MedHeads

On Lifestyle Matters show this week

COLTE – how to entrain your sleep wake cycle.

This week I chatted with Dr Saveena about the factor that help regulate our sleep wake cycle.

Our natural sleep-wake cycle is more than 24 hours. So, we need to constantly entrain our sleep-wake cycle to the natural day night cycle that does last 24 hours. We do this by use of zeitgebers which are environmental time cues. The most significant zeitgeber is light.

Daylight, and particularly blue light which has a wavelength of approximately 480 nm has an activating effect. It suppresses melatonin secretion; it increases cortisol secretion and activates our sympathetic nervous system causing an increased heart rate and blood pressure. These effects are all beneficial in the morning when we need to get up and face the challenges of the day. Prior to the advent of industrial lighting, the evening, associated with dim light allowed the secretion of melatonin which then caused drowsiness and prepared us for sleep. This interaction between external light and darkness therefore kept our sleep wake cycle entrained to the 24-hour day.

However, with the advent of industrial lighting we are exposed to light, including blue light, well into the evening which can have the effect of causing inappropriate activation and interfere with melatonin secretion and the onset of sleep. Lack of exposure to daylight can also have an adverse effect on sleep by rendering the body more sensitive to even low levels of evening light further impairing the natural sleep wake cycle. Therefore, we need adequate exposure to daytime light and night-time darkness to sleep well.

Light however is not the only factor that can affect our sleep. If we look at the COLTE mnemonic C stands for carbohydrates. When we ingest carbohydrates, the insulin rise also stimulates intracellular storage of amino acids, all except tryptophan. Therefore, in the presence of a high carbohydrate load the relative concentration of tryptophan increases. Tryptophan is then metabolised to serotonin and melatonin which as we know contribute to sleep.

This effect occurs maximally four hours after ingestion of carbohydrates so we should be eating our last meal of the day four hours before out anticipated sleep time.

O stands for osmolality. Osmolality refers to the salt and water content of body fluids. During early sleep blood vessels dilate which reduces blood pressure and allows heat to escape from the core to the peripheries. High salt content or relative dehydration impairs the dilation of blood vessels and therefore impairs the reduction of blood pressure and the core body temperature that need to occur in early sleep.

T stands for temperature. AS discussed above early sleep requires a reduction of core body temperature and an increase in peripheral temperature. Therefore, we need to be mindful of the ambient bedroom temperature and we may benefit from wearing bed socks to keep our peripheries warm to facilitate early sleep.

E stands for exercise. Exercise activates our adrenaline and cortisol, hormones which activate us. Therefore, we should exercise in the early morning preferably outdoors to catch the morning light. Exercise in the late afternoon may also be beneficial in promoting unbroken sleep. Exercise prior to attempting sleep however is not advisable. All that adrenaline and cortisol surging through our bodies will just keep us awake.
So, we can see that COLTE (carbohydrates, osmolality, light, temperature and exercise) relate to the factors that can influence how well we sleep at night. An understanding of how to manipulate these factors is an essential component of the lifestyle medicine interventions that we can offer for people with sleeping difficulties.

In this episode of Lifestyle Matters Dr Ferghal and I discuss the benefits of exercise both in primary and secondary prevention of cardiometabolic diseases, heart disease and maintaining a robust immune system.

Some statistics from Diabetes Australia and Australian Institute of Health and Welfare show that:
• In Australia, 1 person develops diabetes every 5 minutes
• An average of 2 people die from heart disease every hour
• 23 Australians die from a stroke every day.

High blood pressure is a well-known risk factor for both, heart disease and stroke. There are studies to show that a modest weight loss of 2kg in a 6-month period can reduce diastolic blood pressure by 2.7mm mercury and systolic by 3.7mm mercury.

This occurs via a variety of mechanisms including the production of free radicals and growth factors that can promote cell signalling and remodelling of our blood vessels. This in turn will reduce the resistance of our blood vessels, thus reducing the risk of high blood pressure.

