Exercise, Nutrition and Mental Health

Preston: [00:00:00] So we're talking about exercise today and you just brought up that. Every time it's kind of discussed in social media, you said these glittering generalities. 

Margaret: Yeah. So I love the term. I feel like even on social in social media. It's one kind of beast. But then even on like podcast where they talk about it.

I think there are episodes that have covered this well, but I find it fascinating when psychiatrists talk about. The studies around exercise and mental health and the bidirectionality of it. And also just, I think it can be really empowering if we can help people get back to movement that they love, but like getting specific, I don't see a lot of it's like, yeah, exercise is good.

Preston: Uh, yeah, I think that's one thing that frustrates me too, a little bit is that. If you asked a room of 10 psychiatrists if exercise is good for mental health, they would probably, 10 would say yes, or all would say yes, but then if you ask them how many have like built workout plans with their patients, or have like discussed exercise with their patients, it's like zero.

Margaret: Yeah. Yeah. 

Preston: The amount of times that someone will a patient will say like I started [00:01:00] exercising and then the doctor is like that's great So good for your mental health, but then they'll never go in with hey Have you thought about starting to exercise or even that there's a connection between exercise and your mental health, 

Margaret: right?

right which I think makes it hard for people to be motivated by if there's and as I like like you and I both understand the Healthcare system who has the time to do this done a lot and I know that you know primary care Pediatricians, psychiatrists, anyone interacting with mental health has limited time, but I also think you can do a lot.

By bringing it up, even just for a couple minutes at the end of the visit and getting specific. So that's what we're going to do. 

Preston: Saying, Hey, did you know that like science shows us the connection between working out and depression? 

Margaret: Yeah. So most 

Preston: people don't even make that connection. So they don't even know to start there.

Like, Oh, I thought it was just a, that was just a means of like getting rid of fat. Like who would have thought this could have helped my mood. And I think on top of that, we learned a lot about diagnosing mental health and prescribing medications for psychiatric illness. But I don't think I learned anything in medical school about fitness besides [00:02:00] it's good for you.

And like, and actually everything I know about fitness has come from my tenure as an athlete and everything I do in personal training. But none of that was like from my medical education. 

Margaret: Well, I think that's actually the question we should start with. As you know, I think it's always important to start with our bias and background, both because it's helpful and because if it's going to be hurtful, we can kind of mark that ahead of time.

Yeah. Because we're gonna be talking about exercise and I think this can be an unexplored topic, but also a difficult topic for some people, depending on their own history with it and their history with body image or experiences around ability or disability. So I just want to mark that beginning that we're going to be talking about exercise, hopefully in a nuanced way.

Um, but I want to start, I 

Preston: don't use nuance. Right, Preston 

Margaret: doesn't know how to. Just kidding. Uh, but I think starting with our own backgrounds with exercise for the first few minutes before we go into some studies around exercise and mental health and then mental health's impact on people's ability to move and exercise.

And then we'll end today with kind of our thoughts on how we might Talk about this in clinic or with friends or whatever. [00:03:00] So Preston, do you want to tell me about your life? 

Preston: I'll start telling you about my life and exercise. Um, my, my first relationship with exercises with my mom said, you have to go outside or I'll kill you.

She did not say I'll kill you. She didn't say I'll kill you, but she was like, When I was your age, I was running around the cornfields and all this stuff. So like, I, I think I was just pretty conditioned to be like running around barefoot in my backyard, finding shenanigans to do, climbing trees, stepping on 

Margaret: rusty nails.

Preston: Exactly. Yeah. Um, we had a Macintosh tree in my backyard that I would just climb to the top of and jump off of. Um. At sequentially higher heights that real time, no, it was actually my trampoline that I did off of not the Macintosh tree, but I was like, I can't, I can't 

Margaret: read the, 

Preston: yeah, so, so it was good. I learned how to roll out of, um, of a landing, which is, it's called a parachute landing fall, actually not in the air force, but I, the point is, I saw exercise at this time in my life as almost like a prescription for my mom.

To stop being like a lethargic kid and then [00:04:00] it turned into an outlet pretty when I was pretty young. So my mom said that we had to do an individual sport and a team sport and my individual sport was track. My team sport was soccer. I was good enough at track that I ended up. Running all through high school and actually got, um, invited to play division one or run division one in college.

So I kind of went from being this person that saw exercise is something just fun to be outside. Almost like a part of my life. It was a job essentially in college. And what 

Margaret: was your event? 

Preston: I was the 800 meter. So it's The 800 is really just a test of like resilience, or I think for me it was self hatred.

Girl. Girl. Well, because, you know, if, if you have a lot of I believe you. I believe you had a trap, not well. But I believe you on that. If you have a lot of self compassion, nobody wants to run that second laps. So every part of you is like, I should give up. And then later mom was like, do you want to be a loser your entire life, or are you going to finish this race?

And that's how 

Margaret: I went [00:05:00] into med school. 

Preston: Yeah. So. Anyways, yeah, really stable sense of self, definitely don't have any idea why I went into psychiatry, but I saw, like, track, honestly, as an obligation, but it was also a source of community for me. A lot of my friends are on my track team. Actually Last weekend went to a music festival with like one of my former teammates who I guess we've known for like seven years now we met on our recruiting visit so our like athletic skill or like our athletic pursuits were the foundation of our relationship for almost a decade now.

So I think if I had a complicated relationship with sports because I also resented it a lot in college, they would. Do DEXA scans of us, like track our body fat percentage. I remember kids would get bullied on the team if you gained body fat. 

Margaret: Wow. Wow. 

Preston: And I remember like being scrutinized over what I was eating, things that were like seen as unhealthy.

So there were like points where I remember like intentionally losing weight just [00:06:00] because I like was unhappy with how I looked and felt like it would affect my performance. I became iron deficient at one point cause I was kind of starving myself. So. I guess in summary, exercise has been a positive outlet for me.

It's been a source of community and it's also been almost like a aspect of disorder in my life. And it kind of hangs out with all of those. Which I think, 

Margaret: I think is relatable to a lot of people, maybe with, you know, different details, but that this both like positive parts of movement of play of empowerment of strength of bonding with others, as well as these negative parts again, maybe with different details of like body image control of image, how much pain tolerance is the right amount and then like avoiding it or not, not knowing how to reintegrate it in a healthy way.

Um, 

Preston: so Margaret, I'm curious, what is your relationship? With exercise, 

Margaret: so I feel like I, so I am the youngest of four and I was raised with a sister and two brothers and I say that because I think it [00:07:00] made my childhood in my view of both food and exercise. A little bit different, like my brothers were like four and eight years older than me.

So they were always eating a ton. They were always in sports. My sister was in a ton of sports. Um, I was like the creative one, so I was definitively not good at any sports, but I still played them because I was in a small town where if you wanted to be on a team, you could be on a team. Um, so I played volleyball badly, uh, and did cheerleading.

Mostly because I wanted to take dance classes, but they didn't, like, have anything besides that. Like, there was no dance team. Um, and then I have remem I have memories in high school. I would say the most disordered with, like, exercise I ever got was me and my friend would, like, exercise more before, like, homecoming or prom.

And Kim Kardashian had this series of DVDs that, with her trainer, that were, like, honestly, actually, like, I'm sure the language in them now is, like, horrible, body based wise, but they were, like, actually decent. Like, they were the first times I, like, picked up, like, I think like a dumbbell, and I'm sure my [00:08:00] dad saw that.

My dad had tried to, like, with volleyball, be like, here's some strength training you can do in the off season. And I was like, no, I need to do Kim Kardashian . 

Preston: But yeah, Kim Kardashian, she was, she was the, the true conduit to strength training. 

Margaret: Yeah. But then I did cross country in high school and I really liked that.

Again, I wasn't very fast, but it was like easy, like my family, like my parents both run. Marathons. My sister is like pretty fast and runs a lot. And then my brother like does crossfit. And so I feel like as in college and then med school and now in residency, I've had a different Like an expanded relationship with movement of like, what do I actually like to do?

Is it running? It's not really running right now for me. Um, but like similar elements of like dance and then also being like, oh, I need to build some muscle like for overall mental physical health as well as just like, I don't want to have weak bone. I'm gonna I'm like likely to have osteoporosis, but I'm like, let's try and fight that off for as long as we can.

