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Update from Dr. Aw

A healthy heart means a healthy brain: The Heart Brain Connection

February 19, 2021

As we celebrate Valentine’s Day this month, we are all reminded of the ones we love, or perhaps a chance to flirt and show our romantic side to someone special. It is curious how powerful emotions, (happy or sad), can deeply affect how we physically feel in the moment. That visceral warm and tingling feeling when experiencing an act of love and kindness or that horrible wrenching chest and gut feeling when someone has “broken your heart”. There is a medical condition called Takotsubo stress cardiomyopathy where you could even die of a broken heart. An intense emotional or stressful event leads to a nervous system response that releases neurochemicals (catecholamines) causing spasm of your heart muscles and swelling in one of your chambers leading to temporary heart failure. On x-ray the heart muscle looks like a Japanese container used to trap octopus (hence named Takotsubo!). There is a higher prevalence of underlying anxiety and depression in these patients, but fortunately, this condition is rare and reversible with supportive treatment.

What about the effects of chronic stress on the heart? The famous Whitehall studies in the United Kingdom in the 1960s looked at stress from “unhealthy work” in civil servants and found a connection between chronic stress from job strain and increased mortality from cardiovascular disease. The more recent Interheart study (25,000 participants across 52 countries) found that emotional stress was a key risk factor associated with approximately one-third of heart attacks and strokes. Acute or chronic stress can activate the “fight-or-flight” response that triggers a cascade of biochemicals like adrenaline that can increase heart rate, blood pressure and lead to other effects (cortisol, neuropeptides, coronary artery spasms). Research is emerging on the connection between the emotional coding part of the brain (amygdala) and heart and stroke outcomes. No surprise that better emotional health is good for your heart!

I have always been fascinated by the Heart Brain Connection. Heart and stroke disease (cardiovascular disease) can accelerate cognitive decline and be a risk factor for dementia. Cardiovascular disease in middle age can be a predictor of future brain functioning decline. The Maastricht Aging Study (MAAS) was a famous 12-year follow up study of cognitively healthy individuals (age 24-82, n=1823) who underwent extensive executive function testing (memory, information processing speed) and found cognitive impairment was more frequent in those with cardiovascular disease. Interestingly – the stronger associations were among younger individuals with risk factors who developed progressive cognitive impairment rather than later in life.

Shared risk factors and mechanistic pathways likely explain the heart brain connection. Several studies have shown the association of midlife high blood pressure, diabetes and low physical activity with lower cognitive functioning. It seems that the accumulation of multiple risk factors over the life course worsens the risk of brain decline as opposed to a single factor. The shared biological mechanisms are also likely a combination of a predisposition to chronic inflammation, clotting, strokes, lower heart function (output) and arrhythmias (like atrial fibrillation).

The heart-brain connection: common risk factors and mechanistic links over the life course.

Life course: 15-39 years - Cardiovascular risk factors: age, smoking, sedentary lifestyle, obesity, diabetes, hypertension, high cholesterol, hyperlipidemia. 40-59 years - Subclinical atherosclerosis inflammation and oxidative stress in: heart, brain, kidney, retina, peripheral blood vessels. 60-74 years - Heart disease / coronary disease: angina pectoris, myocardial infarction, atrial fibrillation, heart failure, cerebral hype perfusion, hypoxia, emboil. Over 75 years - brain lesions: stroke, white matter lesions, neurodegeneration (plaques and tangles_, disruption of BBB, lacunar infarcts and will cause cognitive decline, dementia, mild cognitive impairment.

Source:   Eur Heart J, Volume 38, Issue 43, 14 November 2017, Pages 3229–3231, https://doi.org/10.1093/eurheartj/ehx387

So how do we keep a healthy heart brain connection?

It is important to stay informed (health literacy) on modifiable risk factors and master “self-efficacy” of daily dietary, physical and emotional healthy behaviours. It is always good to assess your “Heart Age”. The CDC has a nice online tool based on the Framingham Study of risk stratification.
(https://www.cdc.gov/vitalsigns/heartage/index.html)

It is also critical to continue any prescribed medications (i.e. statins for lipids, anti-blood pressure pills, diabetic medications, etc.) and check in regularly with your health care provider to avoid delays in testing or treatment. The pandemic has taught us about the importance of societal and behavioural factors on prevention. COVID-19 has led to a significant drop in cardiovascular testing globally and delays in diagnosis and care for preventable diseases. The lack of compliance with universal mask wearing has led to COVID-19 infections which are now known to be associated with cardiovascular, neurological disease and “brain fog” in long hauler patients (long COVID). Simply wearing a mask during a pandemic may protect your heart and brain!

Ultimately - a more holistic approach will be helpful to preserve a healthy heart-brain connection versus an oversimplified disease centric approach (i.e. healthcare in silos). It is important to focus on your emotional and brain health to protect your heart.

Here are five daily lifestyle practices to reduce stress and improve neurochemical responses from cardiologist Dr. Michael Miller who is the author of “Heal your Heart, The Positive Emotions Prescription to Prevent and Reverse Heart Disease”:

  1. Meditation (serotonin activated relaxation practices)

  2. Yoga (GABA induced mood stabilization)

  3. Laughter (endorphin mediated visual effects)

  4. Music (dopamine regulated auditory effects

  5. Massages, hugging (oxytocin activated tactile responses)

Albert Einstein once said, “Don’t let your brain interfere with your heart.” The heart and brain are interlinked as much as humans are to each other. Your brain health affects your heart health and vice versa. During this pandemic, remember to take daily breaks and recharge. Humans were never meant to sit in front of a screen for all hours of the day. Unplug and give yourself permission to take some timeouts. So - for this Valentine’s Day month – give someone (pets count here too!) a hug or share some laughs and music with loved ones. These simple daily acts are great for the heart brain connection and is just what the doctor ordered!

