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1
 Peace of Mind
M O DULE 9

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of Healthy
Habits. Monterey, CA: Healthy Learning; 2021:319-347.
Disclaimer
• ACLM abides by strict professional and clinical standards with published
evidence-based positions and guidelines on the therapeutic approaches that
make up Lifestyle Medicine. These standards are posted for public review at
[Link]/aclm-standards.
• Members and certified professionals are authorized to use ACLM branding,
presentations and approved messaging for the enhancement of our stated
mission and vision. ACLM is not responsible nor accountable for individual
deviations, misrepresentations and misinterpretations.
• Faculty members utilizing this slide deck must acknowledge any slides or
content that have been added as it may represent the viewpoint of the
presenter and not the viewpoint of ACLM.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 3

 Acknowledgements
We gratefully acknowledge Dr. Beth Frates for her generous donations of slides and
content, derived from decades of her esteemed work in the field and educational contributions
at Harvard Extension School.

Editors: Kaitlyn Pauly MS, RDN, DipACLM; Shannon Worthman; Monami Brierley

Reviewers: Brenda Rea MD, DrPH, PT, RD; Wayne Dysinger MD, MPH, FACLM; Amanda McKinney MD;
Susan Benigas, MS

This PowerPoint was created under the umbrella of the

Lifestyle Medicine Pre-Professional Member Interest Group

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 4

Learning Objectives
By the end of this module, participants will be able to:
• Describe the connection between peace of mind and health
• Compare and contrast mindfulness, meditation, and relaxation
• Demonstrate familiarity with the Relaxation Response
• Recognize the barriers to having peace of mind

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 5

 Guiding Questions
• What is meditation?
• What is Mindfulness-Based Stress Reduction?
• What is the Relaxation Response?
• How does meditation affect the mind and body?
• What is the evidence that relaxation, mindfulness, and meditation
have positive effects on the body?

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the
Power of Healthy Habits. Monterey, CA: Healthy Learning; 2021:319.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 6

 Important Terms
• Meditation
• Mindfulness
• Mindfulness-based stress reduction
• Peace of mind
• Relaxation
• Relaxation response
• Relaxation technique
Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the
Power of Healthy Habits. Monterey, CA: Healthy Learning; 2021:320.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 7

Connections
• Themes are building on each
other.
• All these chapters are separate
but interrelated and connected.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 8

When people are stressed
• They may be too upset to sleep.
• They may eat to relieve stress.
• They may stop exercising because there is “no time.”
• They may avoid social gatherings.
• They may find it hard to appreciate humorous situations.
• They may focus on the negative.
• They may start finding relief with alcohol or drugs.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 9

STEPS TO HELP CREATE PEACE OF MIND

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 Recommended stress relievers
• Exercise-build up new neurons and connections
• Relaxation-meditation, tai chi, yoga, or a walk
• Socialization-maintaining relationships with a few close friends
• Empowerment-feeling in control over certain aspects of our own
lives

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 11

 Recommended stress relievers
• Humor and laughter-imagined laughter can reduce self reported
sadness
• Positive Thinking-coaching students to have positive thoughts
before an exam
• Gratitude Journal

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 12

Cross-Training
• Cardio, resistance training, flexibility, balance
• Vegetables, fruits, whole grains, protein (rainbow—variety)
• Stress management (many different modes)
• Peaceful mind (MBSR, meditation, & deep breathing)
• Topic of the day

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 13

THREE PATHS TO REDUCE STRESS AND ATTAIN A
PEACEFUL MIND

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Paths to a peaceful mind….
• Meditation
• Relaxation
• Mindfulness

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PATH #1 MEDITATION

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 Meditation
• “A capacity-building technique to manage stress and build
resilience.”
• SharpBrains
• The act or process of spending time in quiet thought.
• Merriam-Webster Dictionary online

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 17

Meditation and Ancient Times
Buddhists have
practiced meditation for
thousands of years.

