[00:00:00] Speaker A: Welcome to the Heart Rate Variability podcast. Each week we talk about heart rate variability and how it can be used to improve your overall health and wellness. Please consider the information in this podcast for your informational use and not medical advice. Please see your medical provider to apply any of the strategies outlined in this episode. Heart Rate Variability Podcast is a production of Optimal LLC and optimal HRV. Check us
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Welcome, friends, to the Heart Rate variability podcast. I am so excited to welcome my good friend, future guest. We haven't had her on in a while, but she's here to share some really exciting research with us. A recent published article, a really good grant opportunity. So I'm really excited to welcome Janelle Minsinger back to the show. Janelle, welcome.
Just because it's been a while, do you mind introducing yourself a little bit about your background before we dive into some of this exciting news you got for us today?
[00:01:08] Speaker B: Of course. It's great to see you and great to be with you again.
As Matt said, my name's Janelle Mensinger. I am a professor at Nova Southeastern University here in Fort Lauderdale, Florida. So while Matt is sitting up in the mountains, I am sitting down in Palm tree paradise. Palm tree paradise. So we've got one more, about one more good month of reasonable weather before things get really hot and humid down here. So I'm trying to live it up.
So, yeah, I am a, as I said, a professor at Nova Southeastern University in the department of Clinical and School psychology. I teach courses in statistics and theories of measurement, everybody's favorite in the psychology world, but I'm real passionate about statistics and measurement concerns and issues. I also teach a course in eating disorders theory and intervention, and the research I'm doing is a kind of an interface of those two specialty areas.
That is the eating disorders work and the interest in applied health psychology and quantitative measurement. So that's a little bit about, well.
[00:02:30] Speaker A: That is a great entry into the article that congratulations. Just been published in the AAPB journal. So I'll read the title and then you can walk us through it. A pilot feasibility evaluation of heart rate variability biofeedback app, which is optimal to improve self care in COVID-19 healthcare workers. So, I know you, at the last episode, you kind of gave some preliminary information about your work, but I love now that we got this out there in the world, you gotta publish. Congratulations. Just kind of walk us through what this feasibility study was and what some big takeaways were.
[00:03:16] Speaker B: Yeah, absolutely. So the feasibility study really focused on kind of that first level of research in terms of the clinical trials world, where you first want to establish, can this be done? Can we implement it? Is it usable, this intervention? And the intervention, as Matt mentioned, was the optimal HRV biofeedback app. So way back when, in the beginning of the pandemic, maybe not quite the real beginning, but it was in 2021.
So pretty deep into the trials of those bad years where we were all in a lot of social isolation situations, I really was interested in doing something to address the burnout of the healthcare professionals. And I had been collecting data as a faculty member at Villanova University outside of Philadelphia, and we were looking at healthcare professionals, mental health and wellbeing status, and found people, not surprisingly, of course, during the pandemic, were really, really struggling. And what I noticed because of my specialty in disordered eating was that there were a lot of people coping with the social isolation of the pandemic, with maladaptive eating patterns. So I was looking at digital methods for addressing this and discovered optimal as an incredibly simple app to use and wanted to test whether or not we could implement something like this in a population that was so incredibly busy and stressed out. And that's kind of where it started, basically, is do they find this kind of intervention acceptable, usable, and is doing this kind of research feasible? So it was really getting at some of the qualitative early components of figuring out if we can test this at a more scalable or larger level. And that's what was so exciting, was that it was very easy to recruit people into this because of how burnout people are and how people in the healthcare world were really just looking for something to help them kind of cope better, not just with disordered eating and their body distress, but just the trauma of working in healthcare itself. We had indicators of a really significant traumatic stress, indicators of depressive symptoms and anxiety symptoms, insomnia symptoms. So the disordered eating was really, I think, just sort of the coping skill that people were using.
So that's how it started, basically, was, can we do this? And the good news was right away we were able to get people into the study. We only had funding for recruiting 28, and we recruited 28, like, pretty quickly. I think within 30 days, I had done 28 consents.
So that was super exciting. That was right around Thanksgiving, Christmas of 2021. So it was quite a while ago now, but it takes time to run these things and get the data analyzed.
[00:07:08] Speaker A: That's awesome. So I'm interesting some of your, and I know this is your language, because it's been a while since I've taken my statistics and research methodology class in grad school. But what were some of the findings that you had? Obviously, it's feasible, which is really good, but just kind of other. Maybe if they weren't necessarily statistically valid findings, but just kind of some of your takeaways from running this study.
[00:07:44] Speaker B: Sure. Yeah. So the biggest contribution was to establish its feasibility. That was done right. Like we. I think, before I even talk about some of the statistics of preliminary efficacy, I'll note that most research that does pilot work in this realm of digital apps does not show a very encouraging adherence rate or retention rate. We retained. We did. We lost a few, but we retained 86% of the original sample, which was, like I mentioned, 28 people, which means we lost four. And in the context of the COVID-19 wave of early 2022, it was pretty remarkable that we only lost four people from the study. So I do want to first underscore the fact that the app itself was seen favorably enough to get a really strong retention rate through the program.
