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The Transformative Power of Lifestyle Medicine Dean Ornish, M.D. Founder & President Preventive Medicine Research Institute Clinical Professor of Medicine University of California, San Francisco
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Optimal Lifestyle Program Whole foods plant- based diet naturally low in fat & refined carbohydrates Stress management Moderate exercise Psychosocial support
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Lifestyle Medicine= lifestyle as treatment to reverse disease as well as to prevent it.
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Reversing Chronic Diseases Reversing even severe coronary heart disease Reversing early-stage prostate cancer Reversing type 2 diabetes Reversing hypertension Reversing autoimmune diseases Reversing hyperlipidemia Reversing obesity Reversing cellular aging (lengthening telomeres) Changing gene expression 6
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Same diet and lifestyle program for all of these improvements.
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New Unifying Theory The reason that these same lifestyle changes can reverse the progression of so many different chronic diseases is that they are different manifestations of the same underlying biological mechanisms.
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Shared Underlying Mechanisms Chronic inflammation Chronic sympathetic nervous system stimulation Microbiome & TMAO Oxidative stress Apoptosis Angiogenesis Gene expression Telomeres Immune System
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Each of these lifestyle interventions affects each of these biological mechanisms.
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Awareness is the first step in healing.
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What is the cause?
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Your body often has a remarkable capacity to begin healing itself if you give it a chance to do so— and quickly.
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“Impossible”
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Can Lifestyle Changes Reverse Heart Disease?
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Ornish D, Gotto AM, Miller RR, et al. Clinical Research. 1979;27:720A.
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There was a 91% reduction in the frequency of angina in 24 days.
--Ornish D, et al. JAMA.. 1983 Jan 7;249(1):54-9.
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Lifestyle Heart Trial
Men and women with moderate to severe coronary heart disease were randomly assigned to intensive lifestyle changes or to usual care Major endpoints = quantitative coronary arteriography, cardiac PET, and cardiac events Ornish D et al. Lancet. 1990; 336:129 & JAMA. 1998;280:2001.
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Lifestyle Heart Trial
% Diameter Stenosis: Quantitative Coronary Arteriography
52% 50% 48% 46% 44% 42% 40% 38% Control 36% Treatment Baseline (n.s.) 1 year (P<.02) 5 years (P<.001)
Ornish D et al. Lancet. 1990; 336:129 & JAMA. 1998;280:2001. 24
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Lifestyle Heart Trial None of the experimental group patients took lipid-lowering drugs; more than 50% of the control group patients began taking them during the study. Progression was significantly greater in control group patients not taking lipid- lowering drugs (40.7 to 59.7%) than those who were (45.7 to 51.7%). Ornish D et al. Lancet. 1990; 336:129 & JAMA. 1998;280:2001.
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There was a 40% reduction in LDL-cholesterol in the first year without cholesterol- lowering drugs.
--Ornish D et al. JAMA. 1998;280:2001.
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There was a 400% improvement in coronary blood measured by cardiac PET scans after 5 years.
--Gould KL, Ornish D, et al. JAMA. 1995;274:894-901.
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99% of patients stopped or reversed their heart disease as measured by cardiac PET scans after 5 years. In contrast, 45% of controls got worse, 50% showed no change, and only 5% improved (p = 0.03).
--Gould KL, Ornish D, et al. JAMA. 1995;274:894-901.
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Adherence and Change in Coronary Atherosclerosis after Five Years
6% US
3% 1% 0% 0%
-3%
-6%
-7% -9% Low (<56%) Intermediate (56–88%) High (>88%)
Ornish D et al. JAMA. 1998;280:2001
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Lifestyle Heart Trial
There were 2.5 times as many cardiac events in the control group as in the lifestyle group after five years.
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Can Lifestyle Changes Reverse Prostate Cancer?
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Principal Investigators:
Dean Ornish, M.D. Peter Carroll, M.D. William Fair, M.D.
