Potential Risks to Skipping Breakfast

By Carly Smith, BS, MPH(c) 

Potential Risks to Skipping Breakfast

Many people know the saying, “Breakfast is the most important meal of the day” yet fasting until noon (one type of intermittent fasting) has become popular and mainstream. While it may be beneficial for some, Stanford Lifestyle Medicine physicians and researchers caution new fasters and want to highlight some important considerations for those thinking about skipping breakfast.

“Limiting the time frame that calories are consumed has become a popular dietary strategy to improve health and aid in weight management. Fasting until noon is one of these popular strategies,” says Jonathan Bonnet, MD, MPH Stanford Lifestyle Medicine Physician. “For some, this may work well, however, the preponderance of evidence suggests that weight loss is modest and no more beneficial than overall caloric restriction.”

Side Effects of Skipping Breakfast

Delaying the first meal of the day until noon falls into the category of time-restricted eating. Although this eating pattern may help someone reduce their overall caloric intake, it may also lead to disruptive changes to their circadian rhythm, which could negatively affect sleep, as well as insulin sensitivity and glucose uptake.

In a recent review, researchers discussed the potential impacts of skipping morning-time breakfast. The review reported associations between skipping breakfast and an increased risk of developing obesity or type 2 diabetes. These studies primarily focused on the short-term effects of introducing the morning fasting behavior into one’s routine, however, the long-term effects of habitually fasting until noon are still being studied.

Feeding the Circadian Rhythm

Eating breakfast early in the morning is one signal that influences the genetic pathways underlying the circadian oscillations in the gut, which are critical for predicting daily energy levels and jump-starting metabolism. Thus, skipping breakfast could weaken the signaling of these clock genes and could be one reason why some people that fast until noon experience higher hunger levels throughout the day.

 “Skipping breakfast impacts numerous circadian signals within the body that may be suboptimal,” says Dr. Bonnet. “If someone wanted to try a time-restricted approach, they may experience more benefits from having an earlier eating window (to include a more substantial breakfast) with limited late-night food consumption.”

While research is still trying to understand how impactful these circadian changes are long-term, it is possible that irregular or inadequate fueling of the body may negatively affect one’s body weight, glucose metabolism, and overall health. Thus, it may be more beneficial for one’s health to prioritize consistently eating meals at the same time every day.

“From a circadian perspective, regularity is key,” says Jamie Zeitzer, PhD, Stanford University Professor and member of the Stanford Lifestyle Medicine Sleep team. “The circadian system anticipates signals, like food intake, at certain times of the day and synchronizes gut activity in response.”

Not All Fasting is Bad

Fasting until noon is just one type of eating pattern and not all types of fasting have negative health effects. There are other forms of intermittent fasting that are currently being studied in longevity science due to their ability to build resilience to stress and diseases. For individuals facing obesity and related chronic diseases, time-restricted eating approaches (that maintain the morning fasting window), have not been shown to be significantly more beneficial for weight loss than those following overall caloric restriction methods.

“For those with weight-related cardiometabolic conditions like Type 2 Diabetes, most forms of weight loss can improve their condition,” says Dr. Bonnet. “Finding a way to create a sustainable caloric deficit to lose weight is a challenge, so if some variant of intermittent fasting works for them, it may be the key to start improving their overall health.”

Anyone considering any form of intermittent fasting or time-restricted eating should consult with their physician to make sure that it is the healthiest decision for them both physically and mentally.


The Impact of the Western Diet on Diverticulitis

By Maya Shetty, BS

Recognizing the vital connection between colorectal health and diet has never been more important, given the escalating prevalence of colorectal diseases in Western societies. According to Cindy Kin, MD, MS, a colorectal surgeon at Stanford, many of these conditions are preventable and are linked to the dietary patterns we develop early in life.

“Many people in the US have a chronically low fiber diet high in inflammatory foods beginning in childhood that leads to microbiome dysbiosis, as well as actual structural changes to the gastrointestinal tract,” says Dr. Kin. “Over time, this leads to numerous colorectal diseases, some of which are irreversible and require surgery.” 

One specific condition that has seen a significant increase in prevalence in the last 50 years is diverticulosis, characterized by the formation of irreversible outpouchings in the colon. This condition affects approximately one in three individuals aged 50-59 and virtually everyone over the age of 90 in the US.

Diverticulosis itself does not cause symptoms, and most patients only find out about them when they have a colonoscopy. However, anyone with these diverticular outpouchings is at risk of developing diverticulitis, a painful disease triggered by perforations in one or more diverticula. Diverticulitis may range in severity from mild to severe and life-threatening, depending on the size of the perforation. A tiny pinhole perforation that seals itself quickly might cause a little pain and inflammation that can be treated with oral antibiotics. On the other end of the spectrum, a larger perforation that leaks air and stool into the surrounding abdominal cavity can make someone so sick that they would need to have emergency surgery.  

“Three to five million people get some sort of treatment for diverticulitis per year in the US,” says Dr. Kin, “A proportion of those people need surgery, making diverticulitis one of the most common reasons for colon surgery.”

