Fake It Until You Make It

There are a lot of barriers to our health.  One of the biggest one is our attitude about our own health. As I was preparing for this post, I found this very interesting article. It essentially reviews the literature on the idea of “resilient aging”.  It looks at all the available research on the topic and identifies the factors that help lead to a more healthy aging process.  The main factors they identified are:

Resilient ageing
core attributes               Related terms

Coping                           Adaptation and attitude change

Hardiness                      Endure, survive, cope with hardship

Self-concept                  Self-worth, self-reliance, self-esteem, Self-concept, self-                                                        acceptance,  self-identity, self-discover, self-identity, self-                                                      discovery, self-efficacy, self-understanding, self-knowledge, self-                                          competence, self-discipline.

I suspect many of these traits are nature/nurtured into us by our parents and our childhood.  I do think people can make improvements in them. I know I had the fortunate experience to be nurtured into a high hardiness rating. We weren’t allowed to get sick when I was a kid. My mother forbid it.  She was a single working mother when I was really young and didn’t have time for us to not be able to go to daycare or school.  This continued even after she married my step-dad.  I had perfect attendance in 3rd grade and at that time they had a reward for White Sox tickets (I lived outside Chicago).  I went to 3 White Sox games- on the house- for not being sick that year! Talk about positive reinforcement.

Being a physician is probably a good job for me, since I’m around sick people all the time. Even now I’m rarely sick, I’m the only person I know that hasn’t had a cold this winter.  If I do feel like I’m getting sick, it’s never much more then being a little sniffly and tired for a day or two (I’m also aggressive with the zinc lozenges which may help).  High hardiness, thanks to my mother and probably some genetic factors.

I don’t know if you can learn that hardiness later in life. I suspect exercising more helps.  I know that exercise causes “demargination” of white blood cells (release of white cells into the blood stream) which can help fight/prevent infection.  I also think that getting enough activity just makes you tougher. People who were high level athletes deal with labor and pregnancy pain better then others.  I don’t have science to support this, it’s low numbers and from my experience with friends, patients, and my wife.  I have a friend who ran in college and took no pain medication after a surgery.  My wife thought her contractions were indigestion.  The night she was going into labor she kept having “indigestion” every 5 minutes.  So my tip for developing hardiness, if you don’t already have it, is to exercise.

The other two are harder, but they are also less tangible. Things like how much pain you have or how sick you get from a cold are pretty tangible.  They can be measured like in how much pain medication you need or how many sick days you take.  Things like your “coping skills” and self-concept are more ephemeral. People may be able to describe them about you, but in a lot of ways your internal feelings are the measure and our feelings can be pretty intangible.

That said, I think we can improve them.  We can work on not letting ourselves get as bothered by comments made by strangers on the internet.  We can get better at shrugging off the comments made by our family members about us.  We can improve our ability to move past unkind things done to us.  One way to do that is: fake it until you make it.

I’ll illustrate the concept by talking a bit about my life.  In junior high I had very close friends. A circle of buddies that I talked about deep things with, went on adventures, and with whom I played video games. We weren’t the cool kids in school- we were probably more the nerdy kids.  Several of my buddies went on to be pretty popular in high school, but at the time, none of us were.  Add to that- I was the smallest kid in my class.  Ok, there might have been one girl that was roughly my size, but she and I were dead-center front row at our 8th grade graduation.  Small, nerdy, not-cool.  My confidence wasn’t that great.  Let me re-phrase, my confidence in social settings wasn’t that great. I always had great confidence in my intelligence and somewhat of an irrational confidence in my physical ability.  The summer after my 8th grade year we moved from Illinois to Washington.

I honestly showed up in Washington on Friday and was starting high school at a new school in a new state the following Monday.  Usually this wouldn’t be an ideal situation.  I, however, decided that I was going to change my social lot and be “confident”.  I started faking it.  I pretended that I didn’t care about peoples opinions and that I was willing to talk to anyone.  It wasn’t really true. I was faking it.  I definitely had some days those first weeks where I ate my lunch on the walk to the cafeteria so I wouldn’t have that moment where you can’t find a place to sit in a social acceptable spot.  I even recall once or twice eating my lunch in the bathroom, just so someone wouldn’t have to see me eating alone or sitting at a table with the Magic the Gathering kids (more on that in a moment).

