The ability to weather pain and distress arising from the illness could either be augmented or hampered as a consequence of this novel psychophysical factoring. The expressions of ill-health in an individual can be varied even if there were only the previous baseline but this new distribution likely alters the application of our faculties such that any predominant tone and emphases that emerge could become a significant determinant of how closely the non-diseased baseline can be reestablished.

It appears that the modality of attention might be a significant variable with the ill-health induced novel baseline. This is because filtering is amongst the earliest processes that converge on stimulus and attention considerably modifies the intensity of selection. This variable, when viewed as a modality that is both psychic and somatic might be instrumental in developing the capacity to integrate the alteration in psychophysical processing so that any new baseline approximates the one existing earlier.

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The basis of adequate resilience isn’t strength. A moments reflection reveals that we cannot rely on strength, for any foundation of strength are the mind and body. And the mind and body could be afflicted at any moment. If you have meditated on death (see the pdf on spotlight), this fact becomes even more striking. While we are alive, we can move and make and do. At death, even the body is of no help. Death is ever present, it is always. So is ill-health. When we are well, we are actually without ill-health. The bedrock of such an existence cannot be strength. We can however give ourselves some strength, and the ability to do that is in many ways the foundation of adequate resilience.

It might really be more apt to say that we can have firm resolve. Any strength we acquire comes from firm resolve and not the other way around. If we generate the firm resolve to see things through, we might be able to carry ourselves through severely trying circumstances. Strangely, such resolve comes from the difficulty itself. In presenting itself when we are least prepared, difficulty reminds us that we cannot overlook pain. That we have to keep preparing for it. If we keep preparing for pain, we can be firm with and without it. Also, the impetus for this readiness isn’t strength but vulnerability or perhaps more accurately, vigilance.

Thus, firm resolve as well as vigilance with and without ill-health might be thought of as the basis of adequate resilience.

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Hence, recall seems to be closely linked with values. If our value system is coherent, sound and comprehensive, the valence of our processing, while fluctuant could contribute positively to how we handle what we might be experiencing. Interestingly, if this happens, then the stream of experiencing itself might very well be open to our making.

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In considering foods to avoid with arthritis, it may help to know that research is increasingly showing that certain foods can aggravate or even cause arthritis. In this article we discuss what might be best eliminated from the diet and some possible mechanisms of food sensitivity.

Arthritis refers to a range of musculoskeletal conditions in which the individual’s joints become inflamed and/or damaged which could result in pain, stiffness, disability or deformity. Actually ‘arthritis’ is not a single disease. It is an informal way of referring to joint disease of any kind. There are more than a 100 types of arthritis. Conservative estimates suggest that over 54 million adults and 300,000 children suffer from arthritis and other joint conditions the world over.

Until only some years ago, food was not thought to have a significant impact on the symptoms of arthritis. However, more and more emerging research indicates that what we eat can have a significant impact of how distressful or disabling our symptoms are, if we happen to have arthritis. While knowledge about foods to avoid with arthritis has become widespread, what remains poorly understood are the reasons behind the food sensitivity observed with arthritis. We discuss these possible causes first and then present a list of foods to avoid to better manage arthritis symptoms.

Foods to Avoid with Arthritis: Mechanisms of Food Sensitivity

It has been observed that some patients with immunological responses to certain foods such as skin reactions, develop joint symptoms. While studies show no consistent pattern, it is possible that some of these individuals have antibodies to specific foods. The generation of antibodies is an immunological reaction in response to the ingestion of specific foods and the resultant joint pathology could be an effect of these antibodies reacting with different structural elements of joints, for instance the lining of the joint. At times, individuals develop markedly raised levels of specific antibodies to some foods, which might drop dramatically with the elimination of these foods from the diet. Some investigators have suggested that the response to the consumption of certain foods that impinge upon joint structure and function are both immunological as well as non-immunological.

Diets that eliminate certain foodstuffs have been seen to alter gut flora and those in whom this change occurs appear to do well when the offending food is removed from the diet. While still conjectural, it is possible that the type of gut microbe and its metabolism contribute to the course and severity of arthritis. Thus, elimination diets might actually work not only because the offending food is removed but also because of the attendant changes in gut microbial activity, indicating that gut milieu is an important factor to consider in the management of arthritis.

