Using mindfulness to kick my sugar habit.

I’m on day 6 of no sugar. I want to eat all the time. Previously (in 2019) I had been in a decent rhythm of time restricted eating (skipping breakfast and waiting until lunch to eat), but this week with the sugar withdrawal it feels more urgent and I’ve been eating a lot of healthy food (overeating healthy food) as my brain and body try to adjust. 

I’ve been incorporating mindfulness over the past 2 months in order to help me effect change in my eating habit loops, because until this year I have managed my weight by white knuckling — forcing myself to adhere to a food plan and then periodically giving in and indulging my sweet tooth before resisting again. But this way of dealing with food has left me feeling like I am still addicted to sugar (as I confessed last week), and has not helped me to decondition my brain — a brain that has had 40+ years of repeated strengthening of this basic habit loop: feel a feeling or urge (trigger), eat sugary treats (behavior), numb the bad feeling or bolster the good one (reward)... repeat. I want more than anything to break this habit loop. To decondition my brain from expecting a sugary reward every time I feel something, every time a certain time of day arises. But how?

In order to decondition yourself from automatic behaviors/habits, you have to first NOTICE the behaviors, and notice the rewards (or results) of those behaviors: what did you get from it? It’s harder to decondition a rewarding habit or addiction (one that lights up the reward centers in the brain) if you haven’t started paying attention to the negative results you’re getting from that habit in addition to the immediate rewards. You have to start really feeling disenchanted with your results at a gut level to truly want to change. How many times have you told yourself you needed to lose weight on an intellectual level, but not really felt truly committed? This intellectual wanting leads to a temporary change in behavior through forcing it, and an inevitable backslide back into the behavior of overeating. Wanting something is not the same as committing to something. So, in order to really build commitment, it helps to start paying attention to the negative consequences of the actions you are trying to change. Even before you actually try to make the change, first just notice what result you are getting from engaging in the behavior. So for example, if you want to stop drinking, first you start paying attention to how you behave in ways you wish you hadn’t when you’ve been drinking, how crappy your body feels after you drink too much, how it affects your sleep negatively, how it gives you heartburn, and how lethargic, dehydrated and headachey you feel the following day. Noticing all of those effects and feelings can help really make you want to stop drinking on a gut level. This builds disenchantment with what you had previously felt was rewarding. Giving in to your cravings when you are in the early stages of change doesn’t mean you are a failure — it means you are learning, and giving in to urges can be an amazing teacher when you are open minded and aware.

For me, you must know by now that my substance of choice is sugar. Previously I had always felt somewhat out of control when I let myself eat it, but I had never really paid attention to its effects — to how I felt physically or emotionally — during or after eating a big pile of sweets. Instead, I just felt an urge to eat sweets, often urgently, and did it out of habit. Now that I am using mindfulness to help me kick my habit, I am much more aware of what sugar is giving me. Last week when I was binging on sugar, I paid attention to how I felt. And it was really eye-opening. After feeling an urge and deciding to eat sweets, I felt a surge of excitement and happiness. Good ole’ dopamine exploding in my brain in anticipation of the reward. Buying the sweets was like visiting Disney World. The first few bites were amazing. An explosion of deliciousness in my mouth and happiness in my head. Then, interestingly, I just wolfed down the rest of it rapidly and mindlessly, as if I was afraid I’d catch myself. (Quick! Eat it all before she changes her mind!) It was fascinating. After the first few delicious mindful bites (which probably amounted to 200 or 300 calories), the remaining 2000 or so calories was just numbing. I noticed that my reward after that initial exciting dopamine surge was an escape into mindlessness, a peaceful calm feeling. But soon thereafter I felt physically hot, and felt my heart pounding out of my chest- the relatively immediate effects of the excess sugar. Then the delayed effects. My low back, which has been bad for 2 years (a herniated disc and degenerative disease) was screaming. I’d had problems with very mild pain before, but never this significant (it made it hard for me to even sleep). And I realized the only thing different in my life was that I’d been binging on sweets. It turns out that sugar increases inflammation and might affect things like joint pain. Additionally, my sleep quality was total crap. I was running unusually hot at night and was super restless, tossing and turning. Oh, and I felt terribly listless and fatigued all weekend - like a lethargy monster had gotten hold of me and all I wanted to do was lie around and watch TV. Totally unlike my usual busy self. So I was consciously aware that I’d gained 5 pounds, my back hurt, I felt lethargic and just completely crappy, and the only thing that could explain all of those horrible feelings in my body and spirit was sugar. How had I never connected these things before?!

I am now, as I mentioned, on day 6 of no sugar. I have the urge to eat constantly, but my back feels back to baseline, I don’t feel hot all the time, I’ve had no pounding heartbeat, I am sleeping more soundly again, and my energy level feels back to normal. Sure, I’m tired toward the end of the day, but I don’t feel like a blobby Jabba the Hutt anymore. There hasn’t been a magical transformation — I don’t suddenly feel peace around food — but I sure do feel better than I did. I am committed to staying off sugar for the long haul, a minimum of 6 weeks and maybe indefinitely. In the meantime, I am working on getting through the first few weeks of sugar withdrawal and letting myself overeat healthy food as I adjust, even when I am not physically hungry. I’m being kind to myself an accepting that I want to eat a lot right now as part of the process. Paying attention as much as possible along the way. Practicing feeling the feelings, feeling the urges, and curiously noticing how they feel in my body. Allowing them to be there with an open mind and heart, rather than contracting into myself and resisting them or distracting myself away from them. Noticing they don’t kill me. Noticing. Deconditioning. Mindfully.

