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Health Protocols

Stress Management

Lifestyle and Behavioral Techniques to Relieve Stress

People experiencing high levels of stress and its health effects will undoubtedly fare better by reducing their exposure to high-stress circumstances. For many people, however, stress at home or on the job can seem unavoidable. In such cases, a healthy diet, exercise, and stress management practices can have a strong positive impact on normalizing the stress response and preventing stress-related illness.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) refers to a group of patient-centered techniques focused on changing thought patterns associated with emotional distress and harmful behaviors. A large body of clinical studies show CBT is an effective strategy for managing general stress and relieving anxiety.155 In one recent clinical trial, 100 subjects suffering from chronic stress were assigned to participate in a 12-week internet-based CBT intervention or be placed on a waitlist. After six months, measures of perceived stress and stress-related symptoms were lower in those who received the intervention.156 CBT was found in another study to be similarly effective to mindfulness-based stress reduction (described below) in reducing stress and burnout in parents of children with chronic conditions.157

A recent research review showed CBT is moderately effective for treating stress- and anxiety-related psychological disorders.158 CBT has also been recommended as a treatment strategy for stress-mediated chronic pain.159,160 In a study in 46 women with fibromyalgia (a chronic pain condition), a six-month CBT intervention led to improved sense of control over life and increased coping behaviors, and decreased measures of depression, exhaustion, and stress behaviors; these benefits were maintained and enhanced one year after initiation of the intervention.161

Some stress-affected people may be more likely to benefit than others: researchers have noted that factors such as working night shifts, high burnout scores, and elevated inflammatory marker levels may reduce the efficacy of CBT.162

Meditation and Mindfulness

Meditation helps regulate the stress response, reduce chronic inflammation, and maintain a healthy gut microbiome, and numerous studies indicate its potential benefits in treatment and prevention of diverse health disorders.4 Studies in veterans with post-traumatic stress disorder have shown practicing meditation not only improves patterns of cortisol release but also triggers epigenetic changes that might also contribute to its positive impacts on the stress response.163,164

A review of 45 studies found that meditation lowers cortisol output, blood pressure, heart rate, triglycerides, and inflammatory marker levels, indicating its potential for protecting cardiovascular health.165 The American Heart Association issued a statement in 2017 recognizing meditation’s possible role, alongside smoking cessation and treatment of high blood pressure and high cholesterol, in reducing the risk of heart disease.166

Mindfulness-based stress reduction is a structured program that incorporates meditation, body awareness, and gentle yoga, with an emphasis on awareness of the present moment. The benefits of mindfulness-based stress reduction on various psychological and physical health outcomes have been widely reported.6 For example, reviews of studies on healthcare providers and other types of workers have shown that mindfulness-based interventions can increase well-being and reduce anxiety, depression, and burnout, and may improve work performance.167-170 In a controlled trial in overweight and obese women, a four-month mindfulness program led to reductions in stress-related eating behaviors and prevented weight gain.171 Mindfulness programs are usually conducted in person, but the effectiveness of online mindfulness-based stress reduction programs is gaining interest, with positive effects being reported in recent clinical trials.172-174


For many people, stress reduces the desire and motivation to engage in physical activity, yet exercise can improve stress resilience175 and has been shown to reduce symptoms in people with anxiety and stress-related disorders.176

Exercise appears to stimulate anti-inflammatory and anti-stress reactions in the body.177 Engaging in regular exercise improves the body’s ability to adapt to stress and has been correlated with better recovery from illness and surgery.175 Exercise is associated with better sleep,178 less anxiety and depression,179,180 and lower stress reactivity in the nervous and cardiovascular systems.181 A review of the research concluded that approximately 50 minutes per day of moderate intensity exercise is associated with the greatest mental health benefits compared with lower or higher doses; however, sedentary hours erode some of physical activity’s positive mental health effects.182 Clinical evidence also suggests strength training may improve anxiety, depression, and sleep.183,184

Exercise may mitigate stress-related eating behaviors: a number of trials have indicated that even 15-minute bouts of brisk walking can reduce stress-eating in the short term.161 In addition, regular exercise can help prevent or reverse the metabolic, inflammatory, and neurological consequences of chronic stress,66,185,186 and numerous studies support the current World Health Organization recommendation to engage in at least 150 minutes per week of moderate-intensity physical activity as an effective means of reducing death from all causes.187

