Biofeedback, posture and breath: Tools for healthPosted: December 1, 2022 Filed under: ADHD, behavior, biofeedback, Breathing/respiration, CBT, cognitive behavior therapy, computer, digital devices, education, emotions, ergonomics, Evolutionary perspective, Exercise/movement, healing, health, laptops, mindfulness, Neck and shoulder discomfort, Pain/discomfort, posture, relaxation, screen fatigue, self-healing, stress management, Uncategorized, vision, zoom fatigue 2 Comments
Two recent presentations that that provide concepts and pragmatic skills to improve health and well being.
How changing your breathing and posture can change your life.
In-depth podcast in which Dr. Abby Metcalf, producer of Relationships made easy, interviews Dr. Erik Peper. He discusses how changing your posture and how you breathe may result in major improvement with issues such as anxiety, depression, ADHD, chronic pain, and even insomnia! In the presentation he explain how this works and shares practical tools to make the changes you want in your life.
How to cope with TechStress
A wide ranging discussing between Dr. Russel Jaffe and Dr Erik that explores the power of biofeedback, self-healing strategies and how to cope with tech-stress.
These concepts are also explored in the book, TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics. You may find this book useful as we spend so much time working online. The book describes the impacts personal technology on our physical and emotional well-being. More importantly, “Tech Stress” provides all of the basic tools to be able not only to survive in this new world but also thrive in it.
Gonzalez, D. (2022). Ways to improve your posture at home.
Hope for abdominal discomfortPosted: June 21, 2022 Filed under: behavior, biofeedback, Breathing/respiration, emotions, Evolutionary perspective, healing, health, Pain/discomfort | Tags: functional abdominal pain, heart rate variability, HRV, IBS, irritable bowel syndrome, neurasthenia, Rap, recurrent abdominal pain, respiration 3 Comments
Adapted from: Peper, E. & Harvey, R. (2022). Nausea and GI discomfort: A biofeedback assessment model to create a rational for training. Biofeedback, 50(1), 24–32. https://doi.org/10.5298/1081-5937-50.1.05
Abdominal discomfort and pain such as functional abdominal pain, acid reflux or irritable bowel affects many people. Teaching slower biofeedback-assisted HRV breathing with biofeedback is a useful strategy by which the person may be able to reduce symptoms. This essay provides detailed instruction for a first session assessment for clients who have abdominal discomfort (functional abdominal pain). Descriptions include how the physiological recording can be used to understand a possible etiology of the illness, to create a biological/evolutionary based explanation that is readily understood by the client, and finally to offer self-regulation suggestions to improve health.
Background of abdominal discomfort (irritable bowel syndrome, acid reflux, functional abdominal pain, recurrent abdominal pain)
Irritable bowel syndrome (IBS) affects 7% to 21% of the general population in Western cultures with a global prevalence estimated at around 11% (Fairbrass, Costantino, Gracie, & Ford, 2020). The chronic symptoms (i.e., lasting more than 30 days) usually include abdominal cramping, discomfort or pain, bloating, loose or frequent stools and constipation, which can significantly reduce the quality of life (Chey et al., 2015). A precursor of IBS in children is called recurrent abdominal pain (RAP), which affects 0.3% to 19% of school children (Chitkara et al., 2005). Both IBS and RAP appear to be functional illnesses, as no organic causes have been identified to explain the symptoms. IBS and RAP are contrasted to various types of diseases such as Crohn’s disease, inflammatory bowel disease or ulcerative colitis.
Multiple factors may contribute to IBS, such as genetics, food allergies, previous treatment with antibiotics, infections, psychological status and stress. More recently, dietary factors contributing to changes in the intestinal and colonic microbiome resulting in small intestine bacterial overgrowth have been suggested as another risk factor (Dupont, 2014). Generally, standard medical treatments (reassurance, dietary manipulation and of pharmacological therapy) are often ineffective in reducing IBS symptoms (Chey et al., 2015). On the other hand, complementary and alternative approaches such as biofeedback-assisted relaxation techniques (Davidoff & Whitehead, 1996; Goldenberg et al., 2019; Stern et al. 2014), autogenic training (Luthe & Schultz, 1969) and cognitive therapy are more effective than traditional medical treatment (Vlieger et al., 2008).
Biofeedback-assisted relaxation training typically moderates IBS or RAP symptoms by restoring balance in the nervous system (sympathetic/parasympathetic autonomic balance), such as through heart rate variability (HRV) breathing training. For example, Sowder et al. (2010) as well as Sun et al. (2016) demonstrated that functional abdominal pain can be reduced with HRV feedback training. In most cases, increased vagal tone was achieved by breathing at about six breaths per minute. While Taneja et al. (2004) reported that yogic breathing decreased diarrhea-predominant irritable bowel syndrome symptoms significantly more than conventional treatment in a randomized control study.Sympathetic/parasympathetic balance can be enhanced by increasing HRV, which occurs when a person breathes at their resonant frequency, which is usually 5–7 breaths per minute. For most people, the HRV training means breathing at much slower rate. A benefit of slow abdominal breathing appears to be a self-control strategy that can reduce symptoms of IBS, RAP and similar functional abdominal pain symptoms.
Mastery of effortless diaphragmatic breathing can be affected by injury, surgery or similar insults to the abdominal area (Peper et al., 2015). In addition, dysregulation of diaphragm, which is enervated by the phrenic nerve and the vagus nerve, along with dysregulation of other abdominal muscles appears to be associated with irritable bowel syndrome (Bordoni & Morabito, 2018). It is likely that slower biofeedback-assisted HRV breathing training restores abdominal muscles and diaphragmatic movement, theoretically by tonic and phasic regulation of the phrenic and vagal nerve activity (cf. Marchenko et al., 2015; Streeter et al., 2012). The theory, simply stated, is that HRV breathing training at an individual’s resonant frequency produces increases in regulatory neurotransmitters, particularly gamma amino butyric acid (GABA). Many of our students who complain of abdominal discomfort report reductions of symptoms following HRV breathing training.
Consistently for more than 40 years, we have taught undergraduate students a semester-long integrated stress management program that includes modified progressive relaxation, slow diaphragmatic breathing and changing internal language as outlined in the book, Make Health Happen, by Peper, Gibney & Holt (2002). At the end of each semester, numerous students report that their anxiety, gastrointestinal distress and other symptoms related to self-described IBS or RAP have decreased or disappeared (Peper et al., 2014; Peper, Miceli, & Harvey, 2016; Peper, Mason, Huey, 2017; Peper et al., 2020). Abdominal discomfort is prevalent experience of distress by college students. In our recent survey of 99 undergraduate students, 41% self-reported abdominal discomfort (25% irritable bowel or acid reflux), 86% self-reported anxiety, 70% neck and shoulder tension and 48% headaches. After practicing slower breathing (i.e., typically directing them to breath abdominally at a rate of about six breaths a minute) and focus on slower exhalation and allowing the air to flow in without effort as the abdominal wall expands, as a homework assignment for a week, many reported that their symptoms significantly decreased (Peper, Harvey, Cuellar, & Membrila, in press).
Case example illustrating how to use the physiological recording to guide the client discussion and provide motivation
A 16-year-old high school junior suffered from abdomen discomfort for years. The symptoms mainly consisted of frequent constipation, and when it occurred, great discomfort from nausea. After having been diagnosed and undergoing all the necessary tests by the gastroenterologist, there was no identifiable cause of the chief complaints. Biofeedback was suggested as an alternative to medications for symptom reduction. During the biofeedback assessment and training session, the client discussed what she would like to learn from the session. It was challenging for her to respond to those questions. Not being able to report what the client would like from a training session is also a very common experience when working with students. A useful strategy is to describe experiences of other students that the clients could relate to, and imply that their abdominal discomfort is somewhat commonplace in other students.
Discussed during the session was the link between being very sensitive and reactive to other people’s feeling and being concerned about what others think of her. The client nodded her head in agreement. When describing herself, she discussed being very perfectionistic using a scale from being lackadaisical/undemanding to being perfectionistic (i.e., self-oriented perfectionism, self-worth contingencies, concern over mistakes, doubts about actions, self-criticism, socially prescribed perfectionism, other-oriented perfectionism, hypercriticism; see Smith, Saklofske, Stoeber, & Sherry, 2016).
Furthermore, the client sat slouched in the chair. Possibly her slouched posture implied a state of powerlessness instead of empowerment, a state of being ready to react and protect (Carney, Cuddy, & Yap, 2010; Cuddy, 2012; Peper, Lin, & Harvey, 2017).
Working hypotheses. The client was very sensitive and continuously reacted to external and internal signals with sympathetic arousal, while masking her reactions. These ongoing flight/flight responses would decrease intestinal peristalsis and abdominal blood flow, which would result in nausea, constipation and abdominal distress. Namely, the body reacts to the stimuli as signals of danger and blood flow is shunted away from the abdomen into the large muscles to run and fight. To paraphrase Stanford University professor Robert Sapolsky (2004): Why should the body digest food and repair itself, if it is going to be the predator’s lunch? It is only when we are safe that we can digest and regenerate.
