When Miguel Roger began chemotherapy for chronic lymphocytic leukemia last summer, he didn’t realize the challenges he would face with food.
“Once treatment started, I noticed a change in my appetite, and a lack of energy,” said the 65-year-old retired engineer.
His wife Jenny, 61, became his primary caregiver, and found it challenging navigating all the nutrition advice from books, their doctor, and the hospital nutrition centre.
“I once cooked him calf liver to help with his anemia,” she said, “I read it in a book, but when I spoke to Miguel’s doctor, we were told it wouldn’t help, since the anemia was not related to nutrition, but to the cancer itself and the chemotherapy.”
Nutrition is an under-recognized challenge for many cancer patients. And fad diets can cause unnecessary weight loss, disrupt treatment, and sometimes make outcomes worse.
Many patients struggle with navigating the “cancer-specific” dietary information found in popular books, blogs, and websites. A British study released last month found caregivers and patients were concerned about the lack of accurate and clear information — something Canadian health providers are keen to provide.
It’s easy for misconceptions to spread through websites, nutrition bloggers, books, and word-of-mouth.
“In clinic, I once overheard a woman saying how she was getting mega-doses of vitamin C, rose hip tea, bee pollen and antioxidants,” said Jenny Roger. “But I heard the dietitian advise that those things may not be regulated and could be contraindicated during chemotherapy.”
This is a familiar story to many cancer specialists and dietitians, including Thomas Jagoe, director of the McGill Cancer Nutrition Rehabilitation Program in Montreal.
One of his challenges is dealing with diet trends that conflict with what a patient’s oncologist advises. One trend is “short-term fasting” before chemotherapy.
“This is a hot topic of research but at this time the evidence doesn’t support that a patient who is already losing weight starve themselves for a few days,” Jagoe said.
In Halifax, it was an open line of communication that helped Stacey Sheppard, a dietitian with the Nova Scotia Health Authority, identify the real reason behind a patient’s issue.
“One patient with nasal cancer got advice from a holistic nutritionist to omit gluten. When we got to the bottom of the issue we realized that they actually had issues with swallowing crackers — so it was a swallowing issue, not a gluten issue,” she said.
But patients keep looking for answers outside the system. And it’s all about control, says Jonathan di Tomasso, a nutritionist who works with the cancer rehabilitation program at McGill.
“People often lose control over many aspects of their life when they are diagnosed with cancer. Food is something they can control, but the roar of misinformation out there is deafening,” he said.
Toronto-based naturopath Daniel Lander, who has an undergraduate degree in nutritional science, works closely with physicians to offer evidence-based nutrition advice.
“Patients are generally relieved when I tell them they don’t have to follow those strict diets, and I focus on making sure they are getting enough calories and important macronutrients,” Lander said.
He advises a Mediterranean-style plant-based approach that has lean-protein sources, lower animal products and lots of fruits and vegetables and whole grains.
“It’s nothing too exciting or flashy but from the science, that’s the best we can tell people to do,” he said.
In terms of good online sources of information, Daniela Fierini, a registered dietitian at the Princess Margaret Hospital, recommends the American Institute for Cancer Research, BC Cancer Agency and Nourish Online, but still cautions against the “one size fits all” model.
Due to a good response to chemotherapy and radiation, Roger’s cancer has been in remission for the last month.
“Now my appetite’s normal. I lost around 10 pounds at the start of the treatment but I think I have gained it all back … my energy level is fine and I’m no longer swollen,” he said.
The Rogers were cautious about following popular cancer diet trends and maintained open communication with their doctor.
“You can get caught up with reading things on the Internet and I think everyone should be working with their doctor. People need to have a bond of trust with their doctor. Some people don’t, and so they look elsewhere, which can sometimes be overwhelming and can cause more harm than it helps,” said Jenny Roger.
[by Amitha Kalaichandran and Shuang Shan] **Originally published in the Canadian Press/Toronto Star**
When pain researcher Diane Gromala recounts how she started in the field of virtual reality, she seems reflective.
She had been researching virtual reality for pain since the early 1990s, but her shift to focusing on how virtual reality could be used for chronic pain management began in 1999, when her own chronic pain became worse. Prior to that, her focus was on VR as entertainment.
Gromala, 56, was diagnosed with chronic pain in 1984, but the left-sided pain that extended from her lower stomach to her left leg worsened over the next 15 years.
“Taking care of my chronic pain became a full-time job. So at some point I had to make a choice — either stop working or charge full force ahead by making it a motivation for my research. You can guess what I chose,” she said.
Now she’s finding that immersive VR technology may offer another option for chronic pain, which affects at least one in five Canadians, according to a 2011 University of Alberta study.
“We know that there is some evidence supporting immersive VR for acute pain, so it’s reasonable to look into how it could help patients that suffer from chronic pain.”
Gromala has a PhD in human computer interaction and holds the Canada Research Chair in Computational Technologies for Transforming Pain. She also directs the pain studies lab and the Chronic Pain Research Institute at Simon Fraser University in Burnaby, B.C.
