Integrating Wellness & Nutrition: Lessons From University .
MANAGEstressIntegrating Wellness & Nutrition: Lessonsfrom University of CincinnatiSian Cotton, PhDDirector, Center for Integrative Health and WellnessDirector, UC Health Integrative MedicineProfessor, Department of Family and Community MedicineUniversity of Cincinnati College of Medicine
UNIVERSITY OF CINCINNATICENTER FOR INTEGRATIVE HEALTH & WELLNESSMANAGE stresswww.med.uc.edu/integrative
Graduate Medical EducationDrake CenterLindner Center of HopeWomen’s Health CenterHeart, Lung & Vascular InstituteDiabetes & Obesity CenterNeuroscience InstituteCancer InstituteWellness PlatformCenter for Integrative Health & Wellness
Objectives1.2.3.4.5.Briefly review the crisis of chronic disease andminimal attention to lifestyle education in medicalschools and healthcare provider burnout asbackgroundHighlight 2 programs at UC that constitute apreventive and educational approach to fosteringwell-beingProvide overview of first program: Turner FarmStudent Wellness retreatsProvide overview of second program: Mind-Bodycourse, modeled after Georgetown UniversityPresent information on development, outcomes,and sustainability plans for both programs asmodels
CaveatsAcademic Health CenterOne Story
THE PROBLEMCrisis of chronic disease:physical and mental disorders.75% of chronic diseases are influencedby our behaviors / lifestyle
PREVENTABLEHeart DiseaseCancerObesity600,000 die year#1 cause of death in U.S.Reversible with diet1 in 3 cancer casesare preventable withLifestyle changes7 in 10 overweight33% obese in CincinnatiLifestyle changes
CHALLENGEprescribe lifestylechanges
PROBLEMnot taught inmedical schools
Nutrition (Mis)education in US Medical Schools
Integrative Medicine Education NEW: Lifestyle Medicine andWellness Curriculum Task Force Mindfulness Programs Mind-Body Course Integrative Medicine StudentInterest Group 4th Year ComplementaryIntegrative Medicine Elective Interprofessional Initiativesacross Academic HealthCenter Turner Farm Student RetreatsIMSIG presentation Nov 2015
5th Annual SanghviLectureNutrition and Mindfulness inan Era of Global Obesity andDiabetesEstablished June 2014
Program #1Turner Farm Student WellnessRetreats
Turner Farm Teaching Kitchen
Program #1: Background To transform Disease Care to Wellness Care,need to educate health providers Transformation starts with education of students- traditional curriculum does not emphasizelifestyle modification Inter-professional learning grows into interprofessional team-based care Turner Farm’s Teaching Kitchen as platform
Turner Farm’s MissionTurner Farm operations promote connectionsbetween people of all ages and the land that feedsthem, in body, mind and spirit.Through education and example, we nurtureunderstanding of the rhythms of nature, and ourplace in the natural world, fostering recognition ofpersonal responsibility for stewardship of the land,ourselves and development of a nurturingcommunity.www.turnerfarm.org
Turner Farm
Teaching Kitchen
Student Wellness Retreats Seventy-five students haveparticipated in five wellnessretreats 6-hour Saturday retreats Students from: Colleges ofMedicine, Nursing, AlliedHealth, Pharmacy and HealthPromotion Sign-up via email - fills withinan hour Cost to student: 10 Philanthropy off-sets costDr. David Eisenberg and Chef Adam Busbyat Turner Farm Sept. 2016
Turner Farm HostedHarvest to Healing/Seed to Soul DinnersSept. 23 & 24, 2016
Retreat Schedule9:30 - 10:0010:00 - 10:1510:15 - 10:30Wellness10:30 - 10:4510:45 - 11:3011:30 - 11:4511:45 - 12:3012:30 - 2:30kitchen2:30 - 2:452:45 - 3:15Arrival/RefreshmentsWelcome and Introduction to Turner FarmIntroduction to UC Center for Integrative Health andand the Teaching Kitchen CollaborativeOpening meditationFoundations of Disease, Nutrition and Lifestyle didacticsQ&ABreak & Walking Tour of Turner FarmChef and students prepare healthy meals while discussingfundamentals of healthy eating; hands-on teachingexperiential/tasting prepared dishesMindful Eating ExperientialGroup Reflection, Discussion, Wrap-up