The session began by exploring how pressure on the abdomen could potentially affect experiences of nausea and abdominal distress. After explaining how the diaphragm descends and how abdominal content in the stomach can be displaced (spread out) during inhalation, we systematically changed her posture by placing and adjusting a small pillow behind her middle back so that she could sit tall. The tall posture resulted in an open feeling of empowerment not felt during slouching. She observed that breathing was slightly easier and felt there was more space in her abdomen. As she began to feel more comfortable during the training session, we discussed the impact of posture on the body. We also discussed the relationship between thoughts of perfectionism and abdominal discomfort. The discussion also included an exploration of why some people tend to curl-up and slouch in a protective posture (e.g., head down to protect the neck region and big bones of the arms and legs positioned to protect the core organs) when feeling self-consciousness or perfectionistic about body image.
Biofeedback monitoring for assessment
Psychophysiology was recorded with multichannel physiological system (Procomp Infinity System running Biograph Infinity software version 6.7.1, Thought Technology Ltd). Respiration was monitored with strain-gauge sensors placed around the abdomen and thoracic regions (for a discussion on sensor placement see Peper et al., 2016 and Chu et al., 2019). Blood volume pulse was recorded with the sensor placed on the left thumb. The thumb was used because the participant had small and cold fingers (for a discussion about blood volume pulse, see Peper et al, 2007 and Peper, Shafer, & Lin, 2010). Skin conductance was recorded with the sensor wrapped around the left index and middle fingers with the electrodes on the finger pads (for a discussion about skin conductance and normal values, see Khazan, 2019, and Shafer et al, 2016).
After sensors were attached and the signals explained, the client sat comfortably while looking at the screen. Unexpectedly the clinician clapped his hands and made a loud noise. The client reacted with a momentary startle and smile. The physiological response, showed an increase in skin conductance, decrease in pulse amplitude, decrease in abdominal diameter, and increase in heart rate, is shown in Figure 1.
Figure 1. Physiological response to a loud noise (clap) (1) increased skin conductance, (2) decrease in pulse amplitude, (3) decrease in decreased abdominal circumference, and (4) increased heart rate and decreased heart rate variability.
The client was aware that she reacted to the clap; however, she was totally unaware how much her body responded. The computer screen display of her physiological reaction made the invisible visible. It provided the opportunity to discuss how various body reactions related to heart rate, breathing, and skin conductance could contribute to experiences of abdominal discomfort.
She was unaware that skin conductance did not return to baseline levels for more than 20 minutes. An elevated skin conductance level may mean that the body’s reaction to the hand-clap noise triggered a defense reaction and maintained the increased sympathetic activity for more than 20 minutes. Having a sustained flight/fight reaction to external stimuli such as a hand-clap would most likely affect digestive and peristalsis processes, contributing to symptoms found in IBS and RAP. The observations made during biofeedback monitoring led to a discussion of how sympathetic activation affects the gastrointestinal track.
Blood volume pulse amplitude decreased, which indicated a decrease in blood flow through her hands, which would decrease hand temperature and again indicated a systemic sympathetic activation.
Abdominal circumference decreased, which indicated that she tightened her abdominal muscles as a protective response to the hand-clap. She was unaware of the abdominal muscles tightening; however, she stated that she was aware that her breathing had changed. The abdominal muscle, which pulled the abdomen in, took almost two minutes to relax. The sustained muscle constriction around the abdomen increased pressure around the core organs, which may contribute to ongoing abdominal discomfort. A fight-flight reaction includes body bracing (e.g. tightened muscles, head down to protect the neck, big bones of arms and legs curled to protect core organs), and she confirmed that she experienced neck and shoulder tensions.
The discussion of abdominal muscle tension led to another discussion of how holding your stomach in may relate to self-image. For example, tight clothing can contribute to constricted movement around the abdomen. Wearing corsets contributed to psychophysiological symptoms, mainly for women in the late 19th and early 20th centuries, during a time when women who wore very tight corsets were diagnosed with neurasthenia. Simply stated, neurasthenia was characterized as a condition of mental and/or physical fatigue with at least two of the following symptoms: dyspepsia, dizziness, muscular aches or pains, tension headaches, inability to relax, irritability and sleep disturbance.
“Dyspepsia” was the commonly reported symptom of neurasthenia, which included upset stomach, a gnawing or burning stomach pain, heartburn, bloating, and or burping, nausea, and vomiting. The constricted waist region that resulted from wearing a corset in the name of fashion compromises the functions of both digestion and breathing. When the person inhales, the abdomen cannot expand as the diaphragm is flattening and pushing downward. Thus, the person is forced to breathe more shallowly by lifting their ribs; this increases neck and shoulder tension as well as the risk of anxiety, heart palpitation, and fatigue (Cohen & White, 1947; Courtney, 2009).
It also can contribute to abdominal discomfort since the abdomen is being squeezed by the corset and forcing the abdominal organs upward. Even architects of the Victorian era recognized a need for a place to position a chair or chaise lounge, such as at the top of some stairs, because people wearing corsets could faint, pass out or otherwise experience breathlessness through the effort of climbing the stairs with restrictive clothing around their abdomen (Melissa, 2015). Many of these symptoms could be easily reduced by wearing looser clothing and learning slower diaphragmatic breathing. In modern times, a related phenomenon results when people wear items of clothing that are too tight around their waist or abdomen (e.g., tight jeans) in service to fashion trends often labeled as designer jean syndrome (MacHose & Peper, 1991; Stonehewer, 2009). Similarly, when people wear garments that are too tight around their chest or thoracic region (e.g., tight vests) in service to external protection (e.g., athletes, industrial workers, police or soldiers wearing heavy, restrictive gear), then restrictive ventilatory disorders can occur (Harty et al., 1999). Simply stated, when the muscles related to breathing are restricted from moving, respiration is affected.
The client’s heart rate increased and stayed high for more than 30 seconds. The first decrease in heart rate at about 20 seconds after the hand-clap was a long sigh of relief as breathing (i.e., oxygen/carbon dioxide exchange) started again. It took almost 90 seconds before breathing and heart rate returned to normal as reflected by measures of HRV. The computer screen showing increased heart rate was reviewed with the client to explain how her body reacted with a fight-flight response to the hand-clap, as well as how regulating breathing through biofeedback training could lower the heart rate and reduce the sympathetic activation and enhance the parasympathetic activation.
Body responds to cognitive stressful thoughts
After discussion about the psychophysiological response to the hand-clap (a physical external stressor) and how other external stressors (e.g., startling noise) or internal stressors (e.g., perfectionistic ruminations) could trigger a similar response of abdominal muscle tightening, the assessment was repeated by having her relax and then think about a mental stressor, as shown in Figure 2.
Figure 2. Physiological responses to thinking about a past stressor (1) increased skin conductance, (2) decreased pulse amplitude, (3) decreased abdominal circumference, and (4) increased heart rate and decreased HRV.
The physiological response pattern to thinking about a past stressor was similar to the bodily reaction to a loud noise. The skin conductance increased and blood volume pulse amplitude decreased immediately after hearing (e.g., anticipating) the task of evoking/thinking of a past stressor. Most likely, the initial response was triggered by performance anxiety, then 6 seconds later the heart rate increased and breathing changed as she began experiencing the somatic reaction evoked by the recall of a negative stressor. The recordings also showed that her pulse amplitude decreased. The decrease in pulse amplitude suggested that her hands would probably become colder, which was confirmed by her self-report that she often experienced cold hands and feet. She reported being aware of the feeling an emotional reaction, but mainly noticing the change of breathing in her chest, and she was unaware of the abdominal changes. The client was surprised by how her body reacted to emotional thoughts. The recording viewed on the computer screen demonstrated objectively that her thoughts (initial performance anxiety) had a physical effect on her body. Specifically, experiencing the emotions that were evoked by recalling the stressful memory had a direct effect on the body in the same way that a physical external threat leads to a fight-flight response.
Building a psychophysiological model
Using these recorded computer images reflecting physical reactions to the hand clap and emotional thoughts, the discussion focused on how abdominal discomfort could be the result of activating a normal biological survival response. Survival responses would occur hundreds of times throughout a day, especially when worrying. Each thought would evoke the response, and the awareness of body reaction would evoke another reaction. Similar to how awareness of blushing amplifies blushing.
The client shared that she was very sensitive and reactive especially when other people were upset. She reported feeling “cursed” by their sensitivity and reactivity. The linguistic metaphor that could be used to describe her reactions is “she could not stomach what was going on.”
The discussion about physiological reactions provided the client with a model how her disorder (IBS and RAP) could have developed and been maintained over the years. The model matched her subjective experience: when stressed, the discomfort often increased. The discussion shifted to reframing her internal labels. Instead of describing her sensitivity as a curse, the sensitivity was reframed and labeled a gift; namely, she could sense many people’s emotional reactions, to which they would react in a variety of ways. She just needed to learn how to manage this sensitivity. Once she learned to manage it, she would have many advantages in interpersonal relations at home and at work. She would be able to sense what other people are experiencing. By reframing her symptoms as a result of a survival physiological response pattern, it reduces self- blame and offers solutions about how to master and change reactions and thereby have more control in the world.
Training to demonstrate control is possible.
The discussion was followed by teaching her diaphragmatic breathing in sitting and lying down positions. As she had no history of abdominal injuries, similar to many of our students, she rapidly demonstrated slower diaphragmatic breathing as shown in Figures 3 and 4.
Figure 3. The client practiced a few slower diaphragmatic breaths in the sitting and reclining position, which increased heart rate variability, decreased skin conductance and increased blood volume pulse amplitude.
Figure 4. Practicing slower diaphragmatic breathing at about six breaths per minute in a reclining position increased HRV.