The Growing Prevalence of Diverticulitis in the US

Diverticulosis became a known problem in the US in the early 1900s, coinciding with major technological advancements, such as fertilizers, preservatives, and factory farming. These advancements caused significant changes in the American diet. Regular consumption of high-fiber, farm-fresh whole foods was replaced by processed foods lacking in essential nutrients. Diets also became increasingly saturated with meats, fats, and sugars, replacing fruits, vegetables, and whole grains. As our diets followed this trend and became more “Westernized,” cases of diverticulitis significantly increased. 

This US-specific increase in diverticulitis is in stark contrast to the nearly negligible incidence found in regions of the world where diets are rich in fiber. In Asian countries, where the diet is becoming more influenced by Western culture, we observe a rising incidence of diverticulitis in the last 30 years. “Diverticulitis is almost entirely a disease of our Westernized diet, low in fiber and high in ultra-processed foods and saturated fat,” says Dr. Kin.

What to Eat (and Not to Eat) to Reduce the Risk of Diverticulitis



Dietary fiber, found in various forms in vegetables, legumes, and whole grains play a critical role in maintaining soft, easily eliminable stool. Conversely, diets lacking in fiber often lead to hard smaller-caliber stools and constipation, prompting the colon to work extra hard to move it through. Years of  sustained high pressure within the colon is thought to be the root cause of diverticulosis, the presence of outpouchings in the wall of the colon. These outpouchings, or diverticula, form as the colon is squeezing so hard that it pushes out a portion of its own wall. The diverticula are weaker than the rest of the colon wall, and are more prone to bleeding and perforations. Research has consistently demonstrated that diets rich in fiber are strongly associated with a reduced risk of developing diverticular disease.

For many years, the widespread recommendation for those with diverticular disease was to avoid nuts, seeds, and popcorn due to the perceived risk of these foods getting trapped in the diverticular outpouchings. However, research suggests this is not the case and eating these foods may actually reduce one’s risk of developing diverticular disease due to their fiber content. “In all my years operating on diverticulitis, I have never seen a popcorn kernel or a sunflower seed poking out of a diverticulum causing a perforation, yet patients continue to steer clear of these fiber-rich foods due to this persistent diet myth,” says Dr. Kin.

Dr. Kin’s recommended daily fiber intake for women is 30-35 grams and 35-40 grams for men. While there are numerous fiber supplements available to help reach this daily goal, Dr. Kin recommends getting your fiber from dietary sources because foods that naturally contain fiber offer a multitude of advantages that extend beyond digestive health, such as lowering cholesterol and weight management to lower the risk of heart disease, stroke, diabetes, and other chronic diseases.

“If your body is not used to a high-fiber diet, gradually add fiber into your daily meals to allow your body to adjust over a couple weeks,” cautions Dr. Kin. “For most people, the gassiness that can happen with eating more fiber will get better pretty quickly, so don’t give up! A little gas upfront for a lifetime of colon health is a small price to pay.”

Processed Foods

Processed foods often lack the essential dietary fiber that whole unprocessed foods naturally provide. Additionally, the overconsumption of refined sugars and saturated fats in processed foods has been associated with several adverse health effects, including changes in gut microbiota composition and an increased risk of inflammation within the gastrointestinal tract. These factors can further exacerbate the risk of diverticular disease development.

Red Meats

Diets high in red meat are linked to diverticulitis, with a large-scale study finding the risk increasing by 18 percent for every additional serving of processed red meat. Red meat is associated with inflammation within several internal organs, and excessive consumption over time has numerous health consequences, including deteriorating colorectal health.

To prevent diverticulitis and several other colorectal diseases, Dr. Kin highly recommends “adopting a whole food, plant-based diet for its exceptional combination of high fiber content and nutrient-dense antioxidant  properties.”


How female runners can improve speed and safety | 90 Seconds w/ Lisa Kim – Stanford Medicine

The idea that a leaner body makes for a faster stride is common among distance runners. But it’s inaccurate and sets a dangerous ideal. Runners who are excessively lean are prone to injuries, infectious diseases, mental health problems and loss in bone density, said Michael Fredericson, MD, a professor of orthopaedic surgery who has served for decades as the Stanford University track team head physician. Female runners are more likely to suffer these effects, he noted.

During his career as the head team physician, Fredericson has seen so many athletes with problems related to low body weight — including bone stress injuries, menstrual irregularity and osteoporosis, or loss of bone density — he decided to study ways to prevent it.

How long does it take to run a marathon? – TODAY

Michael Fredericson, a practicing physician and director of the Physical Medicine and Rehabilitation division of Stanford University, tells TODAY.com that long-distance running is unique from other forms of cardio as it strengthens muscle fibers, “which makes your muscles increasingly fatigue-resistant,” he says. He adds that research also shows that first-time marathoners “experience beneficial reductions in blood pressure and aortic stiffness equivalent to approximately a four-year decrease in vascular age.”

