Good afternoon. I'm Katrina Rhodes, chair of the American College of Preventive Medicine 2021 Annual Conference, here with Dr. Richard Bruno, our highly regarded vice chair. On behalf of ACPM leadership and planning conference committee, we have the honor to welcome you to PM21 Building Resilience, Preventing Pandemics, Health Inequity, and Climate Change. We are so excited to have you with us today and share with you some of the highlights of this year's conference and today's events. Now while COVID precludes us from meeting in person, we're pleased to offer you an all virtual conference. Our conference theme is building resilience and sub themes include climate change and human health, social justice and health equity, and COVID-19 pandemic preparedness. Our conference tracks with sessions that run throughout the conference include population health management and health technology, public health innovation and community medicine, research, evidence and policy, clinical preventive medicine and lifestyle medicine, global health and environmental medicine, and the future of preventive medicine training and advocacy. Our oral concurrent sessions include updates from the US Preventive Services Task Force, the Community Preventive Services Task Force, and the American Board of Preventive Medicine. Plenary sessions throughout the conference will highlight our conference theme and sub themes, including building resilience during the COVID pandemic, climate resilience and environmental justice, building vaccine confidence with outreach efforts and US regulatory safety practices, social justice and health equity, and building public health resilience, featuring health officials on the front lines and legislative efforts behind the scenes. Keynote speakers include Allison Cassidy from the EPA, Chelsea Clinton from the Clinton Foundation, Peter Marks from FDA's CBER, Amanda Cohn from the CDC and ACIP, Wayne Frederick from Howard University, Anand Parekh from the Bipartisan Policy Center, Reuben Warren from Tuskegee University, Ursula Bauer from the Office of Surgeon General, Wilma Wooten from the San Diego Health Department, and Clarence Lamb from the Maryland State Senate. The conference also includes scientific poster presentations on a variety of public health and preventive medicine topics, and an opportunity to earn more than 25 CME hours to support your maintenance for certification and recertification. Our professional development events include a Young Career Lecture, an advocacy training workshop, and there will also be networking opportunities during our conversation cafes, our Congressional Hill visits, and social events including a virtual museum tour. Our conference will close with our annual ACPM awards, recognizing outstanding member contributions to our college and profession, and remarks from our President-Elect, Dr. Tenet Castle-Wood. Be sure to create a profile and participate in the PM21 Networking Challenge, interacting with your colleagues, attending events and sessions, and earning points to be entered into a drawing to win a complimentary PM22 conference registration. We'll be starting conference events today with the State of the College with our CEO, Donna Grande, ACPM President, Steffi Zaza, ACPM Treasurer, Doni Shen, and ACPM Secretary, Sandra Guerra. This will be followed by our KBS lecture featuring Dr. Aletha Maybank, the Chief Health Equity Officer and Senior Vice President of the American Medical Association. Dr. Maybank will also be featured in a plenary panel on building social justice and health equity on Tuesday afternoon. Remember to join us on social media and use hashtag PM2021. Concurrent sessions for today include a patient safety course, partnerships in public health, and managing stress and weight during COVID. And please join us this evening for the grand opening of our Partner Corner, the poster exhibits, and our virtual tour of the Smithsonian Museum of Natural History with our guide, Dr. Steve Rockauer. We're so glad you're here and hope you enjoy PM21. Hello, everyone. Welcome to our first concurrent session. Thank you for choosing us, or thank you for choosing to join us. In the next hour, we will be discussing. I have the honor of introducing our speakers and we have two speakers today. You can, I'm going to highlight a few things of their biography, but you can find a lot more details about their experience in our PM website. So we have Dr. Wudna Mulugeta and Dr. Robert Schneider. Dr. Mulugeta is a board certified internist and preventive medicine public health specialist at Cambridge Health Alliance in Massachusetts. He is a faculty member at Harvard Medical School. As a diplomat of the American Board of Obesity Medicine, he is dedicated to the prevention and management of obesity in immigrant and underserved populations. And I personally thank you for that. He is also involved in global health, trying to incorporate preventive medicine and public health into the medical curriculum in his native country, Ethiopia. He has taken preventive medicine and global health so seriously that he is determined to climb the highest mountain in each state. He has done about 10 out of 50 so far. That's quite impressive, including the highest mountain in the lower 48 states, Mount Whitney of California at 14,505 feet and Mount Rainier of Washington. And he hopes to do Mount Hood in Oregon sometime in the near future. I am in Eugene, Oregon. We welcome you to Oregon anytime. He will be presenting weight management in primary care during and beyond the COVID-19 pandemic. That was Dr. Mulugeta. I will also introduce Dr. Schneider. Dr. Schneider received his MD from Rutgers Medical School and did his postgraduate training in internal medicine and hypertension at the