The Chair-Cursed Mind
Stress, Stress! This Stress Is Killing Me!
The most highly stressed period of my life was when I got divorced. My ex-wife and two children went back to the United Kingdom, leaving me in Minnesota. The day they left was one of the saddest in my life.
I remember going to the parking lot at Minneapolis Airport and getting in my car. The lot was dimly lit. From habit, I glanced in the rearview mirror at the pair of car seats. I could still hear the voices of my girls in the silence. I could smell them. It was cold and the car seats were empty. I started the engine, and the silence became an engine drone.
I did not drive away but just sat in the silence, the silence of “missing.”
That night I went back to my two-bedroom, newly-divorced-man rental. The next day I spoke with my two daughters, now 4,000 miles away. Their telephone sounds and distant words did not fill the void I felt. That void never goes away; you just move it to somewhere else in your head.
A week later, I was going through the Mayo hospital cafeteria line and pushed my tray past the drink counter; I saw cartons of chocolate milk. Often on Sundays my eldest daughter came to work with me. “Drink the chocolate milk,” I would bargain with her. That lunchtime, I saw the chocolate milk, looked down and she wasn’t there. I was struck still.
I don’t know how I got back home. I went to their room—left as though they were about to visit—and started to cry. I cried until I fell asleep and woke up on the floor between their empty beds; my pager was going off. I had a patient to see.
In the depression that followed, everything white was gray and every shadow a cavern. People were around, friends called to help, but I stopped hearing them. The TV calmed me and microwave pizza warmed me. I stopped fencing, something I had done twice a week. Work became a distraction. I would listen to patients with heightened interest and ask them about how they felt. Many of my patients with obesity live daily with pain, not only from their medical ailments, but from discrimination, stigmatization and self-reproach; my sense of personal pain was so great that I somehow felt closer to the needs of my patients.
When I wasn’t with patients, I was in the lab peering at data as if hidden truths would answer my problems. Work became a safe place; patients in the morning, the lab in the afternoon and sometimes all night. The treadmill desk was in my office—still. I never switched it on.
I knew that I was a rubbish father because my children were so far away. I knew that they wanted me almost as much as I wanted them, so I began monthly treks to London. I would live for those weekends, be happy and then die again.
I gained weight. As I sat more, my sadness worsened. The sadder I became, the more I ate. As work became my sole salvation, I started to view my chair as my safe place. In my clinic room, my doctor’s chair became my place for curing people—for making other people feel better. My lab chair became my place for discovering new universes—as if I could escape there. My home chair became my place to eat, watch TV, study for my board exams and sleep. From one chair to the next, my sadness grew, and my waistband expanded. Then I discovered banana liqueur. I love the taste of banana; my record was half a bottle in one night. I had sunk as low as I could let myself. If living is a journey, I had lost sight of the destination.
The first time I made an appointment to see a psychiatrist, I canceled it. The second time, I sat in the waiting room for 30 minutes and then left. The third time, I made it from the waiting room’s chair to the patient’s chair.
“Why are you here?” the psychiatrist asked. Dr. K was my age. Her gaze was firm, like that of a car mechanic who actually knows what that strange whirring is under the passenger seat. “You can tell me,” she said. “I am a rubbish dad,” I replied.
Sad Sitting
My depression became like a heavy blanket and kept me down in my chair. I had given up fencing, eating right, going to museums. I stopped going to theaters and concerts. I felt ashamed to go to professional dinners; I’d be the only one without a spouse—they all knew. I could not play with my kids because they were not there. I did not impose this chair sentence on myself; it was a symptom of my despair. I was down, done, fat and out.
This cycle of what I call “sad sitting” is commonplace. Getting up—whatever it takes—is part of the cure. Walking regularly—each day, even for just half an hour—is used for prevention and as part of the treatment for depression.1 People with depression have a symptom called anhedonia, which refers to the lack of interest in anything. The chair is the inevitable home of the sad. The chair is where people who are sad end up. I did. One in five Americans develops depression at some time in her life. The chair becomes the depressive’s sanctuary.
