Why We Sleep

At age six, I vividly remember my 1st grade teacher stating that 9-11 hours of sleep each night was the biological requirement for our unique life stage (childhood). That night, I lay awake watching the minutes turn to hours on my Sony Dream Machine clock radio … wondering what terrible fate befalls otherwise good kids who sleep too little because they’re worried about sleeping enough!

What we know is that sleep and lack of sleep affects our whole bodies, not just our central nervous system as previously thought. In the nutrition office, we can’t possibly talk about hunger and fullness, nor even expect nutrition education to be effective, when such basic a need as adequate rest is denied. This readily became clear to me, nearly three decades later, while reading Matthew Walker’s Why We Sleep.

“Sleep, it turns out, is an intensely metabolically active state for brain and body alike.”

Walker writes from more than 20 years of experience studying sleep, first at Harvard Medical School and now as the director of the Center for Human Sleep Science at UC Berkeley. Below, a couple fascinating research findings presented in his book:

• Sleep deprivation can significantly impact release of hormones affecting appetite.1 Study participants whose sleep was limited to 4 hours/night for two nights had significantly higher levels of ghrelin, a hormone responsible for hunger and drive to eat, and reduced levels of leptin, a hormone which suppresses appetite, than participants allowed up to 10 hours of sleep. Sleep-deprived participants reported an increase in hunger which strongly correlated with increased ghrelin-to-leptin ratio. (Neat fact; this randomized study used a within-subject crossover design, meaning that the same participants experienced both study conditions --six weeks apart-- thus serving as their own baseline control.)

• Sleep-deprived study participants consumed more when given unlimited access to food (buffet meals and snacks) than their well-rested counterparts.2

• Sleep curtailment may play a role in the development of insulin resistance, which may int turn increase diabetes risk independent of a person’s weight or body size. Using a similar crossover design, participants were subjected to either 4.5 hours or 8.5 hours of sleep per night for four nights. Cells of sleep-deprived participants were found to be less receptive to insulin, i.e., repelling instead of absorbing glucose (energy!) from the blood.3

• Sleep deprivation may negatively impact our gut microbiome. One mechanism is thought to be via elevated production of the stress hormone, cortisol. It’s no surprise that when we rest, so too does the part of our nervous system responsible for activating our “fight or flight” response.4,5

• (Walker outlines so many more facts and findings, including how caffeine “works”, but for brevity’s sake, will stop here.)

Of course, it’s important to note that the studies mentioned above had limitations including small sample sizes, and lack of gender, age, and size diversity to name a few. Larger, longer, and more diverse studies are needed.

While we’ve so much yet to understand (I’m particularly intrigued by the sleep-microbiome connection!), here’s an important ‘for now’ takeaway: As we sleep, our brains release hormones that support a normally functioning metabolism. When we sleep well and enough, we get our normal amounts of these hormones, allowing our hunger and fullness signals to function properly. Adequate rest is fundamental to our self-care and directly impacts how we nourish our bodies. 

To this point, Walker urges that we maintain a regular sleep-wake schedule to the best of our abilities. But how, when everything in our lives pulls us away from getting to bed? He writes, “Set an alarm for bedtime. Often we set an alarm for when to wake up but fail to do so for when it’s time to sleep. If there is one piece of advice you take, this should be it.”

Note: If you’re worried that knowing too much about sleep (specifically, the detrimental effects of getting too little) could negatively impact your ability to fall asleep, proceed cautiously. However, I will say that I was worried about the same, and grateful to find that ‘ignorance is bliss’ did not hold true here. :p

References

1. Spiegel, Karine & Tasali, E & Penev, P & Van Cauter, Eve. (2004). Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med, 141, 451-846.

