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.

Prescribing yoga (to myself)

As I come to the end of medical school and prepare for a life as a doctor, I have decided to dedicate an additional year to research. This is my time to ask questions and learn how to answer them. I will be designing and running a research study related to preventive health and lifestyle change.

Throughout this process, I will attempt to merge my two worlds of medicine and yoga. My goal for this blog is to keep track of my notes as I study both the science behind prevention and the daily practice of yoga.

Some things I've been thinking about:

Why I want to be a doctor:
To gain skills to help and heal people and communities. To know and understand the human body. To gain the knowledge, skills, and experience to influence policy change. To help shift the health system away from the disease-centric model and towards a model based around prevention and health optimization. To create a career that is an integral part of my life and driven by what I feel passionate about.

Why I practice yoga:
It has become a daily habit and part of my morning routine. It connects me to a wonderful community. It's an intense and challenging physical practice. It prepares me for my day ahead, helping develop focus, discipline, efficiency, confidence, and creativity in all other aspects of my life. It takes me to the edge of where I think my body can go, then further. My mind is quiet, I notice my breath, I get out of my head. I am aware of how my mental and physical body are affected by what I eat, how I sleep, my stress level... it's a daily check-in with my body and mind.  It challenges and humbles me.

When time and sleep are sacrificed during medical school, it is easy to lose sight of our passions, priorities, and goals. In an attempt to reconnect with what initially drove me to medical school, this year I will be prescribing yoga to myself, while also researching lifestyle change and preventive health.

Welcome! Please leave your thoughts and comments!