University of Michigan Medical School. He is also a specialist in preventive medicine and public health and integrative medicine. He is a consultant for the National Institutes of Health and the CDC, and also editor-in-chief of a forthcoming textbook by Oxford University Press on integrative healthcare for preventive medicine professionals. Currently, Dr. Schneider is the director of the NIH and DoD-funded Institute for Prevention Research and dean and professor of the College of Integrative Medicine at Maharishi International University. He started out thinking he was going to be a psychiatrist in the tradition of Jung and Freud. Instead, he got into preventive medicine and preventive cardiology. Over the years, he discovered that the mind and the heart are closely connected. He feels he came full circle in his career in mind-body preventive medicine. We will now have Dr. Mulugeta. Please remember to, if you have any questions, to put them in the chat box, and then we will address them at the end. Dr. Mulugeta, your turn. Thank you so much for having me today to really talk about this very important topic. We'll be talking about weight management in primary care in the context of COVID-19 during and beyond COVID-19 pandemic. This is the objective for our talk today. I hope you will be able to recognize and define obesity as a chronic disease and explain the relationship with COVID-19 and apply evidence-based approach for management of obesity in the context of COVID-19. Let's start by defining obesity. This is a definition from the Obesity Medicine Association. It defines it as a chronic, relapsing, multifactorial condition where an increase in body fat can result in metabolic, biomechanical, and psychosocial health consequences. This is a comprehensive definition, and so that's very helpful. As you may know, obesity has been defined and recognized as chronic disease by AMA as of 2013. Clinically and practically, we use the body mass index cutoff of 30 to define obesity, but there are other ways to define obesity as well, including the body fat percent. But it's important to remember there is ethnic differences when we are using different cutoffs, so that's just something to think about when we are trying to estimate adiposity. And unfortunately, in the past several decades, obesity prevalence has been increasing, and currently it stands at 42% among U.S. adults. And again, there is ethnic differences where Hispanic and African American communities are affected disproportionately. And in the context of COVID-19, we now know very well obesity is a significant risk factor for COVID-19 infection, as well as severe complications of COVID-19. And this is largely because of the pro-inflammatory state, as well as the dysregulation of the immune system and compromised pulmonary function we see among patients with obesity. And then the COVID-19 lockdown has had consequences on the overall wellness of patients. And we now know from many studies, particularly studies from China and Italy, which were hit earlier by the pandemic, there has been increase in psychosocial stress, isolation, anxiety and depression. There's also been increase in unhealthy lifestyle and behaviors, and increase in sedentary lifestyle and decrease in physical activity that's been resulting in unhealthy weight gain among our population. And we recently had a publication where we showed up to 46% of women have reported weight gain during the pandemic. And there's also been significant increase in childhood obesity during the COVID-19 lockdown. And so we have to think about the different setting and mode of care when we think about obesity and weight management. And even before the pandemic, there have been studies which found remote approaches for weight management can be just as effective as having in-person approaches which can be helpful during the pandemic where there was a lot of access for remote telehealth and telemedicine. The other thing is group and shared medical visits can also be more effective as individual visits as also help with getting enough more access to our patient population. And finally, more intensity, the more session, the more contact we have, that's more beneficial for our patients in terms of the intensity of the intervention. This is at our health center, we created and developed this curriculum for weight management and wellness group. And that's really multidisciplinary approach that involves me as a provider, as well as nutritionist, physical therapist, and behavioral care partner. And it has gone since virtually since the pandemic. And it's really creating an environment to support our patients, making sure they are not feeling alone in this journey. And as well as giving them the skills and the tools that they need, not only to lose weight, but also to be able to maintain the weight loss, which has been very effective and very helpful for our patients. So when we think about obesity management, we have to start with a comprehensive assessment for weight management, and that includes assessing readiness. And we can use different tools such as the stages of change model, the motivational interviewing techniques, or the 5As method. And of course, we have to get a comprehensive lifestyle history that includes weight history, nutritional, eating habit, physical activity, stress, as well as sleep patterns. And we need to make sure we take thorough medical and psychosocial history, and we have to rule out and address other conditions such as hypothyroidism, sleep apnea, sleep eating disorders, and also thinking about medication-induced weight gain. And the table you see on the right is it classifies by different drug class. There are a lot of common medication that we use, especially in primary care