The usual article on sleep and health focuses on how we are all sleep deprived and the bad things this does to us. The story is pretty simple: chronic low grade sleep deprivation leads to systemic inflammation, weight gain, excessive eating, and hormonal changes that are associated with all sorts of long term health issues. The drowsiness also leads to poor judgment, more accidents, more eating and other shorter term issues. This is all being made worse as technology ranging from artificial lighting to smartphones that make our days longer and longer. Many of us then get up earlier and jump start the day with a mega dose of caffeine.
The epidemiologists tell us that 7-8 hours per day of sleep is the optimal health sweet spot for most of us. People who routinely get by on 5-6 hours of sleep have about 1.5 times the relative risk of death from coronary heart disease. Interestingly, the risk is about 1.4 times for those who sleep a lot:
“Too little or too much sleep are associated with adverse health outcomes, including total mortality, type 2 diabetes, hypertension, respiratory disorders, obesity in both children and adults, and poor self-rated health. The relationship between duration of sleep and vascular events is U-shaped, suggesting that different mechanisms may operate at either end of the distribution of sleep duration.”
If you are worried that you are getting either too little or too much sleep there are some simple steps you can take that work for most people to promote better quality sleep. Highlights include:
- Avoid napping
- Limit the use of (caffeine) to earlier in the day
- Morning exercise
- Avoid large meals before bedtime
- Get adequate exposure to natural light
- Establish a bedtime routine
- Use your bed for sleeping as opposed to reading and watching TV
- Make where you sleep a comfortable place
As a result primarily of the obesity epidemic there is also an epidemic of sleep disturbed breathing. There is a simple questionnaire that can help determine if you have the problem and need medical follow-up.
Sleep & Exercise Performance
What about short term sleep deprivation and exercise performance? What happens when you have a competition and only get four hours of sleep the night before? What if you are in a multi-day event with little time for sleep? Many of the studies on this topic are from the 1980s and 90s and they tend to show that even 30 hours of total sleep deprivation does not do much to VO2max. Studies on longer term submaximal exercise are limited but they tend to show exercise time to exhaustion is reduced but with some subjects effected far more than others. One general finding appears to be that people rate whatever they are doing as harder to do when sleep deprived.
An interesting source of data on exercise performance and sleep deprivation comes for the literature on physical conditioning and military Special Forces. These individuals frequently do very demanding night operations for several nights in a row with limited opportunities for daytime sleep. In a series of Canadian studies that simulated several days of night operations, caffeine (1-200 mg) improved run time, cognitive performance, and marksmanship.
Another interesting idea is that recovery from days in a row of vigorous activity with short sleep can be enhanced by protein supplementation. There is a lot of discussion in military nutrition circles about 20-25 gms of protein before sleep during periods of high stress physical activity. The idea is that muscle mass will be better preserved during periods of physical stress, sleep deprivation, and limited calorie intake. It would be interesting to know if professional cyclists are adopting similar strategies during the big stage races.
As part of my medical training I have probably spent more time than most people both working and working out while sleep deprived. There are short term strategies to deal with it, but sleep deprivation is no fun and my goal in middle age is to avoid it as much as possible. Advice that is easier to give but harder to act on in our high strung world.
Last weekend there was a “60 Minutes” segment on the emerging sport of free diving. That plus the death of free diver Nicholas Mevoli got me thinking about risk and extreme sports. When things like this happen sometimes I get calls from the press and almost always my physician colleagues want to know “why anyone would try these things?” Here are the ideas I cover in response to that question.
The Power of a Subculture
People who attempt to set extreme records or push themselves to the limit are usually part of an extreme and somewhat closed subculture. Their friends and peer group share an intense interest in an activity and it becomes literally what they eat, breath and dream about. A question like “how are you today?” from a casual friend or co-worker is frequently answered with something like “pretty good, I did a hard 15 mile run first thing this morning, we will see how the 10 miler this afternoon goes.” This might be seen as an odd response in the real world, but totally normal in an extreme athletic subculture.
That sort of dialogue is an example from running but similar discussions can be had with those who are really committed to just about anything. If you have never been part of an extreme athletic subculture three books that describe them in detail are “Muscle”, “Once a Runner”, and the recent the “Secret Race” by Tour de France rider Tyler Hamilton. So, there is plenty of social reinforcement to “go for it” from the subcultures that people who are committed live in.
My Neurotransmitters Made Me Do It
One of the hallmarks of traditional addiction is the need to use ever more external stimulus to get the same satisfaction from whatever you are addicted too. Traditional addiction to drugs rewires brain circuitry and neurochemistry to make this happen and there is evidence that gambling can do the same thing to susceptible individuals. For many a peak and intense athletic experience is sometimes followed by a letdown as the excitement associated with the planning, training, and anticipation of the big event vanish afterward. The obvious solution to this problem is to find an incremental challenge and start the whole process again. Parallels with gambling seem appropriate here and when you mix what is happening in the brain with the right subculture it is pretty easy to see how the need to do ever more extreme things happens.
A lot of disasters and deaths occur in extreme environments. Think altitude, diving, hot and cold. There are tremendous physiological adaptations that can be activated both acutely and in response to training that help us do more or go longer in extreme environments, but when things fail they can fail catastrophically. There is a quote about bankruptcy from the “Sun Also Rises” by Earnest Hemingway that applies to physiological responses to extreme challenges:
“How did you go bankrupt? Two ways. Gradually, then suddenly.”