References:

  1. Tako-tsubo cardiopathy (Broken Heart) https://www.sciencedirect.com/science/article/pii/S2213158219304711?via%3Dihub; https://www.internationaljournalofcardiology.com/article/S0167-5273(16)34540-5/fulltext

  2. Whitehall studies https://academic.oup.com/ije/article/34/2/251/746997

  3. The Heart Brain Connection https://academic.oup.com/eurheartj/article/38/43/3229/3980157

  4. INTERHEART STUDY https://pubmed.ncbi.nlm.nih.gov/15364185/

  5. ​​​​​​​International impact of COVID-19 on the diagnosis of heart disease https://www.jacc.org/doi/10.1016/j.jacc.2020.10.054

  6. Emotional Rescue: The Heart-Brain Connection https://pubmed.ncbi.nlm.nih.gov/32206169/




Dr. Aw Answers More Employee Questions about COVID-19

February 5, 2021

We caught up with Dr. Aw to get answers to more employee questions about COVID-19. (Answers provided January 8, 2020)

Multi-part question:

  • What do we need to know about vaccines?

  • Are they safe?

  • How quickly can those of us who are lower risk expect to get the vaccine?

  • Can you transmit the virus after you are vaccinated?

  • When will we reach herd immunity?


Will the vaccine work on the new strain?


Is there anything I can do to mitigate the impact of the virus?

Read the video transriptgo to video transcript

What role does winter and cold weather play in transmission?


What does it mean if a virus becomes endemic?


Will things get better in 2021?


How Physical Activity Drives Energy

January 8, 2021

Join the conversation with Dr. Aw and Brendan Fox to learn how important it is to cultivate energy, and create a daily routine for yourself. If you are watching I encourage you to join along!



Diabetes Awareness and what you can do

December 16, 2020

The “Borderline Abnormal” Patient – Do you have Pre-Diabetes?

I saw a patient recently who for this article, we will name “Sam.” Sam is a middle-aged man working in finance who has gained 10-15 “pandemic” pounds and his midsection is expanding. He confessed that he is an emotional eater, has a weakness for cookies and late-night snacks during times of stress. Sam is working from home and putting in long days as his workload has increased. He hasn’t been working out and hasn’t yet figured out how to replace the visits to the gym with home exercises. He was experiencing low energy and getting some recurring non-COVID infections (sore throats, fungal rashes). He was feeling stiff from sitting at the computer all day and getting some funny chest pains. Sam checked out his blood pressure at a local pharmacy and was told that he was borderline high. He booked an appointment with me for a checkup.

I ran some tests. His ECG was normal – but his blood pressure (BP) was slightly elevated at 140/90. His blood work was “borderline” abnormal (slightly out of the normal range). His blood sugar was elevated (but not in the diabetic range). His triglycerides (a type of lipid/fat in the blood) were elevated and his HDL (“good cholesterol”; high density lipoprotein) was low. His waist circumference was above average (over 40 cm). Sam had a bunch of little things that when we put them together are classified as “Pre-Diabetes” also known as Metabolic syndrome, Syndrome X, Insulin Resistance, Obesity Dyslipidemia Syndrome and the “deadly quartet”. His future risk of developing diabetes, heart disease and stroke is much higher unless he can convert those “borderline” abnormal results – back into the normal category.

Fortunately for Sam, all of these risk factors can be reversed with a healthier lifestyle. Lose weight (decrease waist circumference, lower blood pressure), eat healthier (lower triglycerides, glucose), cut back on salt (lower blood pressure) and increase exercise (lower his BP, increase his HDL). A strong motivator for Sam to change his lifestyle was the fact that we could avoid (or delay) the need for medications (to treat BP, diabetes, cholesterol).

November 14 was World Diabetes Day and this year marks an important milestone for Canadian history and science. 100 years ago, in the month of November – a young Canadian Dr. Frederick Banting had discovered insulin at the University of Toronto alongside Dr. J.J.R. Macleod (physiologist), Charles Best (medical scientist) and Dr. James Collip (biochemist). Diabetes was and is treatable!

There are two types of Diabetes that are treated with medications, Type 1 (insulin deficiency, earlier in life, requires insulin injections) and Type 2 (insulin resistance, later in life, oral medications). Type 2 diabetes can be heavily influenced by poor lifestyle choices which can tip high risk patients (pre-diabetes) into true diabetes. Metabolic syndrome increases your risk of developing diabetes by about 5-fold and doubles future risk of developing cardiovascular disease. Metabolic syndrome affects 20-30% of individuals in Westernized countries with lower prevalence in Asia.

Dr. Aw - Capture of TIME magazine with Dr. Frederick Banting on the cover.

Source: Time cover, 27 Aug 1923

The accumulation of fat cells around the abdomen (apple body types) can lead to resistance to the effect of insulin which controls the use of glucose and fatty acids. The resulting high levels of blood sugar (glucose), insulin levels and chronic inflammation (fat cytokines) can lead to dysfunction of the lining of the blood vessels and contribute to atherosclerosis (clogging of the arteries if accompanied by high lipid levels and high blood pressure). In other words – increasing your risk of heart attacks and strokes.

Fortunately – pre-diabetes can be reversed with weight loss, physical activity and a healthy diet; particularly the Mediterranean Diet (high in fruits, vegetables, nuts, whole grains, olive oil), and foods with low glycemic index, high fiber and DASH Diet (limit daily sodium intake to less than 2,400 mg) for high blood pressure are helpful. Some patients still require medication to treat elevated lipids, sugars and blood pressure to delay the onset of diabetes (which also has a genetic component).

So back to Sam….

I saw Sam at a follow-up appointment, and he looked fantastic!  He lost 10 lbs. by adopting the Mediterranean Diet, decreasing his daily salt intake, and cutting out the cookies and late-night snacks.  He also started doing daily walks and worked out virtually with a personal trainer a few times a week.  We discussed some of the new Canadian 24 hour movement guidelines (https://csepguidelines.ca/) that emphasizes the importance of limiting screen time and increasing daily activity with time protected for sleep.  His home blood pressure readings were now around 120/80.  We repeated his blood work and his glucose, HDL and triglycerides were trending better.  Best of all – he felt great and energized!

