importance of sleep

Strong Medicine Questions and Answers

December 1, 2016 By Dr. Chris Hardy 2 Comments

Chris Hardy Strong Medicine Questions and Answers

This is the fifth and final post in a series of articles developed from Dr. Chris Hardy’s live presentation at Dragon Door’s Inaugural Health and Strength Conference. Click here to read the first article of the series. These questions were from the coaches, trainers, and fitness instructors in attendance.

Q: How do I measure HRV (heart rate variability) if I have eight people coming in for a group fitness class?

A: You would set this up with your clients beforehand. They would measure it first thing in the morning. In the back of Strong Medicine, I discuss how the optimum time to measure HRV is at first waking, before anything has an opportunity to fill the stress cup. This measurement will give them a baseline. Most HRV apps require two and a half minutes to measure and will use data from a chest strap like a Polar Bluetooth heart rate monitor. The app will determine the HRV as a number. It’s important to measure it first thing in the morning, because if you measure it throughout the day, even someone angering you in traffic will change it.

Measuring HRV is not perfect, but if you measure it the same time every day before anything else has effected your stress cup then it will be a good reference. It will also reflect if you’ve been up all night tossing and turning.

Q: I have a client who has a lap-band, so she’s only eating 200 calories a day. If she eats more she vomits yet she wants intense exercise. She’s stressed and thin but with a huge belly. How would we work with her if we can’t get her to eat more? Do we just take down the intensity?

A: First, it sounds like she’s protein deficient. And you won’t be able to workout with her—you can’t—it will hurt her. It’s like when people come to me and want antibiotics for a viral infection. Then, when I don’t prescribe the antibiotics, they just go to someone else who will. But you should not be training that person, because she could go off the rails in a second.

She’s protein deficient and malnourished. That large belly is basically a bunch of fluid because there’s so little protein in her bloodstream that an osmosis effect happens and draws water from the bloodstream, then it goes into the tissues. It’s called ascites, and patients will sometimes develop huge protuberant bellies. We see it happen in sub-Saharan Africa, and other places where people are malnourished. You need to say no, and she needs medical attention.

Q: We lead boot camps and have workouts on the board, what do you think about having our clients do their self reported health scale on the 1-5 range (will link to article) then adjust the workout accordingly?

A: Or they can monitor their own heart rates. This is also where you can use your creativity and find your own opportunities. You can stratify the workouts. Educate them to let them know that if they’re lower on their rating scale to be smart and that “this isn’t a punishment”. They need to know to be smart because they won’t do themselves any good by crushing themselves on that day—they’re just end up with a lot of cortisol. You’ve seen the ultra-skinny marathon runners that still have a little bit of a belly? It’s because of a cortisol response.

Q: You said that you have your clients measure their heart rates in the morning. My training classes usually take place at 8PM after they come from work and have done finished their day. How will the HRV measurement from the morning reflect how they are when they walk into my gym at 8PM?

A: It’s true that it isn’t perfect, and that’s the problem. But, as long as they’re not doing intense physical training before they get to you, if they measure their HRV in the morning, the biggest thing they will be affected by is sleep. Since HRV is the variability of the heart rate as measured on an app, it gives you an idea of where you were that morning. If your HRV is already low that morning, it will just get worse throughout the day. So, if they come in with a low HRV recorded in the morning, by the time they see you—especially if they have had other stresses during the day—then their HRV will be even lower.

HRV and Stress diagram

The morning measurement will give you a baseline, but that’s why you’ll also want to use the self-reporting scale. There’s too much that can happen during the day, and you’re trying to work with a consistent baseline. So, let’s say I usually run an “80” I’m picking an arbitrary number for my HRV, but that’s pretty high. But, this morning I measured my HRV and it was 62. When I come to train with you later that night I’ll tell you that my HRV was 62 this morning. Since I usually run in the 80s you would drop my workout down some. So in other words we are discounting what happened through the day unless a client did some other kind of training. It’s not a perfect system.

Q: What your favorite strategies for sleep? How do you feel about the different amounts of melatonin in supplements?