Time passed.  I’m not sure how much time, because I ended up running cross country that fall and then wrestling that winter and I started meeting people I also made friends with my neighbor Jenny and made friends with her friends (thanks Jenny and Allison!).  But somewhere along the way….I wasn’t faking anymore. I was confident.  I don’t know how “cool” I ever was. But confidence- yeah I had that.  In-fact it reached a point where Sophomore year I not only wrestled, but I was captain of the chess team (with all the Magic the Gathering kids) and nobody batted an eye lash about it.  In fact the wrestlers would give me a “Go kill ‘em” on my way to chess matches, genuinely impressed and excited.

Fake it, until you make it.  Eventually you won’t be faking it anymore and your elderly self will look back and thank you for putting that work in.

Up date

I haven’t given up on the blog. I’m putting the finishing touches on a E-book right now.  I anticipate I’ll be back to blogging in the new year after the E-book is released.  I also have a few guest blog posts planned for more heavily trafficked websites.  All while hitting a new PR in deadlift this week, starting olympic lifting lessons, working, and enjoying time with my family. Phew! Busy time of year, I’m still posting short stuff over on facebook.

 

https://www.facebook.com/gomaleoh

Calorie Underreporting

This is going to be another post essentially on a graph from a research study.  The study in question leads me to a recurrent finding of mine from research on obesity: the answer is healing your relationship with food.  That step is almost a required first step because as I’ve seen in my own life- until that happens it’s very difficult to get a handle on what’s going on with you.

I’ve covered the theme of calorie underreporting in a previous blog post. The current post however revolves around an older study which was new to me.

http://www.bmj.com/content/311/7011/986

The study involves over 300 Danish adults. “Main outcome measure: Bias in dietary reporting of energy and protein intake in relation to percentage body fat, assessed by comparison of data from an interview on dietary intake with data estimated from 24 hour nitrogen output, validated by administering p-aminobenzoic acid, and estimated 24 hour energy expenditure.”

So they used a 24 hour collection to measure total calorie intake and protein intake and compare that to the subjects’ reported protein and energy intake.  The findings suggest that as people got heavier they actually over reporting protein intake and underreported total energy intake. I found the graph to be fairly telling:

F2.medium

The first thing to notice is almost everyone in this study underreported their calorie intake.  The only people that were able (in this study) to really accurately measure their calories were women under 22.5% body fat. The researchers really don’t report their data in the way that more modern studies would report it- so I can’t say how many subjects this is or what the weight of these women are, but this is the first point I’d like to make:

To maintain what many would consider a low body fat % as a woman likely requires significant effort. Keep in mind that body fat up to 30% in women is considered normal.  It’s not that maintaining a normal body fat % doesn’t require some degree of diligence for a lot of people but you can see that the women between 22.5% body fat and 30% on average under report calories by roughly 15%.  This number is consistent with numbers seen in study after study.

This current study shows that it gets worse and worse (in general) to the point that the women with >42% body underestimated calories by roughly 45%.  Data similar in the men, though not as steep for those included in this study.

The study itself goes on to discuss that the estimated protein intake was less inaccurate than total intake and may imply that sugary/carb-fat predominant snacks may be more under counted.

To me however, it’s kind of a boring place to end. To me I’m always more interested in the WHY of the under-reporting.  Is it really that those people can’t measure as well? Is their ability to estimate calories worse?  Heck this study, like others, shows that almost everyone sucks at estimating calories…so what’s the point?

To me the point is that if your relationship with food and body is a good one, then it doesn’t matter in some ways if you are miscounting, in-fact I’m leaning more and more toward counting only as a gauge of approximate daily intake and having people move toward a more intuitive style. You can’t, however, do that if you are underestimating by 40%.  People who still have that kind of relationship with food likely essentially can’t self monitor.  Underestimating your intake by that degree by definition means a lot of “mindless” eating or binging. Hard to eat intuitively if you are eating mindlessly.  It may actually also include disassociative eating- eating that the body does simply to protect it against your efforts to restrict it.  That’s a theoryof mine I first presented when talking about women who underreported their calories by as much as 2000 in a day!

