October 09, 2017


cancer ›   diet ›   exercise ›   general health ›  

"Finding out you have an increased risk empowers you."

Dr. Jane Pettinga with Dr. Barb

Dr. Jane PettingaDr. Barb: Today our guest is Dr. Jane Pettinga. Jane is a general surgeon at Holland Hospital, specializing in breast cancer treatment, prevention and risk assessment. She is a graduate of Wayne State University and has been practicing medicine for 37 years. Jane and I actually spent some time serving patients together in Holland Hospital’s High Risk Breast Clinic.

Today we’re going to talk a little bit more about women’s health and, specifically, breast cancer and some of the opportunities for risk reduction and prevention and also some screening. So, thanks for joining me today, Jane.

Listen now.

Jane: Pleasure to be here.

Dr. Barb: First I’d just like to hear more about how you ended up being a specialized general surgeon in breast, because that’s a bit unusual, and you might have been one of the early breast surgeons.

Jane: One of the first breast surgeons probably in the countrya handful of us. I was sort of heading towards family medicine, but when I did my surgery rotations, I just had so much fun, and it's so nice to see immediate results. So often in medicine, results come slowly over the years.

Then when I finished my training in surgery, I had one child and one on the way and was married to a very busy surgeon. I really wanted our kids to know their parents, so I looked for something I could do where I could control my time. An opportunity arose for me to join an older surgeon, who was a wonderful man, who was doing just breast surgery. Probably one of the first in the country. And I thought, well, I didn’t do ObGyn because I didn’t want to just take care of women, but I’ll give it a try. And it turned out that it was very challenging and very rewarding, and patients are just wonderful. It’s changed so much over the 30 years that it never became boring, even though it was very specialized.

Dr. Barb: Yes

Jane: It was right for me.

Dr. Barb: It’s interesting you say that. Because as you speak, it reminds me that general surgery was my favorite rotation, and I really aspired to be a general surgeon. But, at the time I was about to be married and a couple of the residencies in the country actually talked about their divorce rate being up to 100 percent. I was very intimidated by what the time commitment might mean and what the ability to, you know, have a successful marriage and start a family. So it’s interesting that you created this kind of sub-specialty within the general surgery field and that I,  in turn, chose ObGyn, so it allowed me to do some surgery along the way too. But, I think we were probably somewhat on the same wavelength back at that time.

So I’m wondering if we can start out talking a little bit about breast screening and if you could review some of the general recommendations, because there’s some conflict in the media about who should be screened and when, at what age, and at what intervals. From your perspective,  (and you’re up to date with what is happening in different fields, not only general surgery), how do you recommend the general, average-risk woman be screened for breast cancer?

Jane: Well, it’s interesting… the U.S. Preventative Task Force came out with recommendations a few years ago that decreased the recommendation for screening and mammography. And I don’t agree with their reasonings, though they have brought up very good points. First of all, on the top end of the age scale, there’s no studies that have included women over 70, so therefore, there’s no evidence that screening helps those women, because the studies simply haven’t been done.

However, the rate of breast cancer goes up as you get older. So more of those women are going to have breast cancer. If a woman gets breast cancer at 95, she’s probably going to survive that and die of something else anyway. But it’s still nice to not have a bigger surgery or need chemotherapy, so finding it early is still helpful to somebody.

The American Cancer Society recommendations are that you keep screening as long as you think you have ten years of life left. And that makes a lot of sense. My mother is 92; she’s very healthy. Her mother and one of my sisters have had breast cancer, so I keep telling her, I think you’re going to make it to 100, maybe next year is your last mammogram.

Dr. Barb: Okay.

Jane: On the other end of the scale, there’s more controversy about when you should start. It had always been starting at age 40 and then going every year. A lot of the studies that showed efficacy of screening mammograms actually did every-other-year screening. So then when you look at the evidence, it’s hard to parse out how much more benefit you get from every year. Nonetheless, as a practicing surgeon, I see so many women who one year before had a normal mammogram and, boom, now it’s a centimeter. Well, how big would that cancer be before it was felt? Maybe 2 or 3 centimeters. and then you’re getting into a higher stage. So, I think the interval should still be yearly.

Dr. Barb: Starting at age 40 as a general rule?

Jane: Correct, all the evidence shows that mammography saves lives at all ages. Even in the 40-year-olds. But, 40-year-olds have fewer cancers, because it tends to occur when [we’re] older. And so because you’re not going to find as many, it’s not going to be as helpful, because most women aren’t going to have cancer. Mammograms in young women are also harder to evaluate because they have denser breasts, lumpier breasts on mammograms. The U.S. Task Force was worried about the inconvenience and fear that having an abnormal mammogram causes when it turns out to be nothing. Some people talk about unnecessary biopsies. They’re not unnecessary; there’s something there that we have to find out about and the question is what is your level of comfort with having a possible biopsy that turns out to be benign. That is, about 15 percent of biopsies turn out to be cancer. We could easily make that 50 percent by biopsying only the most suspicious things, but then we miss some cancers at an early stage when it’s mostly... when it’s more curable.

Dr. Barb: I hear that argument as well and that’s always seemed a little bit of a disconnect for me, because I think most patients who understand there’s something in the mammogram that needs follow-up, most women are pretty willing to undergo a biopsy to clarify for them whether that’s benign or cancer. So this idea of instilling unnecessary fear, I think that uncertainty or the not knowing, in my mind, is a greater risk.

Jane: To me, it seems very paternalistic. In fact, there was an op-ed, in what I think was the Washington Post when these came out that said, “Don’t worry your pretty little head about breast cancer.” You know, women, have a lot of pain and worry and suffering in their lives. To mea few women, it really is tough on, but for most women... “Okay, here’s one more thing, I’ll go get it done.” Almost all the biopsies are done with a needle, it’s a little outpatient procedure that has very few consequences from it. It’s just relatively easy, and usually it can be done right away. So it’s usually done within a week, so that fear doesn’t last that long.

Dr. Barb: Yes.

Jane:  And the other thing is, sometimes the biopsies find things that are benign, but show that the breast tissue is at increased risk for developing cancer; so then women can take steps to decrease the risk. To me, yearly, starting at 40 and of course, it’s good to talk to somebody about it. You know, the recommendations are: Well, to discuss this with the patient and let her make her mind up. You always do that, but I mean, when I go to the doctor, I rely on his or her expertise, to say, well, no, what’s your recommendation. I don’t go home and think, oh well which medicine am I going to take?

