The Proven Lifestyle
People often think that advances in medicine have to be a new drug, a new laser, or a surgical intervention to be powerful—something really high-tech and expensive. They often have a hard time believing that the simple choices that we make in our lives each day—what we eat, how we respond to stress, whether or not we smoke, how much we exercise and the quality of our relationships—can make such a powerful difference in our health, our well-being, and our survival, but they often do.
Awareness is the first step in healing. When we become more aware of how powerfully our choices in diet and lifestyle affect us—for better and for worse—then we can make different ones. It’s like connecting the dots between what we do and how we feel.
Part of the value of science is to raise our awareness by helping us to understand the powerful effects of the diet and lifestyle choices we make each day—and how changing these may significantly, sometimes dramatically, improve our health and well being. In many cases, these improvements may occur much more quickly than people had once believed possible.
In our studies, we used the latest in high-tech, expensive, state-of-the-art measures to prove how robust these very simple, low-tech, and low-cost interventions can be.
For more than 30 years, Dr. Dean Ornish has directed a series of scientific research studies showing, for the first time, that the progression of even severe coronary heart disease can often be reversed by making comprehensive lifestyle changes. These include a very low-fat diet including predominantly fruits, vegetables, whole grains, legumes, and soy products in their natural, unrefined forms; moderate exercise such as walking; various stress management techniques including yoga-based stretching, breathing, meditation, and imagery; and enhanced love and social support, which may include support groups.
These studies also documented that other chronic diseases may be reversible simply by making comprehensive lifestyle changes. These findings are giving millions of people worldwide new hope and new choices, options that are more caring and compassionate that are also more cost effective and competent.
More recently, Dr. Ornish and colleagues published a randomized controlled trial in collaboration with Peter Carroll, M.D. (Chair of Urology at the School of Medicine, University of California, San Francisco) and William Fair, M.D. (Chair of Urologic Oncology at Memorial Sloan-Kettering Cancer Center, now deceased) showing that the progression of early-stage prostate cancer may be stopped or perhaps even reversed by making similar changes in diet and lifestyle. This was the first randomized controlled trial showing that the progression of any type of cancer may be modified just by changing what we eat and how we live. What’s true for prostate cancer may be true for breast cancer as well.
Recent studies at PMRI are continuing to show how dynamically lifestyle changes can improve our health and well-being, even on a genetic and cellular level. In November 2008, The Lancet Oncology published PMRI’s study showing that changing lifestyle significantly increases telomerase and, thus, telomere length. Telomeres are the ends of our chromosomes that control how long we live. As your telomeres get longer, your life gets longer. This is the first time that any intervention, even drugs, has been shown to significantly increase telomerase.
This is the same cohort of patients in whom we reported changes in gene expression in the Proceedings of the National Academy of Sciences in May 2008 (Dr. J. Craig Venter was the communicating editor). In that study, we found that changing lifestyle changes genes. After only three months, over 500 genes were beneficially affected—upregulating (“turning on”) disease-preventing genes, and downregulating (“turning off”) genes that promote cancer, heart disease, inflammation, and other illnesses. This is the first time that comprehensive lifestyle changes have been shown to beneficially affect gene expression in men with prostate cancer.
These studies show how powerful comprehensive lifestyle changes can be, how dynamic these mechanisms are, and how quickly benefits may occur. It’s not all in our genes.
When you make comprehensive lifestyle changes, most people find that they feel so much better, so quickly, it reframes the reason for changing from fear of dying to joy of living. Joy and love are powerful, sustainable motivators, but fear and deprivation are not.
You have a full spectrum of nutrition and lifestyle choices. It's not all or nothing. To the degree that you move in a healthful direction along this spectrum, you're likely to look better, feel better, lose weight and gain health.
People have different needs, goals and preferences. What matters most is your overall way of eating and living. If you indulge yourself one day, you can eat more healthfully the next. If you're a couch potato one day, exercise a little more the next. If you don't have time to meditate for 20 minutes, do it for one minute—the consistency is more important than the duration. Then, you're less likely to feel restricted. Studies have shown that those who eat the healthiest overall are the ones who allow themselves some indulgences.
If you’re trying to reverse heart disease or prevent the recurrence of cancer, you may need the “pound of cure”—that is, bigger changes in diet and lifestyle than someone who just wants to lower their cholesterol levels a few points or lose a few pounds. If you have a strong family history, or if genetic testing shows you to be at higher risk, then this information can be a powerful motivator to make bigger changes in diet and lifestyle than you might have otherwise made. Also, it may be possible to tailor pharmacologic interventions more effectively and efficiently.
If you’re basically healthy, then you can thrive on the “ounce of prevention.” And if you’re somewhere in between—if you have some worrisome risk factors for heart disease (high cholesterol, high blood pressure)—then you can begin by making moderate changes in diet and lifestyle, progressively more intensive as needed. If that’s enough to achieve your goals, great; if not, then you may want to consider making bigger changes.
For example, most people in this country have elevated cholesterol levels. They are initially advised to follow a diet based on the National Cholesterol Education Program or American Heart Association guidelines—i.e., less red meat, more skinless chicken, etc. For some, that’s sufficient to lower their cholesterol levels enough, but not for most people. Many are then told, "Sorry, it looks like diet didn't work for you" or, “You failed diet.” Then, they are usually prescribed cholesterol-lowering drugs, which they are told they will need to take for the rest of their lives.
In reality, most people can make progressively bigger changes in nutrition and lifestyle to achieve their goals—often without medications. If moderate changes in diet and lifestyle aren’t sufficient to lower your cholesterol sufficiently, bigger changes in diet and lifestyle usually are. How much you want to change is up to you.
Likewise, you have a spectrum of choices in how much you exercise and how much of the stress management techniques you choose to do. Even 20-30 minutes per day of walking provides most of the health benefits of more intensive exercise while minimizing the risks. And even a few minutes a day of yoga and meditation can make a profound difference in your well-being.
Spectrum of Choices
Foods are neither good nor bad, but some are more healthful for you than others. You have a spectrum of choices.
Based on the latest science, while recognizing the limitations of research, I have categorized foods into a spectrum ranging from the most healthful (Group 1) to the least healthful (Group 5).
I started to say “most indulgent” to describe Group 5, but that’s part of the problem. Whether or not a food is healthful is not the primary determinant of how good it tastes. How fresh are the ingredients? Where was it grown? Local? Organic? How processed is it? How skillfully was it prepared?
