Marathoning and Mental Health

[00:00:00] Good morning. Good afternoon. Welcome. And good night. Margaret, have you been running from anything recently? Just you, Preston. Anything else or like? Um, I don't think so. I run. I run a lot actually for exercise. I enjoy that, but not like in the social context that you're describing. Not necessarily like running when you don't respond to my texts or well, that's we're working on it.
Yeah. So here's my question to you. What is the farthest you've ever ran? I think 14 miles. It's a long time. Tell me about that. Um, I had cross country in high school and then my family did like worse than turkey trot. We like a half of us did half marathon, a few half marathons together when I was like high school college.
So the half marathons like 13. 1, yeah, but I think a couple of my training did you just get [00:01:00] lost along the no, you're training around a little longer. Okay, I was listening to the hunger games at the time. No, that's yes. And I wanted to finish the chapter. You were hungry. I was hungry for a few miles. Yeah, not very fast, though.
Definitely not fast. Definitely like a nine minute. That's still good. I don't think speed matters, you know, it's. Well, it's a half marathon on a sprint, right? As the saying goes. As famously as the saying goes. What's the longest you've ever run so far, Preston? So, I think it's, I want to say it's 13 miles actually.
Hell yeah. Which is wild. It's less than Margaret. Um, it was in college. I was an 800, 800 meter runner. So like you're training for the half mile. Most of my runs were like five or six miles because I do a lot more like. Repeat training like we do sprints and things like that with like a little bit of aerobic base, but I was trying to do a nine mile long run.
Um, when I was on vacation in Germany. Yeah, I did get lost [00:02:00] because all the sign I was like running through this park in Berlin and all the signs were in German. Well, and I was like, I was like, okay, left turn, right turn, right turn, left turn, right turn, left turn, left turn, right turn. And I was like, Oh no, this is like turning into the labyrinth like really fast.
And then I was like, Oh, I'll just read the signs on the way back. And then it's like, Zookin, Hyven, Schleislin, or like, Gzunkin, Dorkin. And I was like, Oh, none of this is familiar. Like, don't you have a fever dream? And I was like, do any of these structures look the same? Like, no, it's all, it's all just, no, I didn't have my phone.
Um, Because why would you do that? Because it was like 2017. I never really ran with my phone. Oh, to be a man. Oh, to be. I don't know. I like I'm running in a new foreign city phone. It's just vibes only. And it wasn't even a GPS watch. It was just like. Um, a dumb, like, timer watch. Yeah, I was like, those Timex's.
I just [00:03:00] left, I left the hotel and I was like, I'll figure it out. It was, it was fun because by the time I hit, like, mile 11 and realized, like, I was just gonna be lost and running through this city. I, I hit, like, a fourth wind. Like, you know, like, a second wind and a third wind. Like, I didn't even know this, like, last year existed.
Yeah. It almost, like, felt like my body found a new fuel source. It was, like, mile 11. Yeah, yeah, so I wonder if there's like a new level it gets unlocked at 16 or 17 Yeah I feel like my parents and my sister rant shout out to my family ran the Chicago Marathon each a few times and I remember like watching them go out to like go train on training runs on like Saturdays and being like I'll see you guys in three.
Yeah, I'll see you guys later Yeah, it's, it's a long time and you are, I'm training for the marathon and it totally under peer pressure, like not of any desire of my own. My friend just texted me and he was like, come on, man, train for the LA marathon. I [00:04:00] know. Yeah. No, he's like, he's like, don't be a loser.
And I was like, I was like, okay, I guess I'm training for it now. And like, I wanted some structure and it's nice to do it, but it was funny to bring that up in therapy. Uh huh. I was like, I'm training for a marathon. My therapist was like, Ah, Oh, really say more. She's like, do you think this is going to cure you?
And I was like, no, I just want structure for my exercise. And she was like, you're like, I'm going to win it. Actually. She was like, Woo. She was like, cause normally when people say they're going to train a marathon, they really looking for that final piece of achievement to prove to themselves, they can do something.
Well, I feel like this is, I was listening to a podcast the other day that was about someone who works in the space of like post professional athletes, mental health. So like people who finish after like college or like, you know, division one or two or three sports, or after they're in like professional leagues and the transition from being like [00:05:00] in an all consuming sport to then being like, what the hell, where is the structure?
Like what's going on? Um, I wonder what it's like for you, like in working out and stuff or like running, like, do you find it, especially since your background was running, um, is it easy for you to stay like I'm doing this for fun and not get competitive with yourself or is it like hard to not have that, like, I'm performance mode with, with exercise.
It's. I haven't been able to form the, um, I guess hygiene aspect or like the hygiene mentality around exercise yet. I think for me, it still has to be driven towards performance and. When I do just, I want to do it just to be healthy or something, I find that I just kind of stopped doing it, which is really interesting, and I tried to do that with lifting for a while, but it only worked when I had a goal, like I was trying to improve my benchmarks to a certain point or my [00:06:00] deadlift, or I wanted to, like, reach a certain mass, and then I kind of realized that with lifting, I was like, I'm stuck on this, like, performance track, so either I go into bodybuilding, and I'll probably develop an eating disorder, or I'll go into powerlifting, Blow out a lumbar disc or something.
So I mean, like, obviously those can be like great sports that anyone can pursue. I just don't think they were like the best for me and like, or conducive to my training load as someone who's just kind of ran their whole life. And then when I got back into running, I think I just wanted to have a race or something at the end of it to be like working towards.
So I wonder if like one day I'll get to the point where I can just treat running like brushing my teeth, like, Oh, it's just something I'll do. Yeah. Um, but right now I just. I think I just dislike it too much that unless there's like something I'm working towards, I can't overcome that. Well, I wonder how much the like dislike has to do with the fact has to do actually with some of that, that like there's a lot of reps [00:07:00] of it being for a goal or for a purpose and pressured and then rewarded for that, but therefore also the actual exercise itself probably is already always.
Kind of maybe not, not obviously not all the time tough in terms of like effective training, but like has a lot of moments in it that are like excruciatingly painful versus like, Oh, I'm just going on like a 20 minute jog where my heart rate just gets in to like, you know, the one thirties or something in a nice jog through the park.
Yeah, I think the analogy I would use is like eating pancakes. So imagine if you just like enjoy pancakes at breakfast sometimes, but then. Someone was like, Hey, Margaret, you're pretty good at eating pancakes. Why don't you join our pancake eating team? That has been said. Yeah. And then now all of a sudden you're like staying up late at night, shoving down pancakes.
And then you like eat as many pancakes as you can at two in the afternoon after school, and you're vomiting them up. And they're like, no, eat more pancakes, Margaret, eat more pancakes. And they're like, you know, you know, Margaret, some, some other [00:08:00] girls, they're actually eating two more pancakes than you at practice each day.
So if you don't get these pancakes down. Um, like you're not going to be able to stay on the pancake eating team. You understand, you understand what I'm saying? And then now you're cutting out breakfast because you're trying to fit more pancakes into your diet. And then you're, you're, you're freaking geeking, you're, you're using laxatives just so you can get more pancakes.
And then you finally get out of college and you show up to brunch one day and everyone's like, you know what? Let's order some pancakes. And you're like, Oh, I used to eat pancakes competitively. I'd rather not. They're like, Oh, just have one just for the joy of it. And you kind of like look at this pancake on your plate and you're like, uh, yeah, yeah.
That's kind of how I feel about running. Yeah, no, I think that makes a lot of sense. And I feel like a lot of people can relate to that. I think it's something I can't, I can't relate to necessarily. Um, in some ways, as I've like gotten older, I've been more grateful that exercise was not rewarded in any way for me simply because I wasn't good.
I will, I'm not an athletic person. [00:09:00] Uh, and so it was like, well, I'm definitely not going to look cool. Yeah. But it becomes a different question of how do you fit it back into your identity? Um, I feel like this, this, uh, I was about to say cold open this icebreaker. Uh, I feel like we're accidentally touching on a lot of the things we're going to talk about content wise for this episode.
Yeah. So it's really interesting how running and exercise are folded into identities and also like our concept of health and how we promote ourselves as healthy individuals. So I'm really excited about this episode overall. And when we come back from this break, we'll be talking about how running was Kind of health and fitness culture because it wasn't always like that, right?