On my fourth visit, Dr. K said, “You are either going to show me you can break this cycle or you’re taking medication. I don’t think you need inpatient care right now, but I’m not taking it off the table.” She gave me an activity diary. I had to write down one positive thing I did for myself each day—work, TV and pizza did not count. That night I drove to Minneapolis to fence. The best part about fencing was that the fencers knew nothing of my family going away. I was chastised for being out of shape; the eight-year-olds were creaming me!
Sad Sitting: Cause and Effect?
But there is another aspect to sad sitting, one that is more insidious. If walking helps reverse depression, can enforced sitting cause sadness?
What happens to the brain when we sit that might make us sad?2 Most of the data comes from chair-sentenced rats. When you force a rat to be inactive, its muscles fire less because they are not stimulated. In people, that decrease in muscle firing may cause the parts of the brain that make you active to shrink. (The brain is like a muscle—if you don’t use it, it shrinks.) The shrunken activity center of the brain sends out fewer signals to move. You move even less, the brain’s activity center shrinks more and the cycle repeats itself. The brain adapts to your chair sentence. If the chair seduces a person, his muscles sense it, his brain adapts and he becomes sad and sluggish and feels depressed. People who sit adapt to sit more and become sadder.
Consider what happens when you break the sit-sad cycle and take a vacation; you get more sleep, hopefully more sex, perhaps eat more, but also often become more active. A vacation is a temporary escape from the chair sentence. Science backs this up: An active body begets an active brain. When people who have been sedentary walk more, they feel better, brighter, more energized and smarter. It stands to reason that moving more is linked in the brain’s circuitry to feeling happier. Sad sitting can be reversed, but as I discovered, you have to get up to break the cycle.
Over the years, the Mayo NEAT team has conducted chair-release consultancies in countless corporations. The commonest complaint we hear isn’t about pay or hours but stress. Stress comes in many forms, from balancing work and kids, job security and challenging work relationships (e.g., with a terrible boss).
There is a tendency to believe that stress is all bad. This is not so.3 Stress is a natural human response. If you are not stressed out by a saber-toothed tiger charging at you, you become cat food! What is wrong with modern living is how we deal with stressors. We do not routinely get up and run in response to stress; we sit and eat! Stress is one of the most common reasons clients explain excess eating, although the actual stressors vary: rushing, “pressure” and loneliness are frequent examples.4
When researchers examined data from 76 studies, they found that some types of work stress are good; for instance, if you have a presentation due tomorrow and you have the right skills to pull it off, the stress of the deadline will actually help you improve your presentation.5 Negative stress, however, is more common. For instance, if your office is chaotic and you are chasing 30 tasks simultaneously and your kids need soccer cleats and you have to be at soccer practice in a few hours, adding three more tasks (increasing the chaos) induces negative stress, and everything gets done less well. You may recognize this scenario as modern multitasking.
Chronic unrelenting negative stress is like pounding a hammer against a bathtub; eventually the tub will crack. Most often people internalize chronic stress by drinking, eating or self-medicating before it is redirected into anger or negative behaviors, such as violence or high-risk sexual behaviors.
Stress at the brain level is associated with a cascade of stress hormones.6 High stress influences the melanocortin system. This system, housed in the hypothalamus and the brain stem, is linked to the pituitary gland at the base of the brain, which produces a hormone called corticotropin. Corticotropin leaves the brain, enters the blood stream and heads to the adrenal glands, just above the kidneys, to produce the stress hormone, cortisol.
The hypothalamus-pituitary-corticotropin-cortisol cascade is a stress system common to a number of animals.7 During periods of long-term stress, cortisol levels increase. Among early humans, this was valuable; natural stressors were life threatening, so the body developed a response system. The body, however, was never designed for the unrelenting stress of an awful boss, getting kids to gymnastics and soccer, paying rent and keeping a third job while sitting all day. We know from patients who have high cortisol levels—for instance, those with Cushing’s disease (caused by a tumor that makes excess cortisol)—that high cortisol levels can do significant harm to the mind and body.
