Speaker 0 00:00:00 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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Speaker 1 00:00:34 All right. All right. Well, welcome to the podcast, and today I am sitting here with Ms. Teresa. And, um, and if you can go ahead. I want you to introduce to the, uh, to the optimal h RV world to the, uh, heart rate variability podcast world, uh, who you are, what you do, and then we will, we will dive in from there.
Speaker 2 00:01:00 Sure. So, my name is Teresa Lero. I'm an associate professor in psychology at Rutgers, the State University of New Jersey. And I'm a clinical psychologist by trade. Um, so in that role, I am in the doctoral program. Um, and I conduct research in addiction, anxiety, and stress broadly. And I really focus a lot of my work on tobacco, so cigarette smoking and anxiety, and the comorbidity between the two. Um, and I also have a small private practice.
Speaker 1 00:01:37 Oh, awesome. Okay. Well, uh, well, well, first of all, pleasure to have you on. Um, and I didn't realize that you also practice. Uh,
Speaker 2 00:01:46 I do.
Speaker 1 00:01:47 Okay. Very cool. Um, well, I guess, uh, I guess practicing is the best way to learn, right? Um, and, uh, and we get to see that our, our theories actually play out, right?
Speaker 2 00:02:00 So, absolutely. Yeah. Scientists practitioner, it, it definitely, um, the model there is the idea that your clinical work really informs your research and vice versa. Right? And, and your really kind of bouncing in between the two, um, throughout your, your career.
Speaker 1 00:02:18 Indeed. And, uh, and, and I think, um, you learned so much from your patients, uh, too, right? Uh, you'll, uh, always approach a patient and you're thinking of all these high level science things, right. Uh, you know, bouncing back and forth in your head and what the research says about this. Absolutely. And then your patient will make a connection for you that you wouldn't have made in a thousand years, just because they off the cuff say, oh, yeah. And, you know, I notice every time that happens, this also happens. And you go, absolutely. Oh my gosh.
Speaker 2 00:02:47 Yeah. Yeah. Right. It's always that really exciting when you have a name for it, right? Um, but it's equally exciting when you're like, huh, I'm noticing this new pattern amongst this group of clients. Right. And, and I don't think we know a lot about what this is or know what to label it or have even really thought about investigating it. So definitely love that.
Speaker 1 00:03:08 Yeah. And, and then, uh, and then smart people like you go ahead and do a research study on it and publish something <laugh> and put a name to it. Right? Right.
Speaker 2 00:03:17 Hopefully.
Speaker 1 00:03:18 Yeah. Um, so, so you are in a very unique world. Um, you talk about tobacco and anxiety, um, and I imagine the two go hand in hand, right? Um, cuz we think of people who, uh, who have, who have anxiety as people who, uh, who might take a vice like smoking, uh, you know, and might do something like using tobacco or other things, uh, for that matter. Um, so how do those two interconnect?
Speaker 2 00:03:47 Yeah. It's interesting, right? I think what you're alluding to idea of the self-medication hypothesis, right? Yes. We often, um, think of people who use substances as people who are trying to self-medicate, um, certain symptoms away, whether it be depression, anxiety, maybe even physical pain, rather than emotional disturbance, right? And it, I think what is so unique about smoking, um, is the idea that, you know, smoking's actually a stimulant, right? If you, if you really think about it, right? So you're actually activating, right? You're sympathetic nervous system. You're not actually relaxing it when you smoke. Um, but this idea that smoking can mitigate and alleviate anxiety, and, and it does have, uh, other effects that I won't get into, but primarily smoking is, um, nicotine is, is stimulant, and we can agree on that, right? Yes. Yeah. Um, but as you smoke repeatedly, you end up putting your body in a situation where it's going through withdrawal again and again and again, right?
Speaker 2 00:05:04 And that withdrawal is actually characterized by a lot of, uh, the symptoms that overlap with anxiety, right? So really the withdrawal, um, can exacerbate existing anxiety or it can manifest its irritability and anxiety, right? And you smoke to alleviate it, right? So really, you're not necessarily smoking to get rid of anxiety, right? But you're often smoking to get rid of withdrawal, right? And then through those repeated learning trials, smokers start to kind of automatically rely on smoking as this automated way of managing any type of distrust, whether it be withdrawal or something similar to withdrawal. Right? This feels uncomfortable in the way that I usually manage this distrust is via smoking.
Speaker 1 00:06:00 Well, that, that is so interesting. Um, and, and I think, uh, probably a lot of listeners out there don't even realize that, that, uh, you know, smoking, uh, you know, that that is a stimulant to this central nerve, uh, to the, to the nervous system, right? That we are activating the, uh, the sympathetic nervous system. Um, I think a lot of people just automatically correlate that as well. I'm gonna smoke to calm down. Um, absolutely. And, uh, and, and that's so enlightening to say that, you know, oh yes, indeed, that is what's happening. Um, but then, uh, you know, we, uh, you know, you can, uh, also, you know, think about the movies where, uh, you have the person anxiously smoking the cigarette, right? When anything, uh, when anything goes wrong. So that's what I was thinking of as you were, uh, yeah. As you were talking about that. Yeah. Um, now why is it, uh, cigarettes that tend to be used in that regard, uh, rather than something like, um, uh, smoking a tobacco pipe or smoking a cigar, um, or anything of that nature? Is that just cuz cigarettes are the most readily available thing or convenient?
Speaker 2 00:07:04 Yeah, I really think so, right? I think that, uh, cigarettes are so accessible. They're already most of the time, um, in a very usable format, right? You could even, um, buy what we call loose seeds at the store, right? You can buy one, you don't necessarily have to buy a pack. Um, yeah, it's just easy, right? Although I do think that all tobacco products have a little bit of a ritual component around them as well, that can also be really rewarding or really reinforcing, right? You can imagine somebody who likes to roll theirs or, um, who likes to, you know, put it in their pipe. Maybe they have a few different pipes, maybe they have a favorite one. Um, but there are a lot of rituals that, um, around the use of it. Um, you know, I think we can also start to think about, I think today on the news, you're saying cigarette smoking has finally reached an all time low.
