Impact of the Ketogenic Diet on Mental Health

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By Claire Paul

Can food really impact your mood? Nutritional psychiatry, the use of food interventions as a form of mental health treatment, has gained popularity in recent years. While there’s an overwhelming amount of dietary suggestions out there, it is worth noting a 2023 comprehensive review assessing the relationship of the Ketogenic diet with neurodegenerative and psychiatric diseases. Although not recommended for everyone, the ketogenic diet may be one avenue for improving mental health through food. Moreover some principles of the ketogenic diet may be applied more broadly.

Dr. Shebani Sethi, founding director of the Metabolic Psychiatry Clinical Program at Stanford University explains that, “While the ketogenic diet may not be suitable for everyone, its underlying principles of reducing neuroinflammation and supporting cognitive function can be integrated into everyday habits.”

What is the Ketogenic Diet?

While popularized in the media as another low-carb weight loss fad, the ketogenic diet was actually developed initially as a treatment for epileptic patients. It has been used to treat epilepsy since 500 BC but was more popularized by physicians in the 1920s. The diet focuses on fats being the primary source of fuel instead of carbohydrates; however, the ratio of macronutrients is dependent on the use of the diet. A 4:1 fat-to-carbohydrate ratio is typically used in clinical treatment, whereas a 3:1 ratio will be suggested for those who require higher amounts of protein or carbohydrate intake. While many different iterations of this diet exist, the Mentzelou et al 2023 review defined it as follows: 1  gram of protein per kilogram of body weight,  10-15 grams of carbohydrates, and the remainder of daily caloric intake from fat.  The ultimate goal of the diet is to induce the production of ketones, a chemical stored in the liver to break down fat. The state of ketosis modifies metabolic pathways and has been associated with the reduction of oxidative damage and inflammation regulation.

What did they find?

The Mentzelou et al 2023 review contains a comprehensive search of existing peer-reviewed journal papers published between 2000 and 2023. Notably, the authors only included studies based on the classical ketogenic diet, defined above, and for in vivo studies, only research on Caucasian individuals was included. With this inclusion criterion in mind, the authors still found a mountain of evidence, 101 articles to be exact. Interestingly, they excluded over 300 articles because they didn’t fit the classical ketogenic diet criteria, which goes to show much research is actually on this “fad” diet. After collating the data the articles were categorized into in vitro and in vivo research.

In vitro

In general, in vitro (cell culture/mechanism studies) research indicates that ketogenic diets can help to increase mitochondrial health. The authors indicate that this can happen in a few different ways, such as decreasing mitochondrial apoptosis (i.e., death),  increasing mitochondrial biogenesis (i.e., birth), and improving the function of existing mitochondria.  If you remember back to high school biology class the mitochondria are the “powerhouse of the cell” so having more of them, having them not prematurely die, and having them work better, all add up to a more efficient system. Interestingly , the ketogenic diet is postulated to help in other areas as well, such as the microbiome and synapse myelination. A summary of the molecular mechanisms is shown in Figure 1.

Figure from Mentzelou et al. (2023), pg 5.

In vivo

 The study looked at the clinical implications of the Ketogenic diet for the treatment and management of neurodegenerative and psychiatric diseases. In a study without 31 individuals with psychiatric disease (major depression, bipolar disease, schizoaffective disease) who followed the ketogenic diet between 6 and 248, there was a considerable link between improvements in depressive and psychotic symptomatology. A study also examined the effects of the Ketogenic diet on Alzheimer’s disease. After following the diet for 16 weeks, mice showed lower amyloid plaque accumulation and thus decreased neuroinflammation. A study of 23 individuals with mild cognitive impairment also looked at the relationship between following the Ketogenic diet and their symptoms. After following the diet for 6 weeks, they displayed improved memory function. Figure 3 from the study displays the results of the Ketogenic Diet for each neurodegenerative and psychiatric disease in the specific study.

Figure from Mentzelou et al. (2023), pg 8.

Another notable case study examined long-term Ketosis associated with considerable mood stabilization. A 70-year-old women experienced therapy-tolerant schizophrenia for 53 years and implemented the Ketogenic diet. She was able to stay off all psychiatric medications for 11 years and her symptoms subsided.

What can you do?

The principles of the KD can still be implemented by individuals looking to reduce neuroinflammation, diversify the microbiota, and improve overall cognitive functioning.

  1. Reduce Processed Carbohydrate intake
  2. Increase Healthy Fats, especially omega-3 fats
  3. Consume moderate amounts of protein
  4. Incorporate a variety of fiber-rich plants into the diet

 While the ketogenic diet is just one avenue of doing such, the principles listed above are all tied to improved mental health. While food is not the sole determinant of mood, there’s certainly something to be said about its impact on mental health and well-being.

Precautions and Things to Note

It’s important to be aware of many limitations to the findings and potential side effects of the Ketogenic diet. While these are individual studies, clinical evidence remains scarce due to their short term, lack of a control group, or large dropout rates. Though all meta-analyses support the efficiency of the ketogenic diet as a treatment for epilepsy, further studies need to be implemented to draw this conclusion for other mental health disorders. Certain side effects are also necessary to be aware of, including the phenomenon of the “keto flu,” a sickness which typically subsides after a few days. Additionally, maintenance of the diet can be challenging which is why it’s necessary to follow the protocol in accordance to one’s individual needs.

