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The Essence of Health and
Managing Stress Mindfully
Dr Craig Hassed Senior Lecturer
Monash University
Department of General Practice
2
The Essence of Health
Education
Stress management
Spirituality
Exercise
Nutrition
Connectedness
Environment
3
Education
Associated with:
Better physical and
mental health
Lower rate of dementia
Healthier lifestyle
Greater autonomy
Decision-making ability
Confidence
Opportunities
Social and economic
advantage
Education is not just
giving factual
information, it is about
knowing ourselves and
enabling ourselves:
Understanding our own
minds and motivation
Cultivating mindfulness
Stress management
Behaviour change
strategies
Goal setting
Current trends in happiness
In developed countries depression is currently overtaking heart disease as the leading burden of disease
Mathers CD, Loncar D. Projections of global mortality and burden of disease
from 2002 to 2030. PLoS Med. 2006 Nov;3(11):e442.
The mind and body
“You ought not to attempt to
cure the body without the soul
(psyche) for this is the great
error of our day (400BC), in the
treatment of the human body,
that physicians separate the
soul from the body.” Attributed to Socrates by Plato in Charmides
7
Stressful events and heart attacks
Earthquakes
Major catastrophes like earthquakes produce a large but short-lived spike on the incidence of fatal heart attacks
Thought to only occur in individuals who are already susceptible.
Ogawa K. et al. International Journal of Epidemiology 2000;29(3):449-55.
Football
FIFA World Cup (Germany 2006)
On days of matches involving the German team the incidence of cardiac emergencies was higher than usual Men 3.26 times higher
Women 1.82 times Wilbert-Lampen U,
Leistner D, Greven S, et al. NEJM 2008; 358 (5):475-483.
Allostatic load Prolonged stress leads to wear-and-tear on
the body (allostatic load) Mediated through the Sympathetic Nervous System
Allostatic load leads to: Impaired immunity, atherosclerosis, metabolic
syndrome, bone demineralization
Atrophy of nerve cells in the brain Hippocampal formation: learning and memory
Prefrontal cortex: working memory, executive function
Growth of Amygdala mediates fear response
Many of these processes are seen in chronic depression and anxiety
McEwen BS. Ann N Y Acad Sci. 2004;1032:1-7.
Mind wandering and happiness
“In conclusion, a human mind is a wandering
mind, and a wandering mind is an unhappy
mind. The ability to think about what is not
happening is a cognitive achievement that
comes at an emotional cost.”
Killingsworth MA, Gilbert DT. A Wandering Mind Is an Unhappy Mind.
Science 12 November 2010: Vol. 330. no. 6006, p. 932 DOI:
10.1126/science.1192439
Attention Deficit Trait
Newly recognized neurological phenomenon:
attention deficit trait (ADT)
Response to hyperkinetic environment
Trying to deal with too much input, results in:
Black-and-white thinking; perspective and shades of
grey disappear
Difficulty staying organized, setting priorities, and
managing time
Feel a constant low level of panic and guilt
Hallowell EM. Overloaded circuits: why smart people
underperform. Harv Bus Rev. 2005 Jan;83(1):54-62, 116.
Mobile phone use and motor vehicle
accidents
Driver's use of a mobile phone within 5 min
before a crash associated with fourfold
increased likelihood of crashing (OR 4.1) McEvoy SP, Stevenson MR, Woodward M.The contribution of passengers
versus mobile phone use to motor vehicle crashes resulting in hospital
attendance by the driver. Accid Anal Prev. 2007 Nov;39(6):1170-6. Epub 2007
Apr 9.
Multitasking
“In 2005, the BBC reported on a research
study, funded by Hewlett-Packard, and
conducted by the Institute of Psychiatry at the
University of London, that found, workers
distracted by e-mail and phone calls suffer a
fall in IQ more than twice that found in
marijuana smokers.” Christine Rosen, “The Myth of Multitasking.” The New
Atlantis thenewatlantis.com. Spring 2008. Web. 14 Apr.
2011.
Multi-tasking
On the performance levels of extreme multi-
taskers: “These are kids who are doing 5, 6, or
more things at once all the time. ... It turns out
multi-taskers are terrible at every aspect of
multitasking! They get distracted constantly. Their
memory is very disorganized. Recent work we’ve
done suggests that they’re worse at analytic
reasoning. We worry that it may be we’re creating
people who may not be able to think well, and
clearly.” Dr. Clifford Nass on his studies at Stanford University from
Dretzin, Rachel. Rushkoff, Douglas. “digital_nation life on the
virtual frontier.” pbs.org Frontline. Feb. 2010. Web. 14 Apr. 2011.
Simple and Complex Multitasking
Simple multitasking: one task simple and the
other complex (e.g. stirring pasta while talking to
spouse) where one can be safely/effectively
done on automatic pilot while the other is given
attention
Complex multitasking: two complex activities
which demand cognition (e.g. driving while
speaking on phone) where one or both will be
done unsafely/ineffectively
Multitasking or task-switching?
