Saturday, September 22, 2012

Why You Can't Sleep Through The Night

More than 30 percent of adult Americans, about 60 million people, complain of difficulty sleeping. For about a quarter of these individuals, treatment begins with medication. This tells us two things. Sleep is a big problem and a big business.
So how does one of the most basic biological functions become so disordered? After all, what could be more natural than sleep?
The first thing you notice when digging into what we know about sleep is how little we understand. The function of sleep, a state that occupies one-third of our lives, remains unclear. Why is sleep necessary for our survival? Why do we dream?
Sure, we have made some connections by observing what happens to people who are sleep-deprived or perform shift work. Clearly, physical and cognitive function take a hit. Medical interns working on the night shift are twice as likely as others to misinterpret hospital test records that could endanger their patients.[1] The Exxon Valdez oil spill and the Three Mile Island and Chernobyl nuclear power plant accidents were attributed in part to the consequences of compromised night shift workers. We know memory and learning are impaired. Protein synthesis that produces the building blocks needed for cell growth and repair is markedly diminished.[2] But theses are crude observations, not understanding.
The second thing you realize, and this boggles the mind, is that almost everything we do know about human sleep has been learned in the last 50 years. Unfortunately, like the first beliefs in any discipline, many of the early theories about our sleep were wrong.
Until recently, humans were thought to be different from all other animals in having sleep that is consolidated into one continuous nocturnal episode. This notion of uniquely human sleep held sway until the early 1990s when Thomas Wehr, a sleep researcher at NIMH inadvertently stumbled on something that changed everything, or should have.[3]
Wehr selected healthy untroubled sleepers who were accustomed to 16-17 hour days and seven to eight hours of sleep, a routine that many of us live by or envy because we get less sleep. He exposed them to 10 hours of light and 14 hours of dark per day and watched what happened to their sleep. This ratio of light to dark (10:14) mimics the natural light of a typical winter day in a temperate climate. Initially, they slept for 11 hours per night, suggesting a chronic sleep deficit, and then settled into an average of 8.9 hours each night. By the fourth week Wehr saw something that wasn't supposed to happen in humans. They all developed a sleep pattern characterized by two sleep sessions. Subjects tended to lie awake for one to two hours and then fall quickly asleep. After about four hours of solid sleep, they would awaken and spend one to two hours in a state of quiet wakefulness before a second four-hour sleep period.
This bimodal sleep has been observed in many other animals. One such creature turns out to be pre-industrial man. Only recently have anthropologists and historians scrutinized the sleep of other cultures, earlier centuries and prehistoric humans. In the remarkably informative At Day's Close, Night in Times Past, Roger Ekirch unveils nocturnal life in the pre-industrial west.[4]
Drawing from a broad range of sources he found a trove of evidence documenting our history of bimodal sleep. Until the late 1700s, and the widespread use of artificial light, people retired to bed soon after sun down and entered what was called "first sleep." They would awaken three or four hours later and enjoy a couple hours of quiet. During this time they often prayed, chatted about dreams and had sex. A French physician described this time between sleeps as a particularly good opportunity for sexual intimacy when couples "do it better" and have "more enjoyment." The middle night interactions seem to have been essential for social cohesion.
This was followed by "second sleep" that again lasted three to four hours and ended with sunrise. In fact, a study of contemporary cultures across the globe reveals a wide spectrum of sleep habits.[5] Some anthropologists now speak of three sleep cultures: monophasic cultures (the West, where one consolidated sleep period dominates), siesta cultures (where one afternoon nap is added in the afternoon, the word siesta meaning the sixth hour) and polyphasic cultures (China, Japan, India where multiple naps throughout the day of varying lengths are the norm).
Researchers have replicated and expanded on Wehr's work. Several studies have taken subjects to deep underground bunkers free of any artificial light in order to observe our internal clock's rhythm. Again, they observe this biphasic pattern. Subjects sleep in two four-hour solid blocks separated by a couple hours of meditative quiet during which there is a remarkable surge of prolactin, unseen in modern humans. The participants report feeling so awake during the day that it is as if they experience true wakefulness for the first time.
So we find ourselves in a somewhat perverse situation. We have not evolved to naturally drift rapidly into one continuous nocturnal snooze. But according to the medical community and the pharmaceutical industry, if we don't do this, we suffer from a sleep disorder that merits medicating. However, if you ask any sleep expert how some people seem to fall asleep quickly and sleep continuously for seven or eight hours they'll say that such a sleep pattern is characteristic of chronic sleep deprivation.
We evolved in an environment of alternating light and darkness and developed internal clocks to manage in such conditions. Every known organism with two or more cells has an internal clock.[11] In this regard, we are not unique. It is our use of artificial light to extend our day and defy our natural rhythms that distinguishes humans. We have just begun to understand the consequences of this Promethean sin.
Sleep deprivation has been linked to obesity, hypertension, insulin resistance, cardiac disease, and compromised immune function.[6][7][8][9] In the same way that food products/supplements are replacing normal eating with dire health effects, sleep continues to be condensed by the 24/7 culture. The recent rapid growth of a new category of medications that promote wakefulness makes one wonder if sleep will soon be optional or ultimately obsolete.[1]
So what can you do?
The constraints of work schedules and family responsibilities make radical changes in sleep-wake timing difficult. Here are some guidelines:
1. Abandon the idea of going to bed for six to eight hours of sleep at night (unless this works for you).
2. Get a feel for what your sleep cycle looks like. If you wake up before you need to, get up. This is probably a natural cycle end. You will make up for lost nighttime sleep with a nap(s).
3. Napping Guidelines:
  • Timing: Afternoon (3-5 p.m.) -- proven to provide more sleep efficiency, more slow-wave sleep, and less time to fall asleep.[12]
  • Duration: Optimally 10-20 minutes. People experience greater cognitive impairment due to sluggishness after a nap of 30 or more minutes than that due to sleep deprivation.
  • The full benefits of naps comes with habitual napping. Stick with it!
4. If possible, when you feel like reaching for that afternoon caffeine fix, take a nap.

