00:00:23 How Esther got started working on the intersection between mind and body and healthy living?
00:13:32 What impact Ether’s research has on the ability to improve living conditions with autoimmune and inflammatory diseases. Are we getting to few germs and viruses so that our immune system turns on ourselves?
00:21:11 How stress and our environment impacts our body and mind and how we can model it.
00:28:01 How do we identify environments that makes us calm? Why is a view of nature seen as a ‘paradise’ universally?
00:37:13 How chronic stress impacts us? Why do right amount of stress response is so important to function?
00:40:00 What is the differential between an average performance and a properly stressed (healthy stressed) individual?
00:54:33 How does chronic stress impact life expectancy and ‘chromosomal aging’?
and much more!

Esther Sternberg, MD, is internationally recognized for her discoveries in brain-immune interactions and the effects of the brain’s stress response on health: the science of the mind-body interaction. Dr. Sternberg is a Professor of Medicine in the University of Arizona College of Medicine.

She is the author of several books including Healing Spaces: the Science of Place and Well-being as well as The Balance Within: The Science Connecting Health and Emotions.

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Esther, thanks for coming on the judgment call podcast. Really appreciate it. Thanks for doing this. Thanks for taking the time. Thank you. It’s a pleasure. Pleasure to join you. Thank you. You have been researching for quite some time in a field that I’m quoting you 20 or 25 years ago was seen as crazy talk, right? And the field you’re up to is really finding that connection between minded body and between also spaces and the body, which very few doctors really venture into. Maybe you can illuminate that a little bit for us, how you got started with this and what gave you the conviction to execute on it? It’s a great question. So first of all, I don’t think I ever said it was crazy, but there’s no question that when I first started in the field in 1980 is when I first started doing this, that the parent disciplines in the biomedical field of what is now known as the science of the mind body connection, the parent disciplines of neuroscience, immunology and anachronology did not believe that the brain and the immune system could talk to each other. They did not believe that stress could make you sick. It’s something your grandmother told you, but there wasn’t evidence in the scientific literature. And in my first book, The Balance Within, the Science Connecting Health and Emotions, I explore that question, why is it that in Western medicine, these notions that were accepted for thousands of years, that stress can make you sick, that believing can make you well, that if you have an intact connection between the brain and the immune system, that you are healthy and if that connection is broken, you get disease, Western medicine rejected it, or, well, they didn’t just ignore it. I over and over again in my career, I had my supervisors tell me, you’re going to ruin your career Esther by studying this, or you’ll do this when grass grows here on this hand. And so I explore that question, part of it is it was in the popular culture. And part of it is that until the late 1900s, until about, well, 1990s, we didn’t have the technologies to really, in real time, see, literally see, the brain working at its tasks in using brain imaging. We didn’t have the molecular biology. We didn’t have the tools and immunology to really measure how the immune system was responding and how the molecules of the immune system could affect the brain. So we weren’t able to measure, we didn’t have the technologies to measure this communication between the brain and the immune system, which is a two way communication. The brain sensing signals to the immune system that in turn changes how the immune system does its job, and the immune system sends signals to the brain that changes the way the brain functions and changes your moods. So you asked me, well, how did I get started and what gave me the conviction? It was a single patient. I saw a single patient at the end of my training in rheumatology, the last, it was actually Christmas Eve in 1979, I think it was. And I was called to see a patient who had been treated for a very rare and lethal form of epilepsy with a drug that changed brain serotonin. Now it’s not one of the drugs that we have today, but he developed an autoimmune scarring inflammatory disease that looked like what we call scleroderma. And he was encased in sort of a scarring of his whole body, he couldn’t extend his elbows, he was in excruciating pain, he couldn’t extend his knees, the sheets were tended up over his legs so that they didn’t touch his skin, he was in so much pain. So I was convinced from that moment on that if you do something to the brain, you can affect the immune system. And so I then switched from a clinical career, I was going to be a clinical rheumatologist in the family practice clinic that I had worked in before, and I switched to a career of research trying to figure out how the brain and the immune system talked to each other. And my original explanation for this condition that I saw in the patient turned out to be wrong, but in the course of doing the research, I discovered that the brain stress center and this is what I was at the National Institutes of Health prior to coming to the University of Arizona here in Tucson, I was at the National Institutes of Health in the intramural research program for 26 years as a senior scientist and then section chief. And in 1989, I discovered that the brain stress center, the hypothalamus, is very important in susceptibility to autoimmune inflammatory diseases like arthritis in rats. Now if you can prove that in rats and you can prove it molecularly, neuro anatomically, neuro endocrinologically with hormones, cells, molecules, if you can prove that in rats, it gives a basis for the science of the mind body connection in humans. So it explains how stress can make you sick, how believing can make you well, and really that this connection between the brain and the immune system is essential for health. And so that single patient and what I saw gave me the conviction to push ahead and do this research despite the pushback that I received, the real pushback from my supervisors. I did have a few mentors along the way and that’s really, really important. Without the few mentors, the head of immunology allergy and immunology at McGill at the Royal Victoria Hospital was really believed in me and in this and other mentors along the way, including my father, I should add. My father was a physician and research scientist who was one of the pioneers of nuclear medicine. He had survived a concentration camp during the war and he was from Romania and he was in a concentration camp in Russia during the war, found his way to Paris after the war and worked under Pierre Chollaut Curie looking for peaceful uses for radiation and radiation biology and then came to Montreal, which