With tactile coaching, she demonstrated that she could breathe at about six breaths per minute with the heart rate increasing during inhalation and decreasing during exhalation. She reported feeling more relaxed and that the sensations of nausea had disappeared. Additionally, her hands felt warmer. This recording provided proof that there was hope and that she could do something about her body’s psychophysiological responses.
The discussion focused on how breathing affecting heart rate variability. Namely, if she allowed exhalation to occur without effort, her heart rate decreased (the vagal response of slowing the heart) and thereby increased the parasympathetic activation that would support digestion and gastrointestinal functioning. Often when people practice effortless diaphragmatic breathing, abdominal noises (borborygmus)– the gurgling, rumbling, or squeaking noise from the abdomen–occur and indicate that intestinal activity is being activated, and that food, liquids and digestive juice are moving through the intestines. It is usually a positive indicator that the person is relaxing and sympathetic activity has been reduced.
During the last part of session, we reviewed how posture affects physiology, emotions and cognitions, as well as how posture and breathing would be the first step in beginning to reduce symptoms and enhance health. To provide additional information using video and bibliotherapy/education, we suggested that she watches the embedded videos in the blogs listed at the end of the article.
Recommendations for future sessions and home practice
The recommended strategies for future sessions would focus on teaching the client to master slow diaphragmatic breathing and practicing that for 10–20 minutes per day. The teaching techniques would incorporate imagery to imagine air flowing down their arms and legs as she exhaled. . More importantly, the focus would shift to generalize the skill during the day; namely, whenever she would become aware of feeling stressed or observed herself holding her breath or breathing in her chest, she would use that as the cue to shift to slower abdominal breathing. Had the client continued training, future sessions would focus on mastering slower diaphragmatic breathing. The training would include relaxing the lower abdominal muscles during inhalation, increasing control of HRV, practicing imagining stress and use image to trigger slower breathing, and cognitive reframing practices to interrupt worrying and promote self-acceptance. The final goal is to generalize these skills into daily life as illustrated in the successful cases described in the following blogs
Blogs on posture:
Bordoni, B. & Morabito, B. (2018). Symptomatology correlations between the diaphragm and irritable bowel syndrome. Cureus, 10(7), e3036. https://doi.org/10.7759/cureus.3036
Carney, D. R., Cuddy, A. J., & Yap, A. J. (2010). Power posing: brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 10, 1363-1368. https://dx.doi.org/10.1177/0956797610383437
Chey, W. D., Kurlander, J., & Eswaran, S. (2015). Irritable bowel syndrome: a clinical review. Jama, 313(9), 949–958. https://doi.org/10.1001/jama.2015.0954
Chitkara, D. K., Rawat, D. J., & Talley, N. J. (2005). The epidemiology of childhood recurrent abdominal pain in Western countries: a systematic review. American journal of Gastroenterology, 100(8), 1868–1875. https://doi.org/10.1111/j.1572-0241.2005.41893.x
Chu, M., Nguyen, T., Pandey, V., Zhou, Y., Pham, H. N., Bar-Yoseph, R., Radom-Aizik, S., Jain, R., Cooper, D. M., & Khine, M. (2019). Respiration rate and volume measurements using wearable strain sensors. NPJ digital medicine, 2(1), 1–9. https://doi.org/10.1038/s41746-019-0083-3
Cohen, M. E. & White, P. D. (1947). Studies of breathing, pulmonary ventilation and subjective awareness of shortness of breath (dyspnea) in neurocirculatory asthenia, effort syndrome, anxiety neurosis. Journal of Clinical Investigation, 26(3), 520–529. https://doi.org/10.1172/JCI101836
Courtney, R. (2009). The functions of breathing and its dysfunctions and their relationship to breathing therapy. International Journal of Osteopathic Medicine, 12, 78–85. https://doi.org/10.1016/j.ijosm.2009.04.002
Cuddy, A. (2012). Your body language shapes who you are. Technology, Entertainment, and Design (TED) Talk, available at: http://www.ted.com/talks/amy_cuddy_your_body_language_shapes_who_you_are
Davidoff, A. L., & Whitehead, W. E. (1996). Biofeedback, relaxation training, and cognitive behavior modification: Treatments for functional GI disorders, In Olden, K, W. (ed). Handbook of Functional Gastrointestinal Disorders. CRC Press, 361–384.
Dupont, H. L. (2014). Review article: evidence for the role of gut microbiota in irritable bowel syndrome and its potential influence on therapeutic targets. Alimentary Pharmacology & Therapeutics, 39(10), 1033–1042. https://doi.org/10.1111/apt.12728
Fairbrass, K. M., Costantino, S. J., Gracie, D. J., & Ford, A. C. (2020). Prevalence of irritable bowel syndrome-type symptoms in patients with inflammatory bowel disease in remission: a systematic review and meta-analysis. The Lancet Gastroenterology & Hepatology, 5(12), 1053–162. https://doi.org/10.1016/s2468-1253(20)30300-9
Goldenberg, J. Z., Brignall, M., Hamilton, M., Beardsley, J., Batson, R. D., Hawrelak, J., Lichtenstein, B., & Johnston, B. C. (2019). Biofeedback for treatment of irritable bowel syndrome. Cochrane Database of Systematic Reviews, (11). https://doi.org/10.1002/14651858.CD012530.pub2
Harty, H. R., Corfield, D. R., Schwartzstein, R. M., & Adams, L. (1999). External thoracic restriction, respiratory sensation, and ventilation during exercise in men. Journal of Applied Physiology, 86(4), 1142–1150. https://doi.org/10.1152/jappl.19126.96.36.1992
Khazan, I. (2019). A guide to normal values for biofeedback. Biofeedback, 47(1), 2–5. https://doi.org/10.5298/1081-5937-47.1.03
Luthe, W. & Schultz, J. H. (1969). Autogenic Therapy Volume II: Medical Applications. Grune & Stratton.
MacHose, M., & Peper, E. (1991). The effect of clothing on inhalation volume. Biofeedback and Self-Regulation, 16(3), 261–265. https://doi.org/10.1007/BF01000020
Marchenko, V., Ghali, M. G., & Rogers, R. F. (2015). The role of spinal GABAergic circuits in the control of phrenic nerve motor output. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 308(11), R916–R926. https://doi.org/10.1152/ajpregu.00244.2014
Melissa. (2015). Why women fainted so much in the 19th century. May 20, 2015. Downloaded October 2, 2021. http://www.todayifoundout.com/index.php/2015/05/women-fainted-much-19th-century/
Peper, E., Gibney, K. H., & Holt, C. F. (2002). Make Health Happen—Training Yourself to Create Wellness. Kendall/Hunt Publishing Company.
Peper, E., Gilbert, C. D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173–179. https://doi.org/10.5298/1081-5937-43.4.06
Peper, E., Groshans, G. H., Johnston, J., Harvey, R., & Shaffer, F. (2016). Calibrating respiratory strain gauges: What the numbers mean for monitoring respiration. Biofeedback, 44(2), 101–105. https://doi.org/10.5298/1081-5937-44.2.06
Peper, E., Harvey, R., Cuellar, Y., & Membrila, C.(in press). Reduce anxiety. NeuroRegulation.