In isolation – certain risk factors don’t seem so bad if considered “borderline” abnormal.  However – when viewed together it can increase your risk and you may not even know it.  Fortunately – it is never too late to reverse the trend through healthy lifestyle choices and action!

So, what is known about Pre-diabetes aka Metabolic Syndrome?  Do you have it?

Do you recall ever having this type of conversation with your physician?  “Your weight is a little up, your blood pressure is borderline high, and your lab tests are just out of the normal range – but no need for medication right now.”   Well – make sure that you don’t have a collection of these risk factors because it may mean that you are at future risk for diabetes.

The American National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria define metabolic syndrome as the presence of any three of the following five traits:

  • Abdominal obesity, defined as a waist circumference ≥102 cm (40 in) in men and ≥88 cm (35 in) in women

  • Serum triglycerides ≥150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides

  • Serum high-density lipoprotein (HDL) cholesterol <40 mg/dL (1 mmol/L) in men and <50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL cholesterol

  • Blood pressure ≥130/85 mmHg or drug treatment for elevated blood pressure

  • Fasting plasma glucose (FPG) ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose

Source: https://www.nhlbi.nih.gov/files/docs/guidelines/atglance.pdf

Metabolic syndrome (pre-diabetes) has also been associated with several obesity-related medical conditions such as fatty liver, cirrhosis and liver cancer, chronic kidney disease, polycystic ovarian disease, sleep apnea and high uric acid (gout).  Metabolic syndrome has also been linked to chronic inflammation and risk for cognitive decline and dementia.  High blood pressure, lipid levels (cholesterol, triglycerides) and diabetes are a very bad combination for several diseases!

Diabetes infographic. Risk factors for type 2 diabetes: genetics, age and family history of diabetes can increase the likelihood of becoming diabetic and cannot be changed. But some behaviours that increase risk can: unhealthy diet, 1in 3 is overweight, physical inactivity, 1 in 10 is obese.

Key actions: For everyone - eat healthy, be physically active, avoid excessive wright gain, check blood glucose if in doubt, follow medical advice.

For governments: Ensure healthy environments, better diagnosis & treatments and better data.

References

  1. Metabolic Syndrome https://medlineplus.gov/metabolicsyndrome.html 

  2.  Frederick Banting and the Discovery of Insulin  https://definingmomentscanada.ca/news/officially-launched-insulin100-inspiration-and-innovation/ 

  3. Mediterranean Diet https://medlineplus.gov/ency/patientinstructions/000110.htm#:~:text=The%20Mediterranean%20diet%20is%20based%20on%3A%201%20Plant-based,and%20seasoned%20simply%2C%20without%20sauces%20and%20gravies.%20 

  4. Glycemic Index https://medlineplus.gov/ency/patientinstructions/000941.htm 

  5. DASH Diet  https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/dash-diet/art-20048456 

  6. The Metabolic Pandemic https://www.ahajournals.org/doi/full/10.1161/ATVBAHA.107.151092 

  7. Global Prevalence  https://emedicine.medscape.com/article/165124-overview#a6 

  8. Canadian 24 hour movement guidelines https://csepguidelines.ca/wp-content/uploads/2020/10/24HMovementGuidelines-Adults18-64-2020-ENG.pdf 


Dr. Aw Answers Employee Questions about COVID-19

December 9, 2020

As the pandemic continues to evolve, OMERS employees posed some topical questions to our Chief Medical Officer, Dr James Aw about the current state and what to expect as we look to a new year. (Answers provided November 20, 2020)

How long do I need to be near someone to be at risk?


Will there be a third wave?


What's happening with vaccines and treatments?


How long will the pandemic last?



Wellness Checklist with Dr. Aw

Friday, November 20, 2020

Wellness seems easy to understand – but difficult to master. There are many definitions of wellness and our life journeys are unique to each of us. Wellness is personal. The healthiest individuals that I have met over the years in my clinical practice, personal and business life all seem to take a holistic view to wellbeing and don’t take anything for granted. Achieving wellness requires a lot of work, discipline and positive daily habits. It’s not simply excelling in one thing (i.e. physical, mental, financial, job satisfaction, relationships, etc.) - but mastery of many things at the same time.

I have found a few helpful frameworks that address the multiple dimensions of wellbeing. Traditionally – medicine has been more reactive and focused on diagnosing and treating physical and mental health. However – prevention of disease and feeling well requires a broader perspective. One of my medical heroes is Sir William Osler who was a Canadian physician who graduated from McGill University and one of the founders of Johns Hopkins School of Medicine in Baltimore, USA. One of his quotes has always stuck with me. “The good physician treats the disease. The great physician treats the person who has the disease.”

Preventive health strategies recognize that physical and mental health are intimately intertwined with social elements such as interpersonal relationships, community service, occupational satisfaction and financial independence. Social connectiveness, meaning in life and how we feel have huge impacts on our overall wellbeing.

Another medical hero of mine is bestselling author and surgeon Dr. Atul Gawande. He wrote a few books that were influential early in my career (Better and The Checklist Manifesto). Dr. Gawande showed that the simple idea of a checklist applied to different medical scenarios can address complexity and how to get things right. In a busy world of competing interests, high volumes of information and demands on our time - a simplified checklist can help us be better.

Source: “Innovative Ways to Present Well-Being to Families,” by Dr. Isaac Prilleltensky, Dr. Ora Prilleltensky, Dr. Samantha Dietz, Dr. Nicholas Myers, Dr. Yin Jin, and Adam McMahon. (https://perma.cc/DAZ5-ZLW9)

I propose that you create your own Wellness Checklist that you can refer to daily. How would you honestly evaluate yourself in each of the wellness dimensions? How many A’s and B’s versus C’s and D’s would show up on your Wellness Report Card? Wellness is more than how many pushups you can do or feeling good about yourself. What is going well and where do you need more attention? The point of evaluating your wellness areas is to increase personal awareness and not creating additional stress. It is not a competition. It is about being your best whole self.