Dr. Shebani Sethi notes that, “Optimizing brain health goes beyond symptom management; it requires addressing the metabolic underpinnings of psychiatric conditions. The ketogenic diet, with its emphasis on enhancing mitochondrial function and reducing oxidative stress, aligns with the goals of promoting mental health and vitality.”

However, it’s necessary that “As we continue to explore the relationship between nutrition, metabolism, and mental health, it’s essential to approach lifestyle changes with caution and under the guidance of healthcare professionals.”

As always, before starting any new diet to treat a specific symptom or disorder, it is imperative to first talk with your healthcare provider.

A Step Up to Health: The Power of Stairs

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By Anya Higashionna and Jonanne Talebloo

With the increasing automation of the world around us, Levi Frehlich MSc PhD ©,  emphasizes, “We are learning more and more that a sedentary behavior independent of your activity levels can have a profound influence on your health. The environment can be used to break up sedentary behavior and utilizing stairs can be a “great first step.”

How many times a week are you faced with the decision: stairs or elevator? What goes through your head and influences your decision? Maybe you are trying to weigh out the benefits of being healthy versus “saving time” with an elevator. One counter to think about is walking up an escalator – a third option that is both faster and healthier! The contents of this post may change the way you think during this practically daily decision we are expected to make.

Furthermore, it is essential to understand that this question may be more important than we initially perceived. With heart disease being the most expensive medical condition and the leading cause of death, and hypertension being the most prevalent chronic condition, we should look to prioritize ways to prevent them. Luckily, one action can lower the risk of all of these chronic conditions and many others. A recent paper published in 2023 titled “Daily stair climbing, disease susceptibility, and risk of atherosclerotic cardiovascular disease: a prospective cohort study,” Song et al. found climbing more than five flights of stairs daily was associated with a lower risk of atherosclerotic cardiovascular disease (ASCVD) independent of disease susceptibility. Overall, it is safe to say that the question: stairs or elevator, has the potential to have more of an impact in our lives than we may originally think. 

Song and colleague’s research was a prospective study using data from almost 500,000 (458,860 to be exact) adult participants in the United Kingdom. A prospective cohort means that the subjects are followed to observe future outcomes. Baseline data for stair climbing, sociodemographic (e.g., age, sex, ethnicity, education, average annual household income), and lifestyle (e.g., smoking status, physical activity, alcohol intake, and dietary pattern) factors were collected. Five years after baseline, this data was recollected with a median of 12.5 years of follow-up. Individuals were followed until the occurrence of the ASCVD incident, loss to follow-up, or death. The follow-up measured stair climbing and incidence of ASCVD, coronary artery disease, or ischemic stroke. ASCVD was considered to include coronary artery disease, ischemic stroke, or acute complications. To account for the role of individual disease susceptibility, the following were analyzed: levels of genetic risk score, 10-year risk of atherosclerotic cardiovascular disease, and self-reported family history of atherosclerotic cardiovascular disease.

What story did the data share? Among populations with varying susceptibilities, the cohort “demonstrated that climbing more than five flights of stairs daily was associated with over a 20% lower risk of ASCVD”. Participants who reported starting to stair climb at baseline but stopping stair climbing (meaning stair climbing less than 5 times a day) at the second examination had an observed higher risk of ASCVD. However, it is important to note that the behavior exhibited by these participants may actually be due to comorbidities or other risk factors that compelled them to reduce stair climbing. Therefore, interpretations of this data should factor in risk effect as a potential factor in the reduction in physical activity. Nonetheless, the data indicates that those who stopped stair climbing midway through actually showed worse results than those who hadn’t started stair climbing. This may show that consistently performing these smaller acts daily is more important than overexerting yourself for one day a week. 

There are certainly more ways to integrate more daily movement without the use of stairs. Researchers from Icahn School of Medicine at Mount Sinai, New York, recently published a paper titled, “New principles, the benefits, and practices for fostering a physically active lifestyle” where they elucidated how ‘every minute counts’ for lifestyle movements and ‘going from nothing to something is the biggest bang for your buck’ in reference to Albert Bandura’s findings published in a 1977 paper on “Self-Efficacy”. This is important to remember as the biggest threshold isn’t going from 5 minutes of exercise to 30 minutes, but rather 0 minutes to 5 minutes. An effective way to confront these challenges is to think of SMART (Specific, Measureable, Achievable, Relevant, and Time-bound) goals. SMART goals are related to the concept of self-efficacy (REF) which states that “individuals are more likely to pursue goals if they think they can accomplish them.” Since goals that are viewed as easily attainable are more likely to be accomplished, SMART goals can help guide one to create these ideal goals that will get the ball rolling. The moment you decide to increase physical activity in your life, think SMART. A SMART goal you can have for introducing stair climbing into your life would be, “I will climb at least 2 flights of stairs a day for 1 month to improve my cardiovascular health”. You can even practice this by creating a SMART goal for when you want to start implementing the exercise practices stated in this article!

