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Harvard School of Public Health | Managing Stress: Protecting Your Health

CAROLYN GREGOIRE, CORRESPONDENT, HUFFINGTON POST: Good afternoon, and


welcome to the Forum here at the Harvard School of Public Health. I'm Carolyn Gregoire,
associate lifestyle editor of The Huffington Post. And I'll be moderating our conversation today
about the causes and impacts of stress. This conversation is presented by the Forum for
Public Health here at Harvard and The Huffington Post.
Over 70 percent of Americans report experiencing physical and psychological symptoms of
stress. And one in three Americans says that they live with extreme stress. Unfortunately,
according to a recent Stress in America survey, Americans don't have a significant gap
between what they want from the healthcare system and what they're actually receiving.
Sustained over time, stress can undermine our health in deadly and very serious ways. Stress
can damage not only our health, but also our lifestyles, our wellbeing, careers, relationships,
and families. It can curb productivity and creativity. And it's a risk factor in the development of
depression and anxiety.
An extensive body of research has also found evidence of the role of stress in the
development of a number of chronic diseases. Arianna Huffington, editor in chief and founder
of The Huffington Post has called 2013 "The year that we prioritize beating stress." We have
united all of the Huff Post Lifestyle sites under the theme of "Less Stress, More Living." And I
have been working closely with the stress management content.
So I am thrilled to be here with our experts on stress management and mindfulness, who have
been really pioneering in these fields. In today's Forum event, our panel of experts will
examine what we know about stress, as well as the role social status plays in exacerbating or
mitigating these effects. Our panelists will also explore how healthy lifestyles in which positive
wellbeing, mindfulness, exercise and nutrition can contribute to a less stressful lifestyle.
So first, I would like to introduce all of our panelists. To my right is Ellen Langer. Ellen Langer
is a professor of psychology and author of Mindfulness and Counterclockwise: Mindful Health
and the Power of Possibility. A pioneer in the field of mindfulness research, Dr. Langer is the
recipient of the Guggenheim Fellowship and three Distinguished Scientist awards, The World
Congress Award, NYU Alumni Award, and many others.
She has authored 11 books and over 200 research articles on the illusion of control, perceived
control, stress, successful aging, and more. Her research has shown that actually noticing new

things can actually contribute to wellbeing, health and competence.


Next to Ellen we have Dr. Laura Kubzansky. Dr. Kubzansky is associate professor of social
and behavioral sciences. Her work focuses on psychological and social factors and health with
a focus on the role of stress and emotion and cardiovascular disease and healthy aging. Her
work has demonstrated that emotions may play an important role in the development of a
number of disease outcomes, including cardiovascular disease, lung function decline, and
cancer.
Next to Dr. Kubzansky we have Dr. David Eisenberg. He is the associate professor in the
Department of Nutrition here at Harvard. And he is the executive vice-president for health
education and research at the Samueli Institute. He is also the founder of Healthy
Kitchens/Healthy Lives, a conference that aims to educate doctors on the importance of good
nutrition and the links between diet and disease. Dr. Eisenberg will discuss how poor dietary
conditions can contribute to stress and how, as a clinician, he has seen personal health
affected by stress.
And over on the left, we have Lilian Cheung, who is the creator and editorial director of
Nutrition Source at the Harvard School of Public Health and the co-founder-- sorry, co-author
of Savor: Mindful Eating, Mindful Life. She is a practitioner of mindfulness and mindful eating.
And her work focuses on the translation of science-based recommendations into public health
communications and programs to contribute to healthy lifestyles and chronic disease
prevention.
So we will begin with some introductory comments from our panelists on the causes and
impacts of stress. We'll go into some questions from our studio audience here in Boston, and
also our viewers on the web. And then, we will-- the second half of our conversation will focus
on stress management.
So to start, I would like to turn to Ellen. What is stress? What are some of the causes of stress
and the parameters of the problem?
ELLEN LANGER, Okay. Well, when we feel that we can't control things, and that those things that we can can't
PROFESSOR OF

control are going to have a very negative impact on us, we react. And I guess it was Ovid,

PSYCHOLOGY,

quite some time ago, who said, "When the mind is ill at ease, the body is affected," which is, of

HARVARD

course, a gross understatement. That every system in the body is thrown off. Diseases, you

UNIVERSITY:

mentioned, some of them, if you have the cardiac system, we have heart attacks, angina. The

respiratory system, you can get asthma. The digestive system, you have ulcers and-- what
else?-- irritable bowel syndrome. And that's just on the surface.
The immune system is compromised. So basically, that when you're stressed, all of your
resources go to deal with the stress and are not available to promote healthy living. And for
me, the bottom line to a great deal of this stress is our mindlessness. And that I think that,
after 40 years of research on this, I'm reasonably sure that most of us, much of the time, are
mindless. We're not there, and we're not there to know we're not there.
And we have an illusion of stability. So we're holding things still while things are changing. And
what that means, in order to experience stress, you have to see that there is an event that you
believe will happen. And that, if it happens, it's going to be terrible. And both of those are
mindless.
There are big stressors, things like loss of job, war, death of a family member. But then, what
matters most to most of us, are the daily hassles. And those are the things we have most
control over. You know, as I was driving over there, the GPS system reminded me that, if I'm
driving and the person next to me says, "Make a right," and I don't make a right, havoc can
break out. "You're supposed to make"-- and getting crazy. And you have a GPS system that
calmly says, "Recalculating." [laughter]
And there's a lesson we can take from that. We assume that life is such, we have to feel this
kind of stress that results in an inability to concentrate, anxiety. We become irritable, angry at
each other. And the larger part of that is unnecessary, I think. So for me, mindfulness is the
key.
LAURA

