Cortisol, surprise-enhanced cognition, and flashbulb memories: Scaring people with a snake screen and getting a PhD for it!

Cortisol is a hormone that has a number of important functions. It gets us out of bed in the morning, it cranks up our metabolism in preparation for intense exercise, and it also helps us memorize things and even learn. Yes, it helps us learn. Memorization in particular, and cognition in general, would be significantly impaired without cortisol. When you are surprised, particularly with something unpleasant, cortisol levels increase and enhance cognition. This is in part what an interesting study suggests; a study in which I was involved. The study was properly “sanctified” by the academic peer-review process (Kock et al., 2009; full reference and link at the end of this post).

The main hypothesis tested through this study is also known as the “flashbulb memorization” hypothesis. Interestingly, up until this study was conducted no one seemed to have used evolution to provide a basis on which flashbulb memorization can be explained. The basic idea here is that enhanced cognition within the temporal vicinity of animal attacks (i.e., a few minutes before and after) allowed our hominid ancestors to better build and associate memories related to the animals and their typical habitat markers (e.g., vegetation, terrain, rock formations), which in turn increased their survival chances. Their survival chances increased because the memories helped them avoid a second encounter; if they survived the first, of course. And so flashbulb memorization evolved. (In fact, it might have evolved earlier than at the hominid stage, and it may also have evolved in other species.)

The study involved 186 student participants. The participants were asked to review web-based learning modules and subsequently take a test on what they had learned. Data from 6 learning modules in 2 experimental conditions were contrasted. In the treatment condition a web-based screen with a snake in attack position was used to surprise the participants; the snake screen was absent in the control condition. See schematic figure below (click on it to enlarge). The “surprise zone” in the figure comprises the modules immediately before and after the snake screen (modules 3 and 4); those are the modules in which higher scores were predicted.

The figure below (click on it to enlarge) shows a summary of the results. The top part of the figure shows the percentage differences between average scores obtained by participants in the treatment and control conditions. The bottom part of the figure shows the average scores obtained by participants in both conditions, as well as the scores that the participants would have obtained by chance. The chance scores would likely have been the ones obtained by the participants if their learning had been significantly impaired for any of the modules; this could have happened due to distraction, for example. As you can see, the scores for all modules are significantly higher than chance.

In summary, the participants who were surprised with the snake screen obtained significantly higher scores for the two modules immediately before (about 20 percent higher) and after (about 40 percent higher) the snake screen. The reason is that the surprise elicited by the snake screen increased cortisol levels, which in turn improved learning for modules 3 and 4. Adrenaline and noradrenaline (epinephrine and norepinephrine) may also be involved. This phenomenon is so odd that it seems to defy the laws of physics; note that Module 3 was reviewed before the snake screen. And, depending on the size of a test, this could have turned a “C” into an “A” grade!

Similarly, it is because of this action of cortisol that Americans reading this post, especially those who lived in the East Coast in 2001, remember vividly where they were, what they were doing, and who they were with, when they first heard about the September 11, 2001 Attacks. I was living in Philadelphia at the time, and I remember those details very vividly, even though the Attacks happened almost 10 years ago. That is one of the fascinating things that cortisol does; it instantaneously turns short-term contextual memories temporally associated with a surprise event (i.e., a few minutes before and after the event) into vivid long-term memories.

This study was part of the PhD research project of one of my former doctoral students, and now Dr. Ruth Chatelain-Jardon. Her PhD was granted in May 2010. She expanded the study through data collection in two different countries, and a wide range of analyses. (It is not that easy to get a PhD!) Her research provides solid evidence that flashbulb memorization is a real phenomenon, and also that it is a human universal. Thanks are also due to Dr. Jesus Carmona, another former doctoral student of mine who worked on a different PhD research project, but who also helped a lot with this project.

Reference:

Kock, N., Chatelain-Jardón, R., & Carmona, J. (2009). Scaring them into learning!? Using a snake screen to enhance the knowledge transfer effectiveness of a web interface. Decision Sciences Journal of Innovative Education, 7(2), 359-375.

Guest Commentary: Healthcare Quality Calls for Visionary Leadership

Laura Kimberly, MSW, MBE
Director of Special Projects
Jefferson School of Population Health


Do you ever wonder what it takes for a health system to win NQF’s prestigious annual National Quality Healthcare Award? On Friday morning, JSPH had the honor of hosting Michael Dowling, President and CEO of North Shore-Long Island Jewish Health System, this year’s winner of the NQF award. It became clear to everyone present that Mr. Dowling is a truly visionary leader, and his transformative approach to creating a culture of quality at NSLIJ is remarkable. Over the course of the morning, Mr. Dowling shared numerous pearls of wisdom, including his take on the essence of the quality movement – “quality is a value, it is the DNA of an organization, and every employee is a quality professional.”

