Treat Obesity with Mindfulness

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Treat Obesity with Mindfulness

 

By John M. de Castro, Ph.D.

 

“ mindfulness breeds resilience—a quality necessary for one to stick with your diet or exercise regimen. And given how much of our unhealthy eating is essentially mindless—such as stuffing our faces while we watch television—it’s easy to see how simply paying attention could have a significant impact on our diets.” – Tom Jacobs

 

Obesity has become an epidemic in the industrialized world. In the U.S. the incidence of obesity, defined as a Body Mass Index (BMI) of 30 or above has more than doubled over the last 35 years to currently around 35% of the population, while two thirds of the population are considered overweight or obese (BMI > 25). Although the incidence rates have appeared to stabilize, the fact that over a third of the population is considered obese is very troubling. This is because of the health consequences of obesity. Obesity has been found to shorten life expectancy by eight years and extreme obesity by 14 years. This occurs because obesity is associated with cardiovascular problems such as coronary heart disease and hypertension, stroke, metabolic syndrome, diabetes, cancer, arthritis, and others.

 

Obviously, there is a need for effective treatments to prevent or treat obesity. But, despite copious research and a myriad of dietary and exercise programs, there still is no safe and effective treatment. Mindfulness is known to be associated with lower risk for obesity, alter eating behavior and improve health in obesity. This suggests that mindfulness training may be an effective treatment for overeating and obesity alone or in combination with other therapies.

 

In today’s Research News article “Effectiveness of mindfulness training and dietary regime on weight loss in obese people.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5319254/, Asadollahi and colleagues recruited obese (BMI>30) individuals and randomly assigned them to one of four conditions; No-treatment, dietary regimen, Mindfulness-Based Cognitive Therapy (MBCT), or MBCT plus dietary regimen. MBCT was administered in 2-hour sessions once a week for 8 weeks and consists of mindfulness training and Cognitive Behavior Therapy (CBT) that is targeted at investigating and altering the individuals aberrant thought process. Participants were measured for psychopathology and anyone with significant pathology was eliminated from the study. The participants were also measured before and after the interventions and 2 months later for body weight and height.

 

They found that mindfulness training alone or a dietary regimen alone produced significant weight losses that persisted 2 months after the end of formal training. When mindfulness training was combined with a dietary regiment the weight loss was significantly greater at the end of training and 2 months later. So, Mindfulness-Based Cognitive Therapy (MBCT) is effective in reducing weight in obese participants and its effectiveness is amplified by combining it with a dietary regimen. So, mindfulness training can help to reduceobesity alone or in combination with dieting.

 

It is unclear how MBCT produces these positive effects on obesity, but it is known that MBCT can increase mindful eating and that eating food mindfully can results in lower overall intake and weight loss. MBCT is also known to reduce the psychological and physical responses to stress and stress is known to promote eating. So, it is reasonable to conclude that MBCT produces its effects on the body weight of the obese by increasing mindful eating and reducing stress.

 

So, treat obesity with mindfulness.

 

“Mindful eating is eating with purpose, eating on purpose, eating with awareness, eating without distraction, when eating only eating, not watching television or playing computer games or having any other distractions, not eating at our desks.” – Carolyn Dunn

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Asadollahi, T., Khakpour, S., Ahmadi, F., Seyedeh, L., Tahami, Matoo, S., & Bermas, H. (2015). Effectiveness of mindfulness training and dietary regime on weight loss in obese people . Journal of Medicine and Life, 8(Spec Iss 4), 114–124.

 

Abstract

The present research was aimed to investigate the effectiveness of mindfulness training and dietary regime on weight loss in obese people. The research was quasi-experimental with posttest-pretest that used control group. The population consisted of all the individuals who attended two clinics of nutrition advice and diet therapy in Karaj. 60 individuals, whose BMI was more than 30, were selected by using the random sampling method. Moreover, they were evaluated by using the SCL-90 test in order to neglect them in case there existed any other significant disorder. Next, they were selected based on age, sex, and education. After explaining the individuals the ongoing research and collecting the informed consent written by them, the samples were placed in four groups (15 in each group). The groups that received mindfulness training attended the nutrition center for eight to 120-minute sessions. In addition, since all the participants referred to the center were motivated to lose weight, individuals who were placed in the control group and those who received mindfulness training were asked not to follow any specific diet for two months. Moreover, the in depth relaxation CD was prepared for those who asked, in order to train themselves at home. Descriptive statistical methods were employed in order to analyze the data and ANACOVA and variance analysis with frequent measurement were used. The research findings indicated that mindfulness training was accompanied by diet, which resulted in weight loss in obese patients. In addition, the findings of the two-month follow-up indicated lasting results.

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5319254/

Improve Children’s Absorption of Micronutrients with Yoga

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Improve Children’s Absorption of Micronutrients with Yoga

 

By John M. de Castro, Ph.D.

 

“Aside from the physical benefits of yoga, yoga teaches teens techniques for coping with the unique issues they’re faced with everyday—insecurity about their changing bodies, the enormous pressure to fit in, stressful schedules, and uncertainty about their beliefs and their futures.” – Erica Rodefer

 

Yoga practice has been shown to have a large number of beneficial effects on the psychological, emotional, and physical health of the individual and is helpful in the treatment of mental and physical illness. The acceptance of yoga practice has spread from the home and yoga studios to its application with children in schools. Studies of these school programs have found that yoga practice produces a wide variety of positive psychosocial and physical benefits. Teachers also note improvements in their students following yoga practice. In addition, school records, academic tests, and physiological measures have shown that yoga practice produces improvements in student grades and academic performance.

 

In developing countries nutritional deficiencies are common. Many children, even those who receive sufficient calories from food are often lacking in micronutrients (vitamins and minerals). This lack can impair growth and school performance. So, it would be helpful for the health and well-being of children in developing countries, if a safe and effective method could be developed to promote the absorption of the micronutrients in their food. In today’s Research News article “Effect of yoga practices on micronutrient absorption in urban residential school children.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5509603/, Verma and colleagues examine if yoga practice can improve micronutrient absorption in school age children in India.

