An interview with Thomas Goetz on his new venture, Iodine, and why good health data design is critical to patient decision-making

Thomas Goetz is co-founder of IODINE, a new company that uses data information design to inform patient decisions.  He’s been a TEDMED speaker, executive editor of Wired, and wrote “The Decision Tree,” about using technology to help make health decisions. (Reprinted from

You’re now Entrepreneur-in-Residence for the Robert Wood Johnson Foundation, working on two projects to improve the patient experience. Can you first talk about Visualizing Health?

We’ve created a library of validated health visualizations. When people talk about communicating health information to individuals, there’s a dearth of validated examples of what the information should look like.  For example, if you’re trying to communicate heart risk information – if you quit smoking, your risk will of cancer will go down from 50% to 30%  — what does that look like in actual practice?

Thomas Goetz

There are the Edward Tufte’s of the world who have an expert [design] sense.  But we wanted to actually validate, though statistical surveys and other testing instruments, what works best for different groups.  We tested pie, bar and spread charts and different visualizations on various audiences and now have a library. We’ll be putting it online, hopefully by early February, for people to use as a reference point under a creative commons license.  Our hope is that these will become templates that people can inspire and adopt in their own patient communications efforts, whether they are commercial or non-profit.


It seems that over the course of human history we’ve been all too willing to give over responsibility for our health, letting the apothecary leach blood or trusting that the medicine man’s dance will cure us. What accounts for this new era of patient engagement?

In many ways it’s a continuum from the 1950s or ‘60s.  We’re now in a place where we can implement things more deliberately. One of my favorite surveys to reference is a 1961 survey that asked oncologists how many of them would tell their patients that they had cancer. And 90 percent of said they would not disclose the diagnosis; that their patients were probably not ready to know. Of course, that seems completely unethical now. The gradual change in terms of doctors learning to include their patients in diagnosis and care is forced not just by a sense of ethical duty, but also by system structures such as the burden of cost of chronic disease care.  A patient with chronic [illness] may be obligated to do a lot of care on his or her behalf when they can’t have help 24/7.  All of these things are coming to a head, and we’re realizing it’s not just a matter of good practice but one of simply executing what we need to do.  The patient has to be part of the system.

Another of your projects with RWJF is Flip the Clinic, which talks about how to rethink a typically brief doctor’s visit to make it more productive and meaningful.

We’ve been trying to come up with some tools to put in the ecosystem that people can adopt or give feedback on, including ones we’ve gestated internally but also deconstructing things out there that have worked.  We haven’t invented the idea of improving the doctor-patient encounter, but we’ve been amazed to see Flip the Clinic resonate already as a sort of GitHub – the open software collaborating site — around the practice of clinical medicine.  The idea is to help people not reinvent the wheel and [adapt what’s available] to their own needs. When it debuts, will have two main areas: A hub for content – actual tools and strategies people can bring into their own institutions – and secondly will have a community component where people can exchange what they’ve learned, offer new ideas, connecting, say, people from Seattle to New Jersey and helping them understand what has worked in one place that may help solve a similar quandary in a different city.

What qualifies as real change?

It’s a balancing act – we want to have real innovation but we need to  offer tools that don’t just appeal to the converted; they need to work far and wide. Late last month, I had a morning where first I talked to a nurse practitioner at a pediatric clinic in Camden, New Jersey, which is in an underserved community.  They’ve having their clinic budget hatcheted every quarter.  Physicians are frustrated.  This is a facility in true need of new approaches and something that re-orients them toward a positive engagement with their population. I went from that call to one with the Mayo Clinic; they were interested in how they might be able to participate. These are institutions on the opposite end of the spectrum, and one of our core objectives is for Flip the Clinic to work in both places.

In initial discussions, it turned out that both providers and patients wanted more control over clinic visits.  What else do they want?

We also earned there was a mutual yearning for some joy and positive emotional experience out of that encounter from both sides, and especially from the physician.  So one of the things we’ve been trying to be careful about is trying to stuff more into this already limited resource of a 15-minute doctor visit.  For everything we add to that visit, we need to take something off their plate. The challenge is to make these things pragmatic and executable in reality and not just say, “Do more.”

