Fifteen years ago, David Sabgir, a practicing cardiologist in Columbus, Ohio, tried something new that would prove to be revolutionary. Having spent countless years vainly urging his patients to get more active, even if just to take a walk around the block, in a moment of desperation one winter day, he asked a patient to meet him outside the clinic. 鈥淚 decided I wanted this patient to say no to my face,鈥� Sabgir remembers, laughing. 鈥淚 said, 鈥楥an I invite you to join my family and me in the park one Saturday morning?鈥欌�� His patient鈥檚 response was immediate and enthusiastic. 鈥淭hat was really kind of magical,鈥� Sabgir says.

Based on the good response, Sabgir went on to ask other patients to attend a group outing. In the end, when he finally hit the park after the snows of winter had melted, Sabgir was joined by over a听hundred patients and colleagues. Since then, this simple idea鈥攚alk the talk with your patients鈥攈as caught on with health care providers in nearly every discipline. The organization Sabgir went on to found, Walk with a Doc, now supports provider-led walking excursions for patients around the world, with nearly 500 Walk with a Doc chapters leading monthly outings in 48 states and 25 countries, on six out of seven continents.

Sabgir, who has personally led more than 450 outings, estimates that听over the last decade, has helped hundreds of thousands of people get outside. Nearly 40 percent of participants say it鈥檚 their first time out [for the purpose of well-being]听in years, if ever.

We caught up with Sagbir recently, as his organization finished its most ambitious outing yet: 50 consecutive miles.

国产吃瓜黑料: You鈥�ve just led the longest听walk of听your organization鈥檚 history. What motivated you to try for 50 miles?
Sabgir: The idea grew out of these 50-mile walks that leaders in American history have organized over the years. Teddy Roosevelt started it in 1908, to improve the readiness of American troops, and JFK and Bobby Kennedy picked up that mantle 50 years later. It鈥檚 now been over 55 years since the first ,听so we thought the time was right for a big event.

How did it go?
It went great. Collectively, we had 158 people walk over 1,700 miles. I believe 14 people did the full 50 miles. And we exceeded our major fundraising goal.

I鈥檓 embarrassed to say that I myself did not do the walk. Although my training went fantastically鈥擨 still feel the endorphins pumping from a 26-mile walk my wife and I did the previous weekend鈥擨 injured my back lifting a planter a few days before the event. Most likely I herniated a disk.

That must have been disappointing.
Despite being in pain, it was a ten听out of ten听for me. After the event, I went home and was pretty much flat on my back the rest of the day. Thank God the park was literally next to my house.

Our original goal was:听let鈥檚 all walk 50 miles. But seeing the looks on the faces of our attendees when we announced that distance, I realized it just wasn鈥檛 right. A lot of them were thinking, I can鈥檛 walk 50 miles. We want them to be a part of every walk, so we ended up designing options for everyone. The goal became to push yourself: if five miles is a reach, we want to help you do that.

Over the years,听you鈥檝e inspired thousands of health care providers to hit the trails with their patients. Why do you think this idea has caught on?
My goal was pretty simple鈥攋ust get more people outside and moving. Probably 5 percent of my patients were achieving the weekly recommendations, and probably 80 percent were not doing anything at all.

Initially, I didn鈥檛 think the idea was that revolutionary. I know from studies that walking or any physical activity is by far the best medicine. But no one was doing it. I spent months Googling this to see what other people had already done. I knew it had to be around already鈥攊t was too easy, and it made too much sense.

We were also at the right time in history. The internet had been out for, what, eight years听when we started? So it was easy to coordinate, and cell phones made it even easier. We just got to be the lucky ones to ride this roller coaster. We added 189 chapters last year. And this year we are on pace to add about 20 per month. These days, I鈥檓 90 percent cardiologist, 10 percent Walk CEO.

You say the couch is the dangerous thing. How much can something as simple as walking help?
To say exercise is the best medicine is a massive understatement. It is 100 to 1,000 times better than the best medicine.

There鈥檚 this negative cycle to inactivity, a cascade where excess weight leads to back pain, leads to bad sleep. I see it magnified every time I open the exam-room door: back pain, arthritis, sleep apnea, coronary artery disease, depression, anxiety. Being active reduces stroke and heart disease by 50 percent, depression by 50 percent, and 础濒锄丑别颈尘别谤鈥檚 by 50 percent. The answer is right there! The fact that we aren鈥檛 doing this before more invasive or expensive interventions is sickening. We aren鈥檛 taking care of what we can take care of easily. 听

What kind of patients tend听to join a walk?
It鈥檚 pretty diverse.听A lot of times it鈥檚 people that may be scared about either a recent diagnosis or a family member with a diagnosis. And they may bring out someone, like a sick family member, that they are concerned about. But they are so diverse that I have a hard time categorizing them. When we鈥檝e surveyed our walkers, around 78 percent听say that they feel they are getting more physical activity then they otherwise would have without Walk with a Doc.

I鈥檓 constantly impressed by our walkers. I had one patient who came to the walk every month for years, even after she couldn鈥檛 walk. She just loved being in the park with us. It would warm your heart to see her covered with blankets on a 30-degree day, out in her wheelchair. She eventually left us an endowment that we have allocated completely to partnerships with medical schools, to raise the next generation of walking doctors.

Being stretched too thin is a common complaint of doctors. Why ask them to lead walks on the weekend?
People still feel strongly about their health care providers. For a lot of the 30 to 40 percent of attendees听doing this for the first time, it鈥檚 comforting to have a health professional out there with them. A lot of them are scared to do this, even though the actually dangerous thing is staying on the couch. And they think, If my health care professional is out here with me, then it must be good for me.

Yes, doctors鈥攔eally all health care providers鈥攁re stretched thin.听I see in the range of 2,000 to 2,500 patients a year. Visits are 30 minutes each for new patients, 15 minutes for repeats. It鈥檚 easy to get nervous about your numbers. But, gosh, what you get back from these outings is so much more than you put in.

And what has been the reception among doctors who participate?
For starters, it feels really good to help your patients actually meet their goals. So that鈥檚 a primary reinforcer. But there鈥檚 also something special about being outside and opening up with your patients that I didn鈥檛 necessarily expect.

Typically, patients get a very brief allocation of time with their provider. They don鈥檛 love that鈥攁nd听trust me, your doctor isn鈥檛 thrilled about it either. People who go into health care dream about forming connections. On Saturday mornings, suddenly there鈥檚 time to connect. You get to meet your patient鈥檚 family. They get to meet your family. There is time to talk about the bigger picture, health or otherwise. You form friendships very quickly.