Preston: So in part, it's it's self expression [00:09:00] and also kind of A means to preventative health 

Margaret: Yeah, I think so. At this point for me, it doesn't mean I don't have a 

Preston: picture of health 

Margaret: body image days or those concerns. Those are definitely there, but I think I've been lucky and that they've, they've never been super loud for me at any point in my life.

Preston: So overall, you're, you're happy with how you look. 

Margaret: I mean, I think I it's less that and it's more like maybe body acceptance would be a good 

Preston: kind of like you don't see exercise as a means to changing the appearance of your body rather than kind of improving its overall health. 

Margaret: Right, and I think a lot of the exercises I do, I like, like it in and of itself, like it's intrinsically motivating to me versus like the end goal of I need to be able to run this task, which is, I think, a way I used to identify more within cross country, um, or I need to look a certain way.

Which certainly as like a woman, there are glimpses of that always, but I, I also purposely don't put myself in [00:10:00] spaces now as an adult of like exercise classes where they're like, we're going to lengthen in tone first, because scientifically it bothers me. But second, because it's like, girl, let me just enjoy a workout without you 

Preston: with my sexual appeal.

Yeah, yeah, I felt that I've gone to like a spin class and been like, Okay, I, I have a feeling my partner will love me regardless. Why are we talking like this? Why 

Margaret: my thighs like that right now? I like my thighs. They're doing a good job. 

Preston: So can we take a moment to I feel like because I have some passion about this too.

Why is toning not a thing? 

Margaret: Okay, so toning is a word I think made up by the fitness industry and there are people who have talked about this better online specifically shout out to one of my TikTok mutuals, but they have the podcast fit literate which goes into the history of some of these things but toning is like This word that's only used in like female spaces, historically in fitness, that's basically is trying to connotate like getting skinnier while having some muscle tone and not making people [00:11:00] afraid of being like bulky.

Uh, and so tone is just like that. It's not real. It's not a thing that exists. There's losing fat to reveal muscle. And then there's increasing muscle size. So it's more visible. Underneath fat, alongside fat, da dah, dah, dah. Tone is is so there's, 

Preston: there's only two volumes there that exist, right? Right.

There's muscle volume and fat volume. So you can either increase muscle and increase fat, or decrease muscle and decrease fat, or any combination. So, well, I think when people say toning, they mean spot reduction of fat, 

Margaret: which is

Preston: So we don't need to go into the science of this, but if you have fat that you want to reduce on your triceps, doing tricep extensions will not spot reduce that fat. Right? Which is why. Margaret and I are unapologetic haters of the term toning. 

Margaret: Yeah. And I think again, toning is such an aesthetic specific word for women of like, like, make it look this way.

It's nothing about function. It's nothing about strength. It's nothing even about ability. And so I [00:12:00] whenever someone starts using one of those words in a workout class at my like estimation of them goes down pretty quickly. Um, I feel like we have a thousand opinions on this. So why don't we start off with one, what we are here to talk about?

Preston: So now we've kind of gone through our relationship as athletes or self expressionists with relationship with, with our, with our relationship with exercise. Yeah. Let's talk about why psychiatrists should care about exercise. So we'll take a little bit of a break. And when we come back, we'll get into. Why it matters in the clinic.

So, Margaret, I have a confession to make. I'm a psychiatrist and I care about exercise. 

Margaret: I think, well, I don't actually. So the episodes. 

Preston: Okay. So anyways, moving on, let me, let me convince you why this matters. 

Margaret: Okay. 

Preston: Talking point. Number one, exercise impacts. I can read off the run of show if I want to. 

Margaret: We have notes.

You guys. So [00:13:00] the first. 

Preston: The first postulate is that our exercise and mental health related and I think that ultimately most people agree irrefutably. Yes. 

Margaret: Yes. Yeah. And I think it's one of the things that you and I have talked about maybe think about is the bidirectional way that they're related. I eat exercise and movement and Explain that a 

Preston: little bit that bi directional relationship.

Margaret: Yeah, I mean, I think the one that we'll talk about more in depth for the rest of this episode is, is the way that exercise might help with mental health. But I think also a psychiatrist and clinicians, one of the things that we know or that is less talked about is how that there is a difference or change in energy fatigue levels and like overall, Yeah.

Somewhat body movement in different mental health conditions when they're worse. I'm thinking specifically of depression You could also think of anxiety disorders, um in terms of like restlessness pacing shaking legs um And [00:14:00] none of those right we we're talking about exercise But I think if we zoom outside of the term exercise and ask about movement and energy management overall Which is I think intrinsically what exercise is also about There are many aspects of mental illness that can change someone's ability to move or their drive to move that I find interesting.

And I think it's also something we have to think about if we are wanting to help our patients to find exercise that works to help them. 

Preston: Yeah. So when you're talking about the bidirectional relationship, you're describing exercise both as a treatment to mental illness and then mental illness as a barrier to exercise.

And I think there's almost a third aspect there, which is lack of exercise as a risk factor. For developing mental illness. So we know there's a pretty strong relationship between obesity and depression. And that's kind of one of those that also sits with the chicken or the egg phenomenon. It's unclear if there's some kind of metabolic [00:15:00] changes based on like a chronic inflammatory state that predisposes someone to depression with their when they're obese or does there's The abolition and lack of movement when someone's depressed contribute to their weight gain, right?

Or or 

Margaret: or something literally change 

Preston: their metabolic function. Yeah. So let's talk more about how this kind of breaks down in depression. And just for anyone who's, who's not familiar with psychiatry, um, what are the kind of classic symptoms of depression we see as they relate to exercise? 

Margaret: So I think that, you know, whenever we were med students and ask about there's this mnemonic Siggy caps, that is the common depressive symptoms.

It's like low mood or sadness, uh, lack of interest or anhedonia is the fancy word we use guilt or sense of worthlessness. Um, and then energy, usually lower, but there can be irritability sometimes, depending on who it is, and depression that can look sort of like an energy dysregulation, um, and then concentration, [00:16:00] appetite, psychomotor, which we'll get back to, and sleep, and then suicidality as well.

And the psychomotor part, when we think of like a classic depression, we think of something called, as Preston, maybe you want to talk more about this sort of neurovegetative state or the psychomotor slowing. Okay. 

Preston: Yes, so I, I don't fully understand how the like second motor slowing happens, but you could almost observe like a bradykinesia, especially in geriatric patients, similar to parkinson's where I'll ask patients like so good test for bradykinesia is you just have them tap as fast as they can open, close their hands as fast as they can.

And you'll see like pretty market differences. So they're almost like kind of yeah. It's just like they just, they're like, they're moving through molasses. And another thing that's really interesting to me is that in addition to having this inability to move their, their body with the same thrust that they had before, they [00:17:00] also like have trouble paying attention to their environment and kind of viewing things around them.

And so I think a lot of that has to do with suppression of. We know what affects dopamine pathways in the, I would say like the anterior and posterior cingulate cortex, and it has something to do with like post synaptic expression of 5 HT2A receptors. It's about all I'll say, because we don't really know what else from that.

We know that, hey, when someone died and they had depression, they have more expression of these 5 HT2A receptors, and We prescribe medicines that block them and they treat depression, so maybe it has something to do with that, but it could be it could all just be red herring and have something to do with something else 

Margaret: and then to take that, you know, so there's like the neurobiological aspects of that that you were explaining and then from the kind of psychological Aspect, which these things are not actually separate again, different lenses.

Just look at sort of these different phenomenon, but there's the slowing and the, and the, like the physical sense of that. But there's also like, as you might imagine, as any of [00:18:00] us can imagine, or people in health care, if you've been working a week of nights in your 

Preston: interruption brought to 

Margaret: weighing in, she's like, I love movement.

Uh, but The different parts of depression, right? So the decrease in energy and in the increase of fatigue, the lack or increased like the chain, the dysregulation of appetite. Um, also the sense of guilt and worthlessness and then not enjoying things. As you can imagine, all of those things are probably going to interact with your ability to go for a run or enjoy going to the gym.

Um, yeah. All behavior is driven 

Preston: by, like, if you break it down, it's driven by seeking out a positive feeling or running from an unpleasant feeling. So, If you can't feel pleasure anymore, the positive feeling you get is like that incentive is decreased, right? So you have less, you have less of a drive to go work out.