Whether you decide to start today or in a couple weeks, with or without stairs, it is important to remember the research goals to emphasize the simplicity of the activity and time efficient nature of stair climbing detours. People at all stages of life benefit from less sedentary lifestyles, but implementing healthy habits early on further increases the benefits of non sedentary lifestyle practices. Some similar practical ways to increase the amount of steps taken in your life include activities from simply parking further away from your destination to even dancing whenever you hear music you enjoy. As a college student, I like to walk the longer scenic route between classes or even do smaller things like walk to the next bus stop instead of catching the one I am closest to. The first step (pun intended), no matter how small, can pave the way to a healthier, more active life. So, when you first encounter the decision of choosing the escalator or stairs, consider it not just a choice in the moment but as an investment in your long term well being.

Botanical Brain Boost

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Exploring how surroundings impact unconscious cognitive processing during work and rest.

By: Anya Higashionna

As a student who loves the outdoors, I have always found great joy and comfort in curating house plants for my living spaces. When I left for college I was determined to hand carry all my plants through the airport from my room in California to my dorm in Washington. I believe the effort was worth it as the living greenery in my dorm room has enhanced my space and thus my wellbeing. I love the calming effect of having a piece of nature indoors and the curiosity the different colors and shapes of plants inspire. These feelings spurred me to dig deeper into the world within which I surrounded myself. 

With green on my mind, I wondered if there was a possible scientific explanation connecting my botanical buddies and my health. Turns out, there is! A 2022 research paper, “Characteristics of Eye Movement while Viewing Indoor Plants and Improvements in Occupants’ Cognitive Functions”, from the Department of Architecture at Waseda University in Tokyo, Japan researches the cognitive benefits of plants through a series of tests and rest periods in combination with an eye tracking device. While many know plants are beautiful, the researchers wondered: can they help you think better?

So What Happened in This Study?

Imagine you only had four objects to select from to place in your study space before an exam to test your creativity and memory; no object, a real plant, a fake plant, or a row of books. Which one would you choose in order to perform your best on the exam? These conditions were what thirty students from Waseda University were tested under to further dissect the theory of plant improvements on cognitive functions of creativity and memory. They also outfitted participants with an eye tracking device to measure how well the brain was “resting”.

After a general health survey and calibration for the eye tracking devices, participants took a creativity test called the Unusual Uses Tests (UUT). During this task one would be given objects and write down as many unusual uses for each in a given time, requiring the brain to think creatively. This task would consist of a three minute rest period in between a six and twelve minute testing period and would be scored through a uniqueness and fluency score. For example, an object one might be given is a “shoe”. A common idea was using the shoe as a ball, but a less common more unique response that would be scored higher was using the shoe as a boat for a Barbie doll.

Next after another recalibration of the eye tracker, they did a working memory task where they were given sentences written in Japanese with one underlined word. The goal was to recall the words in order as presented for a score of 2 or out of order for a score of 1. There were three six minute tasks periods with two two minute rest periods between each.

What was Found After Analyzing the Data?

The main thinking tasks were creativity and working memory tasks. Surprisingly, they didn’t find many differences in increasing creativity or working memory here! What did they find? Plants may not have helped with thinking, but they seemed to be helpful for resting in between thinking where they had also used eye tracking. The paper’s authors, Dr. Soma Sugano, explains, “Eye-tracking technology offers a unique advantage in that it can measure unconscious visual perception.” Basically, it measures fixations, or periods of staring, and blink rate. If you have low fixation, and higher blink rate, this indicates you are using less brain power and you are “restoring” your attention. Essentially, the eye tracking measured if you were truly resting your brain during the rest breaks.

 “Our study’s novel finding is related to how individuals visually perceive indoor plants during their rest periods while working,” says Dr. Sugano. This is interesting to consider as the results and expectations showed that females would have fewer fixations in case 2 (real plant) than in the remaining cases during the rest period of the UUT task. This measurement of the number of blinks and fixations during the rest periods of each task, “consistently support the understanding that the plants had an attention restoration effect during the rest periods of the RST” (Sugano, 2022, p.10), and UUT for females. 

Soft Fascination on Attention Restoration

“When you care for plants, you feel the joy of connection to another living creature, but you also begin to notice patterns and colors and structure in a way that engages your mind in creative curiosity,” states Katherine Preston, PhD, professor for the plant taxonomy course and associate director for the human biology program at Stanford. An important note made by both Dr. Sugano and Dr. Preston was that while there is further research needed on the cognitive impacts of surrounding plants, physically caring for plants may be a key variable that makes a difference. With the limited scientific evidence, an interesting topic of debate was brought up by Dr. Preston. Dr. Preston brings up an interesting topic of debate that points out that plants most likely don’t have the same effect on people with a surface level understanding about plants and those who consider themselves plant experts may be a result of individual’s “soft fascinations”. Soft fascinations refer to elements in the environment that capture and hold a person’s attention in a gentle, non-demanding manner, such as artworks of calm scenes or being in nature. This can be further explained with Attention Restoration Theory (ART) which describes how modern urban environments can overstimulate and fatigue the mind, but restore it in natural settings with soft fascination.