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MEDITATION IN MODERN CULTURE

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Changing the Culture

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Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children; United States, 2007. 2008.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 21

 Use of Meditation 2012 to 2017
• National Government Survey results US:
• The use of meditation increased more than threefold
• 4.1% in 2012
• 14.2% in 2017
• The use of meditation was higher among adults aged 45–64
(15.9%) compared with those aged 18–44 and 65 and over
(13.4% each)
• Women were also more likely than men to use meditation
(16.3% compared with 11.8%)
Clarke TC, Barnes PM, Black LI, Stussman BJ, Nahin RL. Use of yoga, meditation, and chiropractors among US adults aged 18 and over. US Department of Health and Human
Services, Centers for Disease Control and …; 2018.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 22

TYPES OF MEDITATION

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 Meditation
Go beyond one’s automatic thinking to get to a deeper or more
grounded state.

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 24

 Basic Meditation
Trying to think about nothing

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 25

 Focused Attention Meditation
Focusing on a particular
object, either outside oneself
(such as a sound or a candle
or a mantra) or inside oneself
such as one’s breathing)

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 26

Open Monitoring Meditation
Focusing attention on being open to all aspects of the experience
rather than just one object.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 27

 Activity Oriented Meditation
Engaging in a repetitive activity such
as yoga or walking

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 28

 Transcendental Meditation
• Specific form of mantra meditation that is the most widely
practiced and scientifically studied
• Developed by Maharishi Mahesh Yogi
• Standardized training technique
• Sit comfortably with eyes closed

Wikipedia contributors. Transcendental Meditation. Wikipedia, The Free Encyclopedia. July 2, 2020, 21:08 UTC. Available
at: [Link] Accessed July 13, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 29

 Kirtan Kriya
Engaging in a repetitive
activity such as singing
• Kirtan Kriya
• Sa Ta Na Ma

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 30

 Spiritual Meditation
Engaging in spiritual practice such as
prayer

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 31

 Mindfulness Meditation
Becoming more fully aware, more
“mindful” of the present moment,
rather than thinking about the past
or future

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 32

THE FOUR ELEMENTS OF MEDITATION

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 Meditation and Four Main Elements
• 1) A quiet location
• 2) A specific, comfortable posture
• 3) A focus of attention
• 4) An open attitude

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power of
Healthy Habits. Monterey, CA: Healthy Learning; 2021:325.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 34

CURRENT UNDERSTANDING OF THE BIOLOGICAL
BASIS OF MEDITATION

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 35

 How meditation might work:
• Affecting the autonomic (involuntary) nervous system.
• Reducing activity in the sympathetic system and increasing activity in
the parasympathetic system.
• Breathing air into the lungs temporarily blocks parasympathetic
influence on heart rate.
• Breathing air out of the lungs reinstates parasympathetic influence on
heart rate so heart rate goes down.

Fernandez A, Goldberg E, Michelon P. The SharpBrains guide to brain fitness: How to optimize brain health and performance at any age. SharpBrains; 2013.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 36

 Autonomic Nervous System
Increased
Adrenalin/
Epinephrine

Vinik A. The Conductor of the Autonomic Orchestra. Frontiers in Endocrinology. 2012;3(71).

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 37

 HPA axis
Hypothalamus-Pituitary-Adrenal Axis

The Stress Response…and how it relates to the HPA Axis. Personalized Integrative Therapy. [Link]
Accessed July 17, 2020.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 38

 The ANTIDOTE to the stress response
• Antidote: a substance that stops the harmful effects of a poison:
something that corrects or improves the bad effects of something

The Merriam-Webster Dictionary. Merriam-Webster, Incorporated; 2006.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 39

THE IMPACT OF ROUTINE MEDITATION ON THE 11
SYSTEMS OF THE BODY

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 40

 Meditation and the Circulatory System
• Helps decreases blood pressure
• Slows the heart
• Reduces pulse and heart rate
• Diminishes the likelihood of blood clots and hardening of the
arteries
• Lowers the risk of cardiovascular disease

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:326.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 41

 Meditation and the Digestive System
• Helps stimulate digestion
• Enhances the production of saliva and enzymes in the mouth
• Facilitates the production of serotonin in the stomach
• Affects food choices

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:326.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 42