I’m a sugar addict.

I’m a weight loss “success story,” weighing more than 150 pounds less than my highest weight and currently maintaining a normal BMI. But I don’t FEEL successful. Because I am still obsessed with food. With sweets, to be exact. When I spoke with Gina Kolata of The New York Times a few years ago, I described my experience of weight maintenance as me having to have an “iron grip” on my diet. I told her that my weight fluctuates because each time I relax my guard, the pounds return. Today I’m 55 pounds lighter than I was that day that they photographed me with a 4-day-old Graham, and the truth is, I STILL feel like I have no control — whenever I “relax” and eat what I want, I regain. Since early December when I restarted sugar binging on Graham’s birthday cupcakes and Christmas cookies, I’ve been telling myself I’ll stop eating sugar “tomorrow” and having one last sugar fix today. This past week alone I ate 3 slices of yellow cake, Valentine’s chocolates from 2 separate heart shaped boxes, gelato (several times), two microwave mug brownies (yes, I know how to make a single serve brownie in my microwave using sugar, flour, cocoa powder, and oil) and icing-coated cookies. I have gained 5 pounds or so since Thanksgiving as a consequence, and am now up to 150 pounds this morning. I have really noticed recently more than ever that my behavior around sugary foods is akin to an alcoholic or a drug addict: I experience cravings for my substance, I have made repeated attempts to control or quit using my substance but have been unsuccessful, I’ve started to use larger amounts, and spend an inordinate amount of time thinking about when and where I will get my next fix. I continue to use it despite negative consequences. I have a lot of mental chatter surrounding sweets and feel powerless against them, trying to avoid sugar for a few days (and seeing my weight start to drop again), only to ultimately give in to my primitive brain and eat it again – just “one last time.”

I’ve been calling myself a sugar addict for a few years now, but only recently have I really started to look into this phenomenon as a scientifically proven disorder. Although food addiction is not yet included in the gold standard manual called the Diagnostic and Statistical Manual of Mental Disorders (the most recently published edition being the DSM-5), it has been widely proven in the scientific literature to exist. A year ago, I cut all added sugars and flour out of my diet for a full 6 weeks. The first few weeks were rough and required a lot of willpower and white-knuckling, but by the end, I felt a sense of peace around food that I had maybe never felt. Like, no cravings. Even when I was around sweets, I could see them and not feel compelled to eat them. One of my residents at work even went so far as to ask me to “at least smell” his homemade brownies when I refused to eat one or just taste one (at 8am, by the way!)… and I smelled the brownies, but didn’t feel that irresistible urge to eat one. It was perhaps the most peaceful I’ve ever felt. I ended up going back on sugar over Mother’s Day weekend 2019, and since then have been fluctuating between white knuckling and avoiding sugar vs. feeling out of control and eating sugar seemingly against my will. It’s like, once I’ve made the decision to eat a sweet treat, my prefrontal cortex (the part of my brain with executive function, planning abilities, and self control) goes offline and my primitive brain takes over. Like I’m not even there.

In “Food Junkies,” Dr. Vera Tarman compares food addicts to drug addicts and says, “{addicts} often refer to their drug as their lover or best friend.” (I flash back to the book I’m writing: in my intro to the chapter I wrote about my month on a very low carbohydrate ketogenic diet, I described my trepidation about losing sugar, which I described as a secret lover with whom I had continued trysts.)
“To a food addict, eating even just a little bit of sugar, or any other trigger food, will set off the phenomenon of cravings that leaves her wanting even more. Just one cookie is enough to act as a trigger. Like a lit match to kindling, it inflames a highly volatile reward pathway. It’s just waiting to be set ablaze — an inferno that consumes willpower and makes it impossible to rationally moderate portions after that first taste.”

Yeah, that’s me. So. Now I am in the middle of an existential crisis: do I keep living this way, which allows me to eat sugar periodically and barely maintain my normal weight by losing and regaining and losing and regaining (and suffer with the mental angst that goes along with that), or do I give up sweets forever and practice abstinence to really address my addiction (and maybe even consequently achieve my dream goal weight of 135)? It probably seems obvious, but to an addict in the throes of a passionate tryst, the thought of losing my secret lover forever is almost unthinkable. Especially when that substance is one that is available all around me all the time, cheap and socially acceptable, and even pushed on me by well meaning friends and family. My prefrontal cortex wants me to be abstinent, but my primitive brain wants what it wants, and wants it now. The question of my life: Who will win this battle?

