Role of lifestyle Role of lifestyle in stress and coping: in stress and coping:

practical strategiespractical strategies

Nimi Singh, MD, MPHNimi Singh, MD, MPHDivision of Adolescent Health and MedicineDivision of Adolescent Health and Medicine

Department of PediatricsDepartment of PediatricsUniversity of Minnesota, MinneapolisUniversity of Minnesota, Minneapolis

OverviewOverview

Stress and its effects on cognitionStress and its effects on cognition Shutting of the stress responseShutting of the stress response

– SleepSleep– NutritionNutrition– Physical activityPhysical activity– Stress reduction strategiesStress reduction strategies– RecreationRecreation

Facilitating behavioral change (MI)Facilitating behavioral change (MI)

Psychological HomeostasisPsychological Homeostasis(the good news!!)(the good news!!)

The mindThe mind’’s ability to SELF-RIGHT ( INNATE)s ability to SELF-RIGHT ( INNATE)

Allows us to return to higher cognitive functioning Allows us to return to higher cognitive functioning

During a stress response, blood is shunted from this region to the During a stress response, blood is shunted from this region to the brainstem in order to facilitate the brainstem in order to facilitate the ““fight, flight or freezefight, flight or freeze”” response response

In order to facilitate the mindIn order to facilitate the mind’’s ability to self-right, therefore…s ability to self-right, therefore… … …one needs to shut off the STRESS responseone needs to shut off the STRESS response

Most of the time, we do this automaticallyMost of the time, we do this automatically

…….BUT sometimes we get stuck.BUT sometimes we get stuck

Why do we get stuck in the Why do we get stuck in the “stress” response?“stress” response?

Repetitive negative thoughtsRepetitive negative thoughtsLifestyle:Lifestyle:

– Inadequate sleepInadequate sleep– Inadequate physical activityInadequate physical activity– Lack of self-regulatory skills/ relaxation/ enjoyable activitiesLack of self-regulatory skills/ relaxation/ enjoyable activities– Lack of meaningful connection with othersLack of meaningful connection with others– Sub-optimal dietSub-optimal diet

Micronutrient deficienciesMicronutrient deficiencies Food intolerancesFood intolerances InflammationInflammation

– Turns on stress response (cortisol, adrenaline)Turns on stress response (cortisol, adrenaline)– Energy used for “fight or flight”, NOT healing/ repairEnergy used for “fight or flight”, NOT healing/ repair

Optimizing HomeostasisOptimizing Homeostasis

Stress reduction:Stress reduction:– CRITICAL first steps:CRITICAL first steps:

Optimize sleep Optimize sleep Optimal nutrition Optimal nutrition Increase physical activity Increase physical activity

– Recreational activities Recreational activities – Self-regulatory techniques ( biofeedback, self-hypnosis, Yoga, Tai chi, Qi Self-regulatory techniques ( biofeedback, self-hypnosis, Yoga, Tai chi, Qi

gong, mindfulness/ “present moment” practicesgong, mindfulness/ “present moment” practices

Cognitive/ Behavioral:Cognitive/ Behavioral:– Learning to recognize/ disengage from negative/ distorted thoughtsLearning to recognize/ disengage from negative/ distorted thoughts– Mindfulness-based therapies (Jon Kabat-Zinn, Ph.D)Mindfulness-based therapies (Jon Kabat-Zinn, Ph.D)– Health Realization (focus on innate capacity to self-right)Health Realization (focus on innate capacity to self-right)

SLEEPSLEEP 2003 National Survey of Children’s Health:2003 National Survey of Children’s Health:

– 15 million children/ adolescents: inadequate sleep15 million children/ adolescents: inadequate sleep– Risk factor for development of anxiety and depressionRisk factor for development of anxiety and depression– Anxiety, depression Anxiety, depression poor sleep quality and quantity poor sleep quality and quantity

Optimal hours of regenerative sleep: 10pm to 2amOptimal hours of regenerative sleep: 10pm to 2am What interferes?What interferes?

