The Food Medic - S1 E2 - Exercise is medicine: Mental health and physical activity

Episode Date: June 18, 2018

This week Hazel chats to Brendon Stubbs, a research physiotherapist specialising in physical activity and mental health. We discuss how exercise can treat and prevent depression, how food affects our mood, and if chocolate really can improve our health. You can find Brendon on twitter @brendonstubbs Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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exclusions, and terms apply. Instacart, groceries that over-deliver. Hello, and welcome to the Food Medic podcast. I'm Dr. Hazel Wallace, founder of The Food Medic. I'm a qualified doctor, personal trainer, blogger, and best-selling author of the books The Food Medic and The Food Medic for Life. I'm passionate about maximising our health through how we live our lives, including the food that we eat, physical activity and stress management. We will hear from leading experts in their field who will be sharing evidence-based advice on how we can live healthier lives. And we will cut through the confusing information that we find online.

I like to think of myself as one of the first of a new generation of doctors. Hello and welcome back to the Food Medic podcast. I'm Dr. Hazel Wallace and today I'm going to be discussing mental health, exercise and diet with today's guest, Brendan Stubbs. Welcome, Brendan. Brendan is Head of Physiotherapy at a large mental health trust and is a clinical lecturer at the Institute of Psychiatry, Psychology and Neuroscience, King's College London. His research focuses on how physical activity can improve mental health and how keeping a healthy body keeps the mind healthy and vice versa and how lifestyle contributes to healthy aging. Brendan has published over 350 academic papers and has recently co-authored a book detailing the evidence for the use of

physical activity to improve mental health and many mental illnesses. Wow, that's so impressive. Welcome to the podcast, Brendan. Thank you so much for inviting me, Hazel. I'm so excited to speak to you today because on a personal and professional level, I'm so interested on the benefits of physical activity on not just our physical health but our mental health and I feel like we're only touching the surface on what we know already. Absolutely it's a it's a really exciting time to be in a particular field because you know like you know yourself and probably many of the listeners is when I engage in exercise I feel pretty good about myself and we've we've

known that anecdotal sort of personal feelings for quite some time but we're really starting to get the evidence together now to really put some robust science behind just how beneficial exercise can be for our mental health. Amazing and you are absolutely forefront of this research so what I would love to discuss before we kind of jump into everything is if you could just share your story on how you as a physiotherapist got into researching mental health. So it's a culmination of a few accidents, really, and I'm glad they happened. I started working in mental health after I qualified as a physio. I fully intended on not doing very much for the summer, but my mum worked in a local mental health hospital and just said, said Brendan why don't you go in and talk to the head of physiotherapy and just have a chat so I just thought I'd go in and have a chat just keep my mum quiet over the summer really and before

I knew it I was having a job interview and working at a mental health hospital and I absolutely loved it and I was really fascinated by the the interplay between the mind and the body and just what a powerful impact physiotherapy could have in that particular environment where people were primarily getting help for their mental health condition. And then I quickly realised I didn't know exactly what I was doing and if I was doing it right. So I thought I'd better go and try and find some evidence

to sort of guide me to make sure that I'm doing things right. And I was quickly alarmed that it wasn't very good evidence for physiotherapy or particularly robust evidence for exercise in mental health at that particular time. So after being initially quite alarmed, I thought, perhaps I can do something about this and then started a long and a slow journey to understanding how to do research and particularly evidence why physiotherapy is good for mental health and particularly physical activity for mental health as well. Yeah and now you split your time between clinical work and research is that correct?