setting, which may lead to weight gain. And so it's very important for us to think about alternative for such medications. And it may not always be possible to change medication, but it can be very helpful not only to manage, to help patients with weight loss, to help patients with weight management, but also to prevent unhealthy weight gain and to prevent obesity. And this is just to give you the overall principle of weight management approach. And we will be touching on behavioral approach, nutritional, physical activity, stress, and sleep as really the pillars of weight management in the coming slides. So the behavioral approach starts with helping patients with setting goals. And it has to be patient-centered goals, and it's helpful to do what we call a SMART goal. And that means a specific, measurable, attainable, relevant, and time-paced approach. And it's okay to have a short-term and a long-term goal for our patients. And then also thinking about self-monitoring, that can be very helpful for our patients because it can help them connect the result they are seeing with the behavior and what they are doing. So it can be very powerful and can inform the next step, the next thing, what we can do for our patients. The other things, working with patients on a stimulus control, and that would mean helping patients avoid triggers. It could be meal planning, working with patients to minimize or avoid eating out, for example. Other things include setbacks. And setbacks in terms of weight management journey, that is expected. So communicating that ahead of time with our patients and to use setback as a learning experience can be key and helpful. And then enlisting social support. And this is, I think, where having a group can be helpful, for example. But patients can also use family members, friends, co-workers to have that social support. And nutrition and eating habits, of course, is very key in terms of helping patients with weight management. Generally speaking, the recommendation is 500 to 750 calories less than the baseline calorie in terms of trying to lose weight. But there is some difference between females and also based on the baseline weight for the patient. And there's, as you may know, there's really no one diet that fits all. And it has to be patient-centered and personalized when it comes to eating habits. And especially, you know, given the fact that we might be working with such a diverse patient population with different cultural background, it has to be patient-centered and personalized. And in fact, this is based on the studies that was published in JAMA several years back. It did not really matter what kind of diet patients were using. It was more important that patients were adhering to the specific diet. And so that is more important, more impactful than the type of diet patients might choose. And that can help with also making sure that it is sustainable for a patient rather than something they might do for a month or two months. And in the context of COVID-19, of course, we have to think about food insecurity. And during the height of the pandemic, food insecurity in the U.S. increased by as much as doubled essentially to a prevalence of 11%. And at our health center, we run this monthly free produce market where our patients get up to 30 pounds of fresh produce once a month per household. And we were seeing up to three times more patients than we used to see last year. So there was significant increase, and that's something we need to think about and address as needed. Physical activity is also another key aspect of weight management. And as you know, I'm sure there is a general health recommendation and guideline of at least 150 minutes per week of moderate exercise or the 75 minutes of vigorous exercise at any bout, plus the resistance training at least two times per week. But this is very important to know that this is for general health, and it can be very protective. But for weight management, usually for weight maintenance or to prevent weight gain, the exercise recommendation is much, much greater. It can be up to 420 minutes per week, and that's about an hour per day. So that's a difference we have to keep in mind. Another important aspect of physical activity is not only focusing on exercise, but also reducing the overall sedentary lifestyle. And this is on the left side, you see a bar, the orange one shows. So this is the total daily energy expenditure, and the orange one is the physical activity accounts for 15 to 30 percent of that. And of that, exercise, as you can see, is a smaller portion of that energy expenditure. And this, what we call NEAT, or non-exercise activity thermogenesis, can account for much more of that. And that's essentially how we spend the rest of the day other than the exercise. And in fact, sedentary lifestyle is correlated with higher mortality, higher cardiovascular risk, as well as higher BMI. So it is very important to think about how to optimize and reduce sedentary lifestyle, not just focusing on the exercise patients might do for 25-30 minutes. And now, with the restrictions that are being eased regarding COVID-19, I hope more people are having more opportunities to exercise outside, to go for a walk, and outdoors. But during the pandemic, there was a lot of restriction, and there has been a lot of challenge for our patients. And so, in my practice, I would share a lot of the free websites and apps that were available for patients to do exercise in their own home, where they feel safe, without any equipment. But we also know there was, and there is still, a digital divide where patients may not have access to different videos, and websites, and computers. In those scenarios, I used to, I still do, print specific exercise patients