Regarding your new venture, Iodine, which uses data design to help inform patient decisions: Is good design late to the game with healthcare?  Or it is on the same trajectory as other industries?

I think design is an underexploited tool in healthcare, though it’s ahead of the curve in some ways. Health care and medicine are already based upon a data paradigm; there’s a lot of information flowing through the system. But best practices in design thinking are not well applied, and they’re not oriented towards the patient.  Our goal is to leverage data, to translate it and visualize it, so that ordinary people can act on it and make better decisions about their medications. That’s not an easy problem. It’s a hard thing to get people out of their routine, especially in a demanding world like healthcare. But that doesn’t mean it’s impossible – and design is essential to that. That’s where the inherent data orientation of healthcare offers some low hanging fruit.  Iodine’s core tenets are data-slash-analytics, behavioral science, and design.  They’re the three legs of the stool for visualizing and presenting information in ways that increase the likelihood that any individual will act to do something better for their health. [Ed. note:  Iodine will formally launch in February.]

While you were at Wired you ran a great piece showing how design could help patients understand their test results. How come doctors haven’t already demanded better design for their own information? It must be hard looking at that gobbledygook all day. 

Unfortunately, this brings us to the horrible world of EHRs. The prevailing industry products are really crappy in this regard; they come from an enterprise software perspective that’s 10 or 20 years old. A physician is almost always not making decisions on technology procurement. Unfortunately, sometime it doesn’t matter what your frontline needs are compared to the cost determinations of your IT department. The cool thing is that there is another set of savvy tools going straight to the physician that are lightweight and easy to adopt.  There are some companies like Practice Fusion and Pingmd doing innovative things with communications or messaging component. And other companies are working on visualizing lab data, like WellnessFX. That’s a much more interesting strategy and more fun to watch. Sometimes developers use the iPad strategy — taking what physicians are already using and making that your platform, rather than the institutional computer system.

One can’t imagine the current generation of medical students going into the clinic and being satisfied with old-school data design.

That’s precisely where one of these pressures is going to come. The current generation of physicians is being dragged along into the EHR world.  The next generation is going to lead the way, I think. They’re going to demand better tools, both for themselves and for their patients. That’s the world I want to live in; that’s the world I want to in some way help create.

Like mother, like daughter: Eating disorders run in families

Deborah Belfatto worried that her daughter might have an eating disorder when the 12-year-old eliminated all fat from her diet and started getting very thin.

But she didn’t act on her suspicions until an older family friend commented on her daughter’s weight loss.

“The comment came from such an unlikely source that it gave me a jump-start into taking some real action,” Belfatto says.

A breast-cancer survivor, Belfatto considers herself someone who doesn’t shy away from hard truths. But she was not alone in her reluctance to confront her child’s anorexia. Many mothers resist acknowledging a child’s eating disorder, out of fear, guilt – and sometimes because they’re struggling with their own food issues.

Belfatto’s daughter fit the anorexic “profile,” in that she was a high achiever who rarely gave her parents cause to worry. Disordered eaters, particularly anorexics – who severely limit food intake — tend to be very successful in other areas, and Lindsay was an outstanding student and competitive ice skater.

“These high achieving, outgoing, activity-oriented girls are very perfectionist and anxious, and our perception is they respond differently to dieting than other kids do. They actually find caloric restriction calms their anxiety,” says Cynthia Bulik, M.D., author of “The Woman in the Mirror: How to Stop Confusing What You Look Like with Who You Are.”

Like mother, like daughter: Seeing her child with an eating disorder may hit too close to home for some moms. Research shows disorders run in families; a relative of a person with an eating disorder is ten times more likely to have the illness than someone without a family history of disorders. Read more on

Caregiving can hurt employee health — and increase employer costs

Debbi Heffern was too busy caregiving to go for that colonoscopy.

A dietitian and lactation consultant in St. Louis, Missouri, Heffern had been a caregiver for decades; first, for her mother, who died of cancer; and then for her mother-in-law.

“My mother-in-law was determined to live on her own. I made sure we jumped through all the long-term care insurance hoops in the right order, and had to line up paid caregivers. When she took a turn for the worse or needed new equipment I had to be on top of all that. Then her identity got stolen. Untangling that was a nightmare,” Heffern says.

