Blogs from “Project ECHO”
Starting in September 2016, Jeff Hush and Rachel Hedrick were invited to write blogs for PainNET. This is part of Project ECHO, which is a gathering of clinicians from around the United States who are trying to reform our Medical System. Jeff’s blogs are found in the “Clinicians’ Corner” under Functional Medicine.
Blog #9: “Using Food and Movement, not Drugs, to Treat Depression” Jeff Hush
“Medical misinformation dies hard,” so writes Dee McCaffrey, organic chemist, while discussing the “big ‘fat’ lies we’ve come to believe” (The Science of Skinny, DaCapo Press, 2012, pp. 95-6). Starting in 1985, “scientists involved with omega-3 fatty acids” came up with a new paradigm about dietary fat—one that focused on finding a healthy balance (ratio) of fats instead of demonizing saturated fat and cholesterol. “People made the connection,” said Howard Sprecher, the biochemist who mapped out the synthesis of DHA (an omega-3), “that you could change the behavior of cells through nutritional means” (italics added). “Diseases of the brain” and “depression” became central to this omega-3 breakthrough “because of the high concentration of DHA in healthy nervous tissue. . . . It is the fat that permits animals to think and see” (The Queen of Fats: Why Omega-3s Were Removed from the Western Diet and What We Can Do to Replace Them, Susan Allport, U Cal Press, 2006, pp. 103, 8, 6, 114, 156-7, 184-5, 189-90).
Joseph Hibbeln, the NIH researcher most responsible for uncovering the link between depression and low levels of omega-3s, writes: “The increases in world [omega-6] consumption over the past century may be considered a very large uncontrolled experiment that may have contributed to increased societal burdens of aggression, depression, and cardiovascular mortality.” He also says, as reported by Michael Pollan, that “the billions we spend on anti-inflammatory drugs such as aspirin, ibuprofen and acetaminophen is money spent to undo the effects of too much omega-6 in the diet” (In Defense of Food, Penguin, 2008, pp. 131-2).
So, let’s pause and rethink our priorities. Should our American medical profession serve patients directly, helping them find health? Or should it serve the Siamese twin food-and-pharmaceutical industry that, first, creates the problem, and, finally, manages it for patients at great cost and suffering until their accelerated deaths? It’s really up to individual doctors to decide which road to take. If they choose the patient-centered path, less traveled but more fruitful, they can learn from Dr. Joel Fuhrman: “I am a practicing physician who sees at least five thousand patients a year . . . educating them [about food] and motivating them to do more than others have asked them to do [about changing their diets]. . . . Diseases that are considered irreversible I see reversed on a daily basis [without using drugs]. . . . Most physicians have no experience in treating disease naturally with nutritional excellence, and some uninformed physicians are convinced it is not possible” (Eat to Live, Little, Brown and Co., 2011 ed., pp. 172-3; see also pp. xviii, 123, 173, 343 for curing “depression” through food).
Just as the right balance of fats (and other foods) can heal the brain—making clinical depression much less prevalent—so, too, can exercise remove depression. First, we have to recognize that 30-50 % of the population diagnosed with “depression” is not helped by “the antidepressants now in use. . . . The current medications are inadequate for a significant portion of the population. A large study funded by the National Institute of Mental Health found that the rate of remission after two rounds of drug treatment was about 50 percent. After four rounds, around 30 percent of patients still suffered from depression” (Anna Fels, Weill Cornell psychiatrist, “Can Opioids Treat Depression?,” NY Times, June 5, 2016).
Second, as Dr. Fels points out: “one ‘natural,’ nonmedicinal use of opioids for depression is already widespread. There is a generally accepted hypothesis that long distance running produces a ‘runner’s high’ via the production of endorphins, one of the brain’s opioids. Intense exercise is often ‘prescribed’ for the treatment of depression.” This exercise should be aerobic: whether swimming, biking, dancing, Pilates, strenuous hiking, or intense forms of yoga like Ashtanga or Power Yoga. Weightlifting does not bring the same “endorphin rush.”
This exercise cure for depression is especially urgent right now because of the huge and growing population of Americans taking antidepressants and other “psychiatric drugs” (remember: 30-50% of them are not benefiting from these drugs!). “About one in six [approximately 40 million Americans] American adults reported taking at least one psychiatric drug, usually an antidepressant or an anti-anxiety medication, and most had been doing so for a year or more” (“One in 6 American Adults Say They Have Taken Psychiatric Drugs,” NY Times, Dec. 12, 2016, p. A18).
The elderly are particularly endangered by these psychiatric drugs, with “usage rates . . . higher with increased age, with one in four people of retirement age reporting at least one prescription.” This danger has two sides: 1) the excess drugs, in a cascade, eventually become new medical conditions (see my blog #2 on “polypharmacy”) and 2) “the incidence of diagnosable mental problems, with the exception of insomnia, tends to be much lower in elderly people than in young adults,” and, yet, they are taking a much higher percentage of these drugs. (Why? Because of clinical inertia.) Dr. Mark Olfson, a psychiatrist at Columbia University, said: “We need to be mindful of the trade-offs in prescribing. . . . These are not benign drugs” (ibid.). But it is not only the old who suffer from drugs they don’t need and which make them sicker.
One of our clinical yoga patients, David Brzoska (age 24, suffering from autism and mild schizophrenia) was given Celexa, an antidepressant, and told to take it daily. After several months on this drug, Brzoska felt miserable, much worse than before taking it—now every day he was fatigued, bloated and sluggish, with his mind dominated by scattered, negative thoughts. After he started coming to our Family Yoga classes (Power Yoga) twice a week and began following our food advice (while coming to Rachel Hedrick’s “Whole Foods Cooking” classes), Brzoska improved dramatically: both in how he felt and in how he was able to interact with neurotypical fellow classmates.
“More Americans than ever are taking antidepressants. The prevalence nearly doubled between 1999 and 2012, increasing to 13 percent . . . [as] a study in JAMA found. . . . Use increases with age, with more than one in six of those over 60 taking a drug for depression” (Steven Petrow, “Drinking on Antidepressants,” NY Times, Dec. 20, 2016). A large percentage—likely more than 50 percent—of these seniors don’t need these drugs, which harm them in numerous ways. But this is true of the young, as well. An October 2016 study in NEJM showed that “neither of the two drugs [one was the ‘antidepressant amitriptyline’] used most frequently to prevent migraines in children is more effective than a sugar pill” (Catherine Saint Louis, “Remedies for Migraine May Not Aid Young Much,” NY Times, Oct. 28, 2016). This is a “common childhood condition. Up to 11 percent of 7- to 11-year-olds and 23 percent of 15-year-olds have migraines.” So millions of American children, for years, have been dosed with these drugs—which have no positive effect!—based on zero evidence (just on the assurances of drug manufacturers that they “could” work). Is that right?
By trusting the doctors who prescribe these harmful medications to our children, we are complicit in their harm. Our trust has become toxic. Remember what Dr. Olfson said: “These are not benign drugs.” They have toxic effects on our children’s brains, growth patterns, digestion, hearts, livers, and their moods. Is this the way forward for American health care? Damaging our youngest and oldest patients, our most vulnerable? And for what?
So let’s return to our opening: “medical misinformation dies hard.” The great bulk of doctors, hospitals, and insurers refuses to believe that food and movement can help patients more than drugs. But the evidence for this truth is everywhere, in thousands of studies done worldwide over the past fifty years, and in the blatantly obvious clinical experience of almost every doctor, who has seen with her own eyes what a healthy older patient looks like: a patient who avoids drugs, alcohol and tobacco, who eats a plant-based diet, and who moves a lot every day. Such patients should be the ones teaching doctors about health. Instead doctors rely on the slick patter of pharmaceutical reps.