Speaker 2 00:08:01 Um, but electronic cigarette use has gone up something like six to 9% in the past year, right? And again, think about convenience and ease of use, right? So, you know, people smoke typically many times throughout the day if they're a regular daily smoker, right? So, repeat about, of nicotine withdrawal, you can envision the level of nicotine rising your blood throughout the day. Um, but there are a lot of rules about where you can smoke, right? So you kind of smoke your cigarette and then you go back to whatever it was you were doing. When we think about electronic nicotine, and it's a whole new game, right? Because you can kind of take a few puffs there, you can take a few puffs here, right? Um, you can sneak them in in a public setting. Um, so really the profile is how people even use e-cigarettes. It's, it's different than combustible. I'm kinda going off on a tangent, but <laugh>
Speaker 1 00:09:01 Yeah. No, no. I mean, and that's a, a topic that must be, uh, talked about as well because it, it is the reality of today. The, um, the e e-cigarettes, the vape boxes, uh, you know, that, um, that you see everywhere, which I know I have horrible, uh, you know, damaging effects. Um, and, uh, and all of these things that we now have, uh, you know, again, as these readily available vices. Um, but one thing that you talked about was, uh, was some of the, some of the habits, some of the rituals that go along with, with smoking. Um, so I know something that, uh, that is always kind of a, a back and forth. Is it that people are so addicted to the smoking, to the tobacco, uh, to the nicotine? Or is it the habits, the rituals that go along with it? Um, and, and granted, I know obviously there's both, right? But, um, but what do you see? And then I then as well, I, you know, I, I know a lot of those things are, you know, we'll take the person out of the situation and suddenly they don't have that drive for their addiction anymore. Um, so can you, uh, can you speak to that a little bit?
Speaker 2 00:10:19 Yeah. So your question is that, you know, how do we think about parsing out what part of it you think nicotine really has to do with nicotine and withdrawal and the actual, um, pharmacological effects, right? Um, versus the sort of the habitual learning, right? Cognitive component, right? And I would say they're both really important, right? Um, so we often do, when we think about quitting, want to make sure that we are providing people with some type of replacement, um, to help with the genuine physiological effects of withdrawal via nicotine, right? So anything like nicotine replacement touch or gum or the lozenge, right? Um, a lot of evidence to suggest that that's really, really helpful, at least initially, right? So really a lot, lot of that physiological stuff is what's gonna get in the way, um, during the early part of a quit attempt, right? But as you move into the quit attempt, you really need to get a handle on the habit, right?
Speaker 2 00:11:39 And the automaticity and the, the kind of reliance on nicotine. Um, and this tendency to often light up and be ing it almost subconsciously, right? You know, it's so automatic, whether it be tied to your morning coffee or I'm out at the bar drinking, right? And that is a cue for using it, or, you know, it's just the thing that I do when I feel uncomfortable, when I feel distressed. It's a way for me to take a break from my day, right? It's what I do, um, in the middle of my day at work, right? During my lunch break, right? All of that has to do with context, right? There are a variety of contexts in which we use substances where we're more likely to use, less likely to use. And really breaking down those associations is so important when we think about quitting, and especially when we think about anxiety, right? So how can you tap into your anxiety, label your anxiety, um, express it, um, but also cope with it in a different way, right? How do we interrupt that cycle?
Speaker 1 00:12:52 Yeah. That is, uh, such interesting, uh, things that you have to, uh, you know, go, go route and think about. Um, it, so one thing that always puzzles me, and I don't want to keep marching down this road of, you know, an cigarette addiction and everything, cause that's not, you know, not what we're talking about today,
Speaker 2 00:13:08 Right? Let's talk about our HRV <laugh>.
Speaker 1 00:13:10 But, uh, but I've always been curious about, um, what, what is the difference between somebody who can go out, smoke cigarettes, you know, while they're, you know, out one night and be perfectly happy the rest of their life, never smoke a cigarette? Uh, yeah. And same with a person who can go out drinking and never have a craving for alcohol. You know? Um, what makes that addictive personality? What, uh, what is that? Um, yeah. And, and, uh, and why, why is it so different amongst us?
Speaker 2 00:13:42 Yeah. That is the million dollar question, right? Like, who are these people that are able to say, I am done and never touch a substance of abuse again? And who are these people who will lapse and relapse at time and time again? And just to really struggle, um, to make that long term quit attempt and, and to make it stick, right? Um, so many factors go into it, right? Yeah. There are sex differences, there are sex differences, rather, there are, um, socioeconomic and educational differences we see in terms of youth, right? Um, but I think a lot of this kind of, uh, gets down to psychological vulnerabilities, right? Yes. Um, whether they be more biological, right? Um, more nature, if you wanna think about nature versus nurture or, or kind of environmental, right? Circumstantial, right? Um, but a lot of it, I think is at the level of not necessarily what people's circumstances are and the, the, the level of stress that they're under, right?
Speaker 2 00:15:05 But how they manage it, right? So, um, temperamental differences in terms of emotion, regulation, distress tolerance, a ability to tolerate uncertainty, right? These are all the things that we are really, really interested in better, um, measuring, right? Whether it be through physiological things like heart rate variability. When we think about emotion regulation or self-report measures or behavioral measures, right? We want to figure out what are these underlying vulnerabilities that really explain variability in how dependent people are on a substance, their willingness to quit, the confidence they have in quitting, and, and whether or not they are able to quit. And then the question is, how can we modify these psychological vulnerabilities to help people have a better quit attempt, right? So, you know, maybe they have these innate or trait like vulnerabilities, but we still think that they're malleable, right? And we still think that the environment affects them, right? Um, there's something about the environment, this idea of epigenetics, right? The, the different vulnerabilities that we have are activated based on the experiences that we have, right? So then how do we mitigate, how do we kind of reverse the impact of the environment on these vulnerabilities that people have to, to help them be functioning better?
