As nutrition professionals, we are primed to educate patients on the wonderful healing benefits of food. But even the best nutrition protocol can fall flat when we fail to consider all the aspects of STAIN. The “S” in STAIN refers to stress, which can significantly hinder patient progress, decrease quality of life, and actually lead to the development of disease. To help patients achieve optimal health, practitioners must understand the stress response, how it impacts the body, and how to personalize an effective self-care plan to manage stress not only for their patients, but for themselves.

Stress and the Sympathetic Nervous System

Stress can be defined as any physical or emotional threat to homeostasis that affects one’s well-being (1). While stress gets a bad rap, not all stress is negative. In fact, healthy stressors push one to achieve life goals but also help maintain homeostasis in the body. The elephant in the room for many patients and practitioners is chronic, unmanaged stress and a sympathetic nervous system (SNS) gone haywire.

The SNS is responsible for the fight-or-flight stress response and is characterized by a rapid heart rate, increased respiratory rate, a heightened state of alertness, and mobilization of energy stores. The parasympathetic nervous system (PNS), on the other hand, promotes relaxation, healing, repair, and proper immune system function (2).

A delicate balance exists between these two systems but when the balance is shifted with the SNS being constantly triggered, patients can experience a variety of unsettling symptoms:

  • Brain fog
  • Fatigue
  • Gastrointestinal distress
  • Difficulty sleeping
  • Mood alteration
  • Muscle and joint aches
  • Headaches
  • Sexual dysfunction
  • Anxiety
  • Frequent illness

 

What is the Acute Stress Response?

During acute stress, the amygdala signals the brain stem to release the sympathetic neurotransmitters norepinephrine and epinephrine in a pro-inflammatory response to prepare the body to fight a real or perceived threat. The amygdala then initiates the hypothalamic-pituitary-adrenal axis (HPA-axis). The hypothalamus secretes corticotropin-releasing hormone (CRH) and arginine vasopression (AVP), which signal the pituitary gland to create and send out adrenocorticotropic hormone (ACTH). ACTH then signals the adrenal glands to secrete cortisol (1). Cortisol functions to mobilize energy stores, suppress immune system and non-essential organ function, heighten brain function, and decrease

inflammation (2). Once the threat is neutralized, the elevated cortisol levels inhibit CRH and ACTH to restore homeostasis (1). This system works beautifully in acute situations, but when stress becomes chronic, the continuous cortisol surge ultimately leads to cortisol dysfunction and the subsequent downstream effects.

 

Cortisol and the Stress Response

While it’s become popular to blame cortisol for everything from weight gain to fatigue, it is actually a very important hormone. Cortisol functions maintain blood glucose levels, regulate organ systems to prioritize energy for brain and neuromuscular function, reduce inflammation, and is vital during the acute stress response (2). Cortisol levels are highest in the morning and decrease as the day progresses. Negative symptoms begin to arise when cortisol production is inappropriately increased, as is the case in chronic, unmanaged stress.

When cortisol production is excessive over a long period of time the system becomes overwhelmed and cortisol production becomes altered. Because cortisol functions as an anti-inflammatory in the acute stress response, when it is not working normally, the inflammatory response can then become sustained. This unchecked inflammation is responsible for oxidative and free radical damage, cell death, rapid aging, and even disease development (2). Let’s look at some of the specific ways chronic stress can impact body function.

 

Chronic Stress and Brain Function

Chronic stress can negatively impact memory and cognitive function. The effects are dependent on the type, magnitude, and length of the stress, and are also unique to each person. Whereas acute stress has been shown to enhance memory and cognition, chronic stress has been shown to induce brain atrophy, decrease brain weight, and lead to cognitive disorders and memory impairment (3). These effects are partially the result of chronically elevated cortisol levels, which cause functional and structural changes in the hippocampus, a region of the brain important for both short and long-term memory. In addition, adrenergic hormones halt neurogenesis in the hippocampus. Interestingly, once cortisol levels are normalized, memory and cognitive impairment can be reversed (3).

 

Chronic Stress and Immune Function

It’s no coincidence that people suffering from chronic stress get sick more easily and more often. While acute stress of short duration enhances immune system function, chronic stress has the opposite effect increasing the risk of illness (3, 4, 5).

