obesity - St. Louis Pain Management Center | Best Pain Management Doctor

What to eat?

It’s about a way of life, not some temporary adjustment.

Often times, patients ask, “what should I eat,” or “what is the best diet?”  They focus in on the concept of dieting, which implies a short-term change in food intake, with return to normal eating once they have reached a target weight.  Conceptually this is why less than 12% of people maintain weight balance long term, they resume the same habits that made them obese in the first place.  Keep in mind that the human body and all of its individual cells are highly adaptive, once the body senses a period of starvation or significant nutrient depletion, the fat cells DNA activate a storage mechanism, which causes immediate weight restoration upon nutrient return, often with an overshoot of the fat cell size, in anticipation of a future starvation event.  This overshoot during return of normal food intake results in the paradoxical yo-yo effect where every period of dieting leaves the patient a few pounds heavier than they started.

Don’t think of this as a diet, diets make you feel restricted and are unsustainable.  This is a way of life, the livehealth.com lifestyle, not some fad you will pickup for six weeks and then drop for the next fad.


Food as a nutrient medication?

Food should be considered a medication; it can have specific benefits and adverse side effects.  Approaching your food intake with an eye towards its specific actions and interactions will allow you to program your body; in how you feel, how effectively it works, and how you look.  You should become aware of every item you place in your mouth, and even the cosmetics and creams you apply to your skin.


What’s wrong with eating carbohydrates?

Conventional nutrition seems to focus heavily on carbohydrate ingestion, seemingly focused on what the best grain to eat is.  Conventional farming, with grain harvest and storage, has existed for approximately 10-15,000 years, not enough time for evolutionary adaptation to a continuous nutrient dense carbohydrate intake.

Human evolution takes hundreds of thousands of years, and we have barely begun adapting to the agricultural revolution, let alone the industrial revolution or the new digital age.  Our created environment has changed dramatically, yet our ability to extract nutrients from ingested food remains oriented to periods of feast and famine, unrefined carbohydrates, and high fiber consumption.  Carbohydrate ingestion historically was limited to end of season harvests, ripe berries and fruits, in anticipation of fat storage for long periods of winter starvation.  The continuous consumption of carbohydrates has produced disequilibrium with ongoing storage of fat even when anticipated starvation is improbable, hence the epidemic of obesity.


So what should I be eating to be healthy?

Avoid refined carbohydrates.

Refined carbohydrates are anything that is a processed sugar, whether it comes from a grain or a fruit.  Refined carbohydrates are unnatural and have had the fiber removed, producing over-nutrition.  In addition, the bacterial and parasitic load is refined out of the carbohydrate by industrial processes, which permits much higher gut absorption of carbohydrate. Ingested carbohydrate is converted preferentially to fat reserves; akin to how grain fed beef is finished and produces excess fat and weight, and an unnatural fat deposition pattern between the muscle fibers.


Avoid all liquid carbohydrates

Many patient’s fail to recognize the impact of the liquids they consume, they fail to recognize that soda may contain 300 Calories of straight carbohydrate, without any protein, fat, insoluble fiber or other nutritional benefit.  Some patients consume two to six soda’s per day, and then wonder why they can’t seem to loose weight.  The same goes for fruit juices with the removal of fibrous materials.

Diet soda is not any healthier, as the artificial sweeteners cause tremendous insulin dumping and secondary hypoglycemia resulting in subsequent insulin resistance.


Avoid Milk

Milk from cows contains growth factors to rapidly increase the size of the newborn calf.  Unfortunately these growth factors also rapidly increase the size of adult humans, causing an accumulation of fat tissue since vertical growth is limited by a closed growth plate.  The milk industry has done an amazing job of branding and marketing milk as a healthy substance, geared towards calcium and bone health.  Unfortunatley this is simply not true, milk contains very little Vitamin D and the available calcium is less than what is found in cruciferous vegetables (Swiss chard, broccoli, cabbage, Brussels sprouts, cauliflower, watercress, radish, horseradish, turnip, rutabaga, wasabi, rapini, arugula, spinach, turnip, kale, and bok choy.).  Milk fortified with Vitamin D contains approximately 100 IU per eight ounce glass, whereas being in the sun for 15 minutes produces 20,000 IU of available Vitamin D.  What milk will do is cause rapid fat accumulation.  Whole milk and cheese is not as bad as low fat milk.  Ghee, which is clarified butter with the growth factors and proteins removed is probably far healthier than regular butter.


Eat unrefined carbohydrates (fiber)

Unrefined carbohydrates, such as vegetable, are rich in slowly digestible fiber, which reduces the overall nutrient load density, and facilitates the removal of toxic metabolites.  Additionally, fiber material reduces hunger by maintaining a sense of fullness, and lower peak glucose levels, which prevents the feeling of hypoglycemia.  Dietary intake should include at minimum 10 grams of fiber per meal.


Live harmoniously and eat dirt (micronutrients, bacteria, and parasites)

The human gut has co-evolved with bacteria and parasites, with dietary sterilization leading to in the unintended consequence of obesity and autoimmune disorders.