2. Broussard, J. L., Kilkus, J. M., Delebecque, F., Abraham, V., Day, A., Whitmore, H. R., & Tasali, E. (2016). Elevated ghrelin predicts food intake during experimental sleep restriction. Obesity (Silver Spring, Md.), 24(1), 132–138. doi:10.1002/oby.21321

3. Broussard, J. L., Ehrmann, D. A., Van Cauter, E., Tasali, E., & Brady, M. J. (2012). Impaired insulin signaling in human adipocytes after experimental sleep restriction: a randomized, crossover study. Ann Intern Med, 157(8), 549–557. doi:10.7326/0003-4819-157-8-201210160-00005

4. Benedict, C., Vogel, H., Jonas, W., Woting, A., Blaut, M., Schürmann, A., & Cedernaes, J. (2016). Gut microbiota and glucometabolic alterations in response to recurrent partial sleep deprivation in normal-weight young individuals, Mol Metab, 5(12), 1175-1186.

5. Van Cauter, E., Spiegel, K., Tasali, E., & Leproult, R. (2008). Metabolic consequences of sleep and sleep loss. Sleep Medicine, 9(1), S23–S28. doi:10.1016/S1389-9457(08)70013-3

6. Walker, M. P. (2017). Why we sleep: Unlocking the power of sleep and dreams. New York, NY: Scribner, an imprint of Simon & Schuster, Inc.

New Religion?

In his debut book, Professor Alan Levinovitz argues that dieting has become a form of religion in today’s secular world — filling gaps in our lives where religion was once more prominent, and providing a similar sense of community and ritual. He doesn’t see this as a positive shift.

Overall, this was a thought-provoking and important read. Levinovitz reminds us that anxiety about what we eat can produce the very same symptoms as those linked to non-celiac gluten sensitivity. For our overall health — mental as well as physical — it’s just not constructive to fear food. (And as the author points out, it also complicates diagnosis.)

And yet, it doesn’t behoove us to transfer a misguided fear of gluten to anarchy-like rejection of every mainstream nutrition message we encounter -- a line, in my opinion, that Levinovitz straddled precariously throughout his book. Isn’t there something in-between? Not blind obedience nor complete mistrust, but rather… careful discernment. Where does this recommendation come from? What is the science behind it and what is the quality of that science? Does it work for me without causing undue anxiety? Can I do it without making my eating disorder worse? (honestly?)

If taken constructively, might Levinovitz’ book spur us toward deeper inquiry before drastically upending the way we eat — especially, when confronted with too certain headlines about something we know to be … complex.