Peper, E., Harvey, R., Lin, I. M., Tylova, H., & Moss, D. (2007). Is there more to blood volume pulse than heart rate variability, respiratory sinus arrhythmia, and cardiorespiratory synchrony? Biofeedback, 35(2), 54–61. https://www.researchgate.net/publication/259560204_Is_There_More_to_Blood_Volume_Pulse_Than_Heart_Rate_Variability_Respiratory_Sinus_Arrhythmia_and_Cardiorespiratory_Synchrony
Peper, E., Lin, I-M, & Harvey, R. (2017). Posture and mood: Implications and applications to therapy. Biofeedback, 35(2), 42–48. https://doi.org/10.5298/1081-5937-45.2.03
Peper, E., Lin, I-M, Harvey, R., Gilbert, M., Gubbala, P., Ratkovich, A., & Fletcher, F. (2014). Transforming chained behaviors: Case studies of overcoming smoking, eczema and hair pulling (trichotillomania). Biofeedback, 42(4), 154–160. https://doi.org/10.5298/1081-5937-42.4.06
Peper, E., Mason, L., Harvey, R., Wolski, L, & Torres, J. (2020). Can acid reflux be reduced by breathing? Townsend Letters-The Examiner of Alternative Medicine, 445/446, 44–47. https://www.townsendletter.com/article/445-6-acid-reflux-reduced-by-breathing/
Peper, E., Mason, L., Huey, C. (2017). Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback, 45(4), 83–87. https://doi.org/10.5298/1081-5937-45.4.04
Peper, E., Miceli, B., & Harvey, R. (2016). Educational model for self-healing: Eliminating a chronic migraine with electromyography, autogenic training, posture, and mindfulness. Biofeedback, 44(3), 130–137. https://www.aapb.org/files/publications/biofeedback/2016/biof-44-03-130-137.pdf
Peper, E., Shaffer, F., & Lin, I. M. (2010). Garbage in; Garbage out—Identify blood volume pulse (BVP) artifacts before analyzing and interpreting BVP, blood volume pulse amplitude, and heart rate/respiratory sinus arrhythmia data. Biofeedback, 38(1), 19–23. https://doi.org/10.5298/1081-5937-38.1.19
Sapolsky, R. (2004). Why Zebras Don’t Get Ulcers. Owl Books ISBN: 978-0805073690
Shaffer, F., Combatalade, D., Peper, E., & Meehan, Z. M. (2016). A guide to cleaner electrodermal activity measurements. Biofeedback, 44( 2), 90–100. https://doi.org/10.5298/1081-5937-44.2.01
Smith, M. M., Saklofske, D. H., Stoeber, J., & Sherry, S. B. (2016). The big three perfectionism scale: A new measure of perfectionism. Journal of Psychoeducational Assessment, 34(7), 670–687. https://doi.org/10.1177/0734282916651539
Sowder, E., Gevirtz, R., Shapiro, W., & Ebert, C. (2010). Restoration of vagal tone: a possible mechanism for functional abdominal pain. Applied Psychophysiology and Biofeedback, 35(3), 199–206. https://doi.org/10.1007/s10484-010-9128-8
Stern, M. J., Guiles, R. A., & Gevirtz, R. (2014). HRV biofeedback for pediatric irritable bowel syndrome and functional abdominal pain: A clinical replication series. Applied Psychophysiology and Biofeedback, 39(3), 287–291. https://doi.org/10.1007/s10484-014-9261-x
Stonehewer, L. (2009). Dysfunctional breathing for women’s health physiotherapists. Journal of the Association of Chartered Physiotherapists in Women’s Health, 104, 38–40. https://pogp.csp.org.uk/system/files/stonehewer_hr.pdf
Streeter, C. C., Gerbarg, P. L., Saper, R. B., Ciraulo, D. A., & Brown, R. P. (2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical hypotheses, 78(5), 571–579. https://doi.org/10.1016/j.mehy.2012.01.021
Sun, X., Shang, W., Wang, Z., Liu, X., Fang, X., & Ke, M. (2016). Short-term and long-term effect of diaphragm biofeedback training in gastroesophageal reflux disease: An open-label, pilot, randomized trial. Diseases of the Esophagus, 29(7), 829–836. https://doi.org/10.1111/dote.12390
Taneja. I., Deepak, K.K., Poojary, G., Acharya, I.N., Pandey, R.M., & Sharma, M.P. (2004). Yogic versus conventional treatment in diarrhea-predominant irritable bowel syndrome: a randomized control study. Appl Psychophysiol Biofeedback, 29(1), 19-33. https://doi.org/10.1023/b:apbi.0000017861.60439.95
Vlieger, A. M., Blink, M., Tromp, E., & Benninga, M. A. (2008). Use of complementary and alternative medicine by pediatric patients with functional and organic gastrointestinal diseases: results from a multicenter survey. Pediatrics, 122(2), e446–e451. https://doi.org/10.1542/peds.2008-0266
Addicted to your phone? How to separate from your phone for a healthy lifestylePosted: September 21, 2021 Filed under: behavior, computer, digital devices, education, ergonomics, Evolutionary perspective, Exercise/movement, health, Neck and shoulder discomfort, posture, vision, zoom fatigue 2 Comments
Erik Peper, PhD and Monica Almendras
Our evolutionary traps with technology
Maintaining and optimizing health at the computer means re-envisioning our relationship with technology—and reclaiming health, happiness, and sanity in a plugged-in world. We have the ability to control everything from our mobile phones without needing to get up from our seat. Work, social life and online learning all involve the mobile phone or some type of smart devices.
A convenient little device that is supposed to simplify our lives has actually trapped us into a vicious cycle of relying on it for every single thing we must do. We spend most of our day being exposed to digital displays on our smartphones, computers, gaming consoles, and other digital devices, immersing ourselves in the content we are viewing. From work related emails or tasks, to spending our free time looking at the screen for texting, playing games, and updating social media sites on a play-by-play of what we are eating, wearing, and doing. We click on one hyperlink after the other and create a vicious cycle trapped for hours until we realize we need to move. We are unaware how much time has frittered away without actually doing anything productive and then, we realize we have wasted another day. Below are some recent estimates of ‘daily active user’ minutes per day that uses a screen.
- Facebook about an hour per day
- Instagram just under an hour per day
- Texting about 45 minutes per day
- Internet browsing, about 45 minutes per day
- Snapchat, about 30 minutes per day
- Twitter, about 25 minutes per day
Adolescents and college students interact with media for over 40 hours per week, or around 6 hours per day. That is a lot of hours spent on staring at the screen, which it is almost impossible not to be distracted by the digital screen. In time, we rehearse a variety of physical body postures as well as a variety of cognitive and behavioral states that impact our physical, mental, emotional, and social health. The powerful audiovisual formats override our desires to do something different, that some of us become enslaved to streaming videos, playing virtual games, or texting. We then tell ourselves that the task that needs to be done, will be finished later. That later becomes never by the end of the day, since the ongoing visual and auditory notifications from our apps interrupt and/or capture our attention. This difficulty to turn away from visual or auditory stimuli roots in our survival instincts.
Each time visual or auditory stimuli occur, we automatically check it out and see if it is a friend or foe, safety or danger. It is such an automatic response that we are unaware are reacting. The good news is that we all have experienced this compelling effect. Even when we are waiting for a response and the notifications has not arrived, we may anticipate or project that there may be new information on our social media accounts, and sometimes we become disappointed when the interval between notification is long. As one student said, “Don’t worry, they’ll respond. It’s only been 30 seconds”. Anticipating responses from the media can interrupt what we are otherwise doing. Rather than finishing our work or task, we continuously check for updates on social media, even though we probably know that there are no new important messages to which we would have to respond right away.
Unfortunately, some forms of social media interactions also lead to a form of social isolation, loneliness–sometimes called phoneliness (Christodoulou, G., Majmundar, A., Chou, C-P, & Pentz, M.A., 2020; Kardaras, 2017). Digital content requires the individual to respond to the digital stimuli, without being aware of the many verbal and nonverbal communication cues (facial expressions, gestures, tone of voice, eye contact, body language, posture, touch, etc.) that are part of social communication (Remland, 2016). It is no wonder that more and more adolescents experience anxiety, depression, loneliness, and attention deficit disorders with a constant ‘digital diet’ that some have suggested that include not only media, but junk food as well.
In my class survey of 99 college students, 85% reported experiencing anxiety, 48% neck and should tension, and 41% abdominal discomfort.
We are not saying to avoid the beneficial parts of the digital age. Instead, it should be used in moderation and to be aware of how some material and digital platforms prey upon our evolutionary survival mechanisms. Unfortunately, most people -especially children- have not evolved skills to counter the negative impacts of some types of media exposure. Parental control and societal policies may be needed to mitigate the damage and enhance the benefits of the digital age.
Zoom Fatigue- How to reduce it and configure your brain for better learning
Zoom became the preferred platform for academic teaching and learning for synchronous education during the pandemic. Thus, students and faculty have been sitting and looking at the screen for hours end. While looking at the screen, the viewers were often distracted by events in their environment, notifications from their mobile phones, social media triggers, and emails; which promoted multitasking (Solis, 2019). These digital distractions cause people to respond to twice as many devices with half of our attention- a process labeled semi-tasking’ -meaning getting twice as much done and half as well.
We now check our phones an average of 96 times a day – that is once every 10 minutes and an increase of 20% as compared to two years ago (Asurion Research, 2019). Those who do media multitasking such as texting while doing a task perform significantly worse on memory tasks than those who are not multitasking (Madore et al., 2020). Multitasking is negatively correlated with school performance (Giunchiglia et al, 2018). The best way to reduce multitasking is to turn off all notifications (e.g., email, texts, and social media) and let people know that you will look at the notifications and then respond in a predetermined time, so that you will not be interrupted while working or studying.
When students from San Francisco State University in the United States chose to implement a behavior change to monitor mobile phone and media use and reduce the addictive behavior during a five-week self-healing project, many reported a significant improvement of health and performance. For example one student reported that when she reduced her mobile phone use, her stress level equally decreased as shown in Fig 1 (Peper et al, 2021).
Figure 1. Example of student changing mobile phone use and corresponding decrease in subjective stress level. Reproduced by permission from Peper et al. (2021).
During this class project, many students observed that the continuous responding to notifications and social media affected their health and productivity. As one student reported,
The discovery of the time I wasted giving into distractions was increasing my anxiety, increasing my depression and making me feel completely inadequate. In the five-week period, I cut my cell phone usage by over half, from 32.5 hours to exactly 15 hours and used some of the time to do an early morning run in the park. Rediscovering this time makes me feel like my possibilities are endless. I can go to work full time, take online night courses reaching towards my goal of a higher degree, plus complete all my homework, take care of the house and chores, cook all my meals, and add reading a book for fun! –22-year-old College Student
Numerous students reported that it was much easier to be distracted and multitask, check social media accounts or respond to emails and texts than during face-to-face classroom sessions as illustrated by two student comments from San Francisco State University.
“Now that we are forced to stay at home, it’s hard to find time by myself, for myself, time to study, and or time to get away. It’s easy to get distracted and go a bit stir-crazy.”
“I find that online learning is more difficult for me because it’s harder for me to stay concentrated all day just looking at the screen.”
Students often reported that they had more difficulty remembering the material presented during synchronous presentations. Most likely, the passivity while watching Zoom presentations affected the encoding and consolidation of new material into retrievable long-term memory. The presented material was rapidly forgotten when the next screen image or advertisement appeared and competed with the course instructor for the student’s attention. We hypothesize that the many hours of watching TV and streaming videos have conditioned people to sit and take in information passively, while discouraging them to respond or initiate action (Mander, 1978; Mărchidan, 2019).