Transforming your Space and Mind

Despite the fact that this article was written with the purpose of mainly exploring plants, the benefits of attention restoration can be derived from many different objects depending on the person. Different style lamps, calming paintings or patterns, colored walls or lights, or even a picture of your pet can create the same effect. While there is limited scientific evidence on plants specifically improving one’s cognitive abilities, there is a small detail that one can take away from this research if plants are not a suitable relaxing object for them.

We can be quick to put on a youtube or netflix show as background noise and believe it isn’t distracting us, but is it harmful in the long run? Activities that we do or place around us at our desks while we work and rest should not be overlooked, as the scrolling breaks on Tik Tok and Instagram can drain our mental batteries rather than charge them. Similar to how having books in the background can keep the minds of the subjects in the experiment stimulated, busy screens and visuals will not be as good for attention restoration as objects and activities that take lower cognitive effort to view.

Next time you work at your desk at home you can conduct a mini experiment to test your work space and break activities restoration abilities. First, you can perform your usual tasks at your desk then during your break take a moment to look around you and think about your space and the objects around you. Does the abundance of many different objects or a certain object make you anxious, drain your battery, or distract you? Then while you rest, also think about the activities you do and the spaces you surround yourself with. Personally, when studying for big exams I used to take breaks by just going on my phone. However, one day I saw my friend coloring during our pomodoro break and was inspired by her choice to color and made me reflect. I joined in on the coloring and found myself being able to recharge much faster and relax more. Another thing that I had noticed was that It no longer took me 30 minutes on my phone to feel ready to start up again. It was not only rewarding seeing how much we have colored in as time went on, but seeing the page get colored in also showed us how long we have studied! Just like how plants are not for everyone, coloring might not be for everyone either. Maybe enjoying a good episode works best for you, going on a walk, attending to your plants, or even organizing your space.

However, If you are interested in the star of this experiment, plants, and in college, Dr. Preston recommends,  “Although they are trendy, succulents are not as easy to keep in a dorm room as some people would tell you. Most succulents need the right kind of light and water, and many species are easily broken. Instead, I would try a classic houseplant. One that is very easy to care for is Dracaena Trifasciata, sometimes called snake plant. One of my very favorite plants is the peace lily, or Spathiphyllum. It can grow in very low light and will tolerate a wide range of water conditions. Every once in a while it makes flowering spikes with lovely white sails behind them. When yours gets big, you can divide it and share with friends”. In the end, your workspace should be tailored to your unique needs and preferences. If caring for plants isn’t feasible or of interest to you, there are countless other elements that can contribute to transforming your space into the personal paradise you desire.

Sleep and Academic Excellence: A Deeper Look

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By: Keshav Saigal

In the whirlwind of deadlines, exams, and extracurricular activities that define our lives throughout high school and college, sleep is often sacrificed. Late-night study sessions, scrolling through social media, or binge-watching the latest Netflix series might seem like necessary trade-offs for those hours of rest. However, for those looking to boost your academic performance, optimizing your sleep might be more beneficial and more nuanced than you think. In this article, we’ll go beyond simply discussing getting more rest for better grades, but outline the details of a healthy sleep schedule and tips you can implement. Through the lens of an important study published in 2019, we’ll delve into the fascinating world of sleep hygiene — a term that encompasses the habits and practices that can enhance the quality of your sleep.

The 2019 study was conducted at the Massachusetts Institute of Technology (MIT), where 100 students were selected from an Introduction to Solid State Chemistry class (only 88 of whom met the final criteria). For that semester, the students wore a Fitbit, a wearable activity tracker, which using a combination of movement and heart-rate patterns assessed sleep. This provided researchers, who also had access to the student’s overall scores at the end of the class (sum of all grade-relevant quizzes and exams), an objective measure of sleep duration and quality, rather than self-reports. This was a significant improvement over previous studies.

The prominent findings of the study were that “better quality, longer duration, and greater consistency of sleep correlated with better grades.” In fact, they found that nearly 25% of the variance in academic performance was attributed to sleep.

To understand the distinctions, we have to first understand the science behind why sleep can be such a powerful tool in succeeding academically. Essentially, all the cognitive gains happen when you’re asleep; sleep actually solidifies your memories of the day, which is necessary for you to recall what you studied, by strengthening the “synaptic connections that were active during awake-periods.” Additionally, in studies where people were actually deprived of sleep in the short term (<48 hours), researchers found not only increased fatigue and sleepiness as expected, but also worsened cognitive performance. These results elucidate the importance of studying sleep and its connection to academic performance.

Sleep and your brain: How did they study it?

The data in this research study showcased two distinct ways of characterizing sleep. First, there is a single ‘day’ of sleep: the 24 hours before and after a night of sleep. Here they measured: bedtime, wake-up time, total hours of sleep, and sleep quality (a calculated combination of movement and heart patterns). Second, there is sleep over time: the consistency of sleep schedules over weeks and months. Here they measured: the standard deviation of a participant’s average daily hours of sleep.