Although it would seem contrary to good hygiene, the beneficial effects of coexisting parasitic infections include a reduction in inflammatory mediators, a function of the parasite changing its local environment in order to grow inside its parasitic host.  This anti-inflammatory action prevents expulsion of the parasite, and at the same time reduces the inflammatory activation against key antigens.  Reintroducing parasites has been shown beneficial in Crohn’s disease, Multiple Sclerosis and severe peanut allergies.  It should not be unsurprising that the epidemic rise in rates for multiple sclerosis and food allergies is associated with the advent of flush toilets, which reduced human parasite transmission.  There is also a significant relationship between obesity and chronic gut inflammation.

Gut bacterial biodiversity is necessary for optimal health, and the balance between the different bacteria determines the likelihood of obesity.  These bacteria create a fermentation effect in the gut, historically permitting metabolism of fiber rich compounds, providing nearly 25% of the bodies total energy as a fermented alcohols.  Unfortunately antibiotics and toxic highly concentrated carbohydrates disrupt this bacterial ecosystem.  Bacterial balance is so important that transplanting bacteria from an obese mouse to a skinny mouse causes the skinny mouse to become obese.  The mechanism is related to the overall absorption of nutrients, which is enhanced by bacteria found in obese individuals and can quickly proliferate in thin individuals fed a carbohydrate nutrient rich diet.  An example of this is often seen in individuals who undergo a carbohydrate free diet, but then develop abdominal cramping and bloating once exposed to nutrient dense carbohydrates, due to a change in fermentation capacity and absorption.  Additionally, during the carbohydrate cleanse phase, a tremendous amount of gut inflammation is reduced with mobilization of excessive edema, with many patient’s experiencing ten to fifteen pound weight loss from reduced gut edema alone.

The cleanliness of our food supply, by use of pesticides, herbicides, and meticulous cleaning and removal of soil materials has reduced available micronutrients and vitamins necessary for optimized metabolic function; leaving many people feeling sluggish.  For example, we are experiencing a resurgence of Vitamin D deficiency, at the same time we are experiencing obesity and over nutrition.  The genetic engineering of foods has also dramatically reduced the diversity of insects, some of which contain beneficial cofactors for human consumption.


Eat healthy fats

Avocados, fish oils, olive oil, and ghee are all acceptable fats.  Egg yolks have gotten a bad reputation in the nutrition literature, but the cholesterol in egg yolks is a fundamental precursos for good hormonal health and there is a poor relationship between consumed cholesterol and blood levels of bad  LDL.  The use of animal fat does pose concerns, if burned it is a carcinogen.


Eat plenty of healthy protein

Whether the protein comes from animal or plant is irrelevant, as long as it is not combined with unnatural compounds.  Protein load should be1 gram per pound of body weight per day.  Avoid engineered proteins such as soy, which contains estrogens, avoid proteins from grains, and avoid unnecessary fats hiding in proteins


Eat slowly digesting foods

Proteins combined with slowly absorbing fats in a matrix of insoluble fiber forces the gut to expend energy in metabolizing, as is demonstrated by the significant exothermic heat production necessary to digest a steak compared to the minimal energy used to digest cotton candy.  Similarly a glass of apple juice is quickly absorbed as compared to digesting an apple.  In general, the harder it is to chew, the more energy it will take to absorb, and the better it is for you.


Exercise your metabolism, as you would exercise your muscles

In all things there is an ebb and flow, a pulse of plenty followed by a period of depletion.  This period of fasting runs counter to much of the nutrition literature, which suggests nearly continuous feedings, which is not how the human body was designed.  In fact. the creation of breakfast and lunch is less than three hundred years old, and certainly near constant snacking is related to marketing efforts by the snack food industry hoping to capture revenue dollar.  Timing of feeding is also critical, in that a period of activity should occur after the last meal of the day rather than a period of rest and sleep.  Training the fat cells to release nutrition and accumulated fat cell toxins reduces the inflammatory load.

Nine reasons why weight loss is so important for chronic pain patients.

Nine reasons why weight loss is so important for chronic pain patients.

1. Pain reduces activity

Pain often leads to reduced activity and exercise, which can cause patient’s to gain weight, due to loss of metabolically active muscle.

2. Pain prevents restful sleep

Pain disrupts sleep, reducing growth hormone production, which causes patients to gain weight.  Pain also causes elevated cortisol levels and epinephrine levels, which reduce sleep and independantly cause obesity.

3. Pain effects hormones

Excessive fat accumulation leads to a buildup of visceral fat which produces xenoestrogens, which inhibit the production of testosterone, which causes further fat weight gain and loss of muscle mass.

4. Obesity predisposes patient’s to diabetes

Excessive fat accumulation decreases insulin sensitivity and produces insulin resistance, a form of pre-diabetes.

5. Pain effects your pocketbook

Pain often leads to significant functional disability, reducing the patient’s standard of living, which encourages the consumption of subsidized foods, often rich in carbohydrates (food stamps buy significantly more calories of carbohydrates than protein).

