S L I D E 0 A Holistic Approach to Health and Healing Dr. Ather Ali, ND, MPH, MHS (c) Associate Research Scientist, Department of Pediatrics Integrative.

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A Holistic Approach to Health and Healing

Dr. Ather Ali, ND, MPH, MHS (c)Associate Research Scientist, Department of PediatricsIntegrative Medicine Specialist, Yale Stress CenterDirector, Integrative Medicine at Yale

Atatürk ÜniversitesiMay 2014

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Outline

• A common language• A holistic approach• Responsible practice• Practical steps for busy persons

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Defining health - holistically

• Old English: “wholeness, a being whole, sound or well.” • WHO: “Health is a state of complete physical, mental and

social well-being and not merely the absence of disease or infirmity.”

• Mental, emotional, physical, social, spiritual

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946

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Prevention / Risk reduction

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Attributable Mortality (20 leading risk factors)

0 1000 2000 3000 4000 5000 6000 7000 8000

High blood pressure

Tobacco

High cholesterol

Underweight

Unsafe sex

Low fruit and vegetable intake

High BMI

Physical inactivity

Alcohol

Unsafe water, sanitation, and hygiene

Indoor smoke from solid fuels

Iron deficiency

Urban air pollution

Zinc deficiency

Vitamin A deficiency

Unsafe health care injections

Occupational risk factors for injury

Occupational particulates

Lead exposure

Illicit drugs

Attributable mortality in thousands (Total 55,861)

High-mortality developing

Lower-mortality developing

Developed

D. Yach

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‘Healthy Living is the best revenge’

• 23,153 German participants aged 35 to 65 followed for ~ 8yr

• Assessed 4 factors– never smoking– BMI < 30 – 3.5 hr/wk + of physical activity, – Healthy diet (high fruits, vegetables, and whole-grains; low

meat).

• All 4 factors - 78% lower risk of of all chronic disease– type 2 diabetes, 93%– myocardial infarction, 81%– stroke, 50%– cancer, 36%

Arch Intern Med. 2009 Aug 10;169(15):1355-62.

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Diabetes Prevention Program

Prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years.

N Engl J Med 2002; 346:393-403Lancet 2009; 374: 1677–86

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Influences on (not determinants of) Health

• Food• Emotions• Connections• Physical Activity• Attitudes• Genetics• Environmental• Sleep• ‘intangibles’• many more

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Emotional health

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Stress Mechanisms

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Psychological stress and health outcomes

• Robust literature

• Multiple types of stress (1)– Routine– Sudden negative change – Traumatic stress

• Acute and chronic symptoms• Anger: 2-3x increase in risk (dose-response) (2)

– angina, MI, or sudden cardiac death• Anger (in response to stress)

– 300% relative risk of premature CVD, especially MI (3)

(1) NIH/NIMH(2) Circulation. 1996 Nov 1;94(9):2090-5. (3) Arch Intern Med. 2002 Apr 22;162(8):901-6

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The Disease Prone Personality

• Meta-analysis (multiple studies)– Heart disease: anxiety, depression and anger/hostility– Asthma: anxiety, anger/hostility, and depression– Ulcer: anxiety and depression– Arthritis: anxiety, depression, and hostility

Am Psychol 1987 Jun; 42(6):539-55.

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Perceptions (Beliefs) and Health

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Survival / optimism

• 839 patients followed for 30 years• Optimists lived 19% longer than pessimists

Arch Gen Psychiatry. 2004 Nov;61(11):1126-35. Psychosom Med. 2001 Nov-Dec;63(6):910-6. Mayo Clin Proc. 2000 Feb;75(2):140-3.

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Belief / healing / placebo effect

• 13 students- advised to go to a psychic healer within 24 hr of common cold. – “you’re healed.” – 9/13 students who felt that their colds improved also

demonstrated higher levels of IgA

• 1950s: internal mammary (thoracic) artery ligation was proposed to treat angina and CAD - 70% total relief– 100 patients were given a sham operation– 70% success rate– Many also experienced ECG improvement, increased

exercise tolerance, and significant reduction in pain meds.