And then This kind of growing body of research on all the ways that running protects us from mental health disabilities and also maybe and treat the ones that we have currently and then we'll, we'll start to get into is running the best way to [00:10:00] exercise. Are there other options? And like, are they all the same or is there one that comes out on top and what does it even, how do we even measure what makes one better than the other, right?
And is there different indications we can think about in some way thinking about like how, like all, not all, but like SSRIs, they're all good, but you choose different ones for different folks based on a number of things. But based on that, like, you know, same kind of idea of what we're trying to do, but maybe this person has this response to this kind of, uh, I feel like exercises.
Yeah, in medicine, we love a silver bullet in theory, but it's never one size fits all. Yeah. So we can find out like whose slipper is their own Cinderella shoe.
When did, when do you think running became popular as a sport? Um, I mean, you and I both know that we both have a hyper [00:11:00] fixation on exercise and mental health and then falling down deep rabbit holes. I want to say it was like, It was in the book spark by Dr. John Ratty that talks about mental health and exercise.
Uh, cause there was one big thing with like the Boston marathon, the 19 like seventies. Yeah. So 1970s is when we started to incorporate as a hobby. Okay. If we want to, if you want to get technical going back to running as a sport was the Olympics. So the Greeks included running a distance, running short distances, jumping things like any kind of athletic competition and 600 species.
And actually, Up until about the fifth century running was popular in some Arabic countries in the context of pilgrimages and traveling long distances. So it's kind of seen with this positive air and then from basically the fifth century to like The 18th century [00:12:00] running loss, a lot of his procedure was kind of seen as a dumb thing.
No one will try to avoid it. Yeah. They're like running is for losers. I want to be carried around or like ride a horse or something. I, I was in the museum the other day and I was like looking at the different ways that they would transport like the royalties of old cultures. And so many of it was just like.
It was like a stretcher, like a little house, like people will just carry, like be carried on the backs of servants and walk through like riverbeds and jungles and everything like that. But anything, anything but running. So the first The first big, um, annual race was the Boston Marathon, actually. Hell yeah.
And do you know what year it took place? 1974? Earlier. 71. Much earlier. 1897. Oh, was that early? Yes. Oh, I was thinking when it became popularized. So at the turn of the century, so, so the [00:13:00] oldest global marathon is the Boston Marathon. It started right before the, the 20th century started. Um, and then. Running up until about the fifties of the sixties was solely like a collegiate sport, and it was kind of in this like wasn't really accessible to the average person, but the around the early sixties, this one guy decided to write a book called Jogging.
When he was so, he was so inspired by the New Zealand Aussie run club that he said, you know what, this could be something for the average person. Yeah, it was like the first run club influencing. Do you want to guess who that guy was?
No, I don't know. Okay, it was Bill Bowerman, who is the co founder of Nike. So he was actually, he was working as the assistant coach at the University of Oregon at the time and he's working with his athletes and he was doing a lot of stuff in the competitive running scene and then he goes to New Zealand and kind of [00:14:00] engages with these run clubs that they have there and goes, wow, like this can be something that everyone can do at every level.
So he writes the book jockeying and things start to be kind of popularized around running and then the 70s is what things really take off. So that's what you mentioned, which from recent memory, what you know is, is what makes sense to us. So I picture like Forrest Gump just running for no particular reason, you know, like I just kept running and so things like Steve Prefontaine started to popularize it.
And then I think in the Early seventies, we won our first marathon, like an american one of, um, a big international marathon. It was frank shorter. Okay. So that started to bring like more attention to the stage. And then in the early eighties, they started to incorporate women's track and field. The N. C.
Double A. Which is crazy. How recent that is. 1982. Women hadn't run until 1982. Yeah. So, so women before that, they were just speed walking. Yeah. You guys have read Pride and Prejudice. You know that.[00:15:00] 
So title post title nine basically. Yeah, so it went from being this kind of like nerdy thing or like a sport for elite athletes or collegiate athletes to now something that kind of like people did. Yeah, sporty, sporty folks. Now, looking at it today, run clubs are in a lot of ways a good source of community.
So I saw an article the other day that Was saying that run clubs are the millennial versions of churches. So where before in like the eighties and nineties, a lot of people would use churches, their consistent form of community. And while those still exist, a lot of the like more agnostic or atheistic populations don't necessarily have that, but they can congregate at their run club every Saturday morning.
So it's like a form of exercise and community for them. Yeah. The kind of question of where's like the locus of connection and meaning. Yeah. As is through this, the conduit is exercise and Now, like looking at the population today, 24 percent of people say they've used running as [00:16:00] some form of a hobby or kind of exercise.
And, um, there is a discrepancy between men and women actually. So women take up the majority of road races. There's actually 60 percent women in road races now on the, on the converse. They're only 23 percent of trail runners. So men are more likely to take to the trails, I guess. I wonder what that has to do with safety.
I personally think it probably has to do with safety, too. I think I think there's also more of a like we're gonna run a 5k like all the girls we're gonna do this like Yeah, I think guys could do that But I feel like I've just like anecdotally had front like when like the color run was a thing I don't know.
It probably still is sorry color run. Um, like Being like, Oh, we're going to go do this, like themed 5k, or we're going to like go to Nashville and do like, uh, one of the like rock and roll half marathons or something we've made running, or especially at these 5k races, like a thing to do, something to do on the [00:17:00] weekend.
And like, like I mentioned earlier, it's like a way to engage with the community. Yeah. It's an interesting way though, because it's, I think both you and I know this from our own backgrounds with running, you know, at different levels of teams. Like I did cross country and track in high school badly again, but like, while it is a really interesting sort of team, it also is a lot of like in internal competition, you know, like try and push yourself as hard as you can.
I don't know. That's completely true with like, yeah. Road races and stuff, but it's interesting that it's like a community thing and not a T, but it's not a team sport. It's a very individual sport. Yeah, that's that's a hill. I'll die on that. It's still an individual sport. I think for something to be a team sport, it has to incorporate teamwork.
Yeah, and while you are encouraging each other, like true teamwork is like depending collaboration. Yeah, yeah, which that also makes people more like yeah. There's [00:18:00] something sort of interesting about, like, everyone talks about, like, the loneliness epidemic or third space, not having third spaces in a lot of ways.
Like, this connection is great. It's similar in, like, group fitness classes, right? Like, you're together, but you're not dependent on each other, and I think it can be a double edged sword. So. Some like I was on a soccer team for a lot of my youth, and there was a lot of my my younger years in my younger years.
There's a lot of bonding that happens when you're on a team because you have to work together and you're dependent on each other. But if someone is a weak link, it can become ostracized because of their lack of skill, and it can the social hierarchy is often built off of like who is best on the team.
And that didn't really exist in track in the same way I became friends with everyone was kind of friends with everyone because our team was based on mutual encouragement, but not this like interdependence on skill. Yeah, so I had a friend who the same thing happened with her with volleyball. She said, you know, I try to do volleyball, but there wasn't space for you to be not good and [00:19:00] also accepted as a friend.
Also, that was also me. Yeah, that sucks. But on cross country, everyone, because it's an individual sport, everyone can do their own thing and then you can be socially accepted. So while you don't have that, like tighten it, like we're a team community. Yeah, same way like volleyball has no one's getting excluded either.
Right, right. No, I totally agree. I think there's like as far as like creating accepting open spaces running is perfect for that. And that is an extension of it's. Nature is a individual sport, you know, it's not a, it's not a bug. It's a feature, I guess. And there's like the, like, there's one of the run clubs.
So one of my goals, maybe we'll do it if, well, who knows when this will be released, but like one of my goals for 2025 is to actually go to the November project chapter that's in Boston. Um, specifically they do a stair run at like five 30 and six or six 30 at like the Harvard, um, football stadium. And like, that's like one of [00:20:00] their signature weekly workouts.
It's like a huge thing. And in Boston, in the running world, and I've wanted to go for a couple of years. I was like, no, I need to like train more and do more. So my goal is to like. Run enough and do enough. I now live in a place that has like my gym has a Stair master or whatever. So I was like, okay, we're gonna get enough lung capacity Um, but like the the team the point of that being like the team While someone can have less skill and it's okay there's still this sacrificial part of like Well, my friend said they're gonna be there at 6 30.
