Office of Research & Development

VA RESEARCH QUARTERLY UPDATE
This Issue: Chronic Disease Care | Table of Contents: Spring 2017 | Download this issue

A Chat with Our Experts

Using mindfulness to combat stress-related heart disease in women Veterans


Dr. Karen Saban and research participant Bianca Calhoun demonstrate the EndoPAT machine, used to measure blood vessel elasticity. <i>(Photo by Daniel DuVerney, Edward Hines, Jr. VA Hospital, Chicago)</i>
Dr. Karen Saban and research participant Bianca Calhoun demonstrate the EndoPAT machine, used to measure blood vessel elasticity. (Photo by Daniel DuVerney, Edward Hines, Jr. VA Hospital, Chicago)

Dr. Karen Saban and research participant Bianca Calhoun demonstrate the EndoPAT machine, used to measure blood vessel elasticity. (Photo by Daniel DuVerney, Edward Hines, Jr. VA Hospital, Chicago)

Dr. Karen Saban is a nurse research scientist at the Edward Hines, Jr. VA Hospital. She is also associate professor and associate dean for research at Loyola University in Chicago, Marcella Niehoff School of Nursing. Her area of research is focused on neuroscience, with a special interest in stroke, cardiovascular disease, and traumatic brain injury (TBI). Saban is currently investigating the ways that stress can cause inflammation in the body, which can potentially lead to inflammatory-related disease, such as heart disease.

Saban is the principal investigator for a VA Health Services Research & Development-funded study on "Mindfulness Based Stress Reduction for Women at Risk for Cardiovascular Disease." The study investigates the practice of mindfulness as a way to ameliorate chronic stress in women Veterans and to prevent the development of inflammatory diseases like heart attack or stroke.

KEY POINTS:


  • Dr. Karen Saban and her team are testing the efficacy of mindfulness-based stress reduction (MBSR) in lowering inflammation and heart disease in women Veterans.
  • MBSR is a combination of gentle yoga, meditation, and breathing exercises.
  • The researchers will evaluate different variables before they start the program—such as stress and anxiety, depressive symptoms, and immune function.

               

VARQU recently spoke with Saban about her work to reduce inflammatory diseases using mindfulness techniques.


Dr. Saban, can you tell us why Veterans who have experienced combat are at greater risk for cardiovascular disease, like stroke?

One of the reasons is that chronic stress over time can change the way that our immune system responds to stress. Those changes in our immune system can increase the risk for developing inflammatory-related disease. A lot of chronic medical problems are related to inflammation, such as heart disease and [hardening of the arteries]. Obesity is believed to be an inflammatory-related disease as well. There's also been quite a bit of work looking at the role of inflammation in diabetes. The belief is, and there have been quite a few studies to support this, that chronic stress can at least contribute to inflammatory-related diseases.

Research participant Bianca Calhoun demonstrates a yoga pose that is part of the mindfulness-based stress reduction program. <i>(Photo by Daniel DuVerney, Edward Hines, Jr. VA Hospital, Chicago)</i>
Research participant Bianca Calhoun demonstrates a yoga pose that is part of the mindfulness-based stress reduction program. (Photo by Daniel DuVerney, Edward Hines, Jr. VA Hospital, Chicago)

Research participant Bianca Calhoun demonstrates a yoga pose that is part of the mindfulness-based stress reduction program. (Photo by Daniel DuVerney, Edward Hines, Jr. VA Hospital, Chicago)

There has been some literature that shows that women Veterans may have greater chronic stress in their lives than men. Certainly there's been studies that have shown mostly male Veterans with combat experience do have greater incidence of coronary artery disease. But there's less known about women Veterans. But we can certainly take that information and assume or extrapolate that women Veterans are also at greater risk.


You say that women Veterans experience greater chronic stress in their lives. Do you know why that is?