 Meditation and the Endocrine System
• Helps normalize endocrine activity
• Facilitates a restful sleep pattern
• Promotes appropriate hormonal levels, which helps the body’s immune
system return to a balanced state

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:326.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 43

 Meditation and the Immune System
• Improves immunity
• Helps reduce markers of inflammation

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:326.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 44

 Meditation and
the Dermatologic System
• Helps minimize the production of skin sebum
• Diminishes inflammation in the body, which can result in a
worsening of eczema
• Can help prevent the onset of cold sores

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:327.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 45

 Meditation and the Muscular System
• Helps prevent muscle tension
• Decreases the incidence of various stress-related disorders, such
as a headache

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:327.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 46

 Meditation and the Nervous System
• Helps ensure that the autonomic nervous system of the body
continues to operate smoothly
• Can preferentially increase parasympathetic activity and promote
its far reaching effects on the body

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:327.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 47

 Meditation and
the Reproductive System
• Helps maintain the orderly balance of the hormones involved in the reproductive system
• For men, helps to maintain normal functioning, including the production of testosterone
and the process of spermatogenesis
• For women, diminishes the likelihood of the occurrence of a variety of stress-related
problems with the reproductive system
• Irregular periods
• Painful periods
• PMS symptoms
• Decreased libido
• Vaginal dryness during sex
• Difficulty getting pregnant
Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:327.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 48

 Meditation and the Respiratory
System
• Helps lower the rate of breathing
• Helps prevent the onset of an asthma, hyperventilation, or panic
attack

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:327.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 49

 Meditation and the Skeletal System
• Helps minimize the stress placed on bones and joints
• Helps prevent muscular tension, which can lead to a loss of flexibility

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:327.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 50

 Meditation and the
Renal/Urinary System
• Helps maintain the body’s urinary output by helping ensure the
normal functioning of the body’s urinary system
• Helps prevent selected urinary-related problems, such as
incontinence, urinating too frequently, and low urine output

Frates B, Bonnet JP, Joseph R, Peterson JA. Peace of Mind with Meditation, Mindfulness, and Relaxation. In: Frates B, ed. Lifestyle Medicine Handbook: An Introduction to the Power
of Healthy Habits. Monterey, CA: Healthy Learning; 2021:327.

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THE HEALTH BENEFITS OF MEDITATION

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 52

Mind Body Medicine
• Dr. Herb Benson
• Studying the effects of meditation
and relaxation since 1969
• Stress Management
• Learned Relaxation
• Hypnotic suggestion
• Biofeedback
• Cognitive Therapy [Link]
• Social Support
• Spirituality Medicine
AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 53
 The Earliest Days of Meditation
Research
• Wallace Robert K, Benson Herbert,
Wilson AF. A wakeful hypometabolic
physiologic state. American Journal of
Physiology 1971;221:795-9.
• Wallace Robert K, Benson Herbert.
The physiology of meditation.
Scientific American 1972;226:84-90.

Wallace RK, Benson H, Wilson AF. A wakeful hypometabolic physiologic state. American Journal of Physiology-Legacy Content. 1971;221(3):795-799.
Wallace RK, Benson H. The physiology of meditation. Scientific American. 1972;226(2):84-91.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 54

 Scientific American Article 1972 on
Transcendental Meditation
“By a systematic method that he has been taught, he perceives a
‘suitable’ sound or thought. Without attempting to concentrate
specifically on this cue, he allows his mind to experience it freely,
and his thinking, as the practitioners themselves report, rises to
‘finer and more creative level in an easy and natural manner.’”

Wallace RK, Benson H. The physiology of meditation. Scientific American. 1972;226(2):84-91.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 55

 RESEARCH SPOTLIGHT

Wallace RK, Benson H. The physiology of meditation. Scientific American. 1972;226(2):84-91.

