Moon day, New Year’s Eve, and habits for 2010

It’s a beautiful and snowy moon day and New Year’s Eve.

I’m working on my 2010 new year’s resolutions and trying something new this year: writing down the habits I want to develop, habits I can practice every day so that I don’t have to think about them anymore.

So, the 6 habits I want to develop in 2010:
1) Buy local and in-season food.
2) Cook 2 new recipes a week and write them down.
3) Avoid sugar.
4) Minimize purchasing things – I want to de-clutter my life.
5) Write (blog, journal) every day.
6) Practice pranayama and take long savasana at the end of practice.

“We are what we repeatedly do. Excellence, then, is not an act, but a habit.” ~Aristotle

Asana

It is an amazing feeling to be able to practice with no pain. I have a new appreciation for my body and I will be much more careful with it from now on!

I love what Iyengar writes about asanas, the 3rd limb of Ashtanga:

“Asanas have been evolved over the centuries so as to exercise every muscle, nerve and gland in the body... their real importance lies in the way they train and discipline the mind…

By performing asanas, the sadhaka first gains health, which is not mere existence. It is not a commodity which can be purchased with money. It is an asset to be gained by sheer hard work. It is a state of complete equilibrium of body, mind and spirit. Forgetfulness of physical and mental consciousness is health. The yogi frees himself from physical disabilities and mental distractions by practicing asanas…

The yogi never neglects or mortifies the body or the mind, but cherishes both. To him the body is not an impediment to his spiritual liberation nor is it the cause of its fall, but is an instrument of attainment. He seeks a body strong as a thunderbolt, health and free from suffering so as to dedicate it in the service of the Lord for which it is intended…

Just as an unbaked earthen pot dissolves in water the body soon decays. So bake it hard in the fire of yogic discipline in order to strengthen and purify it.”

A good reason to cut out sugar

A study recently came out looking at the effect of sugar (glucose) on human cells. They found that glucose changes the activity of telomerase (the enzyme we’re looking at in our study). Telomerase keeps chromosomes long and helps cells live indefinitely, which we want in healthy cells, but do NOT want in cancer cells.

The study looked at both healthy lung cells and precancerous lung cells. They split the cells into two groups: One group received a normal amount of glucose, the other group received lower than normal amounts of sugar.

Results: The healthy cells exposed to lower levels of glucose lived longer, while the precancerous cells exposed to lower levels of glucose died off.

Two genes were affected by the restriction of glucose:

1) Telomerase: allows cells to continue to live and divide indefinitely

2) p16: an anti-cancer protein

The genes acted differently in healthy cells and precancerous cells:
Healthy cells: Rise in telomerase and decrease in p16 --> cells live longer.
Precancerous cells: Decrease in telomerase and increase in p16 --> cells die off.

Conclusion: A glucose-restricted diet may help human cells live longer and free of cancer.

Tollefsbol, one of the authors of the study, said:

"These results further verify the potential health benefits of controlling calorie intake… Our research indicates that calorie reduction extends the lifespan of healthy human cells and aids the body's natural ability to kill off cancer-forming cells… Human longevity can be achieved at the cellular level through caloric restriction.”

They talk about caloric restriction but the study looked at glucose levels. I’m wondering if this has more implications for sugar consumption and the resulting spikes and troughs of blood glucose. Diabetics, for example, who have high levels of blood glucose, suffer from end-organ damage, coronary artery disease, and atherosclerosis, all of which have been associated with telomere shortening.

So… as I’m working on my 2010 resolutions this week, cutting out sugar is definitely on there!

Meditative medicine: a new distinction

This article in the Hastings Center Report, “Toward a Meaningful Alternative Medicine” by Vinay Prasad, has shifted the way I think about “alternative medicine” and health care in general. He starts by sharing this quote by Phil Fontanarosa and George Lundberg which I instinctively agree with: “There is no alternative medicine… there is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which data is lacking.” Alternative medicine is often considered unscientific and faddish. But then why are so many people drawn to it? Is there more besides “evidence-based medicine” that we are missing? Is health care more than “an unrelenting devotion to outcomes”?

Prasad suggests we think about meditative medicine in parallel with our evidence-based framework. He refers to German philosopher Heidegger’s work contrasting poetry and technology as differing ways of making sense of the world. Technology represents “calculative thinking,” using objects to achieve a purpose. Poetry and art represents “meditative thinking,” reflecting on the beauty inherent in how things are. Both ways of thinking are important. Heidegger was concerned that “the approaching tide of technological revolution in the atomic age could so captivate, bewitch, dazzle, and beguile man that calculative thinking may someday come to be accepted and practiced as the only way of thinking.”

Prasad then applies this to medicine: 

“The worry, if one takes Heidegger’s perspective, is not that health is an outcome to be optimized by cost-effective, evidence-based medicine, but that this might be the only way of thinking about health – that no alternative exists. Unfortunately, practitioners do little to provide a true alternative when they use complementary medicine in purely calculative terms: sometimes but not always relying on randomized controlled trial data, and sometimes but not always trusting anecdotal evidence. Heidegger teaches us that ‘Western’ and ‘alternative’ are not meaningful categories. A better distinction is ‘calculative’ and ‘meditative.’ And what we need is meditative medicine.”

 The point is: we can’t think of all alternative medicine in terms of the evidence-based model, just like we can’t think about art and poetry like we do technology. So, the distinction is as follows:

Calculative medicine: A medical intervention (can be ‘Eastern’ or ‘Western,’ unconventional or mainstream) that is aimed at producing an outcome (such as reduced cancer recurrence, longevity, reduced menopausal symptoms, etc.) that can be studied with evidence-based methodology. Examples of calculative medicine include giving a statin to lower cholesterol, yoga for blood pressure control, or acupuncture for pain control.

Meditative medicine: Meditative medicine includes practices (exercise, eating healthy, meditation, etc) which “are done not with a particular outcome in mind, but as part of living a healthy life… they provide a way of making sense of health, illness, and the good life. Becoming vegetarian because you wish to lower your LDL is calculative. Does it work? A well-designed trial could tell us, but it would miss the point.” Meditative medicine also applies to the patient-doctor relationship: “Allowing doctors to develop relationships with patients beyond what is necessary for good primary care is meditative.”

As Prasad explains:

“Some people exercise because studies have shown a correlation between twenty minutes of aerobic activity and longevity (a calculative view), while others do so because an active life is healthy (a meditative view). Some drink a glass of wine each night because it has been shown to decrease cardiovascular risk (calculative), while others never needed that study to know that drinking wine in moderation, as part of a broader set of practices, is healthy (meditative).”

Meditative medicine is why I’m a vegetarian, why I exercise, why I do yoga... not for a specific outcome that can be studied with randomized controlled trials, but because it feels right and is part of a healthy, balanced lifestyle. It is also why I want to do family medicine and provide both calculative and meditative health care. So much of healing and health is in the patient-doctor relationship, and that is not something that can be measured with RCTs. 

