A Conversation With Esther Sternberg, MD
Dr. Esther Sternberg is one of the world’s leading researchers in the complex and evolving science of mind-body interaction and its effects on illness and health. As section chief of neuroendocrine immunology and behavior at the National Institute of Mental Health (NIMH), Sternberg has made discoveries that have helped answer such weighty questions as, How and why does stress affect our health, and do our surroundings have the power to heal? Currently, she also serves as director of NIMH’s Integrative Neural Immune Program and is co-chair of the National Institutes of Health’s (NIH) Intramural Program on Research in Women’s Health. Prior to joining NIH in 1986, she was on the faculty at Washington University in St. Louis.
Honored by the National Library of Medicine as one of the 300 women physicians who have changed the face of medicine, Sternberg is the author of two books, Healing Spaces: The Science of Place and Well-Being (Harvard University Press 2009) and The Balance Within: The Science Connecting Health and Emotions (W.H. Freeman 2001). She also created and hosted a PBS special, The Science of Healing, based on her books and on the personal journey she took to find out how the brain helps us heal physically and emotionally. IDEA Fitness Journal recently interviewed Sternberg about the interrelationship of mind, body, perception and place, and how that relationship affects the health and fitness community.
IDEA Fitness Journal (IFJ): You report that one-third of Americans are living with extraordinary stress and that 90% of us live with stress on a regular basis. How do you define stress?
Dr. Sternberg: There are four parts to stress. Most people think about stress as the bad thing that happens to them, the stressful event itself. But there’s another part: how your brain reacts to the stressful event, the brain’s physiological stress response. When you are exposed to a stressful stimulus, your brain’s stress center pumps out a hormone called corticotropin-releasing hormone, or CRH. This hormone comes from the hypothalamus, the brain’s stress center, and travels through the blood vessels to the pituitary gland that sits underneath the brain.This causes the pituitary to make adrenocorticotropic hormone (ACTH), which then stimulates cells in the adrenal glands (located on top of the kidneys) to make still a third hormone, cortisol. At the same time, your adrenaline-like nerves and your adrenal glands have started pumping out adrenaline. The combination of these hormones and chemicals makes you feel stressed through a variety of symptoms: your heart starts beating faster, you feel sweaty and anxious, your attention is focused, and you’re ready to fight or flee. That’s the fight-or-flight response, the stress response. But something else very important has to happen between the stressful event and your brain’s physiological stress response, and that is perception. You first have to perceive the event as stressful in order to react to it. If you don’t perceive it as stressful, you won’t have a stress response. Perception is very important because that’s the part of the stress formula that we can modify with mind-body interventions like exercise, yoga and tai chi.
I want to emphasize that extreme exercise, shoveling snow in the winter or even running at 90% VO2max on the treadmill, can also trigger your brain’s physiological stress response. When you’re running at max, you are pumping out stress hormones and nerve chemicals because you need them in order to give you the energy to run. However, training regularly helps to attenuate the body’s stress response. The reason that people who are trained runners have a much slower heart rate is that their heart pumps blood through their system more effectively. Essentially, regular exercise is good because it helps your heart do a more efficient job. You don’t have to have as many beats per minute in order to pump out the same volume of blood.
IFJ: Does stress make us sick? If so, why, and what are some ways to prevent the detrimental effects of stress?
Dr. Sternberg: Physiological stress response is a good thing on a short-term basis, when you need that burst of energy to fight or flee, to get out of danger. That’s why all animals have a stress response. Without it we wouldn’t survive. We need the stress response, those nerve chemicals and hormones that give us that energy to survive. But if the stress is chronic, if it goes on too long, it takes its toll. Caregivers, people undergoing marital stress or chronic job stress, people who have lost their job or who are afraid of losing their job, people who have lost their home or who are trying to keep their home, these are all [people who are experiencing] major stressors.