Excess Cortisol Leads to Stressed-Out Bodies
In medical school, my first professor in endocrinology came from the north of England. He was brash and brilliant, not a man who held back comment or criticism nor feared controversy. My first patient with Cushing’s disease had increased his eating and gained 40 pounds. His blood pressure was terrible, and his bone scan showed soft bones. I reported all of these facts to the professor. The professor barked, “But how does the patient feel?” The doctor towered over me by a foot. I looked at his shoes and shrugged. We went to see the patient together. With patients, the harsh giant was kindness personified. He held the man’s hand and asked, “So how have you been doing?” The patient was from a tough part of London, but a tear rolled down his cheek. “That bad,” said my professor, and looked at me. He summarized, “You see, Levine, too much cortisol makes patients fat and frumpy.”
This is a vicious cycle: The more stress you have, the more cortisol your body releases.8 As a result of the excess cortisol, you eat more (the melanocortin system, described above, directly impacts appetite), feel sadder (“frumpy”), gain weight and sit. The cortisol system numbs the muscles’ responses to “move-it” stimuli, making it more likely that you’ll sit in the first place.9 Because oftentimes, negative stress is unrelenting, you then eat even more, gain even more weight and your vulnerability to further stress-related fat gain is even greater. To add salt to the wound, gaining weight is itself stressful; people with obesity are discriminated against and feel ostracized, which pumps up stress levels and cortisol even further.10 As a result of this vicious cycle, you get more stressed and the cortisol-sit-sadness-cycle perpetuates. After a while, diabetes and high blood pressure occur and add to the burden.
The population-wide stress experiment is called the modern office. The chair sentence prevents your stress from ever being cured: It prevents the cortisol cycle from ever being broken. The modern office stops you from getting up. How many hundreds of office clients with obesity have told me that they eat under stress? Perhaps if they had not been chair sentenced, they would not have stress-eaten and developed obesity in the first place.
If you see a saber-toothed tiger charging toward you, you don’t fire off an email, you get up and run! If life is stressing you out, break the cortisol cycle and get up!
The Sleep Paradox
When I first entered residency, the call schedule was one night in three. Every third night, instead of going home at 5 p.m., I worked through the night and then the next day. The on-call room and on-call lounge were stocked with free sandwiches and soda—a junior doctor’s dream.
At night, I avoided Diet Coke because of the caffeine and instead drank lemonade. When admissions from the ER slowed down, I would try to nap but could never sleep. At 3 a.m. I would raid the free sandwiches, have free breakfast at 8 a.m. and then have lunch and a snack. After the 40-hour stretch, I would get home exhausted, collapse into a chair, eat and then sleep. Every third night was the same.
That is what sleep deprivation does to you. Because you are up for longer, you eat more, but you do not move more. If you are sleep deprived, you are exhausted, move less and sit more. Sleep deprivation causes obesity—more food, more chair!
To better understand the impact of sleep on NEAT and sitting, I began working with Virend Somers, the Einstein of the sleep world. Dr. Somers had many years’ experience not only in measuring how people sleep but also the effects of experimental sleep deprivation. Shelly McCrady-Spitzer, from my lab, is the Madame Curie of the NEAT world; she began to organize a collaboration between Somers’s lab and ours. Together, we conducted a unique sleep deprivation study. We recruited healthy people who were willing to be sleep deprived for 21 consecutive days for the good of humankind.11 Our volunteers became exhausted, and we measured their responses. The less they slept, the more they ate and the more they sat. Sleep deprivation and obesity sit beside each other on the sofa.
Why Is Sleep Important?