Using VR to relieve or treat acute pain has been done for a while.
In the 1990s, researcher Hunter Hoffman conducted one of the earliest studies looking at VR for pain relief in the University of Wisconsin human interface technology lab. His initial focus was burn victims.
Movement and exercise
Since then, the field has expanded. Gromala’s lab focuses on bringing evidence-based therapies that work specifically for chronic pain, such as mindfulness-based stress reduction. They have published studies on their virtual meditative walk to guide and relax patients.
Movement and exercise are a key part of chronic pain management in general. But for many patients, it can be too difficult.
“Through VR we can help create an environment where, with a VR headset, they can feel like they are walking through a forest, all while hearing a guided walking meditation,” Gromala said.
The team also designed a meditation chamber — where a person lies in the enclosed space, breathing becomes more relaxed and a jellyfish viewed through VR dissolves.
Each experiment gives real-time feedback to the patient through objective measures of pain such as skin temperature and heart rate. For instance, while feeling pain, skin surface temperature and heart rate can increase.
While pain medications can be important, chronic pain treatment should also address lifestyle aspects, says Neil Jamensky, a Toronto anesthesiologist and chronic pain specialist.
“Physical rehabilitation therapy, psychological support and optimizing things like nutrition, exercise, sleep and relaxation practices all play key roles in chronic pain management,” he said.
Other researchers like Sweden’s Dr. Max Ortiz-Catalan from Chalmers University of Technology have looked at virtual and augmented reality for phantom limb pain — the particularly challenging syndrome among amputees who experience pain in a limb that is not physically there.
In his study, published in The Lancet in December 2016, Ortiz-Catalan demonstrated a 47 per cent reduction in symptoms among VR participants.
He believes the reason behind it is a “retraining” of the brain, where pathways in the brain effectively re-route themselves to focus more on movement, for instance.
“We demonstrated that if an amputee can see and manipulate a ‘virtual’ limb — which is projected over their limb stump — in space, over time, the brain retrains these areas.
“Through this retraining, the brain reorganizes itself to focus on motor control and less on pain firing,” said Ortiz-Catalan.
With only 14 patients, this was a pilot study, but he plans to expand the work into a multi-centre, multi-country study later this year. The University of New Brunswick is one of the planned study sites.
There’s an app for this
Others in the United States have published their own findings of VR for chronic pain.
Last month, Ted Jones and colleagues from Knoxville released results of their pilot study of 30 chronic pain patients who were offered five-minute sessions using a VR application called “Cool!” — an immersive VR program administered through a computer and viewed through a head-mounted device.
All reported a decrease in pain while using the app — some decreased by 60 per cent — and post-session pain decreased by 33 per cent. The findings were presented in the journal PLoS.
“What was interesting to observe was that the pain decreased for six to 48 hours post-VR experience. It’s not as long as we would like, but does illustrate that relief can be sustained over some period of time,” Jones said.
His team will be expanding the research this year and will also look at how VR can help with the challenging mental health side-effects of chronic pain.
Jamensky points out while VR could be a promising treatment one day, one challenge with clinical trials is the dependence on looking at pain scores when assessing the effectiveness of VR. This may overshadow individual patient goals.
For instance, while the ability to decrease any individual’s pain score from a “seven out of 10” to a “three out of 10” can be challenging, improving functionality and quality of life can often be more valuable to the patient.
“A pain score may not always be the best way to assess treatment success, since the therapeutic goal may not be to eliminate pain or improve this score, but to ensure better sleep, better mobility, improved mood or even an ability to return to work,” he said.
VR as a technology for chronic pain management is in its infancy. Gromala notes that further research, in addition to standardizing the VR delivery devices, is needed before it becomes a standard of care. And future studies must include practical outcomes.
“It is important to realize that the ‘pain’ of chronic pain may never go away, and that ultimately the individual must learn to deal with the pain so that they can function better,” Jamensky said.
For her, developing an awareness for how sleep, mood and exercise affect her own pain experience has made a huge difference.
In fact, it has motivated her to continue both advocating for chronic pain patients and to partner with clinical pain specialists on research.
” ‘Taking care of yourself’ means a different thing for chronic pain sufferers. It’s much tougher,” Gromala said.
“So as researchers we have a big task ahead of us, and sometimes it means exploring whether out-of-the-box methods like VR can help.”
**Originally published on CBC.ca**
Terri Peters is an architect and researcher whose interdisciplinary work maps new trajectories of ecological design through contemporary practice, academic research and pop culture. She is an expert in sustainable housing and her research focuses on the architectural and social implications of the built environment, with a focus on more holistic qualitative parameters and wellbeing. She has published more than 20 peer reviewed journal and conference papers on sustainable housing and the impact and evaluation of daylight in homes. She is the editor of “Design for Health: Sustainable Approaches to Therapeutic Architecture” Architectural Design, 2017 and author of “Computing the Environment: Digital Design Tools for the Simulation and Visualisation of Sustainable Architecture” John Wiley and Sons 2018 which looks at how environmental data can be feedback into design process. She has a global perspective, having lived and worked in Vancouver, Tokyo, Paris, and London, and Copenhagen which was her adopted home for seven years. After 12 years abroad she is currently back in her native Canada, as an Assistant Professor at Ryerson University investigating the intersections of building science, environmental design, and wellbeing.