A: Sleep might be the same thing as attacking the circadian rhythm first. I hate to keep referring back to the book, but I do have a whole chapter on how to give your brain the right signals. So 2-3 hours before bedtime, no blue light from broad-spectrum sources. You can either use the goggles or my wife and I put yellow lights in the rooms where we spend our evening hours. We also follow basic sleep hygiene ideas—no electronics in the room. In the mornings we make sure to get bright, broad-spectrum light exposure, since most of us go to an office with poor lighting.

As for supplements, I am not a huge fan of melatonin, though I think it is very valuable for getting yourself back into another rhythm in the case of jet lag. The problem is most of the doses are supra-physiological. The pineal gland in the brain actually secretes melatonin on a pulse, about every 40 minutes since it has a very short half-life. Your body metabolizes melatonin supplements quickly, so it may help you fall asleep, but then you’re going to be back up again if you haven’t fixed your circadian rhythm. And it may also suppress your endogenous (internal) melatonin secretion.

Q: On Saturday and Sunday, 25-30 people come in to our gym for group classes. Either myself or the other trainer will greet the people as they are coming in and ask them how they are doing and how they are feeling. If they come in and say that they slept badly, just came home from an intense two-day conference, or they are still sore from working out, then we will then tell them that we will scale the workout of the day. We put up the workout and a scaled version in terms of volume or intensity and say that if we spoke to you and said you should do the scaled version, we can now train 20-30 people together.

A: I love it, but would say from a psychological point of view I would have them self-label.

Q: That was my follow up question. This is a physical/psychological assessment based on how they feel about today themselves that day, etc.

A: If a client comes in and says that they are feeling kind of cruddy, and then you say, “well we are going to do this to you” that takes some of the control from them. Instead you could have them self-label and say “I’m a 3 right now”. Since they put themselves in that category, it will be easier for them to understand that it’s not a punishment. They will just be doing the #3 workout today. It’s part of the psychology of getting them to buy in more because they have self-labeled.

Q: My question is goes back to using heart rate. How would you use the heart rate protocol with someone on beta-blockers?

A: That can be very inconvenient! Beta-blockers basically stick a wrench in the system, and prevent the heart rate from going up. It depends on why the client is on a beta-blocker—and if it is for arrhythmia then you don’t want to mess with it. But if someone is on a beta-blocker because their doctor is trying to use it as an inappropriate way to control high blood pressure, then you might suggest that they ask their doctor about alternatives. When someone is on beta-blockers, they will not be able to get their heart rate up, so rate of perceived exertion may be a better indicator for them.

Q: Melatonin was already discussed as a supplement for sleep, but how would you say performance supplements like pre-workout or protein supplements would affect allostatic load?

A: That’s a great question and, they do affect the allostatic load. It goes back to the idea of feeding your activity. We need the proper amount of protein so that amino acids hit our anabolic pathways—mTOR, the anabolic pathway where certain branched chain amino acids will hit. It can give the body fuel for activity. You need to fuel your body and give it the precursors of what it needs—whole regular food is always the best, but that is not always possible. So, supplementing something like whey protein, or a post-workout combination of protein and some glucose sources can work well, but be sure to tailor it to your activity. Do you really need to load up with a huge serving of starch or glucose for strength training? Probably not. You’ll want to use amino acids instead.

Q: But in regards to pre-workout energy supplements, I’ve tried some that just made me feel extremely crazy and full of false energy…

A: Honestly, if you are going to do one, the supplement I think is best for pre-workout is creatine. It hits the phosphogen energy pathway. But I am not a fan of the supplements that “jack up the nervous system” they can work for younger people, but in the older population it can affect the stress cup.

Q: What are your recommendations for determining optimal heart rates for training and interval training? Do you have any recommendations for estimating or determining maximum heart rate? What if someone is on a beta-blocker? Is a VO2Max test, a stress test, or a simple calculation the best?

A: It depends on your client. If you are working with an elite athlete, then you should probably do one of the more clinical assessments. This is because we all know that the samples for calculating max heart rate are estimates and they’re for a general population. They aren’t necessarily appropriate for everyone because they can be underestimated. If you used the formula on an athletic 50-year-old, it may underestimate their max heart rate. Some of the formulas are better than others—certainly better than 220 minus age.