If doctors and their industrial allies will not listen to reason, perhaps it’s time for us, the patients, to take back our own health care. And to make the elders among us—those who have lived healthy lives—our true physicians. Time to call in new allies in the battle for real American health care: economists, for example. Here’s what Angus Deaton, from Princeton University, who won the 2015 Nobel Prize in economic science, has to say: “I would add the creation of a single-payer health system [to a list of policy ‘correctives’], not because I am in favor of socialized medicine but because the artificially inflated costs of health care are powering up inequality by producing large fortunes for a few while holding down wages; the pharmaceutical industry alone had 1,400 lobbyists in Washington in 2014. American health care does a poor job of delivering health, but is exquisitely designed as an inequality machine, commanding an ever-larger share of G.D.P. and funneling resources to the top of the income distribution” (“When the Rich Get Richer,” NY Times Book Review, March 26, 2017, p. 20).
Blog #8: “The Opioid Epidemic (1): Root Causes”, Jeff Hush
The story begins with “Porter and Jick” in 1980 (NEJM, Jan. 10, 1980, p. 123: “Addiction Rare in Patients Treated with Narcotics”—refers to hospitalized cancer patients only). This paragraph-long letter to the editor (not a “study,” just an observation) became the central piece of “evidence” used by pain specialists like Dr. Russell Portenoy (paid lavishly by pharmaceutical companies) to spread the new American gospel about opioid drugs. This swept through the medical community from 1986 until the present. The new gospel stated, simply, that opiates were only “rarely” addictive, so not to worry about them, and that they should be prescribed freely, not just with cancer patients, but with all those suffering “chronic pain.”
This was a total reversal of what medical education had taught until then. By 1996 when Purdue released OxyContin, doctors were evangelically following this script from the pharmaceutical industry to their moral peril (and to a profound and troubling disrespect for reason and for decades of clinical practice). This has led to the deaths of tens of thousands of their patients.
“’With addicts, their quality of life goes down as they use drugs,’ one leading pain doctor, Scott Fishman, told New York magazine in 2000. ‘With pain patients, it improves. They’re entirely different phenomena.’” Except that they’re not. Dr. Gary Franklin called the opioid epidemic “the worst man-made epidemic in history, made by organized medicine.”
Dr. Hershel Jick, years later, disavowed the use others had made of his legendary 1980 NEJM observation: “If you read it carefully, it does not speak to the level of addiction in outpatients who take these drugs for chronic pain.” Dr. Nathaniel Katz, a pain specialist in Boston, later rejected what he had been taught in medical school: “My instructors told me that when you take opioids for pain you can’t become addicted because pain absorbs the euphoria. That was at Harvard Medical School. It was all rubbish, we all know now. Why do we listen to those messages? Because we wanted them to be true. . . . Porter and Jick is amazing for the absence of information in it. . . . [But] that paragraph gives you relief from your inner conflict. It’s like drinking from the breast. All of a sudden the comfort washes over you” (Dreamland: The True Tale of America’s Opiate Epidemic, Sam Quinones, 2015, pp. 15-16, 85, 107-8, 109, 310, 110, 313, 315).
So what would push doctors across our country to reject decades of received wisdom on opiate addiction? Remember: this is a peculiarly American problem, not an international medical issue—in 2012 “83% of the world’s oxycodone and fully 99% of the world’s hydrocodone” were “consumed” in “the United States”: these are the prescription opiates that drove the epidemic (ibid., p. 190).
Medical education—corrupted by the profit motive so that manufacturers come first and patients last—is the first root cause of our opioid epidemic. This is true for both medical schools and CMEs (ibid., pp. 31, 135-6). Another key component of the U.S. education debacle is that such a large percentage of our new doctors come out of medical schools with huge debts. This makes them desperate to get ahead quickly, leading to two results: these new doctors blindly follow the medical authorities who can advance their careers and they search for ways to make money instead of curing their patients. (See Doctored: The Disillusionment of an American Doctor, Sandeep Jauhar, 2014, for a spot-on expose of current medical practice.)
The second root cause of the opioid epidemic was the construction of “pain” as the “fifth vital sign.” This idea took root across the country in the 1990s, culminating in 1998 when adopted as gospel truth by the Veterans Health Administration and the JCAHO (16,000 hospitals and health care orgs across the U.S.). The “fifth vital sign” campaign was orchestrated by the pharmaceutical industry (especially Purdue Pharma), which spent millions of dollars on astroturf pain-patient groups: these groups claimed to be protecting “patients’ rights” and getting patients the “relief from pain” they deserved. Pain doctors, Kathy “Foley and [Russell] Portenoy viewed themselves as warriors on patients’ behalf” (see their 1986 paper in the journal Pain about “38 of their cancer patients with chronic pain”; see also Dreamland, pp. 92-6).
The most insidious element in constructing pain as the fifth vital sign is that hospital doctors and nurses were now being “judged” on how well they “managed” their patients’ pain: “In some hospitals, doctors were told they could be sued if they did not treat pain aggressively, which meant with opiates.” “Press Ganey patient surveys” became ubiquitous in hospitals after 1998, based on new “pain scales” (two types: 1-10 for adults and smiley/grimacing faces for children). These bureaucratic mechanisms (pain scales and surveys) were pioneered at the Beth Israel Medical Center in New York City, where Dr. Portenoy was “director of the Pain Medicine and Palliative Care department.” “With funding from several drug companies, he pressed a campaign to destigmatize opiates.” A hospital nursing supervisor spoke about the import of these pain surveys in advancing doctors in their careers: “When the Joint Commission [JCAHO] surveyed us . . . pain was the number one thing. They hammered and hammered on pain. You had to control everybody’s pain. The [Press Ganey survey] scores were one way they measured how the doctors were doing” (ibid., pp. 95-8).
Years after his “pioneering” work at Beth Israel and his influential 1986 Pain paper, Dr. Portenoy expressed doubts about the foundation he had built his career upon, saying that his Pain paper was based on “weak, weak, weak data.” He also said: “I believe in drugs. I think pharmaceuticals are a great gift to humankind” (ibid., pp. 99, 85). Out of that weakness combined with his blind enthusiasm for opiate prescribing, tens of thousands of people died. Portenoy, like an alpha among lemmings, led hordes of others off the cliff. But his status and his wealth, like a parachute, allowed him to float above the dead bodies tangled below.
The third root cause of the opioid epidemic is the “clinical inertia” of doctors (“New Study of Opioid Use Finds a Disparity in How Doctors Prescribe Drugs,” Jan Hoffman, NY Times, Feb. 16, 2017: refers to a Feb. 2017 study in NEJM that “tracked about 375,000 Medicare patients . . . in several thousand hospital emergency rooms from 2008 to 2011, as well as the frequency of opioid prescriptions written by the doctors who treated them”). Dr. Michael L. Barnett, “the lead author” of this study and a professor at Harvard, recognized this fault in his own medical practice, but only after dismissing the patient he’d prescribed opiates to: “I told her about the risks of constipation and sleepiness. But I didn’t tell her about dependence and addiction. . . . Doctors don’t even know what they’re doing is a habit. We have to decide to interrupt ourselves. . . . ‘Oh, I need to tell this patient about another risk with this medication.’” Another risk? As if addiction and overdose death are just “another risk” like “constipation and sleepiness.”
There are two other key aspects of this “clinical inertia.” One is that when primary care doctors see patients who come to them with already existing opioid prescriptions, they usually refill them. This is driven by their “belief . . . that if the emergency room doctor’s prescription did the trick, they might as well refill it.” Dr. Lewis S. Nelson, who helped create the CDC and P “opioid guidelines in 2016,” said: “It puts the burden on us in the E.R. to be even more thoughtful about how to do things.” It also “puts the burden” on primary care doctors to break their own bad habits of blindly refilling prescriptions, of failing to inform patients of long-term dangers (it’s not enough that the drug “did the trick” of relieving short-term pain), and, lastly, of building up the myth of “informed consent”—utterly lacking in substance.
“The secret is that informed consent in health care is commonly not-so-well informed,” wrote Drs. Sekeres and Gilligan. “It might be a document we ask you to sign, at the behest of our lawyers, in case we end up in court. . . . Unfortunately, it’s often not really about informing you. . . . Over your lifetime of seeing us we have trained you that we will look impatient and concerned if you say you didn’t understand something or if you have a lot of questions. After all, we’re busy and have other patients to see. Shame on us” (“Informed Patient? Don’t Bet on It,” Mikkael A. Sekeres, M.D. and Timothy D. Gillilgan, M.D., NY Times, March 7, 2017: italics added).