In a Pickle? Unveiling Gut-Friendly Pickles for Your Health

By Maya Shetty, BS

By now, most people have heard about the extensive health benefits fermented foods provide. Fermented foods have become increasingly popular as research continues to reveal that their high concentration of probiotics can improve gut health, boost immunity, and enhance digestion.

“Pickles are fun, tangy, potentially health-promoting ways of eating cucumbers,” according to Dr. Marily Oppezzo, PhD, MS, Head of the Lifestyle Medicine Nutrition Pillar.

However, Dr. Oppezzo cautions that even though the beloved snack of pickles are thought to be fermented, not all of them are, hence, they don’t all have the health benefits. 

Determining whether a particular pickle brand is fermented or not can pose a challenge. In this blog, we will delve into the various pickle varieties, offer guidance on spotting fermented options at grocery stores, and highlight recommended brands to seek out.

How to Choose a Healthy Pickle?

Dr. Oppezzo says that all pickles are a healthy snack, whether they are found on the shelf of the grocery store or in the refrigerated section. However, if you’re looking for a pickle to support gut health, you’ll have to select from the pickles in the refrigerated aisle.

“The pickles that are beneficial for your gut health are the fermented ones, made by brining them in salt rather than vinegar,” says Dr. Oppezzo. “While vinegar pickling is a common method, true fermentation in brine enriches them with beneficial probiotics for your gut. How can you spot these live bacteria-packed pickles? Check out the refrigerated section of your grocery store, as they won’t be found on the regular shelf.”

As Dr. Oppezzo mentioned, pickles essentially fall into just two primary categories: pickled pickles and fermented pickles.

  • Pickled pickles (aka vinegar pickled) are produced using, as you might have already guessed, vinegar. The vinegar kills all bacteria, including the bacteria beneficial to one’s gut. This process effectively sterilizes the pickles and allows them to shelf-stable. Therefore, these pickles are found unrefrigerated in the grocery store.
  • Fermented pickles are produced using brine and go through a natural fermentation process involving bacteria that is inherent within cucumbers. These pickles contain beneficial bacteria for the gut known as probiotics, as long as they have not undergone pasteurization. The pasteurization process, which involves heat, effectively eradicates probiotics from pickles.

So, what you want to look for are unpasteurized fermented pickles, which can be found in the refrigerated section of grocery stores, often in the cheese section. It is always good to double-check the label as well. If vinegar or pasteurized is indicated on the label, chances are probiotics are absent. Instead, look for these terms on the label: “fermented,” “unpasteurized,” , “live cultures”, and/or “probiotic”. Another sign that pickles are naturally fermented are the presence of bubbles on the surface of the brining liquid – a by-product of live bacteria at work.

Dr. Oppezzo also recommends prospective buyers to “spend some time reading labels and look for ‘added sugar’ on the label to be sure you aren’t accidentally getting sugar through your pickles.”

Why are Fermented Pickles Healthier?

Probiotics Support the Microbiome

Fermented foods have a variety of health benefits due to their high concentration of probiotics, 

or beneficial microorganisms aka the “good” bacteria. The microbiome within one’s gut helps to digest food, absorb nutrients, synthesize vitamins, and regulate one’s immune system. Research consistently demonstrates that healthy, stable microbiomes that are high in diversity and beneficial microbes  are shown to reduce chronic inflammation, weight gain, and disease.

Nutritional Benefits

Fermented pickles offer a range of nutritional benefits due to the diverse array of compounds they contain. These include antioxidants like flavonoids and phenols, which fight inflammation and protect cells from oxidative stress. The pickling process may also enhance the bioavailability of these antioxidants. Additionally, pickles contain a high concentration of vitamins and minerals, specifically vitamin K, vitamin C, vitamin A, calcium, and potassium. 

Immune Benefits

Vegetables that undergo the fermentation process typically produce natural substances such as alkyl catechols. Alkyl catechols activate a defense pathway that shields against various chronic diseases linked to oxidative stress. These substances may also boost the activity of cell defense pathways that protect our body from cancer and neurodegeneration.

Be Careful of the Sodium!

Despite all these potential health benefits, pickles are not the perfect snack.

“One major downside of pickles is their high salt content,” Dr. Oppezzo cautions. “A single pickle can contain over two-thirds of the recommended daily sodium intake for an average adult. Excessive sodium can be detrimental to overall health, thus it is important to eat pickles in moderation. If you are going to have them and are watching your salt, eat after you’ve sweat a lot due to exercise or a sauna.”


How to Utilize Stress to Our Advantage

By Sharon Brock, MEd, MS

This blog is part of the Stress Management newsletter. If you like this content, sign up here to receive our monthly newsletter!

Our entire lives, we have received the message that stress is bad for us. From the media and medical professionals to our family and friends, we constantly hear that stress is debilitating and should be avoided at all costs. But Stanford University Associate Professor of Psychology Alia Crum, PhD, claims that stress can potentially serve us in our lives as long as we have the right mindset. 

“Things happen in our lives that we don’t have any control over, so rather than try to avoid stress, which is inevitable, how about we change how we perceive stress for a healthier outcome?” asks Dr. Crum. “By shifting our mindset from ‘stress is debilitating’ to ‘stress is enhancing,’ we can utilize the stress in our lives to achieve valued ends.” 