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 The Physiology of Meditation
• 36 subjects (28 men and 8 women)
• Ages 17-41
• Experience in meditation less than a month to nine years (average
was 2-3 years of experience)
• Subjects served as own controls-spending part of session in
meditation and part in normal non-meditative state
• 20-30 minutes of quiet, premeditative state
• 20-30 minutes of meditation
• 20-30 minutes of post meditation
Wallace RK, Benson H. The physiology of meditation. Scientific American. 1972;226(2):84-91.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 57

 The Physiology of Meditation
Continuous monitoring of
blood pressure, heart
rate, respiratory rate,
EEG, blood samples for
oxygen concentration,
carbon dioxide
elimination and more

Wallace RK, Benson H. The physiology of meditation. Scientific American. 1972;226(2):84-91.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 58

 Oxygen consumption decreased
during meditation

Wallace RK, Benson H. The physiology of meditation. Scientific American. 1972;226(2):84-91.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 59

 Carbon Dioxide output decreased
during meditation

Wallace RK, Benson H. The physiology of meditation. Scientific American. 1972;226(2):84-91.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 60

 Rate of breathing decreased during
meditation

Wallace RK, Benson H. The physiology of meditation. Scientific American. 1972;226(2):84-91.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 61

 Oxygen concentration in the blood remained
constant, even increasing slightly

Wallace RK, Benson H. The physiology of meditation. Scientific American. 1972;226(2):84-91.

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Meditative State
• Requiring less oxygen and clearing less carbon dioxide.
• Maintaining a high level of oxygen concentration in the blood.

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The Early Days of Mind/Body Medicine

2001 1992
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CME-Mind Body Medicine Course at
Harvard Medical School

October 28 - November 1, 2002 Course Participants and Staff

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MEDITATION AND THE MIND

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 Meditation Programs for Psychological
Stress and Well-Being
• PubMed Health, NIH published report Jan 2014
• “After a review of 17,801 citations, we included 41 trials with
2,993 participants.”

• Three months later publication in JAMA (March)

• JAMA Intern Med. 2014;174(3):357-368

Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine.
2014;174(3):357-368.

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RESEARCH SPOTLIGHT

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 68

 Mindfulness Meditation Programs for
Psychological Stress and Well-being
• Moderate SOE for improvement in
• anxiety, depression, and pain
• Low SOE for improvement in
• stress/distress and mental health–related quality of life
• Low, no, or insufficient SOE of an effect for
• positive mood, attention, substance use, eating, sleep,
and weight.

Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine.
2014;174(3):357-368.

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 Conclusions of the Review
• Meditation programs, in particular mindfulness programs, reduce
multiple negative dimensions of psychological stress.
• Stronger study designs are needed to determine the effects of
meditation programs in improving the positive dimensions of
mental health as well as stress-related behavioral outcomes.

Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine.
2014;174(3):357-368.

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Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA internal medicine.
2014;174(3):357-368.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 71

Brain Regions
• Pre-frontal cortex
• Complex behavior, executive functioning, emotion, behavioral
functioning
• Insula
• Self-awareness, perception, cognitive functioning
• Amygdala
• Part of the limbic system regulating emotional control
• Hippocampus
• Modulation of cortical arousal and responsiveness as part of
limbic system
• Also involved in memory and learning
AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 72
 Prefrontal Cortex and Amygdala

Cygan DS. Retrain your brain for better financial decisions. Albuquerque Journal 2016. [Link]
[Link]. Accessed July 17, 2020.

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 Insula

Insula. The Human Memory. [Link] Published 2019. Access July 17, 2020.

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 Hippocampus as Part of the Limbic
System

Image retrieved from:

[Link]

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Effects of Meditation on the Brain
• Sara Lazar, PhD- Research Spotlight
• How Meditation Can Reshape Our Brains: Sara
Lazar at TEDxCambridge 2011

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RESEARCH SPOTLIGHT

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 78

 People with Meditation Experience
had Structurally Different Brains
• Meditation experience is associated with increased cortical
thickness.
• Compared 20 long time experienced daily meditators with 15
people with no experience in meditation or yoga.

Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 79

 1 = insula
2 = pre-frontal
Cortex
3= somatosensory
Cortex

Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 80

 Scatterplot
Insula Pre-Frontal Cortex

Blue = Meditators
Red = Controls

Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893.