To me the answer seems to be to to give yourself permission to eat a cookie (or bowl of ice cream or a half bag of chips or whatever your “thing is”) which might just allow you to realize you are eating those things anyway.  I know that when I fully realized that i had eaten 7 large cookies (after a normal lunch) and a 1/4 of a sheet cake in a single day….that I was probably doing that regularly.  So before even discovering the concept of ETF I said to myself “why don’t I just plan on eating dessert 3-4 times per week and enjoying it…but not ever eat 7 cookies again unless I’m hungry and need them for calories.  I haven’t had a binge like that since (almost 1.5 years).

Sleep all the Sleep (part 3)

This post is the practical “how to” post.  I’m going to break my advice into five groups. The causes of the issues within all these groups are varied beyond the scope of this blog, but I’m going to try to give some practical insight into common problems and hopefully give you a framework on which to work on your sleep.  There is a ton of overlap between these groups.  Frankly most of us likely fall into a few of these categories, but in an effort to organize my thoughts, this is how I think about it.

Group 1: Sleeps enough, feels rested: continue.  Keep doing what you are doing. Though I will say, it’s probably worth considering at least scrolling to the Group 4-sub b (below) with the advice on sleep hygiene. There’s no reason to give yourself sleep troubles in the future by treating your sleep poorly just because you were good at it for your first twenty or thirty years.

Group 2: Sleeps enough (8+ hours), feels they sleep “well” (don’t wake up, fall asleep well) and doesn’t feel rested.  This group is another “easy one” actually.  If you are really getting enough sleep, all the time, with no “getting called into work in the middle of night” (aka I’m in this group) from time to time or “2 year old is up in the night with an ear ache or other problem”, then you need to be evaluated by your doctor.  There are a lot of people who spend 8-9 hours in bed all the time, feel like they are asleep the whole time but never feel rested. They wake feeling tired and are tired all the time. It gets somewhat more complicated from there of course, because there’s a difference between being sleepy (trouble staying awake while driving, fall asleep watching movies) and fatigued (a feeling of being tired without necessarily being sleepy) but that discussion is outside the scope of this post.  Both groups (fatigued and/or sleepy) with adequate sleep quantity need evaluation. The most common cause here will be sleep apnea.  I can’t even tell you how often I diagnose it, but it’s a lot.  If you are in this group and snore…..yeah you need a sleep study.

If you are in group 2 but in that subcategory like me that gets interrupted sleep for any reason outside your control: try to be as diligent about getting enough as you can and limit the tiredness that will come from having interrupted sleep.

Group 3: Doesn’t get enough sleep.  You know who you are.  You are a good sleeper, when you do go to bed you fall asleep pretty well, you stay asleep, and when you get enough sleep you feel good and rested. This group: go to freaking bed.  There’s a lot of people in the other groups that would throat punch you for your dumb pattern of just simply staying up too late and then feeling tired all the time.  I already discussed in the first post in the series that it likely does increase your hunger and intake. There’s a lot of research on decreased exercise tolerance when sleep deprived.

Beyond that, I’ll use my wife as another example of this problem.  She’s a pretty good sleeper and needs a fair amount of sleep (more then me).  She will get into a pattern of staying up excessively late reading for fun. She will be tired the next day and she will have less job satisfaction (domestic engineer raising our two daughters at home), be more irritable with our daughters, everyone will have a worse day, then after the girls go to bed she will “need more free time” because she hated her day so much.  What comes next? Her staying up too late and starting the pattern over again. A few days of this and I’ll basically make her go to bed early. She’ll have a great day the next day. Everyone will be happy. She’ll love her life and after the girls go to bed….she’ll be in a great mood and have no real need to stay up overly late.  Those are days that I come home and there’s been a new photo shoot of the girls at play.  Mom, kids, everyone is happy.  I think many people fall into this group. You’ll like your life more if you just go to bed early enough.  If you like your life more…..you won’t need to stay up so late.

Group 4: Trouble falling asleep:  This is probably the group I get consulted on the most in my office.  In some ways this is the most varied group because the differential diagnosis of trouble falling asleep is wide. Some common causes that I won’t spend some time on, but hopefully if you see yourself in here you will see your provider:

1) Untreated mood disorder, most commonly anxiety or PTSD, but also depression.      2)  Drinking excessive caffeine during the day  3) Restless legs syndrome (an uncontrolled need to move the legs)

4) Magnesium deficiency: I’m putting this one a little separate because people in Group 4 should probably just try taking magnesium anyway.  It’s likely that people that don’t get enough sleep don’t get enough magnesium. Supplementation can help with sleep and a variety of other symptoms (tremor, muscle cramps, insulin sensitivity, eye twitching, low potassium among others).

