Prakash Chandran (Host): Stress touches all of our lives. Racing thoughts, restless nights, and the weight of daily demands can leave us just feeling overwhelmed. And while we often turn to quick fixes, these really rarely address the root of the problem. But luckily, there's a simple accessible practice called mindfulness-based stress reduction that helps us not just manage the stress, but transform how we're experiencing it.

Joining us today to discuss is Dr. Rammy Korkor, an Internal Medicine physician with Southwest General Medical Group located in Brunswick, Ohio. Welcome to Southwest General Health Talk, a podcast from the specialists at Southwest General Health Center. My name is Prakash Chandran.

Dr. Korkor, thank you so much for joining us today. This topic is very relevant to myself. Before we get into the stress reduction piece of it, I wanted to start with the term mindfulness. There are so many definitions and I've heard this on the news, I've read this online, but maybe you could give us a definition of how we should be thinking about mindfulness.

Rammy Korkor, MD: That's right. The buzzwords are all over the place now, so maybe we should clear up what the differences are and understand that. Thank you, Prakash, for having me on. This is an exciting topic that I get to talk about at work every day, but having an interview like this helps, hopefully, get people the chance to see that there's options out there for their stress and their stress management.

So, mindfulness meditation, mindfulness, mindfulness-based stress reduction. It's a lot of mindfulness. What is all this? I think it's a good idea to clear that first and understand those better. So, the term mindfulness is pretty simple. That's the easiest one. That's just sort of having an awareness, an awareness on purpose. If somebody says to somebody, have a mindful day, it means that they're hoping that they're being present for their experience on purpose. You know, if somebody is opening presents around a holiday with family, they could be worried about their agenda or looking at their phone or doing other things or they could be enjoying the present moment. And so, that would be just being mindful, as being aware. If somebody is to have a sip of tea and taste the flavors and the aromas, they're being mindful of that experience. But if they're remembering a conversation from a week ago and they're missing out on the tea right in front of them, they're being less mindful or mindless, you could say.

So, being mindful has been proven just being present for the experience to lower cortisol levels, which is a hormone in our body that secretes a lot of stress, which is what the whole point of this conversation is. How do we combat that and minimize and mitigate the effect of that hormone in our body, the cortisol stress response that has been adapted within us to be secreted under high stress, which is causing a lot of health issues and quality of life issues. So, being mindful is just being aware. The practice of mindfulness meditation, this is the one that you said a buzzword in the intro, which was accessible. Mindfulness meditation is sort of an accessible daily practice that one would do on their own time, whenever they find time, or to incorporate it into activities of daily living.

So, mindfulness meditation is more of an exercise. Think of if one wants to be able to lift something very heavy, they would have to go to the gym regularly and do some exercise in order to strengthen the part of their body that they're going to subsequently lift something with that part of their body later. Sure, pretty simple, bicep curls to be able to lift something heavy with your biceps. Well, the same thing's true for mindfulness meditation. That would be the daily exercise, which causes a lot of anatomical changes in our brain.

The main one that comes up all the time in research studies and in articles is that there's the area of the brain, which is responsible for the stress centers, or you could call it the amygdala or the old limbic system, or it's sometimes referred to as the reptilian brain or the fight or flight response part of the brain. And then, there's the prefrontal cortex. That's the neocortex. That's the area of equanimity, calm, collected, no matter how stressful things get. And that part of the brain is towards the front. And what happens is the blood gets flowed towards that part of the brain more. And where the blood flows, the muscle grows. And same thing is when you move blood, shunting it towards a different region, it makes the region it was originally at get smaller. So in other words, it's taking advantage of something called neuroplasticity and that the brain shape can change. And the areas of the part of the brain that get more blood flow, that give better quality and quantity of life are requiring more oxygen demand. So, they're getting more of that essential blood flow and enlarging. So then, people find that they sure enough have better ability to tolerate stressful situations. They have better concentration. They tolerate pain better. They tolerate difficult situations better. They can handle things in character instead of out of character. When cortisol gets too high after all, we sometimes act out of character, it's typical. So, that's what mindfulness meditation is doing as a daily practice. Typically, it's done to one's own devices, they can learn from home, that's what I teach a lot in the office with a simple regimen of how to do that every day.

