The Sad Triad: Depression, Poor Sleep, and Chronic Pain
For about 15 years, I studied Chinese medicine and practiced acupuncture. As such, I have a deep appreciation for the Eastern perspective on medicine, health, and wellness.
In Western medicine, we tend to sort everything into conceptual silos: “This is a neurological disease, so you have to see a neurologist.” “This is an endocrine disease, so you have to see an endocrinologist.” Cognitively, we’re splitters.
But in Eastern medicine, everything is inextricably linked, which leads to a lot of powerful explanation.
With that in mind, I’d like to introduce “the sad triad” — the link between depression, sleep deprivation, and chronic pain.
The Sad Triad
1. Chronic Pain
One of the most challenging aspects of any medical system is treating pain, especially chronic pain.
At first glance, many perceive the transmission of pain as linear, like the child’s game of tying two cans together with a string to transmit a signal between them.
However, the transmission and sensation of pain are much more complex. A more apt metaphor would be that of a spiderweb: a myriad of interlocking nodes in which modulating any one node changes what happens to all the other ones.
This is why I believe the Eastern view of interconnectedness is a more useful, more explanatory way to address chronic pain.
Pain’s impact on the body isn’t linear. It’s influenced by many other factors — especially the quality and quantity of sleep we get.
2. Sleep Deprivation
Being an adult often means masking our true selves for the sake of social acceptance. We sometimes get a clearer view of human nature by observing children.
For example, a toddler who’s well-rested and enjoying herself at the playground may trip and face-plant while running across the turf. While this will probably draw a shriek from the parents watching, she’ll cheerfully get back up, brush herself off, and keep running toward the next play structure.
However, anyone who’s tried to put an exhausted toddler to bed knows a barely-pinched toe can lead to a hysterical tantrum.
That’s a great illustration of how sleep influences the perception and impact of our pain. Ultimately, poor sleep is a pain multiplier.
3. Depression
The emotional context around pain also influences the pain’s impact.
Although there are no perfect analogies, the example I’ll use here is of two very similar anatomical injuries I’ve treated in two very different contexts.
The first injury occurred when a snowboarder was going for big air and blew it. He jammed his neck and weathered chronic neck pain as a result.
The other injury was the result of a car accident. A woman was rear-ended driving home from work. Because of her injuries, she also suffered chronic neck pain.
Although the two injuries aren’t anatomically very different, the perceived pain is. The snowboarder has much less perceived pain because he had agency over his situation. He himself made the decisions that led to the injury. The woman in the car accident, meanwhile, has much more perceived pain because she felt victimized by her circumstances.
Our emotions interpret pain — they influence how we experience our pain and how it impacts our lives.
A Vicious Cycle
These three realities — chronic pain, sleep deprivation, and depression — feed into each other in a tragic, debilitating way.
If pain is unrelenting and interferes with sleep, the pain becomes more perceived and more impactful. If you’re exhausted and not sleeping, you’re at risk of depression. The cycle continues.
If you’re caught in that cycle, a Western physician will likely diagnose you with chronic pain, then with sleep deprivation, then with depression. Each condition will be treated separately rather than as a whole.
Holistic Treatment
Now that we understand how these conditions are related, we can use this interrelatedness to our advantage. We can turn the vicious cycle of the sad triad into a virtuous cycle.
For example, some of our most potent chronic pain medications are also used as antidepressants. We believe these medications manipulate anti-pain properties through the same neural pathways an antidepressant would use.
I’m a minimalist when it comes to medication, but when a patient tells me their pain is affecting their sleep, I become pharmacologically aggressive. In that case, the benefits of medication far outweigh the risks.
On that note, if you yourself are caught by the sad triad and need help turning that vicious cycle into a virtuous cycle, Banner Peak Health is just a call or click away.
Today’s Takeaways
- Pain severe enough to disturb sleep warrants treatment.
- Hidden depression can present as chronic pain.
- People with chronic pain often categorize good days and bad days based on their symptoms. I posit that a bad day often correlates with not having gotten enough sleep the night before. Paying more attention to sleep may lead to more good days.
- Taking an antidepressant to address chronic pain does not dismiss the physical reality of the pain. In no way am I trying to tell you your pain is “just in your head.”
- Mindfulness/stress reduction classes are an effective means of pain relief. If you can achieve control through mindfulness, you can control your pain relief.
- Physical exercise can also be a wonderful treatment option for the entire sad triad.
How to Stop Jaw-Clenching From Stress
Some people experience a wide range of physical symptoms as a result of unmanaged stress. A clenching jaw is one of them.
Clenching your jaw can lead to unpleasant side effects such as headaches, dental issues, soreness, and disturbed sleep. We’ll explore those later.
While there are many “lists” online that explain, on a superficial level, how to stop jaw-clenching from stress, I believe we need to look deeper. We need to look at the stress itself.
What Is Stress?
I often ask new patients to complete a form titled “Perceived Stress Scale.” The term “perceived stress” encompasses two aspects of stress:
- External stress. These are the more obvious contributing factors. For example, it’s stressful if someone cuts you off in traffic or if you have financial difficulties.
- Internal stress. This is the aspect of stress we often overlook. The term “perceived” incorporates the concept of how your internal self can evaluate, cope with, and handle stress.
I look at both a patient’s external and internal stress to best understand where their symptoms, such as a clenching jaw, are stemming from.