Sure, Heffern had recently turned 50, but she had a healthy life style, except for the stress, and who had time for a colon cancer screening? Unfortunately, she had an ugly surprise when she was tested three years later.

“I ended up with stage four colon cancer, which required multiple surgeries and 32 rounds of chemo. While my employer was very accommodating, recovering from surgeries and all that chemo meant a lot of time away from my own job. If I had gotten my screenings when they had been recommended, I’m told I might have had only stage two or three, and perhaps wouldn’t have needed two of the surgeries or so much additional follow-up chemo,” she says.

“Four in 10 adults in the U.S. are caring for an adult or child with significant health issues, up from 30 percent in 2010,” according to a recent national survey by Pew Research Center. Given our aging population, that number is almost certain to increase, with employers taking a chunk of the burden, at least financially: A 2011 Gallup study says full-time employee absenteeism due to caregiving duties costs employers some $25 billion annually.

What is less obvious is the hidden impact caregiving has on employee health. Byproducts of unrelenting stress, such as depression and poor sleep, and a lack of attention to personal health, including nutrition and exercise or — as in Heffern’s case — neglecting preventive care, take a toll. Eliza Corporation of Danvers, Mass., a leader in health engagement management, in partnership with Altarum Institute, developed the Vulnerability Index (VI) to help insurers and employers measure how life issues like caregiving, financial troubles or marital problems impact employee health. The Company says the index has three times the predictive power of self-reported health problems than traditional measures.

According to their research, these vulnerability factors make people much more susceptible to chronic conditions such as mental illness, lower back pain and diabetes. Caregiving shows a particularly strong link; caregiving employees are nearly three times more likely to be highly vulnerable to health issues than non-caregivers. The Pew study also showed that caregivers were more likely to have faced a recent health crisis than non-caregivers.

Caregiving measurably impacts employer health costs, too; according to a 2010 study of the MetLife Market Institute and the National Alliance for Caregiving, health care costs for caregivers are roughly eight percent more than non-caregiving employees, costing employers an estimated $13.4 billion per year extra.

Tracking a clear relationship can be tough, however, as employees are not likely to bring topics like caregiving — Eliza Corporation calls them “The Unmentionables” — to the fore.

Jon Seaman, Director of Caregiver Solutions at Care Innovations, an Intel-GE joint venture that develops technology for remote care, survived kidney disease and a transplant, then helped his wife care for his elderly mother-in-law through a series of health crises. In talking with him, one gets the feeling that the latter was the more stressful experience.

“I think because it was so obvious that I was ill at work, I was very up front. ‘I’ve got these things going on. Can you support me? But with caregiving, some of the details that would help explain where my time went were very private to my mother-in-law. I didn’t know what I could share. I didn’t think I could really talk about her incontinence, for example. The whole situation was so harrowing and depressing,” Seaman says.

Further, many caregivers don’t self-identify as such.

“People don’t even know they’re doing it. It’s just what they’re supposed to do as a family member. They often have no choice but to be a caregiver. We’re trying to get people to say, “It’s an important point in life to be a caregiver, but you need support,” he says.

The VI research says people are eager for help; about 80 percent of respondents are willing to accept help from their doctor or health plan on an “Unmentionable” issue like financial stress; that rate jumps to 96 percent of people wanting help from either their doctor, their health plan – or just as importantly, their employer – with their caregiving stress. Just being surveyed brings overwhelmingly positive feedback, says Alexandra Drane, Eliza Corporation’s Founder and Chief Visionary Officer.

“The reason people like it is because they know these life stresses are why they’re not feeling well, but nobody asked them these questions before,” she says.

“There is a lot of counseling for cancer patients available both through our insurance company and where I was treated. But I don’t think anybody ever asked me about the caregiving stress,” Heffern says.

Drew Holzapfel, who convened ReACT, a coalition that aims to assist both employees and caregivers, says employers rarely have processes in place to deal with the issue.

“Our data show high awareness of the caregiving responsibilities of employees by their front line manager. What is missing is the action. How do you start the conversation? The tools are not readily available to empower the front line manager,” he says.

Even those organizations that already have invested in tools like this to address caregiving and other life-context issues often have trouble gaining traction – simply because people don’t know about them.