What a great thing to be able to offer a patient: Hey, I鈥檇 like to meet you outside of here鈥擨鈥檒l be at the park next Saturday, and we can catch up, and I can learn more about your family.

What鈥檚 next for you听and for Walk with a Doc?
Every morning I鈥檓 like a kid at听Christmas鈥攜ou never know where a request for a new chapter will come in from. Australia, Nigeria. I want to stay in the game as long as I can, and I want to see thousands of walks around the world.

We now have partnerships with 25 medical schools. That鈥檚 part of our grand vision. We want to transform the way medicine is practiced, to make it more open, accessible, and rooted within a community. I hope that there will be a time, within my lifetime, when people won鈥檛 remember when they didn鈥檛 take walks with their doctors. There are around 855,000 doctors in the U.S.听and so many more nurses and nurse practitioners. With a broad enough net, we can reach every community. That鈥檚 what keeps me going鈥攊magining that this incredible, simple, powerful thing is eventually going to be all over the world.

The post Your Next Doctor’s Appointment Should Be Outdoors appeared first on 国产吃瓜黑料 Online.

Thirty-five years ago, a young researcher at the University of Delaware conducted .听Having spent his childhood听sick with kidney disease, in and out of 鈥済loomy, sometimes brutal鈥� hospitals, Roger Ulrich was interested in finding ways to improve 鈥渢he environments where patients are treated.鈥� So he sought to test the potential influence of an old friend that had brought him comfort as a child: a solitary pine that he could view through the window by his sickbed. 鈥淚 think seeing that tree helped my emotional state,鈥� he recalled .

That small study would give birth to thousands of replications and expansions鈥攁nd an entire movement in architecture. Ulrich managed to find a hospital ward where, for years, patients had recovered from gallbladder surgery in identical rooms that overlooked either a small stand of deciduous trees or a brick wall. After pouring through nearly ten years鈥櫶齱orth of ward records, Ulrich found that patients with a view of the trees fared far better than the miserable patients with nothing but a wall to look at, even if their cases were identical. Those with a view took fewer painkillers, were rated by their nurses as being in better spirits, and, on average, left the hospital nearly a day earlier than those without a view. What was going on?听

We鈥檝e learned a lot about nature and the brain since then. After Ulrich鈥檚 foundational work, more than 100 studies have investigated the potential . From these studies鈥攎any of them small, observational, and imperfect鈥攚e believe that nonthreatening natural stimuli (as opposed to, say, a nearby lightning strike) can play a profound role in the regulation of our autonomic, or involuntary, nervous system. Natural settings that, to quote Ulrich, are 鈥渇avorable to ongoing well-being or survival鈥� appear to signal our brains that it is time to take a breather, allowing us to turn down our fight-or-flight system, restore our resources, and approach things that are good for us, like finding food or socializing. Specifically, we have learned that nature tends to result in reduced circulating levels of the 听and the inflammatory marker immunoglobulin A. It is also associated with lowered blood pressure,听 (or short-term emotional experience), blunted 鈥減erceived stress鈥� after , and lower short-term levels of . We also appear to after we鈥檝e spent time in nature, a phenomenon distinct enough to appear as differences in neural activity during brain scans.

But while compelling, that evidence base has left one glaring question unanswered: Does exposure to nature actually, lastingly improve our mental health? Two groundbreaking new studies have, in part, helped to answer that question.

Imagine that the day you were born you were assigned a personal code, much like听a Social Security number. You used this code when you enrolled in school, visited your doctor, filled a prescription, paid your taxes, got married, got divorced. But unlike a Social Security number, this code tracked your every move, inscribed in a massive system of interlocking data registers that could tell a researcher almost anything they wanted to know about your life. Such a personal identification system is the norm in Nordic countries, where the government provides a wide net of services for its citizens and consequently monitors their health, needs, and use of public services. This year, researchers in Denmark used this system to generate the largest and most comprehensive observational study of mental health and the environment yet undertaken: one million young adults, or from 1985 to 2003 and still living there by their tenth birthday.

The research team, led by Kristine Engemann and Jens-Christian Svenning at Aarhus University, combined long-term data on mental-disorder diagnoses from the Danish Psychiatric Central Research Register (which tracks inpatient and outpatient psychiatric care) with years of land-cover data derived from satellite imagery. They then asked if children raised in homes surrounded by more nature鈥攕pecifically green vegetation鈥攅xperienced better mental health as they grew into adolescents and young adults.

The researchers considered 16 distinct mental disorders, from schizophrenia and depression to anorexia and personality disorders. Based on prior evidence, they had reason to expect that rates of depression or anxiety might be lower among children raised in greener neighborhoods. in the proceedings of the National Academy of Sciences in March, they found, to their surprise, that children from greener neighborhoods were less likely to develop nearly any diagnosable mental illness.

Because those areas tend to be wealthier, the authors adjusted their findings for levels of family and neighborhood affluence, using the rich personal data available, under lock and key, to epidemiologists working in Denmark. They found that the link remained significant for 14 out of the 16 examined disorders. 鈥淲e thought maybe we would see an interesting association within a band of disorders,鈥� Engemann says. 鈥淏ut there was this general association that being surrounded by higher levels of green space in childhood was associated with lower risk.鈥� This was regardless, she says, of where in Denmark children lived or how nice their neighborhoods were. 鈥淭his was not a localized phenomenon.鈥�

All told, children raised in the least green neighborhoods were 55 percent more likely to develop a mental illness than their peers who grew up in the greenest neighborhoods, regardless of social standing, the area鈥檚 level of affluence, or parental history of mental illness.

鈥淭his was a really powerful study,鈥� says Ben Wheeler, an epidemiologist at the European Centre for Environment and Human Health, who designs large-scale听studies of nature and health. 鈥淚 was quite surprised by the scale of the effects.鈥澨鼳 few years ago, Wheeler was involved in a similar, albeit smaller, study in the UK, monitoring the mental health of over 1,000 people as they changed residences across many years. His team found that when people are living in greener environments, they report better psychological well-being and less psychological distress, regardless of what else is going on in their lives or neighborhoods. The new study from Denmark suggests that this lower distress can be measured in actual mental illness averted. 鈥淥nce you look at the numbers,鈥� Engemann notes, 鈥渢hat adds up to quite a large number of yearly cases.鈥�

Of course, correlation does not prove causation. That鈥檚 where the second study comes in, this time observing differences among people exposed to different levels of greenery by actually manipulating the environment听on a city scale.

