Dhru Purohit Show - Is Exercise the Miracle Drug We’ve Been Waiting For? The Number One Way to Strengthen Your Mind and Fight Depression with Dr. Nicholas Fabiano

Episode Date: March 26, 2025

This episode is brought to you by BiOptimizers, Cozy Earth, and Fatty15. When we think about treating depression, we rarely consider exercise. Yet emerging research shows it can be a powerful tool for managing mild to moderate depression, and it works well alongside other therapies—including medication. Today’s guest shares the science behind exercise and explores why more practitioners aren’t incorporating it into treatment conversations. Today on The Dhru Purohit Show, Dhru sits down with Dr. Nicholas Fabiano to explore the powerful role of exercise in treating depression. Dr. Fabiano introduces the FITT protocol for prescribing exercise and sheds light on the disconnect between physicians and patients when it comes to exercise recommendations. Dhru and Dr. Fabiano also discuss how research funding can shape treatment perspectives, the benefits of combining medication with lifestyle interventions, and the emerging role of creatine in brain energy and its potential impact on depression. Dr. Fabiano emphasizes why exercise is essential for mental health and advocates for a holistic approach to treating depression—one that includes lifestyle pillars like diet and sleep. Nicholas Fabiano is a psychiatry resident and researcher at the University of Ottawa. Drawing from his personal background in weightlifting and competitive soccer, Nicholas developed a strong interest in the use of exercise as a treatment for mental disorders, particularly depression. His research focuses on the intersection of mental and physical health, with a special emphasis on lifestyle psychiatry—exploring how exercise, diet, and sleep influence mental well-being. In this episode, Dhru and Dr. Fabiano dive into: Exercise can be as effective as therapy in treating depression (00:27) The importance of finding a provider who exercises and understands its benefits (01:57) The impact of exercise on both the brain and body (04:53) The misperception that all patients want quick fixes (11:11) The side effects of medication and how lifestyle interventions can help counter them (19:18) The FITT protocol and how to prescribe it effectively (23:56) Reframing exercise as an intervention that empowers patients (31:54) Heart rate variability, and why doing what you enjoy matters (31:42) The benefits of stacking exercise with creatine (38:33) How to incorporate creatine into your diet (44:24) Exercise recommendations for beginners, family, and friends (45:02) A lifestyle protocol that can actually induce depression (49:33) Advocating for and educating the public on foundational principles (59:06) An entrepreneurial approach to solving the mental health crisis (01:03:21) How Dr. Fabiano became passionate about brain health (01:05:59) His advice for beginners and how to follow his work (01:11:27) Also mentioned in this episode: John Abramson's book - Sickening Try This: Three Super Crazy Facts about Big Pharma Study on BPA in pregnant women  For more on Dr. Fabiano, follow him on Instagram, X/Twitter, LinkedIn, and his Website. This episode is brought to you by BiOptimizers, Cozy Earth, and Fatty15. Go to bioptimizers.com/dhru now and enter promo code DHRU10 to get 10% off any order of Sleep Breakthrough and find out this month’s gift with purchase.  Right now, get 40% off your Cozy Earth sheets. Just head over to cozyearth.com/dhru and use code DHRUP. Fatty15 is offering an additional 15% off its 90-day subscription Starter Kit. Go to fatty15.com/dhru and use code DHRU to replenish your C15 levels for long-term health. Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Nicholas Fabiano, welcome to the podcast. You know, there is a pretty mind-blowing belief that you have about treating depression. And that belief is that most people, including many medical practitioners, have no idea that exercise can be as powerful as a tool to treat depression as talk therapy and medication. Can you expand on that? Traditionally, we viewed exercise as a treatment for many different things, more so in the physical realm. So you often hear your doctor talking to you about these things for diabetes or weight loss and stuff of that sort.

But it's been more mainstream recently as the research just came out to show that exercise, just similar to, as you mentioned, therapy or even antidepressant medications, can have similar antidepressant effects if prescribed correctly. So I think this notion for some people is received very well, for others maybe not so well. But even for providers, for instance, in Canada here, it's one of the first-line treatment options. that we have in our guidelines. But many people aren't aware of that. So I think with that, we have the evidence for it.

We know its benefits. The next part is really educating people and also the providers about how to do that. And that's where that disconnect really lies. Well, we're going to get into that. But right away, I want to take a quick tip that you have for anybody who's listening who might be dealing with some spectrum of depression. There's mild, medium, severe. Or even people that find themselves in more of a depressive or low,

mood, but maybe don't have a clinical diagnosis. And you have an important tip that I'll steal from one of other podcasts that you were on. And that tip is if you as the patient are looking for a provider, ideally if you can find somebody who has some background in working out themselves. Because if they, as a physician or a health care provider is working out, they're more likely to be prioritizing and recommending this as part of their treatment program. Can you expand on that? Research has shown at a family or primary care physician level that, as you mentioned, people that are exercising more.

So the providers are more likely to have that discussion with their patients. And that extends to things like depression. And that's important. As you mentioned, when you're looking for a doctor, if that's something you want to talk about, it's hard if the physician that you're speaking with isn't open to that discussion. So there's that disconnect there. But the other part stems even deeper beyond people that have. their own experience with exercise and want to prescribe it, I think fundamentally the system fails that's when we're being trained. And I can only speak to my own experience and also having spoke to

a lot of other residents and physicians that throughout medical school, throat residency, we're taught of all of these benefits of exercise. It's brought up for a physical health, mental health sort of thing. But we're not formally taught how to talk about it, how to prescribe it, how to follow up with it, the same way we're taught about medications. So I think there's that degree of uncomfortability. for people that don't have that personal experience with it, which, again, it stems down to education, being able to talk to people so that you're able to have that discussion with your patient. Because, again, as a physician,

your role is to provide information to the patient in front of you so that they can make an educated and informed choice. And with exercise being one of the first line treatment options for depression, it's only fair to have someone that's able to have that discussion and facilitate follow up and make sure that you, the patient, has the most success too. So that would be my advice there. You know, as you mentioned, people that do exercise more often, the physicians are likely to have that discussion.

But I hope to see a future where even people that maybe aren't are able to still facilitate that and have a conversation with the patient in front of them. One of the things that you talk about online on X and we've linked to your profile, as well as a little bit in the paper that you published recently, which we covered in our newsletter, which is called how to prescribe physical activity for depression, which I found super fascinating, is that even though everybody knows, Many doctors know that physical activity helps with depression. They actually don't know how to give the specifics in terms of recommendations. And that often leaves patients feeling that they leave an appointment with the recommendations of, hey, lose a little bit of weight, eat a little bit healthier, and move a little bit more. But that's a super broad spectrum of recommendations that are there. And in your paper, what I found super exciting, which we're going to cover today in a little bit,

is you go into your fit protocol, F-I-T-T, and we're going to break down the specifics. And the punchline of it all is, is that there are actually, even though any type of exercise is good, there are actually recommendations that we know based on the evidence of what leads to the best benefits coming from exercise. So we're going to get into your fit protocol in a second. But first, let's zoom out a little bit more. What does exercise do to the brain and body that it's such a powerful antidepressant? To reframe that even a little bit, there's a lot of controversy over what causes depression, what causes it to continue on, and what changes that has on your brain,

