Tag Archive for: mental health

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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Jumping into the Ice Bath Trend! Mental Health Benefits of Cold Water Immersion

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By Maya Shetty, BS

Key Takeaways

  • Research shows that cold water immersion (CWI) may improve mental health by increasing endorphin and norepinephrine levels. 
  • CWI may also improve resilience to stress by decreasing cortisol levels.
  • CWI can be adapted to meet different wellness goals, whether for immediate relief or long-term mental health benefits.
    • For individuals seeking a quick boost in mood, daily cold water face immersions and occasional full-body plunges might be beneficial.
    • For those aiming for long-lasting benefits such as lowered cortisol levels, enhanced mood regulation, and increased resilience to stress, research shows that consistent full-body CWI may be beneficial.

Have you ever considered how taking a cold plunge might affect your mental state? Beyond the initial shock, CWI is proving to have profound effects on brain health and mental well-being. Initially popular as a recovery technique among athletes, it has now evolved into a bold wellness practice for those seeking to enhance their overall health. This practice, which involves plunging into cold water (roughly 10-15°C, 50-60°F), has ignited significant research interest, and emerging studies now suggest that CWI can improve mood, decrease stress, and potentially slow the progression of neurodegenerative diseases.

“I personally do cold water immersion and find it to be an immensely rejuvenating activity,” says Stanford Psychiatrist, Vanika Chawla, MD, member of the Lifestyle Medicine Cognitive Enhancement pillar.

CWI can take many forms, each involving its own protocol and equipment. The most common forms include:

  • Ice Baths: Traditionally utilized by athletes for recovery after intense physical activity, ice baths require submerging the body up to the neck in ice-cold water. Also known as cold plunging, this practice generally lasts only a few minutes and involves limited movement.
  • Cold Showers: A more accessible form of CWI, taking cold showers can offer many of the same benefits as ice baths but are easier to incorporate into daily routines.
  • Open Water Swimming: This active form of CWI involves swimming in cold rivers, lakes, or oceans, allowing for longer exposure times to the cold.
  • Cryotherapy Chambers: Though they do not involve water, cryotherapy chambers expose the body to extremely cold air temperatures for brief periods, stimulating a physiological response similar to that achieved through water immersion.

Choosing the type, temperature, and duration of CWI depends on your cold tolerance and the resources available to you. It is generally recommended to aim for a temperature that feels uncomfortable but still safe (no colder than 10°C, 50°F). If you have any form of access to cold water, whether it be a lake, a river, or your home shower and bathtub, you can participate in CWI and begin to explore its benefits.

Can Cold Water Plunges Improve Mental Health?

While the idea of diving into extremely  cold water seems unappealing to most, recent studies have shown that CWI offers emotional benefits. In 2021, researchers recruited undergraduate students to take a 20-minute dip in chilly sea water (13.6°C, 56.5°F) and report their emotions before and after using a Profile of Mood States questionnaire. Compared to controls, the students who engaged in CWI experienced a shift in mood, noting a significant decrease in negative emotions like tension, anger, depression, fatigue, and confusion. Moreover, they experienced boosts in positive emotions such as vigor and self-esteem. Further research involving thirty-three adults new to cold-water swimming highlighted similar benefits. After immersing in a cold bath (20°C, 68°F) for just five minutes, participants reported feeling more active, alert, attentive, proud, and inspired.

These studies, which utilize self-reported questionnaires, indicate that cold-water immersion may significantly enhance mood and overall psychological well-being. It appears to activate traits associated with increased motivation and vitality, while simultaneously diminishing feelings of distress and nervousness. 

How to Lower Cortisol Levels Naturally

CWI presents a unique stimulus for the body, prompting significant shifts in its hormonal stress response, particularly involving cortisol, a key regulator of stress. Unlike other stress hormones such as noradrenaline, cortisol levels remain relatively unchanged during the initial shock of cold water. Research highlights an intriguing aspect of cortisol dynamics: while levels do not significantly change during CWI, they significantly decrease afterward.