Dr. Barb: Exactly.

Jane: It just doesn’t make sense to me.

Dr. Barb: Can you talk a little bit about tomosynthesis, which is a newer version...

Jane: Yup, it’s also called a 3D mammography. If you can imagine when your breast gets smashed in that machine, you’re pressing everything together and it all overlaps and you get one view going across, one view going down. So all this breast tissue overlaps and it’s hard to see through that. The tomosynthesis looks at little slices through the breast. It’s like a CAT scan, so that you can see just a small part of the breast tissue without everything else getting in the way. It unfortunately means you still have to get smashed. So to the person having the mammogram, it doesn’t feel any different. But, when you read the mammogram it does two things. It finds more cancers earlierand this is especially helpful in women with more dense breastsbut it even finds more cancers even in women with fatty breasts. And it helps the radiologist figure out the benign things. So there’s fewer call-backs and fewer ultrasounds. They can just sort of figure out just by looking at it the first time around. It’s a win-win situation. It does cost more, it takes longer to read, the equipment is a little more costly. More and more insurances are paying for it, because the additional cost is worth the additional pick up of new cancers.

Dr. Barb: Can you talk a little bit about breast cancer risks and what we understand about what the actual risks are and about what maybe is perceived, but not as much a risk as women might understand it to be?

The rate of breast cancer goes up as you get older.Jane: Sure. Average risk for an American woman who lives to be 90 is about 12 percent. So that’s significant. But, it goes up as you get older, so it’s much less than that if you live to be 75, say. The most important risk factor is having inherited an abnormal gene from your mother or father like Angelina Jolie did. It can come from the father’s side, so look at your family. Look at your family. Are there more two or more women with breast cancer, especially if it was a young age; especially if there’s ovarian cancer in the family, or males with breast cancer, early prostate cancer, pancreatic cancer. Those can all be related in to the most common inheritable gene abnormality which is BRCA1 or BRCA2.

You can imagine if you inherit an abnormal gene the BRCA1 and 2 genes code for a protein that’s involved in the cell that lets the cell to recognize when it’s turning into cancer, and it pushes a self-destruct button. If those genes aren’t working the protein isn’t made, and the cell doesn’t recognize itself being cancerous; it keeps growing. For some reason it affects breast, ovary, pancreas, prostate, and more than anything else.

Dr. Barb: So when you speak of two individuals, we’re including grandmothers, aunts, cousins, nieces, sisters, mother...

Jane: Correct. First-, second-, or third-degree relative. First degree is your mother, sister, daughter. Second is aunt, cousin, grandmother, and then the third degree is their kids and mothers. You look at both sides; you have to look at one at a time. If you have an aunt on each side, that doesn’t count.

Dr. Barb: And the other is potentially the age at diagnosis that also plays a role.

Jane: If you can imagine that every single breast cell has this abnormality, it doesn’t take too much to put something over the top and have the cells actually turn into cancer. Therefore we tend to see the cancers at an early agebefore menopause. So that’s a real clue, because breast cancer is so common, it’s not unusual to have one or two women in the family with breast cancer, especially if you have a large family. But, if they were 40 years old, 40 to 50, then you start looking at it differently.

The other important thing is if someone is Ashkenazi Jewish, there are some gene abnormalities that are more prevalent in that community; So if you have one person in your family that had breast cancer and you’re Jewish, you should ask your doctor about it. Because you can have a simple blood test or cheek swab test. The tests have become much less expensive in the last few years. In fact there’s one company now that will do it outside of insurances for $275, and test several different genes at one time.

Having genetic counseling before the testing is important.The important part about genetic testing is that you really need to know what it means. You know, what does it mean for you, for your family. What kind of impact is it going to have? Will it have impact on insurance? There’s just really a lot of things to know. It’s not just what’s my blood sugar or my blood count. It’s a test that has a lot of implications. So having genetic counseling before having the testing is important. And you say, why should I do this? I’m just going to wait for the shoe to drop, why live in fear? The reason is there’s things to do about it. I will get to that in a minute, but before we get into that I should mention a few other risk factors.

Family history genetics is a very important one. Probably the next important one is having had a biopsy of the breast, that wasn’t cancer, but showed something called atypical cells. Either atypical ductal hyperplasia, atypical lobular hyperplasia or lobular carcinoma in situ. It actually has the word cancer in there. it’s sort of like if someone is very fair skinned, they are more likely to get sunburned. If a woman has these types of cells in her breasts, she’s more likely to have a cancer start.

So that gives significant increased risk. Other things are, being overweight after menopause, starting your family after 30, starting your period before 12. Sort of the longer time you have uninterrupted cycles of estrogen, non-estrogen. There’s not a lot of environmental things that we know about. I expect that we will find out about it sometime.

Finding out you have an increased risk empowers you.Breast density is something that is relatively newly talked about. And you can also think about it as the more active your breast tissue is, the more it will show up on a mammogram, and the more likely it is that it will make a mistake. Once you find out you have an increased risk, it empowers you. There are things you can do. Probably the best thing, is to exercise.

Dr. Barb: And this would be for those women who we don’t identify even as having increased risk. They may be the average-risk woman, who still have a 12-percent lifetime risk of developing breast cancer. The best way she can try to remain in the 88 percent of women who will not be diagnosed with breast cancer, the most proactive thing she can do, is to maintain an ideal body weight. Is that what you wouldor one of the things you would recommend?

Exercise in and of itself, even without weight loss, decreases the risk for breast cancer.Jane: Oh yes. Statistically, body weight makes a difference for postmenopausal women, not premenopausal women. But, if you’re overweight when you are premenopausal, you’ll likely be overweight when you are postmenopausal, so it's always a good time to keep your body weight in check. Exercise in and of itself, even without weight loss, decreases the risk for breast cancer. It’s hard to put an exact number on it, because you have to rely on people telling you how much they exercise. But it can be as much as a 20-percent decrease in risk, which is fantastic! Because it does all these other wonderful things: decreases your risk for heart attack, stroke, diabetes, dementia; I mean, it’s just the best thing any of us can do for ourselves.

Dr. Barb: And how do you advise women in exercise? Thirty minutes five times a week, forty-five minutes five days a week? Where do you set the ideal standard for exercise?