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 What is the Function of Various Brain
Waves?
• Published in Scientific American
• Beta- arousal, actively engaged in
mental activities, goal oriented
• Alpha-non arousal, relaxed
• Theta-drowsy, daydreaming, flow
of ideas
• Delta-deep sleep

Hermann N. What is the function of various brain waves. Scientific American. 1997.

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 Brain Waves
“The fight or flight response is accompanied by low
amplitude, high frequency beta brain wave patterns in the
brain, while the relaxation response so beneficial to
learning and problem solving is accompanied by high
amplitude, low frequency alpha and theta rhythms.”
-Project Meditation

Mackenzie M. Fight or Flight Response V's Relaxation Response. Project Meditation. [Link]
relaxation-response.25/. Published 2007. Accessed June 6, 2020.

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 Brain Waves and Meditation
• Acem Meditation (nondirective method developed in
Norway)
• Rest, eyes closed 20 minutes
• Meditate 20 minutes
• Results—
• Theta waves were most abundant during meditation in frontal
and middle areas of the brain
• Alpha waves were abundant in posterior parts of brain during
meditation

Lagopoulos J, Xu J, Rasmussen I, et al. Increased theta and alpha EEG activity during nondirective meditation. The Journal of Alternative and Complementary Medicine.
2009;15(11):1187-1192.

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GETTING STARTED WITH MEDITATION

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Getting Started
with Meditation Examples
• One-minute breath meditation
• Walking meditation
• Meditative yoga flow
• Lying down meditation
• Zen meditation to be “at one” with the present moment
• Coloring (such as mandala-coloring)

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LIVE AND LEARN

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A WORD OF CAUTION

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Side Effects of Meditation
• Rare reports of worsening of symptoms in people with psychiatric
problems.

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PATH #2: MINDFULNESS-BASED STRESS
REDUCTION (MBSR)

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Jon Kabat-Zinn, PhD
• Student of Buddhist teachers such
as Thich Nhat Hanh and Zen
Master Seung Sahn
• Founding member of Cambridge
Zen Center
• Works with Mindfulness

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Mindfulness Based
Stress Reduction (MBSR)
• Jon Kabat-Zinn, PhD
• 1979-founded the world-renowned
Mindfulness-Based Stress
Reduction Clinic
• 1995-founded the Center for
Mindfulness in Medicine, Health
Care, and Society
• (U Mass Worcester)

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Mindfulness
• 1) The quality or state of being mindful
• 2) The practice of maintaining a nonjudgmental state of
heightened or complete awareness of one’s thoughts, emotions,
or experience on a moment-to-moment basis.

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Jon Kabat-Zinn’s Mindfulness
• According to Jon Kabat-Zinn, "mindfulness means paying attention
• in a particular way;
• on purpose,
• in the present moment,
• and non-judgmentally."

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Mindfulness Based Stress Reduction
• MBSR- developed by Dr. Jon Kabat-Zinn in 1990
• A program of daily meditations and gentle stretching exercises
designed to refocus the body’s response to stressors outside of
one’s control.
• The goal of MBSR is to empower individuals to respond
consciously, rather than automatically, to circumstances.

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 Books

Kabat-Zinn J, Hanh TN. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. Delta; 2009.
Kabat-Zinn J. Wherever you go, there you are: Mindfulness meditation in everyday life. Hachette Books; 2009.

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MBSR Programs
• 8 week program
• 5 day intensive
• Mindful meditation and yoga
• React non-judgmentally to
stressful events
• Focus on breathing, body scan, or
walking Bob Stahl and Lynne Koerbel

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 MBSR as a stress management
intervention for healthy individuals
• Systematic review of 17 articles
• 16 demonstrated positive changes in psychological or
physiological outcomes related to anxiety and/or stress
• Limitations- not all studies were RCT, small sample sizes,
different outcomes
• Conclusions- MBSR appears to be a promising modality for
stress management.

Sharma M, Rush SE. Mindfulness-based stress reduction as a stress management intervention for healthy individuals: a systematic review. Journal of evidence-based complementary &
alternative medicine. 2014;19(4):271-286.