Start where you are at. Set goals and create an action plan in each Wellness area. Keep it simple and actionable with a positive outcome. SMART goal setting is a common approach used for decades which believes that goals should be Specific, Measurable, Actionable, Realistic and have a Timeline. Starting your day in the right mindset and kickstarted with physical activity (something that makes you sweat!) can have huge benefits. I recently read Robin Sharma’s book called “The 5 am Club” which focuses on the power of morning healthy habits.

I have written previously on the challenges of behaviour change (Change Wheel). If change was easy – we wouldn’t keep talking about it. Judith Hibbard from the University of Oregon is well known for her research on patient activation which acknowledges the individual’s role in behaviour change. Individuals require knowledge, confidence and skills to manage their own health and ultimately lead to positive outcomes. Individuals with high levels of activation feel empowered – whereby others with low activation have a more passive approach and less likely to seek help. Try to assess your own level of activation in the different Wellness spheres and seek help, guidance and inspiration in the areas that need some attention.

Source: https://www.england.nhs.uk/wp-content/uploads/2018/04/patient-activation-measure-quick-guide.pdf

In summary – wellness starts with awareness (personal health audit, checklist) and requires action (goal setting, activation) to improve outcomes. Wellness is social. We need each other for support, guidance and inspiration. Have a growth mindset – so that wellness becomes a personal journey of exploration and new experiences. It should be fun and meaningful to be sustainable.

Be a lifelong learner and become an expert on you!

References

  1. Sir William Osler https://en.wikipedia.org/wiki/William_Osler

  2. Atul Gawande http://atulgawande.com/book/the-checklist-manifesto/

  3. Robin Sharma https://booksummaryclub.com/5-am-club-summary/

  4. SMART goals. Doran, G. T. (1981). "There's a S.M.A.R.T. Way to Write Management's Goals and Objectives", Management Review, Vol. 70, Issue 11, pp. 35-36.

  5. Behaviour Change. https://omers.sharepoint.com/sites/Pulse/SitePages/Wellness/Dr-Aw-Behaviour-Change.aspx

  6. Judith Hibbard. Patient Activation. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/supporting-people-manage-health-patient-activation-may14.pdf


Healthy Buildings and Wellbeing

Friday, November 6, 2020

​​​​​​​Over the summer – I picked up a book called “The Healthy Indoors: The Surprising Science of How Buildings Shape our Behavior, Health and Happiness” by Emily Anthes.  Anthes is a science writer who claimed that modern humans are an indoor species who (pre-COVID) spend 90% of our time shuffling between homes, offices, schools, stores, restaurants and gyms.  She looked at how indoor spaces affect our mental and physical wellbeing as well as our emotions, productivity and even relationships.  It was an interesting read considering our current pandemic times where most of us are working from home and avoiding crowds where there is prolonged indoor exposure. 

The new COVID normal has highlighted the importance of indoor air exchange and flow, disinfection protocols and health and safety protocols for buildings where we work and play.  Oxford Properties has been a leader in building design and real estate investment with projects around the world.  I decided to sit down with Dean Hopkins, Chief Operating Officer, Oxford Properties and Claire McIntyre, Head of Brand, Marketing and Communications, Oxford Properties to get their viewpoints on the Future of Healthy Buildings.

Before I get to Dean and Claire – let me share some of the insights that I picked up from Anthes’ book.

Anthes reviewed the research and future trends on “smart” buildings, adaptive and amphibious architecture, biophilic buildings and urban design for mentally healthy cities (links below).  She cited examples of established Green building certification programs (LEED – Leadership in Energy and Environmental Design, Living Building Challenge) and progressive environmentally friendly designs such as the Seattle Bullitt Center and the Powerhouse in Scandinavia.  Other healthy building certification programs include WELL and Fitwel.

Academic institutions such as the Mayo Clinic Well Living Lab and Harvard Healthy Building Program have innovation research labs that are focused on the future of wellness, indoor health and building design.  “Smart” buildings will be able to enhance real time monitoring of VOCs (volatile organic compounds), CO2 (carbon dioxide) ventilation rates, particulates and a host of other environmental conditions in the office.  Organizations such as the Centre for Urban Design and Mental Health in London, Happy City in Vancouver, First Place Autism in Arizona and Tiger Place for the Elderly in Missouri are examples of research focused on the design of cities that address mental health.

Nature is also important in future wellness designs.  Biophilic design is built around the concept that humans have an understandable affinity with the natural world.  A Finnish company called Naava has designed “living” green walls with plants for clean air and the California Earth Institute promotes the use of earth and sandbags to create eco-friendly Super Adobe Dome living and working structures.  New York-based COOKFOX Architects have a mission of designing buildings that foster the well-being of people and a healthy urban landscape. Oxford is working with COOKFOX to create St. John’s Terminal, an adaptive reuse project on the west side of Manhattan that has been fully pre-leased to Google. Amphibious architecture are flexible structures that are built around water.   

The London School of Economics published a paper on the use of a checklist to measure the impact of built environments on wellbeing.   The SALIENT checklist stands for Sound, Air, Light, Image, Ergonomics, Nature and Tint.  The aim was to link behavioural science to how built environments affect what we do and how we feel. 

What is the Future of the Indoors and Wellness during and post COVID?

Dean Hopkins:

​​​“Several nascent trends were accelerated by the pandemic, including the focus on customer health and the opportunities unlocked by the convergence of data, smart buildings and new technologies. Over the last six months we’ve collaborated with progressive thinkers and businesses to fast-track the commercialization of promising products and platforms. With our long-term focus, Oxford is well positioned to create a real point of difference by investing in creating healthier places.”

Dean feels that healthy buildings will become a competitive advantage for tenants. Best buildings will provide healthy experiences for users.  Everything from touch free experience to real time data sharing of environmental conditions powered by technology.  Sensors will automate cleaning protocols, indoor air quality and lighting (smart windows) while optimizing the use of natural sunlight.  Common office spaces will need to be redesigned to maximize creativity and social connection while staying safe.  Buildings of the future will be designed to enhance the emotional wellbeing of occupants.  People need to feel psychologically safe and inspired in their indoor spaces.  He hopes to create a Living Lab at Oxford to pilot innovative designs.

