How chronic stress harms our DNA

Recent research suggests chronic stress damage starts before we’re even conceived and cuts into our very cells. A number of studies have linked stress with shorter telomeres, a chromosome component that’s been associated with cellular aging and risk for heart disease, diabetes and cancer.

How do personality and environment play into this phenomenon? Read more (Monitor on Psychology, Oct. 2014)

The evolution of trans health

Dana Beyer, MD, is a retired eye surgeon who has practiced medicine in Kenya and Nepal, served as candidate for Maryland State Delegate; and fought for the first countywide ban of artificial trans fats in the U.S. She also lived most of her life as a man.

Are there many transgender MDs?

I’m not the only trans physician; I had the honor of performing in the first all-trans performance of The Vagina Monologues and was onstage with two other trans female physicians. I know physicians who have transitioned in place and at work. It’s quite doable in many parts of this country. If you bring something of value to your community, they’re often willing to overlook or ignore identity changes that you’re laying on them. Most people are willing to overlook lots of quirks. When I went to my rabbi to tell him I was going to transition, he said: ‘I only have one question. Are you still going to read the Torah for us?’ That’s America. We’ve got all sorts of diversity so this particular type is not unique in being different.

Is the system coming around? What’s the current biggest barrier?

The work I’m doing with Kaiser [Permanente] is to help them roll out their program of culturally competent, medically comprehensive trans coverage. They’ve got about five million covered out west and they want the mid-Atlantic region to be completely trans-supportive as well. It’s accelerating. The Affordable Care Act is completely inclusive; the law states that anybody who receives any Federal funds has to be inclusive. You cannot discriminate against trans people. That’s the theory. Implementing that, of course, is a whole different thing.

I’m fortunate that I was a practicing surgeon and made enough money that I could survive post-transition. A lot of trans people have never had access to health care because they couldn’t afford it. When the Affordable Care Act gets going, there will be more provisions made available. We’re trying to make Medicare and the Veterans Administration completely inclusive with respect to surgery. There are a growing number of companies now competing with one another to offer it, particularly in the IT sector, because they are realizing that if you want to attract good employees you have to be open to gay and trans people, and the best way to do that is to offer good healthcare. What ten years ago cost me $100,000, I expect in five years will cost no more than a couple of thousand dollars in deductibles and co-pays. Which is a wonderful thing, because this is a, at root, just a medical condition that needs treatment.

Can you speak to the barriers transgender individuals might face as they navigate health care?

The trans community has been so marginalized and oppressed for so long that many have a victim mentality. They’re afraid to even go into a doctor’s office. I was closeted for 50 years, so I speak from experience. If you’ve transitioned to become a male, for example, and you’ve been seeing a gynecologist and now you’re the only guy in the waiting room, this makes you uncomfortable. Trans men have a much easier time socially, in general, than trans women. There is so much misogyny out there; the problems of bigotry I face are far more pervasive fundamentally from a sexist perspective before one even gets to a specifically trans-misogynistic one. But having overcome my personal challenges, nobody intimidates me; nobody gets away with bullying me.

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It’s a hell of a lot harder being a trans woman and even harder being a poor black trans woman. Those are the people who are most likely to be murdered, and are far more often unemployed and homeless and spiritually crushed. All of these different forms of prejudice coalesce.

Often times trans people will not tell their doctors if they pass well, because they want to have a normal relationship with their doctor. But you can’t do that if you’re lying about your basic identity, because it matters whether you’re genetically male or female, when you transitioned, and how long you’ve been on hormones. You can’t hide that stuff from your doctor. Going back into a closet vis-à-vis medical care is crippling, and it’s not helping your physician treat you as a full person.

There are nuances that medicine needs to grapple with to make trans patients feel more comfortable, but that kind of cultural competency doesn’t come easily. The upcoming medical generation will do better than my class has done, and certainly better than teachers who told me – not directly but to the class as a whole -in psych class that I was a pervert and a deviant. I’ve turned the tables; I’ve gone back and taught in the same auditorium where I was told those things 37 years earlier, and I say: The circle is complete. We now know that my life experience is more truthful and real than what we were taught then.

Where are we with the science of studying transgender health?

It’s getting better. There’s very little argument that gender identity exists. When it comes to trans people, there’s enough evidence out there that we’re neurologically who we say we are. Basic neuroscience has validated the existence of trans people, and the concept of brain sex and its difference from genital sex; the work that’s going on with other forms of intersex conditions that has gotten short thrift in med schools — it’s beginning to happen here.