To reduce the deleterious impact of media use, China has placed time limits on cellphone use, gaming, and social media use for children. On February 2021 Chinese children were banned from taking their mobile phones into school, on August 2021 Children under 18 were banned from playing video games during the week and their play was restricted to just one hour on Fridays, weekends and holidays, and beginning on September 20, 2021 children under 14 who have been authenticated using their real name can access Douyin, the Chinese version of Tik Tok, for maximum of 40 minutes a day between the hours of 6:00 and 22:00.
Ways to avoid Zoom
Say goodnight to your phone
It is common for people to use their mobile phone before going to bed, and then end up having difficult falling asleep. The screen emits blue light that sends a signal to your brain that says it is daytime instead of night. This causes your body to suppress the production of the melatonin hormone, which tells your body that it is time to sleep. Reading or watching content also contributes, since it stimulates your mind and emotions and thereby promote wakefulness (Bravo, 2020). Implement sleep hygiene and stop using your phone or watching screens 30-minutes before going to bed for a better night’s sleep.
Maintaining a healthy vision
We increase near visual stress and the risk of developing myopia when we predominantly look at nearby surfaces. We do not realize that eyes muscles can only relax when looking at the far distance. For young children, the constant near vision remodels the shape of eye and the child will likely develop near sightedness. The solutions are remarkably simple. Respect your evolutionary background and allow your eyes to spontaneously alternate between looking at near and far objects while being upright (Schneider, 2016; Peper, 2021; Peper, Harvey & Faass, 2020).
Interrupt sitting disease
We sit for the majority of the day while looking at screens that is a significant risk factor for diabetes, cardiovascular disease, depression and anxiety (Matthews et al., 2012; Smith et al., 2020). Interrupt sitting by getting up every 30 minutes and do a few stretches. You will tend to feel less sleepy, less discomfort and more productive. As one of our participants reported that when he got up, moved and exercised every 30 minutes at the end of the day he felt less tired. As he stated, “There is life after five”, which meant he had energy to do other activities after working at the computer the whole day. While working time flies and it is challenging to get up every 30 minutes. Thus, install a free app on your computer that reminds you to get up and move such as StretchBreak (www.stretchbreak.com).
Use slouching as a cue to change
Posture affects thoughts and emotions as well as, vice versa. When stressed or worried (e.g., school performance, job security, family conflict, undefined symptoms, or financial insecurity), our bodies tend to respond by slightly collapsing and shifting into a protective position. When we collapse/slouch, we are more at risk to:
- Feel helpless (Riskind & Gotay, 1982).
- Feel powerless (Westfeld & Beresford, 1982; Cuddy, 2012).
- Recall and being more captured by negative memories (Peper, Lin, Harvey, & Perez, 2017; Tsai, Peper, & Lin, 2016),
- Experience cognitive difficulty (Peper, Harvey, Mason, & Lin, 2018).
When stressed, anxious or depressed, it is challenging to change. The negative feelings, thoughts and worries continue to undermine the practice of reframing the experience more positively. Our recent study found that a simple technique, that integrates posture with breathing and reframing, rapidly reduces anxiety, stress, and negative self-talk (Peper, Harvey, Hamiel, 2019). When you are captured by helpless defeated thoughts and slouch, use the thought or posture as the trigger to take change. The moment you are aware of the thoughts or slouched posture, sit up straight, look up, take a slow large diaphragmatic breath and only then think about reframing the problem positively (Peper, Harvey, Hamiel, 2019).
When we are upright and look up, we are more likely to:
- Have more energy (Peper & Lin, 2012).
- Feel stronger (Peper, Booiman, Lin, & Harvey, 2016).
- Find it easier to do cognitive activity (Peper, Harvey, Mason, & Lin, 2018).
- Feel more confident and empowered (Cuddy, 2012).
- Recall more positive autobiographical memories (Michalak, Mischnat,& Teismann, 2014).
The challenge is that we are usually unaware we have begun to slouch. A very useful solution is to use a posture feedback device to remind us, such as the UpRight Go (https://www.uprightpose.com/). This simple device and app signals you when you slouch. The device attaches to your neck and connects with blue tooth to your cellphone. After calibrating, it provides vibrational feedback on your neck each time you slouch. When participants use the vibration feedback to become aware of what is going on and interrupt their slouch by stretching and sitting up, they report a significant decrease in symptoms and an increase in productivity. As one student reported: “Having immediate feedback on my posture helped me to be more aware of my body and helped me to link my posture to my emotions. Before using the tracker, doing this was very difficult for me. It not only helped my posture but my awareness of my mental state as well.”
 Adapted from the book by Erik Peper, Richard Harvey and Nancy Faass, TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics, North Atlantic Press. https://www.penguinrandomhouse.com/books/232119/tech-stress-by-erik-peper-phd/
 Correspondence should be addressed to:
Erik Peper, Ph.D., Institute for Holistic Healing Studies/Department of Recreation, Parks, Tourism and Holistic Health, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132 COVID-19 mailing address: 2236 Derby Street, Berkeley, CA 94705 Email: firstname.lastname@example.org web: www.biofeedbackhealth.org blog: www.peperperspective.com
Rest Rusts: Increase dynamic movement to improve healthPosted: September 16, 2021 Filed under: behavior, computer, ergonomics, Evolutionary perspective, Exercise/movement, health, laptops, Neck and shoulder discomfort, Pain/discomfort, posture, screen fatigue, zoom fatigue | Tags: dynamic movement, static postures 2 Comments
In hunting and gathering cultures, alternating movement patterns was part of living and essential for health. This shift from dynamic movement to static or awkward positions is illustrated in Figure 1.
Figure 1. The shift from dynamic movement to immobility and near vision as illustrated by the Hadzabe men in Tanzania returning from a hunt to our modern immobilized work and pleasure positions (Reproduced by permission from Peper, Harvey & Faass, 2020).
Dynamic movement promotes blood and lymph circulation and reduces static pressures. At present times our work and leisure activities increase immobility and static positions as we predominantly have shifted to a sitting immobilized position. This significantly increases musculoskeletal discomfort, cardiovascular disease, diabetes etc. The importance of movement as a factor to enhance health is illustrated in the recent findings of 2110 middle aged participants who were followed up for ten years. Those who took approximately 7000 steps per day or more experienced significantly lower mortality rates compared with participants taking fewer than 7000 steps per day (Paluch et al., 2021). Just having the head forward while looking at the cellphone significantly increases the forces on the muscles holding the head up as illustrated in Figure 2.
Figure 2. The head-forward position puts as much as sixty pounds of pressure on the neck muscles and spine (reproduced by permission from Dr. Kenneth Hansaraj, 2014).
For background and recommendations on what how to reduce static positions, look at our book, TechStress-How technology is hijacking our lives, strategies for coping and pragmatic ergonomics. and the superb article, Static postures are harmful – dynamic postures at work are key to musculoskeletal health, published by the European Agency for Safety and Health at Work (EU-OSHA, Sept 16, 2021) and reproduced below.
Static postures are harmful – dynamic postures at work are key to musculoskeletal health
Our bodies are built for movement – it’s a central part of maintaining a healthy musculoskeletal system and the less we move, the more chance we have of developing health issues including musculoskeletal disorders (MSDs), type 2 diabetes, cardiovascular disease, cancer and more. However, the negative effects of sedentary work can be mitigated by paying attention to the postures we adopt when we work.
Whether workers are standing or seated while working, maintaining a good ergonomic posture is essential when it comes to preventing MSDs. Poor or awkward postures put unnecessary strain on the musculoskeletal system and, over time, can cause the deterioration of muscle fibres and joints.
Poor or awkward postures include those which involve parts of the body not being in their natural position. More muscular effort is needed to maintain unnatural postures, which increases the energy used by the body and can cause fatigue, discomfort and pain. Unnatural postures also put strain on tendons, ligaments and nerves, which increases the risk of injury. For example, the risk of neck pain increases when the neck is rotated more than 45 degrees for more than 25% of the working day.
These postures, including slouching, rotation of the forearms, or prolonged periods of sitting or standing in the same spot, can cause pain in the lower back and upper limbs. The risk increases when combined with repetitive work, static muscle load, or the need to apply force or reach. And even natural or good postures maintained for any length of time become uncomfortable and eventually painful. Everyone has experienced stiffness after being in the same position for any length of time.
What do we mean by ‘good posture’?
For workers, especially those in sedentary jobs such as office work, factory work or driving, it is important to recognise and adopt good postures. A good posture should be comfortable and allow the joints to be naturally aligned. The segments of our body can be divided into three cross-sectional anatomical planes: the sagittal plane, which concerns bending forwards and backwards; the frontal plane, which concerns bending sideways; and finally the transverse plane, which refers to rotation or twisting of the body parts. A good posture is one that ensures that all three of these planes are set at neutral positions as much as possible, in that the worker is not leaning backwards, forwards or to any particular side, and their limbs and torso are not rotated or twisted. Adopting neutral postures will help to lessen the strain on the worker’s muscles, tendons and skeletal system, and reduces the risk of them causing or aggravating an MSD.
In practice, workers can consider the following checklist to ensure that they’re standing or sitting in a neutral position:
- Keep the neck vertical and the back in an upright position.
- Ensure the elbows are below the chest and avoid having to reach excessively.
