Evidence that Mental Health is Inseparable from Physical Health Dr. April Hirschberg

Improving the quality of the diet is huge because that helps our microbiome. It decreases the inflammation by adding in the macronutrients and micronutrients that can enhance our neurotransmitters. We really can improve our brains, really, if you will. We can help combat depression and anxiety because there's this interplay and mood stabilization that happens with a high-quality diet.

Hi, welcome back to the Mind Body Space podcast. This is Dr. Juna Bobby MD, and it's the last Friday of the month. When Dr. April Hershberg joins me to discuss stress management tips to improve everything about our lives. April and I are both mom MDs. I am a board-certified and fellowship-trained radiologist, and I spent decades seeing disease from the inside out. That was frustrating for me, so I wanted to learn everything I could to help prevent diseases and keep us well. And April?

And I am a psychiatrist at Mass General Hospital, board-certified in both lifestyle medicine and mind-body medicine. Happy to be here, Juna.

Our monthly conversations are to answer your questions, and we do our best to get our expert weigh-in and information that you can trust. We also toss in our opinions and life experiences once in a while, right, April?

Totally.

Because whenever we think it's really helpful, we always come back to practical ways to deal with stress because that's what we specialize in. Evidence is overwhelming that stress management and healthy lifestyle choices are at the root of almost all mental and physical afflictions. And if it's not the cause, then it definitely helps prevent, mitigate, or lessen, or even reverse some of the most common diseases that we have today.

So May is, you said stress week or mental health week?

May is Mental Health Awareness Month, and it has, it's been designated that as a month since 1949. So it's been around. And Stress Awareness Month is April. And actually, just a couple weeks ago now was Mental Health Action Day.

I didn't know it's been around that long.

Yes, yep, 1949. The big group now, it's Mental Health America. They have a lot of great programming and suggestions that companies can go on and mental health calendars. There's all kinds of a variety of different tools there.

Awesome. And our conversations are always about stress awareness. So we'll combine stress awareness and mental health. And I really do think stress awareness goes hand in hand with mental health. And today I'm so excited to discuss this paper that you wrote. You were one of the authors on called Incorporating Mental Health into Lifestyle Medicine. Quote, this study aims to highlight the bidirectional influences of physical health and mental health within each pillar of lifestyle medicine. And I love this sentence because in, uh, lay terms, it basically means that our mind and body are connected. And that's one of my— that's one of my biggest pet peeves when it comes to mental health and physical health, because people separate it all the time. I'm hoping people start to connect it more. So for example, I was just having a conversation with a parent today, and I was saying there's a lot of social-emotional learning going on in schools these days, but I think cognitive behavioral therapy and changing perspectives and understanding your emotions are super important, but It's not enough to say that to somebody who's maybe not getting enough sleep or eating a lot of ultra-processed foods or not exercising at all. I know in health lessons, they will teach you about exercise, about sleeping, and all those things, but it's that connection that's missing. So the connection between sleep and emotions and cognition, and I think that's where we come in. I really want this connection to be foremost in people's minds when they're teaching or learning about this, right? It's not disconnected.

Absolutely. I think the biggest take-home message is this bidirectionality. Really, the mind and the body is connected. And when we went to medical school, it wasn't even taught that way. It's, it's crazy now to think that, but I think you're absolutely correct. There's growing attention to these areas. And you and I are both trained in lifestyle medicine, but along with some colleagues, behavioral health field and mental health field, we came together in an interest group within the American College of Lifestyle Medicine and really found that even within lifestyle medicine and just medicine in general, We don't talk about this enough, you know, that mental health is health, that everything has an impact on one another. And what we do with regard to movement or physical exercise really can help promote our physical health, of course, but our mental health as well. And there is growing research in that area, and that has a whole pillar within lifestyle medicine. I think what happens for many people is that when they don't feel well from a mental health perspective, and we know unfortunately millions of people now are not feeling well from a mental mental health standpoint that it impacts all these other health behaviors. And there is a growing field in psychology, behavioral health, and also coaching. There's a lot of ways in trying to get people engaged to enhance their lifestyle behaviors, because if you can target these lifestyle behaviors like physical movement and sleep, you can really improve the conditions. But you get talked at about it without actionable steps.

