#67 Stress Reduction: What Actually Works—and What’s Just Wellness Hype

Stress is everywhere and so is the marketing. Nearly half of US adults say they feel stressed often, and the wellness world is ready with a supplement, a lab panel, or a pricey device for every symptom. We wanted a cleaner answer: what is stress, what can we measure at home, and what actually reduces stress in a way that’s grounded in real studies rather than hype.

We start by defining stress in a practical way: stress rises when the demands you perceive exceed the resources you think you have. That helps explain why stress can feel so intense even when there’s no single “stress blood test” to prove it. From there, we walk through simple, objective tracking tools you can use right away, led by the Perceived Stress Scale (PSS-10). We also talk about supportive signals like resting heart rate and heart rate variability (HRV), and why cortisol testing often creates more confusion than clarity in day-to-day life.

Then we get into what works. The strongest evidence supports unsexy basics like better sleep and regular exercise, plus approachable mind-body tools like breathwork and mindfulness meditation. We also cover two surprising areas with research behind them: music therapy and aromatherapy (often lavender). Finally, we call out common red flags and popular myths, including “adrenal fatigue,” questionable supplement stacks, and consumer vagus nerve stimulation gadgets that borrow credibility from real implantable medical devices without delivering real proof.

If you want a plan you can trust, we outline an N of 1 stress reduction experiment: measure your baseline, test one change for a week or two, re-measure, and keep only what moves your numbers and your life. Subscribe, share this with a stressed-out friend, and leave a review on Apple or Spotify, then send us a note with what you tried and what actually worked for you.

Transcript

Stress Is Big Business

SPEAKER_00 0:01

Nearly half of American adults say they're frequently stressed, and the wellness industry has a supplement, a blood test, a device, or a program for every single one of them. The question isn't whether you're stressed. You probably are. The question is what's real, what's hype, and what actually moves the needle. That's what we're covering today. The good news a lot can help that is grounded in evidence. The bad news? A lot can't help, but is being sold as the true answer. Let's find out which is which. Hi, I'm Dr. Bobby Du Bois. And welcome to Live Long and Well, a podcast where we will talk about what you can do to live as long as possible and with as much energy and vigor that you wish. Together we will explore what practical and evidence-supported steps you can take. Come join me on this very important journey, and I hope that you feel empowered along the way. I'm a physician, Iron Man triathlete, and have published several hundred scientific studies. I'm honored to be your guide. Welcome, my dear listeners, The End of One Nation 2, Episode 67, Stress Reduction. What actually works and what's just wellness hype? Almost everyone says they're stress, but what does that actually mean? Is stress just high cortisol, too much sympathetic activity? And if you want less of it, should you work on sleep, exercise, breath work, or buy some supplements, a grounding mat, or some vagus nerve gadget you saw on Amazon for$500. In this episode, I'm separating what stress really is, how to measure it, what actually helps based on real studies and what's mostly wellness hype, including adrenal fatigue, consumer vagus nerve stimulation, and the red flags that mean it may not be stress at all. We'll divide our discussion into five parts. Part one, what is stress and how common is it? Part two, how can we objectively measure it so we can do something about it? Part three, what actually works and has evidence to support it? Part four, what's hype that will take your money and provide no relief? Part five, how to use the end of one approach to determine how you can objectively feel better. Let me say at the outset that I am not reviewing evidence on seeing a therapist or making life changes. These may truly help your stress and your life, but not the topics for today, and life coaching is not my area of expertise. Well, let's get started with part one. What is stress? The usual discussion begins in Africa, where a tiger is chasing you, and you feel a combination of fear and focus, and that leads you to act. Your sympathetic nervous system kicks in, hormones are released, and you avoid being eaten. Hopefully. But that's not what I want to talk about. There are relatively few tigers to avoid today, and that event causes acute stress. Today I want to explore the more ordinary, chronic day-to-day stress, feeling overloaded, tense, worn out, or like life is asking more of you than you can handle. There's no single clear and measurable definition of stress