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RESEARCH SPOTLIGHT

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 MBSR in Caregivers
• Introduction-overview of MBSR. Studies listed with MBSR as
intervention and the results are summarized.
• Reduced pain, anxiety, and depression in fibromyalgia, irritable bowel
syndrome, and cancer.
• Lung transplant studies showed improved depression, sleep, and anxiety.
• No studies on care givers of lung transplant patients
• Literature gap noted and this study addresses the gap

Haines J, Spadaro K, Choi J, Hoffman L, Blazeck A. Reducing stress and anxiety in caregivers of lung transplant patients: benefits of mindfulness meditation. International journal
of organ transplantation medicine. 2014;5(2):50.

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 Caregivers of Lung Transplant Patients
Materials and Methods
• 30 Subjects
• DVD with explanation of practice
• Watch DVD and practice for 5-15 minutes a day for 4 weeks in
home
• Perceived Stress Scale and State Trait Anxiety Scale
Results
• Some reported watching the DVDs and others did not.
Haines J, Spadaro K, Choi J, Hoffman L, Blazeck A. Reducing stress and anxiety in caregivers of lung transplant patients: benefits of mindfulness meditation. International journal
of organ transplantation medicine. 2014;5(2):50.

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 Results
• Caregivers that watched the entire DVD and practiced MBSR as
instructed reported reduced levels of perceived stress, state anxiety,
and trait anxiety.
• For the caregivers that only watched some or none of the DVD, their
scores did not change significantly.

Haines J, Spadaro K, Choi J, Hoffman L, Blazeck A. Reducing stress and anxiety in caregivers of lung transplant patients: benefits of mindfulness meditation. International journal
of organ transplantation medicine. 2014;5(2):50.

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 Caregivers of Lung Transplant Patients
Discussion
• Limitations of study—no control group
• Other similar studies mentioned in discussion
• Breast cancer study demonstrated decreased mood
disturbance, lower levels of anxiety, depression, anger, fatigue
and confusion.
• Another study on breast cancer survivors showed decreased
depressive symptoms, anxiety and fear of recurrence in addition
to improved energy and physical role functioning.
Haines J, Spadaro K, Choi J, Hoffman L, Blazeck A. Reducing stress and anxiety in caregivers of lung transplant patients: benefits of mindfulness meditation. International journal
of organ transplantation medicine. 2014;5(2):50.

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 Caregivers of Lung Transplant Patients
Discussion continued
• Cancer patient study showed decrease in depression, anxiety,
anger, confusion, stress, irritability, cardiac and gastrointestinal
symptoms plus increased vigor when MBSR was compared to
usual care.
• Fibromyalgia study showed decreased depression.
• Irritable bowel syndrome study showed decreased bowel
symptoms and improved quality of life with MBSR

Haines J, Spadaro K, Choi J, Hoffman L, Blazeck A. Reducing stress and anxiety in caregivers of lung transplant patients: benefits of mindfulness meditation. International journal
of organ transplantation medicine. 2014;5(2):50.

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RESEARCH SPOTLIGHT

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 Mindfulness and
Changes in the Amygdala
• 26 subjects stressed but otherwise healthy
• 8 week MBSR
• Perceived Stress Survey (PSS)
• Longitudinal MRI scans before and after

Hölzel BK, Carmody J, Evans KC, et al. Stress reduction correlates with structural changes in the amygdala. Social cognitive and affective neuroscience. 2010;5(1):11-17.

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 Amygdala Changes
Location of positive correlation between gray matter density
change in right amygdala and change in PSS score.

Red dot =
Right
Amygdala

PSS: Post-
intervention
– pre-
intervention
Hölzel BK, Carmody J, Evans KC, et al. Stress reduction correlates with structural changes in the amygdala. Social cognitive and affective neuroscience. 2010;5(1):11-17.

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 Results of Study
• Post MBSR—reduced perceived stress
• Correlated positively with decreases in amygdala grey matter
density

• Amygdala—part of limbic system (center for emotions) and

important in stress and anxiety states.

