Wegovy, Ozempic, and Mounjaro: Approach Miracles With Caution
When I was a medical student, an elderly physician gave me some sage advice: “Never be the first to prescribe a new drug or the last to prescribe an old drug.”
His admonishment instilled in me a healthy skepticism regarding the risks and benefits of pharmacologic treatment. As it turns out, his caution was well-founded. Over the last 30+ years of practice, I’ve watched dozens of drugs be released and pulled from the market.
The pharmacologic treatment of obesity is particularly rife with examples:
- Fen-Phen (Fenfluramine): Pulled in 1997 for damaging heart valves and leading to pulmonary hypertension.
- Ephedra: Banned by the FDA in 2004 due to increasing people’s risk of heart attack, stroke, and death.
- Acomplia (Rimonabant): Pulled in 2008 due to a demonstrated risk of psychiatric crises, including suicide.
- Meridia: Pulled in 2010 due to increased risk of heart attack and stroke.
However, obesity and its associated health risks continue to need a pharmacologic tool, and the medical establishment continues to explore new treatments for this highly dangerous medical condition.
The latest drugs developed in the fight against obesity, including Wegovy, Ozempic, and Mounjaro, are categorized as GLP-1 agonists. They may be all the rage at the moment, but they’re not for everyone.
Let’s explore these powerful drugs and discuss GLP-1 agonist side effects.
GLP-1 Agonists: The New ‘Miracle’ Drugs
GLP-1 agonist stands for glucagon-like peptide-1 agonist. This class of medication has a wide array of effects on the body, including appetite suppression, increased insulin production, decreased glucose production, and increased glucose uptake in muscle cells.
GLP-1 agonists were originally developed to help patients with type 2 diabetes lose weight, reduce blood sugar levels, and lower the risk of cardiovascular death. However, we’re now facing the expansion of the use of these medications for weight loss in the general population.
In particular, the drug Mounjaro, which has both GLP-1 agonist and GIP (glucose dependent insulinotropic polypeptide receptor) effects, is the most effective weight loss drug to date. Studies demonstrate a five to 22.5% reduction in body weight, which is unheard of compared to prior weight loss technologies.
The challenge we now face is identifying patients for whom the benefit of Mounjaro exceeds the associated risk.
A Note on Risk/Benefit Ratios
Remember, there is no such thing as a “totally safe” drug. The truth is, all drugs have risks. We must inspect the risk/benefit ratio for all medical therapies according to an individual’s unique circumstances and determine whether prescribing the drug makes sense.
For example, an obese person faces many serious health risks. A drug like Mounjaro can effectively reduce those risks by reducing obesity, meaning the benefits of Mounjaro may outweigh its potential side effects. However, there’s no guarantee, and every case must be carefully considered.
GLP-1 Agonist Side Effects
What we’re seeing now, which is concerning, is people who are not obese using GLP-1 agonists to lose those “last few pounds.” This use of these drugs is particularly popularized on social media.
The danger of weight loss enthusiasm occurs when people take a medication without fully understanding the potential risks. Typical GLP-1 agonist side effects include nausea, vomiting, and diarrhea. However, a more subtle and treacherous threat hides in the weight loss itself.
Dr. Peter Attia — a careful and critical reader of medical literature — describes this risk and highlights the need for additional research in his blog.
“...not all weight loss is healthy. While shedding excess fat mass (and in particular, visceral fat mass) has a multitude of beneficial effects on health, shedding lean mass — which includes muscle and bone — is associated with poorer health trajectories and reduced lifespan.”
What Dr. Attia is referring to is our overall body composition, which we mentioned in a previous post. Fat is one component of our body composition, but so is water. We call whatever isn’t water or fat dry lean mass: muscles, bones, connective tissue, etc.
Dr. Attia brings attention to a small sub-study: 140 patients who lost weight using GLP-1 agonists underwent DEXA scans for body composition analysis, which revealed that up to 39% of total weight lost was lean body mass.
In another trial, a subset of 178 patients showed up to 40% loss of lean body mass. This means for every 10 pounds lost, up to 4 pounds of that loss was muscle and/or bone. These results are alarming, as trials of past weight loss drugs showed only a 25% or lower loss in lean body mass.
We want to preserve lean body mass, especially as we age. Unfortunately, the studies cited by Dr. Attia demonstrate that GLP-1 agonist side effects can have an exceptionally high cost.
These studies were small subsets of larger ones and need more exploration, but the initial findings should be enough for physicians to pause and consider all potential GLP-1 agonist side effects prior to use.
Today’s Takeaways
GLP-1 agonists can be life-changing — and life-saving — for certain individuals. It’s an incredible advancement for people with diabetes or who are obese and need pharmacological help.
However, because of GLP-1 agonist side effects, particularly the loss of muscle mass, these “miracle drugs” are probably not a good choice for people who don’t have diabetes or are not obese. Don’t take these drugs if they’re unnecessary or if your doctor doesn’t recommend them.
I’ve seen many so-called “miracle” drugs come and go, and one thing holds true for them all: they’re miraculous until they’re not.