Interestingly, levels of antibodies to a gut microorganism, Proteus mirabilis, might be associated with the activity of the disease process in arthritis. Studies have demonstrated that those who respond to elimination diets have lower levels of antibodies to Proteus, thereby indicating that the immunological handling of this and possible other bacteria is correlated with the body’s response to certain foods and more importantly, to the immunological underpinnings of the disease process in arthritis.

The science behind food sensitivity is not fully explored but it is known that food sensitivity plays a role, especially in 30-35% of rheumatoid arthritis patients and that avoiding offending foods can have immense benefits. The mechanisms of how foods induce or aggravate symptoms of arthritis is yet to be fully elucidated, although there are many promising leads for future research.

Foods to Avoid with Arthritis: Some Examples

Regardless of the type of arthritis one has, cutting back or eliminating foods that contribute to or maintain an inflammatory state can significantly reduce symptoms and ease pain and dysfunction. Some foods to avoid with arthritis include high calorie foods. Obesity is strongly associated with arthritis and fat is known to generate chemicals that can cause inflammation. Reducing high calorie foods helps shed weight which eases the stress and wear and tear of joints.

Advanced glycation end products or AGE’s are present in high fat foods, processed foods and foods that are fried, grilled, microwaved or baked. Eating fewer meats and high fat dairy foods reduce the AGE load in the body and this may help mitigate inflammation. Foods such as fish, vegetables, fruits, grains and low fat dairy products are known to have fewer AGE’s. Also, for those with arthritis, it might be worthwhile consuming food cooked at lower temperatures or by moist heat, such as steaming.

With arthritis, it is important to be aware of food sensitivities. Many people with arthritis report sensitivity to gluten. Those who are sensitive to gluten should avoid wheat, barley, rye and casein found in dairy products. Those who suffer from rheumatoid arthritis often report sensitivity to dairy foods, citrus fruits or plants of the nightshade family such as potatoes or chilli peppers.

Purine rich foods can result in unhealthy accumulation of uric acids in the body and should likely be consumed sparingly. These types of foods include anchovies, asparagus, organ meats, herring, mackerel, sardines, scallops, dried beans and peas. Alcohol consumption is also well known to increase uric acid levels in the body.

Butter is not only high in fat, it is high in saturated fat which can increase swelling and pain in the body. In addition, butter consumption might increase weight which causes joint stress.

Ecological studies have shown that the prevalence of rheumatoid arthritis is higher in regions where there is higher consumption of red meat. Meats such as beef and mutton have been linked to increased inflammation and joint pain from arthritis. Not surprisingly people with arthritis report less pain when they go on a vegetarian diet.

Sugary foods such as candy and chocolate should be used sparingly by those suffering from arthritis. These foods contain no nutrients or fiber and can cause weight gain.

Vegetables of the nightshade family contain solanine, which might aggravate pain and inflammation in arthritis and should therefore be used judiciously. Members of the nightshade family include eggplants, peppers, tomatoes and potatoes.

Fast foods not only contain empty calories, they are often high in saturated fats, trans fats and monosodium glutamate, all of which are known to increase inflammation and pain in those with arthritis. White flour, white rice and white potatoes as well as many cereals are high-glycemic foods that contain AGE’s that stimulate inflammation and should be consumed carefully. Along with fast foods and foods such as fried foods, processed snacks, frozen breakfasts, cookies, donuts and soda’s, sugary foods such as pastries, desserts, chocolate bars and even fruit juices are well known to aggravate joint symptoms and pathology.

While research has yet to definitively link food sensitivity to the severity of arthritis, being selective about the food that is consumed and eliminating certain foods have been shown to have an enormous impact on joint symptomatology and quality of life in those with arthritis. Making dietary modifications often translates to a lesser need for arthritis modifying drugs that have distressing side effects. We hope that you enjoyed this post and that this information about foods to avoid in arthritis will help you manage your condition better.

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Side effects of chemotherapy have been described by cancer patients as more disabling than the cancer itself. Fatigue is increasingly being recognized as an important and pervasive consequence of cancer and chemotherapy. In this article, we review the causes, risk factors and management of cancer and chemotherapy related fatigue.