Jane: The ideal: It’s aerobic exercise that makes a difference. Strength training is great too. But in this case, it’s the aerobic exercise that counts. You don’t have to be dyingjust a little bit out of breath, a little sweaty. Walking is great. It’s ideally four hours a week. Everyone is different, their schedules are different and you have to figure it out. You don’t want to do four hours in one day. That would be too difficult and you wouldn’t get as much benefit. But, if you want to do twenty minutes a day and then more on the weekend; if you want to do forty minutes a day; if you want to do an hour four times a weekhowever it fits into your schedule. And don’t pick something you hate because you won’t keep it up. Get a dog, so you have to take them out for walks. Just figure out somehow to incorporate it. If you have a family, bring them along; it's good for everyone. Everybody go for a walk after dinner.

Dr. Barb: Yeah. As we’ve recently been hearing, inactivity, or being sedentary is the new smoking when it comes to general health. So I think, the good news is that we do have some science behind exercise in reducing breast cancer risk. I think when it comes to women’s health, breast cancer always gets people’s attention, and people are always willing to hear more about it. So, I’m hoping that as we hear more about it and understand the connection, it will encourage women in their wellness to incorporate that as a part of their routine. I think it's an area where we haven’t been bold enough in emphasizing its benefits.

Jane: And it can be done. It seems daunting and especially if you’re busy, raising kids, working. Where do I fit it in? You can find a time to fit it in. Maybe you don’t get up to four hours a week. Anything is helpful.

Don't go on a diet; change your eating habits.Along with that comes your eating patternsyou know; what you eat. And for breast cancer it's a dietlet me step back. For breast cancer, it's even harder to get strong evidence to show the relationship. Again, partly because you have to rely on people’s eating patterns. You can show stuff pretty easily in mice which doesn’t always translate over to humans. But, overall it appears that probably a diet that’s low in animal fats, high in fresh vegetables especiallyfruits, is the best. You know, it's the best for everything.

It can be hard to do thatit's hard at first to figure out. What are my eating patterns going to be like? Don’t go on a diet, just figure out what you’re going to do. Change your lifestyle, change your eating habits so that you’re healthy. Shop around the outside of the grocery store, where all the fresh stuff is. Try to stay away from processed foods. It takes a while to get used to that. But once you do, you can have delicious meals that aren’t going to take hours and hours to make.

Dr. Barb: And the thing that I hear is when women are really able to do that, they just feel better. They have more energy, they sleep better ...

Jane: And it's better for their families!

Dr. Barb:  And we’re talking about breast cancer specifically, but I don’t think we can overemphasize the other areas of their lives that will be impacted by that.

Jane:  Now as far as prevention goes, these lifestyle changeswhich we should all be doing:  exercise, eating well, getting mammogramssome women at high risk we get screening MRIs so they’re getting checked every six months. In addition to all that, a step up from that, for women with increased risk, we do have some drugs for that, that can cut the risk about in half. Which is really significant.

Tamoxifen is the most well known, but we have several drugs. Tamoxifen is the only drug that is approved for premenopausal women; but there are several drugs that can be used in postmenopausal women for this too. All drugs have some side effects, and the side effects vary according to the individual. Again, we have to go over the risk-benefit ratio. It's not appropriate for all women to be on, but for those who are have an increased risk, it can cut their risk by 50 to 70 percent, so it makes sense.

Dr. Barb: And there are some tools to try to help women understand more exactly what their lifetime risk is, taking into consideration...

Jane: Yup

Dr. Barb: A number of the things you mentioned earlier. So for instance, if a woman is 12 percent and for someone they might have up to a 35-percent lifetime risk of breast cancer, you can reduce that risk, nearly back down to an average woman just by considering a medication. And generally these medications are used for a defined period of time?

Jane: Five years.

Dr. Barb: It’s not being on it for life. It's a five-year use of the medication, hopefully giving them, in turn, lifetime risk reduction.

Jane: Right. The easiest time to take it is premenopausally. Because there’s the least side effects and a longer period of benefit.

The last thing is that for women at a very high risk, some women will choose to do what Angelina Jolie did to have the breast tissue removed with immediate reconstruction. That reduces the risk by 90 percent; still not 100 percent, but very significant.

Knowledge is power; it could spur you on to do lifestyle changes.That worry about having that surgery is what keeps some women from having genetic testing. It is a choice. You don’t have to do that. We do have these other things to do. Especially the drugs to decrease the risk, do the lifestyle changes, watch you real closely so that if you do get breast cancer, we should be able to find it real early when it's the most curable. So that fear should notI don’t thinkkeep women from knowledge. To me knowledge is power, and it could spur you on to do some of these lifestyle changes.

Dr. Barb: And every decision along the way as to what might be a consideration is made in conjunction with the patient and a provider. So there’s nothing that says once you know, that you have to follow through with breast surgery. It's all about what makes the most sense and at what particular time of your life that you might consider that next step.

Jane: And even for somebody who has a gene abnormality, you have to look at the family because there’s probably other genes that modulate it... that make a difference. Because some families who have an abnormal gene you should see breast cancer in about half the women in the family, and sometimes there’s only a couple. And you know there’s more women who should get cancer. So it's not 100 percent. It’s somewhere between a 45 and 85 percent chance. If you come from a family where it doesn’t come up as much or it shows up in the 60s or 70s that might make a difference of what your choices are. If on the other hand, half of the women have died of cancer by the age of 50, you probably will be more likely to do the maximum and have the surgery.

Dr. Barb: Be more aggressive in those cases.

As we finish up today, Jane, tell me where do you find richness at this stage in your life?

Jane: Oh, everywhere. [laughs] Certainly in my family, my children, grandchildren, siblings, elderly parents. My siblings are my best friends. And luckily we live pretty close to many of them. I find great satisfaction in my work, with my husband, and I like exploring the world. My last big trip was to climb Mt. Kilimanjaro.

Dr. Barb: I think that when it comes to implementing exercise, you can be a shining star for the rest of us, to look at it in how you’ve really been intentional about incorporating that with your passion for travel.

At a certain age, I have to exercise or I won't be moving.Jane: I like to be active. I’ve always liked to be active. I haven’t always been as faithful in the exercise. But at a certain age, I feel I have to exercise or I won’t be moving. It just becomes more and more important as I get older instead of less important. I’ve really carved out time in my life to make that happen. It's easier with my kids being grown. But it's a very important thing to me, and hopefully I’ll be able to keep it up forever.