Frustrating though it may be, it’s that ‘gray area’ where good science — and optimal nutrition — is found.

~~~

Below, a few highlights that stuck with me from Levinovitz’ book and his interview on Food Psych:

• True science is humble and cautious; it “embraces complexity in all its uncertainty and does not lightly pronounce on facts” (Levinovitz, 2015, p. 115). In other words, terms like “toxic villain” foods and “superfoods” don’t arise from reputable research (sorry!) -- we create them.

• Monotonic fallacy. Coined by UPenn Psychology Professor, Paul Rozin, monotonic fallacy represents the common but often erroneous belief that if something is not good for us in large quantities, it must also not be good for us in small quantities (Levinovitz, 2017). What this thinking creates is essentially two buckets — “good” and “bad” — into which we categorize food. This gross dichotomy not only paves the way for heavily fortified foods and megadose supplements (never a good idea), but also diminishes the variety and joy in eating. (And here I can’t help but think of dietitian Ellyn Satter professing, “If the joy goes out of eating, nutrition suffers.”).

  Rozin is also known for his cross-cultural research suggesting that Americans both worry the most about food and yet derive the least satisfaction and enjoyment from it, as compared with populations in the other prosperous, developed countries of France, Japan, and Flemish Belgium (Rozin, Fischler, Imada, Sarubin, & Wrzesniewski, 1999). Rozin’s research team pointed to an irony that has proven even more relevant with time: To what extent might our food-related stress, meant to protect us from poor health, contribute to the very outcome we fear?

• Diets are medical interventions, not without potential side effects. If it was clearly stated that xyz diet may cause stress and preoccupation with food, reduced relationship satisfaction, potential loss of bone and muscle mass, and weight gain in the long run ... might we pause?

• Learn to recognize diets and nutrition claims that pathologize what it means to be human. To experience fatigue, difficulty concentrating and the occasional “brain fog” now and then is part of being human. Cutting out a certain food or food group will not eliminate these ups and downs of the human experience.

References:

Levinovitz, A. (2015). The gluten lie: And other myths about what you eat. Collingwood, Vic:  Nero, an imprint of Schwartz Publishing Pty Ltd.

Levinovitz, A. (Presenter). (2017, March 5). How to leave the religion of dieting with Alan Levinovitz [Audio Podcast]. In C. Harrison (Producer), Food psych. Retrieved from https://christyharrison.com/foodpsych/4/how-to-leave-the-religion-of-dieting-with-alan-levinovitz?rq=alan%20levinovitz.

Rozin, P., Fischler, C., Imada, S., Sarubin, A., & Wrzesniewski, A. (1999). Attitudes to food and the role of food in life in the U.S.A., Japan, Flemish Belgium and France: Possible implications for the diet-health debate. Appetite, 33, 163-180.

Hunger

Roxane Gay is a critically-acclaimed author, editor, and professor, raised in the US by parents of Haitian descent. In Hunger, she chronicles her experience in a body labeled as "super morbidly obese" in the crudest of medical terminology. That is, Gay writes of the incessant challenges of living in an “unruly” body in a world bent on disciplining and fixing such bodies.

Eliciting controversy, Gay expresses contempt and frustration toward her body albeit a genuine liking for herself - for her weirdness, sense of humor, how she loves and how she writes. Stated in reverse, Gay articulates that we might love ourselves, who we are as people, while not necessarily loving (every aspect of) our bodies. (Is this experience allowed? Yes, it is.) In truth, our body’s appearance and how we feel about it is not who we are; it is but one part of who we are.

To be clear, the fat acceptance movement is important, affirming, and profoundly necessary, but I also believe that part of fat acceptance is accepting that some of us struggle with body image and haven’t reached a place of peace and unconditional self-acceptance. (Hunger, p. 153)

In reference to the quote above, Gay offers an expanded definition of fat acceptance -- one that, I have no doubt, captures the real lived experience of many people. I thought of how important this more human definition is, and how many times my clients express confusing and conflicting thoughts about concepts like fat acceptance and especially, body positivity.

Finally, Gay writes of hunger. Hunger in the form of envy for the things her body cannot do. Hunger for real relationships in which she does not have to apologize or somehow make up for her size. Hunger to feel pretty and to wear clothes with beautiful, colorful patterns -- to shed her unassuming “uniform” of dark jeans and a t-shirt.

My father believes that hunger is in the mind. I know differently. I know that hunger is in the mind and the body and the heart and the soul. (p. 193)