While the human body sleeps, not only does it switch off, but it also enters a self-repair mode. Growth hormone, which is crucial for muscle and bone maintenance, is mostly released while we sleep. The proteins associated with causing dementia are cleared from the brain when people sleep. Also, sleep is necessary for optimized insulin release and diabetes prevention. More subtly, while we sleep, we dream. Sigmund Freud suggested that sleep plays a critical role in repairing the psyche. But also, neuroscientists suggest, while we sleep, a host of neurocircuits are repaired and memories are saved.12
Sleep is different from sitting, even though in both cases we do not move much. When we sit and stare at our computer screens, our bodies are like idling engines. The inactive muscles are understimulated and so break down. When you sit, your body’s natural insulin is less effective; and so sitting is associated with elevated blood sugar and diabetes. With respect to the psyche, we get stressed while seated at work. Your manager may be as threatening as a saber-toothed tiger, but you have to sit through the stress, internalize it and the cortisol cycle is perpetuated. While we sit, our blood triglycerides creep up and up, and our hearts function sluggishly. Blood flow is not returned efficiently from our legs, and our ankles swell. Back pain occurs and our wrists hurt. Prolonged sitting softens the skeleton. As we continue to stay seated, our brains lull and creativity falls. Sleep is as good for us as sitting is bad.
Data suggest that daytime naps benefit the body and energize us to be more active afterward.13 Once I had seen the results from Virend and Shelly’s sleep deprivation study, I started to take afternoon naps wherever I could.
Getting good sleep is critical to energize your chair escape. Close the book and take a nap!
Sit Down—Mind Off
The NEAT lab’s first office experiment was in 2008 in a Minneapolis financial services company called Salo. Workers across the company got up out of their chairs and took on NEAT-active work. As people got up, their health and happiness measures improved, but most interestingly, they also felt a new sense of personal empowerment.
In one case, a woman decided that she wanted to sing at her parents’ fiftieth wedding anniversary. She started to take singing lessons (practicing in the car going to and from work). Not only did she sing at the anniversary celebration, she began a new career (in her off hours) as a jazz singer. Another of our volunteers called me up one morning at 5 a.m. He couldn’t restrain himself. “Dr. Levine. You’ll never believe it. I walked a half-marathon yesterday at work . . . in my business suit.” This same person, three months later, completed his first novel and now runs his own business that promotes active office cultures. In a third example, an office worker started a cooking club. Not your standard let’s-share-recipes group; instead, she hired a professional cook and once a week invited friends to come to her house to learn to cook healthily. This behavior directly affected the workplace; cookies and cakes vanished and were replaced by the healthful snack of the week. The office went on to have cook-offs for prizes. In a fourth example, a worker invented and built her own desk-side workout equipment. A company saw this and commercialized it as a desk exercise kit. In a fifth example, a chocoholic climbed out of her chair and planned her own withdrawal program, which we now use in our programs around the country. (The trick is to buy really good chocolate, in smaller quantities, and savor it!) The final example is the most dramatic. One young worker had dreamed of teaching English in an underserved country. She got out of her chair, took a leave of absence and went to teach English in a remote part of China.
The most common observation I make when we roll out chair-release programs is that by getting up, as a first simple step, people start to regain personal power. It is as though by physically getting up, people are released from a sedentary psychological imprisonment that forbids self-propulsion, self-expression and self-fulfillment. It is true that as we ease people out of their chairs, they see improvements to their blood sugar levels, blood pressures and waistlines. However, the examples I just described tell a more compelling tale. When people get out of their chairs, they blossom as if they finally are free from prison. As people shed their chair shackles and get up, their creativity bursts out; they take steps toward their dreams and move their lives under their own power—step by step by step—forward. They remember the destination they’d always wanted to reach.
I challenge you. Stop for one minute and shut your eyes. How do you visualize yourself in your mind’s eye? What do you want for yourself? Go on, close your eyes (unless you’re driving or biking) and ask yourself those questions.
It is said that Einstein came up with E=mc2 while biking across the Princeton University campus. Get out of your chair and become the person you dream of being.
Isn’t it interesting how all these stress-related concepts intermingle and fit together? Did you notice that “stressed” spelled backward is “desserts”?