Fatigue is now increasingly being recognized as an important side effect of chemotherapy. This is partly because of its negative impact on quality of life. Fatigue is understood to be the commonest side effect of chemotherapy and radiotherapy. It has been shown that 82-96% of those undergoing chemotherapy suffer from fatigue during their treatment. Evidence seems to show that fatigue typically improves in the year after treatment. However, in a significant minority of patients, fatigue persists for months or even years after treatment. Studies of long-term survivors of cancer show that fatigue persists in about 25-35% of patients for up to 10 years after cancer diagnosis.

Side Effects of Chemotherapy: Understanding Fatigue

Among the side effects of chemotherapy, fatigue is probably the most difficult to accurately define and measure. What is reasonably certain is that cancer-related fatigue is more severe, more persistent and more debilitating than normal fatigue. Also, cancer or cancer treatment related fatigue is not relieved by adequate sleep or rest unlike normal fatigue which is usually caused by overexertion or inadequate sleep. Cancer related fatigue is multidimensional and likely has physical, mental and emotional components.

Cancer related fatigue is diagnosed when significant fatigue, diminished energy or increased need for rest unrelated to activity levels is present every day or nearly every day for 2 weeks. Symptoms that signal fatigue and support its diagnosis include generalized weakness or limb heaviness, diminished concentration or attention, reduced motivation or interest in usual activities and also insomnia or excessive sleep. Other possible symptoms which aid a diagnosis of fatigue are also known to be side effects of chemotherapy. These include the experience of sleep being non restorative, poor memory, fatigue after exertion lasting several hours and an inability to complete daily tasks. From a mental health perspective, there is often. marked emotional reactivity to feeling fatigued like sadness, frustration and irritability.

Causes of Fatigue

Inflammatory Processes

Overall, research seems to indicate that inflammatory processes are key drivers underlying fatigue in the treatment and post treatment phase. This appears to be especially true for breast cancer, testicular and ovarian cancer survivors. Cytokines are chemical messengers released by cells in the body that modulate inflammation. A lot of research indicates that different families of these cytokines can signal the central nervous system to generate the symptoms of fatigue through neural processes. These cytokines can be released by cancer cells before treatment as well as by chemotherapy damaged tissue. In a study of patients with colorectal, esophageal and non-small cell lung cancer, chemotherapy resulted in marked increases in inflammatory markers. This finding correlated with symptoms of sickness and fatigue in the subjects of the study.

Even in long term survivors of cancer, these inflammatory markers are thought to underlie fatigue. In a sample of 633 breast cancer survivors, higher levels of these markers were associated with increased odds of being classified as fatigued. This finding was seen despite controlling for age, race, menopausal status and medication use. Also of relevance in the long term, gene activation has been seen to occur in breast and prostrate cancer survivors. Activation and expression of genes that code for inflammatory immunological processes and inflammatory markers has been demonstrated in many studies and more are underway.

Neuroendocrine and Autonomic System Changes

Neuroendocrine alterations might also explain cancer related fatigue. Glucocorticoids are cholesterol derived steroid hormones secreted by the adrenal glands that have potent anti inflammatory actions. Research shows that in cancer, there are alterations in the production of these hormones. Glucocorticoid levels have been seen to be abnormal during onset of fatigue with normalization occurring in the post treatment period. In breast cancer patients, a state of hormone resistance has also been observed due to changes in glucocorticoid receptors. This is thought to result in increased levels of pro inflammatory chemicals in the body that might lead to fatigue.

In a study of breast cancer survivors, elevated levels of adrenaline were noted to be associated with fatigue. Elevated levels of adrenaline (or nor-epinephrine) are a sign of sympathetic system over-activity. This finding coincided with the observation that there was reduced heart rate variability which reflects reduced parasympathetic activity. Fatigue and other side effects of chemotherapy could very well be a result of alterations in the activity levels of systems such as the neuroendocrine and the autonomic nervous system. Generally speaking, sympathetic system activity is associated with increased inflammatory activity and parasympathetic system activity with reduced inflammation. This appears to be relevant, and important, in the cancer and cancer treatment context.

Side Effects of Chemotherapy: What Puts You at Risk for Fatigue?