[1] Veasey S et al. Sleep Loss and Fatigue in Residency Training JAMA, Sept 4, 2002 Vol 288, No.9
[2] Sleep: A Comprehensive Handbook, edited by T. Lee-Chiong 2006 John Wiley & Sons p904
[3] Wehr T et al. In short photoperiods, human sleep is biphasic Journal of sleep research 1992 (2) 103-107
[4] Ekirch AR, At Day's Close, Nights In Times Past 2005 WW Norton & Co, Inc.

[5] C.M. Worthman and M. Melby. Toward a comparative developmental ecology of human sleep. 2002, In: Adolescent Sleep Patterns: Biological, Social, and Psychological Influences, M.A. Carskadon, ed. New York: Cambridge University Press, pp. 69-117.
[6] Ackermann K et al. Diurnal rhythms in blood cell populations and the effect of acute sleep deprivation in healthy young men. SLEEP 2012;35(7):933-940.
[7] Spiegel K et al. Sleep loss: a novel risk factor for insulin resistance and type 2 diabetes Journal of Applied Physiology Nov 2005 vol 99 2008-2019
[8] Knutson KL et al. The metabolic consequences of sleep deprivation. Sleep Medicine Reviews vol 11, Iss 3, 163-178 June 2007
[9] Gottlieb DJ et al. Association of usual sleep duration with hypertension. The Sleep Heart Study. Sleep vol 29, No 8, 2006
[10] Boutrel B et al. What keeps us awake: the neuropharmacology of stimulants and wakefulness-promoting medications. Sleep, vol. 27, No. 6, 2004
[11] Ko CH et al. Molecular components of mammalian circadian clock. Human Molecular Genetics 2006 15 (suppl 2) R271-R277
[12] Brooks A; Lack L. A brief afternoon nap following nocturnal sleep restriction: which nap duration is most recuperative? SLEEP 2006; 29(6):831-840.

Monday, September 10, 2012

What We're Talking About When We're Talking About Cleansing

The 1981 Raymond Carver short story collection "What We're Talking About When We're Talking About Love" masterfully showed us that everyone has a different conception of love. At the end of the eponymous story Carver seems to suggest that while we may struggle to put into words what love is, it's worth the effort, even if we fail.

I think a similar effort should be made with the contemporary practice of "cleansing", a term used here to cover a broad spectrum of behaviors (from colonics to detox diets/drinks) defined by an attempt at purification or elimination of undesirable material from our bodies.

Why make such an exploration?

A Google search on "health cleanses" draws 4 million 430 thousand entries. Clearly this is on a lot of people's minds. And the mind is my focus. The cleansing phenomenon is driven by a perception of self as dirty. Dirt, like love, means different things to different people.

The etymology of dirt (the dirt on dirt, so to speak) is telling. In Olde English "dritan" was a verb meaning to defecate. Middle English coined the noun "drit" for excrement. Over the years the i and the r swopped places giving us "dirt". So it's not a stretch to see where the idea that if there's a place in us that needs cleaning, it must be that final pathway of our feces, the colon.

Our bodies turn food into feces. But we take in more than food. We take in ideas and experiences that are also "metabolized" in the sense that they are broken down and mined for useful material that we store in our memory and use in a variety of ways. They may be nourishing in that they provide a sense of wellbeing or the belief that we're a good person. Alternatively, some ideas and experiences give us mental indigestion. They tamper with our sense of our selves as decent. They make us feel dirty.

We all carry around an idea of what we should be. The distance (in our own estimation) between this ideal and where we actually live, defines how we feel about our self. Traditionally such self-evaluation was based largely on how we felt we were measuring up in our relationships as a spouse or son or mother or neighbor or citizen or religious community member.

Because the distance between our ideal self and actual self is so often a painfully large expanse littered with regret, every culture has had its way of addressing the feelings of being guilty, dirty, impure. We want to "come clean", to start over. Confession, prayer, fasts, sweathouses, service, and yes, now, colonics, all fit into this category.

So how did we get here?

