Animals and ahimsa

My dad wrote this op-ed piece on CNN.com in response to the tragic death of the orca whale trainer this past week.

I especially like the quote by the late Jacques Cousteau:

"There is about as much educational benefit to be gained in studying dolphins in captivity as there would be studying mankind by only observing prisoners held in solitary confinement."

I watched The Cove last night, which I think everyone should see. There is an unbelievable amount of horror and violence occurring, which we unknowingly support by our consumption of seafood and our marvel of beautiful animals at zoos and aquariums.

I couldn’t agree more when my dad writes:

“The best, most compassionate way for us protect, learn about and appreciate the beauty of wild animals is to watch them from a distance, but never, ever touch. We need to leave them alone -- in the wild -- and stop interfering in their lives.”

This all comes back again to the fundamental yogic principle of ahimsa, or non-violence.

Important questions in leaving the good life

My class this week was on Bioethics – a week-long class that we are all required to take before graduating from medical school. I learned many things, and one of the most important being this: make a living will.

The majority of people in the United States die in health care facilities, and many of these deaths are long, drawn-out, painful, expensive, and emotionally draining for all involved.

Advances in medical technology have made it more and more difficult for people to die. Patients are kept alive indefinitely, with millions living in nursing homes on feeding tubes and thousands kept alive in a permanent vegetative state.

We talked about many tragic cases when family members have to make incredibly difficult decisions regarding the care of their loved one. Our discussions were mainly focused around helping others make these decisions, but it’s important to think about for ourselves as well. What would I want if I were in a persistent vegetative state? How long would I want to be kept alive? Would I want a feeding tube? A ventilator? CPR? What would I want one with my organs and my body?

These are really hard questions.

As Caitlin and I were walking to class yesterday, we talked about Scott Nearing’s death. His wife, Helen, writes about in her book Loving and Leaving the Good Life and in this essay.

In an interview in his late 90’s, Scott Nearing said, “I look forward to the possibility of living until I'm 99… if I can be of service, I would like to go on living.”

At age 98 he said, "Well, at least I can still split and carry in the wood."

At the dinner table a few weeks before turning 100 he said, “I think I won't eat anymore.”

Helen said she responded with, “Alright… I understand. I think I would do that too. Animals know when to stop. They go off in a corner and leave off food.”

Helen made him juices. Scott became weak and thin. After a few weeks, he said, “I think I'll go on water. Nothing more.”

He and Helen talked every day as he became weak and bed-ridden. Helen describes the morning of his death:

“In the morning of August 24, 1983, two weeks after his 100th birthday, when it seemed he was slipping away, I sat beside him on his bed. We were quiet together; no interruptions, no doctors or hospitals. I said, ‘It's alright, Scott. Go right along. You've lived a good life and are finished with things here. Go on and up - up into the light. We love you and let you go. It's alright.’”

I find his dying to be a beautiful, natural, painless, peaceful, loving, and spiritual act. He had given everything he could and was ready.

Meditation and the brain

This study just came out showing that Zen meditators had thicker areas of the brain associated with pain sensitivity (the anterior cingulate) when compared with non-meditators.

One of the researchers explained: “The often painful posture associated with Zen meditation may lead to thicker cortex and lower pain sensitivity.”

He suggests that it’s the posture that may lead to this brain change.

I’m wondering what vigorous exercise does to this part of the brain, and especially what the combination of meditation with exercise (i.e. Ashtanga yoga) might have on the brain. Maybe having a certain amount of regular voluntary pain increases our threshold, enabling us to withstand higher levels (back to the hormesis idea).

Passionately curious

I love this idea:

“I have no special talent. I am only passionately curious.”
~Albert Einstein

But how do we cultivate passionate curiosity (in ourselves, our patients, our students)?

I’ve been in a bit of curiosity lull, which I am attributing to the busyness of being back in school (lectures and small group discussions all day, assignments, research work and meetings, emails to catch up on, etc)...

It’s hard to feel curious when my time is cluttered, my mind scattered, and I am exhausted.

Yoga for high blood pressure

I was very excited to meet a researcher at Penn who did this study on yoga for high blood pressure.

They randomized patients (n=57) with early stages of high blood pressure to 12 weeks of Iyengar yoga or a control group consisting of standard dietary modifications.

In the group that made dietary changes, blood pressure significantly decreased in the first 6 weeks but was not sustained at 12 weeks. In the Iyengar yoga group, systolic blood pressure significantly decreased at 12 weeks, indicating a more sustainable and long-term benefit.

This preliminary study enabled them to get NIH funding for a larger, long-term study that is currently underway. They are looking at both dietary changes and yoga for hypertension (along with many other biomarkers and measures)…exciting!