During his tenure as CEO, Mr. Dowling has promoted a quality agenda through radical changes to the structure and organization of the primary hospitals, long term care facilities, community hospitals, and ambulatory sites that now make up the NSLIJ Health System. The health system owns each entity, and all primary administrative and clinical functions are centralized for maximum efficiency, communication, and integration. In addition, the health system has a single board of directors, enabling effective decision-making with a constant eye to the health system’s big picture.

Mr. Dowling faced enormous challenges to bring about the massive systems changes required to create NSLIJ. Nearly every entity within the health system was operating at a deficit at the time of purchase – the health system is now profitable, generating over $6 billion in revenue and employing 42,000 people.

As an example of Mr. Dowling’s paradigm-shifting approach to leadership, he attends NSLIJ’s Monday morning orientation sessions and personally meets every single new hire, on average 70-90 people each week. In another example of his commitment to integration, teamwork and transparency, he has established protected time on Fridays during which all administrative and clinical staff attend patient safety rounds.

Mr. Dowling identified 6 key areas that underlie NSLIJ Health System’s accomplishments:

1) Employee Development
2) Teamwork and Collaboration
3) Commitment to Transparency
4) Commitment to Innovation and Continuous Improvement
5) Focus on Accountability
6) The Big Picture – Manage for the Short Term, Lead for the Long Term

There is a great deal to be learned by studying NSLIJ’s approach to quality, and to organizational culture and leadership more broadly, particularly within the context of the current health care reform efforts.

David Cameron's Big Society as a 'word cloud' with thanks to wordle.net

David Cameron's speech on Big Society presented as a 'word cloud'...
(...does this look like a shark?)

Guest Commentary: College for Value-Based Purchasing of Health Benefits

Marlon D. Satchell, MPH
Project Director
Jefferson School of Population Health

Martha C. Romney, MS, JD, MPH
Project Director
Jefferson School of Population Health


There is a growing recognition that the healthcare system in the United States is in an unhealthy state due to a number of factors, including uncontrollable and unsustainable costs, disparate and inequitable access and quality of care, unaccountable waste, errors, and misaligned incentives.

Employers and employees are facing growing challenges in covering the costs of healthcare, disease management, and preventive care.The public and private sectors are in search of methods to bend the cost curve and have identified value-based purchasing (VBP) as a powerful strategy. VBP has been defined as “a strategy employed by purchasers of health insurance and healthcare services to maximize the benefits received at lower costs.”1

The Jefferson School of Population Health (JSPH) has taken on an integral role in educating employers, benefit managers, insurers and human resource professionals about the principles, application, and measurement of VBP initiatives through its College for Value-Based Purchasing (CVBP). From July 19-22, JSPH – along with the National Business Coalition on Health, and the Healthcare 21 Business Coalition – offered an intensive program focusing on benefit purchasing techniques and skills, which emphasize improvement in the value, quality, cost, and effectiveness of health care services purchased on behalf of employees.

A faculty of national multi-disciplinary experts, including healthcare business coalition CEOs, legal, medical, business, human resource and healthcare research industry leaders, led 12 instructional modules on concepts such as improving and measuring quality of care and paying for performance. Other modules included methods for holding payers and providers accountable for quality care, while empowering and rewarding employees for achieving and maintaining their health through wellness programs, health risk assessments, lifestyle behavioral changes, and disease management.

Attendees included employee benefit managers from academia, health care, real estate, biotechnology, pharmaceuticals, public safety, and more, who learned about the need for VBP and the VBP paradigm from the employers/payers, providers, consumers, business and healthcare coalitions’ perspectives. Additionally, attendees created customized action plans for their own institutions to conceptualize strategies for engaging senior and line management, creating supportive work environments, negotiating with suppliers, and implement change through a systematic, comprehensive, collaborative approach.

1. Slen J, Bailit M, Houy M. Value-base purchasing and consumer engagement strategies in state employee health plans: a purchaser’s guide. Academy Health. 2010.

The baffling rise in seasonal allergies: Global warming or obesity?

The July 26, 2010 issue of Fortune has an interesting set of graphs on page 14. It shows the rise of allergies in the USA, together with figures on lost productivity, doctor visits, and medical expenditures. (What would you expect? This is Fortune, and money matters.) It also shows some cool maps with allergen concentrations, and how they are likely to increase with global warming. (See below; click on it to enlarge; use the "CRTL" and "+" keys to zoom in, and CRTL" and "-" to zoom out.)