You can make Group 1 and Group 2 foods that are good for you and also taste great and feel indulgent. Conversely, you can make Group 5 foods unappealing if they’re not well-prepared.
What matters most is your overall way of eating. I am not saying that you should never consume foods from Group 5 (unless you have a serious health condition). If you indulge yourself one day by eating foods from Group 4 or 5, spend a little more time in Groups 1 and 2 the next day.
If you get on a diet, chances are you’ll get off a diet. Sooner or later. For most people, being on a diet—any diet—is not sustainable.
Even the word “diet” conjures up feeling restricted, deprived, controlled—all the manipulative, fascist feelings that are not sustainable.
In contrast, the Spectrum approach is all about freedom and choice. There is no diet to get on and no diet to get off. Nothing is forbidden. No “Thou Shalt Not’s,” no “You Better!” No guilt, no shame; no right, no wrong.
The Spectrum is based on love, not willpower. It’s about feeling good, not just avoiding feeling bad. Joy of living, not fear of dying. Losing weight and gaining health. What’s sustainable is pleasure, feeling good, and freedom of choice.
OK, here’s how it works:
Find your place on the Spectrum based on the foods that you tend to eat most of the time. Then, according to your own needs and preferences, decide how far, and how quickly, you want to move in a more healthful direction (if at all). In general, the farther you move towards the Group 1 end of the Spectrum, and the faster you move there, the more benefits you’re likely to gain and the more quickly you’ll experience them.
It’s not all or nothing.
In my book, The Spectrum, I describe how you can use this nutrition spectrum for specific conditions—to lose weight, lower your blood pressure, decrease your cholesterol level, and to help prevent or even reverse the progression of diabetes, prostate cancer, breast cancer, and heart disease. Of course, the health benefits of making these changes are not limited to these illnesses; rather, these are examples of how powerful these changes may be.
In general, if you’re healthy and just want to stay that way, you may not need or want to make very many changes at all. If you’re trying to reverse heart disease, then you probably need to make much bigger changes than otherwise.
Foods in Group 1 are, in general, the most healthful. As Michael Pollan writes in the opening of one of his essays, “Eat food. Not too much. Mostly plants.”
Group 1 foods are predominantly fruits, vegetables, whole grains, legumes, soy products, nonfat dairy, and egg whites in their natural forms, as well as some good fats that contain omega 3 fatty acids. These are the foods that are rich in good carbs, good fats, good proteins and other protective substances. There are at least 100,000 substances in these foods that have powerful anti cancer, anti-heart-disease and anti-aging properties.
Group 2 foods are also predominantly plant-based but somewhat higher in fat (predominantly monosaturated fat and polyunsaturated fat) such as avocadoes, seeds, nuts. Oils are included but in small amounts, since they are so dense in calories. Canola oil is a better choice than olive oil, as previously described, since canola oil contains some of the good omega 3 fatty acids and a better ratio of omega 6 fatty acids to omega 3 fatty acids than olive oil. Group 2 also includes foods canned in water (rather than sugary syrup), canned vegetables (if sodium is not too high), low-fat dairy (1 percent), decaffeinated beverages, low-sodium soy sauce, and so on.
Group 3 foods include some seafood, some refined carbohydrates and concentrated sweeteners (in moderation), some oils that are higher in saturated fat, oils that have a higher ratio of omega 6 fatty acids to omega 3 fatty acids, some reduced fat (2 percent) dairy products, margarines free of trans fatty acids, sweeteners containing high fructose corn syrup, and higher sodium.
In Group 3, I have given preference to seafood that is higher in omega 3 fatty acids, such as salmon. Anchovies are high in omega 3 fatty acids but also high in fat if packed in oil. Wild salmon tends to be lower in bad stuff (mercury, dioxin, PCB’s) than farmed salmon, which should especially be avoided in pregnant and nursing women (although pregnant and nursing women should be sure to take omega 3 fatty acid supplements each day, which may make their babies smarter and healthier). The table below is a guide to the content of omega 3 fatty acids in various fish, recognizing that there will be some variability.
Remember, you don’t have to eat fish to receive the omega 3 fatty acids. Three grams per day of most fish oil capsules contain about one gram of DHA + EPA, which is all that most people require. If you take fish oil capsules in which the bad stuff has been removed, then you receive the benefits of the omega 3 fatty acids without the potential toxicities. Also, vegetarian sources of omega 3 fatty acids are now available.
Group 4 foods contain additional fat, higher fat animal protein and fewer protective nutrients. These include poultry, fish that are higher in mercury, whole milk/dairy products, margarine, mayonnaise, doughnuts, fried rice, pastries, cakes, cookies, and pies.
Group 5 foods are, in general, the least healthful foods. They are the lowest in protective substances and are highest in “bad fats” (especially trans fatty acids and saturated fat). Group 5 foods include red meat in its various forms, egg yolks, fried poultry, fried fish, hot dogs, organ meats, butter, cream, and tropical oils.
If you’re consuming red meat, look for brands that are organically raised in which the animals have been raised and slaughtered in ways designed to minimize the animal’s suffering. Sometimes this information is on the label; other times you may need to go to their web site if you’re interested. Compared with natural grass-fed animals, meat from animals raised in feedlots contains more total fat, saturated fat, cholesterol and calories. It also has less vitamin E, beta carotene, vitamin C, and omega-3 fatty acids.
I put “bad carbs” in Group 3 and “bad fats” in Group 5 because the harmful effects of bad carbs can be offset by consuming them in a meal along with good carbs and other high-fiber foods that have a low glycemic index and glycemic load. In contrast, the unhealthful effects of consuming too much saturated fat and trans fatty acids are not mitigated as much by consuming these with more healthful foods. Eating too many “bad carbs” on an empty stomach puts them in Group 5.
The Spectrum of Food Choices Table is just a guide. Other factors can change a food’s category, including the type of food, the amount of food, and other foods it’s consumed with.
For example, you can turn a healthy food into an unhealthy one if you eat too much of it. A little olive oil belongs in Group 2, but pouring it over your pasta and dipping your bread in it will move it to Group 3 or even Group 4 due to the excessive calories, saturated fat, and omega-6 fatty acids from eating so much of it. Margarine made out of canola oil is healthier than margarine made out of oils high in trans fatty acids and saturated fat. A little dark chocolate every day may lower your blood pressure, but eating a lot of chocolate gives you a large amount of sugar, calories, and saturated fat. A tiny sliver of butter may be healthier than a large scoop of margarine. You may want to explore alternatives to both.