For example, a study concluded that a one-hour CWI session, whether in thermoneutral (32°C, 90°F), cooler (20°C, 68°F), or cold (14°C, 57°F) water, did not lead to an increase in blood cortisol concentrations. Instead, cortisol levels tended to decrease across all temperatures tested and remained below initial levels an hour after immersion. These findings suggest that cortisol production is not significantly activated by CWI, contrary to what might be expected under typical stress conditions. In fact, CWI may have potent stress-modulating effects. Further research indicates that cortisol levels remain considerably lower for up to three hours after just 15 minutes of CWI (10°C, 50°F). This pattern of response reveals a sophisticated regulatory mechanism, suggesting that CWI can effectively diminish feelings of stress following a session.

CWI may have the potential to modify our body’s stress response to stressors in everyday life. In a study where participants engaged in winter swimming (water 0-2°C, 32-36°F) for twenty seconds or cryotherapy (-110°C, -166°F) for two minutes, three times a week for twelve weeks, the body adapted remarkably. After just four weeks, participants showed significantly lower cortisol levels post-exposure, with levels continuing to drop in the following weeks. This adaptation contrasted with the noradrenaline response, which remained consistent even as the body became accustomed to the cold stress. This reduced cortisol response not only diminished the stress perceived from cold but also potentially enhanced the body’s capacity to manage other stressors more effectively. 

The main take away from this study is that by reducing cortisol production in response to repeated cold exposure, participants might also release less cortisol in response to other stressors in everyday life, thus fostering a more resilient physiological state over time.

“Resilience is the ability to adapt to life’s stressors and adversities,” says Dr. Chawla. “The body and mind are interconnected, therefore greater physiological resilience may lead to greater psychological resilience as well.”

How Cold Water Immersion Impacts the Brain

CWI has been scientifically observed to influence brain function, affecting mood, stress response, and potentially brain health through several mechanisms. The immediate physiological response triggered by CWI is largely due to the dramatic change in temperature. A dense concentration of cold receptors in the skin detects this change, leading to a surge of electrical impulses from peripheral nerve endings to the brain. This intense stimulation activates various neural pathways, initiating a cascade of chemical responses designed to help the body manage and adapt to the stressor.

During the initial shock of CWI, the body experiences stress and discomfort due to the sudden drop in temperature. To counteract this, endorphins, the body’s natural pain relievers, are released. These endorphins not only reduce pain but also enhance feelings of well-being, akin to the “runner’s high” that often occurs in other physically demanding or stressful situations. 

CWI also activates the sympathetic nervous system (SNS), which controls our “fight-or-flight” responses. This activation leads to a significant increase in noradrenaline (also known as norepinephrine), an excitatory neurotransmitter that not only helps manage stress but also boosts energy and focus. The surge in noradrenaline increases blood flow to the brain, potentially causing feelings of euphoria.

These two neurotransmitters play complementary roles. While norepinephrine prepares the body to handle acute stress by enhancing alertness and readiness, endorphins work to soothe pain and promote a positive mood. This dual response helps individuals cope with the immediate impacts of cold exposure more comfortably and can make the experience of cold water immersion more tolerable–and potentially even rewarding.

Regarding whether CWI has long-term positive effects on the brain, research indicates inconsistent results with respect to the increase of endorphin levels. It is possible that not everyone experiences this endorphin response to CWI, and among those who do, the effect may diminish over time, as the body becomes accustomed to the cold exposure. On the contrary, the increase in noradrenaline continues with each session of CWI, even after the body has adapted after months of regular practice. 

These findings underscore the potential of CWI to be used as a reliable tool for improving energy, focus, and mood. These findings also point to the potential of CWI to be used in the treatment of neurological conditions that involve low noradrenaline, including anxiety and depression. However, more research is needed to understand if CWI has long-term effects on emotional well-being outside the water.

Also, CWI may improve brain function through the release of cold-shock proteins, which are produced by the body in response to cold conditions. Animal studies reveal that proteins like RNA binding protein (RBM3) play a crucial role in repairing and regenerating nerve cell connections after they’ve been exposed to cold. Additionally, studies have demonstrated that over-expressing RBM3 can help prevent neuronal connection loss in mice with neurodegenerative diseases. Although there is limited evidence in humans, these findings in mice suggest that regular CWI could potentially boost the expression of such beneficial proteins in humans, offering protection against or slowing the progression of neurodegenerative diseases by preserving and reinforcing neural connections. 