Retreat Evaluation Presentations Quality - 95% rated “excellent” Usefulness - 85% reported it would be useful Length - 82% said “just right” Experience Inter-professional exposure - 89% agreed with retreat beinginter-professional Enjoyment - 100% would recommend to another student Environment - 100% reported the space to be excellent
What do you think you will change as aresult of this experience? Opportunities for Professional Change: Advocating for patient lifestyle changes with greaterconfidence “Being more prepared to advocate for patients to get dieteticconsults” “Talk more about the importance of diet for many diseases,have ready information about resources like Turner Farm forpatients” “Encourage moving more and eating whole foods rather thaneat less exercise more”
What do you think you will change as aresult of this experience? Opportunities for Professional Change: Seeking more evidence-based knowledge regardingintegrative health “Use evidence to show patients the benefits of lifestyle change” “Use knowledge of phytochemicals in disease prevention, usecurrent research in practice as things change” “Dig more deeply and evaluate more critically the medicalliterature especially regarding integrative medicine”
What do you think you will change as aresult of this experience? Opportunities for Personal Change: Improving dietary habits “Becoming more mindful with food, better understanding/listening to my body, spice up and provide variety to my life andmeals” “I'm inspired to make the small changes to my lifestyle and diet” “I plan on incorporating a wider variety of textures/foods into eachmeal, I would have never expected mixing some of these foodstogether”
What do you think you will change as aresult of this experience? Opportunities for Personal Change: Incorporating mindfulness in self-care “Be more mindful of returning to baseline” “Plan on continuous personal growth especially in the mindfulnesssphere” “Use mindfulness to enjoy more of life”
Additional Comments? “I've thoroughly enjoyed every minute of thisexperience, I believe everyone should be given theopportunity to experience this” “Absolutely loved this, learning and having a chanceto discuss with other healthcare students from otherfields” “Loved the tour, learned a lot, would love to knowhow to get others involved”
Conclusion/Future Directions Student Wellness Retreats at Turner Farm werehighly successful Sought after – Student Affairs promotes Development of personal wellness skills Increasing interest in Integrative Health Greatest challenge: funding/faculty time tosustain Future longitudinal student teaching kitchensessions for continued healthy behavior changeand knowledge
Program #2Mind-Body Course
1 in 2 physicians experience burnoutNot just MDs –all healthcareprofessionalsShanafelt et al. Arch Intern Med. 172(18):1377-1385, 2012
1. EmotionalExhaustion2. Depersonalization3. Low Sense ofPersonalAccomplishment”Burnout is a responseto chronic stressorsthat wear on a personover time—not acuteones such as a bigevent ora big change”- Christina Maslach, PhD
Drivers of BurnoutNine Organizational Strategies toPromote Engagement andReduce BurnoutShanafelt TD, Noseworthy JH.Mayo Clin Proc. 2017
Patient ExperiencePopulation HealthReduce CostProvider SatisfactionThe Triple AimQuadrupleBodenheimer. T Sinsky, C.Ann Fam Med, 12: 573-576, 2014
Courtesy of Colin West, MD, PhD
Mindfulness“The awareness that emergesthrough paying attention,in a particular way,on purpose,in the present moment,and nonjudgmentally,to the unfolding ofexperiencemoment to moment.”Kabat-Zinn, Full Catastrophe Living, 1990/2013
The most commonly studiedinterventions have involvedmindfulness, stress management,and small group discussions, andthe results suggest that thesestrategies can be effectiveapproaches to reduce burnoutdomain scores.