Hölzel BK, Carmody J, Evans KC, et al. Stress reduction correlates with structural changes in the amygdala. Social cognitive and affective neuroscience. 2010;5(1):11-17.

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RESEARCH SPOTLIGHT

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 Mindful Practices and Brain Structures
• 8 week MBSR = changes in brain regions
• Memory, sense of self, empathy and stress
• MRI images of 16 subjects two weeks before and after the
intervention

Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry research: neuroimaging. 2011;191(1):36-43.

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 Mindful Practices and Brain Structures
• Control group with MRI images in same time frame
• MBSR subjects-27 minutes practicing MBSR
• Increased grey matter in the hippocampus (memory + learning, as
well as involved in emotional regulation)

Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry research: neuroimaging. 2011;191(1):36-43.

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 Hippocampus and Limbic System

What is the hippocampus? Medical News Today.

[Link] Accessed July 17, 2020.

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 Learning and Memory

Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry research: neuroimaging. 2011;191(1):36-43.

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 Temporo-Parietal Junction
Perspective Taking, Empathy and Compassion

Red = MBSR

Blue = Control

Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry research: neuroimaging. 2011;191(1):36-43.

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Wikipedia contributors. Temporoparietal junction. Wikipedia, The Free Encyclopedia. May 19, 2020, 20:17 UTC. Available
at: [Link] Accessed July 13, 2020.

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 Teach This to Doctors?
• Literature review revealed 14 med schools teach mindfulness
with a wide range of formats (lecture, workshops, 8 week
programs)
• Questions-when to teach it, what format is best, how do maintain
the skill overtime.

Dobkin PL, Hutchinson TA. Teaching mindfulness in medical school: where are we now and where are we going? Medical education. 2013;47(8):768-779.

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 Compassion and Mindfulness?
• Reducing stress in health care workers can increase
compassionate patient care.
• Mindfulness and self-compassion involve curiosity and non-
judgmental approach towards one’s experience.
• MBSR can be used to develop self-compassion which in turn
holds promise for reducing perceived stress and increasing
effectiveness of clinical care.

Raab K. Mindfulness, self-compassion, and empathy among health care professionals: a review of the literature. Journal of health care chaplaincy. 2014;20(3):95-108.

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It all starts and ends with compassion
• Practice what we preach.
• Preach what we practice.

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 Collaborating with Patients
Be Empathetic

Set Align
Accountability Motivation

Set SMART Build

Goals Confidence

Frates EP, Moore MA, Lopez CN, McMahon GT. Coaching for behavior change in physiatry. American Journal of Physical Medicine & Rehabilitation. 2011;90(12):1074-1082.

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LIVE AND LEARN

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PATH #3: RELAXATION AND THE RELAXATION
RESPONSE

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Relaxation
• Relaxation
• Relax: to become or to cause (something) to become less tense,
tight, or stiff:
• to stop feeling nervous or worried
• to spend time resting or doing something enjoyable especially
after you have been doing work

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 Relaxation Response
• “The response is defined as your personal ability to encourage
your body to release chemicals and brain signals that make your
muscles and organs slow down and increase blood flow to the
brain.”

• Psychology Today about Herb Benson and his work.

Mitchell M. In. Dr. Herbert Benson’s Relaxation Response. Vol 2020: Psychology Today; 2013.
AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 123
Meditation and the Relaxation
Response with Dr. Herb Benson
Dr. Herbert
Benson and the
Dalai Lama. H
MS c238. From
the Harvard
Medical Library
in the Francis A.
Countway Library
of Medicine.

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Relaxation Response by
Dr. Herb Benson
• 1. Sit quietly in a comfortable position • Maintain a passive attitude and
permit relaxation to occur at its
• 2. Close your eyes own pace.
• 3. Deeply relax all muscles feet to face.
• When distracting thoughts occur,
• 4. Breath thru your nose, repeat, “one.” try to ignore them by not
dwelling upon them and return
• 5. Continue 10-20 minutes to repeating "one."
• 6. Do not worry about whether you are
successful in achieving a deep level of
relaxation.