So one of the interesting things about stress is that it comes out of both what's happening in

KUBZANSKY,

the environment, and what's a part of the person, right? So, if something seems particularly

ASSOCIATE

difficult, what resources do I have to manage it? And, in fact, when you think about why stress

PROFESSOR OF

might be linked to health, stress evolved is a mechanism for dealing with short-term crises.

SOCIAL AND
BEHAVIORAL
SCIENCES,
HARVARD
SCHOOL OF
PUBLIC HEALTH:

So I'm trying to cross the street, and I see a car coming at me really quickly. And I need to
mobilize really fast. I need to be able to, you know, behave in a way that's going to help me
get out of the way. So that's a very effective system for the short term. And the thinking about
why it may be problematic for health, is that when you reactivate the system over and over
and over again, with maybe not enough respite, and not enough chances to kind of come back
down and restore, then there's what we call physiologic wear and tear, which ultimately can
damage some of the biological systems and lead to disease initiation.
And then, there are two pathways by which people think this can happen. One is either
because feeling stressed and overwhelmed may make it harder to engage in behaviors that
are healthy for us. So, you know, if I'm feeling stressed, I may not feel like going out and
exercising. It's easier to eat that big chocolate chip muffin. And then, the other pathway is
biological. So, when I experience a sense of stress, there's a release of what we call stress
hormones that flood the body and alter all kinds of biological systems when they're in play for
a long period of time.
So a lot of the research, with the idea that stress influences health, has been around for a
really long time. It's not new. But I would say that, in the last couple of decades, the evidence
for how and why it's linked to health has gotten increasingly better. Some of the best evidence
is in relation to heart disease. So there are many studies, now, that suggest that people with
very high levels of stress are more than two times the risk of developing heart disease relative
to people who are at lower levels of stress.
And this risk is not that different from the risk that's conferred by cigarette smoking. It holds
when you take account of, you know, family history of health and some other factors. And,
while the evidence is not absolutely conclusive, it's very, very suggestive and says that we
should take it quite seriously.
The other thing that's interesting about stress is that it is not distributed equally throughout
society. So people who have less power and fewer resources and fewer opportunities are
more likely to both face many situations that feel very, very demanding, and have fewer
opportunities to develop the tools that will allow them to manage those situations.
And so, what we find is that people with less income, less education, lower socioeconomic
status, tend to report higher levels of stress. And, in fact, we know that socioeconomic status is
associated with health, whereby lower socioeconomic status is associated with worse health.

And one of the ideas for why this might happen is because of the higher levels of stress that
are induced by these more difficult circumstances.
And, in fact, there's been a really interesting finding coming out that suggests that, when kids
live in these very difficult social circumstances, with high levels of stress, where there's a lot of
chaos in the household or in the neighborhood, it actually alters their stress biology, their
ability to respond to stress, to develop the coping capacities and even their brain architecture,
so that they are subsequently more susceptible to stress and also to the health outcomes that
may result from that, much, much later in life.
So one of the goals of research on this topic is to try to figure out, what can we do to help
people with this, to maybe help kids develop better coping capacities, help adults manage
these things? How can we interrupt the link between stress and health?
DAVID

I'm David Eisenberg. I've been asked to participate in the panel wearing three different hats.

EISENBERG,

First, I'm a clinician by training, trained in internal medicine and primary care. And my years of

ASSOCIATE

taking care of patients have shown me, without a doubt, that every symptom, every disease is

PROFESSOR IN

amplified by stress. And, more often than not, people simply don't have a clue that it's coming,

THE

or how to manage it.

DEPARTMENT OF
NUTRITION,
HARVARD
SCHOOL OF
PUBLIC HEALTH:
I think Ellen's terms of "mindless living" is applicable, particularly in the disease population. So,
if somebody has a strain or a sprain or a break or a musculoskeletal problem, it's always
worse. If they have a neurologic problem or a headache, it's always worse. If they have some
physiologic problems, it's always worse. So the relationship between stress and biology is
clear. And, to every clinician, it is well known.
Second, I am a student of Asian medicine and culture. I was sent to China in the '70s to study
herbal medicine, meditation, Tai Chi, hands-on manipulation. Some of these things were to
treat nonstress-related diseases. Many of them, the sort of hidden mainstream of
complementary alternative medicine, in our culture chiropractic, yoga, Tai Chi, meditation, are
used by a third or more of Americans, and globally, probably by half the planet. And many of