I want my patients to tell me about their miracles 25 years from now, not just two or three years down the road. Real results stand the test of time.
BMI vs. Body Composition: What’s the Difference and Why Should You Care?
Being overweight correlates with a long list of bad health outcomes, including but not limited to:
- Increased risk of diabetes
- Coronary artery disease
- Stroke
- Cancer
- Wear-and-tear osteoarthritis of the joints
Fat is necessary, but excess amounts can hurt us. Therefore, we need to quantify and monitor our total weight in such a way as to prevent bad outcomes.
We need to understand the difference between BMI vs. body composition, and how we can track and learn about the latter.
What Is Our Body Composition?
The healthy range for body fat varies according to age and gender, but for men, it runs between eight and 28%. For women, it’s 21–35%.
But fat is only one component of our body composition. We’re also made of water. Men are about 60% water; women are about 55%.
Whatever isn’t water or fat is called dry lean mass: muscles, bones, connective tissues, etc. Dry lean mass is calculated by subtracting your water and fat quantities from your total body mass.
We’re all made of water, fat, and dry lean mass, but a standard scale won’t tell you exactly how much of each you carry. We need another method to determine our body composition.
What Is BMI?
Let’s discuss BMI vs. body composition. Can you use the former to determine the latter, and vice versa?
BMI (body mass index) is a mathematical ratio calculated based on a person’s total weight and height. Unfortunately, it’s flawed and inaccurate because it doesn’t consider individual body composition.
Very healthy people with increased muscle mass can be considered overweight by BMI standards. For example, an NFL player may have a high BMI (i.e., a high weight for their height) because of their tremendous muscle mass, but no one would recommend they enroll in Weight Watchers!
BMI vs. Body Composition
Since BMI has significant limitations, I looked into other technologies used to measure body composition. Unfortunately, there’s often a trade-off between ease of use and accuracy.
One can use a simple caliper to squeeze available subcutaneous fat at different parts of the body, then calculate the percent body fat using a table. This method is straightforward and cheap, but unfortunately, it isn’t accurate.
Another method is hydrostatic weighing, in which a patient’s body is completely submerged in water, and the displacement and density are calculated. The results are accurate, but the test is clinically impractical.
Other accurate technologies, such as a DEXA (Dual-Energy X-ray Absorptiometry) scan, are convenient but may not be geographically or financially accessible.
After weighing the pros and cons of many body composition calculators, we at Banner Peak Health decided upon InBody, a bioelectrical impedance device.
BMI vs. Body Composition: What Is Bio-Electrical Impedance?
Water conducts electricity, and fat doesn’t, a principle of which InBody takes advantage. The device measures electrical resistance across different axes of the body, from which an accurate calculation of a patient’s body composition (body mass, water, and fat) can be made.
By using this convenient, accurate tool, we address patients’ important clinical issues.
For example, patients who want to lose weight often make lifestyle changes, including dietary and exercise modifications, only to be frustrated when the number on the scale doesn’t change. InBody encourages those patients by showing them how their lifestyle changes have impacted their body. Often, their percentage of body fat decreased as their percentage of muscle increased — so while their overall weight didn’t change, the internal makeup of the body did.
Another clinical benefit of InBody relates to weight loss in aging patients. A prevalent problem called sarcopenia (the loss of muscle mass) is associated with many bad outcomes during the aging process. Fortunately, bioelectrical impedance technology allows us to monitor body composition and watch for decreases in muscle mass.
We invested in this technology because InBody allows us to offer a higher standard of preventative care. We’re delighted to provide it in our office for our members.
The Banner Peak Health Difference
When it comes to BMI vs. body composition, it’s important to take the former with a grain of salt and invest in clinically convenient technologies to determine the latter.
At Banner Peak Health, we’re proud to invest in state-of-the-art diagnostic technologies that can give us greater insight into patients’ health to further customize their treatments, better meet their healthcare needs, and maximize their quality of life.
If you’re interested in using InBody to determine your body composition, schedule an appointment today.
Don’t Ignore the Core: How Core Strength Is Essential for Cycling
Core strength is essential to almost all athletic performance.
In nearly all sports, the force generated from a limb (like an arm or leg) must be anchored by a strong trunk — the core. Otherwise, the force is severely diminished.
Imagine throwing a football while you’re floating in an inner tube. Now imagine throwing a football while standing firmly on the ground. The latter football will cover much more distance than the former.
But what are the core muscles? How can we as athletes improve our core strength, especially core strength for cycling? Read on to find out.
What Are the Core Muscles?
The core muscles are a system of muscles covering the pelvis, lower back, hips, and stomach.
Some have names you’ll recognize, like the gluteus maximus, while others are more obscure, like the external obliques or multifidus. Regardless of popularity, they all work together to get the job done, whether that job be teeing off successfully or throwing a football across a field.
How the Core Muscles Work
Each myocyte (muscle cell) contains countless layers of two overlapping molecules: actin and myosin. Biochemical reactions between these two molecules cause the cell to contract. The combined force of these myocytes creates the strength of a muscle. Thus, the more groups of muscles that create a movement, the stronger the force of the movement will be.
