Okay, welcome everyone to the Lifestyle Psychiatry Caucus of the American Psychiatric Association's monthly webinar. I'm Gia Merlot, very excited to introduce today's guest speaker, Melissa Zunderman. Dr. Zunderman is a double board certified physician, internal medicine and lifestyle medicine, and she's practicing for over 25 years. She has training in integrative medicine through the University of Michigan and has completed a professional training program in mind body medicine through the Center for Mind Body Medicine based in Washington, DC. She is known as Dr. Outdoors and is the founding chair of the Nature as Medicine Subcommittee for the American College of Lifestyle Medicine. She currently specializes in longevity and lifestyle medicine with lifespan medicine. Part of this role, she practiced lifestyle medicine at the Canyon Ranch Wellness Resort in Lenox, Massachusetts, and Trinity Health in Ann Arbor, Michigan. She does her best to practice what she preaches and enjoys running, biking, hiking, skiing, and spending time outdoors. She's an 11-time Boston Marathon finisher, three-time full Ironman triathlete finisher, and currently training for several upcoming ultra marathons, which you need to tell us what that means. She truly believes age is just a number and is passionate about spreading this word to all our patients, families, and friends, and I'm honored to say that I will be presenting with her at a conference coming up shortly, and we're going to be merging this whole construct of mental health and outdoors and nature as medicine. So excited to have her here. Thank you for joining us. Yeah, thanks. I think actually two conferences. I think the two that we submitted, we got accepted to. So yeah, super excited to combine our passions and spread this to the world. So thank you for that introduction. Ultra runs are things usually on trails, and they're longer than a marathon, so kind of an adventure. And proud to say, on Sunday, two days ago, I qualified for my 12th Boston Marathon. And the really special things is my daughter is 23 years old, took up running a couple years ago, and qualified for her first Boston. So we are going to run the Boston Marathon together this April. So that's super exciting. All right. I'm going to share my screen. Presentation mode. All right. And Gia, let me know when you can see that. Yeah, we're almost there. It says... Okay. It says you need to double-click. Yeah, there we go. We're good. We're good. Good. Okay. So the title of my talk is Nature is Nurture, the Therapeutic Power of the Great Outdoors. I don't have any disclosures. And our learning objectives tonight are... And if you guys have questions, put them in the chat. I can't see the chat, but I can come to those afterwards. And so, yeah, Gia can maybe let me know what those questions are. So learning objectives tonight, we're going to demonstrate the potential benefits of nature exposure, we're going to share evidence supporting the role of nature and health, and we're going to provide tools to help engage patients to achieve more time outdoors. And before we start, I want you to think, if you are clinicians, which I think we have a lot of clinicians on this call, is whether you are currently spending time outdoors each and every day personally. And then the second question is, are you currently prescribing nature to your patients? So think about those answers in your head, and then I'll repeat those questions at the end of this presentation. So by now, you were part of the Lifestyle Psychiatry Caucus here with Dr. Merlot. And so you're familiar with the six pillars of lifestyle medicine. So in short, food is medicine, sleep is medicine, movement is medicine, avoidance of risky substances and risky behaviors, stress management, and social connection. And as doctor outdoors, I believe there should be a unofficial, maybe soon to be official seventh pillar of lifestyle medicine. Just as Hippocrates, the father of medicine says, the physician treats, but nature heals. And my seventh pillar of lifestyle medicine is daily exposure to nature and fresh air. So the EPA did a study several years ago, looking at Americans and asking them, how much time do you spend outdoors? Shockingly, or maybe not shockingly, the average American spends about 93% of their day indoors. 87% of that time is spent inside buildings. 6% of that time is spent inside automobiles, transportation. So that implies only 7% of our day is spent outdoors. So this is one of my favorite prescriptions to prescribe to my patients. I also love this prescription. So why are these two of my favorite prescriptions? Well, a couple of reasons. Number one, cost. Those of us who have been in this field of medicine for a long time, myself as a practicing internist, primary care, I've written a lot of prescriptions. And even when my patients have good insurance programs with co-pays, the co-pays can really be cost prohibitive. In fact, sometimes when I'm seeing a patient and saying, why aren't you taking the medications that you're supposed to be taking? They say, well, I had to choose basically between picking up my medications or putting food on my table. So we know that pharmaceuticals, the cost can be exorbitant. Now, when we talk about my nature prescription, a lot of times that can be absolutely free. Maybe you can step outside. Outside, if you have a yard, or maybe if you don't have a yard, maybe you can go to a local park or a local schoolyard. A lot of times, this is free. And maybe sometimes there is a small cost to enter a park or to buy. I know my metro park to get access, I have to pay about $40 per year to support that park and the upkeep. But when we compare it to pharmaceutical, the cost is minimal. Another reason, side effects. So I'm sure we've all taken medications or we've heard ads for medications. And you take out that piece of paper out of the pill box that you get, and you can barely read the two-point font, and it is all about negative adverse effects, right? And so when we talk about side effects with pharmaceuticals, we're normally talking about adverse side effects. Well, with my nature prescription, about 99% of my side effects are going to be positive side effects. Now, we do have to be aware of some things that can happen out in nature that could be dangerous. You know, air quality. When I was practicing in Massachusetts, we had to be aware of ticks or vector-borne illnesses, perhaps if you're gardening or hiking, poison ivy. But the majority of side effects are going to be positive side effects. Also, duration. When I prescribe medications, a lot of times those medications have to be taken every day, maybe even sometimes twice a day, or three to four times a day, a very short half-life. There's very few medications that are taken monthly, weekly. Maybe there's some injectable medications that are taken every six months. But the majority of medications have a short half-life. We're going to talk about how nature exposure and share some studies how the half-life can last as long as 30 days. So I want to back up when we talk about nature as medicine and go back to some of the origins of nature as medicine. And many of you have probably heard about shinrin-yoku, forest bathing. And shinrin-yoku is a Japanese practice that promotes visiting the forest for relaxation and to improve one's health. And it literally means forest bathing. So what is forest bathing or shinrin-yoku? Well, shinrin in Japanese means forest, and yoku means birth. So shinrin-yoku means bathing in the forest atmosphere. And it's taking in the forest through all five of our senses. And you don't necessarily need to be climbing Mount Everest or rafting down the Colorado River. It's just being in this forest atmosphere, like this picture of this woman just lying on this big tree trunk and just taking in the forest and connecting through our senses and all five of our senses. So the background of shinrin-yoku, back in about 1982, the National Health Program in Japan was proposed for forest