6. Obesity effects joint load bearing

Excessive weight dramatically increases the amount of load joints must support. For every extra one-pound of fat you have, you increase the force on your lower back by nearly 20-24 pounds. If you are 10 pounds overweight, your back is carrying an extra 240 pounds of force, and if you lose 10 pounds of weight you will reduce load bearing by 240 pounds.

7. High blood sugar reduces the effects of pain medications

Patient’s with elevated blood glucose experience significantly more pain and find that their pain medications are less effective as the glucose level rises and more effective as the glucose levels fall. There is a direct effect on the opiate receptor by excessive glucose, which prevents activation of the receptor.

8. High blood sugar makes proteins sticky (Glycation)

Glucose or sugar is a sticky carbohydrate. Imagine if you poured sticky goo into the engine of your car, it would bind up the machinery. Extra glucose binds onto nearly all of the proteins in your body, making them work less efficiently, and predisposing patient’s to heart attacks and early aging.

9. Carbohydrates are themselves addictive

Although eating sugar may give you an immediate lift or rush, it quickly disappears when insulin drives the blood sugar into the cells, which then leaves you craving for more sugar because your blood sugar level drops precipitously. Elevated blood sugar temporarily seems to partially activate the endogenous opiate receptors and some people do actually become “addicted” to carbohydrates, requiring ever increasing dosages, which leads to fat accumulation.


Nutritional Supplements


Successful weight loss is best complimented by a customized nutrition plan based on your individual needs. Ensuring a daily dose of heart-healthy vitamins, getting your metabolism in balance and ensuring you have all the nutrients necessary will help build the energy you need to transform your body and mind during your weight loss journey.

Policosanol (or polycosanol) is a natural extract of plant waxes (a mixture of alcohols isolated from Cuban sugarcane wax) It is used as a supplement to lower LDL cholesterol (“bad” cholesterol) and increase HDL cholesterol (“good” or “healthy” cholesterol), and to help reduce atherosclerosis.  It also decreases the stickiness of particles in the blood known as platelets, which might help reduce blood clots, and may have a significant blood thinning effect when combined with garlic extract.


Alpha-lipoic Acid (ALA)

Alpha-lipoic acid regenerates other antioxidants.  Antioxidants neutralize “free radicals,” which are waste products that can damage cells in the body.  Most antioxidants work only in water (such as vitamin C) or fatty tissues (such as vitamin E), but alpha-lipoic acid is both fat- and water-soluble, working throughout the body, by regenerating other antioxidants and make them active again.

Alpha-lipoic acid has been used for years to treat diabetic peripheral neuropathy, and diabetes-related condition called autonomic neuropathy such as cardiac autonomic neuropathy.  There is also evidence to support improved insulin sensitivity.


Vitamin B12 (cobalamin)

Vitamin B12, also called cobalamin, is one of 8 B vitamins, which help the body convert food (carbohydrates) into fuel (glucose), and also help the body use fats and protein.  Fatigue is one of the symptoms of a vitamin B12 deficiency.

Vitamin B12 is an especially important vitamin for maintaining healthy nerve cells, and it helps in the production of DNA and RNA, the body’s genetic material. Vitamin B12 also works closely with vitamin B9, also called folate or folic acid, to help make red blood cells and to help iron work better in the body. Folate and B12 work together to produce S-adenosylmethionine (SAMe), a compound involved in immune function and mood.

Vitamins B12, B6, and B9 work together to control blood levels of the amino acid homocysteine. High levels of homocysteine are associated with heart disease.


Green Tea

Green tea extract is an herbal derivative from green tea leaves, which contain potent antioxidants called catechins, which are 20 times stronger than the antioxidants contained in Vitamin C and Vitamin E.  In addition there are caffeine like substances, which increase metabolic rate, amounts of carotenoids, vitamin C, and trace elements (including chromium, manganese, selenium and zinc).   Additionally, Epigallocatechin-3-gallate (or EGCG), which is an important compound found in green tea reduces lipid absorption.  It should be noted that caffeine, independent of its effect on metabolism, is also a cathartic agent and serves to reduce transit time and nutrient absorption in the colon.


Garlic Extract

Garlic is rich in antioxidants, which help destroy free radicals — particles that can damage cell membranes and DNA, and may contribute to the aging process.  Garlic may reduce heart disease, by slowing atherosclerosis (hardening of the arteries) and lowering blood pressure, between 7% and 8%. Garlic also seems to be an anticoagulant, meaning it acts as a blood-thinner, which may also help prevent heart attacks and strokes, and works in conjunction with polycosanol.



Weight loss program using Qsymia.

What is Qsymia?

Qsymia is a prescription medicine that contains phentermine and topiramate extended-release that may help some obese adults or some overweight adults who also have weight-related medical problems lose weight and keep the weight off.

Qsymia should be used with a reduced calorie diet and increased physical activity. It is not known if Qsymia changes your risk of heart problems or stroke or of death due to heart problems or stroke.

It is not known if Qsymia is safe and effective when taken with other prescription, over-the-counter, or herbal weight loss products.

