Caregiver’s Resilience In Parkinson’s Care

Monisha Bhanote, MD, ABOIM, CCMS

Thank you so much, Sandra. I am looking forward to sharing with the Parkinson’s community today.

Sandra Scheinbaum, PhD

Thank you. Well, let us start. If you would, share your background with us.

Monisha Bhanote, MD, ABOIM, CCMS

Yes. As you already mentioned, I am a quintuple board-certified medical doctor, and people are always curious. Well, what exactly does that mean? That means I have done a lot of studying in the last 30 years. I started an internal medicine practice, which many people are familiar with because they go to their internist for an annual checkup. I then spent quite a bit of time in anatomic pathology, clinical pathology, and cytopathology, which is the diagnosis of all diseases. We are the doctors, meaning we have all the answers because we are looking at your body and tissues. I did advanced training and fellowships inside of pathology, looking at single cells at Cornell in New York City.

Then I also did bone, breast, and soft tissue cancers at the University of Rochester. then I did not stop just there because when you are seeing people not getting better, curiosity can get to some people. It did to me. I am, but something does not make sense here. Patients are getting these diagnoses. We are giving them treatment, but their disease continues to progress. When you look at it from that standpoint, it comes back to lifestyle. What do we do in our 24 hours a day, seven days a week? That is where I spent quite a bit of time delving into integrative medicine at the Rew Weil Center for Integrative Medicine and then culinary medicine.

I now combine five different specialties into one, and in my practice, I am helping people connect the health issues that they are dealing with and address them from a lifestyle perspective.

Sandra Scheinbaum, PhD

Wow, what a background! You say your love of learning stands out. You are so accomplished. A term that is bandied about quite a bit is holistic health, but people may not know exactly what that is. Can you define and explain the concept of holistic health, particularly the interconnectedness of mind, body, and gut, and how that may play a role in building resilience, particularly for caregivers of Parkinson’s patients as well as patients themselves?

Monisha Bhanote, MD, ABOIM, CCMS

Absolutely. That’s a great question, Sandra. When you think of holistic health, I want you to understand that it’s both the understanding of health and well-being, not just in the absence of disease, but building this balanced and integrated function of your body, your mind, your spirit, and your whole body. When we look at health care, we often go to the cardiologist for our heart disease or the neurologist for our cognitive things. But at the end of the day, our bodies are closely intertwined. One thing relies on another thing to be optimally functioning. We need to look at it in that aspect. Now, for a caregiver, and both for Parkinson’s patients. This interview focuses on the connectedness of the mind, body, and gut specifically. The reason you will hear me talk a lot about the gut and building resilience is that we eat every day.

Most people do not realize the impact of food on their body’s ability to function or their mood. The way the brain functions. Building your gut health builds your resilience as a caregiver, both emotionally and physically. Because of the challenges of being a caregiver, it can get very overwhelming. If you are healthy, then you can manage this caregiving even better, so that is where the concept comes from. But it includes more than that because it’s the mind-body connection. It is what gut health means for the body. then, of course, that interconnectedness to build that resilience.

Sandra Scheinbaum, PhD

Well, that makes a lot of sense. Getting into the specifics, what would be some evidence-based mindfulness techniques that you think would be helpful for caregivers that they can implement because there is so much stress? How could they implement these strategies? What are some of these strategies to improve their emotional well-being, and how would that also benefit the gut microbiome?

Monisha Bhanote, MD, ABOIM, CCMS

Absolutely. One of the things that I did not mention is that I am a mindfulness-based stress reduction teacher, which means that I teach you how to be mindful and reduce stress. I also happen to be a yoga and meditation teacher. combining all that. What are some of these evidence-based techniques? Well, one of them is mindfulness-based stress reduction, and this is something that combines both being mindful in mindful meditation and yoga. There have been studies done on individuals who go through an eight-week BSR type of experience and found that they can reduce stress, improve psychological well-being, and therefore enhance their coping strategies. 

One would be BSR; the next would be Pranayama, which is a breathing technique for individuals to help them connect with their stress response. Sometimes having somebody sit and simply meditate when there is too much going on in their head is not going to work and will make them more stressed out. With these individuals, I might have them start with a simple five, 7/8 breath, which is a type of breathing technique that can activate the parasympathetic system, which is our rest and digest system. Therefore, it produces relaxation. Those are two. 

