I am very glad Dr Viswanathan shared his valuable insights on Promoting Health restoring and sustaining strategies with the focus on the very profound implications of exercise and weight training in initiating processes that restores homeostasis in a healthier plane.
He has called attention to several important facts that must be taken into account by members of our profession who not only provide treatment in their offices but are Team Leaders or part of Integrated patient centered Teams as I was for years before I retired. I will be sharing a Multi-disciplinary Assessment Panels Check list to illustrate one aspect of clinical collaboration.
These points that he published [I A and I B] are of especial interest to me for the reasons I will be sharing.
I. A
1. “Exercise can promote Neuroplasticity, enhance the release of BDNF increase Brain Hippocampal volume, reduce negative symptoms, and best of all “Neuroimaging and Biochemical measures the have shown exactly that.”
2. “Besides BDNF, exercise also increases release of Endorphins, Endocannabinoids, Serotonin, Norepinephrine, and Dopamine all of which can improve Mood”
3. “Exercise can be as effective as SSRIs in alleviating Depression with both interventions partly acting through promoting neuroplasticity.”
4. “Exercise is also anti-inflammatory which is significant because inflammatory markers are increased in many patients with Depression and Diabetes.
5. Despite all these powerful data this is critical to emphasize as Dr. Viswanathan has done, The point here is Not to offer exercise as a standalone treatment even that might work in some cases, but to incorporate it into a portfolio of treatment such as psychotherapy, pharmacotherapy, other somatic therapies and other Lifestyle interventions. I included Exercise in my Five pillars myself and it is incorporated in the acronym, SENSS that is described in my Health Promotions post.
In my detailed reports A 1 and 2 below that I began to develop, update and share for about 10-15 years I have discussed these key facts. In fact, there is good correspondence between the many points made by Dr. Sanjay Gupta, MD., “Keep Sharp: Build a better Brain at any age.” I outline the key points in my Report A:1 Health Promotion Education Materials. His main focus is to delay the onset of Dementia.
I am delighted and proud that Dr Viswanathan founded the annual 5 K events sponsored by Brooklyn Psychiatric Society. This certainly imparts authenticity to his recommendations and answers this ancient assertion that is cited an ancient Greek dictum “Medice,Cura et Ipsum” by Luke the Physician in his Gospel, 4:23. The doctor in the proverb should heal himself; that is, he should practice his medicine at home. In fact, I am very open that the recommendations I have developed, formulated and shared in the two posts II A 1 and 2 were very helpful to me as I with my Collaborative Medical and Surgical teams diligently and with perseverance over the past 15 years locally and at Yale to manage successfully serious, TIIDM, HTN, Cardiac and Malignancy related threats.
I. B. Dr. R. Viswanathan’s report
1 “People with Mental Illness”
Dr Viswanathan remined us “Physical Activity is one of the conventionally recognized six pillars of Lifestyle Medicine.” And how important it is for persons with SMI and Chronic Medical illness to adopt a fitness-based lifestyle. People with Mental Illness have more metabolic problems, partly due to medications they might take, and partly due to lifestyle, as a result, they can suffer from poorer physical functions and increased mortality. Exercise can counter this. For people who are sedentary, even small amounts of regular physical activity can give big health benefits. “ I totally concur with these observations.
I’m glad to share the acronym SENSS that represents the comprehensive portfolio of Health Promoting recommendations that I have shared to benefit my patients and treatment members to enhance the adoption of helpful effective strategies over 6-7 months that I noticed as rule of thumb for my patients to start walking on a regular basis week after week and begin making changes in their food choices.
The first ‘S’ represents the critical need for Social Connectivity for our patients for our team members and team especially if they are in Recovery [Addictions and Psychiatric illness] while working with persons with active Addictions and SMI to survive and thrive. The ‘E’ that follows represents another vital component of a Fitness promoting Life style- Exercise. This includes all sorts of physical activity from: Jogging, swimming, bicycling, walking, gardening, hiking, walking meditation. Outdoor experiences especially in wooded areas or lake, river, seashores and in areas where you can watch Eagles and Birds of Prey taking in the vegetation and the animals at different elevations of the wood is beneficial. We recommend a total of 150 minutes a week. Tai Chi is an important component of a beneficial physical activity program. ‘N’ the next letter represents the foundational component-Nutrition. I provide cartoons to illustrate how what we pack into our shopping carts will surely get into your heart. I have recommended the graphic of Choose My Plate. Gov, with 50% of the plate set aside for fruits and vegetables, 25% for Whole grain-based food and 25% for Protein sources. I have also suggested the guidelines of the Mediterranean and DASH diet which have a long record of effectiveness and safety in establishing and maintaining fitness in conjunction with Exercise.