And if you feel guilty all the time and you feel hopeless, then maybe you don't have any optimism that This action will [00:19:00] extinguish the negative feeling. So now there's no reason to whereas 

Margaret: to put a body image lens also on this that if you're someone who has dealt with like fat phobia or other things to make you dislike your body exercise in and of itself can be complicated.

And if you're depressed and those feelings can be stronger when you're depressed or more anxious because they happen at the same time, understandably being more present to your body to then is going to be harder. 

Preston: Yeah, and I think one thing that people don't acknowledge about guilt when we think about how it affects our illness is that is this feeling that people deserve the station that they're in so the the idea that I deserve to look this way.

Is it almost a direct extension or manifestation of guilt, which is going to be a barrier to someone wanting to change how they are? I, you know, I think, and just in general, this is a hot take that I think we can [00:20:00] kind of ask about guilt pretty generally, like, do you feel guilty all the time? And I think a lot of people say no to that.

But then you ask them if they deserve what's happened to them or if like, they think that things should get better. They're like, no, like, it's my fault. If everything happened and they don't see themselves as like the villain, but they feel it. They're not worthy of a better existence, which is the self 

Margaret: criticism is super strong.

And especially if you're struggling with anxiety and depression at the same time, having that kind of running critical voice. It makes, I think can really impact whether movement has a possibility of even being possible or feeling good. So there's, there's all of these parts that we're talking about of depression and anxiety, which we're talking about because depression has the highest kind of, um, and we'll cite this in the resources.

But depression, I think at this point, at least this was maybe as of 2020, so it could be different now, but has the second highest. Rate of kind of [00:21:00] years lost disability kind of illness years, at least in the United States and and broadly, I think worldwide. And then anxiety is the most prevalent in the United States.

Preston: I think it's like an estimated one in four have some sort of anxiety traits or or symptoms. And I think we have. We have like 15 to 20 percent diagnosed and we estimate that when we're undiagnosed. Right. Um, and I think I, so I just took pride the in training exam last week. Yeah. 

Margaret: And, 

Preston: uh, I think that actually came up to depression being like the largest source of disability adjusted life years.

So it's, it's regardless, this is a significant burden. And I think when people identify obesity as an epidemic in the U S they kind of forget that, like underscoring all of that. is the ability to fight obesity or to the things that may be tied very closely to it, which is mental illness. 

Margaret: Right. I mean, and, and the reasoning for that mental illness, we, I want to clarify, we do not [00:22:00] necessarily know.

I also just want to state that there's a lot of fat phobia and bias in the world that may also be a kind of variable that impacts mental health, given like existing in a larger body. So just want to earmark that as well, cause this is, we're, this is a complicated topic. 

Preston: Thank you for the nuance. 

Margaret: You're welcome.

Uh, but. I think what might be helpful for us to talk about with this with depression now is to kind of move into the second part of like, how can exercise help? Let's stick with depression. And then we can touch on anxiety a little bit too. But I think depression is a really hard. I think it comes up a lot that like exercise is good for depression clinically, but then Depression also, for all the reasons we've just said, can make access to exercise super, super hard.

And so I think talking about this, a lot of this applies to other mental health concerns too, as well as like schizophrenia and bipolar. Um, but obviously there's different considerations, but in general, I think a general thing we could say [00:23:00] is exercise is probably good for the brain. How much, which kind, and to what intensity we will talk about is a little bit more not yet clear.

Preston: Yeah. So I think. 30, 000th of you. We know that when you exercise aerobically, you release, um, brain derived neurotrophic factor. And we know that other factors like that or similar ones have direct effects on neuroplasticity. So they can affect our expression of acetylcholine receptors and hippocampus, and they can modulate how we affect our mood.

That's about it. That's like, I can't go into any more detail as to like the specifics, but if all you need to know neurobiologically about exercise is like, if I exercise, I'll release BDNF. And that's going to have a lot of positive effects on my brain. Um, like another thing that can affect it, our BDNF is something like ketamine, which we actually see almost like overnight differences in people's affects or their depressive symptoms.

But outside of the kind of vague biologic, [00:24:00] wait, 

Margaret: wait, wait, before we move from the biologic, I do want to say that there's this book that I highly recommend. That's, um, the joy of movement by, I think, Kelly McDonald, uh, and it's a book that goes through different parts of, of why exercise helps people. And it's like kind of a social study as well as some of the neuroscience around, um, um, Why like different exercise helps people both sociologically anthropologically, um, kelly mcgonigal phd, uh, the joy of movement, but so 

Preston: strong name kelly mcgonigal, I 

Margaret: know great, great researcher name, but in the book, they various parts of it going to different communities, but they also talk about the neurobiology, which again, there's a lot that we don't really fully concretely know yet, but just the profile of exercise across kind of neurotransmission and neurohormonal like Components is fascinating and buried and I, I kind of nerd out on that and I think Preston you do too, but I just want to say that that I'm excited to see where the [00:25:00] science goes on that.

I'll have 

Preston: to read that. Enjoy movement. Yeah, it's a great. Okay. 

Margaret: Um, but we neurobiology. I just want to flag that. 

Preston: Yeah. So now we have like a whole Psychological aspect of why exercise is helpful. And when you get down to brass tacks, I think about depression a lot of times as someone's loss of purpose and loss of loss of structure and loss of belonging.

Those are all intertwined depression. And one of them can be the primary driver from a psychological lens. So Weirdly enough, a workout class is a great antidote to a lot of those things. People build a lot of community around their workout classes. So I was an F45 trainer for a while. And that's 

Margaret: a fun fact unlocked.

Preston: Yeah. So shout out to Kira at 45 Chapel Hill. If she ever sees this, Kira is so good at creating a sense of community. Oh, that's like her whole thing around the program. And she [00:26:00] Writes everyone's name down. She, she's so socially inclined. Like I remember I went just as a guest the first couple of times and she remembered my name weeks later when I showed up.

I knew you were a track athlete. How are things? I was like, Oh my gosh, thank you. Yeah. And she, she gets gifts for people when they come to their hundredth class. She makes little gift baskets for them. She always make sure to take their picture and include them in the Instagram. And then they host like.

Movie events and other things outside of fitness for this. So community is really big for them. And so. Someone who's struggling with their belonging, 

Margaret: right? 

Preston: Rather than exercising of itself. Neurobiology biologically, but it was a it's a vehicle for them to find people with similar interests. 

Margaret: I think another one that related to group exercise or whatever.

Transcribed I think obviously it can be done individually, but, or with things like personal training or taking classes that are maybe group fitness, but also things like, like martial arts or [00:27:00] climbing or dance classes where you like build a sense of a skill that you enjoy. So the sense of like mastery in one arena can kind of lateralize to other parts of your life or kind of increase the sense of like an internal locus of control in a small way.

And I think exercise communities can be. A really big place like that is also very helpful in terms of your, the meaning and things that you were talking about, as well as like positive structure, like wanting to progress in something 

Preston: in addition to the. Desire to progress being a form of structure.

There's a schedule around it. 

Margaret: Yes. Yeah, 

Preston: I Want to show up on Saturday because I'm gonna see people so one thing I've been doing recently is like a run club every Saturday And so I have friends that I know Our main form of like interaction is at run club on Saturday because we're both on busy rotations Everyone's kind of stuck, but I know like Teresa needs to get a run in in the morning.

I do too So I'll text her on Thursday, like, Hey, you're going to run club. Yeah. So this is, this is like my [00:28:00] chance to have a schedule and I have now like external accountability for socializing, which independent of exercise, socializing has a lot of value in helping with, um, with depressive symptoms. 

Margaret: Yeah.

Preston: Finally, you brought up like self efficacy as a huge portion of this. So I talked to the beginning about your sense of value being one thing that's lost and it's really easy to kind of build it up, not, not even in the context of your body image, but just like, Hey, I could do this hard thing, I can accomplish this challenge.

Margaret: Right. Well, in the overlay of that, I think one of the things that's interesting and there's this, I'm not going to, we'll put in the show notes, but like there is this one training med psych. Trauma informed weightlifting that they've been doing studies on. I think it's in the Massachusetts area where they've been doing the research on this.

But basically, I've mentioned that because the other thing I was going to say that this is true for anxiety, maybe even more than depression. But the idea of [00:29:00] physiologic distress tolerance, um, and kind of An exposure and exposure therapy sort of way, um, through exercise. So like when you go running, you might feel your heart racing.