Fiber in food and in life: Lessons from the Nearings

“Live hard not soft; eat hard not soft; seek fiber in foods and in life.”

~Scott and Helen Nearing

Scott and Helen Nearing – an inspiring couple!

In the early 1930’s during the Great Depression, the Nearings moved from New York City to rural Vermont in order to practice a new and sustainable way of living.

They read widely. They were experimenters. They valued self-discipline, exercise, a good diet, frugality, environmental consciousness, civic contribution, and social justice.

They learned to grow their own food (challenging in New England winters). They did not want to be dependent on money, thus learned how to provide most of their food needs (they had a year-round solar greenhouse). They tapped maple trees for sugar. They gardened organically. They built their own stone houses and buildings.

They thought cooking should be simple, that it should take less time to prepare than to eat. They made daily “horse chow” for breakfast (raw oats, raisins, lemon juice, and some vegetable oil), and salad and potatoes for lunch and dinner. They did juice fasts every Sunday.

They believed in dividing each day into three parts:
Bread labor: To meet basic needs of food, shelter, clothing, etc.
Civic work: To do something of value for the community.
Professional pursuits/recreation: To learn, read, write, pursue interests.

"Find some form of work - creative energy - into which you can concentrate your being; into which you can go with your whole heart."

~Scott Nearing

An art and a science

I’m reading Yoga: A Gem for Women, and I love how Geeta Iyengar describes yoga as both an art and a science (similar to the practice of medicine). She writes:

Is Yoga an Art?

Living is an art. Yoga enhances the quality of one’s life. Hence it is an art. It lifts up one’s thoughts and enables one to face life’s difficult situations happily and with equanimity; it teaches one to strive to achieve a goal in life; to cultivate friendliness, concentration, piety, contentment, joy, and to discard what is non-essential; to cultivate good habits and to lead a righteous life. Yoga is disciplined action to achieve and attain final emancipation.

Is Yoga a Science?

The science of Yoga consists of acquiring knowledge through observation and experiment. It is a science which deals with the body and the mind, whereby the rhythm of the mind is conquered by controlling the body. Through the practice of Yoga the health and strength of the body and the mind are acquired. Only when a state of equilibrium is reached between the body and the mind, does one become fit for Self-realization. The science of Yoga teaches one to attain this harmony in a skillful and systematic way.

The Low-Methionine Theory

"He who does not know food, how can he understand the diseases of man?" ~Hippocrates

Caloric restriction has been a hot topic in my course on “Aging” this past week, as it is a scientifically-proven method for prolonging life.

I also learned about another method for increasing longevity, and it has to do with the amino acid methionine. Here is a summary of the presentation I gave on it today:

**Note: I apologize for the technical nature of this post... if not interested in minutiae, please jump to the end for the short summary!**

 Food with a high methionine content

 Food with a low methionine content

What is methionine? 

• An essential amino acid
• One of two sulfur containing amino acids
• In the metabolic pathway of S-adenosyl methionine (SAM) and homocysteine
• An intermediate in the biosynthesis of cysteine, carnitine, taurine, lecithin, phosphatidylcholine, and other phospohlipids
• Most fruits, vegetables, and legumes contain very little methionine
• Meats, fish, eggs, and some plant seeds have high levels of methionine

Methionine-restriction and longevity:
This study from 1993 showed that cutting dietary methionine by 80% in rats increased longevity by greater than 40% in both mean and maximal lifespan. The rats had free access to food and ended up eating more calories per gram of body weight. They were not calorie-restricted.

More recently, other researchers have confirmed these results and found that methionine-restricted mice (with normal calorie intake) had:

• Lower levels of IGF-1, insulin, glucose, and thyroid hormones (these changes are also found in calorically restricted animals)
• Delayed onset of clouding of the lens in the eye (cataracts)
• Delayed immune system changes (changes in T cell subsets)
• Livers more resistant to oxidative stress
• Decreased levels of mitochondrial oxidative damage

Potential mechanisms:
The following mechanisms have been suggested to explain these longevity findings from low-methionine diets:

1. Endocrine changes including decreased IGF-1, T4, glucose, and insulin (all of which are important in the aging process)
2. Hormesis (chronic low levels of stress builds “immunity” against bigger stressors)
3. Changes in levels of s-adenosyl methionine (SAM) and homocysteine (thought to play a role in neoplastic, cardiovascular, and other aging-related diseases)
4. Changes in glutathione (glutathione is protective against oxidative damage) 
5. General decline in protein synthesis (may be protective against age-related decline)

What I really want to know is, what happens to caloric-restricted animals when you supplement methionine levels? Does that diminish any of the longevity benefits? Calorie-restrictors cut their methionine intake simply by eating fewer calories...  what if the longevity benefit is coming from the methionine-restriction rather than calorie-restriction?