might be able to do at home, and I would just mail it to them so they can do it at home, where they feel safe, without equipment, again. And there have been also some remote physical therapy for some patients. And then, it can also be helpful to have a specific exercise recommendation, and that may include the frequencies, intensity, the time, and the type that patients might find helpful. And Dr. Schneider will address this a lot, so I'm not going to spend too much time, but chronic disease, sorry, chronic stress and obesity have a strong correlation. And with stress, there's increase in cortisol, increase in insulin, leptin resistance, decrease in metabolic rate, and increase with palatable and calorie-dense comfort food, which is a hedonic drive that can link that to obesity and visceral adiposity. And it's very important that we help patients find a healthy way to cope with the stress, and these are some of the options that can be discussed with our patients, including exercise and CBT, and of course, connecting patients when needed. Another important aspect of weight management is identifying eating disorders, especially eating disorders such as binge eating disorder can be very common in patients who are seeking weight management, help with weight management. And there are some tools and screening tools we can use, such as the BED-7 that can help us screen and diagnose eating disorders. We have to think about things like night eating syndrome, which is essentially where most patients might eat a significant portion of their meal at night. They might wake up at night to eat as well. We have to think about bulimia nervosa and other problematic eating behaviors, such as emotional or stress eating, external eating, food craving and addiction. This might not meet the criteria for eating disorder, but they can still have significant impact. And so it's very important to recognize and address that, and using CBT, mindful eating, and of course, treating related conditions. And this is a study that was published several years back, and looking at the BMI and sleep. And as you can see, there's a U-shaped curve where patients sleeping seven to nine hours tend to have the lowest or optimal BMI healthier range than people who have sleep deprivation and not sleeping as much. And in fact, sleep deprivation has been linked to an increase in ghrelin, decrease in leptin, and increase in eating time, hunger, appetite, and weight gain. So it is very important we address sleep problems, talk about sleep hygiene, and treat underlying causes such as sleep, consider CBT, and connecting patients with a sleep specialist. And we have obesity bias and stigma. Unfortunately, providers can be common source for weight stigma and bias. And in fact, there have been studies where physicians view patients with obesity as to be more non-compliant or lacking in self-control. And in fact, patients with obesity are less likely to receive preventive health care services and examination, and they are more likely to cancel or delay appointments. So it's very important to realize and address our own bias, but also bias within practice and being proactive to reduce stigma. And it's also very important, I think, it's also very important, I think, again, thinking obesity as a challenging, chronic, relapsing condition rather than the patient's fault. It's not the patient's fault. That's very important. And we have to think about using patient first language, respectful communication with our patients, and being able to accommodate patients within our practice. One of the things we did in our practice when we start to help patients with weight management was making sure that we have appropriate size chairs, scales, blood pressure cuffs, and gowns to accommodate our patients. So that's very important. So these are the takeaway points for our talk today. I hope we were able to define obesity as a chronic disease and understand the relationship with COVID-19 and being aware of medication-induced weight gain and thinking about alternative to that and applying evidence-based approach for weight management in the context of COVID-19 during as well as beyond COVID-19 as things seem to be easing up. And of course, finally and importantly, being aware of obesity stigma and bias and addressing that. Thank you so much. I think we'll be taking questions at the end. Hello, everyone. It's a pleasure to be here with you at Preventive Medicine 2021, and I'd like to share some thoughts with you today about stress, stress management, and immunity. So important over this past year, and I'd like to review the evidence with you relevant to the COVID and the post-COVID era. The deaths of despair, as they have been called by the Wellbeing Trust and others, have increased by about 50% during this past year or 14 months during the pandemic. And I'd like to argue with you today that those deaths of despair, or even despair, the epidemic of despair, is related to a loss of connection. Let's talk about this epidemic within the pandemic. We all know that this COVID-19 is having an unprecedented impact on the world. These figures are even a few months old now since I submitted these slides. There are way more than 100 million cases and way more than 2 million deaths of this year. Amongst those deaths from COVID and other causes this past year has been this rate of death and morbidity from despair or depression or the effects of isolation, depression, anxiety, and distress, which have been part of the epidemic of this past year. These rates of mental disorders, at least 25% of the population reports depression, at least 28% or 30% anxiety, more than a third insomnia, and more than a quarter, and I think these all figures are low, common stress symptoms in the general