An amazing animal

“Isn’t man an amazing animal? He kills wildlife by the millions in order to protect his domestic animals and their feed. Then he kills domestic animals by the billions and eats them. This in turn kills man by the millions, because eating all those animals leads to degenerative – and fatal – health conditions like heart disease, kidney disease, and cancer. So then man tortures and kills millions more animals to look for cures for these diseases. Elsewhere, millions of other human beings are being killed by hunger and malnutrition because food they could eat is being used to fatten domestic animals. Meanwhile, some people are dying of sad laughter at the absurdity of man, who kills so easily and so violently, and once a year sends out cards praying for “Peace on Earth.”

~C. David Coates

Research update: Month 2

A quick update:

• My telomere study is evolving to be much than I ever initially envisioned. Writing a grant to do real-time PCR analysis on DNA from peripheral blood mononuclear cells? I honestly never thought I would say that. I love thinking about these questions and realizing that I can actually do it. We have two grant proposals due Jan/Feb. 
• I feel distracted from my initial goal of running a yoga clinical trial. The plan is to submit the yoga study protocol for IRB approval at the end of January. My priority right now is this telomere grant but once I finish that I’ll focus my energies on the protocol. 
• Instead of recruiting on Fridays (meaning I “cold call” patients in the waiting room trying to persuade them to enroll in a research study – an inefficient and poor use of time), I will now be spending my Fridays seeing patients with an oncologist (and enrolling patients within the trust of the patient-doctor relationship – much more effective). I can now build a relationship with this oncologist and learn about breast cancer management, while also talking with patients about the yoga study and finding future participants. I couldn’t be happier about this. I *almost* liked wearing my short white coat again. 
• I’ve been neglecting my interest in HIV and infectious disease and I miss it. I’ve been in touch with some HIV physicians I admire and hope to work with them on some small projects.

Healing process and practice

I’ve been observing myself going through this healing process. At first I felt frustrated, irritable, unmotivated, etc. It’s been over a week and my rib is still hurting, stopping me from practicing normally. But over the past few days I’ve been feeling more content... and actually, I’m kind of starting to enjoy my time off.

Or maybe this new perspective is from “juicing.” I’m on my third day of JUST JUICE (pomegranate, blueberry, carrot, greens & spirulina... anything I can find that’s colorful and antioxidant-filled). I’m getting plenty of calories, but giving my GI tract a much needed rest. And I’m feeling great - energized, steady, attentive. I’d keep it up for longer if it weren’t for all the holiday food to munch on. But maybe I’ll start doing this more regularly, maybe on moon days?

Practice today was slow and tentative, I’m afraid to do anything that might hurt my body (although I did backbends for the first time in a week - they felt good). David said to be “narrow” in what I eat over the holidays, and to make sure to give my body some time without food so it can direct energy towards healing.

Adam Kazan, Guest Blogger Part 2

Guest Blogger, Adam Kazan
Ashtanga Alien Predator and What Is
Part 2 of 2

"you can't be anyone but you 

therefore you are that Other one you love" 

- Ikkyu

Now back to how this all has to do with Ashtanga practice? The real question is why and how we are not with what is... basically what makes us travel away from reality and ourselves? What is our relationship with that which we dislike and that which we want? And all those lovely distractions that assist (3Xper netflix, no cable). From where do these crafty creatures come from? What we repress and not acknowledge arises as Frankenstein, the creature from the black lagoon, hellraiser, sex and the city, racism. We then want to further wall ourselves off from these invaders, to not know our own suffering.

How do we release ourselves from this bondage of our own entrapment? Traditionally and presently it comes from various seemingly spiritual techniques. Like prayer, meditation, yoga, good deeds, mindfulness. Do these work...hummm? What do you think? These methods seem to make us face the suffering. There is a tale that on Buddha's ("life is a chockablock pain") deathbed he said "Work out your salvation with diligence." Yes your very own salvation. What does it take for you, yes the specific you, to wake up a bit more. Different methods for different people. Find yourself shoes that fit.

A 10-day retreat spent with violent turning nonaggresive extraterrarestials is a very particular environment, a special container for awareness. A daily practice of Ashtanga yoga is a daily training of awareness, the paying attention to what is actually happening. Ashtanga is a great way to make this happen for oneself. The force of this yoga brings my mind to reach the mechanisms of how my body is working. It brings an integration and cohesion to the mind body connection. It is an efforted training to be with the body and find out what is there. Yet....

What happens most of the time with my mind... wander and wonder. It goes away from the body, it looks about and gets interested in what is not. Those outer space visitors have all kinds of interesting ways to seek my attentions. My two favorite mind wanderers during practice is clock watching and looking at who is coming into the studio. Practice is a great place to notice the habits of the mind for distraction. Noticing the habits allows for a little more spaciousness. Those spaces give room for different choices.

Ashtanga gives me the opportunity to train the mind and body to pay attention and be focused. After a year and half of steady practice I now stay focused about 10%+ of the time, an over 150% improvement from when I started. What do I get with that...a little more awareness of the outcomes of my actions, a bit more healthy, a bit more spry, a tiny bit more compassion and as an ex-girlfriend said about me "you are less of a jerk." Overall great success.

In a way this practice helps you be you.

Breathing

I bought Iyengar’s book “Light on Pranayama” and am taking advantage of my extra time to study pranayama -- breath control. This is the 4th limb of Ashtanga yoga.

And under my friend Xochitl’s influence, I am doing a three-day juice cleanse. Her family used to do this periodically growing up. She’s read a lot about it and thinks it might help heal my injured muscle.

So, I bought jugs of anti-oxidant filled juice (need to get a juicer!) and am starting to flood my body with it.

Inspired follies

"What is life but a series of inspired follies? The difficulty is to find them to do. Never lose a chance: it doesn't come every day."

~George Bernard Shaw

Last week I worked hard on two grant drafts -- one on the telomere study and one on the yoga clinical trial. I hope something will come out of them because so far it’s just been a lot of ideas, outlines, and drafts. 

I need to work on enjoying the process. 

And the same goes for yoga: it’s about the process. Fellow ashtangis have been surprised when I tell them this is my first injury that has really put me out of practice. It has happened to them, it’s part of the practice, and it’s a necessary lesson… to be humbled, to listen to my body, to protect it. 

Yoga where it’s needed

Check this out -- daily yogic breathing in high schools.

I’d love to see how an Ashtanga practice would help high school kids… anyone know any teachers out there who might be interested in trying this?

Nonacquisitiveness

Yoga Sutra II:30 --

Non-violence, truth, abstention from stealing, continence, and absence of greed for possessions beyond one’s need are the five pillars of yama. 

“In the effort of accumulating material possessions and wealth, in protecting the acquired, in their decline, in the latent impressions they leave on the mind, and in the unavoidable harm caused to other living beings – in all these there lies unhappiness. Thus the yogi practices nonacquisitiveness.” ~Vyasa commentary

“A mind with desires does not ignite and glow, nor does it generate light and warmth when touched with the fire of knowledge.” ~Iyengar

So… I’m working on nonacquisitiveness towards my practice. Today I spent most of my time inverted in shoulderstand and headstand, then sat in bada konasana against the wall and breathed… for a long, long time.