InterventionAn intensive phase (2.5 hr/8 wk)All day (7 hr) session (week 6-7)A maintenance phase (10 monthly)Each Session15 min didactic material (weekly)(awareness, burnout, self-care)Improved well-being and mood;Improvements in mindfulnessassociated with increasedempathy and reduced burnoutJAMA 302:1284-1293, 2009Formal mindfulness meditationBody scanSitting meditationWalking meditationMindful movementNarrative ExercisesAppreciative Inquiry
participating in an abbreviatedmindfulness training course adapted forprimary care clinicians was associated withreductions in indicators of job burnout,depression, anxiety, and stress.Ann Fam Med 11:412-420, 2013
Conclusion 1Although the rates of chronicstress and burnout amongphysicians are rising, practicingmindfulness can reduce burnoutand increase empathy
Physician (Provider), Heal ThyselfMind-Body Medicine CourseWellness Resource Room
What is the Problem?Levels of stress and burnout alarmingly highamongst: Medical students and residents Nursing, pharmacy and allied health Law students Arts and music traineesImplications of Stress and BurnoutProfessional More likely to commit errorsNegative impact on co-working relationshipsDecreased empathyMore unprofessional behaviorsPersonal Increased substance use Reduced quality of lifeBalogun et al., 2002; Deary et al., 2003; Dyrbye et al., 2010; Lloyd et al., 2002; Neumann et al., 2011; Shanafelt, 2003, 2012
Efficacy of Mind-Body MedicineThere is considerable scientific evidence that mindbody therapies are beneficial for many healthproblems: Headaches Insomnia Anxiety/Depressive Symptoms Stress Chronic low back pain Disease/Treatment-related symptomsAstin et al Mind-Body Medicine: State of the Science, Implications for Practice. J Am Board Fam Pract 16:131-147, 2003
Georgetown University School of Medicine Trained over 100 faculty as group leaders 80-100 first/second-years take course annually to learn stress reductiontechniques to apply to daily lifeAfter groups, students report: Greater connections and self-discovery Improved academic function Lower stress levelsMacLaughlin et al., 2011; Saunders et al., 2007
Mind-Body Skills Program9-week course teaches students adaptive stress management skills usingmind-body techniques to foster self-awareness and self-careWeek 1Week 2Week 3Week 4Orientation/Introduction &Drawings IAutogenic Training/BiofeedbackSitting MeditationWalking MeditationWeek 5Week 6Week 7Week 8Week 9Inner sMeditationDrawings IIClosingOver 300 students have participated at UC
More Colleges are Focusing on Teaching Students inMind-Body MedicineGeorgetown University School of Medicine medical students, residentsUniversity of Cincinnati (medicine, allied health, nursing, pharmacy, CCM, DAAP, Law,Arts and Sciences, Cincinnati Children’s)University of Alabama at Birmingham (medical students)University of Louisville (medical students, faculty)University of Florida (medical students)Oregon Health and Sciences University (medical students)University of Washington (medical students)University of Vermont (medical students)University of North Dakota Medical School (medical students)Charite University Medical School, Germany (medical students)University of Essen-Duisenberg Medical School, Germany (medical)University of Liverpool, UK (medical students)Texas College of Osteopathic Medicine (medical students)Stanford University, Anesthesia Residency ProgramUniversity of Western States (chiropractic and other CAM professions)Oregon College of Oriental Medicine (acupuncture and DAOM)Mid-Sweden University, Sweden (nursing students)
Support for ProgramProvost Office
Mind Body Skills FacilitatorsCollege ofMedicineCollege ofNursingCollege ofPharmacyProgramCoordinatorDataManager
Mind Body Skills FacilitatorsIn memoriamCollege ofAllied HealthCollege ofLawCollegeConservatoryof MusicInteractfor HealthHebrewUnionCollegeCollege ofDesignArchitectureArt & PlanningAcademicHealth Center
10 New Mind-Body Skills Facilitators!
Quantitative 7: Brief Resiliency Scale2013-2016: Interpersonal Reactivity Index (IRI)# ofItems6212017: IRI - Perspective Taking and Empathic Concern subscales onlyStress2013-2017: Perceived Stress Scale (PSS)Positive and Negative Affect 2013-2017: Positive and Negative Affect Schedule (PANAS)Mindfulness1410202013-2016: Cognitive and Alternative Mindfulness Scale (CAMS-R) 122017: Five Facet Mindfulness Questionnaire (FFMQ)Attraction to Group2013-2016: Group Attitude ScaleSelf-Reported Health2016-2017: In general, would you say your health is Excellent,Very Good, Good, Fair, or Poor?15201(Interact for Health)Burnout2017: Maslach Burnout Inventory emotional exhaustion anddepersonalizationDepression, Anxiety, Fatigue, 2017:PROMIS (Patient-Reported Outcomes Measurementand Sleep DisturbanceInformation System)216
Perceived Stress Significant difference between groups over time (p .00) Only the mind-body group reported a significant decrease instress (p .00)[n 118]
Student ffectResilienceNegativeAffect
Qualitative MeasuresConstructQuestionImpact asperson/studentImpact as physician/professionalHow did this course impact you as a student and as a person, if atall?Do you believe that this course will contribute to your professionalwork? If so, how?Attitude towardmedical schooland/orprofession/fieldWhat participantwould tell othersHow has this course changed your attitude toward school, if at all?If you could tell your Dean one thing about this experience whatwould it be?If you could tell another student on thing about this experiencewhat would it be?