population and particularly amongst our colleagues, the health care providers. JAMA psychiatry back last March even was talking about the age of depression very early in the pandemic and reviewing its treatments. Why? Well not only does mental stress cause mental disorders, but psychological stress is associated with mortality. This is a large observational study showing the difference between individuals reporting low and high chronic stress and their rate of survival is more than 20% lower if they're reporting higher rates of chronic stress. Why is that? Why are people dying from psychological distress? This is a review that came out in Nature Medicine in 2019 about chronic inflammation, systemic chronic inflammation, or SCI as they call it. On the left hand side you see this gear, there are many causes of systemic chronic inflammation. We've just heard about obesity as one of those causes, diet, dysbiosis, chronic infections, but in the lower, sleep disturbances, the lower left hand corner you'll see the representation of isolation and chronic stress speeding up this wheel of systemic chronic inflammation and that itself contributes to major mental illness like depression and many of the other chronic disorders, cardiovascular disease and cancer and also disturbing, further disturbing the immune system very relevant to COVID-19 as we'll highlight in the next couple of minutes. This is a schematic of social determinants of health. One of the themes of this conference is race, racism and social determinants of health, health justice. Stress generally can be considered a social determinant of health and that has very well documented physiological effects regardless of its cause. The hypothalamic pituitary network is activated, the sympathetic nervous system is activated and other pathways and these two neural pathways activate the inflammatory pathway, psychoneuroimmune path and that affects both mental health and physical health and actually there's a great deal of research now on telomeres. The Nobel Prize was won about five years ago, five to ten years ago for the discovery of telomeres and Dr. Blackburn, the co-winner of the prize, has since been describing the effects of chronic psychosocial stress on telomere length and telomere repair, shortening telomeres and that also contributes to both the mental health outcomes and the physical health outcomes of this, including disorders of the immune system, including exacerbations of infectious diseases like COVID-19. This is some of the physiology of the psychoneuroimmune axis. I won't go into detail but on the top of this diagram you see the brain and the prefrontal cortex highlighted and then the NTS for the sympathetic or autonomic nervous system and the activation of the sympathetics and deactivation of the parasympathetics affects cytokines like TNF, alpha, interleukin-6, other cytokines that affects cell metabolism, affects telomeres and affects cellular senescence. So the psychoneuroimmune pathway sequence is very well understood now and it's active now because people are dying of despair during this age of exacerbation of psychological despair that comes with all the consequences of this physical disease, but they're interrelated and that's the main point of my talk today. In the next slide, let's see, in June of this year JAMA psychiatry, in consideration of these psychoneuroimmune effects, published a systematic review and meta-analysis of psychosocial interventions on immune system functioning as a potential form of lifestyle or preventive therapy for COVID-19 in particular and also more generally. And the conclusion that came out of this review was that psychosocial interventions are reliably associated with enhanced immune system function and may therefore represent a viable strategy for improving immune-related health. Well, isn't that a discovery? We can debate on how that relates to vaccines, but at least this review and the data that I'm generally describing to you today suggests that there may be a psychophysiological vaccine, if you will, or component to prevention. This is the Farr's plot, just showing you the general idea of the effect sizes of psychosocial interventions. Interestingly, this systematic review and meta-analysis didn't distinguish between different types of stress management methods. There are several different types, and that's important, but at least when you lump them all together, there's a significant effect size on immune viability markers. This slide shows on the left the physiological pathways that we've been talking about of various forms of chronic stress, the neuroendocrine axis, immune dysregulation, and then cancer is there, but you can also substitute infectious diseases and actually you can substitute cardiovascular disease also, as we reviewed from the Nature Medicine article a couple of minutes ago. Right-hand side of the slide shows some of the stress management methodologies that contribute to modifying these psychoneuroimmune effects. Social support is a major stress modifier, and in this era of isolation during this past year, it's really been aggravated for many people, a lack of social support, and one can argue about the quality of social support during this period with digital communications. For skills, we've heard about cognitive behavioral skills, which are certainly there and certainly have their value. Exercise has its value, and pharmacologic interventions are more debatable for stress-related disorders for people who do not have major mental disorders, but beta-adrenergic receptors blockers have been used. COX-2 inhibitors may not be used for psychological stress, but certainly may affect the immune cascade. Now, I'd like to zoom in with you, if I can get this next slide, on