When we exercise, our heart consumes more oxygen. If exercise is done regularly, one of the changes that occur is the reduction of resistance to blood flow. This is because our blood vessels have adapted to the repeated shearing forces. This in turn improves our cardiorespiratory fitness. For example, the breathlessness a standard sedentary person experiences when walking up 2 flights of stairs at a fast pace would reduce over time if she/he were to engage in regular exercise.

Cardiac rehabilitation (i.e. a tailored exercise program under supervision) after a heart attack can also reduce the rate of recurrence and further hospitalisations. Commencing with aerobic training for a few weeks followed by strength training under guidance is the best way forward in this regard to minimise any risks and enhance one’s cardiorespiratory fitness.

The Diabetes Prevention Program was a study designed to explore if we can reduce the incidence of developing diabetes by way of lifestyle intervention in those diagnosed with Impaired Glucose Tolerance / Pre-Diabetes. All that was required was a 7 % weight loss and 150 min per week of exercise such as brisk walking. The results were astounding – the lifestyle group had a 27% greater reduction in diabetes compared to the cohort that took Metformin (a medication used to treat diabetes)

Some of the ways exercise helps this is by reducing insulin resistance and triglycerides, weight loss and changing our body composition i.e. increasing muscle mass thereby increasing our basal metabolic rate.

Many are worried to exercise after a stroke for a variety of reasons. But really, exercise has been shown to be just as effective as blood thinners in reducing mortality after having a stroke. Starting slow and building up will be the best way forward, with the support of a rehabilitation physiotherapist or exercise physiologist. Cardio workouts are important to improve our heart and lung function and reserve, stretch and flexibility helps reduce spasticity and improve mobility. Tai Chi; for example can improve coordination, balance and cognition and lastly, resistance training can potentially improve muscle strength. Any or all of these exercises can help improve our mood and social connectivity as we would potentially engage with other people and even join a gym.

When it comes to exercise and our immune system, striking the right balance is important. Exercise has an interesting effect on our immune system. Regular moderate intensity help boost our immune function to ward off a plethora of infections by increasing the function of our T cell lymphocytes and natural killer cells amongst others. On the other hand, prolonged intensive exercises (for example; military training) have been thought to depress our immune system. However, there are many other factors such as stress or lack of sleep that could contribute hence this is slightly controversial at this stage. Following the recommended guidelines and not greatly exceeding it; i.e. no more than 420mins / week should keep us safe.

This week on Lifestyle Matters I chatted with Saveena about the basics of exercise. This episode is the first of a series of shows in which we plan to explore all aspects of exercise and how it applies to health and wellbeing.

Exercise can be classified as: aerobic, resistance, balance, and flexibility.

Aerobic exercise can be thought of as fitness training, and can include activities such as brisk walking, jogging, cycling, or rowing. These are all types of activity that may you puffed out.

The Australian Government department of health advises the following activity guidelines for adults between 18 and 64.

Adults should be active most days, preferably every day.
Each week, adults should do either:

• 2.5 to 5 hours of moderate intensity physical activity – such as a brisk walk, golf, mowing the lawn or swimming

• 1.25 to 2.5 hours of vigorous intensity physical activity – such as jogging, aerobics, fast cycling, soccer, or netball

• An equivalent combination of moderate and vigorous activities.

In addition, Department of Health guidelines state the following regarding resistance training.

Include muscle-strengthening activities as part of your daily physical activity on at least 2 days each week. This can be:

• Push-ups

• Pull-ups

• Squats or lunges

• Lifting weights

• Household tasks that involve lifting, carrying, or digging.

Both balance and stretching activities should performed at least twice a week, especially by older Australians above the age of 65.

Flexibility activities

Activities that focus on your flexibility help you move more easily, and can include:

• Tai chi

• Bowls (indoor and outdoor)

• Mopping or vacuuming

• Stretching exercises

• Yoga

• Dancing

Balancing activities

Activities that help improve your balance can prevent falls and injuries, and can include:

• Side leg raises

• Half squats

• Heel raises.

We also chat about the perils of being sedentary. Sitting increases all-cause mortality and has been found to be, independent of exercise, a risk factor for obesity, metabolic syndrome, cardiovascular disease, and type 2 diabetes mellitus.