How has this course helped you?It has helped me to slowdown. Not to make suchrash decisions or take rashactions. I can appreciateand recognize the presentmuch better. I can also justbe calm and meditate andfocus on my own breathing.This course made me feel more empathetic to thosearound me. Listening to other people share what theyare going through day to day, the ups and the downs,made me appreciate how everyone has somethingthey are going through, and it is important to bemindful of that. I also gained an appreciation of howhelpful it can be for someone just to have an outlet tosimply talk without fear of judgement. school has this way of making you doubt yourabilities and has this attitude that if you aren't perfectthen you aren't good enough. This course taught me toaccept who I am and that I don't need to be perfect.Once I stopped stressing over the need to make nomistakes and recognized that I might need help I sawmy grades increase exponentially - I rarely was gettingaverage and now I'm at the average or above it.I feel better focused andbetter able to respond tostress. This has helped meto better deal with difficultscenarios while workingwith patients and studying.
Will this course contribute to your workas a physician/provider?Yes - this course completely changed my wayof thinking for the better. I hope to helpsome patients with what I've learned in thiscourse, but regardless, I know I've improvedmyself, which will help me be a betterphysician.Absolutely. I really hope to incorporatesome of the things we learned into mypractice later on down the line, but also, Ithink it will help maintain a healthy lifestylein terms of balance, stress, and happinessas my life gets more complex and my freetime becomes more and more limited.Absolutely. I will be betterequipped to take care ofmyself, which will translateinto better care for patients.Additionally, I can nowrecommend certaintechniques to patients as aform ofcomplementary/alternativemedicine.
Do you feel confident in your ability to bounce backfrom difficulties and stressors (i.e. resiliency)?I feel that my ability to cope in themoment has improved. For example,when constantly remunerating pastpainful experiences while trying tosleep, mindfulness meditation hashelped me calm myself and clear myhead a bit.Yes, I used to get really stressed outbefore taking a practical or test andnow I realize it's not going to helpto stress/freak out and just study asmuch as I can and things will turnout okay.Absolutely! While participating in this course, my academiccurriculum was much more involved than the previous semester,often times seeming overwhelming. I found that all I had to do wasaccept my stress and visualize succeeding in my assignments andtasks. Once I was able to accomplish this (theoretically) simple task, Ifound I was more productive and content.
What would you tell other students?I would highly recommend thiscourse! The mindfulnesstechniques that I learned in thiscourse have changed how I viewmyself and my coursework. I feelempowered to face the challengesthat lie ahead.Do it. Put all preconceived notions,skepticism, and worry aside and do it.You'll see a side of medical studentsyou may not have known was there.You'll gain a sense of community andplace that you won't even know youneeded. It is wonderful.Take this workshop. If you do one thing with your time take this workshop. Youowe it to yourself and all the people you care about in your life. Some of thingsyou learn in this course may not be your thing, but I guarantee you some ofthings you learn will be things that stick with you for the rest of your life. It willchange the way you think about and approach stressful situations, I would bevery surprised if at the end of it, you weren't a happier, more laid back person.
What would you tell your Dean?Almost all students would likely benefit fromat least one of the techniques taught duringthis class. Even if you are skeptical about mindbody medicine, taking this elective helpsbuilds relationships and trust betweenstudents from different colleges which leads tomore empathy and compassion. I believe thatyou will have happier, calmer, kinder studentsif more resources related to mind/bodymedicine are made available.Keep this program going & expand itto more people! I know classmatesunable to get a spot who wouldhave greatly benefited from it.This was a much needed experienceand I would push to get thisclass/awareness of mind-bodymeditation out to everyone in theCollege.Please continue to support the health of students. I think it's clear that medical studentsare pretty anxious and stressed people, and that a number of the students suffer fromdepression. I feel that the support for them is not always there and have frequentlyworried about reaching out for fear of being labeled later in my career. These groupshelp encourage a healthier mindset and coping skills.
Summary and Final Thoughts Wellness, through nutrition, movement,mindfulness and connectivity is critical toexpose students to early on Experiential versus didactic-only What is Required? Faculty modelling Integration, rather than “one-offs” Resources“Tell me and I forget, teach me and I mayremember, involve me and I learn”
MANAGE stressTHANK u
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