Multitasking is an illusion (misnomer)
Switching happens so fast that it appears we
are performing multiple tasks simultaneously
like the concurrent performance of several
jobs by a computer
Reality is that we are switching back and
forth between tasks http://ucsdcfm.wordpress.com/2011/07/01/our-brains-
are-evolving-to-multitask-not-the-ill-usion-of-
multitasking/
Three regions of the brain
Frontal lobes (prefrontal cortex) centre for executive functioning
Attention regulation
Working memory
Reasoning and decision making
Emotional regulation
Appetite regulation
Impulse control
Directs immune system
Limbic system – emotion centre
Mesolimbic reward system – appetites
Burnout and psychiatric morbidity in
new medical graduates
8 months into internship: 75% interns
had burnout
73% (of interns) met criteria for
psychiatric morbidity on at least one
occasion Willcock SM et al. Burnout and psychiatric
morbidity in new medical graduates. Med J
Aust. 2004;181(7):357-60.
Doctor health and medical errors
Study determined prevalence of depression and burnout among residents medical staff in 3 US hospitals
20% of residents met criteria for depression
74% met the criteria for burnout
Depressed residents made 6.2 times as many medication errors as residents who were not depressed
Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ, doi:10.1136/bmj.39469.763218.BE (published 7 February 2008)
“The faculty of voluntarily bringing back a wandering attention over and over again, is the very root of judgment, character, and will. No one is compos sui if he have it not. An education which should improve this faculty would be the education par excellence.” William James, Principles of
Psychology, 1890
What is mindfulness?
Mindfulness
Mindfulness is a mental discipline involving
training attention.
It implies intention, presence and attitude
(acceptance)
It is not a method of distracting ourselves or
tuning out, it is about tuning in – engagement
The anxious, stressed or depressed state of
mind is the distracted state
Hence the negative impact upon mood,
performance and enjoyment
Applications of mindfulness Mental health
E.g. depression relapse prevention, anxiety, panic disorder, stress,
emotional regulation, addiction, sleep, eating disorders, psychosis
Neuroscience
E.g. structural and functional changes in the brain, neurogenesis,
(dementia prevention) amygdala, executive function, working memory
Clinical
E.g. pain management, symptom control, cancer, metabolic, hormonal,
weight management, genetic function and repair
Performance
E.g. sport, academic, leadership
Spiritual
21
Results suggest that MBSR may
help a broad range of individuals
to cope with their clinical and
non-clinical problems.
Grossman P. J Psychosomatic
Research. 2004;57(1):35-43.
Symptoms of depression
Depression can be understood as a disorder
of attention
Depressive rumination – default mode
Not present – foreboding about future and reliving
past
Poor functioning – distracted
Anhedonia – lack of pleasure / enjoyment
Reactivity – non-acceptance of state of thoughts
and emotions
Default mode network
Default mental activity flourishes in various forms of
psychopathology including depression, anxiety,
schizophrenia and autism
Default activity decreased or deactivated when paying
attention (e.g. experienced meditators)
In experienced meditators but not novices, even when the
default mode network is active, brain regions associated
with self-monitoring and cognitive control are co-activated
Reduces vulnerability to default thinking
Brewer JA, Worhunsky PD, Gray JR, et al. Meditation experience is
associated with differences in default mode network activity and
connectivity. Proc Natl Acad Sci U S A. 2011 Dec 13;108(50):20254-9.
Mindfulness and depression
Patients with 3 or more previous episodes of
depression
Mindfulness-Based Cognitive Therapy
reduced relapse from 78% (what you would
expect with usual treatment) to 36%
Ma SH, Teasdale JD. J Consult Clin Psychol.
2004;72(1):31-40.
MBCT and depression
RCT investigated the effects of Mindfulness-based
cognitive therapy (MBCT) on the relapse in depression,
time to first relapse and the quality of life
106 recovered depressed patients with a history of at least 3
depressive episodes
Treatment as usual (TAU) vs MBCT plus TAU 1 year f/up
Relapse/recurrence significantly reduced and the time until
first relapse increased in the MBCT plus TAU c/w TAU
MBCT plus TAU group also showed a significant reduction
in both short and longer-term depressive mood, better
mood states and quality of the life Godfrin KA, van Heeringen C. The effects of mindfulness-based cognitive
therapy on recurrence of depressive episodes, mental health and quality of life:
A randomized controlled study. Behav Res Ther. 2010 Aug;48(8):738-46.
Godfrin KA, van Heeringen C. Behav Res Ther. 2010 Aug;48(8):738-46.
Godfrin KA, van Heeringen C. Behav Res Ther. 2010 Aug;48(8):738-46.
Mindfulness, depression and the
stress response Mindfulness negatively correlates with
depressive symptoms and reactivity of the
amygdala Way BM., Creswell JD., Eisenberger, NI., Lieberman MD.
Dispositional mindfulness and depressive
symptomatology: Correlations with limbic and self-
referential neural activity during rest. Emotion. Vol 10(1),
Feb 2010, 12-24.
