How Healing Works

by Wayne Jonas

  However, there is a different path to such knowledge, especially when we want to put that knowledge into action in a whole person. Whole systems science helps us understand how to use behavior to maximally stimulate our internal healing capacity and minimize the harms. We saw in chapter 4 (see this page) how the work of Dr. Mark Mattson of the NIH and others showed that fasting and episodic calorie reduction produced a general reparative and healing response—leading to improved function and longer life. Aadi, Xiao, and Maria were all using dietary manipulations similar to fasting to stimulate healing. Other behaviors can be used in a similar fashion. Exercise, for example, stresses the body—especially the heart, lungs, and muscles. It produces inflammation and generates oxidative damage. In addition, it causes small micro traumas in our muscles, which our body repairs during rest. Provided it is not overdone (yes, you can get too much exercise), these stresses and physical microtraumas become small stimulants to healing that induce our whole system to repair itself and keep us in good health. This is largely how exercise maintains health and increases healing. This is the same mechanism that stimulated Norma to function better with less pain from her arthritis, helped Aadi to improve his brain function, and allowed Bill to finally ease his back pain. Dr. Jordan D. Metzl, author of The Exercise Cure, has summarized much of the research on physical movement and health and provides a step-by-step approach to improving the time you spend moving, even if you have never purposely exercised. Research shows that even small and incremental steps toward greater movement are beneficial for most people. Only at the extreme athlete level do negative effects begin to appear. The type of exercise matters very little.

  This happens with mental exercise also. Differences in the effects of various stress management approaches are minor compared to the general goal of inducing a relaxation response. For more than fifty years, Harvard’s Professor Herbert Benson, author of The Relaxation Response, demonstrated that almost any type of relaxation inducer—prayer, meditation, rhythmic breathing, visualization, or biofeedback—can rapidly reverse the more than five hundred genes that are turned on by stress. In addition, those who regularly practice a relaxation method have better long-term health, recover faster from health challenges, and use fewer medical services.

  Was the specific content of the food Maria switched to in order to lose weight and control her diabetes the most important part of her improvement? While the emerging evidence currently points to a Mediterranean-type diet as good for overall health, it appears that simply changing our eating patterns to almost any whole-food approach provides the most benefit. In a large network meta-analysis published in 2014 in the journal JAMA Internal Medicine, researchers compared all the major diets being used for weight loss—Ornish, Atkins, paleo, Mediterranean, Weight Watchers, high carbohydrate, high fat, and others. While the high-fat diets worked better for weight loss in the short term, in the long run (after a year) all diets were equally effective. How much of the benefit that we get from healthy behaviors comes from the specific behavior we adopt? Is much of it actually—like the benefit from taking a drug, herb, or other treatment—more like a placebo effect, derived from the context and meaning of a behavior?

  As you can imagine, it is a bit challenging to create a placebo behavior. Bill and Aadi knew they were doing yoga, and Maria knew she had changed her diet—those are hard to fake. However, researchers have developed ways to improve the rigor of studies on behavior by producing “placebo lifestyle” approaches and modifying the expectation of benefit from a behavior. These studies have found that much of the improvement from behavior change is produced by what people think about the behavior they adopt. Professor Alia Crum of Stanford University has been studying this idea of mind-set as a determining factor.

  One ingenious study was set up to evaluate the role of mind-set on the benefits of exercise for health. Everyone believes that exercise is good for health—and it is. But is the benefit from the exercise itself or from the belief and meaning we give to it? That was Professor Crum’s question, and she devised this study. Hotel workers who clean rooms all day get a lot of exercise—making beds, cleaning bathrooms, as well as vacuuming and hauling stuff—a workout every day. It should be good for them. The researchers divided a group of these hotel workers into two groups. One group was instructed about the health benefits of activity from the work they did. They were given specific information on how their work activity helped their health. The other half was not instructed in any health benefits associated with their work activity. After one month, the researchers asked the groups about their perceived workload and the management about their actual workload. The researchers also did health measures such as weight, blood pressure, and body mass index. On average both groups did about the same amount of daily work activity—each worker cleaning fifteen rooms. However, the group who knew details about the health benefits from their activities and thought they were getting good exercise showed significantly more health improvement than the group who did not have that knowledge. This included improvements in objective measures, such as decreases in weight, blood pressure, body fat, waist-to-hip ratio, and body mass index. It seems that, as with drug effects, what we know and believe about exercise contributes significantly to its health benefits, well beyond the actual exercise itself! A significant part of the “exercise cure,” then, is the meaning response.