in the field of mental health. And that won't be a problem in a few minutes when we talk about how any supposed expert can explain stress however they wish, alluding to the hype I mentioned earlier. Hans Selja, a Hungarian physician endocrinologist, was the original pioneer in this field. And about a hundred years ago, he made a great point. In his words, stress is a scientific concept which has suffered from the mixed blessing of being too well known and too little understood. Another pioneer, Richard Lazarus, a psychologist, also about 100 years ago, said that stress is where the demands of a situation threaten to exceed the resources of the individual. So stress happens when we believe we don't have the ability or resources simply to cope with the situation. Or simply, the demands you face exceed your resources. It's a perception, not an objectively measured situation. Folks often say, I have my job, the kids, ailing parents, and I need to exercise more, not enough hours in the day. And with that definition of stress, many, many of us feel stressed. Let me give you a personal example. I just did another Iron Man 70.3 triathlon. At age 69, just getting to the start line should be enough of a victory. But the week of the race, I had lots of anxiety that I wouldn't be able to finish. The pain and the fatigue would overwhelm me, and ultimately that I would fail and feel ashamed. Now, the fears felt real, although the likelihood that everything would totally fall apart during the race was probably small. But I felt stressed. It wasn't that I had too many tasks to do and not enough time. It was my perception of the race and what might happen that felt out of my control. I didn't sleep well. My resting heart rate and heart rate variability were a mess. I knew that clearly racing was something I chose to do. Now, I was in a lucky situation that I logically knew that soon the race would be over and my usual life would return. But at other times in my life, and for many of you listeners, the end of one nation, you don't see an end. And that is the essence of stress. Now, there's no simple and clear physiologic definition of stress either. Stress can't easily be summarized as nervous system overload, like your sympathetic nervous system is too active and the parasympathetic nervous system isn't doing enough. Or that your cortisol levels are too high and your adrenal glands can't keep up. There's no simple formula or blood test that sums it up, and no scientifically accepted or validated definition of it. Sorry about that. But if we look at it from a high level and use the definition that stress is when our perceived demands exceed our perceived resources, many polls have been done showing how common it is. As an example, a Gallup poll in 2023 found that 49% of U.S. adults reported they frequently experience stress. They also found that the frequency of stress increased over time, having risen 16 percentage points over the prior two decades and reached the highest in Gallup's trend to date. The data also showed that stress was a bit more common in women than men, but still pretty similar. Before going any further, let's talk about what stress isn't, or how those who are trying to sell you something sum up stress. You might hear you have a dysregulated nervous system, or your nervous system is on overdrive, your hormones, like cortisol, are out of balance, you have adrenal fatigue, meaning your poor adrenal glands that sit on top of your kidneys can't keep up with the demands. If you hear the words adrenal fatigue, in my opinion, it's time to run away. The person saying it is not speaking based upon evidence. Remember my episode called Why Is There So Much Hype in Health? Where I put together the equation that a cool theory plus compelling anecdotes plus a credentialed expert does not equal evidence. Now, adrenal fatigue is a cool theory. It makes hypothetical sense that if your adrenals help balance stress, and then if fatigue in them sets in, you're in big trouble. But the diagnosis of adrenal fatigue doesn't exist. The Endocrine Society, which is the physician group that focuses on all things hormones, they said adrenal fatigue is not a recognized medical diagnosis. In a 2016 systematic review, the researchers went further and concluded there is no substantiation that adrenal fatigue is an actual medical condition. Now that doesn't mean the symptoms we're talking about are fake. Fatigue, tired but wired, poor sleep, and brain fog are real. But the explanation that the adrenal glands are burned out is not. However, if you listen to functional medicine practitioners who talk about adrenal fatigue, then you must get saliva and blood cortisol testing, measurement of your cortisol curve, and then a whole series of supplements and other treatments for this truly invented diagnosis. Now don't get me wrong, salivary cortisol is a legitimate hormone test in endocrinology. And there are very