Pain empathy

This pain in my rib hurts with every breath I take. It is constantly on my mind, it makes me grumpy, it takes me out of my normal routine, and it occupies my mind making it difficult to be creative or thoughtful or compassionate. One positive outcome: it is helping me understand the experience of pain.

In Iyengar’s book Light on Yoga, he writes about the niyamas. Niyamas are the 2^nd limb of Ashtanga and make up the individual disciplines (Yamas, the 1^st limb, are universal ethical disciplines). One of niyamas is Santosa, meaning contentment. Iyengar says, “Santosa or contentment has to be cultivated. A mind that is not content cannot be cultivated.” And a mind distracted by pain cannot be content!

After some desperate googling I came across Epsom salts. A quick PubMed search came up with ZERO on Epsom salts for muscle pain, but I found a few answers on the Internet (though not sure of the science behind them). Epsom salts are made up of magnesium sulfate, which readily absorb through your skin helping bind “toxins” and reduce inflammation. I ran out to RiteAid and bought two big jugs, put 2 cups into hot water, and soaked for about 20 minutes. 

Ahimsa and my pulled muscle

Ahimsa is the first of the yamas (the 1st limb of Ashtanga’s 8 limbs). Ahimsa means non-violence. Non-violence towards other beings, and non-violence towards ourselves.

For me, ahimsa often means doing less. In my practice, it means taking some days off from the physical practice and taking some days for less asana and more breathing. In my life outside of practice, it means saying no to things and protecting my time. It applies to my internal thoughts, my actions, how I eat, the footprint I leave on the earth, etc.

And I can no longer ignore that it applies to my pulled serratus (maybe intercostal?) muscle. I think I overdid my jump-backs and now my right ribcage is terribly painful with almost every movement. Practicing through the pain has not been helping, so I have to rest.

Adam Kazan, Guest Blogger: "Everything terrible is something that needs our love." ~ Rilke

Guest Blogger, Adam Kazan

Ashtanga Alien Predator and What Is

Part 1 of 2

"Everything terrible is something that needs our love." - Rilke

What this blog is not about...Today during practice I thought of the BSG series and the Cylons and how that could be included below. During those thoughts I missed an asana and got very mucked up. Enough said about that.   

If you visit my home you may be fortunate and see the large action figures of Alien and Predator.

I suppose that most readers of this blog have not seen the movie Alien versus Predator  http://www.imdb.com/title/tt0370263/, the one that takes place in like Antarctica. Perhaps you have seen an Alien movie or Predator. I saw the Alien versus Predator movie one week before going to a 10 day silent vipassana mediation retreat in Shelburne Falls, MA. The sits at the retreat were a hour long each. Old aches and pains visited and took a predominate seat in my body. That car accident a few years ago which strained my back. The right knee with its torn meniscus from a jujitsu sparing beatdown. Did these visit or were they always there lingering like a crocodile quietly waiting for its prey.

So sitting sitting trying trying to notice my breath coming in and out of my nose, what did I want? Not to ache and not to pain, no suffering Now!

So my lovely mind tried the not me thing, transferred the pains to images of Predator and Alien. Within the grey matter of my brain Predator and Alien fought deadly battles. Pushing the pain away and let them fight. It just kinda seemed to work for a couple of days, but alas the aches and pains were part of me and I could not get divorced from myself. Woe is me. I think a lot and thought of a solution. Aikido with bamboo swords! Like dancing. Both Alien and Predator were in those Japanese fencing uniforms. 

And I started to investigate my aches and pains. It is a very curious thing to spend time with pain. Arose not the spilling of concentrated acid (Alien's blood) or the cry of a battle won due to the severing of the other's limb, but a desire to be compassionate to myself. A warmth, a knowing of my suffering, an internal gentle hugging. I started then to be able to feel acceptance, tolerance, kindness for the frailties of the body and mind. With this knowing I also knew that others suffer within their own little and big science fiction movie hells (original series Star Trek -Mirror, Mirror, Star Trek: Next Generation - Chain of Command, The Matrix, Bridget Jones Diary, Lost in Space, Terminator ). By the end of the retreat the mental formations of Predator and Alien were sitting flanking me both crossedlegged and meditating. Once home, action figures graced the left and the right of my meditation mat. 

By now you must have already thought at least a couple of times...So what does this have to do with Ashtanga yoga practice? And so await the second installment....

Patient attention

 I like Newton’s concept of patient attention:

"If I have ever made any valuable discoveries, it has been owing more to patient attention, than to any other talent." 

~Isaac Newton

Weeks 3 & 4

I’ve been surrounding myself in everything telomeres. Here’s a quick update on the research front:

• There is a promising grant that seems to fit with our research goals. Writing a draft of this grant is my main project for the next week. I’m learning that the most important part of designing a study is identifying the AIMS. As is true for many things, the key is having a clear vision and setting specific goals. 
• I went to a research meeting with budding physician-epidemiologists where someone was presenting their R01 proposal. The group ripped it apart. It was discouraging, to say the least, and I came out of there questioning whether research is for me. Spending months investing in and developing your project, only to have it rejected. You need thick skin and perseverance in the face of unavoidable criticism. 
• I’m beginning to really understand how hard it is to design a high quality, rigorous, scientific study. No study is perfect and there will always be critical reviewers. The western medicine framework seems inadequate to study many of the questions I’m interested in. Many people in primary care offices in America would never be eligible for randomized controlled trials. People are complicated and real life isn’t randomizable.

The value of yawning

I was unaware of the value of yawning until now! This article is written by Dr. Andrew Newberg, a physician/researcher at Penn who I have admired after reading about his studies on the brain during meditation (he’s also featured in the movie “What the bleep do we know.”)

If you read the article, you’ll see how he talks about how both yawning and yogic breathing stimulate the precuneus in the parietal lobe. The precuneus apparently plays “a central role in consciousness, self-reflection, and memory retrieval,” which helps explain why yoga/meditation can help increase self-awareness. Yawning also improves alertness: “It quickly brings you into a heightened state of cognitive awareness… it rids the brain of sleepiness, thus helping you stay focused on important concepts and ideas.”

And yawning has a social function as well. Dr. Newberg explains how “Yawning evokes a unique neural activity in the areas of the brain that are directly involved in generating social awareness and creating feelings of empathy.” Yawning is only “neurologically contagious” among humans, great apes, macaque monkeys, and chimpanzees! 

Heat your body once per day

I did a little experiment on myself  and found that my body temperature rises about 2 degrees Fahrenheit during my morning practice (today it went from 97.7 before practice --> 99.6 in the middle, though I haven’t been able to measure it at my peak so it may rise even more than that). This isn’t really surprising, as it’s already known that exercise increases core body temperature (and your body compensates by sweating to protect you from getting heat stroke), but I like seeing actual proof of my temperature elevation.