 

They recruited 11 to 15-year old boy and girl students from an urban residential school in India and randomly assigned them to yoga practice or a no practice control condition. Both groups continued with an active schedule of extracurricular activities including sports and dance. Yoga practice was conducted 6 days per week for 1-hour per day for 12 weeks and consisted of chanting, postures, and breathing exercises. The students were measured before and after the training for height and weight and blood samples were collected and serum Iron (Fe), Zinc (Zn), Magnesium (Mg), and Copper (Cu) were measured.

 

They found that in comparison to baseline and the control group, the children who practiced yoga had significant increases in serum Iron, Zinc, Magnesium, and Copper. It is assumed that since the body cannot produce these micronutrients that the increases must have occurred due to increased absorption of the micronutrients from the food. But, intake of food was not measured and it is possible that the higher serum levels were due to greater food intake in the yoga group. There is, however, evidence that yoga practice can improve digestion. So, it is likely that increased absorption from improved digestion as a result of yoga practice was responsible. If this is true then yoga practice may be a safe and effective means of improving the nutritional status of children in developing countries.

 

So, improve children’s absorption of micronutrients with Yoga.

 

“Mindfulness has been shown to help students have better relationships and more positive behaviors and help them perform better at school. A recent study found it can help students improve their memory. Mindfulness has also been shown to improve teens’ physical health and their mental health.” – Kelly Wallace

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Verma, A., Shete, S., Kulkarni, D., & Bhogal, R. S. (2017). Effect of yoga practices on micronutrient absorption in urban residential school children. Journal of Physical Therapy Science, 29(7), 1254–1258. http://doi.org/10.1589/jpts.29.1254

 

Abstract

[Purpose] This study was conducted with a view to find out the effect of yoga practices on micronutrient absorption in urban residential school children. [Subjects and Methods] The study population comprised 66 urban school children aged 11–15 years staying in a residential school in Pune City, Maharashtra, India. A stratified random sampling method was used to divide the students into experimental and control groups. There were 33 students in experimental group and 33 students in control group. Both experimental and control groups were assessed for the status of zinc, copper, iron and magnesium at the baseline and at the end of 12 weeks of yoga training. The study participants of experimental group underwent yoga training for 12 weeks, for one hour in the morning for six days a week. The control group did not undergo any yoga training during this time period. [Results] The experimental group participants showed significant improvement in micronutrient absorption as compared to control group. [Conclusion] The findings of this study indicate that yoga practices could improve micronutrient absorption in urban residential school children.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5509603/

Brief Mindfulness Training may Increase Drinking Impulsivity to Negative Emotions

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Brief Mindfulness Training may Increase Drinking Impulsivity to Negative Emotions

 

By John M. de Castro, Ph.D.

 

“it’s helping people become really aware of what’s happening in their minds. Once they see that, they have a choice and they have some freedom.” – Sarah Bowen

 

Inappropriate use of alcohol is a major societal problem. In fact, about 25% of US adults have engaged in binge drinking in the last month and 7% have what is termed an alcohol use disorder. Alcohol abuse is very dangerous and frequently fatal. Nearly 88,000 people in the US and 3.3 million globally die from alcohol-related causes annually, making it the third leading preventable cause of death in the United States. Drunk driving accounted for over 10,000 deaths; 31% of all driving fatalities. Excessive alcohol intake has been shown to contribute to over 200 diseases including alcohol dependence, liver cirrhosis, cancers, and injuries. It is estimated that over 5% of the burden of disease and injury worldwide is attributable to alcohol consumption.

 

Alcohol abuse often develops during adolescence and it on display with college students where about four out of five college students drink alcohol and about half of those consume alcohol through binge drinking. About 25 percent of college students report academic consequences of their drinking including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall. More than 150,000 students develop an alcohol-related health problem. These are striking and alarming statistics and indicate that controlling alcohol intake is an important priority for the individual and society.

 

There are a wide range of treatment programs for alcohol abuse, with varying success. Recently, mindfulness training has been successfully applied to treatment. One attractive feature of this training is that it appears to increase the ability of the drinker to control their intake, resulting in less binge drinking and dangerous inebriation. Since, mindfulness appears to hold promise as a treatment for excessive alcohol intake, there is a need to better understand its mechanisms of action in order to maximize its effectiveness. In today’s Research News article “Examination of trait impulsivity on the response to a brief mindfulness intervention among college student drinkers.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975969/, Vinci and colleagues examined how mindfulness training might alter impulsivity related drinking urges.

 

They administered the Alcohol Use Disorders Identification Test to college students and identified a group of at-risk drinkers. They were then randomly assigned to receive either a 10-minute guided mindfulness meditation, muscle relaxation instruction, or engaged for 10-minutes in a word search puzzle. Before and after the interventions the at-risk students were administered measures of the mindfulness, positive and negative emotions, urge to drink, drinking motives of Enhancement, Coping, Social Affiliative, and Social Conformity and of impulsivity including Negative Urgency, (lack of) Premeditation, (lack of) Perseverance, Sensation Seeking, and Positive Urgency.

 

They found that mindfulness was increased by the brief mindfulness training. They also found that mindfulness and relaxation modulated the effects of drinking motives on the urge to drink. For participants in the mindfulness group, having low Negative Urgency was associated with a low urge to drink, while participants with high Negative Urgency reported a high urge to drink. The opposite pattern was observed for participants in the relaxation group, such that for those with low Negative Urgency, urge to drink was high; for those with high Negative Urgency, the urge to drink was low.