is where I was born and grew up. And he really believed in public health and he really supported me in everything I did and that was really important too. Yeah. I mean, looking back and maybe give us a little bit of an idea of what the current understanding is, how does the immune system coordinate and talk to the brain? What is this two way channel that you found out about and did research over the last 30 years? How does it really transpire from our current understanding? So I should say I wasn’t the only one, of course. There were others at that time who were looking at the question from different angles depending upon their expertise. So there were neuroscientists, Suzanne and David Felton, who were using neuroscience techniques to trace the innervation of immune organs by nerves, by adrenaline like nerves. So they were able to show that the spleen and the thymus are deeply innervated by nerves and that the nerves touch immune cells and that the neurotransmitters that are released from nerve cells affect how immune cells function. I was coming at it from a neuroendocrine point of view, which is I was working with neuroendocrinologists at the National Institutes of Health who were expert in hormones of the stress response. So when you’re stressed, a whole cascade of hormones gets triggered in your brain and throughout the body. So there’s this brain stress center, the hypothalamus, which is kind of right at the back, right underneath your skull, just behind your nose. And that releases a stress hormone called corticotropin releasing hormone, which then goes to the pituitary gland, which hangs like a cherry right behind your nose in just underneath the brain and that gland releases another hormone called ACTH, which goes through the bloodstream and causes the adrenal glands to release the stress hormone cortisol. Now anybody who’s used cortisone cream for a poison IV rash or cortisone nose spray for allergic rhinitis, knows that cortisone is one of the most potent anti inflammatory drugs that our body makes cortisol when it’s released during your stress response. It taps down the ability of the immune system to do its job. It turns down that activity of those immune cells. And so that’s one part of the stress response and how the brain affects the immune system. The other is the one I mentioned where the actual nerves that innervate the immune organs release adrenaline and adrenaline like molecules that also affect how the immune cells function. At the same time in the other direction, immune cells release their own molecules called cytokines or interleukins. That’s been in the news a lot lately, you know, the cytokine storm related to COVID. That all comes from immune cells releasing their own molecules. Ordinarily, the reason that immune cells are releasing these molecules is because when the body is confronted with an invader, there’s a kind of a battle that goes on and there are different waves of soldiers, of immune cell soldiers that come to the site of the invasion. So say you get a cut in your skin and there are waves of different kinds of immune cells that come in to the site, first of all, to clean it up, then to repair it and cause the scarring. And in order to get the different waves of immune cell soldiers coming into the site, the immune cells have to send signals to other cells, which are these cytokines and interleukins. And just means between white blood cells. And so there are all these molecules floating around when you’re infected or inflamed. And it turns out that those molecules go through the bloodstream and affect how the brain functions. So when you have a flu, when you’re tired, when you have fever, it’s not the fever that makes you want to sleep. It’s the immune molecules, the interleukins, interleukin 1, interleukin 6 that go to the brain and make you want to sleep. You lose your appetite because of these immune molecules. It’s all a protective way that the body has of helping to conserve energy in order to fight infection and to repair. The problem occurs if it goes on too long or too much and you end up with the kind of thing that we saw with COVID of a cytokine storm where the body ends up turning on itself. And that’s harmful. Yeah. I’m fascinated how complicated that machinery inside our bodies is, right, and how sensitive it seems and how well it works in most of the time, right? It’s always fascinating when we learn about another part of the body, so to speak, that we didn’t know, another transmitter, another chemical, and we realize, whoa, someone with a lot of force I must have designed this, right, evolution. It’s really remarkable. And I agree with you. It’s remarkable that it works so well most of the time. We only notice when it’s not working. Yeah. I mean, you mentioned that earlier, that’s how you started out. Arthritis is one of those autoimmune diseases, right? Yes. From what I understand, it’s the immune system is too bored and it kind of finds an enemy in your own body and then arthritis starts. Is that what’s happening? Well, okay. Well, when you say the word arthritis, it’s like saying the word sports. There’s many different kinds of sports. There’s many different kinds of arthritis. There’s many different causes to the different kinds of arthritis. So there’s osteoarthritis, which is wear and tear arthritis. Pretty much every one of us has some degree of wear and tear osteoarthritis in our joints as we age, past age, say 25. And you can have more wear and tear depending upon what you do. If you’re on your knees a lot, if you’re jogging and there’s a lot of injury to the knees, then you’re going to get more osteoarthritis there. The kind of arthritis that we’re talking about is inflammatory arthritis. So rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis is another one. So there’s a number of different autoimmune diseases, they’re autoimmune and inflammatory diseases where it is true the immune system turns on itself, turns on you and they are whether you get or the degree to which you get this inflammation and when you get it and whether you get it depends on the load of genes that you have. So none of these diseases, except for ankylosing spondylitis where there’s one dominant gene for that, most autoimmune inflammatory diseases are caused by many genes. In the case of rheumatoid arthritis and the rats that we were studying, 20 different genes on 15 different chromosomes and each gene contributes a very little amount to whether or not you’re going to get the disease. And it depends on your load of genes. So for example, the rats that we were studying back when I discovered this brain immune connection, there was one strain of rats that was highly resistant to getting any autoimmune disease no matter what they were exposed to. And there was the cousins, very close cousins that were highly susceptible to getting autoimmune inflammatory diseases that looked like rheumatoid arthritis, that was like thyroiditis, multiple sclerosis. The pattern of those autoimmune diseases that those rats got depended upon the inflammatory trigger to which they were exposed. So streptococcal cell walls, bits and pieces