The implication: A rise in global temperatures is causing an increase in allergy cases. Supposedly the spring season starts earlier, with more pollen being produced overall, and thus more allergy cases.

Really!?

I checked their numbers against population growth, because as the population of a country increases, so will the absolute number of allergy cases (as well as cancer cases, and cases of almost any disease). What is important is whether there has been an increase in allergy rates, or the percentage of the population suffering from allergies. Well, indeed, allergy rates have been increasing.

Now, I don’t know about your neck of the woods, but temperatures have been unusually low this year in South Texas. Global warming may be happening, but given recent fluctuations in temperature, I am not sure global warming explains the increases in allergy rates. Particularly the spike in allergy rates in 2010; this seems to be very unlikely to be caused by global warming.

And I have my own experience of going from looking like a seal to looking more like a human being. When I was a seal (i.e., looked like one), I used to have horrible seasonal pollen allergies. Then I lost 60 lbs, and my allergies diminished dramatically. Why? Body fat secretes a number of pro-inflammatory hormones (see, e.g., this post, and also this one), and allergies are essentially exaggerated inflammatory responses.

So I added obesity rates to the mix, and came up with the table and graph below (click on it to enlarge).

Obesity rates and allergies do seem to go hand in hand, don’t you think? The correlation between obesity and allergy rates is a high 0.87!

Assuming that this correlation reflects reasonably well the relationship between obesity and allergy rates (something that is not entirely clear given the small sample), obesity would still explain only 75.7 percent of the variance in allergy rates (this number is the correlation squared). That is, about 24.3 percent of the variance in allergy rates would be due to other missing factors.

A strong candidate for missing factor is something that makes people obese in the first place, namely consumption of foods rich in refined grains, seeds, and sugars. Again, in my experience, removing these foods from my diet reduced the intensity of allergic reactions, but not as much as losing a significant amount of body fat. We are talking about things like cereals, white bread, doughnuts, pasta, pancakes covered with syrup, regular sodas, and fruit juices. Why? These foods also seem to increase serum concentrations of pro-inflammatory hormones within hours of their consumption.

Other candidates are vitamin D levels, and lack of exposure to natural environments during childhood, just to name a few. People seem to avoid the sun like the plague these days, which can lower their vitamin D levels. This is a problem because vitamin D modulates immune responses; so it is important in the spring, as well as in the winter. The lack of exposure to natural environments during childhood may make people more sensitive to natural allergens, like pollen.

BIG SOCIETY: Arts, Health and Well-Being

Hello and a big THANK YOU to everyone who’s taken part in discussions around the Lib-Con Big Society over the last 3 weeks. In Barnsley, Bolton, Ellesmere Port and Manchester, we’ve had some really interesting exchanges.

The last North West Arts and Health Networking Event was one of the most stimulating and animated discussions with lots of thoughts about inclusion, subversion and action, and I can’t begin to reflect your contributions here. I know people are apprehensive about committing their thoughts to a blog, but it’s all good and keeps conversation flowing. Of course, if I can’t persuade you to write anything here, please feel free to carry on emailing me.

B A N K S Y

Following my presentation at the nalgao seminar on arts and health, I’ve written a brief paper with some of the thoughts I raised and this will be published in the next edition of Arts at the Heart magazine in August and on the Arts for Health website.

I can confirm that we will be having a regional arts and health event here at MMU on October 29^th 2010, where we will expand on the idea of a North West Manifesto/Big Society, and I will provide more details as they emerge. This may well include some input from the new economics foundation on the Five Ways to Well-Being.

And a big reminder, if you want to comment on the North West Health and Well-Being Alliance, please email me comments by August 6^th so I can present a cohesive voice for the sector. And if a Year of Wellbeing is being proposed for the North West Region, the arts should be at the heart of this emerging public health agenda.

As I promised at the evening session, here are some links to things we discussed and some anonymous comments that we might expand on.