real patients where their adrenal glands truly fail. Like in a disease called Addison's disease. But this is a life-threatening, but fortunately, very rare illness. And you're likely to end up in the ER. I also want to point out that sometimes a tiger really is chasing us, or there's something clearly wrong in our biology. These red flag problems should be considered. There are tumors that can mimic some of these stress symptoms. And hyperthyroidism can also look like this. Your doctor should consider these pretty uncommon causes and do tests if they suspect it. But it won't be adrenal fatigue as the cause. Time for part two. How can we measure day-to-day stress? The physicist Lord Kelvin said, if you can't measure it, you can't improve it. The business management expert Peter Drucker is supposed to have also said, if you can't measure it, you can't manage it. In part five, we'll talk about using our n of one approach to seeing what might help your stress. So we do need a way to measure it. And again, there's no formally agreed upon approach. I believe the single best way to measure stress is the perceived stress scale. A questionnaire that you can answer. You can take it today, try something to help your stress, and then repeat the questionnaire in a week or two or three. The PSS, as it's been called, has been used in numerous research studies. And it's easy for you to use as well. The PSS 10 has 10 questions and takes just a minute or two to answer. You get a score from 0 to 40 with higher numbers meaning more stress. There are free online calculators. Just Google them. I would normally include links, but they're usually on websites that are trying to sell you something. But the questionnaire itself is great. The questions are worded like in the last month, how often have you felt that you were unable to control important things in your life? Or felt nervous, or felt things were going your way, or able to cope with all the things in your life. You answer from never to very often. I think that as an overall measure that we can easily do and for free, this is the way to go. But there are the things you could also track. You could track your resting heart rate or resting blood pressure. There are many factors that influence each of these, but might be helpful as components to understand how stress affects you. Another one you may have heard about is heart rate variability. Sleep trackers like Aura Ring and other trackers measure this. Heart rate variability looks at how your heart beats from second to second. If your heart rate is 60, it doesn't beat exactly once per second. It may be 1.1 seconds for a moment and 0.8 seconds just after that. So there is beat-to-beat variability, and that is what heart rate variability measures. The reason your heart doesn't beat perfectly like a metronome is that our vagus nerve steps in as we breathe in or breathe out. Breathing out slows our heart rate, just like someone shooting a rifle does before they pull the trigger. Breathing in tends to increase our heart rate momentarily. Those who like heart rate variability as a measure of stress say that if your nervous system is revved up, so you have more sympathetic activity and less parasympathetic activity, your HRV will be lower. In the week before my race, my HRV did get much worse, and my heart resting heart rate did rise. Doing the PSS questionnaire also showed that I felt stressed out. As a package, the questionnaire, stress score, my heart rate, and HRV pretty much told the tale. And fortunately, they all improved after the race was over. No measures are perfect, but easy to measure all of these and see what might work for you. What about measuring cortisol in your saliva or blood? The problem here is that throughout the day, your cortisol levels naturally go up and down, and many other factors can influence it. So measuring it may be fine in a research study, but not real helpful for us in real life. And then you run the risk of a supposed expert selling you some non-evidence supported treatment. All right, we all want some relief. Part three, what actually works. Let's start with some approaches where evidence is pretty clear that these activities can reduce your stress. Then we'll slide down the evidence curve to areas with a little evidence and a bunch with none. You'll recognize many of these activities as they fit into my six pillars to live long and well. First, sleep. Sleep definitely belongs in the first year, meaning good evidence. In a 2021 meta-analysis of 65 randomized controlled trials with 8,000 people, the researchers found that improving sleep led to significant improvements in anxiety and stress. Making it even more convincing, they found a dose response relationship where the more sleep improvement they saw, the more mental health outcomes improved. So by all means work on your sleep. If sleep has been a problem, then this may really help you. I have a whole episode on