Thread by @sol_vidalalmela

My very first #ExerciseIsMedicine #Tweetorial is here: Breaking “it makes me feel good” into pieces🧠😀🏃‍♀️🏊‍♂️🚴#Thread ⬇️⬇️
#TwitterPoll at the END

1/ Are you exercising🏃‍♀️to boost your mental well-being during the pandemic🦠? People exercise because it makes them feel good🙃, but what exactly happens in our body? Keep reading to satisfy your curiosity & learn about the #mechanisms behind aerobic exercise & #mentalhealth

2/ Anxiety and depression are common mental health conditions. The prevalence in cardiac patients is ~20-30% & 2x higher in ♀️ vs ♂️. Social roles (e.g. caregiver role), cultural norms (e.g. societal sexism) and more pronounced hormonal shifts in ♀️ influence this sex-difference

3/ Pharmacotherapy💊 and psychotherapy (e.g. CBT) ⬇️levels of anxiety and depression, yet many patients discontinue (e.g. side effects) or do not respond to treatment😟➡️➡️ Exercise🤸‍♀️comes to the rescue as a low-risk, cost-effective, and easily accessible therapeutic option

4/ ⬆️PA is associated with improved #anxiety #depression & #mood in population studies
MA show⬇️in anxiety & depression with🏃in healthy (-0.38 & -0.50) & cardiac populations (-2.59 & -0.61) Figure: b.link/Chekroud2018; b.link/Rebar2015; b.link/Zheng2019

5/ Anxiety and depression modify the body’s healthy neurobiological state through continued⬆️levels of catecholamines, cortisol, inflammatory markers & ⬇️serotonin; leading to overactivity of the SNS & the HPA axis. It is hard to establish the true direction of this relationship

6/ A key difference between “good” (e.g. aerobic exercise🚶‍♀️💃) and “bad” stressors (e.g. persistent anxiety😟😨) is the prolonged state of hypercortisolemia in the latter, which is associated with inflammation, hypertension, hyperglycemia and dyslipidemia

7/ 🏃‍♀️may reverse the altered neurobiological state & thus⬇️anxiety & depression
Let’s get into the nitty-gritty: #physiological & #psychological mechanisms responsible for the #mentalhealth benefits of🏃‍♀️
(1) Aerobic exercise⬆️release & function of neurotransmitters/neurotrophins:

8/ β-endorphins regulate emotions. ⬆️in the levels of β-endorphins during & following exercise are linked with ⬇️anxiety and better mood (ever felt the runner’s high?🤩). Aerobic exercise🏃‍♀️ can ⬆️the levels of β-endorphins up to 7-fold

9/ Adults with poor mental health have⬇️BDNF. Acute exercise⬆️BDNF (SMD 0.46) and this acute effect is⬆️after an exercise program (ES 0.59). Chronic⬆️in BDNF with exercise have also been reported (ES 0.27). Studies with more ♀️ show smaller effect sizes ☹b.link/Szuhany2015

10/ The⬆️in BDNF with exercise🚴🤼‍♀️has been linked with⬇️levels of depression. Higher-intensity exercise may lead to greater⬆️in BDNF than lower-intensity exercise
b.link/Gourgouvelis20…; b.link/Hotting2016

11/ Persistent anxiety blocks the cortisol feedback loop responsible for down-regulating the HPA axis. Atrial natriuretic peptides (ANP) facilitates the inhibition of the HPA axis to limit overactivity. During exercise, the⬆️in atrial stretch🫀 from⬆️venous return:⬆️ANP levels

12/ In healthy adults, 30 min of aerobic exercise🏃 significantly ⬆️ANP levels & ⬇️anxiety in response to a stressor. Enhanced ANP contributes to the anxiolytic effects of #exercise (r=0.69, p=0.03)
b.link/Strohle2006

13/ Monoamines dysfunction is involved in the pathogenesis of #anxiety and #depression. Exercise ⬆️serotonin synthesis (by⬆️free form of tryptophan) and downregulates serotonin receptors ➡️➡️
⬆️serotonin availability &⬆️release of norepinephrine & dopamine

14/ (2) Cross-stressor adaptation: during🏃🏃‍♀️our bodily systems transiently adapt to meet the⬆️metabolic demand. Repeated physiological challenges with chronic exercise lead to➡️improved physiological control in future exercise bouts which can translate to other daily stressors

15/ As a result,🏃‍♀️⬇️cardiovascular reactivity. E.g. Acute:
#bloodpressure response to a stressor is⬇️if preceded by an exercise bout (ES -0.40). State anxiety⬇️for 2-24h after exercising🧘‍♀️
This is why you should🏃before your exam!
b.link/RaglinMorgan19…; b.link/Hamer2006

16/ Chronic: Trained adults show a lower HR and cortisol response to a stress task vs untrained. How?🏃‍♀️➡️Tranquilizing;⬆️vasodilation,⬇️catecholamine levels & ⬇️TPR due to SNS inhibition & improved β-receptors responsiveness
b.link/Rimmele2009; b.link/DeVries1981

17/ (3) Anxiety sensitivity: tendency to misinterpret anxiety sensations (e.g. rising HR➡️“I’m going to have a❤️attack”🙀)
The repeated exposure to a new environment (sweat, heavy breathing🚴) not leading to bad outcomes:⬇️anxiety when encountering other unfamiliar situations

18/ (4)🙂mood⬇️HPA axis reactivity while ☹mood⬆️ reactivity. Mood is improved for>30 min post🏃‍♀️(ES 0.47). Enjoyment may be key.
High-intensity🏃‍♀️⬆️negative affect more than low-intensity during but NOT after🏃‍♀️. This change may coincide with⬆️self-efficacy b.link/Reed2006

19/ (5)⬆️self-efficacy (ES 0.21) & self-esteem (ES 0.23) are viable mediators of improved #mentalhealth with🏃‍♀️E.g. running 5K regularly⬆️body satisfaction & ⬆️sense of mastery that can be transferred to other situations:⬆️confidence to cope with stressors b.link/White2009

20/ (6) Social #isolation worsens mental health. Anxiety & depression have a greater inverse association with team sports & recreational activities(often group-based🤼‍♀️) than with domestic chores/work-related PA (often individual)
b.link/Harvey2018; b.link/stephens1988

21/ In🚺in particular, group-based💃🚴‍♀️🏃‍♀️with an emphasis on social interactions🤼‍♀️ may maximize⬇️in anxiety & depression. Upon an adverse situation,🚺tend to seek support from others, while🚹are more likely to escape or cope by taking action
Check: b.link/Vidal2020

22/ That was a “brief” summary of major #mechanisms behind the #exercise & #mentalhealth relationship📚 One thing is clear: if you don’t routinely exercise, the time to start is now! Please feel free to share your thoughts and papers to generate discussion

23/ Last but not least ➡️ #Poll time❣️
If you provide care to patients, do you routinely recommend exercise🚴‍♀️🏃🚶‍♂️as a primary treatment for your patients with high levels of anxiety or depression? Why? (Please🙏share comments/successful stories/concerns)

24/ Despite🏃being easily accessible, low-risk and cost-effective with remarkable health benefits, only 5% of physicians surveyed🤪chose exercise as 1 of their 3 most used treatments for depression, while 92% chose medications💊 with multiple side effects b.link/reportuk

25/ Let’s advocate for exercise! Please help get the message across with a #RT, lack of education is often a barrier to exercise referral and participation.
If you liked the #tweetorial ➡️follow twitter.com/sol_vidalalmela for more!
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