In general, choose smaller portion sizes if you’re trying to lose weight, lower your cholesterol or blood pressure, or reverse the progression of a chronic disease than if you just want to continue to stay healthy. If you’re going to eat more indulgent foods, have them with healthier ones.
As I’ve said, it’s not all or nothing. When we eat more of our foods on the healthier end of the Spectrum, it makes us feel better. It also does less violence, helps reduce global warming, and frees up more arable land to grow food for those who most need it. In short, it’s the healthiest way to eat both for us and for our planet.
We all need to find our place on the food spectrum that’s comfortable and congruent with our own personal values as well as with our health needs. And it may evolve, or devolve, over time. The point of the spectrum is to provide you information that you can use to make informed and intelligent choices.
But this I know for sure: only you can decide what’s right for you. Only then is it sustainable.
Click here for the Spectrum of Food Choices
Nutrition Guidelines For Reversing Heart Disease
Fat — No more than 10% of calories are from fat. This is achieved by not adding any fats, oils, seeds, nuts, avocados, coconut and olives to a mostly plant-based diet. The 10% of calories from fat comes from fat that occurs naturally in grains, vegetables, fruit, beans, legumes and soy foods.
Cholesterol — No more than 10 milligrams of cholesterol per day. To meet this goal, non-fat dairy products are limited to 2 servings per day. Non-fat dairy products are optional. Soy products can be used instead of dairy products because they are cholesterol free.
Animal Products — Meat, poultry, fish and any products made from these foods are eliminated. Non-fat dairy foods (no more than 2 servings/day) and egg whites are included.
Calories — Unrestricted unless weight loss is desired. Small frequent meals spread throughout the day help avoid hunger and keep energy levels constant. Portion control will assist in reaching and maintaining a healthy body weight and controlling blood sugar levels.
Sugar — Permitted in moderation. No more than 2 servings/day including non-fat sweets. A serving is equivalent to 1 tablespoon or 12 grams of sugar.
Caffeine — All sources of caffeine are eliminated, including regular and decaffeinated coffees and teas, chocolate, cocoa, and regular or decaffeinated dark colas, with the exception of green tea. Caffeine’s effect on the central nervous system interferes with the mind body connection and therefore meditation and relaxation. Why is green tea an exception? Evidence from recent studies on tea shows that the health benefits of green tea outweigh the risks for most individuals. Green tea contains a variety of powerful antioxidants called polyphenols, especially the flavonoids such as catechins, which may reduce the risk of many chronic diseases. Individuals with arrhythmia and elevated stress should still avoid any caffeinated beverage. Although green tea contains some caffeine and its caffeine content is lower than that found in coffee, black or oolong teas and caffeinated cola soft drinks, it should be limited to no more than 2 cups per day. Additionally, decaffeinated green tea can be consumed. Be sure to purchase green tea that has been decaffeinated with the “effervescence” method (uses water and carbon dioxide), which preserves most of the polyphenols present in regular green tea. Naturally caffeine-free herbal teas, grain-based coffees (i.e. Postum, Caffix and Roma), carob powder, Sprite, 7-Up or Ginger Ale are also good alternatives. For more information on the benefits of green tea, see Dr. Ornish’s recent column, Touting Tea.
Sodium — Moderate salt use, unless medically indicated otherwise.
Alcohol — Allowed in small amounts but not encouraged. If consumed, enjoy one serving a day: 1.5 ounces liquor, 4 ounces wine or 12 ounces beer.
Soy — One serving per day of a “full-fat” soy food. A full-fat soy food is one that contains greater than 3 grams of fat per serving, with none of the fat coming from added fats or oils. Always read the label for portion sizes and ingredient content.
Supplements — A low dose multivitamin and mineral supplement with B-12 (without iron, if not of childbearing age), fish oil and, possibly upon the advice of a physician, calcium supplements. Antioxidant vitamins and folic acid are optional and are based on health history and nutritional intake of these nutrients.
Prevention Food Guide Pyramid
click image for larger version
Moderate exercise, stress management techniques, social support, a multivitamin, and 3 grams/day of fish oil to provide omega-3 fatty acids are also recommended for most people. Fresh, organic produce is optimal.
Dean Ornish, M.D.
Founder and President, Preventive Medicine Research Institute
Clinical Professor of Medicine, School of Medicine, University of California, San Francisco
This pyramid is a visual representation of Dr. Ornish’s dietary recommendations. The foundation of this diet comes from whole, unrefined plant-based foods, as close as possible to their original state. These are whole grains such as whole wheat and brown rice, fresh fruits and vegetables, and legumes (beans, peas, lentils), including soy. These foods provide carbohydrates, protein, fiber, vitamins and minerals and an immense variety of disease-fighting chemicals found only in plant foods (phytochemicals, where phyto = plant), which may help protect us from chronic diseases such as heart disease and cancer.
The bottom two layers of the pyramid, with the addition of 1-2 servings of egg whites and non-fat dairy products, characterize the stricter version of Dr. Ornish diet, meant for people who have heart disease and want to reverse it.
Healthy individuals, who want to prevent disease and achieve or maintain a healthy weight, can add the top layers to the foundation of the pyramid. These include:
- Higher fat-foods, such as nuts and avocados and plant oils low in saturated fat and high in omega-3 fatty acids (e.g. canola oil) can be added occasionally.
- Fish can also be enjoyed in small amounts, especially the varieties rich in omega-3 fatty acids, such as salmon, mackerel, and halibut. Alternatively, one can consume fish oil capsules, and enjoy the benefits of omega-3 fats (decreased risk of sudden cardiac death, lower triglycerides, reduced inflammation (e.g., arthritis) and lower risk of some cancers), without the contaminants that may be present in fish, such as mercury, PCB’s, and dioxin.
- Non-fat dairy products and egg whites can be included to provide excellent-quality protein and important vitamins
- Lean poultry can be added occasionally if a vegetarian diet is not acceptable, as it provides very little additional fat and saturated fat.
Simple carbohydrates such as sugar and white flour are limited in a whole-food diet. These foods are low in fiber, and provide calories that don’t make us feel full, and they get absorbed quickly, causing blood sugar to spike and insulin surges that may cause us to gain weight. Equally important, refined carbohydrates are deprived of many of the vitamins, minerals, and health-promoting phytochemicals present in their unrefined versions.