Pattabhi Jois said to heat your body only once per day. This is based on thousands of years of yogic study and observation. I wonder what measurable effects this has on the body -- Does it alter immune function? Does it alter our levels of inflammation? Does it reverse oxidative damage in cells? Does it help maintain telomere length? We know that exercisers have longer telomeres compared with non-exercisers, but we don’t know exactly how this happens. I wonder if it could be related to the frequent rise in core body temperature and the physiologic effects this has on cells.

The cause of over half of our greenhouse gas emissions

In case the animal cruelty and health factors aren’t enough:

**Meat consumption causes more than half of our greenhouse gas emissions**

Intense exercise keeps us molecularly young

I was excited to see this article on the study that’s about to come out in the Dec. 15 issue of Circulation.

The study compared telomere length in runners versus non-runners, finding that runners have cells with longer telomeres. Longer telomeres mean molecular youthfulness because as cells age, our telomeres (the DNA at the ends of our chromosomes) get shorter. The theory is that if we can stop this telomere shortening, we can slow down the aging process. They showed that professional athletes who run ~50 miles/week have telomeres the length of non-exercisers who are 10 years younger!

I can’t wait to see the paper when it comes out. I’m also curious about people who don’t currently exercise -- if they change their lifestyle and start exercising, what happens to their telomeres then? I wonder what length of time and type of exercise is needed to start seeing molecular changes.

Exercise remodels our brains

Here’s one explanation for why exercise works for mood/anxiety: it remodels our brains to better react to stressful situations.

A study came out comparing rats that exercised (allowed to run) versus rats not allowed to exercise. The rats that exercised grew new neurons in their brains, which scientists called “cells born from running.” These new neurons behaved differently -- while other cells expressed “stress genes” during stressful situations, these new cells remained “biochemically, molecularly, calm.”

Previously, the mechanism by which exercise helps with mood and anxiety has been unclear. This study helps explain that exercise actually “remodels the brain, making it more resistant to stress.” Though the rats exercised for only 6 weeks, it’s not clear how long or how intensely humans need to exercise for this remodeling process to start.

Hemp milk

I thought I’d share my recent love of hemp milk. It’s good cold (plain, vanilla, or chocolate) but my new discovery is *hot* hemp milk. And if you heat it with a peppermint tea bag it makes the perfect winter holiday drink.

Hemp milk is a good alternative to cow or soy milk. It can usually be found in the soy/almond milk section of grocery stores (not yet at Trader Joe’s). It’s basically just made up of hemp seeds and water… and it's so good for us! Just one cup has:

~900mg Omega-3 Fatty Acid & 2800mg Omega-6 Fatty Acid (this is apparently the ideal ratio of Omega 3: Omega 6)

~All 10 essential amino acids

~4g protein, >40% daily calcium, 0 cholesterol, Potassium, Phosphorous, Riboflavin, Vitamin A, Vitamin E, Vitamin B12, Folic Acid, Vitamin D, Magnesium, Iron, Zinc…

Iyengar: Keep it pure and clean

“The body is your temple. Keep it pure and clean for the soul to reside in.” ~B.K.S. Iyengar

I’ve been reading Iyengar’s book, Light on Life, and like this excerpt on “The True Nature of Health:"

“Most people ask only from their body that it does not trouble them. Most people feel that they are healthy if they are not suffering from illness or pain, not aware of the imbalances that exist in their bodies and minds that ultimately will lead to disease. Yoga has a threefold impact on health. It keeps healthy people healthy, it inhibits the development of diseases, and it aids recovery from ill health.

But diseases are not just a physical phenomonenon. Anything that disturbs your spiritual life and practice is a disease and will manifest eventually in illness. Because most modern people have separated their minds from their bodies and their souls have been banished from their ordinary lives, they forget that the well-being of all three (body, mind, and spirit) are intimately entwined like the fibers of our muscles.

Health begins with firmness in body, depends to emotional stability, then leads to intellectual clarity, wisdom, and finally the unveiling of the soul. Indeed health can be categorized in many ways. There is physical health, which we are all familiar with, but there is also moral health, mental health, intellectual health, and even the health of our consciousness, health of our conscious, and ultimately divine health. These are relative to and depend upon the stage of consciousness we are at.

But a yogi never forgets that health must begin with the body. Your body is the child of the soul. You must nourish and train your child. Physical health is not a commodity to be bargained for. Nor can it be swallowed in the form of drugs and pills. It has to be earned through sweat. It is something that we must build up. You have to create within yourself the experience of beauty, liberation, and infinity. This is health. Healthy plants and trees yield abundant flowers and fruits. Similarly, from a healthy person, smiles and happiness shine forth like the rays of the sun...

As long as the body is not in perfect health, you are caught in body consciousness alone. This distracts you from healing and culturing the mind. We need sound bodies so we can develop sound minds.”

Ashtanga in Rwanda - Project Air

Check out this video about a medical NGO which started using yoga to help rape victims in Rwanda.

And this interview with Deirdre Summerbell who started it all.

Deirdre said yoga in Rwanda is a "conceptual void" so the women had no anticipatory skepticism. Deirdre started by doing some demonstrations and the women "were horrified!" But they threw themselves into it and loved it.

They teach Ashtanga yoga, taking the women through the fixed routine. It helps the women heal and reconnect with their bodies, as well as make them strong. She said "Yoga is slow medicine, but it is medicinal in character."

It's gone so well in Rwanda that they're now seeking funding to bring it to other places... (how about Penn!)

Project Air: http://www.project-air.org/

Week 2

It’s looking like measuring telomerase might actually be a real possibility! But there’s a lot of work to do. I applied the 80/20 rule (80% of outcomes come from 20% of the input) to finish a draft of the protocol yesterday. I’m glad I didn’t spend too much time perfecting it because getting my mentor's initial feedback today was incredibly helpful. He gave me some much needed guidance and focus.

Key points from our meeting today:

• Become an expert in ONE thing. The more you put into the study the more you have to defend. I had put about 20 different ideas into the protocol and am now narrowing it down.
• Take the next 2 weeks to become the expert on telomerase. This is the time to focus and be a scientist. Read EVERYTHING about telomerase.
• Don’t get too attached to one idea, research is a lot of back and forth. Try not to get frustrated. If I spend time doing something that doesn’t work out in the end, it doesn’t mean it’s a waste of time -- in 5 years I could come back to a lot of these things.
• Don’t involve too many other people in the study just yet. Be careful of people who want me to do their work for them. This is my year to learn clinical research and pursue MY project.
• Within 6 weeks, write a grant to get funding for the telomerase enzyme assays.
• By mid-January, submit protocol for IRB approval and begin enrolling in March.

Yin yoga

I’m still processing the Yin Yoga class that I went to last night. It was completely different from the Ashtanga practice. The teacher talked the entire class, about nadis and chakras and opening up our connective tissue to let prana flow (prana = energy, life force). Her voice was calm and soothing and nonjudgmental, and I found it incredibly relaxing. We did a total of about 8 poses, holding each for ~4-5 minutes (surprisingly hard to be still for that long). The idea is to relax into the position and allow gravity to take you deeper.