Golf illustrates this principle perfectly.
Many golfers believe the force behind their swing is determined solely by the mass of their arms or pelvis. They have no idea the vital role core strength plays in golf — though having a six-pack may not help your putting stroke.
The same is true in swimming. Your core anchors your arms and legs as you kick, reach, and pull. All those muscles working together generate tremendous power.
Tennis is another great example. When you watch players run across the court, serve, and hit backhand and forehand shots with incredible force, know it’s due to the engagement of their core.
But a favorite and personal example of the core’s influence is cycling.
Core Strength for Cycling: My Personal Experience
When it comes to cycling, core strength is particularly important. The core anchors the pelvis to generate the power the legs need to pump the pedals. It also keeps the torso angled forward for wind resistance.
I started cycling when I was 12, nearly 50 years ago. By age 30, I’d realized the truth behind the adage, “You have to give to your body to receive from your body.” At that point, I’d developed a workout regimen to help me maintain core strength for cycling.
Over the decades, as I’ve changed and as technology has changed, my regimen has evolved.
In my 20s, I did the sit-ups we all learned in gym class — the ones where you touch your elbow to the opposite knee. However, we now know that those sit-ups cause hyperflexion in the lumbar spine, which increases the risk of lower back injury and pain.
Now, I maintain my core strength for cycling through static planking maneuvers, and I’m proud to say I’ve never had any back problems in my nearly 50 years of riding.
Ironically, I did suffer neck pain associated with cycling several years ago. It turned out that I’d neglected my “north core” — the muscles that stabilize the shoulder girdle, upper back, and neck.
I’ve since expanded my workout regimen to address these muscles and have been able to cycle painlessly.
My advice to all athletes — cyclists in particular — is to be diligent and invest in your core strength, both of the middle core and the north core.
There are several ways to achieve this. You can seek out fitness instructors, physical therapists, Pilates classes, online videos, yoga classes, or books.
The avenues are virtually limitless, so find the one that’s best for you and stick with it. You’ll never find a better investment in athletics — and you’ll never regret it.
The Dangers of Overlooking Your Core
Maintaining your core is both offensive and defensive. Core strength training allows you to stay on the bike longer, hit the golf ball farther, etc., but it also prevents injury, especially in aging athletes.
As I’ve said before, an injured athlete is not a training athlete. Time off to recover takes you out of the game.
Maintaining a strong middle core (and north core) is one of the best preventative measures an athlete can take at any stage of life.
Today’s Takeaways
If Pilates isn’t for you, rest assured there are many ways to build core strength for cycling, golf, tennis, and other sports.
Pick the right avenue for you and stay with it. You’ll be glad you did.
Why Do I Get Headaches After a Nap?
There are two types of adults in the world: the ones who benefit from naps, and the ones who don’t.
If you are a “nap person,” you may be one of the many who experience grogginess after a nap. You may have even asked your doctor, “Why do I get headaches after a nap?”
Fortunately, we can help you with these questions.
Sleep has an architecture. You sleep in stages, and when you understand those stages, you’ll understand why your naps aren’t always refreshing and what you can do to change that.
The Architecture of Sleep
Sleep isn’t a random event. It’s made of four individual stages which, together, comprise a 90-minute cycle:
- Stages one and two are light sleep.
- Stage three is called Delta sleep, or deep sleep.
- Stage four is REM (rapid eye movement) sleep. This is the stage in which we dream.
Why Do I Get Headaches After a Nap?
Ever Googled “Why do I get headaches after a nap?” Here’s your answer: The most common cause of that dysphoric, groggy post-nap feeling is waking up mid-sleep cycle.
When you interrupt your sleep cycle, your body doesn’t have the opportunity to complete its natural process. The interruption leaves you feeling out of sync and can result in adverse symptoms, including headaches.
Preventing Headaches After Naps
If you’d like to reduce your potential for grogginess and headaches after napping, there are two techniques I recommend:
- When you lie down to take a nap, set an alarm for 15–20 minutes. This ensures you only spend time in the light sleep stages, making it easier to wake up and less likely you’ll experience uncomfortable side effects.
- If you have time, set your alarm for 90 minutes. This allows your brain to complete a full cycle but wake up before beginning a new one.
Other Advice
If you nap frequently and commonly ask, “Why do I get headaches after a nap?” you may be asking the wrong question.
Perhaps you should ask whether you’re optimizing your sleep at night. For example, are you napping because you don’t sleep well at night? If so, prioritizing your nightly sleep habits should come way ahead of learning how to nap better.
We can help with that, too. Read our most recent blog post on sleep, or contact our office to schedule an appointment. We’re happy to help repair your relationship with sleep.
Today’s Takeaways
- Some people benefit from naps, some don’t.
- Sleep has an architecture of four stages, which take 90 minutes to complete.
- Interrupting your sleep cycle during Stages 3 and 4 can cause uncomfortable side effects such as grogginess and headaches.
- To avoid unwanted side effects from napping, set an alarm for 15-20 minutes so you wake up in a light sleep stage. Or, set an alarm for 90 minutes so you wake up after a complete sleep cycle.