Reaction to Cold Water: Full-Body vs. Facial Immersion

Physiological responses to CWI differ significantly based on whether the exposure is to the full body or just the face. Full-body immersion exposes a significant surface area to cold, inducing thermal stress that can substantially lower skin and core body temperatures. This extensive exposure activates the sympathetic nervous system, which in turn triggers a release of neurotransmitters and hormones that drive the stress response. Consequently, this leads to vasoconstriction, an increased heart rate, and a heightened metabolic rate, all of which help preserve body heat and maintain core temperature.

In contrast, immersing just the face in cold water activates parasympathetic activity, which is responsible for “rest and digest” functions in the body. This effect is likely due to the mammalian diving reflex—an evolutionary adaptation that optimizes respiration and conserves oxygen by preferentially directing oxygen to vital organs. The diving reflex is mediated by the vagus nerve, which activates the parasympathetic system and releases a sense of calm. The trigeminal nerve in the face also plays a crucial role when stimulated by cold, sending signals that further enhance parasympathetic output, decreasing heart rate, and boosting digestive activity. 

These differences highlight how CWI can be strategically used to target specific physiological responses and therapeutic outcomes, depending on whether the exposure is localized to the face or involves the entire body.

“I sometimes recommend facial cold water immersion to my patients as part of the T in TIPP skills to help people with emotion regulation. TIPP stands for temperature, intense exercise, progressive muscle relaxation, and paced breathing,” says Dr. Chawla. “These skills involve changing your body chemistry to shift emotions. Some people find brief facial immersion in cold water or taking a cold shower to be helpful in shifting their body chemistry and thereby shifting their emotional state.” 

Safety Considerations

CWI can offer several health benefits, but it’s essential to approach this practice with caution due to potential risks. One of the most obvious risks is hypothermia, as immersing in cold water significantly drops body temperature. To prevent hypothermia, limit immersion time to no more than 10 minutes. 

Furthermore, it is important to understand the cold shock response. Entering cold water suddenly can trigger an involuntary gasp reflex followed by hyperventilation. Hyperventilation increases the risk of drowning (especially in open water plunging) and can also lead to arrhythmias or even a heart attack, particularly in those with underlying heart issues. To better manage the cold shock response, it’s advised to enter the water slowly, allowing your body to adjust to the temperature gradually. 

It is also important to never swim alone regardless of your swimming strength or experience. Having a partner ensures that help is readily available in case of an emergency, such as cramps, sudden illness, or difficulty in the water.

Finally, remember to allow your body to gradually acclimatize to whatever CWI technique you choose. If you are a beginner, begin with shorter durations (2 minutes) in warmer water (roughly 20°C, 68°F), progressively moving to colder temperatures with longer durations as your body adapts.

“This intervention is not for everyone. It’s important for people to consider what works best for their individual needs,” says Chawla. “If you are going to try CWI, be mindful of how it impacts your mind and body and incorporate the activity into your routine accordingly.”

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Alcohol: Is There a Healthy Way to Drink?

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By Maya Shetty, BS and Sharon Brock, MEd, MS

“Salud!” If you’ve ever raised a glass to your health, you’re not alone. For decades, many have believed that minimal alcohol consumption is potentially beneficial for your health. However, not every researcher would agree. A growing body of evidence reveals health concerns about alcohol use, making it crucial to understand the spectrum from harmless to harmful levels of consumption to keep your body healthy. 

“Alcohol will impact everyone’s health differently,” says Douglas Noordsy, MD, Clinical Professor of Psychiatry at Stanford University School of Medicine and Assistant Director of Stanford Lifestyle Medicine. “Rather than a daily habit, drinking alcohol should be seen as an indulgence, something you have once in a while to celebrate.”

Experts have conflicting views regarding how much alcohol carries risks. Some believe that drinking in moderation is safe, while others believe that even light drinking can cause harm.