 

Negative Urgency is the likelihood of acting impulsively when experiencing negative emotions. A brief Mindfulness experience appears to have an immediate effect of heightening the ability of acting impulsively to negative emotions to affect the urge to drink. It may, by focusing the individual on the present moment, make the individual more aware of their own emptions and therefore they become more responsive to them. A brief relaxation, on the other hand tends to lower the ability of acting impulsively to negative emotions to affect the urge to drink. Perhaps relaxation make the students less aware of their own emotions.

 

These results suggest that a brief mindfulness training of students who are at-risk for alcohol abuse may be counterproductive, sensitizing them to feeling emotionally bad and thereby making drinking more likely. Since, it has been well established that mindfulness training decreases drinking and drinking motives, the results suggest that care must be taken to insure that sufficient training occurs to produce benefits as opposed to sensitizing impulsive responses to negative emotions.

 

So, care must be taken t administer and adequate dose of mindfulness training when treating at-risk college students.

 

“mindfulness . . . just 11 minutes of the therapy can reduce alcohol consumption in heavy drinkers.” – Liat Clark

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Vinci, C., Peltier, M., Waldo, K., Kinsaul, J., Shah, S., Coffey, S. F., & Copeland, A. L. (2016). Examination of trait impulsivity on the response to a brief mindfulness intervention among college student drinkers. Psychiatry Research, 242, 365–374. http://doi.org/10.1016/j.psychres.2016.04.115

 

Abstract

Mindfulness-based strategies show promise for targeting the construct of impulsivity and associated variables among problematic alcohol users. This study examined the moderating role of intervention (mindfulness vs relaxation vs control) on trait impulsivity and three outcomes examined post-intervention (negative affect, positive affect, and urge to drink) among 207 college students with levels of at-risk drinking. Moderation analyses revealed that the relationship between baseline impulsivity and the primary outcomes significantly differed for participants who underwent the mindfulness versus relaxation interventions. Notably, simple slope analyses revealed that negative urgency was positively associated with urge to drink following the mindfulness intervention. Among participants who underwent the relaxation intervention, analysis of simple slopes revealed that negative urgency was negatively associated with urge to drink, while positive urgency was positively associated with positive affect following the relaxation intervention. Findings suggest that level (low vs high) and subscale of impulsivity matter with regard to how a participant will respond to a mindfulness versus relaxation intervention.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975969/

“I am that”

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“I am that”

 

By John M. de Castro, Ph.D.

 

This well-known phrase originated from the sage Nisargadatta Maharaj. When he was young his Guru ordered him to attend to the sense ‘I am’ and to give attention to nothing else. He embraced that instruction totally and devoted himself to meditating upon it. Upon his spiritual awakening he recognized “I am that.”

 

This simple phrase summarizes the core of most awakening experiences, seeing all as one. In this oneness experience the individual disappears and everything is seen as contained in pure awareness which is the one thing. “I am that” actually doesn’t recognize an “I” or a “that.” They are one. So, what we refer to as “I” is exactly the same thing as all other things or “that”. There is no distinction.

 

This is a seminal teaching. It’s so simple that its profoundness can be missed. Meditate on that, the I am-ness, the sense that is behind the senses, the awareness that is the very core of our being. Perhaps, just perhaps, that “you are that” will reveal itself.

 

If indeed everything is the same and simply an expression of the whole inseparable reality then everything should treated with great reverence. We should have as much regard for garbage as we have for ourselves. In fact, a notable characteristic of Zen Masters is that they gladly engage is mundane and seemingly distasteful tasks such as cleaning floors and toilets with the same joy and reverence that they treat meditation. If everything is one then there is no distinction between good and bad things or between engaging and distasteful activities.

 

The modern spiritual teacher Adyashsnti told the story of his first meeting with his Zen teacher. Before entering her home, she asked him to take off his shoes. He casually flung them aside. She instructed him to go back and pick them up and carefully place them in an orderly fashion on the porch. She taught that if he did not revere and respect his shoes, how could he ever revere and respect himself and have any hope of awakening. This was her way of teaching that “I am that” means he was also his shoes.

 

This also holds true for other people. If we are all one then there is no reason to act toward anyone any different from anyone else. The Great Commandment ‘Love your neighbor as yourself’ makes perfect sense as your neighbor is yourself.

 

Acting negatively or destructively toward anything or anyone degrades the whole which includes the self. It makes no sense to do so. It is in essence self-injurious to harm a flea. The environment deserves the same reverence as people as there is no distinction between the two. To cut down rain forests is equivalent to amputating a leg they are equally injurious to the singular one.

 

In most spiritual teachings love is a focus. We are told to love our neighbor and even our enemy. If they and us are one, of course we should love them all. To the sage, the oneness of all things is the essence of love. Everything is love. The first Great Commandment to ‘Love the Lord your God with all your heart and with all your soul and with all your mind’ also makes sense as everything is the Devine and everything is love.

 

So, the teaching of ‘I am that’ is the foundation upon which most spiritual teachings rest. I we truly accept that ‘I am that’ then we will live our lives very differently, with reverence, love, and respect for everything.

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

Improve Knee Osteoarthritis in Older Adults with Yoga

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Improve Knee Osteoarthritis in Older Adults with Yoga 

By John M. de Castro, Ph.D.

 

“Osteoarthritis is a chronic, long-term disease that affects millions of elderly adults. There is currently no known cure for it and treatment options are limited. New research, however, suggests that chair yoga is effective in relieving osteoarthritis pain.” Ana Sandoiu

 

Osteoarthritis is a chronic degenerative joint disease that is the most common form of arthritis. It produces pain, swelling, and stiffness of the joints. It is the leading cause of disability in the U.S., with about 43% of arthritis sufferers limited in mobility and about a third having limitations that affect their ability to perform their work. Knee osteoarthritis effects 5% of adults over 25 years of age and 12% of those over 65. It is painful and disabling. Its causes are varied including, hereditary, injury including sports injuries, repetitive stress injuries, infection, or from being overweight.