You feel sweaty. You feel all of these things that you might also feel when you're having a panic attack, but your brain and like there's a different context. There's also a sense of building tolerance to that feeling. So just going running doesn't necessarily feel like the panic attack, but it has components of it so that the next time you're having the anxiety, there may be a part.

I think that there's research emerging around. Yeah. Okay. Whether this tolerance of this physiologic pain and distress to a certain extent that's helpful, similar to an exposure therapy. We're not just going to lock you in a room with snakes as your first session. But that this built up tolerance of that can, can create a broader sense of sort of well being a reduction of sensitivity to anxiety, which can be true.

And, you know, can be true in weightlifting. It can be true. And I mean, that's also true for like the first time you go to a workout class or a run club and you're kind of [00:30:00] like a social anxiety exposure. 

Preston: Yeah. I mean, that makes sense. Like a lot of running for me has been progressively teaching myself to handle more uncomfortable feelings.

And if. You're exposed to a heart rate of 180 in a totally benign context. I can see how it'd be easier to handle that when You're in the throes of a panic attack or something else or how you're like, oh, I've experienced this fast heart rate before I know I'm not gonna die 

Margaret: right 

Preston: because I've done it when I was running the 5k that makes sense Oh, yeah, and it's really interesting 

Margaret: reason to you're tolerating it for something that's meaningful to you, right?

Which I think is One of the things I really like in acceptance and commitment therapy or like including exposures within that is we're not just causing you pain for the sake of pain, like to make you have a better pain tolerance, because to me, that's kind of meaningless. And to patients, that's kind of meaningless.

But if you really think that it's like, Preston knows this, I'm not wearing rollerblades right now. Joke, [00:31:00] that's a side. Um, but I'm trying to learn how to roller blades. I've never been able to, and it's scary and I have weak ankles and it's kind of painful at first, but it's so cool to me. And I've thought it's so cool for so long that if we can connect movement and exercise for people to something that they think is cool and, and gives them value and creativity, then.

That is another positive in their life in addition to exercise itself. That's 

Preston: kind of how I feel about smoking cigarettes. , like what? I so bite. Because I, because I have, I have asthma, you know? Okay. So I have to continuously increase my tolerance to them. 

Margaret: I also have asthma. I've 

Preston: never smoked a full cigarette.

Margaret: Exercise induced asthma warriors raise up if I 

Preston: wanted to. It would be kind of with the similar tenacity and structure of someone who's learning to run a 5K. So now we can transition into eating disorders. And exercise because now we see there may be some negative aspects of exercise as they fold into these types of psychiatric [00:32:00] illnesses.

So people with body dysmorphia can use exercise almost as a means of purging or suppressing their weight. 

Margaret: Well, I want to even like back up outside of a specific diagnosis because I think sometimes we hear diagnosed like I don't have that. So it doesn't apply to me. I think what you and I both talked about is the pros and cons of our own relationships with exercise, um, and kind of go in psychiatry, we give something a name and a diagnosis when it, you know, is Enough of outside of the quote unquote norm that it's disrupting function, but if we think about it as a spectrum of a positive versus a negative relationship with exercise and recognize that there can be in between the spectrum, I think it can give us a conversation.

And so, what you're saying with body dysmorphia or body image. Um, but if we think about the spectrum of like healthy use versus maybe less beneficial use of exercise, 

Preston: I'd say adaptive use [00:33:00] versus maladaptive use. 

Margaret: Yeah. Yeah. Um, and so one of the things you're saying is like as a mode of purging, which is true, definitely on this more intense, I jumped 

Preston: right to the extreme, 

Margaret: but that's okay.

I mean, I think it helps us to walk it back to. Yeah. And so, so 

Preston: it's actually interesting. Um, as a med student, uh, I worked on a project to kind of define What makes exercise unhealthy. So there's, there's compulsive exercise. There's exercise addition addiction and there's like maladaptive exercise and not a lot of them have these like well defined names.

So a lot of different papers don't have any consistency between trying to assess or even like measure what is unhealthy about someone's exercise. And so they have a lot of these questionnaires that basically ask Do you feel guilty if you don't exercise, do you feel compelled to exercise if you go multiple days without doing it or and then to the even the farther end of the spectrum, do you neglect relationships or other things in your life because of this need to [00:34:00] exercise kind of 

Margaret: an adapted addiction screening or substance use screening pretty much like a 

Preston: substance use disorder screening and then replaced alcohol with exercise and I think there's a lot of those that I felt have been a like part of my life.

Like I, I definitely feel guilty about not exercising if I go two days without doing it. And I think I, I wonder like how adaptive or maladaptive that is because I do have a lot of positive reasons why I want to exercise. I know it's gonna make me feel good. I know I'm going to sleep better. I want to get stronger, but also Kind of feel like crap if you don't and not not in like a physical way like not just in a way but like I'm I'm bad for not working out 

Margaret: where it's it's something more and it's interesting because I think an example of this will not that not to be like I'm such a healthy exercise relationship, but I just, as you know, I just got off of like a month of fellowship interviews and being gone over the weekends and like kind of [00:35:00] intense clinical time, just like being able to balance everything.

And so exercise was like, went from being something I do on purpose, like four times a week to, I guess I'll like to kind of like, Oh, I guess I'll walk to work today. And like no real formal workouts, maybe I went to a workout class or went on a walk with people, but like sort of fell away from me for the last month.

And like this week now I'm. Getting like back into it because I have time again, but you're saying something of like, maybe there's less of that flexibility at least for you in the past of where does like if you think of what your life stress cup that has you stress as in positive stress and negative stress, whatever in it, even when it's like really full for whatever reason, I think of like being on nights or being on surgery when you're a med student, Even then it's hard to have the compassion to say, maybe exercise doesn't look the same here and that's okay.

Cause like my other values in life right now are more important. 

Preston: Yeah. And then for me, it's always been pretty inflexible. 

Margaret: Really? 

Preston: If you didn't [00:36:00] go to the gym, you're a failure or if you didn't go for a run or something like that, 

Margaret: you didn't smoke a cigarette. 

Preston: Yeah. Like pressing 5k today because you weren't able to get down that pack of Camelbacks

Margaret: cigarettes in my life. 

Preston: I don't I don't know. I don't know these brands of cigarettes. But yeah, so and I think that's been something I've been trying to work on. It's funny like I. I spent a lot of time in therapy disentangling my relationship with academia, like if I don't, if I fail this test, I'm not a failure, like I don't become a noun.

But then like me and my therapist totally skipped over all that, all the like athletic stuff and the exercise. You're like, 

Margaret: don't worry about that. That's super cool and not weird at all. Not worried at all. 

Preston: Yeah, but I will say, um, and when you look at the lens of maladaptive exercise, one thing that's helped me has been staying away from these.

Rigid goals. So I think some people will identify and as you see, it's a lot come up in eating disorders is a number on the scale [00:37:00] as the specific goal or something they're trying to shoot for. And that's I refuse to weigh myself. I don't try to go in that context at all. And I think I just kind of see getting to the gym and working out hard as like my end, my end goal.

And if I've done that, I've succeeded, but I have the 

Margaret: process over the product. 

Preston: Correct. And I'm not just yeah. Measuring it based on what I see on a scale in the morning, 

Margaret: I think you have to ask yourself if at any one of a one time in our lives, right? Like you and I are doing this podcast right now, which means we're not doing 1000 other things that we could spending this.

We could be spending this hour doing similar with exercise. It's a great thing. There are a lot of great things in life. What are your values and how does exercise fit into that? To, you know, like the one where, the question on the adapted, like, substance use screening of, does it prevent you from seeing people or going to meaningful, like, functions?

Or have you gotten in fights in relationships because of it? Like, [00:38:00] do I have to go to, go exercise for an hour and a half when a friend really wants to talk to me on the phone and Realistically, I can only do one or the other like, okay, well, if I come down and like, obviously, some of the starts with also being like, none of these define who I am.

But the second part being, um, how do I operate in my values today? And can I go to exercise class another time this week or whatever? Um, but like knowing that our time is a, is a value sort of decision and, 

Preston: you know, and to be, to have the balanced view of yourself that I'm someone who hopes to exercise and also has times where they can't, 

Margaret: right.