1.What prompted you to focus on healthcare architecture/design?
During my PhD work, which was focused on social housing I realized that the aspect of ‘people’ in that housing was missing, specifically the social impact of buildings. We know the buildings we spend time in, and our surroundings, greatly impact our wellbeing, but how does this become part of how we work? We need to be able to back up our observations and claims as designers and I think the new-ish movement towards evidence-based design, where design decisions are based on more than a designer’s intuition and experience, but also on results and interpretations of scientific evidence, can help improve design.
On a personal note, growing up in Canada and then living in bigger cities like London, where I did my professional degrees, and then in Copenhagen where I did my PhD, these places can be seen as quite dark, dreary places but I loved them. I always say maybe this is why I study daylight, because I appreciate every drop of it! In Copenhagen our apartments had lots of natural light and natural ventilation, it really shaped my thinking of how positive and life affirming a home can be. There’s this concept in Danish of hygge, or contentment, a cosy feeling. Another concept in Swedish is lagom which means something like “just enough is enough.” these are important concept in life to me and I lived and experienced them in my time in Denmark and they continue with me now.
So with all of that together, I realized that if we designed spaces in hospitals and other settings to be intentionally mood enhancing, that could make us all feel better.
2.Why is design important to our well-being?
When we design a building, we know that the decisions we make, however small, impact the moods, ideas and wellbeing of people using the spaces. Prioritizing daylight, fresh air, variety of spaces and environments with views to nature are some of the ways we address this depending on numerous other variables like site and program. We know that these decisions about building form, materials, adjacencies and sequence of spaces, and other variables change our perceptions of spaces and places and help shape our interactions with others.
Design, simply put, impacts how we feel, and not just in health care environments, but in our day to day experience in our homes and where we work. According to the World Health Organization, depression is the greatest cause of disability worldwide, and architects have a role to play in making spaces that do more than satisfy program, budget and site, but that make us feel better. In architecture schools, students learn about building performance and aspects of sustainable design, but rarely are methods, metrics or examples of health promotion or spaces that encourage positive social interactions explored in any depth. There is a wealth of knowledge in allied fields such as environmental psychology, and published studies in areas such as public health and sociology that can be tapped into to enrich the architecture curriculum. The increased focus in schools on environmental performance of buildings must be paired with understanding trade-offs and co-benefits for human performance and wellbeing – after all, buildings are for people.
3.You had an interesting personal brush with the healthcare system in two different countries. What was that like?
I had my two children in Copenhagen at Rigshospitalet, the Royal Hospital. It was built in the 1970s, but had windows that open, large rooms, and lots of daylight that enters into the lobby and patient rooms. I am really sensitive to my environment and I found that the quality of that room impacted my mood and experience.
And it was a major contrast with being in a Canadian hospital which wasn’t designed with these well-being components in mind. I broke my elbow last winter and was forced to wait in a place that had a low ceiling, was crowded, no fresh air. I actually felt sicker! And to top it off it was hard to find where I needed to go – I spent a lot of unnecessary time just navigating: it wasn’t designed with ease. In Denmark, the culture is built around design. The way people speak about it and appreciate it is really unique.
4.How did this experience impact your work as an architect and architecture professor now?
I have the challenge of teaching 1st year students what sustainability is, when often the work-life balance of many architecture students is poor. We hear that many of them are very stressed and finding it hard to thrive. We often discuss the power of building design as health promotion tools.
Architecture is unique in that you experience it whether you want to or not: the impact the buildings have on us is so extreme. When it comes to environmental psychology, which links to designing for health, we know that people have a natural inclination towards nature, whether it’s the savannah or long views. The
biophilia hypothesis (biophilic design) specifically describes this affinity to nature, daylight, natural materials.
Salutogenic design is another school of thought, which keeps stress reduction at the core. Earlier this year I became “WELL® Certified,” which is a new modality that evaluates qualitative and quantitative biophilia as it relates to health promotion. They measure things that are really exciting, because it’s centered around how people respond to being in a building. There’s a huge emphasis on daylight and nutrition, fitness, and well-being. For instance, they measure daylight differently. Traditionally in architecture we usually measure how much of the building’s floorplate is well lit without needing to turn on the light, its called spatial daylight autonomy and it means that area doesn’t need artificial light 50% of the time. The idea is related to productivity. The Well® Standard measures “equivalent melanopic lux,” which is a fancy way of describing the impact of light on the physiology of body, so for instance the impact on alertness, and sleep.