What might this mean for humans?
The vegan diet (which includes no animal products) is low in methionine. Here is why:

• The methionine content of plant proteins, legumes, soy, and nuts is lower than in animal proteins
• The overall protein content of plant-derived foods is lower than animal-derived foods
• Plant proteins are digested less efficiently than animal proteins

Studies on vegans provide some evidence for increased longevity:

• Vegans have lower IGF-1 levels (suggested to be a “pacesetter” in the aging process”)
• Vegans have lower insulin levels (lower insulin levels leads to lower levels of IGF-1)
• Vegans have lower rates of diseases of aging, including cancer, diabetes, and cardiovascular disease

Summary:

• A low-methionine diet in animal models has been proven to delay the aging process
• Vegan diets are low in methionine, and human studies on vegans provide some evidence for increased longevity in this population
• There are many remaining questions, and some of mine include: Calorie-restriction versus methionine-restriction – are they additive? What is the impact of methionine-restriction on fertility? How does methionine-restriction impact telomere length/telomerase activity? 

This longevity theory makes the vegan diet even more attractive... adding to the ethical, environmental, and health benefits that are already known.

I am curious about what the Calorie Restriction Society would think about this. Are there any Methionine-Restriction Societies? This idea of methionine-restriction might be something The Vegan Society could discuss/advertise.

Hormesis

I’m taking a course on Aging this week and one idea we keep coming back to is this concept of hormesis. Hormesis suggests that low-levels of poisoning can be protective by building up the body’s immunity against the poison.

 

If a poison/toxin is given in a low dose, 

it will then be inhibited when given in a high dose.

Image credit here

Hormesis is one theory for why caloric restriction extends lifespan – it induces a chronic low level of stress is ultimately protective. People who calorically restrict have elevated levels of corticosteroids (stress hormone), which may then help build resistance to other life stressors.

Maybe this is another reason why the ashtanga yoga practice (or any regular exercise) is beneficial. By subjugating oneself to this daily stressor, perhaps it raises the stress threshold and builds “immunity” against much bigger life stressors (i.e. disease).

Triple negative

This was an inspiring TODAY show segment (~5 min) about Jennifer Griffin, a 40 year-old reporter and mother of three who was diagnosed with Stage 3 “triple negative" breast cancer 5 months ago.

This designation of triple negative is relatively new and means the tumor is negative for both estrogen and progesterone receptors (ER/PR) and the HER2 protein. It is an aggressive form of breast cancer, occurs in about 15% of breast cancers, and is not susceptible to hormonal treatments (but is susceptible to chemotherapy).

Triple negative breast cancers tend to occur in younger women. In Jennifer’s case, it was 8cm - about the size of a lemon - and had been masked by pregnancy and breast-feeding.
 
Jennifer emphasizes the important of exercise throughout her treatment. “You need to exercise every day.” She looks amazing, and as they say in the segment, “she’s in the best shape of her life.”

When she shaved her head before losing her hair to chemo, Jennifer said, “When I first looked at myself in the mirror, I felt very strong… like I was a warrior.”

I also liked how she said she never goes out without her “body armor” – which includes her wig and her lipstick – to make sure she doesn’t feel like a sick person.

Learning from the Ashtanga classroom

“It is the supreme art of the teacher to awaken joy in creative expression and knowledge.”
~Albert Einstein

I’m back in the classroom for the next month for my last structured “class” of medical school. I’m surprised at how hard it is for me to sit for 8 hours, absorbing lecture after lecture after lecture.

There are certainly some wonderful medical school professors -- people who inspire energy, innovation, passion, and ideas. But sometimes I find the classroom environment to be stifling with minimal back and forth communication and questioning... leaving my classmates and me sitting there with dimmed eyes, bored minds, and listless bodies.

I find myself comparing this classroom to my other place of learning -- the Ashtanga “classroom.” There, the learning is active. The teacher is hands-on. We learn by trial and error. Mistakes are expected and welcomed. We are strengthened, challenged, and pushed to our limits. We have autonomy while also having structure and discipline. From this foundation, we are inspired to read and study on our own, to deepen our own learning.

One of the most important roles of the physicians is that of a teacher… and I think we can learn a lot from other places of learning, like the Ashtanga practice room.