As I said, there are four parts to stress. I described three of them: the stressor, the bad thing that’s happened; the brain’s physiological stress response; and perception. The fourth piece is when the stress goes on too long. That’s when you get sick. If you are under constant exposure to stress hormones and nerve chemicals over weeks or months, your immune system will wear down. The reason is that the hormone cortisol tunes down the immune system’s ability to fight infection, and one of the big reasons we have an immune system is to fight infection. The immune system also functions as a surveillance mechanism to get rid of cancer cells, but the big, big reason is to fight infection. When you are chronically stressed, your adrenal glands are giving you multiple shots of cortisol, and because it’s anti-inflammatory, it dampens your immune system’s ability to do its job and fight infection.
I want to emphasize that chronic stress does not cause aging. Aging causes aging. Chronic stress does not cause cancer. Your genes and various environmental factors cause cancer. And chronic stress does not cause the flu or the common cold. The flu bug and the common-cold bug cause the flu and the common cold. But chronic stress, through the effects of these hormones and dampening of the immune system, can feed these kinds of conditions and make them worse. So if you are sick with any one of these conditions, the more you can do to reduce your stress response, the more likely it is that your body will be able to effectively fight those conditions.
IFJ: Can you give fitness/wellness professionals, studio or health facility owners or those who teach people on a daily basis some concrete ways they can communicate coping mechanisms for their stressed-out clients?
Dr. Sternberg: Coping is the important word. You can’t get rid of the bad thing, the stressful event. If you’re a caregiver of a patient, for example, that situation exists, but you can do things to help you cope with that situation. One important thing is to get help from friends and family, help from professionals, because you can’t do it all on your own. An exercise professional is an important component of a network of social support, because people are busy, and they may not feel as if they have the time to exercise. Having a trainer helps people stay with an exercise routine until it becomes routine. It is also important to have a trainer who is familiar with specific physical or medical conditions so [the trainer can recommend] the appropriate exercise. Social support and a network of professionals who can help you get through the stressful patch are very important.
If you can’t work with professionals, then you can at least walk 30 minutes a day. A number of published medical studies show that 30 minutes of walking a day, a healthy Mediterranean diet and mindfulness meditation three times a week increase the enzymes that repair the ends of our chromosomes in only a 3-month period. When you age, the ends of your chromosomes shorten and chronic stress can feed that shortening process, [accelerating it by] 10–17 years. We don’t know if the ends of the chromosomes are actually repaired—those studies are still in the works—but we do know that the machinery is there for the repairs to happen. Regular walking bolsters the immune response, especially those cells that are the immediate defenders against infection. It is people who engage in moderate exercise (around 7,000 steps per day, counted on a pedometer) whose immune systems show the strongest response.
In the armamentarium of professionals whom people should seek to advise them are those with expertise in nutrition and diet who can help design a program to fit individuals’ unique needs. Massage therapy is also very good. We’ve been talking about the stress response, but there’s also the relaxation response that is governed by the vagus nerve (the thick cable of nerve fibers that extends through the spinal cord to the brain) and another set of nerve chemicals called acetylcholine. When you are massaged, the vagus nerve kicks in, and so does the body’s relaxation response. Massage therapy is not only good for relaxing people; it also activates the vagus nerve, which in turn lowers blood pressure, slows the heart rate and puts the brake on the stress response.
IFJ: In your book Healing Spaces, you say our surroundings or “place” can make us ill. Explain this concept. In contrast, does place have the power to heal us and alleviate stress?
Dr. Sternberg: Yes. There are many features of the environment that can trigger the stress response: loud noise, crowding, when you’re in a maze and you have lots of choice points and you don’t know where you’re going. So, for example, imagine an airport or a hospital where you can’t see where you’re going, the signage is poor, and you have to make decisions quickly in order to get somewhere. The place around you figures very importantly in triggering your stress response.
In my book Healing Spaces, I talk about hospitals and well-being and [the fact] that we certainly know the features of our environment that can trigger the stress response. If we know that chronic stress impairs the immune system’s ability to heal, surely we don’t want a hospital where people should be healing to be a stressful place. You want to do as much as possible to help the healing process. There is a new wave of hospital design that incorporates features such as large windows, beautiful views of nature, noise reduction and features of the environment that are calming: soothing colors, elements that remind people of home, views of gardens, places to walk, and places for the family to stay overnight to offer social support.