of ground up streptococcal bacteria in those rats triggered something that looked like human rheumatoid arthritis with the same kind of joint changes as we see in human rheumatoid arthritis. And yet if you gave the same dose, the same amount of streptococcal bacterial cell walls to the resistant rats, they didn’t get anything. And it had to do with their genes. So it’s a balance between how much of the inflammatory trigger you’re exposed to and your genes that you inherit. I happen to have a lot of these genes. I have a family history of many different kinds of arthritis. I don’t think I went into rheumatology because of that. I didn’t really know about it fully when I chose this field, but there’s no question that I have a tendency to autoimmune inflammatory disease, which I came down with an autoimmune inflammatory arthritis after a period of extreme stress. And interestingly, about nine years after I made this discovery between the Brain Stress Center and Arthritis, I go through a period of stress, I developed arthritis. It is not a coincidence that I developed it at that moment in time, because if you are chronically stressed, it can in some cases trigger the onset of some of these diseases. But I had to have the genes in order to have that reaction. Yeah. There is this, I’d say popular science theory that we see more autoimmune diseases because we don’t have enough pathogens. So we don’t have the amount of bacteria, we don’t have the amount of viruses that we all had to fight against. Now we have, we disinfect everything. Now with COVID, of course, that’s another level. But even before that, we were really getting better in public health. And the theory is, and you just said there needs to be an additional trigger in order to get this response to work. But the theory is, from my point of view, is that we’ve been so successful in getting rid of these pathogens, so now our body needs to, I don’t know, try out if the immune system still works, right, and eats our joints up. Is that something that doctors believe and scientists believe too, or that’s just popular science? No, there is some, there is a field of research, it doesn’t happen to be by my field, where this is one of the hypotheses. What I can tell you is that there are good germs and bad germs. We have what we call a microbiome. On every part of our body, inside, outside, you can think of it as an ecosystem like a forest with lots of different plants. And you have lots of different germs, most of which are good microbes, on your skin, in your gut, in your mouth. There’s even a microbiome of place, you know, there are different germs, you can’t completely sterilize a place. And there’s different germs on different surfaces, on the window, on the door, in the dark corners of the room, because it’s a different temperature and a different environment. So you can’t get rid of these germs, most of them are good germs. And one of the theories is that if you get rid of the good germs, then the bad ones can come in and take root. And so that’s something that we’re learning more about, and again, it’s not my area of expertise, but there is a whole domain of research about the microbiome. Yeah, it seems to be an eternal back and forth, right? So there’s this entropied on this viruses that want to propagate their own DNA, right? And there’s bacteria. And we don’t know when, and we see this now with COVID as a new virus, which is obviously mutation from something that was there before. But we don’t know yet if this is something that we can purposefully use, right? So I think these things develop over time that we see a bad bacteria, we make use of it, we adapt to it, it becomes a good bacteria, and then we wait for the next mutation to come. I think this is, we all live in this whole world together, even with the bacteria, right? So they help us sometimes, but we don’t know that yet, but probably they killed a lot of us. Well, I mean, there’s no question that you have to have a healthy microbiome in your gut in order to digest well, and probably what happens in chronic stress, and I’ll bring the conversation back to stress because that’s my expertise. Because of the cortisol that you’re releasing, you are changing the microbiome of the gut. And there’s certainly stress related gut infections that can occur when the good bacteria or the good microbiome is overtaken by the bad. But so there’s a lot of interplay between all the different hormones of the stress response, the neurotransmitters of the stress response, and the environment of your body and around. Yeah, that’s, I think the topic of your second book, right, would you just put out there? It’s really about how places, how our specific environment influences our well being. And you gave me two really good examples when we spoke earlier. Maybe you can help us understand a little more. Well, I don’t know which examples I gave you, but we can rewind it. The one obviously, you know, that’s the, I think, also in popular culture in our well known tree in the hospital, right? Oh yes. So patients who have access to nature, at least outside, they usually have a better path to recuperation. And the other one was the sound effects in specific work environments that change people’s behavior and their stress and in turn their health. Yeah. So, yes, in my book Healing Spaces, the Science of Place and Well Being, I explore how everything that you’re exposed to in your environment, what you see and hear and smell and touch and taste and do in a space can affect all aspects of health. Now health is not a noun. Health is a verb. Health is an active process. And you have physical health and you have emotional health and well being. So well being is sort of the totality of your physical and emotional health. And there’s no question that everything to which you’re exposed to in the environment at every moment of the day and night affects all of those aspects of health that we were talking about, from the genome to the metabolome, so all those metabolites that your body makes, to the physiological responses, the cells within the body, the behavior, your behaviors, and your psychosocial interactions. So everything that you hear and see and smell and touch and do and taste in a space will affect all those aspects of health and well being. And it’s very clear that different elements of the physical environment can stress and different elements can calm. So what are the elements that stress? Love noises, foul odors, bright light, glare, temperature and humidity outside the comfort range, too dry or too wet. And mazes, mazes are, you know, types of structures where you don’t see where you’re going, you have to make many decisions at decision points in order to get from point A to point B. Think of an airport, think of a hospital, it’s very stressful. On the other hand, those same elements can calm. So calming nature sounds, dim or diffuse lighting, circadian light that follows the rhythms of the sun, bright sunlight in the morning and red or dark, lower level light in the evening. Nature fragrances, natural fragrances, not fake ones, but, you know, the smell of citrus or