Injuries and women

Lately, I’ve been practicing next to a significant number of injured women… and seemingly uninjured men. This gender discrepancy could be for many obvious reasons -- maybe there are simply more women practicing yoga (making the odds higher), maybe the injured women have been practicing for a longer time-period (thus more prone to overuse injuries), maybe women are naturally more flexible (and thus push themselves too far), or perhaps some men are injured but are masking their injuries.

After some research, I found that female rowers are injured more frequently than their male counterparts. This study looked at 398 rowers (42% female, 58% male) competing in the Junior World Rowing Championships in 2007, finding overall 73.8% reported overuse injuries, and 26.2% reported injury from a single traumatic event. Females had more injuries than males (110.2 vs 90.5 injuries per 100 rowers). (I'm still wondering if there was a gender difference in traumatic versus overuse injuries).

This is leaving me wondering -- is there something that makes women more prone to injuries from intense physical practices such as Ashtanga or rowing?

I’ve been thinking about the hormone progesterone. During pregnancy, the high levels of progesterone help the woman’s body gain flexibility in preparation for labor and delivery. Progesterone levels also rise in the last two weeks of the menstrual cycle (the “luteal” phase). Could this make women more “open” during this part of the menstrual cycle, and thus more susceptible to injury? (It could be coincidence, but this was the time when I pulled my serratus anterior back in December).

I was glad to see that this question has begun to be studied. Though a very small sample size (n=8), this study showed no difference in flexibility over the menstrual cycle. They divided the cycle phases into menstrual (estradiol and progesterone levels low), ovulatory (estradiol high and progesterone low), and luteal (progesterone elevated), and measured maximal isometric voluntary contraction, muscle activation level, and tendon properties (using ultrasound). They found no significant changes during the three phases.

I would love to see a prospective study of hundreds of Ashtanga practitioners (or a similar daily physical practice), that tracks type of injury along with menstrual cycle phase/progesterone level. In the meantime, I’ll continue with self-observation on this question.

Looking outward

 

“Love does not consist in gazing at each other 

but in looking outward together in the same direction.”

~Antoine de Saint Exupéry

Evidence-based food

This flyer popped out when I opened my miso:

Wow, good marketing! Curious, I searched for the study they cite.

They collected survey data on soy consumption (miso soup, soyfoods, and estimated isoflavones) of 21,853 Japanese females between 40-59 years of age, and followed them prospectively for nine years while tracking breast cancer diagnoses.

They found that consumption of miso soup and isoflavones (but not soyfoods) was inversely associated with the risk of breast cancer (comparing the lowest quartile of isoflavone intake to the highest quartile, the adjusted relative risk for breast cancer in the highest quartile was 0.46, with the 95% Confidence Interval=0.25-0.84). The association was even stronger when considering only post-menopausal women.

I will make sure to start having more miso. Maybe other companies should learn from their marketing strategies?

There is so much emphasis on evidence-based medicine, but what about evidence-based food? After all, food can be thought of as a kind of medicine we take every single day.

Evidence-based food. I like the sound of that.

Substituting coffee, thinking macrobiotic

As I was moving towards the end of my practice today, my teacher came over to adjust me. Please don’t ask me about my coffee detox, please don’t ask me about my coffee detox.

“So how’s the coffee thing going?” he asked as he pushed on my back.

I can’t lie to him!

“Ummm….well…. Ok I cheated. But just a little! It was a really small cup! Green tea was making me sick!”

He smiled, “That’s ok!”

He’s so nice. Then he said, “I forgot, I didn’t tell you what to replace it with. You need to have good substitutes.”

He said to get Dandyblend or Roma (made from malted barley and chicory) at Essene Market where I happened to be heading right after practice to meet my wonderful new friend, Teresa. Teresa has battled breast cancer for over 10 years, both with conventional treatment and many additional holistic therapies.

Several people I greatly admire are on the macrobiotic diet, including both David (my yoga teacher) and Teresa. I keep going back to the idea. If anything, I think this will be a slow and progressive process. I’ll start by making some small additions to my diet: miso soup, vegetables with sesame oil, and steel cut oats.

Caitlin and my miso soup attempt – pretty good!

My main concern with the macrobiotic diet is having to limit my fruit and avocado intake... my favorite foods. I asked both David and Teresa about this today. David said, “No, don't eat much fruit. Maybe in the summer.” And avocados? “Well you can’t be too strict! If you want avocado, not a problem.”

Teresa eats fruit… and lots of it. “I’ll eat a whole carton of blueberries!” she said smiling.

Time for yoga, technology for balance

“Life is like riding a bicycle. To keep your balance you must keep moving.”

~ Albert Einstein

Rather than simplifying our lives, sometimes technology seems to do the opposite…. new gadgets, hours in front the computer screen, google-reader feed and emails flooding in my inbox, and now the latest “google buzz” business.