different discussions about serotonin levels, different brain, physical changes in your brain that occur with depression. And we're not even sure from that lens. So I think it's helpful to really break it down into three different prongs in terms of when we look at what does exercise do to your brain? And it's to break it down into the biopsychosocial lens. So when I say bio, I mean biologically, what does exercise do to your brain? So we know that exercise, it increases the levels of different neurotransmitters. So things like serotonin, norapherin, dopamine, and these are neurotransmitters that are implicated in, you know, the alleviation of depression,

what some of these medications aim to actually increase. So that's a positive thing. Another thing that exercise does is it also increases levels of what we call brain-derived neurotrophic factor or BDNF. And that is essentially miracle growth for the brain. It's such an important thing from a neuroplasticity standpoint, and it helps prevent cognitive decline and all these beneficial things, which we think has a role in depression. And then to speak about the physical changes within the brain, we know that people that exercise

have larger brain volumes, specifically in areas like the hippocampus, which is important for cognition and memory. So those are some of the brain changes that we know that happen. And there's a lot of other things that are in the research area, but those are some of the major areas. And then when we break it down further, if we want to look at the psychological lens of this three-pronged approach, you can imagine when you exercise, and people have probably all have this experience where after you have a good session at the gym, or if you go for a run, or if you go climbing with friends or some sort of sport, immediately after you have this sense of, you know, increased drive, motivation, those stresses that you were worrying about, maybe aren't there anymore.

And that's important as well, too, because that can provide you with the momentum to continue, to maybe get that task done you've been waiting and holding off on, or even to look forward to that next session. So that psychological aspect is important to. And then an often forgotten part of exercise too is the social part or the social aspect of that three-pronged approach, where particularly in populations that are more prone to being isolated or alone, particularly during the COVID pandemic or older populations, exercise may be the only time where people are in a group setting doing something. So whether again, that's at the gym

just talking to other people, whether you're on a sports team talking to other people. And we know that this social connection as well too has antidepressant effects too, because loneliness in itself has been perceived to be a disease and increased the risk of dementia and cognitive decline and even depression. So looking at these three different lenses, we really see how exercise can fit in and may alleviate someone's depression, even without knowing the full scope of what causes depression per se. You know, one of the things that you talk about online is that there is a little bit of a problem that's there. And that problem is because of the research that typically gets funded and how that research makes its way to physicians who largely are all well-intentioned

and want to help patients, there becomes this jaded view that many physicians have, which is that if I'm going to suggest physical activity, even if I know about it, the patient's not going to do it. Patients just want quick fixes. They just want a pill to deal with the issue. Talk about that idea and why it's wrong

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a lot of our formal teaching and comfortability comes with medications. So you have some with depression. The two-pronged simple approaches, therapy medications, maybe both. And that's where maybe that comfort level comes in. I think the other part, too, with exercise and sometimes people wanting this quick fix is sometimes there's this misperception because in depression, innately, there's this a motivation. A lot of people experience that.

So sometimes the provider, kind of rather than speaking with a patient in front of them and seeing what might work for them, just automatically kind of assumes that and jumps to the other treatment options, rather than entertaining that discussion, which I think is an important barrier as well too, which is important to really make sure, you know, is this patient wanting to talk to me about exercise? And then that brings up the other point of the severity level of depression too.

So as a provider, you have a responsibility. You have different treatments to offer. But exercise, and where most of the research lies, is in people that have a mild or moderate depression versus someone that has a severe depression. And to give a picture of what that looks like, someone of the severe depression is someone that is completely bedbound. They're not able to do their activities of daily living.

Stuff is really, really hard. And offering exercise as someone in that setting maybe isn't inappropriate, but perhaps it can be kind of this bridged approach where maybe other interventions can be offered first. and then having that discussion about exercise. But I think before you go into that discussion with a patient, I think you also need to understand that, as you alluded to before, people have probably had poor experiences with other physicians,

whether it be a psychiatrist, whether it be a primary care doctor, surrounding exercise. So if you came in with a physical ailment and you're told, just go exercise, that's not very actionable and it can feel that a finger is being pointed at you if you're the patient, that you're being blamed for this condition. So the patient already walking into this encounter with you, the psychiatrist, can already have that view of exercise or lifestyle measures in general.

So it's important to kind of present it in a way that it's not confrontational. You're not blaming someone for having depression or something because of their diet or because of their exercise regimen or lack thereof. More so framing it in an educational view and feeling if the patient seems interested at this moment. And again, as I mentioned, even if this moment, if they're not able to engage or not wanting to, it doesn't mean that it can't be an option for future discussion as well, too. And I think that's where some of that disconnect lies between the patient and the physician and having or

facilitating that discussion. Yeah, it's an important point. I'm not sure if you're familiar with his work, but there is a Harvard adjunct professor. He is also an expert witness in many of the biggest trial cases against big pharma, including Vioxx, and how Vioxx, many of the side effects around the drug were hidden for years, which led to an excess of, I think, like, over 50,000 deaths, early deaths that came from the drug, side effects being hidden from the medical research. Anyways, he wrote a book called Sickening. And inside of the book, one of the sections that he goes into is talking about how a lot of

the funding that's out there that medical providers get presented is skewed naturally to medication, because it's all being funded. and those are the companies that have the biggest, you know, in the deepest pockets. And very rarely do we look at drugs and say, well, okay, this medication might have some efficacy. But how does this medication compare to the alternative? And when there is research and studies being funded, we wrote a whole newsletter about this. I'll put it in the show notes. In one case, there was a big research study that was funded by the NIH and the National Diabetes Council,

where they looked at metformin by itself. and then metformin with dietary and lifestyle interventions. And then they looked at dietary and lifestyle interventions on their own, which this was a big undertaking. You don't really get studies like this that are funded. It's very expensive and takes a lot of resources. But many of the physicians that were presented with the conclusion of this study were shown that, yes, metformin works well and can work fantastically for diabetes patients.

And when combined with dietary and lifestyle interventions, It works obviously even better. But then the secondary aspect is that they did the comparative on just dietary and physical activity. And they saw that those that were in a committed program that had coaching, resources, education, they saw the most improvement. And often physicians, again, well-intentioned, well-meaning, they're not presented with how does this drug intervention compare to lifestyle interventions on their own? and largely that's a bigger discussion about what gets funded and research and priorities. But I think that also plays into this idea of, I would probably also feel, too, that patients only want a quick pill for their fix if that's all the information that I'm being provided. No, no, that's fair. And I think to that point, too, like you mentioned, it distorts the view from both the provider and patient perspective.

So it looks like that is the quick fix. And where the disconnect lies to is with exercise and different interventions, these trials have sometimes shown that exercise outside. actually has a faster antidepressant response than some of the medications because we typically speak to patients about from a depression perspective that sometimes medications can take four to even eight weeks to start having that immediate effect or a noticeable effect, which can be a long time for someone that's experiencing severe depression or anxiety. Even if the exercise intervention within the first few weeks isn't meeting its maximal effects, I think it's something that providers need to be aware of that it could be something to help bridge that. And this is to another point that's important is sometimes when we discuss lifestyle interventions, so exercise,

diet, sleep, we artificially create these two camps where you're either lifestyle or you're either the regular path of medications and therapy, where the reality is the benefit lies best with everything that you can do that the patient's wanting to do. That works for them. So looking at it, not of these separate camps, but that these are all first-line interventions that can go together, I think is a better way of framing it for patients. Because an example there would be, say the patient comes in, they want to start an antipresent medication, and that's something that I would fully support.