We only recently, last December, removed being trans as a mental illness form the psychiatric bible, the DSM. The trans community finally had its day of de-pathologization, the way the gay community had in 1973, but we’ve only just gotten there.

It’s far better in Europe; there are consortia looking at this whole condition. The Europeans are not prudes like us, so somebody can apply for a grant that can say sex or gender or transgender in the title and it gets accepted like everything else. That would often kill it in this country.

What, in your opinion, tips the level from caring about something to speaking out and mobilizing to make it happen?

When I was recovering from major surgery when I was 13, which was a result of my DES exposure in utero — which made me intersex and a transwoman — I went into renal failure and cardiac arrest. While recovering, I told my mother I was going to be a doctor so nobody would have to go through what I had. She thought I meant the kidney failure, that maybe I would become a nephrologist. What I meant was that nobody would have to go through this intersex condition that I couldn’t share with my parents, because they threatened to have me institutionalized when I came out.

But as long as I was closeted I couldn’t act on it. I was removed from what was important to me; I was removed from myself. I’ve done more than 10,000 surgeries and they had little emotional impact on me because I was shut down. There’s no emotional attachment. I know I did it; I earned a good living; I remember things people wrote and cakes people made for me, but there’s no attachment. It’s only after I transitioned that everything has been more real and alive and colorful. We do know that the memories that most vivid and are easiest to retrieve are those with the most emotional content to them, but you need to be receptive.

It was only when I finally became myself that I realized I needed to — yes, it’s a cliché — pay it forward. I am a physician; I am a scientist. I bring a unique perspective as such to the issues of human sexuality. I knew that I had gotten to where I was because of the work others had done before me, pioneers who were willing to take those risks.

My primary motivation is to help the next generation, to make sure that kids get treated well and don’t have to live in a closet for 50 years. It’s turned out that trans people suffer from post-traumatic stress syndrome from a very young age before they’re treated. Just knowing you’re in a wrong body, and not being accepted for it or being helped to deal with it — that causes PTSD. We can see those brain changes on scans. Those changes already exist in kids. You can imagine what those changes are like with somebody who is to 30 to 40 years old. I like to think of my cohort as dinosaurs. There will no longer need to be people like me who are closeted and married to the wrong person.

Now every day I get up, and I’m just myself. Mine may not be the only voice, or the best voice, but it’s a unique voice. And you have to be yourself, because that’s where you’re most authentic. When necessary you move on. It’s a big world. There’s a lot of stuff to do.

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A young caregiver helps three generations

At least five days a week for the past four and a half years, 17-year-old Jimmy Braat has been traveling two miles to the home of his 73-year-old grandmother in Lake Worth, Fla. Along with his mother, Debbie, he usually stays a few hours, doing household chores, helping to change the wrappings on his grandmother’s legs that prevent swelling from lymphedema, giving her medicine.

Then, he and Debbie may take her grocery shopping. At least once a week he also accompanies her on one of her many doctor visits – to the endocrinologist, podiatrist, pulmonologist, cardiologist, or sleep specialist – lifting the wheelchair that’s too heavy for his mom to manage.

His “Grandma Del” suffers from a range of ailments that limit her mobility, including diabetes, neuropathy, and pulmonary hypertension. Jimmy’s dad passed away in 2008 from heart failure. Debbie, 52, has pulmonary hypertension and is easily winded. His family can’t afford private care, Del does not qualify for Medicaid, and Medicare covers home care only for limited situations and periods of time.

Del refuses to go to a nursing home and doesn’t want to move in with Debbie. So much of the work caring for her has fallen to Jimmy, who is an only child.

“He doesn’t mind.  He never complains,” Del says.  “I took care of him when he was a baby, and now he takes care of me.”

Jimmy is one of more than a million children providing some or all care for ill family members or special needs siblings. According to a survey by the National Alliance for Caregiving and the United Hospital Fund in 2005, at least 1.3 million children ages 8 to 18 help care for a sick or disabled relative, with 72 percent of these caring for a parent or grandparents.

A Growing Problem, Yet Largely Hidden

There are no recent national studies, though as many as several million youths could be caregivers now, says Connie Siskowski, Ph.D., president of the American Association of Caregiving Youth (AACY), an advocacy and resource organization. Demographics may be pushing more children into the role: People are living longer with chronic illness, and single-parent or multi-family households are increasingly common, as are grandparents raising grandchildren.

While adult caregiving has gotten more awareness, the issue of a child helping is less known, says Suzanne Mintz, co-founder and CEO emeritus of The National Family Caregivers Association.