 

There are no cures for knee osteoarthritis. Treatments are primarily symptomatic, including weight loss, exercise, braces, pain relievers and anti-inflammatory drugs, corticosteroids, arthroscopic knee surgery, or even knee replacement. Gentle movements of the joints with exercise and physical therapy appear to be helpful in the treatment of knee osteoarthritis. This suggests that alternative and complementary practices that involve gentle knee movements may be useful for treatment.

 

Various forms of traditional Chinese exercises, such as Tai Chi, Qigong, and Baduanjin involve slow gentle movements of the limbs and mindfulness and have been shown to reduce the physical symptoms of knee osteoarthritis. Another mindfulness practice, yoga, has been shown to be a safe and effective treatment for a wide variety of physical and psychological conditions, including arthritis. So, it would seem reasonable to look further into the effectiveness of yoga practice in treating knee osteoarthritis.

 

In today’s Research News article “Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569242/, Cheung and colleagues recruited elderly (>60 years of age) participants with knee osteoarthritis and randomly assigned them to one of three conditions; Hatha Yoga, Strengthening Exercise, or Education Control. The yoga and exercise training occurred in 8 weekly 45-minute sessions supplemented with 4 30-minute sessions per week at home. The Education Control consisted of the distribution of pamphlets on knee osteoarthritis. Participants were measured before, the midpoint (4 weeks), and after training for knee osteoarthritis pain, stiffness, and physical function, lower extremity function, anxiety, depression, fear of falling, spiritual health, quality of life, program satisfaction, and adherence to the program.

 

They found that compared to the education condition, the Hatha Yoga and strengthening exercise practices produced significantly greater improvements in overall knee osteoarthritis symptoms, including pain, physical function, chair stands, walking, anxiety, and fear of falling. But, the Hatha Yoga practice compared to the strengthening exercise produced significantly superior improvements in overall knee osteoarthritis symptoms, including pain, physical function, anxiety, and fear of falling. Hence, although both exercises produced significant improvements in the symptoms of knee osteoarthritis, Hatha Yoga was significantly better. Importantly, no adverse events were produced by the Hatha Yoga practice.

 

These are important results as, although yoga has been previously shown to improve knee osteoarthritis symptoms, it has not been shown to be superior to other exercise programs. This superiority suggests that the mindfulness components of yoga have benefits for knee osteoarthritis in addition to the gentle exercise components. This may be due to the ability of mindfulness training to reduce anxiety and stress responses which are known to amplify pain and fear. Regardless, the findings clearly indicate that Hath Yoga practice is safe and effective and should be recommended for elderly individuals with knee osteoarthritis.

 

So, improve knee osteoarthritis in older adults with yoga.

 

“For the millions of older adults who suffer from osteoarthritis in their lower extremities (hip, knee, ankle or foot), chair yoga is proving to be an effective way to reduce pain and improve quality of life while avoiding pharmacologic treatment or adverse events.” – Florida Atlantic University

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Cheung, C., Wyman, J. F., Bronas, U., McCarthy, T., Rudser, K., & Mathiason, M. A. (2017). Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial. Rheumatology International, 37(3), 389–398. http://doi.org/10.1007/s00296-016-3620-2

 

Abstract

Although exercise is often recommended for managing osteoarthritis (OA), limited evidence-based exercise options are available for older adults with OA. This study compared the effects of Hatha yoga (HY) and aerobic/strengthening exercises (ASE) on knee OA. Randomized controlled trial with three arms design was used: HY, ASE, and education control. Both HY and ASE groups involved 8 weekly 45-min group classes with 2–4 days/week home practice sessions. Control group received OA education brochures and weekly phone calls from study staff. Standardized instruments were used to measure OA symptoms, physical function, mood, spiritual health, fear of falling, and quality of life at baseline, 4 and 8 weeks. HY/ASE adherences were assessed weekly using class attendance records and home practice video recordings. Primary analysis of the difference in the change from baseline was based on intent-to-treat and adjusted for baseline values. Eight-three adults with symptomatic knee OA completed the study (84% female; mean age 71.6 ± 8.0 years; mean BMI 29.0 ± 7.0 kg/m2). Retention rate was 82%. Compared to the ASE group at 8 weeks, participants in the HY group had a significant improvement from baseline in perception of OA symptoms (−9.6 [95% CI −15.3, −4]; p = .001), anxiety (−1.4 [95% CI −2.7, −0]; p = .04), and fear of falling (−4.6 [−7.5, −1.7]; p = .002). There were no differences in class/home practice adherence between HY and ASE. Three non-serious adverse events were reported from the ASE group. Both HY and ASE improved symptoms and function but HY may have superior benefits for older adults with knee OA.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569242/

Reduce Medical Resident Burnout with Mindfulness

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Reduce Medical Resident Burnout with Mindfulness

 

By John M. de Castro, Ph.D.

 

“Mindfulness meditation introduces a way of cultivating awareness of one’s relationship with the present moment. With practice, it may lead to healthier ways of working with stressful life experiences, including those inherent to residency training.” – Vincent Minichiello

 

Stress is epidemic in the western workplace with almost two thirds of workers reporting high levels of stress at work. In high stress occupations, like healthcare, burnout is all too prevalent. Burnout is the fatigue, cynicism, emotional exhaustion, sleep disruption, and professional inefficacy that comes with work-related stress. It is estimated that over 45% of healthcare workers experience burnout. Currently, over a third of healthcare workers report that they are looking for a new job. It not only affects the healthcare providers personally, but also the patients, as it produces a loss of empathy and compassion. Burnout it is a threat to the healthcare providers and their patients. In fact, it is a threat to the entire healthcare system as it contributes to the shortage of doctors and nurses.