But at the same time, that doesn't now block off the area of also having exercises, intervention at the same time, starting at the same time, or maybe even a staggered approach. And I think being comfortable discussing these interventions at the same time is important to receive proper care as well because there's not a whole lot of data,

but when someone is on an antidepressant, oftentimes, even when that depressive episode resolves, you remain on it for varying amounts of time, depending on the number of episodes that you've had before. But it would be interesting to see for those that adopt a lifestyle change, such as exercise or diet, perhaps you need to stay on that medication for less. And I don't have the data to support how what that interval looks like. However, it would be interesting to see if we can see changes in how these interventions may interact with one another. Because right now, even in the research space, we often see them in isolation. which goes back to your main point where it's hard for the provider to make a decision of what to do best, if these interventions aren't often used together in the research world, now applying it to the clinical setting or the patient in front of you.

That's well said. And as people that, as myself as being somebody that's in the, typically the integrative, holistic, functional medicine space, and I have a bias towards that direction because my own life experiences, I also don't want to create stigma for somebody who feels like they want to seek out medical. I've had many friends seek out medication and you don't want to create a situation where you are making people feel bad for seeking that out. And that goes to my next question here, which is that another powerful thing that you talk about is that for individuals that are on medication, medication often comes with side effects. I'd love for you to talk about what those side effects are and more importantly, how when you combine medication and lifestyle interventions like physical activity, the physical activity can help counteract some of those side effects that you're dealing. So yeah, for medication side effects, specifically within psychiatry,

when we're looking at the treatment of depression, it's easy to look at these two broad classes of medications that we use. So there's obviously the antidepressant medications, and these can have side effects that we turn to be metabolic side effects. And by that I mean they can be associated with things like weight gain, they can be associated with changes in your heart rate, they can change your blood pressure sometimes. And we know that exercise can counteractivity.

a lot of these side effects. And another thing that people don't know is sometimes for people that are on one antidepressant and you see a partial response, sometimes you get your treatment augmented with another medication. And oftentimes these are in the antipsychotic class of medications. And it sounds like a misnomer, but we use these classes of medications to augment the antidepressant. But these antipsychotics have even more of that metabolic burden. So much more weight gain associated than antidepressants. And what this does is you can imagine anyone taking these, having these side effects. You would, that would limit your adherence or wanting to continue taking this if you're

experiencing it because it alters your life and can influence your depression directly as well too. So where exercise comes in is if someone's on these medications and experiencing things like weight gain or any of these other metabolic side effects, exercise can help counteract these. So whether you're weight training, whether you're running, whether you're doing something like yoga, it can help combat those side effects. And you might even see an improvement beyond what those side effects are having just from

having that active lifestyle. So I think for the whole picture, it's important if you're starting someone on these medications, even if it's a small exercise regimen, to at least present it as an option to help counteract that because I think it only makes sense if you're starting something where you know it's going to have side effects to be proactive rather than reactive, because that can really taint someone's next experience with an antidepress and then say, hey, I don't want to do that again because I had X, Y, Z side effects. Whereas if you're a physician being proactive and honest about those side effects that may lead to more rapport with your patient and may lead to better outcomes as well too. You know, I want to take a moment here. I know there's a little bit more groundwork to

cover, but I actually think this is a good opportunity to get into the prescription for exercise and your fit protocol. So if you wouldn't mind, explain what fit is and walk us through the acronym of the recommendations you guys covered in your paper. You know, after I turned 40, I started doing everything I could to understand what was going on with my heart and making sure that I do everything that I could to protect it as I get older. I'm sure a lot of you can relate to this, but metabolic dysfunction and high cholesterol are rampant in my family. So, you know, while I may be genetically predisposed to certain things because of my South Asian

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slash Drew and use the code Drew at checkout. We frame it in a way like this. If you go to see your doctor for a medication that you're being prescribed, you wouldn't just be told, take medication and then the doctor closes the door and walks out. You would be left thinking, What do I do with that? But the parallel being, as we discussed before, people often, when they're discussing exercise with the physician, are told just exercise. And that's the end of the conversation. So the idea for the fit principle comes to make a similar prescription as one would have for a medication, as the same as you would have for exercise. So with a medication, you have the type of medication. You have the route you take it. So is it oral? Is it an injection? You have the dose. You have how often.

you take it. So all of these important variables that go into the prescription. So with the exercise prescription, there's the fit principle. So it's F-I-T-T-T, that stands for frequency, intensity, type, and time. And to break down some of those variables, frequency essentially refers to how often is someone exercising throughout the week? So that can vary from multiple times a day to maybe once a week or even less than that. And that's okay.

But having that benchmark as a prescription. and we usually see the most benefit at around three to five sessions per week. With I, so that's the intensity of exercise, we break that down into low intensity, moderate or vigorous intensity. And the general idea is the higher the intensity of exercise, the greater the antidepressant effect, of course with nuances for different patient populations. And a simple way to see what kind of exercise intensity you're working at is doing something called the talk test. So if you're able to sing, you're able to talk fully while you're doing

your exercise, you're probably at a low intensity exercise. If you're able to talk with your friend, maybe, but you're not able to full sing and you don't have that much air in your lungs, you're probably approaching more of the moderate. But if you're exercising and you need to just focus on exercising because it's so intense, you can't even get a word in, that's probably more of the vigorous side of things. And then the next T is the time. So how long are your exercise sessions. Again, can vary, very broadly, depending on what you're doing

and how sustainable that is. But we usually aim for around 45 to 60 minutes per session to see the maximum benefits from that end. And for the last T, it's the type of exercise. So broadly, we break them up into three different classes. So there's aerobic, which an example would be something like running. There's resistance training. So an example would be weightlifting.

And then there's mind bodies. So an example would be yoga. And of course, you can imagine between that, there's a lot of different mixed type of exercises where maybe you're running but also doing some resistance or maybe there's a mind-body aspect but also some resistance or aerobic activities as well too. So it's just a framework to kind of delineate what type of exercise you're doing. And the important thing is there's not necessarily one clear winner in terms of the type. The largest body of evidence is in aerobic exercise just because it's easy to do in trials for what. or running from a safety perspective. But that doesn't mean that that is necessarily better,

which is an important point to make. When talking with the patient, the most important thing is figuring out what they like to pick that type rather than saying, oh, on this one study, this is the best thing you need to do that. It's not very feasible. It's better to kind of work that in and have a discussion. So the hope is with the fit principle,

you can, when speaking with a patient about prescribing exercise, you can prescribe it akin to how you would prescribe a medication, and that also allows for follow-up. So at appointment to draw the parallel again, when you start a medication, oftentimes with measurement-based care, will measure severity of depression on scales and see how you respond to different doses

and see what side effects there may be. The same thing you can do for exercise, if you have that fit outline of what the person has been doing for the last few weeks, you can see what effect did that have on someone's depression scores and maybe what side effects do they have, and was it feasible? And from there, you and the patient can kind of come to a decision of what may work.