some particular stress management practices which have been shown beyond this general principle of lumping them all together. And now let's begin to dissect some of the particular practices, because they're not necessarily homogenous in their effects. This is a review by Bushnell on meditation and yoga practices as potential adjunctive therapies for prevention of infectious diseases like COVID. The size of these circles relates to the effect size. So they're fairly large effect sizes on immune biomarkers related to COVID hyperimmune response that are very relevant to preventing the excessive immune response seen in COVID. This is a review of the literature up until 2021, but very relevant. And in the next slide, I'm going to zoom in on one particular form of meditation that comes from the yoga tradition that's been very well studied in the West and internationally with several hundred studies. My colleagues and I have contributed to some of those, but certainly not all of them. This is a meta-analysis on transcendental meditation and mindfulness-based stress reduction on anxiety. Transcendental meditation comes from the ancient yoga tradition, but it's taught in a modern systematic scientific format. Mindfulness meditation comes from the Buddhist tradition of the East and is also taught in a modern secular framework. Both of them are. So in this review and meta-analysis shows effects on anxiety of these two meditations. On the left is actually individuals compared to treatment as usual controls, the mindfulness and TM. Both are effective. The transcendental meditation is significantly more effective in the general population in reducing anxiety. And then on the right hand slide, when you look in subjects who have particularly elevated anxiety, both again are effective, and then this transcendental meditation has marginally more effectiveness or borderline more effectiveness. The practices are quite different. The transcendental meditation is about experiencing a silent inner quiet state and it's effortless in its practice. Mindfulness is more about observing and being mindful. It's more active in its practice, but has these effects. This is a study of meditation compared to prolonged exposure therapy in veterans with post-traumatic stress disorder. I think studies of PTSD are very relevant to traumatic stress that so much of the population has been experiencing this past year to current events. This study we published in Lancet Psychiatry a few years ago. The blue bar is meditation, green bar is prolonged exposure, which is a form of cognitive behavior therapy, and the red bar are the education controls. When you look at the interview method of PTSD in this randomized trial, then meditation was non-inferior or was similarly effective to cognitive behavioral therapy, which is a gold standard for treatment of PTSD. When you look at self-report, the meditation is slightly more effective, self-report PTSD, but the primary outcome was the left-hand set of columns, the interview method. Depression was a secondary outcome, and there CBT and meditation were both effective, but the meditation appeared a bit more effective. Meditation is a lot easier to learn and practice. It's four sessions of about an hour and a half per day, and then practice at home for 20 minutes twice a day. The prolonged exposure therapy requires a trained therapist and weekly sessions, in this case. In the next slide where I'm reconnecting, this study came out a number of years ago. It's a cohort study of people who are practicing meditation compared to controls, 700 Ayurveda, which includes meditation, lifestyle program, compared to 4,000 match controls and 600,000 formative controls drawn from the records of Blue Cross Blue Shield practitioner in the Midwest. And then circle above is ENT diseases, including pulmonary disease. These were the categories of the health insurance carrier, so the authors had to use their categories. But the blue bar shows the experimental group had an 80% lower rate of hospitalizations than over five years' time compared to controls for pulmonary diseases. And zooming in, relevant to current events, in the lower bar, you see the blue bar on the right is hardly visible compared to the red and green bars, which are the controls. So there's major reductions in infectious diseases. So this was not COVID, predated by a few decades. But the point here is that the hypotheses that a psychoneuroimmune, or that a psychoneurointervention could affect the immune system, and that could affect clinical infectious diseases, perhaps COVID, is supported by the literature, both in observational studies and randomized trial data. And then one final trial that I want to show you today, as I wait for the slide. Here we are. This is a trial that we did, sponsored by the National Heart, Lung, and Blood Institute in cardiovascular patients who are at high risk for COVID. And these were also black patients also at high risk for COVID and cardiovascular disease and stress. And these individuals were randomized to either health education or meditation and we follow them up over a total of nine years. That was a 10-year um trial and we follow their rates of death MI and stroke verified by hospital records. And as you can see by the end of the trial or over the course of the trial from the survival analysis there was a 48% lower risk of the composite endpoint of death MI and stroke in the group that added meditation to their usual medical care compared to a matched group match for time expectancy in home practice who got a conventional education program. So this is some hard evidence hard at point evidence that a psychoneural intervention added on to usual medical care can affect clinical endpoints like death, uh heart attack