• Components of placebo effect

• Disclosed placebo

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The science of placebo

• Contextual factors and the therapeutic relationship are important factors in the overall effectiveness– especially with subjective outcomes– perhaps stronger with alternative therapies associated with

elaborate rituals and distinct contexts • Ethical imperative to provide therapeutic options that are

safe and effective – with appropriate informed consent– without endorsing approaches that are unsafe or ineffective.

• Emerging literature on the psychobiology of the placebo effect

• Clinically significant effects in a variety of contexts• Intentional use of placebo in clinical practice is routine

Perspectives in biology and medicine. Autumn 2009;52(4):518-539.Clinical and experimental rheumatology. Nov-Dec 2012;30(6 Suppl 74):78-87.Lancet. Feb 20 2010;375(9715):686-695.BMJ (Clinical research ed.). 2008;337:a1938.

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Challenge / Health

• 86 executives (high stress no illness) compared to 75 executives (high stress illness)

• High stress/low illness executives – stronger commitment to self– attitude of vigorousness toward the environment– a sense of meaningfulness– and an internal locus of control

• Perception of stress is important– not the stress intensity itself

J Pers Soc Psychol. 1979 Jan;37(1):1-11.

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Positive Psychology

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The Health Promoting Personality

• People who experience warmer, more upbeat emotions live longer and healthier lives– Fewer colds– Reduced inflammation– Lower likelihood of CVD– Fewer headaches and less chest pain

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Breast cancer / support

• 1989 study• 86 women with metastatic breast cancer

– Randomized: standard care or standard care + support group

– Support group: 90 min 1x/wk x 1 yr• Participants were encouraged to express their feelings

about their illness and its effect on their lives in a supportive environment.– led by breast cancer survivor

• Negative replication studies• Point: support matters

Lancet. 1989 Oct 14;2(8668):888-91.

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Religion and health

• Religious involvement associated with:

– social support– existential meaning– sense of purpose– coherent belief system– clear moral code– religious attendance and mortality

Med J Aust. 2007 May 21;186(10 Suppl):S47-50.

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Love and Survival

“I am not aware of any other factor in medicine that has a greater impact on our survival than the healing power of love and intimacy. Not diet, not smoking, not exercise, not stress, not genetics, not drugs, not surgery.”

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Practical Aspects

• Distilled from Dr. Martin Seligman of the Positive Psychology Center / University of Pennsylvania

• External (things to do)– Alone

• lose track of time• unplug• prioritize exercise• upbeat music• restful and adequate sleep• spend time outside

– With others• surround themselves with happy people• give – time/money• deeper conversation > small talk• spend money on others• make a point to listen• uphold in-person connections• laugh out loud

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Mental/Emotional Exercise

• Internal (aspire to be)– smile when they mean it– try to be happy– mindful of the good – appreciate simple pleasures– ‘walk the walk’– cultivate resilience

• How can we practically implement these?– Bundle

• High-intensity interval outdoor exercise with loved ones

– Partner with friends/colleagues/loved ones– Mentoring trainees– Limit screen time

– Small steps matterhttp://www.ppc.sas.upenn.eduhuffingtonpost.com/The Habits Of Supremely Happy People

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Happiness is contagious

• Happiness clusters in the Framingham social network

• People’s happiness depends on the happiness of others with whom they are connected.

BMJ 2008;337:bmj.a2338

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Practical steps for busy physicians

• Stop smoking – Auricular acupuncture (1)

• Consider high-intensity interval exercise– short intervals

• Snack pack• Control nutritional environment

• Dose response effects of exercise, diet on CV outcomes and chronic disease risk

Am J Public Health. 2002 Oct;92(10):1642-7.Eur J Prev Cardiol. 2012 Oct;19(5):1005-33.Am J Prev Med. 2011 May;40(5):505-13. doi: 10.1016/j.amepre.2010.11.022.

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High-intensity circuit training using body weight

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Resources

• Smartphone apps

• Books

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This work was supported by a grant from

National Center for Complementary and Alternative MedicineNational Institutes of HealthU.S. Department of Health and Human Serviceswww.nccam.nih.gov