jasmine, calming, lavender is very calming. And then there are labyrinths, which are different from mazes. A labyrinth is a pattern on the floor, they’re very ancient patterns, they’re thought to have been maybe in the ancient world patterns of a dance, certainly in the medieval times, the monks used them for walking meditation. And all of those elements of the built environment and the natural environment can calm. We call, there’s a field called biophilia, love of nature, love of seeing nature and being in nature is very calming, very good for the soul. So the study that you mentioned, this Roger Ulrich was really a pioneer of the field of environmental design, who did a study, a landmark study in 1984 in hospital patients recovering from gallbladder surgery. And he found that the patients who had a view of a grove of trees were spent less time in hospital, they were discharged one day sooner, they needed less pain medication. And they had better moods and the people who had a view of a brick wall. And that kind of study has been reproduced over and over and over again. And we know that looking at nature, we don’t know exactly why, but looking at nature and being in nature is very calming and induces a positive mental state. It’s thought that the part of the reason may be that the part of the brain that recognizes a beautiful view is rich in endorphins and those feel good molecules. So it’s possible that when you see a beautiful view, you are giving yourself a shot of endorphins because that part of the brain becomes activated. Yeah. Well, I always wondered where these archetypes come from, right? So I think all of us have this idea of the salty sea, the smell of salt, where we go to an ocean and we immediately love it. We want to experience the sun, the cold water, the hot rocks, that’s something. Maybe when I wonder how this is actually being stored, it’s a very concrete memory and it must have been thousands, hundreds of thousands of years put into our DNA and survived somehow. And it’s there when we’re babies. And even people who’ve never even heard of the sea, you’ve never seen of an ocean, they dream of that scenario. And if you show it to them, they like it, an overwhelming majority, even if they had no prior exposure. I wonder how this works out of their studies that came closer to these archetypes. Yeah. So one of the studies of looking at beautiful views was done by a scientist at the University of Southern California who did brain imaging on people looking at different kinds of views of view of a smokestack, of view of nature, of mountains, and so on. And it’s true universally across cultures, across ages, gender, socioeconomic level, people prefer to look at a view of nature. In fact, if you Google the word paradise and images of paradise on Google, millions and millions, if not tens of millions or hundreds of millions of images come up that are all views of nature, virtually all of them. So there’s something about views of nature that really we all prefer. And so what happens when, and I went through this, I did a public television, a PBS television special called The Science of Healing, where I myself went through the various labs and was tested. And I was in the MRI machine and looking at slides and clicking whether I preferred a view or not. And it was really amazing to see that part of my brain light up that was rich in endorphins that recognizes beautiful views. So yeah, we’re hardwired in some way to prefer views of nature. You talked about odors and fragrances and smells. There are two ways that fragrances affect the brain. One is an actual chemical interaction. So when you inhale an odor, you’re actually inhaling molecules of that odor, their volatile organic compounds, that actually then directly affect the brain function. So lavender, as I mentioned, really does put you to sleep. It relaxes you. If you inhale a little bit of the essential oil lavender, it relaxes you. There have been studies in anesthetized rats that show that the rats go into deep sleep when they are exposed to lavender. So that’s not something that the rats learned. It’s not something that they went to a psychotherapist to understand. This is a chemical reaction. On the other hand, other kinds of fragrances and odors are more personal and they are learned by associations. So just as Pavlov’s dogs learn to associate the sound of a bell with the steak and then salivate, anybody has a dog or a cat and you use the can opener and suddenly they come running and they’re ready to eat, that’s conditioning. That’s associating a certain sound or smell in the environment with a physiological response, in this case, salivation. And so we can learn. It’s just like also Prus Madlen, the French author of the 19th century, where he describes how he tasted some cookie with tea and it brought this warm, wonderful feeling to him and he couldn’t place it and he tried it again and he tried it again and finally he remembered that his aunt used to give him that kind of cookie with tea when he was sick and she would take him in her arms and calm him as a child. So there is an association, a learned association between certain fragrances and odors that will bring on certain emotions in what I just described, positive emotions, but it can be the other way around. You can have an association of a certain fragrance or smell with a negative emotion and it can be just as powerful. Yeah, I think a lot of retail shops have realized this, but you go to certain retail brands that specific smell and you immediately realize, okay, I’ve been there a year ago, even was a different city. I think there’s one, it’s a clothing store, I forget the brand, who has a very strong perfume, it’s kind of dark, music like a nightclub, it’s made more for the younger generation, but they really play with this and it’s like, I think hotel chains have done this too, they have this specific smell. Well, there’s no question, you walk into a hotel lobby or spas are very good at this and if it’s a hotel in the mountains, you smell pine and if it’s in the ocean, you smell the smell of oceans. So yes, the entertainment and the hotel industry are really very, very good at this. Yeah, there is something to it and it’s a different kind of the memory because you can’t access it. If you ask me now how this particular hotel typically smells with this chain, I have no idea, but if I walk into one of those places, I smell, oh, this is the chain of, I don’t know, this is Hilton or this is one particular Hilton brand, this is how it always smells. So it’s a very different part of the brain that’s very difficult to access. When we look at all these sensors, and you talked about that earlier, we have so many things that affect us and this is sounds and this is smells, but we also get a lot of, and I have my Apple Watch here, we get a lot of new sensors, right, they’re talking about the glucose for the next generation, maybe even blood pressure, maybe smell is going to be there too in five years from now or 10 years from now. How does data and big tech influence science and medicine at that point? Because once we can measure all these