The other thing that I think is really important to note is that three out of four people recommend it, said that they would recommend it to their colleagues, peers, friends, and would also continue to do it beyond the study. That is, engage in the biofeedback portion of the app. That's another thing that we often see in the research, is that people have this great motivation to start something like, oh, I'm going to do this, and I'm going to have an app to help me with it. They download the app, and I cited some things in the discussion of the study.
It's something I can't even remember the statistic. It was so sad. Something like 3%, maybe, of the people continue to use it after, like, the first or second time. So it's really hard in the digital world to get people to continue using something. And so I was very encouraged by the potential that I saw in this app because I was able to get people to keep using it. In fact, I set a really high bar statistically, in terms of usage level for me to consider them being fully adherent to the protocol. And I have to tell you a secret, Matt. I did not meet the bar myself. I'm a user of optimal HRV. When I'm testing an intervention, I like to see what I'm asking my study participants to do. So, of course, before even starting to recruit people into this study, I became a user. I wanted to see, could I do this? I'm a really busy person, too. I'm a faculty member. I teach three classes a week. I'm doing research, I'm mentoring students and running a lab. So I wanted to see could I engage in something that I'm asking my busy healthcare providers to engage in. And I did, but I just missed my own mark of engaging in it enough times to be considered fully adherent. So I'm not even. Of course, I wasn't counting myself in the. In this 28 people that I was looking at in the study, but I'm not even in that group. I was able to get 52 or 3%. I'm sort of. I wrote the paper quite a few months back. Now, um, over 50% of the people were. Were meeting that really high bar. So I think I need to revisit the bar because I will also say that myself and of one. Right, this is not like scientific data, but I feel like I get something meaningful out of using the app, even though I didn't use it at the rate of frequency that I was requiring to meet that bar. I think my rate of frequency was just to make it clear they had to use it 67% of the time. I went for two thirds. I don't know why I wanted to say most days. And I felt like, to truly be accurately, I'm very sort of detail oriented about these things in terms of numbers, to truly be doing something. Most days, I didn't feel like 50% was enough. Right. I didn't feel like 60% was enough. I felt like if I said two thirds of the time, I do it right, like, I didn't want to go as high as 75%, but I thought two thirds is good. So they had to be doing it 67% of the protocol days, which ended up being 28 days out of the 42, because we had them do this for six weeks.
[00:13:03] Speaker A: Yeah.
[00:13:04] Speaker B: And I think I did it, like, when I looked at my own practice over a period of 42 days, when I was writing up the results, I think I went back like 42 days and I did it something like 24. And you needed to get to 28.
[00:13:21] Speaker A: Close.
[00:13:21] Speaker B: Right. So. But my point is, I feel like I get something out of the practice, even though I don't. I didn't meet my own criteria. So what I'd love to see in terms of future work, even before I start talking about some of the efficacy results, is that, is there a dose that we can establish as this is what you need before you're going to start getting a benefit? Right. It would be.
[00:13:51] Speaker A: So it's fascinating, too right. Because we throw around 20 minutes.
[00:13:56] Speaker B: 20 minutes. There's the other one.
[00:13:59] Speaker A: Is it 20 minutes all at once? Is it, you know, and I even see Ina, who is the guru that I look to for all things biofeedback, and it's just kind of 20 minutes. Like.
[00:14:16] Speaker B: Yeah, it's a well known recommendation. It's.
[00:14:19] Speaker A: But if you do 20 minutes at residence frequency, is that or 15, like, mindfulness, too, you often hear the 20 minutes. So there's no.
For the advancement of technology where we're breathing at residence frequency, which is, hey, we get more bang for the buck. I think we do. But what does that necessarily.
[00:14:45] Speaker B: What does that translate to? Like, how much more bang for your buck? Because I'll tell you another secret. I can't sit still for 20 minutes.
I'm a really, really kind of hyperactive person. And, I mean, 20 minutes to just sit and breathe with myself was really challenging. And I knew it would be for my participants, so I gave them the out of saying, shoot for 20 minutes. This is the goal. This is what the evidence suggests that we need to do to get the benefit, the optimal benefit. And I said, but you know what? I find it hard. I think if you at least do ten minutes that you're going to get a benefit that's not necessarily evidence based. And I'd love to see some research that tells us a little bit more information about what we really need to do at home. And to my knowledge, there aren't these dose response studies available. So I feel like in the world that we're in, out there in academia, where people are starting to use these kinds of interventions and scale them up, it's now the time that we should test these things because we really need to know if we're going to scale this up and look at true efficacy studies that are powered, fully powered, to find effects.
And in a randomized controlled trial, we want to know what to tell people. Like, how long do you need to do this? Many of my people didn't do the 20 minutes at once. They probably took. I mean, maybe I biased them by saying that I struggled with it, but I do worry a little bit about that. Like, did I, you know, should I not have said, I find that hard?
I mean, this is a human condition, right? Like, users are going to be met with different practitioners, and different practitioners are going to have different kinds of standards and methods of saying, this is what you need to do. Right? So I think we need to kind of, you know, relax a little bit. Some of that, you know, just provide opportunity for flexibility. That, in fact, in the paper was in the qualitative analysis, one of the things that the participants found helpful was the flexibility. In fact, when I was just looking at this today, before we talked, I had kind of forgotten about how so many people found that the flexibility of the intervention was one of the most important things.
