Stress and Staying Alive

Professor John. R. White, Jr.

| Jan 3, 2008

You and everybody else alive encounter stress, daily, hourly and minute by minute. As unavoidable, inscrutable, and sometimes as aggressive as the IRS, stress is part of the human condition. It is not just a sense of being tense but is any event that causes a complex physiologic response called the "stress response."

While most people view stress as being something that is always negative, stress in fact can be good or bad. Negative stress can be caused by many things, such as the death of a spouse or something as simple as being stuck in traffic. Positive stress can be the type you encounter in dating, public speaking, running a 5K race and many other daily activities.

Stress exists at many levels, from physical (injury, dehydration, heart attack) to emotional (loneliness, grief, financial insecurity, job-related problems). The question is not "Do we experience stress?" the question should be, "How do we manage our stress?" Sally Maxwell, a yoga instructor, once commented, "If you do not manage your stress, it will manage you." And if stress is managing you, things will not go well.

There are, however, relatively easy to follow and effective ways to manage stress. We'll take a look at how humans respond to stress, and the problems and diseases associated with it, as well as some of the more notable methods used to mitigate it.

The Evolution from Infection to Stress

During the first part of the 20th century most deaths in the United States were due to infectious diseases. The diseases that our great-grandparents worried about were, among others, pneumonia, influenza and polio. Today, we are more likely to be concerned about heart disease, diabetes, stroke and cancer. While it is not scientifically sound to say that all of these problems are caused by stress, we're on fairly solid ground when we suggest that stress does have an impact on blood vessel disease - heart disease, stroke, hypertension - "metabolic syndrome" (defined below) and even diabetes.

Dr. Robert Sapolsky, a professor of neurology at Stanford University, says that we suffer from diseases of luxury. Generally speaking, we eat too much, exercise too little and live very stressful lives, usually without ever stopping to think about ways to manage our stress. We don't typically die at the age of 35 from pneumonia but live longer and suffer from diseases that are essentially the slow accumulation of damage - with much of the damage due to stress.

In the 1920s, Harvard scientist Dr. Walter Cannon studied the short-term effects of stress on laboratory animals. This was before the term "stress" was even used in physiologic studies. He found that when faced with danger, animals responded with what he referred to as a "fight-or-flight" reaction. This was, in fact, an initial stress response. Further studies suggested that "fight or flight" was a reaction that was innate and consistent across species. Blood pressure, blood sugar, heart rate and respiratory rate all would go up.

What happens to animals placed under longer-term conditions of high stress? Canadian endocrinologist Dr. Hans Selye did much of the early work on stress and was even the first to apply the term "stress" to animal physiology. He discovered early on that stress in laboratory animals caused ulcers, a reduction in their immune response and the ramped-up production of a hormone called cortisol.

It turned out that stress caused a plethora of responses, which came to be known simply as "the stress response." The two primary hormones in the stress response are epinephrine (a.k.a. Adrenaline®) and cortisol (similar to hydrocortisone, prednisone, medrol and others). Both hormones cause an increase in blood sugar. Short term, this makes sense. Long term, it can be devastating. For example, you wake up one night and smell smoke. You stress response kicks in and a number of things happen almost immediately:

  1. Your glucose goes up (your main energy source)
  2. Your blood pressure goes up, your heart rate goes up, your rate of breathing increases (you are now better able to deliver the energy source, glucose, to your body)
  3. You turn off digestion (now is not the time to digest the steak that you ate for dinner)
  4. Your immune response is suppressed (now is not the time for your body to worry about catching a cold)
  5. Your mind is clear, your senses are heightened and the situation may seem to occur in slow motion. You arise, wake your spouse and rapidly leave the house.

This is an effective acute stress response. However if this response is maintained long-term, damage ensues.

One way of describing stress is to say that it is anything that knocks you out of balance; physical, emotional, mental or spiritual. Humans have the ability to not only recognize that they have been knocked out of balance, but also the ability to recognize that they are about to be knocked out of balance.