Activity tracking tools may be useful and effective in incorporating exercise into a stress management protocol.188,189 In a recent preliminary study, 35 sedentary overweight participants were enrolled in a 12-week walking program in which they used pedometers to count the number of steps taken each day. The 30 participants who successfully achieved the goal of 10,000 steps per day not only lost weight and decreased their waist circumference, they also had lower scores on tests of anxiety, depression, fatigue, confusion, anger, and overall mood distress than at the beginning of the study.190 In another trial, increasing physical activity by using a step-counting activity tracker plus a goal setting intervention reduced depressive symptoms in female participants.191

The Stress-relieving Nature of Pets

Researchers have long been interested in the relationships between humans and their companion animals and the effects of such relationships on health. In general, findings suggest pet ownership is associated with less depression and loneliness, better social interaction, and reduced anxiety and stress.192

Several studies have noted that pet owners have lower blood pressure, cholesterol, and triglyceride levels, and are less likely to suffer fatal cardiac events (heart attack and stroke) compared with non-pet owners.193-195 While some of these benefits may be due in part to increased physical activity associated with dog ownership, cat owners too have a lower risk of cardiovascular death, leading researchers to propose that having pets may also impact cardiovascular health by improving mood and reducing stress reactivity.195-197

Studies of dog-assisted interventions suggest even the presence of an unfamiliar dog may lower stress during inherently stressful circumstances, such as during dental procedures.198 In a laboratory setting, the presence of an unfamiliar dog mitigated stress-induced increases in cortisol and heart rate more than the presence of a friend.199 In another study, participants with pets had lower baseline blood pressure and heart rate, and lower cardiovascular reactivity to physical and mental stress tests, than participants without pets. In addition, the presence of their pet during stress testing reduced stress reactivity even further, while the presence of a friend had no effect and presence of their spouse increased stress reactivity.200

Maintain Sex Hormone Balance

The physiologic stress response is strongly influenced by sex hormones (testosterone, estrogen, and progesterone), and gender-related differences in reactions to stress have been widely documented. Although the relationship is complex, stress-induced activation of the HPA axis, in general, is stronger in women than men. Evidence from animal research suggests this may be due to opposite effects of testosterone and estrogen on HPA axis sensitivity: estrogen increases HPA axis responsiveness while testosterone decreases it.201,202 In addition, progesterone appears to suppress sensitivity of the HPA axis and downregulate anxiety.203,204 Furthermore, while acute stress appears to increase progesterone production,204 chronic stress inhibits release of all sex hormones.202 Higher progesterone levels in the second half of the menstrual cycle have been associated with lower levels of premenstrual aggression, irritability, and fatigue in another study.205

In postmenopausal women, whose estrogen and progesterone levels are naturally low, hormone therapy has been shown to affect regulation of the stress response and may enhance some aspects of cognitive function during stress. In one study, 15 sedentary postmenopausal women who had used long-term hormone replacement therapy were compared with 15 similar women who had never used hormone therapy. Those who had never used hormone therapy were found to have abnormal diurnal salivary α-amylase patterns, while hormone therapy users had normal α-amylase patterns. In addition, hormone therapy non-users had less of a rise in salivary α-amylase concentration in response to exercise than hormone therapy users. This suggests that long-term hormone therapy may help maintain normal tone of the sympathetic nervous system.206 On the other hand, another trial found that postmenopausal women using estradiol therapy had a reduced cortisol response and less reduction in working memory after exposure to physical stress compared with women receiving placebo.207

In a preliminary study in 94 postmenopausal women under chronic stress due to caring for a family member with dementia, hormone therapy was correlated with better psychosocial function: those using hormone therapy reported less hostility and fewer negative interactions with members of their support teams than those not using hormone therapy; the greatest benefit was seen in those using both estradiol and progesterone.208

Progesterone therapy alone can help perimenopausal women with symptoms including hot flashes, breast pain, and sleep problems.209,210 Because these symptoms may be a source of stress, progesterone therapy may have anti-stress benefits in peri- and postmenopausal women. Furthermore, animal research suggests progesterone may protect the brain from harmful stress-induced inflammation.211

Taken together, these findings suggest that maintaining balanced sex hormone levels throughout life may be important for regulating stress responsiveness and promoting resilience. Men and women with possible hormone imbalances should review Life Extension’s Male Hormone Restoration , and Female Hormone Restoration protocols.