To look at these two categories of sleep, the researchers selected from volunteers in a chemistry class at MIT. The students were all given a FitBit at the start of the semester and told to wear it for at least 80% of the time each week. They were largely freshmen (97%) in a Solid State Chemistry class with weekly lectures and quizzes, 3 midterms, and a final exam. By the end of the class, 88 students managed to have successfully met their requirements. The researchers collected all of their data from each student’s Fitbit and exam scores, including quality.

What did they find?

In the single-day category, the study had results on four components: bedtime, wake-up time, duration, and quality. Their results are detailed below:

  • Bedtime: “earlier average bedtime was associated with a higher overall score in the chemistry class”
  • Wake-up time: “earlier average wake-up time was associated with a higher overall score in the chemistry class”
  • Duration: “a greater amount of sleep was associated with a higher overall score in the chemistry class”
  • Quality: “there was a significant positive correlation between average sleep quality… and overall score in the chemistry class” 

In order of statistical significance by correlation coefficient r (a measurement of the strength and direction of the relationship between two variables), their conclusions were that going to sleep earlier, sleeping more soundly, sleeping for longer, and finally waking up earlier was associated with better academic performance.

While tracking the single ‘day’ of sleep of the MIT students, the researchers also analyzed the overarching data from the semester. Their primary discovery detailed how “greater inconsistency in sleep duration was associated with a lower overall score.” What does that mean? Poor scheduling over months all add up. One good night of sleep can’t fight a whole semester of inconsistent sleep, which entails all the components of a single ‘day’ of sleep, but day-in, day-out for weeks and weeks. That means a consistent number of hours of sleep from the same bedtime to the same wake-up time every day and lifestyle habits that contribute to better sleep quality. It means that for those of you that sleep poorly during the week and bank on catching up on the weekend – uh oh! The researchers found having a routine of sleeping less during weekdays and oversleeping on weekends was associated with worse performance. 

However, it isn’t all bad news. While poor habits lead to worse grades, one night of bad sleep doesn’t have that large of a difference. Researchers also found that there was “no relation between sleep measures on the single night before a test and test performance; instead, sleep duration and quality for the month and the week before a test correlated with better grades.” For anyone planning on last-minute cramming, this indicates that long-term consistency is of greater importance. It is about setting a routine and getting in the habit of prioritizing all the aforementioned nuances of a healthy single day of sleep.

Sleep and YOUR brain: What can you do about it?

How can we do that? While perfecting your sleep schedule and optimizing for academic success is a complicated and futile endeavor as both high school and college bring many distractions, there are smaller steps we can take. In fact, work from the director of Stanford University’s Behavior Design Lab and pioneer of ‘Tiny Habits’, Dr. BJ Fogg, shows that baby steps are one of the only ways to genuinely improve. You might think you need to overhaul your sleep by changing everything all at once. But what is shown to be far more effective is instead to try and pick one aspect of sleep the researchers focused on and try to change that, e.g., waking up at the same time every day. In practicality, we all know that better sleep habits will help us in every part of life. Perhaps we didn’t know that sleep hygiene encompasses so much or can impact academics so strongly. Understanding the research is a starting point on that journey. But to continue on, we’ve designed a list of tips you can follow, supported by further research.

Category A: The Single ‘Day’ Of Sleep

Tip #1: Set a consistent wake-up time

Tip #2: Get enough sleep

Tip #3: Improve your sleep quality with powerful daily habits

Category B: Sleep Over Time

Tip #1: Maintain a consistent sleep schedule

  • Sticking to a healthy routine has an immense impact on how sleep can improve your academic performance. Research has also indicated that “the consistency of sleep patterns may have a greater impact on GPA than sleep duration.” This means trying to keep your routine for all 7 days of the week. Blips in the schedule and any off-nights shouldn’t have as grand an impact, as long as the routine is kept up for a long period of time.

Tip #2: Reflect on the habits that work for you

  • While we have mentioned several strategies you can follow to boost the quality of your sleep, incorporating all of them can be incredibly hard and stressful. As you attempt to implement some of them, see what works for you and what doesn’t. We are all different and respond differently to various sleep strategies. Create a relaxing bedtime routine that works for you. This can include reading a book, taking a warm bath, and much more. It’s essential to experiment with different techniques and observe how they impact your sleep quality. By reflecting on your habits and preferences, you can tailor your sleep routine to suit your individual needs. And once you’ve identified the sleep habits that work best for you, it can help to monitor your progress and make necessary adjustments. If you find that certain habits are not yielding the desired results, be open to making changes and refining your approach. Remember that improving your sleep habits is an ongoing process, and what works for you may evolve over time. By staying flexible and proactive in managing your sleep, you can continue to enhance your academic success.

Incorporating the approaches outlined in this article can be transformative. By recognizing the impact of sleep hygiene on academic performance, we can take proactive steps to enhance our sleep routines and, ultimately, achieve better outcomes in both our educational pursuits and daily lives. As we navigate the demands of high school and college, let us not overlook the power of a good night’s sleep in shaping our success.