Two Phases of Coping
Not only are there two aspects of stress, but there are also two methods of coping with stress. I often explain these methods as “young adult stress coping” and “mature adult stress coping.”
These don’t relate to our chronologic age; rather, they refer to the mechanisms we use to manage the two aspects of stress.
Young adult stress coping is based on the stress we perceive externally around us. For instance, if a college student is taking too many courses, her solution may be to drop her economics class before the midterm. By modifying her external world, she’s brought her stress to a manageable level.
Mature adult stress coping is the opposite. If we live long enough, we will eventually confront major stressors beyond our control: serious health problems in ourselves and others, losing loved ones, etc.
The question becomes how we cope with and adapt to stress that we cannot modify externally.
Stress Inbox and Outbox
When I instruct patients on how to stop clenching their jaw from stress, I encourage them to imagine that their stress has an inbox and an outbox.
I like this metaphor because it resonates. We’re all acutely aware of what comes into our email inboxes. What is more difficult for people to understand, and where I focus, is the stress outbox — or, how we cope with stress.
When working on identifying, developing, and building a stress outbox, I look at two categories: lifestyle factors, and social connection and structure.
Lifestyle factors include things like exercise, sleep, diet, and substance use. I also like to look at social connection and structure: the presence of a religious community, clubs, groups of friends, and a supportive family. These networks have a huge impact on our emotional health as well.
I’ve been surprised by the number of people who can’t come up with an answer when I ask, “What’s in your stress outbox?”
To their silence, I reply, “We have work to do.”
Biology of Emotions
Catchphrases like “mind over matter” have convinced us that our minds and bodies are connected but disparate. Nothing could be further from the truth.
To even ask “are the mind and body connected?” is to misunderstand that they are one and the same. They’re not even two separate things that are “bridged.” They are inextricably linked.
In order to effectively treat the symptoms that manifest as a result of a stress inbox/outbox imbalance, we must begin with this understanding.
The Canary in the Coal Mine
Many of us, even some doctors, aren’t aware that our overall stress — or, having more stress coming into the inbox than going out through the outbox — can create real, biological problems.
A physical symptom of stress, such as a clenching jaw, is the canary in the coal mine. It’s a way your body warns you of an imbalance in your stress inbox/outbox.
If you ignore that warning and simply treat the symptom, it’s likely additional symptoms will manifest as your stress imbalance worsens. These symptoms include temporomandibular joint pain (TMJ), headaches, insomnia, heart palpitations, impaired concentration, irritability, nausea, and diarrhea.
Yes, the most common cause of a clenching jaw and jaw stress is the temporomandibular joint weakening from bruxism (teeth grinding). Statistically, wearing a mouth guard to bed may help the symptoms of a clenching jaw, but we can’t stop at the biology. We have to look deeper.
We have to learn how to listen to our bodies.
Today’s Takeaways
- How to stop clenching your jaw from stress: Statistically, plastic mouth guards offer significant relief from symptoms like teeth grinding, TMJ pain, and soreness. However, jaw-clenching is a symptom of a greater issue — unmanaged stress.
- There are two phases of coping: Young adult stress coping and mature adult stress coping. YA stress coping means modifying the external world to manage stress. MA stress coping means adapting to stress we cannot control externally.
- Your body has a stress inbox and outbox: Your outbox is influenced by two categories: lifestyle factors (diet, exercise, sleep) and social connections and structure (family, friends, religious community). Your physical health relies on your ability to manage and balance your stress outbox.
Your mind and body are one and the same. When your mind is out of balance, your biological health suffers.
The physical manifestations of stress comes in the form of symptoms such as headaches, insomnia, trouble concentrating, and more. These are the canaries in the coal mine, warnings that your body is out of balance.
To stop clenching your jaw, practice listening to your body. Pay attention to what it’s trying to tell you, and rather than just treating the symptom, get all the way to the root of the problem.
Significant Drug Side Effects Are More Common Than You Think
The power of modern medical pharmacologic treatment is miraculous. During my time as a physician, I’ve witnessed remarkable strides in our ability to prevent and treat horrible illnesses, such as multiple sclerosis, malignant melanoma, and myocardial infarction.
However, medication therapy is a double-edged sword. I’ve detected many instances of illness caused by side effects of medication.
- A young woman forced to drop out of college due to chronic abdominal pain from a medication designed to prevent migraines.
- A middle-aged businessman unable to sleep because of his asthma inhaler.
- An elderly man who became more confused and agitated due to a medicine designed to ease symptoms of depression.
These are just a few of the countless cases I’ve encountered.
Each drug represents the potential for benefit or harm — and that’s a single drug. Commonly, people take multiple medications simultaneously.
This creates the opportunity for drug interactions — that is, the body reacting differently based on the sum total of the drugs — markedly increasing the possibility of side effects.
So, especially when an individual has enough medical problems to warrant multiple medications, the challenge becomes how to discern what’s caused by the underlying medical illnesses, and what’s caused by the medications used to treat those illnesses.
Work With Your Doctor to Avoid Significant Reactions
The first step in detecting a drug reaction is having the active consciousness that drug reactions exist and are common. Be aware that medications can and do interact with each other — and not often in a positive way.
The second step is discerning when a particular drug was initiated and when a particular symptom began, and it requires meticulous record-keeping. This often provides the strongest hints toward a drug reaction.