 

Preventing burnout has to be a priority. Unfortunately, it is beyond the ability of the individual to change the environment to reduce stress and prevent burnout, so it is important that methods be found to reduce the individual’s responses to stress; to make the individual more resilient when high levels of stress occur. Contemplative practices have been shown to reduce the psychological and physiological responses to stress. Indeed, mindfulness has been shown to be helpful in treating and preventing burnout, increasing resilience, and improving sleep. It would be best to provide techniques to combat burnout early in a medical career. Medical residency is an extremely stressful period and many express burnout symptoms. This would seem to be an ideal time to intervene.

 

In today’s Research News article “Mindfulness, burnout, and effects on performance evaluations in internal medicine residents.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5565254/, Braun and colleagues recruited medical residents and had them complete measures of mindfulness, burnout, depression, and stress. They were also rated by the staff for their level of professional development.

 

They found that 71% of the residents met the criterion for burnout and this was associated with poor performance in their residency. Importantly, dispositional mindfulness, particularly “acting with awareness,” was significantly, negatively associated with meeting the burnout criterion, such that low mindfulness predicted a high likelihood of burnout. Burned-out residents tended to be low in mindfulness while resilient residents tended to be high in mindfulness.

 

These are interesting results, but were correlational, so causal relationships cannot be determined. Nevertheless, previous studies have demonstrated that mindfulness training can reduce burnout. This combined with the present results suggest that being mindful and acting with awareness are helpful for preventing burnout.  It remains for future research to demonstrate if mindfulness training can prevent burnout in medical residents.

 

So, reduce medical resident burnout with mindfulness.

 

“Having a greater ability to recognize what’s going on inside allows you to set aside distractions and really attend to the moment. Paradoxically, what you learn in meditation is that turning toward the distress and becoming curious about it rather than being swept away by it is a way to detoxify it. The more we try to escape the stress, the worse it becomes.” – Ron Epstein

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Braun, S. E., Auerbach, S. M., Rybarczyk, B., Lee, B., & Call, S. (2017). Mindfulness, burnout, and effects on performance evaluations in internal medicine residents. Advances in Medical Education and Practice, 8, 591–597. http://doi.org/10.2147/AMEP.S140554

 

Abstract

Purpose

Burnout has been documented at high levels in medical residents with negative effects on performance. Some dispositional qualities, like mindfulness, may protect against burnout. The purpose of the present study was to assess burnout prevalence among internal medicine residents at a single institution, examine the relationship between mindfulness and burnout, and provide preliminary findings on the relation between burnout and performance evaluations in internal medicine residents.

Methods

Residents (n = 38) completed validated measures of burnout at three time points separated by 2 months and a validated measure of dispositional mindfulness at baseline. Program director end-of-year performance evaluations were also obtained on 22 milestones used to evaluate internal medicine resident performance; notably, these milestones have not yet been validated for research purposes; therefore, the investigation here is exploratory.

Results

Overall, 71.1% (n = 27) of the residents met criteria for burnout during the study. Lower scores on the “acting with awareness” facet of dispositional mindfulness significantly predicted meeting burnout criteria χ2(5) = 11.88, p = 0.04. Lastly, meeting burnout criteria significantly predicted performance on three of the performance milestones, with positive effects on milestones from the “system-based practices” and “professionalism” domains and negative effects on a milestone from the “patient care” domain.

Conclusion

Burnout rates were high in this sample of internal medicine residents and rates were consistent with other reports of burnout during medical residency. Dispositional mindfulness was supported as a protective factor against burnout. Importantly, results from the exploratory investigation of the relationship between burnout and resident evaluations suggested that burnout may improve performance on some domains of resident evaluations while compromising performance on other domains. Implications and directions for future research are discussed.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5565254/

Mindfulness is Associated with Reduced Inflexibility and Psychopathology in Adolescents

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Mindfulness is Associated with Reduced Inflexibility and Psychopathology in Adolescents

 

By John M. de Castro, Ph.D.

 

“As present-moment focused, mindfulness, acceptance, and defusion interventions alter the context, behavioral flexibility emerges and, with it, increased sensitivity to context, including that aspect of context we call consequences.” – Kelly Wilson

 

Adolescence should be a time of mental, physical, social, and emotional growth. It is during this time that higher levels of thinking, sometimes called executive function, develops. These executive functions are an important foundation for success in the complex modern world. But, adolescence can be a difficult time, fraught with challenges. During this time the child transitions to young adulthood; including the development of intellectual, psychological, physical, and social abilities and characteristics. There are so many changes occurring during this time that the child can feel overwhelmed and unable to cope with all that is required.

 

Making these profound changes successfully requires a good deal or flexibility, adapting and changing with the physical, psychological, and social changes of adolescence. In today’s Research News article “Inflexible Youngsters: Psychological and Psychopathological Correlates of the Avoidance and Fusion Questionnaire for Youths in Nonclinical Dutch Adolescents.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605724/, Muris and colleagues examined the relationships between mindfulness, inflexibility and mental health in adolescents. They recruited youths aged 12 to 16 years and had them complete measures of mindfulness, psychological inflexibility, thought suppression self-compassion, self-worth, self-efficacy, somatization, psychopathological symptoms, anxiety, depression, and aggression.

 

They found that the higher the levels of mindfulness the lower the levels of inflexibility, thought suppression, somatization, anxiety, depression, emotional problems, aggression, oppositional conduct, and the higher the levels of self-worth and self-efficacy. They also found that psychological inflexibility was inversely related to the same variables, with higher levels of inflexibility associated with higher levels of thought suppression, somatization, anxiety, depression, emotional problems, aggression, oppositional conduct, and the lower the levels of self-worth and self-efficacy. In other words, mindfulness was associated with positive mental health while inflexibility was associated with negative mental health in these youths.

 

They further investigated the effectiveness of psychological inflexibility to affect the mental health of the adolescents while holding mindfulness mathematically constant. They found that each had independent contributions to the levels of anxiety and depression, with mindfulness associated with lower values and inflexibility associated with higher values. So, mindfulness and psychological inflexibility appear to be independently associated with emotional health in adolescents.

