COVID-19 has turned the world upside down. The rising numbers of confirmed cases and deaths, fear of infection, lack of education access due to school closures, the disruption of daily routines from home confinement and social distancing, as well as family financial loss have imposed enormous impacts on physical, mental, and community health. While the COVID-19 pandemic has been absolutely devastating, it has accomplished at least one positive thing in terms of human health: It is causing many people for the first time to urgently ask the question, “How can I optimise my health?” Behind that question is the strong desire to optimise immune function and improve resilience in the face of this unprecedented viral assault. Thus, in the midst of the devastation of a major health crisis, we see the seed planted for a more health and wellness-oriented future. That focus on helping each individual optimise their own well-being was the impetus for the creation of the Integrative Medicine programme at Mayo Clinic over two decades ago. Through that programme, we are now seeing unprecedented numbers of patients (and consumers) reaching out and asking for guidance on how to achieve greater resilience in the days ahead.
INTEGRATIVE MEDICINE AT MAYO CLINIC
We began the Integrative Medicine programme at Mayo Clinic in 1999. This was done in response to the growing interest of our patients in incorporating a variety of complementary therapies into their conventional care. For example, we were receiving a growing number of questions about the role of therapies such as acupuncture, massage, herbs and supplements.
This led to the development of a robust research programme, the goal of which was to scientifically evaluate the safety and efficacy of each of these therapies our patients were choosing to use. Those that were found to have both safety and efficacy and fit within the Mayo model of care were then integrated into our usual care patterns. Thus, for example, a patient recovering from surgery can request a massage therapist visit to help deal with post-operative pain and healing of surgical incisions. Or a child can have a dog and volunteer owner come and visit to help them overcome some of the challenges of being in a hospital environment. In short, we believe this approach fits nicely with the definition of integrative medicine created by the Academic Consortium:
As the research introduced new opportunities to help expand our care for our patients, that clinical experience then helped inform future research projects. As such, we have attempted to maintain a reiterative process whereby we keep reinventing the clinical care of our patients to optimally meet their needs with whatever evidence-based strategies are most aligned with their situation. As a result, we now offer acupuncture, massage therapy, mind-body practices, tai chi, yoga, qi gong, animal-assisted therapy, herbal consults and reiki, as well as many others.
East-West collaboration in healthcare solutions
The HEAD Foundation, together with Mayo Clinic in the USA, Singapore General Hospital (SGH), and the Medical School of Jinan University, is conduting a multi-centre randomised controlled trial (RCT) to investigate the efficacy of Tuina vis-à-vis Physiotherapy in alleviating chronic low-back pain.
Research at Mayo Clinic
Mayo Clinic researchers contribute to the understanding of disease processes, best clinical practices, and translation of findings from the laboratory to the clinical practice. Mayo Clinic is ranked number one in the United States for the 2019-20 U.S. News & World Report Best Hospitals Honor Roll, maintaining a position at or near the top for more than 27 years. Image source: Mayo Clinic
The goal is to integrate these different therapies and practices along with the best of conventional care in a way that benefits the individual patient. While we have always seen a select percentage of our patient population interested in incorporating these various strategies into optimal health and wellness plans, the percentage has never been a majority. With the advent of the COVID-19 pandemic, we are now seeing a tremendous surge in the number of patients who want to optimise health and wellness using all of the tools that are available.
To help meet the demand for evidence-based strategies that can boost immune function and resilience, we have been guided in part by the growing body of evidence related to telomere enhancement (for example, Ornish, Dean, et al. “Effect of comprehensive lifestyle changes on telomerase activity and telomere length in men with biopsy-proven low-risk prostate cancer: 5-year follow-up of a descriptive pilot study.” The Lancet Oncology 14.11 (2013): 1112-1120).
We have used some of the existing clinical data on telomeres that suggest a comprehensive lifestyle approach which incorporates daily aerobic exercise, a whole foods plant-based diet, 30 to 60 minutes of mind-body practice on a daily basis, and structured social support, can yield a statistically significant improvement in telomere length. This serves as a basis for trying to incorporate all of the different modalities, allowing patients to pick and choose from the list of modalities and find those that make the most sense for their individual needs. We then try and focus discussion on defining a strategy within each of the six following domains to help optimise their wellness at a genetic level while also optimising their immune function and overall resilience.
