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?

73

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