Arts and Business and the National Campaign for the Arts have jointly formed a Culture Forum to lobby government and explore these Big Society themes further. 3 of the 26 forum members include representatives of the arts/health sector, including the Chair.

http://www.artsandbusiness.org.uk/Central/arts-services/Culture-Forum.aspx

The lecture that I described about Politics of the Common Good by Professor Michael Sandel as part of the Reith Lectures 2009, should be here: www.bbc.co.uk/programmes/b00lb6bt

The wonderful Public Health pioneer Mark Burns, who harnesses many elements of popular culture has a website here:

http://www.sexanddrugsandrockandhealth.com

Programme for Government, May 2010:

http://programmeforgovernment.hmg.gov.uk/files/2010/05/coalition-programme.pdf

Polly Toynbee commenting on Art and the Big Society:

http://www.guardian.co.uk/commentisfree/2010/jul/28/arts-funding-cuts-big-society

new economics foundation and Five Ways to Well-Being:

http://www.neweconomics.org/publications/five-ways-well-being-evidence

Kind Schools link:
www.peopleunited.org.uk/index.php

The Great Transition link:
http://www.neweconomics.org/publications/great-transition


demos link to Civic Streets report:

http://www.demos.co.uk/publications/civicstreets

Mark Thomas presents The People’s Manifesto:

http://www.markthomasinfo.com

http://en.wikipedia.org/wiki/The_People's_Manifesto

Museum of Modern Art, dementia programme:

http://www.moma.org/meetme

A link to the inspirational Dennis Potter, which is too short, but you can dig deeper on youtube, because he’s worth it…

http://www.guardian.co.uk/news/video/2007/sep/11/dennis.potter

Orange RockCorp, where Orange are already awarding community activists:

http://www.orangerockcorps.co.uk/whatIsOrangeRockCorps

I described the drive to develop a National Arts and Health Forum, well here’s the link:

http://www.cultureandwellbeing.org.uk

Some comments that you may want to further expand on…

‘What stops us from making plans to demonstrate or collaborate?’

‘The mental health impact of increased worklessness will be huge. How will the government address these issues?’

‘People already survive without resources in impoverished areas…there has always been a big society working away.’

‘I wonder where members of the cabinet including David Cameron, volunteer?’

‘The arts will survive and thrive because by their very nature, artists are inventive and collective.’

‘The danger of the Big Society agenda is that it will diffuse everything, so that no one has the power.’

‘As people have to juggle work/life balance, where will they find extra time for new demands?’

‘There is an emphasis on payments by results, but the smaller organisations and community groups won’t be able to compete with larger organisation who have big financial reserves.’

‘How do we stay calm: why should we stay calm?’

‘The Big Society is all about addressing inequalities, but we all have varying degrees of ability in the face of poverty.’

Growth hormone, insulin resistance, body fat accumulation, and glycogen depletion: Making sense of a mysterious hormone replacement therapy outcome

Hormone replacement therapies are prescribed in some cases, for medical reasons. They usually carry some risks. The risks come in part from the body down-regulating its own production of hormones when hormones are taken orally or injected. This could be seen as a form of compensatory adaptation, as the body tries to protect itself from abnormally high hormone levels.

More often than not the down-regulation can be reversed by interrupting the therapy. In some cases, the down-regulation becomes permanent, leading to significant health deterioration over the long run. One can seriously regret having started the hormone replacement therapy in the first place. The same is true (if not more) for hormone supplementation for performance enhancement, where normal hormone secretion levels are increased to enhance (mostly) athletic performance.

Rosenfalck and colleagues (1999) conducted an interesting study linking growth hormone (GH) replacement therapy with insulin resistance. Their conclusions are not very controversial. What I find interesting is what their data analysis unveiled and was not included in their conclusions. Also, they explain their main findings by claiming that there was a deterioration of beta cell function. (Beta cells are located in the pancreas, and secrete insulin.) While they may be correct, their explanation is not very plausible, as you will see below.

Let us take a quick look at what past research says about GH therapy and insulin resistance. One frequent finding is a significant but temporary impairment of insulin sensitivity, which usually normalizes after a period of a few months (e.g., 6 months). Another not so frequent finding is a significant and permanent impairment of insulin sensitivity; this is not as frequent in healthy individuals.

The researchers did a good job at reviewing this literature, and concluded that in many cases GH therapy is not worth the risk. They also studied 24 GH-deficient adults (18 males and 6 females). All of them had known pituitary pathology, which caused the low GH levels. The participants were randomly assigned to two groups. One received 4 months treatment with biosynthetic GH daily (n=13); the other received a placebo (n=11).

The table below (click on it to enlarge) shows various measures before and after treatment. Note the significant reduction in abdominal fat mass in the GH group. Also note that, prior to the treatment, the GH group folks (who were GH-deficient) were overall much heavier and much fatter, particular at the abdominal area, than the folks in the placebo (or control) group.

From the measures above one could say that the treatment was a success. But the researchers point out that it was not, because insulin sensitivity was significantly impaired. They show some graphs (below), and that is where things get really interesting, but not in the way intended by the researchers.