It is not known if Qsymia is safe and effective in children under 18 years old.


[box type=”warning”] Qsymia is a federally controlled substance (IV) because it contains phentermine and can be abused or lead to drug dependence. Keep Qsymia in a safe place, to protect it from theft. Never give your Qsymia to anyone else, because it may cause death or harm them. Selling or giving away controlled medicine is strictly against the law.[/box]

Who can take Qsymia?

Qsymia is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of:

  • 30 kg/m2 or greater (obese), or
  • 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia




WARNING:  Qsymia is a Pregnancy Category X Medication, it contains Topiramate

Topiramate, a component of Qsymia, in pregnancy is associated with a 2- to 5-fold increase in risk of oral clefts.

Females of reproductive potential are women who have NOT had a hysterectomy, bilateral oophorectomy, or medically documented spontaneous ovarian failure, and have not gone through menopause. Menopause should be clinically confirmed by an individual’s healthcare provider.

ALL women, except those who have gone through menopause or undergone surgical sterilization, should be advised to consistently use effective contraception, even women who have had difficulty getting pregnant in the past.

If there is a female of reproductive potential in the house, the patient knows to keep Qsymia in a secure location and not share it with anyone else.




What are the dangers of Qsymia?

Qsymia can cause serious side effects, including:

Birth defects (cleft lip/cleft palate).

If you take Qsymia during pregnancy, your baby has a higher risk for birth defects called cleft lip and cleft palate. These defects can begin early in pregnancy, even before you know you are pregnant.

Women who are pregnant must not take Qsymia.

Women who can become pregnant should:

1. Have a negative pregnancy test before taking Qsymia and every month while taking Qsymia.

2. Use effective birth control (contraception) consistently while taking Qsymia. Talk to your healthcare provider about how to prevent pregnancy.


If you become pregnant while taking Qsymia, stop taking Qsymia immediately, and tell your healthcare provider right away. Healthcare providers and patients should report all cases of pregnancy to:

•FDA MedWatch at 1-800-FDA-1088, and

•The Qsymia Pregnancy Surveillance Program at 1-888-998-4887


Increases in heart rate.

Qsymia can increase your heart rate at rest. Your healthcare provider should check your heart rate while you take Qsymia. Tell your healthcare provider if you experience, while at rest, a racing or pounding feeling in your chest lasting several minutes when taking Qsymia.


Suicidal thoughts or actions.

Topiramate, an ingredient in Qsymia, may cause you to have suicidal thoughts or actions.


Call your healthcare provider right away if you have any of these symptoms, especially if they are new, worse, or worry you:

o          thoughts about suicide or dying

o          attempts to commit suicide

o          new or worse depression

o          new or worse anxiety

o          feeling agitated or restless

o          panic attacks

o          trouble sleeping (insomnia)

o          new or worse irritability

o          acting aggressive, being angry, or violent

o          acting on dangerous impulse

o          an extreme increase in activity and talking (mania)

o          other unusual changes in behavior or mood


Serious eye problems which include:

o          any sudden decrease in vision, with or without eye pain and redness,

o          a blockage of fluid in the eye causing increased pressure in the eye

(secondary angle closure glaucoma).

These problems can lead to permanent vision loss if not treated. Tell your healthcare provider right away if you have any new eye symptoms.



[box type=”warning”] Do NOT take Qsymia if you:

  • are pregnant, planning to become pregnant, or become pregnant during Qsymia treatment.
  • have glaucoma
  • have thyroid problems (hyperthyroidism)
  • are taking certain medicines called monoamine oxidase inhibitors (MAOIs) or have taken MAOIs in the past 14 days.
  • are allergic to topiramate, sympathomimetic amines such as phentermine, or any of the ingredients in Qsymia.


Initial Qsymia dosing guidelines: (Once daily, in the morning, with or without food)

  • 14 days on Qsymia 3.75 mg/23 mg
  • 30 days on recommended dose of Qsymia 7.5 mg/46 mg


After 12 weeks at recommended dose of 7.5 mg/46 mg:

  • 14 days on Qsymia 11.25 mg/69 mg
  • 30 days on Qsymia 15 mg/92 mg


How do I get my Qsymia?

Qsymia is available only through certified mail order pharmacies that provide a Medication Guide and Risk of Birth Defects patient brochure with every prescription and refill.

Patients may receive their Qsymia every 30 days

Patients may receive up to 5 refills


F: 1-401-652-1807      F: 1-800-332-9581



About Vitamin D

What is Vitamin D?

Vitamin D is not truly a vitamin.

Compounds are called vitamins only if they cannot be synthesized , and must be obtained from the diet.  Vitamin D, however, is produced in sufficient quantity in the presence of sunlight and cholesterol and should not be considered a vitamin.

In addition, cholesterol is the precursor for most hormones, and Vitamin D should really be viewed as a light dependent fat-soluble hormone.

Historically we have thought that Vitamin D was involved in the absorption of Calcium and Phosphorous from the intestine, and were concerned primarily about its involvement as an osteoporosis risk factor.  However, the reality is that Vitamin D is involved in a variety of metabolism functions, not just bone health.