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Q: When working with individuals who are nurses, police officers, fire fighters, and other shift workers, how do you help them make improve the sleep they are getting?

A: Shift work is actually classified as a carcinogen by large governing agencies. But they have done studies with shift workers and found that their environmental clues are the most important. Your circadian system is free running—they’ve done studies in caves in isolation—and will advance itself without external cues. Another study with police officers and nurses exposed them to maximum bright lights during their shifts at night—which was their mornings. Even though they are coming to their shift at night, they should get maximum bright light exposure. When they are coming home, they should use amber glasses or something to block out blue spectrum light. When they sleep, blackout curtains can make their environment as dark as possible. Are they getting perfect sleep? No, but these environmental cues can make a big improvement.

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Chris Hardy, D.O., M.P.H., CSCS, is the author of Strong Medicine: How to Conquer Chronic Disease and Achieve Your Full Genetic Potential. He is a public-health physician, personal trainer, mountain biker, rock climber and guitarist. His passion is communicating science-based lifestyle information and recommendations in an easy-to-understand manner to empower the public in the fight against preventable chronic disease.

Don’t Fear the Sleeper!

November 12, 2015 By Michael Krivka 6 Comments

Don't Fear the Sleeper by Mike Krivka

Want to lose fat and gain muscle? Want to improve your cognitive ability and decrease reaction time? Want to increase your ability to heal from illness and injury? Want to do it without taking expensive supplements or complicated diets? Sure, everyone does! Then let me tell you a little secret: Sleep is one of the key factors in losing fat, gaining muscle, staying sharper, and living longer.

We live in an environment where sleep is the enemy and something that is actively avoided and delayed. Is there a cost to this habit? There sure is, and it’s a high one at that! From the increase in chronic illnesses (heart disease, cancer, diabetes, obesity, etc.) to deaths due to sleep deprivation, we are paying a high price.

“Red Bull Nation”

Man is the only mammal that willingly delays sleep and goes to extremes to avoid it. The increase in the consumption of coffee and energy drinks (the fastest growing market segment for soft drinks) should be some indication that people are either avoiding sleep or are trying to cope with the aftermath of not getting enough of it.

If you are an athlete you may have your nutrition and exercise dialed in, but if you don’t get the commensurate recovery (i.e. sleep) it is all for naught. In no uncertain terms, sleep is just as important as diet and exercise. Consider this: your body does not make changes or adaptations during a workout; your body only makes organic changes during sleep. Repair of damaged cells, the regeneration of DNA, the release and regulation of critical hormones are all reliant upon one thing–sleep.

Too Little Too Late

In general, most healthy adults need between seven to nine hours of sleep a night; but if you are regularly training hard, your requirements might be higher. Professional athletes like Roger Federer, Lebron James, Lindsey Vohn and Michelle Wie, regularly get between nine and twelve (yes, twelve!) hours of sleep! There are many factors that contribute to the amount of sleep you will need: environment, diet, medications, stress, etc. The trick is finding the right amount of sleep you need and getting it on a consistent basis. Regardless if it is seven or ten hours, you need every minute of it to meet your potential!

The Benefits of Sleep

Testosterone and growth hormone levels, as well as other key hormones, elevate during sleep. This is part of the body’s physical and mental repair system. These hormones assist in recovery as well as strength and fitness gains. These hormones start to release after being asleep for about 30 minutes. These hormone levels elevate every time you go thru a certain phase of your sleep cycle. The longer you sleep, the more cycles you go thru, and the more of these recovery promoting hormones will be pumping through your body.