The idea behind yin yoga is that it works on the deeper connective tissue and joints, while hatha/vinyasa yoga (the yang of yin yoga) works more on muscles. Yin yoga can be practiced in addition to our regular practice, and can help increase flexibility when muscles reach their limits.

Nadis and chakras are concepts I still have a hard time grasping but they pique my curiosity… for another post another time.

The palm of one hand

Pattabhi Jois instructed his students that meals should not be bigger than what can be held in the palm of one hand (and it's okay to eat every hour if necessary).

I am going to try this.

Endure

"Yoga teaches us to cure what need not be endured and endure what cannot be cured."

~B.K.S. Iyengar

Yoga at the cancer center?

I had an idea today. Instead of providing the yoga classes at a studio in Philadelphia, why don’t we start classes in the hospital at the cancer center? The building is new, huge, bright, and beautiful. 

I would think (hope) that Penn would be interested in offering services such as yoga to patients (not to mention medical staff), especially since major cancer centers are already doing this. Having a small room there for integrative medicine would not only be much more convenient for patients, but also a great service for the cancer center to be able to offer.

Hip openers and partner yoga

One thing I got out of the yoga anatomy workshop with David Keil last weekend was hip-opening. I’m trying to do this sequence every night (for each one, hold center then right then left - each for a few minutes). Thank you, Caitlin, for posing!

We also talked about handstands at the workshop and I have a lot to work on. I need to have much more engagement of my psoas muscles (psoas engagement = uddiyana bandha) and serratus anterior in order to lift up.

Caitlin and I did our first “partner yoga” session last night! We practiced jumping up into handstands, backbends, and then this chair inversion that releases the traps and makes my neck feel about two inches longer:

Week 1

My mentor is giving me the perfect combination of freedom to be creative with my research questions, structure of specific tasks and goals, encouragement of idealism, and reminders of practicality. This week has been busy and engaging and I love how my life and my “work” are beginning to blur.

Check out this article about the status of research on the health benefits of yoga about the following:

• The article is about the growing body of research on yoga and how several major cancer centers are now offering yoga to patients. “A word of caution, though,” says the article, “the studies that have been done so far have yielded soft findings, with little hard data to back up the conclusions. That said, there is no denying that yoga is becoming a presence even in the ivory towers of academic medicine.”
• The article explains that most of the research has proven the efficacy of yoga for emotional and social well-being such as improving stress, anxiety, sleep, quality of life, mood disturbance, and chronic pain. Despite this evidence, there is still little in the way of physician guidelines/recommendations to prescribe yoga.
• Our current plan for the clinical trial is to look at biomarkers before and after an 8-week yoga program. I really want to look at telomerase activity but it seems to require a complicated assay process which I don’t think we’re capable of just yet.
• The problem with the research on yoga thus far is that the interventions studied all fall under the umbrella of “yoga,” yet they are widely variable. Some are gentle restorative yoga classes, some are Iyengar classes focusing on alignment, some are simply vaguely described as “hatha” yoga. But this is important! The interventions have to be consistent and reproducible. This is why I like the idea of studying Ashtanga yoga as intervention because it is the same no matter where you are or who is teaching. I also like the idea of looking at Ashtanga because in addition to the yogic mind-body awareness practice, it is also a vigorous physical exercise.
• Another question I’m thinking about is whether it is possible to study yoga with our gold-standard randomized controlled trial model. Randomization doesn’t really work here. In the study and in real life, people are going to have to want to do yoga and want to make the lifestyle change. Perhaps a better model is a non-randomized controlled trial, where we compare a more self-selecting yoga group and control group. This would introduce confounders and open us up to more criticism, but I also think it’s more realistic for this study and for real life.
• As the article points out, in order for yoga to become more credible among physicians, there need to be more studies on its effectiveness. These studies need funding. And they need to be published in major medical journals so that physicians begin to see yoga less as an “alternative” medicine and more as a tool to improve health and well-being. As one of the doctor’s in the article said, “Research on yoga for therapeutic benefits really is in its infancy, and to look at how many studies are ongoing and being published the temptation is to think that’s a reflection of how good yoga is, and it may not be. We certainly need more research.”

The whole point

Noah (one of Philly's new teachers) talked about the whole point of the ashtanga yoga practice: to quiet the mind.

He explained that our mind is like a lake, our never-ending thoughts are ripples in the lake, and we see and interpret the world through these ripples. The purpose of the ashtanga practice is to clear the ripples so we can see the true reflection.

He talked about the three ways this occurs through the ashtanga practice:

1. Breathing. Slow, conscious breathing through the nose.

2. Gaze (dristi). Our mind follows our eyes so we must control our gaze. Gaze should be at the nose (most of the time), or third eye, toes, thumbs. It should not wandering around the room or looking in the mirror.

3. Physical postures (asana). The word “asana” is translated to “chair.” Asana is the chair from which we practice breath and gaze in order to quiet the mind.

I like this explanation because it takes the emphasis away from the physical yoga postures, and focuses it on the larger purpose of the practice which is to quiet the mind, and the physical postures are just a tool to get there.

Creating habits

While at the CDC, I went to a workshop on behavior change and I’ve been thinking about this for the yoga study. Are we really going to be able to get a group of busy women to start up a yoga practice? It will require creating new habits and new patterns of behavior, and I am wondering if and how that can be taught.

Below are a few of the social science theories discussed that I found useful for thinking about this:

The 11 variables that influence behavior

1. Intention to perform a specific behavior
2. Environmental factors
3. Necessary skills to perform the behavior
4. Beliefs about the behavior
5. Opinions about consequences or outcomes from the behavior
6. Peer pressure
7. Self-standards -- how someone wants to perceive themselves
8. Emotional reactions towards the behavior
9. Perceived self-efficacy -- self-confidence
10. Cultural believes
11. Contextual factors -- including the “social capital” present in communities such as strong churches, a network of moms, etc… any resources in the community that can be mobilized

Stages of Change

When making behavior change, people go through the following pattern of change:

Pre-contemplation --> Contemplation --> Preparation --> Action --> Maintenance

The “Chain of Causation” in public health

Large scale factors (historical, cultural, political, economic, etc) --> Behavioral Predictors --> Risk behaviors --> Proximate Determinants (pathogens, carcinogens, toxins, etc) --> Disease outcomes.

Medical school focuses us on the last two parts of that chain.

One thing missing from the 11 variables list is the power of good leadership. 

Un-numbed at family medicine conference

After studying to numbness for the past three weeks, it was really wonderful being at the family medicine conference in New York this past weekend. It reaffirmed that family medicine is what I want to do with my life. It’s about relationships. It’s about treating the whole person. It’s about inspiring, motivating, and encouraging. And it’s about service.

I just wish family medicine doctors were more visible. I wish they published more influential research. I wish they made themselves indispensible. One of the speakers said, “Family Medicine is the best kept secret.” But why are we keeping ourselves a secret?