Keeping notes in a notebook or on your phone, as long as they’re accurate, is a great way to pass information to your doctor. Digital files are easy to organize and send via email.
The third step involves trial and error. You may be able to work with your doctor to stop taking a single drug, monitor your symptoms, note any improvements, resume taking the drug, and document any symptoms that recur. Keep meticulous records and always update your doctor accordingly.
Please note: There’s no textbook or website that can definitively diagnose a drug reaction in any individual. Trial and error is the gold standard for diagnosing a drug reaction.
Stopping a Drug
While starting a drug is relatively easy, stopping a drug is very, very hard.
From the vantage point of a primary care provider, specialists initiate many drugs. Stopping one of these drugs involves close and careful communication with the original prescribing specialist — and that isn’t always easy.
Diagnosing and treating drug side effects can be extremely difficult in an environment of:
- Time-pressured physicians
- Fractured care among many doctors
- Insufficient time to carefully communicate with patients
Unfortunately, this is the type of environment plaguing traditional healthcare systems.
Concierge Medicine Creates the Right Environment
Here at Banner Peak Health, we have the experience and time to delve deeply and work through the laborious process of diagnosing and correcting drug side effects.
We can spend as much time as we need to diagnose each patient’s drug side effects, both in person and over the phone. We’ll always get the job done right; it’s what our practice was created for.
Today’s Takeaways
Think you’re experiencing a bad reaction from a drug? Follow these tips:
- If a new symptom occurs shortly after starting a new medication, alert your physician.
- Don’t be afraid to ask your physician, “Can one of my medications cause this symptom?”
- Your pharmacist has access to a drug database with drug interaction detection software. Ask them to search for any drug interactions among medications you’ve been prescribed, especially by different physicians.
- Be a critical consumer of medications. Ask your physician, “Do I really need all these drugs?”
At the end of the day, you are in control of your own healthcare experience. Speak up and advocate for yourself — and don’t get comfortable with being uncomfortable!
A Doctor’s 5-Step Guide to Athletic Performance After 50
Most people believe it’s all downhill after 70, 60, or even 50. Our days of athleticism are over, and we should throw in the towel.
I’m here to tell you that’s not the case. Those three or more decades could be filled with personal bests and new challenges.
Our bodies are vehicles — they’re our modes of transportation to our goals. Yes, our bodies change over time, but just because aging is inevitable doesn’t mean we have to abandon our aspirations.
Goals are vital. You can’t get to where you want to go unless you know where you want to go. As we age, the route and the vehicle we use to achieve our goals may change, but the goals themselves shouldn’t.
For example, many people look to athletics for a personal challenge. Let’s say you’re a runner. You may train for a marathon in your 20s or 30s, and you may train for a 10k or 5k in your 60s and 70s. The goal of a personal challenge is still there to be achieved, but you’ve changed the means.
Others look to athletics to socialize. If your goal is to find community through athleticism, you might play five-on-five basketball in college, then tennis or pickleball later in life.
Others, myself included, use athletic endeavors to get outside. For me, nature and athleticism are inextricably linked. I love bicycle riding after work — I do it to relax, stay fit, and connect with nature.
In summary, pursuing athletic performance and getting into shape after 50 is absolutely possible. Don’t abandon your goals just yet.
The Challenges and Implications of Aging
Getting into shape after 50 isn’t the same as getting into shape at 25.
As we age, so do our bodies. Our VO₂ max (the maximum amount of oxygen our bodies can utilize during exercise — our horsepower, in other words) declines, and our post-workout recovery time increases. Preserving muscle mass becomes more challenging, and overall body fat increases.
These challenges are part of aging. The good news is modern physiology and training tactics have given us hacks we can use to compensate for the inevitable.
In the past, we thought aging athletes needed to slow down, to scale back on their performance. However, modern research shows the exact opposite. Us aging athletes need to lean in and, in important ways, be more deliberate about our training.
Previously, we were told to wind down as we age. Actually, we need to double down.
Doubling Down: 5 Vital Steps
Implement HIIT (High-Intensity Interval Training)
One of the most important tools for preserving cardiovascular conditioning and getting into shape after 50 is high-intensity interval training, or HIIT — that is, spending short but repeated episodes in the “red zone,” pushing ourselves to the limit.
To compensate for age-related muscle loss, we need specific weightlifting regimens to provide what’s called a super physiologic stimulus — a stimulus more powerful than you would get from activity alone, using weights. This is vital in preserving the muscles we want to use for sports and performance.
Consider Timing and Tempo
Pop quiz: Does pumping iron make you stronger?
If you answered “yes,” you’re wrong. The recovery is what makes you stronger.
Let’s discuss the physiology of working out. Most of us focus on stress induction — how far we run, how much we lift, etc. We usually aren’t as focused on the stress response — our vital response mechanism to the stimulus, or how our body responds physiologically to stress. This is how we become stronger.
As we age, the stress response process becomes longer. We have to be more strategic in dosing how much stress stimulus we receive and how much time we spend responding to it.
I can’t tell you how many lifelong weightlifters I’ve had as patients. They tell me that the same workout regimen they’ve followed for years now makes them feel weak.
They say, “I’ve always done X, Y, and Z every other day!”
I say, “Yes, but because you haven’t increased your response time, your stress waves are piling on top of each other. You need to change the timing and tempo of your workout to make room for recovery.”