“For the past few years, Cigna has been refocusing its business on the individual,” said Joan Kennedy, vice president for consumer health engagement for the health service company. “We have invested in resources and experts to help people with coaching services, care management programs, and employee assistance programs. The challenge is that many people just don’t realize these resources are available to them.”

Cigna has a pilot program in collaboration with Eliza, using the Vulnerability Index to reach out to individuals that might help, and then connecting them to the resources best matched to their needs, Kennedy says.

As caregiving becomes more common, managers may at least better understand its impact. For one, more executives like Seaman may themselves be caregivers.

“It really does matter if your leadership or direct management has gone through it. When I was a young manager in my early thirties, I had 29 people working for me. I was a stickler at the time for being present in the office during work hours.

“Would I have given them more schedule leniency? Would I have had a team member provide additional support to help them cover issues? I wonder if I would have reacted differently knowing what I know now,” he says.

Published on The Huffington Post

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. “

Reprinted from

How does living with purpose inspire good health?

Reprinted from

Why don’t we always do what’s best for us?

It’s a question that has long preoccupied Vic Strecher, founder and head of the Center for Health Communications Research at University of Michigan and TEDMED 2009 speaker.

After years of teaching health education and helping to create computer-based interactive programs that inspire better personal choices, Strecher is working on a website and a graphic novel based on new thinking in the field and on his own momentous life experience. TEDMED spoke with him about his new projects.

So…why don’t people make more healthful choices? There’s no lack of available health information, and yet lifestyle choices have led many to develop chronic diseases.

VS We know that the choices we make can slowly kill us, like frogs that will stay in water that’s slowly heated until they literally boil to death without jumping out of it. And we’re learning that one reason we resist health messaging is defensiveness. We have this wall around our ego for evolutionary reasons, and ironically our wall has been getting thicker with all the societal messaging we’re getting. With the barrage of junk information and all the choices we face, we’re less able to make competent decisions.

How do you prod people out of that warming water?

VS There’s a relatively new idea being explored called self-affirmation theory. It says that the process of affirming your fundamental beliefs — core values — reduces defensiveness. For example, if you write down or are rating your core values, such as your faith or your commitment to family, and then are exposed to a health message that you may normally process defensively, you’re more likely to accept it.

When you start to put things in writing, you realize, “Hey, my values differ from my behaviors, don’t they?” Research shows that cigarette smokers who affirm their core values are more open to anti-smoking messaging.  People are more likely to participate in diabetes risk assessments if they have just completed their values list.  So how can we get people to start making that kind of connection?

Some of your recent talks have mentioned how empathy can lead to healthier behaviors.  Can you explain? 

VS Jennifer Crocker of Ohio State University, a psychologist who studies self-esteem, wanted to take a look at people’s thoughts while they were affirming their values. And what they were doing was thinking of a connection with loved ones, their friends and family and community, and things bigger than themselves; it drew on something called self-transcendence.

What started you down this path of looking at the bigger picture?

VS Two years ago my daughter passed away; she was 19 years old. I went through a significant grieving process, which included struggling with lethargy, and as a behavioral scientist I was noting my own reactions. I began studying the old philosophers – the Stoics, Existentialists – some like Kierkegaard who were very religious, and some who were atheists.  They all said you have to have a purpose or meaning in your life. Victor Frankl, a Holocast survivor, found out people who were losing their purpose were dying faster in the death camps.

That started me thinking about the epidemiology of this in the medical and health field. People that have a purpose in life are 2.4 times less likely to die from Alzheimer’s Disease, less likely to have a heart attack, and more likely to have good sex. Having a purpose can also help repair our DNA, potentially promoting a longer life. We spend so much time scaring the crap out of people about death and disease, and we should be thinking about teaching them to have purpose in life. We’re so used to telling people, ‘Smoking is bad for you,’ and then ratcheting that fear up. Why not just focus on a totally different direction for this?

You’re working on several new projects with this in mind. Can you share details?

VS I’m self-publishing a graphic novel, “On Purpose,” working with a comic book illustrator and a screenwriter. I decided to put together a story that connects my own personal tale with the related science. It will be about the importance of finding purpose in your life in a nihilistic world, basically. It touches on themes from ancient and modern philosophy, literature, neuroscience, and Egyptology.