Speaker 1 00:16:41 So you went, uh, exactly where I was hoping you would go, uh, which is, um, uh, which is, uh, like you said about this, right? What, what makes somebody more, more vulnerable. Um, and it really does start literally from fetal, uh, from fetal development, right? Um, yeah. What, uh, and and granted, you know, I, I don't know about vulnerability and a, and addiction, that's not my, uh, specialty, uh, by any means. Um, but, uh, but when we talk about their autonomic nervous system and how well they can regulate themselves mm-hmm. <affirmative> and their environment, right? Um, and that all starts from everything that happened to you from the moment you were, you know, this little cell, right? That started be Yeah. That started dividing right until this moment that you are here on earth, right? Yeah. Um, and, uh, and of course that is our, our autonomic nervous system, uh, guiding that whole thing. And, uh, and heart rate variability. Here we go. Yeah. Yeah. Uh, is our <laugh> is our measure here. So, in theory, would somebody who is more prone to addiction have a lower functioning autonomic nervous system? And would we see that in their, uh, in their H R V? Now, I, I, I don't know that, uh, this is answerable, but yeah. Go, go ahead. Yes, please.
Speaker 2 00:18:07 Yeah, no, you know, it's such a good question and we need to do more work in that area, right? And, and really what David's asking is that the classic chicken or the egg, right? And, um, some of the time we see these things are bidirectional, right? Um, but there is some evidence that individuals who initiate smoking as adolescents and continue to smoke, right? So the ones that actually develop a habit out of it, that they do have lower heart rate variability, right? And on the other hand, we know that smoking diminishes heart rate variability. So we've got the evidence of a potential bidirectional relationship where, um, the, the lower your H R V is potentially the greater risk you're at of developing problematic youth, right? And your youth is going to worsen that, right? Which might put you at risk of having more difficulty putting,
Speaker 1 00:19:22 Uh, very interesting and, and awesome that, that, that that does exist. And then, uh, and then when we tie in the anxiety piece with that, yeah. Um, now somebody, uh, somebody with a lower H R V, uh, we know doesn't deal with stress as good as somebody with a higher H R V, right? And that stress of any, any kind. Um, so, um, so that person a again, right, would be, would be more likely to find a vice to help them deal with that stress. Yeah. Because they can't do that internally, correct?
Speaker 2 00:19:52 Yep. Yep. Exactly. Right. So we know that the folk who are have more difficulty managing stress, um, you know, people who actually have diagnoses, right? Of whether it be panic disorder, generalized anxiety disorder, post-traumatic stress disorder, we are seeing lower heart rate variability in these individuals, right? And the comorbidity between anxiety, pathology and substance use is really, really high, right? So, just as one example, um, smoking rates are now below 10% in adults in the United States, right down from, you know, 40 to 45% in the sixties and seventies. Amazing. Right? Unfortunately, when we look at individuals with mental health problems, especially severe mental illness, um, like schizophrenia, you see that, you know, 40 to 50% of them are smoking, right? Um, and then you look at class disorders like anxiety, um, which it's really important given anxiety disorders are the biggest class of disorders, right?
Speaker 2 00:21:06 More people are affected by anxiety than something like schizophrenia, right? Um, and we still have pretty high rates of smoking, right? Depending on the disorder. Um, and all of this is even more important because when people are using something like nicotine, and the same goes for alcohol, when you're using a substance of abuse that has an effect on your autonomic nervous system, whether it be stimulant or depressant, right? You are actually messing up your physiological milieu, right? So you are, um, adding something from the outside, right? This kind of exogenous effect, right? That is having an effect on your blood pressure, your heart rate, your respiration, right? And it in a way, you're kind of causing this repeated stress or wear and tear on your nervous system by drinking regularly, by using tobacco regularly. And all of that breaks you down your H p a access, so your stress system and things like heart rate variability, right? So the combination of anxiety and substance use is going to lead to even worse, the heart rate variability.
Speaker 1 00:22:38 Yes. That, that's, um, that's quite profound. And, and, you know, uh, with, uh, with what you're saying, uh, and all of this, um, as well, it, it's shocking that, that, uh, you know, that cigarette smoking is at an all time low as we just reached the other side of a pandemic where we know anxiety is at an all time high. Yeah. Um, and, you know, in all mental disorders, uh, you know, for that, for that matter. Um, so, uh, is it, is it that there is also a lot of other, uh, substance abuse going on? And that's why I, you know, just, just that cigarettes get bashed so hard that <laugh> that that one is not rising up?
Speaker 2 00:23:21 Yeah, that is, that's a good question. And I think these questions are going to be the emerging questions, right? And I wish I could fit here and fire off to you, ah, but alcohol use, right? But I don't know off the top of my head, um, what we've seen, right? From an epidemiological perspective, um, what has happened with alcohol use over the past few years, right? But we know that anxiety has skyrocketed. There is some evidence right, of, of greater alcohol use and problems, but I don't know, um, what that epi data say quite yet. Um, but I do think when we think about tobacco, that, you know, there is a lot of stigma around it and, um, um, there's been a lot of policy work that has been a major driver of, um, pushing rates of youth down, right? Um, so that's been super effective, right? But I think, you know, paradoxically, we've gotta think of how big tobacco is working around some of this by coming up with new products like, um, electronic cigarettes, right? And, and targeting, um, teens and young adults, right? And using things like flavor, um, to increase the reinforcing effects of it.