Mental stimulation and brain health 65 healthy elderly (av. 76.1yrs) c/w 10 patients with
Alzheimer Disease (74.8yrs) and 11 young controls (24.5yrs)
‘Brain health’ (amyloid deposits) c/w participation in cognitive
activities (e.g. reading, writing, playing games)
Greater participation in cognitively stimulating activities
(particularly in early and middle life) associated with reduced
amyloid uptake
The top ¼ of older participants for cognitive activity had amyloid
uptake comparable to young controls
The lowest ¼ for cognitive activity had amyloid uptake comparable to
patients with AD
Landau SM, Marks SM, Mormino EC, Rabinovici GD, Oh H, O'Neil JP,
Wilson RS, Jagust WJ. Association of Lifetime Cognitive Engagement and
Low β-Amyloid Deposition. Arch Neurol. 2012 Jan 23. [Epub]
Mindfulness and the brain Mindfulness training improves functioning in
areas related to executive functioning,
attentional control, self-regulation, sensory
processing, memory and regulation of the
stress response Thickening of cortex in regions associated with
attention, self-awareness and sensory processing thicker in meditators
“The regular practice of meditation may have neuroprotective effects and reduce the cognitive decline associated with normal aging.” Hölzel BK, Carmody J, Evans KC, et al. Stress reduction correlates with
structural changes in the amygdala. Soc Cogn Affect Neurosci. 2010
Mar;5(1):11-7.
Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to
increases in regional brain gray matter density. Psychiatry Res. 2011 Jan
30;191(1):36-43.
Kilpatrick LA, Suyenobu BY, Smith SR, et al. Impact of Mindfulness-Based
Stress Reduction training on intrinsic brain connectivity. Neuroimage. 2011
May 1;56(1):290-8.
Lazar SW, Kerr CE, Wasserman RH, et al. Neuroreport. 2005;16(17):1893-
1897.
Pagnoni G. Cekic M. Neurobiology of Aging. 2007;28(10):1623-7.
Essence program and student wellbeing
Study of 2006 cohort of medical students found that 90.5% of students personally applied strategies
Improved student wellbeing noted on all measures of wellbeing even in the pre-exam period Reduced depression, hostility and anxiety subscale
Improved psychological and physical quality of life
Hassed C, de Lisle S, Sullivan G, Pier C. Adv Health Sci Educ Theory Pract. 2008 May 31. [Epub ahead of print]
Mindfulness and cognition
Study on brief meditation training effects on cognition
and mood
Four sessions of either meditation training
Participants were assessed with measures of mood,
verbal fluency, visual coding, and working memory
Mindfulness training improved mindfulness, mood, and
reduced fatigue, anxiety, and increased visuo-spatial
processing, working memory, and executive
functioning Zeidan F, Johnson SK, Diamond BJ, David Z, Goolkasian P. Mindfulness
meditation improves cognition: evidence of brief mental training. Conscious Cogn.
2010 Jun;19(2):597-605. Epub 2010 Apr 3.
Stress
Performance
Inertia
Poor performance /
burnout
Stress-performance curve
Peak
performance
“The zone”
Restful
alertness
Mindfulness and mental flexibility
Mindfulness leads to:
reduced cognitive rigidity via the tendency to be
"blinded" by experience
“a reduced tendency to overlook novel and
adaptive ways of responding due to past
experience, both in and out of the clinical setting.”
Greenberg J, Reiner K, Meiran N. "Mind the trap":
mindfulness practice reduces cognitive rigidity. PLoS
One. 2012;7(5):e36206. Epub 2012 May 15.
Mindfulness and doctor wellbeing
An 8-week mindfulness program: improvements on all
measures of wellbeing including:
Mindfulness
Burnout (emotional exhaustion; depersonalization;
personal accomplishment)
Empathy and responsiveness to psychosocial aspects
Total mood disturbance
Personality (conscientiousness; emotional stability)
Improvements in mindfulness correlated with
improvements on other scales Krasner MS, Epstein RM, Beckman H, et al. JAMA. 2009;302(12):1338-40.
Mindfulness and the workplace 8 week mindfulness program for ANU staff
Key findings include:
Increased self-rated performance (ECDP)
Improved wellbeing (PANAS)
Improved eudaimonic wellbeing (meaningfulness) (PWB)
Increase in 2 subscales of work engagement (vigour and
dedication) (UWES)
Increased authenticity (self-awareness, authentic
behaviour, open relationships) (AI3)
Increased satisfaction with life (SWLS)
Improvements sustained at 6 month f/up Atkins P, Hassed C. Unpublished data.
Mindfulness, exercise & the cold RCT evaluating preventive effects of mindfulness meditation or exercise
on incidence, duration, and severity of acute respiratory infection (ARI)
Adults aged 50 years and older randomized to 1 of 3 study groups:
8-week training in mindfulness meditation / training in moderate-intensity sustained
exercise / observational control (no intervention)
Number of ARI and illness days
Control group: 40 ARIs and 453 illness days
Exercise group: 26 ARIs and 241 illness days
Mindfulness group: 27 ARIs and 257 illness days
ARI symptom severity
358 for control, 248 for exercise, 144 for mindfulness
ARI-related days of work missed
67 in the control group
32 in the exercise group
16 in the mindfulness group
Barrett B, Hayney MS, Muller D, et al. Meditation or Exercise for Preventing Acute Respiratory
Infection: A Randomized Controlled Trial. Ann Fam Med 2012 10:298-299.
Roots of Diagnostic Errors
“Cognitive dispositions to respond that influence
the diagnostic process are characterized by a
lack of awareness and responsiveness by the
individual to his or her own cognitive and
affective processes.”
Confirmation bias: the pursuit of data that support
a diagnosis over data that refute it
Anchoring bias: a resistance to adapting
appropriately to subsequent data that suggest
alternative diagnoses Sibinga EM, Wu AW. Clinical Mindfulness and Patient Safety.