  Does this happen with food, too? We know that how a drug or herb treatment is labeled has a major influence on its psychological and physiological effect. Pairing a smell or taste with substances that produce biological effects enhances those effects through a process called “conditioning”—remember the impact of Norma taking her placebo pills four times a day compared to two times a day? The very act of doing something with the intention of benefit produced an effect. We know that the social environment and learning from others further enhances this process—remember Sergeant Martin and his hyperbaric oxygen group all getting the oxygen together and reinforcing its positive effects with each other? Eating combines all these factors. Think about how you have eaten all your life. Every meal is infused with your belief in its relative health value (or lack thereof); you get daily conditioning of that belief from its smell and taste; and, most of the time you get social reinforcement of that belief from what and how you prepare and eat together with family and friends. Are the health benefits of eating, something you do several times a day, also influenced by the meaning response? Professor Crum also investigated this question by examining the impact of food labeling on our hormone responses. In an experiment called “Mind over Milkshakes,” she examined whether the nutritional label and information about food produced biological effects. One milkshake was called Sensishake; the label said it had no fat, no sugar, and only 140 calories, and was “guilt-free.” It seemed very sensible from a health point of view. A second shake was called Indulgence; the label said it contained 640 calories of combined fat and sugar—and delivered the “decadence you deserve.” In truth, both shakes had 300 calories and the same nutritional content. Before and after people drank one shake or the other, they had their level of a hormone called ghrelin measured. The ghrelin level rises when you are hungry and drops when you are satiated and don’t feel like eating any more. It also slows metabolism, so more calories are stored as fat rather than burned. The study found that ghrelin levels dropped three times more when people drank the “indulgent” shake compared to the “sensible” shake. When people thought they had eaten a heavy, calorie-laden food, their bodies responded as if they had. As in drug studies, most of the effect was due to the belief combined with the ritual around the food—not what was in the food itself. Almost all nutritional science tells us what is healthy or not—based on examining the content of what we eat rather that the process of eating itself. This dilemma contributes to the confusing claims.

  Does this mean the content of our diet does not matter? Of course not. Lots of research shows it does. However, how much it matters and the health response genera
ted by food content are markedly influenced by the meaning we attach—individually and culturally—to what we eat. Professor José Ordovás, a senior scientist and director of the Nutrition and Genomic Laboratory at Tufts University in Boston, has studied the effects of the Mediterranean diet on genetic factors related to health. He studies what cultures are eating and measures how those food patterns trigger gene changes related to health and disease. While your doctor may measure your cholesterol and blood sugar and recommend diet changes based on these, Professor Ordovás studies how those factors are influenced by the food-gene interactions that are precursors for them and explain much of what your doctor measures—using the very tools of whole systems science. During his Mediterranean diet research, he noticed there are practically no situations in which the food—healthy or otherwise—is ingested in isolation. Most of the people in countries where the Mediterranean diet is consumed prepare and partake of that food in family and community groups—usually in an atmosphere of friendship, fellowship, and love—like Maria did with her family and friends. When Ordovás measured the gene expression (in the urine) attributed to the Mediterranean diet during the meal preparation, he found that many of the gene expression changes attributed to the health benefits of the food were turned on before a single bite was taken. Eating does not just involve taking in a bunch of chemicals—it is a meaningful social and personal behavior solidified around the “agent” of food. The meaning infused into that behavior influences our bodies—from genes to hormones to cholesterol to our weight. So to help Maria, we had to link her healthier behavior around food to its association with her family and the joy it produced in her life. We needed to use food to induce a meaning response.

  HEALTHY BEHAVIOR

  While there is scientific evidence for the value of each of the elements I explore with patients to help them find and create healthy behavior, I discuss them with patients not in order to tell them what to do, but for them to find just a few—even one or two—that are the most meaningful for them. Jeff used exercise to stop smoking because he loved to run and be outdoors. He used this love to create a positive addiction to replace smoking. Maria used food to facilitate the cure of her diabetes, but in a way that did not bring her joy. Jeff linked his behavior to meaning, which allowed it to penetrate deeper into this life. Maria simply tried to comply with a dietary change that helped her body but created side effects. Both used the behavioral dimension as an entry point on their path to health and healing. Both did the behavior; however, only Jeff induced a meaning response. Maria did not, even though she seemed to have more willpower.

  In most major health systems around the world—both ancient and modern—lifestyle is a cornerstone of disease treatment as well as disease prevention. In ancient China, for example, the head of each family paid the doctor only if everyone in the family remained healthy. When someone became ill, the doctor received no money until the patient recovered. (Think how that would go over in today’s managed care!) The system used lifestyle (diet, exercise, exposure to nature, and energy “chi” balance) for both prevention and treatment. It applied the same practices and principles at different intensities depending on whether they were meant to maintain health or restore it.

  In the equally ancient Ayurvedic system of India, we saw how Aadi’s Parkinson’s disease was treated with a personalized regimen of diet, yoga, prayer, meditation, and oil-based massage customized to his body type and emotional makeup. These same approaches were used outside the hospital to prevent the disease’s return. Both these medical systems are at least five thousand years old. In another part of the world, in the fourth century BCE, Hippocrates, the pathfinder and inspiration for modern Western medicine, declared that food is the best medicine. The ancient Greek health center of Epidaurus provided gardening for teaching nutrition, sport and exercise to regain physical fitness, theater to work out social and mental health issues, and hot and cold baths to cleanse and stimulate the body to promote healing. Prevention and treatment used the same tools and processes. It was one system. But modern biomedicine has split these goals—prevention and treatment—and developed very different ways to accomplish them.