bathing by the Forest Agency of Japan. And the main idea and goal was to actually reduce stress in workers. So nowadays, most organizations have chief wellness officers and chief, you know, working to reduce stress, well-being officers. Well, back in the 80s, Japan was already aware that we needed to think about the wellness of our staff and our colleagues. And so really proposing this as a way to help reduce stress. So in 2004, the Forest Agency of Japan organized a team to investigate shinrin-yoku for human health. And it started off as a $1.5 million initial project. And one of the initial key members was Dr. King Lee. And Dr. King Lee is one of the most prolific researchers and writers on forest bathing. And this is his book, or one of his books. So the research work of Dr. King Lee was really looking at the relationship between shinrin-yoku and immune function. It was already well known that the immune system, including natural killer cells, played a vital role in the defense against bacteria, viruses, and tumors, also known probably as cancer. And it had already been shown that stress inhibits immune function. And those of us who can think back to medical school and college and remember how we'd pull all-nighters, and when I was in residency, we still had those 36-hour call shifts. And you'd be pushing your body to all limits. And then finally, you'd get a weekend off. And what would happen? You'd get sick, right? Because we know that stress can decrease our immune function. So the question was, could forest environments, or shinrin-yoku, reduce stress? And therefore, Dr. King Lee speculated that forest environments could have a beneficial effect on immune system by reducing stress. And this is just to go over natural killer cell activity with cancer. And what we find is that people with lower natural killer cell activity tend to have a higher incident rate of cancer. And people with higher natural killer cell activity tend to have a lower incident rate of cancer. And this is shown with both males and females. So the first forest bathing study that was done in the world was done in Japan. And this was done in 2005. And Dr. King Lee was the principal investigator. And then his work was published in the International Journal of Immunopathology and Pharmacology in 2007. And what they did was they took subjects into the forest for two days. And what they noticed was they checked the natural killer cell activity at baseline, so before they went into the forest, and then at day one and at day two. And you can see an increase in the human natural killer cell activity, suggesting that the immune system is becoming optimized by being in the forest. So they thought to themselves, well, maybe it's just that we took these subjects away from their home environments. They didn't have to do dishes and do laundry and do homework. So maybe it's just being away from home. So they said, well, let's, instead of going to the forest, let's take these subjects into an urban environment. Let's go to a big city, lots of concrete, lots of noise, and see what happens. So they did the same thing. So they took natural killer blood samples for natural killer cell activity at baseline and at day one and day two. And this time, we did not see that increase in natural killer cell activity, suggesting that there is something in the forest environment that is stimulating this immune response. And so this is where we come to that duration. And I talked about why I love the Nature prescription, because it has a long half-life. So these subjects that went into the forest for two days, we saw, compared to baseline, a boost of natural killer cell activity at day one and day two, when they were in the forest environment. And then they went back home. They took blood samples from one week out and one month out to look for natural killer cell activity. And you can see in both men and women, compared to baseline, we still saw an elevated natural killer cell activity at one week out and one month out. So by going outdoors today, you are boosting your immune system for the entire month to come. So researchers said, we're on to something. Let's do a larger experiment. So this was a field experiment across 24 forests in Japan. And each experiment had 12 subjects. So there's 280 subjects total. And this was a crossover. So on the first day, six subjects went into the forest environment, and six subjects went into an urban city environment. They sat for 15 minutes, and then they gently walked for 15 minutes. And then the second day, crossover. Forest went to urban. Urban went to forest. And this time, instead of checking natural killer cell activity, they measured salivary cortisol level, which we know is involved in the stress response, blood pressure, and pulse rate. Well, looking at changes in salivary cortisol level, with the black being forest and the white being city, we saw with both viewing and walking a reduction in salivary cortisol, suggesting that the stress is lower when we're in these forest environments. What about pulse rate? Again, we see a similar trend. Being in the forest environment, both viewing and walking had a lower pulse rate to suggest parasympathetic stimulation compared to the city environment. And what about blood pressure? Top being bars being systolic, bottom being diastolic. Again, a similar trend of lowering blood pressures by being in the forest environment. So the question is, how long do you have to be out there? As Dr. Outdoors, I would love to spend most of my day outdoors, but there's things like jobs and families that we can't just be living in the forest. So this is a study that came out actually from the University of Michigan, where I'm from, looking at what is the nature dose. And how they determined it with this study is looking at salivary cortisol levels. And we know that cortisol levels have a diurnal variation, meaning that they go up and down throughout the course of the day. So what they were curious was, what was the quartile time that showed, on the right-hand side, the greatest percent cortisol drop beyond diurnal effect? And that sweet spot seemed to be around that 21 to 30 minute, around 20 minutes. And paying close attention to the research that's been going on, it seems that most people, when we talk about a nature dose, the nature dose is about 20 minutes per day. And that can be split up, just like we talk about when we're moving our bodies and exercise, how we might say, aim to get at least 30 minutes per day of moderate intensity cardiovascular. We say, but you can break that into bite sizes. Same thing with the nature dose. If you want to get 20 minutes total for the day, 10 minutes in the morning, 10 minutes in the evening, that would be great. And this is another study that came out more recently, again, supporting this nature dose. And what they found on the study, they took close to 20,000 participants, and they surveyed them for over seven days. And compared to no nature contact for past seven days, the likelihood of reporting good health or high well-being became significantly higher with contact to nature greater than or equal to 120 minutes. So breaking down about 20 minutes per day or 120 minutes per week. And this effect, this well-being effect, seemed to peak at about 200 to 300 minutes per week. So it's not like you would need to spend all day, every day outdoors, aiming to get at least 120 minutes per week outdoors. And then this is a study that was looking at actually brain activity. And you guys are psychiatrists here. You know all about the amygdala. When I give this talk to more of a layperson, or a similar talk to more of a layperson audience, I like to refer to the amygdala as Amy G. And I say Amy G is in your brain, and picture her having a pair of boxing gloves on. So if there's ever a threat to you, you're getting chased by a tiger, or someone's breaking into your house, Amy G has those boxing gloves on, and she is just going to take out that intruder, right? She activates. It's highly