What are Mindsets and Why Do They Matter?

A mindset is a core belief or assumption about a category, such as our intelligence, bodies, or a particular skill, that orients us toward certain expectations, attributions, and goals. 

“Mindsets about stress are the core beliefs we have about the nature of stress—it’s not about the belief about the stressor, such as the exam, the divorce, or the illness,” says Dr. Crum. “Having a ‘stress is debilitating’ mindset can add stress to the stress. People might think, ‘Oh no, this stress will make me sick,’ which only adds more stress to the situation.”  

Dr. Crum explains that the mindsets we hold can have self-fulfilling effects. For example, if we have a mindset that we “aren’t good at taking tests,” we might expect to fail an upcoming exam, and often, this belief becomes the outcome. 

Dr. Crum says that it’s not “magic” that our beliefs come to fruition. She says that mindsets have self-fulfilling effects in that they determine, very concretely, the following four mechanisms:

  1. What we pay attention to.
  2. How we feel and expect to feel.
  3. What we are motivated to do.
  4. Our physiological responses to the stress.

Our stress mindset determines how we approach stress, how we make sense of the hardships in our lives, and what we pay attention to. With a stress is debilitating (SID) mindset, one might focus only on the harmful effects, such as the potential to cause insomnia or illness. However, with a stress is enhancing (SIE) mindset, one’s attention may also go to the positives, such as, “What is the lesson here? What skills am I learning? Is there something I can work on within myself? Have I created stronger relationships due to this stressful situation?” 

Our stress mindset also determines how we feel. Someone with a SID mindset may feel fearful, threatened, angry, or resentful for the stressor in their lives. Someone with an SIE mindset could still be angry but also have positive emotions by having such thoughts as, “I acknowledge that this is a hard situation, but I will get through this and become stronger for it. This situation is showing me how resilient I am, and I’m proud of myself for how well I’m handling it.”

What we are motivated to do is also determined by our stress mindset. Those with an SID mindset often shut down or lose emotional control. However, those with an SIE mindset are motivated to endure stress to the extent that it may help them stay focused and push them further to achieve their goals.  

At the physiological level, research shows that those with an SID mindset have higher levels of cortisol and lower levels of DHEA growth-promoting hormone in their blood. However, those with an SIE mindset have moderate levels of cortisol and higher levels of DHEA growth-promoting hormone. Therefore, our mindset can create changes in our bodies that are measurable in the lab. 

“Mindsets are important in that they create our realities,” says Dr. Crum. “I’m not trying to convince people that stress is enhancing and not debilitating—it can be both. But I believe that whichever mindset we choose will influence what happens in our lives through these four mechanisms.” 

Research Backing the “Stress is Enhancing” Mindset

Many researchers promote the message that stress is debilitating, however, Dr. Crum and other researchers have shown that stress can improve these three aspects: health and vitality, performance and productivity, and learning and psychological growth.

The health and vitality aspect may come as a surprise since many of us continually receive the message that stress can make us sick. Dr. Crum acknowledges that many people in various situations have experienced adverse health effects due to stress. However, her research shows that there are cases in which the experience of stress makes people physiologically tougher and more resilient. 

For example, there are many everyday instances of how stress makes our body stronger. When we lift weights at the gym, the stress on the muscles breaks them down in order to rebuild them stronger. Vaccines work because they stress the immune system, which has to figure out the pathogen and how to deal with it. In both cases, the body becomes stronger and healthier in response to the stressor.  

Dr. Crum also says that an SIE mindset may reduce negative symptoms of stress, such as headaches, backaches, rumination, and insomnia.

“I’m not trying to say that stress doesn’t have debilitating effects on our health, but it doesn’t have to, and there’s another side of the story for some people under some conditions,” says Dr. Crum. “The body’s stress response was not designed to kill us; it was designed to boost our body and mind into enhanced functioning, strengthen our immunity, and promote growth at the physiological level.”

Regarding enhanced performance, any athlete or stage actress can attest that the stress of succeeding can improve the quality of their performance. And any procrastinator will say that the pressure of a deadline can make them more productive. This “good” stress is called “eustress” since the effect of the stress is beneficial. 

“There is an implication that eustress is a moderate amount of stress, and when the stress becomes ‘too much,’ we go into distress. But I know many people who endure incredible amounts of stress in their lives, and they become stronger for it,” says Dr. Crum. “So rather than putting our energies into figuring out ways to reduce or manage our stress, I believe it is more useful to transform the way we approach stress by changing our mindset.” 

Stress also has an immense impact on our learning and psychological growth. “When you go through stressful experiences, there’s a shattering of typical assumptions about life, and in the midst of that, as painful as it can be, are opportunities for learning, change, and discovery,” says Dr. Crum. “So, you can utilize the stressful experience to open your awareness to growth, insight, and wisdom that would not have been there if it weren’t for the stress in the first place.” 

How to Change from a “Stress is Debilitating” to a “Stress is Enhancing” Mindset?