Red meat and trans-fatty acids are excluded. Red meat is rich in artery-clogging saturated fat and has been linked with an increased risk of cancer. Trans-fatty acids have been found to be equivalent, or possible worse than, saturated fat in increasing the risk for heart disease.
What this pyramid visualizes is not a “diet” in the common use of the word – one that is followed for a short period of time and than abandoned because it is too difficult to maintain. Dr. Ornish approach, on the other hand, is to embrace a dietary lifestyle that offers a spectrum of choices. If we look at our food choices each day as part of a spectrum of choices, then we feel free rather than constrained. If we indulge ourselves one day, we can eat more healthfully the next. To the degree we move in this direction on the food spectrum, we may lose weight, feel better, and gain health.
Nutrition Supplement Recommendations
Multivitamin with Minerals
1 per day, with vitamin B12 (2.4 micrograms/day), without iron (unless woman of childbearing age or prescribed by your physician), providing 100% RDA.
Fish oil supplements vary in their eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) content. Aim for a dosage that includes approximately 1g EPA and 1g DHA per day. This dosage is usually found in 4 grams of fish oil in capsule form per day.
Strict vegetarians may opt to take flaxseed oil capsules or ground flaxseed. However, this is not the general recommendation, as the omega-3 fatty acids in flaxseed are not as bioavailable as those in fish oil. Flaxseed is not recommended for men, as some studies have indicated that there may be an increased risk of prostate cancer for men with high intakes of alpha-linolenic acid, the omega-3 fatty acid present in flaxseed.
Warning: people who have recurrent angina, congestive heart failure, or evidence that the heart is not receiving enough blood flow when exercising should not take omega-3 fatty acids (fish oil), as taking fish oil may increase the risk of sudden cardiac death for people with these conditions. For more information see Dr. Ornish’s column, The Dark Side of Good Fats.
Omega-3 fatty acid supplements are available at most retail stores, health food stores and local grocery stores. Select brands that have toxic substances removed such as mercury, PCB, dioxin, etc. Products with “liver” in their title, such as cod liver oil, are not appropriate. Fish oil supplements should not contain cholesterol.
Participants are encouraged to check with their physician before taking any vitamin, mineral or herbal supplement.
(Choose food sources first for these nutrients)
Vitamin C: 1-3 grams per day
Vitamin E: 100 International Units per day (Check with your physician if taking statin medications)
Folic Acid: 400-1000 mcg per day
Selenium: 100-200 mcg per day
Food Label Guidelines
These guidelines can be used to determine if a packaged food (other than full-fat soy products) fits within the guidelines of the Dr. Dean Ornish reversal eating plan. Please refer to the Nutrition Facts label on the food package, and follow these guidelines:
1. Look at the nutrient analysis section of the label.
- Check the serving size listed on the label to determine what 1 serving is defined as. All nutrition information is based on 1 serving of this product, not the entire package.
- Look at the “Total Fat” content of the food. Does the food contain less than or equal to three grams of fat per serving? If greater than 3 grams of fat, reject this product and find a better option. If less than or equal to three grams of fat per serving, check the ingredient list to see where the fat is coming from before selecting.
2. Read the ingredient list.
- Reject any food that contains any quantity of hydrogenated or partially hydrogenated fats as an ingredient.
- Reject any food that contains ingredients that are not allowed on the Dr. Dean Ornish nutrition plan, such as whole or low-fat cheeses, whole eggs, other animal products, or unacceptable added fats or oils.
- If there is a trace amount of an acceptable, unsaturated fat listed at or near the end of the ingredient list, 0 to 3 servings per day can be included within the context of a well balanced, plant-based diet. Remember to check the serving size to determine what 1 serving is.
3. Determine if the trace amount of added fat or added oil is an acceptable fat.
- Ornish friendly foods that have 0 grams of fat per serving may contain an acceptable fat or oil anywhere in the list of ingredients. (Total of 0-3 servings per day)
Relax & Renew
Stress can be defined as the response of the human organism to any change or demand. Whether the demand or stress is positive or negative, the body responds automatically. The stress response is coordinated in the body by a part of the nervous system called the autonomic (or automatic) nervous system. This system has two divisions, the sympathetic and the parasympathetic nervous systems. The sympathetic nervous system controls the stress response and the parasympathetic nervous system controls the opposite or relaxation response.
When you experience a life change or demand, the sympathetic nervous system sends messages to muscles, organs and glands, which help the body react. Powerful chemicals like adrenaline, cortisol and aldosterone, and other neurotransmitters released by the adrenal glands and other organs, have multiple effects on the body:
increased heart rate (causing increased need for blood flow
to the heart)
- increased blood pressure (increased tension in blood vessel walls)
- blood vessel spasming
- heart rhythm disturbances
- increased stomach acid which can lead to stomach pain, indigestion and heartburn
- decreased blood flow to the stomach and intestines with decreased ability to digest foods
- increased muscle tension which can lead to headache, neck and backaches
- increased blood clotting and thickness
- increased cholesterol
- increased blood sugar
- short, shallow breathing
- abnormalities in immune functioning
- fluid retention
These effects are adaptive in the short term and help a person prepare for dealing with the stress. When stress is chronic, these physical reactions can lead to disease. For a person with coronary heart disease, for example, some of these effects can lead to chest pain, shortness of breath, palpitations and coronary artery spasm and sudden blockages of coronary arteries (i.e., angina, irregular heartbeats or a heart attack). Other stress- related illnesses can include insomnia, sexual dysfunction, hyperactivity, ulcers, chronic headaches, backaches and high blood pressure.
Aside from the physical effects, there are psychological and mental reactions to stress:
- anxiety, acute or chronic
- depression (especially when stress is chronic)
- anger, hostility and rage
- decreased concentration and memory
When people feel stressed, they generally experience fear or anxiety. Others respond by getting angry at the cause or perceived cause of stress. In addition, numerous studies have shown these emotions increase the risk of heart problems.
Finally, stress, especially the chronic variety and its associated symptoms and reactions, leads to behaviors to cope with stress, and often those coping measures increase stress. We end up caught in a vicious cycle. Here are some ways we don’t want to handle stress:
- lack of sleep
- addiction to substances such as drugs, alcohol, cigarettes and caffeine
The parasympathetic nervous system undoes the effects of stress on humans, and brings about a relaxation response and restoration in the body. Some of these effects include:
- decreased blood pressure
- decreased heart rate and strength of contraction of the heart muscle
- less oxygen demand, lessening workload on the heart
- decreased rate of breathing
- increased lung capacity
- better digestion
- increased hemoglobin (ability of blood to carry oxygen)
- feelings of calm and tranquility
- healthy immune system
There are two basic ways of dealing with stress.