And I have 

Preston: this like black and white view of myself where I'm like, I either exercise or I'm filled. 

Margaret: Yeah, that's that's tough to navigate. Yeah, it's really 

Preston: hard to just operate in between those extremes. 

Margaret: Yeah, 

Preston: I know. I think it's really important. I'm being hyperbolic here. Like having self compassion is so helpful to to navigate your value system.

I think some people that don't [00:39:00] have that. Range of black and white can can set these rules up that like I'm a failure if I don't achieve X number on the scale or lift this much or run this time, 

Margaret: and it's also like in our culture, like if you think and I love these movies like I love, I love the like, you know, black like the uh, But all basically boxing movies like I love the like sports movies where it's like someone pushes themselves and you see the like montage of them like going to the gym and getting stronger and then the superhuman 

Preston: montage.

Margaret: Yeah and so it's like I and again I don't think that that. On itself is like bad, it's just bad when we become blinded by it. So, but we have this fantasy in our culture for men. It looks like a hero's journey of like getting so strong that you're like invincible for women. It looks like becoming the perfect kind of like desirable object in some ways, or at least it has historically.

Um, and those stories like poison us in some ways. Like when we go towards exercise, it's [00:40:00] not okay for you to just like. Okay. Like I have to, you have to go to the gym because you're going to like lift the heaviest thing ever, rather than just like, I like hanging out with two of my buddies and like sweating makes me feel good.

And this is probably good for my bones like that. Those aren't like ideal enough in some way in our culture. 

Preston: Have you ever heard of the term orthorexia? 

Margaret: I sure have. Why are you telling me about 

Preston: it? So this is interesting. It's not in the DSM here in the US, but. Um, I was working with some researchers in Norway and Finland and they said in their equivalent of the DSM Orthorexia is actually a diagnosable condition there.

Mm-hmm . And so it's basically, uh, for those who don't know, orthorexia is the obsession with healthy or perfect eating to the point of creating restrictive behaviors that cause disorder on your life. Mm-hmm . So I, I think. In layman's terms picture an almond mom who is so obsessed with not having any kind of processed food or unhealthy food that it actually is like [00:41:00] confining her diet and making things unhealthy or like Other people in their lives and the same can be for like the gym, the gym, the Silicon Valley gym bro tech boyfriend who like refuses to let a car go into his salad and and and then they like our B12 deficient or they have like such such little fat in the base of their feet that their their bones.

Like grinding on the sidewalk, they can happen. I don't know. So in bodybuilders, when they go through cuts, they, they have such little fat on like the parts of their body that they said it hurts to walk on stage, like to walk barefoot because it's just like basically their joints pressing directly against the ground and, and these, and then the other thing is that the exercise can be unhealthy when um, It's aesthetically driven.

So people in these health spaces that look like super fit and have like 5 percent body [00:42:00] fat also may be using things like anabolic steroids and creating unhealthy standards and then are paradoxically making themselves less healthy. So classically, you'll see someone who looks jacked out of their mind.

They have 4 percent body fat. They can bench. 415 pounds, and then they also have an ejection fraction of 35 percent or 

Margaret: you see like one of these like, and I will say, I think there's been more openness about this on the like female identified side of fitness, but it's still quite bad of like, you know, your favorite workout influencer.

Like if it's hard for. Some slash maybe many women to have a six pack and still have their period and if you're not menstruating for the reason of like under nutrition, then there are other things that are also happening to your body. The most not the most concerning, but one that I am the most concerned with.

Often [00:43:00] is bone health because bone health is hard to get back once you are outside of a certain age range where it's the most building up, which is usually before the age of 30, which when are eating disorders or when is this more like even outside of again outside of a diagnosis, but just behavior because you can.

Do a whole lot. I mean, I think of like time. I mentioned the like Kim Kardashian workouts before prom or homecoming of you know What is normalized that like the lunch table or you know Preston you mentioned like what's normalized on the track team in college? And you you just can't even see what it is Unless it's extreme and then it's some that person has a disorder but not me 

Preston: And so to clarify if if you're not getting your period that's a sign that your HPA axis Your hypothalamic pituitary axis is off, and then you're not producing estrogen and estrogen is what's necessary for bone growth in these individuals.

Margaret: Yeah, I think it's a little more complicated than that. We're not, we're not doing that. Although I do think doing a what is cortisol episode would be [00:44:00] interesting. But yeah, and or there's also reds, which is relative energy, I think deficiency syndrome, which is present in a lot of athletes, especially female athletes, um, that it's like for, you know, Like college girls on the track team, like they need to be eating more than the person who's not doing high intensity exercise for 2 to 3 hours a day.

But there's still this kind of like normalized diet and hopefully this is getting better. You know, I think there is many more conversations about this than there used to be. But 

Preston: so in college we had a physician who would Talk with us every three months about this actually. 

Margaret: Wow. 

Preston: And he'd be like he would he would bring up the female athlete triad Which I believe is Osteoporosis or osteopenia amenorrhea.

I don't know what the third one is 

Margaret: Yeah, I don't 

Preston: not not eating enough. I wasn't I was a male athlete. So I was like, Oh, that's right. Yeah, [00:45:00] I was interesting though, because I remember a lot of people resented him. A lot of the like women on the team resented him for it. And I think he kind of saw it as like, my priority is to make sure you guys are healthy and that you don't get the stress fractures because a lot of women got stress fractures on the team.

I'd say like a high ratio than men. And I think it didn't make sense to me at the time, and it kind of, after going through medical school, seeing things like REDS and HP Axis Disruption made more sense to me, but they, the athletes almost saw him as like another barrier to them performing the way they wanted to, so it's 

Margaret: Well, and there's such mixed messages, so it's like, I'm sure the coach though, because I remember even in cross country in my like midwestern school, the like really good runners, which I was lucky to not be one, so I had no pressure, I was like, I'm doing it, I'm breaking seven minutes, uh But I remember there was still this mythology.

That's like the lighter weight you are, then the faster you'll run. And it's like, well, yeah, you're good. You're gonna be lighter weight, but you know, you're gonna be weighed down by the boot for your stress fracture that you keep getting. Like, you're not gonna make it [00:46:00] to November if you're not eating enough for your bones to take the impact.

Preston: Yeah. And like some of the some of the fastest girls on the team had more muscle and it was. It was like kind of challenging. Cause like, and the same on the, on the guy side too, actually, there's these like kind of big bulkier guys and they were able to run the 10 K. 29 minutes, 28 minutes, which is like N C double A, like almost like all american level.

And then there's like other dudes that their strategy was just to restrict more because if I'm lighter than I can run farther and then they'd end up running worse times. So even even at like the highest level, people will buy into that mythology talking like division one cross country athletics and still 

Margaret: still end 

Preston: up with a negative outcome.

Margaret: I think we can also recognize that there's like again, there's a lot of decisions to be made. Okay. Around performance and that there may be like slight slivers of truth to some of these things and certain really specific [00:47:00] settings much more than the mythology makes it seem and there's the question of like, do you want to run well for a season or do you like how much of your like, let's say that that myth that that was true, right?

What if, if you could, I feel like something I would hear people thinking or talking about would be like, well, I don't care what my bones are like when I'm 45, I just want to run as fast as I can while I'm doing this. Now, I'll deal with it later, which I think is not an uncommon kind of view. 

Preston: I don't care if I die when I'm have a heart attack when I'm 60, I want to look jacked now.

Margaret: Yeah. So that's, yeah, this is like this topic. We're talking about how good it is, but also that it can become, it can be or can become, especially if like, you know, I think about in the eating disorder world that there's conversation around, you know, what are the things that not cause, but like what, what correlates with an eating disorder.

And one of those things is when people get like a GI illness or they have for some reason, or if they like have type one diabetes and for whatever reason, um, Even with sickness, they lose weight [00:48:00] and then people start noticing and complimenting it and I think about this also with someone starting an exercise routine is like, where are you at with your body image?

And if you're talking with your clinician, do they know that? Because if you're someone who struggled with disordered eating in the past, and maybe you were fine with exercise, but then you take on exercise and people start noticing and complimenting you, it can be a real trigger to have more of this rigidity come back on.

Preston: Yeah, it's, it's like. It's reinforcement for the unhealthy thing. 

Margaret: Yeah. 

Preston: Like I'm getting social praise for having food poisoning or like a parasite. 