Dr. Barb: Thanks Jane, and thanks so much for joining me today.

Jane: Thank you!

September 11, 2017


exercise ›  

“On my tombstone it will say, ‘There must be a way.’”

Dr. Joan Vernikos with Dr. Barb

Dr. Joan VernikosDr. Joan Vernikos retired in 2000 as director of Life Sciences at NASA, where she was both a researcher and an administrator. Initially recruited by NASA because of her expertise in stress, she pioneered research on how living without gravity affected the health and post-flight recovery of astronauts. She’s published several books on gravity, aging, and stress, including The G Connection: Harness Gravity and Reverse Aging, Stress Fitness for Seniors, and Sitting Kills, Moving Heals. When she isn’t writing or keeping herself in motion, Dr. Joan consults with organizations on product development and whole workplace design, and serves as chair of the Taksha University School of Integrative Medicine’s Institute for Space, Health, and Aging.

Listen now.


Dr. Barb: Welcome back for part two of our conversation with Dr. Joan Vernikos, a leading researcher in health, who retired from NASA as the director of Life Sciences. She’s continued work as an author, health coach, and speaker, sharing what she learned through the study of stress and gravity, and how they work on our bodies. She published Sitting Kills, Moving Heals, which continues to get well-deserved attention, and Stress Fitness for Seniors.

Now we’ll dive back into our conversation:

So, my understanding of what you are saying is, that culturally—the direction we’ve moved to make life more convenient, we’ve also made our lives more sedentary.

Joan: Yes, absolutely. And in the process, we are robbed of movement we used to do naturally—in the course of living.

Dr. Barb: So the findings of preserving wellness in the art of movement, in the persistence of movement, really is disconnected from weight. Because, I think in our healthcare arena we often focus so much of our discussion around weight and obesity.

Joan: That’s correct, and that’s fallacious, in the sense—well—It's an interesting discussion, I have my views on that, because obviously now you can reduce weight by switching to a fat-burning metabolic ketogenic state—without exercise—and there’s a whole side of the debate that, yes, exercise is good, but it is not the fundamental problem

Dr. Barb: And the reason exercise is good, is that it is movement, but in effect it’s the movement that is the critical part of this.

Joan: Yes, and you’re going to have a lot of trouble through exercise, for really the benefit being quite small. You know now in the exercise world, even the—how much exercise do you need to maintain aerobic fitness even, which I wouldn’t be my first sort of measure. It’s almost easier to maintain aerobic fitness than anything else. But this high intensity interrupted exercise regimes, they are HITT, that they are recommending now, will keep you fit as they say, I wouldn’t know [laughs], but they will keep you fit with two to three times a week, okay?

So what is it doing? High frequency, high intensity movement, and that’s in a way what we are talking about. But, it’s certainly easier and probably a better signal to the body, a more comprehensive signal, to alternate several times—and the other thing that’s very interesting is, throughout the day—let me tell you something. I gave a talk to an AARP group the other day and there was a lady doctor talking about social aspects of medicine. And she came to me afterwards and said, you know I loved what you said, because I have this Fitbit kind of device that measures fitness and this sort of thing, and how many calories I burned each day and the number of steps I take. And I decided that because I can’t go walking ten thousand steps every day, I have to do it during the day. So I walk about eight hundred steps an hour—I measured that I walk about 800 steps an hour. She said, what’s fascinating is that I noticed and this is okay and I told her that I burn 750 calories more an hour doing the same amount of steps, spread throughout the day than in one run of time. Now I thought that was absolutely fascinating.

Dr. Barb: But you weren’t surprised by that I take it.

Joan: No! It was really a reinforcement.

Dr. Barb: Fascinating, so for those of us who sit in front of a computer, my job is a combination of a lot of sitting with some movement throughout the day. But, for many people—it’s hard for them to incorporate movement throughout the day, so do you have any practical approaches to how someone might be more successful in doing their work? I will say our work days are somewhat structured, leisure time we could obviously all improve on and move more, but what about incorporating it into the work environments? Do you have any suggestions about how that might be accomplished?

You change your habits.Joan: Yes, several. First of all I think you have to realize that it’s a question of habit. What are your habits? How did you get to these habits? Nobody made me do it, okay? I had someone in one of my talks say, Well I can’t do that, I’d be fired. I said, oh really? What do you do? He said, I’m a computer scientist. I said, yes, do you drink water? Do you go to the water fountain? He said, we don’t have a water fountain. Just tells you how old I am. And I said, okay, do you drink water? He said, oh yes I do, I have a water bottle I use. I said fine, put it on the desk next to you so that you have to stand up and go to the desk to get a drink

It is restructuring your habits. That’s probably the easiest and most fundamental. Because, once you get into the habit of structuring what you are doing, then, first of all, you raise your awareness. As you know, as a physician, one of the first steps towards a cure is awareness.

Dr. Barb: Of course.

Joan: Which unfortunately is not necessarily the way we practice. But, anyway… Awareness, so you become aware that sitting isn’t good for you, you go do something about it. But you can’t exercise every half hour which Joan recommends.

The other thing is, again, you change your habits. Go to see your colleague two offices down or two cubicles down when you want to say something to them. So you take the opportunity, you drink lots of water—you need to go to the restroom more often. These are all things—you put your printer far away from your desk so you need to get up to go and get it. It’s structuring your day.

Go up and down the stairs to your office.Now, let’s get back to other things that you can do is the stand-up meetings. I used to have stand-up meetings when I was the head of Life Sciences, you know, twenty years ago. Ten minutes of stand up meetings are much more efficient, you get much more done. Everybody was informed and you know—we got to move around. Stand up whenever you can. You go to a meeting, stand, lean against the wall, if you will, whatever. Make it part of your—if you have windows, have the windows open—they don’t have windows that open so much anymore, but if you have one, open the window.

The restroom is a great place. At NASA the ladies room was a great discussion area. The [laughs] government investigator was on the same floor and she would come to the restroom; we used to have some great discussions, got all the gossip I ever wanted in the ladies room. My boss was very upset, he said, “How do you know this?” and, of course, the ladies restroom.