Ok, now the main Group 4 sub-categories I am going to cover are these:

Group 4-sub a: going to bed too late.  There’s a huge number of people who will tell me “I can’t fall asleep until after midnight”.  Frankly this group usually has a lot of overlap with Group 4-sub b, but there’s a particular pattern I see in this group all the time.  They are actually tired at 9-9:30 PM.  Even if they say they aren’t, usually they are.  What happens then is they watch TV, read, Facebook, internet, whatever, until 11 PM and try to go to bed and can’t fall asleep for a long time. What happens is an increase in stress hormones there around 9 PM when you pushed past what should be your bedtime.  Those stress hormones are often what is making you have so much trouble fall asleep at 10 or 11 PM.  It’s just too late. Often these people also don’t have to be up very early so they end up in a pattern of being able to sleep in which partially makes up for their initial poor ability to fall asleep. In general people’s circadian rhythms are heavily influenced by the light of day and waking up much after the sun comes up is a pretty unnatural thing.  People would be much better off going to bed earlier and waking up earlier, much like people 40 years ago did.  Forty years ago the average American slept almost two hours longer than now.  People will try to claim we are getting more done, but mostly that’s Facebook, internet or TV, not real money making productivity or home building productivity.  Just entertainment and maybe some education, which is what I consider my work on this blog.

Group 4-sub b: Going to bed at a reasonable hour but bad sleep hygiene.  Sleep hygiene in general is the idea of “promotion of regular sleep“.  The CDC link has some tips and you can find tips all over the web.  Here’s a few that can help: 1) Dark room, like complete darkness, even cover up your clock. 2) Don’t do anything in your bed but sleep and sex.  Watching TV, reading or even just lying and daydreaming in your bed creates normalization of wakefulness in your bed. 3) Screen time before bed. I recommend turning off all screens 1 hour before your bedtime if you have trouble falling asleep. White light is the signal for our brains to be awake and all our modern screens shine white light directly into our eyes from a few feet away, yeah not ideal.  4) Habit creation: same time to bed, same time to rise every day. 5) Appropriate intake (not hungry and not sick full) leading up to bedtime  6) Avoiding activating medications before bed. If you’ve recently started a medication and find you can’t fall asleep now, consider asking your provider if switching it to the morning would make more sense.

Group 5: Trouble staying asleep.  This group falls asleep pretty easily but has trouble staying asleep.  There are overlap features with other groups in this one. Untreated mood disorder is in here also.  People who are restricting calories will often have trouble staying asleep. People with sleep apnea will wake up frequently at night because their body is trying to make them breath all night long.  Primary insomnia- some people have none of the above and just are light sleepers or wake up overly frequently. Some of those people may need a sleep aid.  Reflux disease (at times associated with over consumption in the evening, other times anatomic factors including obesity) often wakes people at night from the burning chest pain.

Excessive alcohol, people who are drinking too much will often report waking in the early hours of the morning before they want to awake.  Excessive caffeine- I actually fall into this category also. If I drink coffee at night I can fall asleep no problems, but I will awake, alert at 4 AM.  The half-life of caffeine can be such that you will have enough left in the system in the early hours of the morning to provide wakefulness enough to make falling asleep harder.  Bladder disorders, if you have to go more then once per night, consider talking to your doctor about that.  It’s not normal, but it’s also an overly broad topic for this blog post so go talk to your doctor.

There you have it.  My starting primer on sleep issues. This is not intended to be the all encompassing be-all, end-all review of sleep.  Hopefully there’s something that can help you in here.  For most people the best advice of all is: turn off the screen and go to bed earlier, your health will thank you.

Sleep all the sleep (part 2)

This will actually be a short one.  Part 3 will be on improving sleep.  I ran across these two graphs today and thought that the comparison is worth remarking on.