“While many believe light to moderate alcohol intake is safe and even healthy, this reality is far from true,” states Cindy Kin, MD, a colorectal surgeon and Associate Professor of Surgery at Stanford University. “In fact, no level of alcohol can be considered beneficial for our health.”

Isn’t One Glass of Red Wine Good for the Heart?

“Studies have gone back and forth, with some suggesting potential cardiovascular benefits of light drinking, while others point to increased risk of cancer and liver disease even when consumed at low intake levels. As a result, many are confused about headlines proclaiming alcohol as either good or bad for health,” says Dr. Noordsy.

The origin of this belief traces back to the 1980s, rooted in a concept known as The French Paradox–the observation that despite consuming a diet high in saturated fat, France had a low incidence of heart disease. Researchers of the era decided that this unexpected trend was attributed to the widespread consumption of wine in the region. This correlation led to extensive research into wine and the identification of polyphenols, thought to be responsible for wine’s apparent cardioprotective potential. 

Since then, numerous observational studies have claimed that light to moderate wine intake has beneficial effects. “However, these studies overlooked some crucial factors,” says Dr. Kin. While early observations indicated poorer cardiovascular outcomes for non-drinkers than for moderate drinkers, researchers overlooked that many non-drinkers abstained due to existing health conditions that led to overall poorer health outcomes. Additionally, those self-identified as light drinkers were more likely to lead healthier lifestyles overall. This oversight has fostered a misleading impression that associates better cardiovascular outcomes with light drinking, falsely implicating alcohol as the causal factor. As a result, enjoying a glass or two of wine a day has become widely accepted as a  healthy habit. 

While red wine contains antioxidants like resveratrol, found in grape skins as well as in peanuts, dark chocolate, and blueberries, which might have heart-healthy benefits like reducing cholesterol and lowering blood pressure, the quantities are often misunderstood. To achieve the levels of resveratrol observed beneficial in mice studies, one would need to consume an impractical amount of red wine—somewhere between a hundred to a thousand glasses daily. Thus, while the idea of resveratrol’s benefits is enticing, the practical reality makes it an unrealistic source for therapeutic effects.

How Much Alcohol is Too Much?

Many people believe alcohol becomes a concern only when consumed excessively. “Excessive alcohol use” is defined as exceeding the US Dietary Guidelines’ recommendations, which advise males to limit themselves to two drinks per day and females to one drink per day, on average. Two-thirds of adult drinkers report drinking above this level at least once a month.

However, a growing body of recent research shows that even modest quantities of alcohol can be harmful to our health. Such consistent findings have prompted the World Health Organization to assert that “when it comes to alcohol consumption, there is no safe amount that does not affect health.”

The main issue with alcohol is that it enters the bloodstream and quickly spreads throughout the entire body (especially when consumed without food). Unlike most substances, alcohol is both water- and fat-soluble, allowing it to permeate nearly every cell and tissue, including the highly secure blood-brain barrier that protects our central nervous system. 

While the liver does most of the alcohol metabolism, other organs also process alcohol, such as the kidneys and lungs. As our organs work to break it down into a usable fuel source, acetaldehyde is produced, which is toxic due to its ability to damage and kill cells indiscriminately. As acetaldehyde enters the brain, it causes a disruption in our neural circuitry that creates the sensation of “tipsiness” associated with alcohol. And, the more “tipsy” one feels, the greater the amount of toxic acetaldehyde in the blood.

Rather than following strict guidelines about how much to drink, Dr. Noordsy recommends that individuals take note of their personal perceptions of intoxication and pace themselves accordingly. He recommends using the feeling of being “tipsy” as the signal to slow down or stop drinking. “The ‘tipsy’ feeling is the indicator that blood alcohol levels have risen to the point that you’re starting to put your health at risk. And the more ‘tipsy’ you become, the higher the risk,” states Dr. Noordsy. “If you’re having alcohol with food, your blood alcohol level won’t be as high as compared to having drinks by themselves. So, if you’re enjoying a glass of wine as part of your meal, that’s a very different thing than drinking in a way that’s leading to the feeling of intoxication.”