On the figure above, the graphs on the left refer to the placebo group, and on the right to the GH group. The solid lines reflect pre-treatment numbers and dotted lines post-treatment numbers. Indeed, GH therapy is making the GH-deficient folks significantly more insulin resistant.

But look carefully. The GH folks are more insulin sensitive than the controls prior to the treatment, even though they are much fatter, particularly in terms of abdominal fat. The glucose response is significantly lower for the GH-deficient folks, and that is not due to them secreting more insulin. The insulin response is also significantly lower. This is confirmed by glucose and insulin “area under the curve” measures provided by the researchers.

In fact, after treatment both groups seem to have generally the same insulin and glucose responses. This means that the GH treatment made insulin-sensitive folks a bit more like their normal counterparts in the placebo group. But obviously the change for the worse occurred only in the GH group, which is what the researchers concluded.

Now to the really interesting question, at least in my mind: What could have improved insulin sensitivity in the GH-deficient group prior to the treatment?

The GH-deficient folks had more body fat, particularly around the abdominal area. High serum GH is usually associated with low body fat, particularly around the abdominal area, because high GH folks burn it easily. So, looking at it from a different perspective, the GH-deficient folks seem to have been more effective at making body fat, and less effective at burning it.

Often we talk about insulin sensitivity as though there was only one type. But there is more than one type of insulin sensitivity. Insulin signals to the liver to take up glucose from the blood and turn it into glycogen or fat. Insulin also signals to body fat tissue to take up glucose from the blood and make fat with it. (GLUT 4 is an insulin-sensitive glucose transporter present in both fat and muscle cells.)

Therefore, it is reasonable to assume that folks with fat cells that are particularly insulin-sensitive would tend to make body fat quite easily based on glucose. While this is a type of insulin sensitivity that most people probably do not like to have, it may play an important role in reducing blood glucose levels under certain conditions. This appears to be true in the short term. Down the road, having very insulin-sensitive fat cells seems to lead to obesity, the metabolic syndrome, and diabetes.

In fact, in individuals without pituitary pathology, increased insulin sensitivity in fat cells could be a compensatory adaptation in response to a possible decrease in liver and muscle glucose uptake. Lack of exercise will shift the burden of glucose clearance to tissues other than liver and muscle, because with glycogen stores full both liver and muscle will usually take up much less blood glucose than they would otherwise.

I am speculating here, but I think that in individuals without pituitary pathology, an involuntary decrease in endogenous GH secretion may actually be at the core of this compensatory adaptation mechanism. In these individuals, low GH levels may be an outcome, not a cause of problems. This would explain two apparently contradictory findings: (a) GH levels drop dramatically in the 40s, particularly for men; and (b) several people in their 50s and 60s, including men, have much higher levels of circulating GH than people in their 40s, and even than much younger folks.

Vigorous exercise increases blood glucose uptake, inside and outside the exercise window; this is an almost universal effect among humans. Exercise depletes muscle and liver glycogen. (Fasting and low-carbohydrate dieting alone deplete liver, but not muscle, glycogen.) As glycogen stores become depleted, the activity of glycogen synthase (an enzyme involved in the conversion of glucose to glycogen) increases acutely. This activity remains elevated for several days in muscle tissue; the liver replenishes its glycogen in a matter of hours. With glycogen synthase activity elevated, glucose is quickly used to replenish glycogen stores, and not to make fat.

Depleting glycogen stores on a regular basis (e.g., once every few days) may over time reverse the adaptations that made fat cells particularly insulin-sensitive in the first place. Those adaptations become a protection that is not only no longer needed but also detrimental to health, since they lead to obesity. This could be the reason why many people initially find it difficult to lower their body fat set point, but once they lose body fat and stay lean for a while, they seem to become able to maintain their leanness without much effort.

Well, perhaps glycogen-depleting exercise is more important than many people think. It can help make you thin, but through a circuitous path.

And, incidentally, glycogen-depleting exercise causes a temporary but dramatic spike in GH secretion. This natural increase in GH secretion does not seem to be associated with any significant impairment in overall insulin sensitivity, even though glycogen-depleting exercise increases blood glucose levels a lot during the exercise window. This is a temporary and physiological, not pathological, phenomenon.

Reference:

Rosenfalck A.M., Fisker, S., Hilsted, J., Dinesen, B., Vølund, A., Jørgensen, J.O., Christiansen, J.S., & Madsbad, S. (1999). The effect of the deterioration of insulin sensitivity on beta-cell function in growth-hormone-deficient adults following 4-month growth hormone replacement therapy. Growth Hormone & IGF Research, 9(2), 96–105.