These patients are overjoyed! They thought they were “too old for weightlifting,” but now they know that with the right modification, exercise can still make them stronger. They just have to be strategic.
Maximize Recovery
When I use the term “maximum recovery,” I’m referring to sleep.
Here’s a secret: You’ve heard of athletes abusing human growth hormone or testosterone to improve their performance — cheating, in simple terms. We produce these performance-enhancing hormones naturally when we sleep.
You can enhance your athletic performance just by getting enough quality sleep.
Stay Hydrated
Be conscious of your hydration not only during exercise, but also as you recover. Adequate hydration both inside and outside the gym is essential to getting into shape after 50 and maintaining athletic performance into your golden years.
Be Conscious About Your Diet
We all know diet is important, and it needs to change as we age.
Sarcopenia is the medical term for age-related involuntary loss of muscle mass, a real concern if you plan on getting in shape after 50. So far, our focus has been on maintaining adequate training stimulus and using weightlifting to give the body a physiologic stimulus. Now, research reflects that adequate protein in the diet could save the day.
Studies suggest that to reduce the impact of sarcopenia, you should consume between 1.5–2 grams (g) protein per kilogram (kg) of your weight a day. For a 70kg man getting into shape after 50, that means taking in about 150g of protein in a day. That’s a lot. A common concern is that if you eat that much protein, you may be replacing other nutritionally rich foods.
The bottom line is that much more research needs to be done, but we do know protein plays a leading role in preserving muscle mass. Be conscious of it.
Safety First
An injured athlete is not a training athlete. Prioritize your safety, always.
If your normal exercise regimen hasn’t included HIIT up to this point, discuss this option with your physician first. Certain individuals will need cardiac evaluation and clearance.
Observing a meticulous technique when weightlifting is also crucial. The injury-to-benefit ratio with free weights is challenging, and unless your technique is meticulous, the risk is higher.
If you’re using free weights, make sure you have adequate training and observation. Weight machines are much safer.
All sports require good core strength and flexibility. This is vital to preventing injury. Consider Pilates, yoga, or specialized fitness classes. If you want to get into shape after 50, flexibility and core strength are key.
What Athletic Performance Means to You
Athleticism doesn’t have an age limit.
Your age and body will change, meaning you’ll need to adjust your approach to some sports and activities. But that doesn’t mean you should throw in the towel. Whether you’re interested in climbing a mountain or simply getting into shape after 50, any goal is a great goal!
You just need to change the way you think about exercise. It’s not simply about how much iron you pump or how far you can run. It’s just as much about the quality of your recovery.
Rethink what your goals mean to you in the context of your stage of life, and go for them at your own tempo. The best is yet to come.
Why Banner Peak Health Is Committed to Delivering Versatile Healthcare
In medicine, one size does not fit all.
There’s an inherent biological reality for all of us as individuals. We respond differently to medications, have different burdens of illness, different learning styles, and different emotional resilience.
A single approach simply doesn’t work. Maximum versatility is paramount.
For a clinical approach to be successful, it must accommodate the tremendous variation that is the human experience. Unfortunately, traditional healthcare systems often fall short in their ability to accommodate that inherent variety.
At Banner Peak Health, two vital tools allow us to provide personalized, customized, and individualized care for our patients.
The first is our relationships with our patients. We have greater in-depth knowledge of our patients based on deep, long-term connections. We slow down and take the time to get to know each one personally.
Our second tool is our practice’s structure. By removing the time constraints imposed in traditional healthcare practices, we can spend more time with each patient. We use that time to uncover what they need and develop treatment plans for them as individuals.
With these two vital tools, we’re able to explore the differences each of our patients bring to their healthcare interactions.
How Is Banner Peak Health Different?
How We Deliver Care
In traditional healthcare, insurance dictates what care patients can receive and how doctors can deliver that care. They refer to clinical visits as being “seen by the doctor,” because the structure of most insurance plans requires patients to physically be seen in order to receive reimbursement.
Banner Peak Health is free from this constraint. We enjoy more flexibility and can provide whatever care best fits the individual: in person, telehealth, texting, etc. You don’t have to be seen to be seen.
Patients Get Homework
Healthcare is not a single event. It’s how you live your life every day.
Thus, we provide our patients with written homework for almost all encounters, because healthcare is not what occurs under our roof — it’s what you take with you and implement in your daily life. Banner Peak Health is organized to facilitate and systematize that level of communication.
State-of-the-Art Testing
Since we’re freed from the constraints of insurance, we can explore a wider range of medical technologies we feel are vital to patient care.
We’ve been early adopters of state-of-the-art cancer detection technology such as Galleri by GRAIL, which can detect multiple forms of cancer using only a blood draw.
Other excellent detection tests we use include coronary artery calcium (CAC) scans to detect early coronary artery disease and body composition tests instead of BMI. One such test is InBody, which utilizes bioelectrical impedance analysis (BIA) to measure full body composition in under two minutes.
We take a wide array of metrics into account because we care about getting a full picture of each individual.
Today’s Takeaways
At Banner Peak Health, we want to introduce people to options and opportunities they aren’t aware of, usually because they’ve only ever known the constraints of the traditional healthcare system.
We see this in so many patients who come to us from traditional healthcare. They’re used to shoddy service and insurance constraints, and they accept this as the norm.