Doctors are squeezed by more than just the lawyers who represent the financial interests of their institutions (whether hospitals, clinics, or universities); they are also squeezed by health insurance companies. These insurance companies (and other “handlers” of doctors) are the fourth root cause of the opioid epidemic. Since 1980, the amount of time each doctor gets to spend with a patients has gotten shorter and shorter, decade by decade. (What are the “efficiency” metrics now—13 minutes per patient?) When a doctor is rushed, the quickest way to take charge and show a patient she cares is to whip out the prescription pad and offer drugs. When a doctor is rushed, she doesn’t have time to do her own thinking or research and so comes to depend more and more on pharmaceutical reps as her teachers of new practices. When a doctor is rushed, bad habits flourish. When a doctor is rushed, she tends to prescribe a small number of drugs for a large collection of maladies because she only has time to know these few drugs. This hurry-up medical delivery system is hugely to the advantage of a pharmaceutical industry seeking billion-dollar “blockbuster” drugs (that can be prescribed for multiple causes—like the catch-all sinkhole of “chronic pain”).
Yet insurance companies have not only brought on the opioid epidemic through a systematic weakening of doctor-patient trust (too little time), they have also attacked the one local area in health care that could have stemmed the tide of too many drugs: “multidisciplinary pain clinics.” The first American one was started by John Bonica in 1960 at the University of Washington. Its approach “was complicated and required a lot of the patient, but was often effective.” Until the early 1990s, this concept spread around the country. (Then it started dying out, starved of cash.) By 1990, “hundreds of clinics in America followed the UW model [“in which opiates played only a small role”]. Yet, almost from the beginning, insurance companies balked. . . . They stopped funding crucial parts of multidisciplinary treatment . . . physical, occupational, and psychological therapy, in particular” (Dreamland, pp. 86-8, 109, 308-11). In the end, the insurance companies only wanted to pay for the drugs. Dr. John Loeser, who ran the UW pain clinic in the 1990s, was blunt about this: “The people making the funding decisions have nothing whatsoever to do with health.”
The final driving force in the opioid epidemic is the direction our legal system has taken—in which the money and lobbying force of large corporations both create new laws and silence their critics (especially those in government). This fifth root cause is particularly troubling to those of us who would still like to have some shreds of democracy remain in our nation. That its reach should extend into health care is especially disheartening. But not surprising.
When, in the late 1990s, pain started being recognized (by the controlling medical institutions) as the “fifth vital sign” and doctors were being pushed to prescribe opiates (already labeled “not addictive”), many doctors still resisted. They remembered their clinical problems with opiates. Laws were therefore passed to calm their fears. “So, beginning with California, states passed laws exempting doctors from prosecution if they prescribed opiates for pain within the practice of responsible health care. Numerous states approved so-called intractable pain regulations: Ohio, Oregon, Washington, and others” (Dreamland, pp. 95: bold added). Who do you think wrote and paid for those new laws?
Not only were laws passed, but critics were harassed. (Only two examples are given here, but, you can be certain, dozens of other cases could be found in the public record.) In early 1998, an article was published in Ohio in the Portsmouth Daily Times about an “addiction-treatment clinic” run by Ed Hughes, which was already seeing a flood of OxyContin addicts (remember: Oxy was only released in 1996, so this was the canary dying in the coal mine that could have signaled the epidemic from the beginning and could have saved hundreds of thousands of Americans—if bold action had been taken!). “About a week after the . . . story ran, Ed Hughes received a telephone call from a lawyer representing Purdue Pharma. The caller threatened to sue the Counseling Center if Hughes ever said in print that OxyContin was addictive.” Government critics were not spared this type of bullying. “[When the State of Washington tried to issue guidelines to slow opiate prescribing, Dr. Gary] Franklin got a letter from two Purdue Pharma executives. They objected to the idea of a ceiling on opiate doses. . . . Not long after that, a Spokane doctor . . . [supported by five pricey law firms paid for by an invisible benefactor] sued [the State of Washington]. . . . The [opiate] guideline, they alleged in a court brief, was an example of ‘an extreme anti-opioid discriminatory animus or zealotry known as opiophobia that informs, permeates, and perniciously corrupts the development and management of public health policy.’. . . [Guidelines were in limbo until] in May 2011 . . . a judge threw out Dr. Jane’s lawsuit. The next year, Washington issued the guidelines . . . [as] the first state to suggest doctors temper their opiate prescribing. Washington legislators also repealed the intractable pain regulations allowing for unlimited dosing of opiates” (ibid., pp. 146-7, 234-5).
So it took 14 years—from the first sign of trouble in Ohio in 1998 to the first sign of action in Washington in 2012—to begin to shut down the opioid epidemic.
All the root causes of this epidemic are still with us. They have not vanished into some hopeful reforming dawn. Roots are very sturdy after decades of growth. It takes great effort to wrench them up. All the deaths and destroyed lives are still with us. All the tens of thousands of doctors across the U.S. who participated in this epidemic—through the liberal use of their prescription pads—are still with us. They must feel a profound burden of shame—every day they practice medicine—for all the lives they have destroyed by blindly following wishful thinking, short-term thinking, bad medical habits, clinical inertia, unquestioning obedience to their medical authorities, to their institutions, and to their chains of command.
These American doctors must feel a profound burden of shame. Or do they? Maybe, instead, they feel comforted by the fact that they were not prosecuted for their negligence. Well, no matter. We feel their shame.
Blog #7: “Assessing Community Health Needs: A New Vision for Hospitals”, Jeff Hush
It’s a hard time to be a hospital. Being the home base of US health care—a system teetering on the sinkhole of dysfunction—is no softball game. The bad news first klaxoned in 2000 with a JAMA article (284: 483-85) “by Barbara Starfield, M.D., stating that physician error, medication error and adverse events from drugs or surgery kill 225,400 people per year,” (“Is U.S. health really the best in the world?”). “That makes our health care system the third leading cause of death in the United States, behind only cancer and heart disease,” (The China Study (2006), pp. 15-16 and footnotes 11-16 on pp. 369-70). Second, then came the unforeseen (but scientifically foreseeable) emergence of “super bugs,” especially Clostridium difficile infections driven home by “the overprescription of antibiotics.” “By 2011, an analysis by the Centers for Disease Control and Prevention estimated there were 453,000 cases a year and 29,300 deaths from the infection,” (Paula Span, “Doctors Make Gains on an ‘Urgent Threat,’” NY Times, Feb. 14, 2017). Third, and now we are in the midst of a drug epidemic that started on the manicured lawns of the medical profession before leaping the fence into the tortured undergrowth of illicit heroin addiction: “Public health officials have called the current opioid epidemic the worst drug crisis in American history, killing more than 33,000 people in 2015,” (“Opioid Tide from Coast to Coast,” NY Times, Jan. 8, 2017).
Three strikes and you’re out? Should hospitals just call it a game and hang up their cleats? If not, what’s a hospital to do?
If you are Middlesex Hospital in Middletown, Connecticut (a “not-for-profit” hospital), you write an extensive report called “Community Health Needs Assessment 2016” (Catherine Rees, author). At the center of this CHNA report is one concept: “poor health is disproportionately concentrated among those experiencing poverty,” (p. 16). And a lot of people here right now are in that basket: “Combining Connecticut’s households in poverty and the ALICE households, more than one-third of Connecticut households (35%) struggle to earn enough income to pay for basic expenses,” (p. 24).
“Poverty,” in the CHNA, is then broken down into many of the interlocking “social determinants” that lead to such poor health: housing insecurity, food insecurity, mental health problems, less education, little health literacy, discrimination based on ethnicity, high incarceration rates, more exposure to toxic chemicals and pollution (both air and water), violence on a regular basis, unsupportive and unstable communities, substance abuse, transportation limitations, and, finally, a lack of healthy behaviors modelled in these vulnerable, low-income communities. Whether you are elderly or a child, an unemployed adult or a wage-poor worker, poverty eats away at you.