Some favorites from the workshops:

• "Every time someone asks you to do something, ask yourself if you have room for it and what you’ll take off your plate in order to do it. Say ‘no’ to a bigger ‘yes.’”
• "How you spend the first hour of each day acts as a rudder to your ship."
• Only 30% of doctors advise patients about exercise and nutrition.
• “We should be giving more “thought” and less “care” (treatment). Exercise should be prescribed as a drug, as medicine.”
• “If you have a body, you are an athlete.”
• “Doctors are trained to fight disease, not prescribe health.”
• The Magic 6 of Healthy Aging: Don’t smoke. Take to exercise daily. Maintain your weight. Eat close to the earth and sea. Give care and belong. Have moderate alcohol intake (1-2 drinks/day).
• When running (or any exercise), always focus on learning something to keep from getting bored – have good postural alignment, lean forward (using gravity to move forward, like you’re going down a ski slope), lift heals instead of pushing off, relax your body while running, practice belly breathing (relax the diaphragm, exhale belly-button to your back).

A different kind of poverty

“The greatest disease in the West today is not TB or leprosy; it is being unwanted, unloved, and uncared for. We can cure physical diseases with medicine, but the only cure for loneliness, despair, and hopelessness is love. There are many in the world who are dying for a piece of bread but there are many more dying for a little love. The poverty in the West is a different kind of poverty — it is not only a poverty of loneliness but also of spirituality. There’s a hunger for love, as there is a hunger for God.”  

~Mother Teresa

Back practicing in Philly

Finally! It's amazing how the ashtanga community has grown over the past few years. When I first moved here I would bike down to old city every morning to practice (it was usually just myself, Adam, and maybe one or two others). That place closed and there was no other mysore class in the entire city, so I practiced on my own in my little apartment the rest of that year (not very successfully). Karen opened Yoga Squared the summer after my first year and at first I would often be the only one practicing. But the community has been gradually growing and now over twenty of us squeeze next to each other with just a few inches between our mats... it's sweaty and stinky and I LOVE it.

David Garrigues is a great teacher and he's making me think about a lot of things... breath, bandhas, jumping back. I'm trying to study for my board exam tomorrow (I think this is my last exam of medical school) but I can't stop daydreaming about kapotasana. I dread it and long for it at the same time.

Kapotasana

Mind/Body workout for chemo fatigue

After that last post about chemo brain, the findings from this study just came out: "Mind/Body Workout Fights Chemo Fatigue."

The study enrolled 269 cancer patients in an 9-hour/week intense exercise program for six weeks. It included high-intensity physical training, body-awareness training (yoga/pilates), relaxation training, and massage. They found a significant reduction in fatigue and increase in vitality. The findings are not too surprising, but it's still nice to have a study proving it.

Yoga for "chemo brain"

I'm back in DC practicing this week and learned that one of my yoga teachers had B-cell lymphoma and has been going through chemo. He looks great I would have had no idea if he hadn't told me. He has continued his practice through all of his treatments despite his body feeling like "sludge." He just started moving more slowly and holding postures longer. He said he had "chemo brain" and some neurologic problems from the medication, but attributes how well he is doing now to his yoga practice... I bet he's right.

On top of all this, he doesn't have health insurance and laughed at the thought of ever being able to afford it.

The minimalism of yoga

As I am organizing my life and getting ready to start my research year, I realize another reason I am drawn to yoga. It is just you, your body, your breath. You don't need any props, no shoes, no equipment, and no weights except your own self.

Minimalism.

Lifestyle change & your telomeres

There's been some recent talk about telomeres (pieces at the ends of the chromosome that influence the health and aging of our cells) and telomerase (the enzyme that maintains the length of telomeres), as one of the recent winners of the Nobel Prize in Medicine, Dr. Elizabeth Blackburn, helped discover telomerase.

In the image below, the red parts are your telomeres - the pieces of DNA at the ends of your chromosomes:
Dr. Blackburn worked with Dean Ornish and others on a study published last year in The Lancet which showed that lifestyle changes actually increase telomerase, and thus increase the length of telomeres. While most of the medical world is talking about the potential of medications to increase telomerase, Dean Ornish is saying that "Lifestyle changes are not only as good as drugs, but often, as in this case, even better."

The Ornish study enrolled 24 men with prostate cancer willing to make the following lifestyle changes for 3 months:

• A 3-day intensive residential retreat, followed by an outpatient phase where participants met with staff for 4 hours per week and had weekly telephone contact with a study nurse.
• Lifestyle modifications included a low- fat (10% of calories from fat), whole foods, plant-based diet high in fruits, vegetables, unrefined grains, legumes, and low in refined carbohydrates.
• The diet was supplemented with soy (one daily serving of tofu plus 58 g of a fortified soy protein powdered beverage), fish oil (3 g daily), vitamin E (100 IU daily), selenium (200 μg daily), and vitamin C (2 g daily).
• Moderate aerobic exercise (walking 30 min/day, 6 days/week)
• Stress management (gentle yoga-based stretching, breathing, meditation, imagery, and progressive relaxation tech-niques 60 min/day, 6 days/week).
• A 1-hour group support session once per week.
• Participants were provided with all of their food during the intervention period. A registered dietician, exercise physiologist, clinical psychologist, nurse, and stress management instructor were available for education and counseling.

They measured telomerase activity in peripheral blood cells at enrollment and at 3 months to see if there was any change. They found a statistically significant increase in telomerase activity (p=0.031). After only 3 months!

What might they find after several years of these lifestyle changes?! 

Notes on Ashtanga, by Todd Roderick

I like these essays by my yoga teacher here in Atlanta, Todd Roderick:


Yoga as Therapy
Yoga Chikitsa
Ashtanga is a traditional form of hatha yoga and is among a rare few that could be considered a science, continually proving itself as a way to create and maintain well-being on many levels. In India, this science has been passed down from teacher to student for hundreds of generations, keeping this practice refined and alive. Ashtanga's primary series is known as yoga chikitsa, literally "yoga therapy." The practice encompasses a broad range of physical yogic practices which promote balance physically, mentally, and spiritually. Hence it is inherently theraputic. Struggle is an inevitable piece of the human experience, and a mindful yoga practice offers the space to face any type of difficulty. Whether training for a marathon or preparing for another round of chemo, energy and consciouness can facilitate any training or healing process.

Everyone responds to yoga differently. Just like a single pill can't cure an illness, no single yoga pose or class will fix destructive patterns of behavior. Rather than limiting oneself to specific kinds of classes, such as "Yoga for [body part]" or "Yoga for [illness]", a more whole-istic approach is more effective. Healing involves the whole body, the whole mind, the whole self. More importantly, the process takes time. Yoga is the antithesis to instant gratification—longer to occur, longer to remain.