Television viewing has been found to increase all-cause mortality even in those getting seven hours of exercise per week. Interrupting sitting with light to moderate intensity walking every 20 mins reduces blood glucose and insulin levels in obese patients.

On MedHeads

I chat with DR Andrew Rees about a particularly challenging case of a military veteran in his fifties who ahs been a victim of both a traumatic abusive childhood and combat trauma.

He suffers from chronic pain secondary to degenerative disease of both knees and spine (rather than combat trauma) and is dependent on high dose opioids (oxycontin 40 mg bd) and various benzodiazepines. He also suffers form PTS. In terms of his lifestyle, he is obese, he smokes twenty to thirty cigarettes per day. He lives with a partner and has a child from a previous relationship.

We discussed firstly what his needs might be according to the “SPEW CRAFT” mnemonic.
Sustenance – there do not seem to be any unmet needs in this domain
Protection.
His PTSD may indicate an unmet psychological need for protection.
Engagement with meaningful activities.
He does not engage in any meaningful activities; he has no hobbies or interests and self isolates for most of the time.
Wisdom – He may not know how to seek help, or for that matter that help is available
Creativity – there do not seem to be any unmet needs in this domain
Rest – He does not work, and as mentioned above he does not engage in any meaningful activities, but this does not mean he has rest. He does not have rest from psychological restlessness, and his diurnal rhythms are disturbed.
Freedom – He feels trapped and isolated and is not sure who his tribe is. There is a reluctance to engage with the local RSL for fear of exacerbating his PTSD.
Transcendence or Legacy.
He has no idea of his identity or his personal worth.

Starting from this apparently hopeless situation Dr Rees has been able to engage with this patient and help this patient grow by simply asking the right questions.

What does he hope for in life?
This man’s quest for his purpose in life led him to realize that he wanted to re-establish his relationship with his daughter.
What is he good at, what would his spouse think he is good at, what would his daughter think he is good at?
He identified that his strengths included reliability, conscientiousness, and a sense of duty.

After understanding the answers to these questions then comes the miracle question.
“If all your problems magically disappeared overnight, what would it look like for you, what would it feel like for you and what would be the first sign that someone else would notice?”
In this case the answer was that he would smoke less, take less medication, and do more exercise.

The miracle question has unlocked in this patient the potential for deprescribing and a healthier lifestyle. Finding his purpose in life has shifted his focus from being dependent on medication and has unlocked his desire to be medication free, to enjoy mental clarity and to engage with his family.

Archimedes once said that with a big enough lever he could move the earth. Dr Rees has shown us a similarly profound effect: that with the right question we can unlock a willingness for change and a desire for a drug-free life.

Maree Eisma is a mental health social worker who has an expertise in dealing with children who are experiencing school refusal.

School refusal usually presents with an escalating school reluctance before frank refusal occurs. Behaviours can include repeated sick bay attendances or multiple but intermittent absences due to various illness presentations.

I like to classify the presentation of school refusal according to primary, secondary or tertiary gain.

Primary gain refers to the intrinsic benefit of the sick role. In the context of school refusal, it suggests that the child who presents with an illness benefits from being sick in terms of care giver attention. This may be an issue of care givers are very busy or otherwise emotionally distant.

Secondary gain refers to a secondary benefit that the sick child enjoys, which in the context of school refusal may indicate a desire to escape from bullying, a test or other academic pressure or sometimes merely the overstimulation that may occur in a busy school yard.

Tertiary gain refers to the benefit that the care giver may derive from a child’s illness behaviour triggering school refusal. Divorce, separation, or other sources of parental disharmony can perpetuate this.

Underlying the phenomenon of primary gain is the concept of somatisation, i.e. the manifestation of medically unexplained symptoms that are not consciously feigned.

It can be challenging from a. medical perspective to distinguish organic pathology from somatisation, but the distinction needs to be made to prevent harm to the patient in terms of unnecessary tests and treatments.

Further to the diagnostic dilemma it is also important to approach the management of the problem from a socio-psycho-biomedical model of care. it is not sufficient simply to advise parents to “Just make their child attend school”.

In a similar vein I remember telling the parents of a young child who was refusing to swallow antibiotics to “just make the child take the medicine”.