 

It is important to keep in mind that this study was correlational and did not manipulate the levels of any variables. So, causal connections cannot be determined between the variables. The associations though suggest that both mindfulness and psychological flexibility are important contributors to the psychological development of adolescents. It will be interesting to investigate in future research whether training in mindfulness and flexibility will help to promote healthy mental health in youths.

 

“While psychological inflexibility was most strongly associated with Neuroticism , as expected, mindfulness demonstrated the strongest association with consciousness, a trait reflecting impulse control abilities and attention to detail.” – Robert Latzman

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Muris, P., Meesters, C., Herings, A., Jansen, M., Vossen, C., & Kersten, P. (2017). Inflexible Youngsters: Psychological and Psychopathological Correlates of the Avoidance and Fusion Questionnaire for Youths in Nonclinical Dutch Adolescents. Mindfulness, 8(5), 1381–1392. http://doi.org/10.1007/s12671-017-0714-1

 

Abstract

The present study examined psychological and psychopathological correlates of psychological inflexibility as measured by the Avoidance and Fusion Questionnaire for Youth (AFQ-Y) in two independent samples of nonclinical Dutch adolescents aged between 12 and 18 years (Ns being 184 and 157). Participants completed a survey containing the AFQ-Y and scales assessing mindfulness, thought suppression, self-compassion, self-worth, self-efficacy, and internalizing/externalizing symptoms. In both samples, the AFQ-Y was found to be a reliable measure of psychological inflexibility that correlated in a theoretically meaningful way with other psychological constructs. Most importantly, AFQ-Y scores correlated positively with internalizing and externalizing symptoms, and in most cases, these associations remained significant when controlling for other measures. These findings suggest that psychological inflexibility is an important factor in youth psychopathology that needs to be further investigated in future research.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605724/

Improve Emotions of Ethnically Diverse At-Risk Students with Mindfulness

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Improve Emotions of Ethnically Diverse At-Risk Students with Mindfulness

 

By John M. de Castro, Ph.D.

 

“There is plenty of evidence available now that demonstrates the value of teaching mindfulness to young people, and many of the benefits of mindfulness are skills and dispositions that are especially helpful in the context of education. Mindfulness practices help children improve their ability to pay attention, by learning to focus on one thing (e.g., breath, sound) while filtering out other stimuli. Mindfulness also provides kids with skills for understanding their emotions and how to work with them.” – Sarah Beach

 

Adolescence should be a time of mental, physical, social, and emotional growth. It is during this time that higher levels of thinking, sometimes called executive function, develops. These executive functions are an important foundation for success in the complex modern world. But, adolescence can be a difficult time, fraught with challenges. During this time the child transitions to young adulthood; including the development of intellectual, psychological, physical, and social abilities and characteristics. There are so many changes occurring during this time that the child can feel overwhelmed and unable to cope with all that is required. These difficulties can be markedly amplified by negative life events during childhood.

 

At-risk youth confront unique pressures that have been linked to poor psychosocial outcomes, impaired academic performance, and maladaptive behaviors such as substance use and delinquency. These risk factors may include language barriers, low SES, parents’ own involvement in high risk or illegal behavior, restrictive or neglectful parenting, and home environments that expose children to alcohol and substance abuse. Mindfulness training has been found to be helpful for adolescents and also to improve performance in school. So, it is possible that mindfulness training would be helpful for at-risk adolescents.

 

In today’s Research News article “A School-Based Mindfulness Pilot Study for Ethnically Diverse At-Risk Adolescents.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809539/pdf/nihms652885.pdf, Bluth and colleagues recruited adolescents who were attending an alternative high school for troublesome and at-risk students. They were randomly assigned to receive either and 11-week class of mindfulness training or substance abuse training. The mindfulness training included body scan, sitting meditation, lovingkindness practice, walking meditation and mindful movement. The substance abuse training consisted of lectures designed to help adolescents address drug use and co-occurring life problems. The students were measured before and after the trainings for class attendance, retention, program acceptability, mindfulness, self-compassion, social connectedness, anxiety, depression, and perceived stress.

 

At the beginning of the mindfulness training there was considerable resistance and acting out. But, by the end of training the students responded that the class was helpful and wanted it to continue. They also found that the mindfulness training produced significant improvements in the students’ depression and anxiety levels. Mindfulness training has in the past been repeatedly shown to help relieve depression and anxiety. But, it is an important finding that it can do so in these difficult to treat at-risk adolescents. So, the study showed that mindfulness training was feasible and acceptable to these at-risk adolescents and produced improvements in their negative emotions.

 

The results are encouraging. These troubled youths are extremely difficult to work with and treat and that was reflected in the negative behaviors at the beginning of the class. But, by the end of the class the students found the mindfulness training useful and there were fairly large improvements in anxiety and depression. There were trends for other improvements and a larger future trial may be able to demonstrate other benefits of the mindfulness training. Although it was clear that mindfulness training is not a panacea for troubled youths, it can be helpful and provide space for them to destress and explore their inner lives.

 

So, improve emotions of ethnically diverse at-risk students with mindfulness.

 

“But a growing body of evidence suggests that mindfulness practice could be beneficial to teens, helping them cultivate empathy, as well as skills for concentration and impulse control. In short, mindfulness can help adolescents navigate the challenges of adolescence.” Sarah Beach

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Bluth, K., Campo, R. A., Pruteanu-Malinici, S., Reams, A., Mullarkey, M., & Broderick, P. C. (2016). A School-Based Mindfulness Pilot Study for Ethnically Diverse At-Risk Adolescents. Mindfulness, 7(1), 90–104. http://doi.org/10.1007/s12671-014-0376-1

 

Adolescence is a transitional period marked by rapid physical, behavioral, emotional, and cognitive developmental changes. In addition to these normative development changes, adolescents also face a multitude of contextual stressors such as academic pressures at school, changing relationships with peers, and all too often, unstable family life characterized by divorce, frequent moves, income and occupational changes, and disruptions in family routines. Up to a quarter of adolescents suffer from depression or anxiety disorders, and an even larger proportion struggle with subclinical symptoms. Anxiety and depression during this stage can lead to impaired academic, social, and family functioning, and have long-term adverse outcomes.