Margaret: Right. Yeah. And kind of like the social praise, understandably feel so good, especially depending on, you know, what kind of body you're in before, I 

Preston: mean, I mean, who doesn't like social praise just, yeah, no, it's true.

So, so reasonably someone would, would hope to, to modify their behavior to support that. So, so now we're kind of looking at [00:49:00] mental health as being treated by exercise. What is there a best form of exercise that we can use? 

Margaret: Yeah, so that's a complicated, there's a complicated answer, but I think the answer is freeing in that it is complicated, which is that there's a lot of different types of exercise that can help your mental health.

One of the best studied or most frequently studied has been aerobic, um, but there are now studies around like weightlifting, resistance training, and like forms like yoga or Pilates and mindfulness, which is one part we didn't mention is that like mindfulness. As an intervention in itself helps with depression and anxiety, um, done correctly and that there can be a component of that and exercise forms as well.

Um, in terms of 

Preston: I was gonna say, and then I think cardio. Lead the pack unintended because it's really easy to measure those right 

Margaret: and it requires logistically Like sort of less facilities, right? Like if you want someone to like deadlift a 200 pounds or 300 pound [00:50:00] whatever like that requires things Whereas if the study is 30 minute walk outside each day, 

Preston: correct 

Margaret: Um, the, the part about how much and then the question of intensity, I think is also interesting question.

So all of this is to say is to moving a little bit more if you're not moving very much in a way you enjoy and in a way that you can slowly build up and it doesn't and it doesn't interrupt these other positive aspects of your life that impact your mental health is probably going to help out.

Concretely, I think that there's some reason to, I think there's different studies on different interventions and then you ask about effect size. So maximizing somewhere between probably like 90 minutes a week to 150 minutes a week on like the cardio studies, which is also the, um, 

Preston: it's the American health association guideline.

Margaret: Yeah. Yeah. For heart health, which I think that one's more informed by heart health. But like, I think in this case that can also be good, but that sounds like a [00:51:00] lot, right? 

Preston: So what is that? 150 minutes. What does that come out to? Uh, an hour, two and a half 

Margaret: hours, right? 

Preston: Yeah. So two and a half hours. So if I work out an hour, Monday and hour, Wednesday and hour, Friday.

Margaret: Right, that's moderate walk for 20 minutes after dinner while you call your parent or while you are with your kid or what, what have you or your that also 

Preston: like, how do you define moderate intensity exercise? I think it has to do with whatever rate 

Margaret: of perceived exertion. 

Preston: Yeah, our PE. Yeah, exactly. And so I think it has to do with your heart rate reserve as well So I think it's like if you get into a level three 

Margaret: Yeah I think the way that a lot of places talk about this the zones of heart rate is The like kind of talking and breath test during it.

So exactly Walking slowly where you're like, I can talk. No problem is like light or sort of like [00:52:00] 

Preston: so moderate is like barely can have a full sentence. 

Margaret: It's like I can talk to you, but I'm going to be kind of puffy. I'm going to be like, yeah, that was that was a really great point. You made, Preston. And I was like that.

OK, yeah, I can 

Preston: feel it. So I guess the reason why I'm getting granular about this is like, let's break down like what it would actually look like to meet this. Yeah. A goal. 

Margaret: Do you try to meet this goal in your life? 

Preston: Um. I guess I exceed it. So I the other option is 75 minutes of vigorous exercise, which that's the point where you can't really talk, I guess.

Yeah. So I have a soccer game every Wednesday night for about an hour and a half or an hour. So it's about 60 minutes of vigorous exercise. And I go to run club on Saturday morning. Just about 45 minutes to an hour of moderate to vigorous exercise. So you've already 

Margaret: met the 75 minutes. And then I 

Preston: might lift another day or so in the week.

Another day or two, which, which I, I try to make it moderate, but then, you know, you get in the bench press and you just think about how much you hate yourself. And then it becomes vigorous exercise. [00:53:00] Yeah. So. Yeah, I think that that's like realistic for me, but even let's say you couldn't do it. You didn't have a soccer game or run club.

Like, how could you accomplish this? 

Margaret: Like, if you if I was, let's say, okay, so those are kind of the, I will say, I think, like, overall health wise outside of mental health, the ideal is sort of that you're lifting heavy things a few times a week with some regularity to build up muscle to help bone strength.

And also there's some kind of interesting research around cytokines and neurohormonal regulation via BDNF through resistance training as well. So I think that that is in line with Mental health too. So let's say a couple times a week working most muscle groups in a way that is to failure. Um, and then heart rate getting some like 150 minutes is like the ideal, but let's say 150 minutes.

Most of that is kind of this sort of moderate, like walking, dancing, biking, like it's a little tough, but you're not like gas during it. And maybe a couple like spurts of high and higher intensity for like 20 minutes of that a week. [00:54:00] Um, so it's sort of the ideal, but I think one of the things you were getting at Preston is how do we start this conversation with a patient?

Or like, what if they were interested in this? They're like, you know what I did, you know, I used to play soccer when I was a kid and I liked movement. I like this, this and this. Like, I'm curious how you would go about starting. Let's say you're an outpatient and you're like, I'm going to see you in a month, but we'll see how that increase on the Zoloft went.

And I'm going to ask you, this is something I often do is I keep this in my like lifestyle factors, part of my note and I'll say, Hey, This, this, this and this, like I'll have like subs, like not substance use disorder, but like substance connection, hobbies, meaning, making exercise, sleep, things like that.

And so if I say exercise, I'll be like, okay, I'll ask about it in a month. But I'm wondering what that would look like for you. 

Preston: Yeah, it's funny you should say that because I have a, my therapy panel, I'll go through exercise with my patients and I often use sleep as the first way of kind of like bringing up exercise.

Yes. Because [00:55:00] sleep. Is like sleep hygiene is really hard to pin down for people, but one thing that you know is if you work out hard during the day, you're gonna sleep so much better, right? And it was funny because, like, I knew that, um, like didactically, but the time I think it was really hit home this last year.

I'm trying to think about how to help my patients with sleep. And then I went on a like a 20 mile hike in mammoth and we were backpacking and And it was like, terrible ground is cold. I'm sleeping on the rocks. And I slept so freaking well, . I was like, oh my God. 

Margaret: Like is this something? Well, it like, I hiked, I hiked 

Preston: all day and I was just freaking out and like my friend Trevor was with me and his watch was recording sleep.

He was like, yeah. It said like, I, I hit like deep sleep, highest quality within 30 minutes. And so I think the whole time I was walking back down, I was like, honestly, exercise. It really helps. Yeah. Yeah. And so it's funny because that one for being, I guess, an on the car in the back of my head and now something when I ask people how their sleep [00:56:00] is like, Oh, it's, you know, it's kind of, it sucks in this way or I have trouble falling asleep or I'm antsy.

I kind of, I use that to say, well, how do you exercise and then how, and then I kind of. Almost really exercise as a means of helping with their sleep at night, because I think just about everyone can get behind sleep, 

Margaret: right? 

Preston: Right wanting to sleep better and I think it's so much better to do that than approaching it through someone's body image because totally 

Margaret: yeah I really hope people How do you do you feel like you're ugly?

I have a solution for you to my depression. That would be crazy. This is the 

Preston: It's the classic like 1980s like cardiologist approach, which is like you're going to have a heart attack. You don't freaking exercise into 

Margaret: people to exercise. 

Preston: And then they're like the patients on exercising and they go back to their attending.

Like, did you try shaming them harder? Tell them about how they won't be at their daughter's wedding. If they don't exercise, scaring 

Margaret: them more. Also, your cats are fighting in the background for anyone watching the video.

Preston: Okay, they're playing, they were playing chase earlier. One of them just hit 

Margaret: the other one. They're getting, 

Preston: they're getting their moderate exercise for the week. They are 

Margaret: getting their [00:57:00] movement in for the day. Um, so 

Preston: I, I, I try not to shame them. And then I use it, I use sleep. And then the next most important thing I would say is smart goals.

We love a 

Margaret: smart goal in this house. 

Preston: Cause the amount of times, like I'll be in a primary care setting when I'm like rotating with family med or something, and someone wants their goal to be like, I just want to exercise more. I'm late. 

Margaret: What does that mean? And I want to look better. Yeah, yeah, 

Preston: exactly. Like, and I want to write more, 

Margaret: right?

