The Difficulty in Assessing Childhood Obesity

The post is a response to a conversation I have both online and in my clinical practice.  It revolves around the difficulty in assessing the bodyfatness of a child. Specifically I see online a post similar to “Look at this picture of my darling child, can you believe that his/her doctor said they were obese?!!?”  In my clinical practice it revolves around me trying to discuss the family habits in relationship to a child that I have concerns about (often in relationship to BMI).

I’ll begin with a basic explanation of some data gathered in most medical practices.  In medical practice we often gather height and weight at an office visit.  These numbers can be graphed on a chart that compares them to a standarized set of “normal ranges”. These normal range in the US are most commonly drawn from the CDC growth charts which come out of a large range of children’s data drawn from two survey’s done between 1963-1965 and 1988-1994.  So the first important point I’ll make is that most of this data for the comparison groups was gathered prior to the large increase in childhood obesity that we’ve seen in the Western world. So a child, for example, that is “80% for weight”- probably isn’t 80% for weight compared to youth around them right now (because average weight of children has increased)- but 80% compared to children in that historical data set.

So often we will graph a child’s height and weight relative to that data set, but we will also then often graph two other data sets against similar “growth charts”- one for height/weight ratio and one for BMI.  In my mind these are just two sides of the same coin, but because of the way BMI is calculated the shape of the graph is very different (because BMI = Weight in pounds divided by height in inches squared multiplied by 703). Because the height is squared the graph is somewhat less linear. At the end of the day the percentages (meaning where a child appears on the graph relative to that historical “normal range”) will be roughly the same. For the purposes of the rest of this discussion I’ll focus on BMI, in part because BMI often gets a bad reputation in and out of medicine (partially deserved and partially inaccurately). Here is the graph for the BMI nomogram from the CDC.

So this is a graph of BMI on the Y axis and age 2-20 on the X axis.  The first thing you see is that sometime after age 2 is when kids normally “get too skinny”.  I often see kids that parents bring in at age 3-5 “because they are getting too skinny”, but you can see on the graph that is pretty normal.  This is called adiposity rebound- toddlers grow more in height then they do in weight and then at some point they start gaining more mass relative to height and the BMI naturally increases.  My wife got sad over the last year as our 2 year old “lost her baby fat” and transitioned from that normal chubbier toddler appearance to the thinner 3 year old. The graph shows that that’s normal and even the heavier kids historically had some degree of that. The thinner kids often have a longer period of staying thinner.

Two more basic definitions: in medicine the normal range is considered to be 5-85 percentile when compared to this historical data set. Overweight is 85-95 percentile and Obese by pediatric BMI is considered over 95 percentile. This is somewhat different then how we do things in adults where we have ranges of BMI that set those same values, but as you can see above a 3 year old with a BMI of 20 (which is quite thin in an adult) would be off the chart heavy. It’s too complex to set a normal BMI range for each age group so by convention we set the normal ranges by the percentile on that graph.

A note on BMI.  In a recent discussion I was involved in I heard several people disparage BMI as not being accurate and “should be thrown out”.  The issue with that sentiment is that it’s just not supported by science.  That said, you have to have an understanding of what BMI does.  BMI estimates relative body fat for populations reasonably well. Two people with the same BMI can have very different body fat %, but in-total, over large numbers of people, it does a reasonably good job. Part of that is there is a limit of how much lean mass a body can make without the use of steroids to increase mass. So at a certain point (probably somewhere over BMI 30)- if there’s no steroid use it means that excess weight is almost certainly fat.

What BMI doesn’t really do is accurately assess the health status of an individual patient. I myself have real question about what the value of the “overweight range” is on the BMI scale for both kids and adults. Many athletic people have BMI in the overweight range. There was a controversial recent study that showed people in the overweight range died less often then those in the normal weight range, so I do think there’s reason to question what “overweight” by BMI means. I do however think that (in adults) you’d have trouble finding anyone that wouldn’t argue that obese by BMI (especially grade 2 obesity- BMI over 35) correlates very closely with increased risk of many medical problems.

There are several factors that also need to be considered when looking at BMI (from the CDC website):

How good is BMI as an indicator of body fatness?

The correlation between the BMI and body fatness is fairly strong^1,2,3,7, but even if 2 people have the same BMI, their level of body fatness may differ¹².  In general,

• At the same BMI, women tend to have more body fat than men.
• At the same BMI, Blacks have less body fat than do Whites^13,14, and Asians have more body fat than do Whites¹⁵
• At the same BMI, older people, on average, tend to have more body fat than younger adults.
• At the same BMI, athletes have less body fat than do non-athletes. 