And then the important point that I like to make with the fit principle too is that it's not about reaching those ideals right away. That can be very discouraging for a patient. And that's why I'm always hesitant to discuss the quote unquote optimal amount of exercise for depression because number one, it varies for individual people. But number two, sometimes when you have these optimal levels, it can be very off-putting for someone who's already feeling in a state of no motivation to get started. started. So I think starting it off by setting lower goals that are easily attainable and building

it up from there using the fit principle is the best way to really apply that. Yeah, when I was reading your paper, that definitely came through that you don't want to discourage anybody from getting started. But part of what also came through as somebody who's not trained in this, not a physician, but is looking at the role that these recommendations play in somebody's life who's dealing with depression and I shared about my journey in the newsletter that I wrote about your work where I talked about how I was in early college and I was going through an existential crisis of what do I want to do and I didn't feel like I fit in with my peer group at the time and I wanted to become an entrepreneur and I wasn't sure if I wanted to finish school and I went through this period of time where I wasn't

given a formal diagnosis of depression even though my father worked at a psychiatric facility more on the business administration side of it, I definitely felt like I was going through some mild level of depression, which I know is a collection of symptoms. And I think I would have met the standard for those symptoms if I would have seen a physician. And the first thing that I did during that time when I was dealing with all that is I lowered my physical activity just spontaneously.

I didn't choose to do that. I was kind of more introverted. I wasn't spending time with people as much. I didn't feel the motivation to want. want to go and do things. I didn't have my typical sports activities that I would have in high school. And a lot of my friends went to different colleges. So we were all spread out. I kind of probably would benefit from a little bit of tough love from somebody or at least the type of love that was there that said, look, physical activity is going to be so important as you move through this period of time

in your life, which has many layers to it. I'm not going to tell you that you need to go do resistance training five days a week, but I am going to say that if you are spontaneously moving a lot less as you are right now, it's going to be that much harder to get better, whether you decide to go on medication or whether you don't decide to go on medication. At the time, I didn't go on any medication. And so what I'm getting to is that I definitely see the statement that you want to make for people, that we don't want to shame anybody so that they don't get started. But at the same time, physicians, practitioners have to understand that if they can gradually get the patient up to these levels, that's where they're going to see these biggest benefits. And why that's so important

is for my last check on the statistics, depression is one of the most debilitating diagnoses that we have on society. It's one of the main reasons that people leave the workforce. It has a huge economic toll. And on top of that, the toll that it takes on a patient's life and everybody that they love around them. So it's like both sides of the coin. It's, yes, we don't want to say anything that prevents you from just doing something. Any physical activity is good enough. And at the same time, your job is to present the data and the data shows that if you can get up to these levels that you mentioned earlier as part of the FIP protocol, you are going to most likely, based on the evidence, see some freaking amazing results. I think it's an important point you make to in terms of getting into it.

And I think reframing that discussion too, because you said sometimes maybe you, need a little push to kind of get into things. And I think it's helpful to reframe sometimes how we look at exercise or some of these prescriptions. So sometimes people will argue that, you know, whether it's motivation or time, because going to the gym or making this a whole activity, you might be hard to do as a first step. But I think reframing different things where maybe you would take the elevator at work and maybe it's one floor up, maybe this time you could take the stairs instead.

Or maybe when you go to do groceries, it's not too far away and you're able to walk there instead and walk back and get some sunlight exposures well too and and maybe socialize with someone on the way too. So these little things that you're able to do at the beginning is so important for the point that I mentioned before about the momentum of once you start doing it, it also gives people this locus of control over their own help and their own mind, whereas sometimes when someone is starting medications and they feel that they're relying on these medications to be themselves, which isn't the case, but that's a sense that patients often have came to me with saying, I need this because I feel broken and without it, I'm not. Whereas with

exercise, a lot of people will say that I now feel in control of my health. I'm choosing to go for a run. I'm choosing to go for a walk and I feel better because of that. And I think that's a very important point that we need to look at too to make sure that the person in front of us that we're helping get out of that depression feels that they're in the driver's seat of it and they're not just being pushed along. And again, as I mentioned, that can start with very little things. And we know from the research too, when we look at dose response curves in terms of amount of physical activity and antidepressant effects, the biggest gains are seen for people that are sedentary, so not moving at all, going from just a little amount of physical activity. And then a little bit more, and it keeps going up from there. And of course, you're going to have diminishing returns as you get to higher and higher levels. But I think it shows the importance of for those people that right now are struggling to even get just a little bit active, those little amounts of physical activity can go a long way from both.

an antidepressant perspective, but from a moment of perspective and to help get into other things. And maybe that doesn't lead to more exercise, but maybe that leads to engagement in therapy. Maybe that leads to less side effects in the medication that they're having. And overall, it's this whole picture as the person. And maybe that leaves it to improvements to that individual rather than just looking at it through the lens of depression. One area that I've been a little bit confused about that I'd love to get your thoughts on is that, as you mentioned, the body of work on exercise has largely been done on cardio because it's easy. easier often to do. Not all facilities or research centers might have access or have the understanding

of weight training, resistance training. So that's why the body of research shows that cardio. And typically people think of cardio, immediately they go to running. But as part of that, that also could include swimming and rowing and other things like that, riding your bike. Now, one thing that I've seen personally is that when I hear cardio and the benefits of cardio and you need to make sure you have some cardio in your sort of workout routine, I think heart rate generally, right? But when I monitor my heart rate while I'm doing resistance training, and when I turned 40 a few years ago, I got very much committed to resistance training on a regular basis, going in about three to four times a week. My heart rate is always up when I'm resistant

training. And it might come down for a period of time, but sometimes my heart rate when I'm doing like a leg press goes even higher than what my heart rate would be. I really hate running long distance, but doing something like biking cardio or other stuff. So at the end of the day, I have a bias in preference now in my life because I was undermuscled for so long and I was falled into the skinny fat category since I grew up Indian vegetarian. And I'm trying to, you know, fix all that now. So I'm a bias towards resistance training, but I feel like I'm still getting massive amounts of cardio and the mood boosting benefits

and the metabolic benefits that come from adding slow and steady more muscle mass that's there. Is that a right way for me personally to be thinking about it? Yeah, no, I think in terms of how you're framing and I think also when we lump these exercise groups into these umbrella terms

of aerobic resistance, like I mentioned before, there's so much gray area in between. So even how you go about your resistance training can have more of that aerobic approach where depending on how you do it, If you're doing this more hit sort of resistance training where you're doing these high intensity intervals or different things of that sort, you might notice more changes in your heart rate.

