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Thursday, January 31, 2019

Diet and depression

We all want our children to be well-behaved. We want our child to be the one who is kind, says “please” and “thank you,” does as he is told, and doesn’t get in trouble at school or bother kids at the playground. The problem, as any parent can attest, is that raising a well-behaved child is hard work.

Some of it is temperament — every child is different. Some children are rule-followers, and some of them, well, aren’t. But mostly it’s hard because it is an ongoing, exhausting process that requires that we always keep our eye on the ultimate goal (having a well-behaved child) rather than the short-term goal (such as having the screaming child in front of us stop screaming).

After more than 25 years of being both a pediatrician and a parent, here are four tips I think can make a big difference:

1.   Start early. It may be cute when your toddler hits somebody, and they are unlikely to do much harm, but if you wait until preschool or later to be clear that hitting isn’t okay, it’s going to be harder. Your child will be justified in her confusion: if something has been fine up until now, why isn’t it fine anymore? The earlier you teach your child that hitting or biting isn’t okay, and that “no” actually means “no,” the better.

There is a big caveat to this, though: it’s important to understand where your child is developmentally. A toddler doesn’t hit to be mean; she hits out of frustration and anger, or sadness. A 2-year-old doesn’t throw a tantrum to get back at you or ruin your day; he is doing it for the same reasons a toddler hits. So as you start early, the idea is to help your young child understand good and bad ways of expressing those emotions. It’s also important to understand what your child is capable of; there is only so much we can ask of any child at each stage of development. When you go for well-child appointments, talk with your doctor about realistic expectations for behavior at your child’s age.

2.   Be consistent. If jumping on the couch is fun, and sometimes Mommy and Daddy say no, but sometimes they let you, of course you are going to at least give it a try. But if you always say no, then your child learns the rules of the house and is less likely to jump on the couch. Once you’ve said no to something, it always needs to be no, which can be thoroughly exhausting — I understand that well. So pick your battles. Every family draws different lines in the sand. Any behavior that hurts someone (including hurting their feelings) or is dangerous should always be a no. And it’s good to teach children that certain settings (like religious services or public transportation, for example) require quieter, less active behavior — and to be respectful of others (being polite and sharing fall in there). But you can decide on the other rules. Maybe jumping on the couch is just fine in your house.

3.   Be loving. Catch them being good, too. Be very positive about good behaviors or when they pull it together and stop a bad behavior. When a child behaves well, we tend to take it for granted or are simply relieved, but a child deserves kudos for following the rules, not just punishments when they don’t. It also makes a difference to spend time with your children and show them that you are invested in them. It puts discipline in a context and makes it easier and more worthwhile for children to behave well for you.

4.   Set a good example. You can’t expect a child to say “please” and “thank you” if you don’t, or to treat others well if you don’t. Remember that children always pay way more attention to what we do than what we say. Just like Gandhi once said, “Be the change you want to see in the world.” Be the person you want your child to be.

If you are having a hard time, talk to your doctor. Some children have a tougher time than others, for all sorts of reasons; sometimes parents need help. Don’t be afraid to ask for help if you need it; it makes you a better parent when you do.
Spring is just around the corner and if you’re ready to reboot one of your New Year’s resolutions, here’s why exercise should be at the top of the list. Current medical research continues to robustly establish vigorous physical exercise as a major influence on overall health and well-being, in addition helping in the treatment of many diseases including depression, cardiovascular disease, diabetes, and arthritis. A recent study found that regular, intense exercise beneficially influenced the action of 400 genes — that’s right, 400 genes, a huge number — that produce proteins increasing the healthy functioning of mitochondria, the energy-producing machinery inside every cell. Exercise is synergistic with medicines and surgery. Developing, undertaking, and maintaining an exercise regimen is one of the best steps a person can take toward a self-actualized style of medical care.
An exercise “prescription”

We are a physician couple who have been physically active all our lives. We prescribe exercise regularly in our practices (one of us is a neurologist, the other a psychiatrist) and approach it in exactly the same way that we approach prescribing a medication, informing patients of dose and frequency benefits, possible side effects, and mechanisms of action. We describe a concrete regimen of exercise rather than simply saying, “exercise” and leaving it at that. Many patients don’t know how to get started, and specific details about using machines, weights, running, and other techniques prove valuable. Practical details are important, and we take time to answer any and all questions a patient might have. The physician-patient partnership around overall health goals is crucial. As partners, they can work together to include exercise as one tool among many to help achieve good health.

Follow-up is also key to encourage continued elaboration of goals, to educate about the interventions, and to support motivation. An exercise regimen is not static, and for best effect changes organically over time. As part of my 2018 fitness goals, I have resolved to spend two days a week in what I playfully call “the pain cave.”

No, it’s not a setting for Game of Thrones, but one of the most challenging (and rewarding) workouts I have ever tried: spinning, also known as indoor cycling.

Spinning classes are staples at most gyms, and there are even entire fitness centers devoted to nothing but spinning. A class typically lasts 45 minutes to an hour and is led by an instructor who guides everyone through a series of heart-pumping workouts. For instance, you might do speed work, where you pedal fast for brief periods followed by periods of rest and recovery. You also may do incline workouts, where you increase the resistance so it feels like you are cycling uphill.