– School/ after school schedulesSchool/ after school schedules– Intellectually stimulating activities before bedtime (TV, internet, reading)Intellectually stimulating activities before bedtime (TV, internet, reading)– Caffeine-containing foods and beveragesCaffeine-containing foods and beverages

What helps?What helps?– Limiting daytime napsLimiting daytime naps– ExerciseExercise– Sleep environment (quiet, dark, no distractions)Sleep environment (quiet, dark, no distractions)– Sleep routine (meals/ snacks at least 2 hours BEFORE sleep, soothing stimuli)Sleep routine (meals/ snacks at least 2 hours BEFORE sleep, soothing stimuli)

PHYSICAL ACTIVITY:PHYSICAL ACTIVITY: Over 18,000 studies on exercise and mental healthOver 18,000 studies on exercise and mental health

The best exercise? The best exercise? One the individual enjoys, and will maintain over timeOne the individual enjoys, and will maintain over timeIdeally: 3-5 times a week, 20-30 minutes idealIdeally: 3-5 times a week, 20-30 minutes ideal

Mechanism of action?Mechanism of action?Increases blood flow, increasing O2 and nutrientsIncreases blood flow, increasing O2 and nutrientsReduces inflammationReduces inflammationAlters brain chemistryAlters brain chemistryImproves sleepImproves sleep

Improved cognition and memory Improved cognition and memory

Positive findings in research:Positive findings in research:Aerobic activity (including brisk walking)Aerobic activity (including brisk walking)Strength-trainingStrength-trainingYogaYoga

Recreation/ Relaxation:Recreation/ Relaxation: Hobbies (music, art, etc..)Hobbies (music, art, etc..)

Quiet unstructured timeQuiet unstructured time

Creative play: Stuart Brown, MDCreative play: Stuart Brown, MD““Play: how it shapes the brain, opens the Play: how it shapes the brain, opens the

imagination and invigorates the soul”imagination and invigorates the soul”

Being in nature: Being in nature: Richard Louv (journalist)Richard Louv (journalist) “Last child in the woods” “Last child in the woods” “The Nature Principle “The Nature Principle

Relaxation techniquesRelaxation techniques–Mindfulness-based trainingMindfulness-based training

–Biofeedback/ self-hypnosis Biofeedback/ self-hypnosis

Optimizing NUTRITION:Optimizing NUTRITION: What’s the problem?What’s the problem?

1) We’re no longer eating foods that nourish our1) We’re no longer eating foods that nourish our

bodies adequatelybodies adequately

2) We’re developing problems with digestion of2) We’re developing problems with digestion of

certain foods, causing inflammationcertain foods, causing inflammation

3) Inflamed bodies= inflamed nervous system= altered cognition/ mood3) Inflamed bodies= inflamed nervous system= altered cognition/ mood

1. Nourishing foods1. Nourishing foods Standard American Diet (SAD diet): Standard American Diet (SAD diet):

– Processed/ refined foods: NOT REAL FOOD!!!Processed/ refined foods: NOT REAL FOOD!!! Micronutrient poor (vitamins, minerals, phytonutrients)Micronutrient poor (vitamins, minerals, phytonutrients) High in calories (get stored as fat, NOT used as energy)High in calories (get stored as fat, NOT used as energy) High in gluten, casein, whey, high-fructose corn syrup (inflammatory)High in gluten, casein, whey, high-fructose corn syrup (inflammatory) Contributing to rise in chronic inflammatory diseasesContributing to rise in chronic inflammatory diseases

Solution: WHOLE FOODS dietSolution: WHOLE FOODS diet– LOTS of colorful vegetables/ fruits (rich in phytonutrients, keep LOTS of colorful vegetables/ fruits (rich in phytonutrients, keep

our cells working optimally)our cells working optimally)– Lean protein (lean meats, fish, legumes), 4 oz/meal or lessLean protein (lean meats, fish, legumes), 4 oz/meal or less– Some whole grains (ideally non-gluten: rice, quinoa, etc..)Some whole grains (ideally non-gluten: rice, quinoa, etc..)– Healthy fats (fish oil, avocados, nuts, olive oil)Healthy fats (fish oil, avocados, nuts, olive oil)– Anti-inflammatory spices (turmeric, garlic, cinnamon, rosemary) Anti-inflammatory spices (turmeric, garlic, cinnamon, rosemary)