I can often also employ a body scan or meditation. This you can do more of a guided. You can listen to a body scan, or an audio recording, and see where you are holding your tension, allowing that to resolve in your body and identifying it. Part of the thing is that we do not identify what is going on because we do not take the moment to sit back and go. Wait a minute. I am feeling very tense, and I need to take a moment just for myself as a caregiver.

Loving-kindness is another one. I love loving kindness because no doubt taking care of somebody else and not knowing if they even know what is going on can be very frustrating, not only for the patient but also for the caregiver. Having loving kindness, both for yourself and what you are trying to do, and for the patient. This is just a type of meditation that allows you to increase your connection between the person you might be caring for and yourself, of course. Then I often use progressive muscle relaxation, which is another technique where you tense and relax certain parts of the body. I tend to start from the feet, going all the way up to the body, so from your feet to your calves to your thighs, all the way up. 

Another evidence-based one is, of course, mindful eating. One thing we do not think about is that we are taking all this time as caregivers to make sure that the individual is being fed and taken care of because they have their dietary requirements. But also taking a moment to sit down and make sure we are nourishing ourselves. Those are just some evidence-based techniques that caregivers can employ. Then, of course, whether it’s the gut for the Parkinson’s patient or the gut for the caregiver, both are important.

Sandra Scheinbaum, PhD

Those are great suggestions. I am delighted to hear you talk about progressive muscle relaxation. In my background as a clinical psychologist, I focused on mind-body medicine starting in the 70s, and I always used progressive muscle relaxation, which was developed by Edmund Jacobsen in the 20s at the University of Chicago. It is a classic book that he wrote, but it is very simple. For people who have difficulty with breathwork or get very anxious with meditation, just have them tense up and then relax. You could do that with a body scan, where they can exaggerate the tension. then when they let it go, they are letting it go as much as they exaggerated it. It is remarkably effective, and it would be great to hear that you incorporate that into your arsenal, as well as the use of that body scan where you can catch something and then follow it. Often, for me, it is my shoulders and heart at a lower level. You release the tension in my shoulders so constantly. Yes, throughout the day I am doing that. Now, that could be just as effective. Let us turn to nutrition. Can you share some nutritional strategies that caregivers could follow that could promote a balanced gut microbiome and would be very helpful both for them and for the individual with Parkinson’s? What are your tips for nutrition?

Monisha Bhanote, MD, ABOIM, CCMS

Yes, absolutely. Because at the end of the day, digestion is how we are going to produce our energy. Digestion is how we are going to make our cells function. some nutritional strategies that you can do that I often incorporate specifically to keep your microbiome healthy because if your microbiome is not healthy, at the end of the day, you will develop some disease as you age and progress. The goal is always to love our microbiome and give it what it needs. For the caregiver, that might incorporate fiber-rich foods; most people do not incorporate enough fiber into their diet, and that would be things like whole grains, legumes, fruits, vegetables, and dietary fiber. What it is doing is providing food for your microbiome and your gut bacteria.

Think of yourself as having your human cells, but you are a host to all these other organisms. There is a microbiome. With that, we want to make sure we are giving it food; otherwise, it’s going to starve and get a little cranky. What do I call it when the body is cranky and your cells are not getting what they need? They create symptoms that you then experience. We do not want angry cells in our bodies. fiber-rich foods, for sure. How would that translate into the actual situation? For the caregiver, fiber-rich foods are vital. Now for the Parkinson’s patient, fiber-rich foods are also vital. In this case, you might want to do soft, high-fiber foods because cooked foods, as opposed to raw carrots, are more nutritious. Because this cooked food is going to be easier for them to consume. 

Next would be probiotic-rich food.  Before you go grab your probiotic supplement, let us make sure we are incorporating probiotic-rich foods. That would be things like sauerkraut, kefir, fermented foods like miso soup, kimchi, kombucha, or even a drink that can help balance the gut microbiome. These can also be quite easy to digest for Parkinson’s patients. If you think of yogurt or kefir, that might be a good way to incorporate that for them, especially if they are having a challenging time with solid foods. It is something you can have and something they can have. The whole goal is, when you are in one household, to make it as simple as possible. 