Health Concerns Linked to Alcohol Use

Recent data from the World Health Organization reveals that each year, alcohol contributes to three million deaths globally and accounts for 5.1 percent of the worldwide burden of disease and injury. Alcohol’s detrimental effects span more than 200 disease and injury conditions, encompassing everything from alcohol dependence and liver cirrhosis to a range of non-communicable diseases (such as heart disease, cancer, chronic respiratory disease, and diabetes) and mental health disorders.

Liver Disease

Acetaldehyde, a derivative of alcohol metabolism, inflicts significant harm on the body’s cells, especially within the liver. Given the liver’s primary role in detoxifying our bloodstream, it bears the brunt of the detrimental effects of alcohol metabolism. This continual strain can result in the buildup of fat, chronic inflammation, and potentially irreversible damage to the liver. 

A study analyzing the livers of 3,649 participants discovered a concerning correlation: as daily alcohol intake increased, so did the accumulation of fat in the liver. Alarmingly, no identifiable threshold existed below which these harmful effects were absent, suggesting that even individuals who consume alcohol in minimal amounts are not immune to the accumulation of liver fat.

Fat accumulation hinders the liver’s vital metabolic functions, including blood sugar regulation, cholesterol processing, and nutrient absorption. It also increases the risk of inflammation around the liver, known as alcoholic hepatitis. 

“The good news is that abstaining entirely from alcohol can reverse these changes, however, continuing to drink alcohol can lead to irreversible damage, scarring, liver dysfunction, and in advanced cases, liver failure,” states Dr. Kin. “This is especially concerning because fatty liver often presents no early symptoms, with individuals potentially unaware until it advances or results in serious complications.”

Another important consideration is that people who have non-alcoholic fatty liver disease, caused by obesity and other metabolic syndromes, have a much higher risk of developing alcoholic liver disease. 

“This means that even small amounts of alcohol will cause the same level of alcohol-related liver disease (fibrosis, cirrhosis, etc.) as would larger amounts of alcohol consumed by someone without underlying fatty liver,” explains Dr. Kin. “Therefore, people who are already dealing with metabolic diseases should be extra cautious around alcohol because their livers are working extra hard already.”

Cancer

Alcohol is designated as a carcinogen by the International Agency for Research on Cancer due to its association with higher risk for many common cancers.

“Alcohol increases cancer risk specifically in areas it is in close contact with, such as the mouth, pharynx, and digestive tract. It also has carcinogenic effects throughout other parts of the body,” states Dr. Kin.

Underlying its harmful effects, chronic inflammation from alcohol consumption elevates cell turnover, heightening DNA mutation risks. Additionally, alcohol is believed to promote tumor growth while inhibiting tumor-suppressive molecules.

In 2017, the European Union reported nearly 23,000 cancer cases tied to light to moderate alcohol use, with half attributed to female breast cancers. Even at levels as low as three drinks per week on average, there is a slight but measurable increase in breast cancer risk. Notably, raising daily alcohol intake by just 10 grams—equivalent to what’s in a standard beer or wine—escalates the risk of breast cancer by 10 percent.

Cardiovascular Health

Despite popular belief, alcohol consumption, regardless of the amount, is linked to an increased risk of cardiovascular disease. A comprehensive study of 371,463 individuals found that as alcohol consumption increased, so did the risks of conditions like hypertension and coronary artery disease. Light alcohol intake (less than 8.4 drinks per week) led to a minimal but noticeable increase in cardiovascular risk. Researchers also found that when accounting for various lifestyle factors, the perceived protective benefits of modest alcohol intake against cardiovascular risks diminished significantly.

There are numerous reasons hypothesized for these detrimental effects, especially surrounding the metabolic effects of alcohol. “Alcohol offers no nutritional benefits; it’s essentially empty calories that are consumed on top of the calories required by your body. On top of this, alcohol interrupts the body’s regular metabolic functions. As the body prioritizes removing this toxic substance, it compromises processes like nutrient absorption and fat metabolism. This disruption promotes the storage of visceral fat, the harmful fat surrounding organs,” explains Dr. Kin. “This fat increases inflammation and poses significant risks, especially around the heart.”

