Psychiatry & Psychotherapy Podcast - Exercise as a Prescription for Depression, Anxiety, Chronic Stress (like Diabetes) and Sensorium

Episode Date: March 23, 2018

Western society faces is the most unhealthy we've ever been. It's reached epidemic proportions: depression, anxiety, poor focus and sensorium issues, chronic stress, and diseases of chronic stress (like diabetes). The solution is simple—exercise and healthy eating. In this episode, I will be going through 17 studies on how exercise influences and improves these factors. I will cover how it works, and how to develop an exercise program from the perspective of a doctor, not just for body sculpting.   Some things I am covering: Strength training decreases depression Strength training increases cognitive function Fitness decreases risk of dementia Exercise increases BDNF Strength training and exercise in treatment for diabetes By listening to this episode, you can earn 0.5 Psychiatry CME Credits. Link to blog. Link to YouTube video. For PDF with citations: https://psychiatrypodcast.com/my-resources Post questions and comments on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Starting Strength Online Coaching

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Welcome back to the Psychiatry and Psychotherapy Podcast. And today I am going to go into a topic of prescribing exercise for depression, anxiety, chronic stress, and diseases of chronic stress like diabetes, hypertension, heart disease, chronic pain. And the list goes on.

And the problem that we face in our culture is we have chronic stress. We are constantly on the go. and this leads to all sorts of issues. And what I mean by that is people are not dying of infections anymore. Your uncle and your parents probably did not die of Lyme disease. They did not die of, you know, leprosy. They didn't die of, you know, some infection. What they probably died of was something like heart disease, hypertension, cardiac disease,

something like this is a disease of chronic stress. And the chronic stress systems go on and they go on and they lead to a breakdown of usually one organ to start with. And then subsequently it keeps going as we medicate the first organ. And I think depression, anxiety, fatigue. Previously, I talked about issues of sensorium. and this is very, very important to understanding some of the things that we face. So in this article, I am going to go through 17 studies, some briefly, some more time. I will put this all on my website if you follow the link to Psychiatrypodcast.com,

and you can download the PDF from there. And what I'm going to go through is these 17 studies, I'm going to go through. I'm going to go through some of my knowledge from my experience, and I am going to point towards what you can do to start out if you are completely exercise naive. Like you have an absolutely no exercise consistent plan. And I'm going to move away from exercise and call it training as well, because I think exercise is often associated with, you know,

you go to the gym and you do the same thing every time and you do it for a couple years and you get hot and sweaty and you try to get sore and and that's exercise and and i think training might be a better word uh because training would denote that you have a plan that you're slowly getting better and that you're causing sequential stresses to your body um stresses that cause a adaptation Now, for that to occur, you need the stress to be big enough, and you need to allow for a recovery. Recovery is, you know, eating the right food, getting enough sleep, and having enough time between exercises that allows for the stress to recover to the point of adapting. and if you are an 80-year-old man or a 20-year-old man or a, you know, 14-year-old adolescent, this applies to you all the same.

Studies have shown that no matter where you are in life, you can actually gain strength and you can gain cardiovascular endurance, you know, irregardless of where you're starting from, I think that there's something here that you can benefit from. So the first thing I'm going to do is I'm going to lay out some of the arguments I have for the, you know, what does it say in the literature, the scientific literature on the efficacy of exercise and different mental health and physical issues that people can have? in future episodes, I may go into one particular issue and really dive in and talk about that particular issue. But I'm going to leave this broad on purpose because this is the first episode that I'm doing on exercise. And this is something that I have a particular passion about.

I was a football player, rower in high school. In college, I did rowing at Cal Berkeley. We were one of the top three teams every year in the nation. And I had some of the best best coaches in the nation. And I don't say that lightly. I mean, the coach that I had, Jeff Bond, Steve Gladstone, these guys are still doing amazing, amazing work. And so I have a unique experience there,

but I also have the experience as now, someone who's come back to this as a physician, as a psychiatrist, and someone who's, prescribed exercise to my patients for years. And, you know, at first it was, I would prescribe it, and then no one would do anything. And so I'm slowly seeing that I can, you know, with the right coaching and with the right coaching as in, you know, aligning them with their ideals and also helping them get through maybe some of their initial struggles with medication. But

then eventually moving more into a lifestyle type of approach for long-term psychological and physical health. So strength training can improve cognitive function and depression. I did write a long blog on this in the past. I'll put the link of that in my website as well. And strength can keep up Sensorium, so Sensorium, the fluctuations of mental status, the total brain function, strength can keep that up in the face of unplanned medical issues. So let's say, you know, you ended up in an ICU and an intensive care unit at some point in your life. People who have muscle weakness had overall worse survival outcomes in one.