Immunological cells, or lymphocytes, have receptors for the neurotransmitters and hormones that are released during the acute stress response. While catecholamines and cortisol mobilize immune cells to prepare the body to fight a threat, this is very taxing for the body. As stress becomes more chronic, these demanding immunological responses result in systemic changes to the immune response (5).  Specifically, the glucocorticoids, catecholamines, and opioids that are released during the stress response reduce the function of lymphocytes, macrophages, and phagocytes. When natural killer and T-cell function is impaired, patients are at greater risk of developing some types of cancer, as this process can also induce cancer cell and tumor growth (3).  In addition, chronic stress can provoke the reactivation of latent viruses including the herpes simplex virus and Epstein-Barr virus, which can further tax the immune system (5).

 

 Chronic Stress and Gastrointestinal Function

Chronic stress can alter gastrointestinal (GI) tract function in a variety of ways and has been linked to many GI disorders such as Crohn’s disease, ulcerative colitis, and irritable bowel syndrome (6). Firstly, patients can experience changes in appetite, which can further elicit or exacerbate GI symptoms. But, those under chronic stress also experience a myriad of physiological GI changes including altered GI tract motility and digestive enzyme secretion along with an imbalanced gut microbiome. In addition, alterations in the mucin layer and in mucosal blood flow accompanied by increased intestinal permeability are common. And chronically stressed patients tend to have a heightened sense of awareness of the goings on in their guts called visceral hypersensitivity.(6)

 

Self-Care for Patients and Practitioners

The good news for patients and practitioners alike is the negative effects of chronic stress are preventable and reversible with daily self-care. While some patients are hesitant to implement stress management practices, once these techniques are employed, patients can often experience more complete healing.  The options for self-care are infinite and may include:

  • Exercising
  • Journaling
  • Listening to music
  • Taking a relaxing bath
  • Walking in nature
  • Spending time with loved ones
  • Sitting in the sunshine
  • Taking a vacation
  • Creating a healthy sleep routine
  • Reading a book

 

Let’s explore three powerful self-care techniques with clinically-proven results.

Yoga

Yoga, a combination spiritual and physical practice, began in India centuries ago and has gained popularity in the United States as a form of exercise and stress management, but is also being used clinically in the healthcare setting as an adjunct to traditional treatment (7). While yoga may have once been considered a type of religion, it has become more mainstream and patients are often willing to try one of the various forms of this healing practice. Yoga has been shown to have powerful effects when it comes to normalizing the stress response. In one meta-analysis reported in Psychoneuroendocrinology, stress management techniques that included yoga asanas improved both the SNS and responses. Study participants experienced lower evening and waking cortisol levels, lower blood pressure and resting heart rate and improvements in heart rate variability (8).

Massage Therapy

Massage therapy is a very popular and effective integrative treatment. Among its impressive benefits include pain reduction, the alleviation of depressive symptoms, improved preterm infant weight, and enhanced immune system function (9). But massage therapy is also an effective stress management tool. As reported in Complementary Therapies in Clinical Practice, moderate pressure massage to stimulate the pressure receptors under the skin increases blood flow to the amygdala and hypothalamus, but also increases vagal activity, which decreases blood pressure, cortisol levels, and heart rate (9). Furthermore, massage therapy may improve digestive function in those under stress. As reported in one randomized controlled trial, enterally-fed intubated intensive care patients experienced reduced gastric residual volume and constipation after being treated with abdominal massage (10).

Meditation

Meditation is an ancient practice that has gained popularity recently with numerous apps and programs now available. While meditation can be practiced in a variety of ways, the aim is to experience feelings without judgement, to be present in the here and now, and to create a healthy perspective. This process, when practiced consistently, may help reduce anxiety, pain, and depression. In addition, one systematic review and meta-analysis reported in JAMA Internal Medicine, concluded meditation programs can provide small to moderate reductions in several aspects of psychological stress (11).

