Lifestyle choices are critical influences on how long we are likely to live and how good our skin will look along the way. In the second of her two-part series, Dr Stefanie Williams looks at how stress can be a significant ageing factor, not only for our skin, but our entire body.
Stress is a combination of entirely physiological reactions we have in response to certain stimuli, be they external or internal. For our primal ancestors, a short, sharp burst of stress hormone release was advantageous when faced with danger, as the stress-induced fight or flight reaction enabled an optimal response.
The release of stress hormones causes the body to become more alert—blood sugar levels increase to fuel instant energy, heart and breathing rates accelerate, blood pressure rises and blood clotting increases (beneficial, should you be wounded in fight…).
Under circumstances ‘as intended’ by nature, an intense physical activity (i.e. fighting or fleeing) burned off the sugar energy provided and our metabolism would return back to normal very quickly.
However, in our modern society we are exposed to a fairly constant, albeit mostly low-level of stress, for which there usually is no physical release. This type of chronic low-level stress has worse long-term consequences than the occasional strong, but acute burst. It can age our skin and shorten our life.
Types of stress
Two different types of stress have been described: ‘eustress’ (good) and ‘distress’ (bad). Eustress is an enjoyable, elating type of (temporary) stress, which keeps us motivated, challenged and happy. It’s often when we feel out of control however or when stress becomes chronic, that we become dis-stressed. Distress can have profound negative influences on our skin and longevity.
A very interesting study confirmed the highly subjective experience of stress. The study examined the stress levels of ‘leaders’. Leaders who take up more powerful positions in their professional life invariably take on more responsibility and are exposed to increasing demands. As a result, there is a perception that leaders must have higher stress levels.
The study by Sherman confirmed that leadership level correlates to stress. However, surprisingly, this is an inverse relationship, with leaders having lower levels of the stress hormone cortisol and feeling less anxious. The explanation for this seeming paradox might be the leaders’ greater sense of control.
Cortisol is an extremely important stress hormone in the human body. Under normal circumstances, cortisol levels are high when we get up in the morning, then go down gradually until the next morning. Chronic stress, however, may lead to persistently raised levels of cortisol and other stress hormones.
Cortisol is one of our more catabolic hormones. It suppresses our immune response and leads to increased degradation of collagen in our skin. Not without reason, dermatologists use intralesional cortisol injections to break down excess collagen in keloid scaring.
Raised cortisol levels are also known to increase our blood sugar which leads to increased cross-linking of collagen in our skin, known as advanced glycation end products (AGEs) production.
A recent study confirmed that people with higher blood sugar levels are perceived as older.
Whether triggered by diet or stress, high blood sugar levels inevitably lead to increased insulin production. Insulin promotes low-level inflammation, hypes cortisol production even more and hinders the positive work of some of our ‘youth hormones’. Good insulin sensitivity on the other hand benefits many aspects of health and has also been linked to longevity that runs in families.
But it’s not only glucose and insulin levels that are the problem. Cortisol itself has long been known to affect health and even longevity. However, it has now been confirmed scientifically that stress also takes a toll on our skin. A study found that higher levels of cortisol are associated with our face looking older.
Chronic stress can also induce other hormonal imbalances such as reduced levels of certain anabolic ‘youth hormones’ including dehydroepiandrosterone (DHEA) and Human Growth Hormone (GH). DHEA is considered one of our ‘youth hormones’ as its level declines dramatically as we age.
DHEA is a precursor to other sex hormones including testosterone and has an anti-inflammatory effect. It lowers the level of pro-inflammatory cytokines, while enhancing certain immune functions. When applied topically, DHEA has been shown to increase collagen production and improve the structural organization of the dermis.
Levels of the ‘youth hormone’ GH also decline as we age. GH is another anabolic hormone that plays an important role in tissue formation. Decreasing levels of GH are known to lead to an age-related reduction in lean muscle mass as well as a corresponding accumulation of fat. GH decline has also been described as partially responsible for thinner skin in old age.
Oxidative stress and telomere length
Oxidative stress and poor repair or disposal of the damaged material is acknowledged as a key aspect of ageing, not only in skin, but all major organ systems. Every cell in our body generates free radicals. Products of routine metabolism that takes place every second of every day, free radicals are usually neutralised by antioxidants.
