We are gonna go ahead and get started. First and foremost, thank you all for joining us for our first National Grand Rounds event of 2024. Thank you all for being here. And tonight, our topic is transforming health and wellbeing, a lifestyle medicine approach in PM&R. Our faculty this evening is Dr. Saloni Sharma, and our moderator this evening is Dr. Amit Nagpal. And I'm just gonna run through a few brief housekeeping slides and then we'll go ahead and get started here. First and foremost, this activity is being recorded and we will make it available on our academy's online learning portal. For the best attendee experience during the activity, please just go ahead and turn your camera on if you are going to speak, but you can hide non-video participants. This is going to ensure that speakers are prominent on your screen. Go ahead and use that raise your hand feature and unmute if you're called upon, or you can also use the chat feature, which is a great way to ask questions then engage with the group. And just be aware that time may not permit the panel to field every question, but we will do our best to run through things as best we can. And then just so you're aware of those features, we have our video and mute buttons here. We have our chat feature here and those reactions. And this one I'm having trouble seeing. Oh, okay. And we'll talk a bit about our agenda this evening. So we're gonna start out with some introductions and then we'll go forward with our presentation from Dr. Sharma. And we're gonna save about 15 minutes at the end of the call for a question and answer portion. So we can save any pressing questions until the end of the presentation. And from there, I'm gonna pass it over to Dr. Nagpal to introduce Dr. Sharma. Good evening, everyone. I am very excited to introduce my friend and colleague, Dr. Saloni Sharma, who I've known for many years and I jumped at the chance to be the one who gets to introduce her today. Dr. Sharma is board certified, double board certified physician, acupuncturist and medical director of the Orthopedic Integrative Health Center at Rothman Orthopedics in Pennsylvania. She's a popular speaker at Google, award-winning author of a book titled, The Pain Solution, which is a phenomenal book and clinical assistant professor at Thomas Jefferson University Hospital. She specializes in non-surgical pain care and building customized healthy aging programs for patients. Dr. Sharma has studied lifestyle medicine and integrative medicine, as well as yoga, meditation, mindfulness, as well as physician wellbeing. At a national level, Dr. Sharma serves as co-chair for the Spine and Pain Rehabilitation Group for the American Academy of Physical Medicine and Rehabilitation. She serves on the Diversity and Inclusion Committee as well as on a National Opioid Task Force. Furthermore, she continues to support alternatives to opioids and has helped direct national physician courses on navigating the opioid crisis. Dr. Sharma has recently joined the board of directors of the Pennsylvania Pain Society. She has been a top doctor multiple years in a row as voted on by her peers. And it is my pleasure to turn it over to Dr. Sharma. Hi there, everyone. It's great to see everyone here. I am just going to try to get out of this screen mode. It's not listening, that's okay. So today we're talking about how to transfer, transform health and wellbeing. It's a lifestyle medicine approach for PMNR. And let's get started. Thank you very much for having me. Thank you, Dr. Nagpal for that kind introduction. And we'll get started here. This is being a little messy. So these are objectives to recognize how lifestyle factors impact health and function. We're going to focus especially on nutrition. And then the most important part is about how to make this practical for you and your patients. So I want you to stop for a minute. I'm actually going to tell you three stories. The first story is hopefully a common shared story. The second story is a story from my personal lifestyle experience with lifestyle medicine. And the third story is a patient story. And I've been doing a lot of research about education and what makes things impactful and storytelling is sort of the way to make things stick. So I want you to think back to when you were a child and maybe you were like my daughter over here who likes to bandage up her stuffies and gives them shots. You wanted to improve quality of life, save lives. Maybe you're like my son, you wanted to be a hero and make things better for people. And that's really a lot of our common goal. It's to save lives, which is lifespan and save quality of life, health span. And that's really what we're going to talk about today. So what did you do? The next step you did was take a whole bunch of training. And eventually after residency and med school and internship and possibly fellowship, you picked a sub-specialty or you stayed general and you're out in the world, you weren't attending. And what did you face? This is what I faced when I came out. I'm going to date myself a little bit, but when I was training, which is not when this whole terminology of the fifth vital sign came out and fueled some of the pain crisis we have, but it's something that lingered. And I think a lot of us know that function is the key in our field. And that's something that we all share. And I think the fifth vital sign really shouldn't be pain the way it was in the nineties, but it should be function. And that's what we're talking about today is function that all physiatrists focus on sort of cross-specialty. Sometimes I'll talk about pain because that sort of crosses all the sub-specialties or musculoskeletal issues and why it matters. And this is why it matters. So you get out of training and you're face-to-face with this. The top causes of disability, three of the four are musculoskeletal or pain-related, neck pain, musculoskeletal issues and low back pain. And then depression, as we know, is linked to chronic illness, including pain conditions. So where are we now? You get out, you are an attending and everything's supposed to be great, except this is what you're faced with. You're faced with healthcare today, which unfortunately is a lot of band-aids and it's a lot of pigeonholing us into one thing and trying to make us be less than we are. We have a lot to offer, but sometimes the system wants us to just have instant answers, right? The patients want to get better quick. They want to be passive. Sometimes systems want us to be druggist, wants to be injection people. And these tools are useful. I prescribe medications. I'm an interventionist as well. I do epidural steroid injections. I'm an acupuncturist. So I think they have a role. I just think we have more to offer, especially as physiatrists. We help people throughout the care continuum and we help people function. And we have so many tools in our toolbox and adding lifestyle medicine can make a huge difference. It can help us deal with this predicament we're in now, which is not just putting band-aids on problems, but actually looking at some of the root causes and helping with that. So this is also healthcare today. And depending on your hospital system, this may actually be, you know, the kind of computer system you're using, but what is our way out? And I think our way out is having a voice. And when we look at this picture and we feel like we're in