But you have options. You can enter a world where doctors won’t tell you “no,” physicians won’t short-shrift your time, and a human being will answer the phone when you call.
We’re all individuals, and we deserve better than that. You deserve better than that.
Which is why we exist.
A Doctor’s View on the Potential Daylight Savings Changes
Last March, the U.S. Senate passed the Sunshine Protection Act of 2021, which would abolish clock changes in favor of permanent daylight saving time.
Though springing forward and falling back will go forward as usual this year, permanent daylight savings is a hot topic among sleep experts, news outlets, parents, and others. Here, I want to look at it from a medical perspective.
If the Sunshine Protection Act becomes law, here’s what it could mean for your health.
Daylight Saving Time: A History
Before we discuss the modern consequences of permanent daylight saving time (DST), we have to go back to the year 1883. This is when time zones were first introduced by railroad companies in an effort to standardize and adjust for time across our wide continent.
By 1918, those time zones became codified into federal law. 1918 also saw the first experiment with daylight saving time, an attempt to save energy domestically during World War I. However, with the advent of DST came controversy: Farmers disliked dark mornings, setting the stage for generations of conflict.
In 1974, the United States experimented with year-round DST, but it was repealed after just 18 months. The public was so opposed to dark mornings that permanent DST simply couldn’t last.
That brings us to today.
Why I Care as a Doctor
As a doctor, I watch the daylight saving debate from a medical perspective. I’m fascinated by circadian rhythms and the role they play in our lives.
How we live our lives in relation to light can significantly impact our health. Researchers and sleep experts have gathered ample data that the hour shift forward in the spring and backward in the fall is associated with a demonstrable increase in auto accidents, industrial accidents, and negative health outcomes such as heart attacks.
Permanent DST: My Main Concerns
There’s a medical consensus that the shifting back and forth of time may have significant health consequences. In the opinion of sleep experts, daylight saving time is contrary to our bodies’ natural circadian rhythms.
Unfortunately, there is no societal consensus around maintaining DST year-round versus maintaining standard daylight year-round.
Proponents of year-round DST state that the change could bring economic benefits. Having light later in the day theoretically encourages shoppers to stay out later and workers to put in more hours.
In the other camp are opponents of year-round DST, who cite the challenges of waking up in darkness. There’s a potent political lobby around kids going to school in the dark, which has become a rallying cry against year-round DST.
I’m most interested in the medical angle — particularly, the way our lives sync with our internal circadian rhythms.
Circadian rhythms are the cycles that make up our internal clocks. Arguably the most important of these is the sleep-wake cycle. It’s influenced most strongly by light — the cycle of night and day — which is why disrupting your amount of light exposure can lead to side effects like insomnia, depression, and more.
Seasonal Affective Disorder
During fall and winter, I see a flare-up of something called seasonal affective disorder, or “winter blues.” This subvariant of depression is triggered by less light exposure in the darker months — in particular, less early morning light.
It’s believed that the later onset of light in the winter sets people up for circadian rhythm asynchrony, which is felt to be a real risk factor for depression. Symptoms include sadness, exhaustion, low mood, oversleeping, difficulty concentrating, and losing interest in activities you once enjoyed.
The treatment for seasonal affective disorder is to have the patient rise as early as possible and use specially formulated indoor light boxes. These light boxes give the patient the equivalent of sunlight to appropriately re-sync their circadian rhythms in the winter.
Permanent DST is the exact opposite of a morning light box. I fear permanent DST may trigger a pandemic of worsening depressive symptoms.
Why Daylight Savings Makes You Tired
On a related note, patients often ask me, “Why does daylight saving make you tired?” The answer is often more complex than simply losing an hour of sleep.
In fact, you’re not losing an hour of sleep at all. You’re merely pushing your sleep back. But doing so can cause enough change to your circadian rhythm to deal real harm to your sleep and emotional health.
As much as I enjoy exercising in the sunshine after work, I’m particularly leery of a societal shift to year-round daylight saving time because of the increased risk of winter-associated depressive illness.
I agree with the sleep experts; daylight saving time should not become the new standard.
Today’s Takeaways
Be aware of the connection between light exposure and emotional wellness — it’s a biological reality.
If you find your mood sinking with less light, try to get more natural light exposure. Use sunglasses less — they put you at a higher risk of losing connection with your natural circadian rhythms.
If you have the “winter blues,” especially if you’re in a region of extreme latitudes, talk to your doctor about light box technology. Morning light box exposure can help re-sync your circadian rhythms and help you start feeling and sleeping better.
And if your doctor isn’t up-to-date on light box treatments, schedule an appointment with Banner Peak Health. We’d be happy to help!
Why the Traditional Medical Approach to Sleep Is Failing Us
How do we fall asleep? Do we actively go out and get sleep, or do we create a set of conditions where we allow sleep to come to us?
This may seem like a hypothetical or philosophical distinction, but it’s vital to understanding sleep management.
The advent of the sleeping pill has led to the misconception that sleep is something you can actively obtain, or “go get.” Unfortunately, that’s a false promise.
The Sleeping Pill: A Dangerous Path
The sleeping pill has led us down a detrimental path for two main reasons.
First, sleeping pills are dangerous. There’s robust evidence that sleeping pills are associated with an increased risk of falls, pneumonia, motor vehicle accidents, cognitive impairment, and premature death. At the societal level, they’ve created a very high burden of side effects.