I also think the connection is not made frequently enough, even in the screening studies on pediatricians' offices, or when you go see your doctor, they'll screen you for anxiety and depression. But I think in those questions, there should be things like, how many hours of sleep do you get? How many servings of fruits and vegetables do you get? Because those things can affect our mood and our mentation.

Absolutely. And I think—

Is it in there?

Certainly not. The dietary questions are not in that checklist.

Right.

The sleep is. The sleep questions are there.

But we don't know, like, sometimes if you don't sleep because you're having a mental health issue.

Exactly. And that's where I will say, as a psychiatrist, for years we've been talking to people about sleep because we know how important I half joke with people that I went into psychiatry because it was the one field where you never woke up a patient. You would always sleep so people could, in residency, you started later, you weren't like a surgeon waking people up. That's funny. But so the sleep piece I think is there. I think the, the pieces that are coming now, the other pillars to your point, the social connection piece, how important that is to our health and the, the physical movement and the dietary component. But I think what happens is a lot of times when we are feeling low or stressed or distressed, stress impacts sleep first often, and then you stop being physically active because you're tired and you stop eating well because you're sleep deprived and tired.

So, it's, and you want a donut instead.

It's this vicious cycle. Yeah. And I think we just, there's a lot of different ways in which to intervene. And that's why we wrote this paper. It was a summary of a workshop that we delivered in 2021 at the American College of Lifestyle Medicine. We just wanted to highlight the different pillars of lifestyle medicine in ways in which you could potentially see that interaction. Because even for people in non-psychiatric medicine, they didn't always see that maybe when somebody is depressed or anxious, they may be reaching for some alcohol to take the edge off or feel a little bit better. But that impacts their sleep, and then that impacts their motivation.

It's a vicious cycle.

It's a vicious cycle. But I think realizing that people do things that bad for them, but they're really just trying to get through the day because they're struggling so much and trying to change the language in which we talk to people about some of these issues. And rather than making people feel badly or guilty for choosing the donut or choosing the alcohol, but just recognizing that we understand there might be a reason why you're reaching for that a little quicker because you're trying to get some relief.

Great that you bring up that point because the more people understand of their brain and how their physiology work, it's no longer about shame and I'm to blame. And it's more about, hey, this is how my brain is working right now, and this is how my body's responding to the chemicals that are being released in my brain. And that gives you so much more agency and power.

Exactly.

And kids can understand this too, because I teach this all the time. It's life-changing. So—

It really can be. It really can be. We have to take the blame away because you also have to add in the intrinsic motivation or give people things that they can do in bite-sized quantities because nobody's just going to go run a marathon or switch to a whole food plant-based diet, you want to just try to talk less about what you're going to take away, but what are you going to add in.

And so let's, without further ado, go through some of the highlights of this paper, which is actually a review in the American Journal of Lifestyle Medicine.

Mm-hmm. The key reason that we wrote this was really to get, frankly, mental health on the minds of the people in lifestyle medicine, because intervening— so much of the talk had been on how lifestyle medicine can improve physical health, not as much was talked about the mental health improvements that could be made by intervening on these 6 pillars of lifestyle medicine. So it was really to get that information to people and illustrating the bidirectionality. If you could improve one, you would improve the other.

Mm-hmm. Here, I'm gonna quote you guys. 50 million adults in the US have a mental health disorder and 12 million report serious suicidal ideation, yet 57% do not receive mental health treatment. Those are astounding statistics. And now we know, is it almost 50% of young adolescent girls and maybe almost up to 30% of adolescent males also have issues.

Yes, those are statistics from the United States. And worldwide, it's been estimated to be over a billion people struggle with a mental health condition.

Depression. And that's just reported.

Exactly.

That's not like you and me functioning, and we have off days too, where we can also use these lifestyle interventions, right? This paper is evidence-based and basically evidence-based means that there's some research behind it.

This paper has broken everything down into the 6 pillars and provided the evidence base for the way in which that pillar can improve mental or physical health. And one of the reasons why we wrote this at the time, it's now a couple years old, was that it wasn't up until this 4th edition of the Lifestyle Medicine textbook, psychiatry or mental health even mentioned So the first part that you mentioned from Life's on Medicine is nutrition and how nutrition can help mental health.