this situation, sometimes it feels like we don't have a voice, but our voice still has a huge power with patients. And so when we're facing the challenges of healthcare today, we can either sort of rise up and use our voice or we can sort of get lost. And I think lifestyle medicine empowers us to make an impact with our patients still and go back to what our true calling is. We know the data. So, you know, I don't want to beat you over the head data. I do have lots of slides. This article is from JAMA and it talks about how healthy lifestyle is associated with years lived without major chronic diseases. Again, crossing the spectrum of what PM&R physicians treat. So it's increased vegetable and fruit intake, nut intake, whole grains, omega-3 and exercise and decreased sodium intake. The way the study was done, it's BMI, but we know that BMI is a flawed issue. So it's really maintaining a healthy weight for your body type, but the data's there. It's more about getting the message out. And the problem is if we don't use our voices, other people will fill the gaps. And that's what happens. When you watch the Super Bowl, if you read magazines, you don't see spreads about exercise and healthy food, better sleep, stress reduction. You're more likely to see something about the latest infusion, the latest medication, perhaps an injection, perhaps a pain med, perhaps a rheumatological medication. And you're also not going to see anything about the healthy foods. If you do see food ads, they tend to look like this. So this is kind of what we're up against when we're talking about lifestyle medicine. We're up against these billboards. These are sort of found in Pennsylvania. You know, all the different flavors of Coke, Twinkies. And I don't know if you saw this. This really blew my mind. It's Mountain Dew hot dogs, Dew dogs. So just to make the hot dog as unhealthy as possible, it's charged with neon pink Mountain Dew. But this is what we were taught. At least this is what I was taught for five ways to treat musculoskeletal and pain issues. It's lifestyle medicine, physical therapy, medications, injections, surgery. And I'm going to date myself again. When I was a resident and fellow, lifestyle medicine meant weight loss. That's all. We didn't learn about any of the pillars of lifestyle medicine. We didn't learn about nutrition. We didn't learn about sleep. We didn't learn about stress. We didn't learn about exercise, relationships. We didn't learn about any of that. The interesting thing is though, if you listen to drug commercials or medication commercials, the first line is, if diet and exercise fail, then there's a pill X, right? So if diet and exercise don't work, buy pill X. So they're sort of admitting, that's an admission, that that's the first line treatment. And it's something we know, but it's something that's easy to skip over. And if we use our voices, we need to get this message out to our patients. Daily lifestyle choices impact pain, inflammation, and disease across the spectrum. And again, this is a nice visual. I actually use this with some of my patients when I'm seeing them in my orthopedic integrative health center. So we'll talk about why we're going to focus on these left-sided factors. So diet, activity level, stress, medications, sleep, addictions, and social isolation, because it can affect your gut microbiome, can affect your genetics, can affect your cellular level, and it feeds more inflammation, which as we know, leads to more pain, more disease, and more dysfunction. So if we can intervene, we can make a huge impact. This is an interesting article that was in the Journal of Pain, and it talks about barriers to non-pharmacological treatments. And again, even though this article is around pain, it really sort of is across our field. These are the issues when you're trying to use non-pharmacological treatments. It's access, appeal, and awareness. Access is not as huge of an issue as you would think, and I can provide you with resources to address that. I think the first step is really awareness. Patients don't know how impactful these factors are and how much their daily choices impact their inflammation, their pain, and their function. And that's really where we have a powerful voice. And again, even though we don't feel like we have a voice in a lot of aspects of healthcare today, for our patients, our words matter. And it's impactful to have a physician say, your food matters, and this is why, and here's a handout. Here's this resource. And I won't dwell on this, but I think it's nice to have this sort of mental image of awareness, appeal, and access. And that's sort of what we are going to focus on here. But if you try to help people without a practical plan, if you want people to make changes without a practical plan, this is what you're going to do. You're going to be like poor Ralph and sort of bash your head through the glass. You need to have something practical. You need to have something easy. People want simple. And so that's why I sort of frame things around this relief five-hour plan. People also like things that are catchy. So refuel is about food. So natural, unprocessed foods, excuse me, natural, unprocessed food. Revitalize, which is regular movement. And some people shy away from the word exercise. So I really use movement or activity level. Recharge, which is restorative sleep. Refresh, mindset, resiliency, and relate, connect with others. This is a little tongue in cheek. You know, it's cost is basically free. Really no side effects. It's evidence-based and quantity unlimited. So that's what we'll talk about. But even if you have a good plan, if you don't have a how, it can be an issue. So I use a term called micro-boosts that I sort of coined. And it's just little steps that add up to big relief. It's sort of the how of the relief plan. You want to give them a simple lifestyle plan and you want to make it practical. And sort of dive into that. So this is a survey. This is actually in the book that Dr. Nackvall had mentioned to you that I wrote. And you want to ask them some of these questions, if possible. It can be a simple, I'm not used to this, but it can be a simple forum like this that touches on some of the lifestyle pillars. And it really sort of brings it home. People like numbers. People like data. People like seeing a change. They like seeing, oh, when I came to see you at the beginning, this was my number. And after so many visits, this is my number. And I'm making progress. And so that really helps people. And so I think having something concrete like this can be really helpful. So what is the plan? Again, it's the five pillars here. And we'll start with refuel. And we'll sort of dig in the most under fuel and just touch on the others. I could do a lecture on each of these separately. So I will not do that tonight, but we'll start with nutrition. So you may have heard this acronym SAD. That's for the Standard American Diet. And it is SAD. The American Heart Association has done some studies and they found that 90% of people qualify for a poor unhealthy diet. And the SAD diet is added sugar, excess salt, lots of unhealthy fats, artificial ingredients, and it lacks vegetables, fruits, and often nuts. Ongoing SAD leads to more inflammation, more pain, longer recovery time, which is rehab toxin issue, more painful flares, more fat mass. As we know from the JAM article, it