Genes

There is wide variation in the experience of fatigue before, during and after treatment. As pointed out, there is variability in the inflammatory response to treatment which is in turn correlated with variability in fatigue. There are a number of factors that can predispose to fatigue in those with cancer. Genes play an important role in the predilection for fatigue. In two large studies conducted with lung cancer patients alterations in genes controlling cytokine mediated inflammation were found. These alterations were associated with fatigue before as well as after treatment. Alterations in inflammation related genes have been linked to fatigue in breast, lung and prostrate cancer. Interestingly, such changes have been linked to fatigue in other patient populations too suggesting that inflammation promoting genes may serve as a general risk factor for fatigue symptomatology.

Pre-Treatment Fatigue

Pre-treatment fatigue is by far the strongest and most consistent predictor of post-treatment fatigue. It has been found that patients who report fatigue before treatment report elevated fatigue after treatment completion, over the following year and up to 2.5 years later.

Depression

Depression has also been linked to fatigue in cancer. Fatigue can be a symptom of depression as well as a cause for mental illness in the cancer setting since it interferes with social, occupational and leisure activities. There is evidence from several studies that pre-treatment anxiety and depression predict cancer related fatigue before, during and after treatment. A history of major depressive disorder and treatment for mental illness prior to cancer diagnosis predicted post treatment fatigue in many studies with symptoms observed up to 4 years after treatment completion.

Sleep Disturbance

Sleep disturbance has been noted to be a risk factor for fatigue in several studies, including studies of gynecologic and breast cancer. It has been suggested that sleep disturbance may contribute to daytime symptoms of fatigue across cancer populations. Interestingly, getting enough sleep does to necessarily lead to amelioration of fatigue suggesting that other factors contribute to fatigue maintenance over time.

Physical Activity and BMI

Low levels of physical activity and the ensuing decrease in cardiorespiratory fitness are thought to play a very important role in the development and/or persistence of cancer related fatigue. Increased body mass index (BMI) has also been linked with fatigue. In a study of early stage breast cancer, it was found that BMI was one of the key predictors of fatigue at 6 and 42 months post treatment.

Coping and Appraisal

How one responds psychologically to cancer diagnosis is a key element predicting the quality of experience in the following months or years. Patients who engage in negative self-statements and thoughts regarding fatigue report higher levels of fatigue for up to 42 months after treatment. Also, patients who expect to experience fatigue are more likely to report elevated fatigue after treatment. Therefore, having negative expectations and coping strategies early on in the cancer trajectory leads to increased risk of post- treatment fatigue.

There are some other psychological risk factors for cancer related fatigue. These include early life stress, such as neglect and abuse. Early life stress has been linked to fatigue in non cancer populations too. Loneliness in cancer survivors is also associated with higher fatigue and predicts increases in fatigue over time.

Managing Fatigue

A large number of interventions are being studied that might adequately address cancer related fatigue. However, in the absence of a clear understanding of its origins and mechanisms, a definitive treatment is difficult to design. Some approaches that are useful in cancer related fatigue include exercise, psychosocial and mind-body interventions and medications.

Exercise

There is growing evidence that exercise has at least a moderate effect on fatigue. Exercise has been shown to be beneficial during different stages of the cancer trajectory. Exercise can help to buffer the effects of treatment as well as reduce post treatment fatigue. Research shows that aerobic exercise is the most beneficial with evidence being inconclusive for resistance exercises. It is recommended that cancer patients engage in personalized and supervised sessions beginning at modest intensity and increasing gradually in dose and intensity. The American College of Sports Medicine guidelines recommend that cancer patients and survivors undertake at least 150 hours of moderate intensity aerobic exercise each week. Patients should be closely monitored and progress in intensity guided by exercise tolerance and specific diagnosis in order to avoid injury.

Psychosocial Interventions

Psychosocial interventions have been shown to be beneficial in cancer patients especially if they are targeted towards fatigue. Fatigue education and support programs and individualized interventions focusing on fatigue-related thoughts and behavior have been useful in breast cancer patients. A cognitive-behavioral approach combined with hypnosis has also shown promise in reducing fatigue. The Moving Beyond Cancer Trial demonstrated that brief psychoeducational videos help reduce fatigue in breast cancer patients who had recently completed treatment. Multifaceted programs that provided information on cancer-related fatigue, energy conservation, physical activity, sleep hygiene, distress management, nutrition and pain have been shown to be beneficial in decreasing fatigue.