Chairman and Professor, Dept. of Urologic Surgery Clinical Professor of Chairman and Professor, Dept. Medicine, UCSF of Urology, UCSF Memorial Sloan-Kettering Cancer Center
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Patient Selection Criteria 93 men with biopsy-proven prostate cancer, PSA 4–10, Gleason <7 All patients chose to do watchful waiting for reasons unrelated to this study Randomly assigned to intensive cardiac rehabilitation or usual care
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Changes in PSA
6.80 6.74
6.55
6.36 6.30
6.23
6.05
5.98 P=0.002 5.80 Baseline 12 Months
Control (n=41) Ex perim ental (n=43)
Ornish D et al. Journal of Urology. 2005;174:1065
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Degree of Lifestyle Change and Changes in PSA
7% 8% US
4%
2% 1%
-1%
-3%
-6% -5% P=0.001 Low (<48%) Intermediate (48–88%) High (>88%)
Ornish D et al. Journal of Urology. 2005;174:1065
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Change in Prostate Tumor Growth (LNCaP)
0%
-16% -9%
-32%
-48%
-64%
-70% -80% t=6.9, P=.000 %F BS
Control Ex perim ental
Ornish D et al. Journal of Urology. 2005;174:1065
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Degree of Lifestyle Change and Inhibition of LNCaP Tumor Growth
0%
-8% -20%
-40% -39%
-60%
-72% -80% P=0.0001 Low (<48%) Intermediate (48–88%) High (>88%)
Baseline-12m Change in LNCAP Cell Growth
Ornish D et al. Journal of Urology. 2005;174:1065
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Baseline 1 year later PSA—6.4 ng/ml PSA—4.5 ng/ml
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None of the experimental group patients but six control group patients had conventional treatment during the first year.
Ornish D et al. Journal of Urology. 2005;174:1065
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A high-fat diet increases metastasis of prostate cancer whereas a low-fat plant-based diet inhibits it.
M. Chen et al. Nat Genet. 2018 Jan 15, 2018.
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In the Physicians Health Study, men who ate mostly a Western diet had a 250% higher risk of prostate cancer-related death—and a 67% increased risk of death from any cause. In contrast, men who ate mostly a whole foods plant-based diet had a 36% lower risk of death from all causes.
Yang M. et al. Cancer Prevention Research, June 2015 DOI: 10.1158/1940-6207.
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Can Lifestyle Changes Reverse Type 2 Diabetes?
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Over half of Americans have diabetes or pre-diabetes: 12-14% have type 2 diabetes 40% have pre-diabetes
source: JAMA. 2015 Sep 8;314(10):1021-9.
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Lifestyle changes can be better than drugs at preventing diabetes
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Cumulative Incidence of Diabetes
Diabetes Prevention Program Research Group, N Engl J Med 2002;346:393-403
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Epic Study
In 23,000 people, exercising 3.5 hours a week, not smoking, eating a healthy diet, and keeping a healthy weight prevented 93% of diabetes, 81% of heart attacks, 50% of strokes and 36% of all cancers.
EPIC study, Arch Intern Med. 2009;169(15):1355-1362.
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Lifestyle changes can be better than drugs at treating diabetes
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Tight Control of Diabetes with Drugs
sts and offers uncertain benefits in return. Clinicians should prioritize supporting well
Montori VM et al. Ann Intern Med. 2009;150:803-808.
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A plant-based dietary intervention improves beta-cell function and insulin resistance in overweight results in a randomized, controlled trial after 16 weeks.
Kahleova H, Tura A, Hill M, Holubkov R, Barnard ND. Nutrients, Feb 9, 2018
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Complications of diabetes include heart disease, blindness, amputations, kidney damage, impotence
American Diabetes Association
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The complications of diabetes can be prevented when hemoglobin A1C is reduced below 7.0% with lifestyle.