Graded exposure can be used to help children re-integrate back into school. This process relies on a patient and gradual exploration of a child’s situational anxiety and providing coping mechanisms to deal with situations as they arise. It is important that both parents and the school be closely consulted and involved in this treatment.

Watch this discussion on MedHeads

Exercise is for all

‘Exercise not only improves our well-being as we get older, but it can also potentially reduce our biological age by 8.8 years!’

In this episode of Lifestyle Matters, we review the importance of exercise as we get older and briefly touch on the significance of exercise in people with disabilities.

Exercise and individuals above the age of 65:

It is common knowledge that exercise is important for our well-being, but many retirees wonder why they need to exercise after slogging it out for years. I frequently hear retirees ask rhetorically, ” Is this not the leisurely part of life?”.

Indeed, it is true that life in retirement is meant to be leisurely but to reap the benefits of those years and truly enjoy ourselves, the body needs to be physically fit. Exercise has been shown to increase life expectancy. Our DNA strands are protected by telomeres. Telomeres shorten as we get older due to fraying. However, it appears that exercise can in fact lengthen these telomeres which translates to a biological age of up to 8.8 years younger.

First, let us understand the effects of ageing. Some of these effects or changes are inevitable due to the physiological changes that happen in our bodies as we age.

Some of the changes include:

• Sarcopenia i.e. progressive loss of muscle bulk

• Osteopenia i.e. progressive loss of bone density

• Reduced joint flexibility & mobility

• Reduced cardiorespiratory reserve

• Reduced balance and coordination

• Increased susceptibility to mood disorders – multifactorial

However, these can be slowed down with exercise!

“The recommended guideline for individuals above the age of 65 years is 30 minutes of moderate intensity exercise per day on most days or, if feasible, all days. Include the different types of exercises as listed below if possible”

Each exercise category listed below has its own benefit for example, resistance training helps improve bone density and muscle mass whereas aerobic training increases our cardiorespiratory fitness.

Hence try incorporate 1 from each group:

• •Aerobic Training: walking, jogging, swimming, golfing (without the use of a golf cart, of course)

• Resistance Exercise: push-ups on the wall, climbing stairs, lifting groceries / grandkids, ½ squats holding the back of a chair, wall-sits etc

• Stretch / flexibility: Tai Chi ( my favourite as it also improves balance, coordination and cognition), heel raises, hamstring stretches

• Balance: One legged stand- start off with holding on a chair / table, step ups

Consulting an Exercise Physiologist is especially important if one has any physical or medical limitations. Safety is paramount hence I would recommend the use any hearing / visual aids if needed. You must also ensure adequate lighting is available and always use comfortable clothes and supportive shoes to make the exercise more enjoyable and effective.

Exercise and disability

¾ of people with a disability do not meet current guidelines. These guidelines are the same as the age-matched guidelines and should be modified based on a person’s disability. It is extremely important for this to occur as disabilities can come with their own set of cardiorespiratory/metabolic/bone/muscular/joint complications and to decelerate these, exercise can be a huge value added.

Once again, an Exercise Physiologist can be accessed through a variety of systems and one of the easiest ways to do so in Australia is through the National Disability Support Scheme (NDIS)

Apart from all the above benefits, exercise not only increases the likelihood of us getting some sunshine and fresh air, but it also provides us opportunities to increase our social network.

In this episode of Lifestyle Matters, we discuss tools to use when choosing a diet and what a weight loss plateau is.

Over the upcoming weeks, we will be reviewing the various diets that are out there from a medical perspective.

 The purpose of today’s blog is to introduce how beneficial diets can be to our lives when chosen correctly. However, the first dilemma most face is: “How do I choose the right diet?!!” We hear you; it really is quite overwhelming to find that there are over 100 diets out there! So many of these diets are ‘in trend’ and promoted all over social media. For example, just because the Ornish diet worked well for Bill Clinton, it does not necessarily mean it will work for all.

 So, how do we choose a diet? The most important factor is sustainability. Some can follow a rigorous calorie restricted diet to lose weight, but this is rarely sustainable.