So that piece I really want to point out and put those plugs into our field for really understanding better the dose that's necessary to get an effect.
What does that mean in terms of the time, and what does that mean in terms of the frequency? How many days a week are we talking?
This is about a new world for us. We didn't have this technology five years ago. Right.
[00:17:59] Speaker A: Well, and I think another, like, what do we see with now that we can break it down minute by minute as well? What do we see in minute 18? What do we see in minute 18?
Start to measure these things now in very different ways. And I'm assuming, too, it's individualized as well. It's probably. I mean, I do my biofeedback practice, which, ten minutes, I can do that, sit still for 20, and I don't do that very well either. And, like, it's at the end of the day and I'm, I'm exhausted, but it helps me sleep. So I'm not going to not do it at the end of the day because it's really good for that. But what does that versus morning? Cause that's going to be. Our biology is in a whole different. Our rhythms are in a whole different state, too. So there's. I think there's so many questions.
[00:18:51] Speaker B: Questions. There are. The research is just beginning. We are in the infancy of understanding, you know, how to embrace this and kind of harness this technology for people's self care and well being. And I just wish I had all the time in the world to just do research on this because it's so much easier than it ever was before because of apps like the optimal app. And, and I just thinking about even just the thing you just mentioned. Okay, if I do biofeedback in the morning and I do biofeedback in the evening, or maybe randomize people, have them do it in the morning versus the evening, am I going to feel better? Because I notice personally, when I do it in the evening, I don't get. Well, now that you have the optimal zone available in the app, I can see I don't get the benefit. Right.
[00:19:52] Speaker A: Well, but here's my, here's my analogy.
[00:19:55] Speaker B: Compared to the morning.
[00:19:56] Speaker A: Well, but is like, so in basketball, like we, we do sprints at the end and that to me is like the end of the day is like I've sprinted, I'm exhausted. But it's the best time to shoot free throws because you're exhausted, you're like in game. So while you may not spend as much time in optimal zone and for new listeners, that's kind of. We're peaking. Low frequency or heart rate variability during our practice is because I'm in a tired state and I can still get a little of it. Is that practice any less that I come out with a 15% than if I do it at 10:00 a.m. Which seems to be my peak time. And I'm just screening the whole time, kick back thinking about whatever, because I'm in a different biological state. But regulating that state while it's exhausted may have better long term when I'm doing well because I don't need regulated then. But I don't. To be clear, I don't have any data to argue right now one way or the other.
[00:21:03] Speaker B: We need that data.
That's my hope and goal as a researcher that we can understand ten years from now how to prescribe this intervention. Because we know that people can do it. We know that it helps, if you look at table three that I'm looking at right here, it helps people feel calm and relaxed. It helps them with their resilience, their stress relief. It helps them to mindfully connect to their body. Right. So we know that that's happening qualitatively. So when and how can we prescribe that to ensure that we can optimize those benefits is the real next question, in my view, aside from, all right, let's talk about efficacy, right?
[00:21:58] Speaker A: Right.
[00:21:58] Speaker B: So what, besides, can we say, yeah, people, this is feasible, right. We can probably get people to do a lot of different things. Right? That's a good thing. But are they going to help you really change behavior or change the way you feel most importantly? Right, exactly.
[00:22:19] Speaker A: Exactly.
[00:22:20] Speaker B: That's my hope is that this is a low barrier, low cost, do it yourself at home intervention to take care of yourself, to enhance your well being. And I really have high hopes that this can be something that more and more people have access to because of all of the things I just said, the low barriers, the low cost and the ability to do it literally anywhere.
The healthcare practitioners in the study could do it when they got home from work, before they went to work. At work. I mean, I bring mine in my backpack.
I have an armband or an ear monitor to attach to me before I go into lecture to students some days. So just, even if it's only a five minute session. Yeah, just to enhance some regulation. But the question is, does that really do me, like, a substantial benefit on some kinds of health outcomes? So the things that I was interested in, not surprisingly, of course, given my interest in eating disorders, was, can we improve people's disordered eating or loss of control eating behavior by having them engage in an app like this? I mean, that's ultimately where I'd love to see biofeedback take a role. I think biofeedback has a lot of accumulated evidence in so many different areas. Now. We've got depressive symptoms and anxiety symptoms and PTSD symptoms, and we're seeing more and more effectiveness pain related disorders. But there's really not much in the eating disorders world. And I know HRV is a really tricky measure for eating disorders, but can we get biofeedback in that field as an adjunctive treatment modality? It's something that's. That I think, is waiting to happen, and that's where my work wanted to go, and that's why I focused on those outcomes in particular. And the good news is, at least on the preliminary data, I mean, we have really good preliminary evidence for efficacy. So I think that's a great place to start. We have.
I mean, pre post changes everybody knows have drawbacks in terms of rigor, right? We don't have a control group.