How The Biggest Loser sets viewers up for failure

#BiggestLoser #weightloss #obesity #TRE

@kimymami @chefdombells @phinally.me

I had a new patient come to see me for the first time last week. She had class 2 obesity (her body mass index, or BMI, was between 35 and 39.9) and told me that she had been struggling with weight loss and needed my help. She said that she had been emphasizing whole foods and cut out processed carbohydrates, was doing time restricted eating (TRE) with an 8-hour calorie intake window each day (fasting for the remaining 16 hours), and trying to exercise more. “But,” she lamented, “I’m not losing any weight.” When I pulled up the graph of her body weights taken at our medical center over the last year, it turned about that she had actually lost almost 20 pounds in that time! When I showed her these very real and amazingly positive results, she expressed disappointment and brought up The Biggest Loser. Watching the show had informed her expectations about her own weight loss, and she felt that she was failing because she had “only” lost 20 pounds. She wanted to give up.

{sigh}

Watching episode #2 of the show this week, I found myself feeling more and more disenchanted. Not that I was exactly enchanted last week, but I am finding that the show is still really missing the mark when it comes to responsibly teaching the contestants — and viewers — about weight loss and weight maintenance. I find myself falling in love with and rooting for the contestants (how much do I delight in Kim Emami Davis??!) and angrily judging the show all at the same time. As the players stood up again and weighed themselves one by one, the soundtrack switched to mournful music when players lost “only” 5-7 pounds in one week. When Domenico lost 7 pounds (2.27%), he said that he was afraid he was going home and said, “you know, I’m not proud of that number.” When Kim lost 5 pounds (2.16%) she was visibly disappointed: “uh, not great.” Similar negative reaction with silence instead of celebratory music for the weight loss achieved by Phi (6 pounds, 1.71%), who at least – thank goodness – said that she was proud of those 6 pounds! 

It is 100% understandable why the contestants react negatively to those (awesome) weight loss numbers… because they are competing to remain on the show the longest, to lose the most amount of weight in the shortest amount of time, and to win $100,000. I do not blame the contestants in the least. I blame the producers of the show for setting up a situate in which a person with obesity would express disappointment in a 5 pounds weight loss. Showing those negative reactions to 5 or 7 pounds (extreme amounts for a single week!) to viewers at home who struggle to lose 1 or 2 pounds in a week can be, in my humble opinion, harmful. It creates unrealistic expectations for weight loss, and makes it much more likely for regular people to be disappointed in their own weight losses and subsequently give up efforts at improving their own health. I can’t speak to how the current 2020 season of the show was filmed, but during my own tenure as a position on season four and five, I know for a fact that some “weeks“ were actually filmed over the course of up to 14 days but still referred to a a single week, and that contestantswould not only exercise for hours and hours and hours every day (or possible for regular working people who aren’t professionals athletes), but would also intentionally dehydrate themselves right before weigh-ins to boost their weight loss even more. There’s just no way that the average viewer can drop that much weight that quickly without extreme fasting and exercising. 

I’ve said before that I have mixed feelings about the show. I think it’s wonderful that many people feel inspired by it, that it shows that people with obesity are not lazy and can exercise just as hard as anyone else, and the emotional hurt that many of us go through. I always, 100%, support each and every contestant and the effort they made or are making. I fear that the show does harm, though, in perpetuating the idea that a one-week weight loss of 5 pounds is anything short of excessive. Please, anyone out there who watches the show, and even those who don’t, know that a weight loss of a single pound (in someone who is trying to lose weight) is an achievement to be celebrated! After all, a weight loss of 100 pounds can be achieved by losing just ONE pound. A hundred times.

With love, 

Jen

Where the new #BiggestLoser missed the mark.

The premiere of The Biggest Loser on January 28 felt all too familiar, and if it was any indication of the season to come, I have serious doubts that this new version is actually the kindler/gentler bastion of holistic health promised by the network and the show’s host. There were claims in advance that this season will be more about getting healthy than losing weight, yet the show’s formula is the same: hold a massive cash prize ($100,000) over the contestants’ heads to motivate them to produce the greatest weight loss in a fixed amount of time. That is one big carrot, and whether or not they encourage sleep or talk about their feelings, people will do what they have to do to win such a big prize. 

Beyond that elephant in the room, the season premiere had its obvious missteps (nicely pointed out by my friend @NicoleisNik Nicole Michalek), such as continuing to require body-conscious people to expose their half-naked bodies in front of the world during weigh-ins, and forcing contestants to exercise to the point of vomiting. (This might make for good TV, but only serves to reinforce their negative feelings about exercise through conditioning. After all, anyone whose parents caught them smoking as kids and were forced to chain smoke cigarettes until they puked, or who threw up violently after too many tequila shots, knows the power of vomiting on one’s desire to repeat the same behavior that caused the vomiting.) There were a few more subtle statements that I took issue with, as well. Here are my top three:

1.     When @MyTrainerBob Bob Harper said, “literally, you are what you eat when it comes to your cholesterol issues,” that was wrong. There is a wide variety in individual response to a low fat vs. high fat diet (with many people, my husband @KevinBMarvel included, actually improving their cholesterol and lipid profiles on a very high fat low carb diet), and the consumption of dietary cholesterol does not necessarily equal increased blood cholesterol levels. That said, other people do improve their lipid profiles on a low fat diet — it’s complicated and nuanced. So my best advice is to check your own detailed lipid profiles before and after adopting any lifestyle intervention to see how it affects your unique genetics and physiology. 