Other factors that we should look at when choosing a diet so that it is sustainable includes:

• Cultural factors – it can be hard to make a change if rice / pasta is a staple in our diet

• Social and family support – it is always easier when our social circle is supportive of our choices

• Lifestyle – e.g. work type / hours which can impact our ability to meal prep thus requiring us to become more creative

• Budget – making smart choices when buying fresh foods as some can be more expensive

• Underlying medical conditions – may restrict or advocate certain foods Nutrigenomics

When we follow a diet, calorie restriction is only inevitable which then results in weight loss. However, a weight loss plateau can occur over 6-12 months. One of the potential causes for this is the reduction of our basal metabolic rate when we reduce our calorie consumption. A 10% reduction in calorie intake can result in up to a reduction of about 12 % in basal metabolic rate! This happens as our bodies adapt to the reduced calorie intake.

 So, if we continue to consume the same number of calories with a reduced basal metabolic rate, our weight will naturally remain static or increase. Many people tend to perceive this stagnation or increase in weight as a failure on their part which is incorrect. This phase can be overcome with some simple changes and a positive mindset which include:

• Increase or change exercise intensity / style

• Increase Non-Exercise Activity Thermogenesis e.g. park the car further from the shops, take the stairs instead of the lift etc.)

• Make a caloric reduction in diet

• Increase water consumption

• Re- look at our stress level

• Ensure we get the recommended 7-9 hours of sleep

There are many studies demonstrating the benefits of a whole foods plant-based diet for our health. Furthermore, processed red meat has also been classified as a Group 1 carcinogen by the World Health Organisation. Red meat is a Group 2a carcinogen which means it probably increases the chances of cancer in general especially bowel cancer.

 As GP Lifestyle Medicine Practitioners, we advocate eating whole foods that are predominantly plant-based, for a variety of health and environmental reasons.

In this episode of Lifestyle Matters.

Can the Mediterranean diet truly help reduce our risk of cardiometabolic, neurodegenerative and cancer related diseases? Does it truly live up to all its glory?’

This week, we focus on what the Mediterranean diet is and the evidence behind some of its benefits.

The ‘true’ form of the Mediterranean diet (MedDiet) is very different from what we know of it today. The classical form of a MedDiet is a whole- foods plant based diet rich in MUFAs and PUFAs, legumes, beans and wholegrains with moderate consumption of red wine with little saturated fat.
(The Australian Guidelines recommend no more than 4 standard drinks / day, capped at 10 standard drinks / week)

The food pyramid below gives us a general overview on the diet:

This diet was popularised in the 60s by Ancel Keys who conducted the Seven Countries Study in which he studied lifestyle factors that affect our risk of developing heart disease.

He demonstrated that hypertension, hypercholesterolemia, and diabetes are undoubtedly risk factors for heart disease. In the same study he also discovered that a diet high in fibre, MUFAs and PUFAs along with low sugar intake i.e < 25gram / day can reduce risk of heart disease and all-cause mortality. This is exactly what the MedDiet is all about.

Other studies, including the Lyons Diet Heart Study, looked at the protective effect of the MedDiet which demonstrated protective heart effects of the diet such as a 73% relative risk reduction for fatal and non-fatal heart attacks , 70% relative risk reduction for overall cause mortality , and significant risk reductions in developing clots in the lungs and legs.

The Predimed Study was another study showing a possible link between high consumption Extra Virgin Olive Oil (EVOO) and risk of breast cancer reduction. Both olive oil polyphenols and Oleuropin have been implicated in this.

Other potential benefits that have been investigated and demonstrated through various studies include:

• A 50% lower risk of all-cause cancer mortality in certain cancers including prostate, colorectal, head and neck cancers, gastric and pancreatic cancer

• Reduction in neurocognitive disorders such as dementia, Alzheimers Disease

• Improve diabetes control – Hba1c reduced from 0.1-0.6% almost comparable to some pharmacological interventions

• Reduction in the risk of progression to Metabolic Syndrome

• Weight loss

Our awareness of the benefits we can gain from the MedDiet are increasing. This coupled with the fact that it is certainly not a difficult diet to follow, makes this diet quite favourable.