In the free, online course, “ReThinking Stress”, Dr. Crum explains three steps to shift one’s mindset from SID to SIE. 

1. Acknowledge

When you start to feel stress in the body and mind, acknowledge it by saying, “I’m feeling stress.”

2. Welcome

Rather than resist the stress, we can welcome it because it reveals what is important to us. For example, when tension arises, we can ask ourselves, “Why am I stressed?” For instance, if you feel stress when your child isn’t doing well in school, this reveals that you care about your child’s success.  We can use the stressor to help us identify what we value and what brings meaning in our lives—this alone has a beneficial effect on the immune system, according to Dr. Crum.

In the Welcome step, we may also recognize that our typical emotional response may not serve us in getting what we value. For example, if your usual reaction is frustration toward your child when they bring home a poor grade on a test, this may not be the most effective way to motivate your child to improve their performance.

3. Utilize

Instead of our typical emotional response, Dr. Crum invites us to ask ourselves, “How can we utilize the energy from the stressful situation to help us reach our goals?”

With an SIE mindset, we are more likely to channel the physiological stress response, which includes an increase in energy, narrowed focus, and heightened attention in a useful way. For example, rather than reacting with frustration, we can redirect this increased energy and focus to finding solutions to the problems your child is having at school.

Whenever a stressful situation arises, Dr. Crum recommends implementing the Acknowledge, Welcome, and Utilize steps. She also recommends taking the “Rethinking Stress training”, which aims to utilize the power of our mindset to convert the stress we already have into something beneficial. Dr. Crum recommends that we take the course multiple times until the SIE mindset is established and becomes our default perspective on stress in our lives.


The Unexpected Health Benefits of Forest Bathing

By Vedika Patani and Carly Smith, BS, MPH(c)

This blog is part of the Stress Management newsletter. If you like this content, sign up here to receive our monthly newsletter!

Many people know that hiking in nature can help reduce stress and anxiety. But not everyone knows that forest bathing is a way to take the therapeutic effects of a scenic walk to the next level. While hiking is a great way to get outdoors and exercise, forest bathing is a practice of being calm and quiet among trees and being present with our natural surroundings.

“Both hiking and forest bathing harness the power of nature to offer a wide range of benefits for our physical and mental wellbeing,” says Rusly Harsono, MD, head of Stanford Lifestyle Medicine Social Engagement and Clinical Assistant Professor at the Stanford School of Medicine. “Hiking provides an outdoor activity that activates our nervous system for greater physical health, whereas forest bathing calms our nervous system and improves our emotional wellbeing, which is equally important to physical health.”


What is Forest Bathing?

Forest bathing, or Shinrin Yoku, originated in Japan in the 1980s and involves taking deep breaths and experiencing the forest with full presence. Contrary to hiking, where the mind can still ruminate about work or challenging relationships, forest bathing is a mindfulness practice in that it brings the mind into the present moment by taking in the forest with all five senses. For example, a forest bather would visually observe the colors of the leaves and stop to notice the sun’s rays through the trees. They might close their eyes and take in a deep breath through the nose to capture the scent of pine. As they take a step, they may hear the crackling of a fallen leaf from under their shoe, and then pause to notice the sensation of the wind on their cheeks.

During the pandemic, forest bathing grew in popularity in the US as people searched for ways to calm their nervous system and connect outdoors while social distancing. But forest bathing is proving to be more than a lifestyle trend. Research is attributing this practice to numerous health benefits. 

Forest Bathing and Mental Health

While hiking focuses on the improvement of physical fitness, forest bathing fosters improved mental and emotional health. Some people who experience anxiety find that forest bathing calms their nervous system because their attention shifts from their worries to noticing the natural elements all around them—and these results are scientifically measurable.

Studies show that forest bathing can decrease the stress hormone cortisol. In one meta-analysis, researchers reviewed 971 articles and found that forest bathing effectively reduced serum and salivary cortisol levels, indicating its potential to reduce stress. 

Another meta-analysis reviewed studies where forest bathing was introduced to people living in urban environments, who generally have a higher risk of hypertension and psychological stress. Not only did the practice reduce their stress, but it also significantly lowered their blood pressure. 

“Forest bathing can be beneficial for everyone, but it is particularly advantageous for individuals living in urban environments,” says Dr. Harsono. “Urban dwellers typically experience higher stress levels, noise pollution, and reduced access to natural settings. Forest bathing provides them a valuable opportunity to escape these stressors and experience improved wellbeing through connection with nature.”

A Natural Immune Supporter

Forest bathing is not just important for improving wellbeing, but it may also improve one’s physical health. Studies have found that forest bathing could increase immune cell activity and aid in the expression of anti-cancer proteins. In one study, a group of 12 men aged 37-55 spent three days practicing forest bathing in three different forests. Afterward, the men showed a 50 percent increase in natural killer cells (which can kill tumor cells) and an increase in the anti-cancer proteins perforin, granzymes, and granulysin. 