Do these make me more productive, or are they scattering my energy and focus?

In my constant shuffle through information (and emotional) overload, I realize that certain aspects of technology have become daily necessities for my overall wellbeing.

Two examples I immediately think of are e-stickies and e-journaling. E-stickies on my laptop provide daily reminders of short-term projects, long-term goals, daily habits to cultivate, values to live by. The e-journal is my password-protected space where I safely de-clutter my mind… sometimes going months without it, but sometimes opening it multiple times a day.

Hiliary Critchley is an amazing woman, with whom I have had many coffee-date discussions about these issues… questioning ourselves: Is this what I really want to be doing in my life? Where do I go from here? How do I fit everything in? We both came to the practice of yoga, in part because it helps us with these questions.

Below, Hiliary talks about finding balance... and how technology helps, rather than hinders this process.

----------

Guest Blogger, Hiliary Critchley:

Time for yoga, technology for balance

The simple purpose that yoga plays in my life is the maintenance of balance.

The point of balance in an increasingly complex and technical world is to, according to the Wikipedia definition, “maintain the center of gravity of a body within the base of support with minimal postural sway.”

For me, this balance takes many forms:

• Balance in food consumption: A workout routine allows me to more easily walk by those aromas emanating from the closest restaurant. To remember that food is meant to nourish and sustain the body, which brings associated pleasure, but that food can also lead to negative health outcomes if over-indulged in.
• Balance in emotional state: The highs and lows are more easily taken in stride when viewed from a larger perspective. Yoga reminds me of my small place in the world and in history.
• Balance between work and personal life: My life is a mix of both. Each segment of my life should take only a certain percentage of my time and energy. 
• Balance in relationships with others and with myself: If one over-gives to others, yoga is a great way to reconnect with your own true desires. Sometimes these are hidden not within the complexities of the mind, but within the body.

Like most people, my challenge is to maintain a regular practice of healthy, balanced living.

Although there are plenty of arguments about technology disrupting natural human and community rhythms, there are just as many arguments posturing the opposite. While technology can drain my time and energy, it also enables me to squeeze in a yoga practice, to make productive use of time while waiting for people, and to make more time for my significant other, my friends, and myself.

Here are some ways we can use technology to help stay balanced:

• Reconnecting with friends: Social media (Facebook, Twitter) has made this exponentially easier than it was five years ago.
• Cooking: Look up a quick and healthy recipe on epicurious or food.com. 
• Maintaining daily health habits: Use free applications on the iphone like “Lose It” to look up the nutritional value of a meal about to be consumed, or “Yoga Trainer Lite” and “Yoga at Home” to get ideas for a home yoga practice when unable to make it to a class. 
• Traveling: When out of town, quick searches to find yoga and healthy food in a new city.
• Creativity: Blogging, writing, tweets, facebook updates... all opportunities for creativity, getting a message out there, or expressing an emotion when something out of the ordinary happens. 
• Laughter: Watching shows like the Daily Show or Colbert Report on hulu.com when you have a free 20 minutes. 
• Health monitoring: Using tools such as google’s personal health records to keep track of your cholesterol, BMI, vaccinations, etc. These are the wave of the future.

As I continue to work on balancing my time, rather than get distracted by technology, I try to use these tools to help me keep up a regular practice of yoga and health maintenance. In the end, it is that which helps me balance all other aspects of my life.

A gem for women

I can’t wait to get my hands on Geeta Iyengar's book: Yoga, a gem for women.

Thanks to Caitlin for telling me about the book and for sharing this quote by BKS Iyengar (Geeta's father), in the forward:

"The general notion is that Yoga is not intended for women. It is fallacious and it underrates the moral, intellectual, and spiritual legacies to which women are entitled as much as men… Multitudes of women are seen nowadays who equal and excel men in every faculty. More women can now come forward and strive to attain new heights to enrich Yoga, which is one of our ancient heritages."  

~BKS Iyengar

More on calorie restriction & aging

A commenter from the previous post sent a link to this interview that I think deserves its own posting.

If anyone else gets a chance to listen to the interview (~40 minutes), I recommend it. It’s with Greg Critser, author of the book Eternity Soup: Inside the Quest to End Aging.

Aging/Anti-Aging is a topic of much interest to people, for obvious reasons. It is also a hot topic in science among researchers. Why?

1) We now know that aging can be slowed.

2) We know that “aging” is not universal across all living beings. One of the main reasons humans die is because our immune system stops functioning.

A number of species do not really age, but rather, ultimately die because of predation or infectious disease. For example, we know the pacific rockfish lives at least 200 years and their immune system remains intact.