Dr. Barb: [laughs] 

Joan: And of course, he couldn’t go, couldn’t argue with that, because he couldn’t join the conversation. So it was a great advantage to use the restroom.

There are all kinds of things you can do while you are sitting. Yes, there are contraptions of riding a bicycle, I have no idea if they work, but this distracting, I mean, I don’t know about you, but stand-up desks with treadmills is not my idea of getting work done. You don’t need it, if you have a stand-up desk that moves up and down with you, there are ways that you could use that. I prefer just to stand up, to stretch. I know a professor that has his students stand up and stretch at thirty minutes and then sit down again, and he claims their cognitive productivity is far better. So, now they have stand-up desks for children in school, some schools anyway.

Dr. Barb: Well, I think it's helpful to have some insight into this and recognize that it doesn’t have to be complicated. I think one of the things you stated is, all of the gyms that appear along the strip centers in America right now, but are we healthier? No, we’re clearly not healthier. And when you do think back on the generations before us and their lifestyle and just how they incorporated movement, even Europeans, which I’m sure you would agree, they tend to incorporate more of an active lifestyle

Joan: Correct. They do shopping, you see them walking on sidewalks, which is a sight you hardly see over here. You go up and down the stairs to your office, you go up and come down the elevator. I didn’t want to go up the elevator in the morning and see all these people I don’t really want to talk to, just because they happened to arrive at the same time as I did. It’s, you’re getting two for the price of one.

Dr. Barb: Of course, of course.

What we see in nature is what we need to do.Joan: You’re getting a bit of time to think and you’re getting a bit of exercise. Going up is different from going down, different muscles, different activity altogether. So, that’s a simple one. Stretching, the way you sit at your desk, just sitting—pushing your elbows back. The good old business of putting a book on your head—you’re probably too young to remember that, but when I was young we had to put a book on our heads, it shows very quickly if your posture is bad, the book falls off. It is a simple thing that encourages you to sit up straight, it goes halfway to standing up.

Dr. Barb: So, what I’m doing in yoga in the morning, you used to do in your classroom by just placing a book on your head.

Joan: Correct, exactly. And that I think, yoga is fantastic, it is much underestimated. But, when you stop and think about it, yoga mimics what we see in nature. What we see in nature is what we need to do.

Dr. Barb: Another area of interest for you has been stress, and managing stress. As a healthcare provider I feel that many of my patients identify stress as an obstacle to their wellness. They aren’t sleeping well, they can’t find time to exercise, I’ll say. You might say they aren’t motivated to move. I’m interested in better understanding: how do we define stress? Is there a way… we can advise people about that?

Joan: Stress is—yes. Stress is a stimulus, that’s all it is. If you apply stress to a piece of metal or wood, it will snap eventually, and it might bend in the process. It might bend in a way you would, where it’s more productive. It’s more flexible. So, I see stress entirely as a stimulus. Can you have excessive stimulus? Sure. But, it’s the filtration process, which is within you, well, the person—the individual, that is the mechanism.

What you're thinking of in the middle of the night is spam. Delete it!So I say to people, well you’re stressed. Eighty percent of your stress is self-made, easily eighty percent. You wake up in the middle of the night? Oh yes. Two o’clock in the morning, and what are you thinking about? All these things that could go wrong. Can you do anything about them right then and there? Well no. I say, when you turn on your computer, what’s the first thing you do? Well, I delete the spam. I said, bingo! You got it. What you’re thinking of in the middle of the night is spam. You can’t do anything about it. If you can—get up and do it! I find very therapeutic, I used to—that there are a few things, I used to anyway. Turning on the vacuum cleaner.

Dr. Barb: That has not occurred to me.

Joan: My neighbors must have loved me. But, you want to do something that is productive, not necessarily related to the stress you’re conjuring up in your brain, but it is productive. You see an end result. Cook. I used to cook for my kids a week’s worth of cooking and put them in pots and freeze them. What I did was bulk cooking. Do something. Do something that gives you immediate result. And believe me, you’ll go back to sleep, to bed and sleep like a baby.

Don’t turn on the TV. [laughs] Unless it’s something you’ve already seen and you know the outcome, so you’re not going to get upset by what you are going to see, because you already know what is going to happen. And I do that. My husband laughs, because I love mysteries and I’ll stay up late at night to see them. He says, “You’ve seen them before!” I say, “Yes, but the other night I saw one I hadn’t seen before, I didn’t sleep!” Because it upset me. You must not get upset before you go to bed.

You start turning the lights down at least an hour before you go to bed. And when you go to bed it’s absolute darkness. Yes, I say that to my clients. You turn off all the lights. Oh, but where is your cell phone? “It’s under my pillow.” Take it out, especially the young people; it’s amazing. Turn it off! Nothing is going to happen while you are trying to sleep.

Dr. Barb: Has your research reinforced the importance of adequate sleep in bodily function and wellness?

Joan: Oh yes, absolutely! I’m talking about moving during the day, okay? I can give you my night version, as you know, it’s a very active period. But, it’s very interesting, because if you change your—you change the direction of gravity, so you start to expect the changes you see when you’re lying in bed for 24 hours. Well, it doesn’t happen during the night. And this came from a doctor named Reed many years ago. He was at MIT, he’s probably retired, but he was studying calcium excretion as an indicator of loss from bone. And he was a circadian rhythm person, so he collected the samples from times both days and night. And his question was, Okay when I put this person lying in bed and reduced gravity, I increase calcium excretion. What happens during the night? Does calcium excretion increase as well? Well, it doesn’t. The body, the kidneys shut down and you do not get increased calcium excretion in the night—in response to lying down.

Dr. Barb: So, in effect the body knows that sleep is a time of restoration and preservation

Joan: Exactly, and activity, but not in that metabolic active outcome, the hormones increase, the target organ does not respond during the night. Okay? Now, I have been after my colleagues—my sleep colleagues—for heaven’s sake, study the night! Because that’s when it’s really interesting. But, you know, people, we’re lazy, we only work during the morning, during the daytime.