How does a hospital cope with all this—within a society of such rampant income inequality? As Catherine Rees said in her January 10, 2017 presentation about the CHNA, “clinical care is a very small part of health outcomes.” So, that’s it, hospitals should just concentrate on that “very small part of health” they can improve clinically and ignore the facts on the ground (the despair and destruction wrought by poverty)? That’s not what Ms. Rees is suggesting; in fact, she and Middlesex Hospital are ambitiously diving into that despair to try to find solutions, expanding the scope of clinical work by partnering with low-income community leaders.
Vincent G. Capece, Jr., President/CEO of Middlesex Hospital, is confident that his hospital’s new plan has “embedded” within it a drive towards “achieving health equity,” (“Executive Summary” of the February 2017 “Implementation Strategy” for the CHNA). He wants his hospital to strengthen “partnerships” with “community organizations” to develop “evidence-based interventions and innovative practices” that “address the conditions that prevent the realization of good health for these vulnerable groups.” The “Implementation” plan that Capece offers has “four broad priority areas: 1) Mental Health; 2) Substance Abuse; 3) Aging Population; and 4) Asthma.”
Five action plans have been created for the first three priorities here: 1.1 (“Improve access to mental health services through interprofessional collaborative practice”); 1.2 (“Implement an early treatment intervention program for young adults with emerging mental illness and/or substance abuse disorders”); 2.1 (“Develop a treatment program for high-risk patients experiencing severe alcohol use disorders”); 2.2 (“Develop and launch an opioid awareness campaign” and “increase access of naloxone to patients at high risk for opioid overdose”); 3 (“Implement interventions to promote healthy aging in place”).
Noble plans—potentially useful interventions—but will they, even incrementally, be able to tackle the huge problems we now face in health care? What needs to happen to help move our society towards “health equity” in the face of widespread poverty? Remember that 35% of the people in Connecticut (one of the richest states in the US) “struggle to earn enough income to pay basic expenses.”
First, medical staff need to recognize the magnitude of the health equity/poverty problem and how US medical interventions over the past twenty years (“three strikes” in first paragraph here) have greatly worsened this problem, largely through habitual and blind overuse of prescription medications. Unfortunately, the CHNA (p. 39) shows that the hospital’s “active medical staff and allied health professional staff” (526 people: mainly doctors, nurses, psychologists, and social workers) were not even willing to take a few minutes to fill out CHNA surveys to help meet community needs. “Given the low response rate for the Middlesex Hospital Medical Staff” (29 responses: 5.5% response rate), Ms. Rees, President Capece and others in the “Hospital’s leadership” (15.9% response rate) have a large task ahead of them: convincing the people who work directly with patients every day to change their habits and to welcome new “evidence-based interventions and innovative practices.” This is far from easy. Old habits die hard, especially in medicine.
Second, where should these new clinical interventions and practices come from? Why not seek out the best science available—the type that wins Nobel Prizes!—instead of just settling for the less-than-impressive results (from corporate RCTs) generated for the latest profit-seeking medication? Middlesex Hospital is, after all, a “not-for-profit” hospital. Dr. Elizabeth Blackburn, who won “the Nobel Prize in Physiology or Medicine in 2009 . . . for the discovery of the molecular nature of telomeres . . . [and] telomerase, the enzyme that maintains telomeres,” has written a new book (2017), The Telomere Effect, with Dr. Elissa Epel, “a leading health psychologist who studies stress, aging, and obesity.” Telomeres protect our DNA, and as they shorten, due to extreme chronic stress (those negative “social determinants of health” driven home by poverty), we age prematurely. Blackburn and Epel (like Rees in the CHNA) focus on how poverty and misguided “health behaviors” destroy health—on how certain people age quickly and enter the “diseasespan” early (even in their 30s). Such people live for decades with chronic diseases, burdening our health care system and crippling their families and communities. The stresses of caring for their illnesses spread around the society, often damaging the “caretakers” (research studies shown in Telomere Effect).
Other people remain healthy almost to the end of life, with very short diseasespans. This is largely because of how they react to the stresses of life (including poverty) and to the health behaviors they have chosen (linked to food and movement). All patients have the right to know what they can do to prevent early aging and chronic diseases. “Health literacy” is key here. That should be one of the central tasks of “not-for-profit” hospitals: teach health literacy by stressing food and movement not drugs.
Two other recent scientific revolutions—on the profound importance of “mitochondria” and the “gut microbiome” in maintaining health—come to the same conclusions as The Telomere Effect (see Nick Lane’s The Vital Question and the Sonnenburg’s The Good Gut: both from 2015). All stress that health comes from eating whole foods and exercising often; on the other hand, all point squarely at the dangers of relying on “supplements” and “pills” to achieve health (Telomere Effect, pp. xxii and 233-34; Vital Question, p. 270; Good Gut, many times they state that antibiotics are dangerous, except when absolutely necessary, because they destroy the healthy microbes in our guts).
These three new traditions are “evidence-based”—markers can be drawn from patients to test the success of our health interventions: telomere length and telomerase concentrations, chronic inflammation markers, cortisol levels, and the types of microbes residing in the gut. Hundreds of studies have already been done using these markers and pointing us all in a new direction for our health care system. It turns out that “health equity” is actually feasible—and cheaper than our current sinkhole for cash. Let’s use this new evidence to create “innovative practices” that build much longer “healthspans” for all our citizens.
Not-for-profit organizations and individuals need to reenter US health care in a big way—to restore honesty, trust, and real science to medicine—to take health back from a medical industry dominated by the corporate power and greed of the pharmaceutical and food industries. All of us in health care over the past twenty years have seen the widespread destruction of our communities from the opioid scourge. We can clearly see how a perfect storm of conditions in our troubled medical care delivery system—from an overeager pharmaceutical industry to myopic insurance companies to limited-option emergency rooms to rushed doctors to pain-averse patients—all these in lockstep have led to the “worst drug crisis in American history.” The time for new thinking and new approaches to health care is now.
Blog #6: “Treating Autism with Food and Movement, Pt. 1” , Rachel Hedrick
Autistic individuals have compromised immune and nervous systems. Since 70% of the immune system is in the gut, it follows that strengthening digestion (and eliminating problematic foods) can go a long way towards controlling symptoms. Current protocols for treating autism favor a drug regimen heavy on antidepressants (Celexa) and anti-anxiety meds. Instead of adding more chemical interference to an already hypersensitive body, the Food & Movement therapy approach for autism removes as many toxic elements as possible in order to allow the body to heal itself.
In The Good Gut (Justin and Erica Sonnenburg, Penguin, 2015) low GI (Glycemic Index) and high ND (Nutrient Dense) foods are central in managing autism. The stress is on high fiber, whole foods, mainly plant based: “the gut microbiota [was recognized as one of the] . . . ASD risk factors after medical professionals noted that many children with ASD also suffer from gastrointestinal issues such as chronic diarrhea, constipation, gastrointestinal cramping and bloating, and even more serious conditions such as IBD,” (p. 152). To improve the gut’s microbiota (and to lower chronic inflammation), two things need to happen: 1) foods ingested must be whole and, therefore, cleansing of the gastro tract; and 2) toxins and allergens must be eliminated.
The foods we recommend are gluten-free and casein-free (avoid eggs as they are pro-inflammatory and highly allergenic). Whole grains (brown rice, quinoa, millet, buckwheat) make up half the food ingested daily. Yeasted breads should be avoided (use sprouted-grain breads instead), and whole grain pastas (brown-rice or soba noodles) are fine. Oil should be used sparingly (only in cooking). The two healthiest categories of vegetables are “root vegetables” and “hard leafy green vegetables” (kale, collards, leeks, watercress, cabbage, carrot greens). Cold raw foods should be avoided. Vegetables should be cooked slowly and served warm. It is, however, possible to make cooked salads, with the vegetables lightly blanched for one or two minutes. Beans and sea vegetables should be eaten daily. Cravings for animal protein can be eased by eating wild-caught fish (in cans or fresh).