things, we can make it more predictable and we can get better specific recommendations. Right. Well, this is how we conducted our studies with the U.S. General Services Administration using wearable devices to measure the impact of up to 11 different environmental attributes on different aspects of health. So when I was at the National Institutes of Health, I started working with Kevin Campsure, who’s now Director of High Performance Federal Green Buildings at the U.S. General Services Administration. The GSA is the agency of the federal government that builds and operates all nonmilitary federal buildings over 370 million square feet of space for over a million office workers. And Kevin Campsure came to me when I was at NIH and said, can you help us to understand how the different aspects of the office spaces that we’re designing impact different aspects of health. It’s not our workers to be healthy, happy, and productive. And so we started back then, about 21 years ago, using wearable devices and you can imagine back 20 years ago, they were clunky dinosaurs with wires hanging off and sticky things on your chest. So we measured different aspects of the stress response. The way that all of these devices measure your stress and relaxation response is based on your heart rate and your heart rate variability, the variability of the time between the beats. And using mathematical algorithms, you can take that information, the variability between the beats and turn it into an understanding of your stress response and the opposite, your relaxation response. Because just as I described the hormones and nerves of the stress response that kick in when you’re stressed, there are also relaxation response nerves. The vagus nerve is the main one. And the way to turn that nerve on is to do deep breathing. So if you breathe deeply, you’re immediately engaging your vagus nerve, which immediately slows your heart rate and increases the variability between the beats. And that’s your relaxation response. So you want high variability or low? Yes, exactly. You want high variability. It’s counterintuitive because most people think, oh, high heart rate, then I’m stressed. But no, high variability between the beats is a healthy pattern. So when we engage that relaxation response, it puts a break on the stress response. And that’s a quick way to reduce your stress in the moment. Now, I want to make a point that the goal should not be to get rid of stress. You need your stress response to survive. People have tried to make transgenic animals without a stress response. It doesn’t work. It is not compatible with life. Well, what happened to them? What happened to these transgenic animals? Like, they died. So if you have from fruit flies to fish to mice to rats to cats to human, everything in between, you need your stress response in order to be vigilant, to fight or flee when there is an invader or when you’re confronted with a threat, and your stress response gives you the energy to function at peak. The problem occurs if your stress response goes on too long when the threat is no longer there or it stays high or it’s too high for too long of a period. And that’s when you fail, when your performance fails. So the goal is to get your stress response right into the middle. I talk about it like a rainbow. If you think about a rainbow here and to my left, I’d be lying down, I’d be reading a book, I’d be dreaming about being at the beach. I would be very relaxed, you Torsten would be very stressed, your listeners would be very bored, and I would have to get my stress response up just enough to perform at peak. The problem occurs if my stress response becomes too high and I fall over the edge of that rainbow and my performance fails. And that’s a problem. So the goal of all of these mind body techniques is to move the needle back so that you’re performing at peak for the task at hand. If you’re at a spa, yes, you want to be sleeping and lying down and your stress response very low. But if I’m speaking to you or performing a task, I want my stress response just right. So for example, just before we came on, I was having a bit of trouble connecting to this link, internet stuff is always extremely stressful, especially when the connections are not great. And boy, I can tell you my stress response was really, really high. So I had to just do a little bit of deep breathing to get myself calm and get myself back into the middle. And you can do that in the moment instantaneously. When you say peak performance and beneath stress, what does that mean in percentages? So I feel like I have certain thoughts that I wouldn’t have had without caffeine. So caffeine gave me that push over the edge. Riders say they need drugs, simple drugs like nicotine and alcohol, but also more going towards LSD. In order to get this last edge to be better than anyone else, to be that personal on the planet who figures it out. But if we talk about performance between stress and relaxation or between just in the middle, just average, what are we talking about? Is this performance like 10 times better? Is it 20% better? What is the technical measurement? Yeah, I don’t think you can generalize. So let me get back to the question about the built environment and how that can affect this stress in the middle or too much. So with and I’ll give you percentages in the context of that. When we did the studies more recently, so let me get back to the first study that we published with the GSA in 2010. We looked at about 70 office workers in a building that was being retrofitted. So the people were in the same space, in the same building, but in the old space it was dark, it was musty, high walled cubicles, they couldn’t see the light, they couldn’t see the windows, high mechanical noise. And then we measured the same workers in the new space and that space had beautiful views, lots of daylight, lower mechanical noise, fresh air turnover. And we were able to measure on two measures of the stress response, that heart rate variability and the salivary cortisol, that these workers were significantly less stressed even when they went home at night and while they were sleeping, when they were in the new space. And yet when we asked them about whether they felt stressed or not in the different spaces, they were not consciously aware of it. We are generally not aware of how the physical environment affects our stress response, but our stress response is aware of it. So when I came to the University of Arizona, we continued these studies using state of the art wearable devices, a small chest worn device, and also working with a company in the Bay Area called ACLIMA. We measured up to 11 different environmental attributes, sound, light, volatile organic compounds, carbon dioxide, which is what you breathe out, not carbon monoxide, but it’s the gas you breathe out, carbon dioxide, and so on, particulates and so on, temperature and humidity. And we have a whole series of studies where we were able to show that various elements of the physical environment do impact the stress response. In some cases, up to 25% higher, so for example, relative