Claire McIntyre:

​​​​​​​“The most enlightened building owners put customers at the heart of every business decision, and that commitment is critical to advancing the health of customers and communities. The owners that prioritize collaboration, testing and transparent measurement will be the ones who make the biggest impact on people and the ones who win the greatest share of business.”

Claire feels that there will be a focus on understanding and measuring the health impact of various interventions that physical space can deliver and quantifying what customers truly value.  Behavioural data science will help inform building design and investment decisions and pair with smart technology to create adaptable buildings for different communities and populations. The future of the workplace will also be influenced by the type of work and links to productivity.  Office spaces that foster collaboration, problem solving, and professional growth will increasingly be the focal point for the best companies, especially in a hybrid world where some employees work partly from home. Buildings will evolve from a customer service focus to an experience mindset.  Claire also feels that there will be a trend of increasing transparency (data scorecards, rankings) between building owners and customers.  The leading companies will figure out how to incorporate a holistic approach to wellness in their buildings.

There are many exciting innovations to create healthy buildings of the future.  The pandemic has accelerated the pace of change and adoption of these concepts that focus on the human experience.  We all look forward to enjoying a healthier indoors!


References

  1. International Living Future Institute https://living-future.org/

  2. Seattle Bullitt Center https://bullittcenter.org/

  3. Powerhouse in Scandinavia https://www.powerhouse.no/en/

  4. Well https://www.wellcertified.com/

  5. Fitwel https://www.fitwel.org/certification/

  6. Mayo Clinic Well Living Lab https://www.welllivinglab.com/

  7. Harvard Healthy Building Program https://forhealth.org/

  8. Urban Design and Mental Health https://www.urbandesignmentalhealth.com/

  9. Happy City https://thehappycity.com/

  10. First Place Autism https://www.firstplaceaz.org/

  11. Tiger Place for the Elderly https://engineering.missouri.edu/2009/01/tigerplace-where-care-and-aging-with-dignity-go-hand-in-hand-with-technology/

  12. Naava https://www.naava.io/en/

  13. California Earth Institute https://www.calearth.org/

  14. SALIENT checklist https://www.mdpi.com/2075-5309/6/1/9/htm


Influenza Update – Get your Flu Shot!

Friday, October 23, 2020

It’s the time of the year to get a flu shot. However – this year is different because of the COVID-19 global pandemic.

On the positive side – the public health measures of physical distancing, masking, avoiding crowds and washing hands have led to a decrease in global influenza cases, (particularly in the southern hemisphere), because COVID-19 and influenza are transmitted the same way. But - the northern hemisphere is starting the influenza season during the fall and winter months. WHO (World Health Organization) FLU NET and the Global Influenza Surveillance and Response System monitor influenza cases in real time. The good news is that there is an influenza vaccine whose composition is updated annually based on circulating strains. Research is also underway to review the association of influenza vaccination and severity of COVID-19 disease (i.e. could the flu shot help decrease COVID transmission through some cross reacting immune protective effects?). Meanwhile, the scientific community is working around the clock to develop a COVID-19 vaccine, improve point of care testing options and treatments. Hopefully medical breakthroughs will be coming at the end of 2020 and into 2021. Stay tuned!

On the negative side – the symptoms of COVID-19 and influenza are very similar, (links below), and may place additional strains on local healthcare systems and the economy. Both viruses are easily transmissible and can spread before the onset of symptoms. The system may not be able to handle a “twin-demic” surge of testing requirements, hospitalizations and high levels of worker and school absenteeism. Thus – this year it is very important for everyone to get their flu shot since influenza is preventable!

Here’s a quick primer on influenza and its role in past pandemics:

Influenza is a respiratory virus that occurs throughout the year in the tropics and in the northern hemisphere. It starts in the fall, peaks in mid-February and ends in the spring of the following year. There are 4 types of seasonal influenza viruses (types A, B, C, D) – but strains A and B usually cause seasonal epidemics. The WHO estimates that annual influenza epidemics result in about 3-5 million cases of severe illness and 250,000 to 500,000 deaths.

Past influenza pandemics include the 1918 H1N1 (Spanish Flu) pandemic that caused an estimated 30-40 million deaths worldwide (mostly in people aged 15-35 years old), the 1957 H2N2 (Asian flu) pandemic (1-2 million fatalities globally) and the 1968 H3N2 (Hong Kong Flu) pandemic (700,000 to 1 million deaths worldwide). The 2009-2010 H1N1 (Swine Flu) epidemic claimed over 18,000 lives across 214 countries. Sadly – the current COVID-19 pandemic has claimed over 1 million lives (as of October 18, 2020 – https://coronavirus.jhu.edu/map.html).

Who should get the flu shot?

Everyone over the age of 6 months would benefit from a flu shot – but especially those at high risk from chronic medical conditions as well as healthcare workers, caregivers and individuals in long term care facilities. Persons over the age of 65 would benefit from a high dose quadrivalent flu shot (provides approximately four times the amount of antigen) and children aged 6 months to 8 years who have never previously received a flu shot should receive 2 doses that are given at least 4 weeks apart. For those individuals over the age of 4 with an egg allergy – they should receive a cell culture based inactivated vaccine. There are several influenza vaccine options that vary depending on where you live and local public health authority recommendations. The 2020/2021 vaccine will provide protection against influenza strains A (H1N1, H3N2) and B. Safe and effective flu shots have been given for over 60 years and vaccination usually becomes effective 10-14 days after receiving the shot. Remember – you can’t get the flu from the flu shot!