The accuracy of BMI as an indicator of body fatness also appears to be higher in persons with higher levels of BMI and body fatness¹⁶. While, a person with a very high BMI (e.g., 35 kg/m²) is very likely to have high body fat, a relatively high BMI can be the results of either high body fat or high lean body mass (muscle and bone). A trained healthcare provider should perform appropriate health assessments in order to evaluate an individual’s health status and risks.
So what about kids? Well the thing is that kids (because of the difference in hormones) have even more limit on how much lean mass they can truly produce. This study shows that about 85% of kids in other Obese range (on the BMI chart above) are in excess of what is considered the normal range of body fat. So yeah, it’s not all, but 85% of those found to be obese (by BMI)- truly are obese as defined by above normal body fat percentages.

So again, we don’t find that BMI is perfect for defining risk in one single kid, but it does a good job of assessing those that are potentially at risk.

“But how can that be doctor, my child looks perfectly healthy and normal, he can’t be over-fat!”

So lets run some numbers to see how tricky this can be. Without getting too complex, let’s look at an imaginary 10 year old child that is average height (56 inches). A weight of 100 pounds would give him a BMI of 22.4 and put him above the 95% on the graph above. That child is obese by BMI (and therefore an 85% chance that the child has excess body fat compared to what is considered normal).  If that same child weighed just two pounds less at 98 pounds- he would be BMI 22.0 and in the overweight range (and considerably less chance of being over-fat compared to normals).  Likewise if the child weighed 90 pounds he would be at a BMI considered in the normal range (5 to 85 percentile).

I don’t know about you but I’m not sure I would *by visual inspection* be able to identify a kid that had 2 pounds of extra fat on them (and therefore overfat compared to the kid that had 2 pounds less fat).

Let’s look at this another way: mathematically without BMI. Normal body fat % for a ten year old is something like 13-23% and obese is over 27%.  That’s a difference in a 100 pound kid of just 4 pounds!  I really don’t think my ability to visual assess bodyfatness is accurate to 4%.

So what do you do when your kid is obese by BMI?  Heck, what do you do if you are obese and over-fat and want to try to change that?  Examine your families habits.  Take a hard look at things like “Are we eating enough fruit and vegetables?” “How much screen time a day is my child getting?”  “How much sugary beverages is my child drinking per day or week?”

My office has been giving a hand out on the 5-2-1-0.

5 servings of fruits and vegetables
2 hours or less of screen time per day
1 hour of physical activity per day
0 sweet or sugary beverages per day.

I think that’s a good starting point both healthy habits in anyone frankly. I’d also add “looking at how much sleep we are getting” and for most families my advice is “get more”. Most kids need 10+ hours of sleep and we are not good at getting that in the Western world and that is often tied to the screen time.

Biosphere- the unintentional experiment in what happens when you try to eat under 1800 calories.

I haven’t written in a while. Life has been busy and I haven’t been inspired of late. I did however read an article recently that prompted me to write again. The inspiration was to deliver this message:

Failing at your efforts to excessively reduce calories and lose weight is not a moral failure.

Repeat- it’s often your biology protecting you from yourself. I’ve written frequently about calorie under-estimation (especially in chronic dieters) but here’s a really eye opening article I read today about the closed-system experiment called the Biosphere. Anyone that lived through the 1990’s probably remembers the 2 year long experiment where people tried to live in a closed system to mimic what deep space exploration may look like.

The reason I’m writing about this is a very interesting article I read about the Biosphere. This is what I was reading (I’ll summarize some of my thoughts below if you don’t feel like reading the whole thing):

http://www.businessinsider.com/man-spent-two-years-in-biosphere-2015-3#ixzz3Yk1doJOU

The article talks about the trials they had with running out of food and one of the participants ongoing feeling that restricting calories would prolong life.

A very compelling story. I’d like to highlight: as they ran out of food they had to reduce calories to below 1800 calories per day.  To many chronic dieters this sounds like a reasonable number of calories (despite the fact that the average American women of normal weight eats around 2450 calories and normal weight men eat around 3000).  In fact it is very common to hear people report “I’m eating 1500 calories a day and not losing weight.”

So what happened, when in a closed system they reduced calories to below 1800 while still having to work at producing food and running the Biosphere? They lost crazy amounts of weight. Honestly: they were starving.  One guy lost 58 pounds from 208 to 150.  Another guy who started at 145 lost 25 pounds!  Everyone’s BMI dropped below 20.

They also had to lock up food, especially the bananas (the most delicious thing in the Biosphere)- presumably to save them from unplanned for binges.  They also spent time watching people eat hotdogs through binoculars and fantasizing about food.  The issue, of course, while you are on a diet of under 1800 calories….you don’t live in a closed-system. We have access to all kinds of food that is easy to not measure. Handful of nuts here, a few extra grapes there, a spoonful of peanut butter we forget to measure in our diet journal.