  MINDING THE GAP

  In health care today, we have two very different health systems and a gap between them. One system focuses on acute problems such as injury, heart attack, stroke, and infection; the other emphasizes prevention and health promotion through activities like vaccinations, sanitation, and lifestyle changes—like smoking cessation, improved nutrition, exercise, and stress management. The two systems operate in virtual isolation from each other, as if they were in separate buildings—and in most communities, they usually are. What happens, for example, when you have a heart attack? You are rushed by ambulance to a hospital, where elaborate and expensive medical resources are mobilized to help you: a fully equipped emergency room, surgeons, anesthesiologists, nurses, imaging technicians with their machines, and an operating room filled with a dazzling array of medical technology, just to begin. Then, when you have been stabilized with angioplasty, a stent to open up a clogged blood vessel, or surgical removal of a blood clot, you are moved to a hospital room, where nurses, orderlies, technicians and health aides, support staff, and the billing office tend to your needs. All this happens under the supervision of an attending physician, and if you are in a teaching hospital, residents, interns, and medical students join in as well.

  After treatment, you need a calm, peaceful environment in which your body can recover from the medical assault. Instead, machines, staff conversations, and loud announcements over the paging system surround you. You are awaked in the middle of the night, stuck with needles to draw blood, and have devices attached to measure your vital signs. If you’re in the intensive care unit, these machines are a constant presence, with blinking and beeping readouts on display—blood pressure cuff, finger clip to monitor oxygen levels, electrodes, and maybe a catheter. You are given meals high in sodium, animal fat, and refined carbohydrates like white bread or white rice. And when you are out of acute danger, depleted by the ordeal, you are sent home, usually as soon as possible, with minimal home care planning and often without anyone talking to you about the lifestyle that caused your heart attack in the first place. Once you have been labeled with a disease and have crossed the diagnostic threshold to enter the world of acute care, an entire industry awaits you. Everything in this “building” of the medical system is based on the acute care model of health: namely, that there is a single cause for disease. If an artery is blocked, open it up. If cholesterol or blood pressure is too high, lower it with medication. If you have mild to moderate depression, prescribe mood-elevating drugs. The detailed manipulation of the body by this system is impressive—and expensive.

  By contrast, the other “building” in the modern health care focuses on prevention of disease. Here, health care practitioners and public health specialists try to educate you about ways to modify your lifestyle through diet, exercise, stress management, and smoking cessation to address the underlying causes of disease and prevent problems from developing. They supplement your milk and bread with vitamins; your water with chlorine and fluoride; and, repeatedly urge you to eat better, stop smoking, exercise, and, oh, see your doctor for checkups. With a few exceptions, there is still a huge gap between the systems that prevent disease and the systems that treat disease, because they operate from completely different health models.

  So, the first step in creating a personal environment that promotes healing behavior is awareness of this gap and exploring ways to fill it in your life. If you find yourself crossing the diagnostic threshold into the acute care system, you can ask your doctor to help you bridge the gap between prevention and treatment by giving you information on and assistance in finding a health behavior change meaningful for you. Armed with this information, you can then find lifestyle changes that will prevent future problems. At the end of this book, I give you specific tools to help you in that conversation with your doctor.

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sp; You must be persistent in finding this help within the medical system, however. Although primary care, like family practice, is supposed to help fill the gap, payment for primary care is still based mostly on the episodic visit in an acute care system, with minimal coverage for prevention, lifestyle, and healing. So even those tasked with bridging the gap usually cannot. Remember, only 5% of the measured expenditures in our health care systems target lifestyle treatments, health promotion, and prevention. And 95% is spent on treatment of acute disease with nonlifestyle approaches, so don’t expect the medical industry to do this very well for you. When it comes to bridging this gap between prevention and healing, the situation is changing, but it is nonmedical organizations such as companies and even the military that are leading the way. An example of that is Total Force Fitness in the U.S. military.

  TOTAL FORCE FITNESS

  One of my assignments in the U.S. Army was to develop ways to close the gap between prevention and health promotion and treatment. The military realized that very often behavior could both prevent and treat disease, and they wanted to help close this gap for service members and their families. In 1991, the Army Surgeon General launched a massive health promotion and prevention program on all Army posts. I was its medical advisor. Every soldier was to get a Health Risk Appraisal Assessment (HRAA). The HRAA screened all soldiers for their lifestyle habits and risk factors, such as smoking, high-fat diet, alcohol use, exercise, and stress. It measured physical health factors such as cholesterol, blood pressure, blood sugar, weight, and percent of body fat. It explored each person’s stress management and mental health issues. The HRAA eventually replaced the annual physical, which had been around for over a century and was shown to be largely useless.