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DELETERIOUS EFFECTS OF STRESS

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RESEARCH SPOTLIGHT

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 Mental Stress and the Induction of
Silent Myocardial Ischemia
• Dr. Alan Rozanski
• Subjects placed under stress exhibited signs of cardiac
dysfunction

Rozanski A, Bairey CN, Krantz DS, et al. Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. New England Journal of Medicine.
1988;318(16):1005-1012.

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Rozanski A, Bairey CN, Krantz DS, et al. Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. New England Journal of Medicine.
1988;318(16):1005-1012.

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RESEARCH SPOTLIGHT

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 Relaxation for Rehab
• Relaxation Therapy for Rehabilitation and Prevention
of Ischemic Heart Disease
• Review of the literature-27 studies (10 randomized)

van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. European Journal of
Cardiovascular Prevention & Rehabilitation. 2005;12(3):193-202.

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 Intensity of Intervention
• Grading interventions
• Grade 1- abbreviated relaxation training (3 hours or less of
group instruction or 2 hours or less of individual instruction)
• Grade 2- full, traditional relaxation training, with longer training
practice of extended skills and discussion (longer than Grade 1)
• Grade 3- Grade 2 plus other coping skills (for depression,
hostility or anger)

van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. European Journal of
Cardiovascular Prevention & Rehabilitation. 2005;12(3):193-202.

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 Results
• Physiologic Outcomes
• Reduction in resting heart rate
• Increased heart rate variability
• Improved exercise tolerance
• Increased HDL cholesterol

van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. European Journal of
Cardiovascular Prevention & Rehabilitation. 2005;12(3):193-202.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 133
 Results
• Psychological Outcomes
• Reduction in state anxiety
• Reduction in depression

van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. European Journal of
Cardiovascular Prevention & Rehabilitation. 2005;12(3):193-202.

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 Results
• Cardiac Effects
• The frequency of occurrences of angina pectoris was reduced
• Occurrence of arrhythmia was reduced
• Exercise induced ischemia was reduced

van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. European Journal of
Cardiovascular Prevention & Rehabilitation. 2005;12(3):193-202.

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 Other Important Outcomes
• Return to work was improved
• Cardiac events and cardiac deaths occurred less frequently

van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. European Journal of
Cardiovascular Prevention & Rehabilitation. 2005;12(3):193-202.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 136
 Intensity of Training Matters
• Grade 1 only showed resting heart rate changes (decreasing
resting heart rate)
• Grade 2 and Grade 3 were similar in effect.

• The more intense the intervention the more profound the

outcomes

van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. European Journal of
Cardiovascular Prevention & Rehabilitation. 2005;12(3):193-202.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 137
 Discussion
• Relaxation therapy is effective as an adjunct to medical care as well as
standard cardiac rehabilitation.
• Confirming previous studies that already established the important
role of stress management and psycho-education for cardiac patients.
• Specifically, relaxation is beneficial for the emotional and physical
state of the patient.
• Relaxation adds another dimension to rehabilitation and recovery.
• Intensive programs have better results.
• Limitations-sample size, only 10 randomized studies

van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. European Journal of
Cardiovascular Prevention & Rehabilitation. 2005;12(3):193-202.

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FITT PRESCRIPTIONS FOR MIND/BODY WORK

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FITT Prescription Example
• F- five times a week
• I- deep relaxation
• T- 20-30 minutes
• T- mindfulness-based stress reduction

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References
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Goyal M, Singh S, Sibinga EM, et al. Meditation programs for psychological stress and well-being: a
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Kabat-Zinn J, Hanh TN. Full catastrophe living: Using the wisdom of your body and mind to face stress,
pain, and illness. Delta; 2009.
Kabat-Zinn J. Wherever you go, there you are: Mindfulness meditation in everyday life. Hachette Books; 2009.
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literature. Journal of health care chaplaincy. 2014;20(3):95-108.

AMERICAN COLLEGE OF LIFESTYLE MEDICINE JULY 2020. ALL RIGHTS RESERVED. 144
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Rozanski A, Bairey CN, Krantz DS, et al. Mental stress and the induction of silent myocardial
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