(photo credit here)

Critser talks about the Caloric Restriction Society -- people who eat 30-40% fewer calories than would normally be consumed at a meal. The theory for why caloric restriction works is that it lowers growth hormone over time, thus re-channeling energy from growth and development into body maintenance (this is in contradiction to the anti-aging industry selling growth hormone to prevent aging).

Critser was skeptical of this caloric restriction idea, saying the only evidence for this is based on animal studies. The data for humans just doesn’t exist yet.

I agree it would be nice to have evidence in humans. But I am also wondering how long it will take to get that evidence? We may not have it until these human experimenters’ lifetimes are over. And by then, non-members of the “Caloric Restriction Society” may already be dead! Maybe animal studies are the best we can rely on for now to make our own life-decisions. At least future generations will benefit from human evidence that comes along.

There was a caller from the Caloric Restriction Society (who seemed a bit miffed at Critser) who said that actually, there is already evidence for benefits of caloric restriction in humans – improvements in carotid plaque, cholesterol, heart elasticity, and endocrinological changes.

When asked, the caller stated that he eats ~1800 calories/day.

Wait, 1800 calories/day doesn’t seem too restrictive??

Calorie-restriction late in life

This study on calorie restriction just came out (full text here).

It caught my attention because it demonstrates health benefits of short-term calorie restriction late in life, indicating that it may never be too late to reverse lifelong damage done.

The researchers found that older mice fed a calorie-restricted diet (30% of normal) for 8-weeks had an increase in nitric oxide production, and improvement in vascular endothelial function. Nitric oxide plays a key role in vessel dilation (which is impaired in older people, leading to cardiovascular disease). The calorie-restricted mice also had reduced oxidative stress through decreased superoxide production and increased anti-oxidant enzyme activity.

The study did not find changes in inflammation levels, unlike the findings in long-term calorie restriction studies such as this one.

Some of my questions: This study was done in mice -- does it apply to humans? 8-weeks in a mouse life is equivalent to how long in a human life? What would similar “calorie-restriction” look like for humans? Does it matter what type of food is consumed, or just the calorie-restriction?

The minimalism of no addictions

I thought these “simplicity living tips” from the Becoming Minimalist blog were excellent.

In light of my coffee detox, this one is particularly relevant to me right now:

"Reject anything that is producing an addiction in you. Refuse to be a slave to anything: coffee, cigarettes, soda, television, chocolate, alcohol… "

Even though the denial of coffee over the past few mornings has left me tight, tired, and bored during practice, I’m sticking with morning tea for the time being.

I’m also continuing my sugar-weaning (those dark chocolate-covered almonds waiting for me in the kitchen make this nearly impossible).

Struggles with self-practice

No community practice this morning (too much snow). Why is self-practice so hard? There is something powerful about having people practicing around me, or knowing a teacher is watching me.  

This is something to think about when healthcare providers are encouraging patients to make lifestyle change and develop new health-habits. There is power and strength in community.

“There can be no vulnerability without risk; there can be no community without vulnerability; there can be no peace, and ultimately no life, without community.” ~M. Scott Peck

Yoga experimentation

Snowed in... made for a day of tea, reading, yoga experimentation, working on new projects, thinking about how Einstein said “New ideas meet their greatest opposition from those who misunderstand them.” 

I’m going to start making more time for personal yoga experimentation.  Today, this led me to two little tricks that I thought I’d share:

Jumpbacks: I've been making minimal progress on these little buggers. But today at home, I put on socks which helped me slide my feet through my arms without having to pause in the middle for that awkward extra hop. Mariana has been telling me all along that I should get yogitoes, and now I see why. Maybe it's time for me to invest in this.

Handstand: Again, making little progress in my attempt to jump up keeping both feet together. Almost every day, my teacher has been pushing on my upper back between my shoulder blades saying “resist, resist, this has to be STRONGER.” I didn’t really understand what he meant. But then today while at home, I tried pushing my head against the wall while jumping up with my feet together. Somehow that also helped engage my bandhas, and it worked! The resistance against my head transferred to my upper back and I actually jumped up to handstand! Not the most graceful, but I'm learning to take baby steps... 

Innovation

It is rare for me to feel energized and inspired by a big medical school lecture... but yesterday was one of those days. 

Dr. David Brailer gave an excellent talk about innovation and entrepreneurship… and why they matter for health reform. 

Where we are now. 

“No other industry has an output that actually changes the human equation… that makes the human condition better.” 