American Diabetes Association
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In 786 men and women who went through our lifestyle program at 24 hospitals in Nebraska, West Virginia, & Pennsylvania, HgbA1c decreased from 7.4 to 6.6% after 12 weeks (p<0.005) and to 6.9% after 1 year (p<0.005).
Silberman A et al, Am J Health Promot 2010;24[4]:260–266.
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can lifestyle changes beneficially affect gene expression?
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Gene expression in 501 genes was beneficially affected in only 3 months
Ornish et al. Proc Nat Acad Sci USA 2008; 105: 8369. J. Craig Venter = Communicating Editor
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RAS family oncogenes (RAN, RAB14, RAB8A) that promote prostate cancer and breast cancer were downregulated.
Ornish et al. Proc Nat Acad Sci USA 2008; 105: 8369. J. Craig Venter = Communicating Editor
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change in genes linked with breast cancer and prostate cancer (red = turned on green = turned off)
Ornish et al. Proc Nat Acad Sci USA 2008; 105: 8369. J. Craig Venter = Communicating Editor
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Our Genes are Not our Fate
Genes can double the risk of heart disease, but a good lifestyle cuts it in half. Healthy lifestyles lower risk of heart disease regardless of genes.
Khera AV, Fuster V, et al. N Engl J Med Nov 16, 2016
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Control 8 weeks of Long-term group meditation meditation
Downregulated Genes:
Upregulated Genes:
Dusek JA et al, PLoS One 2008;3(7): e2576.
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Can Lifestyle Changes Reverse Cellular Aging?
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Telomerase increased 30% in only 3 months
Telomerase Activity (Ln)
2.4 P < 0.05 (two tailed) 2.3 2.2 2.1 2 1.9 1.8 1.7 1.6 1.5 Baseline 3 Months 1 SEM Ornish D et al. Lancet Oncol. 2008; 9: 1048–57. 65
Mean Changes in Telomere Length After 5 Years
0.0675
0.045
0.0225
0 p<0.004 -0.0225
-0.045 Exp Group Control Group
Ornish D et al Lancet Oncol. 2013 Oct;14(11):1112-20. 66
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There was a significant correlation between adherence and telomere length (p<0.007)
Ornish D et al. Lancet Oncology 2013.
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Several studies have shown improvements in rheumatoid arthritis symptoms with diets excluding animal products.
Alwarith J et al. Front. Nutr., 10 September 2019
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What enables people to make sustainable changes in their lives?
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Fun, freedom, pleasure, & love
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Risk factor modification = fear-based
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Fear is not a sustainable motivator
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Adherence to Statin Therapy
% of 37,000 New-to-Statin Patients Remaining on Therapy
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90
80
70
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30 Lipitor 20 Lesc ol
10 Mevacor Pravachol 0 Zochor Oct ‘97 Nov Dec Jan ‘98 Feb Mar Apr May Jun Jul Aug Sept
Source: NDC Health Invormation Services, 1998
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Adherence was 85-90% in 3,780 men and women at all 24 sites after 1 year
Silberman A et al, Am J Health Promot 2010;24[4]:260–266.
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When people feel loved and cared for, they are more likely to make lifestyle choices that are life-enhancing than self-destructive.
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There’s no point in giving up something you enjoy unless you get something back that’s even better— and quickly!
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Dynamic
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When you eat healthier, manage stress, exercise, and love more…
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…your brain gets more blood flow and oxygen…
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…and you grow so many new brain neurons your brain actually gets bigger…
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Walking for three hours per week for three months caused so many new neurons to grow that it actually increased the size of the hippocampus.
--Toni N et al. Nat Neurosci. 2007 Jun;10(6):727-34.
--Pereira A et al. PNAS. 2007:104, 5638-5643.
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…your skin gets more blood flow, slowing aging…
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…your sexual organs get more blood flow, increasing potency…
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Can Lifestyle Changes Reverse Alzheimer’s Disease?
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We are at a place with Alzheimer’s disease similar to where we were over 40 years ago with heart disease: if moderate changes slow its progression, can more intensive changes reverse it?