of these places. Specifically, if they had worse hand grip strength, it predicted worse outcomes and people with hip fractures. And if people had sarcopenia, which is a low muscle mass, an increased risk of developing delirium in one large study of 588 hospitalized elderly patients. So specifically delirium is, you know, the waxing and waning sensorium issue that is very severe. And these people are pulling out their lines. They're confused. They're hallucinating. They're, you know, they've literally lost their mind.

Family and friends are watching this sometimes. And they just don't know what to think of this. You know, this is someone who previously was functional and could talk and relate. and now they're, you know, talking gibberish and they look psychotic. And this can happen to people as they have a combination of multiple medical issues or one medical issue even sometimes. And if they're elderly, especially if they have dementia, I talk about it in Sensorium, episode number one in more detail.

So in this one study, they found that people with low muscle mass had increased risk of developing delirium. they found that, you know, in one way to say this is that strength makes people harder to kill. So if you have a muscle, it is kind of like your 401K. And 401K is kind of like, you know, your retirement account that you have to put money into and that at some point in the future you're going to cash out, both from a psychological benefit and a physical benefit. So in one study, they did once or twice weekly resistance training over 12 months, and it improved

executive function, selective attention, and even conflict resolution, whereas balance and tone training had deteriorating effects. And so strength training, once or twice weekly, that's all it took, improved executive of function, you know, the ability to plan, to orchestrate your life, to focus, to concentrate, and it also improved conflict resolution. And one of the reasons might be is because when you have a good exercise routine, you're physiologically going to be less reactive. You're at baseline going to be able to handle the smaller stresses of life and conflicts between your spouse or significant and other, those are stresses just like anything else.

But when you have a physical training program, then what happens is the stresses of life are not experienced in your physiological body in the same way. They're experienced less strongly because you've had stresses sequentially that are physically. And it will help you with the psychological stresses that as well. So in another study, they had just 10 weeks of supervised progressive resistance training three times a week, and it showed improvement in depression, as well as improvement in bodily pain,

as in like a decreased bodily pain, increased vitality and increased social functioning. So once again, they found that just in 10 weeks they were able to get an effect that was pretty strong. It was also shown to decrease limitations on routine activities from emotional problems. So the emotional problems can limit us and what we do. And by doing this strength training, resistance training, they had the ability to have less limits to what they were doing on a daily activity. In a study looking at high and low intensity of progressive resistance training in adults greater than 60 years old.

So they took, actually it was three groups of 60-year-old adults. And in one group, they had a high-intensity progressive resistance training. In one group, they had a low intensity resistance training. And in one group, they didn't do anything. And they found that there was a decrease in depressive symptoms more significantly in the high-intensity group. and the high intensity group was, you know, doing three sets of eight reps at 80% of their one rep max, whereas the low intensity group was doing 20% of their one rep max. You know, the depression scale assessed sleep, feelings of guilt, mood, anxiety, slowness of thought,

speech and action. And they found that the high intensity group had the largest decrease in these symptoms. the sleep quality improved greatest in the high-intensity group. Another finding was that there was an associated link between changes in depressive symptoms and gain in muscle strength. That was really interesting to me. So even in the group of the high-intensity group, the people who had the largest strength gains had the largest reduction in depressive symptoms. And the correlation was, I think, around 0.4,

which means, you know, it's not a complete correlation, like it's not like a complete, you know, if this happens, then this happens, but it's still a significant correlation. And so there's, there's a value in gaining strength and the program should be assessed, you know, on is this program helping this person gain strength? So exercise in general, you know, the value of exercise in general. So exercise as in, you know, cardiovascular exercise also has been shown to decrease depressive symptoms. And one study looked at a group of people, groups of people that were followed in 15 studies.

and they found that the high level of physical activity had a 38% lower cognitive decline, and that's pretty impressive. One very recent study, which was of 1,462 women over 44 years, this was just published March 2018, so this is very recent. and they follow these women, you know, over 44 years. And these women early on had done a cycling machine, you know, they got on a bike that measured how much power they could put out and they were, you know, put into groups. They were put into a, you know, low level of fitness group, medium level fitness group

or in a high level fitness group, depending on how they could do on this bike. and the high fitness group had a 88% lower risk of developing dementia compared to those with a medium level of fitness. 88% just compared to the medium level of fitness. And the low level fitness had, you know, an increased risk. If I remember right, it was about 40% of. more increased risk than the medium level of fitness. And those in the high fitness group that did develop dementia, so there was, I think, about 5% in the high fitness group that had developed dementia.