sympathetic. Now, the amygdala, we don't need Amy G to be always getting ready to box. Sometimes we want her to just be able to chill out, take off the boxing gloves, and allow us to get into this more relaxation state, the parasympathetic. So this study was looking at a one-hour walk in nature versus a one-hour walk in an urban environment, and looking at amygdala activity. And what they found was taking a one-hour walk in nature was able to deactivate the amygdala, so allowing us to get into more of a parasympathetic relaxation state as compared to being in an urban environment. So people ask me, yes, Dr. Outdoors, we get it. 20 minutes, go outdoors every day. But what if I can't get outdoors? What if I live in an environment that I don't feel safe going outdoors? What if the air quality is such that I can't breathe when I go outdoors because there's forest fires? What if I have a chronic illness that I'm not able to get outdoors? Can I listen to nature? Does that help? And this is a study that suggests it does. And this was looking at birdsong versus urban sound. So about 300 participants, and they listened to six-minute sound bites. And it was either birdsong or urban sounds of traffic and sirens and horns. And what did they find? Well, when we look at anxiety, anxiety tended to be overall improved listening to birdsong as compared to urban sounds. Feelings of paranoia was also improved listening to birdsong. And feelings of depression seemed to be worsened listening to traffic sounds. So if you live in the country or you live in a place where there's lots of birds, open those windows. If you are living in an urban environment, not that you can't. Open your windows, sure. But maybe put on some, go onto YouTube or Pandora or whatever you use and just select some birdsong and listen to that because that can help make a difference in your mood. And then also, again, what can we do if we can't get outdoors? What about viewing nature? And I absolutely love this study. This is quite an old one. This is back in 1984. And it was looking at post cholecystectomy patients. So they had just gotten the gallbladder out. They were in a hospital setting. And it was a pretty small study, 23 patients. And, or actually, sorry, 46 patients. So 23 of the patients had a window that faced a natural setting. So they saw nature, trees and flowers. And then the other 23 patients had a window as well. But this window was facing a brick wall. What they found was that patients who had a view of nature had shorter hospital stays. This is when we had paper charts back then. Fewer negative evaluative comments in nurses' notes, meaning that they behaved better. And required less pain medication just by having a window with a view of nature. So why do people love forests? What's this quiet atmosphere and beautiful scenery? It feels protected. I know that I live in the woods. And I'll walk out and be like, oh, my gosh, there's no wind out here today. It's so calm. And then I leave my house and I'm like, oh, my gosh, there's actually a lot of wind. So you feel very protected when you're in a forest. And there's this clean, fresh air. And a special good smell. We'll talk about what that is. And I really encourage my patients when, you know, to utilize all five of their senses when they are in nature. So we can utilize our sense of sight, our sense of smell. We'll talk about what fighting signs are. Our sense of hearing. Our sense of touch. And maybe, maybe our sense of taste if it's safe food to consume that's found in nature. And being in psychiatry field, I know that you likely work with mindfulness techniques. And this is a really wonderful grounding technique that I love to teach and prescribe to my patients. And really, you can be any age and do this. Kids can do this very easily and do really well with it. So it's 5, 4, 3, 2, 1. And a mindfulness technique of, you know, really being in the moment. So first starting with five things you can see. And I tell my patients, like, really look around. So often we're multitasking in our brain that we are not even aware of what surrounds us. So maybe even looking up at the clouds and seeing what kind of cloud formations. And looking around, are there creatures surrounding you? Are there plants in bloom? What are you really seeing? And then after that, shift to four things you can feel. Like, actually feel things. Whether there's moss on a rock that feels spongy. Or a fir leaf that you can feel the ridges. Actually grab these and feel them. And then shift to three things you can hear. What are you hearing? Are there different kind of birdsong? Are you hearing squirrels and chipmunks going through the leaves? Are you hearing the branches swing with the wind? And then focus on two things you smell. Are you in a pine forest? Is it spring and you can smell things blooming? Did it just rain and you smell? It's actually called petrichor. Fun fact. That's petrichor that you can smell. And then, again, maybe, maybe one thing you can taste. If there's ramps that just came up. If there's wild berries that you can taste. So a really wonderful grounding and mindfulness technique that can be done in nature. So I mentioned earlier phytoncides. What are phytoncides? So the root, phyton, means plant. And we talk about phytonutrients a lot in lifestyle medicine. This means plant nutrients. So phyton means plant and side means sterilizing power. So phytoncide is a plant sterilizing power. Phytoncides are organic volatile compounds produced by green living creatures such as trees and plants and bushes. And the reason why the trees produce phytoncides is it actually is protective and it helps them build their immune system so that they can stay healthy. Well what happens when we were around green spaces we actually inhale these phytoncides and these phytoncides can help enhance our own immune system function as compared to if we're in an urban environment with pollutants and or smoke or we're inhaling that or poor air quality that can trigger asthma or respiratory conditions. So what are the effective phytoncides? Well studies do suggest they can help with stress relief, they can help us feel more refreshed and restore our energy, they can help improve learning ability and concentration, and they can help boost our immune system with strong antimicrobial properties. So we're going to come back to Dr. King Lee who we talked about before with the original Shinrin-Yoku studies and this time he wanted to look at the effective phytoncides. Now this was a small study only involving 12 subjects and in the study each subject assigned a hotel room for three nights. Half of the rooms were rigged to basically vaporize phytoncides. So they had a humidifier that were vaporizing stem oil from the Hinoki cypress trees and the other six rooms were vaporizing O to nothing. So after three days they took blood samples from the subjects and measured natural killer cell activity and what they found were the phytoncide rigged rooms. Those subjects had a 20% increase in their natural killer cells and they also reported feeling less fatigued whereas the control group saw no changes. And so I've been talking about forest bathing Shinrin-Yoku and then I always get people that say oh Dr. Outdoors I love water. Every time I'm around water I just feel so calm and tranquil. So what about blue spaces? What about you know rivers and oceans and lakes and ponds and streams and fountains and waterfalls? Are those healthy also? And the answer is yes. Now when we look at the research we I do tend to see more research coming out about green spaces but there is research of blue spaces and Dr. Wallace J. Nichols who we lost a couple of months ago is just a fierce advocate for or has been a fierce advocate for the benefits of blue spaces. So absolutely blue spaces are equally important as green spaces. So I'm just going to highlight one study that came out in 2022 looking at exposure to blue spaces in childhood and their effects on adult well-being. And what they found was childhood