Sleeping pills are also often taken for chronic daily use for years on end, which is off-label (meaning it’s not how they were studied and what they were approved for by the FDA). The safety and efficacy of sleeping pills has only been demonstrated in trials of several months’ duration. Even then, the absolute magnitude of sleep provided was minimal at best.
Secondly, sleeping pill culture has created a false understanding of how we fall asleep. The most healthy and efficient route to sleep focuses not on how to obtain sleep, but on how to identify and maximize the multiple necessary prerequisites to create the conditions for healthy sleep.
The sleeping pill masquerades as a single, simple solution to an undoubtedly multifactorial problem. This is far from the truth. Complicated problems require complicated solutions.
Rethinking Healthcare’s Approach to Sleep
Unfortunately, turning to a simple prescription is all too common. Our healthcare system at present doesn’t support a broader, deeper, multifactorial approach that would be more appropriate and help us sleep better.
That’s what I seek to address as a concierge physician.
Rather than seeing you for a 10-minute appointment, hearing a quick rundown of your sleep habits, and writing you a prescription, I may spend an hour speaking with you before I make a recommendation about how to improve your sleep.
And if I ever prescribe any kind of medication, I will be available if you have questions or encounter unforeseen difficulties.
Today’s Takeaways
- Think beyond the sleeping pill. When it comes to sleep, broaden your vantage point to see beyond “quick-fix” medication.
- Think like an internist. Create a “differential diagnosis” by listing the multiple factors you may need to address in order to improve your sleep.
- Remember the fundamentals of good sleep:
- Exercise
- Reduce stress
- Be cautious of your caffeine intake
- Create an environment conducive to sleep
Finally, make sure your physician’s philosophy aligns with your own. Otherwise, you probably won’t see the health results you want.
Why Cholesterol Doesn’t Matter (Without a Coronary Calcium Score)
As an internist, I never want to be surprised.
In my line of work, surprises are almost universally bad. I want to know as much as possible about my patients so we can work together to reduce their risk of bad outcomes.
In our society, the greatest loss of life is attributable to cardiovascular disease manifested by heart disease and strokes. We need to understand, with the greatest accuracy possible, the risk each individual has for a bad cardiovascular outcome.
Since 1948, the Framingham Heart Study has informed us about the risk factors for coronary artery disease, with a prominent role of diabetes and cigarette smoking, and an understanding of cholesterol and its impact on risk.
We in the medical community need to know our patients’ cholesterol panels to help us loosely infer potential risk. But in the last decade, we’ve developed a safe, accurate, and simple method for understanding the actual coronary artery disease burden of an individual.
We can now move from a statistical probability to an anatomic reality. This is possible thanks to the coronary artery calcium (CAC) score.
What Is a Coronary Artery Calcium Score?
Atherosclerosis, or the hardening of the arteries, is not a passive, chemical deposition process analogous to the clogging of pipes in your home. Rather, it reflects an active biological process created by ongoing inflammation in the lining of our blood vessels.
Many studies have proven that this inflammatory process can create calcification, the laying down of calcium within blood vessels in a fashion that is highly correlative with the total amount of plaque and blockage within the arteries.
Calcium has a unique property. It’s radiopaque (meaning it absorbs X-rays) and can be imaged very clearly through a CT scan (a three-dimensional X-ray).
Because the coronary artery calcium (CAC) score is a screening test, a special protocol has been developed which uses a 10th of the radiation of a traditional chest CT. This allows us to quantify how much calcium we see in an individual’s coronary arteries.
The quantity of calcium is measured as an Agatston score and is also given as a percentile rank for an individual of their age and gender.
The coronary artery calcium score is so helpful because it’s an early warning system — the best available. It can detect inflammation and calcium deposition when it’s only in the lining of blood vessels before there’s any blockage of blood flow.
For example, an individual with an Agatston score of 104 and a percentile rank of 90% would have more calcium in his or her arteries than 90% of their age- and gender-matched peers. This alerts us that there is a real anatomical risk of this individual’s arteries leading to a bad outcome.
Other tests, like the treadmill test, are not as accurate for detecting early disease. In fact, the treadmill test requires at least 70% blockage in an artery to register a result. The CAC score gives us a much earlier warning, before any blockage has occurred, and enables us to take appropriate steps to prevent a blockage from ever happening.
Who Should Get a CAC Score?
CAC scores help us better understand individuals who are at intermediate risk for coronary artery disease and may need more aggressive treatment than they’re currently receiving.
On the spectrum of risk, there are three categories:
- High-risk individuals who have already manifested coronary artery disease.
- Intermediate-risk individuals with no manifested coronary artery disease, but at least one risk factor including but not limited to: men over the age of 50 or women over the age of 60, family history of heart disease, high blood pressure, cigarette smoking, diabetes, high cholesterol.
- Low-risk individuals, or younger individuals without any existing risk factors.
The intermediate-risk group is quite large. Because cardiovascular disease is the greatest medical threat to this group, which already has additional risk factors, it makes sense to gather information that will help create an effective, personalized risk reduction plan for them.
Why Cholesterol Doesn’t Matter Without a Coronary Artery Calcium Score
Merely knowing a patient’s cholesterol panel gives a rough approximation of their risk for coronary artery disease. But if you know their coronary artery calcium score, you know their anatomy.