However, today’s lifestyle with chronic stress significantly increases free radical generation. Our natural antioxidant pool can’t cope with the increased demand – oxidative stress and cell damage are the inevitable consequences.
It’s also been demonstrated that chronic stress depletes glutathione, our ‘master antioxidant’, and disturbs mitochondrial (energy) function, causing further increased oxidative stress.
Chronic stress also accelerates the shortening of our cells’ telomeres. Telomeres are the protective end parts of our chromosomes, there to maintain the integrity and stability of our genetic data. Every time a cell divides, our chromosomes naturally erode and shorten a little.
To keep our vital genetic data safe, telomeres bear the brunt of each cell division so that the functional part of the chromosomes is replicated without damage. Telomere length is therefore seen as a good marker for biological age as opposed to chronological age.
Shorter telomeres have been linked to a shortened life span. Skin cells have been described as particularly susceptible to accelerated telomere shortening because of their high proliferation rate and exposure to DNA-damage from influences such as oxidative stress.
We know today that telomere shortening happens at different rates and our lifestyle plays a role too. Chronic stress and raised stress hormone levels have been linked to telomere shortening.
We need to raise awareness about the influence of stress on skin health and ageing. Naturally we can’t offer an easy solution to combat stress to our patients. However, I would like to share some selected, interesting ‘tricks’ to lower stress hormone release, with scientifically proven benefits.
Stress and the subsequent hormonal and metabolic changes are designed to put us in an ideal situation for a physical response (i.e. fight or flight). However, as in our modern world, there’s hardly ever a physical response needed to stress so we suffer with the long-term health consequences of chronic stress.
So when feeling stressed, do the one thing your body wants—move! This will greatly help to ‘neutralise’ the high-alert stress state and return our hormones and metabolic changes back to balance. How about doing some jumping jacks in the clinic room after the next demanding patient or running up and down the stairs after receiving a stressful email? Every little helps…
The other important thing is not to eat sugary snacks or quick release starchy foods, when you are feeling stressed, as this will further elevate glucose and insulin levels, which are already out of sync when we are stressed. Drinking stimulants such as coffee or energy drinks will also contribute to cortisol release and should be avoided, especially when feeling stressed.
Another influencing factor is our general outlook on life. Having a mostly positive mindset not only makes life more enjoyable, but may also have anti-ageing benefits. A recent study involving nearly 1000 participants revealed that optimistic people have higher levels of antioxidants in their blood.
Fascinatingly, it’s been shown that ‘power postures’ (think leaning back in your chair with your elbows behind your head or standing upright with your hands on your hips) can actively help to release stress, pretty much instantaneously. A study conducted by a team of psychologists found that sitting or standing in a power posture for two minutes significantly lowers the level of cortisol, while raising testosterone.
Interestingly, smiling or laughing can also partly override the stress response in our body. Via biofeedback, you are essentially ‘tricking’ your body into thinking you must be happy if you engage those smile muscles.
Don’t forget to breathe slowly and deeply as you ‘power posture’, since this is another technique that instantly helps to lower stress levels. Again, you are ‘tricking’ your body into thinking you are relaxed, as opposed to registering the signals of fear and anxiety that rapid, shallow breathing triggers.
The biofeedback theory ties in with recent studies, which confirm that treatments with botulinum toxin can significantly improve clinical depression.
Increasing mindfulness is another useful method to reduce stress levels and stress hormone release. Studies have shown that trying to focus calmly on the moment instead of mindlessly multi-tasking can reduce the inflammation marker C-reactive protein (CRP) in our body.
One method of stress reduction that has been successfully applied by many different cultures throughout the ages is meditation. Studies have confirmed that regular meditation can lower cortisol levels and even improve telomere length. In an interesting study, it was shown that practicing meditation for only three months was able to induce telomerase, the enzyme that lengthens our telomeres.
People who meditate regularly have also been shown to sleep longer and more deeply. One of the reasons for improved sleep might be that meditation increases the levels of serotonin and melatonin.
Melatonin, a hormone derived from serotonin, is a neurotransmitter produced in the brain’s pineal gland. Melatonin is a powerful antioxidant with receptors expressed in many different types of skin cells.
As patients found the stress aspect of lifestyle anti-ageing particularly difficult to tackle, I now give all my new cosmetic patients a specially produced, guided meditation CD.