- One way is to avoid it. Reduce external stressors when you can, but this is not always possible or even desirable.
- The other way is to manage stress by changing how you react to a situation. The circumstances don’t change, you do.
Stress management techniques can help you react to potentially stressful situations in more healthful and productive ways. Your ability to handle stress increases. In other words, your short fuse gets longer.
Stress Management Techniques
An important component of the Dr. Dean Ornish Lifestyle Program involves opening one’s heart to one’s feelings and to inner peace through the practice of a variety of stress management and relaxation techniques:
Stretching, Meditation, Deep breathing, Progressive relaxation, and Imagery
These techniques are much more than simple strategies to help us cope with or manage stress. They are designed to increase our awareness of what is happening inside us — physically, emotionally and spiritually. Increasing our awareness extends our capacity for control over what is happening within us. As a result, we are better prepared to recognize the symptoms of stress and make changes before we develop unhealthy conditions such as heart disease.
A number of the practices described here are derived from the ancient system of yoga. They have been popularized in recent decades by medical researchers, psychologists and others who have rediscovered their benefits. Yoga is not a religion. It is a system of powerful tools for achieving union, and healing, within us, with others and with a higher force. In this sense, yoga techniques not only calm the body, but also are a means of healing the sense of isolation that can lead to stress and illness.
Basic Stress Management Guidelines
Here are some general instructions for beginning the regular practice of these stress management techniques. Before you begin, it is important to consult your health care provider to be sure that the practices are safe and beneficial for you. It is also very important to find a qualified yoga teacher to work with, rather than trying to teach yourself from a book. In the resource section below, we offer some suggestions for finding a teacher.
Consistency is one of the most important aspects of developing a personal practice.Stress management relaxation techniques are a form of physical and mental training. They are far more effective when done regularly and correctly. There is no magic to learning how to relax. Training your body to enter a deep, regenerative state takes time. Some people will learn quickly, while others may need more time and individual instruction.
For the first several weeks, do yourself a favor and do not focus too much on the effects of the stress management techniques, or your own performance. The gains may not be apparent until you have practiced for a while. If you have any problems during the first few sessions, difficulty concentrating, or feeling some momentary discomfort, discuss this with your instructor.
Develop a Routine:
Habits, good or bad, are developed over time. If you choose a regular time and place to do your relaxation, you will be creating a habit you soon will look forward to.
To help you develop a routine, you may want to keep a relaxation log, which you can fill out briefly before and after each of your relaxation sessions. Keeping a chart for the first several weeks is a useful incentive and allows you to watch your progress.
A Safe Place to Relax:
An important part of developing a routine is to create a safe and quiet place to relax. This may mean asking for cooperation from the other people around you, maybe explaining to them that you need to be alone so you can just concentrate on relaxing. Disconnecting your telephone and putting pets out can help guarantee quiet time alone. Do whatever you think is necessary to ensure you will not be disturbed. Try to keep your special place orderly and full of fresh air so it is always a pleasure to go there.
The best time to do stress management is an individual decision based on your schedule and lifestyle.. It’s important to have an empty stomach, so be sure to wait at least an hour after a meal. Many people choose to do relaxation techniques early in the morning to set the tone for the day, or just before dinner. It can also be done after vigorous activity. Another good idea is to do your relaxation techniques before going to bed,which will help ensure a restful night’s sleep.
The mental attitude required for relaxation and meditation is different than the mind-set required for most task-oriented activities. Sometimes it takes awhile to become comfortable with the attitude of “passive attention.” Do not push yourself or try too hard to concentrate. Rather, let your attention focus on your breathing, an object such as a flower or candle, a pleasant mental picture, whatever technique you find best. If your mind wanders (and it surely will many times in the course of each exercise), simply finish the thought and then bring your mind back to your object of attention. Do not be critical of yourself, or try to keep your mind from wandering. This will only defeat you and may make you tense up while you are trying to relax and meditate.
Passive attention is best described as paying attention to the process, rather than the goal. Do not think about getting relaxed, which is your goal; pay attention to whatever sensation you are having at the moment, no matter what it is. If you find it hard to do the exercise or to relax, pay attention to your body and try to find out why. You may need to change your position, write something down, make a phone call, or finish a task before you are fully ready to relax.
Problems and Discomfort:
Because we all have expectations about the benefits of relaxation, many people begin to practice stress management and feel they are not doing it right. It seems too simple! Their experience does not fit their expectations, however vague and unrealistic these expectations may be. Trust yourself.
Sometimes a person will experience some discomfort, either physical tension or anxiety, during or after stress management. This is because in relaxing you may become aware of tension in your body that you had ignored or not even realized you had, or you may be letting feelings or thoughts into conscious awareness that you had previously repressed. In most cases the solution is to wait for a while and then continue the exercise; however, if discomfort or anxiety persists, it is wise to consult with a professional.
Hints and Resources
- Avoid meditating immediately after a meal. Wait at least one hour.
- For early morning meditations, do a few stretches and splash some cold water in the face to help you fully awaken.
- A straight backed chair, a firm cushion or pillow or a folded blanket placed under the buttocks helps to make sitting more comfortable.
- Make sure your clothing is comfortable and sufficiently warm (the body will cool down as you relax).
- Meditate in a well-ventilated room.
- Decorate the meditation room with pictures, candles, inspirational books, sacred objects, etc. - anything that would remind you of your purpose in meditation.
- It’s best to meditate in the same place, at the same time every day.
- Two sittings daily of 15 to20 minutes is a good start for meditation practice; sit in the morning when you get up and in the evening before retiring. Very early in the morning (4:00 to7:00 a.m.) is an especially good time to meditate.
- Breathing practices help to center the mind and relax the body in preparation for meditation.
- Meditating regularly is very important. It is through regularity that the habit of meditation can be cultivated. Thus, when meditation becomes a habit, “second nature” to you, it will actually be harder for you to skip your meditation than to meditate.
- Don’t be anxious or disturbed over distracting thoughts coming into your mind during your sitting. Simply try to ignore them. Know that your intention is meditation — if these thoughts want to sit for awhile in your mental “room,” that’s up to them. Don’t try to force them out — you’ll create an enemy. Learning to LET GO of these distracting thoughts is a valuable technique.
