Surgery 171 (2022) 94e95
Contents lists available at ScienceDirect
Surgery
journal homepage: www.elsevier.com/locate/surg
Adrenal
Shinrin-yoku, yoga and other strategies in the fight against COVID-19
Janice L. Pasieka, MD, FRCSC, FACSa,*
a Clinical Professor of Surgery and Oncology, Section General Surgery, Division Endocrine Surgery, Cumming School of Medicine, University of Calgary,
Calgary, Alberta, Canada
article info
Article history:
Accepted 15 July 2021
Available online 31 August 2021
In March 2019, the world changed when the World Health Or-
ganization declared coronavirus disease 2019 (COVID-19), a novel
coronavirus, a pandemic. Countries around the world locked down
their borders, isolated their citizens and hospitals, and healthcare
workers (HCWs) had to adapt very quickly to the changing needs of
their patients. The added stress of working in a health care envi-
ronment during infectious outbreaks has been shown to take its toll
on HCWs. In a review of 44 studies on the psychological impact of
epidemic and pandemic outbreaks, Preti et al found between 11%e
74% of HCWs reported post-traumatic stress symptoms (PTSD),
with symptoms lasting beyond the outbreak in 10%e40%.1 During
the initial COVID-19 outbreak, 70% of HCWs suffered distress, 50%
had depressive symptoms, and 44% reported anxiety.2 This
appeared to be more severe in women and in professional staff.
Additional stressors, such as child and eldercare disruptions, social
isolation or entrapment, financial distress, and relationship
dysfunction, have plagued many of us during this crisis.
The acute stress response is mediated by the hypothalamic-
pituitary-adrenal axis (HPA), causing an increase in serum
cortisol. Acute self-limiting cortisol elevation in response to stress
is beneficial. However, during chronic stress, there is a degree of
cortisol resistance resulting in dysregulation of the HPA axis and
daily cortisol secretion. Maladaptive secretion of cortisol under
chronic or repetitive stress conditions can be challenging to capture
as plasma, salivary, and urine cortisol levels only measure a snap-
shot in time. However, hair cortisol concentrations (HCC) have the
advantage of providing retrospective data by examining different
segments of hair. In Stalder’s meta-analysis, they found overall
This paper is a Distinguished Moderator Presentation from the AAES 2021
Virtual Meeting presented April 26, 2021. The statements in this paper reflect the
opinions of Janice L. Pasieka.
* Reprint requests: Dr Janice L. Pasieka, 1403 29th Street NW, Foothills Medical
Center, Department of Surgery, North Tower Floor 10, Calgary, Alberta Canada T2N
2T9.
E-mail address: janice.pasieka@ahs.ca (J.L. Pasieka).
Twitter: @JanicePasieka
https://doi.org/10.1016/j.surg.2021.07.044
0039-6060/© 2021 Elsevier Inc. All rights reserved.
stress-exposed groups exhibited a 22% increase in HCC and
increased by 43% in those groups where there were ongoing
stressors.3 It was therefore not surprising to see that Rajcani et al
found a significant increase in HCC corresponding to the first wave
of the COVID-19 pandemic compared with the pre-COVID period in
67 nurses.4
I believe, as surgeons, we are not immune to having some de-
gree of cortisol dysregulation during this ongoing pandemic. As
such, I looked into the literature to find non-medical ways of
reducing one’s serum cortisol levels in order to help manage the
‘subclinical’ Cushing's state we find ourselves in. I would encourage
each of you to personally explore and examine these therapies and
incorporate some of them into your daily lives going forward.
Exercise Versus Yoga
The benefits of exercise are well known to physicians. For those
of you who exercise regularly know very well, the B-endorphin
‘high’ from exercise is a welcomed relief from the day-to-day
stresses in our busy lives. The endocrine response to acute exer-
cise is related to both intensity and duration. Exercise increases
serum cortisol, allowing for the availability of metabolic substrates,
protects from the immune cellular response at the tissue level, and
maintains vascular integrity.5 Inactivation of cortisol into cortisone
is protective of the deleterious effects of high cortisol levels.
However, over-training impairs this inactivation. In other words,
excessive exercise as a mechanism of coping during COVID is likely
adding to an already chronically high cortisol level. Yoga, on the
other hand, has been shown to not only increase B-endorphins but
also decrease cortisol levels, reduce inflammatory cytokines, such
as interleukin-6 and tumor necrosis factor-alpha, improve bio-
markers of neural plasticity, and improve the quality of life.6,7 The
added advantage yoga has on increasing ones’ flexibility, as well as
the mindful mediation of quieting the mind, has become an
invaluable tool to me, particularly after a long day in the operating
room.