In collaboration with external experts we have combined the neuro-linguistic programming (NLP) of a skin and longevity oriented voiceover with a high-tech, EEG-tested ‘brainwave entrainment’ background audio, which guides the listener into regenerative alpha, theta and delta brainwaves. Our meditation audio has been shown to be able to successfully lower cortisol levels after only 20 minutes (unpublished data).
Sleep and Skin
Average stress hormone levels such as cortisol are not only elevated in chronic stress, but also rise when we are not sleeping enough. Incremental sleep debt has become a hallmark of our Western society. Over the past five decades, our average sleep duration seems to have decreased by about two hours, due to ‘voluntary bedtime curtailment’.
Good quality, restorative sleep is crucial for cellular repair, regeneration and immune function. Every night, we go through repeated cycles of two distinctly different sleep phases: Rapid Eye Movement (REM, when the most active dreaming happens) and non-REM sleep (NREM, the deeper sleep).
During NREM, blood flow is directed from our brain and body core, more towards the body’s periphery including the skin. Thus, a restorative hormone flow is established and cellular repair is enhanced.
Sleep deprivation is known to contribute to systemic inflammation, even after a short period of only a couple of weeks. In fact, sleep deprivation is thought to increase age-related processes as well as chronic health problems.
Sufficient sleep is also important for the nightly peak of our anti-ageing hormone GH. If we don’t get enough sleep, our natural GH level is sub-optimal and this gets worse as we get older.
At night we naturally release the ‘sleep hormone’ melatonin. Melatonin levels start to rise in the evening and peak around midnight before slowly subsiding again. This diurnal sleep-wake cycle is governed by the changes of light and darkness. If we don’t get enough sleep however, our melatonin levels are impaired.
Interestingly, melatonin can even protect our skin from the sun’s damaging effects and counteracts mitochondrial and DNA damage. Unfortunately, like so many other skin-friendly hormones, our melatonin level declines with age. Sleep debt will only hasten this decline.
Sleep deprivation is also known to impair insulin sensitivity and glucose tolerance and is connected to the development of diabetes. With regards to the skin, higher blood sugar levels mean higher generation of AGEs, which accelerate the skin’s ageing process.
Sleep is even connected to telomere length. Shorter telomeres have been associated with poorer sleep quality in women and shorter sleep in men. And in a fascinating genomic study, it was shown that sleep debt of only two nights led to a change in the expression of 500 genes. These changes were notably related to DNA damage and repair as well as stress and diverse immune system responses.
Several studies now also confirm that lack of sleep as well as other types of stress can impair skin integrity. An animal study in wound healing (which is a good model for skin rejuvenation) furthermore showed that sleep deprivation leads to a reduced number of skin fibroblasts.
Lastly, a paper published in 2013, clearly linked good quality sleep to better skin and the ability to recover from stress. Scientists from the University Hospitals of Cleveland assessed sleep quality in women aged 30 to 50 using a special sleep questionnaire.
They then compared this data to signs of the women’s internal (biological clock) and external (environmental) skin ageing and tested their skin barrier function.
What they found was that poor sleepers had significantly higher scores for internal ageing than good sleepers, who slept 7–9 hours per night. Poor sleepers also displayed an impaired skin barrier function.
Apart from actual sleep deprivation, there is another important factor to consider. This is the circadian rhythm. The circadian rhythm is an endogenous time-keeping system that monitors a daily cycle of roughly 24 hours. A disruption of this internal clock is associated with ageing and disease, while trying to keep to our natural rhythm improves wellbeing and increases lifespan.
So it’s not only about how many net hours we sleep, but also when and how we sleep. Respecting our circadian rhythm means that we should try to adhere to a regular bedtime when possible.
Try to darken the room completely during sleep time, since exposure to light at night can disturb the circadian clock. Good sleep hygiene also includes avoiding artificial light and digital stimulation just before bedtime—so say goodbye to the TV and laptop in bed…
I hope that I have given you some food for thought on the connection between stress, sleep, diet and skin ageing. It’s a difficult topic to address, but I advocate integrating this subject routinely in our consultations with aesthetic patients.
Dr Stefanie Williams is a Dermatologist and Medical Director at European Dermatology London. W: futureproofyourskin.com
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