In my courses I describe a concept I coined called “superarchitecture,” which means buildings that do more than minimize the impact on the environment but that exploit and maximize the synergies and benefits to people: everything from building strategies like green roofs, daylight, fresh air and natural ventilation, shading where appropriate, outdoor spaces all these strategies that we know improve the environmental performance but that really also benefit our quality of life in tangible ways.
5.What does thriving mean to you?
Thriving is having time and energy to purposefully devote yourself to what you want to do. Technology can play a role in that, not only in making us feel more connected to each other, but by helping us make better decisions about what we want to do. It also involves how our environments help bolster our ‘emergency reserves’ to handle the unexpected, a protective buffer in other words. Last, when I think of thriving I think of resilience. There’s an emerging interest in architectural research and practice around building resilience and passive survivability. Much of how we think of the resilience of buildings may be applied to people as well. Daylight and views to the outside are big ones – we need these to feel at ease and to have the capacity to deal with disturbance and change. The current thinking around building resilience in building science and architecture is too focused on how buildings would survive in extreme weather or in an earthquake – what about us? How can our buildings help us survive and bounce back?
6.What are you most looking forward to with health design in general?
Looking forward to more interdisciplinary studies – for instance working with more healthcare professionals and building partnerships. I’ve been collaborating with psychologists regarding concepts of resilience in architecture and environmental psychology, which is undergoing a resurgence right now. I’m also excited about how we apply data, specifically how we can visualize the results of simulations, and how people can interact with visualizations and change our behavior to do more of what we want to.
I go to lots of industry meetings and workshops to understand what the potentials are with data and how they can benefit people.
“Bring yourself back to your awareness,” said Sara Auster, a self-proclaimed sound healer, after 45 minutes in a ballroom at a hotel in Chicago where she created vibrations using crystal bowls and tuning forks as well as a traditional Indian accordion, known as a shruti box. Seventy-five people got up like a gaggle of toddlers being shaken from a nap.
The session, which cost $30, and was like many popping up in churches, community centers and even some prisons and hospitals. The goal, practitioners say, is to use sound to tackle individual and collective anxiety, depression, insomnia and more.
Recently, musicians like Erykah Badu and the Icelandic band Sigur Ros have also dipped into sound healing.
Over in the tech world, mindfulness is deeply in vogue. Jack Dorsey, the chief executive of Twitter, swears by meditation. Since 2016, Ms. Auster, 40, has been invited as well to perform for various Google company initiatives. This past April, Adrian DiMatteo, a musician in Brooklyn who has a degree in jazz performance, led a sound bath in the neighborhood of Greenpoint for leaders at Instagram. (“They approached us to do a corporate bonding event, as they’re moving towards doing more events without alcohol,” Mr. DiMatteo said. “They had lots of questions about the instruments and the bowls.”)
Some health facilities have taken note as well. Ms. Auster has performed for Harlem House Clubhouse, an outpatient psychiatric rehabilitation program at Harlem Hospital in New York. Darren Austin Hall, a ceremonial musician and sound healer in Toronto, has performed in the atrium of Toronto General Hospital with a Canadian organization called Music Can Heal.
The Children’s Hospital of Philadelphia has also discussed incorporating sound baths. Mr. DiMatteo has offered them in the waiting area at NYU Langone through a program called Music That Heals, as well as at Coney Island Hospital and “about a dozen others,” he said.
Diane Mandle, who has offered sound healing in Encinitas, Calif., for 19 years, said: “It’s not curing, it’s healing.” She has also provided sound sessions in an oncology unit at Sharp Memorial Hospital in San Diego, as well as at a workshop for inmates at the Vista Detention Center.
“Healing is an ongoing process that contributes to a better sense of well-being,” Ms. Mandle said.
What are sound baths?
Sound baths are an experience in which a group of people gather, often while lying on a mat, to listen to sounds produced through various instruments. There is no licensing procedure for leading sound baths, and though Ms. Auster wouldn’t say where she received her training, her music background and meditation training are strong influences.
For centuries, various cultures, including my own, South Asian, have used sound as a part of religious ceremonies and prayer, with one goal being to promote and facilitate meditation. In that sense, it’s not terribly different from singing hymns in a church. Most religions and cultures use music and sound for spiritual reasons.
But what about the promise of healing? After all, the use of sound is advertised as an activity that can do many things, including “realigning your chakras” and “mind expansion.”
“Personally I have an issue with the word ‘healer,’ which is why I turn down a lot of wellness events,” Ms. Auster said. “There are all sorts of expectations with that label, and I don’t want to be seen as some magical guru person or for people to assume they could not possibly have an understanding of the experience.”
Like other forms of music, sound baths bring people together, but with an added meditative element. Anaïs Maviel, a musician in New York, said that she is often asked to perform for grass-roots organizations as part of “community-building” efforts.
Does sound have an effect on our health?
One way sound is related to health is through noise pollution: traffic noise, planes flying overhead, loud concerts. The World Health Organization lists noise pollution as an increasing threat to human health, and recently set limits on environmental noise.