Pause is really, I think, fundamental.But what happens that is very exciting, as you probably know, it’s like a cleaning service in an office. When the office shuts down, the cleaning service comes in to clean the place during the night. And the cleaning service starts out by emptying the garbage cans, by tidying up, picking up and eventually it goes through a process-and that’s what happens with the brain during sleep in the various cycles. And then what happens, is you detox. You don’t just detox during the day, you detox your brain, and there’s a brain detoxing mechanism involving the glial cells that has now been identified. That goes on only during periods of deep sleep. So, if you wake up and you don’t sleep well, not only are you going to make mistakes the next day, but you’re just not going to detox your brain. Well, imagine having a non-detoxed brain, because you’re not giving it a chance to detox. Of course you’re going to get dementia, of course you’re going to get all kinds of neurological conditions, because the poor brain hasn’t had a chance to pause. And pause is really, I think, fundamental. It’s not just moving, but pauses, it’s the interruptions that are—intermittent interruptions are so necessary to maintaining good  health.

Dr. Barb: Well, these discussions are fascinating and I think important for so many people to hear, because by nature, we—most of us—have not created a life that is conducive to living well as you’ve just described to us. So, I appreciate your clear descriptions and explanations of why some of these things are vitally important to our aging and wellness.

I’d like to turn away from science, although science is fascinating to me, and ask you a more personal question. Having had a career in NASA and having seen the movie not too long ago, of Hidden Figures, and understanding women in that industry—can you share what it might have been like to be a woman working in such a male dominated area?

Joan: Yes, and I—Hidden Figures I think was fantastic. But that was a lot more than just being a woman. As we are aware. They had the double whammy really.

Dr. Barb: Of course.

Joan: I always considered myself extremely fortunate, extremely lucky in my career.

On my tombstone it will say, "There must be a way."First of all, my father was sixty years old when I was born, so I had what other people considered an old father. I never thought of him that way. He was a physician at the time when they didn’t have MRIs and scans. So he was known for being a good diagnostician, using his hands, listening to you. And having a conversation with these patients. So, I was used to that. And then he would discuss if there was anything interesting, my sister and I—he didn’t have any sons, so my sister and I and my mother, who didn’t have a university education, would ask him and listen to what had happened that he could describe that day. And so we learned how he went about solving the problem.

My husband says, on my tombstone it will say, “There must be a way.”

Dr. Barb: I love that! That is wonderful

Joan: I think that it is a great compliment

Dr. Barb: It is a beautiful compliment!

Joan: And so, I—people say, well what’s your asset? What do you bring to this thing? I say, solving problems, and I don’t mean crossword puzzles and the like, because I’m not very good at that sort of thing. But, I love the mystery of the human body, and that’s what it is, it’s an absolute mystery. We think we know a whole bunch and every so often there’s a whole fad of measuring weight or measuring DNA or ATP or whatever is discovered and everything is interpreted in those terms. And it’s good, but certainly not the last word.

So, I was, I started telling about my father. I got an apprenticeship education, let’s put it that way. That was a great fundamental sort of foundation to my approach to things. And also, stepping back and looking at things from a different perspective—not from the way the book said. That’s where I got my flair if you will, and I must also tell you that I retired from NASA in 2000, almost twenty years ago. I started really thinking after I retired, I did not have time to think before. Now, NASA—so anyway, my father expected both my sister and I to become doctors. My sister became a doctor and I chickened out. The first time I went through the morgue it, you know, turned me off. Which was unfortunate, but that’s okay. I made good in the long run

Dr. Barb: It worked out for you.

Joan: Yes! I would have taken a different career, I’m sure. So, it’s how can I put it? I was not used to being treated differently; he expected us to become professionals. When you stop and think that he was born in 1875, it was miraculous that a man would expect his daughters to become professionals. And we’re talking eons ago.

It never occurred to us to be anything else. It just didn’t happen. When I went to England to do my PhD, I was very lucky, because the way they treated women professionals was no different than they treated men. They were as tough on you with questions after a presentation, they would not open the door for you to enter a car [laughs] or treat you differently. And they were as harsh as could have been. There were exceptions obviously, there was misogyny along the way, but I wasn’t treated differently. So when I went to Ohio State to teach for oncology and medical school I couldn’t believe how everybody was doubling up to come and open the door for me and at presentations or conferences the questions after my paper were very mild. And then, word got around to me that so and so were having this discussion about you and your paper and oh it was very critical. I thought, you know, why didn’t they tell me?

That gradually made me turn around and say, hey, I’m treated differently here! I would come along and say, I don’t know. After a while they believed I didn’t know. But that was not the way I was using, “I don’t know”; I was using it because I wasn’t sure about it, or I wouldn’t speculate necessarily. But, it was taken as “Aha”! You see, you really are reinforcing that you do not know. I changed. My first husband called it the rejuvenation of Joan, the reorientation of Joan, because I suddenly acted American. There is a lot more discrimination here than in the rest of the world.

Dr. Barb: Hmm, so some of this was cultural.

Joan: Cultural, yes. Now, when I went to NASA, there were people—I discovered that leading from behind was more important than forefront, if you understand what I mean. And if there was a discussion, and if people were rude, I would not hear it as discrimination for me, I would hear it that they’re rude. They are rude people. So, I did not—it didn’t impact me as an individual. And I found that I could be very effective leading from behind, given the right kind of people to work with. I never applied for a job except the job of Director of Life Sciences. Somehow or another, someone always promoted me, put me up for this or that or the other.

Dr. Barb: So, as we wrap up our time together, Joan, I’d like to ask the question about: Where do you at this stage in your life find richness?

Joan: Oh, I have passion for my work and for communicating to the public.

You realize as a scientist, you know, we talk to each other, I wrote scientific papers galore. And when John Glenn, bless his heart, flew the second time around, I was very instrumental, because I was director of Life Sciences. I had a lot of interaction with him to persuade the political forces to let him go the second time around. And there was resistance from the other younger astronauts, because he was taking up one of their spots—cherished spots. Anyway, he flew as you all know, but in the process, I had to guard and do a lot of interacting with the press and beginning to interact with the public, to some extent. I had to present why he flew, how he did, and what we’re going to learn from it. A lot of criticism.

And to field that, and I found out at the end of my talks, that people would come up to me and say, how come we’ve never heard of this before? Where can I read more about it? And I scratched my head and thought, well, there isn’t anything. There's a textbook in aerospace medicine, but nothing for the general public. When I finally two, three years later, decided to leave NASA, I left NASA so that I could write something. I expected to write a few notes, and it ended up being The Gravity Connection, the G connection book. To be able to say to people, here is a book that might help you.