- Keep the shoulders relaxed and use back and arm rests where possible and ensure that they are adjusted to the size and shape of the worker.
- Avoid rotating the forearms or excessively moving the wrists.
- Ensure that any work tools can be held comfortably, and that clothing doesn’t restrain or prevent movement.
- Allow room to comfortably move the legs and feet and avoid frequent kneeling or squatting.
- Ensure that long periods of standing or sitting in the same posture can be broken up.
Employers can assist workers in adopting good postures by communicating checklists such as this one, and by promoting physical activity where possible, encouraging the fair rotation of tasks between employees to avoid them consistently making repetitive movements, and ensuring that workers have the capacity to take regular breaks.
Why our next posture is the best posture
However, maintaining a good posture at all times is not enough to reduce the risk of MSDs, and can even be harmful. Static postures, even if ergonomic, are still a risk factor if over-used. Our body requires movement and variety, which is why the best approach is to use a variety of ergonomic postures in rotation, breaking up long periods of static working with stretching, exercise, and movement. This is known as adopting ‘dynamic positions’.
It is important not only for workers who spend much of their day seated, but also for workers who primarily stand – such as factory workers in assembly lines. In both cases, sitting and standing are not opposites. The opposite of both is movement. Changing postures between sitting and standing is not sufficient for any worker – the working environment must still offer ways of varying their postures and incorporating movement into their daily working routines. What’s more, if standing work cannot be avoided, workers do not need lots of space in order to adopt dynamic positions in a healthy way. Blood flow propulsion mechanisms can still work correctly even if the worker is only moving around in one square metre. However it is still the case that they should have a break after 30 minutes of standing.
Work should therefore not only facilitate good postures, but ensure that good, ergonomic postures are also dynamic. Switching between sitting, standing and moving while ensuring that the musculoskeletal frame is not under any unnecessary tension can help sedentary workers avoid the onset of MSDs and other health problems. For more information visit the priority area on sedentary work.
EU-OSHA. (September 16, 2021). Static postures are harmful – dynamic postures at work are key to musculoskeletal health. https://healthy-workplaces.eu/en/media-centre/news/static-postures-are-harmful-dynamic-postures-work-are-key-musculoskeletal-health?
Hansraj, K. K. (2014). Assessment of Stresses in the Cervical Spine Caused by Posture and Position of the Head. Surgical Technology International, 25, 277–79. https://pubmed.ncbi.nlm.nih.gov/25393825/
Paluch, A.E., Gabriel, K.P., Fulton, J.E., et al.(2021). Steps per Day and All-Cause Mortality in Middle-aged Adults in the Coronary Artery Risk Development in Young Adults Study. JAMA Netw Open, 4(9):e2124516. https://doi.org/10.1001/jamanetworkopen.2021.24516
Peper, E., Harvey, R. & Faass, N. (2020). TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics. Berkeley: North Atlantic books. https://www.penguinrandomhouse.com/books/232119/tech-stress-by-erik-peper-phd/
Useful resources about breathing, phytonutrients and exercisePosted: June 30, 2021 Filed under: behavior, Breathing/respiration, cancer, Evolutionary perspective, health, Nutrition/diet, self-healing, Uncategorized | Tags: diet, exercise, immune system, nasal breathing, phytonutrients, respiration 1 Comment
Dysfunctional breathing, eating highly processed foods, and lack of movement contribute to development of illnesses such as cancer, diabetes, cardiovascular disease and many chronic diseases. They also contributes to immune dysregulation that increases vulnerability to infectious diseases, allergies and autoimmune diseases. If you wonder what breathing patterns optimize health, what foods have the appropriate phytonutrients to support your immune system, or what the evidence is that exercise reduces illness and promotes longevity, look at the following resources.
Breath: the mind-body connector that underlies health and illness
Read the outstanding article by Martin Petrus (2021). How to breathe.
You are the food you eat
Watch the superb webinar presentation by Deanna Minich, MS., PHD., FACN, CNS, (2021) Phytonutrient Support for a Healthy Immune System.
Movement is life
Explore the summaries of recent research that has demonstrated the importance of exercise to increase healthcare saving and reduce hospitalization and death.
Reactivate your second heartPosted: June 14, 2021 Filed under: behavior, computer, digital devices, ergonomics, Evolutionary perspective, Exercise/movement, health, Pain/discomfort, posture, screen fatigue, self-healing, zoom fatigue | Tags: blood clots, blood flow, calf muscle, cardiovascular disease, deep vein thrombosis, edema, exhaustion, Sitting disease, tired legs, Type 2 diabetes 5 Comments
Monica Almendras and Erik Peper
Adapted from: Almendras, M. & Peper, E. (2021). Reactivate your second heart. Biofeedback, 49(4), 99-102. https://doi.org/10.5298/1081-5937-49.04.07
Have you ever wondered why after driving long distances or sitting in a plane for hours your feet and lower leg are slightly swollen (Hitosugi, Niwa, & Takatsu, 2000)? It is the same process by which soldiers standing in attention sometimes faint or why salespeople or cashiers, especially those who predominantly stand most of the day, have higher risk of developing varicose veins. By the end of the day, they feel that their legs being heavy and tired? In the vertical position, gravity is the constant downward force that pools venous blood and lymph fluid in the legs. The pooling of the blood and reduced circulation is a contributing factor why airplane flights of four or more hours increases the risk for developing blood clots-deep vein thrombosis (DVT) (Scurr, 2002; Kuipers et al., 2007). When blood clots reaches the lung, they can cause a pulmonary embolisms that can be fatal. In other cases, they may even travel to the brain and cause strokes.
Sitting without moving the leg muscles puts additional stress on your heart, as the blood and lymph pools in the legs. Tightening and relaxing the calf muscles can prevent the pooling of the blood. The inactivity of your calf muscles does not allow the blood to flow upwards. The episodic contractions of the calf muscles squeezes the veins and pumps the venous blood upward towards the heart as illustrated in figure 1. Therefore, it is important to stand, move, and walk so that your calf muscle can act as a second heart (Prevosti, April 16, 2020).
Figure 1. Your calf muscles are your second heart! The body is engineered so that when you walk, the calf muscles pump venous blood back toward your heart. Reproduced by permission from Dr. Louis Prevosti of the Center for Vein Restoration (https://veinatlanta.com/your-second-heart/).
To see the second heart in action watch the YouTube video, Medical Animation Movie on Venous Disorders, by the Sigvaris Group Europe (2017).
If you stand too long and experienced slight swelling of the legs, raise your feet slightly higher than the head, to help drain the fluids out of the legs. Another way to reduce pooling of fluids and prevent blood clots and edema is to wear elastic stockings or wrap the legs with intermittent pneumatic compression (IPC) devices that periodically compresses the leg (Zhao et al., 2014). You can also do this by performing foot rotations or other leg and feet exercises. The more the muscle of the legs and feet contract and relax, the more are the veins episodically compressed which increases venous blood return. Yet in our quest for efficiency and working in front of screens, we tend to sit for long time-periods.
Developing sitting disease
Have you noticed how much of the time you sit during the day? We sit while studying, working, socializing and entertaining in front of screens. This sedentary behavior has significantly increased during the pandemic (Zheng et al, 2010). Today, we do not need to get up because we call on Amazon’s Alexa, Apple’s Siri or Google’s Hey Google to control timers, answer queries, turn on the lights, fan, TV, and other home devices. Everything is at our fingertips and we have finally become The Jetsons without the flying cars (an American animated sitcom aired in the 1960s). There is no need to get up from our seat to do an activity. Everything can be controlled from the palm of our hand with a mobile phone app.
With the pandemic, our activities involve sitting down with minimum or no movement at all. We freeze our body’s position in a scrunch–a turtle position–and then we wonder why we get neck, shoulder, and back pains–a process also observed in young adults or children. Instead of going outside to play, young people sit in front of screens. The more we sit and watch screens, the poorer is our mental and physical health (Smith et al., 2020; Matthews et al., 2012). We are meant to move instead of sitting in a single position for eight or more hours while fixating our attention on a screen.
The visual stimuli on screen captures our attention, whether it is data entry, email, social media, or streaming videos (Peper, Harvey & Faass, 2020). While at the computer, we often hold up our index finger on the mouse and wait with baited breath to react. Holding this position and waiting to click may look harmless; however, our right shoulder is often elevated and raised upward towards our ear. This bracing pattern is covert and contributes to the development of discomfort. The moment your muscles tighten, the blood flow through the muscle is reduced (Peper, Harvey, & Tylova, 2006). Muscles are most efficient when they alternately tighten and relax. It is no wonder that our body starts to scream for help when feeling pain or discomfort on our neck, shoulders, back and eyes.
Figure 2a and 2b Move instead of sit (photos source: Canva.com).
The importance of tightening and then relaxing muscles is illustrated during walking. During the swing phase of walking, the hip flexor muscles relax, tighten, relax again, tighten again, and this is repeated until the destination is reached. It is important to relax the muscles episodically for blood flow to bring nutrients to the tissue and remove the waste product. Most people can walk for hours; however, they can only lift their foot from the floor (raise their leg up for a few minutes) till discomfort occurs.