Jimmy Braat

“It’s always been assumed that family cares for family, and that, of course, is true. But in the modern age when medical science performs miracles that help people live so much longer, it’s not just kids helping dad or helping grandma, it’s them actually doing medical procedures.  And it’s not just for a couple of months, it’s for years and years,” she says.

A Born Helper

Jimmy’s caregiving journey began at the age of nine, when he began helping to care for his great grandmother, who suffered from dementia. He brought her newspapers, ground her pills into applesauce, and warmed meals in the microwave. She passed away when he was 13.

“He’s always been such a sweet little boy,” says Debbie Braat. “When he was real little, around six years old, I had to have surgery on my feet — one foot one year, one foot the other year. When I had the surgery I couldn’t walk around at all, but he would get up and he would do the laundry. He couldn’t even reach the washing machine, but he would pull himself up and sit on the machine.”

Of his grandmother, of whom he has always been close, Jimmy says, “She’s a difficult person. It’s not really her illness. She’s got a one-track mind. My trick is, when me and her start to argue, I just put my headphones on.”

Still, he says, ” I had a period of time when my grandmother was in the hospital for a few months and on life support for two of those months. The hardest thing for me was seeing her on life support for the first time.”

Jimmy is about three years behind in high school, he says; according to a 2006 report sponsored by the Bill & Melinda Gates Foundation, some 22 percent of high school dropouts surveyed left to take care of a family member. Now he takes high school classes through an online course offered by Palm Beach County. He is often so tired that, he says, “I end up passing out in at least one of my classes each day.” He also suffers from depression; research suggests caregiving raises the risk for depression and anxiety in child caregivers.

When he does have free time, Jimmy joins activities like camping, cooking classes and dinners sponsored by The Caregiving Youth Project in Palm Beach County, Fla., a pilot program that offers kids ages 10 and up who help family members care instruction, tutoring, home visits and activities. Though the AACY hopes to start a national network, to date it’s the only support program of its kind.

Jimmy will care for his grandmother, he says, “Up until the point where she passes away. There’s no exit strategy. Besides, there’s no one else to do it. “

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Why Stress is Public Health Enemy Number One

The following is an interview with Elissa Epel, a UCSF psychologist who has studied the health impacts of stress, from its effects on our DNA to its relationship to overeating, for two decades. Published on The Huffington Post, 4/3/2013

Some of your research has centered on the way that stress hormones contribute to increasing our drive to eat, particularly high-carbohydrate and high-fat “comfort foods.” To what degree is stress contributing to our national obesity crisis, in your opinion?

EE We can’t quantify exactly how big of a role stress plays. It could be huge. It’s invisible and it’s easy to ignore; it’s pervasive. Most of us have gotten so used to living in a matrix of stress – time pressure, demands, rushed social interactions, rushed eating – that we don’t even notice it. So we might not realize how stressed our body really is. But the effects of stress can still stimulate our appetite, and shift us to choosing more ‘white food’ – what we call “comfort food,” – high-calorie, high-fat food. This promotes metabolic disease because it causes us to store calories in the visceral area and liver. And that stored fat is at the core of many chronic diseases, not just diabetes.

I was surprised to see your study showing educational attainment is also related to telomere length. Why might that be?

EE That relationship is multi-layered and needs to be unpacked. One common theme in trying to understand health disparities is testing whether part of it stems from greater stress exposure or reactivity over a lifetime. For example, the effects of more years of education early in life can be seen decades later, in longer telomere length. Higher education, or maybe it’s the quality of education, can create an infrastructure in the brain for more adaptive coping – it can help with strengthening what we call ‘executive function’ -which helps us think clearly under stress.

Conversely, there are many active ingredients in the milieu of low socioeconomic status that cause wear and tear. Interestingly, though, perception can play a large role here. We have measured this by giving people a picture of a ladder and asking them to place themselves on a rung (the bottom rung being the lowest status). Rating oneself as low, regardless of actual income or education, relates to poor adaptation to stress. Specifically, when given the same task to do in the lab, people low on the ladder reacted hotly each time, as if it were new, instead of habituating to it. There is also the built environment of low socioeconomic status, which doesn’t leave opportunities for buying healthy food and places for exercise or safe walking. And the built environment can feed back and affect how people feel. For example, fewer parks or more liquor stores predict a decreased feeling of neighborhood trust and cooperation.