Mind you, I had to struggle, because as a scientist I have a hard time writing. I can communicate, but I have a difficult time writing, so I had to struggle to put that book together. But it was my first entry to the general audience. And how to present and how to make it simpler and simpler and simpler… And how to develop analogies and examples so that people could take it away with them. So that’s what I did and that’s how slowly the one book led to the other, led to the other.

And my husband kept saying, “You have to write a book about stress,” and that’s where Stress came from. I’ve got another book that is finished, but needs to be published called Stress Beyond 50 but I haven’t had time to go get it published. But, talking to people, I’ve gotten questions that I had to answer. So I learned, they thought, they gained, and so it goes. I’m passionate about what I do.

Dr. Barb: It’s obvious that you are and I’m thrilled that I could have this time with you today. And that we can share this conversation with so many other women, to be inspired by your work, your vision, your aspiration, and that you continue to be inspired about a very important area and that you are able to continue to communicate it so broadly. Thanks so much for your time today, Joan.

Joan: Oh thank you so much! As you can see, I love talking. [laughs]



August 29, 2017


conditions ›   exercise ›  

“The body is designed to move all day long.”

Dr. Joan Vernikos with Dr. Barb 

Dr. Joan VernikosDr. Joan Vernikos retired in 2000 as director of Life Sciences at NASA, where she was both a researcher and an administrator. Initially recruited by NASA because of her expertise in stress, she pioneered research on how living without gravity affected the health and post-flight recovery of astronauts. She’s published several books on gravity, aging, and stress, including The G Connection: Harness Gravity and Reverse Aging, Stress Fitness for Seniors, and Sitting Kills, Moving Heals. When she isn’t writing or keeping herself in motion, Dr. Joan consults with organizations on product development and whole workplace design, and serves as chair of the Taksha University School of Integrative Medicine’s Institute for Space, Health, and Aging.

Listen now.


Dr. Barb: Our guest for conversation today is Dr Joan Vernikos, who inspires me in so many ways. Joan has been a leading researcher in health, retiring from NASA as the director of Life Sciences. She has continued to work as an author, health coach, and speaker, sharing what she learned through the study of stress and gravity and how they work on our bodies. She published Sitting Kills, Moving Heals, which continues to get well-deserved attention, and Stress Fitness for Seniors as well. Welcome, Joan, thank you for joining me today.

Joan: Thank you very much for inviting me. I look forward to it.

Dr. Barb: I think that we share a passion for science, both of us having had our backgrounds primarily in science. For me it was the science of medicine. For you it was probably a bit more broad than that. One of your books is called, Harness Gravity and Reverse Aging. Certainly the idea of reversing aging is probably a topic that Americans could be consumed by, but I’m interested if you could expand to your today knowledge and help me understand more about: What role does gravity play? And what do you mean by this idea of reversing aging?

Joan: Well, the studies I did at NASA involved the question of how does gravity, or living with minimum gravity—which is 10 to the minus 5 in space, not absolute zero, people call it zero-gravity, but it isn’t—we call it micro gravity. And the studies that we did, there were of course very few astronauts who flew, so we had good data, but few data.

So we had to do something about expanding our knowledge on ground research. When we are on the ground we have gravity around us all the time, pulling in one direction, only towards the center of the earth. But, some German and Russian scientists had developed a model—simulation model—for studying the effects of reduced gravity. By lying in bed, for example, when you lie in bed, when you stand up, gravity pulls through your body in a head-to-toe direction. When you lie in bed, it pulls across your chest. So the vertical influence of gravity is diminished to a very low level. And the changes that accompanied lying in bed for example 24 hours a day, mind you—you don’t get up at all—are very similar to those we see in astronauts. Granted, maybe a little less intense.

So we used that model, I certainly introduced it from the Russians, we used that model extensively to study the effects of lying in bed for long periods of time. In fact, you don’t need to lie in bed too long, in as little as four days, well even one day, but four days you get very significant changes and my early studies were seven days and went on to thirty days. With where we could do both provocative and monitoring observation of work, on fluid metabolism, on metabolic cardiovascular changes and responses to stress, hormonal… Whatever we could do and wherever we could get collaboration from our colleagues in the broad science community, to join us to get expertise, to join us.

That’s the studies I really did. And during one of the early studies, I happened to visit a friend’s mother in a nursing home. She happened to be Greek, didn’t speak any English, ended up in a nursing home and, of course, didn’t budge from bed and she was terrified to get up. And she declined rapidly, as you can imagine. And since I was doing these studies I went in the evenings to see her. And I looked around and many of the changes were very similar to what I was seeing in my volunteers. And that got me thinking, and I thought, well, yeah, these are age-like changes, the loss of muscle, loss in bones, the orthostatic hypertension—the loss of pressure when you stand up, balance problems when you stand up again, and coordination. For starters, reduced plasma volume of 10 to 20 percent reduction in blood volume.

I was intrigued, well, yes, fine, but obviously my subjects are not getting old in bed. Because, after all when they do say, get up and move about they recover, as do astronauts when they return from short missions in the shuttle, which in those days was four to seven days. And of course, what’s happened, to cut a very long story short, astronauts now don’t recover in many areas. After six months—we have a lot of astronauts now who have been in space for six months—one in fact lost 30 percent bone in six months—bone density.

Dr. Barb: Whoa, that’s amazing.

Joan: That is amazing. But there are a couple who haven’t lost very much at all. So it is a very interesting phenomenon and I’ve been trying to encourage my colleagues to look at their genetic code—their DNA. Because obviously, there must be a predisposition somewhere. But that hasn’t been done yet as far as I know.

Dr. Barb: So, in summary, gravity really is our friend.

Gravity is our friend. Joan: Gravity is our friend. So, the conclusion I came to was, okay, in space you have minimum gravity. In lying in bed you have reduced the influence of gravity. But what about the rest of us as we get older? Well the only way I could explain it is, we use gravity less and less and less. From 20 on, when perhaps, we have peak development, to whenever we reach what I call “the risk zone,” when you start breaking bones and falling over, which, in the early days, used to be around 80, and now, unfortunately, it’s getting earlier and earlier.

So, this trajectory from age 20 to age 60, 50 or 80 or 90, when you reach the risk zone, I attribute to a great extent to reduced activity. What I call moving. It’s not exercise. We can jump to that topic in a while.