affects longevity and healthspan. So more heart disease, more diabetes, more liver disease, and decreased body mass. And this is just a great graphic because it shows sort of the value meal and in a very concrete way, how this affects upregulation of inflammation. And I have a whole bunch of references everywhere as we go. Okay, so what are we fighting? We talked about the billboards, but it's more than the billboards. The processed food industry actually has something called a bliss point. This is something they spend millions of dollars on every year. It's the exact ratio of sugar, salt, and fat that creates a perfect crunch and gives us a little bit of a high. It triggers a reward system, almost akin to opioids. And so there's that old potato chip saying, you can't just eat one. And that's actually true because it's scientifically engineered so that you can't. And so we really need to speak up about this and have a voice for why this matters for them. Oops. There's some more geniuses here working. This is actually a sundial designed by McDonald's. It tells you every hour of the day what type of processed food to purchase from them. So it's really very creative and clever. This is a sign we need for them, food choices impact function from us, your doctor. This is some more data. So this is for osteoarthritis and rheumatoid arthritis. They've found that using Mediterranean diet, which is the most well-known, easiest one, I think, for patients. There's several, there's DASH diet and there's anti-inflammatory, and there's a bunch of them. But I think Mediterranean is well-known and well-researched and they found that it really significantly impacts joint health. So having a favorable omega-3, omega-6 ratio, high fiber or low glycemic index, high antioxidant, vitamin D, probiotic, and I would even add prebiotic. So sort of increasing that increases quality of life. It can delay the onset of degenerative changes and can delay progression. The opposite of that is sort of some of the SAD diet we talked about, but also substances that people may have intolerances to. We talk with patients about phytonutrients. So if you're not familiar with phytonutrients or what gives plants their color, protection, and strength, it protects them from predators. For humans, they act as antioxidants and help with inflammatory changes. So a type of phytonutrients are polyphenol, so berries, turmeric, green tea. There's been data that shows this helps with decreased oxidative damage, decreased cell death, and increased joint strength. So again, going back to that micro-boost term, so you would talk to patients about adding foods that are rich in cerebral vitals, such as grapes, blueberries, small berries, palms, apples. And there's a lot of studies on this, and it's not just arthritis, it's also from inflammation in general, which contributes to all sorts of chronic diseases. It's not just subjective. So there's been studies using MRI, and they've showed that a higher adherence to Mediterranean diet shows improvement in knee cartilage. So this is not just subjective. My pain level is better, or I can walk a little better. This is actually on imaging, which is great. And that's even after adjusting for confounding factors. Speaking of what we show patients, I actually love this image for the Mediterranean diet, because it talks about some of the other pillars, right? So it talks about activity. It talks about socialization, and that's the basis. And then it gets into food, and the veggies, and the legumes, and what to do with that. This is a little sort of just fun sort of brain break. So this is Santa, since we're not that far off from the holiday season. And this is Santa on a plant-based diet. Let's talk about the gut microbiome. So this is sort of a hot topic that people are very into these days. There's tons of data on this for all kinds of illnesses. And obviously, there's multiple microbiomes. The gut microbiomes are the hot topic right now, but they have done studies. There was an article not that long ago in the Annals of Internal Medicine, also in osteoporosis research, rheumatological research, that high-fat diet, high-sugar diet, especially can lead to gut dysbiosis. Dysbiosis is an imbalance in the gut microbiome. The gut microbiome is a balance of microorganisms, bacteria, viruses in your gut. Dysbiosis is an imbalance, so it's more, quote-unquote, bad guys and good guys. And these are the things that impact it. So it's diet and supplements, exercise, prebiotics, probiotics, and specifically a high unhealthy fat. I think that should be clarified because there are definitely good healthy fats too. This can lead to more inflammation, more osteoarthritis changes, more rheumatoid arthritis changes. It can also lead to sarcopenia, which can be a big rehab issue and low muscle mass. There's also some studies on it in terms of osteoporosis and osteopenia. So the gut is sort of a new target for inflammation, for pain, and really all sorts of physical medicine conditions. So what do we tell our patients? Um, so you want to sort of make things that are easy for them, um, talk about staying hydrated, real foods. Okay. So those are things that have less than five ingredients or hopefully just one ingredient, like a pear or a peach or a carrot, high fiber fermented when avoided or added sugar as much as possible. People always ask about this things with natural sugars, like roots are fine, especially if you take them with the skin and you get the fiber juicings, not so great as far as have the whole fruit. Um, it's the added sugar we want to watch for. Um, you know, these other things impact the gut microbiome to, uh, stress. So another pillar process foods, low fire, excuse me, low fiber, chronic infections. Um, it gets a little tricky with some of these medications because obviously, you know, antibiotics are needed when they're needed. It's more of the overuse chronic NSAID use and acid altering medications actually affects the pH and it can affect your gut. So when we're talking about this with patients, um, you can also mention that there is a gut joint access, um, and to really make it simple, we can talk about prebiotics and probiotics. And if that's all you give them, I think that's funny. Uh, for people who aren't familiar, prebiotics are foods that support a healthy gut microbiome. So they sort of feed the good guys. So you want to think of fibrous things. I have a list. There are some things like onions, apples, flaxseed, leafy greens, and then probiotics are the actual good guys, the beneficial bacteria. So you want to think more about culture and fermented foods, yogurt, and you want to be careful that it's not a tons of added sugar and processed yogurt, but unsweetened yogurt, kimchi, sauerkraut. Uh, and there's a lot of studies again, which I can give a list of me if needed. Okay. So let's take a breath for a minute. I was telling people that I need to slow myself down. I get so excited about this. I talk fast, but why is there a picture of a fun-sized snicker bar in a talk about not eating processed food? And this goes to story number two. So story number one was our shared story. What our calling was, why we started in medicine and how we can get back to sort of empowering ourselves and our patients. Story number two, which is a story is about how I got into lifestyle medicine. So maybe I shouldn't be telling you this, but, um, you