Given the need to better understand both the implementation and potential benefit of mindfulness programs for at-risk youth, we conducted a randomized pilot study to investigate the feasibility and acceptability of such an intervention with ethnically diverse, primarily Hispanic youth enrolled in an alternative high school. We specifically examine intervention effects on psychosocial wellbeing and school performance relative to the control group, a class which focused on substance abuse prevention.

this study contributes to the literature by confirming the feasibility and acceptability of a mindfulness intervention with this population, and expands our knowledge on what works.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809539/pdf/nihms652885.pdf

Improve Multiple Sclerosis with Meditation and Yoga

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Improve Multiple Sclerosis with Meditation and Yoga

 

By John M. de Castro, Ph.D.

 

“Studies show that for some people with MS, chronic exposure to stress is associated with worsening neurological symptoms and increased brain lesions. Researchers believe that mindfulness may help people better respond to stress by fostering healthier coping strategies. Mindfulness practice appears to be a safe, drug-free approach to coping with stress and anxiety, which may in turn help reduce your MS symptoms.” – Amit Sood

 

Multiple Sclerosis (MS) is a progressive demyelinating disease which attacks the coating on the neural axons which send messages throughout the body and nervous system. It affects about 2 million people worldwide and about 400,000 in the U.S. It is most commonly diagnosed in people between the ages of 20 and 50 years.  Unfortunately, there is no cure for multiple sclerosis. There are a number of approved medications that are used to treat MS but are designed to lessen frequency of relapses and slow the progression of the disease, but they don’t address individual symptoms.

 

Although there is a progressive deterioration, MS is not fatal with MS patients having about the same life expectancy as the general population. Hence, most MS sufferers have to live with the disease for many years. So, quality of life becomes a major issue. Quality of life with MS is affected by fatigue, cognitive decrements, physical impairment, depression, and poor sleep quality. There is a thus a critical need for safe and effective methods to help relieve the symptoms of MS and improve quality of life.

 

Mindfulness practices have been previously shown to improve depression, sleep quality, cognitive impairments, emotion regulation, and fatigue. It has also been shown to improve the symptoms of multiple sclerosis.  Yoga is a mindfulness practice that has the added feature of exercising and stretching the muscles. It would seem likely that yoga practice might be an ideal treatment for improving the quality of life and lessening symptoms in patients with multiple sclerosis.

 

In today’s Research News article “Mindfulness in Motion for People with Multiple Sclerosis: A Feasibility Study.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649345/, Gilbertson and Klatt examined the combination of meditation and chair yoga practice which in the treatment of multiple sclerosis. They called this program “Mindfulness in Motion.” In a pilot feasibility study, they recruited patients with multiple sclerosis and provided them with 8 weeks of the “Mindfulness in Motion” program. The program met once a week for one hour and participants were expected to practice at home for 20 minutes every day. Participants were measured before and after the 8 weeks of practice for mindfulness, fatigue, anxiety, depression, behavior control, and positive affect, physical functioning, role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health.

 

They found that compared to baseline after completing the “Mindfulness in Motion” program the participants showed significant improvements in physical functioning, role-physical, vitality, mental health, anxiety, depression, and positive affect and cognitive and psychosocial fatigue and mindfulness including observing, acting with awareness, nonjudgment, and nonreactivity. Hence, after the 8-week “Mindfulness in Motion” program the participants showed marked and significant improvements in the psychological symptoms of multiple sclerosis.

 

It needs to be kept in mind that this study was a pilot feasibility study that did not have an active control condition, so conclusions must be made carefully. But, this is an extremely encouraging first step that suggests that the combination of two practices which individually produce symptom relief, meditation and chair yoga practice, is a particularly effective treatment for the psychological symptoms of multiple sclerosis.

 

So, improve multiple sclerosis with meditation and yoga.

 

“Studies in multiple sclerosis, these have shown that mindfulness can improve quality of life and help people cope better with their MS. The studies also found that it decreased stress, anxiety and depression.” – MS Trust

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Rachel M. Gilbertson, Maryanna D. Klatt. Mindfulness in Motion for People with Multiple Sclerosis: A Feasibility Study. Int J MS Care. 2017 Sep-Oct; 19(5): 225–231. doi: 10.7224/1537-2073.2015-095

 

Abstract

Background:

Mindfulness in Motion is an 8-week mindfulness-based intervention that uses yoga movement, mindfulness meditation, and relaxing music. This study examined the feasibility of using Mindfulness in Motion in people with multiple sclerosis (MS) and the effect of this program on stress, anxiety, depression, fatigue, and quality of life in people with MS.

Methods:

Twenty-two people with MS completed the 8-week mindfulness program as well as assessments 1 week before and after the intervention.

Results:

Pre/post comparison of four self-reported questionnaires—the Mental Health Inventory, 36-item Short Form Health Status Survey, Modified Fatigue Impact Scale, and Five Facet Mindfulness Questionnaire—showed significant improvement in physical functioning, vitality, and mental health. Specifically, improvements were seen in anxiety, depression, and positive affect; cognitive, psychosocial, and overall functioning regarding fatigue; and mindfulness in the areas of observing, acting with awareness, nonjudgment, and nonreactivity.

Conclusions:

Due to the uncertainty in disease progression associated with MS, and the multiplicity of mental and physical symptoms associated with it, programming that addresses anxiety, depression, and fatigue is a key area of future research in MS disease management. Mindfulness in Motion proved to be a feasible program yielding positive results, supporting the need for research to determine the extent to which the program can improve quality-of-life outcomes for people with MS.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649345/

Slightly Improve Substance Use Disorder with Mindfulness

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Slightly Improve Substance Use Disorder with Mindfulness

 

By John M. de Castro, Ph.D.