IFJ: Can you elaborate?
Dr. Sternberg: The Center for Health Design initiated a project called the Pebble Project, where the effects on health outcomes of these kinds of design features were included. The project measured these effects in about 40–50 different hospitals that were building new units. You can’t build a whole new hospital and then say, “Oh, we did it wrong. We’ll tear it down and build another one.” But you can measure the effects of each of these smaller units; it’s like throwing a pebble into a pond and seeing the ripple effect.
These kinds of design innovations have generated tremendous health benefits that include reduced infections; improved patient, family and nursing satisfaction; reduced nursing turnover; shorter hospital stays; and fewer medical errors. The extra costs of building a so-called “stable hospital” that includes all of these beneficial features is approximately $12 million. Calculations show that $11 million would be recouped in the first year of operation simply because of the improved health outcome, fewer re-admissions, shorter hospital stays and so on. So what’s good for people in the hospital is also good for the bottom line.
Also, when we think of these design features, it is good for the environment. What turns out to be green and good for the earth is also good for our health. In my book, I talk about healing cities, healing worlds and how you can take these principles into urban design as well.
IFJ: Can the design of an exercise studio or a large workout facility contribute to a client’s well-being? And can you give exercise professionals advice in how their “place” can function better from a visual and physical perspective? How will this help their clients?
Dr. Sternberg: Nobody to my knowledge has actually specifically addressed exercise facilities, but I think you could consider them in the same way that these newer hospital wings are designed. The beneficial design features include views of nature. Now, often an exercise facility is in a city and you don’t have a view of nature. For example, my exercise facility is located underground, but the pool area has skylights, and I just love to swim looking up at those skylights. So you can add features that include views of the environment or nature.
But if you don’t have the luxury of having a view of nature, lighting is important. Lighting and colors. It is difficult to do well-designed studies to prove the effects of colors on the walls, but blues and greens are thought to be calming and reds and yellows are thought to be stimulating and exciting. There are a number of studies showing that full-spectrum sunlight or lighting that mimics full-spectrum sunlight is good for improving people’s moods. In depression literature it is well-established that any form of full-spectrum sunlight is beneficial.
A recent article from the Proceedings of the National Academy of Sciences showed that blue and green light changes people’s emotional processing in the brain. Using brain-imaging studies, scientists were able to show that people who were hearing angry or emotionally charged voices [experienced] different effects when they were looking at, or exposed to, blue and green light as opposed to . . . regular light. So there’s no question that calming colors, whether it’s with lighting or on the walls, can help to calm and soothe people.
Also, sounds of nature are very important—flowing water, for instance. Smells, fragrances, are extremely important in reminding people of comfort. I find when I go to my health club that the smell relaxes me because I’m anticipating the feeling I will get when I swim. It’s learned association. It’s an association that comes from me having repeatedly gone into that environment, feeling relaxed with the whole ritual of swimming, sitting in the hot tub and then taking a hot shower. The whole ritual is very relaxing. There’s no question that smells can trigger memories that can either be stressful or relaxing. If you learn to associate a certain fragrance with feeling relaxed, then it will trigger relaxation even without the benefit of having done that ritual.
IFJ: You’re really saying that people who own the studios need to pay attention to things like color, sounds and aromas?
Dr. Sternberg: Absolutely. A noisy studio is not going to be relaxing. Now, people may argue, well, we don’t want people to be relaxed and falling asleep. But there’s a certain level of noise that is stressful, and no matter how much you want people to be stimulated, you don’t want them to be overstimulated. Attention should be paid to all of the features of the environment that you see, hear, smell or touch that can affect people’s moods and, ultimately, their desire to exercise.
IFJ: Can you also talk about the effects of music in an exercise facility?