know, I, I struggled with pregnancy. I was finally able to get pregnant and then my family history got me, I was diagnosed with gestational diabetes. So, you know, everyone has their own choices and do does what's right for them. Um, they started talking to me about diabetic medications and insulin, and that wasn't right for me. And, and, and that's right for some people. It just wasn't right for me. And so I started to dig a little deeper and I said, well, how can I do this with diet and exercise? And, and it really blew my mind that I had gone through, and I go back elementary school, middle school, high school, college, medical school, internship, residency, fellowship. And I didn't know how to read a nutrition label. I'd never been taught how to read nutrition label. I'm supposed to be a health expert. Um, we're also supposed to be health experts, right? We're sort of the cream of the cop. We're the physicians. We're supposed to be, uh, the knowledge people. We know everything about health and I couldn't read a nutrition label. I didn't know how to calculate net carbs. I didn't know you could take carb and do minus fiber and actually get the net carbs. Um, I didn't know until I had gestational diabetes that if I took a walk, I could have a fun size little candy bar and not bump my blood sugar. Uh, so there was a lot of things I learned and that's really what led to my deep dive into lifestyle medicine and eventually taking a lifestyle medicine and integrative medicine fellowship. But, um, you know, it's not about restriction. It's about moderation and balance. I think that's part of it, but I think it's, it's sort of opening our eyes to there's a lot we don't know. And if we can sort of learn how to feel ourselves and we can also learn how to feel our patients better. That's my little side note on that. I'm talking about timing. So circadian medicine is also, uh, somewhat of a hot topic. Um, we know that illnesses have a circadian pattern. People talk a lot about neuropathic pain being worse at night. People talk about certain headaches at certain times of the day. Um, and what happens is there's social jet lag, which just means that you stay up later on the weekends in general, um, than you do on the weekdays and your sleep schedule gets all kind of messed up, miss time, eating jet lag, shift work, a lot of overhead light at night. And that can actually affect your circadian rhythm and it can change your pain threshold and it can change your immune function, uh, in a lot of ways. So that is something I will talk about with my patients. Sometimes I'll say things like the kitchen closes at seven, right? And people have other medical illnesses or other issues, and it was something we can work around. But I think just giving people that general idea that it gets later at night, you want to eat less, um, can be helpful. And we're not necessarily talking about weight loss. It's more for inflammation. It gives your time, your body time to process it in general will reduce calorie intake for most people. Um, but it's sort of matches the way our bodies are designed in terms of circadian rhythm so that we can get that nice melatonin spike and get better sleep. And we can also have time for autophagy, which is cellular cleanup and not just be processing food, but where I can focus actually cleaning up, um, that prevents since the nesting cells are zombie cells, it's sort of a fun term, um, which are actually known to cause more inflammation. They're kind of cells are like half alive, half dead. They don't work. They spout a lot of inflammatory molecules. And so, um, that's something we can avoid with what I like to call circadian eating. So let's see, um, which is the easy way is to just eat 7 a.m. to 7 p.m. But is there's a lot of data again for less pain, less information, better immune function, better gut health, better metabolism, better sleep, better weight control, and it can help with metabolic diseases in general because of the information. This isn't like another easy thing to talk about with your patients. Um, that's not too onerous. It's not changing who they are. It's not changing, um, what they eat necessarily, if that's something hard for them, um, but just changing the timing and that can have an impact as well. It can also be really empowering for them food order. So, uh, I don't know how many people are on social media, but, um, there are people on social media who wear continuous glucose monitors and then post the results of this. Uh, and so food order actually matters. Um, you can see here, she started with rice. She started with the carb first, high glycemic index carb. Then she did the tofu, then the broccoli, and she got more than a 30 point spike in her glucose. Okay. Um, and the bigger, the spike sort of leads to a cascade of more inflammation, which leads more pain and more inflammatory disease. You start with the broccoli. So if you start with the veggie, then the tofu, then the rice, essentially, if you do the carb last, um, it makes a big difference. It doesn't even get close to three point spike. And this is measured two hours later. So that peak spike is, is right there. Um, and there's thoughts about vegetables actually coding like that lining, um, is slowing down absorption of carbs and the fiber stuff, as we talked about is good for your guts. It's prebiotic. Um, it feeds your good guys and helps with dysbiosis and prevent dysbiosis. But this is another way to sort of meet patients where they are and not say it's all or nothing, but be more practical. Another analogy I like to use for this is, um, those sort of like a typical Italian meal, which wouldn't be like bread and pasta and meatballs. What you want to do is have the meatballs first, then the pasta, then the bread, preferably you just have one carb. So if it's something like, um, bread, a chicken and a veggie, um, you can have the like cooked zucchini first, then have your meat. And then with what's left, have the bread. And it does a couple of things. Once one thing it helps with this big spike, but second, you're also more full. And so you tend to eat less of that carb. Here's another one. And the way things are cooked makes a difference too. So again, when we were talking about the juicing, the vegetables a little bit, um, and the juices, you know, you'd rather have the whole vegetable. You're going to take that or a whole fruit, not just juice, either of them. Same thing here. You really want to have that skin for the potato. That's the fiber. That's what slows down that spike and prevents, excuse me, that big spike here, which is over 30 points. Um, so they're both potatoes. So potatoes, not necessarily potato, um, the four matters, the cooking matters, uh, and the fiber matters. Excuse me. Okay. Um, and you have to have a practical plan. So, uh, this is something I've written about. I want you to think about when you go to a grocery store, the things they want to move, the things they want you to buy, we're actually at eye level. And so we want to do the same thing when we're trying to set up our pantry or set up our home or for our patients. So the acronym is relief here, because again, people like catchy things. And so the first step would be remove barriers. So a lot of times patients will say, let's eat healthier. I want to eat healthy snacks, but that's not specific. It doesn't have a plan. So it's really not going to