and stroke and I think data is being collected now on death rates from COVID that should come out in the near future. And to sum it all up we have the psychoneuroimmune people are talking about the connectome now how the brain is connected to the rest of the body um this is uh Jung and Freud brought up to date by about 100 years. The psychoneuroimmune connection stress, stress management and immunity and this is the point if isolation is due to a loss of connection and if despair is a loss of connection then today we've been talking about reconnecting uh one's mind and body for optimizing mental health, physical health and immunity in the COVID-19 era. Pleasure to speak with you today. All right so thank you both for these great presentations loaded with information lots of evidence and experience. I know I'm not alone when I say that I've certainly gained some weight and have had a lot more stress during this pandemic. I want to go over some questions here and I want to invite the audience to please continue to ask questions. We have about 14 minutes to discuss this a little bit more. So this question goes to Dr. Snyder. To what degree does your expertise in integrative medicine contribute to your clinical practice in preventive medicine? Very much so. I think that this specialty of lifestyle medicine within preventive medicine is is a theme of today's session and it's very important that lifestyle factors contribute um so much to chronic diseases and integrative medicine means bringing in methods of methods of understanding and methods of of intervention that have not been part of conventional medicine until recently. But integrative medicine is also a science and and is can be evidence-based and so I find that expanding the domain of preventive medicine to other methods from wherever they come from around the world or from where whatever culture they come from examining them with our scientific tools and bringing in those methods that that are valuable for me expands my practice of preventive medicine to a lot more than it would have been otherwise and brings in a lot of tools and some of them I've mentioned today. All right, thank you for that. We have another question and I believe that this one goes to you as well. What suggestions do you have for a physician to integrate some of these principles into an already busy practice? And actually I think this can go to to both. Dr. Mulugeta as well talking about obesity with our with our patients. So Dr. Schneider if you want to go first. Yes, well there are two main methods. One if you as a physician are trained in in these in these lifestyle and integrative methods of preventive medicine then you certainly can instruct your patients. Many physicians in the 10-minute session or their 15-minute sessions cannot take the time, don't want to, or cannot take the time for patient education. So in that case I recommend working with a team. Team-based care is is the big thing now in medical homes or or in in primary care. So working with we heard earlier about and we'll hear more about diet and nutrition specialists. That's very important. And then you can have a meditation specialist, a mind-body specialist on your team too. I recommend this relates to another question if I'll answer at the same time. I refer patients to the local meditation instructor, actually to local transcendental meditation instructor. You know there are a lot of apps out there to learn meditation and just because something is popular doesn't mean it has evidence. And what I find has the strongest evidence in the mind-body arena are are two of the meditations that I mentioned today. And of those I find that this TM practice is easiest for the patients to learn and continue practicing and has the widest range of effects and in the area that I've been working in the most in cardiovascular disease and certainly the most data of any mind-body intervention in the area of preventive cardiology. But funnily enough the causes of heart disease including inflammation are also the causes of of other serious disorders like COVID and and serious mental health disorders. So every city has its own TM center that I refer patients to and often work with them those instructors in my practice. And they have an app too for some parts of their instruction but it's mostly one-to-one personal for a short course. Okay Dr. Moolugaitar. So I would say I think in terms of weight management and I'm primary care myself so I understand it can be very difficult to help patients with weight management as a busy primary care provider. So I would say one is really treating and seeing obesity as a chronic disease right. Just like we would see patients for high blood pressure, diabetes, having that specific appointment to address obesity is I think key and that's what I've started in my practice when I start to see patients for weight management. And so it's not really something we live at the end of the visit for two minutes to counsel patients. It really is its own appointment. I would say that's probably a key in terms of how to help patients with obesity. And you know the new coding system might have made things a little bit easier for us because we can't code by time for example and I think those changes using those changes for us to be able to code. But I think seeing it as a chronic disease just like we are seeing other things like hypertension, diabetes and making sure that we see patients specifically for weight management and not just try to rush it at the end the last two minutes. Okay thank you for that. I have a question here that a few people are actually quite interested. Thoughts on community level interventions we can put in place now to build healthier or healthy habits and prevent future weight