Setting the Stage for a Perfect Night’s Sleep

Hopefully it won’t take a lot of convincing to get you to devote a little more effort to getting more and better quality, sleep. So, what do you need to do to get a good night’s sleep? You really need to make the effort to “set the stage” to stack the odds in your favor. The following are some things you can do to give you the best chance at getting a restful and productive (yes productive) night’s sleep:

Go to bed and get up at the same time every day – …Even if you are on the road or in a different time zone. You should try to follow this, within reason, so that you don’t disrupt your set sleep cycle. My instructor, Guro Dan Inosanto, travels somewhere every weekend teaching workshops. He gets up at the same time every day, around 4:00AM PST, so that even when he is on the East Coast he will be getting up in time to be at a workshop that usually starts at 10:00AM. While he should be suffering from horrible sleep deprivation because of his teaching, training, and traveling schedule, he is still going strong at 78 years old.
Use “sleep aids” sparingly if at all – Some studies show promise for the use of melatonin in shortening the time it takes to fall asleep and reducing the number of awakenings, but not necessarily total sleep time. Other studies show no benefit at all with melatonin supplementation. If you are traveling or trying to recover your natural sleep cycle, then a dose of a melatonin supplement might be just what you need to get you back on track… but it might not be beneficial to take it every night. How important is melatonin? Extremely! Melatonin holds the key to not only sleep but also cellular and DNA regeneration, the release of growth hormones, and is a natural anti-inflammatory. Do you really think that missing sleep isn’t important now?
Sleep in a dark room – Block out all of the light sources in the room… and that includes ambient light from clocks, night lights, phone chargers, etc. “Black out” curtains are another option if you live in an urban environment and have a lot of “light pollution” from the outside invading your sleep space. Can’t block out all of the light in the room? Then get yourself a high quality sleep mask that will block out all light.
Eliminate sources of noise – One of the best investments I’ve made in the past few years was replacing the windows in my bedroom. The old ones allowed as much noise into the bedroom when they were closed as when they were open! Try to make your sleep space as quiet as possible, but a little noise might be a good thing. White noise from a fan or even a white noise machine (or an app on your phone) can help you drop into sleep faster. Another alternative is getting ear plugs. There are a number of different configurations on the market, from wax to foam, and you’ll need to find ones that are the most comfortable for your ear configuration and which block an acceptable amount of noise.
Cool is better than warm – Keep your bedroom as cool as possible (somewhere between 65-72 degrees is optimal). Even if you are sleeping under several blankets, you need to have the ambient air as cool as possible. This will help you fall into a deeper sleep and fall to sleep much faster.
Ice, ice baby – If you are up to something a little more extreme, try taking a ten minute ice bath one hour before bedtime. After your body has returned to normal temperature from an ice bath, the aftereffects of the cold will help you drop into a deep slumber. Another use for ice is to go bed with an ice pack, “ice cape”, or blanket. I was told by several people that an ice pack, ice blanket, or cape across your shoulders will reduce the time it takes to fall to sleep. Tim Ferris mentions this in The Four Hour Body and I’ve heard it from athletes as well.
Establish a sleep ritual – Create a routine that allows you to relax and transition into sleep mode. Turn off the television, phone and iPad–get away from all electronics. Read a book, listen to relaxing music, or do something that is not too stimulating. Remove any blue light generating items from your environment prior to sleep. Dr. Chris Hardy, author of Strong Medicine, recommends wearing “blue blocker” sunglasses in the evening as well as switching the lights in the bedroom over to “bug lights” or any type of light bulb that doesn’t generate blue light.
Just say no to drugs – Regular use of prescription sleep medications can lead to long term problems. I have talked to a number of doctors about if and when they prescribe sleep medications, and they all do so with great hesitation. Instead of prescription medication, you can always try natural sleep aids–at least they don’t come with several pages of warning and possibly fatal side effects. NOTE: Tim Ferris recommends Yogi Soothing Caramel Bedtime Tea and there are other brands that seem to work as well. I have had several people recommend aromatic oils as well.
Don’t go to the (blue) light! – Light is the most powerful stimulator of the circadian system and can have positive or negative effects. Broad spectrum light stops the production of melatonin and pushes us into a waking state. This spectrum of light, in particular blue light, has the most impact on our circadian clock. So how much blue light do you get? If you have incandescent lights going, are watching television or using your computer or phone, you are bathing in the stuff.
Sunglasses at night? – How can you minimize blue light in the evening so that you can make a smoother transition into sleep? There are two easy ways that are not only inexpensive but effective. First, eliminate your exposure to blue light 2-3 hours before your bedtime by turning off the television, phone, and computer, and by installing lights in your evening living space that have a low blue light emission. Low blue light bulbs are those that have a yellow or orange color to them and are have a low CCT (Correlated Color Temperature). Inexpensive “bug lights” work well but there are other low cost alternatives on the market that you can find with a little research. The second way is to wear “blue blocker” glasses. Yeah, I know the old “sunglasses at night-thing” sounds a little weird but they work.