- If find yourself asking “Why do I get headaches after a nap?”, don’t just focus on napping better. Optimize your nightly sleep habits, as well.
What Is a ‘Stress Belly’ and What Does One Look Like?
You may not believe this, but not everything you read on the internet is true — especially when it comes to medical facts.
Shocking, I know.
You may have heard of something called “stress belly” and wondered what it looks like. Stress belly is a real phenomenon, but it’s very different from the images and blog posts you’ll find if you Google “what does a stress belly look like.”
Those images are total BS.
There’s no way to immediately identify the cause of abdominal fat deposition simply by looking at the belly. (Plus, anyone who carries so much fat on their abdomen won’t look like a supermodel everywhere else.)
That being established, what is a stress belly, and what does a stress belly look like?
What Does a Stress Belly Look Like?
Stress belly is the result of a direct physiological link between the emotional stress you experience and increased fat deposition in your abdominal cavity.
Not everyone with abdominal obesity has a stress belly. Likewise, not everyone who experiences excess stress develops a stress belly or abdominal obesity. However, there’s enough overlap to ensure a genuine phenomenon, although it’s not explanatory for all instances.
Causes and Symptoms of Stress Belly
There are many instances of powerful, intricate relationships between our emotional state and our physical state.
A lot of literature links socioeconomic status to health outcomes. For example, if you’re struggling financially, you may not be able to consistently provide food or housing for yourself or your family. The amount of stress engendered by a lower socioeconomic status is considerable.
When we experience chronic stress, we see elevated levels of adrenaline and cortisol, a glucocorticoid which can be measured in saliva, blood, and even hair. These elevated levels correlate with worse health outcomes.
Too much cortisol can set a whole host of other hormonal changes into motion, including putting more adipose (fat) cells within the abdomen. These visceral fat cells are hormonally active, pro-inflammatory, create insulin resistance, and worsen hypertension, which are all risk factors for coronary artery disease.
They’re part of a worsening feed-forward loop that also influences hormones that regulate appetite, like leptin and ghrelin. This causes people under stress to crave comfort foods (foods high in sugar and fat), which compound obesity and continue the feed-forward loop.
Together, all these factors form an unfortunately strong and documented pathway — starting with socioeconomic status and emotional state and leading to increased fat content, heightened cardiovascular risk, and many other downstream health complications.
Risk Factors for Stress Belly
The risk factors for stress belly begin with its namesake — stress. Despite the documented link between socioeconomic status and stress, stress can affect anyone in any circumstance.
Stress isn’t always caused by emotion, either. For example, chronic pain can cause stress. It’s like kicking someone when they’re down.
Another cause of stress — and therefore excessive cortisol, or hypercortisolism — can be a lack of sleep. If you consistently fail to get the proper quantity or quality of sleep, your body generates more adrenaline and cortisol. This especially affects night shift workers, whose circadian rhythms are all out of whack.
The same thing happens when you consume alcohol. Most people equate drinking with relaxation. However, as your body metabolizes alcohol, it releases adrenaline and cortisol, which stresses your body and induces hypercortisolism.
Stress Belly Treatment
So you’ve gotten past “what does a stress belly look like?” and moved on to “how do I get rid of my stress belly?” I hear you.
The best way to combat stress belly is to identify and address its contributing factors. Then, double down as much as you can on removing or managing the factors that cause undue stress and lead to hypercortisolism.
Emotional Stress
When emotional stress weighs heavily, meditation, cognitive behavioral therapy, exercise, and other techniques and tools can relieve some of the burden. Don’t wait until you feel overwhelmed before you ask for help.
Chronic Pain
If you’re experiencing chronic pain, you may not be able to remove the pain or the source of the pain completely, but there may be ways to improve your quality of life. For instance, through meditation, therapy, or other modalities, you may be able to emotionally reframe your pain so it’s less stressful to your body.
Alcohol
Alcohol consumption can be simpler to limit (or omit), but not always. Alcohol is not part of the solution for stress — it’s part of the problem.
If you need help limiting or abstaining from alcohol, contact your doctor or a support group near you.
Sleep
Sleep is crucial to wellness. However, improving sleep can be incredibly complicated.
If you’re having trouble sleeping, please talk to your doctor or contact us here at Banner Peak Health. We’ll be glad to speak with you.
Today’s Takeaways
- All the charts that pop up when you Google “What does a stress belly look like?” are BS.
- Stress belly is real. No, you can’t tell if you (or anyone else) have it just by looking.
- Stress belly increases the risk for a wide array of illnesses, including diabetes, high blood pressure, and coronary artery disease.
- Treatment for stress belly involves managing and omitting the causes of stress. These can include emotional stress, chronic pain, alcohol, and poor sleep.
Text Neck: The Hidden Epidemic We Shouldn’t Ignore
Everyone’s heard the mantra of the “core,” defined as the lower back, hips, pelvis, and stomach. We all know the core is essential for movement and athletic performance.
But what about the north core?
Never heard of it? I’m not surprised.
What I define as the “north core” is the group of muscles surrounding your neck. Unfortunately, the neck is the forgotten part of the spine.