As part of a comprehensive plan for healing, self-care can be life-changing for patients. But just as with nutrition, self-care should be personalized. IFNA training takes a deep-dive into the stress response and provides valuable self-care resources for practitioners to utilize with their patients and themselves. In addition, IFNA offers a wonderful community of supportive integrative providers who are happy to share their wisdom and expertise.

by Kellie Blake RDN, LD, IFNCP

 

References:

  1. Joseph, D. N., & Whirledge, S. (2017). Stress and the HPA Axis: Balancing Homeostasis and Fertility. International journal of molecular sciences, 18(10), 2224. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5666903/
  2. Hannibal, K. E., & Bishop, M. D. (2014). Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical therapy, 94(12), 1816–1825. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263906/
  3. Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body function: A review. EXCLI journal, 16, 1057–1072. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579396/
  4. Dragoş, D., & Tănăsescu, M. D. (2010). The effect of stress on the defense systems. Journal of medicine and life, 3(1), 10–18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3019042/
  5. Morey, J. N., Boggero, I. A., Scott, A. B., & Segerstrom, S. C. (2015). Current Directions in Stress and Human Immune Function. Current opinion in psychology, 5, 13–17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465119/
  6. Konturek, P. C., Brzozowski, T., & Konturek, S. J. (2011). Stress and the gut: pathophysiology, clinical consequences, diagnostic approach and treatment options. Journal of physiology and pharmacology: an official journal of the Polish Physiological Society, 62(6), 591–599. https://pubmed.ncbi.nlm.nih.gov/22314561/
  7. Duan-Porter W, Coeytaux RR, McDuffie JR, et al. Evidence Map of Yoga for Depression, Anxiety, and Posttraumatic Stress Disorder. J Phys Act Health. 2016;13(3):281-288. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5459483/
  8. Pascoe, M. C., Thompson, D. R., & Ski, C. F. (2017). Yoga, mindfulness-based stress reduction and stress-related physiological measures: A meta-analysis. Psychoneuroendocrinology, 86, 152–168. https://doi.org/10.1016/j.psyneuen.2017.08.008
  9. Field T. Massage therapy research review. Complement Ther Clin Pract. 2014;20(4):224-229. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467308/
  10. Dehghan, M., Fatehi Poor, A., Mehdipoor, R., & Ahmadinejad, M. (2018). Does abdominal massage improve gastrointestinal functions of intensive care patients with an endotracheal tube?: A randomized clinical trial. Complementary therapies in clinical practice, 30, 122–128. https://pubmed.ncbi.nlm.nih.gov/29389471/
  11. Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(3):357-368. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142584/

 

As nutrition professionals, we are primed to educate patients on the wonderful healing benefits of food. But even the best nutrition protocol can fall flat when we fail to consider all the aspects of STAIN. The “S” in STAIN refers to stress, which can significantly hinder patient progress, decrease quality of life, and actually lead to the development of disease. To help patients achieve optimal health, practitioners must understand the stress response, how it impacts the body, and how to personalize an effective self-care plan to manage stress not only for their patients, but for themselves.

Stress and the Sympathetic Nervous System

Stress can be defined as any physical or emotional threat to homeostasis that affects one’s well-being (1). While stress gets a bad rap, not all stress is negative. In fact, healthy stressors push one to achieve life goals but also help maintain homeostasis in the body. The elephant in the room for many patients and practitioners is chronic, unmanaged stress and a sympathetic nervous system (SNS) gone haywire.

The SNS is responsible for the fight-or-flight stress response and is characterized by a rapid heart rate, increased respiratory rate, a heightened state of alertness, and mobilization of energy stores. The parasympathetic nervous system (PNS), on the other hand, promotes relaxation, healing, repair, and proper immune system function (2).

A delicate balance exists between these two systems but when the balance is shifted with the SNS being constantly triggered, patients can experience a variety of unsettling symptoms:

  • Brain fog
  • Fatigue
  • Gastrointestinal distress
  • Difficulty sleeping
  • Mood alteration
  • Muscle and joint aches
  • Headaches
  • Sexual dysfunction
  • Anxiety
  • Frequent illness

 

What is the Acute Stress Response?

During acute stress, the amygdala signals the brain stem to release the sympathetic neurotransmitters norepinephrine and epinephrine in a pro-inflammatory response to prepare the body to fight a real or perceived threat. The amygdala then initiates the hypothalamic-pituitary-adrenal axis (HPA-axis). The hypothalamus secretes corticotropin-releasing hormone (CRH) and arginine vasopression (AVP), which signal the pituitary gland to create and send out adrenocorticotropic hormone (ACTH). ACTH then signals the adrenal glands to secrete cortisol (1). Cortisol functions to mobilize energy stores, suppress immune system and non-essential organ function, heighten brain function, and decrease

inflammation (2). Once the threat is neutralized, the elevated cortisol levels inhibit CRH and ACTH to restore homeostasis (1). This system works beautifully in acute situations, but when stress becomes chronic, the continuous cortisol surge ultimately leads to cortisol dysfunction and the subsequent downstream effects.