humidity. When it’s too dry, it’s not good. When it’s too wet, it’s not good. So if it’s less than 30% relative humidity, we found that the stress response was 25% higher in people in very dry conditions. Similarly, people in very wet conditions, greater than 60% relative humidity, the stress response was higher. We found that the layout of offices affected the stress response. So open office design, which I can explain to you more about, but people are up in arms, they hate their open offices, but open office design, which is really more active office design with lots of choices of where to sit, to sit in quiet, small areas, in larger gathering spaces, in open spaces with bench seating, where you have lots of sunlight coming in. So the people in the open office design were significantly more active during the day, 32% more active than people in private offices, 22% more active than people in cubicles. And those people who were more active during the day were significantly less stressed at night. They also had better sleep quality. They fell asleep faster, they had better sleep quality, and they had better moods upon awakening. Circadian light is very important. So bright sunlight between 8 a.m. and 12 noon is very important for healthy sleep. So to fall asleep faster, to have better moods, and to have a better quality of sleep noise. We talked earlier about noise. One of the big distractors that people complain about in open office settings is noise, but it turns out when it’s too quiet, it’s also not good. And if it’s too noisy, it’s not good. So there is this sort of, again, a rainbow, an inverted U shaped curve for what is comfortable for people’s stress response. But for every person, it’s different, right? You say it’s 25% different. What for some person we’d say is their normal, is for someone is an elevated response would be, we would assume that person is stressed, right? So it’s really dependent that when we think about performance, it’s really dependent on your own base level, right? Yes, so where the studies are going now, we build on each study builds on another one. Individual differences are a huge, huge variable. And one of the things we’re learning from these studies of the office space and office design is one size does not fit all. You cannot design a whole building to make everybody comfortable. There, of course, there are certain things that are universal. Carbon dioxide, for example, the longer the more people in a space, the longer they are in the space and the poorer the ventilation and air turnover, fresh air exchange, the higher the carbon dioxide will be in the space. So what we’re learning is that much lower levels of carbon dioxide that were thought before actually affect your cognitive performance and fatigue. So at about 450 parts per million of carbon dioxide, you’re fully, you’re functioning at 100%. At 950 parts per million, you’re down to 85% cognitive performance. And at about 1400 parts per million, you’re down to 50% cognitive performance. What does that mean? You make more errors, you’re not even aware that you’re making the errors, your judgment is poorer, and you feel sleepy. So when I give a lecture to people, to audiences, I say, if you’re falling asleep, it’s not me, it’s the carbon dioxide and the ventilation system in the room, which is always a good way to make me feel good. So carbon dioxide is pretty universal, but temperature and humidity, that’s quite individual. And so the future is designing elements of the built environment to be more individualized. So we have a researcher, a faculty member at the University of Arizona, Dr. Alithia Aida, who is developing bio responsive materials that can be embedded in furniture and in walls to give a person their own cocoon of comfort, of temperature and humidity. Those are the kinds of technologies that are being developed that can be tuned to individual needs. Yeah, there’s all this data that Apple has about my health, right, collected from all these sensors. I do know this apps for hard rate, where you can at least see a hard rate. There is a workout app, there is an app for sleep now, I think someone else developed it and Apple just integrated it, they copied it. I haven’t seen one for stress or stress levels. Ideally, my Apple, which would go off and say all your stress, they could be breathed for 20 minutes. No, there are, I mean, they’re not necessarily called stress. I mean, on the one that I have, I’m wearing, I don’t want to advertise any particular brand, but I’m wearing this ring, and it calls it resilience. Your resilience today is so and so. Part of the reason for that is in order to measure hard rate variability continuously and in the moment, you need to be not moving. So most of these apps, certainly the one that I’m wearing, but most of them will take a short piece of time while you’re sleeping, where you’re relatively not moving, and you’ll often see, if you look at the trace for hard rate variability, which is measuring the stress response and the relaxation response, if you look at the trace and you happen to have woken up in the middle of the night, there’s going to be a gap. And that’s because you’re moving too much. So there’s movement artifact during the day that prevents these devices that are on your wrist or on your ring from measuring hard rate variability continuously. It’s a technological thing. That’s interesting, but it works at night, right? It works at night and with research grade, so we were using research grade chest worn devices where there’s less of this movement artifact, we were able to measure hard rate variability throughout the day. But on the commercially available ones that are worn on the wrist or the finger, it’s really hard to get rid of that movement artifact. It can be done and there are some of these that are available where they can give you the raw data and you can kind of do all kinds of algorithms to get rid of the movement artifact, but it’s not something that I’ve seen really readily available commercially throughout the day in the moment. Yeah, I understand. One of the things when we talk about peak performance, I always wonder about when we go back to the Middle Ages, it is being said that because of reasons of water supply, most of the drinks that actually people consumed were alcoholic. They weren’t very strongly alcoholic like what we have right now, 14%, but it was more like 2%, like a light beer, like a really watered down American beer. That’s what people would drink basically for breakfast and they would never stop drinking it. There was an interesting movie just a few months ago that made that hypothesis that said, well, maybe our peak performance is at a certain promel level and it’s not zero. I think a lot of us feel this, we are different people when we drink a little bit, we are terrible when we drink a lot and we might also be terrible when we don’t drink anything, but somewhere in between we get really social, we have new ideas, we get creative, we kind of live in a slightly different planet. Have you seen real studies that really looked into this, if we maybe our alcohol level is too