The next ‘S’ is early identification one is being stressed and take the responsibility to ameliorate the Stressed State. Stress Management- I have addressed this in my Health Promotion Recommendations and the treatment recommendations for restoring Wellbeing. [ II A 1 and 2]
The last ‘S’ represent Self compassion is the most crucial component that is foundational to all the five components of Health restoration and sustenance. One way by which Self-compassion can be activated and practiced by reviewing the impact work demands on working effectively on a fitness building lifestyle. Nearly 20 years ago after consulting my Medical Team and family I switched my employment. reduced my work week, without on call or weekend demands, and began to develop my personal fitness routines and changes in dietary habits which are based on the Mediterranean and DASH diet principles and the recommendations of My Plate .Gov. In the Link II A1 below there are illustrations to denote my concepts and suggest f how the treatment approach I have developed, utilized and shared with my patients and team members can over time reduce the levels of depression, lower the levels of the Inflammatory Cytokines and improves the Telomerase length, Telomerase level, Reduces the discrepancy between Epigenetic Age and Chronological age by reducing DNA methylation and increase the Level of Brain derived Neurotropic Factor BDNF.
I offer tis link to introduce our readers to Dietary Inflammatory Index of individual dietary items and of the Mediterranean Diet and the rationale for adopting these diets into a fitness lifestyle. The anti-inflammatory effects of a Mediterranean diet: a review - PubMed (nih.gov) Chronic noncommunicable diseases remain the leading cause of morbidity and mortality worldwide and the majority are preventable with a healthy diet and lifestyle, but controversy remains as to the best approach. Greater adherence to a traditional Mediterranean diet has consistently been associated with lower morbidity and mortality from cardiovascular disease, diabetes and many cancers, and lower all-cause mortality. This is a controlled study: Exercise and Nutrition in the Mental Health of the Older Adult Population: A Randomized Controlled Clinical Trial - PubMed (nih.gov) which suggests that a non-pharmacological approach to improving overall well-being in this demographic..
There are several reports that suggest the key food items in the Mediterranean Diet are conducive to extended Longevity. I am sharing this link to Dan Buettner's report: https://www.cnbc.com/2022/12/06/5-foods-the-communities-with-high-rates-of-living-to-100-eat-often.html. In his new book, “The Blue Zones American Kitchen: 100 Recipes to Live to 100,”
Dan Buettner “identified the world’s longest-lived areas (blue zones) and studied the patterns and lifestyles that seem to explain their populations’ longevity.” Blue zones are defined by Buettner as populations with the highest rates of living to 100 – or becoming centenarians – and the highest middle-age life expectancies. The people in the blue zones live up to a decade longer than average Americans and spend a fraction of what most [of] the rest of us do on health care,” Buettner wrote. Across the world, these groups include communities in Japan, Italy, Greece, Costa Rica and even a Seventh Day Adventist community in California.
Mr. Buettner has identified the five pillars of longevity diet which helps people forget to die.
Buettner found that 65% of dietary intake in blue zones came from complex carbohydrates, and these foods are “the five pillars of a longevity diet on four continents”: 1. Whole grains like corn, rice and oats (complex carb),2. Greens, 3. Tubers, including potatoes and yams (complex carb),4. Nuts,5. Beans (complex carb)
In this recent study Anti-Inflammatory Diet and Dementia in Older Adults with Cardiometabolic Diseases | Neurology | JAMA Network Open | JAMA Network Abigail Dove. M.Sc., et al reported-on August 12, 2024 the results of their study which included 84 342 participants (mean [SD] age, 64.1 [2.9] years; 43 220 [51.2%] female).