get done. So it's moving the nuts to the front of the pantry and either getting rid of the processed food or having it in the back or high to reach shelf where you actually need to get a stool. So it's a treat you can get, but it's not easy. It sounds silly, but that makes a difference. If it's right in the front, it's easy. You can just grab it. You're trying to help the kids. You're trying to run out somewhere else, trying to get to the store. It makes a difference. Drink more water is not really a great intention. If you translate that to a micro boost, it would be each night, um, filling up a water bottle and having ready to go in the fridge. So the next morning you have the morning rush, you're trying to run to work, do a million things. You can just grab your bottle. It's ready to go. Same thing with eat more plant-based food. Um, it's really gotta be more concrete. So the microbeast would be also half my plate with vegetables, right? That's the way to translate to who's going to actually do this and make it happen. And I won't read through all of those, but, um, you sort of understand the concept really want to make it simple and doable for our patients and ourselves. So we talked a lot about, uh, nutrition there. I want to touch on these just a little bit, not quite as in-depth so that we have time for questions and things like that as well. So let me flip over here, revitalize, and this is, you know, kind of like preaching to the choir, right? Uh, as a psychiatrist, um, you know, I hope we're champions of movement and exercise in some form. So we know exercise has no age limit in some form. You can move your body in some way or another for most people. Um, it helps with longevity. It helps with muscle mass. It lowers your risk of dementia and fracture. It helps with most metabolic diseases. Uh, it can help reduce your risk of stroke. Some cancers, depression, mental health issues, insomnia, joint disease, and osteoporosis. I like to explain it like this to patients. Um, we're also in the book, uh, here are the four ways that activity and movement help. Again, some people feel like a little stigma. They don't love the word exercise. So it will say activity or movement. Um, it releases endorphins, it activates endocannabinoid system, it improves mood and helps decrease inflammation. So basically what we're saying here is that it's like an opioid, medical marijuana, an SSRI, and an ibuprofen all in one, right? They're actually trying to bottle the effects of exercise. It's called exercise mimetics. It's a whole field of study, um, that scientists are trying to recreate the benefits of exercising I think it's a lot simpler just to move throughout your day. Um, and there's a lot of easy ways to incorporate that into your lifestyle and for your patients. This is an interesting study that came out, um, recently in sports medicine, and they found that light walking after a meal, even just five minutes can help with your blood sugar spike. Um, you know, people in the endocrine world have been talking about this for a long time, but it's nice to see it translating into our fields too. So if you do an activity before the glucose peak, which is typically 69 minutes, 90 minutes after eating, um, it can help blunt that glucose spike. And if it's not safe to walk outside, if it's too dark, the weather doesn't allow, um, it can be household work, which doesn't sound very fun, but it could be doing the dishes. It could be sweeping, or it could be, um, sort of dancing it out, like embrace anatomy just moving your body a little bit. A lot of us tend to come home from work, make our dinner, have our dinner, and kind of just sit after that. So just having a little bit of movement, again, the site should have been five to 10 minutes to make a big difference, excuse me, that's dry air is getting to me. So we talked a lot about refuel, some about revitalize, recharge is a whole topic. Sleep hygiene is a whole thing that we can get into. You want patients to have a relaxation routine, sort of build a sleep cave. We talked about not eating too close to bedtime. That can be a big issue. Um, and these are all a lot of ideas, again, that we can sort of dig into another time, but I'm so sorry, but, um, that can make a big difference. There's also integrated methods, um, which are beyond the scope of this talk, but I have resources on that as well that can help us sleep hygiene. So we talked about refuel, revitalize, recharge, the next one would be refresh. I'm actually going to be right back and just get something from my throat so I don't keep coughing at you. Just a reminder for everybody, um, while we take our quick break, if anybody has any questions, please feel free to drop them into the chat and after Dr. Sharma finishes, uh, her discussion, which has been amazing so far, uh, we will try to get to as many of those as we can, uh, during that time in which we have the, uh, the question and answer session. I'm so sorry about that. It was dry. It was really getting to me. Thank you, Dr. All right. So, um, we'll talk about the big one, which is refresh. Um, and this is really about stress management, resiliency mindset. I think as physicians, we all know this, and unfortunately we've all experienced it. So chronic fight or flight activation leads to chronic inflammation leads to chronic pain that leads to a more dysfunction. So we really want to help our patients work their way out of this. Um, we know that if we're sort of stuck in that survival mode, we are not at our best and we really can't problem solve. So if we're in stress induced survival brain mode, it's hard to regulate our emotions. It's hard to not be reactive. It's hard to handle challenges like pain and dysfunction. So what do we do? How do we get out of this mode? How do we help our patients get out of this mode? Um, the first step is to recognize that the path to recovery and rehab is not sort of this straight line, like we think it's kind of back and forth. It's up and down. Um, and I think just laying that groundwork can be helpful for patients. And I think we're all aware of the benefits of mindfulness based stress reduction. Um, this is just one article, um, talks about 30 randomized controlled studies showed it affects depression, quality of life, and pain relief. So how do we trigger this? How do we trigger this for our patients and really for ourselves? And um, you know, sort of the opposite of a fight or flight is a relaxation response or a parasympathetic response. Um, and a sticky micro boost is, is breathing exercises. There's one that, um, Dr. Andrew Weil has popularized and it's called four, seven, eight breathing. And that's where you inhale for four, hold for a count of seven and exhale for eight. Um, it sounds very simple, but it's very effective. You're supposed to do it for a count of four and have your tongue in the roof of your mouth. The reason you have your tongue in the roof of your mouth is to sort of prevent saliva and sort of dripping. Um, but it's four, seven, eight, uh, there's teenage size, which most people love. So actually we'll show these to my patients and integrative patients. And so something I learned in my mindfulness course, but if you remember being a teenager, if you have a teenager, um, it's a little tongue in cheek and I am involved in DEI. So, um, it is low HS, but it's, it's, it's for a good cause. So put it that way, but there's