And the important point is that maybe while you're doing the activity, you have these spikes in heart rate and different changes there. But the evidence is shown that when we're looking at heart rate at heart rate variability, the associations with mental illness is usually at your baseline heart rate variability or baseline heart rate. So by essentially revving your heart up when you're resistance training, when you're running, it's to help bring it back down to a level. That's that lower heart rate variability or sorry, higher heart rate variability and lower heart rate

where you have those lower associations with things like depression and anxiety. But I think your approach makes sense too where it's good to have a mixture between the two where, you know, as you mentioned, maybe you like resistance training more and the biggest part of exercise and being adherent to it. And same thing with diet is doing something that you like and enjoy because you can prescribe someone the most optimal regimen from a physical perspective from a mental perspective, and maybe you adhere to it for a week or a month. But over time, if you're not enjoying that, it will become something that you resent and you

don't end up doing to your full capacity. So an example would be resistance training. If you really enjoy it and you're set on hitting a specific number or you're really just invested in getting your squat to a specific level or your bench to a specific level, you're going to work that much harder at it, whether you consciously know it or not. And then that feeds into what I spoke about from exercise intensity in antidepressant effects, where whether you know it or not, as I mentioned, you are going to be having that higher intensity that you bring to each of those sessions,

which will lead to those greater benefits. So like I said, although we put them into categories of aerobic, resistance, and mind-body, oftentimes these exercises, they can really be used interchangeably. There's greater areas between them. And I think it's best to do the one that you find the most benefit from

and you find the most enjoyable. I want to take a quick side, bar here to talk about something that you've recently been publishing on that's related to this. And that's the topic of stacking things like exercise with one of the most common and evidence-based supplements that's out there, which is creatine. Talk about how those two things can be combined together and also play a role potentially in things like depression. Yeah. So creating, as you mentioned, is a substance that's been around for a long time, especially within the fitness. industry. And I always, whenever I talk about it, I like to make the disclaimer that it's not a steroid supplement. Some people have that misconception. But as I mentioned before, creatine, when used, it's traditionally more viewed as something that can be helped to, for someone who's lifting weights or running, to increase the amount of reps you can do, to maybe allow you to run a little bit further. And how it works without getting too much into the complexities is when you take creatine, you essentially allow your body to store more of that creatine in your muscles.

So phospholkretin is how it's stored. And when you're exercising, you're using up the currency of energy in your body, which is called ATP. And creatine essentially helps you recycle that more efficiently. So you can imagine if you're able to recycle your energy more efficiently, then you're able to exercise more. So you can imagine from a pure performance perspective, if you're able to do this more efficiently, you're going to have better outcomes from strength, you're going to have better outcomes from muscle mass and all these different variables. and that will also likely coincide with your ability to have more intense workouts and more antidepressant effects. And where the research has been for this recently has been with pairing

creatine to these first line measures for depression. So there's been a few trials around pairing creatine with antidepressants as a treatment for depression versus the other arm just being the antidepressant alone. And what these trials have shown has been that creatine results in a faster antidepressant response, so as soon as two weeks, and a better response in the long term as well, too. And then a recent trial within the last few months came out pairing it with cognitive behavioral therapy. So that's a therapy that we use to treat depression. And it found the same thing, where there were benefits to the response from a cognitive behavioral therapy. And we know beyond the physical aspects of creatine, there's cognitive benefits too. So the creatine has direct

benefits to your cognition, your memory, and all these different things. So that may allow. allow someone to engage more in therapy. Where I think it's interesting, and it gets a little bit more complex here, is an increasing view of mental disorders is from what we look at from a bio-energetic perspective. So as we discussed before, the traditional view of mental disorders is looking at it from neurotransmitters like serotonin and all these different things. However, the more recent view has been conceptualizing it from energy. So as I discussed before, creatine is stored in the muscles as something called phosphocreatine, but what I didn't talk about was it's also stored in the brain. So about 95% is stored in your muscles. The remaining five

is around in your brain. And it also stores itself as phosphocreatine. And without getting into too much of the complexities here, the how your body, when stuff is working in a healthy state, so a non-depressed state, is your body uses this process called oxidative phosphoryation to regenerate the ATP molecule and allow your brain to also have energy. However, we know that when people are experiencing a depression, the brain itself is not able to do this process of oxidative phospholation as well. So it's slower. It's not efficient. It's a time of increased metabolic demand on the brain. And what the brain is able to do is tap into some of these creatine stores that you have to use that as a short cut to replenish the ATP. But you can imagine that if this

goes on for days, for weeks, for months, for years, that creatine store that you have in your brain is slowly going to be depleted. So now there's no longer that shortcut. And the usual way that you're making the ATP is not as efficient either, which can lead to this prolonged state of depression. And that's where so the hypothesis lies. So where creatine comes in is, again, you can get it from your diet, but oftentimes when we're talking about creatine in the fitness industry, it's from supplementation. So people take it in their scoops, they put it in their water, put it in their coffee. And creatine by this, the thought is that it can replace both the muscle creatine stores, but also the brain creatine stores to help the brain essentially get out of that process,

where there's that increased metabolic demand. So that's the complex thoughts between or behind how creatine might help depression and how it may even facilitate exercise and depression. And the interesting part is in the paper that we wrote, we summarize some of the evidence around creatine with therapy and medications, but there's actually no study comparing creatine and combining it with exercise to see its effects on depression, because that makes the most sense, right? The majority of people that are taking creatine are people that are exercising, and in a real world setting, that's where we would be most interested in the outcome. So we would hope to see studies in the area soon to see what the antidepressant effect of actually.

exercise plus creatine is because we know from both that bioenergetic perspective, but also from the performance perspective of creatine, that there should be benefits. But we don't have that clinical data yet, but it is so relevant and I'm hoping to see that soon. While we wait for more research that's out there, who knows if you do it or somebody else does it, but generally the recommendations for creatine are for people to, you know, start around maybe five grams. If you have maybe a sensitive stomach, sometimes creatine can, create some loose stools for people so you can kind of parse out that dose maybe two and a half grams two and a half grams um and generally creatine is seen as well researched well tolerated

minus the GI issues is there any challenge for somebody who's listening today who either is diagnosed with depression or might feel that they're going through a period of time in their life where they're dealing with low mood is there any challenge of them just starting creatine and start starting to add to that. Are there any contraindications with medications or anything else? All being said that you are not anybody's physician and this is not medical advice. Yeah, yeah. I think the important caveat, as you mentioned, is before starting any supplement, you want to speak with your doctor. But as you mentioned before, creatine is a very well-research substance, but very minimal side effects compared to a lot of other medications or other substances

in the fitness industry. And there have been alarms around different side effects that didn't really substantiate. So just to bring up a few that are commonly brought up in terms of side effects that I've seen people ask me about is the concept of renal impairment or kidney impairment has been brought up in terms of what happens for creatine as a side effect. And that was based on a very small case study of an individual who was actually restricting their diet. So limiting their fluid intake while taking high doses of creatine so an athlete. And they saw it rises in their cratinine levels, which makes sense. But apart from that, in the literature where they've done meta-analysis combining all these studies together, there's no evidence of renal dysfunction. And the caveat that I will add, though,

is for those that have pre-existing renal dysfunction, that's maybe something you'd want to speak about your doctor and make sure everything is okay before supplementing. But for the general public, from a kidney perspective, stuff is generally safe. Another concern that's often brought up by people is hair loss in creatine. And I see that a lot whenever I write about creatine, people always say, but that causes hair loss. And to give some background for that as well, too, that came from a very small study as well, I think about 20 years ago

where they looked at rugby players and they supplemented creatine and they found an increase in something called Dht. And DHT is a hormone that's related to hair loss. But it's interesting to show that with that, that's been really one of the only studies to show that. There are no changes in testosterone level or any of these other hormones.

