The Power and Connection of the Six Pillars

“One practical suggestion is to take 10 deep breaths prior to sitting down for meals to help lower stress levels.”

Lifestyle medicine is powerful because of the interconnected power of its six pillars. All the pillars interact with each other, and when they are all factored into the lifestyle medicine treatment plan, a person’s health can be optimized. These pillars can come in the form of prescriptions, and these prescriptions can have doses. The more intensively the pillars are managed the greater the impact.

New research in all six pillars is regularly published in the medical literature. Many of the research studies connect one pillar to another. For example, one recent study, from the Journal of Applied Physiology, discusses the utilization of amino acids for myofibrillar protein synthesis during prolonged bouts of sitting. ¹ Many people sit for extended periods of time, to the extent that sitting is considered the new smoking by many. The best solution is to stop. However, there are days when people are sitting in zoom meetings, at conferences, or while writing articles. We’ve known for years that there is a sedentary physiology that includes lowered lipoprotein lipase, increased triglycerides, reduced HDL, and disrupted glucose. ² This information may stop prolonged sitting in some. But for others it will take some solutions and data to change their minds and their behaviors. In the study on myofibrillar protein synthesis, subjects were sitting 7.5 hours in the day, ate meals composed of carbohydrates, protein, and fat, and engaged in “activity snacks” every half an hour. Even though they were sedentary, they were able to use the amino acids consumed in their diets to synthesize myofibrillar proteins in their muscles. The subjects broke up their sitting hours with two easy exercises or “activity snacks.” One was performing fifteen “body weight squats” which were described as a chair stand to a calf raise. The other activity snack was walking at 3.1 mph—average walking speed—for 2 minutes. These are two easy exercises that most people can do. It is recommended that people stand up every hour after bouts of prolonged sitting, and the American Diabetes Association recommends that those with diabetes or pre-diabetes stand every half an hour. ³

By breaking up a 7.5-hour day of sitting with these “activity snacks” each half an hour, people could change their physiology such that the amino acids from protein in their diet could be used for myofibrillar synthesis in their muscles. This connects what people eat with what happens with their muscles in a tangible way. It is important to consume protein and to maintain our muscle mass as we age, especially since we start to lose muscle mass around the third decade of life.

This is good news for people who may need to spend a large part of their day sitting. Instead of succumbing to the fact that their lower number of steps and their lowered activity levels can lead to lower rates of myofibrillar protein synthesis, there are concrete steps they can take to reverse this—(1) eat legumes, nuts, and seeds, and (2) enjoy “activity snacks” of squats or walking every half an hour.

Exercise is medicine in so many ways, as it can lower blood pressure, increase insulin sensitivity, increase fibrinolysis, increase endothelial cell function, increase high density lipoproteins, lower triglycerides, decrease sympathetic hyperactivity, increase serotonin, increase dopamine, and increase BDNF (brain derived neurotrophic factor) which promotes neurogenesis.

With regards to the two pillars of exercise and nutrition, recent research is demonstrating how exercise may impact appetite. ⁴ Exercise causes the release of the myokine, irisin, which has been shown to have an impact on the brain to decrease appetite. More recently, in the journal Nature in June 2022, a new metabolite named n-lactoyl-phenalalanine (or Lac-Phe) was identified by a research group at Stanford. Lac-Phe was found to increase with exercise, and reduced food intake and appetite. ⁵ How we move may impact how we eat.

Exercise also impacts another pillar in that it helps improve sleep. Sleep is essential for good health and that is why the American Heart Association added sleep to their Simple 7 to create the Life’s Essential 8 in April 2022. ⁶ The National Sleep Foundation recommends sleeping between 7 to 9 hours. Sleep can also impact food consumption. Research demonstrates that the amount of sleep we get at night can impact the amount and the type of food people consume during the day. Lack of sleep is associated with a significant increase in desire for high calorie foods and the more sleep deprived people are, the more intense the desire. ⁷ That speaks to the quality of food chosen with sleep deprivation. As for the quantity of food, in one study the subjects who slept only 4 hours consumed an extra 300 calories the next day compared to those who got 9 hours. ⁸ The fact that with lack of sleep ghrelin increases and leptin decreases is likely partly responsible for this increased intake in calories. ⁹ In addition, our eating patterns can influence our sleep. Eating close to bedtime, specifically 3 or fewer hours before, may lead to sleep disruptions. Consuming large quantities of food increases the chances of sleep disruption and eating later in the evening is associated with increased adipose tissue. ¹⁰ Future research will reveal more details with the connection between nutrition and sleep.

Regarding sleep deprivation and disease, lack of sleep has an impact on insulin sensitivity. It has been reported that five nights of sleep restricted to four hours per night resulted in a 24% decrease in insulin sensitivity. ¹¹ With partial sleep deprivation, a person is more likely to lose fat-free soft tissue not fat mass. ¹² If you are losing weight by calorie reduction or increased energy expenditure with exercise, you need a good night’s sleep to have a positive impact on body composition. Optimizing sleep is important for lifestyle medicine providers because it has an impact on a person’s nutrition and biology with hormonal changes that impact appetite, body composition, and glucose control.

Research has demonstrated that people are in an increased stress state when they are sleep deprived. This could be behavioral in that sleep deprivation often leads to a lack of energy and often a diminished desire to exercise. And exercise is known to lower stress. When people are sleep deprived, they are more likely to have amygdala flares due to lack of suppression from the anterior cingulate cortex. ¹³ Thus, they are more likely to respond with a fight or flight response to negative emotional stimuli. Stress impacts our behaviors and often leads to changes in our routine, affecting our eating, exercise, social connections and in some people, it can increase the use of risky substances. There is a connection with stress and nutrition that many people feel for themselves. Stress eating or not eating during stressful times are patterns experienced by many. Stress increases cortisol, which can increase appetite, and it signals the body to shift metabolism to store fat. ¹⁴

There are many ways to reduce stress including exercise, sleep, and meditation. Mindfulness practices may also help. Eating mindfully is another way people can reduce stress. Mindfully eating a raisin may be a useful exercise for some. Deep breathing can help turn off the sympathetic response of fight or flight and turn on the parasympathetic response of rest and digest. It is important that people work to reduce stress prior to eating. And it is important to sit at a table, slow down, think about the food, and use all the senses to savor each bite. Many people are rushing around, eating while standing or driving in traffic which is often a high-stress situation. One practical suggestion is to take 10 deep breaths prior to sitting down for meals to help lower stress levels.

Another pillar that helps reduce stress is positive social connections. Connecting with friends and family can help people gain perspective and relax. According to a survey of 1,000 adults from September 2022 by the American Heart Association, 91% of parents in the study said their family is less stressed when they eat together and 84% of adult participants reported that they wished they could share a meal more often with loved ones. ¹⁵ A great way to socially connect is to cook with friends and family. Research reveals that regularly cooking dinner at home is associated with eating healthier foods. ¹⁶ This combines the pillar of nutrition with social connection in many ways.

Some people connect alcohol with mealtime. One of the pillars of lifestyle medicine is avoidance of risky substances, and research indicates that men who drink excessive alcohol are at increased risk of developing abdominal adiposity. ¹⁷ In addition, alcohol consumption close to bedtime has been demonstrated to delay the onset of REM sleep and reduce overall REM sleep. ¹⁸

All six pillars are important for health, and they are all connected in various ways. The lifestyle medicine-trained provider is able to evaluate, educate, motivate, and encourage their patients to participate in reaching the guidelines for all six pillars. To optimize health, we need to optimize all six pillars.