these techniques that are age-old are really oriented towards bringing us back to being
present and mindful. And that's why they persist. So I've been a student of complementary
Asian integrative medicine for 40 years.
But the reason I'm here is mainly because of my third hat. I direct this unusual course that
brings together nutrition scientists, medical experts, registered dieticians, and chefs, to try to
instruct people we know, and the medical establishment, the practitioners, on how to make
better choices about food and living more healthfully, because we all know we have an obesity
and diabetes problem, which, in large part, is being amplified by stress yet again.
I suspect everybody in the room knows, without a literature base, that we eat less thoughtfully
when we are stressed. And yet, when we are in an exercise pattern and in a good place
emotionally, we make better choices. So thus was born this conference, Healthy
Kitchens/Healthy Lives, that was mentioned. That's really co-sponsored by the Harvard School
of Public Health and the Culinary Institute of America, to instruct the medical establishment on
how they can change their own behaviors, so they in turn are more apt to change the
behaviors of the patients they serve.
And the last thing I'll say is, in that conference that brings together nutrition experts, meditation
experts, exercise experts, the modalities are not just the science of nutrition, or even the art of
cooking healthy, delicious, quick, affordable, great food. We also bring in the notion of
movement, which has a great stress management aspect. To anybody who exercises, you
know this. It's a great stress-producer. We bring in mindfulness meditation, which I will turn
over in a moment to my colleague Lilian Cheung. Because, without being mindful about the
foods we pick, and how we cook them, and how we eat them, as Michael Pollen says, the
banquet is in the first bite. Most people in current society eat mindlessly. They're watching
television. They're reading a paper. They're in deep discussion. But they're not present with
their food, let alone the amount of food that's going in.
So our approach to stress and its relationship to food has to include the science, exercise, a
lot of mindfulness, and how to teach people who are stuck, to make a difference. So those are
the frames of reference I'll bring to the discussion. And, in terms of mindfulness and its role, let
me share that now with Lilian.
LILIAN CHEUNG, Thank you. Mindfulness was not in my vocabulary as training in my career. So how did it
EDITORIAL

happen that I end up practicing mindfulness? The year was 1997. I was totally spent, juggling

DIRECTOR OF

between family and career. And one of the statistics that you talked about, the 70 percent. And

THE NUTRITION

my son, my oldest one, the teenager, came home one day from middle school, and was trying

SOURCE,

to share with me his challenges at school. And I heard him say to me, "Knock, knock, mommy.

HARVARD

Are you there?" It woke me up. It pierced my heart. How can I be so mindless? And I need to

SCHOOL OF

change my life.

PUBLIC HEALTH:
And then, around that time, a mailer came to my home, talking about a mindfulness retreat,
opening the doors to healing and transformation in Key West. I said, "I better go." [laughter] So
I went there. To my shock, over 900 people. Who were they? Almost all psychotherapists,
social worker, and psychologists. They were learning how to practice mindfulness with Zen
master Thich Nhat Hanh, who is world-famous. And there, within the week, what happened to
me was, by the third day, I had some bliss, glimpses of bliss. At the end of the retreat, I
declared to my husband that I touched Nirvana. And Zen master Thich Nhat Hanh is a great
teacher. He said, "Many of you would have touched some piece in this retreat. But, if you don't
go home and continue to practice, you're going to lose it all. So knowing is only the first step.
Practice is the key."
Fast forward, back to the School of Public Health, and what I realized is that, as we dwell into
ways to manage and control the obesity epidemic, not only Americans eating mindlessly-- And
Dr. Brian Wansink in Cornell has done a lot of work on that. We are facing a very toxic food
environment that is bombarding our senses all the time, getting us to condition overeating.
The first book by Dr. Kelly Brownell, Food Fight, talking about toxicity in the food environment.
Then we have Dr. David Kessler, a former FDA Commissioner, who talks about the fact that
there is a lot of data within the food industry that really understands how to condition us to eat
all the time. And his book was End of Overeating.
Fast forward, recently in the New York Times Magazine, we have Michael Moss's article, again
addressing the fact that the food industry knew how to get us hooked and get us craving for
these foods that are high in fat, salt and sugar. And creating a condition that is hooking our
brain that we will feel better. But we cannot stop. We override our satiety.
So with that understanding, I thought it's so important to think out of the box in the traditional
way of working with this epidemic. And having David around is wonderful, because he
understands mindfulness. And so, I took a big leap forward, trying to integrate this science,

together with a practice that is over 2,500 years, to try to get the best that together, so that we
all can have a glimpse of what bliss is about, but not the bliss state that the food industry
wants us to be by eating. [laughter]
And it's really just through three simple things, routines: mindful breathing, mindful eating, and
mindful movements. And it is quite profound. And all we did in the retreat was learning how to
walk mindfully, how to eat mindfully, and how to breathe mindfully.
CAROLYN

Well, thank you all so much for being here. It's wonderful that we have such a variety of

GREGOIRE:

perspectives. And I would love to turn it over to our studio audience. If you have any questions
for any of our panelists. Yes.

