. Noordsy. “I’m proud to be part of a new approach to care that promotes mental health by fostering relationships, savoring nutritious meals, and experiencing the beauty of nature at sunrise.”

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