Yeah that's absolutely correct so it's a wonderful wonderful job and a really great mix so I manage a team of physiotherapists in a large mental health hospital in South London and then I also do a weekly clinic for men and women who are in secure care with severe and enduring mental health problems so I'll typically see 14 to 16 patients over the course of the day and that's typically people who have perhaps schizophrenia, bipolar disorder or personality disorder and they're in a secure environment so they can engage in rehabilitation for their mental health but often these people have a lot of physical health problems as well because it's quite a confined environment so it's

a real good role for physiotherapy within that particular setting as well. You touched on it at the beginning we all know that feeling after we've come back from a run or something and we feel absolutely on top of the world what they call runner's high but we know that that feeling is actually real and that even though it does feel fleeting it does lend itself to benefits in the long term so I'd love if you could tell us a little bit about how exercise actually benefits the mind yeah so there's a number of different mechanisms which we're still trying to understand in more detail and with really robust evidence going forwards you alluded to the runner's high and you know i've experienced that as well and and more and more we believe in

this is due to stimulation of like opioid or endocannabinoid receptors within the brain which really gives you that sense of of euphoria after you've engaged in exercise and that immediate pleasure once you've engaged in any type of physical activity as well. So that's one of the mechanisms through which it may help. There's also evidence around how it can reduce stress, particularly cortisol, one of the chemicals which is related to stress is good evidence that exercise can help reduce this stress marker within our body and that can contribute to feelings of good afterwards there's a number of other mechanisms also which can really contribute to that as well so there's emerging evidence just how inflammation may precede the onset of various mental health

conditions as well and exercise is a really potent anti-inflammatory so it may really act to reduce inflammation and a state of arousal within the body but as with any of these things there's a number of different mechanisms and clearly psychological mechanisms you feel naturally good about yourself once you've engaged in exercise you have that feelings of pleasure and satisfaction so that all contributes to that good feeling after we've engaged in some exercise. Yeah that good self-esteem. We were discussing depression and mental health before but does this apply to all mental health conditions? Exercise is beneficial. Yes it is really robust evidence for lots of different mental health conditions and I can just talk about some of those with with you now. Within anxiety and stress-related disorders there's good evidence that aerobic exercise in particular

can reduce symptoms of anxiety and people with anxiety and stress-related disorders as well including like general anxiety disorder and also we've looked at post-traumatic stress disorder as well which is you know really good evidence that aerobic exercise and also yoga can reduce symptoms for people with post-traumatic stress disorder. And if we look at other mental health conditions, such as schizophrenia, there's really good evidence that aerobic exercise and also muscular exercise, such as resistance training, can reduce some of the mental health symptoms, but also improve physical health and also cognitive health, which is often common across many of the mental health conditions as well.

You touched on it already, but what I was going to ask you is what is the best type of exercise for mental health? Is it a bit of both aerobic and getting your heart rate up and then a little bit of weights or is there one in particular that comes on top yeah so i think the exercise around aerobic exercise is the best established in terms of evidence and larger studies which have been done so there's really good evidence that aerobic exercise particularly 90 minutes or more over the course of a week for 12 or 14 weeks can improve mental health symptoms across lots of those different conditions as well but there's an emerging evidence base which is really exciting about the role of resistance training yeah um for treating um as an adjunct to depression symptoms and also anxiety as well but the key thing with

any of this is if you do have a mental health condition is finding something which you enjoy because if you enjoy it and you're able to do it and you feel good when you do it then you're more likely to do it in the longer term and that's probably just as important as any particular mechanism absolutely and i think anecdotally i find resistance training and going to the gym very relaxing because it's so methodical and i'm i'm there i'm doing something for myself i'm very mindful in the moment. Whereas if I was asked to go on a 5K run, I can imagine all the thoughts would be running around in my head. But it's different for everyone, right? Absolutely.