By eating our selection of foods, the most toxic chemicals in the food industry are avoided (MSG, food colorings, artificial sweeteners and sugar, preservatives, trans fats). The best foods are organic because they also eliminate pesticide and herbicide residues.
People with autism have trouble communicating, are socially isolated, are often awkward in their movements, and are locked into repetitive habits; they appear to be trapped in their own heads. Their inability to make eye contact accentuates all this. Our stress on food and movement brings them down to earth, so they feel grounded and balanced.
Animal experiments (Caltech in 2013) have induced a state like autism in mice. “Mouse pups [in this experiment] . . . display many of the gastrointestinal and behavioral hallmarks of human sufferers of ASD. These pups have greater permeability in their intestine [“leaky gut”] . . . . [They] are more anxious, engage in repetitive behaviors, and don’t communicate and socialize like normal mice,” (Good Gut, p. 153). The “Caltech research team” was able to reduce these autistic-like behaviors in mice by changing the bacteria in their guts (pp. 153-156). The best way, however, to change the bacteria in our guts is to eat the right whole foods. When we are healthy, we create the chemicals we need, largely in our own guts. As the Sonnenburgs state: “our microbiota is a drug factory dispensing pharmaceuticals [produced by them] from our gut—with direct access to our brain,” (p. 144).
Blog #1: “Food and Movement Therapy” Jeff Hush
As a public intellectual and activist, I teach people about health. I am not a medical doctor; I have no interest in diagnosing people’s illnesses. I have a simple, though daunting, task: to make people see that health comes from performing healthy practices they enjoy, not from suffering through medical interventions they fear. “Food and Movement Therapy” (www.famtusa.org) is what I call these sustainable, lifelong practices.
The hardest part of my work is convincing people to break through the “habits” that are killing them: smoking, being sedentary, eating mainly nutrient-poor and empty calories, destroying their livers with a toxic load of alcohol and drugs (both prescription and illegal), overloading their minds and senses with the demands of electronic devices, letting dark thoughts circle their minds constantly thus blocking their access to simple joys, and being out of community with other people. I start by trying to get a person hooked on simple though profound movement patterns, usually from tai chi or yoga. Most people feel some immediate relief from chronic aches and pains and they sleep better; the deep breathing in these traditions helps people calm down, thus removing for a while their darkest thoughts, depression and anxiety. After a couple of movement sessions, most people start to become excited by the challenge of getting stronger.
The problem that arises for all of us in health care is that people (including us) are attached to their bad habits—they love them one day, hate them the next, but they don’t want to give them up. Their identities are bound up with their habits, which come from their parents, their friends, their cities, and the culture of music, films and sports engulfing them. When a person breaks through her old habits, she becomes a new person altogether—defined by new routines, new feelings, new thoughts, even new brain connections and new healthy bacteria in her gut (microbiome). To help someone do this, you have to help her find unusual courage within herself.
Even though I am not a doctor, I work within the Western medical tradition, with the scientific studies I cite and the doctors’ advice I follow coming almost exclusively from leading American and British journals and books. (My scholarly medical research started when I was a PhD candidate at UC Berkeley—“medical history” became the lens through which I investigated Shakespeare and his profession—and it continued while I was a professor at the University of Chicago: 1985-1994.)
I understand the movement and breath techniques from both Ayurvedic and Chinese medical traditions, but that’s all. I use these techniques for a simple, practical result: to get patients to enter the parasympathetic nervous system. In my clinical work, I practice and teach tai chi (starting in 1980) as well as yoga and meditation (from 1973, at age 15). My clinical teaching has benefited patients primarily at Community Health Centers (2011-2016) in central Connecticut (Meriden, New Britain, and Middletown), where I have worked with those suffering from many maladies and ranging in age from 3 to 90.
Dan Wilensky, MD, a Family Physician in Meriden CHC, who has referred patients to me, said this recently about my work: “[Hush] can help my troubled patients get moving again. He can guide them to understand from within the connection between mind and body. This insight is critical for all of us and it is the most overwhelming obstacle for many of my patients.”
Eating real food is also central in what I teach patients, but I find that food addictions are the hardest of all to break, so movement comes first in my work with people. Only later, little by little, do I introduce suggestions about healthy eating. The sequencing and gradual introduction of new healthy practices is crucial here. Changing destructive habits takes astute psychological guidance from the teacher. Presentation is also important here; patients can easily see if you are practicing what you preach. I became a vegetarian in 1979; currently I am almost exclusively vegan. So the practices shown to my students/patients unite three sources: scientific studies, clinical practice, and lifelong personal experience. I teach what I live.
So what is this Western medical tradition that I follow? The doctors and scientists listed here have all used food, movement and/or meditation to tackle our most serious diseases (or they have been persuasive critics of cash-driven mainstream medicine): Dean Ornish (who revolutionized the treatment of cardiovascular disease), Caldwell B. Esselstyn, Jr. (Cleveland Clinic), T. Colin Campbell (Cornell), H. Gilbert Welch (Dartmouth), Robert Sapolsky (Stanford), Ronald D. Siegel (Harvard), Joel Fuhrman (a doctor whose practice is primarily about food), Neal Barnard (author, Foods that Fight Pain, 1998), Mark Hyman (Cleveland Clinic), Marcia Angell (former editor, NE Journal of Medicine), David Servan-Schrieber (U Pittsburgh), Daphne Miller (UCSF), Marion Nestle (NYU), Loren Fishman (Columbia), Jon Kabat-Zinn (U Mass), Justin and Erica Sonnenburg (Stanford).
The insights and clinical work of these pioneers (starting in about 1980) have driven many of us—patients, teachers, and healers—away from the old American medical paradigm which reveres “miracle cures” and “technological breakthroughs” or declares a “war on cancer.” Distinguishing ourselves from this tired old paradigm, we want people to understand the basics: how the human organism depends on real food and which types of movement strengthen our bodies and minds.
We practice “functional medicine”—teaching students/patients to bolster their immune systems, to protect their joints, and to boost their metabolisms, using natural means whenever possible.
So what does this new functional medical tradition have to say about pain? I will not speak for the other doctors and scientists mentioned here, but I will speak from my own experience working for 5 years with patients from three Community Health Centers who suffer from chronic pain. Knees, shoulders, wrists, sacroiliac joints, hips, intervertebral disks: these are the places where people hurt the most, and these pains make normal life and deep sleep nearly impossible to attain. The mind is preoccupied and fogged over with pain. People become depressed and anxious.
This is why so many people turn to experts like doctors to escape their pain; when doctors see people suffering so much, they, of course, want a “magic bullet” (opioids or the like) to remove that pain. The problem with these doctors’ understandably sympathetic reaction (prescribing drugs) is that it doesn’t respect the normal “functioning” of the body. Our bodies, minds and immune systems (when functioning well due to the proper foods and appropriate movement practices) generate very powerful internal chemicals—both hormones and neurotransmitters—that lower inflammation and lessen pain signals. The drugs prescribed by doctors, on the other hand, are not nearly as effective as our bodies’ own chemicals in dealing with these pains. And these drugs lead to horrendous unintended consequences like addiction, destroyed lives, and suicide.
Reason tells us that we should trust the body and its own incredibly complex and effective mechanisms. When we don’t, problems rise up. The majority of people can be guided back to health through the right food and movement practices. But these patients need a lot of slow, patient encouragement and support to break old habits. And doctors need to support this process by pushing patients to work with dedicated people like me. The problem is not the “lack of evidence” for what the right foods and movements are; the problem is that most people, especially those from “underserved,” “vulnerable” and low-income populations (such as most CHC patients) are ignorant of these healing practices. And to guide people to make major lifestyle changes is a slow and delicate process, taking the concerted efforts of many health care workers. This is why the health care system in America needs Food and Movement therapists and Cognitive Behavioral therapists to drive the process, building trust with patients and guiding them back to health. There is no quick fix here.