Speaker 1 00:24:47 Yeah. Yeah. Yeah. So, so interesting. Um, and, and yeah, w with, uh, with everything that you're saying there, you know, uh, numbers wise to, you know, we go from, uh, uh, doctors in our government endorsing the use of cigarettes, right? When you talk about, you know, in the, the fifties and whatnot, and then, uh, and now we're, we're at a place where it is completely 180, right? Um, and thankfully, you know, um, there is so much in place, um, you know, discouraging the use of cigarettes and, uh, and the price alone. Like, uh, I look at that, uh, the taxes on cigarettes, and you go, oh my gosh. Like, you, how can you even afford that? Uh,
Speaker 2 00:25:22 Absolutely. Yeah. Uh, some states they're much worse than others, but you look at the correlation between those, that taxes and prevalence of youth, right? And, uh, it's, it's astounding, right? You know, um, the tri-state area where I live used, it's really, really low, right? But if we look down at like Mississippi, right? Um, gonna be quite different picture.
Speaker 1 00:25:47 Yeah. Yeah. Well, interesting. Um, okay, so, so let's go, uh, and let's talk about heart rate variability and how you use that, uh, within your therapies. Yeah. Um, so you're, you're looking at the autonomic nervous system, uh, with everything that you do. And, um, and as you know, uh, H R V is, is the best way to measure that. Um, so well, let's start with, what, what do you use to measure, um, and how do you design studies around this? What's your therapy, um, with, uh, with any of this?
Speaker 2 00:26:23 Um, so we are really, really interested in heart rate variability, um, and it, how it might be targeted to help people quit smoking, especially individuals who are high in emotional distress, right? Um, so let's talk about the treatment end first. So that's kinda the direction I'm going in, right? Yes. Um, so when we think about heart rate variability, as some of your listeners probably know, we really think of it as the, um, an integrated, the theological marker. When I say integrated, I'm thinking about the vagus nerve and, um, it reflecting, uh, communication between central nervous system and peripheral peripheral nervous system, right? So, um, the vagus nerve really provides a feedback loop between the two, right? Um, and in that way, we've found, again, kind of thinking about your central nervous system and cognition, right? Um, and peripheral kind of that your physiology, right? Like heart rate, respiration, blood pressure, um, that it is correlated with our ability to regulate not only our physiology, but our emotions, um, the way we are able to think and plan and execute behavior.
Speaker 2 00:27:54 And, um, even things like social sensitivity, right? And how we relate to other people. So heart rate variability is critical to self-regulation. So when I say self-regulation, we're talking about your physiology, your cognition, your emotions, right? Um, and, and your social world, right? Um, so if our smokers, especially those that have greater levels of emotional distress, have low heart rate variability, we can hypothesize that when they make a quit attempt, they're going to be somewhat impeded, um, by poor self-regulation, right? Because when those triggers to smoke come out, come up, whether they be withdrawal, whether they be, um, emotional distress, whether they even be external, right? I made a plan to not use tobacco when I go to this wedding, right? Um, but I'm not able to kind of execute that plan or stay focused on the plan, right? Or my emotions, my cognition, um, is getting hijacked in part because of my heart rate variability, right?
Speaker 2 00:29:16 So we're kind of thinking about all these things. Um, and the question being, if we're able to give people a tool that is going to result in acute improvements in their heart rate variability, potentially in the moment, right? Um, but also a tool that they can practice over time to have long-term improvements in their heart rate variability, are they going to be better able to make a quit attempt? And is that going to be because, um, they're experiencing less emotional distress? Is it going to be because they have a tool that they can now use kind of in the moment, um, moment to manage emotional distress? Or is it going to be, cause we actually see that the people that use this tool have greater improvements in their heart rate variability over time, um, following a quit attempt than those that don't have that tool.
Speaker 1 00:30:19 Okay? I know I, I'm on the edge of my seat and I'm sure everybody listening as well. Uh, what's the tool?
Speaker 2 00:30:25 Yeah, good for the tool. Ok. So we actually manipulate heart rate variability through respiration. So we're really thinking about respiratory sinus arrhythmia. So this idea that when we breathe in, our heart rate, our pacemaker, right, our vagus nerve, right? The break that is constantly holding our heart place heart rate in place, it, it kind of releases a little bit, right? So your heart rate's gonna speed up when you breathe in, right? And then it's gonna slow down when you breathe out, right? Um, and again, this is the idea of respiratory sinus arrhythmia, right? It's, it's changes in the heart rhythm that occur and can be manipulated, uh, a function of your respiration. And what's really, really cool about that is that we all naturally, and I'm sure David has talked about this, um, might take deep breaths or he might hear that taking a deep breath is really helpful in terms of relaxation.
Speaker 2 00:31:28 Yawn is the way that we take a deep breath, right? Um, sighing all these things. Um, but if you change your breathing, if you slow it down to a prescribed rate where you basically get synchrony between your respiration and your heart rate, you get what's called a resonance effect that, um, it resonance is this idea of like, almost like reverberation or this exponential effect, um, within your body's physiology because you thinking your aligning your heart rate and your blood pressure, right? Um, and you're doing all of this again by manipulating your breath. So on average, if you slow your breathing down to a pace of about, um, six breaths per minute, right? That's, that's on average across all adults, right? So you can imagine breathing in for five seconds, breathing out for five seconds, you are going to get your breathing and your heart rate in better sync with each other.
Speaker 2 00:32:45 You're going to maximize your heart rate variability and not wanna get too far into the weeds, but you also start to see effects on what's called your barrow reflex. So these, um, receptors in your blood vessels that fire, um, to kind of help control blood pressure, right? And of course, that is gonna have immediate feedback on heart rate, right? So your whole system is really kind of working at maximal capacity when you target your NCE breathing. And again, on average it's about six breasts per minute. Um, but when we do this as an intervention, we really, um, tailor it, it can be anywhere from 4.5 breasts per minute, up to 6.5 breasts per minute, depending on the individual. And we really have them looking at their physiology while they're doing it, right? So it's biofeedback. They're actually looking at how well their breathing, um, can increase their heart rate and decrease their heart rate, and really trying to kinda maximize these amplitudes, um, through, through the respiration.