PHYTONUTRIENTS:PHYTONUTRIENTS: Health-protective, disease-preventing compounds produced by Health-protective, disease-preventing compounds produced by

plants when stressed by the environment (why GMO is not good)plants when stressed by the environment (why GMO is not good)

Have anti-oxidant propertiesHave anti-oxidant properties

Help the cells get rid of environmental toxinsHelp the cells get rid of environmental toxins

Help the body promote healthy “cell-signaling:Help the body promote healthy “cell-signaling:

– Two main chemical reactions in the body:Two main chemical reactions in the body:

STRESS (pro-inflammatory, fat-storing, disease-causing)STRESS (pro-inflammatory, fat-storing, disease-causing) GROWTH/ HEALING (anti-inflammatory, optimize health)GROWTH/ HEALING (anti-inflammatory, optimize health)

PHYTONUTRIENTS:PHYTONUTRIENTS:Rainbow DietRainbow Diet

REDRED– Lycopene, ellagic acid: cooked tomatoes, strawberries, Lycopene, ellagic acid: cooked tomatoes, strawberries,

raspberries, pomegranatesraspberries, pomegranates ORANGE/ YELLOWORANGE/ YELLOW

– Alpha and beta carotene, hesperitin, cryptoxanthin: carrots, Alpha and beta carotene, hesperitin, cryptoxanthin: carrots, pumpkins, oranges, tangerines, cantaloups, sweet potatoes, pumpkins, oranges, tangerines, cantaloups, sweet potatoes, lemons, squashes, pepperslemons, squashes, peppers

GREENGREEN– ECGC, Isothiocyanate, lutein, isoflavones, catechins: ECGC, Isothiocyanate, lutein, isoflavones, catechins:

cruciferous vegetables (broccoli, kale, cabbage, watercress), cruciferous vegetables (broccoli, kale, cabbage, watercress), dark leafy greens, green teadark leafy greens, green tea

BLUE/PURPLEBLUE/PURPLE– Anthocyanidins, resveratrol: blueberries, elderberries, Anthocyanidins, resveratrol: blueberries, elderberries,

red/purple grapesred/purple grapes

2. Hidden Food Intolerances2. Hidden Food Intolerances

““Hidden” because they don’t always cause Hidden” because they don’t always cause discomfort after eatingdiscomfort after eating

History of:History of:– Colic/ feeding problems/ reflux as an infantColic/ feeding problems/ reflux as an infant– Frequent infections treated with antibiotics (kills off Frequent infections treated with antibiotics (kills off

good bacteria in the intestines)good bacteria in the intestines)– Development of chronic inflammatory conditions:Development of chronic inflammatory conditions:

Asthma, allergies, eczema, dysmenorrhea, migraines, anxiety Asthma, allergies, eczema, dysmenorrhea, migraines, anxiety depression, IBS, fatigue, insomnia, autoimmune diseasedepression, IBS, fatigue, insomnia, autoimmune disease

Hidden Food IntolerancesHidden Food Intolerances

Most common culprits:Most common culprits:– Cow’s milk protein (casein, whey)Cow’s milk protein (casein, whey)– Gluten (wheat, rye, barley)Gluten (wheat, rye, barley)– SoySoy– CornCorn– EggsEggs

Note: refined/ added sugars increase inflammationNote: refined/ added sugars increase inflammation

Hidden Food Intolerances: Hidden Food Intolerances: DiagnosisDiagnosis

Elimination (“anti-inflammatory”) diet:Elimination (“anti-inflammatory”) diet:– For four weeks:For four weeks:

NO gluten, dairy, corn, soy, eggs, processed foods or NO gluten, dairy, corn, soy, eggs, processed foods or refined sugarsrefined sugars

Diet consists of MOSTLY vegetables and fruits, some Diet consists of MOSTLY vegetables and fruits, some lean protein and non-gluten grains, nuts, healthy oils/fatslean protein and non-gluten grains, nuts, healthy oils/fats