  • Abnormal low levels of Vitamin D are associated with increased risk of death and disability from cardiovascular disease and cancer.


  • Vitamin D is also involved in general metabolism and reducing obesity through effects on testosterone, thyroid hormones, and insulin.


  • Vitamin D is also involved in neurologic autoimmune dysfunctions such as Multiple Sclerosis and Alzheimer’s.


Why is my Vitamin D level low?

There are a variety of  reasons why Vitamin D levels are found to be low in an otherwise healthy person:

Inadequate Vitamin D intake, which could be a function of poor diet or a diet contaminated with other fat-soluble agents, such as organochlorine pesticides, which prevent adequate absorption.

Inadequate sunlight exposure, due in part to industrialization and conversion to an indoor lifestyle and also to medical recommendation to reduce sunlight exposure and in fact even use sunlight blocking agents.  Sunscreen blocks sunlight and an SPF (sun protection factor) of 8 blocks 95% of the sun, so there needs to be a careful balance between over- and under- sun exposure.

Drinking milk is not a good source of Vitamin D, as an 8 oz glass of fortified milk contains merely 100 IU in comparison to 15 minutes of sun exposure which generates 20,000 IU of Vitamin D.


How do I replace my Vitamin D?

We typically replace Vitamin D only if the measured levels are found to be low; and this is usually associated with other endocrine abnormalities which can be addressed simultaneously.  Vitamin D replacement therapy is done by oral supplement, typically using a once a week preparation.  Retesting of the level should be done after three to six months of consistent replacement.  Replacing Vitamin D should only be done after a blood test confirms that the levels are low, because too much Vitamin D can also cause serious complications.


Where to buy Vitamin D?

Vitamin D3 is typically prescribed, but is also available over the counter.  I typically recommend purchasing it inexpensively through Amazon, since a two year supply of Vitamin D3 (50,000 units) taken once a week is cheaper than copay for a one month supply from the traditional pharmacy.


Sleep disturbance and pain

There is a dramatic upsurge of diseases and related conditions resulting from the Sleep Apnea and the Obesity Epidemic.  According to the National Sleep Foundation, 75 million Americas are affected by some type of sleep disorder and more than 18 million suffer from obstructive sleep apnea (OSA) alone.  It is estimated that a staggering percentage of those affected, 92% of women and 80% of men remain undiagnosed.  Complications from untreated sleep disorders include excessive daytime sleepiness and neurocognitive deficits including decreased intellectual capacity and psychomotor vigilance (such as the ability to drive).  Additionally, patients with untreated OSA are at increased risk for diabetes, hypertension, heart failure, stroke, and other co-morbidities.


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Symptoms of significant sleep disturbance include:

  • Loud nighttime snoring
  • Daytime sleepiness
  • Insomnia
  • Narcolepsy
  • Obstructive sleep apnea
  • Restless leg syndrome
  • REM behavior disorder (abnormal body movements during dreaming)



If you’re not sure if you need to have a sleep test, the Epworth Sleepiness Scale might help you decide. It  is a useful measurement of daytime sleepiness that doctors use to initially evaluate patients for sleep disorders.

People with sleep apnea experience cessations in breathing during sleep, and the condition is associated with a range of serious side effects and illnesses. It used to be that you had to go into a sleep lab to have polysomnography, or a sleep test, in order to diagnose sleep apnea. At home testing is also now possible if ordered by your physician, so you can take the test discreetly, in the comfort and privacy of your own home.

Linkage of pain to sleep disturbance

Sleep disturbance is perhaps one of the most prevalent complaints of patients with chronically painful conditions.  Of all medical conditions, pain is the number one cause of insomnia. With chronic pain problems, difficulty falling asleep is one of the most prevalent types of sleep disruption.  However, awakening during the night and awakening earlier than desired are also frequent problems.

Research surveys of those with chronic pain problems have found that 65% report that they are awakened during the night due to pain and 62% report waking too early due to pain. In addition, many patients with chronic back pain problems do not feel “refreshed” in the morning when they awaken, a sleeping problem termed “non-restorative sleep.”  The National Sleep Foundation reports that 2/3 of chronic pain sufferers experience sleep problems. Approximately 15% of all people have sleep problems. Compounding the problem of disturbed sleep in people who hurt is the fact that some chronic pain medications tend to disrupt sleeping patterns.


Chronic pain sufferer experiences fragmented sleep due to:

  • Positional discomfort
  • Elevated Epinephrine/ Norepinephrine from stress responses as part of a flight or fight reaction, with secondary cortisol release.
  • Excessive carbohydrate consumption from ingestion analgesia and from sodium retention due to cortisol elevation
  • Obesity which occurs due to reduced Basal Metabolic Rate and due to excessive ingestion and preferential visceral fat deposition due to cortisol

Fragmented sleep leads to a vicious cycle– sleep disruption caused by chronic pain exacerbates the pain and obesity, which in turn interrupts sleep. With repetition, this becomes a hardwired pattern, a concept called neuroplasticity (the brain’s ability to reorganize itself by forming new neural connections throughout life is often referred to as  neuroplasticity and is the basis of learned behavior).  Sleep deprivation increases neuroplasticity-related gene expression, strengthening synapses in brain regions involved in mood regulation, creating a hard wiring of pain-insomnia-obesity behavior.