Speaker 1 00:34:05 So that is absolutely amazing. And, um, and I, I would highly endorse that tool as well. <laugh>. Um, so, uh, so, uh, and you may not know this actually, um, but shameless plug, we are the only mobile application with a residence frequency assessment on our app. Uh, and, and we use, uh, low frequency, um, as, as our guide for, uh, which, uh, which for those of you listening, um, that's essentially a measure of barrow receptor, um, function. So we use that as our guide for the residents frequency rate. Uh, that's awesome. And, uh, and that was all designed by, uh, by, uh, ina, uh, en Kaan, um, out of Harvard. Uh, and she, um, so she developed that whole portion of the app so that patients could do a resonance frequency assessment on the app and then do the residence frequency breathing, um, at their specific pace and do the, um, and do the actual exercises right there within the app. That's great. Uh, so we do have the ability to do that. Um, and yeah. And, and it's just amazing, uh, the more and more that I learn about residence frequency breathing, um, the more and more you go, oh my gosh, everybody needs to be doing this. Yeah. Uh, and uh, and like you said, six breaths per minute tends to be, tends to be on average what most people fall at. Um, but as the research shows, right, if you are, if you aren't doing it at your actual rate, you would miss the benefit.
Speaker 2 00:35:48 Absolutely. Yeah. They're really, really, um, great and empirical studies that have documented this, and it's, it's remarkable. Yeah. You, you can just miss the mark, right? Um, and to, to really make it work. Um, having an app like the one David is plugging here is so important, right? If you don't have other tools to really pinpoint what that is for you.
Speaker 1 00:36:16 Yes. Yeah. No, it's, um, so it's, it's, it's really cool. It is such a powerful tool. And, um, and, you know, I could go on and on about, uh, about resident frequency breathing, uh, respiratory sin, rhythmia and all that. Um, but what do you see happen? So, um, yeah, so we know that there is profound health benefits from doing this breathing, um, you know, in, in multitudes, uh, of ways. But what do you see specifically with, uh, with these patients that you work with?
Speaker 2 00:36:48 Yeah, so with our smokers, so we are really employing this tool before their quit attempt, right? We want them to have it as a tool, um, and we teach them just about a week ahead of their quit attempt, right? Cause we also don't wanna prolong a quit attempt that they're ready to make. Um, but we develop it as a tool that they can use. And, you know, I do think that it can feel a little bit tricky, or let me be more descriptive. It can feel a little bit uncomfortable to shift your breathing, right? And one of the things we really want to be careful of, and for any of you folks out there who are trying to learn this on your own, is we really wanna make sure that people don't inadvertently, um, hyperventilate, right? When we slow our breath down a lot, we almost have this immediate compensatory reaction to take a really kind of deep breath or take too much air, right?
Speaker 2 00:37:55 The volume of, of our inhalation might increase because it feels like we're not getting enough, right? Because they're really slowing it down. So we use a lot of tools to make sure that they're doing it the right way and keeping their breath kind of shallow while they're slowing it down. And what we see, um, and I hope this is okay to say on the podcast as an addiction scientist, but it almost feels like you have had a glass of wine, right? The way that you trigger your parasympathetic system by manipulating the breath feels like really relaxing, right? Um, but also people report feeling very alert, right? So it's kind of this sweet spot of just like you feel good and relaxed and chill, right? But also able to kind of focus, right? Um, so people love to do it in the morning, um, when they're about to begin their day.
Speaker 2 00:39:03 They love to do it at night before bedtime to kind of unwind. And we have had so many smokers report using it when they have a craving, right? Or even, um, using it throughout the day, once they quit, during those usual times, that they would take a 15 minute smoke break. So people really like it. Um, you know, I I, it's always so rewarding when you have those patients in your trial who just rave about it and you see them practicing, um, really frequently, right? And they, they really view it as a tool that they'll continue to use long term.
Speaker 1 00:39:51 That is so amazing. Uh, and, and so cool to hear, uh, and I can definitely speak to that as well, that, um, you, you are in, um, a very unique zone, uh, after, after you've done your RF breathing for, for a, an extended period of time. Yeah. Um, yeah, it does, it does put you in a very unique place. Um, a great place. Yeah. But, uh, um, so something that, you know, as you were talking, uh, something that, you know, made me think so, uh, so I've seen it with my patients. Um, I know I've heard ENO talk about it as well, uh, is that it's hard to do this breathing exercise and, and actually doing the, uh, you know, the 14 minute assessment, uh, to find out what your resident frequency rate is. That's not easy at all. No. Um, in fact, it's very challenging. And I've had patients who aren't smokers not be able to complete the, um, not be able to complete the assessment because it was difficult. So I can only imagine that somebody who has a decreased lung capacity as a smoker is going to struggle with this more. So do you run into that issue?
Speaker 2 00:41:01 Yeah, definitely. And ideally we have people practicing for 15 minutes a day, but we tell them they can break it into five minute bins. Ok. Um, you know, with five minutes being kind of the lower end of things, and, and especially when we are trying to identify the resonance frequency, we're keeping all of this in mind. Um, you know, there can be practice effects too, where, you know, maybe because it's the last frequency that we're checking, um, it feels the best to them because they finally have got a down pat. Right? Um, so we wanna be keeping all of this in mind. It can be really uncomfortable. And a lot of our smokers report that it gets easier once they quit. Um, and it, you know, I have to look at our data. We're just finishing our trial now. Um, it'll be interesting to see what percent of our, um, sample, uh, had kind of an adjusted resonance frequency before versus after their quit attempt.