the 12 ways to improve your sleep. Now, if your sleep is already good, then probably trying to make it a tiny bit better may not help you. Testable, but unlikely. Second, exercise. Exercise also improves stress. In a large meta-analysis of 1,039 randomized control trials and over 128,000 participants, the authors found that physical activity improved many mental health symptoms like depression, anxiety in general, psychological distress. And higher intensity exercise was associated with even more improvement. Here's an interesting twist. You hear about the benefits of exercising out in nature, or what is called green exercise. Turns out from a meta-analysis that exercise is great, but doing that in nature doesn't help your mental state compared to working out elsewhere. Oh well. For me, I already exercise a whole bunch, so that wasn't the source of my recent stress problem. Third, breath work, which fits into my third pillar of mind-body harmony. If you want refreshers on each pillar, just go to my first series of podcast episodes. Breath work can also be helpful, although the benefits are not quite as striking. And researchers are still learning what does and doesn't work. In a recent meta-analysis, the researchers looked at whether breath work reduced stress. There were 12 randomized control trials in about 800 people. They found modest improvements in stress and anxiety. Not perfect evidence and not major improvements, but easily testable for you and might be a secret weapon for you. Fourth, also in the same pillar, mindfulness practices like meditation. In a really interesting study, the investigators created a smartphone-based meditation app, where the app randomly told you whether to meditate that day or not. 343 folks participated in the clinical trial. Compared to the control group that did not meditate, the meditators showed improvements in measures of distress. And many of the folks only meditated five minutes per day. In a related study, the researchers looked at meditators and found that those who did meditate had reductions in a blood inflammation marker called IL-6. This suggests that not only does meditation affect the brain and our level of stress, but may also affect important blood measures of health and disease. So meditation, even short amounts, may help stress based upon reasonably good evidence. Fifth, music therapy. Sounds like a good idea, but I didn't think there would be much evidence. Turns out there is a meta-analysis of 47 studies and 2,700 people that looked at stress. Studies have shown that music reduces heart rate, blood pressure, Pressure and cortisol levels. But did folks feel better? I should point out these studies looked at music therapy performed by a music therapist who selects the type of music, the rhythm, the melodies, and other characteristics based upon the pay on the patient. So I can't say whether just listening to Beethoven is sufficient. Back to the meta-analysis. Those who underwent the music therapy showed significant improvements in stress-related symptoms. Sixth, another surprise area for me, aromatherapy, often with lavender. There are actually a number of clinical trials looking at anxiety and stress and the use of various essential oils. I generally thought aromatherapy was hocus pocus, but there is a meta-analysis of 14 studies in about a thousand people, which showed statistically significant improvements. Not huge, but there. I would put aromatherapy in the category of can't hurt, might help, sure, try it out. As I say, I am an open-minded skeptic. I went into this topic thinking that music therapy or essential oils weren't going to be helpful. And ended up being surprised. They may have a role. There were a few other approaches where I thought, I thought that evidence might exist, but couldn't find any. I didn't find studies looking at yoga or sauna for stress. Lots of studies looking at other endpoints, just not the ones for this episode. Now, part four. We need to dive into the hype. There are so many folks trying to sell you cures for stress. These could be supplements like ashwagonda, magnesium, Ltheanine, rhodiola, kava, saffron, lion's mane, or reishi mushrooms, or red light therapy boxes, or earthing or grounding mats, detalk cleanses, and ivy drips of vitamins and minerals and other stuff. Lots of hype, lots of money, not much evidence. Now here is a cautionary tale. Ashwagand, which is an Indian herb, has gotten lots of attention for sleep, stress, and other uses. There's studies that suggest that ashwagandha might help stress, but here is the caution. Ashwagand might also interfere with various key hormones in your body in potentially negative ways. Just because it's grown in nature does not mean it has no potential harm. I'm not here to say whether it's a good or bad idea to try oshwagand, but here is a data point. Oshwagon was banned in Denmark because of these health concerns. Also, supplements aren't