- Tend to the PROCESS of meditation rather than the goal. If you do it properly, you will get results.
- Sometimes it may seem that your mind is more disturbed in meditation than during other times. Usually this is because you’ve never been still or quiet enough to notice all the “static” on your mental radio. It’s all always been there — it’s you! Enjoy the “music” — all the drama, romance, intrigue, comedy—it’s all there, in you. Listen to the show as it goes by, but don’t get caught up in any of the scenes, no matter how dramatic. Remain as a witness. Use your object of meditation as your anchor.
- Be loving but firm. Don’t make your mind afraid of you. After all, it’s just doing the best it can under the circumstances. Let it know WHY you want to meditate.
- Approach your practice with a sense of fun and adventure.
- If possible, be around others who meditate; you will inspire each other.
How To Find a Yoga Teacher / Stress Management Specialist
The stress management program at an Ornish Retreat derives from common sense and the historical source of yoga: stretches, breathing practices, deep relaxation and meditation techniques. Yoga encourages comfort, healing and mental poise. Many styles and schools of classical yoga exist, and many variations for stress management are developing. Some emphasize physical practice, some meditation, others relaxation, etc. Some styles are more physically vigorous, some more contemplative.
When searching for a stress management specialist, interview several yoga teachers to find someone you trust. Describe your your health profile, including your physical condition and experience with yoga and exercise, sharing any perceived or diagnosed limitations. Be sure to mention that you are on a comprehensive lifestyle change program.
- Ask if the teacher has had experience with yoga as stress management for people with heart- health considerations.
- Ask if the teacher would have a student with heart disease call you to talk about his or her reactions to the class, and if yoga has helped in managing stress.
- Ask yourself if you have confidence and trust in the teacher and feel the experience of working with this teacher will benefit you.
Here are some suggestions to follow in your search for a yoga teacher specializing in stress management:
- Search online or in your local Yellow Pages under “yoga” for gentle or restorative yoga classes.
- Check bulletin boards in health food stores, book shops, YWCAs and YMCAs, community and recreational centers, local colleges, adult education programs, etc.
- Ask friends for references.
- Browse the shelves at your library and video stores, and you may find yoga audio and video tapes. More new and improved yoga material is coming out all the time. You can usually rent and review tapes before buying them.
- Two excellent yoga magazines that provide directories of teachers & studios, as well as workshops, retreats & conferences are: Yoga Journal, and Yoga + Joyful Living.
Regular Moderate Excercise
*Always talk to your physician before starting an exercise program.
The emphasis in the Dr. Dean Ornish Lifestyle Program is on regular, moderate exercise. Research studies have shown that most of the health benefits from exercise are achieved when an individual transitions from not exercising to becoming moderately active.
Slightly more benefits are gained from increasing the duration or intensity of the exercise. But, there is a risk-benefit ratio that may be different for each person. Therefore, the comprehensive lifestyle change program encourages participants to exercise aerobically a minimum of 30 minutes a day or for an hour every other day for a total of 3-5 hours of aerobic exercise per week. More intense exercise is allowed if medically appropriate and if desired by the participant. Resistive or strength training exercise is also crucial to maintaining health. If medically appropriate, participants are also encouraged to engage in strength training exercise 2-3 times per week.
Benefits of Regular Aerobic Exercise
Activity and aerobic exercise can improve one’s physical health in many ways. As stated earlier, most of the health benefits of physical activity are gained with only moderate levels of activity. A proper aerobic exercise program will:
- increase the efficiency of the heart by making it able to pump more blood (increased stroke volume) with fewer beats (decreased heart rate) resulting in increased oxygen availability to the heart
- increase the ability of muscles to pick up, carry and use oxygen efficiently
- decrease the oxygen requirements of the heart during rest and activity
- decrease resting blood pressure such that blood pressure medications may be decreased
- increase the ability to exercise at higher workloads for longer periods of time, before being limited by fatigue, shortness of breath or chest pain
- decrease triglyceride levels in the blood and increase the HDL-Cholesterol (good cholesterol) levels, thus making it harder for fats to collect inside artery walls
- decrease blood sugar and triglyceride levels in the blood such that the types and amounts of blood sugar lowering drugs may be decreased or changed for those individuals with diabetes
- decrease the blood’s ability to clot and stick to blood vessel walls which decreases the risk for blood clots to block small arteries
- increase one’s ability to move, thus making it easier to perform daily activities
- decrease body fat and increase muscle mass
- increase metabolism
- increase tolerance to stress by improving one’s outlook on life
- decrease hostility
- increase control of stress hormones
- increase one’s self-confidence and general sense of well-being
- decrease risk for osteoporosis
Aerobic Exercise Guidelines
The comprehensive lifestyle change program exercise recommendations are based on the distinction of three levels of exertion: inactivity, activity and exercise.
involves no effort and is illustrated by sedentary pastimes such as watching television or sitting at the computer. The effects of inactivity on the body are negative. In fact, most of the benefits of exercise previously discussed are reversed with inactivity.
The next level of exertion is activity
. This category includes stop-and-go or low intensity movements such as gardening or golfing.
The third level is exercise
, or more specifically, “aerobic” exercise. Aerobic exercise is continuous movement, using arms and/or legs at a moderate to high level of intensity, and lasts at least 20 minutes. Some examples of aerobic exercise are swimming, biking and walking.
While it is best to minimize the amount of inactivity
and important to increase our general level of activity
, it is essential that exercise
be an integral part of our daily lives.
The “FITT Principle” of Aerobic Exercise
There are four conditions that must be met for aerobic exercise to produce the desired cardiovascular training benefits. These conditions are adjusted according to the interests and level of fitness of each individual.
F - Frequency (How often to exercise)
I - Intensity (How hard to exercise)
- This will vary from several times per day to 3-6 times per week depending on the exercise intensity and time.
T - Time (How long to exercise)
- 45%-80% of an individual’s maximal functional capacity determined by a treadmill test.
T - Type (The type of exercise)
- Exercise should be sustained for 30-60 minutes, for a minimum of 3 hours per week up to 5 hours per week.
- Walking, jogging, aerobic dance, bicycling, swimming, rowing, cross-country skiing, etc.
- Activities in which you move only intermittently or that are “stop and go”, such as golf, basketball, baseball or bowling, tend to activate the anaerobic system and thus do not help to achieve as much of a training effect.