Speaker 2 00:42:11 Um, because I can imagine it, it shouldn't, right? Based on what we know. But this is the unique population. We haven't studied them before. And we know that once you quit, your, your heart rate variability does change just from quitting, right? Going from smoking to using the patch, going from the patch to having no nicotine in your body at all. Um, so it's possible that, that there's a certain percentage of people in our study who the NCE frequency appeared to be, um, six, right? But then when they quit, we noticed it kind of shifted down to 5.5. Um, but yeah, absolutely it is tougher in this population. Um, but it does get easier once they kinda get some days of abstinence behind them.
Speaker 1 00:42:57 Yeah. Yeah. Uh, that is, uh, that's really cool. A and interesting. So I, so I always, um, you know, I think about everything. I know I've said this before in the podcast too, but, uh, but I think about everything whenever somebody says something doesn't change in biology or This is how it is, I always say that's just cuz we haven't figured it out yet. We don't have, yeah. So, uh, so with, uh, resident frequency rate, it is, it is said, um, you know, and I know you know this, I'm saying this for the, uh, for the listeners, it is said that whatever your resident frequency rate is, that's what it is for your entire life. Um, and, uh, and I always think that that can't be right, um mm-hmm. <affirmative> and, but it's based on the size of your vascular treat. Um, and, um, so in theory, if you're a full grown adult, it shouldn't change. Um, but I always think, well, what if you get really big over, over a lifetime, right? Um, whether that's, you know, obesity or whether that is through muscular work, uh, either way you're, you're increasing the vascular tree and vice versa. Um, you know, if you shrink down, we are also decreasing that, um, as, uh, as vessels do decrease in size and quantity. Um, yeah.
Speaker 2 00:44:13 Can I jump in? Yeah,
Speaker 1 00:44:14 Yeah, please.
Speaker 2 00:44:15 Um, yeah, I just have a, a funny anecdote. Um, you know, as the researcher, it's so important to go through an experiment that you're doing, whether it be just to make sure you understand what the participant is, experi experiencing, training, training, et cetera. So I actually went through my own trial when I was pregnant.
Speaker 1 00:44:36 Oh,
Speaker 2 00:44:37 Blood volume changes drastically when you're pregnant. Um, and at the time my interventionist, one of my graduate students, I don't think she knew I was pregnant yet. Um, and we're doing a lot of things over zoom. Um, but I talked to Paul there about this, and we have a lot of my data and we need to look at it because I don't know if we have enough for a case study, but it would get at a lot of what David is asking, right? Did my resonance frequency change during my pregnancy as a function of blood volume? Right? So when you're pregnant, your blood volume, um, what is it like 20% higher or more? Um, but yeah, uh, we wanna look at that because I think that these little case studies that we dunno, right? Um, they're so important and can be so informative as researchers and interventionists to, to kind get a handle on.
Speaker 1 00:45:45 Yes, absolutely. And, uh, and, and, uh, my gosh, yeah. Talk about the, uh, the most dramatic case of, uh, of going up and down in every way, right? Uh, that is, that is what every mother has experienced <laugh>. Um, so, so indeed, uh, that would be so cool to see, cuz without a doubt, I'd imagine that your, your rate changed, um, throughout that. Uh, and, and that is, you know, like you were saying about, you know, the people in your research study too, like, uh, you know, that, that they are having a physiological change. So, so do we see this happen over here too? Yeah. Um, yeah. And this, uh, both, uh, and actually the, um, the, the pregnancy, uh, as well would, that would be so interesting to dig into. Um, so yeah, just
Speaker 2 00:46:33 That the loop back
Speaker 1 00:46:35 <laugh> Yes, yes, indeed. Then we need, uh, then we're gonna need to get a, uh, a whole bunch of women, uh, before they get pregnant and then, uh, and then during and after, right? <laugh>
Speaker 2 00:46:45 Absolutely.
Speaker 1 00:46:46 See what happens. I
Speaker 2 00:46:47 Think, I think HRV all day for everything, right? I thought about it so much and, and practiced a lot when I was pregnant and, and thinking about labor and, and all of that. Um, and I don't think anybody has done anything in that area again, but, um, yet, but yeah, whoever's out there listening, <laugh> open area,
Speaker 1 00:47:10 So, so with H R V and pregnancy, um, the only thing that I've seen on that is, uh, is it, uh, unfortunately, H R V goes down with pregnancy. Yeah. And, uh, and the more pregnancies that you have, uh right. The more babies that you, that you have, um, the lower your H R v, uh, be dips with the pregnancy. Um, now I'm not sure about the bounce back on that. Yeah. Um, but that's, uh, that's, you know, and it makes sense, right? That your body is, you have an extra stress on you <laugh> obviously mm-hmm. <affirmative>, right? Um, so yeah, it would make sense that your H R V would drop down and then, um, and then with multiple pregnancies, uh, you're going to dip even lower. Um, but yeah, I, I'm actually uncertain on the, uh, on the bounce back portion of that.
Speaker 2 00:48:00 Yeah. So interesting.
Speaker 1 00:48:02 Yeah. Uh, yeah, again, uh, there's, I with H R V, it's so cool because it is, um, you know, by no means new right? But it's so readily available now. Yeah. Um, that the potential for use in research, um, has just gone through the roof. So it's a, it's such a cool place to be, uh, in such a cool field to be within. Um, it
Speaker 2 00:48:27 Really is even 10 years ago, right. Um, we wouldn't be doing anything wireless. Um, and if we did, it wouldn't be too reliable, right? Yes,
Speaker 1 00:48:39 Yes.