This may also explain the boom in A.S.M.R. — soothing sounds that, like sound baths, aim to address stress and anxiety. A.S.M.R. has become an internet phenomenon, particularly on platforms like YouTube.
Sound, in the form of music, has been used for various conditions, including dementia. As Oliver Sacks wrote in his book “Musicophilia,” a variety of neurological conditions including symptoms of dementia and psychiatric conditions like depression and schizophrenia may also benefit from music.
But where is the evidence for sound baths? It’s unclear when “sound healing” was first used. However, medicine has used the concept for years specifically for acoustic therapy for tinnitus, a condition that involves hearing unwanted noise without a clear stimulus.
With tinnitus, essentially, the brain perceives sound as entering the ear, even though there is no sound. It is similar to phantom pain in that regard: a situation in which there is a misperception that can cause immense grief.
Often described as “acoustic therapy,” sound healing was listed as an appropriate treatment in clinical practice guidelines. But this therapy involves neither bowls nor chimes. It is typically a form of low-frequency white noise played through a hearing aid or through an app.
A 2013 study of tinnitus, led by David Baguley, a professor of hearing sciences at the University of Nottingham, listed acoustic therapy as one of several interventions. However, in December 2018 a review of existing studies found no evidence of using sound versus placebo for tinnitus.
“Well, the absence of evidence doesn’t mean absence of benefit,” Dr. Baguley said. He also noted that some patients choose calming nature or ocean sounds as opposed to white noise, which could overlap with the suggested benefits of sound baths.
“It’s more than just a distracting noise,” Dr. Baguley said. “We know that sound has a massive influence on how the brain is organized.”
So, do sound baths actually heal?
A 2014 study found that for patients being weaned off mechanical ventilation, providing them with sounds of nature significantly reduced agitation and anxiety, as measured through heart rate, expressions of pain and blood pressure, when compared with patients who did not listen to these sounds.
More recently, a research psychologist reported that singing bowl sound meditation was helpful in reducing tension, depression symptoms, fatigue and anger in a group of 62 adults.
So far, the evidence for sound healing is limited, and is aligned with what we know about the effects of calming music and the benefits of meditation.
Ms. Auster also believes that one of the biggest benefits of sound baths is that they facilitate community.
“It’s people coming together to release and let go, but in the company of others around them,” she said. “If meditation is taking the stairs, a sound bath is taking the elevator.”
**Originally published in the New York Times**
When hospitals fail to create a culture where doctors and nurses can speak up patients pay the price
By: Blair Bigham and Amitha Kalaichandran.
It seems too often that reporters—not doctors—sound the alarm when systemic problems plague hospitals, where whispers in the shadows indicate widespread concerns, but individuals feel unable to speak up. Recently, reports surfaced that children were dying after surgery at the University of North Carolina at higher than expected rates, despite warnings from doctors about the department’s performance. And whether in Australia, the United Kingdom, Canada, or the United States, reports show that bullying is alive and well.
This pervasive culture—where consultant doctors, residents, and other hospital staff feel that they cannot bring up critically important points of view—must change. It shouldn’t take investigative journalism to fix the culture that permits silence and bullying. But it does take all of us to rethink how physicians and leaders work together to improve hospital culture.
Investing in improving hospital culture makes a difference to patient care and the quality of the learning experience.
Recent studies on workplace culture show how important it is. In a new JAMA Surgery study, surgeons who had several reports of “unprofessional behaviour” (defined as bullying, aggression, and giving false or misleading information) had patient complication rates about 40% higher than surgeons who had none. Domains of professionalism include competence, communication, responsibility, and integrity. Last year, hospital culture was directly linked to patient outcomes in a major study led by Yale School of Public Health scientist Leslie Curry. Risk-standardized mortality rates after a heart attack were higher in hospitals that had a culture that was less collaborative and open.
Curry’s team created a programme to improve hospital culture, namely by enhancing psychological safety—a term that signifies a willingness of caregivers to speak freely about their concerns and ideas. When hospital culture changed for the better, heart attack outcomes drastically improved and death rates fell.
There are examples of good practice where psychological safety and transparency are valued, and these centres often boast better patient outcomes. A recent systematic review of sixty-two studies for instance found fewer deaths, fewer falls, and fewer hospital-acquired infections in healthcare settings that had healthier cultures.
The impact of healthcare workplace culture doesn’t just end with patient safety. Physician retention, as well as job satisfaction and teamwork, all benefit from a strong organizational culture in hospitals. This is crucial at a time where burnout in medicine is high. Hospitals can also learn from the tech industry which discovered early on that psychological safety is key to innovation. In other words, those who are afraid of failing tend not to suggest the bold ideas that lead to great progress.
So how can hospitals make improvements to their culture?
The first thing is to shine a light on the culture by measuring it. Staff surveys and on-site observations can illuminate negative workplace cultures so that boards and executives can consider culture scores in the same regard as wait-times and revenue. Regulators and accreditors could incorporate workplace culture indicators in their frameworks to increase accountability. We recently saw this in Sydney in Australia, where a third residency programme lost its accreditation due to bullying of junior doctors.