There seems to be a big disconnect between what people know is good for their health, and their actual behaviors. Is mindfulness – focusing on what we’re doing right now, in the present moment – the missing link, do you think?

EE I think that’s right on. We can’t possibly regulate our behavior and feelings, and suppress those pesky but strong impulses and other distractors, if we are not paying attention. In a high-stress environment, our brain activity shifts toward the limbic system and the emotional stress response, and away from the parts of the pre-frontal cortex that house executive control systems, the rational and analytical drivers of our behavior. So we react automatically and impulsively when we are under stress and not paying full attention.

And even if we are focusing a lot of effort on eating better or exercising, but in a really self-critical way, this can sabotage our efforts as well. Very few people meet their exercise, sleep, and nutrition goals each day. So mindful attention includes both an intention and a kind attitude, and these help clear our mind of unhelpful or intrusive thoughts, and improve our ability to carry out our intentions.

Eating is an interesting example of a behavior that is not under our full conscious control, although we have not admitted that yet. Eating is something that we can do without paying attention. Otherwise, if it took focus and effort, that wouldn’t be part of adaptive evolution. Overeating is related to stress but also altered neurobiology of the reward system, the source of our strongest motivational drives. This reward area responds to palatable food. This can drive compulsive behavior that feels out of control, an experience similar to being a drug addict for some people. We have to better understand how powerful certain types of foods can be, and that certain conditions, including stress, make people especially susceptible.

In some of our studies, we are trying to help low-income people who feel very little control over their life, with their weight. We are teaching mindfulness to pregnant women, and it looks like the training might be helping not only them but also their babies. We have to think of ‘stress reduction’ where it matters most – which includes the womb. Prenatal stress exposure can affect a child’s health for a long time, possibly a lifetime. For example, mothers who have experienced major stresses while pregnant have offspring with shorter telomeres.

One of many intriguing facts you mentioned in your TEDMED 2011 talk was that technology can actually increase stress in various ways. At the same time, we’re seeing a slew of new apps aimed at helping us to calm down.

EE I think mobile apps for stress reduction are a fabulous potential use of technology, if they really work. For example, we could be using our mobile phones to remind us to rejoin with the moment, and to breathe fully, to notice our physical body and become embodied again. We live mired in our thoughts, above the neck, and this is made worse by multitasking.

But technology devices can become part of multitasking, thus adding to the strain on our limited attention, splitting it yet one more way. There are a lot of wellness apps out there, but I also think that we need data. Almost none of them are evaluated so although they seem promising, do people really benefit from them in a way that would lead to meaningful change? This is a powerful way to reach people, and I admit that even I am involved in an effort to test a stress reduction app!

There are so many answerable questions: Can we take people deeper into a meaningful life, or do these technology interventions contribute to fractured attention and more shallow social interactions? Do people stick with them? Do the apps make a dent in chronic stress arousal over time? As a society we desperately need stress reduction. Let’s hope we can use technology to get there.

If you had the power to enforce one public health measure based on your research, what would it be?

EE Public policy makers try to use their resources well to help people, but don’t always think about how to make policy motivating to an individual, nor take into account fundamental causes of societal and individual stress. Stress is caused by a perception of lack of control and unpredictability. Policymakers can promote empowerment, helping disadvantaged people gain a sense of control over their daily life. Social scientists understand which social and structural factors need to change to help individuals change.

A main message of research today, from epigenetics in basic models to epidemiology, is that adult health is shaped early in life, in important ways we can no longer ignore. So resources are best spent early in life, with the goal of promoting good health and habits, and preventing disease. Good quality education is critical, particularly for girls. It directly translates to better health behaviors and eventually health for the next generation. Resources are just much less effective when applied to diseases that are incurable and costly to manage. Our money is spent in an unbalanced and illogical way. We skimp on education — particularly in California — and spend a tremendous amount of money and time trying to cure incurable diseases such as obesity. Instead, we spend big money on bariatric surgery and costly band-aid procedures.

Has your research changed any of your own personal or work habits?

EE It has, but only in an incremental way over many years. I have been studying the field of stress for almost 20 years, so I know all too well what we should be doing, and how my behaviors such as curtailing sleep and having too many demands placed on me affects my daily physiology, and cellular stress. Does that mean I get enough sleep, exercise, meditate every day, keep work manageable, and prioritize the things that are most meaningful, versus the most urgent? No. I am closer to that than I used to be, and maybe in another stage of life… I still experience plenty of challenging situations, and have my reactions, but now in a more mindful way, and that is a qualitatively different experience. Like most people, I am a work in progress.