 

Cortisol and the Stress Response

While it’s become popular to blame cortisol for everything from weight gain to fatigue, it is actually a very important hormone. Cortisol functions maintain blood glucose levels, regulate organ systems to prioritize energy for brain and neuromuscular function, reduce inflammation, and is vital during the acute stress response (2). Cortisol levels are highest in the morning and decrease as the day progresses. Negative symptoms begin to arise when cortisol production is inappropriately increased, as is the case in chronic, unmanaged stress.

When cortisol production is excessive over a long period of time the system becomes overwhelmed and cortisol production becomes altered. Because cortisol functions as an anti-inflammatory in the acute stress response, when it is not working normally, the inflammatory response can then become sustained. This unchecked inflammation is responsible for oxidative and free radical damage, cell death, rapid aging, and even disease development (2). Let’s look at some of the specific ways chronic stress can impact body function.

 

Chronic Stress and Brain Function

Chronic stress can negatively impact memory and cognitive function. The effects are dependent on the type, magnitude, and length of the stress, and are also unique to each person. Whereas acute stress has been shown to enhance memory and cognition, chronic stress has been shown to induce brain atrophy, decrease brain weight, and lead to cognitive disorders and memory impairment (3). These effects are partially the result of chronically elevated cortisol levels, which cause functional and structural changes in the hippocampus, a region of the brain important for both short and long-term memory. In addition, adrenergic hormones halt neurogenesis in the hippocampus. Interestingly, once cortisol levels are normalized, memory and cognitive impairment can be reversed (3).

 

Chronic Stress and Immune Function

It’s no coincidence that people suffering from chronic stress get sick more easily and more often. While acute stress of short duration enhances immune system function, chronic stress has the opposite effect increasing the risk of illness (3, 4, 5).

Immunological cells, or lymphocytes, have receptors for the neurotransmitters and hormones that are released during the acute stress response. While catecholamines and cortisol mobilize immune cells to prepare the body to fight a threat, this is very taxing for the body. As stress becomes more chronic, these demanding immunological responses result in systemic changes to the immune response (5).  Specifically, the glucocorticoids, catecholamines, and opioids that are released during the stress response reduce the function of lymphocytes, macrophages, and phagocytes. When natural killer and T-cell function is impaired, patients are at greater risk of developing some types of cancer, as this process can also induce cancer cell and tumor growth (3).  In addition, chronic stress can provoke the reactivation of latent viruses including the herpes simplex virus and Epstein-Barr virus, which can further tax the immune system (5).

 

 Chronic Stress and Gastrointestinal Function

Chronic stress can alter gastrointestinal (GI) tract function in a variety of ways and has been linked to many GI disorders such as Crohn’s disease, ulcerative colitis, and irritable bowel syndrome (6). Firstly, patients can experience changes in appetite, which can further elicit or exacerbate GI symptoms. But, those under chronic stress also experience a myriad of physiological GI changes including altered GI tract motility and digestive enzyme secretion along with an imbalanced gut microbiome. In addition, alterations in the mucin layer and in mucosal blood flow accompanied by increased intestinal permeability are common. And chronically stressed patients tend to have a heightened sense of awareness of the goings on in their guts called visceral hypersensitivity.(6)

 

Self-Care for Patients and Practitioners

The good news for patients and practitioners alike is the negative effects of chronic stress are preventable and reversible with daily self-care. While some patients are hesitant to implement stress management practices, once these techniques are employed, patients can often experience more complete healing.  The options for self-care are infinite and may include:

  • Exercising
  • Journaling
  • Listening to music
  • Taking a relaxing bath
  • Walking in nature
  • Spending time with loved ones
  • Sitting in the sunshine
  • Taking a vacation
  • Creating a healthy sleep routine
  • Reading a book

 

Let’s explore three powerful self-care techniques with clinically-proven results.