The key thing within any of this, if you're looking at physical health benefits and mental health benefits, is find something you enjoy and continue with it. And that's not only the mode of exercise, but also where you enjoy doing it, finding an environment that you feel comfortable, whether that be a gym or doing a class with some friends or perhaps playing a sport that's some of the key things yeah in terms of time you mentioned 90 minutes per week kind of produced benefits in it in that population and recently you and I had that discussion around

the hunt study and how one hour of exercise a week can prevent 12% of future cases of depression, which I find is an incredible statistic. So even like one hour a week, I mean, that's something we can all do. Absolutely, it is something which we can all do. And it's really, really exciting in terms of these robust studies, including the Hunt study,

which has demonstrated that, you know, just small amounts of exercise, whether that be 10 minutes minutes a day just going for a brisk walk just something to get in going can really help build up your resilience and protect against the development of depression and i know we had initial conversation about one of our papers recently which looked at all of the literature and we looked at 49 studies specifically between physical activity and the future risk of getting depression. And we looked at over 260,000 people all over the world. And over seven and a half years, we found that physical activity consistently protected against the risk of depression in the future, even when you considered other factors which are important, such as body mass index or smoking as well but the most potent

effect to protect against the development of depression in the worldwide literature was 150 minutes a week which is government guidelines yeah yeah and i think that sounds like a lot when we say 150 minutes and kind of put it out there but for me i find if we break it down into you know five days a week that that's 30 minutes. And that could be a brisk walk home, right, from work or a yoga class. Absolutely. Any type of movement is, you know, conceptually within physical activity is defined by any bodily movement. So moving at a brisk pace, whether that be walking or taking the stairs, these all add up and accumulate the amount of time which we're engaging activity and can improve our physical and also our mental health yeah i last week was

it last week was mental health awareness week yeah and i was speaking about it on instagram and someone quite rightly said well you know when i'm feeling very low i find it very difficult to actually exercise and what they were asking was what can I do if I'm feeling very low in mood and I don't feel like going and to the gym or exercising what advice can we give to those people? Yeah that's a really important point and that applies to all of us regardless if we do or don't have a mental health condition motivation can be particularly challenging for us to engage in physical activity or exercise but for people who are particularly low and that is one of the core symptoms of depression, which gives you lethargy, makes it difficult to get up and going, then what the evidence suggests is that adding a

motivational component, perhaps doing it in a group and being supervised by a recognized exercise professional can help increase adherence to exercise over the longer term. So one of the other pieces of literature which we looked at was around 40 randomized controlled trials and looked at what influences people with depression engaging or stopping in exercise over the course of time. And we did find that motivational components were a key factor and also people who were educated to a bachelor's or higher within an exercise recognized professional predicted less dropouts so whether that be exercise physiologists or physiotherapists yeah it was really key to helping people getting up and going and also

engaging in the longer term i completely agree with you and i think when you are held accountable by you know a trainer you're less likely to kind of slide out early. But the difficult thing is so many people don't have the access to a physiotherapist or even a personal trainer if they can't afford it. Is there any evidence around using apps or journals? Because I'm a big believer that apps, journals, even watches that track your step count can be quite useful for certain individuals when it comes to staying motivated. Would you agree or is there any evidence on this?

There is emerging evidence that encouraging people to track their own physical activity, whether that be diaries or watches or apps, can help people to stay motivated to engaging in physical activities. There is emerging evidence within depression of several mental health conditions. And one of the interventions which we're developing and going forward is helping people

with severe mental health conditions in the community with schizophrenia, bipolar disorder, or major depression. And we're giving people mobile devices to monitor their activity. And then they're meeting a health coach every other week to talk about the barriers and facilitators to physical activity and we found that that can actually reduce people's sedentary behavior time and increase people's activity so that can be really beneficial for people also. Wow I think we should have this available for most people in the community it sounds like I can see this rolled out for so many different conditions from you know high blood pressure type 2 diabetes people at risk of heart disease and not just depression and mental health disorders. Kauai and just as

you mentioned there that you know talking about cardiovascular disease diabetes and heart disease we've also done previous research which has demonstrated that people with mental health conditions have really higher levels of increased blood pressure increased heart disease and are more likely to die from cardiovascular disease as well so this is a group who could benefits from also the physical health benefits of exercise as well yeah absolutely so it's just i mean i come back to it time and time again exercise really is that like one pill that can you know there's nothing that we have no medicine in the world that can help prevent all of these diseases from mental health to physical health and also act as a treatment. And we