AMY GUTMAN:

Hi. Thank you. That was-- That was wonderful. That was interesting on so many levels. I have
a question. I write a blog called "Plan B Nation," about the psychological impact of the Great
Recession. And many people in our culture, as I'm sure you all know, are dealing with
prolonged stress, due to very serious ongoing issues, job loss, the risk of job loss, financial
troubles. And to some extent, it seems to me that stress is sort of a structural issue, at this
point.
And I was wondering if any of you have any thoughts on structural solutions, things that the
broader culture can do. And in particular, I'm thinking of any insights from behavioral
economics, if people can be nudged in the direction. So I'd be interested in anyone's thoughts
on that.

LAURA

I have a lot of thoughts on that, although I'll try to, you know, limit them a little bit. So it's a

KUBZANSKY:

great question, because I think one of the issues that comes up a lot with stress, is it feels like
it's a very individual, very personal experience, which it is at one level. And often, the solutions
are very individually based and very personal, which can be very, very useful, right. So we
want something that's going to help us in the moment, and I have most control over sort of
what I am doing, you know, in many ways.
But it's always good to remember that it's the transaction between the person and the
environment. And so that there is another way to try to manage what's happening, in terms of
stress, by thinking about other ways of kind of intervening. And so, you know, one of the things
we talk a lot about is, well there may be institutional, you know, things that you could do, that
would reduce stress, that we don't necessarily think of as having an effect on health per se, or
having an effect on stress per se, but are implemented for other reasons.

But, for example, there's lots of work-family policies that workplaces could think about, that
would reduce the exposure that people would have to these very challenging circumstances,
where they feel like they just can't cope, because it gives them, essentially, alternatives or
more resources for coping. Or, there's been some discussion about changing the structure of
employee, the way people have to work, so that they have a greater sense of control over
their work. So that, even if it's a very demanding job, they've also got more control over what
they have to do.
So there are institutional level things that people could do to try to think about, well what are
the circumstances that really put people in a place where they begin to feel totally
overwhelmed by what they can do? And it may be really hard to, you know, implement some
of these wonderful strategies. But I may be in a place where that just feels impossible. Or I
don't have access to, you know, the food, or the time to cook, or whatever it may be.
There are also higher level policy kinds of interventions that people could think about. So, for
instance, ways to reduce the chaos in various neighborhoods. And, you know, again, a lot of
these-- a lot of these kinds of ideas are not typically thought of as being health-related. They
come up in other domains of policy. But, in fact, we could think more broadly about how they
may impact individuals and impact their health.
So things about housing, and housing stock, and the kinds of resources that people have
available, sort of the social welfare nets that are available to people, so that in times when the
economy has, you know, collapsed, people are not absolutely left on their own and said, "Well,
good luck to you. I hope it works for you" kind of thing. That we have some systems in place
that essentially reduce that sense of, "How could I possibly manage this on my own?"
So I think it's a great question, because I think we often tend to feel like, somehow, if only I
could just think a little more clearly about this, I would do this better. But there are real
situational constraints. And everything happens in a context. And so, it may be, in some ways,
there are lots of ways to nudge the context so that people have more opportunities to do a
better job kind of managing the difficulties.
ELLEN LANGER: One part of the social system that Laura didn't mention is our schools. And that right now, that
our schools teach people to be mindless. I mean they do, you know, that you get your A's, and
I got plenty of them, by memorizing things, context-independent. And so that, what happens is,
you end up bringing people up into a world where they're sure there are right answers. They

you end up bringing people up into a world where they're sure there are right answers. They
know they don't have them. That itself sets them up to be stressful. They end up less mindful,
less able to understand, to come up with mindful solutions to problems, because they haven't
been taught that in the early years. I mean the education should be changed at each level.
And so then we would avoid some of the problems that we now have.
LILIAN CHEUNG: One arena that I'm thinking of is in companies. Many companies have started to, through most
of them, the human resources branch, aware of the fact that employees are quite stressed.
Especially on the west coast. And I was invited along with Zen master Thich Nhat Hanh to
Google, for a day of mindfulness. And it was really quite an eye-opener, because Google is so
progressive in terms of thinking about emotional intelligence. They have a program called
"Search Inside Yourself" that has been implemented for a while. And they're very open to
mindful eating, because they get really wonderful food. [laughter] And you can be eating a lot
of it is free. So mindful eating is crucial to them.
And another trend that I can think of is health coaching. Health coaches are becoming more
and more popular in companies. And one of the key, I would say, to the health coaches use, is
the practice of mindfulness, the skills that they themselves have to embody, as well as helping
the client. So I do see a lot on the horizon that is increasing awareness to be of service to the
greater good that way.
In terms of behavior economics, I think that whole area, even within now Harvard University,
we have in the Harvard Business School, researchers working on it. And, there is definitely
very important to look at how we can get people to eat more mindfully, because the way we
put the meals together, to make the dishes much more attractive, and putting it somewhere
that they can see it, because it's lit. And so, there is a lot of work that is going on. It's very
exciting.
ELLEN LANGER: I have a slight disagreement. Are we at the stage where we can disagree with each other or
add to it? That I think that, you know, yes people should engage in mindful eating. They
should engage in mindful movement, mindful speaking, mindful listening. And that I think,
rather than-- And I applaud those programs.
But I think, rather than pick each activity and teach people how to mindfully engage that
activity, we need to teach people how to be mindful in general, so that whatever they're doing- I mean we've done so many studies where we take people, we teach them to be mindful.
And, at some point, we'll discuss mindfulness as I study it. Although I did work on meditation