How Joy is Linked to Gratitude and Well-being

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By Donovan Giang

This blog is part of our Gratitude & Reflection newsletter. If you like this content, sign up to receive our monthly newsletter!

With the holiday season upon us, the spirit of joy is in the air. From magazine advertisements of happy families having a delicious meal to hearing Christmas carols in department stores, we are constantly being fed the message that we should be joyful at this time of year. However, if we are not feeling joy, these messages can be a continual reminder of what we are missing, often making us feel worse.

Luckily, researchers such as Akivah Northern, DSci (c), MDiv member of the Stanford Lifestyle Medicine Gratitude and Reflection pillar, explore different ways to experience and cultivate joy in our lives. Northern is a chaplain, doctoral candidate at Loma Linda University and she received her Masters of Divinity from Yale University. Her dissertation research is a Stanford IRB approved study, exploring medical students’ joys and challenges as they were expressed during Reflection Rounds, a required course for medical students taking their core clinical clerkships at Stanford School of Medicine. Northern co-facilities Reflection Rounds with Bruce Feldstein, MD, BBC who brought Reflection Rounds to Stanford seven years ago.

“We know that medical students are challenged, however less is spoken about their joys, which are equally as important,” says Northern. “Joy in medicine is an ancient aspiration that dates back to the fourth-century Hippocratic Oath, which is still taken by physicians today. Experiencing joy as a physician is part of the very foundation of medicine, so it is essential to cultivate it as medical students begin working with patients.”

So, how does one define joy? In Hebrew and Greek, joy has many meanings, such as delight, exaltation, rejoice, gladness, cheer, exuberance, and triumph. Northern shares that during challenging times, feelings of sorrow and grief are valid and a natural part of the human experience.

“There are times when life brings us situations when we have to lament, but we don’t have to stay there ,” she says. “There are so many different types of joy, such as received joy, divine joy, announcing joy, profit joy, fruit of the spirit joy, and jumping for joy, joy! So, even during hard times, we can choose to savor the myriad of joys and intentionally create reasons for joy.”

 Joy Linked to Gratitude

In exploring joy, researchers examined the relationship between joy and gratitude. This study consisted of self-report measures from university students. To measure joy, the researchers used scales developed within the study, such as the State Joy Scale and the Dispositional Joy Scale. To quantify gratitude, the researchers used scales of Dispositional Gratitude, a Gratitude Questionnaire, and a Gratitude, Resentment, and Appreciation Test. These self-report measures found that joy can increase gratitude and gratitude can increase joy, suggesting an “intriguing upward spiral” between the two.

“Research linking positive emotions like joy and gratitude to well-being is vital for patients as well as for  healthcare providers,” says Northern. “For example, preliminary results from my research showed that medical students’ expressed joy when they were grateful for teachers, peers, and for the profession of medicine, but especially for their patients”

Looking at her data, Northern found that in 30 expressions of joy by medical students, 17 were associated with gratitude. For example, one medical student expressed joy as gratitude for being “deeply honored” to have met and had “easy, comfortable conversations” with a patient, his spouse and family. Another student expressed joy as appreciation for the way his physician mentor engaged with a patient, describing the interaction as “beautiful and wonderful.” The student appreciated seeing the physician be present with the patient, admiring the quality of the physician’s presence and the “commonality” the physician and patient shared. A third medical student expressed that although she could not deliver medical care to a distraught patient with overwhelming life stressors, she still felt joy because “ultimately, just being a listening human was the number one therapy delivered that day.”  

“A surprising finding from the research was when medical students’ expressed joys and challenges simultaneously, they often had a breakthrough to a discovery or new joys and insights,” says Northern. “When we allow joys and challenges together, we become more resilient and emotionally buoyant, and often something new emerges from the experience.”  

Joy Linked to Well-being

In recent years, joy has become an object of study in the humanities and medicine. Joy, as a positive emotion, has consistently been suggested to be a key aspect of well-being in the field of positive psychology. Martin Seligman, the founder of this field, developed the PERMA+ Model. The “P” in PERMA+ stands for positive emotion (joy, gratitude, and optimism), the “E” for engagement, the “R” for relationships, the “M” for meaning, the “A” for accomplishments, and the “+” for other elements beyond these. 

In further research on joy as a positive emotion, researchers conducted a study to examine the pre-existing strategies individuals use to maintain high levels of positive emotion. To measure the strategies the participants (university students) used, the researchers applied an Emotion Regulation Profile to categorize participant reactions to hypothetical situations. One result from this study found that mindfulness (being present in the moment) was positively correlated with positive affect.

Another way positive emotions (including joy) increase well-being at the physiological level is by increasing one’s resilience. In this study, university students prepared a short speech, which served the purpose of stimulating a stress response. Using cardiovascular measures (to gauge the stress response), ambient mood and emotion measures, and psychological resilience measures, the researchers found that positive emotions hastened cardiovascular recovery (a lower amount of time needed to return to baseline cardiovascular measures, including heart rate and finger pulse data) after the experimental stressor. 

Another study examining the influence of positive emotions on physiological stress processes was the first to demonstrate that gratitude and thankfulness can buffer against the negative effects of acute stress on cardiovascular responses.