discussed how being physically inactive can increase your risk of mental health disorders, in particular depression. Are there any self-care practices that we can do at home to reduce our risk of depression? And if we feeling lower mood kind of help alleviate some of those symptoms yeah well physical activity and being active is one which we've discussed quite a bit already we've also looked at all of the evidence to say what are the robust environmental or non-genetic risk factors yeah for depression within that and we looked at over 130 meta-analyses or pooled data. And what we were able to demonstrate within that is being obese was a convincing risk factor for developing depression in the future. Having metabolic or diabetes-related factors is a key

risk factor as well. And also relationship issues is a key risk factor as well. So drawing on the evidence and maintaining good relationships, also having good is a key risk factor as well. So drawing on the evidence and maintaining good relationships, also having good employment is key for protecting people against depression in the future. There's also evidence to suggest that when people stop smoking, if people are smokers, that people's mental health symptoms actually improve despite the common health belief that people get more stressed when they stop. So there's good evidence to suggest in the long term that when people stop their mental health symptoms improve so that's another key risk factor which people can take control of as well yeah and what i'm

super interested in is kind of like the little things that we can do at home and things like stress management so practicing meditation and mindfulness, sleep hygiene. I know sleep is hugely implicated in mental health conditions and diet. And I know that you guys have also been looking at dietary interventions and what foods are related to mood. Can you tell us a little bit about that one? Yeah, absolutely. So we've recently, with some colleagues in the States, looked at how an inflammatory diet, so a diet typically high in fats or processed food, may be a risk factor for developing depression in the future. And these very smart colleagues in the United States have validated this food questionnaire against inflammatory markers within our bloodstream.

And what we found is that those who have the highest inflammatory potential within their diet are more likely to develop depression in the future as well and inflammation seems to be implicated really quite a lot in the onset of mental health conditions and depression so you know processed foods is a particular one which is associated with a high inflammatory potential so foods with lower inflammatory potential are you know higher in grains sort of vegetables typical mediterranean type oily fish is has a lower inflammatory potential and is protective against the development of mental health conditions in the future and the study which is led by joe firth who's based in australia Felice Jacqui, who works at the Food and Mood Centre.

That's such a good name. It is a good name. Has demonstrated when we look at diet as an intervention for depression and also anxiety, compared to treatment as usual, can have a positive impact on people's symptoms compared to what people get as typically as usual. So that's really exciting to demonstrate that as an insulin intervention diet, particularly around a Mediterranean type diet, can help reduce people's symptoms. Yeah, and what I love about the Mediterranean diet is that it's not really diet per se. It's more of a lifestyle, a way of living, doesn't have set rules,

and people can be really flexible with it. So, you know, like lots of fruits and vegetables, whole grains whole grains like you mentioned good healthy fats from olive oil oily fish but also the kind of mediterranean way of living where people sit down and enjoy their meals they're more mindful they share it together there's that social aspect which we know is also a protective factor in these mental health conditions and even the provenance and sustainability of food, like they kind of tick all the boxes, which is great. And we know that the Mediterranean diet doesn't just improve our mental health, but also all the other physical conditions that we suffer from today. Because, you know, there's so many theories coming out that a lot of the chronic disease that we suffer from is driven by chronic inflammation. And just to

kind of touch on that for our listeners, inflammation is kind of like a response that we have in our body to something that is what the body perceives as dangerous. And this could be pollen or it could be an injury or it could be a toxin or a disease. And in the acute setting, so if you bang your knee or cut your finger, you will have that inflammatory response and you will have like a red finger, it will be hot, swollen, you won't move it. That's a good thing because that's a healing process.