2.     When 47 year old contestant @coachjim2020 “Coach” Jim DiBattista was told by Bob that he has type 2 diabetes, he had an emotional outpouring of shame and regret: “People have diabetes — like real, type 1 diabetes — like, they don’t have a choice. They’re genetically built that way. I did this to myself. I ate myself into a sickness.” My heart broke for him and for all of the viewers watching this show who have type 2 diabetes and are wrongly blaming themselves. Type 2 diabetes has a strong genetic component, and although it is absolutely a weight-related condition in that your risk of developing the disease rises as your weight rises (and weight loss can cure it in many), there are also countless people of normal weight who suffer with the disease. In fact, a study

that was just published last month examined almost 5 million Americans and found that there was a high rate of diabetes in normal weight people. It varied greatly based on race/ethnicity, with normal-weight whites having the lowest prevalence (5%) and normal-weight Hawaiians and Pacific Islanders having the highest prevalence (a whopping 18%). A diagnosis of type 2 diabetes is not your “fault,” just as obesity is not your fault: our brains evolved to predispose us to overeat highly rewarding (calorie dense foods), some people are more genetically predisposed than others, and our environment in this modern era (with abundant processed foods engineered to get us to overeat them and technology making physical movement almost obsolete) is worsening that predisposition. That said, once someone realizes that their quality life and their health could be impacted for the better by doing the long hard work of making informed choices and changing their lifestyle to lose weight and eat fewer processed carbohydrates, they can often melt way the type 2 diabetes in addition to the body fat.

3.     Trainer @ericafitlove Erica Lugo wasn’t exactly accurate when she claimed that high intensity interval training (#HIIT) is the best for weight loss: “when you spike your heart rate up and then back down it kinda tricks your body ‘cause it never gets used to the same tempo so it’s awesome for losing weight and burning fat.” Ok, again, this is complicated, and I am by no means saying that HIIT isn’t good for weight loss. But it’s not “tricking” your body, and it’s not necessarily better than traditional moderate intensity continuous exercise. First, note that energy consumed (diet) has a much greater impact on weight loss than does energy expended (exercise) in study after study, at least in the real world where the amount of exercise we’re talking about is realistic for most working adults (when contestants on the Biggest Loser or professional athletes work out for 5 hours a day, that’s an entirely different story). Even our own research found that the amount of weight loss during the Biggest Loser competition was significantly correlated with calories eaten and not with calories burned (whereas 6 years later the exercise became more related to successful maintenance of weight loss). Indeed, one of my most successful weight loss patients today is a veteran who is disabled enough that he rides everywhere in a scooter, but has lost almost 100 pounds by changing his diet. So please, those of you out there who can’t be as active as the professional athletes also known as Biggest Loser contestants, don’t think that you can’t change your life! That said, regular exercise can help marginally boost weight loss beyond what you’d achieve with diet alone, and there have been many scientific studies of different types of exercise and their effect on weight loss. Deciding which exercise method is best depends on how you compare them. A large meta-analysis comparing moderate-intensity continuous training compared with high-intensity interval training found that the two types of exercise produce no difference in body fat percentage reduction (though HIIT in the specific form of intermittent sprints may produce greater absolute fat mass reduction – meaning more pounds of fat lost — than moderate continuous exercise). Another study found that overweight and obese adults had similar rates of adherence to and enjoyment of HIIT vs. moderate-intensity continuous training, but did not lose weight with either intervention over the 8 weeks of the study (more evidence that diet is more impactful than exercise for weight loss!). Interestingly, the HIIT group had greater drops in LDL cholesterol and (as expected) greater increases in VO2 max, a measure of peak aerobic exercise capacity, but conversely, had increases is blood inflammatory markers (interleukin-6 and C-reactive protein). Moderate intensity continuous exercise actually improved inflammatory markers in participants. Another study found that belly fat reductions in young obese women were comparable between moderate continuous exercise and HIIT when work-equivalent training sessions were conducted. How to interepret this? If you spend 30 minutes doing a HIIT workout one day and 30 minutes walking quickly the next day, you’ll burn more calories and lose more weight with the HIIT workout — but that’s intuitive, because your work is greater. If you compare a work-equivalent (calorie-burning equivalent) HIIT workout of 15 minutes to say 30 minutes of fast walking, you’ll burn the same calories and lose the same amount of fat. So HIIT allows you to be more efficient if you’re pressed for time and trying to condense your calorie burning into a shorter session, but not necessarily better if you’ve got time to do a proper moderate-intensity workout. There are other benefits to HIIT workouts and I am a fan of them, but technically they may not be better than moderate continuous exercise specifically for burning fat when you compare equivalent work loads. A great overview of other studies and how HIIT isn’t necessarily the magic bullet that Erica Lugo claimed was written here last year.