In my opinion, we focus too much on the main core — that anatomy is extremely solid. We really haven’t focused on the ergonomics and protection of the north core, even though those muscles give the neck strength and flexibility.
The seven cervical vertebrae are tiny, and we aren’t conscious of the surrounding muscles... that is, until the pain of text neck starts.
The Neglect of the North Core
Neglecting the neck can lead to a domino effect of symptoms in our musculoskeletal system.
When we ask our muscles to perform tasks they simply can’t do, they become stretched and inflamed. They spasm. As they spasm and contract, they create tension in adjacent muscle groups.
What starts as overuse of a small group of paraspinal cervical muscles turns into trapezius spasms, shoulder pain, and headaches. And it’s all driven by overuse of these little muscles.
To prevent a pain syndrome cascade, we need to better protect and be conscious of our cervical muscles.
Let’s Talk About Text Neck
There’s an epidemic of neck pain, and the driver is poor ergonomics and how we interact with screens — particularly handheld devices like phones. The condition is called text neck, and recent studies show astounding results.
The average human head weighs 10–12 pounds. As you tilt your head forward, you increase the force applied to the base of your neck.
As you can see in the graphic, even slight increases in tilt angle drastically increase the amount of force transmitted to your neck. By the time your head is tilted to a 45-degree angle, the force on your neck has increased fivefold!
Heavy is the head that stares at the phone.
Imagine the effect of this amount of sustained pressure over hours every day. Voilà — text neck!
What if We Ignore Text Neck?
Who doesn’t have neck pain?
My best friend once asked me to refer him to a good acupuncturist because his neck was killing him. I told him I’d refer him to a good acupuncturist if he promised to stop resting his laptop on his chest while he used it in bed.
Don’t put a Band-Aid on a bullet hole. There’s no reason to provide a small, momentarily effective treatment if you don’t do anything to address the root cause of the problem.
As I mentioned earlier, the issue with neglecting your north core is the domino effect it can cause throughout your musculoskeletal system. Overuse leads to stretching and inflammation, which leads to spasms, which leads to pain in the neck, which migrates to the shoulders and back and causes headaches.
Simply put, it’s not just about neck pain.
Stop Blaming Your Pillow for Text Neck
Often, patients ask me what the best pillow is for neck pain. When I ask why, they tell me they wake up every morning with terrible neck pain and insist it must be their pillow.
Let me assure you — it’s not your pillow’s fault.
The mechanism for generating the pain you woke up with is the muscle you overused the day before, the inflammatory process that set up overnight, and the spasm you woke up with. Just because you woke up in pain on your pillow doesn’t make it your pillow’s fault.
What We Can Do About Text Neck
First, we must be aware that text neck syndrome is real and common. The signs are frequent neck pain, headaches, shoulder pain, and pain anywhere from the top of your head to your armpit. The problem is widespread, and we need to address it.
Amazingly, there’s an app for that!
Some brilliant people have found a way to use a smartphone’s motion sensor to determine the angle at which the phone is being held. The app alerts the user with a red light when the angle of view is too severe.
Using tools like this can significantly improve your posture during device use and reduce your risk of developing text neck. Taking advantage of voice-to-text functions and voice assistants like Siri and Alexa more often can also help.
Finally, you can improve your range of motion and alleviate pain by stretching regularly. Since pain is caused by muscle spasms and tightness, stretching those muscles can help reduce pain and prevent further damage.
Today’s Takeaways
- Your “north core” deserves just as much attention as your main core.
- Text neck is real and incredibly common.
- A new pillow won’t solve the problem. Instead, try posture-improvement apps, voice-to-text assistance, and stretching exercises to improve your north core strength and prevent text neck.
COVID 2023: Are We There Yet?
For over three years, we’ve waited for the COVID pandemic to be over. An analogy to intensive care medicine seems appropriate.
I was taught that “a patient enters an intensive care unit with dramatic catastrophes and leaves with incremental, slow, methodical improvements.” That is, the beginning is more obvious than the end.
We’ve made tremendous strides in reducing the number of infections, hospitalizations, and deaths attributed to COVID. With these gains, our societal focus has shifted elsewhere. Emergent government policies to address the economic and health effects of the pandemic are being scaled back. But is the pandemic over?
On one hand, the data in Contra Costa County and at the national level demonstrate markedly reduced levels of COVID viral particles in the sewer systems, fewer people in the hospital due to COVID, and fewer people dying.
On the other hand, based on the national data from April, we’re still losing 1,300 people per week to COVID. This yields an annual death rate of 68,000 more people than the number lost to influenza in any year for the last decade. Unfortunately, the risk of COVID is still with us.
Fight On
Vaccination has been our best weapon against COVID. After three years, most of us have had multiple vaccinations and, often, a COVID infection or two. We’re beating back the pandemic because of the level of immunity generated by this process. The obvious question becomes: What is the incremental benefit of yet another vaccination?
The answer depends on your level of risk for a bad outcome from COVID.
