In this ninth anniversary issue we turn our attention to health and healing. Historically, health has meant freedom from disease, and healing hasn't been a treatment, or even a common word, in the doctor's approach to patients' conditions, except for the surgeon's reference to wound healing.

Based on the articles in this issue, I'd like to suggest that health and healing are broad in scope and multidimensional. We must increasingly define health for ourselves and for our patients in the three realms: health of mind, health of body, and health of spirit.

Physician Health

One of the questions I added to the Fall 2003 Northwest Permanente (NWP) Physicians' Worklife Survey was "How would you rate your health in the following three areas: Mind, Body, Spirit?" We had 500 responses out of 750 physicians, so these results are statistically significant. The rating in percentage is expressed as the top two points--"very good" or "excellent"--on a five-point scale. The results are graphically displayed in Figure 1. Physicians rated their health of mind - 86%; health of body--81%, health of spirit--71%. The follow-up question was: Would you like emphasis on, or education in, the following areas? (Figure 2).Under mind, I included and they chose: psychological hardiness--40%, creativity--24%, meditation--20%. Under body, they chose: fitness--51%, physical activity--44%, nutrition--23%; under spirit, they chose present in the moment--29%, discovery of meaning--19%, deep listening--12%. This was a first attempt at surveying how physicians rate themselves in mind, body, and spirit in the context of their worklife. Many physicians expressed appreciation that such a question appeared on a survey that routinely asks about clinic team practices, visits, and patient relations. They felt permission to talk about mind, body, and spirit and to include these in their clinical practice, although physicians may not yet know how to do that well. Because this survey was a statistically significant representation of NWP, I am assuming similar interest across the Permanente Medical Groups. In Spring 2004, the Northwest Healthy Eating and Healthy Active Weight (HEHAW) Group offered a conference on "Promoting Physical Activity." This conference was a first intervention to meet the needs of 44% of Worklife Survey respondents ("Body"). In Spring 2005, this group's follow-up conference focused on "Nutrition and Health."

Nutritional Health

How is your nutritional health? I wondered about mine so I attended the first Nutrition and Health Conference, sponsored by Andrew Weil, MD, Director of the Program of Integrative Medicine at the University of Arizona School of Medicine, in March 2004. It was a remarkable experience for me. I learned a great deal about nutrition, which was personally helpful, and I returned with good information for readers of The Permanente Journal (TPJ). At the close of the meeting, there was a community symposium on the state of the nation's health and the importance of understanding and practicing better nutrition. A Call-to-Action was read and simultaneously issued to the national media. We are publishing this national press release to make you aware of it and to meet your need for information on nutrition.

Figure 1.

Figure 2.

End of Life

In this issue the article about end of life, Mario Milch, MD, and Richard D Brumley, MD, talk about a good death, and "dying well". That is a healthy spiritual state to achieve. When Carol Evans, RNP, addresses malnutrition in the elderly she notes it is a common manifestation of depression. Treating depression and restoring an appetite for good food to nourish an aging body enhances the health of the body and the mind and uplifts the spirit.

Healing Metabolism

In her article Healing Metabolism, Elizabeth Sutherland, ND, asserts that before we expect to change our obesity-prone metabolism through a diet, we may first need to heal or normalize our metabolism. Keith Bachman, MD, and Brenda Buck, PhD, present the health practice of enrolling the premorbidly obese into a new weight management program in a truly engaging effort to prevent the need for bariatric surgery and its life-threatening consequences (page 52). This approach exemplifies the advocacy by Manuel Diaz, MD, and Brad Larsen, CRNA, for assessing a person's readiness for change in Preparing for Successful Surgery.

Postoperative Health

As for postoperative advice I recently witnessed, is it really the best, most advanced and sophisticated medical thinking to say, once a nonmetastatic carcinoma has been skillfully excised, "Let's just watch this really closely for reoccurrence." Isn't there a place for physicians to consider what we can do to prevent reoccurrence by means such as assessing and altering our physical environment, our lifestyle, our food and nutrition, our stressors, our sleep pattern, our isolation, social support and community, our physical habits, our psychological state, our meditation practice, our antioxidant levels? That is a healthy practice.

A Life in Medicine

Anna Luise Kirkengen, MD, PhD, a primary care physician from Oslo, Norway, writes in Encountering Particulars: A Life in Medicine, that: "Our challenge is understanding ... literally, to stand below ... to be in the same place and, from there, to share somebody else's perspective". We, as primary care doctors, have not only the privilege of coming close, but also the obligation to come closer: to familiarize ourselves with the lives, hopes, intentions, defeats, and longings of our patients--respectfully.