back in the '70s, the mindfulness that I have looked at is basically mindfulness without
meditation.
And that we, in all different environments, we instruct people, get people to be more mindful,
and we find improvements in virtually everything. Not just their health and a decrease in
stress, but an increase in competence, a decrease in accidents, and increase in health,
longevity, vision improvements. We have weight loss. This is without any focus on what they're
eating in particular. They become more charismatic, better leaders, nicer people, you know.
[laughter]
So, if you can achieve that, then those red plates-- You know, for me, personally, if you give
me a big plate, yes, I'm going to put more food on it than a small plate. I don't know if we gave
the Dalai Lama different sized plates, for argument's sake, whether that would affect the
amount that's being eaten. So two different solutions. And they're not mutually exclusive.
LILIAN CHEUNG: Actually, Ellen, I agree with you more. The whole notion of mindfulness is about being in the
moment, being open and curious, and using a beginner's mind. However, for a lot of people,
this is so mystical. How do you go about it? So we need some toolbox to help them, to come
back to themselves. In the modern age of living, it's multitasking, also pilot. You've got to snap
them out of it. And some of these ways of moving around, eating, helps them to refocus, and
to be in touch with themselves, their feelings, their body sensations, what they are thinking.
And all that's around the world.
CAROLYN

We'll take one more question from the audience. Yes.

GREGOIRE:
Q: It seems to me that there seem to be two almost opposing visions. One is very individually
oriented, and this notion of mindfulness, which I must admit, I support as a practitioner of the
Pasha. There's something very wonderful about it. On the other side, there seems to be an
emphasis on social action from the policy perspective, like behavioral economics, which can
be a bit manipulative.
And perhaps, from the public health perspective, we should explore and consider a middle
path. Is there some mechanism of combining the two, and thinking about mindful, collective
action, that really engages people in the issue of observing their environment, and taking
action to change their environment on a collective, community, organizing basis? Because I
hate to think of the either/or, the individual action, which really sometimes could reek of victim-

blaming ideology. And the social action, which can sometimes reek of a manipulative action.
Where is that middle ground for collectivity, for action together?
ELLEN LANGER: I don't see them as in opposition to each other, although one can attempt to change in either-at either level. I think that, when you have people at the individual level being more mindful,
they're less stressed. They're more compassionate. They're less evaluative. They're going to
be less violent. They are going to be less susceptible to some of the tricks, as you put it,
before. And that will result in the group that they're in behaving differently. It will be less
competitive, again, leading to less stress.
You know, we have the idea that there are clear rights and wrongs and right ways of doing
things, as you have in many businesses, that that makes people afraid because they don't
know what the right answer is. And they're afraid to admit that they did something that perhaps
led to some problem. And so, you have a system that's closed, rather than that's open, where
people are sharing information.
And so, there are ways of changing things on the individual level, that lead-- And it can start
either way. You know, I as the CEO can decide to open things up, and have more-- teach
people how to have more respect for each other. And, I can also start with the individuals and
have them have more respect for each other. And then, the company will change.
Some of this sounds sort of soft and pie in the sky. But I don't think it is. I think that what
people don't realize is, many of the patterns of behavior in which they engage are the very
things that are making them miserable, you know. And that this, "I have to win. I have to get
there fast. I have to get there first," that mentality makes it so that, even when you get there,
you don't value where you've gotten to.
So that I think realizing that there are advantages to many of the things that we're not sure
that we want, you know, that part of the reason people become sick or stay sick-- and I'm not
talking about chronic illnesses-- but it's nice to take a breather from the stresses of the day, to
sit at home and eat those chocolate chip muffins, and watch television or something, and just
feel at peace.
And that, what we need to do is arrange it so that that feeling can arise without having to pull
out of society, you know, that we have to create our social groups so that they're actually
supportive of us. And we can do that in part by being less evaluative. And we become less

evaluative when we understand behavior from multiple perspectives.