I I maybe I would not go if this is just me in the stairs Mutual accountability still exists. Yeah, which sounds like absolutely is probably true. And are you in a run club? Um, I mean, not, I show up, but like, not officially, no one's like, where's Preston if I don't come adjacent? Yeah, I, it's funny. Like I see all the memes that run clubs are like these sexual water holes for millennials now, which I don't think that like, not for me at least.
I mean, like I show up and I just see like all the grandmas with their weights [00:21:00] and like the 50 year old dudes. And then we have this guy named Mo who just like kind of, he just like prattles on for like 15 minutes and we take a picture and we go run. Yeah. That's about right. That's about right. And then I go on TikTok and everyone's like, oh my God, these run clubs are so boring.
Yeah. The New York Run clubs are like . The New York Run clubs are crazy. Not here. . Um, yeah. Yeah. So, so I feel like yours sounds more like what cross country felt like, even though we were all young at that point. It was like, there's, there's some interesting personalities afloat. Uh, but we're here, we're sweaty.
We're gonna take a weird kind of cringey picture as a group photo, and then we're gonna go, it'll get ice cream after I know. Well, I know I'm going to get those moths fruit snacks after and some granola and their Gatorade. Like they, they have supply all that stuff is awesome. Yeah. Yeah. So outside of the social benefits of running, it turns out there's some physical benefits too.
And we can go into all the cardiovascular benefits and the way cardiologists recommend exercise, but we're psychiatrists. So we're going to stick to the neuroscience as best we can. Um, [00:22:00] So there's a couple of ways that we think about how running can benefit our mental health. And one of those that we're going to focus on today is through the lens of neuroplasticity and a couple of different biomarkers that come out of running.
So the proposed mechanism that we get benefit from running is through metabolizing different products. So as you know, We use sugar for energy, right? So you have a single molecule glucose and you break it down and you oxidize it and then that gives you ATP. That's where you get all your energy from. So in order to kind of handle energy for long periods of time, we stack Glucose together in these chain links and put them in our muscles, and it's called glycogen.
And so we break down glycogen while we're running. Then when we run out of glycogen, we have to use other sources of fuel. So it turns out when you can't just readily use sugar, you have to kind of [00:23:00] convert fat directly. And so when you convert fat, you create these ketone bodies. So keto diet. Exactly. Yeah.
So it turns out that even just running for like 45 minutes can be enough to induce catabolism of fats and dependence on ketone bodies for energy because you can only use glycogen for so long. You actually start pulling from both sources. So your body is like, okay, I have freestanding sugar hanging out.
I have glycogen I can use and I have fat I can use. Let me get through as much of this as possible. And the engine is going to be pulling from different sources as you go through. Okay. The thought process is that once we start using those ketone bodies, there's a, there's several, like four or five different ones.
There's like acetoacetate and, um, like acetyl ketones. And then there's, uh, beta hydroxybutyrate is a famous one that's constantly stuck. So beta hydroxybutyrate gives us a lot of energy, but it also crosses a blood brain barrier and can actually fuel our brain. [00:24:00] And so this is where a lot of people think that the keto diet has all these benefits, because if I.
Never eat sugar. Basically, if I never eat a car, my body has to use fat. And if it has to use fat to power itself, it has to use these ketone bodies. So that's kind of the thought process behind the ketone keto diet, which I will say no shit. There are definitely clinical indications and personal preferences for the keto diet that make A lot of sounds to me.
Yeah. And especially for people who have, um, metabolic dysfunction and they like can't break down fructose or glucose in the same way. It's actually can be life saving for them, right? So I, yeah, I don't mean to come across tongue in cheek when I'm talking about the keto diet because there are some people that treat it like the end all be all when for the purposes that we're serving sometimes like, well, you could, if you really just want to get access to beta hydroxybutyrate, you can just go run five miles, right?
Um, So, now, beta hydroxybutyrate enters your brain, what does it do? Turns [00:25:00] out, it induces your brain to grow a lot of, um, good proteins for it. So, there's, the region, the region of the brain that we're going to talk about right now is the hippocampus. So, what's, what do you recall the hippocampus does?
Memory storage. Yeah, exactly. Uh, short and long term question mark. Yeah. And then, and then there's a bunch of different ways that you can remember stuff, right? So you can remember language of things. You can remember numbers. You can remember spatially where things sit and a lot of that hangs out in your hippocampus.
And so for anyone who's kind of trying to picture where this is in your brain, think about the hippocampus being on like the bottom part, bottom inner part of your brain. So we would say that that's like the inferior medial part of your brain using medical terminology. So I kind of picture the temporal lobes like my princess Leia buns kind of sitting under right under the brain inside part of those guys.
My, if [00:26:00] my understanding, and this could be wrong, is that The hippocampal area you're going to talk about as well as the, is it the sub there's a, there's a temporal mesial part that is implied in like the neuroplasticity neurogenesis that has made this maybe what you're going to be talking about, but that there's a few distinct regions that we think are particularly plastic and adults and mediated by exercise.
So the, the dentate gyrus is one. Yeah, yeah. And that's just that innermost cleft. Got it. So to kind of take a pause here, the hippocampus is something that we care a lot about because we study this in many different diseases. And it's easy to detect changes in the sides of the hippocampus when we're measuring with something like fMRI or MRI, though these changes are probably happening everywhere else in the brain.
So it turns out that across the board, whether you're looking at [00:27:00] Alzheimer's, depression, Polytrauma PTSD we observe decrease in the size of the hippocampus and decrease in activity in the hippocampus under fMRI So we don't exactly know the mechanism of depression, but we know the damage it leaves if that makes sense Yeah, we know sort of correlate correlated.
Yeah, all we changes on image or some sort of like prospective sort of labs and things that are we're like this is happening and how why what Question mark. Yeah. And so there's a couple of proposed hypotheses and one of them is that there's high levels of cortisol when you're constantly stressed and you're depressed and you're anxious.
That's what the girls on TikTok are talking about. I'm just kidding. It is and is not what they're talking about. So those chronic high levels of cortisol may be causing hippocampal shrinking, or it may be really suppressing the normal healthy pro growth factors that will be kind of maintaining the plasticity of the hippocampus.
And then [00:28:00] over time, it kind of. Steals out, I guess. So now, so let's say we introduce exercise and we get this, these ketone bodies. Beta hydroxybutyrate comes in. It turns out that it actually goes into our neuronal cells and it helps transcribe for certain proteins. And one of those is called BDNF. Hell yeah.
Brain derived neurotrophic factor, which is something that everyone gets excited about. My number one girl. Yeah. BDNF is cool because it promotes plasticity and it helps your brain with BDSM. Yes, right. Yeah. Well, BDSM also uses plastic things or I guess latex. Commonly. We need to do an icebreaker sometimes where it's like the most like embarrassing, confused abbreviation or pronunciation you did of a medical word during training or like during med school.
Yeah, uh, the classic one's always like. [00:29:00] Pussy. Like, the word was pussy, and you're like, did you just write pussy? Yeah, like, what is this? My, uh, I knew someone who didn't realize because they just, like, had only ever read the word how to pronounce, um, edema. And so they were on rounds as, like, an intern, and they said there was someone who was constipated, and they were like, Or no, no, sorry, there was someone, I just ruined my joke, there was someone who was like, uh, had swelling in their lower legs, they had edema, um, and he pronounced it like edema, and they were like, I'm sorry, what did you do to the patient, you interned my, he was like, they have edema, I just took care of it this morning, anyway, sorry, that was off, off side tangent, um, Yeah, so, um, not to be confused with BDSM, BDNF, it does a lot of great things, and, or we think it does.
[00:30:00] What we should say now to kind of temper ourselves is, great things happen when BDNF levels are high. Yeah. It's like a party to what extent we know for sure it's either driving it or or whenever it shows up. It has a friend that also helps out. But we know that's a kind of a marker when there is induced neuroplasticity.