Almost everyone currently hospitalized with COVID falls into four broad and potentially overlapping categories:
- Over 50
- Multiple comorbidities (such as obesity, diabetes, heart disease)
- Immunocompromised
- Unvaccinated or under-vaccinated
In fact, 90% of those currently hospitalized have not received the most current bivalent COVID vaccine. This version contains two strains, one against the original Wuhan variant and another against a new omicron variant. Since this vaccine’s release in fall 2022, numerous studies have demonstrated its greater efficacy than the original single-variant vaccine, which will be phased out.
Most of you have already received a bivalent COVID vaccine booster. If you haven’t, please consider getting your first dose of the bivalent COVID vaccine now.
Who Needs a Booster?
What if you’ve already received the bivalent COVID vaccine? On April 19, 2023, the CDC updated its recommendations for booster vaccinations this spring. They identified risk groups who should receive an additional bivalent COVID vaccine, and they’ve included timing recommendations:
- If you’re over 65 years old, you should wait four months from your last vaccination or COVID infection to receive this booster.
- If you’re immunocompromised, you should wait at least two months from your last vaccination or COVID infection to receive this booster.
I sense a growing frustration with being asked to get a COVID vaccination again and again. We remember getting childhood vaccinations that lasted decades, and we can tolerate getting a tetanus booster every 10 years or so. However, the biology of the COVID virus and the vast numbers of infected individuals have allowed rapid evolution to occur, which continues to select for variants that can partially evade our vaccines.
We’ve been able to develop vaccines that work against these newer variants, such as the current bivalent COVID vaccine. Researchers are working to develop vaccines that target parts of the virus that don’t mutate as rapidly as the spike protein, the target of current vaccines.
Also, to compensate for the decline in efficacy over time, we increase the frequency of vaccination to get a recurring boost in our antibody levels, which are at their peak for one to six months after vaccination. Thus, recommendation for frequent vaccination allows us to extract maximum performance from our current vaccination technology, which is needed to maximally protect those at the highest risk.
Who Doesn’t Need a Booster?
It also makes sense to discuss who does NOT currently need a booster vaccination.
The incremental benefit of each additional vaccination has become ever smaller. Thus, for populations whose overall risk of a bad outcome is already very low, such as children and younger adults, a further tiny reduction isn’t worth the discomfort and rare (but not zero) risk of a serious vaccine complication.
Today’s Takeaway
Please get a COVID bivalent vaccine now if you fall into any of these categories:
- If you’re over 50 and haven’t yet had a bivalent COVID vaccine
- If you’re over 65 and haven’t had a COVID vaccine or infection in the last 4 months (or wait until 4 months have elapsed)
- If you’re immunocompromised and haven’t had a COVID vaccine or infection in the last 2 months (or wait until 2 months have elapsed)
Please reach out if you have any questions or concerns.
Circadian Rhythm Manipulation for Insomnia and Sleep Habits
Complicated problems often require complicated solutions. Problems with sleep are no exception, and they frequently require what’s called a differential diagnosis.
A differential diagnosis encourages doctors to think comprehensively across a range of possibilities to identify what factor(s) may be causing a patient’s problem. That’s how we arrive at a specific, patient-focused solution.
This is in marked opposition to what often happens in a time-pressured healthcare environment where “if-then” statements dominate. This reductionist logic boils complex problems down to linear, one-size-fits-all solutions: “If X is the problem, then Y is always the solution.”
Such reductive thinking may be fast, but it isn’t effective.
I want to clearly distinguish from this linear logic a more expansive, inclusive thought process. Doctors often translate the sentence “I can’t sleep” into the medical term “insomnia,” but what is the differential diagnosis for insomnia?
Many factors can contribute to not being able to sleep. Circadian rhythm problems are one of them.
The Circadian Rhythm
The circadian rhythm is a biological rhythm unique to each individual, lasting about 24 hours. We’re most aware of it in the context of sleep, but actually, every biological function is timed with a daily clock — digestion, reproduction, cognition, etc.
The word “circadian” comes from the Latin circa, which means “approximately,” and diem, which means “day.” Together they mean “about a day.”
Let’s focus on the word “approximately.” Reflected in this word is the fact that not everyone follows the 24-hour sleep cycle exactly.
There are some individuals for whom the sleep cycle is less than 24 hours. We refer to these people as morning sparrows. They do their best thinking in the morning, have the most energy early in the day, and follow the “early to bed, early to rise” adage.
Then there are those whose circadian rhythms run longer than 24 hours — night owls. These are the individuals who don’t want the night to end. They’re most focused and animated late in the evening and have difficulty settling down and sleeping. They’re also the ones slamming the “snooze” button come morning.
Understanding and observing an individual’s circadian rhythm can yield valuable insights into potential causes of their insomnia. Let’s look at a few examples.
The Circadian Rhythm and Insomnia
Example A: Teenagers
If you have a teenager in your life, he or she likely falls into the night owl category, unable to fall asleep at an appropriate time to wake up for school the following day.
Don’t be so quick to attribute this to laziness. Not only is there individual variation in a person’s circadian rhythm, there are also age-related variations affected by hormones. As children approach and go through adolescence, their circadian rhythms lengthen, and they’re biologically programmed to stay up later and wake up later.