Preston: Neither of us are going to be going to accomplish that. But if you sit down and say like, okay, what does exercising more look like? And I make a small goal of 20 minutes a day on the treadmill, Monday, Wednesday, Friday. And then I'll try to get really granular with them. I'll say like, what, what are we going to set the angle of the treadmill at?

What speed or is it going to be set at? 

Margaret: Yeah. So. Yeah. 

Preston: One thing I've adopted sometimes is like the 12 330. Have you heard of this? 

Margaret: Yeah, but that's like a really hard one. And if you're having people do it, 

Preston: it is hard. Yeah, I do. I do it myself. Hot girl walks 

Margaret: mentioned heard. 

Preston: So I'll do like a [00:58:00] modification of that.

I'll be like, okay, set it to, um, you know, an angle of six. One and a half miles an hour two miles an hour and do it for 20 minutes I don't be like watch an episode of the office or something and then they're like, oh I can do that and then like I think the more details you give to someone the less uncertainty they have about accomplishing it or or even like Telling someone to join a soccer league or something can be like one of our therapy goals if they're looking at finding that community So that's kind of how I approach exercise.

I guess no, I 

Margaret: think that's awesome. I think I approach super similarly I think also like Yeah, taking out as much barrier as you can, especially if you're someone having this, like there's benefit. And I think also from us sharing our backgrounds, we have very different backgrounds, but both of us have a lot of experience of being in movement or exercise or sport communities and therefore having like kind of an easier on ramp onto exercise.

Like it's so hard if you're someone who's never been to the gym before, like it was like, and so much of that is [00:59:00] also in. Your childhood, not just it's an intimidating 

Preston: place the chain, 

Margaret: but even like going to a soccer league or going to a run club or like. Trying these things out and as we talked about with like the internal narrative around these things, it can be really hard if you're like, I'm someone who's not an athlete.

I've never done this and it's too late. And I look embarrassing and everyone's looking at me. Um, so also again, making it the right size exposure is something I think a lot about in my therapy cases. And I think about with exercise too. So someone's never been to the gym, but if they sort of like dancing, then like, yeah.

Or they sort of like stretching, then maybe I'll tell them to try a Pilates like YouTube video, or I'll be like, have you heard of the fitness Marshall, who is been my favorite dance, like exercise instructor for forever. And it's like millions and millions of videos or views or whatever on YouTube, but making things.

As straightforward as possible and then kind of measurable, like you're saying, and then I also will step people back because I feel like [01:00:00] people normally say something to me, like, Oh, I can do this, this and this. And I'm like, that sounds like a lot. Like, what if we made it? So you thought you felt like you were 100 percent sure this would happen before I see you next.

And what does that 

Preston: amount look like? Yeah. Going, going to salsa dancing on Tuesday night. That's it. 

Margaret: Which would be awesome. I think. Yeah. Yeah. 

Preston: That's the only goal rather than I'm going to go to salsa. I'm going to go to Pilates. I'm going to lift right start. Changing my diet as well, I think I found like when with those types of goals, the lofty goals, the second you start to realize that you're not going to complete it, you just give up right together.

Margaret: And that, like, recognizing that thinking about movement in a different way, similar to thinking about anything in a different way, takes a lot of, kind of, reps or walks down a new neural pathway. If we've always thought one thing about movement, or if we've gone to the gym a hundred times, like, while berating ourselves and being like, pain means you need to push harder, it's going to take some time, some reps, behaviorally and psychologically, for that to feel different too.

But just because it doesn't change [01:01:00] quickly doesn't mean it doesn't change. 

Preston: Yeah. And I think that that's something that I say to my patients, too. I'm like, if you like workout today. What's what's gonna be different tomorrow? Like probably nothing. I'm like, you're right. Probably nothing. 

Margaret: Yeah, 

Preston: but you keep doing it and it becomes a part of you.

Then it changes. And there's a saying that the man who loves walking is going to walk farther than the man who loves the destination. 

Margaret: Yeah, yeah, 

Preston: yeah. And so so really just trying to get people to like walking and then and with that goal setting, I guess I like to add I'm really against any kind of Goal setting around weight.

So if I don't think 

Margaret: even health behavior that is even indicative for like, 

Preston: yeah, please throw the scale away because it doesn't make sense. Like, I'll ask, like, so your goal is to weigh 100. Like, yes. And I was like, why? So I look a certain way. I'm like, so is your goal to weigh 100 or is it to look a certain way?

Oh, and the problem [01:02:00] with making a goal numerical like that is As you approach that number of 100, you're like, well, now what? Oh, let me lower the goal to 90. Let me lower to 80 lower to 70. And so it's not, it's not scalable. Like, I can't continue to build off of this goal if it's something around weighing less.

Whereas if my goal is to have fun while I And consistent about attending dance classes, you can scale that and you can add other things onto it without it kind of question 

Margaret: becomes not. How do I like restrict more exercise more and get down to the size or even this aesthetic? And listen, I'm not totally against aesthetic goals.

Like I don't I don't think it's like bad for people to have them. I just more I'm opening the conversation. I don't think you do either. But 

Preston: yeah, 

Margaret: but then the orienting question becomes less of how do I get my weight Further down on the scale and it becomes like how do I have more fun doing this or how do I become a better dancer?

How do I get stronger? How do I get to do that move? I saw someone [01:03:00] do at CrossFit or something that I thought was really cool and looked like a superhero like And those questions are the cats are fighting the girls fighting They're good. They're good. Um, but The values based question. That's why I think it's so individual with patients of asking.

I always ask them like, you know, before you knew about changing your body with exercise or weight or whatever, like performing, what kind of play did you like to do? Like, did you like I like playing this game big bopper, which is like, Oh, yeah. Easier version of wiffle ball that me and my siblings used to play in the backyard, like, okay, and like, that's like a simple one.

I don't, I'm not playing wiffle ball now here in Boston, but like asking people like where was joy and delight and then building from that rather because then the pain is on the way to delight. It's not pain in and of itself or control delight 

Preston: rather than running from Shane. 

Margaret: Yeah. Yeah, and then like meaningful delight might mean like, okay, if someone's running like a marathon, they still might kind of hate their long runs.

They still [01:04:00] might hate that. Like, there might be some pain obviously involved in that, but if it's valuable to them because they're like, I just think it means something really cool and it would mean something about me if I could do this and can I do it in a self compassionate way, but help me grow and push myself in a positive way.

Then like that is a good goal for them, but it might not be for someone who wants to like, you know, be able to climb up the side of a cliff or something. Clearly I don't climb because I don't know any of the verbiage, but finding the value with patients like you mentioned you like this and you used to like this or you think this is really cool.

Like you go to Broadway all the time and love the dances. 

Preston: You already mentioned you like the documentary Free Solo and you wanted to climb El Capitan. 

Margaret: Right. 

Preston: So let's get behind that. 

Margaret: Right. 

Preston: But don't fall off. 

Margaret: I think one of the coolest parts of being a therapist or a psychiatrist, if we can have like even just a minute or two for it, is, uh, being able to, like, co imagine with our patients, like, what is a full life look like for them?

Preston: And 

Margaret: I think this is true 

Preston: with 

Margaret: [01:05:00] exercise 

Preston: too. This exercise is a component of a full life. I think it's silly that it always comes down to goal setting almost. And then, and then when, and then when you have this really surgical discussion about goal setting, it turns into like, well, what is the meaning of life?

Yeah, always so fast. It always happens. Cause it, cause it's like, well, I want to be fit. Well, why do you want to be fit? So I can spend more time with your family. Why do I want to spend more time with your family? Because. Because the meaning of life is having, it's having like a passion interactions with my family, like, you know what I mean?

Margaret: Because they annoy me, but I love them. 

Preston: Yeah, exactly. So it's funny how quickly it comes down to that so fast if you asked a couple of pointed questions. 

Margaret: Yeah. Well, I think the last thing that I'd like us to end on is we started with what's our background with exercise. But I think like what you just talked about, like, what is that you think the most meaningful reason you have for exercise?

And it doesn't [01:06:00] You can't cop out and be like, I want to be around for my family because like, yeah, all of us want that, but like, what is the thing that you feel like is the most positive or delightful part of why you work out or your, your current kind of workout schedule? I can start with mine. No, I'm thinking, 

Preston: actually, you go first, please.