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Eating 5 or more portions of fruit and/or vegetables a day was significantly associated with a 47% decreased prevalence of cognitive impairment.
—Dong L, et al. Arch Gerontol Geriatr 63, 36-42.
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In those age 65 or older, consuming omega-3 fatty acids once/week or more had a 60% lower risk of developing Alzheimer’s disease.
--Morris MC et al. Arch Neurol. 2003;60(7):940-6.
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In those age 65 or older, consuming saturated fat and trans fats more than doubled the risk of developing Alzheimer’s disease.
--Morris MC et al. Arch Neurol. 2003;60(2):194-200.
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Can Lifestyle Changes Reverse Early-Stage Alzheimer’s Disease? 100 men and women with early-stage Alzheimer’s disease (MOCA =16-25) living in the Bay area Study conducted at the nonprofit Preventive Medicine Research Institute in collaboration with the Memory & Aging Center at UCSF, Harvard Medical School, UCSD, & UCLA.
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What is an optimal way of eating?
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The “Ornish diet” was rated “#1 for heart health” by a panel of independent experts convened by U.S. News & World Report for eight years since 2011.
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Convergence of Nutrition Advice
Consume mostly plants: fruits, vegetables, whole grains, and legumes in their natural forms. What you include in your diet is as important as what you exclude. Eat food as close as possible in its natural form.
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Convergence of Nutrition Advice
Reduce intake of hydrogenated fats, saturated fats, and trans fats. Consume 4 grams/day of omega-3 fatty acids. Organic is better (taste + health). Reduce intake of sugar and refined carbohydrates.
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Diets high in animal protein: • 75% increase in total mortality • 400% increase in cancer risk • 500% increase in diabetes • significantly higher IGF-1 levels
—Levine ME et al. Cell Metabolism 19, 407–417, March 4, 2014
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In 37,698 men and 83,644 women, red meat consumption was associated with a significantly increased risk of all-cause, cardiovascular, and cancer mortality.
Pan A, Willett W. JAMA Internal Med. 2012;172:555.
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Egg yolks and red meat increase TMAO levels, causing atherosclerosis. Hazen S et al. N Engl J Med. 2013 Apr 25;368(17):1575-84
TMAO levels were 3.3 on an Atkins diet, 2.6 on a Mediterranean diet, and 1.8 on an Ornish diet. Park JE, Hazen S et al. Nutr Metab Cardiovasc Dis. Feb 22, 2019
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The only diet proven in randomized controlled trials to reverse heart disease without drugs is a whole foods plant-based diet very low in fat & refined carbohydrates. —Ornish D et al. JAMA. 1983;249:54. —Ornish D et al. Lancet. 1990;336:129. —Gould KL, Ornish D, et al. JAMA. 1995;274:894. —Ornish D et al. JAMA. 1998;280:2001.
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A low carb diet high in animal protein and fat was associated with a 33% higher all-cause premature mortality and a 51% higher cardiovascular mortality in a dose-response pattern.
Li S, et al. J Am HeartAssoc. 2014;3:e001169 doi: 10.1161/JAHA.114.001169
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Smith S. N Engl J Med 2009;361:2286-2288
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Our Food Choices Profoundly Affect Three Major Areas: Hunger Crisis Global Warming Crisis Health Crisis
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Personally Sustainable = Globally Sustainable Good for You = Good for our Planet
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Global Warming Crisis Livestock causes more global warming than all forms of transportation combined Responsible for 18% of the world’s total greenhouse gas emissions In contrast, the entire global transportation system accounts for only 13% of greenhouse gas emissions
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Health Crisis 86% of the $3.6 trillion in health care costs in the U.S. are due to chronic diseases Most of these chronic diseases can often be prevented or even reversed by changing diet and lifestyle
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the multicenter lifestyle demonstration projects
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Lifestyle Medicine Saves Money Quickly
50-80% of U.S. total health care costs are due to 5% of the population. 22% of U.S. total health care costs are due to 1% of the population. Heart disease = #1 most expensive condition in terms of total health care spending.
source: Conwell LJ, Cohen JW. Statistical Brief #73. March 2005. Agency for Healthcare Quality and Research, Rockville, MD.