Yoga

Yoga, a combination spiritual and physical practice, began in India centuries ago and has gained popularity in the United States as a form of exercise and stress management, but is also being used clinically in the healthcare setting as an adjunct to traditional treatment (7). While yoga may have once been considered a type of religion, it has become more mainstream and patients are often willing to try one of the various forms of this healing practice. Yoga has been shown to have powerful effects when it comes to normalizing the stress response. In one meta-analysis reported in Psychoneuroendocrinology, stress management techniques that included yoga asanas improved both the SNS and responses. Study participants experienced lower evening and waking cortisol levels, lower blood pressure and resting heart rate and improvements in heart rate variability (8).

Massage Therapy

Massage therapy is a very popular and effective integrative treatment. Among its impressive benefits include pain reduction, the alleviation of depressive symptoms, improved preterm infant weight, and enhanced immune system function (9). But massage therapy is also an effective stress management tool. As reported in Complementary Therapies in Clinical Practice, moderate pressure massage to stimulate the pressure receptors under the skin increases blood flow to the amygdala and hypothalamus, but also increases vagal activity, which decreases blood pressure, cortisol levels, and heart rate (9). Furthermore, massage therapy may improve digestive function in those under stress. As reported in one randomized controlled trial, enterally-fed intubated intensive care patients experienced reduced gastric residual volume and constipation after being treated with abdominal massage (10).

Meditation

Meditation is an ancient practice that has gained popularity recently with numerous apps and programs now available. While meditation can be practiced in a variety of ways, the aim is to experience feelings without judgement, to be present in the here and now, and to create a healthy perspective. This process, when practiced consistently, may help reduce anxiety, pain, and depression. In addition, one systematic review and meta-analysis reported in JAMA Internal Medicine, concluded meditation programs can provide small to moderate reductions in several aspects of psychological stress (11).

As part of a comprehensive plan for healing, self-care can be life-changing for patients. But just as with nutrition, self-care should be personalized. IFNA training takes a deep-dive into the stress response and provides valuable self-care resources for practitioners to utilize with their patients and themselves. In addition, IFNA offers a wonderful community of supportive integrative providers who are happy to share their wisdom and expertise.

by Kellie Blake RDN, LD, IFNCP

 

References:

  1. Joseph, D. N., & Whirledge, S. (2017). Stress and the HPA Axis: Balancing Homeostasis and Fertility. International journal of molecular sciences, 18(10), 2224. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5666903/
  2. Hannibal, K. E., & Bishop, M. D. (2014). Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical therapy, 94(12), 1816–1825. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263906/
  3. Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body function: A review. EXCLI journal, 16, 1057–1072. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579396/
  4. Dragoş, D., & Tănăsescu, M. D. (2010). The effect of stress on the defense systems. Journal of medicine and life, 3(1), 10–18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3019042/
  5. Morey, J. N., Boggero, I. A., Scott, A. B., & Segerstrom, S. C. (2015). Current Directions in Stress and Human Immune Function. Current opinion in psychology, 5, 13–17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465119/
  6. Konturek, P. C., Brzozowski, T., & Konturek, S. J. (2011). Stress and the gut: pathophysiology, clinical consequences, diagnostic approach and treatment options. Journal of physiology and pharmacology: an official journal of the Polish Physiological Society, 62(6), 591–599. https://pubmed.ncbi.nlm.nih.gov/22314561/
  7. Duan-Porter W, Coeytaux RR, McDuffie JR, et al. Evidence Map of Yoga for Depression, Anxiety, and Posttraumatic Stress Disorder. J Phys Act Health. 2016;13(3):281-288. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5459483/
  8. Pascoe, M. C., Thompson, D. R., & Ski, C. F. (2017). Yoga, mindfulness-based stress reduction and stress-related physiological measures: A meta-analysis. Psychoneuroendocrinology, 86, 152–168. https://doi.org/10.1016/j.psyneuen.2017.08.008
  9. Field T. Massage therapy research review. Complement Ther Clin Pract. 2014;20(4):224-229. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5467308/
  10. Dehghan, M., Fatehi Poor, A., Mehdipoor, R., & Ahmadinejad, M. (2018). Does abdominal massage improve gastrointestinal functions of intensive care patients with an endotracheal tube?: A randomized clinical trial. Complementary therapies in clinical practice, 30, 122–128. https://pubmed.ncbi.nlm.nih.gov/29389471/
  11. Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(3):357-368. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142584/