Margaret: Um, I have never been able to do a full push up in my life and I'm slowly. Inching closer to that and that is a delight to me because it just I don't know. I'm so proud of myself that I'm getting closer to it and I it's because I've been doing more strength training. It doesn't look in any way. Good. And this is like not a goal for anyone else, but the fact that it says something to me and is meaningful to me of like, wow, I never thought I'd do a full push up, but I'm going to be able to, I think soon.

So that to me, that kind of feeling of strength and empowerment and function is delightful. And I think it just seems cool to me, for lack of a better word. [01:07:00] 

Preston: I mean, it is cool. Push ups are badass. I would say for me, it's. Reclaiming a sense of joy. So I, I had my like first rec adult soccer game, uh, last week and my shoe fell apart.

I hadn't worn these shoes since like high school when I played competitively. So. The whole bottom plate came off and I went onto the sideline. I like wrapped it in tape and I like MacGyver this thing came back on and and it was weird like sitting this moment while I'm like wrapping my shoe in tape going like I'm gonna get back on the field.

I was just having fun. 

Margaret: Yeah, I 

Preston: was like, wow, I'm exercising and I'm having a good time and like we lost so bad and I didn't care because I was just doing so I was like being with people and and enjoying the moment and I think for so long soccer or track or lifting whatever it was just so much. Pressure around it.

Like I don't list this lift doesn't work a certain way. If I don't achieve this time, I'm going to suck. I need to perform well. [01:08:00] My coach is going to cut me. And I was like, holy crap. I'm just having fun. You know, like we just got scored on so bad. I'm like watching my teammates get frustrated. They're like, they're like the goalkeeper's a liability.

And I'm like, I think he's having a good time 

Margaret: having fun guys. 

Preston: Yeah. So like taking the pressure off of myself and just kicking the ball and running up and down the field and having a good time was. It was liberating. Yeah. So I think that's probably what what doesn't the most for me. I because as a kid when you pose that question, what did you do for play for you was always running around outside?

Margaret: Yeah, it was jumping off that tree or the trampoline. 

Preston: Yeah. Yeah. And I lost that somewhere. The plot was lost somewhere along the story of me taking my talents as an athlete and marketing them. And now that they're no longer a part of my story. Economic output, I guess I can have fun with it. So that's what it does for me, 

Margaret: the sake itself.

There's this, um, the book, the wisdom of your body, which is by Dr. Hillary McBride, um, is a book about kind of [01:09:00] embodiment. Um, but the metaphor she uses that is used in like objectification and feminist theory, but I think is applicable for everyone is this idea of when you're a kid, like it's this metaphor of the house, which is When you're a kid, you just live in the house.

You like, you know that the kitchen has food for you. You like have a nice soft bed to rest and it keeps you warm in the winter and covered in the rain. And as you get older, you see that other people are making comments about their houses, about how like the roof is kind of bent, funky and the paint is peeling and it looks this way from the street and da da da da.

And then they tell you you can make improvements on it and eventually it gets to the point where you're no longer living in the house. You're just sitting in your front yard looking at it. And so to me, I think, okay. It's such a powerful metaphor for everyone of just the bringing people back inside into the house for all the beauties that it is to have a house or to have a body that moves you around and lets you play and lets you belly laugh and allows like love and intimacy and playing soccer, right?

[01:10:00] Or singing or whatever, all of these things. 

Preston: Because no matter how compulsively and meticulously you try to keep it from being damaged, It's going 

Margaret: to get damaged. It's 

Preston: going to get damaged regardless. Where are the Paris sneakers, you know, that's what that's what your body is 

Margaret: existential kind of like we are all gonna die So we might as well get kind of 

Preston: You you have a means of experiencing fun like your body.

Yeah, do it, bro 

Margaret: They're not they're resting there okay 

Preston: good yesterday, um Lilac was just charging Maggie and Maggie's developed this new move. She just, she just, she just jumps. She gets like three seconds of airtime and it's just like, just drill straight under her. It's pretty, she's 

Margaret: developing new learning and competency through exercise.

I 

Preston: think Maggie actually has been more pleasant. Like her affect has shown some improvement having lilac in the household. I think a big part of it is just the exercise and behavioral activation of having, 

Margaret: hey, a [01:11:00] crazy, 

Preston: like half. Half torty half tabby little sister who's running around 

Margaret: good little pals.

Preston: Yeah, they foil each other Well, so it's been actually nice to see this this year. I can't enjoy it 

Margaret: movement Yeah 

Preston: By by dr. McBride. Okay, so Yeah, I think this was a good conversation to start for a lot of people. How exercise is a fun topic in in how much it folds into mental health. I think one thing 

Margaret: both.

Oh, sorry, I say clearly both of us enjoy this topic. So if there are questions or their comments or things that you feel like we got wrong, like, let us know in the comments, like, send us messages. But like, we are happy to come back, I think, to this topic and more depth because both of us kind of nerd out on it and like it.

Preston: Yeah, yeah, I'm like all my pride is in being correct and not approaching the truth. So if you 

Margaret: Yeah, so if [01:12:00] you 

Preston: confront me, I'm just gonna tell you that you were probably wrong I'm gonna question the viability of your study if it disagrees with anyway, cuz the truth doesn't matter at all We don't care about that.

We care about our pride and being correct 

Margaret: cigarettes, despite what our doctors around our asthma 

Preston: I'm, I'm just kidding. I really, I, I care way more about being right. So like, please correct us. We'll make sure it's, it's the proper information for everyone. And this is a good segue into our next episode, hopefully, which is going to be on motivational interviewing and attacking ambivalence and people that have a gap between what their desires are and what their actions are.

Very commonly it's, I wish I exercised more, but I don't. Right. And so there are like methods you can use within therapy to help people kind of move past those barriers. 

Margaret: I guess. 

Preston: Yeah, our first guest. First guest, our, our guest, our, our maybe third guest , 

Margaret: our third guest here, , Maggie . 

Preston: So thank you guys so much for listening.

Um, please let us know how the show was. Like [01:13:00] we said, any feedback is always welcome. You can find us on our socials at Human Content Pods, or you can contact the team at How to be patient pod.com. Please shout out to. Um, all the listeners that left us kind feedback and we'll be reading some of that off soon and let us know if you have anything fun coming up in your life.

If you have a recent graduation or a match coming up or something you want to celebrate, we want to celebrate that with you. Or exercise that you 

Margaret: think is underrated. Yeah, or an exercise that and I are going to be forced to try, I'm going to get Preston to try a Reformer Pilates class at some point. 

Preston: I, I have done Pilates once.

Reformer? No, not Performer. Reformer. Oh, Reformer. Okay. So I can spot correct my fat. If you want to find full episodes, they'll be on my YouTube channel at ItsPrezro. And sometimes I'll post them on my TikTok, but like just the soundbites and stuff on my TikTok. You know, the things that they generate clicks and revenue and the things that matter the most in the world.

Margaret: And you can find me at my tick tock, which is bad art every [01:14:00] day, uh, where I don't talk about that much about mental health, but I do talk actually quite a bit about avoidance and exercise. So that's true. I do. Thank you 

Preston: for listening. We're your hosts, Preston Roche and Margaret Duncan. Please connect with us at how to be patient pot dot com.

Our executive producers are me, Preston Roche, Will Flannery, Kristen Flannery. Aaron Corny, Rob Goldman, and Shanti Brooke. Our editor and engineer is Tracy Barnett and our music is by Omer Benzvi. Please check out our show notes and see the references and resources that we discussed at the end of this episode, because we did go over a lot of facts this episode that we will make sure we got right or mostly right.

And to learn about our program, disclaimer and ethics policy, submission, verification, licensing terms, and our HIPAA release terms, go to the website, how to be patient pod. com or reach out to how to be patient at human dash content. com with any questions or concerns. How to be Patient is a human content production.

I'm Preston Roche, that's Magnolia Smalls, Lilac, doesn't have a last name, and this is Margaret. I'm Margaret. Thank you. Bye. [01:15:00] Bye.

If you want to see more of us, or if you want to see, this is Lilac, she's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the background.

I said twelve, I said twelve, she said eight And [01:16:00] I said I did the fifth, but I figured burvin Shred. We're learning to make us know, Know cares nothing about the world was itself.