these big size that teenagers often do are known for doing. And it's kind of like, boom, it's the eye roll, it's a shoulder shrug. It's a big inhale, but the key is it's the long exhalation. That's what activates the relaxation response. Um, and so that's something that we can go over with patients. If you're looking more for concentration, and these are all the benefits of mindfulness. We're not going to dwell on that. We know that. Um, if you're looking more for concentration, there's also something called box breathing, the American heart association and the military uses this. This is breathing in for a count of four, holding for a count of four, exhaling for a count of four and pausing for a count of four. So, um, it's another great one to use. So we talked about refuel, we talked about revitalize, we talked about recharge, we talked about refresh. Um, I'm not going to dwell on relate, but I do want to touch on it. So, um, why is social connection and wellbeing important? I think we all know that. So that's why I don't want to dwell on it, but there's a lot of data that poor social connections are related to more information, more pain, obesity, antisocial behaviors, difficulty of problem solving lots of mental health issues, but also, um, abuse, diabetes, heart disease, dementia, stroke, stomach problems, and affecting the health span and lifespan So, uh, good social connections, uh, help decrease the, uh, impact or the risk of some of these things. And so this is sort of the clouds that people like these clouds, cause it's sort of easy to visualize. Um, there's a lot of data that shows this is what people have sort of been trained and believe will make them more happy, but it's often a promotion being thinner, more attractive, nicer clothes, more money. It actually shows that what makes people have a better sense of wellbeing and cope with stress better and challenges better is changing their mindset as much as possible. They need a little more towards optimism, mindfulness practices, like we talked about a little bit, time with family and friends, and really think all aligned with, uh, working on a life purpose or goal. Some of the other ones are savoring experiences and helping others. These are things that are big topics, but we encourage our patients to sort of focus on what is their life goal or purpose? How can they help others? What can they savor? So even though we can't control other people, what can we do to savor things ourselves to impact our health? And we know social connection is important because the worst punishment you can give someone and they do this in prison is solitary. And those people that they follow out of solitary, those people have higher rates of inflammatory disease and chronic no-skills double pain. There's data on that. So we know this makes a big difference in our field. Going back to the three A's that we started with a little triangle in the beginning. These are some of the barriers to non-pharmacological treatments. Awareness. So I think we can work on that. We can use our voice and be a voice. Appeal. So are people willing to do it? What would you be willing to try? Can you think about what you might not like as a word of the barriers? Does anything about this thing make you think it would not help with your pain or your rehab condition? And access. I think access is not really an issue. I think we have enough resources where people can sort of do this on their own. It's really more of the awareness that we need to focus on and making it appeal to their life. So how do we empower our patients? I'm very much food first. I usually get a lot of questions on supplements. I think it's food first and supplements second. So this is the anti-inflammatory pyramid, which again is very similar to the Mediterranean diet pyramid. The American College of Lifestyle Medicine has handouts for free that you can print out and give to your patients. Again, I think we have a special voice with our patients and a power that we may not recognize that. So coming from you, you saying, I think this will help with your pain. I think this will help with your inflammation. I think it's a help in your recovery. I think it's a help with your function. It makes a huge difference. Your MA or someone else can actually give them the handout. But if you're able to have a handout and actually hand it to them yourself, I think that makes a huge impact. This is the Harvard healthy eating plate. It's really similar to the MIGO plate. It's half the plates, vegetables, and fruits. You can see more veggies and fruits. The other half is whole grains, healthy protein. They emphasize water where my gut emphasizes milk and healthy oils. And of course it's full of stay active thing on the side, which is nice. This is my book. Most of the figures from today's topic came from this book. It's really helps with the access, really makes health and well-being more accessible for everyone that's available. But I want to get back to the voice. This is us here. And it's sort of the social ripple effect. If we can sort of spread the words about lifestyle medicine and empowering our patients, it can affect their family, which can affect community, which can affect society as a whole. It can really be a movement that we can help empower people to fuel their lives for better health. And we can help them engineer their environment to live easy and live with better health. We got to make these things easier. Our patients don't do them. And that's really where the concepts of micro-boost come in. And I would be remiss if I did not mention this topic, which is burnout in medicine. This is something dear to my heart and I'm sure to most people. Well, there's a lot of factors to it. And like Dr. Knopfball had mentioned, I have done some training in this. I think there's two parts where lifestyle medicine touches on this. One is personal resilience. So I think if we incorporate some of these factors into our own life, it can be helpful for building our personal resilience, mental, emotional, and physical. And also this other one, loss of personal accomplishment. When you help a patient without a medication or an injection or without something else that may be temporary, when you help change their lives and empower them to take care of their health, that's a huge sense of personal accomplishment. It really helps you connect with why most care and back into medicine. And so that's why I think it's really important to mention this really in all talks. I think burnout medicine should be mentioned in all talks, but especially here because it's something we can use for ourselves, but it's also something we can use for our patients. So you are the change, right? You are the voice. You are the change. We can get away from just Band-Aids and pills as our mainstay. Again, they're useful tools, but not as isolation. You had a calling and you can educate, empower, and really help your patients heal. When I was a pre-med student at my very liberal arts school, they didn't call it pre-med. They call it healing arts. Okay. And so that might sound a little bit woo-woo to some people, but I think there was some truth to that. I promised you three stories. So I have told you two. Well, first is our shared story about our calling to medicine. The second was my fun-sized candy bar story and how I got into lifestyle medicine. And the third is a patient story