Dr. Sternberg: Music is important, too. Yes, I talked about the negative effects of too much sound and noise, or the pleasing and soothing sounds of nature. Certainly music is very important, but it should be the right kind of music for the activity. Ambient music in the background can certainly often set the mood and the tone at an exercise facility. People have always known that music can alter moods—we know this from generations of art and culture, but only recently have scientists developed technologies that could be used to understand how emotion and music are connected, and to prove that music can affect moods.
IFJ: Exercise professionals are dealing, like the rest of the country, with the obesity epidemic, and you describe in your book how place can affect this important issue. For example, you say that obesity predominates in rural areas and the suburbs and is less common in the more compact urban areas. Why is this, and how can this be changed?
Dr. Sternberg: People tend to walk more in urban areas. So there’s a debate as to whether people choose to live in the suburbs because they don’t like to walk and people who choose to live in urban areas like to walk and, therefore, are already predisposed to being less overweight.
There are incentives to exercise in the urban areas and disincentives to drive, whereas in suburban areas there are incentives to drive because you’re generally too far from anywhere to walk. There are also disincentives to walk because there are no sidewalks. People need an incentive to make it easier and more pleasant to exercise. If a health or exercise facility has incentives to make it more pleasant, such as a nice environment, then it is more likely that people will come because they really want to be in that environment, rather than feeling that they have to be. And the same thing applies in the urban or suburban environment—if it’s easier to exercise, if there are parks where you have choices of whether to play tennis, walk your dog or run, or if there are sidewalks that allow you to walk and see interesting things, then people are going to be more likely to exercise.
IFJ: Before we end the interview, would you talk about the future of mind-body medicine? How will it change current views, practices and thoughts in this country?
Dr. Sternberg: I think we are living in a very exciting time in which science is giving evidence and credibility to the effectiveness of mind-body approaches. I have just talked about not only healing and treating disease but also prevention. And that’s where the future is, in prevention. Because if we can reduce the obesity epidemic, 20 years down the road we’re going to have prevented thousands of cases of diabetes, heart disease, stroke and osteoporosis. Once you get one of those diseases, it’s more expensive and much harder to function for the individual who has the disease. It is more unpleasant to treat the resulting disease than it is to prevent it with regular exercise and a healthy diet, by not becoming obese and, to the extent that you can, by coping with and reducing stress. All of these approaches are essential for prevention. And again, what’s good for the body is good for the bottom line, because prevention is a great deal cheaper than treating these diseases.
IFJ: Do you see in the future that exercise and fitness professionals will be working hand-in-hand with people in the medical field?
Dr. Sternberg: I think it’s heading that way already. Another exciting thing about the future of the medical field is the team approach. In the days of Father Knows Best, Ben Casey or Dr. Kildare, the doctor was the “great white father,” the paternalistic doctor who tells you what to do and you go home and do it. Now there is a more equal interaction between the patient and the healthcare professional, a team approach where it’s very clear the doctor can’t know everything. The doctor is good at technological, pharmacological and genetic advances, but you really need a whole team of people to give an individual the best care. You need a physiotherapist, an occupational therapist, an exercise and massage therapist and, perhaps, you need a psychologist. You need to treat the mind and the body together and use professionals who know how to do all of the above. I find that in the past I did not have to consciously pay attention to all of this [in my personal life], but as we age we have to consciously make a regimen, a program, so that we do all the things that are good for our health. If not, we tend to forget and fall back into our old ways.
I want to say one other important thing: positive outcomes [vary, depending] upon the individual. A lot of people feel extremely guilty if they can’t get rid of the stress, if they can’t lose the weight, if they can’t exercise, but they shouldn’t feel bad. The danger of this kind of self-help approach is that they will feel sad about themselves—so sad, in fact, that they’ll just give up. [The reason it’s important to get] professionals to help you is that you can’t do it on your own. It’s not your fault that you can’t. But if you have a team, “Team You,” they will help you do what’s healthy. When people say, and I even say this, “But I don’t have time to exercise,” ask yourself this question, “Do you have time to get sick?” If the answer is no, then you have time to exercise.
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