TCPR: What is lifestyle medicine?

Dr. Frates: Lifestyle medicine is a specialty that focuses on the lifestyle causes of chronic diseases, such as cardiovascular disease, diabetes, obesity, metabolic syndrome, and psychiatric disorders like depression (www.lifestylemedicine.org). We do this through six pillars: 

1) Routine physical activity

2) A whole-food, plant-predominant eating pattern

3) Restorative sleep

4) Stress resiliency

5) Positive social connection

6) Avoidance of risky substances

Through these pillars, we can manage, treat, and in some cases even reverse chronic conditions.

TCPR: How are those pillars relevant in psychiatry?

Dr. Frates: We have the most data in depression, and a recent study from the UK Biobank illustrates the relevance of the pillars very well. The authors looked at how lifestyle influenced the risk of depression over nine years in 287,282 people. The lifestyle factors they arrived at are very close to the six pillars, but what is interesting is that sleep rose to the top. A healthy sleep duration of seven to nine hours decreased the risk of depression by 22%. The other factors were social connection, regular physical activity, low to moderate sedentary activity, healthy diet, never smoking, and moderate alcohol consumption. People could lower their risk of depression by 72% by having all these factors in place. By comparison, good genes reduced the risk by 25% (Zhao Y et al, Nat Mental Health 2023;1:736–750).

TCPR: Could the causation go the other way, though? I mean, people with genetic risk for depression may also be prone to unhealthy lifestyle, and perhaps they would have developed depression independent of lifestyle.

Dr. Frates: Yes, this was not a randomized trial, so that is possible. The authors did use a technique called Mendelian randomization to control for influence of genes, however, and we do have other studies that have tested out the pillars as truly randomized interventions for depression. Some have brought all the pillars together in a group lifestyle modification program, but most have tested them individually (Aguilar-Latorre A et al, Front Med (Lausanne) 2022;9:954644). Three studies tested a Mediterranean-style diet and several dozen tested aerobic exercise. For example, the SMILE trial compared exercise to an antidepressant (sertraline 50–200 mg/day) over four months. At the end, both interventions had similar effects on depression, and both worked better than a placebo pill. The dose of exercise was 45 minutes of physical activity three days a week, and the authors randomized people to do it on their own or in a supervised setting—there was little difference between the two (Blumenthal JA et al, Psychosom Med 2007;69(7):587–596).

TCPR: How does exercise change the brain?

Dr. Frates: It’s not just postexercise endorphins that make us feel good. Exercise modulates dopamine, serotonin, and norepinephrine. After an aerobic run, there is a measurable increase in brain-derived neurotropic factor and—down the road—an increase in hippocampal volume. Exercise also has cognitive benefits that antidepressants do not. It helps consolidate memories. 

TCPR: What do we know about lifestyle and anxiety?

Dr. Frates: Compared to depression, the studies we have for anxiety are less rigorous and less conclusive. The best we can say is that exercise, diet, and behavioral interventions for sleep might reduce anxiety, but it’s not definitive (Stonerock GL et al, Prog Cardiovasc Dis 2023;S0033-0620(23)00054-3; Aucoin M et al, Nutrients 2021;13(12):4418).

TCPR: How do you work with patients on these pillars? Let’s start with sleep.

Dr. Frates: Make the room like a cave—that is, dark and cool. A drop in core body temperature is a signal for sleep, and I recommend a room temperature between 60 and 70 degrees (67 degrees seems to be the sweet spot, but this has to be personalized). For darkness, use blackout curtains or an eye mask to enable a deep sleep for seven to nine hours each night. Dim the lights and shut down computers and screens two to three hours before bed to reduce blue light, which is the wavelength that blocks melatonin release. If screen use before bed is unavoidable, there are computer apps to reduce blue light (eg, f.lux for Windows, Candlelight for Mac), smartphone settings (Nightshift or Twilight mode), and blue light–blocking glasses. Wearing these glasses two to three hours before bed improved insomnia and sleep quality in a few small controlled trials (Janků K et al, Chronobiol Int 2020;37(2):248–259). (Editor’s note: The glasses in these studies blocked 65% or more of blue light and can be found in Uvex Skyper or Ultraspec models or at www.lowbluelights.com.) Stay on a regular schedule and get sunlight in the early morning to set circadian rhythm. Patients who live in a noisy neighborhood should use ear plugs or a white noise machine. 

TCPR: What about caffeine?

Dr. Frates: Caffeine binds to the same receptor as adenosine, which is one of the chemicals that helps us fall asleep. It runs the “sleep drive,” which is one of the two physiologic forces that regulate sleep. The other force, circadian rhythm, is circular and is driven by light and darkness. Sleep drive is linear—the longer we stay awake, the more adenosine rises. Adenosine builds up throughout the course of the day and usually peaks around 11 pm. Caffeine blocks this effect, and its half-life is four to six hours, so drinking a cup of coffee at 6 pm means half of it is still in the system at bedtime (Frates B, Am J Lifestyle Med 2023;17(2):216–218). 

TCPR: What about alcohol?

Dr. Frates: Alcohol disrupts sleep. A lot of people use it to fall asleep, but the data show that it actually disrupts sleep. 