The second is to hire talented leaders not based just on their clinical competence, but also on their ability to foster inclusiveness, integrity, empathy, and the ability to inspire. By setting the “tone at the top,” leaders can influence the “mood in the middle,” and chip away at ingrained attitudes that tolerate, or even support, bullying, secrecy, and fear of speaking out.
Another solution rejects the hierarchy historically found between doctors, nurses and patients, and embraces diversity and inclusion. Effective collaboration helps shift the tribe-versus-tribe attitudes towards a team mindset. Part of this involves amplifying ideas from voices that are traditionally not heard: those of women, the disabled, and ethnic and sexual minorities. As well, leadership must change to be more diverse and inclusive, to reflect the patient population.
The field of medicine attracts motivated, intelligent, and caring people. But being a good caregiver and being a good leader are very different, and training in the latter is sadly lacking.
For every investigative report that uncovers a hospital’s culture of silence—whether it’s unacceptable bullying, unusual death rates, or pervasive secrecy—there are surely hundreds more left uncovered. The fix to this global epidemic requires deep self-reflection and a firm commitment to choose leaders who promote transparency and openness. Implicit in the physicians’ vow “to do no harm” is the vow not to stay silent as that too can be harmful. We must first and foremost create cultures that ensure we feel safe to speak up when things aren’t right. Our patients’ lives— and those of our colleagues—depend on it.
**Originally published in the BMJ**
Nira Kehar is an award-winning chef trained in French cuisine. She is also self-trained in Ayurvedic principles, which she incorporates in her cooking. For almost six years, Kehar ran the restaurant, Chez Nini, in Delhi, India, serving clients from around the world. Married to a musician, Kehar now spends her time between New York City and Copenhagen. Her cookbook, Ojas, was released in 2018, just months before a chilling diagnosis of breast cancer sent her life reeling. She spoke with me in July from St. Adolphe, Quebec where we cooked a meal of kitchari, salmon, and garlic scapes.
So what are we making today?
We are making Kitchari, which is a slow cooked dish traditionally made of rice, lentils and spices. Kitchari in modern times is often associated with a bland porridge, that Indian moms give their children when they are ill or have a bad stomach, but historically it was known as a delicacy for the royal families. It is rich in nutrition and easy for your body to break down and digestion because of the longer cooking time. Kitchari can also be made with any variety of beans or grains and I also like to top it with either vegetables, all type of proteins and different nuts and seeds. Today we are making a red lentil and quinoa kitchari topped with garlic scapes and pan seared wild-caught salmon.
What drew you towards the culinary arts?
After a debilitating spinal injury I suffered at work, I was catapulted into a life-changing existential crisis. The 8-month recovery period was filled with contemplation and an eventual re-engineering of my life, which brought to light how much I really craved a more creative path for my career. Having been raised in a house where food was the currency for love, I naturally gravitated to the idea of cooking, flavors and feeding.
But your academic background was somewhat untraditional.
I graduated university as a computer engineer, but after my injury, I went to ITHQ in Montreal to do their French culinary program. The prospect of cooking and living a life of creative expression was the most welcome and transformative experience of my life.
What is ayurvedic cooking?
From the young age of ten, I had always been very interested in Ayurveda and it’s very well known sister science, Yoga. This interest had actually stemmed from the book “Autobiography of a yogi” which I first read in an attempt to impress my mother, but it ended up being the equivalent to my “Harry Potter” as a child. This curiosity continued throughout my life and I found myself studying and practicing Ayurveda more than ever when I was cooking professionally. Ayurvedic cooking very organically became synonymous with how I expressed the flavors and compositions in my cuisine. I used the backbone of my Ayurvedic knowledge in order to nourish people instead of just feeding them. I tweaked recipes for the everyday foods people already enjoyed, to incorporate principles of eating for your body type and using herbs and spices for balance.
I think the trouble with many ways of cooking, especially when food comes into the picture in wellness discussions are all the trends out there. There are ‘blood type’ diets which have no scientific basis for instance. But when you describe Ayurveda using broad strokes, it makes sense. A whole-foods approach. Many people get turned off by the term ‘Ayurveda’ because it sounds different, even though the principles have been used for centuries.
Yes I definitely agree with you. We have been eating from the time we are born and will eat pretty much till the day we die. Unlike a lot of the habits and lifestyles that we hang on to and protect whether for cultural reasons or sentimental, I have found that people tend to be surprisingly ready to just completely change what and how they eat based on diets or fads. I find this extremely unhealthy and counter intuitive. Ayurveda on the other hand is fully based on balancing your individual body in an intuitive and gradual way. It’s about building your instincts about your own body type and then slowly making adjustments to strike the balance that nature has implicitly intended for you.
What does the title of your cookbook, “Ojas,” mean?
The closest translation is similar to what is termed “Chi” in Chinese medicine. Ojas is the most subtle bi-product of your digestion. Everything you eat, experience, feel and live all result in this vital energy, which is responsible for your being alive. It is the encapsulation of the “you are what you eat” idea. Eating not being limited to only food, but everything that is taken in by your perceptions and senses.