It is estimated that influenza vaccines are up to 70% effective (~ 50-60% for strains A, 70% for B) depending on the year’s strain. No vaccine is perfect. Therefore – it is very important to practice the usual precautions to limit the transmission of respiratory diseases including COVID-19 and influenza:

  • Wear a mask

  • Wash your hands frequently

  • Avoid crowds

  • Outdoors is better than indoors to limit transmission

  • Physically distance. If you can’t avoid close contact with people, then wear a mask

  • Cough and sneeze into a tissue or your sleeve and not your hands

  • If you are sick with symptoms of the flu or any respiratory virus – stay home and check in with a healthcare provider.

Simple behaviours can make a huge difference and limit transmission of infectious diseases. Let’s work together so we can all stay safe!

Source: https://www.hopkinsmedicine.org/Health/Conditions-and-Diseases/Coronavirus/Flu-Prevention-And-Coronavirus-Infographic

References
1. Flu vs. COVID symptoms. CDC https://www.cdc.gov/flu/symptoms/flu-vs-covid19.htm; WHO https://www.who.int/westernpacific/news/q-a-detail/q-a-similarities-and-differences-covid-19-and-influenza; Johns Hopkins https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-disease-2019-vs-the-flu; Mayo https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-vs-flu/art-20490339
2. Flu Shots. Ontario Flu Facts https://www.ontario.ca/page/flu-facts; CDC Flu Shots https://www.cdc.gov/flu/prevent/keyfacts.htm
3. WHO Flu Net and Global Influenza Surveillance and Response System https://www.who.int/influenza/gisrs_laboratory/flunet/en/
4. WHO Seasonal influenza https://www.who.int/en/news-room/fact-sheets/detail/influenza-(seasonal)5. Medscape – Influenza Review https://emedicine.medscape.com/article/219557-overview#a66. Johns Hopkins COVID Map https://coronavirus.jhu.edu/map.html


The Power of Music and Dance

Tuesday, October 20, 2020

During my early days at OMERS – I was warmly welcomed by colleagues Anne Soh, VP of Actuarial Services and Plan Actuary and Lisa Conway, Director of Growth Equity, who spoke to me about their exciting community work with Canada’s National Ballet School, who was doing some interesting work with Baycrest, a global leader in brain health and aging. Anne and Lisa were both very passionate about a wonderful program run by the school called “Sharing Dance Seniors.” In response to the pandemic, they shifted the program online and offered several free events providing instruction on dance and movement virtually. The broader National Ballet of Canada also offered virtual ballet lessons to front line health care workers at a hospital in Toronto. What great wellness initiatives!

Physical benefits of dancing include improved aerobic power, muscle endurance, strength, flexibility, gait (balance), bone density and reduced risk of falls and cardiovascular disease (1). This program also allows participants a healthy outlet for creativity, artistic expression and belonging to a community.

In my medical practice – I have found many of my healthy aging patients incorporate some form of creative art into their life (2). Some play instruments, sing, act in community theatre or paint. Even my parents who are both in their 80s surprised me a few years ago when they told me they started line dancing!

The link to music and wellbeing has been around for centuries – mainly in a social and cultural context. It seems intuitive that music can have a healing effect on the mind and body – but quality studies in the past have been sparse. However, the research is getting deeper on the health benefits of music interventions (playing instruments, singing, dancing).

Engagement in visual arts for adults with mental health conditions have been found to improve subjective wellbeing, reduce anxiety, improve self-esteem, enhance quality of life and prevent readmission to psychiatric hospitals (3). The impact of music therapy for cognitive improvement is still being debated. The first study to compare the effectiveness of art therapy and music reminiscence activity to prevent cognitive decline as a preventive strategy in a randomized controlled trial is being done with the National University of Singapore (4). Reminiscence therapy with music involves listening and discussing events and experiences related to music. In this trial, they will use music videos and link them to personal photographs for community living elderly individuals with mild cognitive impairment. The role of music is also being investigated in the rehabilitation of stroke, Alzheimer’s and age-related neurological diseases.

Studies (5) are also finding music interventions may be beneficial in movement disorders (Parkinson’s Disease, Huntington disease, Tourette syndrome, progressive supranuclear palsy). Evidence is emerging on the benefits of group dancing, singing and instrumental music performance particularly in Parkinson’s disease.

The social benefits of dance are many and include combating loneliness through human connection. Let’s also not forget the emotional importance of joy and play. There is lots of research on child play – but emerging studies are looking at the importance of adult “play time”. We all need to recharge and have fun as part of an overall wellness strategy. I found a study (6) from Carnegie Mellon University that elegantly defined play in adulthood as “a behaviour or activity that is carried out with the goal of amusement and fun, involves an enthusiastic and in-the-moment attitude or approach, and is highly interactive among play partners or with the activity itself) and identifies potential immediate outcomes (e.g. positive affect, feelings of being accepted and valued, reductions in daily stress) and long-term outcomes (e.g. psychological, physical and relational health) of play in adulthood, with an emphasis on play occurring within the context of close relationships.” Or stately simply. Sing and Dance!

I will leave you with lyrics from the 1987 song “Come from the Heart” by songwriters Susanna Clark and Richard Leigh:

“You’ve got to sing like you don’t need the money
Love like you’ll never get hurt
You’ve got to dance like nobody’s watchin’
It’s gotta come from the heart if you want it to work.”

Stay healthy!

References

  1. Physical Benefits of Dancing for Healthy Older Adults. https://journals.humankinetics.com/view/journals/japa/17/4/article-p479.xml

  2. Art for life’s sake. https://nationalpost.com/health/art-for-lifes-sake-the-health-benefits-of-culture

  3. Engaging in Visual Arts Improves Subjective Wellbeing for Adults with mental health conditions https://www.mcmasteroptimalaging.org/full-article/es/engagement-visual-arts-improves-subjective-wellbeing-adults-mental-health-3098?hl=art

  4. Art therapy and music reminiscence activity in the prevention of cognitive decline. https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-017-2080-7

  5. Music therapy for Movement Disorders. https://pubmed.ncbi.nlm.nih.gov/31720865/

  6. Young at Heart. https://journals.sagepub.com/doi/10.1177/1745691615596789


September 10 marked Suicide Prevention Day

Friday, September 18, 2020

On September 10, the World Health Organization (WHO) marked Suicide Prevention Day to raise awareness that suicide can be prevented.

