B is for Body (Physiological considerations)

Dr. Kaufmann, Director of the Ontario Medical Association’s Professionals Health Program

This is a new series of articles contributed to Focus by the Professionals Health Program (PHP). The PHP is a program that helps veterinarians with issues of substance use, family and/or partner difficulties and emotional distress. The program is administered by the PHP staff of the Ontario Medical Association, promoted by OVMA and is funded by the College of Veterinarians of Ontario.

A human physician, Dr. Kaufmann understands a scientist’s intrinsic need/desire to dissect life’s challenges so that they make quantifiable sense. He has devised the acronym, “BASICS” to help illustrate how things like physiology, attitude, society, intellect and spirituality affect us each day – particularly if we fail to keep each of them in check. Please remember that the PHP is your source for information and guidance for issues such as stress, gambling addiction, substance use, sleep issues, depression, relationship strains, etc. If you (or a veterinary colleague) is in need of assistance, please call the toll-free, confidential line at 1.800.851.6606. You are not required to provide a name or contact information when you call.

Homeostasis

The biology of stress is interesting. Consider first the concept of homeostasis, the maintenance of the internal physiological environment of an organism within healthy limits. Homeostasis means that we eat when hungry, drink when thirsty, and sleep when tired to restore ourselves. This is the physiology of our regular patterns, routines and diurnal variations – the baseline biochemical “hum” of existence. Homeostatic processes and mechanisms have been long studied and are well understood.

Allostasis

But what happens when we don’t eat when hungry or fail to sleep when tired? A newer concept is that of allostasis(1). The body adapts to potentially diverse and dangerous situations through the activation of neural, hormonal, or immunological mechanisms. Liberation of cortisol and adrenaline are just two such stress responses. The problem is that the organism is fatigued and otherwise stressed by such an attempt to deal with “danger” (which might be only skipping meals on a very busy day). Allostasis is the combined physiological and psychological adaptation to adversity and threats which creates wear and tear upon the organism. Allostatic responses are mediated by the brain and nervous system, but probably affect every cell and system within the body.

When allostatic challenges are few, the body has time to recover and return to a healthy homeostatic state. When the individual is challenged repeatedly or when the allostatic systems remain turned on when no longer needed, the mediators of allostasis can produce a wear and tear on the body that has been termed "allostatic load". Examples of allostatic load include the accumulation of abdominal fat, the loss of bone minerals, neuronal atrophy, to name only a few(2). In short, when we are chronically stressed, the physiological changes that result render us less resilient, more susceptible to the diseases and disorders that we know through experience often occur in that context.

Veterinarians are not exempt from these physiological fundamentals.

Working long hours, facing demanding patient care situations, missing meals and losing sleep causes lasting physiological changes in the body that predisposes medical professionals to the kinds of diseases (especially those to which the individual is genetically susceptible) that they are trained to treat. How ironic!

Nutrition

The food we eat is our physiological fuel. Feed ourselves properly, according to sound nutritional principles, we feel well and perform at our best. But just as running high performance engines on low octane fuel can result in reduced performance and engine damage, eating poorly drains energy and, over time, can cause health problems.

The notion of “sound nutritional principles” is constantly evolving. Documents such as Canada’s Food Guide to Healthy Eating and the American Heart Association (AHA) Dietary Guidelines are available and offer useful suggestions(3,4). If AHA’s argument that diet can reduce the risk of coronary artery disease is true (specifically, high blood cholesterol, high blood pressure and excess body weight are targeted), then healthy eating can modify these risks, decrease allostatic burden and increase resilience and our ability to cope with stress.

Basic recommendations include:

Eat a diet rich in vegetables and fruits, whole grains and high fibre foods.
Eat fish at least twice a week.
Make sure your dairy and meat products are low-fat and lean.
Minimize your salt intake.
Limit saturated and trans fats (foods prepared with partially hydrogenated vegetable oils).

Toxins

Besides eating healthy foods, you also need to be aware of substances that may not be great for you, such as caffeine and alcohol.