Do you wanna give us a sentence or two on that?

Yes. And you know this, and some of our listeners do too, Juna Bobby MD, but the way in which we eat, our dietary patterns are important, of course, and then the dietary quality are important. So we really wanna intervene on both, but improving the quality of the diet is huge because that helps our microbiome. It decreases the inflammation. By adding in the macronutrients and micronutrients that can enhance our neurotransmitters, we really can improve our brains, really, if you will. We can help combat depression and anxiety because there's this interplay and mood stabilization that happens with a high-quality diet. By decreasing our brain inflammation, we can improve our mental health. Dietary changes are really key in that.

Amazing. And of course, our GI system is our third brain. So our enteric nervous system has more than 500 million neurons, and that's outside of the brain. It's in our gut. So yes, it directly speaks to our brain, and it even affects our epigenetics, meaning it could turn certain genes on and off. So that's pretty wild, right? Just from the quality, high quality of diet, whole foods. Now the next topic is substance use. Of course, we can only imagine that substance use could affect our mental health. It could go both ways, like you said before. It could either be that a mental health issue is causing someone to use substances to self-soothe, probably a little both. And then there's the addiction aspect, right?

Right.

You also talk about alcohol, tobacco, and cannabis. So do you wanna say a few words on that?

One of the key pieces in terms of the risky substances, as you point out, that alcohol's like the top one we think of, and that is so important because it's so prevalent in society. And a lot of people do perceive that as a relaxation tool. Uh-huh. But what they don't, and what they don't really remember or factor in is how much it impacts their sleep. And I'll go back to that sleep point is that people think it helps them fall asleep, but it really disrupts their sleep and it disrupts the quality and the quantity of that restorative sleep. Alcohol is like a double whammy because it's a depressant in itself, but it also, it's a sleep disruptor. So it adds a lot of problems to our mental health when people are going into it thinking it's somehow positive. And there's been a lot of research that alcohol was beneficial in terms of cardiac health, and that's just not been shown to be true.

And it directly affects our frontal lobe, alcohol.

Yes.

Yeah.

Absolutely.

And over time with heavy use, you can see massive changes in the brain. And you mentioned smoking tobacco. I know in Europe it's still common to smoke, and even in the US, I believe it's still the number one cause for lung cancer, right?

Yes.

And I think younger people are actually using more cigarettes recently.

It's cigarettes and the vaping, and that we didn't even mention the vaping in the paper actually, but it's really true that product product because that's another delivery mode for marijuana. So there's a lot of growing research in that area, cannabis. And we don't really touch upon the illicit substances, but we also know that there's a lot of literature that supports that opiates or misusing prescription drugs or street drugs really do impair mental health, lowering mood. And people think it helps their anxiety, but again, it really, it doesn't. In the long run.

And there's something really interesting here that the Kiara work that you guys talk about, that there's dopamine levels are increased with tobacco, which I actually didn't know about. So these alterations in the dopamine reward pathway, it says, quote, frequently result in craving symptoms, which are similar to anxiety. So that was with tobacco.

Yeah.

And then you guys mentioned cannabis. So in order to get people to stop using cannabis for better success, you had to treat anxiety as well. Basically, maybe they were self-treating for anxiety with cannabis, right?

It happens, yes.

Yeah. Okay. Physical activity.

Yeah.

Physical activity, we know, improves overall general well-being, but there are growing studies that show that there is and can be a great benefit with physical activity as an actual treatment for major depression. It's now being recommended as a first-line treatment for mild to moderate depression because similar to the Healthy eating, it's through a number of different mechanisms because the physical activity is shown to improve our brains, increasing our hippocampus volume, and also lowers the whole body inflammation. And it helps us behaviorally because we feel better. We have what's called increased self-efficacy and self-motivation that if we're feeling better overall, then we are more apt to choose the healthier substance or avoid the risky substance or ingest something better for us. Go to sleep earlier. And there's all kinds of research that shows that people who are more physically active with others has that added benefit for the social piece as well. I think physical activity and the sleep is really where my money would go. If we could increase the physical activity and improve people's sleep, that we would really be doing people a great service.