When the response to hunger and appetite is one of shame, a disordered relationship with food is a possible, if not likely, consequence (see also previous blog post). And yet, our proclivity to care for our body is in our blood. Now in her forties, Gay describes a surprising and newfound form of healing: Learning to cook. Inspired by Ina Garten of Barefoot Contessa, Gay writes of Ina symbolizing a “plump," confident woman who celebrates her love of food and good ingredients. In doing so, Ina gives Gay permission to both acknowledge and satisfy her hunger in healthy, not destructive, ways.

A Kinder 2018

Recently, a client told me that he’d been reading about self-compassion in the context of healing from the cycle of restrictive/binge eating; it seemed so radically opposite his own experience. He wondered aloud, 'How is self-compassion different from self-indulgence -- from giving myself permission to eat whatever appeals to me because I deserve it?' For as long as this client can remember (and he is not alone), he has been motivated by a harsh, self-critical voice.

So how is being self-compassionate not simply letting oneself “off the hook?”

As a healthcare practitioner, it’s easy to urge a client to be ‘kind’ to himself without addressing the inner dialogue (or outright confusion and fear) this idea brings up. As a human, I certainly understand my client’s questions.

Self-compassion or self-indulgence?

According to Dr. Kristin Neff, a pioneer researcher in the field of self-compassion and Professor of Psychology at the University of Texas at Austin, self-indulgence involves choosing short-term pleasure at the cost of long-term harm. In contrast, self-compassion aims to alleviate harm.1 Neff uses a parenting analogy to illustrate. Compassionate parents wouldn’t (typically) allow their children to stay up all night watching television and eating bottomless bowls of ice cream; they know that allowing this behavior would ultimately prove harmful for their kids. Instead, compassionate parents set healthy boundaries for their children, asking them to complete their homework and get to bed at a reasonable hour.

This logic isn’t as easy to apply to ourselves but the idea is the same: When we practice self-compassion, we naturally want the best for ourselves, too.

Additionally, research suggests that practicing self-compassion may lend to forgiving ourselves more easily in the face of an undesirable event; and, far from being an excuse to "let oneself go," self-compassion actually increases personal responsibility surrounding an event.2

Choosing New Year’s resolutions motivated by compassion

Neff believes that if criticizing ourselves seems to work as a motivator, it’s often because we’re driven by a desire to avoid self-judgment when we fail. Yet, what if failing didn’t have to mean an endless barrage of self-punishing thoughts? For starters, it might be a little easier not only to set challenging goals (i.e., less frightening to try), but also to keep working towards these goals when obstacles arise. As Neff articulates, “Self-compassionate people set high standards for themselves, but they aren’t as upset when they don’t meet their goals.”1

Approaching our 2018 resolutions with compassion sets the stage for curiosity when things don't go perfectly (newsflash = things won't go perfectly!). If the voice in our head is kinder, we can honestly examine what's not going well and why -- and adjust our goals rather than discarding them altogether.

References

1. Neff, K. (2015, November). Self-compassion: Why it makes us happier, more resilient, and kinder to others. Shambala Sun, 58-63.

2. Leary, M. R., Tate, E. B., Adams, C. E., Allen, A. B., & Hancock, J. (2007). Self-compassion and reactions to unpleasant self-relevant events: The implications of treating oneself kindly. Journal of Personality and Social Psychology, 92, 887-904.

See also: self-compassion.org/the-research/#

On Mindfulness

There are two main theoretical frameworks defining mindfulness. The first of these, developed by Jon Kabat-Zinn, relies on paying attention to the present moment, non-judgmentally and therefore free of emotional and moral assessment. Meditation is an important tool for mindfulness in this approach.1 In contrast, Ellen Langer’s concept of mindfulness does not rely on nor promote meditation. Rather to be mindful is to actively notice novelty and the full context of a situation, guarding against repetitive thought patterns and habitual  categorizations from the past (e.g., How does my spouse’s face look different across the breakfast table this morning as compared with yesterday morning?).

I find that more often when we talk about mindfulness, we implicitly refer to Kabat-Zinn’s concept, equating mindfulness with meditation.