So you see this thing that seems awful from another perspective is not. You dislike me
because I'm impulsive. But, if you were more mindful and noticing my behavior from my
perspective, you would see I was spontaneous. Then you'd no longer dislike me. And, if you
thought, why am I so wishy-washy, and then you recognized, well from another perspective,
I'm open-minded, flexible. And so on, with everything that we call each other.
And so then, once we have this different vocabulary, a way of respecting each other,
everything falls into a different place. And we end up with the social support that the literature
is very clear on. Basically, helping us lower our stress level.
ee if we have a question from the online audience. AND I'LL CIRCLE BACK TO THAT.
DAVID

I don't think stress will ever go away. I think there's a good chance that our children and our

EISENBERG:

children's children will actually have to cope with even more stress because of the perpetual
over-stimulation and connections to technology, etcetera. So I want to just put out a rhetorical
question. What should mental health centers of the future look like? And we would be derelict
if we didn't also include, you know, the conventional psychopharmacology, talk therapy, as well
as movement. And, to a further extent, health coaching, exercise.
But, it's an interesting question. Two generations from now, when there is even more collective
stress, what should that portfolio of options look like? Because, if we don't envision it now, and
showcase that there is no one way to ad?dress stress, either at the individual level, or at the
community or corporate worksite level, or at the larger social level, if we stay in those narrow
silos, we will really limit the possibility of inventing a better delivery model. And I think it's all of
these things.
So I don't think any of these are mutually exclusive concepts. But we're talking about stress.
And I think it's going to get more challenging. And we have to invent these models of the
future.

ELLEN LANGER: I agree. Yeah, I guess I'm the oddball here. So for me, I think one of the big problems in
society is that everybody takes stress, a certain level of stress, as the baseline, that that's sort
of normal. And so, we don't question things until it gets even beyond that point. And I think that
we should set up a support system and all of the things that you rightly say, David.
But I also think that we should get people on the individual level, and in schools and in

businesses, to question. You know, when I was growing up, people had always said to me,
"Why are you smiling?" And I pulled back. You know, finally, you know, now I say, "Why aren't
you smiling?" You know. So it's sort of to change the norm.
LAURA

Well also, just to put a sort of public health prevention orientation, I think, you know, there are

KUBZANSKY:

lots of ways of thinking about sort of how we're going to manage the issue, and going forward,
and what kinds of systems do we want to put into place. And I think a really interesting way to
think about it is to think about it developmentally. So how do we get people or kids to a point,
as adults, where they have these tools that they can bring to bear, whether it's mindfulness,
or, you know, other tools that they are able to really implement, that will adapt to the different
situations? Because not one tool is going to work in every single situation.
And one of the interesting topics that's come up out of the stress research literature, has been
this notion about the importance of being able to self-regulate. So being able to focus attention
when you need to, shift attention when you have to, regulate your emotions so that when
something bad happens, you can kind of manage it and come back from it.
And it is one of the major developmental milestones that kids have to meet. And this is, I think,
what you were talking about with schools, where we could think about how to give kids, you
know, more systematic capacity for being able to regulate, so that as they become adults in
these very different systems, they have got a set of tools, as well as thinking about what are
the environments that we want to have, that will facilitate the ability to regulate and the ability
to make different choices, depending on what the array of options are, because not every
situation will be the same. And not every tool will work in the same situation.
So I think, you know, if you think about it from a prevention orientation, then we should
probably think really carefully about how do we hand these tools to kids, so that when they
become these adults, facing all kinds of challenges and choices, which are inevitable, you
know, they have some mechanisms for kind of managing these.

CAROLYN

And Lilian, with your work in mindfulness, how have you found educational methods? What

GREGOIRE:

has been helpful in teaching mindful eating, mindful movement, and all of these things?

LILIAN CHEUNG: I have not worked with kids, per se. But there are some research going on in school-based
work in mindfulness. I think Dr. Herbert Benson has started that. There is a lot of interest to
have mindfulness in the schools, to really help children managing their stress. Going back to

the question, in terms of the policy aspect, I just want to point out a very, very interesting and
promising book for us. And that is, A Mindful Nation, written by Tim Ryan. And he is a
Congressman in Ohio. He himself is a practitioner of mindfulness. And he sees the importance
of having, you know, the government officials themselves, politicians, be much more mindful in
everything that they do.
DAVID

On both the personal and public health.

EISENBERG:
LILIAN CHEUNG: Absolutely. And there have been mindfulness retreats that Thich Nhat Hanh actually went to
D.C. twice and did Congress "Mindfulness Days." So I think there is an openness about this
type of practice.
CAROLYN

Do you have another question from online?

GREGOIRE:
LISA MIROWITZ, Here is one question from Jill, from Muskegon County, Michigan. How do you convince your
EXECTIVE

physician to take your concerns about stress seriously, like weight control? The topic is often

PRODUCER, THE ignored, or they tell you that you're overreacting.


FORUM:
LILIAN CHEUNG: What I know in the research is about 40 percent of people who are stressed would overeat. So
it's quite a big number. And I think it's important to work with that and ask the primary care to
refer to a dietician in order to manage that type of eating, if it's a weight-related issue. Yes, I
think we have a long way to go in convincing primary care physicians to have that modality in
the offering. But some companies, healthcare companies are opening up. And they really-- like
Harvard Pilgrim Healthcare, they are very big on mindfulness. So the trend is changing. I think
we will see more.
DAVID

I think, through no fault of their own, most trained physicians in this country have learned very