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The Multicenter Lifestyle 1 Demonstration Project
Almost 80% of 333 patients who were eligible for bypass surgery or angioplasty were able to safely avoid it by changing lifestyle
Ornish D. Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 1998; 82: 72T–76T.
Koertge J, Weidner G, Elliott-Eller M, et al. Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project. American Journal of Cardiology. 2003; 91: 1316–1322.
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Mutual of Omaha calculated saving almost $30,000 per patient in the first year.
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The Highmark Blue Cross Blue Shield Demonstration 2 Project: Cost Comparisons After 3 Years
Experimental Group (CAD) vs. Matched Cohort (CAD) Members Year by Year
$10,000
$7,500
$5,000
$2,500
$0 Baseline Year 1 Year 2 Year 3
Ornish Members (CAD) Matched Cohort Mem bers
Experimental Group (CAD) (N=75) Baseline vs. 3 year average=8.7% decrease in costs Matched Cohort Members (CAD) (N=75) Baseline vs. 3 year average= 47.2% increase in costs
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Highmark BCBS High Cost Study
In the year after entering our lifestyle program, there was a 400% reduction in patients with claims costs greater than $25,000 compared to matched controls
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Highmark Blue Cross Blue Shield Demonstration Project
In 3,780 patients who went through this lifestyle medicine program at 24 sites in Pennsylvania, Nebraska, and West Virginia, there were significant improvements in all metrics after 12 weeks and after 1 year.
Silberman A et al, Am J Health Promot 2010;24[4]:260–266.
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Weight Loss
All Participants (N=1,908)
200 199lbs
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190 188lbs
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180lbs 180
175
170 P<.000 Baseline 12 Weeks 1 Year
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Reduced Angina (% of Participants with Any Angina in Preceding 40 Days)
All Participants (N=1,908)
30 27 25
20
15 14
10 8
5 P<.000 Baseline 12 Weeks 1 Year
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96.5% of patients reported significant improvements in angina severity after one month
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Increased Functional Capacity (METs) All Participants (N=1,908)
11 11 METs 11 METs
10
9 METs 9
8 P<.000 Baseline 12 Weeks 1 Year
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Improvements in Quality of Life (SF-36)
All Participants (N=1,908)
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71 70 70
65
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56 55 P<.000 Baseline 12 Weeks 1 Year
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Reduced Systolic Blood Pressure
Systolic BP (mm HG)
150 150 145 140 136 135 130 129 125 120 115 All P<.001 Baseline 12 Weeks 1 Year
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Reduced Diastolic Blood Pressure
Diastolic BP (mm Hg)
86 86 84 82
80 79 78 76 76 74 72 70 All P<.001 Baseline 12 Weeks 1 Year
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Improvements in Blood Sugar
Fasting Glucose (mg/dl)
160
150 150
140
130 125 120 120
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100 All P<.001 Baseline 12 Weeks 1 Year
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These improvements occurred even though most patients reduced or discontinued medications to lower blood pressure, lipids, and blood sugar. These reductions would have been even greater if medications had remained unchanged.
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CED-D Depression Scores
All Participants (N=1,908)
12 11
9
6 6 6
3
0 P<.000 Baseline 12 Weeks 1 Year
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3 Medicare On January 1, 2011, Medicare began covering “Dr. Ornish’s Program for Reversing Heart Disease,” the first time Medicare has covered a program of lifestyle changes as treatment in a new benefit category, “Intensive Cardiac Rehabilitation.”