The Components of Each Aerobic Exercise Session
- Warm-up. 5-10 minutes of several range-of-motion exercises and slow aerobic activity designed to prepare the muscular and cardiovascular system for exercise. If you begin exercising too quickly, without warming up, you’ll draw too heavily on your anaerobic system, a system that is relatively inefficient due to a lack of oxygen available for the working muscles. As a result, you increase the risk for angina (pain in the chest or another part of the body) and you’ll fatigue quickly and build up a lot of lactic acid, which causes muscle cramps and pain.
- Aerobic Activity. 30-60 minutes consisting of continuous, rhythmic exercise performed at the target heart rate and perceived exertion level prescribed by the staff and your physician.
- Cool Down. 8-10 minutes of slower aerobic activity and stretching designed to allow the body to gradually return to its pre-exercise state and increase the body’s flexibility. If the body does not have enough time to “cool-down,” it generates large amounts of lactic acid (the same problem outlined in “Warm-up”), which causes muscle soreness and pain. This is the easiest area to cut short when “hurrying” from exercise to your next activity. It is very important to allow the body enough time to return to its pre-exercise state. In order to achieve the effects of the relaxation response that occur after exercise — the sense of calmness and well-being — you need to cool down fully.
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Now that your heart and lungs are developing strength, stamina and efficiency, it’s time to start working on the other muscles of the body!
In the past, we have emphasized the value of cardiovascular exercise, but we are becoming aware of how crucial resistive or strength training is in maintaining muscle tone and function. Incorporating strength training into your daily routine will allow you to continue doing the things you’ve always done, from carrying groceries and climbing stairs, to playing tennis and dancing till dawn.
After the age of 20, people who don’t engage in physical activity will begin to lose muscle. The most significant loss comes after the age of 60. Aging may contribute to some of this loss, but it is primarily caused by a decrease in physical activity. Cardiovascular exercise such as walking may be good for the heart, but it will have little effect on muscle mass. Only strength training has been shown to dramatically slow down the process of muscle loss. Two research studies by Dr. Maria Fiatarone and colleagues at the Center for Aging at Tufts University demonstrated that people in their 80’s and 90’s can make strength gains in just a few months of resistance training. Study results showed that subjects increased their strength by at least 100%, and improved their walking speed and stair-climbing ability. So remember, it’s never too late to start.
Strength training works on the “overload principle,” which involves making the muscles work a little harder than they are accustomed to by increasing the resistance to movement or the frequency and duration of an activity. In the past, strength training was used primarily by athletes to improve performance, or for physical rehabilitation after an injury. This kind of training used to be considered unsafe for populations like the elderly or people with cardiovascular disease, but recent studies have shown that strength training can be safe and effective for both of these groups when appropriately prescribed and supervised.
Strength training does NOT require expensive equipment and large amounts of time. It can be practiced at home, for 20-30 minutes per session, 2-3 times per week, using a minimum amount of resources. Hand weights, resistive bands and tubing, calisthenics and even plain old water jugs or soup cans can be used to provide the needed resistance.
Create a balanced exercise program by combining cardiovascular exercise, resistive/strength training and stretching for flexibility.
Benefits of Regular Strength Training Exercise
- increased strength and flexibility of muscles, tendons and ligaments
- increased functional capacity
- increased lean tissue and metabolism
- increased bone density (which may help prevent bone loss)
- better balance and stability
- injury prevention
- increased self-confidence, improved self-image
- improved ability to perform occupational and
- leisure time activities
- improved exercise adherence (because of the diversity of exercises)
Strength Training Guidelines
- Breathe! Exhale (blow out) during the exertion phase of the lift. Remember this: Exhale on Effort.
- Maintain proper speed of motion with slow, controlled movements.
- A repetition is the lifting and lowering of the weight. Lift on a 2 count and lower on a 4 count.
- Exercise through the full range of motion but within your comfort level. Emphasize complete extension of the limbs when lifting.
- Pause for a brief moment at the end of a movement (extension) to avoid using momentum (swinging).
- Never sacrifice form for resistance. Stay within your limits!
- Use a partner to help you when necessary.
- Select exercises for both the upper and lower extremities.
- Loosely hold handgrips when possible; sustained, tight gripping may evoke an excessive blood pressure response to lifting.
- Because resistance training is muscle specific, each exercise may require a different weight.
- Stop exercise in the event of warning signs or symptoms, especially dizziness, arrhythmias, unusual shortness of breath and/or angina pectoris (chest pain).
- Do not perform strength-training exercises with any kind of musculoskeletal pain or injury.
The “FITT Principle” of Strength Training
F - Frequency
(How often to exercise)
I - Intensity
- Weight train a minimum of 2-3 times per week with one rest day between sessions.
(How hard to exercise)
T - Time
- To prevent soreness and injury, initially choose a weight that will allow the performance of 12-15 repetitions (1 set) comfortably.
- Avoid straining. Ratings of perceived exertion (6-20 scale) should not exceed fairly light (10) to somewhat hard (15) during lifting.
(How long to exercise)
T - Type
- Initially, perform 1 set of each exercise.
- Keep rest periods between sets relatively short (30-90 seconds).
- Complete 10-15 repetitions of 8-10 different types of resistive exercises that concentrate on large muscle groups of the upper and lower body.
(The type of exercise)
- Free weights/barbells/heavy hands/ankle weights
- resistance bands/ surgical tubing
- calisthenics (body weight)
- household items (water jugs, canned food)
Pollock, ML, et al. Resistance Exercise in Individuals With and Without Cardiovascular Disease. Circulation. 2000; 101; 828.
Progression in Your Strength Training Routine
- After the initial training phase is completed (2-4 weeks), select a weight that provides a challenge without sacrificing form at the completion of each set.
- Increase the weight gradually by 1-5 pounds when 12-15 repetitions can be comfortably completed. This is important in order to see continuing improvements in muscle strength.
The Components of Each Strength Training Session
5-10 minutes of general, rhythmical-type exercise with some stretching and range of motion movements should be done before and after each session. Your aerobic exercise can be your “warm-up” for your strength training.
Strength Training Activity
15-30 minutes consisting of 12-15 types of resistive exercises that concentrate on large muscle groups of the upper and lower body. Perform 1-3 sets of each exercise. Keep rest periods between sets relatively short (30-90 seconds).