So EDNF can help promote. Um, new neuronal connections, and it also actually has measurable effects on things like memory. So they've done studies where they will have mice run on treadmills long enough to induce beta hydroxybutyrate, and then they will actually improve their spatial memory of things like mazes.
Um, we also can see like people litter or in mouse models, they'll like literally regrow um, some of the mass of their hippocampus in response to things like pdf. So we, so we can notice like the size of these, um, neuronal tissues changing in [00:31:00] response to this molecule. Yeah. BNF is also can be induced by like some of the other interventions that we give.
So ketamine, for example. Can induce brain derived neurotrophic factor. There's a couple SSRIs that do it too. Famously, um, Sertraline fluoxetine. Also have been shown to do that. ECT. Yep. electroconvulsive. So I've, I've some attendings that will prescribe sertraline to patients with dementia just solely on the basis that it will theoretically increase BDNF and maybe theoretically help with neuroplasticity.
Huh. That's interesting. Yeah. It's interesting. So the question though is when you're exercising, do you have to get that beta hydroxybutyrate to get that increase in BDNF? Yeah. Yeah. Yeah. And what are your thoughts? That's that's kind of where I'm sure, right? Because when we look at the clinical data, we see that [00:32:00] people improve their scores on anxiety.
And depression when they both lift and when they run, yes, but it's unclear if molecularly we have those like same effects that same neuroplasticity so people subjectively report feeling better, but it's unclear to what extent the exercises affecting that, if that makes sense, because there's things that make us feel better subjectively, like having community and like having structure and like having a place to go consistently possibly being like.
Out in nature or having like a different view or like, we think about like the behavioral activation therapy approach, which, um, is in a paper that I read preparing for this episode on like an integrated review for, I think, 2021 on exercise for mental health and talks about similarly, like how do these studies, especially the human studies, like rate controls and kind of take out, like, Building relationships or getting outside of like your house doing these other things, um, that aren't necessarily physiologically the [00:33:00] exercise per se and how much of the effect is mediated by these things, which some studies do control really well for it.
Yeah, so now kind of looking at a lifetime of running. Why do we care about BDNF? I know we're talking about its effects for things like depression, anxiety and PTSD, but even in aging There's some thought that BDNF or at least is mechanistically related to Some of the about four of the major aspects of aging so we all know Telomere shortening is like one hypothesis that actually can prolong like telomere resilience You It also reduces oxidative stress, stress, it can have oxidative, oxidative stress, it reduces, um, mean, I'm sorry, that's fine, and it has, uh, anti inflammatory properties and it, it can prevent, um, DNA [00:34:00] damage.
I feel like there's the question of long term running or long term, you know, conditioning, aerobic exercise versus like interventions for mental health, but there's like the protective part of it versus also like interventions that study people who actively like have a dementia or have like Parkinson's and how, maybe not running, but like how these different types of conditioning activities can be preventative and then also palliative in older populations, even who aren't moving before a study.
Yeah, like it's, it's almost like its own treatment for them. And, and I guess this, this part is purely anecdotal, but one thing I've noticed whenever I have an older patient who's like just an absolute rock star and they're like consistently taking care of themselves or knocking out all their ideals and they're like 86, I don't know if like what the unifying factor is, but I've noticed they always exercise.
I [00:35:00] like I'm trying to think of like one older patient I've had that like that was crushing it. That didn't exercise. Like I've had some that smoke to be honest. And I'm like, dang, you smoke. And they're like, yeah, but I still run like three times a week. I'm like, oh, wow. Like, dang. So it's just something like I've kind of just been picking up implicitly.
Like I've noticed like among a lot of the patients have great longevity. It's like Exercise might not be the secret, but all of them still exercise. Yeah. Well, I mean, I think there's like, what makes a meaningful life and like how all these other factors that we talk about that impact someone's psychological and mental health.
Which is we try to separate these out on these studies, but, you know, a lot of people struggle with chronic pain and immobility as they get older for a number of reasons and what is the number one? The number one intervention for reducing pain. Um, at least pain perception and overall dysfunction is graded exercise.
Right? [00:36:00] And so I do wonder with these kinds of things also that like, how much is it that exercise does mediate these other problems? Things that are obstacles to people having a life that they consider meaningful at different stages. Um, and then that makes their mental health better. But also, I think there's physiologic parts as well that probably are the impact too.
Yeah, and it's probably a combination of both where this is one of the situations where our hands are tied again with correlation. So we don't know if exercise is the reason, but where exercise is meaningful life. Longevity is so if we want to look at the numbers now specifically in a meta analysis of 58 studies, they looked at people that did any form of aerobic exercise and they found the lifetime risk of dementia was decreased by about 15 to 20%.
Huh? Just pretty significant. Yeah. And then actually for running specifically, they controlled for, um, the distance that they would go. And so in [00:37:00] patients that are in subjects that ran consistently more than 15 miles a week. So instead of just any amount of exercise, this is extended periods of aerobic endurance training.
The risk of dementia was reduced by 40%. Yeah. So it's almost twice as much as the original group. Well, I, I wonder too, with like a dementia type perspective, like how common is vascular dementia? Um, and how much does running I know we are not cardiologists. There's cardiologists listening to this. Sorry, but we may butcher this.
We'll try not and we'll try to stay out of your lane thinking about even people who don't have a diagnosis of like vascular dementia, but how we like, there'll be like normal changes of aging right present whenever we get an MRI read if there's. That no one like running, obviously cardiovascular, long distance exercise, improvement in vasculature and overall heart health, how that impacts this long term question is like.
Is does the protective benefits from the endovascular side of [00:38:00] things have more of an effect on dementia? Um, yeah, and running on. Yeah. Yes. Yeah. And it's confounded by running. Yeah. So to clarify, if if you were to look at an older person, like someone over the age of 70 who died of any cause and we were to look at their brain, it's likely that you're going to find some evidence of amyloid and some evidence of towel.
Somewhere. It's just kind of gunk that we build up over time. So I think in a study that in Hawaii with like 300 or some odd biopsies, about 90 percent of people had some evidence of Alzheimer's related proteins in their brain. The question is, does the burden of that protein build up enough to cause a dementia?
And so Um, to clarify, like a dementia is the disability or the inability to, like, kind of, like, execute the activities of daily living in your life due to an acquired cognitive impairment. So. You and I may pick up this amyloid and over [00:39:00] time Die of another cause or something else and it's kind of like along for the ride and we die with em the common die with Yeah, exactly.
Yeah, but for us to have an Alzheimer's dementia the burden has to build up in right specifically our temporal lobes Obviously there can be different types of Alzheimer's but that's what's commonly what happens And you develop this classic amnestic dementia where you're have no registration memory, so you can't store any memories.
And then everything kind of like starts to decompensate from this. Yeah. So with these running studies, I wonder if It's specifically so protective against Alzheimer's because a lot of that is focused around the temporal lobes. So we know Alzheimer's hits the hippocampi first and running has such a protective benefit on the hippocampi.
So I guess my question is like, does it help? With other types of dementia because there's several different types of dimensions, mostly combined, or is it like Alzheimer's specifically granted Alzheimer's is the most common type of [00:40:00] dementia that most people will come across. So I think regardless, we know that running is a great way to promote longevity for multiple reasons, but I wonder, is it just because we happen to be improving neuroplasticity in a specific region?
And I end. The other thing, too, is this could be beyond my knowledge, like maybe it promotes neuroplasticity really well in other regions of the brain, and I've just read all the studies about hippocampus because I'm not an expert on this, and this is just kind of like the area that I've focused in, but it is what I've noticed.
I wonder how you think about or how we think about, um, maybe not just the metabolic changes in the way that, like, metabolic or metabolic syndrome is used commonly in medicine, but like, Metabolism, like you were talking about earlier at the level of the brain in terms of sort of there was a paper I was reading that was talking about the increase in a number of different things, BDNF, one of them, but also like VEGF and an [00:41:00] increase in, um, microvasculature in the brain, um, from exercise interventions, particularly kind of these more conditioning aerobic based ones.