Normal Sleep Patterns

Sleep is divided into 2 different phases – Rapid Eye Movement Sleep (REM) and Non Rapid Eye Movement Sleep (NREM).  Microarousals are quite common.

We spend about 70% of our time in NREM sleep and 30% in REM sleep. The proportion of each changes through our lives from infancy to senility.

  • REM sleep has the following features:-
    • Rapid eye movements associated with typical saw tooth brain wave patterns on EEG (Electro-encephalogram)
    • A rise in heart rate, blood pressure, associated with an irregular breathing pattern
    • Susceptibility to being woken by sensory stimuli – light, noise, touch, pain
    • Paralysis of all muscles except the diaphragm
  • NREM sleep can be divided into 2 phases – transitional and deep:-
    • Transitional sleep is divided into stages 1 and 2
      • Stage 1 – The transition from wake to sleep occurs within minutes of the onset of slow rolling eye movements. The subject is less aware of their surroundings then just a few minutes ago. They may waken by a whisper, or noise. They are relaxed, their breathing is more regular and there is slower, rolling eye movement noticed. There may also be  “hypnogogic experiences” – dream-like sensations of falling, hearing voices, or seeing flashes of pictures. It takes 5 – 10 minutes to progress to Stage 2. Stage 1 accounts for only about 5% of the total sleep time.
      • Stage 2 – Stage two is the first stage of true sleep and accounts for about 50% of total sleep. The subject is even less aware of their surroundings and is characterized by as light sleep since individuals are easily aroused from this sleep state. Stage 1 & 2 are “transitional” stages of sleep. It takes approximately 30 minutes to complete these stages and enter Stage 3.
    • Deep sleep is divided into stages 3 and 4
      • Stages 3 and 4 are also referred as Slow Wave Sleep (Delta Waves). As the subject is in a very relaxed state, they have a slow, regular heartbeat and respiratory rate. Their muscles are very relaxed. It is very difficult to arouse a patient in “Slow Wave Sleep”. If they are awakened, they are confused and slow to react. It is normally easy for them to go back to sleep.
  • Normal Sleep Cycles
    • Cycling  from deep sleep to REM sleep and back again occurs several times during a normal nights sleep. There is tendency to have more deep sleep at the beginning of the sleep period and increasing amounts of REM later in the period.


Diagnosing sleep apnea

Sleep apnea is an under-diagnosed condition that results in breathing cessations during sleep, up to hundreds of times a night, which can critically lower blood oxygen levels. If left untreated, sleep apnea is associated with a host of problems including daytime sleepiness, increase in car accidents and serious illnesses such as heart disease, stroke, and diabetes.

Symptoms of sleep apnea can be hard to define because they are vague and often can be explained away by a patient’s overall condition. Snoring and daytime sleepiness are two hallmarks of sleep apnea, but do not in and of themselves prove someone has the condition. The first step in evaluating those symptoms is for your doctor to rule out other medical reasons for sleepiness such as interrupted sleep due to environmental reasons, narcolepsy, night shift work, etc.

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Additional indicators of sleep apnea that merit a sleeping test or an evaluation by a sleep specialist include:

  • Sleepiness that is dangerous to others (pilots, truck drivers, and anyone who drives).
  • Sleepiness that affects quality of life.
  • Partner reports of choking and gasping spells during sleep.
  • The presence of strongly associated conditions such as high blood pressure or diabetes.
  • Children who snore loudly and have difficulty with concentration and paying attention in school.


The best options for diagnosing sleep apnea are either an overnight polysomnography, which is conducted in a sleep lab, or a home sleeping test. Both tests evaluate the various sleep stages patients go through, and both monitor changes in breathing, episode of apnea (breathing cessation) and blood oxygen levels. Sleep lab studies are more labor-intensive and expensive, and home tests offer significant savings and patient comfort. However, home tests may not be appropriate for evaluating other sleep disorders, so if the results are unclear, a full polysomnography in a sleep lab may be necessary.

Many people prefer home sleep testing because it is more private, more comfortable, and is accurate in evaluating for the number of apneas, drops in oxygen, and heart rate variability. People with certain kinds of jobs such as pilots and truck drivers may choose home testing because it is more discreet and participation in a sleep study is less likely to be known to employers.

No matter where or how you get tested, greater than five episodes of apnea lasting longer than 10 seconds is considered significant sleep apnea if you are sleepy, and more than 15 episodes regardless of how sleepy you are. The good news is that there is effective treatment for sleep apnea, including CPAP or Continuous Positive Airway Pressure. Lifestyle changes such as losing weight may also help the condition. The most important thing for symptomatic people to do is get tested, either at home or in a sleep lab, so sleep apnea doesn’t interfere any further with their quality of life.