This understanding provides insight into how we can help young people function better.
For example, the first thing I as a physician would suggest is that this teenager limit his or her screen time in the evening. When we look at screens, we absorb a specific blue light wavelength directly into our eyeballs. Our retinas have receptors that detect this wavelength and send our brain a signal that the sun hasn’t set yet. Our brain then knows not to initiate the hormone cascade that helps us sleep.
In short, screen time right before bed sends our bodies the opposite signal we need.
To combat this and help teenagers sleep, I recommend limiting any white/blue light that would hit the eyes.
I would also suggest using melatonin supplements, if necessary. Melatonin is a hormone released in the brain, increasing when it’s dark and decreasing when it’s light. It’s basically the hormone of darkness that enables us to sleep.
A Personal Example
When my daughter was 17, her summer break was like that of most teenagers. Left to her own biological rhythms, she was going to bed progressively later, 1 a.m. or 2 a.m. Without the confines of school, she followed her natural sleep cycle.
Well, one day, much to her horror, she realized she had to wake up and take an SAT in just three days. She didn’t have a ton of time to change her sleep pattern.
We got to work right away. First, I had her wear blue light-blocking glasses, which would mute the neurological signals from any lights she’d be exposed to. She’d wear these for two hours before bedtime. I also gave her a very low dosage, six-hour sustained-release melatonin to help shift her circadian rhythm earlier.
With these tools, she went to bed several hours earlier each night. She woke up on time by her deadline and did fine on her SAT.
The tools we have at our disposal are deceptively simple and safe, yet powerful — as is our ability to modify circadian rhythms.
Example B: Aging
A common sleeping problem in older folks is called pre-terminal insomnia. Pre means “before,” terminal means “the end” (in this case, the end of the night), and insomnia means you can’t sleep.
You’ve likely deduced that this is when people wake up in the middle of the night — 2 a.m., 3 a.m., etc. — and can’t fall back asleep. This can be caused by many factors, including depression, anxiety, and advanced sleep phase disorder, a form of circadian rhythm disorder.
Just as teenagers see their circadian rhythms lengthen as part of the hormonal changes of adolescence, as we get older, our circadian rhythms often become shorter. For example, the older a person gets, the earlier they typically prefer to hit the hay.
Sometimes, the circadian rhythm gets too short. Those poor morning sparrows’ hormones are being activated too early, and they end up waking at 2 or 3 a.m. because they’re experiencing circadian rhythm activation before dawn.
When your hormones activate before the sun rises, it’s time for intervention. In this instance, I’d recommend small quantities of rapid-acting melatonin that dissolve in the mouth, as opposed to something longer-acting, which we’d use for teenagers. Morning sparrows would take this when they wake up in the middle of the night to tell their hormones, “It’s too soon to activate!”
These older individuals also have to be careful to remain in darkness. Any light stimulus that reaches the eyes in the early morning further confuses the body by signaling that the sun is rising.
How to Tell if You’re Experiencing a Circadian Rhythm Issue
If you’re experiencing sleep problems, it could be due to issues with your circadian rhythm — but often, it’s a combination of factors.
Sleep can be very complicated. The best advice I can give is to seek out the appropriate medical care.
This isn’t a DIY fix or diagnosis. Please don’t try this at home. Sleep treatment often requires a professional.
Today’s Takeaways
- Complex problems require complex solutions. When it comes to sleep problems, differential diagnoses are important.
- Circadian rhythms are individual and change over time.
- Using appropriate medical intervention, we can shift circadian rhythms when necessary.
Sleep is complicated. If you’re having trouble sleeping, please consult your doctor or contact Banner Peak Health.
Overlooked Screenings That Belong on Your Preventative Care Checklist
As a doctor with over 30 years of experience, I’m always seeking to better understand the overall context of my patients’ lives. This helps me better customize my care to address their health needs.
Our bodies are the vehicles, the cars, with which we transport ourselves through our lives. As a physician, I don’t just want to kick the tires and perform some maintenance; I want to know where each vehicle is headed.
For example, if I’m asked to do a preoperative evaluation on a patient for a hip surgery, I’m not just looking at their physical readiness. I also want to know whether their circumstances are conducive to a successful surgery.
Will they have adequate care at home, or are they the sole caregiver for an ailing spouse? Or, perhaps they have hidden depression that the pain and immobility of a major orthopedic surgery will exacerbate. Or, maybe they’re an athlete who’ll tell me, “You can’t take my joint; golf season’s coming up!”
The same medical question can have very different answers depending on the overall context of an individual’s life. For truly high-quality, responsive healthcare, the full picture is necessary.
The same is true in determining how to maximally leverage preventative healthcare for each patient. At its core, prevention is really about individual lifestyle. Anyone can recommend a mammogram to a woman over 40, but to really address the deeper fundamentals of prevention, you have to understand how a person lives. Then you can work with them to modify their lifestyle.
True prevention isn’t checking off boxes on a preventative care checklist in a cookie-cutter fashion. It’s a much more personalized, intimate process.