In a first-of-its-kind randomized control trial, the Journal of the American Medical Association Network Open in July 2018,听researchers from multiple U.S. universities, funded by the National Institutes of Health and the Centers for Disease Control and Prevention, discretely altered the environment of an entire city to ask if changing the quality of open and green spaces results in a detectable shift in residents鈥� safety, criminal behavior, and mental health. 鈥淲e presented this as how a randomized trial for a new drug would go鈥攂ut for spaces and places,鈥� recalls one of the project鈥檚 leaders, Charles Branas, chair of the department of epidemiology at Columbia University鈥檚 Mailman School of Public Health.

Branas and his colleagues selected 541 vacant lots across the city of Philadelphia and randomly allocated each to either receive no intervention, receive regular trash removal and mowing, or be turned into open pocket parks, with trees and a pleasant, short wooden-perimeter fence. Survey teams blind to the intervention were sent out to question residents at random听before and after the great experiment, eventually interviewing nearly 450 people about their mental health. When the study was complete, its architects found that residents of neighborhoods where lots had been greened were much healthier psychologically than those whose lots had merely been cleaned. Around greened lots, neighborhood-level rates of feeling 鈥渄epressed鈥� dropped by 42 percent, feeling 鈥渨orthless鈥� by 51 percent, and having generally 鈥減oor mental health鈥� by 63 percent.

鈥淚t鈥檚 a big finding,鈥� says Eugenia South, the study鈥檚 lead author, a doctor of emergency medicine at Presbyterian Medical Center of Philadelphia and the University of Pennsylvania. 鈥淭his is the first study to show that changing the environment prospectively can change the way people feel听and improve their mental health.鈥� She notes that interviewed residents were not always aware that a change had necessarily occurred in their neighborhood, which suggests that you may benefit from having nature around you even if you aren鈥檛 conscious of it.

For now, these recent studies provide suggestive but compelling evidence of nature鈥檚 lasting effects on our mental health. But one mystery still remains: just how precisely it calms us down. Does the magic happen through autonomic stress reduction,听having a place to meet people and get active, or just by seeing something beautiful every day? 鈥淲e still don鈥檛 know,鈥� says Kathleen Wolf, a social scientist at the University of Washington who has studied this phenomenon for decades. While her younger colleagues call these new studies 鈥済ame changing,鈥澨齭he can only shake her head in amazement at the recognition and funding that the field is finally getting.

But the lingering questions shouldn鈥檛 stop us from filling that free mental-health prescription by spending more time in natural settings听regularly and intentionally. As we reported in 国产吃瓜黑料鈥檚 May issue,听clinicians, public health departments, and even some health insurers are deciding that they don鈥檛 need to wait for more evidence before acting. Many are beginning to experiment with using the outdoors as the stage of the next great health intervention. Maybe you should, too.

The post The Incredible Link Between Nature and Your Emotions appeared first on 国产吃瓜黑料 Online.

鈥淗ow often do you all get outside?鈥� primary-care physician Ryan Buchholz asks. It鈥檚 a Thursday afternoon in October, a warm one for Washington, D.C., where Buchholz practices. His patient, a young boy named Ariel, doesn鈥檛 answer. Maybe his mind is on the flu vaccine he just heard administered to a child in the room next door. Maybe he doesn鈥檛 understand the question鈥攈e鈥檚 only two years old, after all. Ariel clutches a blue teddy bear as his father, Fernando, answers. No a menudo. Not often.

In exam room three of the , Buchholz is performing a routine wellness exam. To Buchholz, wellness means a child is eating right, brushing their teeth, getting vaccinated鈥攁nd spending time outdoors. On a desktop computer, the modern doctor鈥檚 stethoscope, he pulls up a , which was created by another pediatrician at the center, Robert Zarr, founder of the public-health nonprofit Park Rx America.

Buchholz is warm and earnest, with short brown hair flecked with gray. He navigates quickly and finds some good-sized city parks near the family鈥檚 home. After he coaches Ariel鈥檚 father on the benefits of outdoor play鈥攃hildren who spend time outdoors tend to experience better physical and mental health鈥擣ernando鈥檚 phone pings with a text message, which shows the locations of the parks, outlines a new nature prescription, and includes a link to notify Buchholz whenever the prescription has been filled. Five seconds later, the doctor rises to test Ariel鈥檚 lungs, brandishing an actual stethoscope.

You could have missed the nature talk if you hadn鈥檛 been paying attention. It consumed less than three minutes out of twenty. But when the Floreses left the clinic that day, they had a map and a mandate from an authority figure to go play鈥攐utside and often. There鈥檚 a movement brewing in America鈥檚 hospitals, clinics, and outpatient treatment centers. As depression and anxiety rates climb and the obesity epidemic rages on鈥攂y the Centers for Disease Control and Prevention鈥檚 last count, one in three U.S. adults and nearly one in five children are now obese鈥攈ealth care providers are losing patience with traditional tools. They aren鈥檛 abandoning pills and procedures by any means, but to help their patients avoid growing heavier, sadder, or sicker, they are looking far outside their offices.

Research institutes for nature and health are opening at major medical centers, electronic health-record systems have begun to incorporate nature prescriptions just as they do pharmacological ones, and at least one major health insurer has begun offering incentives for nature prescriptions. Those prescriptions take many forms, from general encouragement to get outside at least twice a week to specific instructions for activity, location, duration, and frequency. In a world where we increasingly live our lives indoors, says Zarr, one of the movement鈥檚 pioneers, 鈥淲e are starting to think about nature not just as a place to recreate, but also as a social determinant of health.鈥� There鈥檚 no diagnostic code for nature-deficit disorder鈥攖he term coined by Richard Louv in his 2008 book 鈥攂ut if there were, Zarr says, 鈥淚 would use it a lot.鈥�

Later in the day at Upper Cardozo, the mood in exam room three is a bit more tense. Another of Buchholz鈥檚 patients, an 11-year-old named Jason, explains that he wanted to skip his checkup. Jason is on the gray exam table as his mother, Roxana, sits beside him, holding her infant daughter. 鈥淚鈥檓 scared that you might get mad at me,鈥� Jason tells Buchholz. 鈥淏ecause of my weight.鈥�

Buchholz looks tired but not terribly surprised. Jason has been overweight for the past eight years. After making a plan with Buchholz to go outside more and drink fewer sugary drinks, Jason had begun to lose weight. But lately he鈥檚 been gaining it back. He鈥檚 been good about the sugar, he says, but he hasn鈥檛 been getting out as much, even though he loves to play soccer in the park near his home. Buchholz pries, gently, and the reason emerges: a bully. 鈥淗e gets mad at me when I take the ball away from him,鈥� Jason says. 鈥淚 say it鈥檚 just a game. Then he starts calling me stuff, like fat.鈥� The boy tears up. 鈥淓very time when I start running, he makes fun of my stomach,鈥� he says. 鈥淚 just want to be skinny.鈥� He seems defeated. 鈥淚 hate being fat.鈥滲uchholz puts a hand on Jason鈥檚 shoulder. 鈥淚 think you are just fine,鈥� he says. 鈥淚 want you to know that.鈥� He frowns. 鈥淟et me see if we can find another park close to where you live.鈥� Buchholz opens the Park Rx America tool and begins to hunt.

鈥淗ave you ever been to Bancroft Elementary School?鈥� he asks. Jason hasn鈥檛. Buchholz scans the park details to make sure there鈥檚 a soccer field and plugs in a new prescription. 鈥淚 can go once a day,鈥� Jason offers.

Roxana swipes her phone to see Jason鈥檚 updated prescription, with maps, images of green fields, and descriptions of a number of park options. She puts the phone down and Jason picks it up. He sniffs lightly, rubs his eye, and begins scrolling.

Buchholz turns away from his computer. 鈥淚n my experience, kids who try and make other kids feel bad usually have a problem, and they don鈥檛 want anyone to know about it,鈥� he says. 鈥淪o they try to make everyone else feel bad.鈥� He鈥檚 trying to provide some comfort, but Jason isn鈥檛 listening. He鈥檚 reading his prescription.

鈥淥h, this is Bancroft?鈥� Jason asks.

鈥淢尘-丑尘尘.鈥�

Jason whistles. 鈥淏ancroft is nice.鈥�

Doctors have been encouraging their patients to go outside for millennia. Hippocrates called walking 鈥渕an鈥檚 best medicine.鈥� Han dynasty physicians encouraged outdoor 鈥渇rolicking exercises鈥� to ward off aging. And until the mid-1940s, tuberculosis patients were sent to mountain retreats to take in the 鈥渕agic airs.鈥�

What鈥檚 happening now is different. It鈥檚 widespread, systematic, and, at least in aspiration, evidence based. Though boutique wilderness treatments for trauma and some behavioral disorders have existed for years, the idea that your primary-care physician, psychiatric nurse practitioner, or cardiologist might prescribe a park before a pill is quite new. Most credit the concept to a regional Australian recreation department, Parks Victoria, which began to link the outdoors and human health through initiatives with medical providers in the early 2000s. Soon after, the first mainstream, provider-based outdoor programs in the U.S. started to tackle common diseases. In 2005, in Columbus, Ohio, cardiologist David Sabgir invited his heart-disease patients for the first of what would become hundreds of group park walks. (His organization, Walk with a Doc, now has some 450 chapters in 25 countries.) In 2006, 鈥攖he nation鈥檚 first nature-prescription program鈥攚as founded in Albuquerque, New Mexico, with the aim of encouraging chronic-disease and other patients to hike and walk outside.

Since then 鈥渢he movement has exploded,鈥� says Betty Sun, the health-program manager at the , a San Francisco nonprofit that has expanded its mission to include public health, in part by coordinating knowledge sharing across nature-prescribing programs. According to Sun鈥檚 most recent survey, in July 2018, the U.S. now has 71 provider-based nature-prescription programs in 32 states, with the potential to reach hundreds of thousands of patients. The programs tend to fall into two camps: some, like Park Rx America and Tennessee鈥檚 Park Prescriptions, are widely available and center on doctor counseling supported by digital tools to help patients find nature and remind them to go out in it. Others, like California鈥檚 Santa Clara County ParkRx, are available to high-risk patients at select clinics and follow up on doctors鈥� orders with phone reminders, transportation support, and group outings.

For health care providers, there are two reasons to prescribe nature. The first has to do with what it may do for us. Exposure to nonthreatening natural stimuli, scientists have discovered, lowers blood pressure, reduces stress-hormone levels, promotes physical healing, bolsters immune-system function, raises self-esteem, improves mood, curtails the need for painkillers, and reduces inflammation. One leading theory is that these stimuli鈥攖he scent of plants, the sight of trees swaying in the breeze, the sounds of birds, streams, and rustling leaves鈥攃ombine to activate the unconsciously controlled 鈥渞est and digest鈥� functions of our bodies, which are regulated by our parasympathetic nervous system. These functions are suppressed when a threatening stimulus, whether a venomous snake or an aggressive work e-mail, triggers our sympathetic 鈥渇ight, flight, or freeze鈥� system. If that response stays active long enough, our immune, digestive, reproductive, and psychological health suffers. In an increasingly urbanized world, in other words, nature cues our brains to shift us from a depleting to a restoring state. 鈥淭he environment of our original adaptation is all outdoors,鈥� says Chao-ying Wu, a pediatrician in Bellingham, Washington. 鈥淚t just makes sense.鈥�

The second鈥攁nd more common鈥攔eason that clinicians prescribe nature is that with the parasympathetic system happily activated, the outdoors becomes a great place to do beneficial things that we might not otherwise enjoy doing鈥攍ike exercising.