Because Ashtanga requires students to practice consistent sequences of poses, this idea can seem counterintuitive. Yoga chikitsa works on everyone because it targets the foundation of physical health: the body's various systems (such as circulatory and digestive) functioning fully. In other words, the lack of optimum physical health often proves to be the root of most ailments and imbalances, physical or otherwise. All yoga enables the body to become stronger and more flexible, and Ashtanga combines that strength and flexibility with pranayama (breathwork) to allow openings on multiple levels.


Yoga, the essence of self-discipline
Hatha Yoga Pradipika:
“Success comes to him who is engaged in the practice. How can one get success without practice; for by merely reading books on Yoga, one can never get success”. [Verse 67]

Yoga, in its many forms, essentially is a self-discipline, of both body and mind. Yoga practice is not intended only for the days when one feels good, inspired, awake, enthusiastic, or energetic. Yoga is meant to be practiced through all that life brings us. Steadfast daily practice is the only way to progress through yoga's many stages of personal development. Whether sick, worried, sad, injured, tired, or even indifferent, the discipline of yoga calls us into that present moment to face life's constant changes.

The mind will always provide opportunities to rationalize not practicing. In other words, one must resolve to practice in spite of lack of motivation. Sri K. Pattabhi Jois always stressed the importance of consistency. Through his decades of experience, he knew that yoga was not only a tool to face difficulties in life, but also a way to create the capacity and potential for growth. In tough times, when one hones the ability to make excuses, a steady practice can make a huge difference. Pattabhi Jois advised students to come to class, roll out their mats, begin their practice, and see where that led. This teaches not only discipline, but detachment.

Ashtanga is a demanding form of yoga, both physically and mentally. Establishing a foundation requires consistent effort. Once formed, it must be maintained for safe and steady progress. Daily practice will always challenge you, and saving those challenges for “good” days makes the difficult even more so. Feeling under par doesn’t guarantee a negative experience on your yoga mat. In fact only practicing when you feel at your peak can actually be more discouraging than coming to class consistently, even with lower energy.

In a crazy week, coming to class every morning for half an hour is more beneficial than one day for ninety minutes. Yes, there are times when rest is needed and you shouldn't practice, such as running a fever. It's not essential to have a kick-yourself-in-the-ass practice. A modified practice is appropriate for weathering most maladies. Overall however yoga is more effective in frequency than duration. As you practice, you allow your body to accommodate what your breath is capable of. Likewise, you must allow your practice to accommodate what your life is capable of.

Self-discipline, like many other qualities, must be cultivated. Progress in any form is accomplished through sustained effort. There are no shortcuts. The truest essence of yoga is not in any outward physical manifestations, but rather in the deeper, more subtle and profound changes, gained only through meeting the challenges that a daily practice reveals.

Some tips we've gleaned over the years, all relating to maintaining as consistent a schedule as possible:
~Maintain a regular sleep schedule; sleep no longer than 6-7 hours a night.
~Go to bed early, no later than 11pm.
~For morning practitioners, eat a light dinner (easily digestible foods) no later than 2-3 hours before bed.
~Drink a glass of water before sleeping.
~Shower briefly first thing in the morning.
~Drink a small cup of tea or coffee half an hour before practice.
(not a venti latte)

Yoga, 99% practice, 1% theory - Sri K. Pattabhi Jois

Health reform

The new director of the CDC, Tom Friedan, spoke to us about the CDC's priorities and challenges and gave us some insight into health reform. He said we are closer than ever to changing the health care system. He discussed the 3 main challenges in doing this:

1) Expanding access - to the millions of uninsured.
2) Reducing cost - we spend $2.5 trillion per year - every $1 out of $6 goes towards health care.
3) Improving the health value for the health dollar - currently if a doctor doesn't prevent illness, they make more money - the incentives are all wrong.

He then discussed some of the areas where CDC plays a role, including increasing the emphasis on prevention, creating community guides for preventive services, and helping create a "Prevention Trust" as part of health reform. The goal is to spend $10 per capita per year for prevention. Right now it's $0 per capita for prevention and $8,100 per capita per year for treatment. 

He quoted President Obama saying, "Facts and evidence must never be twisted or obscured by politics or ideology." 

The Power of Yoga

Excellent article from 2001 Time Magazine, and some key points and questions raised:

• Can the benefits of yoga be measured by conventional medical standards? Can yoga be a science? Or is it possible that yoga cannot be studied with western methodology where truth and fact are proved through randomized, double-blind tests. As the article says:

"The double-blind test, beloved of traditional researchers, is impossible when one group in a study is practicing health yoga; what is the control group to practice--bad yoga?"

•  The issue of funding (funding --> studies --> evidence): 

"The traditional funder of studies, the pharmaceutical giants, see no financial payoff in validating yoga: no patentable therapies, no pills."

• The medical world's skepticism of yoga: 

"At the heart of the western medical establishment's skepticism of yoga is a profound hubris: the belief that what we have been able to prove so far is all that is true. At the beginning of the 20th century, doctors and researchers surely looked back at the beginning of the 19th century and smiled at how primitive "medical science" had been. A century from now, we may look back at today's body of lore with the same condescension."

• How little the medical world actually knows, how fragmented it is, how specialists have conflicting opinions, and how disempowering this can be for patients. Complementary and alternative medicine is appealing because it gives patients a feeling of control over their health. People aren't going to wait for doctors to have the "evidence" so it's important for physicians to be aware of what their patients are doing.
• At the time of this article (2001), there had been a few controlled studies on yoga. They discussed Dean Ornish's 1990 study that demonstrated how lifestyle changes of yoga and a low-fat vegetarian diet could reverse coronary artery disease. Ornish then published a study in 1998 showing that 80% patients in the experimental group avoided bypass or angioplasty, and that these lifestyle interventions would save an average of $18,000 per patient (while the cost in the control group was over $47,000). Thought it may seem more likely that this change was from diet alone, Ornish said, "Adherence to the yoga and meditation program was as strongly correlated with the changes in the amount of blockage as was the adherence to diet."
• The discussion on yoga and the immune system (I'm looking for these studies!): 

"Exercise in general activates the flow of lymph through the body, speeding up the filtering process; but yoga in particular promotes the draining of the lymph. Certain yoga poses stretch muscles that from animal studies are known to stimulate the lymph system. Researchers have documented the increased lymph flow when dogs' paws are stretched in a position similar to the yoga "downward-facing dog." 

•  Ornish's discussion of the reception of his findings by his colleagues: 

"I used to think good science was enough to change medical practice, but I was naive. Most doctors still aren't prescribing yoga and meditation. We've shown that heart disease can be reversed. Yet doctors are still peforming surgery; insurance companies are paying for medication -- and they're not paying for diet and lifestyle change education." 

• For yoga to be a sucessful preventive health measure, it has to be accessible to everyone, not only the wealth and already-fit:

"America has the fittest people inthe world, and the most obese. Yoga, typically, is practiced by the fit. Exercise, the care and feeding of body and possibly mind, their second career. The folks in urgent need of yoga are the ones who are at the fast-food counter getting their fries supersize; who would rather take a pill than devote a dozen hours a week to yoga; for whom meditation is staring glassily at six hours of football each Sunday; and who might go under the surgeon's knife more readily than they would ingest anything more Indian than tandoori chicken."