Rule of Thumb
You should always be able to carry on a conversation while exercising. If you can’t, there is not enough oxygen available for the working muscles. Slow down. Remember the phrase:
“You should be able to talk while you walk”
Pathways to Success with Exercise
Fulfill the 3 C’s: Comprehension, Commitment and Confidence.
- Comprehension - understand the reason why it is important for you to exercise on a regular basis by talking with a health care professional or by reading educational exercise materials. This will provide a strong base for your commitment.
- Commitment - make a personal decision to place exercise as a priority in your day’s activities. Make exercise a ritual. Write time for exercise in your appointment book — in ink.
- Confidence - set small, reasonable goals. Reward and praise yourself when reaching the steps that will lead you to your ultimate objective. Don’t let small setbacks sabotage your long-term success.
Bring Physical Activity Into Daily Life
The most efficient way to increase your physical activity is to make it part of your daily routines.
- Instead of driving, walk or bicycle to work or to the store. If that’s not practical, park a little farther away (where the parking places are usually easier to find, thereby also reducing your stress level).
- Take the stairs instead of an elevator, especially if you’re going only one or two floors.
- If you use the moving sidewalks at airports, don’t just stand there — walk!
- If you play golf, walk instead of using an electric cart.
- Exercise with family or friends to provide social support, for more motivation and a double benefit.
- On a vacation, walk rather than drive to see and experience the sights.
Love & Intimacy
At the Heart of Healing: Connection
Loneliness and Isolation
Medicine today tends to focus primarily on the physical and mechanistic: drugs and surgery, genes and germs, microbes and molecules. However, there isn’t any other factor in medicine – not diet, not smoking, not exercise, not stress, not genetics, not drugs, not surgery – that has a greater impact on our quality of life, incidence of illness and premature death from all causes than loneliness and isolation.
Love and intimacy -- our ability to connect with ourselves and others, is at the root of what makes us sick and what makes us well, what causes sadness and what brings happiness, what makes us suffer and what leads to healing. If a new drug had the same impact, virtually every doctor in the country would be recommending it for his or her patients. It would be malpractice not to prescribe it -- yet, with few exceptions, we doctors do not learn much about the healing power of love, intimacy, and transformation in our medical training.
There is a deep spiritual hunger in this country. The real epidemic in our culture is not only physical heart disease, but also what I call emotional and spiritual heart disease. The profound sense of loneliness, isolation, alienation, and depression that are so prevalent in our culture with the breakdown of the social structures that used to provide us with a sense of connection and community. It is, to me, a root of the illness, cynicism, and violence in our society.
We are creatures of community. Those individuals, societies, and cultures who learned to take care of each other, to love each other, and to nurture relationships with each other during the past several hundred thousand years were more likely to survive than those who did not. Those people who did not learn to take care of each other often did not make it. In our culture, the idea of spending time taking care of each other and creating communities has become increasingly rare. Ignoring these ideas imperils our survival.
Awareness is the first step in healing, both individually and socially. Part of the value of science is to increase the level of awareness of how much these choices matter that we make each day. Not just a little, but a lot, and not just to the quality of life but also the quantity of life - to our survival. When we understand how important these issues are, then we can do something about it. These include:
- spending more time with our friends and family
- communication skills
- group support
- confession, forgiveness, and redemption
- compassion, altruism, and service
When we increase the love and intimacy in our lives, we also increase the health, joy, and meaning in our lives.
Group support is the part of the comprehensive lifestyle change program that allows individuals participating in the program to connect with each other. For those men and women who have forgotten the power of connection or perhaps never had the “techniques” required to create it for themselves, group support is a tool to this end. What is learned in these groups is available to all. It taps into the healing power of connection that can result in emotional and spiritual transformations that include:
- Rediscovering inner sources of peace, joy, and well-being
- Learning how to communicate in ways that enhance intimacy with loved ones
- Creating a healthy community of friends and family
- Developing more compassion and empathy for both yourself and others
At the Heart of Connection: Communication
Our feelings help to connect us, whereas thoughts – especially judgments – tend to isolate us. Our emotions are more likely to be heard by someone than our thoughts. Sharing ideas may, or may not, bring our minds closer together, whereas communicating emotions unites our hearts. Emotions influence us more than thoughts. Thoughts are processed and filtered through our heads. Feelings go straight to the heart. Appealing to one’s emotions often works more effectively than “rational” discourse.
Good Communication Skills
There are basic guidelines one can follow to improve one’s ability to connect with others:
- Identify what you are feeling
What you are really feeling, not what you believe you ought to feel. Part of the value of quieting your mind with meditation or prayer is that it can help you pay greater attention to what you’re really feeling.
- Express what you are feeling
Tell the other person directly and clearly what and how you are feeling. Be careful to express your feelings and not your thoughts.
- Listen actively with empathy and compassion
- Know the difference between empathy and sympathy
Empathy is not the same as sympathy. Empathy means listening with compassion — trying to experience and understand what the other person is feeling.
Sympathy means feeling sorry for someone, a usually well-intentioned gesture that often creates more distance between people.
- Acknowledge the other person’s feelings, with empathy, caring and compassion – practice fluent listening
“Fluent listening” describes finding an experience inside yourself that is equivalent to the one being expressed by the other person. Fluent listening can facilitate feelings of connection. When you respond to the person talking with an understanding from within that resonates with their experience, they feel heard, understood, and a connection is felt.
Fluent listening requires sufficient connection to oneself and to one’s experiences, to know what it feels like to be the other person on the inside. As you listen, it is important to monitor yourself to ensure that you avoid making judgments or criticisms of what the other person is saying.
Your role is to try to understand how it would feel to be where the other person is.
It is often a struggle to be a fluent listener. Oftentimes, people are excellent advice-givers, but it is far more challenging to respond from within by finding and connecting with one’s own similar feelings and experiences.
Some people assert that they don’t want to be where the other person is.
- I don’t want to feel like that.
- I don’t want to listen to that or have anything to do with that.
- I don’t want to have to deal with anyone else’s stuff. I have enough to deal with myself.
This kind of response tends to make people feel alone. It can make others want to move away from you. This way of wanting to avoid the experience of another person is at the core of the isolation that many of us feel.
As a fluent listener, you can respond briefly, since your role is not the central one at that point, but a supportive one. It is a time to give something back to the speaker. You might say, “I understand and it makes me feel sad or happy or worried or apprehensive.” It is appropriate at times, if you can’t directly relate to the experience of another, to say, “I’ve never had that experience. Could you tell me more?”