The Typical Preventative Care Checklist
You’re likely familiar with many of the items on the typical preventative care checklist in conventional medicine. You’ve heard about them your entire adult life. They include studies such as:
- Mammograms
- Pap smears
- Colonoscopies
- Prostate exams
- Lung CTs
As practitioners of concierge medicine, we don’t believe your health is adequately protected with a simple checklist. You need something much more comprehensive for true prevention.
Of course, at Banner Peak Health, we still recommend all the above tests — but we go much deeper. And there’s no one-size-fits-all checklist for the amount of customization we do.
In addition to the tests and screenings on the standard preventative care checklist, we also take advantage of state-of-the-art screenings and equipment. Here are just a few of the ways we help our patients stay proactive about prevention:
- Coronary artery calcium score — early detection test for cardiovascular disease risk
- GRAIL Galleri test — early cancer detection test administered through a simple blood draw
- InBody — body composition screening that goes beyond BMI to consider what percentage of your body weight is fat versus muscle
- Emotional health screening tools — means of diagnosing hidden depression and anxiety. These are very intimate, and vital in understanding how to best treat other physical needs.
The unique model concierge medicine provides allows us to offer this more in-depth, customized care. We aren’t beholden to insurance companies, who would dictate what tests we can run and what equipment we can use. We’re free to prioritize your health, rather than commoditize it.
Banner Peak’s Priority
Your body is your vehicle, and it needs to stay in proper working order. To make that happen, we need to know your destination. That way, we can help provide the right maintenance along the way and get you there in the best condition.
We’re proud to offer a robust preventative care checklist — but one that’s customized to every patient. By connecting with each of our patients and taking the time to learn about their lifestyles, priorities, and health goals, we’re able to offer the individualized care they need and deserve.
If our approach sounds like it would be a good fit for you, contact us today. We’d love to help!
What Is Sleep’s Effect on Athletic Performance?
We know sleep is vital for all our emotional and physical endeavors — but it’s not enough to just get sleep. We need the appropriate quality and quantity of sleep.
Obstructive sleep apnea — a common form of sleep deprivation which affects 15–30% of men and 10–15% of women in North America — manifests by closing off the airway during the deeper phases of sleep, preventing air from reaching the lungs and oxygen from reaching the brain. This creates an adrenaline/stress hormone surge that prevents us from reaching the more restful stages of sleep.
I spend a good amount of time in the clinic identifying which of my patients are at risk for obstructive sleep apnea and convincing them to undergo testing and receive appropriate treatment.
To help my patients understand the importance and value of treatment — and to aid in my sales pitch — I direct them to literature that demonstrates sleep’s effect on athletic performance.
Sleep’s Effect on Athletic Performance
The following are three ways sleep — or a lack thereof — can affect athletic performance.
Cognitive Ability and Physical Endurance
Golfers will do anything for an edge up.
Golf relies on cognitive abilities to strategize and calculate risk/return, physical endurance for strength and accuracy, and emotional control to manage pressure.
All these abilities can improve with adequate sleep. Data shows a statistically significant improvement in a golfer’s handicap after treatment of obstructive sleep apnea.
Training and Recovery
Let’s look at the fundamental core of fitness and working out. How do we get in shape?
When we exercise, we stress our body — by weightlifting, running, etc. That stress manifests as low-level cellular damage to our muscles. It’s the response to this stimulus, this damage, that allows our body to recover and come back stronger. This is how we build ourselves through training.
As I’ve said before, recovery is the process that makes us physically stronger, not the stimulus.
Sleep is absolutely vital to this recovery. The hormones we need to build back better — such as testosterone and growth hormone — occur in adequate quantities during sleep. That’s when our bodies recover and grow stronger.
Jet Lag and Circadian Rhythm
One potential threat to obtaining the adequate quantity and quality of sleep is jet lag.
Almost every bodily function is regulated by our own internal clock, our circadian rhythm, which is synchronized to our local time zone. With travel, there’s a risk of jet lag and impaired sleep.
In 2013, researchers analyzed over 40 years of NFL games, specifically questioning whether circadian rhythm-induced jet lag influences a team’s performance. They found that for night games played on the West Coast, the home team beat the predicted point spread twice as often.
It’s fascinating evidence linking sleep with the peak performance of professional athletes. It’s also something to keep in mind during your next trip to Vegas: Give yourself an extra day to recover before hitting the casino. You’re welcome.
Today’s Takeaways
- When you’re traveling to compete in an athletic event, be cognizant of sleep’s effect on athletic performance. Do your best to compensate for your circadian rhythm by giving yourself a few extra days to recover before you compete. In other words, you shouldn’t fly to Paris and ride in the Tour de France the next morning.
- Be cautious when you get up early to work out. Patients often ask me whether it’s better to get up early to work out or to sleep for an extra hour. I tell them, “Do both.” If you can get up early to work out and still get enough sleep, that’s fine, but to lose an hour of sleep for an hour of workout isn’t maximizing your potential athletic gain.
- Be open to discussing obstructive sleep apnea with your physician. Diagnosing this disorder and treating it effectively can yield many health benefits, including better athletic performance.