The traditional roles mentioned remain powerful. But a new metric for assessing how we measure up has taken root. Now the moral meter appears to be our bodies, our diet and exercise. What do you weigh? How much red meat? Did you really have pizza last night? How often are you exercising? What is your cholesterol? How many cocktails? Are you flossing? Did you get your annual checkup or colonoscopy (not colonic!) or mammogram or Pap smear?

Don't get me wrong. We should take care of ourselves. But obsessing about our bodies will not replace the cleansing feelings that come from caring for others.

Our culture is attempting to substitute diets and detoxs for self-exploration and the hard plodding work of accepting what can't change and trying to change what can, for the better. As Raymond Carver said about love, it's worth the effort, even if we fail.

Monday, September 3, 2012

Let’s Talk Dirty: The Trouble with Cleanses, Colonics and Wipes

Cleanliness may be next to godliness, but it also may do us in.  A growing body of data suggests that a wide range of ills, from allergies and asthma to inflammatory bowel disease, may be the consequence of our fetish for clean.

A quick look at the shelves of pharmacies and supermarkets speaks volumes to the priorities of a culture. The aisles of cleaning products continue to metastasize claiming more space and new frontiers. The territory in need of a good scrub now ranges from our garage to our gut, from our teeth to our toilet. Whether it’s the surface of our kitchen counter or the surface of our face, cleaner is not just better but safer.

A kind of homeland security mentality has invaded the cosmos of clean. The axis of evil here is bacteria and all bacteria are bad. But nothing could be further from the truth. We can’t live without bacteria. The bottom line: we are part bacteria.

Our bowels are a perfect example.  There are way more bacterial cells living in our gut than the total number of our own cells in our entire body. We are, so to speak, colonized. These gut microbes turn out to be incredibly important. Anyone who has been on antibiotics, which kill many of these bacteria, can attest to the stomach misery caused by upsetting the balance of these little lodgers. Growing evidence suggests that a reduced diversity of these bugs is with inflammatory bowel disease, metabolic syndrome (prediabetes) and obesity. So why would you want to “clean” a colon?

Decreased exposure to the bacterial world has been cited as a cause of the explosion in childhood allergic conditions. For instance the rate of peanut allergies in children more than tripled between 1997 and 2008. Children living in urban centers are twice as likely to have peanut and shellfish allergies compared to kids in rural areas. 5.9 million children in the US under the age of 18 (1 in 13) have a potentially life-threatening food allergy. An allergic reaction to food sends an American to the ER every 3 minutes.

When a species develops an allergy to its food, that species is in trouble.

The explanatory theory for this phenomenon is called the Hygiene Hypothesis. Without the exposure to bacteria that we experienced historically and that our bodies evolved to cohabitate with, our immune systems go haywire. We develop hyperactive immune reactions to all sorts of things, i.e. we develop allergies and autoimmune disorders.

So how did we get here?

Let’s start with the new improved soaps, the antibacterial soaps. Studies have demonstrated that they provide no greater protection from contamination. In fact, they appear to be associated with an increased frequency of fevers, and upper respiratory tract symptoms. Apparently, these agents are non-specific killers. They knock out both the invading pathogenic bacteria that cause illness and the friendly “flora” or usual bacterial tenants. The problem here is that our bacterial flora actually provide protection from many invading bacterial bad guys, preventing them from finding a niche in our bodies.   

Don’t get me wrong. Hand washing is good. Just do it with regular soap.  Interestingly, good old-fashioned soap does not seem to kill off the non-pathogenic bacterial flora and is therefore ironically more effective in preventing contamination.

Another pervasive culprit is the “wipe”. What a great name, with its double-barreled implication of total elimination of the enemy (“wipe out”) and ease of victory (with a mere “wipe down”).

The “magic bullet” in antibacterial wipes is some form of the antibiotic called Triclosan. And it seems to be everywhere. Surfaces in food-processing plants, chopping boards, and refrigerator shelves are impregnated with this titan of the microbial battle. But in any confrontation between humans and bacteria we win pyrrhic victories only.

The bacteria have seen our ante and raised the bet. Not only have bacteria developed a resistance to Triclosan, there are now strains that eat it. As you might imagine, all this Triclosan finds its way into our waste grounds, sewers and water supply. In these fertile domains, the bacterial number has not diminished. In fact there has been an increase in the bacterial populations that are resistant to prescription antibiotics.

Any story of this kind would be incomplete without mentioning the bonfire of resistant bacteria steadily stoked by the misuse of antibiotics. This includes prescribing them for every sniffle (most of which are viral and therefore unaffected by antibiotics) and their pervasive use in the animals we consume. 75% of all antibiotics are used in the service of promoting growth in livestock.

Let me close with a plea for a dirtier world, a relinquishing of the desire for a squeaky clean colon. We are not dirty. We may feel dirty, but we do not need cleansing. There is a difference between guilt and contamination. It can be difficult not to fall prey to the idea of a Spring Cleaning of our bodies, a return to some innocent beginning.

We know the hard work of how to clean up our lives.  Attempting to sterilize the environment or our bodies won't do it. 

And when it comes to dangerous bacteria, we must cultivate the good bacterial part of us to survive them. Diversity is a good thing in man and microbe.