Employing Mindfulness in Lifestyle Medicine

‘Research shows that mindfulness alters attention systems, increases resilience, improves self-esteem, and increases well-being and can be used to treat a variety of disorders.’

Background

It is estimated that more than three-fourths of all doctor’s visits are related to stress ¹ and that stress costs America more than $300 billion annually. ² In the 2012 American Psychological Association Stress in America Report, researchers found that 42% of Americans report lying awake at night because of stress. ³ The demands faced by health care professionals are linked to increased stress and burnout. ⁴ In a 2009 survey of 763 California physicians, 53% of participants reported having severe to moderate stress. ⁵

Chronic stress has negative health effects on every organ system of the body and may cause disease either as a result of direct physiological changes in your body or as a result of the indirect effects of unhealthy methods of coping with stress, such as overeating or abusing risky substances. ⁶ With such widespread impact and negative ramifications, it is imperative that all members of the health care team be familiar with the ways of not only reducing stress in their own lives, but also helping their patients do the same.

Mindfulness

Mindfulness has been used as a nonpharmacological path to reduce stress and create a peaceful mind for many years. Research suggests that mindfulness interventions can increase self-compassion among health care workers, which in turn holds promise for reducing perceived stress and increasing effectiveness of clinical care. ⁷

According to the Lifestyle Medicine Handbook, mindfulness is the quality or state of being mindful and the practice of a person maintaining a nonjudgmental state of heightened or complete awareness of their thoughts, emotions, or experience on a moment-to-moment basis. ⁸ By this simple definition, mindfulness can take on many different forms and can be applied in many different settings, making it a very versatile tool for all health care workers. Because developing strategies to manage stress reduction is 1 of the 6 pillars of lifestyle medicine (LM) and mindfulness has been shown to be effective in this area, LM practitioners should be aware of how to apply mindfulness techniques in their lives and in their practices.

Mindfulness-Based Stress Reduction

Perhaps the most popular and scientifically validated application of mindfulness for stress reduction is mindfulness-based stress reduction (MBSR), developed by Dr Jon Kabat-Zinn. MBSR has been identified in the Lifestyle Medicine Board Review Manual as a skill that can help patients during stress reactions and help them take better care of themselves. ⁹ There are more than 800 MBSR programs done by trained professionals. ¹⁰ MBSR is delivered as a 9-class, 8-week evidence-based program that offers secular, intensive mindfulness training to assist people with stress, anxiety, depression, pain, and suffering.

In a review of 17 studies using MBSR as a stress management technique, 16 of the 17 demonstrated positive changes in psychological or physiological outcomes related to anxiety and/or stress. ⁸ Another meta-analysis of 20 both clinical and nonclinical controlled and observational studies demonstrated that MBSR may help a broad range of individuals to cope with their clinical and nonclinical problems. ¹¹

Research shows that mindfulness alters attention systems, increases resilience, improves self-esteem, and increases well-being and can be used to treat a variety of disorders. ¹¹ It can also lead to lasting reductions in both physical and psychological symptoms related to inflammation, pain, anxiety, depression, and addiction.^12,13 These benefits may be a result of changes to the brain that occur in response to mindfulness interventions. Eight weeks of mindfulness training can increase activation of the left prefrontal cortex, increase gray matter density of the hippocampus, decrease gray matter density of the amygdala, and increase other brain structures. These areas of the brain are responsible for planning, personality and happiness, learning and memory, and emotion and problem solving as well as self-awareness, compassion, and introspection. ¹⁴

The ultimate goal of MBSR programs is to teach integration and application of mindfulness into daily living and how to apply a mindful approach to the mental and physical challenges life brings. Mindfulness itself teaches attitudes of nonjudgment, nonstriving, acknowledgement of what is happening, patience, self-reliance, and a beginner’s mindset. It is different from meditation practice because it is not concentrative as much as a practice of keeping an open field of awareness that is kind, accepting, self-compassionate, and present. In this way, mindfulness can be done in every moment and in every place and can become a way of living or being. ⁹

Mindfulness in the Largest Integrated Health Care System of America

The Veterans Health Administration is the largest integrated health care system in the United States. ¹⁵ Posttraumatic stress disorder (PTSD), stress, depression, and wellness have been cited as Veterans Association (VA) priority areas. The VA recently conducted a systematic review of evidence and published an Evidence Map to explore mindfulness intervention research and related outcomes. Although this evidence map found unclear evidence of mindfulness as an intervention for stress at the time it was conducted, new research has been published that may support a reanalysis of the data. In addition, the map did find evidence of a potential positive effect of mindfulness for chronic illness, depression, mental illness, cancer, psychosis, anxiety, pain, and general health. The report summary concluded that the most consistent effect of mindfulness-based interventions is reported for depression and that data indicate positive effects of MBSR on overall health, chronic illness, and psychological variables. It also shows positive effects of mindfulness-based cognitive therapy (MBCT) in mental illness and positive effects of mindfulness interventions for somatization disorders compared with passive control groups. ¹⁶