At baseline, 14 079 (16.7%) had at least 1 CMD. Over a median follow-up of 12.4 (IQR, 11.8-13.1) years, 1559 individuals (1.9%) developed dementia. With the use of joint effect analysis, the hazard ratio of dementia was 2.38 (95% CI, 1.93-2.93) for people with CMDs and a proinflammatory diet and 1.65 (95% CI, 1.36-2.00) for those with CMDs and an anti-inflammatory diet (reference: CMD-free, anti-inflammatory diet). Dementia risk was 31% lower (hazard ratio, 0.69; 95% CI, 0.55-0.88; P = .003) among people with CMDs and an anti-inflammatory diet. On brain MRI, participants with CMDs and an anti-inflammatory diet compared with a proinflammatory diet additionally had significantly larger gray matter volume (β = −0.15; 95% CI, −0.24 to −0.06 vs β = −0.27; 95% CI, −0.38 to −0.16) and smaller white matter hyperintensity volume (β = 0.05; 95% CI, −0.04 to 0.14 vs β = 0.16; 95% CI, 0.05-0.27). Conclusions and Relevance In this cohort study, people with CMDs and an anti-inflammatory compared with proinflammatory diet had a significantly lower hazard ratio of dementia, larger gray matter volume, and smaller white matter hyperintensity volume.
They explained the beneficial effects of an Anti-Inflammatory Diet thus. Dietary intake can influence systemic inflammatory processes in the body.12 For example, the Western dietary pattern—characterized by red meat, high-fat dairy, eggs, refined grains, and processed foods—has been associated with higher levels of inflammatory biomarkers, such as C-reactive protein, interleukin 6, and tumor necrosis factor12 On the contrary, dietary patterns characterized by consumption of higher amounts of vegetables, fruits, whole grains, fish, and legumes tend to be associated with lower levels of these biomarkers. [I am encouraged that these specific Biomarkers have been included in my post in the Illustrations and Graphs over the past decade II A.1.Health Promotion Educational Matters.]
The Dietary Inflammatory Index (DII) was developed to capture the inflammatory potential of an individual’s diet based on consumption of various macronutrients and micronutrients, bioactive components, foods, and spices.13 In addition to reduced risk of diabetes, cardiovascular disease, and other cardiometabolic risk factors,14-16 lower dietary inflammatory potential, as measured by the DII, has been linked to lower dementia risk,17-19 better cognitive function,18,20-22 and more favorable magnetic resonance imaging (MRI) markers of brain aging.19,23 However, the extent to which an anti-inflammatory diet may support brain and cognitive health among people with CMDs has not yet been explored. Using 15-year longitudinal data from more than 80 000 older adults in the UK Biobank, including more than 8000 who underwent brain MRI, we examined the role of CMDs and dietary inflammatory potential in dementia risk and MRI markers of neurodegenerative and vascular brain damage using joint effect analysis.
in this cohort study, participants with CMDs and an anti-inflammatory diet had a lower risk of dementia compared with those with a proinflammatory diet. Moreover, people with CMDs and an anti-inflammatory diet had significantly higher GMV and lower WMHV than their counterparts with a proinflammatory diet. Together, these results highlight an anti-inflammatory diet as a modifiable factor that may support brain and cognitive health among people with CMDs.
In 2005-2006 I began working on researching, documenting and updating the information because so many of our patients with Severe Mental Illnesses were living significantly shortened lives because of the Metabolic Syndrome which the medications we were using and their lifestyle as well as social habits plus to keep me and my teams become healthier over time. It was actually helpful to me address my actual serious health concerns.
I have made my dietary recommendation based on the recommendations of the Govt office that produces My Plate. Gov communications. Briefly this includes a.25% Protein source b. 25% whole grain source food c 50% of plate- fruits and vegetables. d. a cup of dairy sourced or non- dairy sourced yogurt or milk e.g. Almond Milk Yogurt with the 7 key bacteria that can augment immune systems and ameliorate the humoral factors that kindle and sustain background Inflammation that is the progenitor of the major life shortening illnesses including obesity, Heart Disease, TIIDM, Hypertension, Cancer, Depression. In addition, we observed that for some persons with SMI who were living into their fifties and were still affected by the pathophysiology of the various components of the Metabolic Syndrome. E.g. HTN, TIIDM, Obesity and were developing components of Alzheimer’s and significant issues with Cognition, Executive functions, Emotional dysregulation and in some instances delusions and hallucinations.