And this, the like buildup of Immolator towel, like how it's impacted. I can't speak to that in a way beyond what the question I sort of just pose. But one I know one of the mechanisms is also maybe thought to be the like idea that there's an increase in not just PDF, but that Jeff. And so there's an increase in sort of micro vasculature within the brain, which is probably good from like a stroke perspective, but also, um, greater ability to kind of clear waste products from the brain because they're When exercising individuals, there's an increased sort of level of blood flow capacity.
From the VEGF increase. Yeah, so it's funny you should say that. Um, there's a paradoxical effect in other things like smoking, uh, for example. So anything that induces VEGF. So smoking induces VEGF the same way exercise does because you're [00:42:00] in transient hypoxic states. And so that hypoxia induces, um, things like adenosine, which help promote that Jeff and other like new vascular vasculature.
So basically your blood vessels don't get the oxygen they want. So they grow new blood vessels to help cover everything better. So it turns. So the paradox with smoking is that smoking itself increases your risk of a stroke. But because of the new vasculature that you form in your brain, your outcomes of that stroke are better than people that don't smoke.
Fascinating. Yeah, right. So yeah, they're all just always they kind of like when I wrote to them, they laugh about that a little bit. They're like, yeah, like I've never encouraged smoking, but then like they do better. And and they're the ideal thing to do is exercise though, because if you're not getting the downside of smoking and you get the extra bachelors, so if you don't have a stroke, you'd have like kind of these more satellite or ancillary like capillaries or arterials or vinyls to help you.
Yeah. Yeah. Collect oxygen, remove [00:43:00] waste. The same thing actually happens in your heart, too. You can grow more connections, your heart from exercise and from smoking. So increases the risk of heart attack, but also maybe have more collateral blood flow, right? Well, it's I like to take a step back. I feel like this is like, this is kind of a meta comment now.
I'm just like this podcast in general. I know to our listeners, we're like a little in the weeds right now, but like, I feel like this, what we're talking about, what you just said of the like, well, Here's a consideration that you probably, you know, in your 20 or 30 minute visits with your doctors don't have time to talk about just like the really frustrating but beautiful complexity of what it is that we're talking about when we talk about physical and mental health of like, it's not just this thing is bad and we have one thing that's happening and that's how we talk about it.
It's like when you really dive into this stuff, uh, and study it. It's this really complicated cascade of multiple things happening [00:44:00] all at once, which I think everyone knows to some extent, but I think when you really go into a topic that you're interested in. You find, like, all of these different iterating factors.
Yeah, and it's wild to me, like, with biochem or with exercise physiology, it starts out with exercise is good. Yeah. And you go through an insane amount of complex nuance. Yeah. And you're like, oh, this factor, it, like, induces these growth transcription factors, which activates this tyrosine kinase. And then at the very end, you get to Exercise is good and you're like, nice, but now I know, but now I like really know exercise is good.
It was like that paper I sent you where I fell into the weeds about like what I'm not going to talk about this because I really can't, but the like is lifting weights and your heart rate going up during like a bench press or something or like a squat. Is that the same? Health wise, like for heart health and your cardiovascular system is when your heart rate goes up during like running for 45 [00:45:00] minutes.
Um, And it got this paper. I was in the weeds. I probably didn't understand the paper that well. We may have a cardiologist on sometime given the number of like cardio vascular metabolic risks in the psych population, but it was fascinating. It was the same thing of like, well, technically, if it's responding against the vasculature in this way during lifting because your muscles are squeezing like it's fascinating.
It's really complicated. It's not a good job. If you want certainty, I think yeah. Yeah, and I think anyone who wants certainty shouldn't pursue science. Unfortunately, it's just hard either sir. Certainty sells. Yeah, it does. Um, so now that we kind of have like seen or or discussed some of the ways that we know exercises correlated with Increased brain health and maybe actually, um, longevity and aging and reducing your risk of dementia.
There's this kind of question everyone loves to compare exercise modalities. So when we come back, we'll take a look at how exercise racks [00:46:00] and stacks against other forms. Racks and stacks. Yeah, how does it, how does it stratify? Yeah. When it comes to things like weight lifting, who wins? Yeah. Because as is a crucial question when you're exercising for your health, right?
Because if, if I'm not winning, what am I doing? Then you're, if you're not win, if you're second, you're first loser, as they say . Okay. So, okay, when we come back, the exercise. Hierarchy, exercise, the exercise Olympics, and
we're back and we're back with the exercise Olympics. So it's dancing through life. You've been judging or racking, stacking these different modalities. Have I been? Well, I've, I've just been eager to see what, what do you manage to dig up? Yeah, so I think one of the things that we think about with this is that, like, running is one form of conditioning or cardiovascular [00:47:00] exercise, um, and it is a great one, I think, as both you and I think, but it is not the only one.
And I think sometimes at least currently it gets more kind of accolades or kind of respect than other forms as if it's like the ultimate thing to do, um, and so it is the ultimate thing to do, right? Right. I mean, uh, sure. So that one threw me for a loop for some reason. I don't know why Margaret's trying to temper.
She's like, how do I, how do I watch my words here? I'm like, I'm like, you know, running is clearly superior. Next question. Um, yeah. No, but this question of like, right, I think actually to go to something basic, like what are the guide, the fitness guidelines like the U. S. Fitness guidelines, which are 150 minutes a week of moderate intensity.
I. E. Like this is kind of hard. I can't super talk during this, but I can say a couple sentences or 75 minutes a week minimum for kind of like across the lifespan of [00:48:00] adulthood, um, of vigorously the second one or a mixture of those two. And While running is one way to get those minutes in, it also is limited to a lot of people.
A lot of people do not like it, um, or don't know how to start running. And so then the question becomes, is running the only thing that's doing this, right? We've talked a little bit about lifting and we'll leave that for now in terms of like, lifting and like, resistance exercise can also be good for your mental health.
In probably different ways. Maybe maybe some probably some overlap in some distinct ways in terms of the neurobiology. Um, but aerobic exercise has maybe particular things in terms of the physiologic process is happening. And so if we want people, which I think we do for a general health perspective, given the increased risk and the psychiatric population, specifically the severe, the SMI or severely mentally ill population around, um, [00:49:00] shortened lifespans, especially related to cardio metabolic health.
Then we have to think about what is the ideal, if there is one, which question mark maybe, but also then what is the most ideal and that'll help the most people with their health and having a longer life that is more functional for them. Yeah, that reminds me of the Pete's quote, the best medicine is the one your patient will take.
Mm hmm. Yeah. And so that takes me to if skydiving was the greatest form of exercise, you could get like big whoop that we did so many studies on the benefits of skydiving, like who has access to a parachute and a plane daily, uh, cold water plunge sauna and skydive protocol. Yeah. Just keep a cold plunge in your backyard.
It's just 4, 500. That's it. I got a bucket. Meanwhile, and also high altitude created a created a high altitude chamber room too. You have to go. It turns out having a private chef prepare all of your meals [00:50:00] also reduces your cholesterol. What if we did a study that was like escape room benefit on mental health and it was like, Clinical implications, like you must recommend to your patients to go cue three times weekly to an escape room or like some other like mini golf, like mini golf.
Honestly, I think that would be awesome. I think mini golf for mental health. We should do a study on that. You could probably. Get enough data to make a new syndrome, the DSM, like escape room syndrome or something. Escape room syndrome, low mini golfism. That's a problem in my life. Yeah. But so. You're mini golf deficient.
I am mini golf deficient because Boston doesn't have that many that are close enough by. I'm like, what, what is this? I thought this was a city. Yeah, that's so funny because everywhere in the Midwest, I feel like it's just, it's just mini golf and go karts wherever you go. Bowling, of course. Where's the culture here?
Like, are you telling me Paul Revere didn't mini golf? You guys just have like a bunch of like, what, speakeasies and like [00:51:00] pretentious bars. What? Okay. Yes, but I like those two. So I just want to, I want like to mini golf and then follow it up with a pretentious speakeasy, you know, and then go LARP the Paul Revere trail or whatever, the freedom trail.
Yeah. You want to, you want to put a golf ball into a hippopotamus's mouth under a windmill before you go drink a lager in a basement that's candlelit. Ideally in the Boston Common and Mayor Wu, if you're listening to this, what I would have is. A mini golf subset part of it. Like there's always, you know, parks and shit for kids.