They had a delayed onset by 9.5 years compared with those in the low fitness level. So that, this study was very impressive. Number one, it was over 44 years. and it showed that the high fitness group had both the lowest level of future dementia, and it also had the furthest delay in the onset of dementia. And that's really impressive. So what does exercise actually do? Exercise changes our genes.

And how it does that is not through, you know, the one set of genes that we get from our mother and our father, that it doesn't change those genes, but it upregulates and down regulates different things in the body. And I would say in the way that we were made, like we were not made to sit on our couches and to not move. And, you know, we were made to move around the world and to move around our environment.

And so when we exercise, it's like our genes, open up in some areas and close in other areas. And this is called epigenetics. And one change that occurs is brain-derived neurotrophic factor increases. And this increases brain plasticity, brain plasticity, meaning the ability of the brain to actually change. It increases this. and in the previous podcast on exercise, I talked about how good diet could increase brain plasticity.

Exercises is another one of those things. And I also say that antidepressants actually can increase brain-drive neurotrophic factor, and ECT can increase brain-derived neurotrophic factors. So a lot of the treatments that we give for depression increase brain-derived neurotrophic factor. One way that you can get it naturally is through good diet, through good exercise. And we know that also there's other epigenetic phenomena phenomena that occur. And Dean Ornish did a really amazing study on exercise and lifestyle change, exercise, diet. And it wasn't just like 10 genes that

changed. It was thousands. So there's literally thousands of things that get upregulated and downregulated from a healthy lifestyle. Another one of those is uncoupling protein two, which is important for learning and memory. So all of these things go together and they increase executive function. So your ability to increase your ability to schedule, plan, monitor, task coordination. They increase neuroadaptive functions like the ability of the brain to adapt to new challenges. they are also neuroprotective, meaning that they, you know, can help you overcome things that are coming at you that could be damaging. Further, it counteracts the effects of stress, both future stresses

and present stresses. So by decreasing future stresses, we will decrease our learned helplessness when subjected to overwhelming stress. And, you know, if I were to force a rat to exercise, it actually doesn't increase brain-derived neurotrophic factor. It actually decreases it. So I cannot force anyone to do this. Like, you have to, in your mind, decide that exercise is going to be something that's a part of your life, that you're going to create some margin in your life

because it's so important. And out of that margin, you know, And really, all you really need is like three days a week of exercise to have a good, and have a good plan and move forward like that. So exercise in the elderly is associated with, you know, increased executive functioning, increased processing speed, you know, exercise in one study reduced the risk of cancer occurrence, progression, and mortality. exercise in another study comparing zoloft to you know which is an antidepressant to exercise in a

group of you know moderately depressed individuals showed that exercise in zoloft both improved outcomes and it was about the same there was no statistical significant difference between the two groups this was a nice study that was done at duke and it showed that you know group exercise three times a week can reduce depressive symptoms. You know, when I think about exercise in chronic stress, I think about one of the main diseases of chronic stress is diabetes. And one study where they looked at strength training, specifically, and type 2 diabetes, they had these diabetic patients train one of their two legs.

So they only allowed the diabetes patients over the course. course of six weeks to work out basically one leg, you know, on one side. So they like chose the right leg and they would work out this leg three times a week for about a half an hour. And then they did these studies where they like clamped off blood flow on both legs. They did biopsies of, you know, both the people who did this exercise routine on their their leg and the control group that didn't have diabetes. So they compared all these different groups of people. And they found that the trained leg had better blood flow, increased leg glucose clearance, which was larger than just the increase in muscle.

And, you know, because if you just increased muscle, you would say, well, you have more muscle, you can, you know, clear more glucose, but it was, it was more than that. They had increased glute four, insulin receptor protein kinase, B was increased. and they had a change in their glycogen synthase and GS total activity. All that to say is that strength training enhanced insulin action in skeletal muscles. So insulin actually worked better in these skeletal muscles. Insulin is what drives glucose into the muscles, and insulin is what we give to diabetes patients.