Map of Sleep Insufficiency:

The map below depicts age-adjusted* percentage of adults who reported 30 days of insufficient rest or sleep† during the preceding 30 days. Data is from the 2008 Behavioral Risk Factor Surveillance System, United States.‡

map

Source: http://www.cdc.gov/sleep/data_statistics.htm

brfss-self-reported-obesity-2012

Certainly this is not scientific.  I haven’t calculated the p value of correlation, but notice anything on these two maps? These are maps of self reported sleep deprivation (darker blue is more sleep deprivation) and self reported obesity (red is higher rate).  It’s not 1 to 1 perhaps, a few states buck the correlation, but the similarity of distribution seems obvious.

Sleep all the sleep (part 1)

If you’ve read any of the posts I’ve made you’ve already heard my recommendation to get more sleep. In fact if you read any of the blogs that I read, you’ve read a few other sciency posts on why sleep is important.  Stephen Guyenet outlines a study in this one that found that people who got more sleep lost more weight from fat when they lost weight.

There’s a lot of information about why you should sleep more.  Many of us don’t get enough for a variety of reasons.  I have a strong feeling that our reduced sleep time is as influential as any other single factor in the rise of obesity.  The CDC calls it a public health epidemic!

http://www.cdc.gov/features/dssleep/

That report says: “According to data from the National Health Interview Survey, nearly 30% of adults reported an average of ≤6 hours of sleep per day in 2005-2007. In 2009, only 31% of high school students reported getting at least 8 hours of sleep on an average school night.”

Ok, so it seems pretty clear that lots of people aren’t getting enough sleep.  I think there’s a lot of emphasis on the effects on our movement and exercise when we are not getting enough sleep.  I’d like to highlight some big picture studies that talk about some of the hormonal impacts that occur from even short term sleep reduction.

We all know that one of the goals of exercise is to improve insulin sensitivity.  Well these two studies show that just 7 days of 4-5 hours of sleep resulted in signs associated with insulin resistance in healthy young men:

http://www.ncbi.nlm.nih.gov/pubmed/20585000  http://www.ncbi.nlm.nih.gov/pubmed/22844441

In one of the studies they tried to attenuate the effect with modafinil, an alertness medication, which had no effect.  This shows that it’s not just “fatigue” causing the metabolic changes, it’s neurohumoral.  The reduced sleep causes real modifications in the people’s biology.

The gurus try to tell us that it’s the carbs increasing our appetite.  Lustig is selling a “sugar blocks leptin” theory also.  That has some merit to it, but what if it was more simple then that?  What if we are sleeping on average 2 hours less per night then 40 years ago and THAT is making us hungry.  What if wide swaths of America are overweight as much because we stay up too late watching TV or doing facebook?  Well I’ve been thinking that may be the case ever since I saw this doozy:

http://www.ncbi.nlm.nih.gov/pubmed/23392199

This is a great study.  It was a group of normal weight but relatively sedentary individuals. They were brought into the hospital and all their food was measured, but they could eat ad-lib.  They were split into two groups and spent 2 nights in the lab getting used to the environment and getting their food measured, etc.  Sleeping how much they wanted the first nights the groups were matched for sleep.  Then they took the experimental group and limited them to 2/3 their normal, which in the study was an average of 5.2 hours while the control group continued to sleep an average of about 7 hours.  This lasted for 8 nights.  They continued to measure both groups calorie intake during that time and also measured their activity through a physical activity monitoring system (PAMS).

The results are pretty surprising.  Mostly surprising at how big the change is.  No change in activity levels between groups.  No change to levels of ghrelin or leptin (which was actually the hypothesis).  Huge change to calorie intake.  The sleep deprived group increased intake by over 600 calories and the control group decreased by about 100 calories per day during the experimental period.  Let me repeat: an hour and a half decreased sleep resulted in a nearly 600 calorie increase in intake.  This persisted even after two recovery nights (where the experimental group slept a lot more than their baseline) with the calorie intake still being increased by ~150 kcal.  This resulted in a statistically significant increase in weight over the study period of 0.9 kg (~2 pounds).in less than two weeks.

There are some limitations to the study. The groups were small and the experimental group had a much lower baseline intake during the free living period. This could imply some baseline metabolic differences between the two groups, but even that doesn’t bother me. Even without a control group this would be an interesting result.  The fact that the controls aren’t perfectly matched, but still had roughly static intake during the study period does help suggest the increase in intake is heavily influenced by the sleep deprivation.

By sleep deprivation of course I mean, “being forced to sleep like large portions of the American population.”

Go to bed.