Despite my reservations, I’ll be watching the show again next week, and will try to come back here to discuss other topics and/or clarify issues as I see them arise. I’m disappointed that the premiere of the show had many of the problems that plagued the original series, but hopeful that the 12 brave folks who signed up to lose weight on TV for our viewing pleasure are living their best lives right now and happy that they participated in the show. I know that being on the show changed my own life in ways I couldn’t have predicted, and I wouldn’t change a thing about my own involvement. Cheers to my BL brethren!

My shocking and deadly sleep diagnosis (Part 3 of 3 on sleep)

If you’ve been following my posts over the last few weeks, you know that poor quality or short sleep predisposes you to weight gain, and that I personally struggle with insomnia. For me, it’s been ongoing at least 5 or more years and seemed to get worse after I had Graham 3 years ago and simultaneously started to have my first hot flashes, signaling the beginning of perimenopause (women start to have hormonal shifts and can experience hot flashes as early as ten years before they actually arrive at menopause!). To be clear, Graham started sleeping through the night at 8 weeks old, so it wasn’t the usual sleep struggles that a new mom experiences routinely. I DID get up every night for an hour around 2am to pump breast milk as he slept, but by the time I returned to work about 3.5 months after he was born, I had adjusted my pumping schedule to 3 times a day and could wait until 5:00am. Despite a sleeping baby and no obviously external disruptions to my sleep, I continued to struggle with middle of the night awakenings and often had difficulty returning to sleep. When you can fall asleep easily (me!) but awaken earlier than desired, it’s called maintenance insomnia. I talked to my primary care doctor about it, and we both suspected anxiety may be playing a role (I’d also felt somewhat more anxious than usual in the year or two after Graham was born). She prescribed an antidepressant called Lexapro (which can also be used for other mood disorders like anxiety). I gave it a try, finding that it was maddeningly activating for the first 1-2 weeks (meaning, it kept me awake as if I’d had 4 cups of coffee before bed), but I knew that it can take weeks to adjust so I kept at it. By the 6 week mark I found that Lexapro did absolutely nothing for me, neither improving my sleep nor seeming to have any effect of my mood or anxiety. So I quickly tapered off it. I then spoke to my OB-gyn about it, because it really felt hormonal to me. Just as I’d started to notice a few hot flashes, I’d been experiencing the increase in anxiety – and I noticed a significant worsening in my tossing and turning in the days leading up to my period, and unusually sound sleep in the days following my period – suggesting that hormones might be a big player. She prescribed a low estrogen birth control pill for me to help “smooth out” my hormones. I stayed on them for three straight months, unfortunately finding that they did get rid of the rare hot flashes, but did nothing to improve my sleep (if anything, I lost the good quality sleep that I’d been noticing in the week after my period). So, I stopped those, too. I finally saw a sleep specialist at the George Washington University as a last ditch effort. Pondered whether I might have narcolepsy because I do have this weird thing called “cataplexy” when my muscles suddenly lose strength sponge to strong emotion (I even almost fell off a treadmill while running due to sudden leg weakness when I was suddenly overcome with joyous laughter watching Steve Carell in “The Office!”) — narcolepsy is often associated with cataplexy. But our suspicion was low because I had never actually fallen asleep during the day. He gave me some advice based in cognitive behavior therapy for insomnia, or CBTi (no more looking at the clock, get out of bed and go do something mindless if you can’t fall back to sleep within ten minutes). I had a few nights of somewhat better sleep when I employed these methods, but over the year that followed still had pretty profound trouble with multiple awakenings. 

I started to worry more and more about my sleep, because I felt like my own cognitive function was starting to falter (especially forgetting names, and having more trouble paying attention to anything that I didn’t care a lot about). Well-meaning doctor friends reassured me it was normal, that I was in my mid 40s when we ALL start to forget names, and that I had simultaneous “mommy brain” with a baby at home. But my deep seated fear that I was in the very early stages of Alzheimer’s disease (given my own young mother’s diagnosis), and my knowledge that adequate and good quality sleep is critical for the brain to heal itself kept me searching for ways to improve my sleep. 

One day about 4 months ago, I was watching a TED Talk about sleep in which a slender-appearing gentleman spoke about his own disrupted sleep and how he would often get up multiple times to urinate as if something else was waking him up. DING DING DING!!! This was me! I would awaken and visit the bathroom usually three times during my fragmented night, but when I peed it never seemed like much. Certainly my bladder was never full enough to have woken me. So what WAS waking me?? 

Well, this man was diagnosed the obstructive sleep apnea (OSA) — a sleep disorder in which the soft tissues in your airway relax and collapse during sleep, thereby blocking your airway and preventing you from breathing. In the 15 minutes that it took me to watch his talk, it suddenly dawned on me that *I* could have OSA. The weird thing was, I was very low risk according to the usual screening questions: I was not overweight (anymore), didn’t snore (at least not loudly enough for Kevin to notice), didn’t have high blood pressure, and although I definitely felt tired during the day, I was never sleepy enough to fall asleep sitting in a lecture or stopped at a red light. But man, the disrupted sleep and especially my own subjective sense of cognitive impairment sure could be explained if I had OSA. So, I contacted that sleep specialist again (about a year and a half after I met with him) and asked if he would order a sleep study for me to rule it out.