JAMA 2010;304(22):2532-3.
Mindful practice
Mindfulness is essential underpinning for self-monitoring
“Mindful practice is conscious and intentional attentiveness to the present situation – the raw sensations, thoughts, and emotions as well as the interpretations, judgments and heuristics that one applies to a particular situation.”
Avoids automatic pilot Epstein R, Siegel D, Silberman J. Self-monitoring in clinical
practice: a challenge for medical educators. J Cont Educ Health Prof 2008;28(1):5-13.
Epstein RM. Mindful practice in action (II): Cultivating habits of mind. Fam Syst Health . 2003;21: 11-17.
Self-monitoring leads to;
1. Early recognition of cognitive biases
2. Avoidance of technical errors
3. Awareness of emotional reactions
4. Facilitation of self-correction
5. Development of therapeutic relationships Epstein R et al, 2008
Emotional Intelligence & mindfulness
Mindfulness related to aspects of personality and mental health
Lower neuroticism, psychological symptoms, experiential avoidance, dissociation
Higher emotional intelligence and absorption Baer RA, et al.
Assessment. 2004;11(3):191-206.
EI Definition
Self-
awareness
Ability to recognise and
understand emotions,
drives and effects
Self-
regulation
Can control or redirect
disruptive impulses, can
think before acting
Motivation Passion for work that goes
beyond money or status,
energy and persistence
Empathy Ability to understand
emotions of others, skill in
interacting with others
Social skill Can manage relationships
and build networks, can
find common ground,
rapport
Meditation and compassion
Limbic brain regions implicated in empathic response to another's pain
Meditators have more active empathic response
Activation in insula greater in expert than novices
Empathy w/o stress reduces carer fatigue Lutz A, Brefczynski-Lewis J, Johnstone T, Davidson RJ.
PLoS ONE. 2008 Mar 26;3(3):e1897.
Genetic ageing and pessimism
The combination of lower optimism and higher
pessimism increases risk for disease and early
mortality
Sample of healthy post-menopausal women
Pessimism is independently associated with
over 10 years accelerated ageing
Shorter Telomere length and higher Interleukin-6
concentrations Lin J,Dhabhar FS, Wolkowitz O, Tillie JM, Blackburn E, Epel
E.Pessimism correlates with leukocyte telomere shortness and
elevated interleukin-6 in post-menopausal women. Brain Behav
Immun. 2009 May;23(4):446-9.
Mindfulness and cellular ageing
Meditation may slow genetic
ageing and enhance genetic
repair
“...we propose that some forms
of meditation may have
salutary effects on telomere
length by reducing cognitive
stress and stress arousal and
increasing positive states of
mind and hormonal factors that
may promote telomere
maintenance.” Epel E, Daubenmier J, Moskowitz JT, Folkman
S, Blackburn E. Can meditation slow rate of
cellular aging? Cognitive stress, mindfulness,
and telomeres. Ann N Y Acad Sci. 2009
Aug;1172:34-53.
The importance of sleep
Poor sleep is detrimental for mental and
physical health and performance
E.g. poor immunity, depression, poor
concentration
Poor sleep is a common cause of depression and
much depression resolves with improved sleep
Regular sleep patterns (time of rising and going to
bed) highly recommended
Avoid screen time close to bed time
If sleep is a problem then utilise behavioural
approaches rather than medications (e.g. Sleep
Better Without Drugs) 45
46
The role of meaning
The lack of meaning in life is a soul sickness whose full extent and full import our age has not yet begun to comprehend. Carl Jung
Many different ways of exploring and expressing meaning
Philosophy, religion, science, altruism, environmentalism, art …
47
How does one define spirituality?
Spirituality
Meaning
Connectedness
Sense of purpose
Belief in a ‘higher
intelligence’
Philosophical inquiry
Can be ‘religious’
without being
‘spiritual’
“Religious commitment”
Overlaps with spirituality
Membership of religious group
Attends church
Religious upbringing
Can be ‘spiritual’ without being
‘religious’
48
Religious commitment and health
Religious commitment is widely used in the medical
and psychological studies
Most common interpretation of spirituality / easy to measure
Protective for:
Depression and suicide
Substance abuse
Physical illness
Longer life expectancy
Links hold even when controlled for other risk factors Arch Fam Med 1998;7:118-24.
Religious commitment and suicide
Religious commitment is inversely related to suicide risk including risk in those with co-morbidity such as childhood abuse and psychosis
Gartner J, Larson D, Allen G. J Psychol Theol 1991;19:6-25.
Gonda X, et al. Prediction and prevention of suicide in patients with unipolar depression and anxiety. Ann Gen Psychiatry. 2007;6(1):23.
Dervic K, Grunebaum MF, Burke AK, et al. Protective factors against suicidal behavior in depressed adults reporting childhood abuse. J Nerv Ment Dis. 2006 Dec;194(12):971-4.
Huguelet P, Mohr S, Jung V, et al. Eur Psychiatry. 2007 Apr;22(3):188-94.
Protecting adolescents from harm
According to large population studies of
adolescents, among the most important
protective factors for mental health and reduced
risk of harm were ‘connectedness’ (esp. home
and school) and ‘spirituality’ Resnick M, Bearman P, Blum R. et al. Protecting adolescents
from harm; findings from the National Longitudinal Study on
Adolescent Health. JAMA 1997;278(10):823-32.