So, you know, one study that compares strength training with endurance training on diabetic patients found that in the group that was strength training, they had a reduction in the hemoglobin A1C. You know, a reduction that was significant. It was a drop from 8.3 to 7.1 just with the sort of bringing in the strength training. And that's a pretty significant drop. you know, that could be the difference between out of control or more in-control diabetes. And, you know, so hemoglobin A1C, it looks at the glucose that's sort of floating around in the blood and sticking to, you know, blood cells over the course of three months.

So, you know, blood cells last about three months and the, if you have a lot of increased sugar in your blood, then that'll kind of kick on to those, you know, floating around blood cells. So basically it's the difference between having, you know, a nice old-fashioned donut, you know, that would be a healthy donut if donuts could be healthy. And so you have this old-fashioned donut, which doesn't have any sugar on the outside or sugar-coating compared to like a donut with a sugar coating. you know, that would be a high hemoglobin A1C. And so in the strength training group, not the, not the cardio group actually,

not the just the, you know, like jogging or, you know, the cardiovascular exercise group, that group didn't show a decrease. It was the strength training group that showed the decrease. And there was a decrease in blood glucose from 204 to 147. There was a decrease in total cholesterol from 207 to 183. There was a decrease in LDL from 120 to 106 and triglycerides from 229 to 150 to 125. All that to say is that the strength training group, not the cardio group, had the reduction on all of these things. So that leads me to where do I recommend that you get started?

I am a believer in strength training. I'm also a believer in cardio. I think that you can start with the strength training because you really don't want too much of a stress. You just want the right amount of stress to cause an adaptation. So when I wanted to get back in shape a year ago, I started something called starting strength. And I will put a link of this stuff

on my website if you follow it from this podcast. And the starting strength model, you can learn on your own. There are people who just get the book and watch YouTube videos. I'll put some links to those things. And basically you do three sets of five of the big exercises, squat, deadlift, bench, and press. So all these studies on strength training, it wasn't just upper body bros. You know, you see a lot of guys. going to the gym and they're doing their bicep curls and they're doing their bench and,

you know, maybe a couple other upper body stuff, but they, but they don't do legs. Like you need to get the full benefit, you need to do your biggest muscle groups, which is, you know, the squat and the deadlift. And so in this program, you do squat three times a week, three sets of five. you do deadlift starting out three times a week you know one set of five and you do bench alternating with press three sets of five and the technique is really really important to get right um i actually went to a conference where i where i had my technique critiqued i've uh i've worked with coaches um and if you're considering you know looking up like where coaches might be located compared to where you live.

I'll put a link on that on my website as well. There's also a starting strength online coaching. And if you use the discount code courage, then you can get a really nice discount on your first month. I'll put a link to that in my show notes on my website as well. And the benefit of an online coach can be, they can look at your, you know, squat form, your deadlift form, your bench and your press. They can tell you exactly what you're doing the following week.

There's a good app that they can sort of look at your different movements and give you critique, and slowly you can have the right form. You know, it's interesting as I talk to people about this, and I prescribe this to multiple patients, and there have been some that have followed through. some some haven't and some have gone the way of you know physical therapy and they're doing like band exercises and isolated movements and i really believe in the compound movement the natural movement the way that the body was intended to move and i think that the starting strength model really hits the nail on the head in this capacity so when i started this out for example i was squatting 95 pounds, three sets of five.

I was deadlifting like 135. And within three months, my squat was up to, you know, 300, three sets of five. My deadlift was up in the 300s. Since then, I've added on a little bit of cardio on my rowing machine. And I, you know, since I used to row a cow, I rowing is something that for me is really great cardiovascular training. So I train a couple people out of my garage gym three days a week, friends, colleagues, people that want to learn how to do this. And at this point, I don't charge anything. These are just people that have sort of seen the results that I've had and asked me to help them out.

And I have a nice little community of people that, you know, and the value of the community for me is really nice. and as you progress in this, you move from being able to adapt three times a week to being able to adapt once a week. And that's going from like a novice to an intermediate level. And eventually you may go from being able to adapt once a week to maybe once every two weeks or a month. And that would be more of like the advanced. So everyone starts out as a novice in this sort of way of approaching.

strength gains. And you're a novice because you can make gains from Monday to Wednesday to Friday when you squat. You can add five pounds to your bar each time. And a lot of people don't realize that you can do that. If you're eating right, if you're sleeping right, you can keep adding weight to the bar. And your muscle, because you have so many muscle groups that are sort of coordinating a squat or a deadlift, you can add that weight and sequentially get stronger. You know, adding for a squat, if you're adding five pounds, if you're adding it three times a week, that's literally up 60 pounds per month jump. So it's not about where you start out from.