Because my BMI was in the normal range, my insurance company would only pay for a home sleep study (rather than the gold standard polysomnogram that you have in a sleep center). I completed the test at home on November 8, 2019. I never heard from anyone about the results. About 6 weeks after the study I had a follow up appointment in the sleep clinic…. 

“You were right: you have moderate sleep apnea.”

WHHHAAAAAAA????!!!!

I was actually shocked. I thought it would be a negative study. Even *I* didn’t think I actually had OSA, since my body weight was normal. I always thought of it as a disease that plagued people with obesity. Obviously, so did my primary care doctor, my OB-gyn, AND the sleep specialist I went to! It turns out that I was having a respiratory event (either partially or completely obstructing my breathing) on average 23 times per hour. That’s once every 2.6 minutes. No WONDER I was awakening multiple times each night and feeling tired every day! (The sleep study also showed that I do indeed have “intermittent snoring” — I guess it was just never loud enough to bug my ever-tolerant husband!)

So, I needed autoCPAP — a machine to blow air into my nose/mouth while I sleep to keep my airways from collapsing and blocking my breathing. I had to wait a couple of weeks for the new machine to be delivered, but I’ve since been faithfully wearing my mask every night. Honestly, the first week or two was rough — getting used to having a lamprey attached to my face took a while. I am still sorta getting used to it, although I must say it’s getting way more “normal” feeling… and the good news is, I am sleeping a lot better already! I still wake up once or sometimes twice, but I have a much easier time getting back to sleep. Last night I slept 7.5 hours and woke up feeling fresher this morning, and more than 7 hours was essentially unheard of for me before I started treatment for my OSA! I do still notice that I sleep a lot worse leading up to my period and much better right after, so there are certainly also other factors at play with my sleep… but I feel such a huge sense of relief to finally have a diagnosis that explains my crappy maintenance insomnia that nothing seemed to help. And thankful beyond belief that I advocated for myself and asked for the sleep study even when my doctors didn’t think I was really at risk.

Why is figuring out whether you have OSA important? Because when left untreated, it’s deadly: it causes car accidents caused by falling asleep at the wheel, difficult-to control high blood pressure, heart disease, stroke, diabetes, depression, and perhaps most importantly to me personally, cognitive impairment and Alzheimer’s disease. OSA is extremely common, affecting more than 22 million Americans including up to 23% of women and 49% of middle-aged men, and the prevalence increases with age (and with peri/postmenopausal status in women). Despite it being this common, it’s extremely underdiagnosed: estimates suggest that 80% of men and 93% of women with moderate to severe OSA have not been diagnosed. Being overweight is a risk factor, but I was shocked to learn that about 20% of sleep apnea cases are in people of normal weight! People with a normal BMI who have OSA tend to be more easily aroused from sleep, and may have a family history of OSA, suggesting genetic predisposition. Indeed, both my father and my brother have OSA. 

Treatment is generally with an AutoCPAP machine like the one I am now getting used to, but in people who can’t (or aren’t willing to) tolerate wearing a mask to sleep, there are other treatment options, including dental appliances that change the way your jaw sits thereby opening your airway to stop the snoring and the blocked breathing, and even surgical implantation of a nerve stimulator that moves your tongue out of the way when you sleep!

When I took the standard “STOP-BANG” screening questionnaire, I answered yes to only one question and was told I was at low risk for OSA – yet I was actually suffering from moderate OSA that was bad enough to require treatment. So with that in mind, I have taken this standard screening questionnaire and added a few of my own symptoms and risk factors here to create my own invalidated-but-valuable Dr. Jen Kerns’s Sleep Apnea Screening Tool:

1.     Do you snore?

2.     Do you often feel tired, fatigued, or sleepy during the daytime? 

3.     Do you generally fall asleep within 2 or 3 minutes when you lie down to sleep at night?

4.     Has anyone observed you stop breathing or choking/gasping during your sleep, or have you ever woken up feeling like you are choking?

5.     Do you have or are being treated for high blood pressure?

6.     Is your body mass index (BMI) more than 27 kg/m2? Calculate your BMI here.

7.     Are you older than 50?

8.     Is your neck size (measured around the Adam’s apple) 17 inches/43cm or larger if you’re a biological man, or 16 inches/41cm or larger if you’re a biological woman?

9.     Is your biological gender male?

10.  Do any of your first degree relatives (parents, siblings, or children) have sleep apnea?

11.  Do you have fragmented sleep and wake up more than once or twice at night without an obvious cause?

If you answer “yes” to 3 or more of these questions, I strongly suggest that you ask your primary care provider to order a home sleep study for you to rule out sleep apnea. Untreated sleep apnea has been shown to increase your risk of death by almost 4-fold. If you have it, treating it could truly save your life. 

Until next week, sleep well! 

Jen

Strategies to improve your sleep (Part 2 of 3 on sleep)

Last week we explored a bit about how important sleep is to health and life. (5 word recap: it’s as important as water.) This week in part 2 of a 3 week series on sleep, I get into the details of many of the various strategies I’ve explored in an attempt to improve my own sleep. As I was preparing to write this post, I started jotting things down… and realized it could turn into a 100 page treatise. So in this post I’ll try to keep it as concise as possible, and then can go into a lot more detail for a few of these strategies in future posts for those of you who are interested in more of the scientific evidence behind them.