And the evidence for how beneficial it is, is I like to think of an analogy or similarity is like brushing teeth. Dentists were telling us to brush teeth for a long time before people actually started doing their tooth brushing twice a day. And sure enough, the moment they did it, their quality of their gingival health and their gum health got much better, and there was less disease there. So, the mountains of evidence to suggest how beneficial mindfulness meditation is something that no matter what condition you have, you could be in great health, but just a little bit of stress with something in life or have multiple health conditions, this practice helps improve that.

And then, the simplest one is mindfulness-based stress reduction, MBSR. That one is an eight-week course, typically once a week, typically around two to four hours, that's an eight-week formal course to help make sure that somebody's doing their mindfulness meditation practice correctly.

And so, that's the difference between mindfulness, awareness, mindfulness meditation and daily practice, and then mindfulness-based stress reduction, of course.

Host: So, that is a very comprehensive explanation as to helping us relieve stress. And I think one of the main and really enlightening things that I took away from that was, generally, if you are more present, or if you put in a practice of being more present, the body can start to heal itself, and you don't necessarily need to take the medications that we generally turn to. But just by being aware and this potential mindfulness meditation practice, your body will start to change over time, just as if you were going to the gym, you can naturally train your body to do that. is that generally correct?

Rammy Korkor, MD: That's 100% correct. Actually, the research tells us that, for example, GMS JAMA Psychiatry Journal in 2023 published a big study about comparing medications to treating anxiety disorders, and generalized anxiety disorder being the most common one of those, comparing it to mindfulness-based stress reduction, it was non-inferior. So in other words, it worked equally well, but that was only one study to confirm what dozens and dozens and hundreds of studies at this point since the '90s, when MRIs became cheaper. That's what really led all of this. We've known that mindfulness meditation has been working for about 2,600 years for many people in the Eastern part of the world. So, it's become a little bit more easy to digest and more tangible and has been presented to the Western world more recently, especially in the '90s when we thought this thing was a placebo and turns out it's actually just a skill that the body has. And when it's activated, you get these incredible results of quality and quantity of life. So, it was in the '90s that MRI scanners became cheaper and they could see the anatomical shift, and they realized this wasn't just placebo. It even helped with people having less memory loss later in life, dementia, help people with chronic pain conditions like fibromyalgia, et cetera. So, you're absolutely right. It's activating a part of our brain that we already have there, which is the ability to be calm and handle stress wisely. And so, that's what the practice is strengthening.

Host: One of the things that I wanted to bring up is just that practice itself of trying to be present because I can even speak for myself. I've got multiple kids, I've got a business, I've got a wife, I've got all of these activities and I'm trying to balance it all to even think about being aware and present is difficult. And even if I am thinking about that, I'm thinking about, "Hey, let me be present. Oh my gosh, I am present with all of my responsibilities, all of the stress, all of the things that I have to do in my life." So, Dr. Korkor, I'm curious, for those of us, and I know I represent a lot of people that are going through that, what is the shift, right? When you have all of these responsibilities, what is the shift to start being more present so you can start getting some of these benefits?

Rammy Korkor, MD: Great question because it's nonstop. The stress is nonstop for even the kids. It's not just the parent taking care of the kids. So, how to incorporate mindfulness meditation into a very stressful busy life. Just a few sessions of getting the mind in 10 minutes by yourself in a quiet space, just a few sessions of that, just to feel what is it like to be there on purpose with your breath, which is a simple anchor you can hone in on any time. Of course, it could be other senses as well, smells, sounds, laying still and just listening to the HVAC unit in your home, things like that. It's just when the mind starts to wander off, bringing the attention back to that sense, that is what we're looking for.