Behind closed doors, some providers will also admit that prescribing time in nature makes them feel better personally. 鈥淚t鈥檚 hard for us, through the fatigue and burnout, to be focusing all the time on the problem list,鈥� says Zarr. 鈥淚 sometimes need a break from the negativity.鈥� Talking about getting outdoors, he says, is 鈥渁 positive thing to do in the room.鈥�

For Zarr, a typical park prescription starts with two questions: What do you like to do outside? And where do you like to do it? 鈥淲ith that,鈥� he says, 鈥渉alf my prescription is done already. It gives me a baseline place and activity that they feel good about. Then it鈥檚 my job to push it up a notch in terms of frequency and dose.鈥�

Zarr has the bookish air of a Manhattan intellectual (glasses, receding hairline) combined with the physique of a triathlete. Despite a busy clinical and travel schedule, he walks, cycles, or hikes outdoors three or four times a week. 鈥淚 try to get out for my own mental health,鈥� he says. On his desk, review articles about hypertension share space with how-to guides on Shinrin-yoku, the Japanese art of forest bathing. But nature medicine is a relatively new preoccupation for Zarr. Around 2010, 鈥渟omething shifted,鈥� he says. That鈥檚 when he heard Richard Louv give the keynote speech at the American Academy of Pediatrics鈥� national convention, connecting the rise in childhood obesity and ADHD to kids spending more time inside. 鈥淲henever I go to a talk or read a book,鈥� Zarr says, 鈥淚 ask myself, Is that what I see in my own clinic? And I realized that there was a lot of truth to what he was saying.鈥� So many of Zarr鈥檚 pediatric patients and their family members were suffering from anxiety, obesity, and attention-deficit disorders. 鈥淭hey were on their devices constantly,鈥� he recalls. 鈥淭heir routines were horrible. I thought maybe a nature prescription would solve a lot of these seemingly unrelated problems.鈥�

The timing was right. Inspired by news coming out of Australia, leaders from the Golden Gate National Parks Conservancy, the National Park Service, and the U.S. Fish and Wildlife Service had just begun training clinicians and offering funding for pilot projects. In 2011, when Zarr was president of his local chapter of the American Academy of Pediatrics, he began to test the use of nature prescriptions at Upper Cardozo, as well as at George Washington University鈥檚 Children鈥檚 National Medical Center. In the summer of 2013, he and his colleagues launched a web-based prescription tool, , connected to a database of green spaces around D.C. They took it national as Park Rx America in 2017. Providers in 16 states now use it. Erin Wentzell, a doctor of physical therapy at George Washington University who works with children with disabilities, remembers when Zarr first pitched her department the idea. 鈥淚 thought, This is amazing鈥攖his is exactly what we need. For kids, being outside is so motivating,鈥� she says. Some of her patients鈥攆or example, children with developmental disabilities who have difficulty walking鈥攎ay give up quickly if they鈥檙e inside a clinic or at home. 鈥淏ut if there鈥檚 a really big hill and we鈥檙e going to collect leaves at the top of it,鈥� she says, 鈥渢hey鈥檒l keep going.鈥�

Now the million-dollar question is: Do these programs work? While it鈥檚 too soon to say whether health outcomes, like depression or obesity, will shift noticeably in patients who are told to get outdoors, we have reason to be optimistic. For starters, a doctor鈥檚 recommendation can matter a good deal. Meta-analyses of multiple studies suggest that, for example, you鈥檙e almost four times more likely to attempt to lose weight if your doctor suggests it.

鈥淧roviders can motivate people to change their behavior,鈥� says Megan McVay, a psychologist who studies weight-loss decision-making at the University of Florida. The trouble comes when the new behavior is difficult to sustain. 鈥淧eople鈥檚 motivation comes and goes. A prescription could get people to the park, but it may not keep them going back,鈥� McVay says. She believes that regular programs in parks, like ranger outings or meditation classes, can help people who arrive based on a nature prescription build a habit out of a suggestion.

Last May, when Zarr presented his prescription software to Georgetown University鈥檚 family-medicine department, one of the final questions from the largely receptive audience was about any evidence from randomized control trials. Zarr acknowledged that no large trials existed yet. 鈥淚 promise that I am trying to get that evidence,鈥� he told the physicians, 鈥渂ut let鈥檚 not wait for that.鈥� A few months later, the National Institutes of Health declined to fund a trial that Zarr and his collaborators had proposed, though they have since resubmitted a revised version. But such studies are expensive, says Charm Lindblad, executive director of the program behind New Mexico鈥檚 Prescription Trails. 鈥淚f we had money, we would have done them a long time ago.鈥滻n terms of clinical evidence, the movement is still in its infancy, says Bita Kash, director of the Center for Health and Nature at Houston Methodist Hospital in Texas, which was established last year in collaboration with the Texas A&M Science Center and former first lady Laura Bush鈥檚 program Texan by Nature. 鈥淲e are where physical exercise used to be about 30 years ago, when it started to take off,鈥� Kash says. She is confident that exposure to natural stimuli improves health. 鈥淏ut,鈥� she adds, 鈥淚 know I have to prove it.鈥�

Tina听Igbinakenzua was speechless. We were in a forest just outside Oakland, California, surrounded by 150-foot-tall coastal redwoods. A shaft of light illuminated the ground before her, and she was overcome with emotion. Soon enough, her natural exuberance overcame her awe. 鈥淥h, my God,鈥� she said. 鈥淚 love this place.鈥�

Igbinakenzua was brought to the woods by a program called (Staying Healthy in Nature Everyday), run by pediatrician Nooshin Razani at the University of California at San Francisco鈥檚 Benioff Children鈥檚 Hospital. An early adopter of prescribing nature, Razani had noticed that despite wanting to, patients in her clinic often struggled to spend time outside. 鈥淲e serve extremely diverse clients,鈥� she says, 鈥渂ut the common thread is poverty.鈥� Getting out is hard, and critics of park prescriptions argue that those who could benefit most may be too busy, poor, or unwell to make it happen.

For this reason, Razani says, 鈥渨e felt that it was unethical to simply tell our patients to go outdoors.鈥� Trained as a physician in San Francisco during the AIDS crisis, she takes an activist鈥檚 approach to medicine. Convinced that her low-income patients needed nature as much as the wealthier Bay Area residents who flock to Yosemite and Muir Woods, she launched SHINE in 2014 and in 2016 founded the UCSF Center for Nature and Health, the country鈥檚 first hospital-based nature research program. One day each month, Razani and her colleagues lead an outing for around 50 children and parents in the UCSF network. When I visited last fall, she鈥檇 just received a referral for a cancer patient who had completed chemotherapy.

On the first Saturday of November, a crowd of kids and parents gathered in the lobby of the hospital鈥檚 Oakland clinic. One by one, families headed into private rooms for brief wellness checkups and counseling sessions about the health benefits of nature. Waiting parents leafed through an outdoor brochure published by the East Bay Regional Park District, which supports SHINE, while kids lined up at a child-high water fountain to fill Nalgene bottles emblazoned with the EBRPD logo. Sunlight streamed in from a glass-roofed atrium stairwell, illuminating two 16-foot paintings of redwoods.