Movement is what we need to do and play is a great way to do it. Dr. Joan Vernikos (2016) who conducted seminal studies in space medicine and inactivity physiology investigated why astronauts rapidly aged in space and lost muscle mass, bone density and developed a compromised immune system. As we get older, we are hooked on sitting, and this includes the weekends too. If you are wondering how to separate from your seat, there are ways to overcome this. In the research to prevent the deterioration caused by simulating the low gravity experience of astronauts, Dr. Joan Vernikos (2021) had earthbound volunteers lie down with the head slightly lower than the feet on a titled bed. She found that standing up from lying down every 30-minutes was enough to prevent the deterioration of inactivity, standing every hour was not enough to reverse the degeneration. Standing stimulated the baroreceptors in the neck and activated a cardiovascular response for optimal health (Vernikos, 2021).
We have forgotten something from our evolutionary background and childhood, which is to play and move around. When children move around, wiggle, and contort themselves in different positions, they maintain and increase their flexibility. Children can jump and move their arms up, down, side to side, forward, and backward. They do this every day, including the weekends.
When was the last time you played with a child or like a child? As an adult, we might feel tired to play with a child and it can be exhausting after staring at the screen all day. Instead of thinking of being tired to play with your child, consider it as a good workout. Then you and your child bond and hopefully they will also be ready for a nap. For you, not only do you move around and wake up those muscles that have not worked all day, you also relax the tight muscles, stretch and move your joints. Do playful activities that causes the body to move in unpredictable fun ways such as throwing a ball or roleplaying being a different animal. It will make both of you smile–smiling helps relaxation and rejuvenates your energy.
It is not how much exercise you do, it is how long you sit. The longer you sit without activating your second heart the more are you at risk for cardiovascular disease and diabetes independent of how much exercise you do (Bailey et al., 2019).
Use it or lose it! Activate your calves!
- Interrupt sitting at your desk/computer every 30-minutes by getting up and walking around.
- Stand up and walk around when using your phone.
- Organize walking meetings instead of sitting around a table.
- Invest in a sit-stand desk while working at the computer. While working, alternate positions. There should be a balance between standing and sitting, because too much of one can lead to problems. By taking a short standing up break to let your blood pump back to the heart is beneficial to avoid health problems. Exercise alone, a fancy new ergonomic chair or expensive equipment is not enough to be healthy, it is important to add those mini breaks in between (Buckley et al, 2015).
For a holistic perspective to stay healthy while working with computers and cellphones, see the comprehensive book by Peper, Harvey and Faass (2020), TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics.
Bailey, D.P., Hewson, D.J., Champion, R.B., & Sayegh, S.M. (2019). Sitting Time and Risk of Cardiovascular Disease and Diabetes: A Systematic Review and Meta-Analysis, American Journal of Preventive Medicine, 57(3), 408-416.
Buckley, J.P., Hedge, A., Yates, T., et al. (2015). The sedentary office: an expert statement on the growing case for change towards better health and productivity British Journal of Sports Medicine, 49, 1357-1362.
Hitosugi, M., Niwa, M., & Takatsu, A. (2000). Rheologic changes in venous blood during prolonged sitting. Thromb Res.,100(5), 409–412.
Kuipers, S., Cannegieter, S.C., Middeldorp, S., Robyn, L., Büller, H.R., & Rosendaal, F.R. (2007) The Absolute Risk of Venous Thrombosis after Air Travel: A Cohort Study of 8,755 Employees of International Organisations, PLoS Med 4(9): e290.
Mahase, E. (2021). Covid-19: Unusual blood clots are “very rare side effect” of Janssen vaccine, says EMA. BMJ: 373:n1046.
Matthews, C.E., George, S.M., Moore, S.C., et al. (2012). Amount of time spent in sedentary behaviors and cause-specific mortality in US adults. Am J Clin Nutr, 95(2), 437-445.
Peper, E., Harvey, R. & Faass, N. (2020). TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. Berkeley: North Atlantic Books.
Peper, E., Harvey, R. & Tylova, H. (2006). Stress protocol for assessing computer related disorders. Biofeedback. 34(2), 57-62.
Prevosti, L. (2020, April 16). Your second heart. https://veinatlanta.com/your-second-heart/
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Zhao, J.M., He, M.L., Xiao, Z.M., Li, T.S., Wu, H., & Jiang, H. (2014). Different types of intermittent pneumatic compression devices for preventing venous thromboembolism in patients after total hip replacement. Cochrane Database of Systematic Reviews, 12. Art. No.: CD009543.
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 We even wonder if excessive sitting during the COVID-19 pandemic is a hidden risk factor of the rare negative side effects of blood clots in the brain, that can occur with the AstraZeneca and Johnson and Johnson coronavirus vaccine (Mahase, 2021).
Are you encouraging your child to get into accidents or even blind when growing up?Posted: May 12, 2021 Filed under: ADHD, behavior, computer, education, ergonomics, Evolutionary perspective, Exercise/movement, laptops, Neck and shoulder discomfort, posture, screen fatigue, Uncategorized, vision | Tags: glaucoma, myopia, nearsightedness, palming 3 Comments
Erik Peper and Meir Schneider
Adapted in part from: TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics by Erik Peper, Richard Harvey and Nancy Faass
As a young child I laid on the couch and I read one book after the other. Hours would pass as I was drawn into the stories. By the age of 12 I was so nearsighted that I had to wear glasses. When my son started to learn to read, I asked him to look away at the far distance after reading a page. Even today at age 34, he continues this habit of looking away for a moment at the distance after reading or writing a page. He is a voracious reader and a novelist of speculative fiction. His vision is perfect. –Erik Peper
How come people in preliterate, hunting and gatherer, and agricultural societies tend to have better vision and very low rates of nearsightedness (Cordain et al, 2003)? The same appear true for people today who spent much of their childhood outdoors as compared to those who predominantly stay indoors. On the other hand, how come 85% of teenagers in Singapore are myopic (neasighted) and how come in the United States myopia rate have increased for children from 25% in the 1970s to 42% in 2000s (Bressler, 2020; Min, 2019)?
Why should you worry that your child may become nearsighted since it is easy correct with contacts or glasses? Sadly, in numerous cases, children with compromised vision and who have difficulty reading the blackboard may be labeled disruptive or having learning disability. The vision problems can only be corrected if the parents are aware of the vision problem (see https://www.covd.org/page/symptoms for symptoms that may be related to vision problems). In addition, glasses may be stigmatizing and children may not want to wear glasses because of vanity or the fear of being bullied.
The recent epidemic of near sightedness is paritally a result of disrespecting our evolutionary survival patterns that allowed us to survive and thrive. Throughout human history, people continuously alternated by looking nearby and at the distance. When looking up close, the extraocular muscles contract to converge the eyes and the ciliary muscles around the lens contract to increase the curvature of the lens so that the scene is in focus on the retina — this muscle tension creates near visual stress.
The shift from alternating between far and near vision to predominantly near vision and immobility
Figure 2. The traditional culture of Hdzabe men in Tanzania returning from a hunt. Notice how upright they walk and look at the far distance as compared to young people today who slouch and look predominantly at nearby screens.
Experience the effect of near visual stress.
Bring your arm in front of you and point your thumb up. Look at your thumb on the stretched out arm. Keep focusing on the thumb and slow bring the thumb four inches from your nose. Keep focusing on the thumb for a half minute. Drop the arm to the side, and look outside at the far distance.
What did you experience? Almost everyone reports feeling tension in the eyes and a sense of pressure inside around and behind their eyes. When looking at the distance, the tension slowly dissipates. For some the tension is released immediately while for others it may take many minutes before the tension disappears especially if one is older. Many adults experience that after working at the computer, their distant vision is more fuzzy and that it takes a while to return to normal clarity.
When the eyes focus at the distance, the ciliary muscles around lens relaxes so that the lens can flatten and the extra ocular muscles relax so that the eyes can diverge and objects in the distance are in focus. Healthy vision is the alternation between near and far focus– an automatic process by which the muscles of the eyes tightening and relax/regenerate.
Use develops structure and structure limits use
If we predominantly look at nearby surfaces, we increase near visual stress and the risk of developing myopia. As children grow, the use of their eyes will change the shape of the eyeball so that the muscles will have to contract less to keep the visual object into focus. If the eyes predominantly look at near objects, books, cellphones, tablets, toys, and walls in a room where there is little opportunity to look at the far distance, the eye ball will elongate and the child will more likely become near sighted. Over the last thirty year and escalated during COVID’s reside-in-place policies, children spent more and more time indoors while looking at screens and nearby walls in their rooms. Predominantly focusing on nearby objects starts even earlier as parents provide screens to baby and toddlers to distract and entertain them. The constant near vision remodels the shape of eye and the child will likely develop near sightedness.
Health risks of sightedness and focusing predominantly upon nearby objects
- Increased risk of get into an accident as we have reduced peripheral vision. In earlier times if you were walking in jungle, you would not survive without being aware of your peripheral vision. Any small visual change could indicate the possible presence food or predator, friend or foe. Now we focus predominantly centrally and are less aware of our periphery. Observe how your peripheral awareness decreases when you bring your nose to the screen to see more clearly. When outside and focusing close up the risk of accidents (tripping, being hit by cars, bumping into people and objects) significantly increases as shown in figure 3 and illustrated in the video clip.
Pedestrian accidents (head forward with loss of peripheral vision)
Figure 3. Injuries caused by cell phone use per year since the introduction of the smartphone (graphic from Peper, Harvey and Faass,2020; data source: Povolatskly et al., 2020).