Besides the diagnostic and therapeutic challenges , the impact on ADLs and ability to engage in Recovery fostering and sustaining activities which can and has resulted in loss of ability to live in the community and admission to Extended Care Facilities with Specialized Memory Care Centers -which greatly hinders participation in activities that supports psychosocial recovery and the ongoing deficits of their SMI makes it a challenge to provide the socialization and rehabilitative interventions that can enhance quality of life for persons who are admitted to Memory Care Centers. It made immense sense to work on their diet and nutrition, exercise, meditation, stress management, and self-compassion early in the course of treatment in their 30s and 40’s if clinically feasible to delay the onset of processes involving Beta Amyloid 42, and Phospho-Tau components. There are other diagnostic options using samples of Blood, CSF, and Bio-Marker PET Scans, Neuropsychological battery of tests based on clinical assessment with contributions on all aspects of functional capacity of the individual.
I offer this Link: Cognitive- Behavioral Assessment -Multi-dimensional- panels 1.docx. This has been an evolving document that started as check list to assist decision making for our integrated family centered multidisciplinary team some fifteen years ago. The data helped to manage the key health concerns, ameliorate the risks of developing Dementia and where possible discover concerning trends in Bio Markers I have indicated. We monitored update Medication Records to optimize the choice of medications for managing SMI and concurrent potentially disabling and life shortening Illnesses.
I want to share that I have studied the role of Enteric Nervous System [ENS] in supporting and promoting Fitness based Lifestyle. There are two components: Submucosal and Myenteric. The bowel and beyond: the enteric nervous system in neurological disorders - PMC (nih.gov) The Gut Brain Axis is a vital component of Milieu Interior that is critical to restore and sustain. Homeostasis. This link provides useful information about the ENS and Peripheral Nervous System including illustrations. These neurons communicate through many neurotransmitters similar to the CNS, including acetylcholine, dopamine, and serotonin. The large presence of serotonin and dopamine in the intestines are key areas of research for Neurogastroenterology. These two reports provide useful data on the process of signaling between Enteric Endocrine Cells [EEC] and afferent nerve endings of the Vagus nerve in the mucosa of the Colon.
How does gut-brain communication affect emotional well-being? (msn.com)
Identification of vagal afferent nerve endings in the mouse colon and their spatial relationship with enterochromaffin cells | Cell and Tissue Research (springer.com)
Recent advancements from Flinders University have initiated a significant reevaluation of the operational mechanisms behind antidepressants and other emotion-regulating drugs, highlighting the intricate communication between the gut and the brain.
The research introduces a notable shift in understanding the gut-brain axis, a complex network facilitating bidirectional neural interactions between the gastrointestinal system and the brain's emotional and cognitive centers.
"The gut-brain axis consists of a complex bidirectional neural communication pathway between the brain and the gut, which links emotional and cognitive centers of the brain," said lead author Nick Spencer, a professor at the College of Medicine and Public Health at Flinders. The study emphasizes the role of vagal sensory nerves, which transmit signals from the gut to the brain, influencing mental health and well-being.
Serotonin is predominantly synthesized in the gut's enteroendocrine cells (EECs) and plays a pivotal role in mental health. The research challenges prior assumptions about the direct synaptic communication between EECs and vagal sensory endings, proposing instead a diffusion process.
The Vagus nerve is crucial in the gut-brain axis, influencing fluid and food intake (Borgmann et al. 2021), heart rate, energy metabolism, respiration, and gut motility (Breit et al. 2018). Additionally, its role in managing anxiety and depression is gaining interest
The axons that make up the Vagus nerve are predominately sensory in origin that extensively innervate much of the gastrointestinal tract Progress in understanding vagal afferent innervation along the gut has been significant but their activation by hormones from mucosal enteroendocrine cells (EEC) is not fully understood. Enterochromaffin (EC) cells are the most abundant type of EEC and synthesize high quantities of 5-hydroxytryptamine (5-HT)
The findings suggest that any substances released by 5-HT-containing ECs are likely to act via diffusion onto mucosa-projecting vagal afferent nerve endings suggesting paracrine signaling, which then relay sensory information to the brain.