If you correctly predict a stressor, then you may be able to avoid unpleasantness or an emergency; for example, paying your bills on time or moving out of the way of a speeding taxi. However, if you constantly incorrectly predict stressors or view small problems as being larger than they really are then the volume on your stress-response system will be turned up all of the time.

Too Much of a Good Thing

In today's society, most of us probably have stress-response volumes turned up to eight or nine out of 10. Dr. Saplosky said about the stress response system, "It was a system designed to be turned on for 30 seconds and we turn it on for 30 years worrying about Social Security." We turn on this very effective, but archaic, system, which was primarily designed to allow us to escape physical trouble, and we keep it on long-term for psychological reasons.

Does long-term activation of the stress-response system cause psychological and physical problems? Yes. Continuous long-term stress run amuck can result in or worsen fatigue, digestive problems, impotency, amenorrhea (the abnormal cessation of menstruation), increased infections, elevated blood pressure, elevated blood sugar, post-traumatic stress disorder, depression and more. Not surprisingly, it also causes a reduction in a sense of wellbeing.

Several years ago, Gerald Reaven, MD, now a professor emeritus at Stanford University School of Medicine, noticed that many of his patients with type 2 diabetes often would come to his clinic with high blood pressure, obesity, amenorrhea, high blood fats, cardiac disease and several other problems. Because of his observations, this collection of problems came to be known as Reaven's syndrome. Later it was called insulin resistance syndrome and syndrome-X, and is now referred to as metabolic syndrome.

You must have at least three of the following problems in order to be diagnosed with metabolic syndrome:1) abdominal obesity; 2) high triglycerides; 3) low HDL (good cholesterol); 4) high blood pressure; and 5) high blood glucose. Many people with type 2 diabetes also have metabolic syndrome and many people with metabolic syndrome who do not have diabetes will eventually develop it.

Last year researchers published a study in the British Medical Journal that evaluated the association between stress at work and the development of metabolic syndrome. This study, carried out in London, measured job-related stress in more than 10,000 people working in civil service over a 14-year period. Researchers found that the greater the demands of the job were and the less control that the worker had over it, the greater the stress - and also a greater chance of developing metabolic syndrome.

Workers with chronic stress had a twofold greater chance of developing metabolic syndrome. Scientists reasoned that high stress levels caused elevated cortisol levels in the workers, which in turn caused elevated glucose, elevated insulin resistance, low HDL, and other abnormalities in fat disposition.

What Can You Do About Stress?

So what, if anything, can be done to mitigate the deleterious effects of chronic stress in an era of information overload, long work hours, constant e-mails, 999 television channels, war, global warming and the sky-is-falling mentality fostered by the contemporary press? Could ancient solutions be useful for today's problems? The answer appears to be a resounding "yes"!

In the 1970s Harvard cardiologist Herbert Benson, MD, coined the phrase "relaxation response," the key to managing chronic stress. Benson published a seminal manuscript in the journal Psychiatry in 1974 that reported that after 20 minutes of meditation (not medication) an individual's blood pressure, heart rate, respiratory rate, oxygen use, lactic acid production and carbon dioxide production all dropped. This short period of quieting the mind seemed to cause reversal of the stress-response.

A more recent work published by Tobias Esch at The Mind/Body Institute at Harvard suggests that the relaxation response can be achieved by not only meditation but also by some forms of prayer, Tai Chi and Yoga. Other activities, such as imagery, affirmations, biofeedback and distance running may have the same effect but have not been as well studied. It does seem, based on what we currently know, that you must get yourself into a quiet state of mind in order to realize the benefits of the relaxation response.

Dr. Jon Kabat-Zinn, an expert on meditation at the University of Massachusetts School of Medicine, says that for the majority of his patients, regardless of diagnosis, meditation resulted in reduced anxiety, depression and hostility. Also, studies have also shown that meditators have a more profound positive response to the same immune system stimulus when compared to non-meditators.