exposure to blue spaces was associated with better adult well-being. And whether this is you know you start going to blue spaces when you're young and maybe it's open and and you fall in love with just playing in the sand and feeling safe and get used to the rhythm of the waves and develop this positive relationship with that experience that you then in turn gravitate to visiting those blue spaces over and over again as you get older. So my take-home message is if you have kids if you have nieces and nephews or grandkids take them to blue spaces when they're younger because the study does suggest it could help boost their well-being when they are adults. So another concept I want to introduce or talk about if you've already heard about is biophilia. And you probably have been hearing about biophilia a lot. We're talking about people talk about biophilic designs and even hospitals that we talk about with the neck colic cystectomy study is that there's benefits to having biophilia and biophilic design. Well this term originated in 1973 by Eric Fromm who's a social psychologist but most of us are familiar with biophilia by the prolific work of E.O. Wilson. And biophilia is described as the passionate love of life and all that is alive. It is a wish to further growth whether a person, plant, an idea, or a social group. It's basically the innate emotional connection of human beings to other living organisms. I love this picture here that I found because this is biophilia. We humans, we are nature. We are connected to all things living. And I think we innately know this as kids, right? I grew up in the 70s. I spent as much time outdoors as I could. I would look for worms. I would catch fireflies. I'd look for butterflies. I would climb trees. I would spend hours building a tree fort. We wanted to be connected to the earth and all of those living organisms. And then as we get older, life sort of happens and we get jobs and we spend more time indoors and we get more disconnected from nature. And so really biophilia is about getting back that relationship. And being a psychiatrist, the attention restoration theory, this is a theory about why nature is therapeutic. One of many theories. And this was actually, came out of the University of Michigan out of Rachel and Stephen Kaplan's lab. Rachel Kaplan is, I don't think she's teaching anymore, but she is still doing research. And this is, suggests that tension and restoration can be restored by exposure to natural environments. And that we propose that individuals benefit in nature because they're able to be away from everyday stresses and they can experience expansive spaces and contexts. They can engage in activities that are compatible with our intrinsic motivations. And we talk about the soft fascination. So it suggests that this combination of factors encourages involuntary or indirect attention and therefore enables our voluntary or directed attention capacities to recover and restore. And I know this is so true for me. If I'm really feeling stressed or I have a problem that I need to solve, or I need to think through something, if I go for a walk, I can just disconnect. All of a sudden my clarity of thinking, or maybe my creative processes seem to be amplified just by spending time in nature. So I'm going to talk about next, just some research that's going on about health benefits of nature exposure. And I always joke that, you know, when we go to a lifestyle medicine conference, there's always talk about the gut microbiome. And actually now it's going to be any medical conference that's going to be talking about the gut microbiome. The 38 trillion organisms living in our gut microbiome, 70% of our immune system is there, 90% of our serotonin being produced there. So we know that the gut microbiome is integral to the health and wellbeing. As Hippocrates said centuries ago, all disease begins in the gut. So we know that food has a huge impact on the composition of the gut microbiome, but what about nature exposure? So this is a study called the Play and Grow trial and involved little kids, 54 preschool age children. And they were involved in a 10 week nature related structure, the Play and Grow program. And so they basically were told to get outdoors, play in dirt, get dirty, just spend as much time outdoors as you can. And after the 10 week, they did assessments and what they found was they had more significant connection to nature. That's pretty much to be expected. But they also found that they had decreased perceived overall stress and anger after connecting with nature for 10 weeks. And they also took fecal samples. And what they found was an increase in roseburia, which produces butyrate. And butyrate is one of the short chain fatty acids that is produced. So when we talk about short chain fatty acids, we talk about butyrate, propionate and acetate. And so these short chain fatty acids are messengers that go all over our body to help with inflammation and to help with healing. So we saw a shift in the good bacteria by spending time in nature. And they also saw an increase in fecal serotonin level. And knowing that about 90% of our serotonin is produced in the gut microbiome, 50% of our dopamine, suggesting that when they saw the increase in fecal serotonin level, that we are optimizing the gut microbiome by spending time in nature. And what about green spaces and type 2 diabetes? So some studies that showed that green space, exposure to green space, is inversely related to type 2 diabetes. Now, again, this is one study, right? And that neighborhoods with more tree canopy and open grass reduced fatal and non-fatal cardiovascular events in people with type 2 diabetes. So we're starting to see, this is very early, but starting to see more studies coming out looking at chronic disease and tree canopy. And again, this doesn't mean that you have to live in the woods. This means that if there's cities, you know, when we're looking at city and redevelopment and development, the importance of urban planning and trying to optimize green canopies and access and exposure so that people who live in cities can get to green spaces. And then looking at neurodegenerative diseases, this was 62 million Medicare beneficiaries. And what they found was that older adults who lived in a zip code with more green space had lower rate of hospitalizations for Parkinson's, Alzheimer's, and dementias, including Alzheimer's, such as vascular dementia and Lewy body dementia. And then when they looked at blue spaces, we talked about blue spaces, rivers, oceans, ponds, lakes, that the amount of land, their proximity to that of their zip code was also associated with fewer hospitalizations for Parkinson's, but not for Alzheimer's disease. So looking at green spaces and getting exposure to green spaces and blue spaces for Parkinson's, and then more importantly, green spaces for Alzheimer's, dementia, and neurodegenerative diseases. And then looking at green spaces with stroke. And this was actually a retrospective study. And what they found was that proximity to green spaces was inversely correlated with a 19% lower odds risk for stroke. And that people who were in the most deprived areas, so lack of green space, had a 28% greater stroke risk. So there have been studies looking at air quality and pollution as far as brain health and stroke. So again, importance for access and for that all people can have access to green space. And then telomeres. A lot of talk about telomeres. Dean Ornish, who is one of our pioneers of lifestyle medicine, did a wonderful study looking at telomere length with Elizabeth Blackburn. And telomere length, as we, the ends of the chromosomes, and as we age, our telomere length tends to shorten. So we talk about lifestyle and optimizing our lifestyle behaviors. We're hoping to elongate those telomeres. And we don't know if, you know, nature exposure could have anything to do. However, this study that looked at the NHANES sample found that green space exposure tend to have an association with