And there's no studies to show that creatine actually results in hair loss. So no clinical trials to support that data. So although there's that study from a while ago to show maybe concern around dht levels, we know it's much more complicated from that perspective. So just another thing to talk about. So those are some of the common things that when I talk to people about creatine that come up, but overall, in a general sense, it's relatively safe for someone that would want to start at those lower doses. And as you mentioned, if you are experiencing some of those GI side effects, either having a lower dose, or breaking up that dose to morning and night rather than taking it in one dose can be helpful.

But again, caveat being always, I'm not your doctor, so you want to make sure that you speak with your physician about it. But it is generally a safe supplement to take. Well said. I've also heard that sometimes people do better that have GI issues on a micronized version of creatine monohydrate versus a non-micronized version. And that's simply the manufacturing process and method. And then the other thing that I'll add in is that often the supply chain is all over the place for creatine because it is one of the most popular supplements that are there. You know, not to throw any one country or other things under the bus, but generally if you

find creatines that are made in Europe, there are a few different brands that come from Germany. Anecdotally and from some friends that have creatine brands, I've heard that the supply chain is a little cleaner and less likely to have contamination, et cetera. so that could be one other thing that people could try. So a micronized form of a creatine from a German or European manufacturer. So again, that's just my own anecdotal experience that's there. And I think another point from that, too, is the form of creatine.

So the most studied form of creatine is creatine monohydrate. So that's creatine essentially paired with water. And that's what I would recommend most of the time just because that's where most of the evidence lies. However, there's other forms too. So you mentioned the different formation of creatine, but also things like creatine paired with HCL. so creatine HCL or hydrochloric acid. Sometimes that's easier on someone's stomach. It's a little bit more expensive.

However, there's arguments to be made that it's easier, digested. You actually need a lower dose because of that as well, too. And then one that's not as commonly heard is creatine nitrate. So that's comparing it with a nitrate group. And that takes advantage of some of those vasodilatory effects, where in the gym terms, you get a pump more when you go to the gym. So some people like to take creatine nitrate before the gym to kind of have both of those things at the same time.

So just being aware of the different ones out there, but to say that most of the research and when I'm discussing these different things, it's around creatine monohydrate, just because it's the one that's been around for so long. So coming back to exercise and depression, a lot of people that are listening today, they're not a healthcare practitioner. They're individuals like myself that consider themselves to be what I call them, call myself, is a professional amateur. I love to learn about health. I love to follow people like you on X, formally. known as Twitter. I love to read newsletters. I love to read books. And for many of my friends, I'm kind of the go-to in my little community of, hey, what's a good resource on this? What's a good resource on that? And I can point people in the right direction. And I would say that a lot of my audience feels the same way. So what often happens for those individuals is that somebody will come to

you and whether it's a person struggling with depression themselves or it's a friend of a friend, and they're often asking you, or you might even know that somebody in your community is dealing with depression. Could be a family member, a coworker. What sort of recommendations would you have for the non-health care practitioner, the non-physician who's listening to this episode

wants the best for the person that they love and care about? What are some of the do's and don'ts when it comes to bringing up this topic that we've covered on today's episode? First off, if you have your suspicion that someone may be experiencing depression, making sure that they have that professional help around them. But from having a discussion around exercise,

I think it is really important to frame it in that way, as I discussed before, where you're not coming from this stance of the lack of activity or diet or something is necessarily causing their depression, because that can be very off-putting for the patients and make them feel that they don't want exercise, and it's almost the resistance to doing it. I think if someone's coming to you with that and saying,

you know, what should I do from an exercise perspective, I think just helping them do the small things. So whether that's going for a walk, whether that's, as I mentioned, taking some of those more passive modes of activity before and making it active is a good step in the right direction and working with them. And if you're able to, if it's someone that's close to you,

maybe doing some of those activities together, maybe if they wanted to go on a walk together, if you wanted to go to the gym together. Because getting into fitness, and I can speak from my own personal experience too, I was someone who I played soccer my whole life and I was comfortable with that. But when I started getting into the weights and the gym, it was very overwhelming.

So at that time, someone told me, hey, you just need to go to the gym. I was already scared enough to go to the gym and see all these muscular people and stuff. And I was 100 pounds, probably soaking wet. So I think being able to be with someone in that moment and help them do that, especially if it's something that you enjoy. And if you're that person that people see as having knowledge and fitness or different things, then maybe taking them to the gym or taking them for a run. because it can be overwhelming and even simple things like running,

there's so many different terms and things that come up zone too. And for someone who's not interested in running or wanting to get into it, it can be overwhelming and off-puting. So my suggestion would be just to be there for them and to help them walk through these different things and help facilitate their interest. So maybe they don't like weightlifting like you. Maybe they don't like running like you,

but maybe there is something that you can find that they do like and helping them adhere to that because that's where you'll find the most success. That's a great recommendation. I have a men's group and at various stages we've had different guys in the group that were never formally diagnosed but might be going through a period of their time in their life well-reasoned. It could be through great tragedy, loss of a family member. They might be going through a low mood and feel like they're not themselves. And I've seen that regularly creating something on the calendar. Like, hey, every Thursday we play pickleball. You know, come anytime. It's just like a fun. opportunity, something low stakes that they can get involved with, that doesn't feel, that feels inclusive, maybe feels like a group activity. We even do this thing where every Saturday we all go to the gym together and sometimes we'll reach out to somebody in the group or a friend and say, hey, just come and join us. It's like, it's okay.

Anybody, regardless of your skill level, it's just more of a fun thing for us to do. So having that open invitation to somebody and not making it too much about their symptoms or what they're going through, whether they have a diagnosis, whether they don't. I've found is a great way to have people feel like there's a low barrier to entry to get the social benefits of hanging out with people, but also the physical benefits of doing something like working out or going to the gym together. I think it's a great point. Like you said, making it something that's fun to do and not seem like a chore

and also extending that hand for someone that maybe wants to do something or is hesitant to learn something new but willing to and being able to be that bridge to have that conversation, I think is so important. You know, I want to zoom out a little bit more. and I often ask this question to guest. And the question is, if I gave you a group of, let's say, 50 people, and I said, all right, I know this is a completely unethical study, but I want you to induce depression into these 50 people and give me the opposite of your protocol, both with physical activity, maybe some dietary stuff.

I know that's not your area of expertise, but you do pay attention to it a lot based on your post on Twitter and anything else. So what would be the perfect protocol to induce depression in a group of 50 people? To reverse kind of the things I would do, how I view kind of the fundamental pillars of your health are your exercise, your diet, and your sleep patterns. So if we're to flip those upside down and want to induce a depression, for exercise, I would say, you know, remain completely sedentary. Don't even get off the couch. Just Uber-Eate stuff straight to your couch. And what you're eating too, that leads to the next point, is purely ultra-processed foods. So just eating the most processed stuff you can have. So whether that's fast food, stuff with maximum amount of

calories packed into small amounts of food, that would be kind of the exercise diet. And then sleep-wise, I would say completely have no schedule to your sleep, kind of fall asleep whenever, to stay up during the day and have your circadian rhythm be all messed up. And with those three things, and the reason why I say this is as a resident physician, some of these things happen to us indirectly sometimes where we're on a 24 hour shift. We haven't eaten. We haven't had the chance to exercise in a week because it's so busy. And again, not to say and discredit someone that's experienced a depression, but in these states, it's so hard. You feel that mental bird on you, especially if it's prolonged for a period of time, that I can imagine how if someone's lifestyle was like this day after day,

week after week, year after year, how it would be almost impossible not to develop symptoms of depression or an overt clinical depressive symptom. And that's why I think beyond just the medication therapy and what our standard is, we need to make sure that we have these fundamentals in check because it's hard to piece someone back together if you don't have that foundation there. And that's why it's so important, not necessarily to perfect it. but to at least restore some balance to it and not just have this bandage approach of, oh, here's a medication. This will make stuff better.