And that's opposite of the vicious cycle because this is an upward cycle of, um, upward.

The virtuous.

Yeah, the virtuous cycle.

The virtuous cycle.

And as it says in this paper, exercise directly, quote, increased synthesis and release of neurotransmitters and neurotrophins. These are all words about of chemicals that are released in our brain, right?

Exactly.

And it increases neurogenesis, meaning regeneration of neurons. Right. So we get more brain cells. Yeah. Angiogenesis, which is all vascular renewal and synaptogenesis. That just means how the brain communicates with each other, the neurons communicate with each other. So this is amazing. I taught medical students how to write the prescription for exercise. So there's literally a way to write a prescription for exercise. So the acronym is FITT, F-I-T-T, and F stands for frequency. It's like saying 2 times a day, 3 times a week, and how many sets performed. Then I is for intensity. It's the intensity and it depends on the person's tolerance for discomfort, but also not injuring yourself. Mild to moderate intensity. This could relate to aerobic exercise or stretching. And then T stands for time, duration of this exercise. And then T is— the final T is for type. So what kind of exercise are you doing? So FITT: frequency, intensity, time, and type. That's the prescription for exercise. So you can even write one to yourself. You don't need a lifestyle medicine physician to write that for you. But if your physician does write it for you, you might have an increased chance of sticking to it.

Absolutely.

Especially if you have a good rapport with the physician. Research shows that too.

Absolutely. And it's important to put yourself on the calendar. Your time is going to fill up with other things, but if you put yourself first on the calendar, you're going to be more likely to do that physical activity.

So I know you have to go, but we are going to talk about stress for just a few minutes before you go. We'll finish up the rest of them next month. Absolutely. So let's do stress now, 'cause last month April was stress and this month is mental health awareness. And yeah, stress could definitely affect your mental health. So stress we know is normal. It can help us with performin', like it says in this paper. However, we can have chronic toxic stress. That's the kind that will make us disorganized and could lead to other mental health issues. So do you wanna elaborate a little bit, April?

I do. In the paper, we talk about the importance of stress as a pillar. Stress is not bad. Bad. It's a part of life. And so many medical professionals or mental health professionals will just ask somebody, what's your stress level like? Or how's your stress? And that's not really the question we should be asking. And one of the suggestions in the paper is potentially doing some screening. There's something called the Perceived— PSS— Perceived Stress Scale. It's a little more nuanced because, as you point out, some stress is useful. But when we perceive that stress as being too much that we can handle or that we can't cope with the stress, that's when the stress can become chronic or toxic and/or toxic. And we need to just have clinicians or people who are dealing with people and trying to affect some change have a little bit more of a nuanced conversation and not just asking, do you have stress in your life? Yes or no? We need to have a little bit more of a conversation. And that's one of the big things we wanted to convey in this paper is to ask a little bit more about that for that individual in the office with you.

That's a great point because it is the perception of stress that leads to all those physiological changes. You could have the same exact stressor for two different people. I always use the roller coaster as an example because roller coaster will make you stress physiologically, and one person would love that roller coaster ride, and so that is seen as something exciting and fun, and another person could see it as frightening and life-threatening. They're going to have similar physiological responses, but it's going affect them in a more negative way, mentally and physically. So with that, we're going to end today. We'll pick up again next month on the stress, and then we'll continue with the remainder of the 6 pillars of lifestyle medicine.

Thank you so much, Juna Bobby MD. I'm glad to get this conversation started. It's always a pleasure to be here with you and let people know about some of these important topics that they can really start to affect some changes for themselves.

Well, thank you so much for writing this paper, this important review of all the studies out there. You and the whole team.

Yes, it's a whole team and we can talk more about them next time because I'm continuing to do a little bit of work with them in a new organization, but it's still similar information in lifestyle psychiatry at the APA now.

All of the authors are in the show notes as well as the link to the paper.

Yes.

This is a free paper, right?

Yep. Yep.

So anybody can read it.

Anybody can. And it's really written in a way that's very readable.

Excellent. I can't wait to continue this conversation. Thank you so much, April.

All right. Yes. Thanks so much, Juna Bobby MD. Look forward to seeing you again soon.