Mental health is one of the toughest areas of medicine to treat and losing a patient to suicide is one of the saddest experiences for a physician. My first experiences with suicide actually involved two professional colleagues. One was a medical classmate of mine who took her life during her residency training. Our classmates were shocked, as she always seemed to be the happiest and most upbeat person. In retrospect, she was probably covering up so much pain and lack of hope despite being successful in her career path. Another incident involved a physician colleague of mine who suffered quietly from postpartum depression and tragically ended her life by jumping in front of a moving subway train with her six month-old-child. She had stopped taking her anti-depressant medications as she was worried that it would harm her child during breastfeeding. We worked together at the same clinic where she was a physician psychotherapist and we shared some patients. Again – she always seemed to have her act together, never revealed sadness or despair during interactions and was a kind and caring physician. The tragic news was shocking and a chilling reminder of the depths of despair of depression. Even physicians who are trained to identify the signs and symptoms of depression and are surrounded by health care professionals daily can feel alone and helpless. Both events still haunt me today.

COVID-19 has caused an increase in mental health cases. Early during the pandemic, the media reported about a top New York emergency physician who took her life at the age of 48 after telling her family about the psychological trauma of seeing patients die of COVID. Another tragic story affecting a frontline worker.

The CDC (Centres for Disease Control) recently published data that shows that COVID related depression is disproportionately affecting young adults (aged 18-24), certain ethnic groups (Hispanic, Black), lower educated, essential workers, unpaid caregivers for adults and those who were already being treated for previously diagnosed anxiety, depression and post traumatic disorder. Uncertainty about the future (education, employment, financial independence, social network) is particularly affecting young adults. Domestic abuse and addiction (alcohol, illicit substances) have also been troubling and increasing trends. Mental health may be worsened from fear, isolation and COVID stigmatization.

Past studies have shown increases in suicide deaths during the 1918-19 influenza pandemic and more recently among older people in Hong Kong during the 2003 severe acute respiratory syndrome (SARS) epidemic. Many studies are now emerging about the mental health pandemic from COVID-19 which will have short- and long-term psychological effects.

Suicide prevention is complex because of multiple risk factors (biological, psychological, social, environmental).

Figure 1. Suicidal behavior in vulnerable populations in the COVID-19 era. Source: https://doi.org/10.1093/qjmed/hcaa202
Traditionally, the approach to suicide prevention has been split into universal, selective and individual preventive interventions. Universal preventive interventions are directed at the general public and include social media awareness campaigns, wellness campaigns, screening tools, community support services and hotlines. Selective interventions are targeted at those at risk (pre-existing psychiatric conditions, elderly, frontline workers, COVID survivors) and may involve active outreach programs, telemedicine and increased interaction with mental health professionals. Individuals in a suicidal crisis need immediate medical attention with experts. If you or someone you care about is at risk for suicide then please familiarize yourself with local and global resources through your physician, public health, social services, employer and community leaders.

Access to timely mental health services, however, has been a challenge and more studies and real time innovation (people, process, technology) will be required to cope with COVID effects.

It is worth mentioning again the risk of the infodemic and fake news. Vulnerable persons should avoid and limit excessive exposure to negative news stories through traditional and social media. Irresponsible media reporting can also be linked to suicide risk.

It is well known that social isolation is a risk factor for mental health issues. Conversely – social connectiveness is critical for emotional health. Make sure you stay connected with people. It’s OK to not be OK during this pandemic – but you need to reach out and seek help from loved ones and health care professionals to prevent a downward spiral of hopelessness if you or a loved one are at risk. Remember - there is always hope and those willing to help.

The World Health Organization has compiled a list of risk factors for suicide and actionable steps.

Do you know someone who may be considering suicide?

What you should know if you are worried about someone

  • Suicides are preventable.

  • It is okay to talk about suicide.

  • Asking about suicide does not provoke the act of suicide. It often reduces anxiety and helps people feel understood.


Warning signs that someone may be seriously thinking about suicide:

  • Threatening to kill oneself.

  • Saying things like "No-one will miss me when I am gone.

  • " Looking for ways to kill oneself, such as seeking access to pesticides, firearms or medication, or browsing the internet for means of taking one’s own life.

  • Saying goodbye to close family members and friends, giving away of valued possessions, or writing a will.


Who is at risk of suicide?

  • People who have previously tried to take their own life.

  • Someone with depression or an alcohol or drug problem.

  • Those who are suffering from severe emotional distress, for example following the loss of a loved one or a relationship break-up.

  • People suffering from chronic pain or illness.

  • People who have experienced war, violence, trauma, abuse or discrimination.

  • Those who are socially isolated.


What you can do?

  • Find an appropriate time and a quiet place to talk about suicide with the person you are worried about. Let them know that you are there to listen.

  • Encourage the person to seek help from a professional, such as a doctor, mental health professional, counsellor or social worker. Offer to accompany them to an appointment.
    If you think the person is in immediate danger, do not leave him or her alone. Seek professional help from the emergency services, a crisis line, or a health-care professional, or turn to family members.

  • If the person you are worried about lives with you, ensure that he or she does not have access to means of self-harm (for example pesticides, firearms or medication) in the home.

  • Stay in touch to check how the person is doing.

Remember: If you know someone who may be considering suicide, talk to them about it. Listen with an open mind and offer your support.

References


Stretches and tips to put your best foot forward

Join OMERS Chief Medical Officer Dr. Aw and fitness guru Brendan Fox as they discuss the common complaints when it comes to your knees, ankles and feet, and work through a series of movements that will help! (Why are there loons in a video about foot and knee stretches? Watch and find out!)

Our feet are the first point of contact with the world, do not forget about the health of them, follow along for:

  • Practical tips that you can easily do outdoors for your feet, knees, and ankles

  • All you need are your legs, and a small towel

  • Common complaints in the four foot, the midfoot and hind foot from sedentary lifestyle or extra body weight - how this can lead into osteoarthrosis, certain autoimmune diseases, and gout.