Listen to the voice of one yoga-and-food student, Steve M. (age 28):
“Before I began my transformation, I was deeply depressed and angry at the world around me. I could see healthy people enjoying their lives laughing and living what seemed to be a much happier life. I on the other hand took the easy way out and stayed sheltered within my home watching countless television programs and movies. I always had an excuse to why I couldn’t do something and it became apparent that I had settled for a less fulfilling life. My weight had spiraled out of control and my eating habits were shameful. It had gotten so bad that I seemed to have a hatred for anyone who had enough motivation to interact in socially and properly take initiative to better their own lives. I had become jealous of the world and felt like I had let myself down.
The moment this all changed was when I took a leap of faith from the advice of my best friend. She told me about a man who she did free Yoga classes with a few times a week. That man is Jeff Hush. For weeks I discredited her advances to come and join her. I was actually jealous of her happiness and that she was trying to better herself and that I had settled for such a miserable existence. Then one night I finally had enough of sitting on my ass. I took a leap and for me it was a big one. I finally had worked up enough courage to face my anger with myself and do something about it. I started doing Yoga with Jeff Hush in April. Since that first class I have made the effort not to miss any classes offered. This is where my journey to becoming a Health Ambassador began.
I am 28 years old currently and have made a full body transformation, inside and out. I am 100% vegan now and have lost over 25 lbs. to date. I attribute the changes in my diet to Rachel [Hedrick]. She along with teaching Yoga, also pioneered a “Healthy Bites” cooking class [at New Britain CHC]. It is a vegan cooking class where we the student gets to try 100% vegan food. . . . Through healthy eating and movement I have changed my entire life. I have opened up doors to my health that I couldn’t even imagine. . . .
Jeff and Rachel have been 100% pivotal in my life’s journey of happiness and health. The kindness they show to everyone who wants to better themselves through movement and food is indescribable and the efforts they make to help the world are truly remarkable.”
END Blog #1
Blog #2: “Polypharmacy and its Discontents” Jeff Hush
“Polypharmacy itself should be conceptually perceived as ‘a disease,’ with potentially more serious complications than those of the diseases these different drugs have been prescribed for,” writes Doron Garfinkel, MD, in “Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults,” (Arch Intern Med; 170/18; 2010; 1653).
Why does polypharmacy arise (5 or more prescription drugs daily), and why is it so dangerous?
Medical logic has long dictated: one disease (or condition) demands one medicine. Thus, if over the course of a life a person has been diagnosed with several chronic comorbidities, several medicines are taken in reaction. Starting new therapies is easy; stopping them is hard. As Dr. Garfinkel writes, “the physician may be reluctant to review decisions or discontinue or change drug regimens determined by ‘experts.’ . . . A scheduled, formal drug reevaluation may never be performed,” (ibid. p. 1652).
Current medical logic, under pressure from the newest multiple-med studies (“increased effectiveness”) coming out of the pharmaceutical industry, is starting to prescribe multiple meds for just one condition, leading to even more extreme versions of polypharmacy. In Dr. Garfinkel’s 2010 study, one of his “participants” was taking 16 meds; the “mean” per patient was “7.7” medications (p. 1650).
“Most individuals who are prescribed five or more drugs are taking unique combinations, [leading to] an uncontrolled experiment with effects that cannot be predicted in the literature,” writes Steven Werder in Current Psychiatry (vol. 2/2, 2003, p.1). In speaking of this “prescribing cascade,” geriatric pharmacologist Lori Daiello resists the impulses of her own profession: “A medication—drug number 1—causes an adverse effect that is interpreted as a new medical condition. Drug number 2 is then prescribed to treat this ‘new’ condition. Drug number 2 causes an adverse drug effect or interaction, interpreted as a new condition, so drug number 3 is prescribed, and so on,” (Psychiatric News, Oct. 20, 2000, p.1). “Roughly half of Americans ages sixty-five and older take five or more different drugs or supplements every week. Twelve percent use ten or more different brands of pills every week,” (Our Daily Meds, 2008, p. 299: from JAMA Jan. 16, 2002 study).
All these medications (toxic substances) head to the liver to be processed and then to be flushed from the body. The liver, however, cannot handle all these extra poisons. “Drug-induced liver injury (DILI) . . . is a common occurrence, though one that is not always easy to diagnose or confirm. There are no lab tests to determine if a specific medication caused the liver injury. . . . Complicating diagnosis is the fact that many other conditions can mimic drug-induced liver injury. . . . What’s more, a medication that triggers the DILI has usually been prescribed for a condition totally unrelated to liver disease, such as high blood pressure or a bacterial infection,” (The Cleveland Clinic Guide to Liver Disorders, 2009, p. 147). “As the . . . FDA, the . . . AMA, and every leading medical institution in this country and abroad has noted, liver damage, once rare, is now the leading reason for withdrawing a drug, usually . . . new . . . from the market. . . . The growing, lifelong ‘drug load’ on the liver is [of major concern because] . . . we now initiate prescriptions at a younger age than ever, take them for longer periods of time and often in greater amounts,” (Generation Rx, 2005, pp. 7-8).
Seniors in America are being led away from health and toward liver failure and cognitive decline (see the research of Jacobo Mintzer in Generation Rx, pp. 216-17) by three forces: by the seniors’ own misplaced trust in the “miracles” of modern medicines, by the marketing power of the pharmaceutical industry, and by the ignorance of their primary care physicians who are too eager to placate their own patients by prescribing more pills. Geriatric specialists are well aware of the dangers of polypharmacy and of how RCTs (Randomized Clinical Trials) do not take into account the vulnerabilities of an elderly population (see Gen Rx, p. 215, on “the typical supersenior body” which has problems with “pharmacologic ‘clearance’” because, with age, the “metabolism of drugs becomes harder, less efficient, prolonged”; see also Dr. Garfinkel’s study, p. 1652: A) “one disease-one therapy” is an “unrealistic approach” because of how prolonged our chronic conditions are, “an unprecedented situation in human history”; B) “older patients and those with significant comorbidity are usually excluded from evidence-generating RCTs”).
As Marcia Angell, “former editor in chief of The New England Journal of Medicine,” puts it—the pharmaceutical industry creates a myth about itself (persuasive to both patients and physicians), a myth about how it spends huge sums on research and development to drive innovation. “While the rhetoric is stirring, it has very little to do with reality. . . . Research and development . . . is a relatively small part of the budgets of the big drug companies—dwarfed by their vast expenditures for marketing and administration, and smaller even than profits.” Angell shows how a key part of this marketing budget is “education” of doctors through CMEs (the huge bulk of retraining that doctors go through, to maintain their licenses, is paid for and written by the pharmaceutical industry). “Continuing medical education gives drug companies an unparalleled opportunity to influence doctors’ prescribing habits, and it seems to work,” (The Truth About the Drug Companies, 2005, pp. xxiii, 141).
So those of us who are clinicians need to work very carefully and persuasively with our elderly patients—to convince them of the dangers of polypharmacy and of the safety of lifestyle modifications driven by wise food, movement, and deep relaxation practices.
Blog #3: “Moving Well is Medicine” Jeff Hush
“Exercise is one of the most potent anti-inflammatories [#1] and antioxidants [#2] known (not to mention that it helps control hunger signals [#3], improves insulin sensitivity [#4], burns off stress chemicals [#5], boosts thyroid function [#6], and helps your liver detoxify [#7]),” (UltraMetabolism, Mark Hyman, MD, 2006, p. 170). Dr. Hyman lists seven key functions of exercise here. None of them concerns the heart or muscular system, where we ordinarily locate the primary value of exercise. As clinicians, we need to expand our understanding of why movement matters and how it heals multiple interconnected bodily systems. Think of all the single-function medications (7 in this example) that can be eliminated from a patient’s daily regimen if we use movement wisely.
How do we use “exercise” to heal? First, we recognize the limitations of the term “exercise” and replace it with “movement” so that people who garden or work outside or play with kids and pets or dance or walk a lot (instead of driving) get the credit they deserve. The biggest problem for health is being sedentary not the lack of formal “exercise.” Second, we need to honestly evaluate the dangers of our most common forms of exercise (running, weightlifting, biking, most sports) and recognize how they overstress particular joints, leading to a multitude of injuries.