 

“though it may seem paradoxical, by increasing your ability to accept and tolerate the present moment, you become more able to make needed changes in your life. . . Also, practicing balanced emotional responses can reduce your stress level, and anxiety and stress are often triggers for substance abuse and addictive behavior. In addition, when you choose a neutral rather than a judgmental response to your thoughts and feelings, you can increase your sense of self-compassion rather than beating yourself up, which is often associated with addictive behaviors.” – Adi Jaffe

 

Substance abuse is a major health and social problem. There are estimated 22.2 million people in the U.S. with substance dependence. It is estimated that worldwide there are nearly ¼ million deaths yearly as a result of illicit drug use which includes unintentional overdoses, suicides, HIV and AIDS, and trauma. In the U.S. about 17 million people abuse alcohol. Drunk driving fatalities accounted for over 10,000 deaths annually. Obviously, there is a need to find effective methods to prevent and treat substance abuse. There are a number of programs that are successful at stopping the drug abuse, including the classic 12-step program emblematic of Alcoholics Anonymous. Unfortunately, the majority of drug and/or alcohol abusers relapse and return to substance abuse. Hence, it is important to find an effective method to prevent these relapses.

 

Mindfulness practices have been shown to improve recovery from various addictions. Mindfulness-based Relapse Prevention (MBRP) has been developed to specifically assist in relapse prevention and has been shown to be effective. “MBRP integrates mindfulness practices with cognitive-behavioral Relapse Prevention therapy and aims to help participants increase awareness and acceptance of difficult thoughts, feelings, and sensations to create changes in patterns of reactive behavior that commonly lead to relapse. Mindfulness training in MBRP provides clients with a new way of processing situational cues and monitoring internal reactions to contingencies, and this awareness supports proactive behavioral choices in the face of high-risk relapse situation.” – Grow et al. 2015

 

In today’s Research News article “Mindfulness-based Relapse Prevention for Substance Use Disorders: A Systematic Review and Meta-analysis.” See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5636047/, Grant and colleagues review and perform a meta-analysis of the published research literature on the effectiveness of Mindfulness-based Relapse Prevention (MBRP) in treating substance use disorder. They identified 9 randomized controlled trials and examined the effects of MBRP on relapse, frequency and quantity of substance use, withdrawal/craving symptoms, treatment dropout, depressive and anxiety symptoms, negative consequences from substance use, and health-related quality of life and also its safety

 

They found that the summarized published research literature reported few and small positive effects. On most of the outcome measures there were no significant improvements produced by MBRP. Small significant improvements were found for withdrawal effects and cravings and the negative effects of substance use. They found that there were no adverse effects of MBRP. These are disappointing results that suggest that Mindfulness-based Relapse Prevention (MBRP) is safe but only slightly effective in treating substance use disorder.

 

These are surprising results as individual trials have reported significant effects. But, it appears that the different trials reported significant effects on different variables with some finding effects on a measure while others finding no effects on the same measure but reporting effects on different measures. When summarized, the reported effects appear to average away. Substance use disorder is such an important social and health issue where there are few viable treatment options, that further research on Mindfulness-based Relapse Prevention (MBRP) is warranted to investigate what components are effective and which not and how to optimize effectiveness.

 

So, slightly improve substance use disorder with mindfulness.

 

“Modeled after mindfulness-based cognitive therapy for depression and mindfulness-based stress reduction, MBRP tackles the very roots of addictive behavior by targeting two of the main predictors of relapse: negative emotions and cravings.” – Carolyn Gregoire

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Sean Grant, Benjamin Colaiaco, Aneesa Motala, Roberta Shanman, Marika Booth, Melony Sorbero, Susanne Hempel. Mindfulness-based Relapse Prevention for Substance Use Disorders: A Systematic Review and Meta-analysis. J Addict Med. 2017 Sep; 11(5): 386–396. Published online 2017 Jul 19. doi: 10.1097/ADM.0000000000000338

 

Abstract

Objectives:

Substance use disorder (SUD) is a prevalent health issue with serious personal and societal consequences. This review aims to estimate the effects and safety of Mindfulness-based Relapse Prevention (MBRP) for SUDs.

Methods:

We searched electronic databases for randomized controlled trials evaluating MBRP for adult patients diagnosed with SUDs. Two reviewers independently assessed citations, extracted trial data, and assessed risks of bias. We conducted random-effects meta-analyses and assessed quality of the body of evidence (QoE) using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Results:

We identified 9 randomized controlled trials comprising 901 participants. We did not detect statistically significant differences between MBRP and comparators on relapse (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.46–1.13, low QoE), frequency of use (standardized mean difference [SMD] 0.02, 95% CI −0.40 to 0.44, low QoE), treatment dropout (OR 0.81, 95% CI 0.40 to 1.62, very low QoE), depressive symptoms (SMD −0.09, 95% CI −0.39 to 0.21, low QoE), anxiety symptoms (SMD −0.32, 95% CI −1.16 to 0.52, very low QoE), and mindfulness (SMD −0.28, 95% CI −0.72 to 0.16, very low QoE). We identified significant differences in favor of MBRP on withdrawal/craving symptoms (SMD −0.13, 95% CI −0.19 to −0.08, I2 = 0%, low QoE) and negative consequences of substance use (SMD −0.23, 95% CI −0.39 to −0.07, I2 = 0%, low QoE). We found negligible evidence of adverse events.

Conclusions:

We have limited confidence in estimates suggesting MBRP yields small effects on withdrawal/craving and negative consequences versus comparator interventions. We did not detect differences for any other outcome. Future trials should aim to minimize participant attrition to improve confidence in effect estimates.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5636047/