Speaker 2 00:48:39 Indeed. Different world now,
Speaker 1 00:48:42 <laugh> very different world. And it's like every six months you see a dramatic jump in technology and you go and you go, oh my gosh, this is possible now <laugh>. Yeah. Uh, heck we can get respirations from a P P G reader, right? Like it's, uh, you know, it's, um, it just, things like that just blow my mind. Um, but, uh, anyway, um, I, I wanted to ask, so with your participants, are you measuring their heart rate variability on a daily basis multiple times per day? Or is this just a check-in like once a week when they're, uh, how, how does that go and how often are they doing their RF breathing? Um,
Speaker 2 00:49:21 Great question. Um, so in our study, in part because of covid in part, um, to actually make the study feasible, we don't have them come into our lab to frequently. So they come in before their quit attempt, um, they learn everything in person. Um, and we use, um, you know, pretty well validated close to medical grade equipment, right? To, to make sure that we're getting a, a really good handle on their baseline physiology. And then we measure it again one month after their quit attempt and three months after their quit attempt in between, um, when they're actually doing the intervention, um, which we do, um, using basically health telehealth. Um, they do have a device, uh, that clips to their ear where, where they're able to basically use the PG to, to estimate respiration, right? Um, and, and look at heart rate so they can see that in real time.
Speaker 2 00:50:34 And we measure it, um, and we can actually extract the data using cuo. Um, but we don't, we're not planning to use that as primary outcome, right? So we have all of that, but because the technology is good, um, but not perfect, right? Um, we, we won't be using that in terms of our main outcome publications. Um, but we do have, have all of that data, which is, um, weekly or twice weekly with their interventionist. And then in addition, they're asked, um, to practice up to 15 minutes a day, and they're incentivized to practice 15 minutes a day throughout the entire duration of the study. Um, there is a lot of variability there, <laugh>
Speaker 1 00:51:27 Naturally,
Speaker 2 00:51:28 You know, as we see, um, in, in humans, right? Not just research participants, right? Um, so there is quite a lot of variability there, but that's kind of the, the gold standard that we're going for.
Speaker 1 00:51:42 Okay. Well, very cool. And, and I can only imagine that the correlation is there that the, those who practice more see more benefit.
Speaker 2 00:51:50 Yeah. So, um, in our open trial, our first open trial, which is just an N of 10, um, again, we expect everybody to have an improvement in heart rate variability, but we saw, um, significantly greater improvements in heart rate variability in the people that stayed in the intervention and fully quit, right? So, you know, we're looking for, uh, a signal of, of this with, with these, um, initial studies so that we can do some randomized controlled trials, hopefully in the near future.
Speaker 1 00:52:28 Oh, so cool. Um, so, so for those people listening, you know, I know there's, um, you know, a lot of, uh, a lot out there right now about, you know, we, we want to get our H R V to, to go up, we wanna see our H R V increase, right? And, um, it, and what kind of an increase are we seeing, seeing in those kind of people when we see them? When you see somebody before, you know, as they're, when they're, uh, when they do their before test, when they are a smoker, um, to afterwards when they have gone through the RF breathing, when they have quit smoking, um, what kind of a jump are we seeing in H R V?
Speaker 2 00:53:07 Yeah, it's such a good question. So first off, I think it's important to note how different something like respiratory sin, arrhythmia looks and a healthy young adult versus a smoker, right? Um, the work we're thinking about respiratory sinus arrhythmia, the, the metric being MS squared, right? Um, we might see something like, I don't know, six to 10 in a healthy person. In our smokers, we're often seeing two to five.
Speaker 1 00:53:43 Wow.
Speaker 2 00:53:44 Yes. Wow. Um, and these are smokers who are pretty healthy, otherwise we have a lot of exclusionary criteria because we wanna ensure that, um, they don't have other, uh, health comorbidities that might also have a significant effect on their heart rate variability, right. Um, or impact their ability to do the trial. Right. Um, so I wanna preface it with that. Um, smoking has a very, very bad effect on your heart rate variability. Um, in terms of what we can expect to see for improvement, I haven't looked at the data quite yet, but not too big, right? Probably, um, two to, to three, um, level improvement, right? So we might see it improved by 50 to 100%, I would say. But again, thinking, keeping in mind that they're starting on a pretty low end. Um, but, you know, it, it's just, it's a tough population, right?
Speaker 2 00:55:01 And, and any improvement we see, I'm gonna say it's great, right? Absolutely. Cause they're not like healthy people where, you know, when you tell them to concentrate on a puzzle, right? Or you stress them out, you're gonna see their, um, heart rate variability drop dramatically, and then you're gonna see it rebound as soon as they're done doing whatever it's you told them to do. Right? Um, smokers are characterized by a lot of rigidity as well, right? We just don't see it move that much. Um, there's been a lot of wear and tear on their systems, so, you know, we're looking for little improvements, but, but hopefully significant improvements and hopefully, um, not just statistically, but clinically meaningful, right?