Telomere length as an indicator of biological aging
Telomeres are the caps at the end of each strand of DNA that protect our chromosomes, like plastic tips at the end of shoelaces. They are an important part of human cells that affect how our cells age. Progressive shortening of telomeres leads to senescence, apoptosis or oncogenic transformation of somatic cells, affecting the health and lifespan of an individual. Shorter telomeres have been associated with increased incidence of diseases and poor survival. Image: Skypixel / Dreamstime
For many consumers and patients alike, nutrition knowledge is limited. So our goal is to provide broad principles (for example, prefer whole foods over processed foods) which are relatively easy to understand and which allow some early successes in the transition to healthier eating. We also use the Mediterranean diet as a good example of a diet that can help reduce the risk of heart disease, cancer and dementia, while helping to improve telomere length, immune function and resilience. Emphasising vegetables, minimising red meat and using healthy oils (like olive oil) are key components we emphasise. It has especially been shown with COVID-19 that following the Mediterranean diet pattern can potentially decrease the risk of viral respiratory infections. While many people are particularly motivated to make health-enhancing dietary changes, we generally counsel small changes to start – since draconian diet plans rarely last and miss the concept of continuously evolving one’s dietary choices to increasingly healthier options as a lifelong process.
The Mediterranean Diet
This is based on the dietary traditions of Greece and southern Italy in the 50s and 60s, when the rates of chronic disease in these areas were among the lowest in the world and adult life expectancy among the highest, despite having only limited medical services. Photo: wundervisuals / iStock
Evidence suggests that physical exercise may promote telomere length maintenance. Almost everyone understands the benefits of routine exercise at some level. But it has taken the COVID-19 pandemic to shift people’s understanding to value consistent exercise for the role it plays in building and maintaining a healthy immune system. Here again, we counsel patients and consumers to start small and work up to a daily goal of around 45 minutes of brisk activity most days of the week. It is very important to recognise that some people are starting from a very sedentary lifestyle. Asking them to achieve 45 minutes of brisk activity right away risks injury and disappointment – which in turn can reduce the likelihood that they will stick with any exercise programme. So we ask patients to identify an activity that they can currently do which is not exhausting and does not cause them excess pain or fatigue the following day. Many people will state that they can comfortably walk for, for example, five blocks. We then use that as their baseline and ask them to walk five blocks every day for a week or two. When that becomes relatively easy, they can increase the distance by adding another block to their route. This incremental approach allows for some sense of mastery early in the process and builds endurance slowly over time, reducing the risk of injury and burnout from being pushed too hard, too soon.
For those patients who are really deconditioned, or simply have a sense that they cannot be successful with exercise, we start with a simplified tai chi course. If needed, they can do it as a seated participant. The simple flowing movements are not as intimidating as ‘exercise’ and studies have shown that many patients gain a sense of self efficacy in regards to exercise with tai chi. There are of course many similar practices (for instance, qi gong, yoga, and so on). The key is to allow the patient to explore different options so that they can find one that resonates with them.
Relaxing on the go
In New York, BEtime meditation studio on wheels comes to clients, allowing them to do their mindfulness meditation class without having to travel. There are also an estimated 1,500 meditation and mindfulness apps that make meditation more accessible. Image source: BEtime Practice @betimepractice
- Mind-body Practices
Even before the pandemic, stress was recognised as a major health problem in the United States. Several studies of major employers consistently found stress to be the number one health problem in employees. Now, with all of the challenges and restrictions related to social interactions, stress levels have skyrocketed, reflected in disturbing trends of increasing depression, domestic abuse, and drug abuse. Yet, at least in the US, acknowledging stress in one’s life is not routinely done. And when it is, very few consumers or patients have the tools to deal with it effectively. At the same time, a growing body of research confirms that a daily mind-body practice, as part of a comprehensive lifestyle approach, can help lengthen telomeres, reduce anxiety, improve sleep and boost immunefunction. Thus, we believe that learning and practising a mind-body therapy on a daily basis is a foundational element of health promotion that is critically lacking in most patients.