- Myopia increases the risk of eye disorder. The risk for glaucoma, one the leading causes of blindness, is doubled (Susanna, De Moraes, Cioffi, & Ritch, R. 2015). The excessive tension around the eyes and ciliary muscles around the lens can interfere with the outflow of the excess fluids of the aqueous humour through the schlemm canal and may compromise the production of the aqueous humour fluid. These canals are complex vascular structures that maintains fluid pressure balance within the anterior segment of the eye. When the normal outflow is hindered it would contribute to elevated intraocular pressure and create high tension glaucoma (Andrés-Guerrero, García-Feijoo, & Konstas, 2017). Myopia also increases the risk for retinal detachment and tears, macular degeneration and cataract. (Williams & Hammond, 2019).
By learning to relax the muscles around the lens, eye and face and sensing a feeling of soft eyes, the restriction around the schlemm canals is reduced and the fluids can drain out easier and is one possible approach to reverse glaucoma (Dada et al., 2018; Peper, Pelletier & Tandy, 1979).
- Increase in neck and upper back compression when the person cranes their head forward or looks down while reading books/articles, looking at a cellphone or a laptop screen, This often results in an increase of back, neck and shoulder pain as well as headaches (Harvey, Peper, Booiman, Heredia Cedillo, & Villagomez, 2018; Hansraj, 2014).
- Decrease in subjective energy and increase in helpless, hopeless, powerless and defeated thoughts when the person habitually looks down in a slouched position (Peper, Booiman, Lin, & Harvey, 2016; Peper, Lin, Harvey, & Perez, 2017).
WHAT CAN YOU DO?
The solutions are remarkable simple. Respect your evolutionary background and allow your eyes to spontaneously alternate between looking at near and far objects while being upright (Schneider, 2016; Peper, 2021; Peper, Harvey & Faass, 2020).
For yourself and your child
- Let children play outside so that they automatically look far and near.
- When teaching children to read have them look at the distance at the end of every paragraph or page to relax the eyes.
- Limit screen time and alternate with outdoor activities
- Every 15 to 20 minutes take a vision break when reading or watching screens. Get up, wiggle around, move your neck and shoulders, and look out the window at the far distance.
- When looking at digital screens, look away every few minutes. As you look away, close your eyes for a moment and as you are exhaling gently open your eyes.
- Practice palming and relaxing the eyes. For detailed guidance and instruction see the YouTube video by Meir Schneider.
Create healthy eye programs in schools and work
- Arrange 30 minute lesson plans and in between each lesson plan take a vision and movement breaks. Have children get up from their desks and move around. If possible have them look out the window or go outside and describe the furthest object they can see such as the shape of clouds, roof line or details of the top of trees.
- Teach young children as they are learning reading and math to look away at the distance after reading a paragraph or finishing a math problem.
- Teach palming for children.
- During recess have students play games that integrate coordination with vision such as ball games.
- Episodically, have students close their eyes, breathe diaphragmatically and then as they exhale slowly open their eyes and look for a moment at the world with sleepy/dreamy eyes.
- Whenever using screen use every opportunity to look away at the distance and for a moment close your eyes and relax your neck and shoulders.
BOOKS TO OPTIMIZE VISION AND TRANSFORM TECHSTRESS INTO TECHHEALTH
Vision for Life, Revised Edition: Ten Steps to Natural Eyesight Improvement by Meir Schneider.
TechStress-How Technology is Hijacking our Lives, Strategies for Coping and Pragmatic Ergonomics by Erik Peper, Richard Harvey and Nancy Faass
YOUTUBE PRESENTATION, Transforming Tech Stress into Tech Health.
ADDITIONAL BLOGS THAT FOCUS ON RESOLVING EYES STREAN AND TECHSTRESS
Andrés-Guerrero, V., García-Feijoo, J., & Konstas, A.G. (2017). Targeting Schlemm’s Canal in the Medical Therapy of Glaucoma: Current and Future Considerations. Adv Ther, 34(5), 1049-1069.
Bressler, N.M. (2020). Reducing the Progression of Myopia. JAMA, 324(6), 558–559.
Chen, S. J., Lu, P., Zhang, W. F., & Lu, J. H. (2012). High myopia as a risk factor in primary open angle glaucoma. International journal of ophthalmology, 5(6), 750–753.
Cordain, L., Eaton, S.B., Miller, J. B., Lindeberg, S., & Jensen, C. (2003). An evolutionary analysis of the aetiology and pathogenesis of juvenile‐onset myopia. Acta Ophthalmologica Scandinavica, 80(2), 125-135.
Dada, T., Mittal, D., Mohanty, K., Faiq, M.A., Bhat, M.A., Yadav, R.K., Sihota, R., Sidhu, T,, Velpandian, T., Kalaivani, M., Pandey, R.M., Gao, Y., Sabel, B,A., & Dada, R. (2018). Mindfulness Meditation Reduces Intraocular Pressure, Lowers Stress Biomarkers and Modulates Gene Expression in Glaucoma: A Randomized Controlled Trial. J Glaucoma, 27(12), 1061-1067.
Hansraj, K. K. (2014). Assessment of stresses in the cervical spine caused by posture and position of the head. Surgical Technology International, 25, 277–279.
Harvey, R., Peper, E., Booiman, A., Heredia Cedillo, A., & Villagomez, E. (2018). The effect of head and neck position on head rotation, cervical muscle tension and symptoms. Biofeedback. 46(3), 65–71.
Min, L.P. (2019). Speech by Dr. Lam Pin Min, Senior Minister of State for Health, Singapore, at the opening of the Sangapore National Eye Centre’s Myopia Center, 16 August, 2019.
Peper, E. (2021). Resolve eyestrain and screen fatigue. Well Being Journal, 30(1), 24-28.
Peper, E., Booiman, A., Lin, I.M., & Harvey, R. (2016). Increase strength and mood with posture. Biofeedback. 44(2), 66–72.
Peper, E., Harvey, R. & Faass, N. (2020). TechStress: How Technology is Hijacking Our Lives, Strategies for Coping, and Pragmatic Ergonomics. Berkeley: North Atlantic Books.
Peper, E., Lin, I-M., Harvey, R., & Perez, J. (2017). How posture affects memory recall and mood. Biofeedback.45 (2), 36-41.
Peper E., Pelletier K.R., Tandy B. (1979) Biofeedback Training: Holistic and Transpersonal Frontiers. In: Peper E., Ancoli S., Quinn M. (eds) Mind/Body Integration. Springer, Boston, MA.
Povolotskiy, R., Gupta, N., Leverant, A. B., Kandinov, A., & Paskhover, B. (2020). Head and Neck Injuries Associated With Cell Phone Use. JAMA Otolaryngology–Head & Neck Surgery, 146(2), 122-127.
Schneider, M. (2016). Vision for Life, Revised Edition: Ten Steps to Natural Eyesight Improvement. Berkeley, CA: North Atlantic Books.
Schneider, M. (2019). YouTube video Free Webinar by Meir Schneider: May 6, 2019.
Susanna, R., Jr, De Moraes, C. G., Cioffi, G. A., & Ritch, R. (2015). Why Do People (Still) Go Blind from Glaucoma?. Translational vision science & technology, 4(2), 1.
Williams, K., & Hammond, C. (2019). High myopia and its risks. Community eye health, 32(105), 5–6.
Nutrition to support the Stress ResponsePosted: April 17, 2021 Filed under: behavior, Evolutionary perspective, health, Nutrition/diet, stress management, Uncategorized | Tags: food 5 Comments
Let food be thy medicine and medicine be thy food
-Hippocrates, the Greek physician and father of medicine.
What should I eat? More greens, more Vitamin D, more fish, no meats, no grains, or should I become a vegetarian, go on a ketogenic diet, or evolutionary diet? There are so many options. What are the best choices?
The foods we eat provide the building blocks and energy source for our body. If you eat high quality foods, the body has the opportunity to create and maintain a healthy strong structure; on the other hand, if you eat low quality foods, it is more challenging to create and maintain a healthy body. The analogy is building a house. If the materials are high quality, the structure well engineered and well built, the house has the opportunity to age well. On the other hand, if the house is built out of inferior materials and poorly engineered, it is easily damaged by wind, rain or even earthquakes.
Although we are bombarded with recommendations for healthy eating, many of the recommendations are not based upon science but shaped by the lobbying and advertisement efforts of agribusiness. For example, the scientific recommendations to reduce sugar in our diet were not implements in the government guidelines. This demonstrates the power of lobbying which places profits over health.
Officials at the Department of Agriculture and the Department of Health and Human Services rejected explicit caps on sugar and alcohol consumption. Although “the preponderance of evidence supports limiting intakes of added sugars and alcoholic beverages to promote health and prevent disease.” (Rabin, 2020).
To make sense out of the multitude of nutritional recommendations, watch the superb presentation by Dr. Marisa Soski, ND, Nutrition to Support Stress Response.* She discusses how and what we eat has direct impact on how our bodies manage our reactions to stress.
*Presented April 16, 2021 at the Holistic Health Series on Fridays: Optimize Health and Well-Being Lecture Series. The series is sponsored by the Institute for Holistic Health Studies and Department of Recreation, Parks, Tourism, San Francisco State University.
Rabin, R.C. (2020). U.S. Diet Guidelines Sidestep Scientific Advice to Cut Sugar and Alcohol. The New York Times. https://www.nytimes.com/2020/12/29/health/dietary-guidelines-alcohol-sugar.html