When the checkups finished, Razani stepped up onto a chair near the front door. Her dark curly hair was down, and she looked excited. 鈥淐lap your hands if you can hear me!鈥� she shouted as children ran to circle her. The outing had begun.

鈥淲hen you are here, you feel so relaxed,鈥� Igbinakenzua told me later, after we鈥檇 disembarked from a yellow school bus into the redwood grove. 鈥淭he light, the shade. It鈥檚 so beautiful.鈥� Igbinakenzua was referred to SHINE for stress. An immigrant from Nigeria, she works as a nurse鈥檚 assistant at a local hospital. She鈥檚 up by 5 a.m. every morning, and between working full-time and raising two children single-handedly鈥斺�淥h, my God, there is so much stress,鈥� she said, laughing. Patients are welcome to attend as many outings as they like, and this was her family鈥檚 fourth with the clinic. We had just begun a picnic of turkey or tempeh sandwiches (lunch is part of every SHINE trip), and soon her children, Alex, five, and Lisa, seven, would head off with a ranger on an ecological scavenger hunt.

By wrangling transportation, food, guides, and other families, the program seeks to eliminate any potential barriers to getting outdoors. But does it make patients healthier? Is it more effective than just telling them to go outside? In 2015, Razani undertook a randomized trial of 78 parents to find out. All were counseled on potential health benefits (鈥淚n nature, you experience less stress and anxiety,鈥� they were told) and received family outdoor-activity prescriptions for three weekly park visits. About 65 percent were then invited on a nature outing that included transportation, food, and programming; the others were simply given a map of local parks. To Razani鈥檚 surprise, both of the groups saw similar health benefits. In fact, as she reported last year in the journal PLOS One, the two groups had largely indistinguishable results, experiencing small but statistically significant improvements in their physical activity and mental health. Many followed a dose-response curve, with higher numbers of nature outings correlating with greater improvements. 鈥淭he effects were modest,鈥� Razani says. 鈥淏ut so was the intervention.鈥� Her study also found that the poorest and most stressed families failed to make it to the group nature outings, suggesting that further support may be necessary to reach those with the greatest need.

鈥淢ost people here, they don鈥檛 have rides to ever go to the park,鈥� Igbinakenzua said. 鈥淥r they don鈥檛 know the way.鈥� Many of the other families agreed that they would struggle to get outside if there were no guided trips. 鈥淲e would never know this place existed,鈥� one father told me.Igbinakenzua says that SHINE has helped her make new friends, grow closer to her children, and try things like boating that she never thought she鈥檇 do. But for her, the most important impact has been psychological. 鈥淚 have so many things I have to think about,鈥� she said as we began the walking portion of the trip. 鈥淏ut when I am here, I am very OK. When I leave, I just pray to be the same way I am now.鈥�

Winter comes听quickly to western Wyoming. In September, the mountains get their first dusting of snow while the aspens begin to color in the warmer valleys. In Jackson, the cooler weather of October marks the start of an annual conference on conservation and recreation, the (鈥淪haping how we invest for tomorrow鈥�). Last year鈥檚 theme was Public Lands, Public Health, and as the elk ventured down from their high-altitude summer range, several hundred scientists, doctors, conservationists, land managers, nurses, and outdoor-recreation leaders convened to discuss the health benefits of nature.

Across several brisk days consistently described by the outdoorsy group as 鈥渂luebird,鈥� the attendees sat through presentations by Zarr and Razani, went on walks led by cardiologist David Sabgir, and listened to testimonials from guides and park rangers. They debated how to achieve greater scale within the movement, find consistent funding, and generate hard evidence of health benefits. Over the course of the talks, mild tension formed between those who were coming to nature via medicine and those who came to medicine via nature. Conservationists worried that calls for more research would delay action; doctors grumbled about the need for precision. At one point, John Whyte, the energetic chief medical officer for WebMD, admonished the participants to improve their social-media habits. 鈥淒on鈥檛 use the term forest bathing,鈥� he pleaded. 鈥淭hat鈥檚 going to turn people off.鈥�

As became clear during the debates, the movement still faces a number of hurdles. Chief among them are who should pay to keep existing programs open and where to find money to start new ones. So far, efforts have been developed and funded largely by partnerships between environmental nonprofits, local parks agencies, and public-health departments or individual medical institutions. Money for software, brochures, prescription pads, park surveys, and group outings tends to come from grants or charitable giving. Programs ebb and flow with the whims of their funders and the enthusiasm of their champions. That may change. Intrigued by nature as a potential low-cost intervention, health insurers have begun dipping their toes into the waters. Kaiser Permanente, the nation鈥檚 largest not-for-profit integrated health care system, began funding the Golden Gate National Parks Conservancy鈥檚 work around 2012. Since then, says Betty Sun, its support has been instrumental to the movement. And in April 2018, the North Carolina licensee of Blue Cross Blue Shield, the country鈥檚 oldest health-insurance association, began offering modest incentives to clinics for participating in the regional nature program .

For likely the first time anywhere, providers willing to write park prescriptions could potentially receive higher reimbursement rates. Since then, requests from clinics to participate have swelled, with nearly 125 clinics鈥攑otentially 500 providers鈥攅nrolled. 鈥淚鈥檓 honestly having trouble keeping up with demand,鈥� Jason Urroz, the director of Kids in Parks, which runs Track Rx, told me shortly after the insurance initiative鈥檚 launch last year.

One obstacle holding other insurers back is tracking. Unless you physically escort your patient to a park, how do you know if a prescription is filled, or at what dose and frequency? Most programs don鈥檛 yet track compliance as closely as researchers would like. Clinics that use Park Rx America can monitor adherence only if their patients click the link provided in the prescription, ideally only after they鈥檇 visited a park. Track Rx patients must register their hikes through an online portal. The SHINE program has no system for tracking park visits outside of its group trips.Many at SHIFT voiced confidence that the designers and managers behind these programs would soon innovate their way out of these problems. Tennessee State Parks, for example, plans to refine its phone app to passively record prescription fulfillment via location tracking. Greg Wiley, the app鈥檚 developer, hopes it will also monitor how long you鈥檙e out and how vigorously you move. 鈥淭his technology already exists,鈥� he says. 鈥淚t鈥檚 just a matter of adapting it.鈥�

In a show of faith from the outdoor industry, shortly after the festival REI announced the donation of $1 million to help launch a Nature for Health research initiative at the University of Washington. (To date, REI has also granted Nooshin Razani $200,000 for her work.) 鈥淲e are trying to catalyze the movement,鈥� says Marc Berejka, REI鈥檚 director of government and community affairs. The research initiative ultimately aims to inform health care practice, says Nature for Health director Josh Lawler, an 颅ecologist at the University of Washington. 鈥淲e鈥檒l know it worked if people end up happier and healthier.鈥�

Great advances in public health don鈥檛 always come from the shelves of pharmacies. Historically, a large number have arrived through collective efforts for change鈥攖o channel waste away from cities, screen food for contamination, or remove deadly toxins from the water supply, to name just a few. It鈥檚 a paradox of modern life that some of the most promising innovations in health care seem to be the outcome of collective action involving not just health care providers, but also journalists, insurers, park agencies, and conservationists, to reconnect us with things we鈥檝e recently discarded. Maybe we need food that wasn鈥檛 developed in a lab. Maybe we need to talk face to face. Maybe we need time outside. Treating nature as medicine can鈥檛 overcome the forces conspiring to make us chronically unwell. It won鈥檛 clean our air or make our cities more walkable. But in the gentle insistence that we need to spend some portion of our days in natural spaces to feel normal, it could motivate us to welcome nature back into our lives and give more attention to those who lack the means of doing so.

In the meantime, as the movement grows, patients are finding themselves venturing outside for the first time and discovering that it suits them. This was Rick Bulcroft鈥檚 experience. For most of his adult life, Bulcroft sat. A 65-year-old sociologist at Western Washington University, Bulcroft sat for work and he sat for leisure. (鈥淎 lot of TV watching,鈥� he says.) Then, during his annual checkup two years ago, Bulcroft鈥檚 primary-care physician, Greg Anderson, a former Navy doctor, warned him that his cholesterol, blood sugar, and blood pressure were too high, putting him at risk for diabetes, heart disease, and premature death. Reluctantly, Bulcroft had already started blood-pressure medication. Now Anderson added a prediabetes intervention program that encouraged calorie counting and regular exercise鈥攐utdoors if possible.

Anderson believed that the active ingredients in nature鈥攖he sights, the sounds, the smells鈥攚ould do as much for Bulcroft as the calorie counting. Bulcroft had tried to get in shape in the past, largely by logging hours at the gym. But this time鈥攚andering quiet trails in the woods, smelling fresh cedar in the morning鈥攕omething clicked. 鈥淲ith the park it didn鈥檛 feel like exercising anymore,鈥� Bulcroft says. 鈥淚 was just being outside.鈥�

Six months later, Bulcroft had lost 60 pounds. His blood pressure, cholesterol, and blood sugar were normal. He was so healthy, in fact, that Anderson told him he could probably go off the blood-pressure med. 鈥淚 feel great now,鈥� Bulcroft says. 鈥淭he only problem is that I鈥檝e had to buy new clothes.鈥� Last year, Anderson wrote 165 nature prescriptions. 鈥淭here鈥檚 no downside,鈥� he says. 鈥淭he worst thing that can happen is they don鈥檛 go. If they do go, then 100 percent of the time they feel better and they鈥檙e glad they went.鈥� 鈥淲e don鈥檛 see a lot of ads for parks on TV,鈥� Anderson tells his patients. 鈥淏ut if you put the power of nature in a pill, it would be a billion-dollar drug.鈥�

This article originally appeared in print and online with the rubric 鈥淣ature Rx鈥� and the headline 鈥淎sk Your Doctor If Nature Is Right for You.鈥� Both terms were originally developed by writer/director Justin Bogardus and Dream Tree Film as a part of a viral comedy series on the power of reconnecting with nature at nature-rx.org. 国产吃瓜黑料 has hosted some of these award-winning films on its website since 2015.

NatureDose is an app that measures your therapeutic time in nature. Set your weekly goal, then go outside and feel good.

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A good day for Katherine Schreiber begins with an hour of yoga. Without a morning stretch, 鈥淚 just don鈥檛 feel okay in my skin,鈥� she says. A health and fitness writer who lives in Manhattan, Schreiber leaves a yoga mat stretched out on the floor of her apartment at all times, 鈥渏ust in case.鈥� After yoga Schreiber will usually head to the gym for a quick hour or so of mixed exercise, 鈥渃ardio and core,鈥� before heading to work.听

Once several years ago, according to Schreiber, the soft tissue inside one of her spinal disks escaped its enclosure. The resulting herniated disk compressed a nerve running along the nearest vertebrae, creating throbbing pain in her lower back and intermittent, shooting pains down her legs.听鈥淭he doctor said I needed surgery,鈥� Schreiber remembers, 鈥渂ut there was no way I could take the time off from exercising.鈥� Schreiber, who has structured her life around exercising, is addicted to her workouts. Her apartment is minimally furnished and instead boasts free weights, a TRX machine, a body bar,听and spin bike, 鈥渁nd I have an elliptical coming,鈥� she says. Schreiber relies on her routine to feel okay, and the thought of missing a workout causes extreme anxiety. As a consequence, she holds memberships to two separate gyms in Manhattan, so she can workout at nearly any time, regardless of where in town she finds herself. 听

Told she needed surgery, Schreiber instead hit the gym. 鈥淚 had a herniated disk for over a year and I went to the gym everyday,鈥� she says. 鈥淗unched over鈥� an elliptical machine, Schreiber worked out in agony. 鈥淚 couldn鈥檛 even hold my back upright,鈥� she remembers. 鈥淚t was excruciating.鈥�

As it is for most living creatures, movement is a fundamental part of daily life. It is, or should be, as natural as eating or sleeping. In the developed world, though it clearly is not. We鈥檙e constantly told that too many of us are inert. But now a select few are too active. As a sedentary society struggling to reckon with the confining world we have built, our relationship to movement lurches between extremes. Eighty percent听of us do not exercise regularly鈥攁nd a small but notable portion of the rest may exercise too much. The research is limited but the best estimate鈥攆rom a 鈥斕齭uggests that three听percent听of regular exercisers are exercise addicted. If that rate holds for the U.S., nearly two million Americans could have an unhealthy dependence on their daily workout. These millions are apt to exercise to the exclusion of friends and family and the loss of work and social relationships. Sometimes they will cause themselves intense and possibly irreversible physical harm. And they cannot stop. Small reviews of dedicated athletes paint a more troubling picture: as many as one out of every five amateur runners could be exercise addicted. For marathoners and triathletes that number is one in two.听

Schreiber is tall, and blond, with a wide, friendly smile, and the built of an athlete. She has, she believes, struggled to control her dependence on exercise for more than a decade. In that time she has experienced several of the 鈥渨ake-up call鈥� moments familiar to addicts with more common addictions. She recorded one salient post for Addiction.com. The wake-up came one day when a stress fracture of her left foot, 鈥済ot so painful that I could no longer run nor get on an elliptical without agony pulsing from my toe to my knee,鈥� she wrote. That injury proved 鈥渁 blessing in disguise鈥� forcing her to step off the treadmill of her regular routine and downgrade to less activity. Nevertheless, she concedes in the post, she continued to exercise everyday, her fractured foot encased in a plastic surgical boot.