Omega-3 fatty acids (fish oil) 1000 mg a day Omega-3 fatty acids (fish oil) 1000 mg a day – GREAT for brain functioningGREAT for brain functioning

Probiotic once a dayProbiotic once a day Vitamin D3 (have level checked, then supplement)Vitamin D3 (have level checked, then supplement) Multivitamin once a day (depleted soil)Multivitamin once a day (depleted soil)

Hidden Food Intolerances: Hidden Food Intolerances: TreatmentTreatment

Elimination (‘anti-inflammatory”) diet:Elimination (‘anti-inflammatory”) diet:– At the end of the 4 weeks:At the end of the 4 weeks:

Reintroduce foods one at a time, every 2-3 daysReintroduce foods one at a time, every 2-3 days Track symptoms (headaches, joint pain, insomnia, GI Track symptoms (headaches, joint pain, insomnia, GI

problems, anxiety, depression etc..)problems, anxiety, depression etc..) If food causes symptoms, remove from diet, allow If food causes symptoms, remove from diet, allow

symptoms to resolve, and then try next food on listsymptoms to resolve, and then try next food on list At the end of the diet, only reintroduce foods that do not At the end of the diet, only reintroduce foods that do not

cause symptomscause symptoms If not feeling 100% better, may want to consult with If not feeling 100% better, may want to consult with

practitioner trained in Functional Medicine practitioner trained in Functional Medicine

Optimizing nutritionOptimizing nutrition Food is informationFood is information (Real) Food is medicine(Real) Food is medicine Food is relationship (self, others, the planet)Food is relationship (self, others, the planet) Mindful eating:Mindful eating:

Reduces stressReduces stress Improves digestionImproves digestion Increases enjoyment of foodIncreases enjoyment of food Leads to consumption of fewer caloriesLeads to consumption of fewer calories

– Dalen J, et al.. Complement Ther Med (2010)Dalen J, et al.. Complement Ther Med (2010)

Screening: The BasicsScreening: The Basics Sleep:Sleep:

– What’s your typical nighttime routine?What’s your typical nighttime routine?– What time do you get into bed?What time do you get into bed?– How long does it take for your to fall asleep?How long does it take for your to fall asleep?– Do you stay awake thinking about things/ what Do you stay awake thinking about things/ what

things?things?– Do you wake up sooner than you want?Do you wake up sooner than you want?– If yes, is it hard to fall asleep?If yes, is it hard to fall asleep?– Do you feel well-rested during the day?Do you feel well-rested during the day?

Screening: The BasicsScreening: The Basics NutritionNutrition

– Whole foods vs processed foods?Whole foods vs processed foods?– Multivitamin, supplements?Multivitamin, supplements?– Essential micronutrient intake?Essential micronutrient intake?

ExerciseExercise– How often? How much? If not, was there a time How often? How much? If not, was there a time

when you did? What would you be willing to do?when you did? What would you be willing to do?

Recreation (creative vs passive is better)Recreation (creative vs passive is better)– Art, music, journaling, hobbies, etc. Art, music, journaling, hobbies, etc.

Motivational InterviewingMotivational Interviewing(Miller and Rollnick, 2002)(Miller and Rollnick, 2002)

Empathetic, patient-focused, guiding counseling style Empathetic, patient-focused, guiding counseling style (not just a set of techniques)(not just a set of techniques)

Seeks to create conditions for positive behavioral Seeks to create conditions for positive behavioral change by having change by having patientpatient articulate reasons for change, articulate reasons for change, and how to achieve itand how to achieve it

Well-suited for brief clinical encountersWell-suited for brief clinical encounters Evidence-based (>300 clinical trials, both adults and Evidence-based (>300 clinical trials, both adults and

adolescents)adolescents)(grounded in theory, verifiable, generalizable, delivered by wide range of (grounded in theory, verifiable, generalizable, delivered by wide range of

health care practitioners, addressing a wide range of health behaviors)health care practitioners, addressing a wide range of health behaviors)

Two Assumptions:Two Assumptions:

1. Motivation: can be elicited by 1. Motivation: can be elicited by interpersonal interpersonal interactioninteraction (not just innate character trait) (not just innate character trait)