Speaker 1 00:55:49 So, uh, so you're talking, um, you know, and, and I completely agree, any improvement is, is a great thing. Um, but, um, but you're talking in terms of respiratory sinus ayia, um, yeah, yeah. You know how much we're seeing that swing. Yeah. Um, I'm assuming you're measuring R M S S D, uh, as well with all this. Yeah. And, and, uh, and I, I should have prefaced with that. Um, and, and for everybody listening, um, there are so many different ways to measure H R V. Um, so there's no, uh, there's no, when you say this is what somebody's H R V is, you could be referring to one of Right. You know, 30 different metrics. Yeah. Um, so, uh, so in terms of R M S S D as that's, you know, what our app, um, you know, what, what we primarily show on there, um, you know, we can see everything else as well. Um, but, and what most apps, uh, and wearables are going to show is the R M S SD score. Mm-hmm. <affirmative>. Um, so in terms of an R M S S D score, what is, uh, would you, would you know what kind of a difference you're seeing in that? And also Yeah. Uh, what are most of the people walking in the door? Um, because I'm imagining that their R M S S D is, is quite low, uh, given that their, uh, that their R S A is so low. Um, yeah,
Speaker 2 00:57:11 I almost, I'm wondering what can I pull up really quickly to look at? Yeah. Um, and I think David's bringing up a really important point, right? So there are so many ways to think about heart rate variability, right? And, and respiratory sinus arrhythmia, typically it's gonna reflect high frequency, right? And, and people will use them interchangeably, but that depends on what the person's doing, right? When we talk about something like resins breathing, um, high frequency goes out the window, right? Cause you're pushing all your variability down into a different frequency range, right? Some of the time, low frequency, which then we're talking about the bear receptor. Um, so, you know, he's totally right in that a lot of the time, um, people instead are gonna talk about arm, right? And I don't wanna misspeak, so I'm gonna be agnostic. Um, but next time I come on
Speaker 1 00:58:10 It, and
Speaker 2 00:58:11 I'll have my data from this study and I'll be able to say, but,
Speaker 1 00:58:15 Oh, well, yes. And, and that would be, uh, that would be awesome. And yeah, I don't want to, uh, yeah, I don't if that's not on, you know, the, the primary thing that you guys are looking at or concerned with by no means. Um, but yeah, it is, it is so funny, uh, when you get into the H R V world, uh, how everybody's talking and looking at something just slightly different, but so many people, right? We're all referring to it as the, as the same thing here. Yeah. Um, so yeah, I, and, and of course, I think,
Speaker 2 00:58:45 Oh, go ahead. I was gonna add that there are like acute changes too, right? That you mm-hmm. <affirmative> might be able to immediately see in real time, which I think David is also, um, wondering if I have any insight into, right. And then, you know, what we hope for, in addition to those acute changes are kinda those long term, um, changes.
Speaker 1 00:59:06 Yeah. Yeah. And, um, and you know, with a smoker, um, you know, if you're able to successfully get somebody to stop smoking, um, you know, I I, I forget off the top of my head and you, and you might know, is it a seven or 10 years that, uh, that they're considered, um, you know, that they've regained their physiology? Um, yeah. So at that point, what changes happen, right? You know, I, and what's, what does that look like from here to there? But then also you have to factor in that age also drags down HR <laugh>.
Speaker 2 00:59:38 Exactly. Yeah. You
Speaker 1 00:59:40 Know, there's a,
Speaker 2 00:59:42 The physiological effect that David's talking about, we don't actually have data on hrv, right? So there's this idea that your, your body is that of a non-smoker, your, your lungs, right? Really is what they're talking about. Um, look like that of a non-smoker. Um, but yeah, what does that mean for H I V? Right? So what we really want to be able to see is that if we look at folks that are quitting, um, without the aid of resonance of breathing, right? Versus folks that are quitting with the aid of residents breathing, that we see greater improvements in all of our measures of heart rate variability in the individuals who are basically doing kind of physical therapy on their cardio respiratory system. That's really how we think of it, right? So, you know, it's not something that we can do all the time or should be doing all the time, right? Yes. Um, but regular practice is gonna, um, hopefully, um, act as physical therapy, right? Improve your cardio respiratory system.
Speaker 1 01:00:49 Yeah. Yeah. And I, there's, um, this, uh, this lady that I was, um, she was, uh, she's out of Amsterdam, I think, uh, and, uh, and she was, uh, teaching me all these things about, um, about residence frequency, uh, in one of our meetings. And, um, and she was telling me, she goes, she goes, this shouldn't be easy. This is literally exercise for your cardiovascular system. Yeah. She goes, you should not be looking at this as it should be a relaxing, breathing thing. And, um, yeah. And, you know, I was her like, you know, almost yelling at me about that because I made the suggestion that, well, you know, I'm doing a breathing exercise, I should feel relaxed, you know, I, I made a comment like that and it was, uh, no, nope, <laugh> absolutely not. Right? Um, yeah, this is, this is hard work. This is cardiovascular work, um, which is a, a crazy to think, right? That you can sit there and breathe and literally be doing a cardiovascular exercise. Uh, so it's, uh, it's very cool.
Speaker 2 01:01:55 Yeah. It makes me think of, as you're talking right now, that feeling that you get when you have gone for a long swim, right? Like you don't realize because it's low intensity, um, the impact, right? And then you stop and you're like, wow, <laugh>, right? Like, I'm actually really kind of relaxed, right? A little bit tired, right? But, um, kinda focused alert. It, it's a unique feeling. For those of you out there who haven't played around with this, um, I definitely encourage you to try.
Speaker 1 01:02:32 You, you know, you, you, uh, you bring up a great point with the, with the swimming analogy, uh, because yeah. You don't, uh, you with that you lose your cues of, of, uh, of a cardiovascular workout, right? Yeah. You, you're not sweating because the pool is taking that away. You don't feel hot because the pool is taking that away. Um, yet you feel this odd exhaustion. Um, yeah. And it's, uh, it's very similar. And for me, uh, you know, a long swim is one length of the pool, uh, <laugh>, that, that's about all I got. Um, that's, uh, the hardest sport in my opinion. But, um, but yeah, no, it is a very similar thing cuz you don't have your normal cues, um, yet you still get to a similar point. Yeah. Uh, so yeah. But, uh, but Teresa, I don't want to, um, I, I wanna respect your time. I know that we are, uh, we're going over an hour here at this point. Um, so, uh, so let's meet again at the Yeah. Uh, after the conclusion of your study. And I, and I would love to hear all about, uh, what, what happened throughout and, um, and then we can, uh, prod a little bit more into, uh, into questions about the outcomes and who followed the therapies, who didn't, uh, you know, all of those kinds of things.
Speaker 2 01:03:44 Oh yeah, definitely. That sounds great.
Speaker 1 01:03:46 Yeah.
Speaker 2 01:03:47 Thank you so much for having me.
Speaker 1 01:03:48 Yeah. Thank you so much for coming on.
Speaker 2 01:03:51 Yeah, absolutely. I.