Religious commitment and longevity
22,000 people - 9 y f/up
All-cause mortality reduced for those with active religious dimension to life
Life expectancy
75 y - non-attenders
79 y - < once per week
82 y - once per week
Controlled for other variables Demography 1999;36:273-85
Significantly protective against all-cause mortality
relative hazard 0.64 and when controlled for social and physical variables still 0.76 Am J Public Health 1998;88:1469-75
52
Exercise levels in Australia
“In 2004-05, 70% of Australians aged 15
years and over were classified as
sedentary or having low exercise levels. Of
these, just under half (48%) recorded no or
very little exercise in the previous two
weeks (sedentary exercise level) and 52%
recorded a low level of exercise.”
ABS – Australian snapshots
Inactivity and health
Chronic conditions related
to inactivity include:
Heart disease
Hypertension
Type II diabetes
Cancer
Depression
Anxiety
Osteoporosis
Obesity
Parkinson’s Disease
Dementia …
Put another way: physical
exercise is therapeutic for
these and other conditions
Exercise has protective
effect via many pathways
e.g.:
Metabolic
Genetic
Physiological
Immunological
Neurological
How fast does the Grim Reaper
walk? Population based prospective study on 1705 elderly men
(>70y/o) over 2 ½ years
Older men who walked faster than 0.82 m/s were 1.23
times less likely to die than those who walked slower
No men with walking speeds of 1.36 m/s or greater had
contact with Death
“As none of the men in the study with walking speeds of
1.36 m/s (about 5 km/hr) or greater had contact with
Death, this seems to be the Grim Reaper's most likely
maximum speed; for those wishing to avoid their allotted
fate, this would be the advised walking speed.” Stanaway FF, Gnjidic D, Blyth FM, et al. How fast does the Grim Reaper
walk? Receiver operating characteristics curve analysis in healthy men aged
70 and over. BMJ. 2011 Dec 15;343:d7679.
55
Exercise and mental health
Elevation of mood seen with aerobically based exercise programs in both the healthy and clinically depressed Antidepressant and anti-anxiety effects
Also useful in alcohol and substance abuse
Mechanism of action in depression: Self esteem
Therapeutic distraction from worries
Improvement in general health
Release of pent up hostility
Increased serotonin
Improves insomnia Byrne A, Byrne DG: J Psychosom Res 1993;13(3):160-170.
Chaouloff F: Med Sci Sports Exerc 1997;29(1):58-62.
King AC, Oman RF et al. JAMA 1997;277(1):32-37.
Physical activity & academic
performance
High overall sports participation: less likely to participate in a range of risky behaviors Adolescent risk behaviors (eg, truancy, cigarette
smoking, sexual intercourse, delinquency), other weekly activities (eg, work, academic performance, sleep), self-esteem.
Active teens less likely to have low self-esteem and more likely to have higher grades (eg, active in school).
Nelson MC, Gordon-Larsen P. Physical activity and sedentary behavior patterns are associated with selected adolescent health risk behaviors. Pediatrics. 2006 Apr;117(4):1281-90.
57
Physical exercise and cancer survival
2987 women with breast cancer followed for up to 18y
Risk of death halved for those who engaged in >9 MET-hr/wk (~ walking 3-5 hr/wk)
JAMA. 2005;293(20):2479-86.
47620 men, ~3000 with prostate cancer, 14y follow-up
In men >65 1/3 risk of advanced prostate cancer
Arch Int Med 2005;165:1005-10.
526 patients with colorectal cancer followed for over 5y
Risk of death halved for stage II&III
Gut 2006;55:62-67.
58
Exercise and dementia
Physical exercise, even if moderate, protective
against cognitive decline and stimulates growth
of new brain cells (neurogenesis)
Exercise halves risk of Alzheimer’s Disease
For patients already suffering from dementia,
physical exercise, especially when combined
with music, is associated with improved
cognitive function within weeks Archives of Internal Medicine 2001;161:1703-8.
Arch Neurol. 2001;58(3):498-504.
Clin Rehabil. 2004;18(3):253-60.
Curr Opin Psychiatry. 2006 Mar;19(2):190-3.
Exercise, stress & telomeres
For non-exercisers a one unit increase in the stress
scale related to a 15-fold increase in the odds of
having short telomeres (a marker of rapid ageing and
chronic illnesses)
For exercisers, perceived stress was unrelated to
telomere length (i.e. exercise buffered against the
effects of emotional stress on ageing)
Puterman E, Lin J, Blackburn E, et al. The power of
exercise: buffering the effect of chronic stress on telomere
length. PLoS One. 2010 May 26;5(5):e10837.
Perceived stress, telomere length and exercise
Physical activity
categories are based on
whether the participant
met CDC recommended
levels of exercise per
week. Perceived stress
ratings are based on the
Perceived Stress Scale.
The relationship between
perceived stress and
telomere length was
significant in sedentary
participants only.