For example, a potentially risky, dangerous cholesterol panel in an individual that has shown no evidence of actual calcification or plaque formation is much less worrisome than someone with a “safe” cholesterol panel who has already manifested coronary artery disease as evidenced by their coronary artery calcium score. One person might need aggressive medical management, while the other may not.
Today’s Takeaways
- Be aware that you may be at risk for coronary artery disease. So many people assume it won’t happen to them until it does. Ultimately, it’s the leading cause of death in our society.
- If you have any constellation of risk factors discussed above (male over 50, female over 60, etc.) ask your doctor about getting a CAC score.
Remember: prevention is about identifying and addressing issues before bad outcomes happen. It could happen to you just as easily as anyone else, so talk with your physician before it does.
How Long Does It Take for Caffeine to Kick In?
Over half of all Americans start their day with a cup of coffee or tea.
When you have a long day ahead, you may feel like that streaming mug makes all the difference. In fact, there are several ways we can consume caffeine throughout the day.
But if you find yourself asking, How long does it take for caffeine to kick in?, I implore you to consider a different question first: Are you using caffeine as a substitute to achieve the energy and focus you lack because you’re not getting enough rest?
In other words, are you using coffee as liquid sleep?
How Long Does it Take for Caffeine to Kick In?
The answer to the question “How long does it take for caffeine to kick in?” is pretty straightforward. For most people, caffeine kicks in about 15 minutes after consumption and reaches its maximum effect in 30–60 minutes.
But let’s get more specific. When we say “kick in,” we’re actually describing a process with three distinct characteristics.
- How fast caffeine absorbs into your body — This part of the process varies very little from person to person.
- How many milligrams of caffeine are needed to produce an effect — This varies tremendously from person to person. It’s why one person might only feel slightly more alert after a cup of coffee and another might feel jittery and anxious.
- How long the caffeine stays in your body — This also has a high variability in individual response. It’s why one person can drink tea before bed and fall asleep without any problems, and why someone else drinks a cup of coffee at 2 p.m. and can’t fall asleep at 9.
The second and third characteristics of this process contain a very high level of individual variability. How is that variability determined?
What Determines Caffeine Variability?
Individual Factors
The effect of caffeine depends on only two known personal factors: body weight and use history.
Your body weight is a determining factor for the effect of any chemical, since dosages are measured in milligrams per kilogram. Your history with caffeine is also important because, with habitual use, your metabolism changes and begins to process caffeine faster.
Beyond those two factors, there’s enormous individual variability we can’t account for. We’re all genetically different, and very simply, different people have different responses to different substances.
Half-Life
Half-life is another crucial piece of this puzzle and is one of the most variable aspects of how caffeine affects us.
Half-life is defined as the amount of time it takes for a substance in your body to be reduced by 50%. This ranges from 1.5 to 9.5 hours for equal amounts of caffeine.
This also means it could take between six and 38 hours for different people’s bodies to clear the same amount of caffeine. To put that into perspective, two different people could drink the same cup of coffee at the same time for the same amount of time, and one person might feel the effects for six hours while the other person continues to feel the effects of that single cup o’ Joe for a full 38 hours!
This wide variance in half-life is not unique to caffeine. That’s why it’s so important to be cognizant of the potential treatment and side effects of any drug, especially a drug that’s new to you.
As we seek the benefits of caffeine, including alertness, energy, better mood, and focus, we’re also at risk for side effects of anxiety, insomnia, headaches, and heart palpitations. Although caffeine is a part of our everyday lives, it’s important to remember it’s still a drug with potential side effects.
Your Individual Experience With Caffeine
Even though “How long does it take for caffeine to kick in?” is such a common question, most of us know from our own experience how long it takes for us to feel the effects of a cup of coffee or tea. We also know how much we can drink before we start to feel uncomfortable.
We have so much experience with caffeine as a chemical that we can understand our tolerances and adjust our consumption accordingly. Some people are more sensitive to the chemical and have to exercise more discretion. My wife and I, for example, have to avoid even dark chocolate after lunchtime for fear of it keeping us awake too late. Other people can chug an espresso at 10 p.m. and be snoring by 11.
Our familiarity with caffeine allows us to view the risks and benefits with less concern than we would with, perhaps, a medical prescription.
However, although prescription drugs demonstrate the same variabilities in intensity and duration from person to person that caffeine does, they are commonly prescribed in standard dosages based on very little information rather than in customized dosages based on individual history.
I think this proves why we need a healthcare system with more robust communication and observation. As with your individualized experience involving caffeine, healthcare should offer you individualized dosages and results for every medication that you establish.
Personalized Healthcare
What concierge medicine offers that the conventional healthcare system cannot is time spent with each patient to gather the information necessary to provide the best, most personal care possible.
I want to understand your history as completely as I can so I’m able to make the best possible decision about your treatment. Rather than seeing you for a 10-minute appointment, hearing a quick rundown of your symptoms, and writing you a prescription, I may spend an hour speaking with you before I make a recommendation. I’ll also be available if you encounter questions about your medication.
Just like your current caffeine intake, every prescription should be customized to the individual. That requires information gathered over time, which is something our current healthcare system simply can’t support.
Today’s Takeaways
- If you need caffeine daily, ask yourself if you’re getting enough sleep.