EISENBERG:

little about nutrition, and even less about its translation to giving advice to patients, about food
or their anxiety about food. It's not their fault. You know, the average number of hours spent
by a medical student across all medical schools studying nutrition, is 19 hours in four years.
It's a scandal. And most of that is biochemistry.
Furthermore, this conference that the Harvard School of Public Health and the Culinary
Institute have created, which has been offered nine times, has sold out every year. Because

physicians come, realizing they are ill-equipped to sit before Jill and understand her
predicament. And, more importantly, have evidence-based, clinically relevant advice to help
her. That's why they show up at the conference.
I think we need a robust effort on the part of medical educators to realize that we can't
graduate another generation of physicians who don't understand the translation of nutrition
science into practical advice about food, cooking, exercise, mindfulness, behavioral
optimization, health coaches. That's the portfolio. And it's relatively new. But we're trying. And
we hope a lot of people pay attention.
And I think the physician who is facing Jill is ill-equipped. And it's coming out through a
nervous response of, "I don't know." And that's what she's feeling.
LAURA

Well, I'm just going to say, I think there's also a related problem, which is that we don't-- you

KUBZANSKY:

know, we don't really know, from a medical perspective, what to do about stress. Stress is one
of these terms that's out there. It's everywhere. You talk to anyone on the street, and they'll tell
you, "Oh yeah, I have so much stress." And, you know, sometimes it ends up being a
diagnosis of exclusion. "Well, I can't find anything else, so I'll just tell you you're stressed."
But there's not a very systematic approach to it medically. And I think that's where I'm hoping
that the science will help, as we get a better handle on kind of how these things work, the
interrelationships between stress and behavior and health, we will be able to train people to
actually manage it better. Whereas right now, I think what happens is, if you happen to get a
clinician who is very sympathetic to that notion, they will try to sort of address it.
But there are still clinicians who will say, "Well, you know, that's-- Yeah, everyone has that.
You know, there's nothing I'm going to be able to help you with that, you know. Try to eat
less," kind of thing. So I think that's another sort of gap in both medical education, and then
just sort of more broadly, in terms of what should we do about it? We all talk about it. But we
need a systematic approach to kind of managing it.

DAVID

Last reference I wanted to make. There is a very rich literature by Professor Erica Frank, who

EISENBERG:

is now in Vancouver, that says, "Physicians who exercise advise their patients to exercise."
Physicians who wear seatbelts, physicians who wear sunscreen, physicians who check their
lipids religiously, they advise their patients to do these things.
I think if we could get more of the medical establishment, and not just physicians but nurses,

registered dieticians, allied health professionals, complementary alternative medicine docs to


work, to really model, once they understand the techniques-- mindfulness, yoga, Tai Chi, you
name it, they're much more well positioned to advise the patient on a set of options that might
be relevant. Whereas, if they know nothing about them because they've never experienced
them, they simply can't. So I think we need both. I'm completely agreeing with you. But that's
the toolbox.
LISA MIROWITZ: I know we only have about 10 minutes left, but shall I ask one more question? Because we
have a live chat going on. And a lot of people are participating. I thought this was an
interesting question. How can technology help us reduce our stress? And how does
technology also add to stress?
ELLEN LANGER: We're doing some work now where we're creating-- we have this new mindfulness app,
mindfulness as I've studied, again, which at some point we should really clarify for people, but
not right this second. And basically, that when your mind-- Well, I'm going to do it. When you're
mindful, what you're doing is, since you're in the present, you're actively noticing new things.
That gives you an attention to variability, by seeing change. And if you have an app where-let's say you think you're always depressed. Well, no one is always anything. And, if you are
depressed, you're not always depressed at the same level.
And so, if you had your phone call you, text you, or some gadget call you periodically, and just
check in-- "How are you feeling right now?" two things would happen. You'd come to see, gee
there are times you're not stressed. The second, when those times occur, it would lead to the
question, well why? And that would lead you to a search for a solution. That search itself would
probably be mindful and would be good for your health. And you might actually come up with a
solution.
There are apps about healthy eating. If one is on their computers and they're being creative,
mindful, that's going to be good for their health. There's a social network that, you know, I
have this Words With Friends, that people who I didn't know I was such friends with, playing
the game with me. And so, there is a sense of a relationship that's easy to facilitate when you
might be infirmed.
It's never the fault of the gadget, of the technology, that we feel stressed. It's a thought that we
impose on ourselves in using these gadgets. I have to be more proficient. Oh my God, the
machine is not working at this moment. My email is down. The world is going to fall apart