longer telomeres. So again, could this be part of helping us to age healthier and expand and extend not only our lifespan, but our wellspan, is by getting outdoors? And so I also am a big advocate, as you could tell by I like to run and hike and ski and bike and all those kind of things, is what if we combine moving our bodies, exercise as medicine, in nature? And I feel like that's just a wonderful combination. And moving our bodies in nature can help lower blood pressure and stress hormone levels, cortisol levels. It can help reduce our nervous system arousal with the amygdala, can enhance our immune system function with natural killer cell activity, increase self-esteem. We saw that with being around blue space and reduce anxiety. So I always, when I'm counseling patients and we talk about exercise and they say, well, what's the best form of exercise? And I say, well, what do you like to do? And I tend to use the term movement rather than exercise. I think movement is more inclusive and people say, well, I just really love to go swimming in the lake. And like, that's great. That's the form of movement that you should do because you enjoy doing it. And it's going to be creating more sustainable lifestyle habits. So this is not an exhaustive list, but I love to just talk about the different ways that we can move our body in nature. We can take walks. We can go jogging. Gardening is absolutely wonderful. Hiking, biking, swimming, skiing, birdwatching, practicing yoga or Tai Chi, kayaking, canoeing, fishing, tennis, pickleball, yoga, or I said yoga, basketball, playing tag football. All of these ways are moving our bodies in nature. And as my bio says, I love to practice what I preach. So these are some of the ways that I like to move my body in nature. And what helps me is that I engage with our people who enjoy doing the same thing. So in the middle, you can see my family. And most of our trips that we take as a family are two natural environments. We love to go skiing together and hiking together. The bottom left are some of my best friends that we love to go trail running together. And I love to run with my husband and just cultivate really hopeful and fun activities. And the Blue Zones, Dan Buettner, and now everyone is starting to learn about the Blue Zones. People are places in the world where people tend to live the longest, the five original Blue Zones, and now Singapore is the sixth. And so the nine pillars of health for the Blue Zones, one of them is move naturally. So when we talk about movement and exercise, and people say, well, I can't afford a gym, or I don't have a plan of fitness near me. Well, the Blue Zones certainly do not have a purple plan of fitness on every corner. It's about moving our bodies. And our bodies are not meant to sit in a chair indoors all day. Our bodies are meant to move. So taking lessons from the Blue Zones on ways to move naturally. So I mentioned gardening. And I know, at least where I live right now, the summer is ending. Students who's logging in from Australia, your summer is probably going to be starting pretty soon. But when people talk about movement in nature and the benefits, I think gardening is just a wonderful activity. So we know that digging that dirt is going to optimize our gut microbiome. We're outdoors around all those phytoncides that can help boost our immune system. It actually can be a mindfulness activity as we are weaning, or gardening, or pruning, and making things beautiful. That can actually be mindfulness. It's a great workout. I know when I mow my lawn, or spread mulch, or go weeding, that is definitely working my body. Again, we're digging in the dirt. We're getting exposed to bacteria. It's going to help optimize our gut microbiome. And anything we grow in our garden, we are basically eating the rainbow and full of phytonutrients. So gardening is a wonderful way to keep active and healthy. And we all are familiar with a food pyramid. But I want you to look at this nature pyramid. And I love this resource. The source of the resource, you can see, is there. And starting at the bottom of the pyramid is things we should do every single day. Get outdoors. Now, this is geared to a younger audience. So it says run on grass and climb trees. I'm 54. I'm not climbing trees anymore. I don't want to fall out of trees. But basically, try to get outdoors every single day. And then weekly, try to make time to work in your garden, if you have a garden, to go for a nature walk. Maybe grab some binoculars, go bird watching. And then monthly, try to get to your local parks. So if you live in a city, try to go to one of the urban parks. If you live where I live, we've got metro parks or a state park. One of the biggest reasons these parks close is because people don't support it. So maybe invest the money to buy that park pass and really support your local parks. And then if you have time off during the year and you can take a trip, maybe consider making nature a part of that. We've got so many wonderful natural parks and national parks in this country. So consider that when you have time off, bring your family, bring your friends, relatives, and go spend time in nature. So we're familiar with this place, right? I think you guys know this is, well, you guys are at NYU, or some of you are. So you know this park very well. And I love the history of Central Park because back in the 1850s when Manhattan was getting developed, the city planners were really smart. And they knew that people were going to be coming from very rural environments, expansive landscapes, and moving to an island that was going to be built up and largely full of concrete buildings. And they thought, wow, that might not be so good for our health. So let's make a place for the city dwellers that can be a haven. And hence the idea of Central Park was born. So in 1850, they spent at that time a lot of money and trucked in a lot of trees and shrubs and bushes and created Central Park, which today I just love visiting New York City. And I love going for walks and runs through Central Park. When I'm in Central Park, I forget that I'm even in a huge city. So again, just a lesson that if you are in a big city, you can always, most of the time, try to find a park, even a tree-lined street where you live that you can get exposure to nature. And so for people who are forward-facing to patients, clinicians, I want to talk about next, just give you, we're wrapping up here just with some resources of how you can prescribe nature to your patients. So this is Park Rx America. Robert Czar helped create this. And this is a robust website that you can sign up as a clinician. And it really is a turnkey way to prescribe nature prescriptions. So this is an example of my nature prescription. And I can put in a location where my patient lives and it will come up with a resource of parks around that area. I can be as specific or not specific I want with what type of activity. I can put a frequency in there. I can put a duration. And then I can submit it and either it will be sent to my patient via email or text. And so I can see the text email. You can have it show up every single day. You can have this last one week or up to three months. And so this is a really great way to start prescribing nature to your patients. And things that are going around with social prescribing in other parts of the world, this was the Edinburgh in Scotland, their nature prescription trial. And so they gave prescription, nature prescriptions to about 350 patients. 69% received it for mental health conditions. 