And maybe it transling will, but it won't solve that foundation and prevent relapse and different things of that sort. I appreciate you mentioning that. And also the fact that even at some points of time in your career, you know, becoming a physician, that you've gone through a routine that looks not too far off from that. Maybe not exactly. It was unfortunately a necessary part of your training. I have a lot of physicians in my family, and I know that they've gone through many similar things.

And to zoom out a little bit, you know, I think that there's a lot of people that are listening today, and I know I feel this way a little bit too, that you hear yourself talking about that. And obviously, there's various degrees of extreme on those protocols you mentioned, staying on the couch, never getting up, Uber eats, you know, door dashed directly to your couch. Maybe most people are not in that situation, but there's a lot of people that by definition, of a sedentary lifestyle, which I think one definition is getting less than 4,000 steps a day, a huge percentage of the population is in that camp. And unfortunately, the scariest part is that there's a lot of kids especially that find themselves in that camp, especially because gym or recess or other things are not as popular as they once were, you know, 10, 20, 30, 40 years ago.

And then on the dietary side, there are many people that do eat a diet that is largely based on caloric excess calories from ultra-processed food, and especially a lot of kids find themselves in that standpoint. And then, you know, the last components, you know, being, you know, sleep that you mentioned, that a lot of people do have very disruptive sleep and not just because they're a shift worker or a physician or a resident in training, whatever it might be. And I think I have empathy sometimes when I listen to my community who hears an episode like this. And it's like, why the hell are we not shouting through the rooftops that we need to shift the way that we think about medicine?

Because even though a lot of people would listen to this episode or see your paper and say, okay, yeah, I get it. Physical activity is important for depression. When you actually look at the population, people are largely. doing the opposite. And they see the medical establishment as being kind of quiet about these things and instead putting all their emphasis on maybe infectious diseases or other aspects that are there in health, which sure, those things need attention. But if we look at the per person impact of something like depression, it's like, why are we not mandating that every school in the school system has some of these basics but actually is implementing there. So I guess I'm just saying

that I have a lot of empathy and I'd love to get your perspective on this when people feel a sense of outrage after hearing an episode like this and then also looking at the population and saying we're not even doing those things and no wonder people are so depressed. What are your thoughts on that? Yeah, no, I completely agree because at one level it seems so obvious that these fundamentals even need to be communicated or that the research needs to be done to solidify it. And I think it falls down to that educational level and actually implementing it. So making sure, so at a physician level, being able to discuss these important things with your patients, because oftentimes how patients view an interaction with their physician is,

I see the doctor, I get my medication adjusted, I leave, I follow up. And the lifestyle measure has kind of fallen out of practice as a commonplace beyond, as we mentioned before, that vague, oh, go exercise, without clear instructions. And then I think from an incentive perspective as well, too, when we're looking at research that is done or reimbursements, oftentimes how the medical model is set up now is for trials to be done on antidepressants or drugs. You're going to have that financial backing from these different companies because there's incentive for that to be done. Whereas right now, I think for a lot of the lifestyle measures, so whether it's optimizing your exercise, whether it's optimizing your diet or sleep, there's not those same incentives that exist from a superficial level.

So there's not that immediate return to someone who's going to be funding X research or different things. So I think we need to really restructure how we approach different disorders. And it comes down to how we perceive these disorders. Because this comes to one of the other things that I come up with in medicine is we often see this divide between mental and physical health. And I don't think it's useful to separate the two because then we try to treat them in isolation. And in doing so, we have approaches by saying, you know, we should just do therapy or we should just do medical. and we ignore the physical side of it, with the caveat being that the physical side directly influences that mental side as well too. And I think that's where the disconnect lies

as well too and how we're taught, how we look at mental disorders and how we even look at physical disorders where we're treating these conditions in isolation rather than looking at the unifying treatment of them both. So I think the medical model in society, we need to kind of restructure how we view these conditions so that we can see a better way to both treat. And then beyond that, be proactive and prevent. Because a lot of this discussion today has been about treating depression with exercise. But there's also a large body of literature to show that we can prevent depression with exercise. We can prevent depression with dietary measures.

We can prevent depression with sleep. So how our system is set up now is treatment. We treat what is currently happening. And it's almost like the sinking ship where there's rising levels of depression, there's rising levels of anxiety. And we're trying to develop the next best drug. to reduce those levels. But in reality, we can look at it from a different way and say, is there a way to prevent the new cases of depression and anxiety?

And oftentimes lifestyle measures, again, as I mentioned, are that fundamental aspect to treating them. So I think that was a long-winded way just to say that we need to kind of restructure how we view these mental disorders, but also how we treat and place more emphasis on prevention and being proactive. You know, one more thought experiment that I want to toss your way. There's a lot of folks that listen to this podcast that maybe they might not be a health care practitioner, but they are somebody who enjoys building businesses, they're entrepreneurial.

If somebody found themselves in that category, maybe had a personal story related to depression themselves, a family member somehow is touched by that, and was thinking about, okay, the medical system, we ask a lot of the medical system. And there are all sorts of constraints, both in Canada, which has obviously universal health care and the United States, which doesn't, there's different constraints that are there that prevent physicians from being able to do, even what they want to do, time constraints, et cetera. If there was an entrepreneurial approach to combining this idea and some of the themes of this episode today, physical activity to combat depression, and even to prevent it from happening in the first place, could you see some

sort of business that somebody could create that would leverage maybe community, accountability, coaching. What would you like to see as something that could be a potential that was created out there? Yeah. So I think that's a great question in terms of what can be done. I think there's two levels where we can look at where there could be intervention. So I've spoken about the first a lot is from the educational perspective. So I do think that there's room, whether it's a third party intervention, whether it's

directly into the curriculum to provide education. to provide educations or extra certification to physicians to be able to have these discussions with patients and feel well equipped and perhaps if there's some sort of incentive as well for physicians to want to know this so that it can become ingrained within the culture of medicine. The second is more from a supply demand issue. So lots of people perhaps want to get involved with exercise for depression. They want to have that one-to-one support. And number one, there's not that expertise to have that discussion a lot.