Interesting word. There are definitely people that seem brighter and more alive, and having healthy ways to deal with stress might be part of it. Perhaps children in general have lots of it. I’ve also seen photos of people who meditate regularly who just look less tense.
Ojas is also enhanced by mediation. A person with good or high Ojas has a bright energy and a glow. Good eating habits, stress managements, the right amount of sleep, loving relationships and an understanding on how to balance your unique body are all very good ways to manage your Ojas. I am determined to be part of the community that is bringing Ayurveda to the mainstream and in turn helping people improve their Ojas.
Shifting gears: What was it like owning a restaurant in India?
Owning my own restaurant was one of the most beautiful experiences of my life. I felt so privileged every day to have each and every customer walk in and allow me to feed them. With the incredibly steep learning curve, came a deep sense of responsibility on what I served these patrons. Where I sourced the ingredients, how I stored them and cooked them was of prime importance. Even more important was the well being and growth of the people who worked with me and put their entire vitality into the everyday running of the restaurant. What they put in would be what the customer would feel. Having a restaurant is famously known to be one of the toughest businesses in the world, and I would say that if you can do it in India you can really do anything. It is not a job for the faint hearted.
Lets talk about what happened in 2018. Your book just came out and you got some unexpected news.
I was diagnosed with breast cancer in April, a month before I was meant to start the promotional tour for my book. The cancer was discovered completely by chance and my doctor truly saved my life, because of a nagging feeling she decided not to let go of.
Five surgeries, fertility treatments, chemotherapy and radiation are all done now, and I have been cancer free for 8 months. It was an indescribably challenging time and in many ways continues to be, but I do also think in has been a surreal sort of blessing. I can never un-know the value of being present and grateful to be alive.
I’m so glad you were able to move through that period, though I know you have to continue to be monitored. It’s also interesting that your doctor had a sense that something was wrong — I’ve written about clinical intuition in that regard, and it’s fascinating. Moving to food and cancer now — there is a lot of misinformation out there around the role of nutrition when it comes to cancer. How did you approach food during all of this?
There is definitely a lack of information and guidance from most doctors on the subject. I was astonished to be told I can eat and drink whatever I wanted and even that it was ok for me to drink wine. I chose to take guidance from my Chinese medicine doctor and Ayurvedic practitioners, to integrate the allopathic treatment with a holistic diet as well as a fasting protocol during chemotherapy. I am not qualified to know what would be best for any other cancer patient to do, but I would strongly suggest making all the efforts to find the right foods and guidance for your body during this very taxing treatment. Even if your medical doctor isn’t qualified in nutrition to give you the right guidance, it is imperative to figure it out with other holistic practitioners. One important thing I made sure to do was to consult with my doctor, about any supplements I was taking because they can severely interfere with your treatments.
The role of nutrition is an interesting area of research, and admittedly I’m reexamining some of my old beliefs about the role of food as we learn more about whether there is a role for intermittent fasting in general and various new protocols for cancer treatment that look at the role of nutrition. It’s a fascinating area to keep an eye on, and like with many areas of medicine, once more data comes in we’re able to re-orient how we approach care. Was there anything else that helped you through this devasting period?
I went to a therapist through most of my treatment and continued for some months afterwards. Your life is turned upside down and it isn’t always possible for those around you to understand what you are going through. As physical as cancer and the treatments are, I experienced a deep sense of calm and vitality by using tools like therapy and transcendental meditation.
What does well-being and ‘Thriving’ mean to you?
Eating whole foods and lots of vegetables. Finding ways that you like to eat them and not falling into the pressures of all the overwhelming information coming our way from all directions. Finding whatever way to laugh everyday and be grateful for whatever it is you have. I write a gratitude journal daily and that really shifted my daily perspective. Also re-evaluating this expectation of constant happiness and instead being content with the little things in life. The second page of my book has the quote that I like to live and cook by, which is “More and more with less and less, until you can do everything with nothing.”
What are you most looking forward to now?
I am trying not to look forward but be in the now. I work everyday on my next book as well enjoy my good health and loving friends and family.
**Originally published in ThriveGlobal**
NO MATTER WHAT you think about the causes of climate change, we know the planet is getting warmer. What most of us don’t realize is the impact climate change has on our health, which is why it’s concerning that last week’s UN Climate Change Summit did not identify health as one of the key action areas.
While about 70 percent of Americans believe that climate change is real (and in Canada, where I live, it’s a key issue ahead of the upcoming election), the majority of Americans surveyed do not believe it will harm them personally, according to a recent Yale Climate Opinion Map of public opinion data. In an earlier survey, less than one-third could name an example of climate endangering health. It’s time for a reality-check.