"Heat Therapy" for cancer?

At the European Cancer Organization/ European Society of Medical Oncology joint meeting, some interesting study results came out on "heat therapy."

The study enrolled 341 patients with advanced soft tissue sarcomas. All patients received surgery, radiation, and chemotherapy. Half were randomized to heat treatment in addition to chemotherapy, and patients were followed for three years.

The heat treatment provides "regional hyperthermia" using "focused electromagnetic energy" to heat the tumor and surrounding tissues to 104-109.4 degrees Fahrenheit. According to this article, it works by improving blood flow to the area which allows more chemotherapy to reach the tumor. This increased blood flow also increases oxygenation to the tumor, making it more sensitive to radiation. They also report that "the heat interferes with cancer cells' repair mechanisms and they die off."

The results are pretty interesting -- finding that patients that received the heat therapy were:

• 42% less likely to have recurrence of their cancer or die.
• 30% less likely to experience recurrence or spread of cancer or die.
• 30% more disease-free time (32 months in heat treatment group versus 18 months in control).
• 66% less likely to die (when analyzing only the 269 patients that followed through on all treatments).

They say the treatment has promising findings for cervical and bladder cancers... and I would think for many others as well. 

Regional hyperthermia. Are there other ways to create this? Does it have to get as high as 104-109 degrees F to see benefits? What about the beneficial effects of a milder systemic hyperthermia?

Skepticism from a CDC doc

I spent the day at the Tuberculosis (TB) clinic with an infectious disease doctor. We chatted during the breaks between patients and my research project and interest in yoga came up. He had a little smirk on his face and I asked him about his skepticism.

He was quiet for a few moments, then said, "What would you say if I told you I was studying yoga in TB patients?" We both laughed and then ended up having a good talk... and he brought up some good points that I appreciated:

• "[Studying something like yoga] has to be randomized... otherwise how will you know it's not all placebo effect? Anything that offers community, support, time for reflection, etc, will be show benefits."
• "You know, yoga will never be reimbursed." (Then a few minutes later) "Well, if you can show that you can reduce long-term costs with these interventions, that would be a really beneficial study" (and maybe eventually would be reimbursed).
• "Why breast cancer patients? We already have good treatments for that. But if you were to study yoga in blue-collar hypertension patients, now that would be an interesting study... Bringing a new cultural practice to that population." 
• He eventually became more encouraging: "Breast cancer patients do suffer from pain, anxiety, depression for which he could see yoga being beneficial... And we do need to figure out how to help people exercise more." 

He then advised me to go into a procedure-oriented specialty so I can make more money... because that is what will be most important to me in 20 years!

Macrobiotics: medicine for humanity?

I had lunch with my mentor at the CDC and his wife who is also a physician. She did residency in social medicine, followed by an adolescent medicine fellowship, then spent twenty years running a community clinic in downtown Seattle working with street children. Now, she wants to get more involved in bringing integrative health and lifestyle changes to the hospital system in Atlanta. She told me about her own history with breast cancer, and a mindfulness meditation program that she found really helpful. She said we have to start moving towards a prevention and empowerment model and that I have to be "part of the revolution."

We talked about her friend, also a physician, who was diagnosed with Stage 4 aggressive bilateral breast cancer in her 30's while pregnant with her third child. She received all of the standard treatment (surgery, chemotherapy, radiation) but on top of that she also radically changed her lifestyle.

Central to this lifestyle change was a switch to a macrobiotic diet. Now, 13 years later, she is still in remission and has had another three children.

A macrobiotic diet? Not something we learn about in medical school! But, it is one of the most popular lifestyle changes in cancer patients. There are case reports of people going on the macrobiotic diet and having complete recoveries from aggressive metastatic cancers (but not too many scientific studies behind them).

The macrobiotic diet 40-60% whole grains, 20-30% vegetables, 5-10% beans, a small amount of fish and seeds/nuts, weekly seasonal fruit, and the avoidance of meat, poultry, animal fats, eggs, dairy products, refined sugars and foods with artificial sweeteners or other chemical additives.

This study demonstrates that women on the diet have lower estrogen levels and higher levels of physotestrogen metabolites in the urine (possibly due to phytoestrogens in plants consumed in the diet). This finding provides some physiologic answers as to why the diet might be beneficial for women with hormone-sensitive breast cancer (similar to the reason Aromatase Inhibitors are effective drugs - they lower estrogen levels).

George Ohsawa, the Japanese prophet and philosopher who popularized the macrobiotic diet, said:

"No illness is more simple to cure than cancer through a return to the most elementary and natural eating and drinking diet." 

And Michio Kushi, Ohsawa's student, said after his experience in World War II:

"I realized that it was essential to recover genuine food, largely of natural, organic quality, and make it available to every family at reasonable cost. Only then could consciousness be transformed and world peace achieved." 

I like Kushi's explanation of macrobiotics:

"Macrobiotics is not simply or mainly a diet. Macrobiotics is the universal way of life with which humanity has developed biologically, psychologically, and spiritually and with which we will maintain our health freedom, and happiness. Macrobiotics includes a dietary approach but its purpose is to ensure the survival of the human race and its further evolution on this planet. In macrobiotics -- the natural intuitive wisdom of East and West, North and South -- I found the Medicine for Humanity that I had been seeking."

The Medicine for Humanity. I like that.

The social determinants of health

I went to a talk at the Centers for Disease Control about the social determinants of health and the need to strengthen the evidence-base in order to address these issues. The speaker, from the Cochrane Group, emphasized the need to move away from simply describing/summarizing the social inequities and to begin intervening and taking action.

They discussed the World Health Organization (WHO) Commission on the Social Determinants of Health (2008) three recommendations:

1) Improve daily living conditions.
2) Tackle the inequitable distribution of power, money, and resources.
3) Measure and understand the problem and asses the impact of action.

Previously, recommendations such as these came from "expert committees" where the evidence was not always clear. Now, WHO is pushing for more real evidence in their guidelines.

Some interesting issues came up with regard this push towards evidence and "evidence-based medicine."

• If you do studies, yes you will find evidence... but funding is what controls the kinds of studies that are done. If there is no funding to look at certain issues, how will there ever be any evidence?
• Are under-served communities equitably represented in these studies?
• The scientific evidence and numbers are not always congruent with, or representative of, what is happening on the ground. Can qualitative analyses adequately capture issues of social injustice and social inequities?

The speaker then listed the areas where the Cochrane Group is doing systematic reviews and making policy recommendations: income distribution, education, public safety, housing, employment, social networks, food supply, natural environment, transport, health systems.

All important, but what about diet? exercise? preventive health measures? Their challenge is that the evidence does not exist for them to conduct their systematic reviews. So, they end up doing "empty reviews," which in themselves are a powerful indicator of the areas that need more attention and funding.

To me, all of this is even more reason to study lifestyle interventions and preventive health, especially in underserved populations.