That's the first thing that we have to always remember. We don't know what would have happened to a set of people who had pre and post measurements who weren't engaging in HRV biofeedback. Right. Maybe they also would have improved. Maybe just like the six weeks that I did it in 2022, happened to be a time where everybody in the world was starting to feel a little bit better about life. Right? That can happen. So that's the next step. We need to really take this to a controlled trial. But I'm definitely encouraged by the fact that there was really only one outcome that did not change substantially, and that was one of the areas of interoceptive sensibility. This is obviously for people who know about biofeedback, probably one of the most important mechanisms of the reason it does work for people, whether it be reducing anxiety or depression or PTSD symptoms, has something to do with the mind body connection.
How well does it get people to connect to their mind and body? And the. I guess the one component of interoceptive sensibility that it did not have a significant change on was. Was called not distracting. And interestingly, not distracting is one of the. There's eight. Eight subscales on the multidimensional assessment for interoceptive awareness, which is really the primary tool that the fields moved towards using for mind body interventions like HRV, biofeedback, like mindfulness type interventions, yoga interventions, anything that has to do with kind of that holistic mind body type, you know, framework.
The not distracting subscale of the MIA was the one scale that didn't move significantly.
And it's related to pain.
It's about pushing through pain or not distracting yourself from pain. When you have a discomfort or a painful sensation in your body, the idea is to be able to, I guess, sit with it. I'm not an expert in this area, but it sounds like fun, right?
But the idea is that it's more adaptive. It's better to not distract yourself. So if I have a headache, like, you know, not trying to, you know, get my mind on something else to avoid feeling the pain. So this sub skill really made me struggle personally because of the kind of reality that we all have to cope with when we're in pain. Right. How do you get through pain? You push through it. Well, in this world, this interoceptive sensibility world, that's not adaptive. So I'm really intrigued by that and intrigued by it also being the one subscale that HRV biofeedback did not move. Right.
[00:28:54] Speaker A: Can I ask you a question as you think about one of the things that's always fascinated me with heart rate variability, especially as we start to think about this, as we start to measure the impact of it, as I always love to think about like, states and traits, when you do a five minute breathing practice before teaching a class or I do it before a big presentation, we're really adjusting in many ways our state to perform at a higher level. Whereas repetition over time is starting to build healthier rates. We're starting through neuroplasticity.
See those changes? I think the best research I've seen out there is kind of like the. I think the 20 hours because you're kind of told 21 days to build a habit, which I guess is just bunk, but I don't want to like, say it's too much bunk because if you don't get to 21 days, you're not going to get to 66 days, where we may be able to see some neuroplasticity changes. And if you hear the angst or the hesitation in my voice our measurement tools as they get better might like. I think that number is 966. You can remember it. It's kind of like 21. It's three weeks, so I'm not going to die on that hill by any stretch of the imagination. But I sort of wonder, as you think about this, I think you had folks for six weeks, if I'm correct. Like, do you think we started to see, were we helping people regulate states, were we helping to build new traits and just kind of love to get, as you think about moving forward with some of this, just some of your thinking around short term regulation versus long term maybe building resiliency traits.
[00:30:47] Speaker B: That's a great question. And I think you're right on the mark with, you know, in what we're talking about. It's. We're trying to move states, right? Because these people were in a state of anxiety, of trauma, in the midst of being healthcare workers during COVID-19.
So in this instance, I would say we're talking mostly about state. State level shifts.
And I think this has a huge potential to totally develop traits. And that's where I think I want to go and see more long term.
[00:31:35] Speaker A: Yeah. How.
[00:31:36] Speaker B: How does this get sustained? Right. And what. At what level of practice is required? Yeah, that's trait establishment. To become a self regulated, resilient person who can just kind of handle external things and not be bothered.
[00:31:59] Speaker A: Yeah, yeah, yeah. Because it's interesting you say this. I'll stop here, because this is working in the healthcare field. I think your study is incredibly interesting because it's like, it brings up one of, I think the challenges healthcare is facing now. So I would imagine maybe a lot of our listeners who's not in healthcare thinks, well, COVID was years ago, which is kind of nice to say.
Yet, you know what I find fascinating about healthcare is healthcare. Workforce was a mess pre COVID. That's what we don't talk about. It was a mess pre COVID, and it is a mess not because of the individuals, but because of the industry. Destroys its workforce.
It's a mess. One, because we went through COVID. Two, there's no healthy place to go back to. So, you know, it's. I think healthcare is a very fascinating group to study because, like, has the anxiety just become a trait because you've been in this environment for so long? And that's just like. I think it's fascinating. I love that you picked this group because it's. It's the ones I work with most and who the crisis didn't.
And I tried to convince people this wouldn't be true. Just because we've got vaccinations didn't mean that the healthcare workforce would just go back to normal. And if they did, that was incredibly dysfunctional and unhealthy as well. So it's a fascinating. I love that you picked this group to work with.
[00:33:35] Speaker B: Yeah, it is one of those. It's how I started the paper. In fact, in terms of talking about before COVID-19 the burnout rates were incredibly high. Like, this is a workforce that. I mean, you're the one that actually talked about this recently. In terms of numbers, I don't know if I have them right. But it was like the majority of people. Didn't you say four out of five or some crazy number? Yeah.