A 2016 Global Change Research Program Report listed seven broad areas in which climate change can affect health: through temperature-related death and illness, air quality, extreme events (such as disasters), vector borne diseases, water-related illness, food safety and nutrition, and mental health. Particular populations – such as low-income Americans, people with chronic medical conditions, Indigenous peoples, and persons with disabilities — may be disproportionately affected, as climate change has a direct impact on worsening every social determinant of health. Hurricane Dorian, which devastated the Bahamas, is yet another reminder that often the poorest communities are hardest hit.
A warmer planet means more potential for death and illnesses related to higher temperatures. It means lower air quality, especially in densely populated areas. Mosquitoes, ticks, and other carriers of infectious diseases can cover a wider geographic range and for a longer span of the year.
Let’s take Lyme disease: due to global warming, the ticks that carry Lyme are appearing in many more states, notably in the Midwest and in much of Canada. Other vector borne diseases are also likely to increase, though, as one researcher pointed out, the exact impact is unclear without further research.
Global warming also raises the chances of suffering heat stroke and heat stress, both risk multipliers for heart attacks. Asthma sufferers experience worse symptoms from the additional carbon dioxide in the atmosphere as well as dust and other particulate matter.
Air pollution currently causes up to 7 million premature deaths, according to the World Health Organization, and millions more visits to hospitals: One study points to the increase in amounts of near surface ozone as our planet warms as the cause. This issue was highlighted by the WHO at the UN Youth Climate Summit through immersive experiences in “air pollution pods.”
And those of us who enjoy seafood are at risk of neurotoxin exposure, due to increases in ocean algae blooms caused by warming temperatures. One study found that the toxic “domoic acid” increased as sea conditions became warmer.
Pregnant women are also at risk. In 2017, an extensive review of previous research on maternal health and climate change found that there are significant connections between extremes in temperatures and premature birth, low birthweight, and stillbirth.
We know that the US is one of the most sleep-deprived nations in the world, and a landmark paper has even linked warm temperatures related to climate change to insufficient sleep among those surveyed.
Lastly, we can’t forget the toll that climate change takes on mental health. The American Psychological Association summarized the effects in an extensive report, linking climate change disasters such as droughts and flooding to increased incidence of posttraumatic stress disorder and depression. And they found that worry about global warming can increase anxiety and depression, as well as substance abuse. This can be especially the case in places that have faced an environmental disaster.
Globally, no one is untouched. The WHO compiled a comprehensive set of resources that detail country-specific ways in which climate change affects human health. It estimates that between the years 2030 and 2050, 250,0000 additional deaths globally could be related to climate change, costing billions. The WHO hosted the first humanitarian conference on health and climate change in April.
In a 2017 article for the New England Journal of Medicine, the authors suggest a few ways in which doctors and patients can combat the effect of climate change on human health. For one, there is a unique opportunity to advocate for ‘green’ hospital design and eating less meat (which may also have health benefits, and have an impact on greenhouse gas emissions).
Earlier this summer, over 70 prominent medical organizations, including the American Academy of Pediatrics and the American Medical Association, called climate change the “greatest public health challenge of the 21st century,” and published a series of recommendations which include reducing greenhouse gases and improving access to clean water. In late August, the Doctors of British Columbia identified climate change as a major health care issue, which was followed by a similar alarm sounded by the Australian Medical Association.
Yet these calls to action can only go so far. Globally, all of us share the aspiration to obtain the highest level of health and well-being possible, however climate change has made this goal unreachable for many, and poses new challenges that even the best medicine won’t be able to fix. And as with most public health challenges, the most disadvantaged in society face the highest burden of risk. A public health approach values “upstream,” or preventative approaches to health disasters, which is why the WHO’s emphasis on the health impact of climate change matters.
While it’s unclear why it was not a core area identified in this year’s UN Climate Change Summit, weaving the health impact into the discussion will be crucial to setting much needed priorities for change before it’s too late.
**Originally published in the Boston Globe**
All residents doctors in Canada are required to work on a research project, and I was excited to apply my research/epidemiology training towards an issue that is particularly important in pediatric medicine: why parents use complementary/alternative medicine, and more importantly, perceptions on how effective various therapies and approaches might be.
My research team, led by Dr. Roger Zemek and Dr. Sunita Vohra, was excellent, and brought a variety of expertise in both emergency medicine (which was the population we surveyed) and integrative pediatrics. We worked with some excellent biostatisticians and epidemiologists as well, and were able to present at two different conferences, publish two papers, and write about our findings for the New York Times. It was a testament to the power of having a great team with skills that complement each other, with shared goals and values.
Here’s what we found:
~ About 62% of participants used complementary health approaches (CHA) for their children over the previous 12 months, with vitamins/minerals and massage being particularly common. And higher parental education was associated with a higher odds of using CHA, and most parents believed that the CHA used was effective.
~ When it came to acute conditions that required an emergency room visit, about 29% of caregivers used CHA within the previous 72hours specifically for that complaint, and use for gastrointestinal complaints was most common.
~ Open and honest discussions between parents/caregivers and their doctors about CHA are crucial, and in our NYT article myself and my research supervisors outline some of our suggestions.