So now, when you're having a very busy day, you're able to, notice that there's stress building up in your body because it gets us better at noticing what's happening within our body and the thought processes that are happening in our mind that are leading to the stress in our body. So, you can incorporate it into daily living. For example, let's say you're having an extraordinarily busy day, but there's an agenda there, which is at some point you have to do the dishes. If during the washing of the dishes, you are watching a news update on your phone about something going on on the other side of the part of the world, well, you're not being mindful, or if you are trying to get the kids to quiet down behind you, you're not being very mindful. However, when you are doing the dishes and you're sort of feeling the warm water on your skin, listening to the clickity clackity of the dishes, smelling the soap that's right next to you, feeling your weight on the ground, bringing your attention to your senses. It only takes a few moments of just redirecting your attention to that, and then it simply just lowers your cortisol down. So now, you can organize your thoughts in a more reasonable manner, acting in character, thinking about creative problem-solving and activating the part of the brain that's usually getting suppressed by all this high stress of the constant motion of life.

So think of it, the way I like to explain it is, you're riding on this raft through a really tortuous river, a river of life. Some parts are tortuous, some parts of are calm. Whenever stress gets extraordinarily high, well, bringing your attention to your senses is sort of like an anchor that you would just drop to pause the boat, take a breather, and just calm yourself and bring your cortisol down. The moment you do that, it's almost like a cup of muddy water. If you let it settle and just sit there for a moment, the sediment falls to the bottom and the water comes to the top, and you get that clarity of how to solve that problem you're trying to figure out or, you know, how to handle that situation. So, that's where it can be useful is just incorporating into daily life. I start my morning meditations just from my walk to my car, to my office, by feeling the heel and the midfoot and the toe, press on the ground and lift off one foot after another. It can be easily accessible. At first, it's very difficult and unnerving to pause. But then, people start to see the benefits and it helps them a great deal. Just channeling it is what I do in the office, is helping people guide them through how to actually use this and how to apply it to their health.

Host: Well, I also think that we kind of live in this society of stimulus and input. You kind of gave this example of washing the dishes, and I know I'm guilty of this. When you're washing the dishes, you're like, "You know what? I'm going to put in my AirPods, and I'm going to listen to a podcast, right?" And it never really gives myself or individuals time to actually just process. I always am trying to take in something. So, what I'm hearing you say is part of being present is to remove all of those inputs and to focus on something and being really aware and present with the thing that you are doing, rather than trying to think about or take in inputs externally.

Rammy Korkor, MD: That's absolutely right. Society is a programming the opposite. And so, we're trying to unprogram, trying to let go of that constant running that happens and can convince people that pausing is doing something, putting on your agenda a moment to pause. is probably one of the more important things on that agenda when you look back at it.

Host: As we start to come to a close, I'm wondering if there is a quick mindfulness exercise that people can take away from this conversation. If they're feeling stressed, is there something that you could give them that they could practice right now or right after they're done listening to this?

Rammy Korkor, MD: Sure. Like I said, there's just as much evidence for this as the benefits of brushing teeth. So, I think this practice starts off as like a slide on a PowerPoint in medical school of like, "Oh yeah, by the way, there's this thing that works just as good as medication." so if you have a contraindication to taking a medication, you can do this and get same results. So it's like, "Whoa, you just brushed over that," right? But the mountains of evidence that leads it to all the PowerPoints that are in med schools, it's like this little pearl of really useful resource to have in life.

You know, I just want to quickly touch on the health benefits, then give a little four-step practice that anyone can try. When we look at, from the World Health Organization, since 2005 to 2015, they looked at the number of deaths in America for adults over 40, and it was 61% were related to diet-related conditions. Mindfulness meditation has the power to improve preference, to program preference, just like society is trying to program preference with advertising and marketing, and, we can actually program those unwholesome preferences and program some wholesome preferences. So, that's a huge swath of diseases that can be improved by choosing better foods that make your body feel different. And you can notice that with practice and meditation. A lot of conditions for chronic pain from especially patients that work in jobs that it's inevitable they're going to end up with some chronic pain. It helps prevent. And then, the anxiety and the depression, this, about a third of our patients have that issue. And 10% of all Americans are on an antidepressant or anti-anxiolytic and it seems like it doesn't have to be the case necessarily, especially since they stopped working after 10 years. So, this actually has the same results, and it has better long lasting effects. It also seems to be contagious to the people in the household where their stress ends up less because they're seeing it less in mom, dad or brother or sister, et cetera. So, there's just so many applications.