Running feels wonderful, but most of us in the West lack the long, graceful muscles of our ancestors, who squatted instead of sitting on chairs. This makes all the difference, for our modern hamstrings are rigid and thus pull excessively on the lower back and behind the knees, leading to an epidemic of running injuries. I know; I hurt my knees running. Lifting small weights is an excellent way to isolate and strengthen individual muscles; I do this often. But when a person puts the spinal disks, knees and shoulders at risk by piling on the weight, this shows a lack of understanding of how each part of the body is stacked upon the parts below. Biking is one of the most exhilarating experiences we have, but its sitting posture simply reinforces the caved-forward chest, forward-rounded shoulders, and rounded back so familiar from sitting in chairs too much. The spine is not allowed to lengthen or to arch backwards.
Whether a person’s pain comes from underusing or overusing her body, in the end it is still unnecessary pain. (Increased inflammation and excess lactic acid should not be the goals or byproducts of our movement systems.)
Third, we use movement patterns that lengthen and strengthen numerous muscles at once and in opposition (not just a few large muscle groups), so that we are balanced and smooth in how we move, so that our joints are protected not threatened, and so that our strong bones carry us safely through the inevitable falls that accompany our busy, distracted lives—to a secure old age.
Our bodies have a complex architecture that is understood and respected by a few movement systems like yoga, tai chi, and Pilates. Instead of pounding our knees or crushing our spinal disks, we should be wise enough to see that human culture has invented and evolved these beneficial systems to help us avoid (or handle) pain.
Fourth, all these beneficial movement systems, just as with meditation, use the breath to modulate the stress on the heart and to take us into a state of flow (parasympathetic nervous system). You can experience this even while briskly walking barefoot on sand or hiking over uneven ground—simply maintain deep breathing solely through the nose. Eventually you can train yourself to do the most vigorous movement forms while breathing calmly and slowly through the nose. This becomes second nature, and your breathing sinks down from the chest into the belly. This is how elite athletes reach the peaks of their sports. While all around you people are losing their heads, you keep calm, so your vision and thinking hold to clarity and balance. It takes years of work to reach this pinnacle of breath control, but this path is open to almost all people. You don’t need any special skill or notable strength.
Fifth, as clinicians, we have to find many ways to motivate different personalities—from addictive to depressed to sluggish to autistic to traumatized to hyperactive—helping each person to find ways of moving that are healthy and suit him or her. One size does not fit all. Let me share two of my clinical cases.
Gertrude is in her mid-fifties with a troubled history of auto accidents, botched surgeries, and dependence on painkillers. She is only a bit overweight, but she moves gingerly, especially through the hips. The fear and sadness in her eyes tell you her story. She works in health care with patients suffering from serious disabilities, and she has to maintain a constant appearance of calm strength and authority to keep her patients feeling safe. This masking places a huge burden on Gertrude. Her work is her life. As a mother also, she has found very little time in her life to take care of herself. My job as a movement therapist is to convince her that if she takes better care of herself, she will be able to take better care of her patients. Every time I see her for a group yoga class, I have to adjust my approach to deal with the specific pains of that day, pushing her to test self-imposed limits but not so hard that she will feel horrible the next day and abandon moving for a few days. What she really needs are frequent one-on-one chair yoga classes, but there is neither the time nor the money for that. It is easy for me to maintain my patience and encouraging approach with Gertrude, because I can feel her positive heart through her pain, but it is very hard not to get frustrated since I know I could help her so much more in different circumstances.
Daniel is in his early 20s; he is autistic and very bright. When he first came to me 2 years ago, he was very self-contained and angry. His immigrant parents had always treated him as “defective” and “embarrassing,” and he eventually was forced to live in their basement without a toilet or shower. Back then he was in a psychological support group whose main purpose, as he described it, was to make sure he took his meds (Celexa). He was very anxious around people and the meds made him feel sick most of the time. He felt the medical profession, like his parents, had little to offer him. Then he fell in love with our power yoga system; he loved the difficulty and the predictability of the routine—how he felt himself growing stronger and more slender every week. He stopped taking his meds and felt much better almost immediately. He began to open up to others in our yoga group (no one else in the group was autistic), eventually gaining respect and frequent hugs from much older men from different races (one man had spent most of his life in prison). Daniel also started to become an expert on food—eating much healthier—because our group added a food class (vegan cooking by Rachel Hedrick). Daniel’s family troubles finally forced him to move to Waterbury to escape his parents, but he still frequently texts many of us from the yoga community with questions and facts about food.
“The CDC [Center for Disease Control] says that a combination of exercise and cognitive behavioral therapy is more effective for chronic pain than taking opioids for a year or more. But, the agency noted, ‘Multimodal therapies are not always available [#1] or reimbursed by insurance [#2] and can be time-consuming [#3] and costly [#4] for patients,’” (Mara Lee, “Insurers Seek Opioid Treatment Shift,” Hartford Courant, July 11, 2016, p. A10). My work, as a clinician, must go beyond teaching food and movement to patients, for I must also work tirelessly to overcome these four obstacles (as noted by the CDC). I must push both to shift policy priorities away from excess use of drugs and to educate patients that making themselves healthy is a “time-consuming” process—well worth the effort. Daniel is just one of our shining examples of how this works. (See “Testimonials” at famtusa.org.)
Blog #4: “The Impact of Structure on Function, Pt. 1” Rachel Hedrick
This blog is a comparison of two people with similar shoulder injuries, one from underuse, the other from overuse. In my clinical practice as a bodyworker, I use myofascial release and active release to restore range of motion and treat chronic pain. These techniques are invaluable because the MFR lengthens the fascia that shapes each muscle (also freeing it from adjacent ones) and the active release engages the clients in the process, yielding deeper results.
Drugs and surgery had been offered to both individuals, but they refused, preferring to treat their conditions more naturally and less invasively. These two people are similar only in that they share 3 or 4 muscles that are chronically shortened. In one case, underuse is the underlying cause; in the other, it is overuse and overload.
Norm is 55 and an accountant. When I met him, he had had the shoulder injury for 5 years, and the pain was getting worse, at times waking him during the night. His right shoulder was quite visibly protracted or rolled forward. While standing, he was unable to lift his arm to the side higher than a foot from the side of his body. A greater restriction of motion was evident when he attempted to raise the arm in front of his body—the arm went up only about 7 inches before his shoulder shrugged up to his right ear, and he would grimace in pain.
Doctors had examined him, X-rayed him and given him MRIs, but they hadn’t been able to figure out what was wrong. Norm was desperate and afraid of the unknown and of surgery. There was no one precipitating event that had triggered the onset of his pain and restriction. My hunch was that it was a combination of poor body mechanics, poor diet, and chronic underuse of his whole body.
Sean is 45 and works as an electrician. He is a weight lifter and works out every day—sometimes twice a day. His injury occurred 7 years ago when he picked up a piece of equipment, weighing about 100 lbs., from a standing position without bending his knees or even thinking about his form. He felt a strange pop in the underarm area at the time. Later, the entire shoulder joint tightened up. His range of motion has not been compromised to the extent that Norm’s had. The most painful thing for Sean to do is to take his right arm and reach across his body to the left.
Standing, Sean’s shoulder is almost imperceptibly protracted, but when he is lying prone you can measure the distance from the spine to the right and left scapula and see that his right shoulder is anteriorly placed. His shoulder aches around the top of the trapezius and through the deltoid. His main complaint, besides the pain, is a loss of strength and muscle mass. He is now the lightest he’s ever been.
Treatment was very similar for both individuals. I began by lengthening pectoralis major and minor. Then the neck was worked through the scalenes and traction given to the occiput. Next I pressed the shoulder joint backwards with the client lying supine. In Norm’s case this proved almost excruciating. After this I worked the latissimus, serratus anterior, and had both people extend the arm from a 90-degree angle to as straight as possible, with the biceps alongside the ear, while I held down trigger points in the subscapularis.