This next statement might sound unusual coming from the perspective of the Professionals Health Program, but alcohol is not evil! Most who use alcohol do so safely and responsibly. Guidelines are available that refer to low-risk use of alcohol, but here are some general principles you may wish to consider:

Over the course of a week, have no more than about 12 standard drinks (a standard drink being one bottle of beer, one and a half oz. of liquor, 5 oz. of wine)(5). Note: Women metabolize alcohol differently than men and should drink a little less.
Daily drinking should usually be avoided.
Limit the number of standard drinks you have to 2 or 3 per drinking occasion.
Drinking specifically to relax or to aid sleep is not a good idea.
Alcoholism runs in families. Be careful if there is a strong family history of alcohol-related problems.
Don’t drink while working, or while on-call. (The best alcohol serum level for a medical professional is zero while at work!)

Caffeine is a mild stimulant well known to medical professionals. In medical school I always picked up my first cup of the day on the way to the morning lecture and appreciated the boost in concentration I felt. Coffee is ubiquitous in the medical world, as in many others. It’s there in the lounges, wards, and always at rounds. And of course caffeine is present in tea and other beverages and foods, sometimes naturally, sometimes as an additive. So, it’s hard to avoid.

While caffeine use has been associated with palpitations, bone loss, breast tenderness, infertility, and other conditions, the good news appears to be that used in moderation, few but the most sensitive will ever suffer any adverse effects. Moderation means about 300 mg of caffeine or less per day. This is the equivalent of about three regular size cups of coffee. Probably best to discontinue caffeine use in the afternoon and evening if sleep is a problem, though.

I’d like to include a word about tobacco use. One would think that this would not be necessary for a medical audience, and indeed, when compared to the general population, only a small proportion of doctors smoke. But we have had calls from some doctors who began smoking during medical training, or after, and many of the doctors who have problems with substance abuse and dependence are smokers. There is no amount of tobacco use that is safe. If a smoker, keep trying to quit. And if not a smoker – don’t start!

Sleep

I doubt there is any other issue that affects medical professionals more than sleep – or the lack of it. Providing emergency services via on call working hours, is only one of the reasons why veterinarians are so good at losing sleep.

Sleep loss is associated with increased irritability, anger, depression, sensitivity to criticism, decline in cognitive performance including the ability to solve problems and learn new skills, daytime drowsiness (nodding off) and more. Losing sleep impairs psychomotor function. In fact, it has been shown that four hours of sleep loss results in the kind of impairment usually associated with a breath alcohol level above the legal limit for driving in most jurisdictions(6). In short, being sleep deprived hurts – us, and potentially those we serve.

Consider that human beings need about seven to eight hours of sleep per night. How many of us achieve that even if not on call? Long hours of work, complex client and professional problems, home and family demands all create night-time thoughts that seem to whirl endlessly in our minds once the head hits the pillow. (I’ve heard this referred to as “monkey mind”.) And don’t forget that our natural diurnal rhythms would have us sleep some time in the afternoon as well. Who gets to do that?

The truth is that our physiology demands sleep in the right amounts and at the right time. There is no overcoming that basic need no matter how long we have trained, how often we lose sleep, or how important we perceive ourselves to be. There is no such thing as conditioning our physiology to adapt to less sleep in a healthy, homeostatic way. Chronic sleep deprivation only adds to our allostatic load. Chronic sleep loss reduces resiliency, adds to risk of illness, or even causes illness, depending on individual circumstances and genetic predisposition.

Here are some suggestions for healthy, restorative sleep:

Listen to your body’s rhythms. There are times when falling asleep is easier because it’s natural to do so. Plan bed-time and naps accordingly. To the best of your ability, don’t let anything else interfere with this schedule. (I know one family doctor in a small town who has lunch at home followed by a brief nap before returning to the office. He’s done that for years and swears by it!)
“Close shop” sufficiently early in the evenings to give your mind a chance to wind down. This means avoid work-related emails, calls, journal reading, paper work and so on for a few hours before retiring.
Engage in relaxing activities before going to bed to signal to your body that sleep is coming (whatever works for you e.g., watch TV, listen to music, take a walk, read a novel).
Avoid alcohol, caffeine, excessive fluids or heavy foods right before going to bed (but a light snack can help prevent over-night hunger).
Arrange your sleeping quarters according to your preferences considering light level, quiet, temperature, etc. (I’ve found a mask and ear plugs work wonders.)
Light exercise helps promote good sleep, but exercise should be avoided just before retiring.
Develop a bedtime “ritual”. Even after being on call, a bedtime ritual helps facilitate sleep.
If at all possible, grab a quick nap (about 45 minutes) during the day prior to an over-night or on call shift.
Be sure to get extra sleep on days off. This is the way to achieve sleep homeostasis, that is to repay the “sleep debt.”
Generally, avoid sedative drugs for sleep unless for short periods and as prescribed. This includes over-the-counter preparations.