But if this happens over years and years, we know that exercise is anti-inflammatory in the long term and also we can have a diet which is anti-inflammatory, which we mentioned the Mediterranean diet. So I think that's really positive. something i also um i'm super interested about that you guys have been researching is the benefits of chocolate and kind of health outcomes so can you tell us a bit about that absolutely and i'm a big chocolate fan myself as well so yeah we just had a paper come out last week looking at all of the available published evidence to say how good is the evidence for chocolate,

you know, small amounts of chocolate for health outcomes and every health outcome that's ever been investigated. And we looked at over a million people all across the world. protective effects in observational data for cardiovascular disease and related death from cardiovascular disease from diabetes and stroke as well however there is a caveat to that this is observational data so you know there's other factors which can be at play within this and the evidence when you really rate it and you look at the numbers was rated as was relatively low but there is some indication that it may protect against some of these unwanted outcomes for us. And we probably think that may be due to some of the flavonoids,

which is commonly found within chocolate. But when you look at trials, so when people specifically give people chocolate and people have a control condition, there was evidence to suggest that it can help improve blood flow and some of the insulin markers within the body as well. And that's probably more robust evidence to say, is this truly chocolate which is having an impact on our health?

So it's slightly reassuring for people like me who really are partial to a bit of chocolate that it may protect against those outcomes. But I think we do need to add another caveat to that. And the chocolate that they're using in these studies probably isn't a Mars bar now, is it? No, it's probably not a Mars bar or a Galaxy or something else and people did use different types of chocolate. Yeah and we know that the richer the percentage of chocolate the more health benefits or flavonols as you mentioned it tends to be richer in antioxidants as well so

if you although we don't know the evidence is quite there yet if you are looking to try get some of these health benefits going going darker is better right absolutely and just moving on from that you also have been researching i know this doesn't apply to everyone but the benefits of exercise and post-traumatic stress disorder and there's benefits there also absolutely so there is really good evidence and this was again led by a colleague simon rosenbaum in in sydney and we looked at all of the previous evidence and it's really encouraging to demonstrate that over 12 to 14 week period aerobic exercise or yoga can reduce people's symptoms of post-traumatic stress disorder yeah which is really really exciting to have a an important part of people's symptoms of post-traumatic stress disorder, which is really, really exciting to

have an important part of people's whole treatment. And there's also emerging evidence, again, that physical activity may be protective against the development of post-traumatic stress disorder in the future. So people are more active, are less likely to go on to develop post-traumatic stress disorder in the future. And is it something that you, or have you come across GPs prescribing exercise for, you know, mental health conditions from depression to anxiety? Is that something that you see or something that you'd like to see? I would like to see it very much, particularly trained exercise professionals being a first point of contact and people go and see their GP and then get help with exercise would

be absolutely fantastic. I think there's pockets of good practice, particularly where GPs are very interested and very forthcoming in their views and valuing lifestyle as an intervention. And there's really good examples within GP practices within that. Relating it to my own setting, when I work in secure mental health services, there's a really fantastic consultant who gives the leave from the ward every single time the first time he's to the gym. So people, you know, it's their first leave is always to the gym is their first leave to go and see how people get on. That's so great. I love that. I think it's going to be up and coming. I think I definitely know a lot of

doctors are super keen on lifestyle medicine now it's become a bit trendy but I do feel like it needs to be I guess we need some not regulation but some guidelines there on what to prescribe how much time how can like we said earlier telling someone 150 minutes is not exactly motivating or it's not easy to break down in actionable steps and although there is that personal trainer referral scheme from GP practices in my experience it's not being utilized it's not being used and personally I feel like we would do so much better if we had a designated personal trainer slash health coach slash physio attached to general practices where we can meet people who are at the beginning of their journey or, I guess, nip it in the bud before it becomes out of control. Absolutely. I think that would be absolutely fantastic. And there is some good examples of when physical activity doesn't help for people with mental health conditions.