Starving yourself ultimately results in your body taking measures into it’s own hands to prevent you from harming yourself.  In the Biosphere- “it became accepted practice to lick one’s plate clean after every meal, so as not to miss a single precious calorie.” In fact I read an account elsewhere that several members of the Biosphere got so desperate for food that they ultimately broke into emergency supplies of food that had not been grown in the dome.

Now on a certain level the details of this diet may not apply to the chronic dieter in the Western world.  They were eating a very low fat diet. They also had a fair amount of activity which in this paper is thought to be equal to 3-4 hours of manual farming per day. This is likely more activity then most people in the Western world are getting, though the participants had gone into the Biosphere with a year of the same activity- which further supports that these people must have been eating much more when left to their own devices, when they weren’t in the Biopshere.

So again my conclusion is: it’s not moral failing if your attempts at calorie reduction aren’t working. Sometimes the issue is having an inappropriate idea of how low to reduce calories.  A more moderate deficit and a good relationship with food and body image are going to be important factors in success at weight loss.

Superheroes of Health

My E-book as part of the incredible bundle Superheroes of Health is now officially available.  To see the content available and purchase the book click here:

https://gokaleo.com/superheroes/#/ap/joshkern

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:

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.‡

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

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.

On The Other Side

Written two and a half years ago:

I’m about 30 hours out from joining the legions of appendectomied people. For me the actual appendicitis wasn’t that terrible of an experience. Sunday afternoon had a vague feeling of abdominal discomfort. Largely right sided, though somewhat more around the belly button. (For anyone not medical reading this: my description of symptoms is basically directly out of a textbook for presentation of appendicitis.) We went walking around 3:30 PM and my baby’s bottom (she was in the carrier on my front) bouncing against my lower abdomen was sort of uncomfortable. I tend toward constipation so I was thinking constipation or gas pain.

As the evening wore on I developed increasing right lower quadrant (RLQ) pain. Around 9 PM I emptied my bladder which evoked a somewhat more significant but brief RLQ pain. I came out to the living room and was lying on the floor examining myself and told Dorothy, “I wonder if I have appendicitis,” to which she responded, “shut up”. I went back to playing at the computer and about 11 PM I took a shower and was starting to feel vaguely ill- like mild body aches. Dorothy has had a cold so I started hoping, “please start getting a sore throat”. I was asleep for about 30 minutes when I was awakened to terrible nausea, significant chills, and somewhat increased RLQ pain. I still only rated the pain at 3/10 at the worst. The nausea is what sent me to the ED. That was terrible. I knew at that point what I had. I woke Dorothy and told her I had appendicitis and she said, “Are you sure you don’t just need a laxative or something.” I’ve been joking since that she was trying to keep me home to collect the life insurance money.

I called up to St. Ben’s to make sure that we didn’t have a surgeon available (we didn’t) so I drove myself to St. Luke’s for evaluation- the baby was sleeping and I was well enough to drive myself.

What a strange, bordering on fun (if having appendicitis and eventually getting a few thousand $ bill can be called fun) experience being a patient. As an adult I had been to the ED once before for something minor, never for anything major. I also have a vague memory of getting stitches in the ED at age 3. Early Monday morning about 1:45 AM: They got me settled in, IV placed, the Physicians Assistant came and evaluated me (listened to my heart and lungs through my gown). Labs drawn. Then I carried my IV bag to X-ray and had my first ever chest x-ray and abdominal flat plate. Lying on the X-ray table was very uncomfortable with appendicitis. It’s a very flat and hard table that they must chill to about 10 degrees. I gave a urine sample after that, which was tricky with a gown on and my IV bag slung over my shoulder. Then I saw the ED doc (also examined me through my gown). He was basically like, “you’ve got appendicitis and the surgeon is on his way in”. Yup, I sorta thought the same thing. WBC was 10.5 (barely elevated), CRP was 2.9 (pretty  elevated- a general marker of inflammation).

I also saw Garth, whom is my favorite Murse of all time (one of my favorite nurses over-all too, but that’s largely because he acts and sings and I saw him in a local show of Jekyll and Hyde and he killed it as the main role of Jekyll/Hyde- unfair advantage), in the ED. He gave me a shot of promethazine after the 2 shots of Zofran had not touched my nausea at all. I did not enjoy the promethazine. It made me very altered (keep in mind it’s now about 2-2:30 AM and I haven’t really slept). Drowsy but not exactly falling totally asleep. I was slurring my words and couldn’t think straight. I think next time I’ll just stick with the nausea. I later wondered if they had given me some morphine or something too, though I don’t think so, I told them I wasn’t having much pain and didn’t need anything.