My med school friend Al Chun joked last week about expecting me to tout the benefits of cutting back on caffeine and alcohol, and indeed, he was correct:

1.     CAFFEINE. After you wake for the day, a chemical called adenosine starts to slowly build up in your brain, gradually slowing down your neuronal firing until you fall asleep and the adenosine is washed away. Caffeine decreases the soporific effects of adenosine by competing for its receptors in the brain, thereby speeding up neuronal firing and leading the pituitary to sense an emergency and trigger you adrenaline (thus the feeling of shakiness or cold hands from blood vessel constriction if you overcaffeinate). This can obviously disrupt your sleep. (Caffeine also disrupts the architecture of your sleep even if you are able to fall asleep after having that after dinner espresso.) Common wisdom suggests that you avoid caffeine after noon, but I would go farther than that and suggest that you should avoid caffeine for a full 12-14 hours before your intended bedtime. (!) Yes, that means that if you want to go to sleep at 10:00pm, you should avoid caffeine after 8:00am. The reason is that caffeine has a half life of 6 hours — meaning that a full 25% of the caffeine dose that you ingested this morning is still coursing through your veins 12 hours after you drank it. Cutting out caffeine entirely might be even smarter, but I don’t dare take away your morning joe, you coffee addict.

2.     ALCOHOL. While many people believe that a night cap helps ease them into sleep, alcohol actually has a very detrimental effect on sleep. While it can indeed induce the onset of sleep, it disrupts your sleep architecture dramatically and ruins the quality of your sleep by depriving you of much-needed restorative REM sleep. In addition, as you metabolize the alcohol, you can go into a mild period of alcohol withdrawal which includes stimulation of your brain and circulatory system. If you want to drink responsibly with minimal effect on your sleep, have a single drink if you’re a woman (1.5 ounces of hard liquor, 5 ounces of wine, or 12 ounces of beer), or no more than two drinks if you’re a man, a full 2 hours or more before bedtime. 

Beyond caffeine and alcohol, there are many other things that impact sleep quantity and quality:

3.     LIGHT: First of all, a bedroom that isn’t dark enough can seriously ruin your ZZZs. Blackout shades and/or a sleep mask can make a world of difference. Also, avoid bright and/or blue light for several hours before bed. Exposure to light in the blue spectrum after sundown is getting more and more common (with compact fluorescent and LED bulbs becoming ubiquitous and our iPhone and Android screens being ever-present in our lives) — this suppresses the production of sleep-inducing melatonin. This keeps you awake and shifts your circadian clock to create a false jet lag in your brain. Use the function on your phones and tablets that turns the light color to an orange hue (with Apple products it’s under Settings -> Display and Brightness -> Night Shift), avoid TV in the hour before bed, and turn down the lights in your home. If you want to get really geeky about it, you can even buy these sexy blue-blocking glasses.

Interestingly, I personally found that I was usually exhausted by 7 or 8pm and could fall asleep easily once I let myself get into bed, but often woke around 3:00am with a surge of warmth and adrenaline, as if my cortisol (which usually peaks around 6:00am) were peaking early. So for me, blue light in the evening wasn’t impairing my ability to fall asleep, but rather I seemed to have the opposite problem. So I started wearing these blue blockers in the early morning hours if I got up before 5:00am to help prevent my brain from thinking it was already daylight out. Similarly, I bought a cheap bright light therapy box to shine into my eyes around 7pm when I was fading early, to try to adjust my own circadian rhythm to a slightly later schedule.

Strategically using and/or blocking blue light to your advantage might be a useful part of a comprehensive sleep overhaul.

4.     NOISE: Ensure your bedroom is extremely quiet. If you’re unable to create a quiet environment, I highly recommend playing white noise to block out random sounds — there are many free white noise apps available. I own several and like to play a rain/shower sound — without it, even the sound of the aircraft onditioning unit outside our window turning on and off wakes me up! Sleep with a partner who snores but who themselves can’t stand to hear white noise? Buy a set of sleep headphones that are more comfortable for side sleepers than ear buds – if you put them over your eyes instead of your forehead, they can even double as a light-blocking mask.

5.     TEMPERATURE: Make sure your sleeping environment is cool. For optimal sleep, it turns out that the room temperature should ideally be about 65 degrees Fahrenheit. Sleep relies on the cooling of your core body temperature, so a warm room can hinder this. I invested in a pricy product called the chiliPAD™ (I bought a refurb and waited for 25% off!) which goes underneath your sheets and pumps water throughout the night to regulate the temperature of your bed anywhere from 55 to 115°F — I have mine set for 64 degrees. (Side bonus for my 40/50-something lady friends out there – the chiliPAD™ can eliminate the middle-of-the-night hot flashes that so commonly disturb the sleep of perimenopausal women!)  Taking a hot bath or sauna before bed can help by warming your body up enough to dilate your surface blood vessels, which can then help dissipate heat from your core more quickly as you slide into bed in your cool room. Wearing a pair of warm socks (or placing an old school hot water bottle at your feet) has the similar effect of warming your extremities and allowing your surface blood vessels to dilate more, thereby helping you sleep more soundly. 