Types of exercise
Aerobic – e.g. running (makes you puff)
Resistance – e.g. weights (strength)
Balance / flexibility – e.g. yoga, pilates, tai
chi
Disease prevention recommendations Illness Recommended exercise modality
Arthritis Aerobic / Resistance
Cancer Aerobic
Chronic renal failure Aerobic / Resistance
Heart failure Aerobic / Resistance / Balance
Coronary heart disease Aerobic / Resistance / Balance
Dementia Aerobic
Depression Aerobic / Resistance / Balance
Osteoporosis Aerobic / Resistance / Balance (falls prevention)
Stroke Aerobic / Resistance / Balance for rehab.
Type-2 diabetes Aerobic / Resistance
Adapted from Fiatarone-Singh M. (2007) Physical fitness and exercise.
MET
One MET equivalent to the resting metabolic rate (energy expenditure in kcals/min)
Optimal health in middle age associated with approximately 12-15 MET
70kg person METs Kcal/hr Sleeping 1.0 80
Desk work 1.5 110
Driving 1.6 120
Sitting 1.4 100
Walk (3k/h) 2 150
Walk (5k/h) 4 330
Swimming 4 300
Tennis 5 420
Shovelling 5 400
Cycling 6 440
Squash 8 600
Run-jog 8.7 640
Run-fast 16.3 1200
Barriers to exercise
There are a lot of perceived barriers to
exercise
E.g. time, money, pain, convenience…
Important to be aware of them and be able to
find ways around them
65
Nutrition and depression
Omega-3 fatty acids, folate, vitamin E, vitamin B6, vitamin D, S-adenosyl methionine, phenyalanine and dark chocolate
Reducing or avoiding alcohol, sugar and caffeine
Medical Journal of Australia 2002;176:S84-96.
Lipids Health Dis. 2007 Sep 18;6(1):21.
British Journal of Psychiatry 2007
Nutrition and mental health Study of 7114 adolescents aged 10-14 years: Healthy and
unhealthy diet quality scores compared with incidence of
depression Adjusted for age, gender, socioeconomic status, parental education,
parental work status, family conflict, poor family management, dieting
behaviours, body mass index, physical activity, and smoking
Compared to the lowest quintile, the adjusted OR for
symptomatic depression across increasing quintiles of the
unhealthy diet score were:
Q1 = 1.00, Q2 = 1.03, Q3 = 1.22, Q4 = 1.29, Q5 = 1.79
“Our results demonstrate an association between diet
quality and adolescent depression that exists over and
above the influence of socioeconomic, family, and other
potential confounding factors.” Jacka FN, Kremer PJ, Leslie ER, et al. Associations between diet quality and depressed mood
in adolescents: results from the Australian Healthy Neighbourhoods Study. Aust N Z J
Psychiatry. 2010 May;44(5):435-42.
67
Calorie restriction
“Caloric (or dietary) restriction (CR) extends lifespan and lowers risk for age associated diseases.” including cancer and heart disease
Willcox DC, Biogerontology. 2006 Jun 30; [Epub ahead of print]
CR is not under-nutrition but having a diet which does not contain calories excess to requirements Most westernised diets are calorie-dense (empty
calories with little nutritional value)
68
Omega-3 f.a. and the heart
Review of 97 trials on (anti-lipidemic) ‘cholesterol-
lowering’ drugs
Most effective therapy for reducing all-cause and cardiac
mortality was omega-3 fatty acids
High concentrations in fish and flaxseed oils
N-3 fatty acids should be the preferred and first-line
treatment for high cholesterol (hyperlipidemia)
Clearly superior for effectiveness, side-effect profile,
availability, cost and safety Studer M, Briel M, Leimenstoll B, et al. Effect of different antilipidemic
agents and diets on mortality: a systematic review. Arch Intern Med.
2005;165(7):725-30.
Nutrition and telomeres
Associated with shorter telomeres Smoking
Processed meat
High BMI
High homocysteine
Lin J, Epel E, Blackburn E. Mutation Research 2011 (in press)
Associated with
longer telomeres
Vitamin D
Folate
Omega-3 f.a.
Vitamin C
Vitamin E
Lifestyle and cancer: WCRF
1. Be as lean as possible without becoming underweight
2. Be physically active for at least 30 minutes every day
3. Calorie restriction: avoid sweet drinks and limit energy-dense foods particularly processed foods high in added sugar, low in fibre, or high in fat
4. Eat more of a variety of vegetables, fruits, whole-grains and pulses such as beans
5. Limit red meat, e.g. beef, pork and lamb, avoid processed meat
6. Limit alcoholic drinks to 2 for men and 1 for women a day
7. Limit consumption of salty foods and food processed with salt
http://www.wcrf-uk.org/research_science/recommendations.lasso
Nutrition and breast cancer “Women in the highest quartile of plasma total
carotenoid concentration (marker of intake of vegetables and fruit) had significantly reduced risk for a new breast cancer event (HR 0.57).” (i.e. a 43% reduction in risk and controlled for other factors influencing prognosis.)
Rock CL, Flatt SW, Natarajan L, et al. J Clin Oncol. 2005;23(27):6631-8.
“For genistein (phytoestrogen), the risk estimate (breast cancer) for the highest versus the lowest tertile was 0.68 (95% CI, 0.47 to 0.98).”