regulated, and we don't actually know what's in or not in what's being sold to you. In one study that looked at what was actually in adrenal support supplements, they found thyroid and steroid hormones. For me, I don't buy any supplements unless the evidence is quite clear. And for stress, none of them have clear and convincing evidence. I want to add one other therapy that's been hyped. Vagus nerve stimulation. And I plan to do a full episode on this topic because it's really interesting. The vagus nerve is the granddaddy of all nerves in the body, and it controls breathing, heart rate, digestion, and a myriad of other processes in the body. It starts in the neck and works its way down the body. When I first looked into this, I was ridiculously skeptical. But there are now devices implanted in the neck which periodically stimulate the vagus nerve. Some of these devices have been approved by the FDA, and good evidence showed they can help folks with unrelenting seizures, untreatable depression, and in a recent remarkable study, even help folks with rumined arthritis stop their biologic treatments. Nerve stimulation in the neck changed joint symptoms. Amazingly, the vagus nerve stimulation also has an impact on inflammation and inflammatory markers in the blood. But, and this is the key but the FDA has approved a very sophisticated implantable vagus nerve stimulator. Not the type, not the type you see on Instagram that strap on your neck. These$300 to$500 or more hyped devices sit outside the skin. And those selling them tout they can reduce stress and treat a myriad of problems. This is hype. Once again, we have the dreaded combination of a cool theory, you need to help your vagus nerve, compelling anecdotes of amazing benefits, and so-called credentialed experts saying how great these devices are. Save your money and your time. These are not ready for prime time. Time for part five. What to do with all of these potential approaches to stress? I've just talked about a dozen or so ways to treat stress, some with good evidence, some with a bit of evidence, and a bunch with no evidence. Given that most all of the evidence-supported approaches are safe and easy to try, like better sleep, exercise, meditation, and somewhat lesser evidence, like lavender and other essential oils, the only way to figure out what might work for you is to do the N of 1 trial that I've talked about so much and why we call you, my listeners, the N of 1 Nation. This is a great area for N of 1 testing. There are measures of stress, and there are various approaches you can look at, and you should see benefits pretty quickly. A perfect area for you to try. What might that look like? Step one, measure objectively the stress you're experiencing. As I mentioned, there are online perceived stress questionnaires to use that will give you a score from zero to 40. Step two, choose one of the stress-relieving approaches. Give it a try for a week or two or more. Step three, reassess using the same questionnaire approach. Did things get better, stay the same, or get worse? Step four, depending upon what happens, you can either try other stress approaches or if the one you tested was successful, stop that one and see if things deteriorate, restart, and hopefully get the same benefit. Easy to do, gives lots of information. Who knows? It might reduce your stress and change your life. Let's wrap up. Stress is common and affects most of us. It's uncomfortable and takes joy out of life. You might need to make changes in your work or personal life to reduce demands and increase resources, but that's not my area of expertise. There are ways to help your stress that evidence supports like several of my six pillars to live long and well. These may not be sexy, but they can work, like better sleep, regular exercise, mindfulness, or breath work practice. When my stress level was high in the week before my race, I doubled down on meditation, really trying to take time out of the day for mindfulness and five-minute breath work. It really helped me. In my end of one trials, meditation and breathwork helped a lot. Here's my call to action for you. Try one of the approaches and see if it helps. It could change your life. I want to hear from as many of you as possible. Please, please send me a note about your levels of stress, what you might try, and what actually seems to work for you. I hope that you live long and well, and that if you have stress, that you find ways to reduce it. Until next time, I am Dr. Bobby, your ever-open-minded skeptic. Thanks so much for listening to Live Long and Well with Dr. Bobby. If you liked this episode, please provide a review on Apple or Spotify or wherever you listen. If you want to continue this journey or want to receive my newsletter on practical and scientific ways to improve your health and longevity, please visit me at Dr. Bobby Livelongandwell.com. That's doctor as a dr bobby live longandwell.com.