This summer, TIME Magazine issued a Special Edition: Mindfulness: The New Science of Health and Happiness. In an article titled Can You Shed Pounds on a Mindfulness Diet?, Kathleen Mulpeter describes research investigating the effects of mindfulness on health outcomes and weight status. In one study, participants asked to answer a set of mindful questions while eating fared better at maintaining weight loss than those who practiced  self-compassion meditation.2 These mindful questions included “How does this meal taste?” but also “How kind are you to yourself now that you ate this meal?” While participants in this group were instructed to record their answers in a food diary, benefits extended to those who chose not to write anything but simply kept the diary open while they ate. In short, the journal’s sheer presence was a reminder to approach the meal with a little more thoughtfulness, and a little more kindness.

To me, these findings suggest how truly accessible mindfulness can be. In the above study, mealtime mindfulness involved focusing the mind on what research refers to as concrete construals (e.g., How am I eating?) versus abstract construals (e.g., Why am I eating?). As much as mindfulness could be about counting the folds on the raisin or meditating for 40 minutes before picking up the fork, it doesn’t have to be. We need not feel guilty that our monkey minds jump around instead of settle as we sit down to eat. In fact, rather than judging our busy thoughts, could we use them in a mindful way? That is, can we keep asking questions especially when we think we know the answers?*

[*According to Ellen Langer, the reason we often don’t notice things is that we assume we already know them. And yet we’re more apt to enjoy an experience when we notice its newness!! Well, the thing is, it’s always new. Every time we sit down to eat. Even if we’ve warmed up the same leftovers for the past five nights -- or always order the same dish, cooked the same way, sitting with the same person, at the our favorite restaurant. When we think we know the taste already or how it will our make our body feel, we fail to really taste and really feel.]

References

1 Pagnini, F., & Philips, D. (2015). Being Mindful about Mindfulness. The Lancet, 2. Retrieved from www.thelancet.com/psychiatry

2 Mantzios, M., & Wilson, J. C. (2014). Making concrete construals mindful: A novel approach for developing mindfulness and self-compassion for assisting weight loss. Psychol Health, 29(4), 422-41.

...Like Gifts from the Universe

Appetites, a memoir by Caroline Knapp, is an astute observation on the late-20th century female experience.

In Knapp’s view, the emergence of disordered eating and body dissatisfaction in the U.S. coincided with the end of the second-wave Feminist movement in the late 1970’s. Knapp writes, “The second wave, after all, was in so many respects about appetite, about demanding the freedom to take in … the freedom to hunger and to satisfy hunger in all its varied forms.*” Coming of age as feminist activism quieted, Knapp describes feeling the movement intellectually -- and yet its transformative potential, its radicalizing power, did not have the time to reach “gut level.”

There you have it: intellectual belief without the corollary emotional roots; feminist power understood in the mind but not known, somehow, in the body. (p. 124)

As feminist momentum slowed, the rise of an externalizing consumer mindset occurred in lockstep: “A powerful combination, and also a powerful loss," writes Knapp. During the Feminist movement, the female ‘appetite’ was one to feel entitled and to be heard; as consumer culture took hold however, appetite began to center around the right product or substance. At once, the pursuit of happiness and wholeness reduced--to the pursuit of “things.”

If something was missing in the air back then, if something’s missing still, it was a sense of broad alternative vision, a language that might have encouraged women to talk not about new things to want but about new ways to want. (p. 153)

For many women, a significant part of consumerism was directed toward outward appearance and image--in essence toward ”fixing” the body. In a paragraph that really struck me, Knapp writes of the seduction of taking such vast and varied forms of hunger (e.g., one’s desire to feel connected, or competent) and distilling these to a single hunger to be managed: One’s hunger for food.  

Throughout Appetites, Knapp writes candidly of a time in her life when she wanted more than she knew how to ask for. She lends compassion to her younger self by setting the historical context--depicting decades that many readers may only know through books or parent’s stories. Knapp walks us through her recovery: A gradual, nonlinear process of satisfying an appetite for life, a recognition of the less literal forms of hunger.

For there is no unequivocal answer, no final resting place, no pinnacle reached, all appetites understood and sated at last. Instead, there are moments of contentment, moments of sudden alignment between body and mind and spirit, moments of feeling fed that arrive unexpectedly, like gifts from the universe. (p. 192)

*at the time, a hunger for economic, legal and/or sexual freedom among other forms.

[Note: After any good book, I find myself researching its author... Having felt Caroline Knapp’s aliveness in each written word, I was shocked and saddened to learn that she passed away from lung cancer in 2002 (age 42), one year before Appetites was published. Above, I felt compelled to share Knapp's words, which no doubt have touched many individuals across gender and generation.]