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4 Commercial Coverage Aetna (in all 50 states) Anthem Blue Cross Blue Shield (in all 14 states it covers, including NY & CA) Highmark BCBS (including diabetes or 2 risk factors) Blue Shield of CA (incl. type 2 diabetes) HMSA (including diabetes or 2 risk factors)
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We train a team of six health care professionals:
• Physician = Quarterback • Nurse • Stress management specialist • Exercise physiologist • Registered dietitian • Clinical psychologist
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Patients come for 18 four-hour sessions with 15 patients/class (twice/week for 9 weeks):
• 1 hour of supervised exercise • 1 hour of stress management • 1 hour of a support group • 1 hour lecture + group meal
Reimbursement = $135/hour
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If it’s reimbursable, then it’s sustainable.
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Ornish.com
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Ornish D. Love & Survival. New York: HarperCollins, 1998. 141
The deepest roots of suffering and healing — both personal and social— come from transforming isolation into intimacy.
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Information is not sufficient to motivate most people to make sustainable lifestyle changes
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Depression and Mortality 6 months After a Heart Attack
30
25
20
15 Depressed (n=35)
% Mortality % 10 Nondepressed (n=187) 5
0 0 1 2 3 4 5 6
Months Post—MI
Frasure-Smith, N. JAMA 1993;270:1819.
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Patients who scored above average in loneliness had significantly lower immune functioning.
Kiecolt-Glaser J, Glaser R, Adv. Biochem psychopharmacol. 1988; 44:217-224.
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Duke Study 1,400 men & women had angiography; at least one vessel severely stenosed. After 5 years, those who were unmarried and did not have a close confidant were more than three times as likely to have died (15% vs. 50%).
Williams RB, et al. JAMA. 1992;267(4):520-524.
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Social Networks & Health If your friends are obese, your risk of obesity is 45% higher If your friend’s friends are obese, your risk of obesity is 25% higher If your friend’s friend’s friend is obese, your risk is 10% higher--even if you’ve never met them
Christakis N, Fowler J. N Engl J Med. 2007; 357 (4): 370–379.
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Social Networks & Health
This pattern also seen with smoking, drinking, depression, happiness, altruism, and predicting epidemics Social distance is more important than geographic distance
Christakis N, Fowler J. N Engl J Med. 2007; 357 (4): 370–379.
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Support Groups DOUBLED Survival in Breast Cancer
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0.8
0.6
0.4 % Surviving %
0.2
0 0 20 40 60 80 100 120 140
Control Treatment Spiegel D et al. Lancet 1989;2:1209
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Trust→ Intimacy→ Healing & Meaning
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Hostility and CAD Wong JM et al. J Am Heart Assoc. 2013 Sep 30;2(5):e000052. doi: 10.1161/JAHA.113.000052.
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Twitter Language Predicts Coronary Heart Disease Mortality
In 148 million tweets, language patterns reflecting negative social relationships, disengagement, and negative emotions— especially anger—predicted CHD mortality better than 10 factors including smoking, diabetes, hypertension, and obesity.,
Eichstaedt JC et al. `Psychol Sci. 2015 Feb;26(2):159-69. doi: 10.1177/0956797614557867. Epub 2015 Jan 20.
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“I feel deprived because I can’t eat this food” is not sustainable.
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“I’m choosing not to eat this because what I gain is much more than what I give up” is sustainable.
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Choosing not to do something imbues it with deep meaning & purpose, making it sustainable.
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“Why do you want to live longer?”
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Not just how long we live but how well we live.
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Meaning is malleable: You can take it out → nihilism and despair; you can put it in → sacred
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Meaning is the antithesis of depression.
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If it’s meaningful, it’s sustainable
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If it’s pleasurable, it’s sustainable
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Dis-ease De-fine
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Double Vision
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The Other vs. We are That
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Altruism, forgiveness, compassion, & love
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Conspiracy of love
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Reclaiming our role as healers, not just technicians
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Love is more powerful than fear
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Light drives out the darkness.
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Transformatio n
T
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Epidemic of Depression/Loneliness 1 veteran commits suicide every hour! 1 active duty soldier commits suicide every day!
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