[00:34:03] Speaker A: It's getting to a crisis, especially if you take burnout as a traumatic response, which I'm. I'm working on my language on that. But burnout being a amount of stress, mostly over time, because we could talk about moral injury, moral distress, or secondary trauma being more of a traumatic or experience, but it's like, under that stress load for extended periods of time.
You had my go to pre COVID by the American Medical Association. 53% of physicians pre COVID had severe. Severe. When I hear that, I'm definitely advocating that this is a traumatic response. Severe symptoms of burnout.
So your provider. You're your provider who you go through to for healing. Cognitively not functioning at optimal levels, emotionally not functioning. We're close to optimal socially. Nope. You know, so, you know, medically, our healers are sick. So, yeah, I mean, you've got this, and you know that that number is just getting worse. I went to a conference. The feds are like, it's the first time I heard the feds, and I kind of try to sugarcoat something. It's like the car has driven off the cliff. We're just hoping to save maybe the back left seat passenger. Like the rest.
It's too late. Like, it's getting to that level, which. Which makes your work all that more important is that if we could give this group an affordable, easy to use solution to help, because if you're still in a burnout industry and we're also burned out society right now, it's going to be really difficult. But at least there's. There's a way to regulate the nervous system at some point in your day.
[00:35:51] Speaker B: And that. That's what excites me. I really, truly think that just that ten minutes, even if it's just ten, not okay. We should say 20. I guess I should say 20 and not ten, but 20 minutes just to be in a state of regulation and how that can kind of just reset what the nervous system is doing and all that you've talked about the allostatic load, right. The load that's currently on, folks, is just. It's, you know, it's, like, ready to load, right? So. So when I look at this. This idea of. Of helping people adaptively cope and. And not use food or, you know, body related distress to. To kind of deal with these feelings, I. I see this as, like, an opportunity to look at the mechanisms that are helping us get there. And that's what my current research is moving towards. Yes.
[00:37:11] Speaker A: Let's go. Let's go there. We got excitement. We got future thinking.
Where are you going with this, my friend?
[00:37:18] Speaker B: So my NIH grant was just funded, so I'm super excited. It's called the assure mechanism, and this is an r 16 for your grant, where I will be.
[00:37:32] Speaker A: What's our 16 reals?
You gotta help us lay people who may or may not take a nap during statistics.
What are these big words you're throwing.
[00:37:43] Speaker B: At us, my friend, has nothing to do with statistics. So that's the good news. The r 16 is just one of the research grants that the National Institutes of Health gives to investigators at universities. And the 16 reals is just the code that they use, as opposed to, like, the 15 reals or the r zero three or the r zero one or the 20.
[00:38:05] Speaker A: Fed speak. So we're in fed speak, not statistics.
[00:38:08] Speaker B: Exactly. Okay, we're in fed speak.
[00:38:11] Speaker A: I slept during that class, too, by the way.
[00:38:15] Speaker B: So, yes, it's an r 16, which has nothing to do with statistics, and it is a four year grant that we are going to where we are going to delve into the construct that appears to me to be one of the most important mechanisms in why mind body interventions work, how they help people. And that construct, as I've talked about briefly, is this notion of interoceptive sensibility. And interoceptive sensibility is getting at how people are. I mean, in very layperson's terms. I think I even started out, like the grant application, with this phrase, how do you feel? Can you describe how you feel? And that skill, that is a skill is something that some people struggle with. Right? Like, I don't know. Right. Some people just say, I don't know. I don't know what I'm feeling. I don't know how to describe my feelings.
And there's a lot of facets to the ability to read our body's cues. But interoceptive sensibility is the self report component of one of those facets, because the umbrella term, let's be clear, is interoception, which is the one that kind of, sort of. I envision it as sort of living above interoceptive sensibility and within interoception lives.
There's a number of models that have been posed, but the most common one, I think it was Sarah Garfinkel's work, she posed three prongs, or, like, three facets. Interoceptive sensibility, which is the self report component. Interoceptive accuracy, which is really your behavioral tasks. How well can you, for instance, read your report? Your heart beat? Like, how fast your heart's beating.
How well do you do on tasks like what we call the gastric water load test? If you drink water and you can't see how much you're drinking, you're drinking it through a strawberry. Like, can you make a good guess on how many liters you consumed? Right. So we have tests like this. And. And if you're a good guesser, if you're a good, uh. If you're. If you can accurately estimate what you drank based on how full you feel, you're said to have good interoceptive accuracy. Right?
[00:41:00] Speaker A: Yeah.
[00:41:01] Speaker B: So it's all about how well we can read the signals our body is telling us. Reading how fast your heart is beating is one of them. We also have some respiratory tests where I'm not as familiar with the respiratory tests, but there's another set of tests that look at breathing. And HRV falls right into this. Into this. Because in my view.
Well, I've seen some literature. In fact, it's not just in my view. And I've seen some literature that shows that HRV is positively correlated with interoceptive accuracy.
[00:41:42] Speaker A: Yeah.