because of it. But the machine is just not working for a brief time.
As far as multitasking, no matter what it is you come up with, it is not in the activity that we
experience stress.
Multitasking can be fabulous. You're multitasking all the time. That right now, you are-- Okay,
so I just moved around. And I'm looking at you. And I'm talking. And I'm thinking of different
things. and I'm aware, you know, that I don't want to move the microphone. And all of this is
happening. But I call it by one name. I am just being part of this podcast.
So that, if you see yourself-- well, let me explain this differently. Let's say you're a student, and
you're doing your social studies homework. And you're doing your history homework. And you
keep going back and forth. And you can get yourself crazy, thinking of yourself as multitasking.
If you raise it a level of analysis, and you see yourself as doing your homework, then you're
not multitasking.
And we have some research where we have people mindfully multitasking. And one task is
actually enhancing the performance on the other task. So, if you have rigid boundaries around
these tasks, that they have nothing in common, and that you have to be expert at both of them
and get them done immediately, yes, doing them both at the same time is going to be
stressful. If you have a sense of that they're integrated in some way, and you leave the time
pressure, you don't have to suffer with it.
LILIAN CHEUNG: I agree. Depending on circumstances. If we text and drive, it would not be good. It would be
dangerous. So it depends on the circumstances.
ELLEN LANGER: Sure, I mean, you know. And if you were shooting yourself while you were texting, I mean
there's no argument that we can use, you know. But it's not the texting. It's not the computer,
the gadgets, that are causing the problem. I mean you can have your opportunities to text.
And you could have your opportunities to drive. You shouldn't be driving and eating, I would
assume you would say, right. We don't want to ban cars or, you know.
LILIAN CHEUNG: But it's so common as a problem in our society, with the texting and driving.
ELLEN LANGER: Well the reason it's common-- yeah-- No, it's because people don't realize that they don't have
control, you know. So that, when phones first came out, cell phones, my guess-- and I think
there's data from The Netherlands, but I'm not sure-- that what happened is, there was a
reduction in accidents, because you knew that your attention was being pulled, all right.

Now we don't realize that. We think we're so expert on it, that we mindlessly do it, and
accidents occur. There's a place in Mexico I frequent, where you come in the street, where
there's no stop sign, there's no traffic light. And there are no accidents. Because everybody is
aware that they have to be there, right. So it's not the texting even, it's the thinking that, "I've
mastered this. So I can text, and I can drive, and I can do 12 other things at the same time."
And so people need to be shown that they can't.
CAROLYN

And what about from a nutrition perspective? Do we have technology that's being helpful to

GREGOIRE:

promote healthy diets?

DAVID

You know, in Healthy Kitchens/Healthy Lives this year, we're having a presentation by Mark

EISENBERG:

Berman, who is a physician internist, worked at the Robert Wood Johnson Foundation, looking
at childhood obesity. And now he's in this tech space, looking at all these fit bit like designs. It's
a huge industry. And, you know, technology startups are everywhere.
Will there be a device in the next five years that everyone must have, to track how many
calories they're taking in, how many calories they're burning. I don't know if this will appeal to
everybody. I'm one of these people who finds it very difficult to log in everything on all of these
internet-based programs. It doesn't help me. It sort of stresses me.
On the other hand, if I do it for a few days, I'll realize how little I'm moving and how much I'm
eating. I think we're in the early days. And I have a lot of faith in the 20, 30 and 40 year old
engineers, working with psychologists, to figure out a way that non-digital natives like me might
have a device to help us, and that the younger generation, my kids included, who are always
wired, will just see it as part of life in the next century.
I think we're really in the early days. And I think it's such a big market there, that, you know,
the competitive marketplace will refine those tools. And they will be helpful. Right now, I think
it's a little rocky, and the jury is out. But I think it's part of our collective future, in the area of
stress and food in particular.

LAURA

Well I'll just jump in and say I think, you know, technology can be both, like anything, good and

KUBZANSKY:

bad. So, you know, on the sort of increasing stress side, you know, I think what technology has
changed is a lot of our expectations. So now everything can be done faster and sooner and
quicker. And you should hurry up and respond to someone because they sent you a message
five minutes ago. And how come you haven't responded yet?

And so actually, it's not the technology itself, but the expectations that have come up around
the technology, you know, about what you should be able to do, how much more work you can
now do, because you can take your work home with you. You can do it from anywhere.
Everything is in the cloud, right. You can do it in the car. You can do it wherever you are.
And so, I think one of the interesting things to think about, from again, what are the kinds of
ways that we're going to-- you know, the systems we could put in place to help people with
managing this, is to think about, again, either organizational policy level, individual level,
systems, that would maybe change some of those expectations.
So I actually heard an NPR report not that long ago. And they were interviewing the CEO of
this company who decided that everybody was doing everything by email. And no one talked
to each other anymore. So he declared-- I can't remember if it was a week, a month or a day
out of each week, where no one was allowed to communicate with each other by email. They
actually had to go and talk to different people. They had to get up out of their desk, walk to
someone else's office to actually talk to them.
And it was a really interesting interview on sort of, you know, what his experience with that
was. And I was thinking, "Well, what an interesting intervention. It's very little. It's not that
hard." But it really forced people to kind of, you know, dial back some of the expectations for
the speed of response, and how quickly. And did they really need that piece of information
right away? Or could it wait a little bit?
So I think, you know, technology, as with anything, is both a benefit and then something that
we have to also think about managing. And we're in the very early stages of understanding
sort of the demands, again, the demands it imposes, and trying to figure out the tools that
we're going to bring to bear to manage those demands.
CAROLYN

Well, unfortunately with that, we're going to have to wrap up our conversation. [laughter] But

GREGOIRE:

thank you all so much for being here and sharing your expertise. Thank you to our studio
audience. And this discussion will continue online at the Forum website. You can also
download Huff Post's Stress Relief app, GPS For The Soul. And Yes, have a great day. Thank
you.

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