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Sleep Like a Baby

There you go! Ten tips that will have you sleeping like a baby in no time at all. Try one or several to see if they work for you. I would recommend first setting up your sleeping space to be optimal, and working from there. If you have any tips or thoughts on how to get to sleep faster and easier I’d love to hear about them in the comments section below.

Until we meet again, Sleep Well!

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Michael Krivka is a Senior RKC with Dragon Door and has been training with, teaching, and sharing the gospel of the kettlebell for over a decade. As a life-long martial artist, he is a Full Instructor under Guro Dan Inosanto in Jeet Kune Do (JKD); the Filipino Martial Arts of Kali, Escrima and Arnis; and Maphilindo Silat. He lives in Gaithersburg, Maryland with his wife and two sons. He owns CrossFit Koncepts where he runs strength and conditioning classes with an emphasis on kettlebell training, mobility and longevity. Follow him on Facebook.com/CrossFitKoncepts or Instagram.com/Michael_Krivka

Finding a Balance Between Building and Repair: Part 2 Intermittent Fasting

July 16, 2015 By Dr. Chris Hardy 1 Comment

Finding a Balance between Building and Repair part 2

Prolonged calorie restriction seen in many fad diets is not a sustainable practice. Weight will be lost for sure, but a significant amount of the disappearing pounds will be from valuable muscle mass. Loss of muscle mass with prolonged caloric restriction has a huge health cost in the long term, especially for those with metabolic diseases such as diabetes and the aging population. Adequate muscle mass is vital to maintain metabolic health and prevent frailty as we age. It is also impossible to work out at high enough intensities to achieve the beneficial adaptive responses to exercise while undergoing long term calorie restricted diets. Our engines need adequate fuel to perform optimally.

Prolonged caloric restriction has been shown to extend the life span of rodents, worms, and fruit flies, but longer life spans have not been seen from fasting in higher primates and humans. What is clear is that periodic fasting has been shown to improve the health span in humans and can be highly effective in reversing chronic diseases if done properly.

The issues with prolonged calorically restricted diets for weight loss and the proven benefits with periodic fasting have led many of us to experiment with intermittent fasting (IF). Intermittent fasting is the practice of scheduling short term periods of calorie restriction, followed by normal caloric intake. Recent science has shown that many of the metabolic benefits of fasting can be achieved with IF without the loss of our prized muscle mass. For this reason, IF has gained popularity in recent years. For some IF works fantastically to achieve a lean physique and metabolic health, while others have not been so successful with their experiments with short scheduled fasting. What gives? Why do some people see great results with IF and others crash and burn? Much of the variability with results likely is from the “environmental” context IF is used. Let’s go back to first principles to establish a framework for successfully using intermittent fasting.

Intermittent fasting is an environmental stress (remember that our environment includes all aspects of our lifestyle) on the body and brain. The short-term stress of IF activates the repair and recycling system of autophagy we covered in Part I. Intermittent fasting will temporarily shut off the mTOR building pathway in favor of repair. The autophagy system improves the health and metabolic efficiency of our cells which translates into beneficial effects for our entire body. “Dosed” correctly, IF can be the missing link in your quest for optimum health, body composition, and prevention of chronic disease. The important point to remember is that although potentially beneficial, intermittent fasting like all caloric restriction contributes to your daily “stress cup” (aka allostatic load discussed in Strong Medicine).

Calorie restriction with IF contributes to your daily Stress Cup

The proper dose of IF is a moving target, as the other contributors to your daily stress cup determines how much caloric restrictions you can handle (if any) on any given day. If you have had a night of bad sleep and significant work or social stress, there will be very little room for the added stress of intermittent fasting. If you don’t take into account a nearly full stress cup and press ahead anyway with a significant fasting period that day, your stress cup will overflow (allostatic overload). This will create a substantial response from the HPA axis (stress system) and increase your cortisol levels. Your brain is protecting itself utilizing increased HPA axis activation and resulting high cortisol levels during allostatic overload situations. This response ensures the brain has adequate glucose, even if it has to get it from your precious muscle mass (from amino acids using gluconeogenesis- see Strong Medicine for more).