low for what our genes adapted to a thousand years ago? This is not my area of expertise, so I’m not going to answer this. It’s an interesting hypothesis, but there is no question that there are studies of the Mediterranean diet which include, I think it’s two glasses of red wine a day and that seems to be healthy. It’s again an individual difference. Some people have very low speed, they don’t metabolize alcohol very well and so it affects them more. There is fast metabolizers and slow metabolizers, and again, this is not my area of expertise, so I really can’t address it. I thought it’s fascinating, it also obviously eases my consciousness when I drink, but typically the alcohol is watered down a lot, and I think in the old Greeks had that rule, they would take, Eric was telling me this, it’s five times water and two times alcohol, like a typical wine that we have right now, and this sheer amount of water that you would consume at the same moment with this watered down wine, it just makes it impossible to get really drunk, you can’t drink that much, unless you have a crazy bladder. The Romans also were drinking it out of lead cops, so they got lead poisoning, so again, this is not my area of expertise, so I can’t address it. Another question that a lot of people raise, if you’ve looked into psychedelics, if you talk about peak performance and things that are different in that universe, psilocybin, DMT, have you ever looked into those? No, that’s again not my area of expertise. I deal with integrative health, mind, body interactions, so deep breathing, Tai Chi, yoga, all of the things that can engage that relaxation response in a natural way and reduce your stress response again in a natural way, so there’s no question that meditation changes how the brain functions, it changes how the body functions, so there are many studies showing that different kinds of yoga breathing change heart rate variability and engage the relaxation response, meditation, long term meditators have a different pattern of brain function where the frontal lobe, the part of the brain that’s involved in executive function and resiliency is enhanced in long term meditators, this is Richie Davidson has done these studies with brain imaging, with EEG, and that’s when he started working with the Dalai Lama and the Dalai Lama’s monks to look at how his words, the Olympic athletes of meditation, how their brains function, so meditation is a very powerful tool to enhance resiliency not only of the brain but also of the whole body, there are studies on gene expression in long term meditators and there’s no question that they are different than in people who don’t have that experience. When we look into yoga or meditation as another example, when we look into lifespan and life expectation, how far are we in these specific technologies, the research that we are able to see, what kind of stress are we exposed to, how to be mediated the best, when we think about life expectancy on average, do you think it pushes us 10, 20 years extra or is it just two years on average, where do you feel that our research is? There are studies on this, not so much on life expectancy but on chromosomal aging. On your chromosomes, there are little ends of chromosomes called telomeres, it’s kind of like the plastic ends of shoelaces, so as you age, the telomeres get shorter and shorter and fray, just like your plastic ends of shoelaces fray with age, and you can calculate a person’s biological age by measuring the length of their telomeres. People who are chronically stressed, their telomeres can look 10 to 17 years older than their biological age, that’s a lot, chronic caregivers of Alzheimer’s patients, people who are chronically stressed, there are many studies looking at this. In contrast or the flip side of that is that these mind body interventions can actually not only prevent that shortening of telomeres but can reverse it. So Alyssa Eppel and Dean Ornish published a study where they looked at, actually a couple of studies where they looked at patients who were recovering from prostate cancer, who had been trained on a mind body integrative health intervention that included a healthy Mediterranean diet, meditation three times a week, and 30 minutes of walking a day. You didn’t have to go to the gym and run a 90% VO2 max, just 30 minutes of walking a day. The people who followed that regime for five years, well let’s reverse it, the people who did not follow that regime, five years later their telomeres continued to shorten. The people who followed that regime for five years, not only did their telomeres not shorten but they actually began to lengthen. So you can start a healthy lifestyle, integrative health diet and exercise and meditation of whatever sort and at any time, no matter how long you’ve been a couch potato and you can reverse that effect of chronic stress on your aging of your telomeres. That’s really good news and I really feel there’s a lot out there and just also living quality is this clarity that you develop. If you have a healthy body, your mind also, obviously meditation is another way to achieve that but you get more clear about what you want and what you want from life and we do have that time now, right? So either because it’s COVID or we are richer or we don’t really have to fight over shelter and food anymore but we have the ability and the time to look into philosophy and see what the old Greeks and all the people after that were thinking about how we should lead life and it’s, I think it’s starting, it’s happening. Maybe I’m too optimistic but I feel like a lot of people that never cared about philosophy, that never cared about how should I live, now suddenly say, oh well, maybe I should change my diet a little, maybe I should live slightly healthier, go out there and do something even if I’m 40, 50, 60, right? People in their 20s have a different start. Oh, for sure, for sure. And that’s really new. Yeah, in the PBS television special that I did, the Science of Healing, we actually went to Greece and we visited an Asclepion. Asclepions were all over Greece. They were healing spaces, they were healing places where people came to engage in these healthy activities and Hippocrates, the father of modern medicine, he prescribed 60 different diets. A diet to Hippocrates was not simply what you ate, it included what you ate, but it included a prescription for exercise, for training, for social support. The reason the Asclepions all had an amphitheater as part of it is that theater was very important in the healthy lifestyle and getting people to heal, sleep was very important. Belief, prayer was very important. It didn’t matter what you’re religious, well, of course, in ancient Greece you believed in the various gods, but belief and prayer is very important. We call it the placebo effect, unfortunately, the word placebo is usually preceded by the word just, but the placebo effect is not just the placebo effect, it is a very powerful effect that engages brain regions that are rich in anti pain and feel good endorphins, they’re rich in feel good dopamine reward pathways, and they affect