I'll give you a little glimpse into what the exercise that I would have someone do twice a day for 10 minutes, just like part of the tooth brushing regimen. So, it's four simple steps. The first is, even though it seems trivial, it's a very, very important step because you're almost declaring your intention. And in order to be present, you have to declare some intention to do it, have some intentionality to do it. We're being present on purpose.

The first step is just to maybe set a time for 10 minutes, before incorporating it into life, like dishwashing or walking to a car, it's better to just get a sense of how does this work? Setting some time aside in a quiet space, in a peaceful space. It could be out in nature, could be in your office in a chair, setting a timer for maybe 10 minutes. The research says that anything over five minutes was clinically significant. The ideal time is 40 minutes daily, but it takes time to work up to that. So, 10 minutes is a good start.

The second step would be to pick a sense to focus on. I mentioned some of them. one could be, in the shower, just listening to the water rush or feeling the temperature of the part of their body under the water and part of their body out of the water where it's warmer versus it's cooler, or could be sitting in an office waiting for a busy primary care doctor to show up on time and just have some 10 minutes to kill, just sitting in a chair, feeling the effect of their gravity, being pulled down to their chair, where the pressure points are where they're standing.

I said right now, the easiest one is the breath, because the breath never leaves us. If it does, we're in big trouble. But the breath is always with us. And it happens in the background and it's happening to both of us right now. So, bringing your attention to your breath is the more common of the senses that people choose. but just keep in mind, this is not a breathing exercise, it's more of an awareness exercise. So, noticing the breath from the moment the air enters either the nose or the mouth, all the way up until it's reached its full lung capacity, your lung capacity, and then letting go of the breath. It doesn't have to even be particularly deep breaths, maybe a bit longer just to notice it. But that's a simple one. So, step one is setting a timer for 10 minutes, and declaring the intention to do this.

Step two would be picking your breath, let's say, to pay attention to the rise and the fall of your breath, how it affects your belly or the air going in and out of your mouth.

The third one is, this is where the old reptilian ancestry comes in, the old amygdala response, which is that the mind is It's inevitably going to wander off into multiple different directions, past regrets, future fears, issues, setting your agenda for the day, emails you haven't sent yet, whatever it might jump off to, the mind is certainly going to wander away. And we don't want to condemn it for doing that. We don't want to be upset that that's happening. We don't want to judge ourselves that "I'm never going to be able to meditate. This is never going to happen for me. Even though it works for over 80% of people, I'm not one of those people," and like, "No, no, we don't want to judge." We're actually training the lack of judgment and getting rid of judgmentality in this practice as well, in addition to other things like concentration.

So if step one is setting the timer, step two is picking a sense to focus on, step three is mind is going to wander off. Step four is the most important, which is noticing that the mind has wandered off, briefly giving it maybe a one-word analysis, or a one-word recognition, or naming it is what they call it, is a simple term that's used a lot, is naming it, like, excitement. "I'm excited about that thing I keep thinking about" or fear, fear of missing out. Or my mind went off to anxiety over something. Just naming where it went off to, then bringing the attention back to the sense that was chosen in step two. Just doing that, mind wander off without the intention for it to, but it does. And then, bringing the attention back to the sense. Doing that step over and over and over is a simple regimen that one can do to get started. Because later on in life when we are exposed to something extraordinarily stressful, we're able to bring our attention to our senses, drop that anchor, like earlier on. We talked about dropping the anchor, and then being able to respond to the stressful stimuli of life instead of react. And being able to respond is an incredibly freeing and health improving action. Reacting, not as great.

Thank Well, Dr. Korkor, I think that is the perfect place to end. You know, I think one of the things that I take away from this conversation is that It is a little uncomfortable to be still sometimes. It almost feels unnatural in this society that we live in. But you said something that's going to stick with me, which is being present on purpose. And that's the first step of the four that you gave to initiating and instilling a practice in your life to let the body heal itself. So, thank you so much for your time. I really appreciate it today.

Thank you for having me on.

Host: That was Dr. Rammy Korkor, Internal Medicine Physician with Southwest General Medical Group. To request an appointment with Dr. Korkor, you can visit swgeneral.com. if you found this episode to be helpful, consider sharing us on your social channels and check out our full podcast library for topics of interest to you. My name is Prakash Chandran, and this has been another episode of Southwest General Health Talk. Thank you so much.