American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, December 12, 2013

Lose weight; find health? Sleep on it

We have long known that sleep is of profound importance to health. It is a requirement for living, much like breathing, but with awake and asleep playing out over longer spans and to slower rhythms than inhalation and exhalation. Sleep is essential. We must turn off if we are to go on.

Unlike many of the factors that affect health profoundly, the impact of sleep is both immediate and intimate. You have no need of me, or clinical trials, to tell you that sleep matters. All of us have, at some time, slept well, and awakened to feel the invigoration of having done so. All of us have, and most of us, alas, too often do, sleep poorly or too little, and thus know all too well that feeling of a head stuffed overfull with cotton and far too heavy for our necks.

While we need no science to tell us sleep matters, science can enhance our understanding of all the reasons why. Over recent years, no doubt due largely to our preoccupation with the epidemic obesity we keep choosing to lament rather than fix, the links between sleep and weight have received particular attention.

Relevant research consistently associates sleep deprivation with obesity risk, and invokes a number of potential mechanisms. Some are fairly self-evident. For instance, lack of sleep tends to mean lack of energy, which is apt to discourage exercise. Sleep deficiency also tends to produce irritability, and all the wrong foods tend to provide, albeit briefly, all the right comfort to dull this pain.

Some mechanisms are less apparent, and likely more important. The quantity, quality and timing of our sleep are tethered to our endocrine system. The circadian rhythms of our hormones influence our capacity to sleep and wake, and are in turn influenced by them. Disruptions in sleep patterns inevitably disturb hormonal balance, which in turn reverberates through the endocrine system like ripples in a pond. Cortisol levels are perturbed, unbalancing levels of insulin, and subsequently, appetite-regulating hormones such as leptin and ghrelin. Brain neurotransmitters, several of which double as hormones, are affected as well, including norepinephrine and serotonin. The stress of sleep deficiency stimulates epinephrine release. The result in general is increased appetite, an increased tendency to store calories as fat around the middle where it does the most harm, increased inflammation and the initial steps toward insulin resistance.

We knew all of this from a large and growing body of research addressing sleep. But relatively little of that research is of the direct cause-and-effect variety in people, because it’s challenging to randomize people to different sleep patterns for extended periods.

A new study in Pediatrics is something of an elegant exception, and all the more so for being carried out in children. While most of us adults would likely welcome more and better sleep, kids tend to go the other way, so they lack our bias. For research purposes, that’s a good thing, even if it’s not so good when it makes bed time a battle. I’ve got 5 kids. I know that gig.

In the new study, researchers assessed appetite, hormone levels, weight and food intake in a group of roughly 40 children ages 8 to 11. They randomized the kids to a sequence of different number of hours in bed within a reasonable range, and monitored brain waves to tally hours actually slept. In 1 assignment, the kids had an extra 90 minutes in bed for a week. In the other, they lost 90 minutes. The result, measured by EEG, was an average of more than 2 hour differences in sleep time between assignments.

The effects on all measures of interest were clear and compelling. 2 hours less sleep, even without rising to the definition of sleep “deprivation” was still enough to disrupt hormone levels, increase hunger and appetite, and increase daily calorie intake. In the sleep reduction phase of the trial, fasting leptin (a hunger suppressing hormone) levels were lower; reported food intake was higher; and weight increased slightly. And again, this was in kids, who may if anything be less prone to treat sleep-related irritabilities with food than we are.

The new study doesn’t change what we thought we knew, but it certainly lends emphasis. The physiologic effects of even moderate changes in nightly sleep time are rather potent, directly relevant to the prevailing health problems of our time, and nearly immediate.

Sleep has long been on my short list of top priorities for health, even if I’m slightly less good at it than I am with all the others. If it isn’t on yours, I certainly think it should be. Any parent or grandparent concerned about weight gain or diabetes risk in a child they love now has cause to make it a priority for those children, too. As a society subject to epidemic obesity and diabetes in children and adults alike, we may have new reasons to cultivate the respect for sleep it clearly deserves.

Action items begin there, with respecting sleep as much more than down time. Busy people may feel they don’t have time to sleep. However, for sustained productivity, let alone health, the truth is that none of us has time not to sleep.

At times, sorting out sleep problems may require assistance, such as undergoing polysomnography to identify sleep apnea. But often, the problem is behavioral and under our own control. There is a simple skill set for optimizing sleep hygiene, which any of us can learn and practice to good effect.

Finally, there is an important argument here for approaching our health holistically. Perhaps you want to lose weight or avoid diabetes, you could decide, reasonably, to focus on diet and exercise. But if you ignore other aspects of your health, such as sleep, your own daily routine may conspire against your objectives. A culture widely prone to both obesity and sleep deprivation may be a quintessential case of meeting the enemy, and finding it is us.

I have seen just such patterns in my practice over the years, and a holistic view of health, orchestrating into a logical sequence of tweaks, can be just the fix. Often, with the requisite insights and skillpower, you can oversee just such troubleshooting on your own, no docs or drugs required.

We can’t be too busy to get the sleep we need, unless we are also too busy to get the health and weight control we want. If you remain unconvinced, I can only think to suggest you sleep on it.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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