Then fiber-rich, probiotics, and next would be hydration. The number of people who forget to drink water during the day is surprising to me. We do not forget our coffee. I do not know anybody who has ever told me they forget to drink coffee. But coffee is dehydrating. Caffeinated drinks will dehydrate the body even more. Make sure you are hydrating. One of the things that I always think about for hydration is if you think of your kitchen sponge and you have not washed your dishes in a day or two and that kitchen sponge gets super crunchy and you put it under the kitchen sink faucet and the water rolls off it and then eventually it absorbs. That is your human cell. If you have not drank enough water in a day or two when you drink a lot of water, what happens? You run to the bathroom because all it is doing is going out of your body. That is why continuously staying hydrated, even if it is with smaller sips, will be better for your cells. When your cells are hydrated, they communicate better. When they communicate better, you feel better. Hydration is number three. 

The fourth one would be limiting sugary and processed foods. Yes, everybody knows that. No, not everybody does that. But they do impact your gut microbiome from the perspective of causing inflammation in the body. limiting that as much as possible to maintain gut health. Then I will focus on what we should be incorporating. We already talked about fiber-rich foods, probiotic-rich foods, and healthy fats. I do not remember when in the 80s, everybody went low-fat or no-fat and everybody was so cranky in the world. Our body is fat. Okay. Usually, when that low-fat label is on there, it is replaced by some other chemical ingredient that our body just does not identify or register very well. Think of high-quality fats. These would be your omega-3-rich nuts, seeds, and avocados. I always say to eat an avocado every day, or at least a serving of avocado every day, and high-quality olive oil, which is going to be great for gut health. It has also got to be great for reducing inflammation in the body, and that can apply both to the caregiver and the patient.

Additionally, I would want the individual to consider polyphenol-rich foods, such as berries. I and green tea can have great nutrients that can promote gut health but can also promote brain health. Just make your function so much better and clearer. The easiest way to do this is to make ROYGBIV, your new best friend. Remember the colors of the rainbow. We always forget that. When I am preparing foods in my functional culinary medicine kitchen, what I call it is making sure, as much as possible, I am eating the colors of the rainbow every day, and I do not mean the Skittles rainbow. real rainbow. Then, from the perspective of the patient, you can take all these foods, and what I often do is make sure we have a great smoothie on rotation and a great soup on rotation that is going to include all these fiber-rich nutrients, these polyphenols, and these different colors. The best part is that you can prepare them in advance in your functional culinary medicine kitchen and freeze them. That way, you are not always trying to figure out, What am I going to give my mother or what am I going to give my husband this week? These are just some small things to consider.

Sandra Scheinbaum, PhD

Wow. Those are great things to consider. I am with you on Eating the Rainbow, and a variety, we have been hearing about whether you have 30 different plants and spices too. When we think of variety and we think of color, we will think of spices and how they can add additional color and choices as well. Great suggestions. You talk a lot about the resilience toolkit. Can you talk about some of these essential components that you would include in your caregiver’s resilience toolkit? Perhaps mindfulness practices, traditional guidelines, and gut health tips What would go in there?

Monisha Bhanote, MD, ABOIM, CCMS

Yes, absolutely. This toolkit is something I want you to think of as your go-to whenever you are feeling challenged or stressed, or you just do not know what to do. We have already talked about mindfulness-based practices for emotional resilience. Just as a reminder, those would be your favorite basic breathing exercises, whether that is, of course, 4-7-8 breath box breathing or simply an inhale and exhale where your exhale is long-held, longer than your inhalation. To get into that parasympathetic state.

Sandra Scheinbaum, PhD

We take a moment, and just for those who might not know what a 4-7-8 breath is and what a box-breath is, can you perhaps demo those or show what they are?

Monisha Bhanote, MD, ABOIM, CCMS

Absolutely. A 4-7-8 breath as you; it is hard for me to do and talk at the same time, so I am going to try, but you are basically inhaling for four, holding for seven, and then, with a swish sound, exhaling for eight. The premise behind it is that you are inhaling, then holding, and then exhaling for a longer count to get into that parasympathetic state. Now a box breath is just a little bit different where it’s you inhale, maybe for a count of two; if that is all you can do, are you inhale for a four-hold and then you go across exhale, and then you are just continuing this pathway? I find that four, seven, or eight is one of the easier ones to start with, and you only need to do it four or five times. It takes you less than two to three minutes to recalibrate into that parasympathetic state.  

Sandra Scheinbaum, PhD

Yes, and sleep as well? 