Love that. Great for them. Mini golf. And then you're right across from the Cheers bar. What can't you tell me that wouldn't improve Boston's mental health? No, it would. So how does mini golf compare to running? Right? What is the data show? There's not been studies on that. That is a lacking part of the field.
But well, what have there been studies on? I'm getting there. Um, there have been a bunch of different studies [00:52:00] on different basically aerobic interventions. Running has been one of them. Walking has been one of them. Um, dancing has been one, one, one of them, which we will talk about. Just I think it's an interesting kind of cross comparison.
Uh, but there's also been, you know, I think I mentioned swimming. There's been like, basically, if there was. A machine or a sport related to it for like aerobic exercise, I think there's been small and sometimes large studies, but running has definitely been very well studied. I would say walking is probably second in terms of like the like studies on overall mental health.
And then as we talked about earlier, like you can't think about mental health of your patient in front of you without also thinking about their physical like pain level, um, and cardio metabolic health and functional like ability. Okay. And so that is another reason why we have to think about like these different, um, modalities.
I won't get into all those other ones. I think an interesting one to think about and that's prevalent in the kind of older population is swimming or like water aerobics because they don't have like as much [00:53:00] joint bit like load bearing and they can be better for pain in some ways. Um, although I'll leave that to our physical therapy and PM and our colleagues to talk more on what the paper I'm referencing.
There's a paper from, uh, December 2023, uh, by Yon and Nicholson, which is the effectiveness of dance interventions and psychological cognitive health outcomes compared with other forms of physical activity. A systematic review with meta analysis. Um, I won't bore you with the details of this, but I wonder if we kind of parse out things about exercise, right?
Because there's like the, what we mentioned earlier, the kind of simple, like good, bad for brain or not. But there's these different parts, as you were mentioning and kind of going into like, why is this good for different types of dementia or this different cognitive capacity that if we're really thinking about the brain in a robust way, different parts of the brain are interact differently with different kind of neurochemical [00:54:00] cascades that we might cause with exercise, right?
Like how high of a receptor density is on one part of the brain versus another. Um, and so I just say that to say, okay. If we get specific, I don't know that literature is totally there yet, but like thinking about different parts of exercise that might be active ingredients in someone's overall well being, um, can you think of anything just anecdotally or like that?
You might hypothesize that dance might be a better form of like aerobic heart, like cardiovascular exercise for someone for a population or for a certain function compared to like running per se. So, dance incorporates spatial movement and music in a way that running doesn't. And so I know that for a lot of patients, um, even when parts of their memory go, their music is intact.
And so being able to connect your musical centers, I don't know [00:55:00] where they, what broad and area they are, but be able to connect those with your mind muscle connection. makes a significant difference. So, so that's kind of like what I'm thinking is, okay, you're, you have to move along to the beat, which is a much more complicated task.
And then I think the other part of it too is dancing is often with another person. So you have to like kind of interpret body language and use your mirror neurons, things like that, where you're using your full brain in a way that you may not when you're running. Cause you can socialize while you're running, but you're not actively playing off of another person.
Right? Right. So I guess that's what I would guess. Yeah, no, I think that's right. I mean, I think the first time I start with is just that compared to running interventions or some other, like more machine based or very repetitive forms of aerobic exercise, which I think at this point, We have reason to think again, resistance and lifting also has mental health impacts and benefits, but the most robust for anxiety and depression at present, the most evidence we have is for these aerobic based exercises, [00:56:00] but the first one is just do people like it?
I. E. What is the adherence? Right? Yeah, just it's fun. Dancing is fun. Dancing through life is fun. Thank you. Jonathan Bailey. If you want to be on our podcast, um, it's dancing. The stars aren't running with the stars. Yeah. Yeah. Well, that might be a show, but so. Um, I think that's one thing that they talked about in this study is just like, what is the adherence rate?
And like, how much do people continue to do it? One of the things that I believe they mentioned in this study also is that it doesn't necessarily seem, while there are long term positive impacts on like epidemiologic studies for exercise, It's not clear how long like depression is better. Like if someone starts with depression and they do it like an eight week intervention of running and they improve during the intervention, if they stop the running, then the intervention has seems to not, if they stop running, then they are going to go back to the depression to some extent.
Um, [00:57:00] and maybe if you reached it, if we did studies, it was like five years and years on run for two years. Like, would that be a change? Totally. Like, Right? I don't think we can say that. I think about like the idea of like studies and exercise science on like muscle change and it's like if you did a six week study versus a year, it's gonna be very different.
Um, but point of that being is that if the benefit doesn't happen once that you stop the intervention, then we really, really need to care about the ability to do it sustainably long term. And one of the things that will drive that is the intrinsic motivation is just, I kind of just like to do this. Yeah.
Yeah, I think that like that applies to the ketogenic diet to like we see the benefits of the ketogenic diet but staying keto long term kind of sucks and Like someone you're talking about if you're gonna relapse a second you stop keto how realistic is this as like our a long term solution to something if Because I think what else to say to patients that I go keto They're like I'm gonna do keto for the next eight months Like well, we don't know if keto like as soon as you stop doing keto you lose the benefits.
[00:58:00] So Right. Are you going to do your ketogenic diet the next 50 years? Right. Right. And what do we lose in your life if. Yeah. Like, right. Like, what are the risk benefits of. Yeah. And how much does it cost you mentally to do something that you hate? Right. Breakfast. That's just like a block of cheese. I'm having the pancakes as I said prior with my career.
Yeah. Uh. But yeah, how much does it cost you? How much if you like, just really do not like running and it's not fun. And even if you're doing it year after year, it's not a good intervention. Yeah, like we want to like when we think about quality of life, it's also like if someone's going to spend a quarter of a portion of their week and time in mind dedicated to this, if we could make it fun.
And something that's good for them, I think that from a quality of life perspective, that's what we would want, right? Like, not just for them to have to kind of like force it out. Um, as my brother once told me, set the bar really high and then do the least amount of work to get over it. So, um, definitely.
So that's, that's the first one is just there was an easier retention, right? [00:59:00] Um, the second one, the second part was what you had mentioned, which is the idea of interacting with folks and it being social. Um, especially with this kind of you mentioned kind of the mirrored activity, but in coordination, which is a combination of the social elements as well as this paper actually talked about, like, positive, like, like, wanted social touch, like, just even like a pat on the, like a friendly, like, high five that, like, there is something that.
Within human biology of being a co regulating, I mean, this is what interpersonal like neurobiology kind of talks about more than I'll be able to right now, but that that kind of interaction that is also not antagonistic. Like it's not I don't I think if you looked at like doing like. A tango is someone versus someone like tackling you in football.
I don't know that the touch part would be mediated quite the same. Well, I think when someone tackles you they just squeeze the oxytocin out of you. They say love you, baby. [01:00:00] Yeah Um, but there is that element right and like this human contact when we talk about like the loneliness epidemic Um, it's not just in connecting like here I am walking around in my like meat suit body and then we're gonna have a meeting of the minds.
It's also like Being around being the presence of other people and having the kind of interaction with their body language with you're both interacting with music and That level of connection is something distinct just from agreeing on an idea, right? So dance is unique because it's fun and it has this interpersonal interactions Yeah, this wanted human touch that others other forms of activity don't have okay when like, you know to our what we talked about earlier at the beginning of the podcast like You are doing something together and in most of these settings, unless you're like on Dancing with the Stars or a professional dancer, it's a lot like play, like you're built, you're just doing it for fun.
You're not doing it because someone's looking at you and is like scoring you again, unless you're a professional dancer [01:01:00] versus you're In a sport where like you're playing against another team and you're working with someone else. You like can lose. Whereas this is like we're actually just like building a sort of Lego tower together and it's just for the hell of it.
Um, so I think there's that kind of unique team is about it. Um, and then one of the things that they mentioned in this paper is so there's less studies. There's emerging studies. They don't think it's not effective for those. Um, like there's kind of like a split they mentioned in this paper, which is at 55 years.
Um, and it says in those 54 years and under the current literature pool focuses on psychological outcomes. While those for 55 years and over, there's a greater focus on cognitive capacity, which I think we can guess why that's part of kind of how our conversations been flowing to. Um, but it says the effectiveness of dance interventions is most evident in the domains of self efficacy, anxiety, anxiety.