The results of treatment were startlingly different. Norm’s range of motion had been almost totally restored after one treatment. However, he had a long road ahead of him to maintain proper alignment. I instructed him in some stretches for the pec muscles and strengthening exercises for the lower trapezius and rhomboids. A huge portion of his healing came from the psychological relief that his condition was no longer a scary mystery requiring surgery that might not even help. Norm’s future health depends on his lifestyle choices following treatment. If he can be diligent about regular exercise (both cardio and the prescribed shoulder work) and a healthful diet, then he will not have a recurrence, but with a complacent attitude he is likely to relapse into poor structure and reduced function.
Sean’s ability to endure the intense “discomfort” of the MFR and active release (especially in the subscap) was way beyond that of Norm. His tissues were much healthier, with better blood supply and nutrition. However, there are some injuries to tissues that Norm didn’t have. For example, the tendon of pec major felt like steel guitar string, and the lower half of brachialis is bumpy and gristled. Though he has eliminated certain exercises he perceives to aggravate the injury (mainly pull-ups and bench presses), he still continues to lift heavy weights and dedicates a whole day to chest and another to arms. Though strength and range of motion are improved post-treatment, the results are not as dramatic as in Norm’s case. Psychologically, Sean is addicted to weight lifting. I’m sure that if I told him not to lift weights like he does, he would discontinue treatment. It is doubtful that the injured pec and brachialis will ever be completely healed because, with his current regimen, he re-injures the area each week after treatment.
“Twentieth-century medicine,” writes Ida P. Rolf, “which has worked so many miracles, has been chemically, not structurally, oriented. Hence, the lay mind thinks of chemistry as the only outstanding healing medium—a drug for this, a shot for that. But any mirror or photograph would reveal that a great many problems are matters of structure, of physics—of a three-dimensional body fitting very badly into a greater material universe (the earth), which has its own energy field (gravity),” (Rolfing, 1989, p. 17).
Blog #5: “The Science of Movement, Pt. 1” Jeff Hush
The evidence that “exercise” is healthier for us than pharmaceutical drugs is overwhelming. So why don’t doctors prescribe “exercise” (better terms are “movement” or “physical activity”)? In Chinese medicine, they do (the treatment called “chi gong”). Different drugs damage different parts of our bodies, but almost all of them have detrimental effects on the liver, the heart, and the brain, because they interfere with mitochondrial function. We know that alcohol damages “mitochondria” in our cells, but do so statins (“Jogging the Brain,” NY Times, Nov. 27, 2016; UltraMetabolism, Mark Hyman, 2006, pp. 163-4).
“Mitochondria are the parts of your cells that combine the calories you consume with oxygen and turn this mixture into energy, used to run everything in your body. A single cell may have anywhere from 200 to 2,000 or more mitochondria. Cells that work hard, such as those in the heart, liver, or muscle, contain the greatest number. . . . The rate at which your mitochondria transform food and oxygen into energy is called your metabolic rate, and is determined by two factors: the number of mitochondria you have and how efficiently they burn oxygen and calories. . . . Fortunately you have the ability to dramatically influence both of these factors. The answer lies in one word: exercise. . . . By increasing your muscle mass, you increase the number of cells in your body that contain large numbers of mitochondria. . . . Muscle is much more metabolically active and burns seventy times as many calories as fat cells. . . . What most people don’t realize is that these calories [burned during exercise] are only part of the story. The calories you burn when not exercising are just as important. By increasing the number and function of the mitochondria in your body, you increase your ability to burn calories at rest,” (UltraMetabolism, pp. 160-1: bold added).
Let’s look at the largest and most respected studies that show how moving well makes us healthy. To show long-term continuity in the science, we will concentrate on the 1980s, on 2010, and on 2016 (30 years of studies that tell the same story, while upping the volume).
Two large studies in JAMA (1987, led by Dr. Arthur S. Leon; 1989, led by Dr. Steven Blair) stressed that only “moderate exercise” was enough to greatly lower “all-cause mortality” (Dr. Dean Ornish’s Program for Reversing Heart Disease, 1990, pp. 324-5, 327-8, 330-1, 338, 600-1). This “was defined as at least 30 minutes a day of light or moderate intensity activities such as walking, gardening, or home repairs. . . . During seven years of follow-up, those who exercised moderately had one-third fewer deaths from all causes (including heart disease) than those who were sedentary,” (Ornish, p. 325).
On February 2, 2010, the American Heart Association published its hugely ambitious “Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction,” chaired by Donald M. Lloyd-Jones, M.D., in the journal Circulation. Here are some key insights. “It is increasingly evident that health is a broader, more positive construct than just the absence of clinically evident disease,” (p. 590). “The definition of ideal cardiovascular health should . . . be simple and accessible to individuals to provide nonmedical guidance regarding lifestyle components . . . [and] contain actionable items on which individuals, practitioners, and policy makers could focus to improve cardiovascular health. . . . The committee defined a total of 7 health behaviors and health factors critical to the definition of ideal cardiovascular health.” Four of these seven were “health factors”: bmi, blood pressure, total cholesterol, and fasting plasma glucose. Then there were three “health behaviors”: smoking (not), “physical activity,” and “healthy diet,” (p. 591).
What is most striking about this study is how the doctors and scientists acknowledge the primary importance of these three health behaviors. Never smoking (or having stopped years earlier) is the first step toward health, but it is a “negative” step (“not”), whereas the other 2 health steps are “positive.” What really matters, then, is how both “physical activity” and “healthy diet” interact to create robust health. This robust health is then seen in the medically tested numbers: bmi, blood pressure, total cholesterol, and fasting plasma glucose. The message from this impressive 2010 study is clear: if you move well and eat well, you will generate healthy numbers in the tests and, more important, you will enjoy “health . . . a broader, more positive construct than just the absence of clinically evident disease.”
In other words, when you behave in a healthy way, the doctors can show you evidence for this in their/your diagnostic numbers. But they do not control your health, they simply show you—in your numbers—that you are either living well or damaging your body through sitting too much and eating empty or dangerous substances (not real foods). This 2010 study cites more “evidence for health behaviors” from a 2007 Swedish “study of 24,444 postmenopausal” women that shows “a 92% lower risk for MI [myocardial infarction] among those with an optimal diet and lifestyle pattern,” (p. 591).
The strongest statement about the value of lifestyle behaviors (and the much lesser value of pharmaceutical drugs) summarizes a 2006 American study of “42,847 US male health professionals 40 to 75 years of age”: “having even 1 health behavior was associated with substantially lower risk [“54% lower risk”; all 5 health behaviors had “87% lower risks for CHD”], and a strong dose-response relationship was present for each additional health behavior. Notably, the strong protective associations of health behaviors with CHD risk were very similar whether or not the men were receiving drug treatment for hypertension or high cholesterol, which indicates that drug treatment for these conditions do not alter the importance of lifestyle,” (p. 592; bold added).
This is a weakly stated version of a much stronger truth that emerges from this 2010 study: namely, that the drugs matter little, and the health behaviors matter a lot. A new study in JAMA Cardiology (June 2016) reinforces the power of this message. Jane Brody (NY Times, August 2, 2016) sums up this new CDC report: “cardiovascular benefits from medical interventions [from 2010 to 2014] may have reached a saturation point and that further improvements depend largely on changes in society and personal behavior.” Drugs, which are used to lower “high cholesterol levels” and “hypertension (in males),” are bringing down these diagnostic numbers, but that is not changing the overall mortality rates. Why? Because this drug-based medical approach is simply shifting the problem from one side of the scale to the other, without eliminating the core problem. “Anticipated declines in the prevalence of smoking, high cholesterol levels, and hypertension (in males) would be offset [by 2020, the “strategic goal” year] by substantial increases in the prevalence of obesity and diabetes” [“the prevalence of diabetes nearly tripled from 2.5% in 1990 to 7.2% in 2013 . . . 29 million US adults have diabetes”], (JAMA Cardiology, p. E5). So we are back to the “mitochondria.” When we damage them using drugs or alcohol, our metabolism becomes sluggish, and we become overweight and diabetic. This is compounded, of course, by our sedentary lives and poor diets.
So we return to the insights of the 2010 heart study, led by Dr. Lloyd-Jones: “We shouldn’t assume that chronic diseases automatically occur with aging. Living healthfully until we die is an achievable goal,” (Brody article, NYT, p. D5).