• • Confrontation leads to resistance Confrontation leads to resistance

•• Empathy, understanding and exploration of patient’s Empathy, understanding and exploration of patient’s experience creates a space for self-reflection and desire experience creates a space for self-reflection and desire for changefor change

2. Ambivalence to change: normal and natural2. Ambivalence to change: normal and natural

•• CCompeting positive and negative feelingsompeting positive and negative feelings

• • Decision balance: pros and consDecision balance: pros and cons

Motivational Interviewing (conMotivational Interviewing (con’’t)t) Patient: articulates arguments for change and the Patient: articulates arguments for change and the

treatment plantreatment plan

Health care provider: facilitates, guides patient through Health care provider: facilitates, guides patient through questions and reflections:questions and reflections:– Share information in a respectful wayShare information in a respectful way– Allow patient to direct treatment planAllow patient to direct treatment plan– Supports client self-efficacy: Supports client self-efficacy:

Acknowledges difficulties of making behavioral changeAcknowledges difficulties of making behavioral change Points out strengthsPoints out strengths Points out previous successesPoints out previous successes Avoids resistance by not lecturing/ arguing with patientAvoids resistance by not lecturing/ arguing with patient Asks patient what Asks patient what theythey want to do/ are willing to do want to do/ are willing to do

Giving information and adviceGiving information and advice Ask for permission before giving adviceAsk for permission before giving advice This supports patient’s sense of autonomyThis supports patient’s sense of autonomy

– ““Of course, while my job is to give you information, youOf course, while my job is to give you information, you’’re re ultimately the one to decide…ultimately the one to decide…””

Elicit – Provide – ElicitElicit – Provide – Elicit– ““What do you know about what causes depression ( or other health What do you know about what causes depression ( or other health

condition/ problem behavior, etc)” “It sounds like you know quite a bit condition/ problem behavior, etc)” “It sounds like you know quite a bit about…”about…”

– ““There is some other information that might be helpful to you…may I share There is some other information that might be helpful to you…may I share that with you?”that with you?”

– “ “ What are your thoughts about that? How might you use that information? What are your thoughts about that? How might you use that information? Is there anything that might be relevant for you?”Is there anything that might be relevant for you?”

Giving information and adviceGiving information and advice

When given permission to offer suggestions, offer several, not one When given permission to offer suggestions, offer several, not one (otherwise it looks like the (otherwise it looks like the ““rightright”” answer) answer)– ““Here’s what we know about how lifestyle affects moods… Here’s what we know about how lifestyle affects moods…

which one do you think is most out of balance for you?” which one do you think is most out of balance for you?” (depression: Would you like to work on sleep, diet, exercise or stress (depression: Would you like to work on sleep, diet, exercise or stress

reduction first?)reduction first?)

– What do you think you could do to improve your (sleep)?What do you think you could do to improve your (sleep)?– When would you like to start?When would you like to start?– When would you like to come back and see me?When would you like to come back and see me?

If you offer solutions one at a time, it creates resistance, and the If you offer solutions one at a time, it creates resistance, and the patient is more likely to offer reasons why each one won’t work patient is more likely to offer reasons why each one won’t work

TAKE-HOME MESSAGETAKE-HOME MESSAGE

The MIND is connected to the BODYThe MIND is connected to the BODY

If ONE gets out of balance, it throws the If ONE gets out of balance, it throws the OTHER out of balanceOTHER out of balance

There’s A LOT we can do to help others There’s A LOT we can do to help others get back in balanceget back in balance

ResourcesResources Henry Emmons, MDHenry Emmons, MD

– ““Chemistry of Calm”Chemistry of Calm”– ““Chemistry of Joy”Chemistry of Joy”– ““Chemistry of Joy workbook”Chemistry of Joy workbook”

““Ultramind diet”, Mark Hyman, MDUltramind diet”, Mark Hyman, MD

Motivational Interviewing: www.motivationalinterview.orgMotivational Interviewing: www.motivationalinterview.org

Internet search terms:Internet search terms:– Institute for Functional MedicineInstitute for Functional Medicine– Mark Hyman, MDMark Hyman, MD