Depression motivation and health related quality of life, especially in older individuals. Um, and then there's [01:02:00] minimal in those less than 16. So like kids, but there's emerging evidence that it may lessen the impact of somatization hostility. So sort of like dysregulation in the body through emotion or physical sensation that it may have play a part in sort of a it.
Mostly maybe they postulate like a mindfulness sort of component to it that allows that sensation and distress regulation to be better So does that do that in a way that running can't I guess my question because yeah, this is yeah This isn't all play. This is a competition right is is running right?
Yeah, right. That's my question
I think that there are different cognitive things that is superior then so I guess the one thing I should say is like in this Meta analysis they talked about a number of studies where it compared it. So I guess what I'm getting is I I saw a A tree diagram that was looking at every different modality of exercise, and it put running.
It put dance at the top, actually. So they looked at efficacy of depressive symptoms with the [01:03:00] intervention over several studies, and the effect size was the greatest with dance and running was comparable with SSRIs, but dance was above them. And then down at the very bottom was Giving the patient information about their disease.
Yeah, that sounds right. That sounds right, yeah. So, I just, I found that interesting. We have one paper that, when it tried its hardest to stratify these, Dance was the one that came out on top. And I was like very surprised by that. Yeah, I think, yeah, we were talking about two separate papers. I think that this paper was like saying not against that, but was saying, it's also hard to know, like this paper is breaking down into different psychological functions, like the ones where dance wins.
And that one is kind of saying like. What was it ranking it on? Was it like a PHQ 9? Right. Was that what it was? I think it was a PHQ 9. Yeah. Which has its own [01:04:00] flaws. Right. And so this, a PHQ 9 being, for those who don't know, Yeah. It's basically a depression, the most common depression. And it's a self reported subjective screener Mm hmm.
On how depressed you feel. Yeah. So yeah, this question of like the results of a paper and what does it mean, you know, famously, we study simply, we pick our symptoms and then we ask a very concrete question versus if we asked like people after intervention, there was a podcast I was listening to talking about like trying to study psychoanalytic therapy and its outcomes versus studying like in, in PTSD populations versus studying like outcomes based on a PHQ nine.
So all of that to say, um, I think that there is maybe parts where we could think about maybe how we can spend the last few minutes of this episode is how to help people think about or help their patients think about choosing. [01:05:00] In this episode, at least cardiovascular exercise that might be the most like from our understanding so far how we talk to our patients about like cardiovascular exercise.
That'll be the most likely to benefit them as an individual. And I have some thoughts on this, but I'm curious yours or if you have more to say on the dance part too. Yeah. So I don't have anything else to say on dance. I do know, um, yeah. I was looking at how does lifting affect BDNF because I'm stuck on this BDNF rabbit hole.
It turns out there's not a lot of conclusive evidence that BDNF is increased or beta hydroxybutyrate are increased when you're lifting some. Um, I think CrossFit studies found people at increased levels of BDNF, but other lifting studies, they didn't. Yeah. And CrossFit is such a cardio metabolic lifting.
Right. Yeah. So is it the cardio benefit of it? So is it really just sustained endurance activity? But that's that's how to be said that people We still see people feel better clinically when they lift the weights period, and that [01:06:00] could just be through another mechanism. And maybe we're siloing ourselves too much when we just look at something like the enough.
I think I think it's a good mechanism, but it also the fact that we see people get better with these other modalities should remind us that there are like probably thousands of other like neurotrophic factors that we don't know about and are not measuring that are also being affected. And I think Um, insulin is another important one to think about and something like lifting actually can increase your insulin sensitivity because you're up regulating your glute receptors on your muscles and that has a lot of different downstream functions that I can't speak intelligently about, but that's not something that happens at the same rate when you're not inducing muscle hypertrophy, right?
Well, that's what I was. I was Thinking about we're, we're, we're going to do a third, we're never, we're going to do a third exercise episode since this is our, our micro interests on maybe lifting and mental health or putting these pieces together. But [01:07:00] like, there is such a bidirectional relationship between lifting, like resistance training and cardiovascular training, like that, if you.
If you're someone who is mostly a runner and running helps you and running is the thing that helps your mental health, like you still probably need to do some cross like additional training with strength so that you don't get injured so that you don't have to just suddenly stop running and then you lose that benefit to you and with lifting.
I mean, I think there's a fair bit. I think one. I think we need to care about for people's longevity. Like we are MDs. So like we do need to care about their overall health again, given that our population Struggles with their, like, cardio metabolic and, like, full body well being, uh, but the other side of it being like, if you lift a lot besides you should care about your heart, it's also that, like, doing cardiovascular exercise can improve your ability to, like, maintain some.
To have less fatigue during like your lifting session. So I just say that as like, uh, [01:08:00] I think there's a reason the guidelines for fitness, like recommend both of these things, but I think also from experience, I mean, not even just my patients, but with like. Friends or other people like talking about those, the fitness minimum guidelines, because that's what they are, uh, they feel overwhelmed and they feel like I hate all of this.
I don't know where to start and so kind of back to how, how you talk about it with your patients. I think that the most salient thing you pointed out. about dance was that it was fun. And that's actually probably the most important factor I include with my patients is, you know, we can split hairs over the effect size on the PHQ 9 difference of like a, like a half standard deviation difference on this, like one, uh, tree line diagram or something.
The reality is if you don't want to do it, you're not going to do it as much. The person that likes walking is going to walk farther than the person who [01:09:00] likes the destination, I guess, to quote Sam Solidge. So I just try to find the activities they like. So, so, for example, I had one, um, um, patient who it was like a similar scenario and I was like trying to talk about run clubs or maybe soccer or something that I just asked them what they would do if they had time off.
They said hiking. I was like, let's hike. Like, you know, let's make hiking our goal because it's not helpful to you. Tell someone like shove someone all the information about how BDNF is going to like include increase hippocampus if they just hate running, but if they like hiking and they do it, it's going to be like a very similar effect and it's something that they can do long term.
So I think that when we get into the weeds, we can look at things like the ketogenic diet and all these different activities, but then forget how well we can adapt it into our lives. So that that's for me, it's really just. What do you like? It has to be something, but like, what do you like? Yeah, yeah. And how do we try something new?
No, I totally agree. [01:10:00] I think I often start with the same place of just like, I actually will often start in my, now all my patients, I think I started doing this in the eating disorder patients when we were starting to talk about like what movement and exercise might look like for them in the future, especially if they had chronic pain and their pains worsened when they can't exercise also worsened by not getting enough nutrition.
But, um, asking like, what did you like to do when you were like six? Like, did you play outside trying to catch fireflies? Did you like kicking a ball around with your siblings? Did you like, you know, dancing with your mom in the car? What did you just like before there was any rules that you were aware of of how you had to move your body?
And then how can we start there? Um, something you like and add active elements that are the least painful for you. Like if you like a group fitness setting, okay, great. Well, and you like dance, let's have you go to a Zumba class. Let's have you go to this. If you don't like that. Maybe more individual at home, [01:11:00] and then like, how do we find kind of like, I think it often sounds for me like the conversation I have around exposures and like exposure and response prevention where it's like, what seems like it would be for the next couple weeks before I see you again.
Like 3 percent harder than where you're at right now, but only 3%. So it feels like, oh, yeah, I can definitely do that. Um, and then go from there and like, maybe still build up to like an quote unquote, optimal longevity slash, like meeting the guidelines for their mental health, because I think a lot of these studies are like a certain amount of dose, right?
That the dose does matter probably for impact. But similar that we don't start like Zoloft at 200 percent with OCD. We're like, well, we're going to start at 25 or 50 and see. Yeah, and I think the important thing there is dose and it being specific. So like one thing that I Pitfall ran into early in residency was I'd be like, what do you do for exercise?
And they're like, oh, nothing, but I want to walk more. Okay, walk more. That's a [01:12:00] good goal. Well, I don't say. Try Zoloft and they're like, what dose you're like more than you have before like, you know what I mean? Like we want a specific like 25 minutes 50 So so now when I talk about it with patients if they are motivated to do it I say like let's try to 20 minute walks.