[00:41:43] Speaker B: So what I would like to know is how much is HRV related to interoceptive sensibility? The other self report part of interoception that I'm focusing on in my grant. Can we. And this isn't the migrant doesn't look at HRV solely. It's actually looking at the measurement of interoceptive sensibility. I have this dream for an offshoot project that will really look at HRV and how it relates to interoceptive sensibility. But the idea for this, Gran, is understanding some of the biases in measuring the construct of interoceptive sensibility. We're talking very difficult to conceptualize and operationalize ideas. Right? Like, literally, how do you feel so how do you, how do you operationalize that exactly? How do you ask people like their.
How well they read their body's signals? And we've had researchers been trying to do this for decades now. We have a lot of tools, but like I said earlier, the most commonly used one now is the MIA, the multidimensional assessment of interoceptive awareness. It has eight dimensions, and I mentioned earlier, the one that we didn't shift, which was the not distracting dimension, but it also looks at self regulation, attention regulation, body trust, listening to the body, noticing the body's sensations and attention to emotions and how they relate to feelings in the body. Am I missing any? Oh, and not worrying. Not worrying about painful sensations in the body. There's this long list of various dimensions. And the problems that I found with this scale was that one thing we assume when we measure a construct, a psychological construct, including things like eating behaviors and depressive symptoms and anxiety symptoms and trauma symptoms, is that we assume that everybody is interpreting the questions the same way. Right. That's a critical assumption. Well, there's some tests for that. And what I discovered in my preliminary data that I wrote up for this grant was that we may be having what we call some non invariance. It's a terrible term the statisticians like to use. Difficult to, you know, all I can say, it's a terrible term. Basically, we don't have measurement equivalence. Right. Non invariance means there's not equivalence in terms of the way different groups are interpreting and understanding and responding to the measure. So the research is limited, then, by not having a good method of measurement, I can't do the study of how well HRV biofeedback works if my measure of the outcome has some bias in it.
Yes. So the problem I came up against was I really want to look at mind body interventions. I want to see how things like HRV biofeedback can be paired with some other work that I do to help people with disordered eating. But if I can't accurately measure the mechanism that's responsible for making people better, then I'm back before I'm ahead. Right? Like I'm a trouble. I can't. So, the goal for this first grant is to, what I say in the title, optimize the validity of the multidimensional assessment for interoceptive awareness. And I'm doing that through some complex, which I won't go into statistical analyses.
But the short story or long story is that I'll be looking at trying to adjust for personal characteristics when I create factor scores. So when I. When I ask these questions to people, their personal characteristics, like how old they are, the level of disordered eating that they're reporting, the level of weight discrimination or internalized weight bias that they're reporting, their body image, all of those things will be factored into the.
The actual calculation, the algorithm that's getting them a score on interoceptive sensibility. So it's a complicated set of tests that I kind of need to put this measure through, but my hope is that if we do this, then I can get scores that are what we would call equivalent across groups, and then that opens it up for being used as an outcome or a mechanism of these mind body interventions. So when I do test the HRV biofeedback as an intervention, I can actually measure this mechanism of interoceptive sensibility without bias. So I can see how and to what extent, if it does actually improve people's eating behaviors, their traumatic stress scores and so on and so forth. So it's a long, long process.
[00:48:06] Speaker A: So. So you're.
So I have so many questions, but I.
Do you? Well, can I even ask you what your assumptions are going in, or is that off limits?
[00:48:22] Speaker B: Because, I mean, I think it's a really good question.
The assumption going into this is that we have something we call differential item functioning, meaning that there isn't. So what does that mean? Right?
[00:48:38] Speaker A: Yeah, yeah, yeah, right.
[00:48:41] Speaker B: So, basically, the assumption, based on the preliminary work that I have done, the 1294 people that I've currently analyzed, the assumption is that we don't have equivalence across groups. Assumption one, that we have bias. That's by saying there's not equivalent across groups is essentially, you know, equivalent to saying there's some measurement bias here. People. People aren't interpreting this in the same way.
[00:49:16] Speaker A: And when I hear, and I probably. A lot of our listeners hear the word bias, we probably think about racial, social, economic, and our thinking. I'm thinking, like, trauma, because, like, damage to broker underdevelopment in the brokers area would be huge for saying, how do you feel today? Like, that becomes much more difficult. So, like, help me understand your bias. When you use that word, is it a kind of a catch all, or do you. Are you seeing or looking for anything specific when you say bias?
[00:49:53] Speaker B: So, that's a really great point, because I'm not using bias in the way that most people are probably thinking about bias, right? So I'm using bias in that the scores that we have to capture somebody's levels of this trait or state this characteristic, this psychological attribute may not be wholly valid. And that's a little bit different than you're thinking about. Right.
So now the goal is then to eliminate that bias. Right. We're going to have noise and bias in every measurement. That's just part of measurement. It's part of. It's why we have measurement error and that's accounted for. And we look at that when we do our statistical analyses, we always try to reduce our measurement error. But when we have this, this non equivalent across groups, and I say there's bias, it starts to get at this issue of validity. So can we compare scores from a group of men versus a group of women versus a group of folks who identify as non binary? Can we compare the way that they integrate signals from their body across groups with this measure? And the idea is, given this evidence that might be flawed, so we need to fix that. I can't just say, oh, it's non equivalent. That means we can't look at this because we have to look at it. Interoceptive sensibility has been, fortunately now, I think, recognized as one of the most critical kind of.