who I actually saw today. So that's coincidental and follow-up, not for the first time. So this patient is a 50-year-old female and we'll call her Sarah. She has beautiful white pixie hair, and she had a lumbar fusion two years ago. She presents to me after a reoccurrence of her pain. She has already met with her spine surgeon, did some imaging. Cardio looks great, of course, everything looks great. Go see the pain doc, get an epidural. So she sees an outside pain doc. The pain doc says, look, you have axial back pain. I really don't think this epidural is going to help, but let's do it anyhow. She's already kind of a little annoyed. She does, the epidural gets done. I'm surprised she has no relief. And then he says, you know what? This might be more of a hip SI thing. Why don't you go see the sports medicine doc? She's a sports medicine doc. He does some SI injections and versus stuff. No relief. He says, you know what? Actually, I think this is more of a teniotomy issue and you probably need a teniotomy procedure. Now she's seeing the fourth doctor. She gets a procedure done. Now it's been another year since this pain started. She had her back surgery three years ago now. Well, for two years, pain reoccurred. She saw her spine surgeon. She saw the pain doc, saw the sports med doc. She saw the extra sports med doc doctor. And then that doctor said, look, there's nothing else we have. Go back to your pain doc. So the pain doctor says, look, your body's not responding to treatments. There's some of these system failures to talk about in that case, but that's the main thing is, um, you know, we really shouldn't be blaming the patient that her body's not responding. Right. If, if we haven't found the best treatment for her, but she comes to see me for acupuncture because her body's not responding. And so in our first visit, she gives me the story. She's very upset naturally, um, and sort of acknowledge some of her symptoms, um, legitimize them as real, uh, and not her body not responding and we'll start doing acupuncture. But along the way, we talked about the lifestyle medicine pillars and I will say it's a gift. When I do my acupuncture on patients, uh, when I work with them, it's a gift because I have a little more time with them. Her nutrition was not as big of an issue. Uh, she was more of a type a person, go, go, go. Very health aware, health conscious exercise was an issue because of her pain. Sleep was an issue because of her pain relationship, a certain issue because of her pain and stress. Stress was actually her main issue, feeding a lot of information. And once we were able to sort of talk about that and I just sort of broached it with, are you open to trying a mindfulness app? And she said, you know, my daughter had mentioned that, but she didn't say how she didn't say when she didn't say where. And so I told her on a free app that I like told her how to use it. We talked about some stressors in her life. And I started two weeks later, another acupuncture treatment, a little better at four weeks. She felt a lot better at six weeks. She felt better than she had in more than a year. And I don't think it was all the acupuncture. I think most of it was the work she was doing. She started doing mindfulness exercises multiple times a day. So three, five minute practices, not too onerous. So it makes someone can do in their car before work, after work and in bedtime, she started being a little more selective with some of our real estate clients. And she started carving out some time to relax at home. I saw her again today, but prior to that, I'd seen her eight weeks into the treatment. And she looked up at me and instead of sort of being like this crumpled person hanging on the table, sad and sulking, she was tall. Her back was strong and her eyebrows are furrowed. And she's staring at me and she says, you know what doc, I think this is some kind of magic. And the scientist in me just kind of showed her the word magic. I said, no, you know, thinking we're evidence-based, we're not science, we're all science. We're not magic. But you know, I just, I nodded and I smiled and I kept it together. And I was like, Oh, magic. And then a little part of me sort of applauded me. And I was like, okay, let me look up this word magic. If you get past hocus pocus definitions, there's definition of magic that is a feeling of enchantment or joy. If you take it to another level, joy is a factor of quality of life. Some of you may be familiar with author Elizabeth Gilbert. She has a book called Big Magic. She talks about that being a sense of joy and purpose. And I think that's sort of is what we do with lifestyle medicine and with physiatry in general. We improve people's quality of life, their health, their wellbeing, and their function. So maybe in some way it is a little bit of magic. Maybe, you know, she wasn't wrong using that term, but to go from your body's not responding. This is some kind of magic, but a little bit of acupuncture and some lifestyle medicine is pretty impressive. And I have lots of stories like this. I think it just helps us remember that it really can make a difference. We do have a voice together. We can empower ourselves and our patients to improve quality of life and longevity. We are some resources. Remember, I really want you to remember this. You're the change and our voice makes a difference. These were objectives. I have stuff on the website and Instagram if you're interested. I think I will stop there and let Dr. Nenek Paul moderate. Thank you. Thank you, Dr. Sharma. That was awesome. And I'm confident that if we were in a real room, there would be a round of applause right now. I'm pretty confident that everybody's clapping at home and that just everybody's on mute, which is why I don't hear it. There are some really great questions. And some people are even doing the virtual clap, which I find challenging to find on Zoom as compared to teams, but I'm metaphorically clapping. So there are some great questions that I would like to try to post to you in the short time we have left. We can't get to all of them, but I'll do my best. The one that is the most, I think the one that's going to be the most challenging for you to answer is, but I think one that's so important is how do we apply the principles of what you described as the refuel stage to cultural food ways? And that comes from Dr. Ankam. I know major too. Okay. Just giving me tough questions. I think it is sort of, if you have time, which is always a big thing, or maybe a nutritionist you can refer to, but it's understanding sort of what their cultural food staples are. And maybe going back to that picture with the tofu, broccoli, rice, and the Italian food metaphor. And it's maybe working with food order. So we talked about the tofu. We talked about Italian food. Well, if I take my own heritage, for example, Indian food is very carb heavy, but it also was very veggie heavy too. And some people eat meat and some people don't, and that's fine. So we'll be starting with the veggies. So we'll be starting with something like okra or cauliflower and eating that first, salad first, and then your legumes, and then saving the rice or the roti or the breads for last. You can also make protein breads now. I've made protein roti. You can actually use protein powder to make your roti. So you can still get that carb, but also have protein in it. So I think