Mind-Body Interventions

There is a growing number of studies that are studying the effects of interventions like acupuncture, mindfulness meditation and yoga on cancer related fatigue. In a trial of 302 patients where 6 weeks of acupuncture was administered, there was significant improvement in fatigue, post chemotherapy. In another study, 100 cancer survivors with severe fatigue were randomized to a 9 week mindfulness based cognitive therapy intervention. The intervention focused specifically on fatigue and instructed the patients on becoming aware of and inhibit unhelpful automatic responses such as feelings, thoughts and behaviors. A significant reduction in fatigue was observed post treatment and this reduction was seen to be maintained over the 6 month follow up. Similarly, studies with restorative and passive yoga poses have been shown to reduce fatigue post treatment.

Pharmacologic Interventions

A considerably large number of studies have investigated the role that specific drugs might play in reducing side effects of chemotherapy and especially fatigue. Evidence appears to indicate that psychostimulants such as methylphenidate (which is an amphetamine based stimulant) could be helpful in reducing fatigue. Interest is growing in Modafanil, which is a non amphetamine based stimulant. Antidepressants such as paroxetine and sertraline have also been studied in the cancer related fatigue context but the results are mixed and somewhat inconclusive.

Based on the research that there is an inflammatory basis of fatigue, several anti-inflammatory drugs have been studied such as steroids like dexamethasone and anti-cytokine drugs such as etanercept and infliximab. All these agents have been shown to have more than a moderate effect on post treatment fatigue. Authoritative and conclusive results on the benefits of anti-inflammatory agents are yet to emerge.

Despite interest in supplements to treat fatigue, there are only a handful of trials studying the potential benefits of these agents. In one trial, the supplement L-carnitine was not seen to have any benefit against fatigue in those receiving cancer treatment. On the other hand, American ginseng was found in one large multisite trial to have beneficial effects, particularly among patients undergoing active cancer treatment.

Fatigue is increasingly being seen as a major impediment to well-being in those with cancer. In order to increase resilience, it is important to be aware of the causes, risk factors and potential management of this common cancer related symptom. We hope this article helped shed some light on this distressing and all too common effect of cancer or its treatment.

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Resilience in Cancer is an important topic of consideration in the medical academic community. In this article, we discuss what resilience in cancer actually means, what its facets are and how it might positively influence the suffering of cancer.

Why Resilience?

There are 14 million cases of cancer worldwide every year. The diagnosis of cancer heralds immense anguish, suffering and stress. Along with the prospect of prolonged, painful and invasive treatment, cancer patients have to make sense of the fear of death and uncertainty and anguish about their future. The diagnosis of cancer implies severe disruption to all domains of daily life including the ability to work and earn, be physically and socially active and stay independent. The perception of cancer as a traumatic illness is further strengthened by the possibility of relentless progression of the disease as well as invasive treatments such as surgery and chemotherapy which can lead to tremendous physical pain, disability and ill health.

Resilience in cancer might be viewed as an individual’s ability to maintain or restore relatively stable psychological and physical functioning in the face of the stress and adversity that cancer entails. It refers to a person’s protective attributes and/or personal characteristics that are thought to be modifiable and to promote successful adaptation to cancer. The good news is that more and more research seems to show that resilience is a dynamic process and can change over time, contexts and environments. This means that resilience can be trained and acquired irrespective of supposedly fixed personality traits and situational variables.

Adaptation to cancer can be influenced to a significant extent by multiple resilience factors, and strengthening these factors can aid successful adaptation, flexibility and growth despite the trauma of having cancer. Some of these resilience factors include optimism, self esteem, cognitive flexibility, positive emotions and refocusing, acceptance, coping, social support and spirituality.

During the process of strengthening resilience, people change, and these changes are thought to be brought about by new attitudes and views, newly acquired strengths and competencies, partial immunization to the effects of future stressors and surprisingly, possible changes in gene expression. Another heartening factor is that more and more research is showing that cancer patients can benefit significantly from resilience-enhancing interventions especially in the period immediately after diagnosis and in tandem with physical treatments.

What the Research Shows

Increasingly, research is showing that resilience in cancer plays a vital role in maintaining and improving quality of life. There appear to be several personal as well as disease-related factors related to resilience in adult cancer patients. Among the personal factors, gender is certainly correlated with resilience. Studies show that females generally have lower resilience scores than males. Lung and gastric cancer specific studies have shown that resilience scores are higher in those who do not live alone. In breast cancer, it appears that not having a partner does not affect resilience while in oral cancers, those with a partner had higher resilience scores.