Verheus M, van Gils CH, Keinan-Boker L, et al. J Clin Oncol. 2007 Jan 2; [Epub ahead of print]
RCT on women with 2437 women with breast cancer found that a low-fat diet was associated with a 24% reduction in recurrence and 19% improvement in survival after 5 years
Chlebowski RT, Blackburn GL, Elashoff RE, et al. J Natl Cancer Inst. 2006 Dec 20;98(24):1767-76.
Weight management
Achievable and sustainable goals
Positive attitude towards food
Non-hungry eating
Being physically active
Body image
Slowing down Kausman R. Tips for long term weight management.
Aus Fam Phys 2000;29(4):310-3.
Kausman R. If not dieting then what?
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Social support
High social support associated with:
Better mental health
Less heart disease
Greater longevity
Less substance abuse
Better immunity
Less dementia
Quantity and quality both important
Social isolation associated with poorer health
Social isolation and health
Social isolation associated with double death rates independent of other lifestyle variables
Social interactions important for both quantity and quality
Protective are: Marriage
Contact with family and friends
Religious dimension
Group affiliation House JS. et al. Social relationships and health. Science
1988;241(4865):540-5.
Bereavement and immunity
Significant immunosuppression during
bereavement
Six times higher rate of pneumonia in year post-
bereavement Bartrop R et al. Lancet 1977;1:834-6.
Schleifer S et al. JAMA 1983;250:374-7.
Even more significant immunosuppression during
marital separation Kiecolt-Glaser J et al. Psychosom Med 1987;49:13-34.
Kiecolt-Glaser J et al. Psychosom Med 1988;50:213-29
Connectedness and adolescent health
Parent-family connectedness and perceived school connectedness protective against health risk behaviors
“Family and school contexts as well as individual characteristics are associated with health and risky behaviors in adolescents … diminish risk factors and enhance protective factors for our young people.”
Resnick MD, Bearman PS, Blum RW, et al. JAMA. 1997 Sep 10;278(10):823-32.
Marriage and health
Review of nearly 300 references indicated that
marriage, and in particular healthy marriage, is
beneficial for good social, mental and physical health Kiecolt-Glaser J, Newton T. Marriage and health: his and hers.
Psychological Bulletin 2001;127(4):472-503.
Marriage protective for both men and women Litwak, E American Sociological Review 1989;54:49–66.
Ross C. J Marriage and the Family 1990;52:1059–1078.
Hibbard, J. H. Social Science and Medicine 1993;36:217–225.
78
Environment
Environment impacts upon every aspect of mental and physical health
‘Environment’ can mean different things
Ecology: climate, air, water, soil, radiation
E.g. living near high voltage power lines or a freeway entrance associated with illness
Social: home, friends
Educational: school
Urban: home, architecture, town planning, safety
Some health effects of environment
Health
E.g. air quality, infections or chemical exposures
Emotions
E.g. sports crowd or garden
Behaviour
E.g. casino, retail, health messages
Productivity
E.g. workplace or study space
Social interactions
E.g. service provider or restaurant
Opportunities
E.g. social advantage or school
Safety
E.g. occupational exposures or natural dangers
Lifestyle
E.g. exercise and safety, availability
Sunlight Too much sunlight
BCC, SCC
Premature ageing
of skin
Cataracts
Sunburn
Malignant
melanoma
Message: avoid
sunburn but not
regular moderate sun
exposure especially
in winter months
If inadequate sun
exposure then most
need Vit D
supplements
Over 1/3 of Australian population now vitamin
D deficient
Sunlight important for maintaining vitamin D
Regular, moderate sun exposure beneficial for,
or protective against:
Coronary Heart Disease
Various cancers including malignant
melanoma
Mental Health (e.g. depression)
Rickets, osteomalacia and fractures
Psoriasis
Autoimmune disorders (e.g. Multiple
Sclerosis, Rheumatoid Arthritis,
Inflammatory Bowel Disease…)
Diabetes
Hassed C. Are we living in the dark ages: the
importance of sunlight. AFP 2002;31(11):1039-41.
Psychosocial factors may
contribute to development and
promotion of CAD in 3 basic
ways: (1) promote pathogenesis
of atherosclerosis: (2) contribute
to maintenance of unhealthy
lifestyle behaviors, such as
smoking and a poor diet: (3)
coexisting psychosocial stresses
form a barrier to successful
modification of lifestyle
behaviors.
Rozanski Circulation
1999;99:2192-217
Is heart disease reversible?
Heart disease is reversible given the right lifestyle
Significant improvement possible in both the disease progression and quality of life.
People with already well established CVD given conventional medical management plus or minus an intervention (comprehensive lifestyle program)
Ornish D. et al. Lancet 1990;336:129-133.
The Ornish Program
People followed angiographically and symptomatically
The program (intervention) consisted of:
group support
stress management consisting of meditation and yoga
a low fat vegetarian diet
moderate exercise
stopping smoking
Stress management was central to being able to
improve other lifestyle risk factors
Results
Intervention Control
Progression 82%
regressed
53% progressed
Symptom
frequency
91 165
Duration 42 95
Severity 28 39
Reduction in healthcare costs
$3,900 for the Ornish program
C/w $40,000 for bypass surgery
Average cost savings were $US58,000 per
patient after 3 year follow-up
BMJ. 1993;307:465.