You want to start out. You want to get the correct technique with the people that I train. Specifically, you know, I slow them down sometimes when I see the technique is changing. that's why there is a benefit of having a coach or someone who can sort of help you with this. And with the deadlift, you can literally make jumps of 10 pounds starting out. The bench and the press, you can make jumps of 5 pounds. But eventually, because the muscle groups tend to be smaller in your upper body, you may need to drop it to like 2.5 pound increases, or even less than that.

can women do this? Absolutely. And there are some really amazing success stories of women who do this and they get super strong, even stronger than men. And for a lot of my patients who have had, you know, precarious situations in life where maybe they felt threatened by men, having, you know, a good amount of strength can really make you feel a lot more safe. So in this model of starting strength, you do the squat, you do the deadlift, you do the bench, and you do the press. And that's what you do starting out for maybe the first couple months. So that's one paradigm. And I'll put the link to different resources to get you started on that, if that's something

you're interested in, that you can do to get strong fast. And I don't know any other program. After all of my years of strength training and doing sports at a high level where you can get stronger faster than starting strength if you're if you're a novice if you're starting out or even if you've been doing it for a while like let's say you've been going to the gym for a couple years and you feel stuck you know that would be a good paradigm for you to sort of launch out so one other thing I'll say is that let's say you don't have access to a gym right now you're you're going to be reading about this you're going to be learning about it but you want to start somewhere what do you

you start. If you just simply want to do cardio and you're totally novice, naive to this, one thing you can do is you can go, you can go out, you can go for a walk, and then maybe every three minutes, you jog for one minute, and then you walk for three minutes, and then you jog for one minute and you, you know, walk for three minutes, and that's how you start out. And then maybe after a month of doing it, you move from, you know, jogging for one minute, walking three minutes to, you know, jogging for two minutes, walking for two minutes. So there are different ways that you can set up your stresses to be sequential, where the stress is increasing a little bit, and your body is adapting to the stress. So once you understand the paradigm of stress,

recovery, adaptation, and that what you're doing in exercise or training is you're applying a stress to your body, and you want your body to recover and adapt. Now, there are some models of training, like CrossFit, for example, where they almost apply too much stress. So if you're completely naive and you go in and you do this huge workout and you get totally destroyed, you could literally spend a week in recovery and just completely in debt. And it doesn't necessarily cause the adaptation that you want. So there's almost like a sweet point. And if you're doing whatever you're doing to consider like, okay, am I recovering from

this stress? Am I recovering to a point that I am able to adapt? And how long is it taking me to recover? And there's kind of an optimum place where, you know, 24 hours, 48 hours, as a novice, you should be able to recover and adapt. Now, if you get, as you get older, the recovery may take a little bit longer. So instead of 24 hours, it may take, you know, 48 to 72 hours at first. So even, you know, strength training two days a week for someone who's a little bit older,

and by older I mean, you know, in 60, 70 years old. And you may wonder, like, can someone who's older like that have at a lot, adaptations and get stronger? Absolutely. I once heard this, the biggest myth from one of my friends that you could only get stronger into your 30s and then you're basically stuck. And so he was like, I'm going to get stronger. And that's just not proven to be the case once you're in like, you know, a community that shows that there are people who are older that can get really strong. So that is my basic talk on how to optimize exercise. And I will put all of these notes. in my website, you can post a question on one of my social media sites. And if this was helpful for you, I would ask that you please share it with a friend, get the word out. This is so important as we combat the diseases of chronic stress that are in our society, the issues of obesity, the issues of, you know, depression, anxiety, you know, and the disease of chronic stress. You know, and the disease of chronic stress with chronic pain, chronic diabetes, hypertension, heart disease.

We really have to think through ways of treating this, and hopefully this can be one hammer in the way that you can overcome it or help someone else overcome their issues. And I'd really, yeah, so I'd really love to hear from you, if post something up on your social media that you took something away from this, that's very encouraging to me. if you share it, that's very encouraging to me. If you leave a review in iTunes, that's very encouraging to me. All right, I'm going to leave it there. Have a great day.