J.L. Pasieka / Surgery 171 (2022) 94e95
95
Shinrin-Yoku and Greenspace Interventions
Shinrin-yoku is a Japanese tradition of stress reduction and
literally translates into “forest-bathing.” In other words, walking in
the forest and breathing in the fresh air. In a recent systematic re-
view that included 22 articles and a meta-analysis (8 articles),
Antonelli et al evaluated the stress-reducing effects of “forest-
bathing” and found that in all but 2 studies, the cortisol levels were
significantly lower in the Shinrin-yoku groups compared with ur-
ban environment groups.8 Most interesting was that the data also
saw a reduction in cortisol levels in a sub-group analysis of ‘forest-
watching’ compared with visiting an urban environment. Although
the sun and microbiome exposure, as well as the calming sounds of
nature while walking in the forest, likely plays some role in stress
reduction, observing the forest and/or natural environment seems
to also influence cortisol levels. The degree to which HPA can be
influenced by visualization alone of a forest requires further
investigation.
Since not all of you live within 100 kilometers of a national park,
I looked deeper into whether greenspace exposure (gardening,
visiting urban parks, outdoor active, and passive activities) has an
effect on cortisol levels. It appears that greenspace interventions
can also reduce cortisol and stress levels, yet most studies on this
topic are limited by data collection methods and heterogeneity of
the study design.9 Although more research is needed, the current
data would suggest that greenspace exposure is associated with
numerous health benefits, enough to encourage policymakers and
urban planners to create, design, and maintain accessible green-
spaces in urban centers.
that many of these digital ‘tools’ will remain, thus making it even
more important for each of you to find ways to maintain a healthy
balance of internet use.
Music, Art, and Canine Therapeutic Interventions
There are many other activities that have been utilized to
decrease stress and cortisol levels. Music therapy has been shown
to not only decrease salivary cortisol in dental patients but, in a
recent systematic review, has been shown to decrease stress and
anxiety in critically ill patients.11 Both art and canine therapeutic
interventions have been shown to decrease cortisol levels in HCWs
as well as help reduce stress in university students, palliative-care
patients, and military personnel suffering from PTSD.
In summary, it is important for each of us to recognize that this
past year has brought unprecedented stressors into our already
stressful lives. The “sub-clinical Cushingoid” state we find ourselves
in needs to be addressed now and going forward. The onus is on you
to take care of yourself in order to be able to take care of your pa-
tients and family. The added stressors that the pandemic has
brought may ease up, but the stressful career we have chosen will
continue. Consider taking up yoga and/or mindful meditation.
Bring music back into your life. Do not underestimate the value of
the family pet. Learn to draw or paint. Putter in your garden. Get
outside and bathe yourself in a forest or a greenspace. And, once in
a while, take some time to disconnect from that smartphone and
learn (or re-learn) to enjoy and appreciate the simpler things in life.
Funding/Support
Nomophobia
The digital world has, in many ways, been beneficial to us during
the pandemic. It has allowed us to stay connected to family and
loved ones, allowed us to switch to digital learning platforms, and,
for many, enabled us to work safely from home. Yet, the de-
pendency on the digital world also has added to our chronic stress.
Cal Newport, in a recent article in The New Yorker, talked about how
history has shown us that technology can provide superficial con-
veniences that are poorly matched to human nature. He goes on to
say that we are in a chronic state of anxiety because of a workflow
pattern based on constant messaging and emails. Although at first,
digital meetings were a way to stay connected and productive, they
have become, at times, invasive and exhausting. The constant
‘connectivity’ does not allow much time for oneself. Nomophobia is
the fear of being without access to a working smartphone and was
first described in 2015. It appears that between 60%e80% of pro-
fessionals have some degree of moderate to serve nomophobia.
Serve nomophobia, however, leads to a 14-times higher rate of
problematic phone/internet use. With the digital world encroach-
ing more and more on our daily activities, a balance between
leisure-time internet use and work-time use must be found. An
online cross-sectional survey of 446 individuals found that those
with a work-time internet use between 5e28 h/wk reported a
higher perceived quality of life than those who exceeded 28 h/wk.
They also found that addictive/problematic internet use was asso-
ciated with higher leisure-time utilization, and ideally this should
not exceed 4 h/wk.10 The onus is on the surgical leadership to
recognize the added burden of the digital work-time environment
that this global pandemic has created and find ways to contain the
work-time utilization for its members. Many organizations have
done so by limiting the number of internet meetings during a given
week and have given their employees the ‘right to disconnect.’ As
this pandemic subsides, it is important to be cognitive of the fact
There was no funding provided for this paper.
Conflicts of interest/Disclosure
Janice L. Pasieka has no financial disclosers.
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