Whether a result of this evidence or otherwise, the Office of Patient Centered Care and Cultural Transformation at the Department of Veterans affairs recently made the first step toward implementing a new model of care called Whole Health that places mindful awareness at the heart of the delivery model. You can see this depicted at the center of the Whole Health model’s Circle of Health visual, which can be found along with a variety of other resources on the Whole Health online library of open-access resources. ¹⁷ The Whole Health model of patient care aims to treat more than a symptom or disease but rather places emphasis on recognizing the patient as a whole person and partnering with each patient to empower him or her to be an active participant in his or her own health.

Whole Health emphasizes mindful awareness interventions to facilitate practice and teaching; these are collectively known as mindfulness-based interventions and include previously described MBSR and MBCT. Whole Health also uses 2 mnemonic techniques for mindfulness, TIES and SOLAR, as a way to facilitate mindfulness. TIES is described as a way to characterize moment-to-moment experience and individuals’ internal landscape. It more or less covers everything that can come up during mindful awareness practice, including Thoughts/talk, Images, Emotions, and Sensations. SOLAR builds on the use of TIES to fully embody our moment-to-moment experience and includes the instructions Stop, Observe, Let it be, And Return as often as possible. ¹⁸ In addition to these techniques, Whole Health leverages a variety of patient and provider facing handouts and digital tools.

Not only does the Whole Health model of care place mindful awareness at the center, but it also leverages 8 aspects of health that greatly align with the 6 pillars of LM. These aspects, called circles in the Whole Health model, include moving the body, physical and environmental surroundings, personal development, food and drink, rest and recharge, family/friends/coworkers, spirit and soul, and power of the mind.

The Whole Health model of care has been described as transformational. Benjamin Kligler, MD, MPH, National Director of Integrative Health Coordinating Center and Director of Research and Education in the Veteran Health Administration Office of Patient-Centered Care and Cultural Transformation states, “Whole Health has the potential to transform not only the VA but all of American health care from a system designed strictly to prevent and fight disease to one designed to create and sustain health and well-being.”

With implementation of the Whole Health model of care and its Complementary and Integrative Health (CIH) approaches, such as mindfulness, at 18 flagship sites a little more than a year ago, anecdotal evidence suggests that many VA medical centers have faced challenges. They have shared lessons learned in an article titled, “What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration.” ¹⁹ In the article, the authors identify several barriers and recommend several strategies for successfully implementing CIH modalities such as mindfulness in health systems that may or may not be receptive to the practice.

Mindfulness in Lifestyle Medicine

In a medical model that asks doctors to take an oath to “first do no harm,” educating and using mindfulness as a first line of stress management plan makes sense when a referral to a mental health provider or use of pharmacotherapy is not indicated. Because there is little to no evidence to demonstrate harm in practicing and promoting mindfulness, the benefit potential for chronic disease outweighs the cost of the harm of not implementing mindfulness.

Mindfulness interventions are simple-to-use tools that have little cost and great potential to improve health outcomes in chronic conditions that many LM providers may not only suffer from personally, but may identify in a large amount of their patient populations. LM certification requires providers to have an understanding of nonpharmacological approaches to manage stress, including mindfulness and meditation, among other techniques. Certification also requires LM providers to learn how to promote empower self-management techniques to improve emotional well-being and treat depression.

Overall, mindfulness skills enable presence, clarity, and curiosity in the clinical encounter and can improve the patient-provider relationship. LM-certified practitioners are qualified professionals trained to deliver mindfulness interventions. Mindfulness has been used in the largest integrated health care organization in America based on evidence to demonstrate its power to improve a variety of chronic conditions in patients and health care workers, including stress. Although more research is needed to determine all potential benefits of mindfulness and overcome barriers to implementing mindfulness and other nonpharmacological techniques as a first treatment for stress management in clinical settings, there is a strong evidence base to support its use and very little to negate it. Regular practice and promotion of mindfulness skills in LM encounters may help normalize the intervention and maximize its potential benefits and allow researchers to collect data needed to prove other potential clinical uses.