there's ways to modify people are open, but I 100% agree. We're not telling people to not be who they are, or to just go eat steaks if that's not part of their culture. Really want people to be within their culture, but maybe modify the order and think about how they're preparing it, and maybe use some more protein based powders. Some people will do protein shakes. So you could have them drink some water first to just get hydrated, and then also have a protein shake, and you're not going to eat as much of the carbs. But I think thinking about the order is important. That makes a lot of sense. And every culture has these food habits, some of which are good and some of which are bad. So if you can restructure it and perhaps reorder the decision making that you're putting into your brain about what pathway you're going to take, that makes a lot of sense. I'm going to push it a little farther and ask, there are many cultures where the vegetable, which is good to eat towards the beginning of the meal, is deep fried. I live in Charleston, South Carolina. We deep fry everything here. So when you're having these, and I'm going to segue that into a question that I was going to ask, a lot of patients are going to have this conversation with you and are not quite in that part of the pathways of change and the stages of change that they're ready to have this type of conversation. Maybe they're not in even the pre-contemplation stage, but what are some of the strategies that you use to talk to your patients, to engage them, to get them to move into the change cycle so that they can understand and hear the things you're telling? Yeah. And so, yeah, that's a great point. And, you know, you're referring to sort of like the action decision-making stages. I think it really has to be internal motivation, right? So you have to sort of frame it. There's a whole courses, courses on motivational interviewing, but, you know, why do you think it would be helpful not to have a fried Oreos or whatnot and let them have the answers, right? So not feed them things that aren't meaningful to them and say, well, this is what happened to cholesterol and your blood pressure and your diabetes, you know, say, how do you think this would be helpful? Why do you think that would be a hard thing to do? What could you eat instead? Is there a way you could have that last instead of first? You could also get into the whole circuit eating and say, well, I won't eat after a certain time period and maybe not change everything they're doing if they're not at that point. I have a patient I see for acupuncture and she always stops at McDonald's before, because, you know, she's always in a rush. She is retired. You know, not that, you know, people are retired, aren't busy, but she does have some flexibility of her schedule. And so we talked about just eating the chicken patty and not the grilled. And so sometimes it's meeting people halfway, don't eat the fries, have the salad and chicken patty. And, you know, that's a step forward for her. And so sometimes it's meeting them where they are. That's great. There is a few questions that we just, I feel bad we're not going to get to some of these great questions. I think this is a good one because you spent a lot of time talking about gut and microbiome. Do you have any particular thoughts on intermittent fasting as a treatment option for people with various stages of inflammation? Yeah, I think there's good data for that. And sort of a spin on that is the, what I was calling circadian eating. You know, we sort of try to spin things positively. So fasting implies when you can eat, eating sort of upsize your eating window when you can eat. And circadian eating is basically intermittent fasting, like the 7am to 7pm. But there is good data for that. I think intermittent fasting just has, sometimes it can be like a loaded term, but I definitely think can be helpful. Yeah. And you know, I'm sure many people have recently watched the Blue Zones because it was such a big hit on Netflix and they'd speak all those Blue Zones. They all are using circadian eating habits. Great. I think we'll do one last question. Any work on pediatric populations? This comes from Dr. Nneneng Aglu in, not in Texas anymore. I think she moved, I can't, I think she moved to Boston if I remember. Yes, I'm in Boston. Thank you. And any work on pediatric populations on lifestyle interventions that you recommend? Yeah, this is a great question. I was actually thinking about just writing like an ebook on this. It's like taking information from my book and sort of tailoring it more for kids. I have two young children myself. And so I see the importance of this. I mean, I definitely think that's where it starts, right? It's where like healthy habits start young and what you see at home and what you learn at home. So I think these principles can be applied to a certain degree of children too. For example, with the food, like I'll talk with my kids about you have to have a protein at every meal because I think just that's just like a basic step. And my daughter knows she gets hangry and she kind of has this blood sugar spike and she doesn't get a protein. And so I was like, do you want guacamole or do you want peanuts or what do you want to add a protein to your meal? So I think starting little stuff like that can be helpful for mindfulness. It's sort of that, you know, blow in, it's like smell the roses and blow out the birthday candles. So sort of changing the mindfulness breathing exercise, more customized for kids can be helpful. So, yeah, I think there's ways to enact this, the bedtime routine, which I call the relaxation routine for adults. I mean, that's, that's the kid's bedtime routine, right? It's like bath, brush teeth, read story, go to bed. And that's sort of like eases your body into bedtime. And at the same time, the same sleep schedule. So I think a lot of this is really intuitive and natural for kids. But we can sort of tell her a little bit more to them. I'm just gonna throw this one out because it's a quick answer. Someone asked, what's the free mindfulness app that you use? So there's a bunch, obviously, I really like insight timer. I n s i g h t, I believe timer, they have a free version. And of course, they have a premium version to headspace 10% happier. These are great ones, too. But insight timer is just, it's really neat, all the free stuff you can get on there. Great. And just so everybody knows, for headspace, at least, and this may be true for many of the other ones, there is a discount for healthcare workers that started during COVID that they have retained. And I use headspace all the time for meditation and mindfulness myself. And I love it, but I'm not paid by them. And nor is Dr. Sharma, there are plenty of other options. We are out of time. There's that I really wanted to get this question about marijuana, but we're not getting there. So maybe next time. So I think you're going to get invited back Dr. Sharma, because you did such an amazing job. Thank you all for listening and participating. Please do send any feedback you have towards the AAPMNR. We appreciate everyone being here today. Thank you so much. Have a good night, everyone. Thank you so much. Have a wonderful evening.

National Grand Rounds

Dr. Saloni Sharma

health and well-being

lifestyle medicine

PM&R

nutrition

exercise

stress management

social connections