Another research study showed that forest bathing improved immune function. When we inhale the oils released from trees (phytoncides), our cortisol levels decrease, and natural killer cell activity increases. These findings suggest forest bathing may have a preventive effect on cancer due to its ability to stimulate immune responses; however, more research needs to be conducted to better understand this phenomenon.

Forest Bathing Everywhere

One would think that forest bathing is only possible if you live in the country, however, this study showed that urban forest bathing (i.e. being mindful at a nearby park) still brought feelings of peacefulness to adolescents that live in metropolitan areas. This study observed the changes in the mental wellbeing of 44 adolescents before and after urban forest bathing. The results reported reduced anxiety, rumination, and skepticism, as well as increased feelings of social connectedness.

Lastly, landscape designers have taken note of the research supporting the healing effects of nature. At Stanford’s Lucile Packard Children’s Hospital in the heart of the San Francisco Bay Area, patients and their families have access to gardens and outdoor spaces to stroll and mindfully take in the natural beauty.

“Lucile Salter Packard’s vision for the hospital was to nurture the body and soul of every child by creating a restorative environment by integrating nature and art,” says Dr. Harsono, Pediatrician at Stanford Medicine Children’s Health. “We frequently bring children to the hospital garden during their recovery to help them manage their treatment and discomfort. Research supports this idea of incorporating forest bathing experiences into the care of sick children to improve their health outcomes and overall quality of life.”


Stress Management Resources

This blog is part of the Stress Management newsletter. If you like this content, sign up here to receive our monthly newsletter!

We all know that stress is a part of life, and our wellbeing depends on how well we manage it. When we are reactive to stress, our nervous system can go into survival mode, and we may lose our abilities to cope and see the situation clearly. But when we utilize wellness practices in times of stress, such as taking five deep breaths, we are letting our nervous system know that we are safe enough to access compassion, reasoning, and perspective—and we are able to handle our challenges with grace and experience our full lives with greater ease.

Stanford University promotes the education of research-backed wellness practices and resources that support the general public and Stanford students to manage their stress, such as:

1) Stanford Psychiatry YogaX – Free Online Yoga and Wellness Classes

– for the public and mental health professionals to bring yoga into healthcare

With the mission to bring yoga into healthcare, YogaX is a special initiative of the chair of the Stanford Department of Psychiatry and Behavioral Sciences. The instructors of YogaX are trained psychologists, both researchers and clinicians, who promote the science and application of therapeutic yoga.

YogaX’s YouTube Channel offers free online yoga and wellness classes and provides integrative tools for patients to navigate their health journey with greater resilience. YogaX also offers yoga teacher trainings specifically tailored for mental health professionals to bring yoga practices and philosophy into the healthcare setting. YogaX teaches integrated holistic yoga that is grounded in modern neuroscience, neurobiology, and psychological research. The program honors the ancient philosophical and psychological teachings of yoga and aims to combat the stigma and stereotypes associated with the westernization of yoga.

“Our vision of yoga is one of inclusiveness, access, diversity, health, wellbeing, and resilience for all. Ours is a yoga of integration that honors the mind as much as the body, the breath as much as the calming of the nervous system, stillness as much as movement, and effort as much as ease.”

— Christiane Brems, PhD, YogaX Director, ABPP, ERTY500, C-IAYT

2) Stanford Lifestyle Psychiatric Clinic

– for the general public

The Stanford Lifestyle Psychiatry clinic provides high quality care for people with psychiatric disorders who prefer to take an active role in their recovery through implementation of evidence-based lifestyle interventions. Researchers at the clinic also conduct research into the most effective methods for lifestyle change among various subgroups and for specific psychiatric conditions.

We also provide opportunities for the next generation of providers to train in Lifestyle Psychiatry and offer leadership in the incorporation of lifestyle interventions in medicine across Stanford and throughout the world.

The Stanford Lifestyle Psychiatry clinic provides:

  1. Medication management
  2. Health coaching
  3. Nutritional counseling
  4. Mind-body practices
  5. Supportive psychotherapy

“Care in the Lifestyle Psychiatry clinic starts with a comprehensive assessment of current and lifetime lifestyle behaviors. This communicates the importance of lifestyle to health and provides the basis for identifying contributors to current symptoms and opportunities for improvement. Once we’ve established the person’s past lifestyle preferences, current behaviors, and current symptoms, we review the potential risks and benefits of a range of therapeutic options including medications, psychotherapy, and lifestyle interventions. Then, we develop a plan for building successful lifestyle changes, set manageable goals, and revise the goals until the patient achieves the results they are seeking.”

— Douglas Noordsy, MD, Director of the Stanford Lifestyle Psychiatry Clinic

3) Stanford Living Education (SLED) Program

– for Stanford University students

The Stanford Living Education (SLED) program offers experiential and research-based, unit-bearing courses where students learn the science and practice of wellbeing. Each quarter there are roughly 15 courses, including: Meditation, Financial Wellbeing, Sexual & Emotional Intimacy Skills, Athletes as Leaders, The Art of Grief, Laughter Yoga, Tools for a Meaningful Life, Digital Wellness, and more. Classes range from one to four units, some are graded S/NC, and many are WAYS designated.