We can frame the “dosing” of IF using the concept of hormesis. From Strong Medicine, we know that hormesis is the phenomenon of something that is potentially bad for us can be beneficial at the proper dose. Calorie restriction certainly follows the concept of hormesis- small amounts produce a beneficial response while large amounts lead to a starvation state. A crucial concept to understand is that the same dose of fasting can be beneficial one day detrimental the next day depending on the state of your stress cup. This is how hormesis and allostasis are intertwined.

Area “B” represents the optimal dose of calorie restriction this day. The level of your stress cup is relatively low allowing a longer period of fasting resulting in a beneficial autophagy (repair and recycling) response.

This is a day when your stress cup is filled with other sources of stress such as poor sleep, social stress, or high levels of exercise. The length of your fasting this day has to be reduced (to the area of the green”B”). If you did the same length of fasting you did in the first example (yellow “B”) you would “overdose” fasting and overfill your stress cup. On especially high stress cup days, fasting periods should not be attempted.

The benefits of IF-induced autophagy will not be realized if you overdose your fasting period. This point deserves repeating- intermittent fasting is a stress on your body and has to be balanced with the other stresses in your life to do it successfully.

Exercise and Intermittent Fasting

Finding the right mix of high intensity exercise and fasting can be a very tough to consistently pull off. High intensity resistance training and interval training stimulates the mTOR building pathway, increasing/maintaining our muscle mass and promoting fat loss through the actions of growth hormone. High intensity exercise is also a significant stress (which is why it works) on the body and needs to be figured into your daily stress cup evaluation. This type of training directly after a period of fasting can be especially stressful and should be approached with caution and careful assessment of your stress cup.

General guidelines

For the lucky few that live idyllic lives (my Strong Medicine co-author, Marty Gallagher, comes to mind) and have relatively empty stress cups, you can get away reckless forays into fasting experimentation and be just fine. Most of us are not that lucky and need a few guidelines to keep us out of trouble:

Assess your stress cup daily. Fasting is never a good idea with an already-full stress cup.
Start with brief fasting periods when beginning IF. The most popular is fasting from dinner the night before until lunch time the following day.
Avoid fasting when planning high intensity exercise sessions that day (“feed your activity” concept from Strong Medicine). Fueling your post-workout time periods will help maximize mTOR and muscle building. If you are getting good results starting your work out in a fasted state, make sure you feed yourself adequately post-workout.
Avoid fasting after a night of poor sleep. Poor sleep is one of the biggest contributors to the stress cup.
Plan fasting on your non-exercise recovery days. This can help maximize effectiveness of the repair/recycling autophagy system.
If you can’t handle complete fasting try a reduced protein day. Recall that amino acids from protein are potent triggers of the mTOR building system and reduced protein intake will trigger autophagy without abstaining completely from food. Meals consisting of high fiber vegetables with additional fats from olive oil/coconut oil or avocados will work well for this reduced protein strategy.
For those of us pushing middle age it is important that we give potent stimulation of the mTOR pathway to slow the muscle wasting of aging (sarcopenia). It is harder for the aging trainee to stimulate mTOR compared to the younger person. If this applies to you, consider a weekly schedule with less overall fasting and more attention to resistance training with increased protein intake to find your optimal balance between building and repair.

Conclusion

Intermittent fasting practice that is informed by daily monitoring of your stress cup can be hugely beneficial. The key is to be flexible and not overly rigid with planning your fasting. If you are having a high stress cup day, don’t be afraid to ditch your fasting plans. Failing to take allostatic load (stress cup) into account will just hurt you in the long run and slow progress to attaining your fitness and health goals. Start slowly with short fasting periods and increase with small increments. Using the conceptual framework we have created with intermittent fasting and the stress cup you can find your optimal individual balance between building and repair.

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