A classic example of this is watching soldiers faint while at attention on a hot day or seeing a patient respond to potentially life threatening blood loss. If you were to measure the vital signs they would be pretty normal until just before loss of consciousness when there is a sudden drop in blood pressure. When this happens many of the physiological systems that are compensating for the challenges of not enough blood returning to the heart fail essentially at the same time. You can tell a similar story about catastrophic physiological failure in response to other severe stresses as well. So, people feel OK until they don’t and in extreme environments the distance between OK and death is not that far.
You Are On Your Own
Of the people injured in the Boston Marathon bombing essentially everyone who made it to the hospital alive survived. This is one of the main lessons from military combat casualty care for civilian medicine. Extreme sports take place in extreme environments distant from the types of comprehensive medical care that make an incredible array of injuries and illnesses survivable especially in young otherwise healthy patients. Other things that come to mind are the availability (or lack thereof) of specific equipment and logistical support needed to do challenging things in a safer way. Getting a lot of hardware and a support crew to a remote location is challenging and sometimes there might be a temptation to try to do more with less.
Extreme environments, the limits of physiology, and logistical issues are all risks but they are all amplified by poor judgment. I like to tell people that taking four 3% risks at the same time doesn’t mean you have a 12% risk of failure. Instead the risk is more like 3x3x3x3 or 81%. This is a theoretical example but things really do seem to multiply while doing extreme things in extreme environments. Time and time again you hear about people choosing to push it just a bit more prior to a disaster.
I Am All For It
Based on the observations above you might think I oppose people taking on extreme challenges in fact I am all for it. Back in 2011 when Diana Niad was attempting to swim from Cuba to Florida I commented to PBS that questions about “why” do it
“miss the point, at some level, you’ve got to admire anybody who wants to test the limits of human potential in general, and her own limits, in specific…It’s a good thing we’re not all average.”
That having been said, I just want people to understand what they are getting into and avoid getting sucked up by their subculture and neurochemistry into challenges they are not prepared for in truly unforgiving environments.
For most of us when I say doping you say Lance Armstrong, or Barry Bonds, or Roger Clemmons or Marion Jones. However, what about the rest of the world and our individual and collective drive for improved performance? Here are a few thoughts on the topic and questions for all of us.
Doping With Tylenol?
“Using acetaminophen, participants cycled at a higher mean power output, with an increased heart rate and blood lactate, but without changes in perceived pain or exertion. Consequently, completion time was significantly faster. These findings support the notion that exercise is regulated by pain perception, and increased pain tolerance can improve exercise capacity.”
Is this doping? Should Tylenol be banned? You can tell a similar story and ask the same questions about caffeine.
What About Middle Age?
A recent piece in the Velo News tells the story of a late 50s recreational cyclist with clinical testosterone deficiency who went on testosterone replacement therapy for a number of issues including osteoporosis. The athlete in question self-reported and asked for a therapeutic exemption so he could keep competing in local races. The exemption denied because he did not have a clearly defined endocrine problem. You can also make the case that Viagra like drugs might improve performance in some people especially at altitude. What does this mean for master athletes who take these compounds for other reasons?
For women there is at least some evidence that hormone replacement therapy (HRT) improves exercise capacity but the data are far from clear cut. What about the aging news anchor who uses botox to keep her job?
Is any of this doping when the drugs in question are used for legitimate medical purposes? Search the internet for anti-aging clinics and you will find all sorts of outfits offering unproven (usually hormonal) therapies purported to slow the aging process. Recently, some elite younger athletes have been tweaking their thyroids levels. Where does the “legitimate medical purposes” justification end and doping or snake oil sales begin?
For the twenty somethings reading this article the idea of academic doping – using ADHD drugs obtained on the black market to do better on a test is old news. This practice appears to be pervasive on college and even high school campuses. It also appears to be drifting into the rest of the world where decision making and concentration are critical.
There are all sorts of drugs that enhance or might enhance cognition and more are in the pipeline. Who gets them and when is it fair to use them? Is this just another potential edge for the children of the well-off? In a world of high stakes testing for admission to an elite school or academic program should these substances be banned and test takers subject to doping control? The discussion in the cognitive enhancement world mirrors in many ways the sports doping discussion:
“Drugs developed to treat cognitive impairments are proving popular with healthy college students seeking to boost their focus and productivity. Concerned observers have called these practices a form of cheating akin to athletes’ use of steroids, with some proposing testing students’ urine to deter “academic doping.” The ease with which critics analogize the academic enterprise to competitive sport, and the impulse to crack down on students using study drugs, reflect the same social influences and trends that spur demand for these interventions-our hyper-competitive culture, the commodification of education, and our attraction to technological quick-fixes. Rather than focusing on the technologies that are being put to troubling uses, we would be better served reforming the culture that makes these practices attractive.”
Are We All Dopers?
All of us are surrounded by performance enhancing choices beyond the things like the drugs or nutraceuticals we can inject or put in our mouths. The pervasive invasion of technology into almost every aspect of life offers even more opportunities for performance enhancement. In the end, what does it mean to be human in the 21st century:
- What happens when things like Tommy John surgery are used to pre-emptively improve pitching performance before an injury?
- Who draws what lines about what is ethical and fair?
- Should we even strive for a level playing field?
- What does it mean to be a human in a world where almost every imaginable activity might be subject to high tech performance enhancing strategies?
In the end is there any value left in the lone individual struggling against his or her own limits, or is all about return on investment thinking where the individual is just part of a supply chain leading to a more desirable outcome?