What is polysomnography?

Polysomnography is considered the “gold standard” for diagnosing obstructive sleep apnea or OSA. OSA is a common but under-diagnosed condition in which breathing ceases temporarily during sleep, up to hundreds of times per night, resulting in lowered blood oxygen levels.  Polysomnography is a study of how you sleep, or how you try to sleep. It is usually performed to evaluate sleep problems and diagnose possible sleep disorders.

Trained sleep specialists perform Polysomnography at a sleep lab or sleep center. Patients sleep in beds at the center, at their usual bedtime, in a comfortable bedroom. They are monitored both visually and electronically. The test is done at night in order to study normal sleep patterns.

Electrodes are placed on the chin, scalp, and outer edges of the eyes, and monitors are placed on the body to record heart rate and breathing. The sleep specialists directly watch patients while they sleep and record changes in position, breathing and heart rate. Episodes of apnea, or cessations in breathing, are also recorded. A video camera records position changes throughout the night. In addition, airflow through the nose and mouth, blood pressure, and blood oxygen levels are monitored.

The electrodes send signals indicating the two states of sleep; Rapid Eye Movement (REM) sleep and Non-rapid eye movement (NREM) sleep. REM sleep is associated with dreaming, and NREM has four different stages that the electrodes can detect. Normally, REM and NREM sleep alternate approximately every 90 minutes during the night. That means most people have four to five cycles of REM and NREM each night.

People with a normal sleep patterns will show normal brain waves and muscle movements during sleep, and no significant breathing difficulties. Abnormal results can lead to diagnosis of a sleep disorder. Reduced airflow through the nose and mouth, along with a fall in blood oxygen levels, may indicate sleep apnea.

Sleep disorders are associated with serious complications and effective treatment is available, so polysomnography is a highly useful tool for people who suspect they have sleep apnea or another sleeping problem.


Linkage of Obstructive Sleep Apnea (OSA) to obesity.

New research reveals that obstructive sleep apnea (OSA) may cause more severe consequences in overweight people than in people of normal weight. A study, published in the October 15 issue of the American Journal of Respiratory and Critical Care Medicine, found that greater oxygen depletion occurred in the blood of overweight people with OSA both during and after apnea events.

Apnea events are cessations in breathing during sleep that can happen up to hundreds of times a night, and that can cause significant reductions in blood oxygen levels. These reductions appear to be greater in overweight people, possibly leading to more severe outcomes. Since sleep apnea is related to the development of serious conditions such as heart disease and stroke, as well as daytime sleepiness and increased automobile accidents, all of these risks could be greater among overweight people with OSA. The study revealed that overweight people have more frequent episodes of apnea during sleep.

The researchers were careful to account for age, gender, and body position during sleep, so they can be sure it was body weight that contributed to the severity of oxygen saturation reductions in the people with OSA. They note that it isn’t just obese people that suffer from more severe episodes of apnea; anyone above the normal maximum Body Mass Index (BMI) of 25 is at increased risk. A 10% increase in BMI led to a 10% increase in oxygen depletion associated with sleep apnea. In other words, the greater your weight, the greater the consequences.

This study adds to the growing body of evidence that excess weight is a significant risk factor for the development, progression, and severity of OSA. Doctors and sleep specialists need to be aware that their overweight patients might be suffering from greater oxygen depletion related to OSA, even if they have the same number of sleep apnea events during the night as normal weight patients. People with sleep apnea who are overweight should keep in mind that any reduction in body weight would be beneficial to reducing the severity of their sleep apnea events, and to improving overall blood oxygen levels during sleep.


Improved sleep leads to better weight loss.

It may come as no surprise that being overweight causes sleep problems, but new research shows that the reverse may also be true! Sleep problems may be the reason you are putting on weight or unable to reduce weight with diet and exercise.

There are several explanations for why sleep loss causes weight gain.  Two key players are the hormones leptin and ghrelin.  Leptin suppresses appetite while ghrelin does just the opposite – it stimulates it. In just a few weeks of not sleeping well, your leptin levels can decrease by as much as 15%. Instead of registering that you are no longer hungry, your brain receives the message, ‘Hey! I am hungry. I need to eat.’  Uh oh!

A few years ago there was great hope in the obese community that leptin would be the magic weight loss solution everyone was looking for – but this proved not to be the case. Obese patients typically suffer from a condition called leptin resistance where despite having high leptin levels, which should help them lose weight, they no longer respond to the hormone effectively. To regain leptin sensitivity, patients first need to decrease body fat, because leptin is produced by adipocytes and the brain becomes resistant to the excessive leptin production in obese individuals.

Once sleep apnea is treated, you will be able to lose weight.   Getting a good night’s rest contributes to proper hormone function as well as providing energy for exercise – both of which are essential for effective weight loss. Patients need to recognize the importance of sleeping well for long-term weight control, as well as for overall good health.  Many people unknowingly suffer from sleep disorders. Sleep apnea, the most common sleep disorder, affects over 20 million Americans, yet the majority remains undiagnosed. A person who suffers from sleep apnea typically stops breathing for periods of 10 to 60 seconds, possibly hundreds of times throughout the night, resulting in a very poor quality of sleep.


