By Ann C. Jorn, Copyright 2008
Two of the major complaints expressed by people with chronic pain include weight gain and poor sleep but many do not under stand the relationship between sleep and wieght gain. In fact, there are many reasons why you may gain wieght as a result of suffering from chronic pain. Understanding the various reasons why you have gained weight may appear overhwelming. Do not overhwlme yourself because at a minumum it is totally unhelpful. What you are going to try to do is develop a plan to talk to your doctor about which will address your pain, sleep, mood and weight. I will give you a outline of a plan later in this chapter to talk to your doctor about. It is important to remember that you can figure out how to lose some wieght by looking at wieght loss from a broader perspective and making not just one change such as changing you diet but making some simple changes that can help you lose weight and feel better overall. So lets start by looking at the pain – sleep loss- weight gain triad.
Common Sources of Weight Gain
The most commonly discussed sources of weight gain include genetic factors, cultural factors, history of repeated dieting, and reduced physical activity. Repeated dieting has been shown to disrupt the bodies ability to modulate energy storage and metabolism. Readily available foods tend to be high in fat, calories, salt, and sugar. Fat contains the majority of calories of all foods. Sugar, which has little nutritional value, turns into fat that the body stores. While initially you may want something sweet to boost your energy, sugar will only give you a very short burst of energy and then leave you feeling tired and groggy. Several foods have high sugar contents like alcohol, white bread, crackers, and fruit.
When you suffer from chronic pain, you tend to have reduced over all physical activity. As a result, your metabolism decreases and you do not burn fat like you used to when you did not suffer from pain. Another consequence of reduced activity is reduced muscle mass. Muscle increases your resting metabolism. The American Dietetic Association notes that maintaining or minimizing the loss of fat-free mass (muscle) during periods of restricted energy intake appears to be particularly beneficial for weight loss, since muscle mass is the most important factor influencing resting metabolism. Healthy exercise includes aerobic activity and exercises that maintain muscle such as resistance training. A very important fuel for maintaining lean muscle mass is protein. Also, protein slows sugar absorption and ensures that you have a normal supply for the bodies needs. A rule of thumb is for every unit of sugar you eat you should have two units of protein. Weight loss and exercise together reduce total cholesterol, low density cholesterol, triglyceride, plasma insulin, and blood glucose levels thereby reducing the risks, type 2 diabetes, and heart disease.
A proper diet is essential for both physical and emotional health. The importance of a healthy diet for weight management is frequently stressed in the media and by health practitioners but many people are confused as to what a proper diet includes. A good approach to the problem of weight management is stated by the American Dietetic Association.
It is the position of the American Dietetic Association that
successful weight management to improve overall health
for adults requires a lifelong commitment to healthful
lifestyle behaviors emphasizing sustainable and enjoyable
eating practices and daily physical activity.
In general, a healthy diet includes a lot of fruits and vegetables, and moderate amounts of whole grain breads, and small amounts of foods high in fat and cholesterol such as red meat. Foods to use in moderation are sugars, salt, caffeine and alcohol. Body weight is tightly regulated . Increased fatness results from the failure of this sophisticated regulatory system that balances total energy intake and output. High levels of fatness are induced by combinations of genetic, environmental,
and psychological influences. It is likely that obesity represents the manifestations of a range of disorders, each arising from distinct defects or groups of defects in the cortical, hypothalamic, endocrine and/or metabolic components of the weight regulatory system. I strongly recommend that you go to the following web site www.mypyramid.gov. Here you can use and interective program that will help you to design an appropriate diet. Also in addition to the food log you will complete as part of your homework go to www.mypyramid.gov/professionals/food_tracking/wksht.html. This sheet I think is very helpful to understand how your eating daly eating habits fall in line with the recommendations of the food pyramid. Keep this worksheet on your refrigerator and it will really help you to keep on track.
Other Factors Associated with Weight Gain
People eat a variety of foods for a number of reasons that are not about refueling the body. Studies suggest that genetic factors account for 60% to 80% of predisposition to obesity. By the way just because your mother or father was overwieght does not mean you have a genetic pre-disposition. Some people engage in what is called “emotional eating.” The data analysis from the National Health Epidemiological follow-up study to the first National Health and Nutrition Survey revealed that depression played a substantial role in the patterns of weight change in US adults. Persons who gain weight with one episode of depression tend to gain weight with the next, just as persons who tend to lose weight with depression have a similar response with the next occurrence of depression. Studies have indicated that brain chemical called serotonin is critically involved in controlling mood, sleep and appetite. Many patients learn they can transiently reduce depressive symptoms by eating. This is frequently seen in seasonal affective disorder, premenstrual syndrome, and nicotine withdrawal.
Several classes of psychotropic medications used to treat depression and other emotional disorders are associated with unwanted weight gain including antidepressants, mood stabilizers, and to a lesser degree anti-anxiety medications. In general, the medications that block receptors for serotonin, and dopamine are known to be important in weight regulation and associated with weight gain. Other medications that also may cause weight gain include steroids and insulin. If the dosage of these medications is reduced or discontinued, the weight increase may resolve.