Education and employment have a positive association with resilience. Studies show that those who are educated score higher on resilience ratings and among the educated, the higher the education level, the higher the resilience scores.

Family economic status is an important determinant of resilience, as is the nature and extent of social support available. A study on lung and breast cancer found that the higher the household income, the higher the resilience scores. Similarly, studies with bladder and colorectal cancer patients have shown that the more the available social support, the higher the resilience levels.

How age affects resilience is still unclear. Some research shows that the elderly have lower resilience scores and among patients with lung, breast and colorectal cancer under treatment, those who were 71 or older had lower resilience scores that those between 51 and 60.

There are several disease-related factors that influence resilience. These include but apparently are not limited to physical symptoms, time after diagnosis, type and stage of cancer, treatment stage, the number of times treatment is changed and comorbidity. While the effects on resilience of most of these factors is still under debate, it does appear that physical symptoms are strongly correlated with resilience. Some studies have noted that the more severe the physical symptoms, the lower the resilience scores. Also it seems that if patients are able to spend daily lives without problems, their scores are higher.

Coping and Resilience in Cancer

Coping has been defined as the cognitive and/or behavioral efforts that are made to deal with stressful or difficult situations that test people’s resources. Generally speaking, two kinds of coping are identified – problem oriented or adaptive coping and emotion oriented or disadaptive coping. Problem oriented coping purports to manage or modify the problem that is causing the difficulty whereas emotion oriented coping tries to regulate the emotional response to difficulties. Evidence seems to support the notion that in cancer several kinds of coping strategies are employed and that coping effectiveness varies with variables like time since diagnosis, medical treatment, cancer stage etc. In addition, the way one copes is intimately linked with resilience levels and both work in concert in determining the success or failure of meaningful adjustment to the disease.

Some investigators have noted that coping strategies like acceptance, positive reappraisal and seeking social support are more conducive to well-being in cancer patients than the more disadaptive strategies such as rumination, blame, avoidance and negation. Not surprisingly, coping has been linked to resilience. Research has shown that some of the more adaptive ways of coping such as planning, putting into perspective, acceptance, positive refocusing and reevaluation are positively related to resilience with those employing these strategies having higher resilience levels. This in turn improves quality of life and perceived well-being. Coping methodology and resilience levels interact in a complex fashion with resilience moderating the influence that coping with the disease has over the more distressing symptoms such as anxiety, fear and depression.

Factors Related to Resilience in Cancer

‘Meaning making’ is a notion that tries to explain someone’s adjustment to his or her cancer experience. In the first few months after diagnosis, cancer patients are forced to reevaluate their general sense that life has order and purpose as they battle existential distress, concerns over health and safety and fears over dependency and lost autonomy. This process of searching for new meaning as cancer patients struggle to come to terms with a new reality is termed meaning making. Meaning making has been suggested to be contributory to the successful adaptation to cancer. However, the meaning has to be arrived at via the process of the evaluation of the cancer experience and evidence also shows that the meaning has to really be attained for actual benefits. On the other hand, fruitless rumination and worry and attempts to derive meaning result in unnecessary distress and discomfort rather that give rise to successful adaptation.

Another concept that is closely linked to resilience in the context of the cancer experience is called ‘sense of coherence’. The sense of coherence is described as a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that events in one’s inner and outer world are structured, predictable and explicable; the resources are available to one to meet the demands of these events and circumstances and that these demands are challenges worthy of investment and engagement. More and more research is accumulating that shows that SOC is a health promoting factor and is positively correlated with quality of life, much like resilience is. Significantly, in a study of breast cancer patients, it has been shown that patients with a higher SOC score had a 63% lower risk of cancer progression and an 80% lower risk of cancer related mortality than those with lower SOC scores.

This post on resilience is by no means exhaustive and the Resiliency Initiative hopes to present more articles related to resilience in cancer introducing conceptual notions such as post traumatic growth. Hopefully, this article will have given you a reasonably thorough grounding of the notion of resilience in the context of cancer and why it might be important if you happen to have cancer. Do watch this space and also bear with us as we gradually introduce more information and resources that will be of benefit to the chronic illness community.

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