17% were for physical health conditions like obesity and diabetes. After this, three-fourths of the patients reported benefiting from the nature prescription. And the majority of people who felt that benefit kept doing it, right? So once we start doing things that make us feel good, we're going to want to keep doing them. This is a way that a resource or application that can be really helpful for your patients. I use it for myself. And it helps track your time spent outdoors. And this is Jared Hanley, and this is his company. He's the founder for NatureQuant. And this is the app NatureDose. This is free. So on your smartphone, you can download this. It's available on the Apple App Store. And it will, you know, if you got to keep your phone with you, so maybe just put in your pocket if you're out hiking, but it's geared towards that nature prescription of 20 minutes per day or 120 minutes per week. So maybe you've had a week that you've been working like crazy and you haven't been able to get outdoors. You're going to get a reminder at the end of the week, oh, you know, you've only been outdoors for 30 minutes this week. Let's see if we can get to that NatureDose goal. So again, NatureDose, free app that's really good for some resource for your patients. This is a book written by Bart Foster. And Bart is a big advocate of bringing business outside. So whether this is, you know, in your organization that you have board meetings or you have big clinical meetings, I say consider taking that outdoors, maybe a walking meeting, or if you've got a courtyard sitting outside. And so Bart is really working with getting the C-suite, so your CEO, your CFO, your CMO, out of the stuffy boardroom, out of their three-piece suits and getting in high heels and getting into nature. What he's finding is that all of these executives, they get outdoors and they're in hiking shoes and poles, and really their productivity and their thinking and their creativity is boosted by being outdoors. This is being done in the UK, Dose of Nature, and a GP or PCP there, if they have someone they think could benefit from a nature prescription, they are referred to this program and then hooked up with a psychologist who works with them for 10 weeks and it's basically a nature exposure where they spend time outdoors. And they've been having really good success with this 10-week program of using nature as medicine, nature as therapy. In Canada, Melissa, Dr. Melissa Lem, I said she's the doctor outdoors of Canada, She has been very instrumental in getting Park's program and this was launched in November of 2020 and it's Canada's first nature prescription and if the PCP prescribes a nature prescription to their patient this patient gets free admission to over 80 destinations across Canada and again it's geared towards that 20 minute intervals trying to get at least two hours per week so this is really great so if you know of anyone who lives in Canada they just have to ask for a Park prescription and then they get free access to 80 destinations in Canada. Here in this country we don't have that quite yet but once you are 62 you can pay the one-time fee of $80 and get this Park's pass. Once you have this Park's pass for the rest of your life you get free access to any national park in this country. If you have a fourth grader or you know a fourth grader during their fourth grade year free access to any national park. So my hope is that Melissa Lund will be able to create in Canada that we are going to be able to do this in our country as well if someone a practitioner prescribes nature that we will have better access to our national Park system. This is a paper that came out last year that I co-wrote with my other committee member or other leaders leadership committee from our Nature as Medicine subcommittee from American College of Lifestyle Medicine so you can find this in the American Journal of Lifestyle Medicine we're really proud of it so it really talks about the seventh pillar of lifestyle medicine. If you want to learn more these books I feel are excellent. I mentioned Wallace J Nichols in his book Blue Mind and then for Green Spaces Richard Blue who is just wonderful and a very prolific writer and just such a leader in this. These are three amazing books and then Florence Williams the Nature Fix I also love her book. If you love podcasts I know I do. I love learning and podcasts are usually free. This is Dr. Mark Campbell launched this podcast probably about a year and a half ago called the Nature of Wellness podcast. Richard I just spoke about has been a guest I've been able to be a guest on his podcast and so it's really just talking about the benefits of nature with both physical and psychological wellness. So if you want to subscribe to his podcast I know you're going to learn a lot. And I'm going to end with two more Hippocrates quotes because Hippocrates was actually a doctor as well. So Hippocrates says nature itself is the best physician. And then one of my favorite if you're in a bad mood go for a walk. If you are still in a bad mood go for another walk and I'll add preferably outdoors. So with that I will stop sharing and I thank you for your time and your attention tonight. And I'm going to ask those two questions and you'll answer inside your head or maybe a raise of hand. So after listening to my presentation who is going to try to spend at least 20 minutes outdoors every day or 120 minutes per week. Raise of hands if you're going to try to do that. Okay great. And those of you who are clinicians who is going to who has been or now is going to consider prescribing nature as medicine to their patients or their clients. Great. Mission accomplished. All right. Well thank you so much Dr. Merlo for this opportunity. Of course. Melissa we're so excited to have you here. This is amazing. Can you stay a few minutes for questions. Would you. Absolutely. Absolutely. I'm good. I'm good. Wonderful. So I'm going to usually Dr. Dr. Viz is the first person who is our president of the APA. He usually gets the first question but unfortunately he could not make it today. He's in another meeting. So I'm going to ask the first question and then I'm going to open it up. David are you. David Baron are you able to speak. Are you able to speak. He just had dental surgery. So usually I'll go to the most senior person I know in the room. So I'm going to go to Dave. Dave do you want to say something first to ask a question first or a thought. You have to unmute yourself Dave. You have to unmute yourself. Yeah. Well I hope you can hear me. I want to thank you. So I happen to live in the mountains and I spend the weekends at the beach. One of the things that perfect is and I'd love for you to comment on this and I really enjoyed your presentation is not only prescribing but asking patients what they like because we prescribe it's like telling them and what I found and I deal mainly with athletes but you know so I provide them all that but I found just a little bit of a tweak on what you said is saying what do you really like to do and then they almost always say something and I say that's great. So I'm wondering if you ever if you ever use that as opposed to prescribing i.e. telling them what to do or what they should do asking them what they enjoy. I happen to live on one of the largest hiking trails in Southern California. I literally buy properties on it. I can sit out and watch the people and one of the things that I find very interesting is how it's shifted generation that we're getting more and more older folks going out and walking and hiking for me I think is a very important message but having it be something that they choose to do as opposed to we're telling them you know eat your green vegetables you know don't eat fried foods which is all healthy as well but taking that more positive approach to it. Absolutely and thank you for bringing that up and I I think we talk about nature prescribing that is the perfect way to present it just like when I talked about movement and asking patients like do you like to move your body what resonates with you because as lifestyle medicine physicians we're looking for sustainable changes and that's meeting individuals where they're at right something that that works for me doesn't necessarily work for you and I absolutely thank you for bringing that up and that I think will help me when I'm giving this kind of presentation of to not presented as being so so prescribing because you're