there's personal trainers, there's different things of that sort for more of that physical standpoint, but perhaps adapting it from the mental standpoint. There's not as many people that you can talk to compared to a therapist or more of your traditional routes. So there may be avenues for someone to develop almost a systematic approach to exercise for depression, similar to something like cognitive behavioral therapy, which is, again, it's a very systematic therapy that we do, but the same thing for depression. And with AI and all these different tools that we have available, there may be something that, again, maybe it's not as perfect as a human coach that you could have

going to these sessions with you, but perhaps having a routine made for you, having this agent that can kind of adapt to what you're doing, track depression scores and see how you're doing over time. And having that is something that you could present to your doctor and say, you know, I have this, this is what I've been doing. This is the numerical score that I have because of this. What do you think? And maybe that could be something that's commonplace and facilitate these exercise interventions at a more realistic level, because I do acknowledge that when we tell patients to exercise, and even if we're telling them to go to a gym and get a personal trainer, that's not maybe well versed from the mental health realm. Even just having a personal

trainer, some of these things can be very expensive and time consuming. So perhaps there's room to make this more accessible for more people. Again, not as perfect as having that person in front of you, but in a structured approach to engaging in this. And again, the big thing is getting that ball rolling and starting that momentum. So I think that could be two areas for intervention. Let's touch on your personal story a little bit. From my understanding, you are in your psychiatry residency. How did you get so passionate about the brain? And where did the lifestyle element as being part of the treatment protocol? Where did the passion and inspiration for that come from? Yeah. So as you mentioned right now, I'm in my psychiatry residency. And I've always been

someone that's been active throughout my life. So in my early years, I played competitive soccer, and that was my main thing, did some track here and there. However, when I got to medical school, it wasn't as feasible to have that because it was more of this time-based thing. I didn't have as much time that I can allocate to these things. I needed to do something where I had more freedom that I could exercise in my own time. So I started picking up weight training more. And something funny happened, actually. I was in my first year of medical school, I was arm wrestling someone, and I broke my humorous. And I'll show you the scar here. Oh, wow.

It's massive. Those that are listening, that's a massive score. Yeah. So I broke my dominant arm. I needed to have a plate with screws placed in there. And in that moment, I think I realized how important my physical help was for my mental health because my whole life I took for granted being able to go to soccer practice, to go to these tournaments, to be able to run, be able to sprint.

And now I was just getting into the gym, having a lot of fun with it. My mood was great. and then I went to just break my dominant arm. And I was like, wow, I can't do the things that I want to enjoy now. Like, I can't even really go for a run because I was in the sling. I just had a surgery. And there were weeks and months where I was almost not completely immobile, but I wasn't doing the things that I liked.

And I saw the direct impacts that that had in my life. And that was probably one of the lower parts of my life. And after that, I had this newfound motivation where the second I was out of my, my sling and my cast, I was doing my physiotherapy. They told me it was going to take 12 weeks. and I wouldn't regain full range of motion of my arm, but I said no to that. And I essentially held a 30-pound weight as I was studying

just to straighten my arm the whole time. And I regained full range of motion. And from there, I had this newfound motivation where I was just getting back into things. I wanted to succeed from that front. And I found the immediate switch from being in this state of, again, it was never formally diagnosed with depression or started on a medication.

But I was, you know, in retrospect, looking at it, it was not a good time. to do a complete 180, which parallel with the benefits to my physical health, I really saw those changes. And from there, I continue to adapt different things like my diet and then focusing more on my own sleeping patterns as much as you can within residency. And I saw those benefits and even things like creatine. And having that as a supplement, a lot of my research that I'm doing now stems from my own experiences with different things that I've had. So whether it be exercise, the injury, the creatine, all these things I've noticed benefits.

in myself, but I wanted to quantify it and see how it could be applied elsewhere. So, yeah, and then from there, I've continued to do that, and I've continued to adapt different regimens from what I'm reading and different things of that sort. So it really stemmed from my lifelong pattern of being active, that being disrupted from my broken arm, and then getting back and but noticing those stark contrasts in those periods of time. You know, it reminds me a little bit about this German physicist, Max Planck. Are you familiar at all? Yeah, I think so. Yeah, yeah. He was a Nobel Prize winner. I don't know too much about his life, his work, everything, but there are some very famous quotes that he has. And one of his quotes that he has is that,

paraphrasing here, advances in science, and obviously we can include this to medicine as well, advances in science and medicine, they don't happen when the old guard wakes up one day and says, oh, we've been doing it all incorrectly. It happens one funeral at a time, which is a crude way of saying that when the old guard that was doing things one way dies off and the new young group that's been doing things a different way and is more open-minded, that's when things end up being advances. And your journey really reminds me of this growing group of physicians who now, have really grown up through eating healthy, training regularly. They have a personal interest.

So naturally, they're going to bring that into their work where a lot of my friends and family who are physicians, but might be in their 50s, 60s and older, it wasn't super common for people back then to be working out on a regular basis in a way that was mindfully related to improving their mental health. now hopefully through people listening to podcast and following accounts like yours on on x and other places or even listening to this podcast we have a new group of people that are this is just like normal and so now that's being brought into every line of work that people are up to so i appreciate you sharing a little bit about your uh about your uh about your story and that was gnarly about uh your your arm so that

i've never heard of somebody uh breaking their humor in a in a armlessing contest the person that you were arm wrestling against, they must have done some real damage there. They did some real damage. That's probably the biggest victory you can have in an arm wrestling competition. And it was funny, he had a lot of popularity in the class after for the arm, right?

Brutal, brutal. Nicholas, this has been fantastic. Anything else that you want to share with our audience? And if not, what's the best ways for them to keep in touch with you and your ongoing work in the space? Yeah, I think the last message that I'll leave is with exercise, just framing it as both

that preventative and treatment aspect. And for people wanting to get into it, anything really counts. Don't let these numbers be off putting and you have to hit this threshold or compare yourself to another person in your life because that's easy to demotivate yourself. I think if you have that motivation

to just even go for a walk or do these little things, that will take you so much further and you'll notice that momentum build. So that's kind of the last piece that I wanted to add there. But for people that are interested in hearing more about myself or some of the work that I do, the place that I'm most active is probably on X or Twitter.

There I either post my own research, stuff about exercise, or I try to summarize usually one scientific paper a day, and I usually do that in the form of threads. So my Twitter is at NT Fabiano. But yeah, thank you again for having me. It was a pleasure to have a chat.

I look forward to future discussions. Absolutely. There's so much stuff that you've written about that I know may not be your main area of expertise, but I'm like, oh my God, I wish I could talk to him about this. You posted a study that will link to that was showing that pregnant mothers that had the highest levels of bisphenol and thalates in their blood system had a much higher degree, again,

associative study of having a child on the autism spectrum. And I just thought that is nuts, especially with the world waking up to the impact of pfas, microplastics, that's something that everybody should be knowing about. So there's just one of probably 50 things that you've tweeted that I thought,

man, I need to talk to this guy about this. But I appreciate you at least coming on to talk about your main expertise, which is depression and physical activity. I thought you gave a great breakdown of your paper and provide a lot of inspiration for those who are listening that even if they're not struggling

with depression themselves, we all know somebody who is. And if we can be somebody that lowers that barrier of entry through many of the things that we've learned about on today's episode and creates an inclusive place where people can start working out or being more physically active with us in whatever way, the gym pickleball, you could make a massive difference in somebody's life just through that small intervention alone. So thank you for that reminder, Nicholas. It's been a pleasure to have you on the podcast. Likewise. Thank you for having me.