the immune system in a positive way. So going back to ancient Greece in western medicine, there’s no question that there was a belief that all of these approaches helped healing, and when you think about it, animals in the wild, they didn’t have surgeons and antibiotics to heal, they had to have a way of healing themselves, and so the whole system of the immune system and the brain, it’s all set up to help us heal, however, it is important now that we have the space age modern medicine of surgery and antibiotics and antivirals and so on, you can’t do it on your own. You need these medications to help you heal, to get rid of the cancer, but you can either help your body to work with those medications by doing what you can to reduce stress and enhance well being, or you can work against them, and then it takes more effort for the medications to do their job. Now another thing I want to mention in this context that’s very important is that in the self help domain, people often feel if they can’t do it on their own, if they can’t reduce their stress, then they failed, and they feel guilty, and they feel there’s something wrong with them. Well you can’t do it on your own necessarily, just like an Olympic athlete needs a trainer, you need an expert who can help you guide you through these lifestyle interventions or guide you through the understanding what is causing the stress and what you can do to reduce it, and often you can’t get rid of the stress. We can’t control everything, and certainly with COVID, everyone worldwide was stressed. We could not get rid of that stress, but we can do small little things in our own world to help reduce that load of stress on our bodies and our brains. One of the things is to fool your brain into thinking that you’re in some degree of control. So at the beginning of COVID, people were making masks, people were going online doing yoga trainings, teachers were teaching online, I turned my research to pivot to help COVID in the domain that I could help with, so you’re never going to help the whole thing, but it’s like a huge enormous jigsaw puzzle, and each little piece of the jigsaw puzzle is important for the whole thing. So if you can help a neighbor, if you can drive, if you can deliver groceries to somebody who can’t get out of the house, you’re helping that person, you’re also helping yourself, and you’re reducing your stress response by feeling that you’re in, by actually getting in some degree of control. So I think that’s important to remember, and if you can’t get rid of the stress, seek help from an expert who can help with that. Yeah, I think it’s surprising that we have all the knowledge that we’ve been soaking up about living healthy and make our bodies healthy. We have this epidemic of mental illnesses, so we have 15 layers of technology between people, we don’t talk to people, I live here in San Francisco, nobody talks to each other, it’s definitely not the random people, everyone looks down, it’s like, did the nuclear bomb just go off? Well, maybe COVID felt like this, but it isn’t the same death rate, right? Nobody actually died, few people in San Francisco only died, luckily enough. But it’s the mental impact, it’s basically like a nuclear bomb. It’s huge. Right. Out of control, what you just said, the ability to be in control and take on this challenge of post COVID voluntarily that hasn’t dawned on people yet, maybe it’s just happening, but this city has been in heart, definitely with mental illnesses. Well, it’s huge. So in the wake of the COVID viral pandemic, which killed a lot of people, and in that wake, there is a pandemic of mental health, mental illness, of stress, of anxiety, of depression, and there’s so many causes, loss of jobs, loss of income, social isolation is a huge stressor, just having to adapt to this whole new world is a huge stressor. So there are many, many challenges, having large families at home in a small space, having to homeschool your kids, you know, isolation is a stressor and then crowding is a stressor. So there are so many stressors that different people were exposed to and are continuing to be exposed to through COVID, that, you know, again, you can’t get rid of all of it, but you can do small things in your own space to try to reduce that stress. Being out in nature is one. Being out in nature, planting, a lot of people have started to grow their own gardens and vegetables and a lot of people have got pets, you know, dogs and cats. So there are ways to reduce, even a small amount of that stress can help. And again, as I said, if you can’t do it on your own, seek help. One of the wonderful things that’s happened in the medical field is that there’s been this rapid transition to telemedicine. It used to be that there weren’t that many doctors and health providers online, but now, certainly with psychotherapy, you can do telemedicine exactly the way you and I are doing this now. Yeah, I think that’s, that was absolutely overdue and I remember not too long ago it was almost impossible to email your doctor. You could email, but they never replied, so I don’t know if they ever got the email. And then it was also impossible to get lab results from many places. Some were already up to date and you had to go there and take the printout, scan it yourself and write it down. So it was terrible and I think a lot of these things finally are readjusting. So that’s, as you say, it’s a wonderful news because there’s a ton of iPhone apps. I think they, you just take a picture of whatever you have, whatever symptoms or if it’s on your skin and rushes and 15 minutes later you get like, okay, it might be this, call me. So this is awesome. Right. So this is finally happening. So that’s a good one. A silver lining. I’m a big believer that when there is huge, huge change, when there is catastrophe, humans are very resilient and very creative and a lot of people worldwide stepped up to the plate and scientists all over the world turned their expertise to addressing every aspect of this pandemic and there is going to be positive silver lining coming out of it, including what we just talked about, the technologies that will help long distance diagnosis. And just think about it if you’re post COVID and you’re housebound because you can’t get without your elderly or you have some sort of illness that prevents you from going out. How wonderful that you’ll be able to contact your healthcare provider via the phone. Yeah. And you can watch a lot of Netflix too. I’m reaching that limit where I’m at the end of what would at least to me appeals in kind of streaming services and it’s become a big problem. How do we entertain ourselves? That’s seeming me the biggest problem now. Maybe that’s the luxury, the price of this luxury. Well I hope people will be entertaining themselves by listening to this podcast. I hope so too. Maybe they’ll learn a thing or two. I definitely did. Yeah. Esther, thanks so much for coming on. That was awesome. It’s really been a great pleasure and thank you very much for inviting me. Thank you and be home. I hope we get to do this again. Talk to you soon. Okay. Take care. Bye bye.