Monisha Bhanote, MD, ABOIM, CCMS

Yes, it is great for sleep. Right. The other mindfulness-based technique we talked about was a body scan. We talked about BSR; we talked about loving kindness and mindfulness while eating, but one that I did not mention, which I will give you, is singing. Even if you cannot sit and be quiet and do that, my goal is for you to activate your parasympathetic nervous system and your relaxation system, and part of that is activating your vagus nerve.

What I often do is for individuals who are, Dr. B., you are not going to get me to meditate. I am, Okay. Tell me the things you have to do. I often find that singing to your favorite song is at the top of the list. Just by singing, you activate the voice box, which is closely connected to your vagus nerve, which is the nerve that participates in your relaxation response. That is something you can do. I often give that to children to do because they just love singing. Gargling can also have the same effect of activating the back side of that nerve. They are so that is just a little extra one. Then the other thing in the tool kit, so we talked about the mindfulness-based practice is nutritional things. I want to make sure that you guys have down, the fiber-focused foods, Make a list of the foods that you enjoy. The hardest thing is that people pick foods that they are not. I do not like Brussels sprouts, but now I need to eat Brussels sprouts. I think to put it in there, there are plenty of other vegetables that are rich in fiber that you can pick.

I would just like to ask you to try and do as much of the color of the rainbow as possible and limit your intake of white potatoes because I want you to have more nutrition. More color equals more nutrition and more polyphenols and phytonutrients, and then have your favorite probiotic and prebiotic-rich foods. Whether you are a coffee drinker or maybe you have your nightly cap of kombucha, have something and try it if you can at every meal to have something. Hydration, I know water gets super boring. I understand you. I am a fan of making ice cubes with different things in them. I will do mint and lemon. I will do turmeric ice cubes. I will eat whatever fruit is going bad in my fridge. Or I will put that in ice cube trays. Just have an array of ice cubes ready. That way, you are not having produce that is going to the garbage, and you are also able to get some of the nutrients and a little bit of natural flavoring there. 

Number four would be anti-inflammatory foods, limiting or avoiding processed fried fast food as much as possible would be a great thing for your gut and also for Parkinson’s gut, and then incorporating those healthy fats. Those were your mindfulness; those were your nutritional guidelines. then I think also having some resources, whether it is your favorite mindful app or maybe your favorite place you go to do new recipes. This is also quite useful; be kind to yourself. If you do not do it for a week, it is okay. Just jump back on it the next day. We tend to be very critical of ourselves as if it is a failure. I do not want you to see yourself in that way. That is why I am saying love on yourself, because there is going to be good at this and there are going to be bad days. But the beauty of what I talk about for my patients is incorporating rituals, because when you go from something, habits or routine habits for me always have a negative connotation. Routines are what we do every day and bore us. But I want you to think of these things as rituals. You get to do them in your life and have a blend of them for wherever you need them. If that makes a little bit of sense,

Sandra Scheinbaum, PhD

That makes perfect sense. I think that is particularly important for caregivers, who may feel guilty taking time away from their caring responsibilities. Taking time for themselves might be something that they feel guilty about. To be an effective caretaker, caring for yourself comes first. It is very important. That is why we are told to put on our oxygen masks first on an airplane and then attend to the others around us. Do you have any real-life examples of landing or how effective it is to blend these mindfulness techniques, nutrition principles, and caring for the gut microbiome so that you can be a better caretaker and have more resilience?

Monisha Bhanote, MD, ABOIM, CCMS

Yes, absolutely. I have many, many examples, but let me give you a couple, so maybe these will resonate with the people watching now. One example would be Sarah. Sarah is taking care of her husband, who was diagnosed with Parkinson’s, and Sara is only 55 years old. She is a younger woman, and now she is juggling her part-time job and taking care of her husband, who has this new diagnosis. What she is experiencing are symptoms of caregiver burnout. What might caregiver burnout look like? That might look like fatigue, irritability, a little bit of a short fuse, and then digestive issues, to which she does not even connect that they are all related. What was the intervention we did with her?

Well, we did give her an eight-week mindfulness-based stress reduction strategy. We walked her through that. It was specifically tailored from the perspective of caregivers. We also helped her from a nutrition standpoint, showing her how to create balanced meals for the gut. She does not feel like she’s preparing two sets of meals. That’s the hardest thing in a household when you prepare one for the person who has a health issue, then you prepare another one for the children, and then you prepare another one for the dog. It gets very overwhelming. We streamlined that. She is just spending a limited amount of time doing that. Then, of course, we were making sure that she was getting her daily probiotic supplement and replacing her processed snacks with things that were going to give her more energy to do what she needed to do and get through the day. It was helping her understand that the food she was eating was impacting whether or not she was able to have energy or if she was feeling fatigued. That was impacting her irritability. 