You do not need a guru, or even a trip to India in order to get into the state of mind that causes this relaxation response. You need only four things:

  1. A relatively quiet place (or a loud place with noise-canceling headphones)
  2. A mental device - something to focus your thoughts on. This can be a simple word like "peace" or "hope;" or a short prayer or phrase that you can repeat over and over; or a sound like "Om," the traditional Hindu chant; or simply focus on your breathing
  3. A passive attitude that in a non-judgmental, non-critical manner will allow you to return to the object of focus when other thoughts intrude - and other thoughts will intrude
  4. A comfortable position, such as sitting in a chair with your feet flat on the ground or on a cushion on the floor (but either way with your back uplifted).

Spend 10 to 20 minutes as relaxed as possible while focusing on your chosen mental device. When outside thoughts intrude simply refocus on the mental device. If you do this daily for a week or two you will see a profound shift in your perception of daily life. Try it and see.

Another useful technique for stress mitigation is yoga. Yoga, depending on the type that you practice, may serve the dual purpose of quieting the mind and offering a physical workout. Yoga studios have proliferated almost as fast a cell phones over the past decade and it is difficult to walk more that a few blocks in any urban area without coming across one or more of them.

However, to the uninitiated yoga can be confusing, complicated, and even a bit strange. Before you launch into a yoga class for your first time, shop around and do a bit of research. Call the studio and talk to an instructor and tell him or her about your current level of physical activity and your previous experience or lack of with yoga. If you are not physically active, talk to your physician before starting yoga.

Keep in mind that yoga comes in many flavors: Ashtanga, Bikram, Iyengar, Kundalini, Hatha and others. Some forms are extremely physically demanding and some, such as Bikram, could even potentially be dangerous for a person with diabetes. For first-timers, Hatha yoga is a good bet. It is widely practiced in the United States, is relatively gentle, focuses on poses and breathing, is very relaxing and is a great stress reliever.

Does yoga really offer benefits? Yes. Studies have demonstrated that yoga, along with psychosocial support, low-fat diet and moderate aerobic exercise, has dramatic effects on reducing and even perhaps reversing cardiovascular problems. Many of the studies in the area were carried out by Dean Ornish, MD, from the University of California, San Francisco. More recently, Dr. Sally Blank at Washington State University did a study on cancer survivors that demonstrated that yoga intervention caused an improvement in the immune status, a reduction in anxiety and pain, and a reduction in depression in the study subjects.

What else can we do to mitigate stress? Generally speaking, studies have suggested that stress is more damaging if we:

  1. Have no outlet for it
  2. Have no way to predict when stress will occur and have no control over our stressors
  3. Are socially isolated.

Interestingly enough, social isolation is one the strongest predictors of negative medical outcomes. Socially isolated individuals have threefold higher death rates, cardiovascular disease, high cholesterol, are more likely to smoke, and are more likely to be obese than are similar individuals who are socially affiliated.

So, the key is to work on developing outlets for stress; learn something new, create something, challenge yourself. Try to gain the advantage over the situations that cause you stress. Ask for help, talk with others to seek a solution, set limits. Have friends and take good care of them. Thomas Jefferson said, "But friendship is precious, not only in the shade, but in the sunshine of life; and thanks to a benevolent arrangement of things, the greater part of life is sunshine."

Selected References

Benson H, Beary JF, Carol MP. The Relaxation Response. Psychiatry 1974;37:37-46

Chandola T, Brunner E, Marmot M. Chronic Stress at Work and the Metabolic Syndrome: prospective study. BMJ, 2006;332:521-525

Esch et al. The Therapeutic Use of the RR in Stress-Related Diseases. Med Sci Monit, 2003;9(2):23-34

Ornish et al. The Lifestyle Heart Trial. Lancet 1990;336:129-33

Sapolsky R. Why Zebras Don't Get Ulcers. Third Edition, 2004

Dr. White has been extensively involved in the field of diabetes since 1987. He has published two books, 17 book chapters, and more than 70 manuscripts on the topic of diabetes. He has secured more than $1.5 million in diabetes-related research grants and has received numerous awards, including Teacher of the Year at Washington State University's College of Pharmacy in 1992 and 1996. Currently, he is serving as a diabetes consultant and primary care provider at the Indian Health Service Clinic in Wellpinit, Wash.

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Jan 3, 2008

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