gain. So community level intervention. Well I'm sure my colleague will comment on diet and so I'll leave that for him. In terms of mind body health you know I think primordial prevention is really the key. We can't really predict when the next pandemic will be. There certainly may be another pandemic and there have been others before this. I really and if the immune system can be strengthened or modified in a preventive way then I think one needs to think about community-based stress management programs. I'm a fan of mind body interventions beginning in the schools. I think our children heart disease begins in childhood. If I'm not mistaken obesity begins in childhood. Mental health begins in childhood. So I think the schools need to integrate formal stress management programs. School is a very good at increasing stress and you know but now we should have some stress reduction programs. I think meditation should be part of the educational system so the students learn to manage their own mind body connection while they're learning all the knowledge for their different future careers. That's one venue through education that we can do a community level intervention for primordial prevention or primary prevention. Yeah and I would also second that especially schools you know I am internal medicine physician but I do agree schools can be I think very helpful and you know childhood obesity is also increasing and that also tracks. That means if someone as a child is a patient with obesity they are likely to keep that and have the obesity also into adulthood. So I think preventing in a school setting I think that can be ideal increasing physical activity PE courses and the other thing that I have been noticing around my practice is there's really a kind of disconnect between what's available in our community and what we do in our clinical practice and you know preventive medicine is one that kind of links these two silos right this clinical medicine and this preventive medicine and this public health. And one community program that I've been utilizing is the DPP and that's been actually run usually in the local YMCA and you'll be surprised how many of your patients might qualify especially pre-diabetic patients can qualify and that's one opportunity you can utilize. But it is a very complex problem and it needs a systemic and multi-faceted approach. I've heard about the DPP program it's a quite intensive program with very good outcomes. Can you remind us what DPP stands for? It is for the prevention of diabetic prevention program I believe and Dr. Schneider probably shaking his head he probably knows and it is mostly for pre-diabetic patient population and it has been studied many times and it has good health outcomes. Yes and I know people that actually went through the program and they have very good outcome. Dr. Schneider you wanted to say something? Yeah I see one of these questions is about the presenter slides. I think all these talks are recorded through the conference and my email is on the speaker contact list so anyone who wants to get a copy of the slides slides more directly I'd be happy to send or provide any follow-up information also. I also want to mention someone may I answer this other thing about free? Please go ahead. I mean there are many sites and applications out there I mentioned one. My university I'm allowed to say has some continuing education courses that are available for stress management and lifestyle miu.edu. Several of those courses are free particularly during this pandemic period in addition to the Transcendental Meditation sources that I mentioned earlier. Okay a participant made a statement and they said such an important distinction about needing a separate appointment for intervention and management and I think that goes along with us adding talking about the importance of having a separate appointment for intervention us adding talking about lifestyle changes and obesity and nutrition and whatnot as an afterthought rather than it being the center of the appointment and taking the importance that it has. So thank you for for stressing that point as well. Another question here we have a minute and a half but I wanted to ask Dr. Molugueta if you have any statistics available on your wellness group in terms of the duration that patients were in the program any average pounds lost what were any outcomes that you were able to see in terms of pounds lost what were any outcomes that that you have that you're able to. Sure so we kind of had some we had to make some modification to adapt to the change and we have gone virtual initially it used to be in person actually and I don't have the numbers with me and we did not do any kind of any research but I do look at it what I've seen is everyone seemed to have lost weight whoever joined the group. I do see initially reluctance to join the group but once people join they really like the group and they like to continue to be in the group and so those are the things. The other thing one more thing I want to add is those who attended more sessions tend to do better tend to lose more weight than those who might not have attended as much. And I think that's why the DPP program actually works because there's so many appointments that they have to go to. Anyway we have five seconds I'm afraid we're going to get caught off so I want to thank you both for coming and thank you for the audience for saying and and listening to to you interesting topics. Thank you so much and let's move on to other presentations. Thank you for joining us. Pleasure to be with you. you

weight management

stress management

health

obesity

COVID-19

chronic disease

clinical practice

remote approaches

behavioral approaches

nutrition

physical activity