• A child born today has >50% chance to living over 100. Over the past 100 years we’ve added 5 years to our life expectancy (in the past 30 years, we’ve added 1 extra year of life per year). 
• A lot of this increase in life expectancy is from living in a safer society – better public health, fewer homicides, fewer accidents. But a lot of this is also the result of innovation. Penicillin, Insulin, Antiretrovirals. These are the building blocks from which life expectancy grew. 
• Many inventions do not come out of laboratories, but rather they are concepts. The Framingham study (from which many cardiovascular and other treatments have stemmed), early cancer detection, evidence-based medicine. These are not treatments, but they make our treatments more effective. 
• As more and more companies suggest new products, he asks, “So what? What is this really going to contribute?” 

Health information technology.

“The great lifesaver of the 21st century will be health information technology.” 

• A patient needs to be able to go to the emergency room and have their medical records available right away – similar to how we can quickly get cash from an ATM.
• When a doctor uses a computer, they deliver better care (access to evidence-based medicine, health alerts, drug-dosing, drug-interactions, etc.) 
• The single largest growing item in federal budget is health information technology. We are living through this transition now. 
• Personal health records: Consumers thirst for being more involved in their care. They want to be more knowledgeable, more empowered. They want access to information. There is going to be a tremendous change in health literacy over time. 
• Where we are heading in terms of health information technology: 
• Telemedicine -- Getting specialists out to rural areas. 
• In-home monitoring -- Keeping a patient at home with an “electronic garden” rather than putting them into expensive skilled nursing facility. 
• Teleradiology. 
• "Autopilot" controls -- Just as planes have systems which don’t allow pilots to make unsafe maneuvers, this would similarly prevent physicians from cutting too close to vessels, etc. 
• Pharmacogenomics -- Looking at how genetic influences responses to drugs. 
• Data mining -- Sifting through clinical data to find powerful associations (this is how COX-2 inhibitors were taken off the market). 
• Real-time monitoring -- Of outbreaks, pandemics, etc. 

The culture of innovation. 

• We live in a “culture of health innovation.” 
• On one side, there are the inventors and entrepreneurs: 

“It is not usually that they have a new and different idea, but it is that they never give up on that idea. They push, break rules, frustrate conventions, risk careers, push push push. It’s not the discovery (though this happens as well), but it’s the hard work.” 

• On the other side, there is the more cautious, scientific discipline. The standards of conduct, inertia, status quo… all pushing back against ideas. 
• The purism and methodology of science lives in a messy and complicated real world, and it is the balance of these forces that creates our culture of innovation. 

How innovation happens. 

• Absolute persistence. Repeated failures, challenges, setbacks. This has been true for dialysis, organ transplant, the discovery of mRNA, the development of the CT scanner, etc.
• What IS innovation? It is when people work against norms and fears. It is relentlessness and not giving up. It is losing reputations. It is not working years, but working decades. 

Lessons from the arts: two types of geniuses (most innovators fall under category #2!). 

• One: The conceptual genius -- Picasso example. Picasso did his best work in his 20s. His earliest works are astronomically priced, while his works later in life are reasonable. His price curve goes down. As soon as he looked at the world, he knew. He painted each painting ONCE. He did not go back. 
• Two: The evolutionary genius -- Cezanne example. Cezanne did his best works in his late 50’s. His price curve goes up higher and higher. He went through iterative, exploratory processes. He repeated paintings, destroyed them, and painted them again 20 years later. It took him decades to evolve his style. He did not give up. 

What is holding back health reform. 

• The health system is protected. It is in the American psyche that we will find cures for diseases and live longer, healthier lives. People are scared that if we change policy too much, it will interfere with our system capable of discoveries and cures. 
• The health system is inertial. Current policy protects the status quo, even if it’s a bad status quo. For example, despite evidence on the dangers of tobacco, the federal government subsidized tobacco production until 2004. They subsidized the price per pack by more than half. Similar stories for getting insulin pumps, seatbelts, intensive care units into the system… the policy world is really hard to change. 

Protecting innovation.

• Americans have a depth of perseverance and relentlessness. No policy will change our culture of innovation. The innovation system works precisely because it goes against the status quo. 
• The question is: How can our health system encourage more innovation?

Guest blogger, Caitlin White: Different perspectives on injury

Different perspectives on injury

Caitlin White

Since deciding to enter the medical profession, I have found myself analyzing the personal interactions I have with health care providers. I keep a running list in my head of ways in which I would like to emulate them, or ways in which they leave me with a sour taste in my mouth. I tend to dwell on the latter, asking myself: "What is it about that interaction that left me feeling so empty? So unheard?"