“Stress is part of a meaningful life: traveling, relationships, family, meaningful work, and being a student at Stanford. Stress doesn’t mean you’re doing life wrong; stress means you care. How we respond to our stress has a dramatic impact on our sense of wellbeing. In our SLED courses, students learn research-backed practices to manage stress in a healthy way, while earning academic credit.”

— Sarah Meyer Tapia, PhD, Interim Director of SLED


How to Be Mindful When You’re Stressed Out

By Carly Smith, BS, MPH(c)

This blog is part of the Stress Management newsletter. If you like this content, sign up here to receive our monthly newsletter!

I first began practicing mindfulness during my third year at Stanford University. I remember feeling overwhelmed by every aspect of my life – school, work, life, etc. Even the idea of being stressed would further stress me out. With the help of various mentors dedicated to student mental health and well-being though, I learned how I could best practice mindfulness and feel more in control of my mind.  

Mindfulness is an internal practice in which one shifts their focus to what and how they are feeling without much interpretation or judgment. If you’re reading this, perhaps you have already crossed off the first step in the process: name your feeling. 

What Am I Even Feeling?

The power of naming one’s feelings has been studied thoroughly in neuroscience. It is estimated that most people will spend nearly half their lives letting their mind wander. This mind wandering sensation is actually the heightening of our brain’s default mode network (DMN), an evolutionary adaptation that keeps us alert and is often overactive in individuals that suffer from anxiety. Consciously shifting one’s focus to perform a task – like labeling your feeling – centers brain activity to the prefrontal cortex, effectively inactivating the DMN. Another study conducted at UCLA found that the simple act of naming one’s emotion shifts brain activity from the amygdala (a structure that registers danger and fear) to the prefrontal cortex (the center of reason and logical thinking). Neurological studies show that when we are in the present moment, the prefrontal cortex is active and the amygdala and DMN are inactive.

“Mindfulness has been my go-to practice to reduce stress for many years now,” says Sharon Brock, Stanford Lifestyle Medicine Program Manager and UCLA-certified Mindfulness Facilitator. “Oftentimes, just labeling my emotions is enough to bring me back into balance.”

Whenever I practice mindfulness, sometimes all I need to do is call out my emotions. For me, this is often equivalent to calling out to a friend walking down the street or when Hogwarts students figure out what their patronus is. It is relieving to focus on what is right in front of me. The aforementioned switch from our brain’s DMN into the present moment keeps me grounded and helps repair my mental floodgates before becoming overwhelmed.

Listen to the Label Practice by mindfulness teacher and author, Sharon Brock.

Feel It to Heal It

Strong emotions like stress, anger, love, etc. all tend to really let us know they are with us by also manifesting themselves physically. Like many people, stress feels like a stiff neck and a tight chest for me. Once I have taken a moment to label my stress, I can turn my attention to how it is affecting me. Recognizing these emotions can give a quick explanation to why I feel off kilter, and allow me to become more aware of my physical self. My emotions become something more tangible for me to understand and experience.  

“If you can experience your emotions as a sensation in the body, it creates some space between you and the emotion,” says Brock. “By observing the sensations, you realize what emotions actually are: energies in motion. We don’t have to take our emotions so personally, they are just energies constantly coming and going in our experience.”

This act of feeling your feelings is a mindfulness tool offered as an alternative to other responses we can take when emotions are high. Observing before responding also helps to center one’s attention and direct brain activity to a calmer region, just like naming the feelings. Dr. Jon Kabat-Zinn developed a mindfulness-based stress reduction (MBSR) program as a non-pharmacological treatment for anxiety. This program heavily incorporates the mindfulness technique to observe our physical feelings with guided breathwork, body scans, and mindful movements. Body scanning, in particular, increases one’s bodily awareness by paying attention to how different body parts feel in the moment. 

Listen to the Observe Practice by mindfulness teacher and author, Sharon Brock.

Tips for Self Compassion

The most impactful thing I learned from my mindfulness course is that practicing mindfulness for stress reduction also requires practicing self compassion. Self compassion is the offering of love and kindness to ourselves and our emotions. Doing the opposite, criticizing oneself for feeling certain emotions, reactivates the amygdala and reintroduces stress to the body and mind. Recent research conducted at the Henry Wellcome Laboratories for Integrative Neuroscience & Endocrinology demonstrated that guided self-compassion exercises helped to significantly lower cortisol (the primary stress hormone) levels and increase heart rate variability. Participants with greater tendencies of self-criticism benefited greatly from learning to offer themselves gentleness when experiencing strong emotions. These findings indicate that practicing mindful self compassion has a physiological soothing effect on the body. 

“Many of us have a harsh inner critic, so it might feel strange at first to be nice to yourself, but the research shows that offering ourselves kindness reduces our stress,” says Brock, UC San Diego-certified Mindful Self-Compassion instructor. 