Five year follow-up of Ornish program
Most of the original
intervention group
maintained changes
Outcome for Ornish
group was even better blood flow through the
coronary arteries
2.5 times the risk for
cardiac events 2.47 in
control group
JAMA 1998;280:2001-7
Ornish program for cancer
92 men with early prostate cancer who chose to watch and wait
Randomised to lifestyle (experimental) group vs. usual treatment (control) group
Ornish D. Weidner G. Fair WR. et al. Journal of Urology. 2005;174(3):1065-9.
88
Ornish lifestyle intervention
Vegan diet Fruits, vegetables, whole grains, legumes and soy
10% calories from fat
Supplemented by soy (tofu), fish oil (3gm daily), vitamin E (400IU daily), selenium (200mcg daily), vitamin C (2gm daily)
Exercise Walking 30min 6 times weekly
Stress management Gentle yoga, meditation, breathing and PMR
Support group 1 hour weekly Ornish et al. Journal of Urology 2005;174:1065-70.
89
PSA readings
After 1 year PSA decreased by 4% in experimental group and increased by 6% in control group
No patients in the lifestyle group had gone on to have aggressive prostate cancer vs. 6 in the control group
The more people applied the program the better their outcome Ornish et al. Journal of Urology
2005;174:1065-70.
Ornish lifestyle intervention
2-year follow-up
27% (13/49) patients in control group have gone on to require cancer treatment because of disease progression but only 5% (2/43) patients in lifestyle group
Frattaroli J, et al. Urology 2008 July 2 Epub ahead of print.
Ornish program down-regulated prostate cancer gene expression
Ornish D, et al. PNAS 2008;105(24):8369-74.
Comprehensive lifestyle change increased genetic repair (telomerase activity)
Ornish D, et al. Lancet Oncology 2008 Sept 15 Epub
Lifestyle change and telomeres
Telomere shortness is a prognostic marker of ageing, disease, and
premature illness
5 year follow-up study to investigate long-term effects of lifestyle
change on telomere length on men who had biopsy-proven low-risk
prostate cancer
Intervention group followed a programme of comprehensive lifestyle
changes (low fat vegan diet, exercise, stress management,
meditation and social support)
Control group underwent active surveillance alone
At 5 years compared relative telomere length and telomerase
activity and their relation to the degree of lifestyle change Ornish D, Lin J, Chan JM, Epel E, Kemp C, Weidner G, Marlin R, Frenda SJ, Magbanua
MJ, Daubenmier J, Estay I, Hills NK, Chainani-Wu N, Carroll PR, Blackburn EH. Effect of
comprehensive lifestyle changes on telomerase activity and telomere length in men with
biopsy-proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study.
Lancet Oncol. 2013 Sep 16. doi:pii: S1470-2045(13)70366-8. 10.1016/S1470-
2045(13)70366-8
Lifestyle change and telomeres
Relative telomere length increased from baseline in the lifestyle
intervention group, but decreased in the control group
Adherence to lifestyle change significantly associated with relative
telomere length after adjustment for age and the length of follow-up
“Our comprehensive lifestyle intervention was associated with
increases in relative telomere length after 5 years of follow-up,
compared with controls, in this small pilot study. Larger randomised
controlled trials are warranted to confirm this finding.” Ornish D, Lin J, Chan JM, Epel E, Kemp C, Weidner G, Marlin R, Frenda SJ, Magbanua MJ,
Daubenmier J, Estay I, Hills NK, Chainani-Wu N, Carroll PR, Blackburn EH. Effect of comprehensive
lifestyle changes on telomerase activity and telomere length in men with biopsy-proven low-risk prostate
cancer: 5-year follow-up of a descriptive pilot study. Lancet Oncol. 2013 Sep 16. doi:pii: S1470-
2045(13)70366-8. 10.1016/S1470-2045(13)70366-8
Lifestyle and MS
Study on 5-day residential retreat for people with MS
(based on Prof Jelinek’s Overcoming MS program)
promotes lifestyle modification within a patient-
centred model of care
Analysis of the health-related quality of life (HRQOL)
of the retreat participants was undertaken using the
MSQOL-54, prior to attendance, 1 and 5 years after
the retreat
274 retreat participants (71%) completed baseline
questionnaires Hadgkiss EJ, Jelinek GA, Weiland TJ, et al. Health-related quality of life
outcomes at 1 and 5 years after a residential retreat promoting lifestyle
modification for people with multiple sclerosis. Neurol Sci DOI
10.1007/s10072-012-0982-4
Lifestyle and MS Participants demonstrated clinically and statistically
significant improvements in HRQOL
At 1 year median improvements of 11.3% in overall QoL
18.6% in the physical health
11.8% in the mental health
At 5 years there was a 19.5% median improvement in
overall QoL compared to baseline
17.8% in the physical health
22.8% in the mental health
“Non-drug therapies should be considered as part of any
comprehensive treatment plan for people with MS.” Hadgkiss EJ, Jelinek GA, Weiland TJ, et al. Health-related quality of life
outcomes at 1 and 5 years after a residential retreat promoting lifestyle
modification for people with multiple sclerosis. Neurol Sci DOI 10.1007/s10072-
012-0982-4
SMART goals
SMART stands for: Specific
Measurable
Attractive
Realistic
Timely
Mnemonic to provide a framework for successfully setting goals
Goals are often not achieved because one or other of the steps were not attended to.
SMART goal activity
Set a SMART goal for yourself