If you haven’t tried spinning — or are looking for a way to liven up your exercise routine — you should give it a whirl, as it offers a wide range of benefits for people of all ages and fitness levels.

“Spinning is a great cardiovascular workout and can help build lower-body muscle strength,” says Greg Robidoux, a physical therapist with the Cycling Medicine Program at Harvard-affiliated Spaulding Rehabilitation Network.

It’s also perfect for people who don’t enjoy, or have difficulty doing, higher-impact cardio activities like running. Spinning is a low-impact exercise that places less stress on your joints, which makes it ideal for older adults with knee or hip issues or those recovering from orthopedic injuries.

Spinning classes are safe for most people, but get your doctor’s okay, especially if you have a heart problem or are recovering from an injury or surgery. “Once you are more comfortable on the bike, you easily can do your own workouts,” says Robidoux. “But you should experience several classes to get a feel for everything before going solo.”
Guidelines for a safe and effective workout

Look for proper credentials. Most spinning instructors are certified to teach spinning. Others may be only certified to teach aerobics, and while they may be experienced with spinning, they might be less knowledgeable about the equipment and how to move smoothly through different positions on the bike. Robidoux says to look for instructor certifications like Mad Dogg Spinning Instructor Certification, AFAA [Aerobics and Fitness Association of America], Indoor Cycling Certification, or Schwinn Indoor Cycling Certification.

Get fitted. Ask your instructor how to adjust the handlebar and seat height and position to ensure proper alignment, so you don’t put too much strain on your lower back and knees. Your legs should move in a circle with no jackhammer-like bouncing.

Take it easy at first. Only pedal at a pace that allows you to stay stable in the saddle, and never feel you have to do what everyone else is doing. “Go at a lower intensity if needed, stay in your comfort zone, and progress at your own pace,” says Robidoux. “It is perfectly fine to skip a workout, recover, and jump back in when you are ready, or do your own thing and just pedal.”

Keep it short. It’s okay to stay for only 20 or 30 minutes of a class at first, until you are more comfortable and your endurance increases.

Don’t forget a towel and water. You will sweat, so always have a towel handy to wipe your brow and a water bottle to stay hydrated.

Sit right. Also, invest in a pair of cycling shorts, which can make sitting on the saddle more comfortable. Just this week, I have seen three patients with depression requiring treatment. Treatment options include medications, therapy, and self-care. Self-care includes things like sleep, physical activity, and diet, and is just as important as meds and therapy — sometimes more so.

In counseling my patients about self-care, I always feel like we don’t have enough time to get into diet. I am passionate about diet and lifestyle measures for good health, because there is overwhelming evidence supporting the benefits of a healthy diet and lifestyle for, oh, just about everything: preventing cardiovascular disease, cancer, dementia, and mental health disorders, including depression.
Diet and emotional well-being

Diet is such an important component of mental health that it has inspired an entire field of medicine called nutritional psychiatry. Mind-body medicine specialist Eva Selhub, MD has written a superb summary of what nutritional psychiatry is and what it means for you right here on this blog, and it’s worth reading.

What it boils down to is that what we eat matters for every aspect of our health, but especially our mental health. Several recent research analyses looking at multiple studies support that there is a link between what one eats and our risk of depression, specifically. One analysis concluded:

“A dietary pattern characterized by a high intake of fruit, vegetables, whole grain, fish, olive oil, low-fat dairy and antioxidants and low intakes of animal foods was apparently associated with a decreased risk of depression. A dietary pattern characterized by a high consumption of red and/or processed meat, refined grains, sweets, high-fat dairy products, butter, potatoes and high-fat gravy, and low intakes of fruits and vegetables is associated with an increased risk of depression.”
Which comes first? Poor diet or depression?

One could argue that, well, being depressed makes us more likely to eat unhealthy foods. This is true, so we should ask what came first, the diet or the depression? Researchers have addressed this question, thankfully. Another large analysis looked only at prospective studies, meaning, they looked at baseline diet and then calculated the risk of study volunteers going on to develop depression. Researchers found that a healthy diet (the Mediterranean diet as an example) was associated with a significantly lower risk of developing depressive symptoms.

So, how should I counsel my patients on diet? There are several healthy options that can be used as a guide. One that comes up again and again is the Mediterranean diet. Another wonderful resource for folks is the Harvard T.H. Chan School of Public Health website with an introductory guide to healthy diet.
The bottom line

The gist of it is, eat plants, and lots of them, including fruits and veggies, whole grains (in unprocessed form, ideally), seeds and nuts, with some lean proteins like fish and yogurt. Avoid things made with added sugars or flours (like breads, baked goods, cereals, and pastas), and minimize animal fats, processed meats (sorry, bacon), and butter. Occasional intake of these “bad” foods is probably fine; remember, everything in moderation. And, for those who are trying to lose weight, you can’t go wrong with colorful fruits and veggies. No one got fat eating berries or broccoli. Quality matters over quantity. And when it comes to what we eat, quality really, really matters.

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