Meditation, Prayer and Spiritual Healing

A special feature of this health and healing issue is A Symposium on Meditation, Prayer and Spiritual Healing. Five experts present the evidence for, and their experience of, incorporating one or more of these practices into their treatment approach. Marilyn Schlitz, PhD, presents the overview from her international perspective as the Director of Research and Education at the Institute of Noetic Sciences in Northern California. In Spirituality in the Medical Encounter: The Grace of Presence, Dr Sutherland explores enhancing the spirit of both the patient and clinician. Naomi Newhouse, CNM, recounts a spiritual encounter of a crosscultural healthy birth with the whole family present. Charles Elder, MD, demonstrates, through the current literature, the effective outcomes of meditation as an internal medicine practice. And Chaplain Kurt Smidt-Jernstrom relates his hospital practice of spirituality in assisting patients coping with serious illness and death.

Soul of the Healer

Finally, we are proud to announce the publication this summer of Soul of the Healer: The Art & Stories of The Permanente Journal: The First Seven Years. Motivated by our readers' comments, we created this book to bring together the art and stories they note are so beautiful and uplifting.

The editors hope you enjoy a healthy and healing journey as you read through this issue and our subsequent publications.

A Call to Action
by The University of Arizona College of Medicine's Program in Integrative Medicine and The Rosenthal Center for Complementary and Alternative Medicine of Columbia University College of Physicians and Surgeons

1. We believe that the population of North America is in great nutritional peril. People are consuming increasing amounts of low-quality foods. There is an epidemic of obesity and in its wake rising incidence of type 2 diabetes in younger and younger children. More people than ever are following extreme and fad diets that may pose long-term risks to health. The food served in schools, hospitals, and senior facilities promotes obesity, chronic inflammation, and accelerated development of age-related diseases. We are also concerned about food safety, given the practices of factory farming, conventional agriculture, and the genetic modification of foods. And we are dismayed to watch the successful exportation of our unhealthy foods and eating habits all over the world.

2. The current state of nutrition education of health professionals is nonexistent to substandard. This is particularly true in the training of medical doctors. The scientific literature is exploding with information about optimum diets and the effects on health, both good and bad, of particular foods, components of foods, and dietary supplements, but this information does not find its way into the training of clinicians.

3. Some consequences of the nutritional illiteracy of physicians are:

4. The nation is in the grip of low-carb mania, the latest dietary craze. It is important for people to understand that an optimum diet includes a balance of carbohydrates, fats, and proteins. Carbohydrates are not bad foods any more than fats are. It is important for people to understand, however, that there are good and bad carbohydrate foods, good and bad fats, and better and worse protein choices.

5. If there is any category of foods that are bad, it is highly refined and processed foods. Modern food technology tends to reduce the nutritional benefits of natural food sources and increase their health risks, as exemplified by the refining and processing of vegetable oils and the processing of whole grains into unhealthy snack foods.

6. We recommend that people decrease consumption of the following foods: foods of animal origin (other than fish), refined and processed foods, fast food, high-glycemic-load carbohydrates, and polyunsaturated vegetable oils. We recommend that they eliminate margarine, vegetable shortening, and products made with partially hydrogenated oils.

7. We recommend that people increase consumption of the following foods: fruits and vegetables, vegetable protein sources, low-glycemic-load carbohydrates (eg, beans, whole grains, sweet potatoes, winter squashes), monounsaturated vegetable oils, nuts and seeds, and omega-3- fatty acid sources (eg, oily fish or fish oils, walnuts, flax seeds, hemp seeds).

8. We recommend counseling consumers that dietary supplements are not substitutes for the whole foods that contain them. They may be useful as insurance against gaps in the diet and as natural therapeutic agents to help prevent or treat specific diseases. Pharmacists, physicians and other health professionals must be educated about their appropriate uses, benefits, and dangers.

9. We strongly support organic agriculture and better production, distribution, and marketing of organic produce to make it available and affordable to more people.

10. We call on industry to demonstrate leadership in improving the eating habits of North Americans instead of defending their current practices as "giving people what they want." We want to see a new generation of fast food restaurants with healthy offerings, modification of snack and convenience foods to conform to current nutritional guidelines, and downsizing of portions. (Typical portions served in restaurants or packaged for individual sale are two to three times the standard serving size. Giant-sized soft drinks sold in convenience stores cost much less per ounce than small ones.) We applaud companies that have begun to do this, for example by removing sources of trans fats from processed foods. We encourage the public to patronize food companies that follow the principles set forth here.

11. We believe that the obesity epidemic in North America must be addressed by attention to physical activity as well as to eating patterns. Physical activity has gone down in our population, with many people exercising less than 30 minutes per week.

12. We must work to develop strong programs in nutrition education for physicians and other professionals, including pharmacists, who should be reliable experts on the benefits and dangers of dietary supplements. We must also work to educate consumers about nutrition and healthy eating and get this information into K-12 curriculums for our children.

13. We emphatically state our belief that healthy food can be delicious, convenient, and affordable.

Reprinted with permission from the University of Arizona College of Medicine's Program in Integrative Medicine. Available from: http://integrativemedicine.arizona.edu/nutrition/callaction.html