- If you’re asking “How long does it take for caffeine to kick in?” because you want it to kick in faster, know that an empty stomach allows for faster absorption.
- Understand caffeine’s potential side effects — anxiety, insomnia, headaches, and heart palpitations — and, if you experience them, reexamine the quantity and timing of your intake.
Caffeine isn’t dangerous for most people. It’s sometimes perceived as a guilty pleasure, but doctors have spent generations trying to prove that long-term use of caffeine is bad for you — and they’ve found just the opposite. It’s actually been shown to have many health benefits, such as decreasing your risk of type II diabetes and depression, to name a few.
So, caffeine’s not a guilty pleasure after all. Just a pleasure. Enjoy your coffee, tea, and chocolate — in moderation, of course!
NSAIDs: How Much Anti-Inflammatory Medication Is Too Much?
The medical community may be at an inflection point in how we think about nonsteroidal anti-inflammatory drugs. I’ve always been skeptical of their risk/benefit ratio, and I’m excited to see a growing body of medical literature supporting my position.
You’ve likely heard the acronym NSAID: nonsteroidal anti-inflammatory drug. NSAIDs work by blocking an important biochemical pathway, which reduces inflammation in the body.
NSAIDs are known by both brand and generic names: Motrin and Advil (ibuprofen), Aleve (naproxen), and Voltaren (diclofenac) are among the most common. We use them to reduce inflammation — more plainly, to reduce the pain associated with inflammation.
I believe any discussion about NSAIDs as pain treatment has to begin with the fundamentals of pain. From a medical perspective, we’ve gotten into the habit of thinking pain is universally bad; something that must be pharmacologically stamped out.
But pain serves a very real purpose. As humans, we’ve evolved to have an exquisitely nuanced and sensitive pain system.
From a simple but effective signal that the pan on the stove is hot and you need to let go of it immediately, to shin pain as you jog that warns you to alter your stride to avoid further injury, pain is useful. It’s an unmistakable communication that our connection to the environment needs to be modified. Our approach to pain relief needs to take this useful communication into account.
Yes, pain can be terribly destructive, but as we discuss NSAIDs, we need to keep an open mind about pain and why it exists in the first place.
Why Are NSAIDs So Popular?
Why are NSAIDs so popular? I’d say it’s because they occupy a sweet spot on the spectrum of pain-relieving drugs.
Tylenol (acetaminophen), when taken at recommended dosages, has very few side effects, though taking too much can be very toxic to the liver. However, Tylenol is not a very effective pain relief modality. On the other hand, medications such as glucocorticoids, which reduce inflammation, or narcotics, which blunt the body’s pain response, are much more powerful but have a much more formidable side effect profile.
In the middle of the spectrum are NSAIDs. With their moderate risk-to-benefit ratio, they’re a compromise and obvious first choice for many.
But in spite of their popularity, I believe NSAIDs shouldn’t be so hurriedly grabbed off the shelf.
My Unpopular Take on NSAIDs
We’re beginning to build a body of information that demonstrates that the acute use of NSAIDs for pain, in fact, may worsen the risk of acute pain becoming chronic pain.
There are some preliminary observational studies looking at temporomandibular joint pain and lower back pain, demonstrating that individuals who had taken NSAIDs early on for pain control were at greater risk for these syndromes developing into chronic pain.
The theory is that early inflammation is an adaptive response we’ve evolved to help our bodies heal in a way to prevent chronic pain from developing. By using NSAIDs to block that route of inflammation, we’re increasing our risk of developing chronic pain.
Certain studies conducted on mice look at neutrophils, a prominent component of the inflammatory response. These studies demonstrate that when an early rise in neutrophils is blunted by NSAID administration, mice are at greater risk of developing a chronic pain response.
While these studies are new and haven’t yet undergone large, full-scale, controlled trials, they do point to a truism that evolution exists for a reason. The fact that we’ve evolved pain mechanisms that do this and we’re still here on Earth suggests it’s an adaptive response that we shouldn’t readily block with drug therapy.
It indicates that, indeed, pain has a purpose.
In addition to the conceptual problem of NSAIDs for acute pain interfering with the healing process, nonsteroidal anti-inflammatory drugs also come with a long list of potential side effects which pose a very real risk.
The Side Effects of NSAIDs
Outside of stunting our body’s adaptive responses, nonsteroidal anti-inflammatory drugs are associated with a very long list of significant side effects: upset stomach, bleeding, ulcers, rising blood pressure, swollen legs, kidney impairment, even increased risk of heart attack.
Next time you take a trip to your local pharmacy, read the list of potential side effects printed on your preferred NSAID. You may be quite shocked!
Today’s Takeaways
- If you have pain, don’t ignore the message it’s sending you! Pause and reflect. Ask yourself why you have pain in the first place, and see if you can modify the source.
- NSAIDs should only be used for pain relief, not for healing. We now know they actually interfere with overall healing.
- If you need to take an NSAID, use the lowest dose possible for the shortest period of time needed to experience pain relief.
- If you need to take an NSAID for more than several days, also take a stomach acid blocker such as Pepcid (famotidine) to reduce the risk of upset stomach and ulcers.
BONUS TIP: Diclofenac (brand name Voltaren) is available over the counter (without a prescription) in a topical formulation that works well for joint pain near the skin — such as in the hands and feet — with minimal risk of side effects.