Yeah Yeah, and just I try to give them like a very specific number because that kind of gives them a dose also gives them something to work towards because when you wake up in the morning and say, like, I have to knock out a single 20 minute walk today, you can plan that instead of just, oh, I want to walk more, right?
And that that vague. Objective and turns into nothing, unfortunately, or a lot of times it does. Well, I think also recognizing the adaptability and helping people plan for that, like this is going to feel tough and we want to choose the right amount of tough, but like, don't this will change over time if we keep doing it and want to do it.
And kind of, again, this is very similar to how I talk about exposure is that it's like, there's gonna be part of you that maybe things like, oh, it's so hard for me to even do this small exposure. If someone has like agoraphobia and they [01:13:00] like my, their challenge that week is to like step on the sidewalk.
Um And kind of helping them frame like this is where we're starting and the same ability to push yourself to the next 2 percent harder beyond your comfort zone. This process will be the thing that gets you to where you want to go. But yeah, right now, it won't look like that. It will look really slow.
Yeah. And what I found even for myself is that my discomfort tolerance improves like a muscle. Yeah. And also. There's less discomfort. The more you do it, like you don't even have to tolerate as much discomfort. Like I've been training for about three weeks now, like, like consistently running the first week.
So, oh, my God, like I was dogging it. I was running slow. My heart rate was like, you're not gonna have that dog and you're just talking. It was awful. And then today I ran six miles and the six miles around felt easier than the two I ran three weeks ago. And [01:14:00] so Three weeks ago, I had to tolerate more discomfort for those two miles than the amount of discomfort I had to tolerate for these six miles.
So, it's almost like you, I also kind of try to say like, hey, you're going to have to tolerate this discomfort, but then once you kind of get through this two week period, it just gets easier. And like, it's not only you getting tougher. It also is just easier after that, I think, I think helping people, if I was your therapist, I might the way I might help you would also be like noticing patients who are hard on themselves or like might be perfectionistic or this is not necessarily you, but like getting a sense before we ever talk about exercise, like how someone is with themselves and then grading how I talk to them based on their behavior.
Likelihood that I think they're going to like overpressure or put in their mind that I'm going to like judge them really harshly if they don't do some like really intense routine and I'll actually actively get ahead of it by saying like, and I'm gonna be mad at you if instead of walking for three, three times [01:15:00] a week for 20 minutes, you ran, you know, four miles when you've never run a day in your life for five times.
So we talked about how you wanted to change this because like, I think that you can be kind of not nice to yourself and your body and your mind needs time to adapt to this. Yeah. Um, and I think also the idea that like, you know, 80 percent or something of like in of workouts in the cardiovascular domain at least should be zone two.
And I think it's helpful to use that metaphor, that lens to frame exercise as a medication, because rather than A punishment. And here's, here's the minimum amount of punishment that I'm prescribing you. And they're like, well, I'm going to punish myself more. Therefore I'll run even further. It's like, well, if you viewed medication as a punishment, I'm like here, take 20 of this pill.
No, I'm going to take a hundred because I deserve more punishment. Like, well, no, I don't want you to take a hundred. We'll work up to a hundred, but right now your dose is 20. Right. So. How long do I know if it's working doc? Six to eight weeks, maybe three months. Yeah, exactly. So I, I, I kind of like that. [01:16:00] It, it says like, Hey, this is, this exercise is really your prescription.
It's not. You beating yourself into the ground. So like, don't go over it. Don't go like, don't try to go under it. Like just try to hit it right on the mark. And that's actually something I had to learn in college when I was running. Like, we had this idea, like, if I just run more, then I'll be more deserving, then I'll show more grit.
But taking the easy days easy and the hard days hard is like the best thing you can do. It's a life lesson at this point. Yeah. Yeah. Really. I love our exercise episodes so much because I'm like, I'm fascinated. Yeah. So I like, I'm really curious as to how like all these other like niche exercises, things like Pilates or yoga or meditation, um, compare when they're folded into that.
So I think it could be kind of cool to incorporate that aspect of things as well. And then one thing I've been stuck on recently is sleep. So I kind of want to come [01:17:00] back to. You need to do a sleep episode. You need to do one of, we're probably, knowing you and I, we're probably going to need to do like eight sleep episodes.
We'll be like, well, we got into dreams during this part of your sleep cycle. So I got a, I have a garment now. Uh huh. It tracks my sleep cycle and gives me a little score, which is not, I don't know if it's the greatest thing to be like obsessing over my sleep, but it's also kind of like biofeedback, which is helpful.
So I've now just been like thinking a lot more about how like my performance on like a run or something correlates with my sleep at night and my sleep stages are and fortunately it tells me how terrible my sleep is when I have a 24 hour shift and it's like your sleep score is like 15 out of 100. You heathen.
Why did you do that? Why did you do that? You're never going to recover. No, you will. Um, yeah, no, I think. All of these parts of the lifestyle parts of mental health are important and often people come and see us and. This makes a lot of sense. Given [01:18:00] the current medical model in the U S we've 20 minutes to see them.
We have a lot of questions we have to ask and answer, but it often leaves us with not a lot of time to talk about these things. Like it leaves us with maybe two minutes if you're efficient and lucky. Um, but not these more in depth things about these parts that can have like the same effect size on your mental health, like depression or anxiety as an SSRI I'm prescribing, but we don't often get to dedicate time to it.
Exactly. And I think like as psychiatrists. It's our organ is the mind and it's our responsibility to look at every medication or medical intervention that affects the mind, like, just like how a cardiologist will spend a lot of time talking about exercise before they jump on a stat. And I think we should do that, too, before we talk about SSRIs, because if so, if the patient before us was exercising consistently, that could be almost as strong as their SSR or stronger, depending on, um, like how they respond to it.
So, like, it's. They're both powerful treatments that we should be considering. I think that's a good place to wrap up for [01:19:00] today. And it's got me saying, yeah,
I don't want to run on, have too many run on sentences. You don't want to keep running your mouth. I have been running my mouth. I think I'm just going to run out of ideas if we try to keep talking. Yeah, I've run out of ideas for responding to that. So, but I am excited about like kind of these new pot, these new episodes that we can look into in the future.
So, um, if you're in the room with us, the listener, I'm talking to you, hi listener. Who is he talking to? so much for being here and joining us on this exercise podcast. How do you like it when we talk about exercise? Because I know I like talking about exercise. Margaret loves talking about exercise. Do you like listening to us talk about exercise and are there specific things with an exercise you'd rather have us cover?
I know we can get into the weeds. We can get more into the weeds or we can get less into the weeds. [01:20:00] Yeah. Do you want us to go in the lawn or in the concrete or something else? Anyways, if you have any ideas like that, please come chat with us and let us know. We're on IG and tick tock at human content pods, or you can contact the team directly at how to be patient pod.
com shout out to all the listeners, leaving the kind and thoughtful feedback and shout out to all the listeners, leaving other kinds of feedback too. I'm in a good mood. So honestly. All you guys are great. You're interacting. You're like, I love the world. I ran earlier today and like all interaction is good interaction.
I'm doing a dance workout after this. So perfect. Well, I'm in bad mood. So haters, just kidding. Boo to anyone who criticized Margaret. It's good. It's good exposure therapy. You know, if you want to see the full episode on YouTube, you can go check out my channel at its pressure. We'll be posting all these as well as shorts and stuff from the pot as well.
Thanks again for listening. We're your hosts. Preston Roche and Margaret Duncan. Our executive producers are Preston, Roche, me Will Flannery, [01:21:00] Margaret Duncan, Kristen Flannery, Aaron Corny, Rob Goldman and Shanti Brook. Our editor and engineer is Jason Porto. To learn more about our program, disclaimer and ethics policy submission verification, licensing terms, and our HIPAA release terms, go to our website, how to Be Patient pod.com, or reach out to us at how to be patient@humancontent.com with any questions or concerns.
How to be patient is a human content production.
How.
Thank you for watching. If you want to see more of us, or if you want to see this is Lilac, she's my cat, she's going to 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 probably exist for real. But in the meantime, I'm just going to pet Lilac. And [01:22:00] then I'm gonna go dance in the background.