Hormone Imbalance

Alcohol consumption raises estrogen levels in both males and females by increasing the activity of the enzyme responsible for converting androgens to estrogen. This accelerated conversion can lead to issues like gynecomastia (enlarged breasts in males), decreased libido, and increased fat accumulation. Additionally, consistent alcohol exposure can reduce testosterone levels over time, which is associated with reduced libido, fatigue, decreased bone density and muscle mass, and potential fertility issues in both males and females.

Additionally, regular alcohol consumption of more than 3.5 drinks per week for males and 2.6 drinks per week for females can cause chronic changes and reduced control of the hypothalamic-pituitary-adrenal axis. This disturbance may lead to an increase of the stress hormone cortisol released throughout the day.

Microbiome Issues

Alcohol also disrupts the gut microbiome by killing beneficial bacteria and other essential microbes. Additionally, alcohol’s pro-inflammatory properties trigger the release of inflammatory cytokines, causing gut inflammation and making the intestinal lining more permeable. This increased permeability can allow undigested food particles to enter the bloodstream. Over time, chronic alcohol consumption can further imbalance the gut microbiome, promoting bacterial overgrowth and dysbiosis. These disruptions can trigger immune responses, increasing susceptibility to food intolerances.

Brain Health

When alcohol is consumed, it enters the brain and suppresses neural networks involved in memory formation and storage. Through chronic consumption, this disruption can have permanent effects. A study involving over 36,000 middle-aged adults revealed that even moderate drinkers, consuming one to two drinks per day on average, displayed thinning of the neocortex and other brain regions, indicating neuron loss. This research also found that increased alcohol consumption correlates with diminished brain volume and reduced gray matter, which are the areas of the brain highly concentrated with neurons. As alcohol intake rose, so did the severity of these detrimental effects. 

Fortunately, for most casual drinkers, abstaining from alcohol for two to six months can reverse damage to the prefrontal cortex and neural circuitry. However, chronic users may only experience partial recovery and might endure lasting effects.

“As alcohol consumption increases, so does one’s risk of cognitive decline and dementia,” states Dr. Noordsy.

Mental Health

As anxiety and depression continue to rise in the US, alcohol use also increases as individuals self-medicate to reduce stress. Also, the nightly glass of wine may cause more stress the following day since it impairs cognitive and physical performance, reducing one’s ability to cope. “During the pandemic, we observed a startling rise in cases of alcohol-induced hepatitis, indicating a growing reliance on alcohol as a coping mechanism,” says Dr. Kin. 

One study, however, showed that light to moderate alcohol consumption may be beneficial to mental health by offering short-term relief by reducing stress signals in the brain. Although Dr. Noordsy acknowledges this study, he states that “learning to manage stress through physical exercise, mind-body and mindfulness practices can lead to safer and likely more effective mediation of impacts of stress than relying on alcohol use.” 

Is There a Healthy Way to Consume Alcohol?

Given the extensive research on the detrimental health effects of alcohol, both Dr. Kin and Dr. Noordsy recommend abstaining from alcohol, or at least drinking very rarely, if one is experiencing or has a family history of liver disease, cancer, cardiovascular disease, hormone imbalances, gut microbiome issues, dementia, or mental health disorders, including addiction.

The precise amount of alcohol that is harmful is difficult for experts to confirm because it’s different for each person. Therefore, when it comes to alcohol and health, Dr. Noordsy recommends a balanced, personalized approach keeping in mind one’s individual risk factors and health goals.

“While heavy, regular consumption is linked to health problems, an occasional drink with meals may pose little risk for most adults,” says Dr. Noordsy. “However, individuals with personal or family histories of certain cancers or other conditions may need to be more careful with alcohol intake. We put thought into our nutrition and exercise habits, and we need to be just as thoughtful about the role that alcohol plays in our lives and make informed decisions regarding how much is the right amount for ourselves.”

Although less inclined to recommend light alcohol consumption, Dr. Kin acknowledges that it is an ingrained part of people’s social and cultural lives, similar to many other things that individuals consume that do not contribute to health. So, she encourages individuals to reframe their mindset around alcohol. 

“Rather than viewing alcohol as a daily routine, consider it a treat reserved for special occasions or celebrations, much like enjoying a slice of birthday cake,” she says.

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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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