I recently injured myself while coughing - of all things - and after several frustrating weeks of practicing through the pain, I re-injured my muscle worse than it had originally been. After about a week of giving up practice to allow it to heal, I found myself back at the studio and impatient for its resolution. It didn’t seem to be getting better so I made an appointment with a sports medicine MD and an acupuncturist/massage therapist, while also soliciting guidance from my Ashtanga teacher (the health care provider I see most regularly!!). Each one left me with a completely different impression.

1. The MD: My visit was less than 15 minutes, and she examined me for less than two of those. Her diagnosis? 

"It is probably a just pulled muscle. I am not going to have you go through range of motion or strength testing because these chest wall injuries are difficult to tease apart anyway."

She told me to take off completely (not even stretching) for 6-8 weeks and take nine ibuprofen a day (3 tabs three times daily).

2. The Acupuncturist: My visit lasted an hour. Of that, he spent about 20 minutes examining my side, rib alignment, and range of motion. His conclusion?

"I think you will respond better to acupuncture than massage. I suspect you pulled an intercostal muscle because your pain tracks along the rib, however I am also concerned that you injured your rib because there is a painful ridge in it near your spine, and it is tender from its origin to insertion. I would like to you see me at least three times over the next three weeks, and I believe that it will improve greatly in that time."

3. My Ashtanga teacher: Our discussion lasted about 10-15 minutes after I finished my practice. His advice?

1) Continue coming to practice daily.

2) "Listen to your body- it is your instrument for exploration; observe and respect it. Do not force it to do something that is painful, otherwise it will not heal."

3) "You likely pulled a muscle. Try not to get too frustrated, and remember that this is not permanent."

4) "Sometimes an injury like this is the body's way of slowing us down. Perhaps you were asking too much of it in the first place, moving too fast. Now is the time to take it slow and reconnect with your body."

Our interactions with people can be so different while trying to accomplish the same goal. I am disappointed that my appointment with the MD was time wasted, I am optimistic that the acupuncturist will help my side heal faster, and I am inspired by my teacher to focus less on the physical poses (asanas), and more on being present in my daily practice.

Coffee detox

I ran into my teacher as I was locking my bike for practice this morning. Riding up the elevator together, I decided to risk disapproval and ask him his view on pre-practice coffee (throwing in the Sharath coffee endorsement: “no coffee, no prana”). 

No…“not good,” he said.

Hmm, but I *love* my morning hour of coffee and reading!

He said, “just try it without.” Replace coffee with green tea. And not just for two days – it has to be for at least two weeks to really get it out of my system. 

“And anyway,” he said, “coffee tastes way better after practice.” I then cringed as I confessed to also having coffee after practice. He shook his head, “no, that’s too much!” Too much. 

So, tomorrow I will start a two-week pre-practice coffee detox.

Prescribing fasting

In our culture of consumption, we rarely hear about the benefits of fasting. Many of us have probably never gone a day without eating (sick days don’t count).

That’s one reason I found this study so intriguing (thanks Stephan for drawing my attention to this).

Not surprisingly, fasting is not a concept touched upon in the medical school curriculum. In fact, it seems that the reverse is modeled. Unless a patient is NPO (nil per os = nothing by mouth) in preparation for surgery (or for some other medical condition), hospitalized patients are fed abundantly with typical hospital food (not to mention juice and gram crackers for snacks).

The study tested “alternate day calorie restriction (ADCR)” in overweight asthma patients. They enrolled 10 overweight asthma patients and assigned them to 8 weeks of this diet intervention, looking at effects of the diet on asthma symptoms, lung function, oxidative stress, and inflammation.

The diet: Every other day, study subjects ate whatever they normally ate. On intervening days, they ate <20% of their normal calorie intake = a canned meal replacement of 320 calories for women and 380 calories for men.

The results:

• 9 of the 10 subjects adhered to the diet and lost an average of 8% of their initial weight over the 8 weeks. 
• Asthma-related symptoms, quality of life measures, and pulmonary function tests improved significantly.
• On days of calorie restriction, energy metabolism shifted towards fatty acid utilization (marked by increased levels of beta-hydroxybutyrate and decreased levels of leptin) - this means subjects were adhering to the diet. 
• Serum cholesterol and triglycerides decreased. 
• Markers of oxidative stress decreased, and uric acid levels (an antioxidant) increased. 
• Markers of inflammation decreased. 

While this study was small and over a short time period, it introduces an important question (and is easy enough to reproduce on a larger scale).

When patients struggle with new and foreign diet changes, I wonder if a first step might simply be prescribing regular days of fasting.

Regardless of any potential health benefits, here is another good reason to fast:

“For now, it seems that some fasting is the best way to remind myself of the millions who are hungry and to purify my heart and mind for a decision that does not exclude them.” 

~Henri J. M. Nouwen