Of course there will be nights when sleep is difficult. Most authorities suggest getting out of bed and doing something else for awhile rather than lying there ruminating about not sleeping. After that, try repeating the usual pre-sleep ritual, then returning to bed. Remember, an occasional experience of insomnia, while unpleasant, will do no harm.

If your sleep is regularly disturbed, it’s a good idea to seek medical attention (a sleep study is sometimes necessary).

Exercise

It’s common knowledge that regular, moderate exercise benefits health in many ways. Benefits include better sleep, improved sense of energy, reduction in physical and emotional tension, fewer feelings of depression and anxiety, lowered risk of many physical illnesses, including cardiovascular disease, and much, much more. In short, thinking physiologically, exercise can contribute significantly to the reduction of our allostatic burden, creating resilience and good health – immediately and in the future.

So why don’t we all exercise regularly?

Not enough time – clients and family come first.
Not enough energy – the long work day leaves little reserve for much else, let alone exercise.
Not enough motivation – that couch potato life is just too appealing.
Not enough expertise – we aren’t already the best at running, rowing, dancing or whatever.

There are ways to overcome these barriers to an active lifestyle. A moderate exercise routine can easily be built into our daily lives. Consider walking, jogging or biking to work. Use stairs instead of elevators. If you live in a condo with a gym, go for a quick swim after work. Build dedicated physical activity, such as group walking, into professional meetings.

Think about recreational activities you really like and which may have been abandoned. Skiing, golf, dancing, playing squash or tennis are just a few examples. Find some friends to join you. Take some lessons.

Hire a professional trainer to keep you motivated and on schedule.

The trick is to start small. Commit to a few minutes two or three times a week. Give yourself permission to be slow and inept at first. Understand that there might be a little discomfort, very soon offset by the many, immediate benefits. Then gradually build on those initial gains. Before you know it, you’ll be the beneficiary of an active lifestyle you won’t want to part with.

I’ll offer the usual caveat before concluding this discussion: consult your personal physician before engaging in vigourous physical exercise – that is, if you have a personal physician. If you don’t… find one.

Personal Medical Care

PHP experience is that the majority of those who call with personal problems don’t have a family doctor, or won’t involve them in their care. A PHP survey (unpublished data) of 800 Ontario physicians revealed that approximately half of the respondents did not have a family physician at all.

Make sure you have a personal physician and see him/her regularly (just as you suggest that your veterinary clients see you regularly for their pets physical examinations).

Don’t let being a medical scientist get in the way of seeking professional medical advice from a physician.

Nutrition, exercise, sleep… these are just a few of the most important considerations regarding our physical health. And while attending to them all at once may appear daunting (and tempting to the perfectionist) doctor, it helps to remember that even small changes towards better physical self-care can result in noticeable benefit.

REFERENCES

Charney DS. Psychobiological Mechanisms of Resilience and Vulnerability: Implications for successful adaptation to extreme stress. Am J Psychiatry 2004; 161: 195-216.
McEwen BS. Allostasis, allostatic load, and the aging nervous system: role of excitatory amino acids and excitotoxicity. Neurochem Res 25(9-10):1219-31. 2000.
Health Canada website: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html
American Heart Association website: http://www.americanheart.org/presenter.jhtml?identifier=1330
Guidelines On Low-Risk Drinking; in Management of Alcohol, Tobacco and other Drug Problems – A Physician’s Manual; edited by Bruna Brands, PhD; Centre for Addiction and Mental Health, 2000.
Howard Steven K. Sleep Deprivation and Physician Performance: Why should I care? Proc (Bayl Univ Med Cent). 2005 April; 18(2): 108–112.