“Even in stressful times, joy can be a choice,” says Northern. “Even in a hard situation, we can look for joy. Even if we can’t see the joy currently, we can anticipate the joy that may come in the future from accepting the challenge, resolving it or reframing our understanding.. When we choose to approach challenges in the company of  joy and hope,  we are investing in our own well-being and our future.”

 

Optimism as a Means to a Longer Life

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By Jonanne Talebloo

This blog is part of our Gratitude & Reflection newsletter. If you like this content, sign up to receive our monthly newsletter!

We have all heard the saying “mind over matter” when it comes to athletics and physical challenges. But can this saying be applied to health, healing, aging, and longevity? Studies suggest that optimism may play a leading role in improving not only one’s emotional well-being but also physical health and increasing lifespan.

Optimism, defined as the tendency to be hopeful and expect positive outcomes, has been linked to improved mental health and well-being in that it uplifts one’s mood and outlook on life. Optimism alone may not be the silver bullet for health and happiness, but studies show that it is one of many factors that can positively influence health, longevity, and lifespan.

For example, research shows that optimism helps diminish stress and anxiety, which lowers the stress hormone cortisol. Elevated levels of cortisol and blood pressure have been linked to an increased risk of stroke, hypertension and heart attack. Chronic stress can have negative effects on almost all of our bodily systems, including the endocrine system, where stress can impair communication between the immune system and the hypothalamic-pituitary-adrenal (HPA) axis, and potentially lead to immune disorders.

Optimism also assists with healing. Akivah Northern is part of the Stanford Lifestyle Medicine Gratitude and Reflection Pillar and earning her doctoral degree in Religion and Health at Loma Linda University. She is a chaplain, which are professionals who listen and accompany patients and their families in life-threatening, physical, existential, moral, or spiritual distress. Northern is the founder of a soon-to-open healthcare center that incorporates lifestyle medicine, chaplaincy intervention, and the arts.

“Optimism is not just helpful, it is vital for those who are suffering,” says Northern. “As a chaplain, I engaged patients in optimism and hope, instilled a sense of the sacred, and offered explorations regarding ultimate meanings. These conversations served as calming, hope-filled, and relieving medicine for patients.”

Optimism and Longevity

Recent studies have explored the connection between optimism and longevity and how a person with a positive outlook has the potential to live a longer, healthier life. A recent study revealed that optimism (defined as “the global expectation that things will turn out well in the future” and measured by cortisol stress reactivity and questionnaires) was linked to decreased cortisol levels, which is an important factor regarding increased longevity. Another study found that higher levels of optimism (assessed using the Revised Optimism-Pessimism Scale) were linked to increasing lifespan by as much as 15 percent.

In a review article examining a variety of health and longevity benefits associated with optimism, researchers found a whole host of benefits. Highlights from the review were that greater optimism predicted greater career success, better social relations, and better health. The article also concluded that the positive effects of optimism appeared to reflect individuals with a greater engagement in pursuit of desired goals. Another large-scale study showed that the link between optimism and increased longevity was independent of ethnic origin and applied across many racial and ethnic groups.

In order to understand how optimism can make such dramatic impacts on our health and longevity, the neural underpinnings of optimism have also been studied. Research suggests optimism activates areas of the brain involved in mood regulation, attention allocation, emotional expression, language processing, and perception of oneself. Modulating these areas with our thoughts may improve psychological well-being by improving one’s perception of the world, themselves, and self-expression.  

“Optimism is the opposite of stress, worry and anxiety, which can increase inflammation and chronic illness in the body,” says Northern. “By leaning toward a calming and optimistic way of being, we are increasing not only our mental, emotional, and spiritual well-being, but also our physical health and longevity.”

Optimism can be Cultivated

Although optimism is defined as a trait ingrained in individuals, people can learn to develop optimism over time. Learned optimism can be cultivated through music, gatherings, and culture in community. This sense of community strengthened by optimism can promote individual well-being, contribute to advancements in public health, and even inspire social change on a global scale.

An example of cultivated optimism through culture and community is the fact that millions of Iranian women worldwide have learned to adopt an optimistic attitude in their fight for freedom and equality. Research also shows that optimism improves resilience, another essential characteristic for Iranian women. Optimism and resilience among the Iranian diaspora have been the foundation of a global community that continues to inspire change regarding women’s rights. 

Optimism can also be developed at the individual level by working with internal thoughts, such as breaking pessimistic thought patterns or cultivating the experience of gratitude by keeping a gratitude journal. Another way to work towards adopting an optimistic mindset is by challenging and re-writing negative self-talk. For example, this can mean changing phrases such as “I will never be able to do this.” to “This is a challenge I look forward to working towards overcoming.” Furthermore, one study notably found that optimism can be increased through a very simple intervention in which individuals imagined their best possible self for five minutes each day.

“Our internal dialogue is everything. What we tell ourselves, the language we use on the inside will come out on the outside,” says Northern. “So, we need to be intentional about being optimistic, generous, and forgiving—this will make such a difference not only for those around us, but for our own health and healing.”