What's the word? It's just a very wide umbrella construct that has so much to do with many mental, many mental health issues and physical health issues. So you lack interoceptive skills, you will likely struggle in very different areas across life. So bias really needs to be minimized, right? At best. And that means that we need to enhance the validity, optimize the validity. And correcting for that bias is hopefully not going to be as onerous as. As it currently is. The hope is that we can, like, get it to a place where maybe correcting that bias is something we can do more easily without spending, you know, hundreds of hours of analysis and things that most people don't want to do because they don't get excited by it.
[00:53:03] Speaker A: That's awesome. So, like, if I'm hearing you right, the goal is to maybe not only.
It's not like a validation or invalidation, it's almost an improvement of the gold standard to measure intro, ception, interoception, introception.
Am I in the ballpark with my simplification?
[00:53:34] Speaker B: Yeah, exactly, because I think that it is. I'm calling it, you know, among the gold standard tools. It, you know, it was developed in 2012, it was supported by. It was supported by NIH, developed by Melling and colleagues, and since then, it's been translated into 30 languages.
Hundreds and hundreds of studies have used it successfully. So there's a really good tool here that just because I saw problems with measurement equivalents doesn't mean the tool's not going to be good. Right.
Let's fix that. Let's come up with a solution and not just reinvent the wheel and say, let's make a better tool. Let's fix this tool. Because I think the tool has a lot of strengths. It's so multidimensional and it hits areas of this construct that no other tool does.
So that excites me. I really think that if we can correct some of the problems I found, we're going to be able to do the research on the mind body interventions even more rigorously. Is the point is to enhance the rigorous our work?
[00:54:59] Speaker A: Well, I could go on, like, because I think your research could invalidate, it seems like a few thousand studies, if, depending on your findings, which is just, you know, I think research is fascinating in, like, what we're finding about some of these long standing studies. That one of my favorites, and this is not an area of expertise here, but the, uh, stages of grief, uh, that have been around forever, might not be valid, but we've all lived through them, is, did we, did we create this model that now is how we grieve? Because this is how we were told we grieved. I I think there's endless fascination there. But, but let me bring this back to heart rate variability, because I just to see, I want to say something because it's probably better if I say it than you're saying, because you're the resource researcher and I'm. I can speculate freely, like, you know, I'm thinking about, like, and especially around, you know, disordered eating, which I know, you know, at least I, correct me if I'm wrong, has a, you know, there's a lot of people who struggle with that. Not all of them, but also have a trauma history, which is sort of more in my area of expertise. And I know that that's one of the. Sometimes a. A result of untreated trauma can be disordered eating. You know, as you're talking about, I'm thinking about the window of tolerance, which I'm starting to call the window of executive functioning and the relationship between stress and all this. So your healthcare workers and in your feasibility study, who were, you know, again, if you think about bubbles of burnout, you've got burned out society, burnout in the most burned out industry, a lot of burned out organizations. Then you got the poor individual there who should reflect all those other levels.
Looking at that, the connection between the prefrontal cortex, the ventral vagal nerve, all connecting to higher heart rate variability scores. And just having the capacity to look inside oneself, to sit with pain, to not worry, which is, you know, a stress response as well. So, like, you know, I just, I'm fascinated by, like, how stress, you know, your ability to handle or recover from stress, as my layman's definition of HRV, you know, kind of plays into this. It's just, I think it's an endless pathways we could go down probably on all aspects of the measure.
[00:57:40] Speaker B: Oh, for sure, for sure. So did you have a question in there?
[00:57:45] Speaker A: I did. Really? I think I have 20 questions. And I realize, yeah, it's way past dinnertime for you. Don't want to keep you too long. But yeah, I mean, I think it's just, to me, it's really interesting, and I think I'm hearing a lot of folks in the HRV arena thinking about this topic. That's why it's funny to see, I think people who probably aren't talking to each other, but I get to talk to really looking at, can we give people more insight to their internal states through opening up that window of executive functioning through the biofeedback pieces. But obviously, having a good measure is critical for us getting there, and then we can look at those different domains. So I'm just back with excitement.
[00:58:38] Speaker B: And this is really the perfect segue to just kind of bring it back to. This is why it's so critical in my field of eating disorders, because if we can give people more insight into their internal states, I mean, this is one of the really well known areas that a lot of people who struggle with eating disorders have deficits in. We have a lot of literature to suggest that the ability to read emotions or to understand, I shouldn't say read emotions. I should.
Are you familiar, I'm sure, with alexithymia?
[00:59:23] Speaker A: Yes, but I'm not sure everybody listening will.