We try to allow patients to sample a large variety of practices (such as meditation, guided imagery, computer-assisted biofeedback, tai chi, qi gong, yoga). With a bit of trial and error, most patients find one or two practices that resonate with their world view. We then ask them to find 30 minutes each day to do these practices. Allowing them to break up the practice (say, 15 minutes in the morning, 15 minutes in the evening) seems to help patients who are new to mind-body practices achieve success.
- Social Connectedness
Due to social distancing, selfisolation and travel restrictions, the socio-economic shock presented by the COVID-19 pandemic is likely to reshape perceptions of individuals and organisations about work and living at home. Some of the studies looking at telomere enhancement utilise a support group as part of the intervention. Most consumers (and even many patients) are not enthusiastic about joining a support group or may not have ready access to one. We therefore operationalise this concept as ‘social connectedness’. We encourage patients to think strategically about those people or activities that ‘fill their tank’ or bring joy to their lives. In our busy culture, many patients and consumers forgo those activities or social connections which are so critical to maintaining well-being. Making time in the calendar each week to honour these relationships or activities is a formal step we encourage patients to do. At the same time, it is equally important, if not more so, to focus on activities or relationships which are ‘draining their tank’. Some relationships or activities are simply more fatiguing or draining and need to be either curtailed or eliminated to maximise health going forward. We talk about kind ways of putting ‘buffers’ (agreed upon limits) around family or friends when they are the cause of the extra challenges.
Seven hours the magic number for sleep
People who sleep more or fewer than the recommended duration of seven hours a day, including naps, are increasing their risk for cardiovascular disease. Photo: Danai Jetawattana / iStock
- Optimal Sleep
Sub-optimal sleep is a risk for shorter telomeres and impaired health. Very few of the patients coming to us who are trying to optimise their immune function have even a basic notion of good sleep hygiene. Once they understand the critical role that sleep plays in helping maintain immune function, they are generally more engaged in learning how to improve their sleep hygiene. We start by emphasising the importance of daily aerobic exercise and its impact on helping to improve sleep quality. We then talk about caffeine consumption and encourage patients not to consume caffeine after 10 am. Next we have patients try to structure their bedtime so that all electronics are turned off at least one hour before bedtime. Reading an ‘old-fashioned’ physical book in soft lighting, perhaps with some classical music or other soothing sounds, can help prepare the brain for sleep. We also recommend a number of guided imagery CDs that further help prepare the brain for sleep.
The effects of religion on telomere length have been discussed in previous literature, although this area is not fully studied. It is evident that spiritual interventions play a significant role in public health crises. Many studies have suggested that patients who have a regular spiritual practice have enhanced health compared to those who do not. While this is often thought about in the context of a religious experience, some patients find meaning in nature or specific relationships. Spiritual interventions provide hope, refuge, counsel and rejuvenation for people amidst the COVID-19 crisis. We encourage patients to consider deeply the things or practices that bring great meaning to their lives and then honour that by making time each week for observances or practices.
It may be too early to state that a fundamental change has taken place in the US population. But each day, I see more and more patients coming to Mayo Clinic seeking not only care for their complex medical problems, but increasingly also asking for help and guidance to improve their overall health, boost their immunity, and improve their resilience. We believe Integrative Medicine, with its large tool chest of evidence-based therapeutic approaches, will play a critical role for both patients and consumers in future-proofing our recovery.
DR BRENT A. BAUER
Dr Brent A. Bauer is Director of Research for the Integrative Medicine Program at Mayo Clinic, USA. He is also a consultant at both the Division of General Internal Medicine and Division of Geriatric Medicine and Gerontology at the same clinic. Dr Bauer’s research interest spans mind-body applications, herbal and dietary supplements, acupuncture and massage therapy. To date, he has published more than 100 papers on integrative therapies.
DR JUAN YANG
Dr Juan Yang is a Research Fellow in the Integrative Medicine programme at Mayo Clinic. She specialises in the management of chronic pain with integrated traditional Chinese and conventional medicine, specifically in acupuncture for musculoskeletal pain, cancer pain and pathological neuralgia. Throughout her career, Dr Yang has published many papers on her areas of expertise and written a book on pain rehabilitation. She is also actively involved in many research projects supported by the Shenzhen Municipal, Guangdong Province and Mayo Clinic.