 

The Unexpected Health Benefits of Forest Bathing

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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.”

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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.”

 

Aerobic & Resistance

Aerobic & Resistance Exercise Improves Sleep

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Sleep, a fundamental element of human biology, plays a crucial role in various physiological processes. A good night’s sleep is essential for immune function, cognitive performance, emotional well-being, and overall physical health. Exercise is another critical lifestyle factor with tremendous potential to improve your health. Regular physical activity has numerous benefits, from reducing the risk of chronic diseases to improving mental health. However, could exercise improve your sleep?

Impact of Resistance Exercise on Sleep

A 2017 review found that “chronic resistance exercise improves all aspects of sleep, with the greatest benefit for sleep quality” in individuals with sleep problems. In this study, Kovacevic et al. employed a systematic review methodology by conducting an electronic database search of randomized controlled trials. Many studies fit the criteria, but three acute resistance exercise studies, seven chronic resistance exercise studies, and three combined aerobic and resistance exercise studies met the researchers’ inclusion criteria and were analyzed for sleep outcomes. The primary finding from this review was improvements in sleep from chronic exercise; these improvements were “moderate-to-large, and commonly affected overall sleep quality, sleep latency, sleep efficiency, mid-sleep disturbance, and daytime dysfunction”. In comparison, the primary medications prescribed to improve sleep quality had “only small-to-moderate effects on sleep quality” and instead have “adverse effects such as rebound insomnia, depression and anxiety, cognitive impairment, and an increased risk of falls, cancer, and overall mortality” if used in the long-term. Kovacevic et al. call for further research and more data on aerobic exercise but cites an earlier paper that noted how aerobic exercise could improve sleep quality.

Furthermore, their work highlighted how “higher intensity and greater frequency of training offer greater sleep benefits”. More specifically, the chronic resistance exercises studied that had the most benefits included machine-based resistance exercise, circuit training, and resistance bands for an average duration of 14 weeks total with approximately 60 minutes per session. Studies with high exercise intensity as compared to low-to-moderate intensity, and with a frequency of 3 days/week as compared to 1-2 days/week, had a larger beneficial effect on sleep quality.

The review presented another pathway by which exercise could improve sleep; exercise improves levels of anxiety and depression, both of which deeply affect sleep — “notably, exercise has been shown to be an effective treatment for major depression and sleep disturbance is one of the core symptoms of depressive illness” and “the majority of chronic studies included in this review reported significant improvements in neuropsychological outcomes”.

Impact of Aerobic Exercise on Sleep

Additional research has also shown the further benefits of aerobic exercise for people with established sleep disorders. One study showcased how “4 months of aerobic exercise training in a sample of older adults with insomnia significantly improved sleep quality while also reducing daytime sleepiness and depressive symptoms”. Another study found that “12 weeks of moderate-intensity aerobic and resistance exercise resulted in a 25% reduction in OSA [obstructive sleep apnea] severity”. Lastly, studies have even shown that the circadian rhythms disrupted in neurodegenerative disease can be improved with exercise — “exercise has proven to be a low risk and beneficial intervention to improve overall health and sleep disorders in AD [Alzheimer’s disease] and PD [Parkinson’s Disease]”. In particular, “physical activity, even at low intensities, has been reported to improve sleep quality, reduce time to fall asleep, and increase the duration of sleep in the elderly… evidence indicates that exercise increases total sleep time and slow-wave sleep”.

We all strive for better sleep even if we do not have a known sleep disorder, and it could be within our grasp through a novel route. Exercising for an hour three times a week at high intensity with machine-based resistance exercise, circuit training, or resistance bands can improve your sleep quality and decrease issues in the day. Even once a week at a lesser intensity for 40 minutes showed beneficial effects! Sleep and exercise are significant pillars in lifestyle medicine, and it is fascinating how one affects the other. Rather than relying on medications that can have adverse effects, research suggest exercise is a natural way we can improve our sleep. While further research is needed, recognizing the interconnectedness of exercise and sleep as critical components of a healthy lifestyle is crucial.

By: Keshav Saigal, BS(c)

Sources:

  1. Kline, Christopher E. “The bidirectional relationship between exercise and sleep: Implications for exercise adherence and sleep improvement.” American Journal of Lifestyle Medicine. 2014 August
  2. Kline, Christopher E et al. “The effect of exercise training on obstructive sleep apnea and sleep quality: a randomized controlled trial.” Sleep. 2011 December
  3. Kovacevic, Ana et al. “The effect of resistance exercise on sleep: A systematic review of randomized controlled trials.” Sleep Medicine Reviews. 2018 June
  4. Memon, Adeel A et al. “Effects of exercise on sleep in neurodegenerative disease.” Neurobiology of Disease. 2020 July
  5. Reid, Kathryn J et al. “Aerobic exercise improves self-reported sleep and quality of life in older adults with insomnia.” Sleep Medicine. 2010 October
  6. Yang, Pei-Yu et al. “Exercise training improves sleep quality in middle-aged and older adults with sleep problems: a systematic review.” Journal of physiotherapy. 2012 September