There was a big trial looking at GP services where people came in with depression and people met a physical activity coach. And essentially they were told just to exercise and given a written exercise prescription. And surprisingly, when people are given a written exercise prescription and met at several time points and not engaged any supervisor encouraging exercise people didn't have any changes in their depressive symptoms so we know that just telling people just do x y and z in terms of minutes or type of exercise doesn't work for any physical or mental health condition what really would benefit is if people take a proactive approach and supportive approach and get alongside people and tailor the interventions for people's needs yeah and I guess that's you know it's more holistic when you have someone there working with you because

I often find you know the kind of personal trainer role or even like any health care professional you almost become you know you have a couple of jobs because you become a counselor you're a listener you there for that person you're acting as a support system which is going to help with their symptoms as well right absolutely and that's the really powerful thing when you're engaging in exercise and particularly you become you know slightly disinhibited and you're more willing to talk about other areas of your life which may be going well or may not be going so well and you get the opportunity to listen to lots of aspects of people's different lives and be really that sounding board and also at the same time engaging in exercise to reduce any stress levels that may

be accompanied by it. I talked extensively about how nutrition isn't really taught at medical school um you know there's only a couple of hours but physical activity is not taught at all like we don't get any lectures on it or well, I didn't at my time. Is this something that's changing? Do you think it should be taught at medical school? Physical activity can have a really potent impact on lots of physical mental health conditions, as we've discussed throughout this podcast. So I think it should be a frontline treatment for many physical and also mental health conditions

in the prevention and also management as well. So getting into medical schools and teaching would be really essential. And there is a really good movement happening in medical schools led by Anne Gates at Exercise Works, who is going into medical schools and teaching the evidence for exercise in lots of different physical and mental health conditions to try and increase the amount which doctors in training are hearing about the health benefits of exercise. I think that's really great because it's something else that we can have, like as doctors can have in our toolkit

and it's unlikely to do any harm. It's free, you know, and in most cases it's free. It's something that we can all prescribe and something you're going to benefit from anyway regardless of what health condition. If you don't have your health condition as well it's going to protect you in the future finally i would love if you could give us your kind of three top tips that people can take away to live a healthier life and doesn't have to be exercise can be anything that you feel could add to someone's life well naturally being biased most of my time writing

about the benefits of an active lifestyle, I would say that taking time to be active would be my number one tip, whether that be just getting off the bus a stop earlier or going out for a walk on your lunch break, taking time to engage in activity and move would be my number one step. And there's a real beneficial impact for being outdoors when you're doing movement as well. The second tip i would say

is keep connected with your social circles and maintain sort of good friendships and relationships yeah i love that one um which is really key for all of us to you know to to enjoy the the good parts of life and then also help us deal and you know bumps come along in the road which is really important as well and the final part i would say would also be looking at diet and nutrition as well. I think that's based on some of the recent evidence as well. And I think looking at whole person health, being active, having good relationships and eating well is essential

for good whole person wellbeing. That's really great. And that includes a little bit of chocolate, right? Just a small amount of chocolate. Just a small amount of dark chocolate. Amazing. Well, thank you so much for joining us today that was really interesting for me and i know it'll be really interesting for everyone else but before you go can you please tell us where we can find you yeah i'm on twitter at brendan stubs you can find me there i'm also very happy to take any

email questions brendan.stubs at kcl.ac.uk and that's the best place to find me amazing and i will link all of that in the show notes if you didn't catch it but thanks so much for listening guys and make sure to tune in for the next one see you soon thank you so much for tuning in to the Food Medic podcast. Please do subscribe so that you are the first to hear about any new episodes. And if you are enjoying them, please leave us a five-star rating and a review so that we can reach as many people as possible. Check out my website, thefoodmedic.co.uk,

where you can find tons of recipes and articles. Follow me on social media, Instagram, Twitter and Facebook at The Food Medic. And my new book, The Food Medic for Life is out now, which is packed full of loads of recipes, nutritional advice, myth busting and feature pages on topics such as sleep and mindfulness. You can grab both my books on Amazon or in any good bookstore thanks for listening and I'll see you next time Thank you.