6.     MENTAL CHATTER: We’ve all probably lay down to go to sleep, or awoken in the middle of the night, only to start ruminating about the big presentation we have to give the next day, or what you wish you had said during that argument, or simply your long To Do list looming over your head. There are several strategies that might help. One is keeping a notebook next to your bed and brain dumping all of your worries out onto paper before you go to sleep. (Jotting down the thing that pops into your head at 3:00am can also help you release it and go back to sleep.) Similarly, avoid mentally engaging with anything that might be stressful in the hour or so before bed, such as watching the evening news or reading potentially annoying work emails. Starting a meditation practice can also do wonders. There are several popular apps out there. I personally like Headspace (which has a great “mindful eating” course in addition to several courses on sleep, by the way); I’ve heard many people tout the benefits of Calm, and if you think meditation is froofroo, Ten Percent Happier is another popular meditation app which is geared toward people who might approach mindfulness and meditation with a bit more reluctance. I found that with practice (just 10 minutes of guided meditation each afternoon), I was able to more easily tap into that relaxed head space in the middle of the night and clear my mind, meditating myself back to sleep successfully as often as not. I also suggest trying the “military method” of falling asleep, which focuses on muscle relation — since incorporating it (especially focusing on relaxing all of the muscles in my face), I’ve had a much easier time drifting back off to sleep than I used to.

7.     NAPS: No matter how tired you are, if you’re not sleeping well at night, try to avoid napping. Remember adenosine, which we discussed above under caffeine? Well, a long enough nap will discharge the adenosine that’s been building up in your body and thereby worsen your nighttime sleep. If you do need to nap, keep it to 20 minutes or less to refresh your mind without discharging all that sleep-inducing adenosine. 

8.     FASTING: Don’t eat or drink within the two hours before bedtime. Having your digestive system actively processing that big dinner or late-night snack when instead it should be resting has been shown to impact sleep negatively.

9.     SUPPLEMENTS: I could write an entire blog post solely on potential supplements to use for sleep, so I won’t get into all of the evidence (weak or strong) behind these here. But a few supplements that I personally have incorporated are low-dose melatonin (it has a very short half life so will help you fall asleep, but won’t really help you stay asleep - I sometimes take a physiologic 300mcg dose when I awake at 2 or 3am), ashwagandha 300mg twice a day, GABA 100mg at bedtime (it doesn’t cross the blood-brain barrier to make you sleepy, but may relax the peripheral nervous system), and L-theonine 100-200mg at bedtime (btw to simplify things, Jarrow Formulas makes a single supplement called “GABA Soothe” that contains GABA 100 mg, theanine 100 mg, and ashwagandha 225 mg). I also take my daily magnesium supplement (Magtein) for cognitive preservation/function in the evening since some people claim that magnesium relaxes them and makes them sleepy. Two kiwi fruit an hour before bed, as well as sour cherry juice, have been studied and are potentially promising as well. The gut Microbiota can affect the architecture of our sleep, and certain prebiotic fibers have been shown to improve sleep in rodent studies - specifically, these fibers are contained in the supplement Bimuno Daily, which was touted as an effective supplement in a BBC documentary entitled “The Truth About: Sleep.” I put a sachet of Bimuno in my coffee every morning just for kicks. 

I recommend AGAINST using sedative-hypnotics such as Ambien (zolpidem), as they adversely affect sleep architecture and have been associated with a higher risk of mortality even in people who use them only occasionally. Similarly, the use of antihistamines (such as Benadryl or diphenhydramine, Unisom or doxylamine, and meds containing these antihistamines such as Tylenol PM or Advil PM) has been associated with a significantly increased dose-dependent risk of dementia (attributed to the anticholinergic effects).

10.  DIVORCE: Did I get your attention? Ha. But seriously, I feel strongly that a “sleep divorce” might do wonders for your and your partner’s sleep. A hot topic recently covered by the New York Times and the Today show, the “sleep divorce” simply entails partners sleeping in separate rooms. This can make a huge difference if either or both of you are disturbed by the other, whether from snoring, different bedtime and rising times, movement in the bed, the sleep disorder of one or both partners such as restless legs syndrome or obstructive sleep apnea, or different temperature preferences. It turns out that up to 40% of people, when surveyed anonymously, admit to sleeping separately from their partner, and the sex lives of these people may actually be better than those with disturbed sleep… because who wants to get busy when you’re exhausted?? Indeed, a sleep divorce might help prevent a real divorce!

I know this was a long one, guys, but hope at least some of it was new and helpful to you! Let me know in the comments below whether you’ve had success with any of these methods, or plan to try one or more of them. And if any of my posts have been interesting or helpful to you, please do share with others you think might be interested — sharing really helps me spread the wisdom more effectively!

Next week in Part 3, I will cover one more critical topic in the realm of sleep, and reveal my own shocking (and life changing) sleep-related diagnosis! Until then, sweet dreams!

Love, Jen