I used to believe that being my harshest critic was what guided my academic success. Not only was this method unsustainable, but it was often doing more harm than good. When we accept that emotions are transient and natural experiences, we do not need to judge ourselves for having them. In fact, we can offer ourselves compassion. For me, learning to offer myself self compassion was the mindfulness lesson that required the most practice. However, it has become a necessary aspect of my everyday life and has given me a reliable stress-management technique to keep in my mental toolbox forever.

Listen to the Self-Compassion Practice by mindfulness teacher and author, Sharon Brock.


How Yoga Affects the Brain and Body to Reduce Stress

By Vanika Chawla, MD, Stanford Psychiatrist

This blog is part of the Stress Management newsletter. If you like this content, sign up here to receive our monthly newsletter!

As a clinician at the Stanford Lifestyle Psychiatry clinic, I consider the impact of lifestyle factors such as sleep, nutrition, exercise, and mind-body practices such as yoga on my patients’ mental health and integrate these modalities into my treatment plans. I especially have a clinical and research interest in the therapeutic use of yoga as a lifestyle intervention. Yoga has been instrumental in my own wellbeing, therefore I am passionate about sharing the practice as a holistic intervention that promotes wellbeing in the body, mind, and spirit.

I was first immersed in yoga when I completed my 200-hour yoga teacher training in 2010, prior to medical school. I discovered that yoga was much more than physical postures – yoga is an integrative and holistic system of practices that aims to alleviate suffering. 

There are many different lineages and traditions of yoga, each emphasizing various components of the practice, including postures, breathwork, meditation, lifestyle, ethics and values, and recognizing our interconnectedness. There is a famous aphorism that captures the essence of yoga: yogas chitta vritti nirodhah. This Sanskrit phrase translates to, “Yoga is the calming of mental fluctuations or storms of the mind.” Thus, it was no surprise that on my journey to become a psychiatrist, I noticed parallels between yoga and psychiatry, including yoga’s therapeutic potential in addressing unmet needs in our current mental health care treatment models. 

On a personal note, my yoga practice provided me with a set of tools to manage the stresses and rigors of medical training, whether it was cultivating new perspectives when faced with challenges or practicing breathwork before a big exam to help with stress. 

How Yoga Improves Mental Health

While yoga is an ancient practice originating in India, it has only recently been applied for therapeutic purposes, and thus, the clinical evidence is in its early stages. There are many possible mechanisms for how yoga may improve mental health and counteract stress. One well-accepted mechanism is that yoga helps regulate the autonomic nervous system (ANS) and hypothalamic-pituitary axis (HPA), both of which are stress response systems. While stress is an inevitable and necessary part of life, prolonged and chronic stress can lead to dysfunction in these systems, potential negative physiological and physical consequences, and can even contribute to the development of mental health disorders. 

Yoga is proposed to exert its benefits through top-down and bottom-up processes facilitating bi-directional communication between the brain and body. Top-down mechanisms are conscious and intentional inputs from the brain to the body, such as setting an intention to relax. Bottom-up processes are inputs from the body to the brain, where signals travel from the muscles, heart, lungs, and other systems to different parts of the brain. Practices like yoga postures and breathing can change the signals that are carried to our brain, such as assessments of our sense of safety and wellbeing. Through top-down and bottom-up pathways, yoga can counteract the “fight, flight, or freeze” responses that may persistently arise in the face of stress. Accordingly, yoga has been shown to confer several changes in physiological markers implicated in stress, including cortisol, inflammatory cytokines, heart rate variability, as well as the release of neurotransmitters, such as GABA. 

The Neuroscience of Yoga

In addition, there is evidence of changes in both brain structure and function related to the practice of yoga. These include changes in the prefrontal cortex (PFC), amygdala, hippocampus, and default mode network (DMN). The PFC manages our highest-order cognitive abilities, such as decision-making and goal-setting. Stress and other strong emotions can negatively impact the abilities of the PFC. 

Research shows that regular yoga practice leads to increased activation of the PFC and thus may counteract deleterious effects of stress on the brain. Further, yoga impacts the activity of the amygdala, which is involved in processing emotions. Yoga may also increase the volume of the hippocampus, which is involved with memory and learning and is known to decrease in size with age. Finally, the DMN is involved in rumination and mind wandering, which may interfere with cognitive function and lead to decreased wellbeing. The DMN is implicated in many psychiatric disorders, such as depression and ADHD, and yoga has been shown to modulate the activity of the DMN. 

While yoga cannot change our external stressors, it can allow us to respond rather than react to stress. Yoga can counteract the harmful physical effects of stress and lead to changes in the body, brain, and mind that increase resilience and adaptability. 

Tips for People New to Yoga

From Kundalini to Vinyasa flow, there are many different types of yoga, so I recommend those new to yoga try different styles and see which practice aligns with their needs and feels safe and supportive. I suggest taking classes from credentialed teachers (with a minimum of RYT-200 hr training) who offer modifications and adaptations. There are resources like Yoga-X online classes, which provide holistic yoga practices at no cost. If you are seeking yoga for a specific health or therapeutic purpose, then community classes may have limitations. You may instead look for therapeutic yoga classes or yoga therapy in conjunction with support and consultation from your healthcare provider.