Now, we did not just stop there. Of course. We incorporated other things, making sure her sleep was addressed, because sleep is a big part of it. We do not get enough sleep; we get cranky. Everybody knows that, right? There were some other things that we incorporated there. Then the outcome was that after about three months, she did have none of these overnight fixes. Please realize that everything we do builds upon each other. However after about three months, her stress levels decreased, and her rate of anxiety, self-scaled anxiety, and depression scales decreased. She also found that her digestive issues improved, and she had more energy and focus, which allowed her to be more patient and present while addressing her husband’s illness, which is important. That is, is one example. Is that what you would want? Would you want another one?

Sandra Scheinbaum, PhD

We would love to hear another one if you have an example.

Monisha Bhanote, MD, ABOIM, CCMS

Okay, I have another one. I met my patient Mark, who is a young 35-year-old, very active, and in the prime of his career. However, he is the primary caregiver for his mother, who was diagnosed with Parkinson’s. Now that Mark, who has got this highly demanding career, has to take care of his mother, he’s starting to experience anxiety attacks around the whole situation. We started with him with 10-minute body scans. Because that is somebody who is always on the go. He is at the gym; he is here. But he never took the moment to slow down and scan his body. We began using those. 

Then we also began doing meal prep every Sunday, because now, mind you, he’s got a 9-to-5 job in addition to taking care of his mother. Meal-prep sunday. I am a huge fan of meal prep. When you are a busy individual going into the kitchen every day and trying to prepare, it can be overwhelming for anybody, whether you are taking care of somebody or not. Every Sunday, we would make sure that both he and his mother would have access to gut-friendly and healthy food as opposed to picking something up on the drive home from work. We did that and incorporated simple recipes for him. Then, from his perspective, we also added a prebiotic and a probiotic after testing him. I am a big fan of testing. I do not guess because some individuals might not need a probiotic and might need something to improve their digestion. I always test individuals as we are putting our plans together.

For him, his outcome was that his stress levels did decrease, and what he felt good about was that he noticed both his and his mother’s digestion improved, which at the end of the day led to better sleep. Rest, and digest. When you digest better, you rest better. then also led to less irritability for both of them. The best part was when he took his mom in for one of her doctor appointments, and the doctor felt that she was even doing better. They are; what are you doing with her? That makes you feel good as a caregiver that someone is doing something because you do not know if it is unless you are paying attention. But then to also have the doctor say to you, well, her mental state looks better, and overall, her stability feels better. That increased positive quality of life is shown, and it feels good for you, too. Those are just two examples.

Sandra Scheinbaum, PhD

Well, those are powerful examples, and I hope that those listening can take those examples and feel inspired to implement all of the strategies that you have talked about so that caregivers and patients can build resilience and get healthier. It has been a delight to speak with you. Where can people find you, Dr. Bhanote?

Monisha Bhanote, MD, ABOIM, CCMS

Yes, I am super easy to find. I am on all social media platforms, Instagram, YouTube: @DrBhanote. It is just my name. My website is drbhanote.com. Easy. There is only one Dr. Bhanote. 

Sandra Scheinbaum, PhD

Well, thank you so much for participating in the Parkinson’s Solutions Summit.

Monisha Bhanote, MD, ABOIM, CCMS

Absolutely. I have a great gift for them as well. 

Sandra Scheinbaum, PhD

Wow. 

Monisha Bhanote, MD, ABOIM, CCMS

Yes, I do. I have a very simple cookbook. It is called the Self-Care Plate. What I have done is incorporate functional culinary medicine from a gut and brain health perspective, where we are thinking of foods a little bit in a more intentional way and incorporating nutrients. All of these recipes have been tried and tested by people who do not cook in the kitchen, and they love them. They are all plant-based and gluten-free, so they are allergen-free. I hope you enjoy them.

Sandra Scheinbaum, PhD

I am sure that we will. Thank you. This will be a very popular gift. Thank you, and thank you for participating.

Monisha Bhanote, MD, ABOIM, CCMS

Thank you so much, Sandra.