Sleep Loss and Weight Gain
Studies have also shown that those who suffer from sleep loss (under 7-8 hours a night) have impaired metabolism. "Sleep loss is associated with striking alterations in hormone levels that regulate the appetite and may be a contributing factor to obesity," says Michael Thorpy, MD, director of the Sleep-Wake Disorders Center at Montefiore Medical Center in New York. The body's hormones have a 24-hour rhythm and when sleep is disrupted says Joyce Walshleben, PhD, director of the Sleep Disorder Center at the New York University School of Medicine, your hormones are disrupted. This disruption in turn causes glucose intolerance which causes you to want to eat more but also reduces your ability metabolize what you eat as well. In other words, higher levels of insulin are needed to metabolize sugar. Loss of sleep has also been linked to higher cortisol levels, and increased sympathetic nervous system arousal (increased blood pressure and heart rate), and increased risk for heart disease and diabetes. Noted in the National Institutes of Health's 2003 National Sleep Disorders Research Plan studies have shown that getting 4 to 6 hours of sleep a night causes a progression in cognitive functioning, insulin resistence an important precursor to diabetes, obesity, and mood distrubances. Both sleep loss and chronic pain are linked to reduced stress tolerance. Stress tolerance refers to the body's ability to recover physiologically. High levels of cortisol in our blood system negatively affects our immune system Low serotonin is also linked to sleep loss. Serotonin is also an appetite suppressant. When you do not produce enough serotonin you may have problems sleeping and controlling your appetite. There is a great deal of research to be done on the affect of sleep loss on weight gain but one thing can be safely asserted and that is that increasing daily exercise is beneficial for weight loss, improved sleep and reduced pain.
Getting the Sleep You Need
You wake up – you hurt, you turn on a lamp, and get your medication. Maybe you walk around or turn on the TV and get something to eat. You feel irritated because you can’t seem to return to sleep. You stay up for an hour or more and finally get back to sleep. During the day, you are exhausted and your pain seems worse. You may have a caffeine drink to stay awake or take a long nap. The next night you wake up at exactly or close to the time, you woke up the night before and start the whole sleepless routine again. Does this sound familiar? It may surprise you to know that pain is not the only cause of your sleep loss. People with pain, particularly if it is chronic, often experience less deep sleep, more arousals and disruptions with waking as well as less efficient sleep.
The National Center for Sleep Disorders notes that 50 to 70 million people suffer from poor sleep in the United States. It is estimated that over half of chronic pain sufferers have trouble falling and staying asleep. While pain interferes with sleep, disturbances to deep sleep result in light unrefreshing sleep, muscular aching, stiffness and fatigue. The poor quality of sleep and waking pain create a vicious cycle affecting mood, energy, behavior and safety. Pain disorders can also be associated directly to sleep disorders such as headaches. Poor quality of sleep contributes to the persistent muscle pain, tenderness and low energy of rheumatic illnesses, people with osteoarthritis, rheumatoid arthritis and fibromyalgia should be evaluated for primary sleep disorders. In general, there is a high prevalence of sleep problems in various medical conditions with pain often altering the sleep process, and at the same time, the sleep problem interacts with the disease process. For example, patients with heart disease tend to have less deep sleep, more fragmented and less efficient sleep. This poor sleep can affect their well-being.
There is some debate about what the number of hours one should sleep a night. It appears that people have varying sleep needs. Some people need less sleep, some more. But there is no doubt that getting good sleep is a very important health habit. The National Sleep Foundation notes that poor sleep causes impaired alertness, increased accidents, reduced concentration and attention, disturbed mood, pain, increased appetite, weight gain, reduced immune function, high blood pressure and other cardiovascular diseases. The amount of sleep any individual needs involves a number of factors such as age, gender, if you have had sleep loss (sleep debt), chronic illness, hormone levels, depression and anxiety. The National Sleep Foundation has the following general guidelines for how much sleep is needed.
Age Hours of Sleep
Infants (1 -2 month) 10.5 to 18
Infants (3 – 11 months 9 – 12 plus naps
Toddlers (1 -3 years) 12 – 14
Preschoolers (3 – 5 years) 11 – 13
School aged Children ( 5-12 years) 10 – 11
Adolescents (11 – 17 years) 8.5 – 9.25
Adults (17 years and older) 7 – 8 hours
There are also a number of specific sleep disorders your doctor should assess and you should be sure to talk to your doctor about any difficulties you have with sleep because unfortunatley the medical community often fails to assess patients' sleep pattern ( section 7 Education and Training, 2003. p. 115). Sleep problems fall into several general categories. Primary insomnia refers to problems getting and or staying asleep. Sleep problems that are due to voluntary restrictions such as working the third shift or having a new baby. Sleep problems can also be a result of disease or illness or alcoholism, caffeine, depression, etc..(pvii). Furthoremore, the narcotic medication to treat pain can cause sleep disturbance of dream sleep or Rapid Eye Movement sleep in particular (p21). The Primary Insomnias are considered medical conditions in and of themselves and are described in the Diagnostic and Statistcal Manual for Mental Disorders IV TR which can be found at major book stores. Below I have listed a summary of these diorders.
The Stages of Sleep
The Importance of Napping
One of the import things that you can do is to improve your sleep hygiene. Sleep hygiene concerns the behaviors around the activity of sleep and how they contribute to disturbed sleep. Every animal has an internal biological clock. Your biological clock can be reset quite easily by the activities you engage in during the day, before you go to bed and when you wake at night. Below are guidelines to improve your sleep. It is also very important to talk to your pain specialist about sleep problems associated with your pain and problems with sleep that you experienced before your pain began.
The rules for a good night sleep below will help get your biological clock back in line. Resetting your clock will take 2 to 4 weeks but the results are well worth the effort.
Use your bed for sleep (and sex) only
Get up and go to bed at the same time every day
Do not take a warm bath or shower less than two hours before bed. A warm bath or shower actually serves to increase alertness so taking one too close to your bed time will wake you up.
Do a relaxation exercise to help you go to sleep and to help you get back to sleep if you wake up at night
Get up if you have been awake in bed for 15 minutes and do your relaxation exercise. Be sure to keep your lights low. Our skin is actually sensitive to light and too much light at night signals the body that it is morning and time to get up and be alert.
Avoid becoming irritated with yourself for waking up because this increases your adrenaline