absolutely right and that we're gonna get yeah yeah yeah we're getting we get better buy-in right when individuals take ownership of this right and feel I think it's important to deliver this information like this can be really beneficial and here's how it can be beneficial is this something that you know you would think could benefit you so that's a really good point I really appreciate that just one second just one second Dave so I just want to I want to circle back to what you said Dave just give a little bit so I live in both spaces in the American College of Lifestyle Medicine in the APA space so I would just want to put a little perspective here we have redefined the word prescribing in the American College of Lifestyle Medicine so our movement has redefined that we're not talking about prescribing in the way that it's become bastardized within the medication prescribing world we're talking about prescribing as the way that it was originally attended which is a non-hierarchical what doing it together so we're using that and we're redefining the word so Melissa is using the word in the way that we're used to using it within the motivational interviewing techniques and the way that we approach it which is actually a partnership so you know and we're prescribing lifestyle psychiatry I have a prescription pads that I give out to my patients and of course it's not I'm not prescribing hierarchically and telling them to do this but we're deciding together and then I give a prescription pad so we can gently change the conversation about what a prescription is is that just real quick on that I've actually gone one step further and said can you help educate me about the type of stuff outside that you enjoy so they feel a partner and I've had some people they've actually started dance classes outside in nature so that they'll do a dance class or they'll do who can have the goofiest movement but doing it outside so I think flipping it where we're not telling them and thank you for that clarification Gia but asking them what do you do outside that just makes you feel good because I'd love to share that with other people I'd like to share for myself changing that dynamic I found to be very positive particularly with athletes that's great thank you so Susan before we go to Ari you're next and then we're going to go down but Susan had that comment just to round off this conversation and she said I believe that having a doctor prescribed helps people understand that there's something good for them trust in the white coat so that's the second point beautiful Susan thank you for bringing that up yes Ari what was your conversation sure it was actually a question and a sharing sometimes I when I'm prescribed outdoors or nature I get stories back from my patients they almost treat the wilderness as a museum where they look but don't want to touch so I begun to do a little bit more of exploring with them think about going to the woods or the park as a child how would a child behave if he or she went into the woods okay grab their arms around the tree would they would they pick a lean down and smell a flower because if I ask them to just go they observe and when they act like a child they really not observe but absorb you know the experience yeah yeah thank you and I think that's the five four three two one you know when we talk about using the senses and the touch that's just it right you know hug a tree pick up a rock you know throw it into the water I mean that's can really be utilized for connecting instead of just observing as an outsider you know the only one other thing on that is dimension that in EMDR walking through the woods but looking from left to right has an extremely calming experience it's the it's a dual stimulation effect and that very action you might if a patient is very anxious and they're going through with asking them to observe one side and then the other and seeing what it's like on both sides but the ultimate result is it has that kind of anti-anxiety removal of that stressful thought pattern beautiful okay thank you mm-hmm Sarah had a comment in the in the chat uh does it the time of day that one takes a walk with respect to any of the measures uh make a difference yeah so thanks for bringing that up um I need to put this add to the slide so there has been research looking at early morning sunlight exposure and if you listen to the Huberman podcast he talks about this a lot so ideally well I say anytime you can get outdoors just like we talk about so many things anytime you can move your body is a good thing so anytime you can outdoors if it fits your life that's what we want to happen if you do have some flexibility getting outside without wearing any sunglasses before the hour of nine or 10 a.m. and not looking up but just having that that those infrared rays can help to align your circadian rhythm can help boost your serotonin can help modulate the cortisol so we're getting more and more research coming out about the benefits of early morning sunlight so first and foremost if you can get outdoors great if you do have a choice I would say try to get outdoors in that early morning it doesn't have to be at 6 a.m. at sunrise but preferably before like 9 or 10 a.m. I just wanted to say thank you for that it was an amazing talk and I'm so motivated it's getting dark here in Canada I'm in Niagara and I just want to go out so going on to that like in the night we can still hear sounds we can still hear but is there something like for example with pineal gland stimulation or melatonin that works when you have light versus darkness yes so that's why when you have that early morning sunlight we basically want our you know melatonin to be or stimulated within the evening right so we're with these things that's why we want to dim things at nighttime so when you get outdoors in the morning that basically signals that melatonin okay like calm down now we're outside we're gonna you know not getting as much stimulation to the pineal gland so but if this is the time of day that you can get outdoors and sort of just use this as a mindfulness practice and listen and just be connected to nature then absolutely do that um and if you can get out in the morning sometimes too that would be great and one other quick comment is when I was a kid there were some really nice teachers that as a treat would take us outside not to do like a nature activity but just have Shakespeare in the grass or whatever and I used to love that and I always wish that we would have like open wall like a place that outside the school where there'd be so we'll be shielded but we could just sit and and be in a beautiful environment but nobody seems to have taken me up on that idea and I was wondering your research have you come across open-air classrooms where the subject is not like going to study the nature but just sitting outside and learning yeah yeah so um a woman who is really uh leading this charge her name is becca katz k-a-t-z her non-profit is good natured learning and really what she's trying to do is bring nature into the classroom classroom into nature uh so she is from ledville colorado she and she's living in kenya right now because her husband does renewable energy so they're there for two years but if you go to good nature learning becca katz um she has a she's a wonderful writer she's stanford um undergrad and master's smart smart smart so you can subscribe to her newsletter and learn about her efforts to bring nature into the classroom and instrument in nature thanks so much thank you thank you sarah for your questions lorenzo yeah dr norris lorenzo please oh an amazing presentation i wish i would we recorded this right this is yes uh colleague already actually read my mind and asked a question ahead of time but what i was going to ask you is is two questions one uh were you aware of any studies that built in nature exposure directly into the medical student curriculum in which it was an embedded part of the curriculum so that was the first question the