[00:59:26] Speaker B: So if you want alexithymia, also very related to. To interoceptive sensibility, it's on that same kind of, like similar constructs, tells us it's got, well, the Toronto Alexithymia scale, which is the most common tool for measuring this, says it has three dimensions. One is the difficulty in describing your feelings, the difficulty in identifying your feelings and then having an external orientation to life. So not really being internally focused. This is very related to interoceptive skills. I mean, they're almost like people have thought about them in some ways as being the same thing. And the tool that's actually been most frequently used in the eating disorders world to measure interoceptive deficits. It's called the interoceptive deficit subscale of the eating disorder inventory really gets at. And it's the problem I have with the tool. It gets at alexithymia. It talks about people's inability to describe their feelings more than anything. It doesn't get at the multidimensional nature of attention regulation, self regulation, listening to the body for insight and trusting your body. Feeling safe in your body, right. Feeling your body is like your home. That is not part of the interoceptive deficits questionnaire. It's more about, can you describe your feelings? Are you confused by the way you feel? And giving people the insight through HRV biofeedback.
It's like that window into your internal state is, to me, how we're going to target these deficits that we know people with eating disorders struggle with.
This emotional.
This difficulty with identifying emotional feelings or describing them. Yeah, well, that's where I'm excited.
[01:01:42] Speaker A: Being able to then apply the tool as well to help to manage that. That state. I mean, that to me is when, you know, this was even before I got resonance frequency breathing, and now I'm way more regulated than even. This example is like, what mindfulness allowed me to do after not a whole months of continuous practice was I was able to catch my internal stress state increasing. You know, I could almost feel my cortisol level increasing and then take action before that turned into. Usually I get really stressed out when I'm late to meetings. So, instead of going 100 miles an hour through a residential neighborhood, which is not good for anybody's public health, you know, just, I can breathe that. That skill that I built, which is my breath, take that low and slow breath, regulate, and basically, I then can put in cognition into my emotional state of the world's not going to end if I show up five minutes late to this meeting. Right, exactly. Then I reassess, I reevaluate, and now I'm in control of my stress response. Whereas before, no, Google Maps has no idea how to get me there, which is always better than my ideas. I won't get off here and go 100 miles an hour. Right? So that's where, like, those two things, at least in my personal experience, have been life changing. Like, and I didn't have an control problem before, but I. I was driving 100 miles an hour through residential neighborhoods at times because I was scared to share up five minutes late for a meeting. So that's where I think all this comes together in a really cool way.
[01:03:31] Speaker B: Right. Providing you insight into your internal state, I think, is the most. The simplest, most basic way to say what we can do with HRV biofeedback and the app that is tested in this paper that we started out talking about is really an incredibly simple tool to get there.
What I'd like to see is if that can, in a person with a clinical eating disorder, ultimately, can that help them take their symptoms down a notch?
I don't think this is like the magical licks are. This isn't the pill that's going to cure an eating disorder. God knows that's really complicated.
But if we can give people tools to regulate their distress outside of the therapy office, I mean, people can't be in therapy five days a week, seven days a week. Right. So if they can have a take home tool that really provides them that regulation skill, we can really make more progress when we are with them in the therapy room. So that's my long range goal. Far from there.
We've got a lot of barriers. And the first barrier is just, can we measure the mechanism that I think is causing this to work? Right. That's the first step. If I can't measure the mechanism, I can't do the trial that says whether or not it's actually working.
[01:05:10] Speaker A: I think that's a great place to wrap up this episode. And thank goodness there's people in the world like you, my friend, because there's no way I could delay gratification long enough to like, oh, I got to validate the tool.
[01:05:25] Speaker B: Healthy.
[01:05:26] Speaker A: I just love it. I love you exist, and people like you exist in the world because. Yeah, I just do. Because then I don't have to be that person because you exist. I appreciate you, by the way. I'll just put a plug out. Janelle and I are doing a workshop together, which I actually wanted to open that can of worms on this episode. And I was like, no, my friend, that's got to be another separate episode. We're really going to look at heart rate variability, being a replacement for the BMI. And I know that'll get a lot of people. We're doing that at the AAPB conference. It's just down the street from me in Denver, Colorado. Janelle, I know you've been there. I'm not an official spokesperson for AAPB, but I'm an official one. Go.
[01:06:15] Speaker B: That's how we met in person via Zoom before that. But that was what. That was our first in person meeting. And my HRV. The last thing I'll say about HRV, not biofeedback, but about HRV monitoring is that it skyrocketed after meeting Matt.
[01:06:38] Speaker A: And you too can meet Matt and Janelle, you know, and Doctor Gewirk and Anna and basically all the other great guests, Moss and Lear and all these great Daina, all these great guests that we've had over the years. So if you want to see the Janelle and Matt show in person, we'll do a podcast on that at some point as well. There's a lot to unpack there as well. Well, Janelle, it is such an honor to support your research, being your HRV biofeedback app of choice for the feasibility study. And just to have you in my orbit is a, one is a professional gift, but two is also a personal gift to call you my friend. So thank you so much. We'll put some information about Janelle in the show notes as well. I'll put a link to the AAPB conference as well. We're also doing some trainings through optimal, so if you can't make the AAPB conference, we got a great series coming up. Doctor Dave Hopper, Doctor Ina Hazan. Hey, they even let me talk a little bit as well. So I'll put the link in for that if anybody's interested, too. So, Janelle, my friend, thanks so much for joining us. There is no way in heck I'm going to let you go another like two years without being on the. So it's always a pleasure, my friend.
[01:07:59] Speaker B: Been a pleasure. Take good care.