Well, there are higher rates of abuse in women Veterans. There have been a number of studies that have looked at that. For example, one study showed that 59 percent of women Veterans may have been abused as children. And they do report higher rates of childhood maltreatment. Then there is this belief that early childhood stress can set up inflammation or [prime] the immune system to be at higher risk for inflammatory disease later on in life.


Are you saying that childhood stress can carry through a person's lifetime and cause greater risk for disease in adulthood?

Yes. Are you familiar with epigenetics? Our DNA generally does not change. Epigenetics—you can think of the term "epi" meaning "surrounding"—essentially controls the extent to which our genes are expressed. It's almost like the volume switches on our genes. And so by changing that epigenome you can increase gene expression or silence it. There's been quite a few studies, especially with animals, even social maltreatment in early life can turn on or off, or change the epigenetic signature, so that later on, if a person is dealing with stress or chronic stress they have those volume switches set at a certain level—which may then allow them to develop certain diseases.


There have been many studies done on the effects of stress and inflammation for male Veterans, but few studies that focus mainly on women Veterans. Why is that?


I think that is a big part of it, that there are fewer women Veterans. I think the research is shifting more toward including women in research [studies]. But if you think about years ago, most research (not just in the VA) was with men. I think we started realizing that women and men are very different from each other—we respond to things differently, we have unique needs [psychologically and physiologically].


Can you tell us about the mindfulness-based stress reduction (MBSR) technique that you are using in your study?

It was developed in 1979 by Jon Kabat-Zinn. He was at the University of Massachusetts Medical School. He developed this program which is a combination of gentle yoga, meditation, and bringing your attention to your breath. And he developed this program primarily to use with patients who had chronic pain. He developed it over several years, and found that it really worked, that people were able to deal with chronic pain and cope better by practicing MBSR.

It's an eight-week program; it's pretty standardized. The trainers are trained and certified in the technique. They go through different modules or different components of MBSR over that period. It's a two-and-a-half-hour class every week, for eight weeks. Participants complete the class usually in small groups (15, maybe 20 people), and they are trained in these different techniques: breathing, relaxation, focusing your attention to your breath, and then going through some gentle yoga poses, which are very adaptable for people who have disabilities or physical problems. They learn those techniques and then are asked to practice them for 45 minutes to an hour each day. The whole point is to help them really focus on one thing, to bring their attention to one thing, and to be able deal with stressors that will inevitably come up in their lives throughout the day.

Dr. Karen Saban and research participant Bianca Calhoun discuss the MBSR program. <i>(Photo by Daniel DuVerney, Edward Hines, Jr. VA Hospital, Chicago)</i>
Dr. Karen Saban and research participant Bianca Calhoun discuss the MBSR program. (Photo by Daniel DuVerney, Edward Hines, Jr. VA Hospital, Chicago)

Dr. Karen Saban and research participant Bianca Calhoun discuss the MBSR program. (Photo by Daniel DuVerney, Edward Hines, Jr. VA Hospital, Chicago)


What exactly does the term "mindfulness" mean?

It is this combination of increasing your awareness of your stress or different things that are happening in your body and then just being able to be aware of it, not judging or evaluating. You are looking at yourself and saying, "OK, I feel tense," or you are aware of your heart rate going up. So you take on [an attitude] that you won't react to it. You say, "You know what? This is where I am right now. My heart is racing right now." You don't say, "Oh my gosh! I'm getting so stressed out." So you just observe it and then let it go. It is really teaching people how they are going to respond to different stressors or reactions in their bodies, and not to judge it.


After the Veterans are trained in MBSR, are they asked to go home and practice it?

Yes, they practice it throughout the whole program, and then they are asked to continue practicing it after the program ends. We evaluate as part of our research study different variables before they start the program: things like stress and anxiety, depressive symptoms, and we also look at immune function. So we are looking at certain pro-inflammatory cytokines.


Can you tell us what endothelial dysfunction is, and why it's important to this study?

Well, endothelial dysfunction is really a change in the blood vessels that can indicate early changes before actual cardiovascular disease starts. That is one of the things that we are looking at in this study, and we are measuring it with a noninvasive device called the EndoPAT. We are looking at how blood vessels recover from compression.