second question is a little bit more ambitious given what you know if you were to redesign the typical medical student classroom if you had free reign what would it look like what would you do so to answer your first question i'm not aware of any part of medical school curriculum where this is um happening i'd love to see that happen and i'm happy to you know be a part of that um to you know we're dr merlot and i are really involved in american college of lifestyle medicine so we're starting to see lifestyle medicine curriculum you know in the medical schools and the residency which is really exciting um i don't know anything of nature specific and as far as the environment i mean we're starting to see this um in health systems so i live in ann arbor michigan and uh at the university of michigan medical center which is a major major institution they they actually have a couple of rooms called recharge rooms where it's virtual nature um they do have some courtyards that you can go outside but for um this was they got a grant really to support nursing staff and when they were doing the long shifts and they these rooms are absolutely beautiful so an entire wall it's like a virtual screen and you can select uh different areas of nature you want to go to so whether it's a lake whether it's a mountain and it's real-time um video and sounds and there's candles and there's scents so they're doing some virtual reality um virtual reality nature um at some hospitals i think that you know a lot of hospitals will have um green um uh courtyards and you know places that staff can go where patients can go um at medical schools again like if what we find with lifestyle medicine is if we can teach the young minds this at inception this is just the way that we approach um uh care including you know food is medicine movement is medicine you know all of these pillars um i would believe that you know if we teach the benefits of nature as medicine from day one of medical school then we're going to create or educate our future clinicians to be utilizing this um not only for their patients but for themselves one other super quick question sorry just what um the presentation call rooms and i think the term was the uh phytocides a study that looked at what it looked like in that car room environment to actually have those that present and if there was a difference between call rooms that had it or didn't have i don't think so these are great these are great studies to to think about and do but yeah i don't believe that's been done there are some studies about looking at just looking at greenery like pictures of greenery and how that can actually affect change as well so the that's actually been done as well with stress reduction but i wanted to say something to what melissa was just saying right now because i think it's really important to point out that you know we you know we we believe in um academic differences of opinion right we're good with that melissa can i can i go can i go there okay so in in lifestyle psychiatry the way that we're studying it in our study groups we're using nature as medicine as one of the pillars of connectedness so the way that i'm defining connectedness and the way that we're studying it within the apa right now is that connectedness involves from our knowledge melissa and psychiatric knowledge is that connectedness means not more much more than just social connection that the way that the american college of lifestyle medicine is talking about it connection to ourselves it's a connection to society our communities and it's a connection to the world at large which includes spirituality and nature so i absolutely have and we don't have an in in aclm we're not we're leaving out spirituality we're leaving out connection with ourselves and we're leaving out connection with nature and i think they all belong on that same pillar because it's i i agree i yeah direction at all it's just social connection because therapeutic benefits for mental and physical health with all levels of connectedness yeah absolutely beautifully said so we don't i i would rather not have it as a seventh pillar i would rather it actually be incorporated into the sixth and it's not social connection it's connectedness connections yeah so it's connectedness and that's so lorenzo i think that as we're doing our work in our study groups and as we're moving this forward and as we're writing our our practical guidelines we are including it and part of the goal of all this work that we're doing within our lifestyle psychiatry caucuses and our study groups and our work group is to then ultimately push that forward to graduate medical education and ume so i think that that's a backdoor way we're going to get it in what yeah without belaboring a point i agree with everything that you all gia said it beautifully but in our earlier point that you all made or that i would say melissa made is that early introduction of these concepts to medical learners and then carry them through the continuum and i also feel as though this would readily uh not only would they practice better they'd have no lifestyle principles they'd be able to engage and connect with their patients more and get better outcomes but also the other element of this i think that certainly this could give us every opportunity to start to another way to chip at burnout and suicide in that which is also one of my ends so i mean uh i see all of these things very much interrelated uh so but let me shut up because i'll just no no no and i just want to point one more thing in the chat um our colleague uh susan i'm sorry um uh who from australia i don't know if you want to just unmute yourself and just talk about this but it seems like there are doing that at university students and medical students so they've already integrated it susan yes thank you for the opportunity and thank you for the excellent presentation melissa anything that's going to make a change needs to be evidence-based so thank you for presenting all of that and here in australia our organization is working closely with governments to offer free forest therapy sessions at university on university campus because the way to make change and to influence change of future generations we believe is getting university students out there in the most stressful part of their lives to experience the benefits of nature connection to be able to go on a forest therapy trail and and notice those difference why a forest therapy trail what is included and then you know taking those experiences into their learning and and into the future into promoting and advocating for nature connection for this relaxation for the fight on sides for all the health mental and physical benefits that these practices offer you know we're talking about the mental health statistics about young people today there's we we have hit a wall we have no further solutions and this is one solution that is out just right outside our doorstep and people like us the doctors wearing the white coat i i firmly believe that when your doctor says this is good for you people take that there's a stronger uptake on that so it's experience it's advocacy it's research that's going to make the changes beautiful beautiful i yeah thank you so much susan i am gonna have to say thank you so much for everyone attending thank you so much for dr sunderman uh susan for joining us uh from australia lovely and for all of the psychiatrists in the room uh we have another meeting that started 12 minutes ago so i need to actually thank you so much guys thank you so much so i'm on um linkedin melissa sunderman if you guys want to connect and continue conversations um i've just so enjoyed being able to speak to your group so thank you g i thank you for the invitation thank you so much for have a great night everyone bye

Lifestyle Psychiatry

American Psychiatric Association

Dr. Melissa Zunderman

nature as medicine

phytoncides

mental health

nature exposure

green and blue spaces

prescribing nature

lifestyle medicine