Please consult with a health care provider before engaging in any new physical activities as appropriate.


Stretches for your knees

Join Brendan as he leads Dr. Aw in another set of exercises, today's focus is on knee pain.

Loosen up your tight muscles that contribute to knee pain by doing different variations to strengthen glute medius.

You will need:

  • chair

  • small towel

Please consult with a health care provider before engaging in any new physical activities as appropriate.


Stretch it out

Fitness expert Brendan Fox leads Dr. Aw in a series of movements focusing on neck pain. Today's video will go through different postural positions that you will have to try out to get the full effect. You can work your way up to the different levels of progressions. You will need: swiss ball or a bosu ball.

Please consult with a health care provider before engaging in any new physical activities as appropriate.


With the start of summer, we wondered, “Does heat impact the coronavirus?” Dr. Aw provides his perspective.


In a video Q&A, Dr. Aw provides his perspective on that topical question: Should I wear a mask?


In a video Q&A, Dr. Aw looks at the question of packages and groceries coming into your house - to disinfect or not to disinfect?


In a video filmed on May 14, Dr. Aw looks at the signs that medical and government authorities are considering as they determine their guidance.


Dr. Aw on Practicing Good Sleep Hygiene

James Aw
Chief Medical Officer

I remember speaking with Medical Director, Johns Hopkins Sleep Disorders Center, Neurologist Dr. Charlene Gamaldo who told me once that “rest is a weapon” for optimal performance and health.  Sleep can be just as important as exercise, nutrition and stress management for physical and mental health.  Poor sleep has been associated with impairment in motivation, emotion, cognitive functions and increased risk for certain medical conditions like diabetes, cardiovascular diseases and cancer.  Most studies suggest that at least 7 hours of sleep a night is optimal – but of course there is some variability and we all know some individuals that seem to function on less sleep or require more sleep. It boils down to whether you feel rested in the morning. 

As we know - sleep routines are easily disrupted during stressful life stages at work and home, raising young children, worrying about aging parents, business travel, academic pursuits and the list goes on.  We also live in a 24/7 society and it is becoming a norm of modern life. Somehow – we manage on less sleep. Life must go on.  As Darwin said – it is not the strongest, most intelligent, but the ones that adapt that survive!

All patients with insomnia should first make sure that there is no existing medical condition that is causing sleep problems. Common causes are sleep apnea, chronic pain, psychological stress or mental health conditions (depression, anxiety, etc.).  Always consult your physician to rule out treatable causes. 

However – several patients suffer from poor sleep and don’t have an existing medical condition. ​​​​​​​

The first step is to practice good “sleep hygiene”:

1.     Sleep only as much as you need to feel rested.

2.     Keep a regular sleep schedule.

3.     Avoid forcing sleep.

4.     Exercise regularly – preferably 4-5 hours before bedtime.,

5.     Avoid caffeine after lunch.

6.     Avoid alcohol near bedtime.

7.     Avoid smoking – particularly at night.

8.     Don’t go to bed hungry.

9.     Avoid prolonged use of light emitting screens before bedtime.

10.   Deal with your worries before bedtime.​​​​​​​

It is best to avoid naps that are greater than 30 minutes during the day.  However – short naps (less than 30 minutes) may be beneficial for cognitive performance, alertness and mood.

Unfortunately – sleep hygiene may not be enough for some individuals. Other interventions may require engaging your personal physician or other clinicians.  Behavioural techniques include relaxation, biofeedback, stimulus control and sleep restriction. 

Relaxation therapy includes techniques such as progressively relaxing your muscles from the head down – where biofeedback may use sensors that provide you feedback to slow down breathing to release tension.  Stimulus control therapy strives to de-program patients that associate the bedroom with staying awake rather than sleeping.  Strategies may include tips such as not spending more than 20 minutes lying in bed trying to sleep and getting up to another room to read or find another relaxing activity until you feel sleepy (while avoiding activities that “reward” staying awake like eating, doing chores, watching TV, etc.).  Sleep restriction therapy involves avoiding naps and induce sleepiness by gradually decreasing the time allowed in bed per night as long as it isn’t less than five hours.

​​​​​​​Some patients benefit from cognitive therapy and/or cognitive behavioural therapy (8-10-week sessions) with a psychologist.  Phototherapy (light therapy) and chronotherapy are other techniques which try to alter the body’s “sleep clock” (circadian rhythm) by either sitting in front of a light box (30-40 minutes) or delaying sleep by 2-3 hours on successive days to make you sleep at the desired time. 

If none of these techniques work – then it may time to review the use of medications with your personal physician. However – medications is the last resort because of concerns of side effects and dependency, other treatments for insomnia have mixed evidence of benefit –
but include melatonin, acupressure, tai chi and yoga.

Sleep is complex, and one size does not fit all.  Hopefully – one of these techniques may be helpful for you.  Sweet dreams!

Resources

Johns Hopkins Medicine
https://www.hopkinsmedicine.org/health/wellness-and-prevention/sleep

Medline Plus
https://medlineplus.gov/healthysleep.html

Canadian Sleep Society
https://css-scs.ca/resources/links

Dr. James Aw, a practicing physician, is OMERS Chief Medical Officer.


Introducing Dr. Aw

Speaking on his first day at OMERS, Dr. Aw, a physician since 1991 and son of a federal public servant and pensioner, said that what drew him to OMERS was both its reputation as a well-run organization and the opportunity to contribute across the OMERS Community.

“This is a golden age of medicine right now in terms of innovation with genetics, genomics, big data, artificial intelligence, different health care systems, molecular medicine, immunology. There are a lot of interesting things that have an impact on the big scale, but also on the local scale. It is also the age of the internet – and with way too much information, how do you connect with people to provide them with information that is impactful in language that is easy to understand.”

Dr. Aw has been a valued and trusted source of information, insight and guidance during the current COVID-19 crisis and we look forward to sharing his thoughts with you here.