Taking a pill will not improve your sleep; it will just make you forget you slept poorly.

A New York Times article reports that about 42 million prescriptions for sleep medication were issued in 2005. Aside from being over prescribed, sleep medications these days can have strange side effects (parasomnias) such as sleep driving, sleep-sex, and sleep eating.  Drug makers target and capitalize on the public perception that “modern day lifestyle” is frenetic, and that a restful eight hours of sleep is an absolute necessity; although physiologically our natural pattern of sleep is supposed to include short periods of microarousal.

Sleeping Pills (benzodiazepine family) are often used to treat insomnia, but long-term use is not recommended. They have been shown to disturb the normal NREM:REM sleep ratios during the night, causing the sufferer to awaken unrefreshed even though they’ve had a reasonable number of hours sleep. They also cause rebound sleeplessness on withdrawal, making them highly addictive. Sleeping pills also worsen obstructive sleep apnea.

These days, we all live with more stress than usual and it may be affecting your sleep. While it’s normal to have the occasional night when you can’t sleep very well, having those kind of nights more often can indicate a more serious problem. If you regularly take medications to fall asleep, even over-the counter medicines, you could be masking a sleep disorder – and not solving the problem causing it.

Insomnia is a symptom of an underlying issue, and is not an illness in itself. By simply taking pills and not dealing with the underlying causes of your sleeping problems, there’s little chance it will ever go away – and it could get worse. And if you are taking prescription sleep medications, there is the potential for addiction, which is a very difficult habit to break that may require professional help.

There are additional risks to allowing a sleep disorder to continue while simply taking sleeping pills at night. Sleep disorders are associated with serious health risks such as heart disease, diabetes, and stroke – not to mention quality of life issues such as daytime sleepiness, general fatigue, and increased car accidents.

If you find yourself needing sleeping pills more than very occasionally, it’s important to talk to your doctor about treating the cause of your sleeping problems. A good physician will do more than simply write a prescription. He or she will talk to you about what’s going on in your life, any other physical or emotional problems you are dealing with, and what might be affecting your ability to sleep well at night. You will also be evaluated for a possible sleep disorder such as sleep apnea. Sleep apnea is a very common sleep disorder in which a person’s breathing ceases for a period of time, up to hundreds of times a night. It is associated with a host of serious health problems but can be effectively treated – without pills.

You can also make some simple lifestyle changes to sleep better at night. Getting 30-60 minutes of moderate exercise each day is an excellent sleep enhancer. Avoid alcohol or caffeine within 5 hours of bedtime, and try to maintain a regular sleep schedule even on the weekends. Your body will get used to the routine and you will feel sleepier at night and better in the mornings.

If these changes don’t help and you continue to experience insomnia or symptoms of a sleep disorder (loud snoring, daytime fatigue, inability to concentrate) – don’t turn to pills to fix the problem. Talk to your doctor and get to the root of the problem, so you can eliminate it without having to turn to medications.

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How to sleep better with chronic pain:

  • Optimize pain relief by using interventional techniques and minimize benzodiazepines and narcotic analgesics.
  • Maintain a schedule – Go to bed and get up at the same time every day, including weekends and vacations, maintaining a circadian rhythm.
  • Regular exercise improves sleeping habits. Exercise between twenty to thirty minutes a day for the best results, but take care not to exercise within five hours of bedtime.
  • Don’t Lie Awake – If you cannot fall asleep, don’t lie in bed awake. Worrying about sleep actually keeps many people awake. Get up and do something else until you feel sleepy.
  • Limit Alcohol, Nicotine and Caffeine – Nicotine and caffeine are both stimulants, and should be avoided up to 12 hours before bedtime. Alcohol is a sedative, and may appear to promote sleep in the early part of the night, but may then cause a very disturbed sleep pattern for the rest of the night.
  • Eat and Drink Long Before Bedtime – A heavy meal before bed can cause indigestion, which can keep you up.
  • Drinking fluids before bed can interrupt your rest by causing you to get up to urinate. Try to avoid both food and fluids for at least two hours before bedtime.
  • Relax – Spending some down time before bed can relax you enough that falling asleep comes easier.
  • Meditation, relaxation techniques and breathing techniques may all work. Relaxation could be as simple as a warm bath, or quiet reading (but not in the bedroom).
  • Consider Melatonin supplements – Melatonin is a natural substance that builds up in the body as daylight fades, making people drowsy.
  • Taking a warm bath in the evening, which can relax muscles.
  • Stretching for three to five minutes before going to bed, which can loosen joints and make assuming a comfortable position in bed more likely.
  • Drinking a warm, non-caffeinated beverage about an hour before bedtime, such as warm milk, or herbal tea.
  • Keep the Bedroom for Two Things (sleeping and sex) – Watching television, paying the bills, reading a book, and listening to music in the bedroom are not recommended.