Sensing the Beat

Earlier this year, Evelyn Tribole and Elyse Resch released The Intuitive Eating Workbook: Ten Principles to Nourish a Healthy Relationship with Food.

Tribole and Resch describe intuitive eating (IE) as a process of relearning instincts we once knew. They write, “We are born intuitive eaters, but cultural messages to diet and lose weight often infiltrate our minds and sway us away from listening to our bodies.” Intuitive eating therefore stands in direct opposition to dieting. While the latter relies on external rules to dictate what, when, and how much to eat, intuitive eating honors the importance of nutrition knowledge (especially if you have certain health conditions) yet puts your inner experience front and center.

The workbook includes an entire section devoted to discerning our inner experience, an ability more technically referred to as interoceptive awareness. Of all the workbook’s self-assessments and activities, my favorite was: “Can You Perceive Your Heart Rate?,” summarized below in three parts:

Part 1. Physically Monitor Your Pulse (Warm-up). By placing your right index & middle finger on the wrist of your left hand, count your heartbeats for 60 seconds.

Part 2. Perceive Your Heart Rate (Note: This may take time and practice). From a calm and comfortable position, and without manually finding your pulse, silently count your heartbeats for 60 seconds.

Part 3. Reflection. e.g., “What was your self-talk like when you were trying to perceive your heart beating (especially if this took a great deal of patience)?” If your thoughts were harsh and critical, what would it be like to do this exercise from a curious place instead?

The practice of perceiving our beating heart is one way to build interoceptive awareness. To be clear, the authors argue that the more awareness we have of our inner sensations (such as hunger, taste preferences, and fullness -- or the unique physical manifestations of our emotions), the more effective we are in determining what we need. At once logical and revolutionary, Tribole and Resch remind us that building inner attunement (though no small feat) may be our guide to self care.

Recommended for clinicians: 5/5

Recommended for individuals trying to make a change: 5/5

(i.e., Recommended :)

Motivational Interviewing

Thoughts on Motivational Interviewing in Nutrition and Fitness by Dawn Clifford, PhD, RD, and Laura Curtis, MS, RD

Motivational Interviewing (MI) is a goal-oriented, client-centered counseling approach around since the 1980’s. I’ve been exposed to it throughout my career and it has certainly influenced my counseling style. And yet, only upon reading this book has it occurred to me how helpful MI may be in freeing us from preconceived mindsets. As used in nutrition counseling specifically, MI could be seen as an antidote to the diet mindset.

In essence, diets involve looking outside of the self for what (and sometimes when) to eat. I’ve often wondered if the help-seeking process can inadvertently mirror or perpetuate this outward-based “quick fix” mentality. That is, if a client has spent a lifetime trying one and then another diet, am I not offering more of the same if I give him a new detailed plan to follow the day he arrives to my office?

MI assumes that clients come to the office already bogged down with knowledge and awareness of what to do -- yet, for many reasons, have been unsuccessful in making changes. While a nutrition counselor who uses MI may be the “expert” in nutrition, this counselor regards their clients as the expert in well, themselves. MI seeks to empower clients to trust this self-knowledge whilst wholeheartedly supporting their autonomy. In contrast, rigid diet plans do little to support self-knowledge and autonomy and may indeed erode these over time.

Motivational Interviewing in Nutrition and Fitness is an invaluable resource for  “professionals who care about the success of their clients, not just the day, week, or month after their visits, but for years to come (p. 4).” This book devotes entire chapters to each MI microskill: Asking open-ended questions, giving strategic reflections and summaries, and perhaps most important, avoiding the “righting reflex.”

In my counseling practice and in this gem of a book, I am continuously reminded that what I know is only as valuable as how I share this information; and if a client is not ready for it, information can do more harm than good.

After all, with MI, “The purpose is not to give advice. The purpose is to cultivate change (p. 177).” As revolutionary as it sounds, only after the client has been given time and space to come up with their own ideas, does the practitioner offer hers -- and in true MI spirit, they ask permission before doing so!

Recommended for clinicians: 5/5 (designed with the clinician in mind: almost every concept is followed by examples of clinician-client dialogues)
Recommended for individuals trying to make a change: 2/5 (the concepts in this book might be more useful if formatted as a workbook)