What we do is put a blood pressure cuff on a study participant; we basically restrict the blood supply to the hand for a few minutes and then we release it. We have a probe on the finger and we are measuring how quickly that blood supply returns to normal. It's noninvasive and it isn't painful—it might be a little uncomfortable having that tight blood pressure cuff on for a while. And from that we get a measure of how quickly that blood flow returns to normal. And that is an indicator of potential endothelial dysfunction—how quickly that blood vessel can accommodate the difference in blood flow. That can give us an idea of what a study participant's cardiovascular risk is in the future.


Once you teach study participants MBSR, do you assess their cardiovascular health—specifically, their endothelial function—by taking these measurements throughout the study?


We do a battery of tests including the EndoPAT, we take blood samples, and collect cortisol levels from their saliva. We ask study participants to collect their saliva at home at five different time points throughout the day. We are looking at patterns of cortisol levels throughout the day. There has been some evidence that some of those patterns may become dysregulated in people who have chronic stress. That then can give us an indication of how they are responding to chronic stress.

We measure study variables halfway through at four weeks, and then we measure them at the end after participants complete the entire eight weeks of MBSR training. And then we also have them come back after six months and we do all the measurements again.


So this is a technique that ideally participants will take with them and continue to practice?

Yes. We did get some additional small amount of funding to evaluate an app that they can put on their phone. It also has some of the classes and recordings from the MBSR program, so then they can listen to it on their phone and do it. We are looking at that, too, to see if it will help sustain their practice, because there really haven't been a lot of whole studies looking at sustaining MBSR practice.


What are your goals for this study?


Well, I would like to see if the MBSR training could reduce cardiovascular risk. We are measuring things like cholesterol levels, hemoglobin A1C, and blood pressure and other variables related to risk. Our hope would be that women Veterans who participate in the mindfulness class will have reduced risk. We are randomizing women to a control group as well. The other group takes part in health education classes that have nothing to do with reducing cardiovascular risk, of course. The whole point is to tease out that it is not the attention that is [reducing risk and] making the changes.

When we look at the male Veterans, we see that they hang out a lot together, playing cards and socializing. We see a lot of older male Veterans who I think use the VA as a social spot; they stop in and have coffee together.

We don't see a lot of that with the women Veterans. I think it is because women spend more time with their children and families. Some of the women in our groups have said, "This is the first time I've actually sat down with other women Veterans." A lot of them end up becoming friends with one another.

I think it is important for us to control for new friendships among women Veterans to make sure the outcomes that we see in this study aren't related to the fact that these women are socializing together and offering each other support.


Mindfulness has been in the news quite a bit lately—for instance, using it to treat chronic pain. What are the benefits of practicing mindfulness over the long term?

I think we would expect people to cope better with those inevitable stressors, that they would feel calmer, have a greater sense of well-being, and improved quality of life. And this certainly is in the literature. There have been studies that have shown that it can improve relationships. It teaches you to stop and observe, and not do that kind of quick reaction.

We have another study with preschoolers in the Chicago Public School System looking at using mindfulness to help young children who live in socio-economically depressed neighborhoods to copy better with daily stressors and to sleep better.

I hear what you are saying about mindfulness being in the news and being touted like it will solve everything. And we know nothing does. But I do think that one thing that people tend to underestimate—it does take a lot of practice and a commitment. And not everyone is able to do that. I know that I've gone through the course myself. I work full time and I have kids. It's not easy to find the time during the day to meditate when you feel you have a thousand things to do. But I think it's making that commitment, maybe it's not an hour a day, maybe it's 10 minutes in the morning when you are taking a shower. There are ways to work it into your life.

As the trainer used to tell us, "It's the intention of doing it," that you intend to take care of yourself. And even if it's just 10 minutes today, you are making an effort to think about your mental health. Ultimately, that will help you in the long run.


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