It dawned on me later that I was never afraid. I wasn’t just being tough or stoic. I knew what was wrong with me and I just simply wasn’t afraid. My personality is somewhat like that (which is why I quit bike racing- I had become afraid). I don’t get nervous about much anymore, which definitely comes from surviving the experience of medical school and residency- it changes you. It also just never really felt life or death to me, I pretty much felt like it was going to turn out fine. I really never was that “sick”.

Sometime after the promethazine I saw Dr. B, who’s quite a young guy. He’s a very calm person, I liked him immediately. I could barely follow him because I was altered. They took me to the pre-op area, which I can’t remember well because of the promethazine kicking my butt. I had to strip down (I left my socks on) and pee in a urinal so I didn’t have to get a foley catheter. I peed all over the edges of my gown. I think I was having more pain at that point and being all altered from the promethazine, not being able to stand up straight from pain, and trying to pee in a urinal in front of people was pretty awkward. I could feel my pee from the bottom of my gown on my leg when I was lying back on the bed to be wheeled into surgery.

They wheeled me back to the OR and I vaguely was aware of the anesthesia person giving me something in my IV. I scooted over to the OR table and my next memory is about 3 hours later with a nurse asking me all these questions and me falling asleep. The nurses were turning over at 7 AM and the outgoing nurse was trying to get her work done before the next nurse came on. It was sort of comical. I’m pretty sure I asked, “Is my appendix out,” which is so classic- ahhh anesthesia. Then about 8:30 I really woke up. Another very strange feeling. I was really awake. I was feeling pretty comfortably tucked into a bed and knew where I was and was clear minded. No pain to speak of, no nausea.I also knew at that point that I was clearly cured of whatever had been making me sick. A weird feeling to have post-operative pain which is worse then your appendicitis pain but to “feel better”.

I hit the button and called the new nurse in because I felt I needed to pee. Jessica was my nurse for the rest of the day and she was very nice. Getting out of bed was awful. I’d rate it as the worst pain I’ve ever felt. What’s weird was the pain was now in the left lower quadrant (LLQ) where the biggest of the laparoscopy ports was. I imagine that pain is what it feels like to be stabbed. If the appendicitis pain was 3/10 this pain standing up was about 8. Peeing in a bed-side urinal while a female nurse is 6 inches away was pretty weird. Trying to get the flow of urine started with 8/10 pain and a female nurse standing 6 inches away was not easy. I got about 600 cc and struggled my way back into bed. She gave me 2 mg morphine IV and two hydrocodone right after. I slept away much of the morning. I called various family members and eventually my wife and baby came to visit which was nice. Later I micturated an amazing 750 cc of urine!

I improved quickly through the morning. Getting out of the hospital bed was still a 6/10 pain struggle, but even walking or sitting up wasn’t that bad. I had solids for lunch and walked 150 feet in the hall without much trouble. I even danced a little jig for Jessica near the nurses station. Eventually I saw Dr. B and he discharged me home. I was home 13 hours after getting my appendix out.

I’m home now. I’m doing ok, still pretty painful moving around, but it’s a different kind of pain now, more like “man I worked out too hard” type of pain. I let myself go a little long without pain meds last night and had a weird response to the pain- shivering. Happened again in the middle of the night after I had slept soundly for 5-6 hours. Shivering for about 10-15 minutes until the pain medication kicked in. Very weird. At first I was getting a little spooked that I was having a sepsis response or something, but it definitely faded with my pain and it didn’t start until I tried getting out of bed in the middle of the night. It’s amazing how much you use your abdominal muscles. Even weird little things like passing gas or flushing the toilet uses a surprising amount of abdominal muscle.

I can’t say that I really learned much about how to be a better doctor or about how we can provide better health care at our hospital as a result of my experience. I’ll probably just have a bit more empathy going forward. I really feel for C-section patients more then before. The amount of pain I have from these little port sites, I can’t imagine the C-section incision- even more so because you want to get up and take care of your little baby. Less C-sections!

The worst part for me (besides the eventual bill) is not being able to play with Ruthie. I really can’t get down on the floor yet and I definitely don’t feel up to picking her up yet (she’s very squirmy). Just picking a shirt up off the floor is tough! I’m also sad about having to take several weeks off from Kung-fu. I was really starting to get into shape again. I imagine I’ll be able to practice some of the forms again in a few weeks, but I definitely won’t want to do anything aggressive for 6 weeks. That sucks.

Our first major medical situation as a family! I can’t thank my wife enough, I can’t imagine trying to get through stuff like this without her. Even just knowing that if I needed her to she would get me something or pick something up without griping about it- that’s love.