It is vital to consider the role of the Gut Microbiota on the regulation of Neurotransmitters and the effects on Cognition and Neurological disorders. I have written about how to manage the concerns about the Microbiota in both my posts II.A.1 and II A 2 This is a source I found useful to learn about the complex connections that constitute the Brain – GUT and assist myself, my patients and my team members to figure out what may be effective and safe interventions to optimize the relationship of the Gut Microbiota to underlying Inflammation that has profound impact on the onset, exacerbation and amelioration of significant potentially lethal medical including psychiatric disorders which can be sadly unnecessarily disabling if the role of the Microbiota and ENS in our health and wellbeing at all ages regardless of our race and national origin. : Regulation of Neurotransmitters by the Gut Microbiota and Effects on Cognition in Neurological Disorders - PMC (nih.gov)
I have discussed the vital roles on the Microbiome influence through the Neurotransmitters and the Enteric Nervous System in mediating the beneficial effects of Lifestyle Interventions, Pharmacological, Psychotherapeutic and Mindfulness based therapies in re-establishing and sustaining a healthful homeostasis in the Links that follow.
These two Links from my website describe my perspective on health promotion strategies that can restore and sustain your health and can even stabilize your emotional wellbeing and ameliorate depression. The first document offers detailed Illustrations and graphs delineating the major factors that influence the strength of the underlining Inflammation including Neuro- Endocrine- Bio-social and the awesome power of Microbiome which is innervated with thousands of nerve Terminals connected to the Vagus nerve and produces much Neuro Endocrine hormones that influence our health and well-being
I have briefly described the information offered in these Posts in this letter.
II A.
1. HealthPromotionEducationalMaterials
2 TreatmentRecommendationsforRestoringWellbeing
My website velandymanoharmd.com has many related posts especially on the Role of Inflammation and strategies to monitor Immune system responses and ameliorate its potential to initiate not only the pathogenesis of dementia but also to slow the progression of the medical disorders to cause disability.
I have offered Testimony to the US Govt. [2025 Dietary Guidelines Advisory Committee] in response to their request. [II.B.1]. Coincidentally I had the opportunity to respond to National Institute of Nutrition/Indian Council for Med. research. [II.B.2]
II. B.
1. Response to request for Comments from My Plate. Gov. 2025 Dietary Guidelines Advisory Committee (velandymanoharmd.com). I have communicated with My Plate. Gov since it was launched in 2011
2. Health Promotion- Response to NIN-ICMR Dietary Guidelines 2024 (velandymanoharmd.com) I am not sure if the Guidelines formulated by the National Institute of Nutrition is applicable in the
main to our discussion, but I have offered some responses based on my personal experiences as student, Internship Senior House Surgency and in Private Practice with my sister who was a Pediatrician. DietaryGuidelinesforNINwebsite.pdf-I have had contact with Physicians in India in the past decades despite having emigrated to the USA during my visits and by email. I wonder if this can be shared with our colleagues in the Indian Psychiatric Society and Indian members from India of the APA. I would love to receive their feedback about their experiences in India.
This very powerfully moving matter for me and others who worked with these little ones who were in agony a good part of time at many different levels especially because the terrible health consequences my sister and I and our colleagues dealt with in the 60’s in Tamil Nadu sill persist inflicting severe pain and anguish and suffering for millions of people and especially the preventable, needless loss of precious defenseless little lives. I mourn their passing and grieve that we have not done a better job. I have not forgotten their terrible suffering and short painfilled lives. My sister has passed. She would have suffered much and been inconsolable if she had access to these facts in this Report back in India. I wouldn’t have been there to comfort her. She was dedicated for decades to the care of the children with cancer and their mothers who came to the Institute for Child health in Egmore, Tamil Nadu, India. “This must end, we must attain the goals of SDG 2030 [both 3.1 and especially 3.2 earlier than 2030 especially since Kerala and another 10 states have accomplished these goals now.” [SDG-Sustainable Development Goals of WHO.]
I am grateful to Dr. Viswanathan and Psychiatric News, and I am looking forward eagerly to read Dr Viswanathan’s reports on the other pillars of a Fitness fostering Lifestyles, “that we need to pay more attention.” I learned much while enjoying reading this report more than a few times over the past. I congratulate him for starting the Annual 5K Run by the Brooklyn Psychiatric Society. This is practicing what he believes in can benefit each and every one of us at all races, ages, backgrounds and national origin. I am happy to share I used to be in team of runners from Mx Health who participate in the CT Hospital Association 5 K Race. I am glad to say based on our ages and times we were ranked second one hot year.
I welcome your responses.
Velandy Manohar, MD.,
Distinguished Life Fellow, Am. Psychiatric Association