If given the choice a rat will run. A lot. When housed in a cage with a wheel a rat will run at night, 鈥渕ore and more and more,鈥� says Ben Greenwood, a neuroscientist and exercise physiologist at the University of Colorado-Boulder. In rodents, as in humans, exercise burns up stress hormones鈥攃ortisol in humans, corticosterone in rats鈥攁nd triggers the release of pleasant and potentially addicting chemicals, like endogenous morphine. A few weeks of exercise will lead to increased activity in the neurons of a rat brain鈥檚 pleasure and reward networks, according to , and an almost simultaneous downgrade in the sensitivity of neurons implicated in anxiety and depression. Not surprisingly, 鈥渞ats like to run,鈥� says Greenwood. 鈥淎nd if you take their wheels away they develop anxiety.鈥澨�

Exercise dependence has been called a 鈥減ositive addiction.鈥� But that鈥檚 a stretch. The severe addict is compelled to exercise two, three, sometimes more than four hours a day, everyday. Often a traumatic event鈥攖he fracturing of an arm, or passing out in a spin class, both actual examples鈥攃an act as a wake up call. But like any addiction, cessation can lead to withdrawal, symptoms which include nausea, insomnia, anxiety, anger, and irritability. Tolerance to the exercise dose, meanwhile, forces the addict into increasingly longer or harder workouts. Some will go into debt pursuing their activity. Others will be told by a doctor that, without rest, they will end up in a wheelchair or worse.听

鈥淭hey know they need to cut down, but they can鈥檛,鈥� says Heather Hasenblas, an exercise psychologist who studies exercise addiction at the University of Florida-Gainesville. Even those who do cut back, 鈥渞educe how much they exercise but they keep going,鈥� she says. Those unable to switch activities after an injury are often in constant pain, 鈥渂ut it is worth it to them because the alternative is intolerable.鈥�

Schreiber鈥檚 addiction began gradually, as most exercise addictions seem to. 鈥淲hen I started exercising regularly it was very easy to get away with over-doing it,鈥� Schreiber told me. 鈥淚t was a behavior that seemed healthy.鈥� The phenomenon may work a bit like this: we all have stressors in our lives, large or small, that we must cope with. You like to be healthy, to do things that are good for you. So when you get anxious or upset, you don鈥檛 grab a beer, instead you lace up, clip in, pull down, or whatever else makes you feel good and productive. Rather quickly the work pays off: circulating stress hormone levels drop soon after exercise has begun and stay low, especially at night. If you are anything like a rat, you will also experience a lowered stress response in the future. For a lot of people the story ends there.听

鈥淢any people can exercise two or three hours a day safely,鈥� says Hasenblas. But others, when they arrive home and towel off, find that their stressors waited for them. Anxiety, though dulled, returns, and the next time they head out, they stay out longer. The stress melts away and the endorphins kick in and the cycle repeats itself. Other coping mechanisms with less immediate physiological feedback, like devoting time to friends or family or community, tend to fall away.听

鈥淔or most people who are addicted it鈥檚 about escaping the problems in their life,鈥� says Mark Griffith, a behavioral addiction researcher at Nottingham Trent University in the United Kingdom. 鈥淭he paradox is that mood modification is an absolutely fundamental core to addictive behavior. People use the behavior either to get buzzed up, to get high, aroused, excited鈥攐r to do the exact opposite, to tranquilize, to escape, to numb, to relax.鈥� It is self medication. 鈥淎nd people use chemicals in the same way听to produce a reliable, consistent change in mood. Exercise is one of those activities that when you are absolutely in the moment you can鈥檛 think about anything else.鈥� That鈥檚 one of the things that makes exercise so great,听and potentially addictive. 听

Exercise dependence may be unique among addictions (save workaholism) in that a physical and emotional dependence builds within the confines of a socially-acceptable behavior. 鈥淣obody鈥檚 ever like鈥攐h you smoked three packs? Awesome!鈥� says Schrieber. This can make it easy to begin an addiction, and hard to tell when a line has been crossed. Inevitably, exercise provides all the rewards necessary for addiction: physical, psychological, social, and, if you are a professional, financial. 鈥淓ach of these is going to contribute to your addiction,鈥� says Griffith.

To听Hausenblas听the difference between safe and unhealthy exercise hinges on 鈥渢he underlying motivation.鈥� Is it to escape鈥攐r to achieve? 听To punish, or heal?

The handful of studies that have examined exercise addiction in professional or elite athletes suggest that they may not be immune to addiction. Far from it. In a small study of ultrarunners, Griffith only found three percent that met his criteria for exercise dependence. However, when he looked at a larger group of students training for careers in sports, the number of addicted jumped to nearly seven percent. Reported rates of addiction in competitive amateur runners have varied from 22 percent to nearly 40 percent, depending on the study population and the testing protocol used. A survey of more than two hundred triathletes selected randomly from international competitions classified half as highly exercise dependent.听

To Schreiber the hinge between healthy preoccupation and unhealthy obsession is flexibility. Does a committed exerciser 鈥渕aintain their schedule when they have a stress fracture or tear a muscle?鈥� she asks. 鈥淐an they take a break? If they do, can they sleep?鈥� Schreiber writes about addiction professionally and may understand her disease better than most. (She recently co-wrote, with Heather Hausenbla, the first popular manual on the disease). Yet she still finds herself absolutely compelled to exercise. 鈥淩elapses are involved,鈥� she says, and admits that she hasn鈥檛 taken a day off from exercise in years.

As most of us try to increase our time spent moving within or between stationary jobs, incapacitating commutes, and sedentary social activities, we all must struggle to find the right balance between no movement and too much. 听

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