I’m also working on a web site. There will be a blog app for people to share their stories. I want to build a community where people can record their purpose and see others’. There will be some kind of filter to group people through their common core values, in a way they might not expect. Some of the real beauty of life is discovering things that you wouldn’t expect to discover or to agree with.

The Smartphone Physical: Checkup of the Future?

Imagine a comprehensive, clinically relevant well-patient checkup using only smartphone-based devices. The data is immediately readable and fully uploadable to an electronic health record. The patient understands — and even participates — in the interaction far beyond faking a cough and gulping a deep breath. For real?  From The Huffington Post

Johns Hopkins medical student and Medgadgeteditor Shiv Gaglani says it is not only possible, but may in fact be the checkup of the future. Gaglani and a team of current and future physicians will do a first-of-its kind demo of a “smartphone physical” for hundreds of attendees at TEDMED 2013 on April 16 to 19 in Washington, D.C.

The checkup will capture quantitative and qualitative data, ranging from simple readings of weight and blood pressure to more complex readings such as heart rhythm strips and optic discs. Measurements and instruments will include:

• Body analysis using an iHealth Scale.

• Blood pressure reading using a Withings BP Monitor.

• Oxygen saturation/pulse measured simultaneously with blood pressure, using an Masimo iSpO2 placed on the left ring finger.

• Visual acuity via an EyeNetra phone case.

• Optic disc visualization using a Welch Allyn iExaminer case attached to a PanOptic Ophthalmoscope.

• Ear drum visualization with a CellScope phone case.

• Lung function using a SpiroSmart Spirometer app to conduct a respirometer test.

• Heart electrophysiology using the AliveCor Heart Monitor.

• Body sounds: A digital stethoscope from ThinkLabs auscultates and amplifies the sounds of a patients lungs and heart.

• Carotid artery visualization using a Mobisante probe.

While it all sounds very slick and tech-y, Gaglani says the smartphone-enabled checkup will actually improve doctor-patient relationships. For one thing, the related medical devices are generally smaller and less invasive than their predecessors.

“For example, thanks to the AliveCor Heart Monitor, it has never been easier to get a one-lead ECG reading. Similarly, the Withings and iHealth blood pressure cuffs are plug-and-play so a clinician doesn’t have to fumble around with both a stethoscope and sphygmomanometer to assess whether her patient is hypertensive,” Gaglani says.

Second, smartphone-based devices usually provide a visual or auditory output that patients can actually see and hear, hopefully increasing their understanding of their bodies and engagement during the checkup. For example, the Welch Allyn iExaminer captures an image of the retina that is displayed on the phone screen, and digital stethoscopes like ThinkLabs’ record heart and lung sounds that can be replayed through the microphone.

Third, the patient can participate in data gathering. As Gaglani says:

“These devices can abstract away the mundane and standardize the unreliable aspects of the physical exam. Measurements such as weight and blood pressure are so variable day-to-day, or even hour-to-hour, that an annual exam doesn’t provide much insight into an individual patient’s health status. Some of the smartphone devices are already being used by patients to collect and store their data so when they see their clinicians they can have productive and informed conversations, rather than relying on fragmented and unreliable metrics.”

Hypothetically, once the data is uploaded to an electronic medical record, back-end clinical decision support software can help both patients and clinicians come up with treatment plans.

The technology may of course be particularly helpful for mobile physicians, particularly in emergency health care settings, and for global health workers, as even untrained staffers can carry the tools to low-resource settings to collect data and then, via telemedicine, receive instructions for how to treat patients. Some of these tools are already being combined into a versatile clinical data-gathering device, called a Tricorder, Gaglani says.

How long will it be before we’re all having our own smartphone physicals every one or two years? Devices such as the body analysis scale, blood pressure cuff, pulse oximeter, and ECG are already in use as teaching devices in med schools and by some patients, and some early adopting clinicians are using them in daily life. Dr. Eric Topol, for example, has used his AliveCor not once but twice to diagnose patients with arrhythmias on airplanes.

While there will be an inevitable learning curve and hopefully constant assessments of cost-effectiveness and value to patients, Gaglani says some of these devices, or at least second and third generation versions, will successfully make their way into the clinic.

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.