TCPR: Most patients are more concerned with whether they fall asleep than with the quality of that sleep. How do you change the conversation?

Dr. Frates: This is particularly difficult for people with anxiety and depression, who often have racing, ruminative thoughts that keep them up at night. Lying awake for 10 minutes can feel like an eternity. What I recommend is for them to write down the worries they have, put them on a list, then put the list aside and focus the brain on something else. One suggestion is gratitude—thinking about things the patient is grateful for and trying to name as many as possible. I also get them to focus on their breath.

TCPR: How do you do that?

Dr. Frates: Focusing on the breath is a skill that requires practice. If other thoughts come in, patients can treat those thoughts as a gentle reminder to return focus to the breath. There are several breathing techniques patients can use, and I like to give them options. One is 4-7-8 breathing: Breathe in for a count of 4, hold for a count of 7, and exhale for a count of 8. Another is boxed breathing: Breathe in for a count of 4, hold for a count of 4, and exhale for a count of 4. Some patients find boxed breathing easier to remember than 4-7-8. The key is to practice the techniques with them in the room. 

TCPR: You gave us targets for the six pillars. How do you work those in with patients?

Dr. Frates: I am collaborative, not prescriptive. I don’t say to patients “You need to exercise 150 minutes every week.” Instead, I start by being curious, so I’ll say “Tell me about what you do right now with movement.” A lot of people don’t like the term “exercise,” so calling it physical activity or movement is an option. “How does that movement impact you? How do you feel after you walk your dog in the morning?” Usually they respond with positive experiences, and I follow up with “Well, what would you like to do with it moving forward? Do you know about the guidelines?” Then I ask permission to share the research. “Would you like to hear about some fascinating research I just found from the UK Biobank?” And I share it and ask what they think. Another possibility is to focus on the sedentary behavior. “Do you want to talk about sitting and sitting disease?”

TCPR: That sounds like a more empathic approach.

Dr. Frates: I start with empathy. When I put my coach hat on, I’m curious, open, and nonjudgmental. There is no shame, blame, or guilt in the room. I’m appreciative of the person in front of me, what they bring as their own strengths. If they’ve already made some movement, any movement, toward a healthy pattern, terrific. I am compassionate with that empathy. Finally, I’m always honest. That’s my coach hat. 

TCPR: And if they don’t have progress?

Dr. Frates: If they say “I don’t do anything. I am way too busy. I have two jobs. I’m going through divorce and raising teenagers!” I’m not going to respond with “Well, if you did do exercise, your mood would increase and you’d be less likely to have depression.” Clearly they’re not ready to talk about it. If, however, there is an opening, I’ll say “You are going through a lot. What do you think would help at this time in your life?” They might say “I’d be a different person if I could just sleep.” I’ll be open, curious, and ready to follow their lead. I’ll say “What motivates you to want to feel better, to want to change?” They’ll probably respond with something like “Well, my kids need me.” I’ll empathize and ask what they think they need to do to be there for their kids. This will likely result in a statement like “I need sleep. I need energy, so I need to exercise more.” 

TCPR: What comes next?

Dr. Frates: Next we go to building confidence. The patient is motivated to change but doesn’t feel confident that they can. If I ask what’s holding them back, they might say “I’ve tried all these different apps and exercise classes and nothing works. Back in the day, I used to walk, but I can’t walk anymore.” I’ll focus on the evidence that a new pattern is possible and say something like “Tell me about the time when you were walking. What were you doing?” They might share that they used to have a routine where they met with friends to walk after dinner, for example, but having kids made sticking to the routine difficult. I’ll reflect on this and suggest options. For example, I might say “It sounds like social connection helped you stay motivated. I wonder if there is a way you could do that now. Could you walk with your kids? Could you walk with people in the neighborhood after dinner?”

TCPR: How do you wrap that up?

Dr. Frates: After I’ve started with empathy, aligned motivation, and built confidence, next is making a SMART goal, which means making a goal that is Specific, Measurable, Action-oriented, Realistic, and Time-bound. I’ll ask “What could you realistically start with this week?” The patient might say “Well, two of my neighbors are trying to lose weight, so I bet they’re going to want to walk with me.” Now I leverage that information to make the goal specific. “Which day are you going to call them? What are you going to say?” Once we have the details down, we set up accountability. Hopefully, the patient has a buddy who can check up on this goal, or it could be me as the provider at the next visit.

TCPR: How do you check in on their progress?

Dr. Frates: I like to meet with them every week. I start with empathy. “How did it go? How was your week? Were you able to call your friends?” They may say “Yes, and they’re really interested.” Indeed, most people are interested in joining a walking group. I’ll ask “How is that working for you? How is your mood and energy?” I connect this inquiry with their motivator by asking “How are you feeling with your teenagers?” I keep following that empathy and aligning with the values that motivate them. 

TCPR: Do you have patients track their progress?

Dr. Frates: That is part of accountability. For movement, some people use actigraphy—step counters—through their cell phone or wearable devices. Some like pen-and-paper logs. All of this work has to be personalized. 

TCPR: Thank you for your time, Dr. Frates.