Dr. Barb: Yes, I think that’s a really, really important message you just shared. I think now, moving into that discussion, as a health care provider, as a physician for women’s health, most of my days, most of my patients, I’m trying to encourage them to improve their health and wellness, and much of my message is around exercise and trying to get them to move more. You indicate that there’s a difference between movement and exercise and I’m not sure I’ve appreciated that there’s a difference, and maybe I need to change the message I’m giving my patients. I’d be interested in having you share a little bit more about how you see the difference between movement and exercise, and how we can better inform our listeners and people like me who are interacting with individuals and trying to improve their lifestyle and therefore, wellness.

Joan: I’m delighted to have the opportunity to do it.

I discovered this as I went along, really looking back at the data and thinking it through. What became obvious to me is that the earth goes around, and as the earth goes around we have night and we have day. During the night we go lay down to sleep. And when we lie down, it’s like my bed is subject to gravity, and the effect is reduced, but it hasn’t changed, but our orientation to gravity is such that the influence of gravity is reduced. And then we have day, we have light, and we have day. And what do we do? Well what do you do when it is daylight? I’m asking you.

Dr. Barb: I start my day, and I get up, and I spend my day in motion, mostly.

Joan: Ah, you said the key word—you get up. And it is amazing how difficult it is to get audience members to come up with that simple thing. [laughs]

The first thing you do is you open your eyes, and pretty soon you stand up. And then you go to the bathroom and you make your coffee and all the other things. But from the moment you get up until you go back to bed when it’s dark again, or it’s night—you move.

Our parents and grandparents used to move all day long.And certainly our parents and grandparents used to move all day long, as a consequence of living. Because they had to move, they bent over and reached up and made beds and cleaned and washed and gardened. And went and bought groceries and walked home or rode a bicycle, or whatever. But they moved all day long and did it until it was time again to go back to bed. Our ancestors just, they didn’t have chairs, but they squatted and they stood, and they squatted and they stood and they went searching for food, or whatever they did. Once in awhile they would chase or were chased by a wild animal. But, they would build and cook and get wood to do it and so on.

So, the body is designed to move all day long. Not to sit and not just stand. Now, the literature when I wrote my Sitting Kills book, there was no research that was cause and effect with sitting and consequences. There was research that looked at diabetic predisposition and how sitting worsened diabetic predisposition. That, in fact within thirty minutes you can get an increase in triglycerides in a non-diabetic person. Which is fascinating to me, because it takes thirty minutes to see a doctor most of the time and you're sitting in that time. Or you’ve driven an hour to get there—that’s a difference subject.

The body is designed to move all day long, not to just sit or just stand.You then, gradually between 2011 when that book came out and now, there have been a fantastical number of studies—mostly meta-analysis and I have my reservations about them, but they do serve a purpose. That absolutely—that sitting makes worse absolutely everything. Whether you’re talking about cancer—prostate, breast cancer, cardiovascular conditions, stroke, metabolic conditions, diabetes, obesity—you name it, it makes it worse.

Now, as an interesting bit of information, what has become even more interesting, because I used to talk about moving as the foundation of activity. Then you can add onto that exercise up to becoming an elite athlete where you really do all kinds of exercise-specific programs. But, you can’t exercise without the foundation. Studies have come out, clinical studies, showing that when you have people sitting for a long period of time, that most of us do these days, unfortunately. You might exercise once a day, but exercising once a day does not counteract the effect of sitting these hours of sitting, okay?

Even there is a study showing no exercise, mild exercise, slightly more than moderate exercise and vigorous exercise. And lo and behold, the mild-to-more-than-mild exercise is the best and vigorous exercise is not as good.

Sitting makes worse absolutely everything.Now, it still is early days, because the studies I would like to see designed and done don’t ask specifically that question. Because one of the things I then went on to postulate, coming at it from space side, is it’s a change in posture rather than just a metabolic consequence that is the key factor. And it is the neurovestibular mechanism that is involved every time you stand up. Because you only burn 12 calories every time you stand up. And okay, those can add up if you stand up often enough. And you probably need to stand up about 36 times a day from a sitting position.

The last study I did at NASA, took volunteers, they laid in bed for four days. That way I know the plasma volume is reduced, the O2 maximum is reduced, you get insulin resistance and orthostatic hypertension, you can see all that—and you increase your calcium excretion—presumably coming from both. All that happens rapidly, within four days and probably sooner. So, I had the subjects (it was a randomized test) either stand up every hour on the hour, and that time I had them stand up for 15 minutes (which is way too much, they don’t need that) or stand up and walk. I was not, frankly, looking at the walking, how the walking would prevent the changes we saw lying in bed 24 hours continuously.

And the standing up without the walking was my control, because after all, to walk you had to stand up. Well, this fancy statistician-biased statistician who worked with me, when the results were in and the randomized results were sorted out, he said to me, “You’re not going to like this.” I said, what do you mean, I’m not going to like this? He said, “The standing is better than the walking.”

Dr. Barb: Fascinating.

Joan: So I scratched my head and I thought, oh Joan, not again. How do you come up with these unusual observations? So when we published that paper it got all kinds of awards. But I still didn’t think it really got the implication of that, because we’re so used to having to move. But the movement can just be standing up. And the standing up is fundamental. And when you stop and think about it what are we? We’ve got circulation, we’ve got neuro and metabolic changes that are going on all the time, and, yes, energy management.

The whole integrated system [of our body] needs to be looked at.So that’s what our body is made of and the water that everything sloshes around in. So you can’t look at one thing, unfortunately you just can’t. Not just bone, or just muscle atrophy or just circulation. The whole integrated system has to be looked at. And it’s amazing to me that just the mere act of standing up, for, people say, how long? You just stand up, a minute, you wave your arms around if you like, you can do whatever you want, but it’s the postural signal.

So I started looking at it as a signal, as a tuning mechanism if you will, in a sort of wild way. That the body, when it is inactive, when it is lying down or sitting down for hours, is not stimulated. And gravity was responsible for our evolution and our health, our development and our health.

So, it makes a sort of fundamental sense that if you do not provide that stimulation, what is the consequence? Well, the consequence is lose what we seek after so many years of doing that. And now we’re seeing these consequences showing up in children with strokes and diabetes and younger people and it’s tragic.

Dr. Barb: I had so many questions that we let the interview run beyond its allotted time. Look for part two to learn more about the science of health, gravity, and movement.