Sleepless Nights, Growing Waistbands: Circadian Rhythm & Metabolic Health

1. Sleepless Nights, Growing Waistbands: Circadian Rhythm & Metabolic Health MINNESOTA ACADEMY OF NUTRITION & DIETETICS 2019 ANNUAL MEETING APRIL 24 – 26, 2019 Laura Andromalos, MS, RD, CD, CDE Nutrition Program Manager Northwest Weight & Wellness Center Bilingual CDE Coach Cecelia Health

2. Disclosures Consultant: LEVL

3. Objectives At the conclusion of this session, participants will be able to: • Assess sleep patterns and promote improved sleep hygiene • Assist clients in reversing distorted meal timing patterns • Provide clients with diet modifications to minimize negative impacts of a shift work schedule

4. Agenda Sleep • Sleep cycle & circadian rhythm • Sleep adequacy • Effects of sleep deprivation • Promoting improved sleep health Meal Timing • Effects on health • Realistic modifications for traditional and non-traditional schedules

5. Sleep 101

6. Sleep • Sleep is a state of unconsciousness when the brain is more responsive to internal than external stimuli • We (should) spend 25-30% of our lives sleeping! Stevens 2015

7. Types of Sleep IOM Committee on Sleep Medicine and Research, 2006

8. http://www.centerforsoundsleep.com/sleep-disorders/stages-of-sleep/http://www.centerforsoundsleep.com/sleep-disorders/stages-of-sleep/

9. Non-REM Stages IOM Committee on Sleep Medicine and Research, 2006

10. EEG Activity IOM Committee on Sleep Medicine and Research, 2006

11. REM Sleep • Skeletal muscle has no tone or strength • Rapid eye movements • Breathing erratic & irregular • Increased heart rate • Most vivid dreams IOM Committee on Sleep Medicine and Research, 2006

12. http://www.centerforsoundsleep.com/sleep-disorders/stages-of-sleep/http://www.centerforsoundsleep.com/sleep-disorders/stages-of-sleep/

13. Sleep Regulators Johns Hopkins Medicine, n.d.

14. Physical, mental, behavioral changes that follow a daily cycle Circadian Rhythm Master Clock National Institute of General Medical Sciences, 2017

15. Sleep Adequacy

16. Hirshkowitz et al. 2015

17. Hirshkowitz et al. 2015

18. Self-reported Sleep in Adults >7 hours sleep in 24 hours Liu et al. 2016

19. Effects of Sleep Deprivation • Physical health • Mental health • Quality of life • Safety Sleep deprivation is a relative concept and often unrecognized by the individual experiencing sleep loss Stevens 2015

20. Obesity Spaeth et al. 2013

21. Obesity Harvard MedicalSchool, 2007

22. Hormones Poor sleep leads to… Leptin Cortisol Ghrelin Insulin after meals Harvard MedicalSchool, 2007

23. Diabetes Risk factor for insulin resistance; possibly diabetes Reutrakul & Van Cauter, 2014

24. Mental Health 50 to 80 percent of people living with typical psychiatric illnesses also report chronic sleep problems Which comes first? Chronotherapyis a possible treatment for mental health disorders. • Changing the time you go to sleep and wake up by a small amount of time each day • Studies have shown success in improving bipolar disorder Harvard Medical School, 2007; Wu et al. 2009

25. Safety Bukowski 2014

26. Drowsy driving is as dangerous as drunk driving Safety NationalSleepFoundation, 2014

27. Ask Your Patients… Do you feel sleepy when driving or in meetings? Are you experiencing sleep problems? Do you notice changes in your productivity, health, and happiness based on the number of hours you sleep? Do you depend on caffeine to get you through the day? National Sleep Foundation, 2018

28. Self-report Sleep Health Questionnaire Not Validated Buysse 2014

29. Sleep Hygiene National Sleep Foundation, 2018

30. Meet Pat 39 y.o. male. Married with 3 children (7, 4, and 1 y.o.). He works as an insurance agent; office and field 5’10”, 183#, BMI 26.3 Has a few cups of coffee in the morning. Sleep is sometimes disrupted when children wake up.

31. Pat’s Room

32. When to Refer • Sleep apnea – STOP Bang • Insomnia • Unable to fall asleep or stay asleep • Acute: days or weeks; often from stress or traumatic event • Chronic: month or more • Restless leg syndrome • Irresistible urge to move • May be described as aching, throbbing, itching, crawling

33. Night Eating Syndrome • Delay in the circadian rhythm of eating • Diagnosed by: • eating at least 25% daily calories after evening meal • at least 2 instances/week of waking up at night to eat • Can be treated with cognitive behavioral therapy (CBT) Allison & Tarves 2011

34. Allison & Tarves 2011

35. Meal Timing

36. Update on Pat • Pat has gained some weight in the past year. His PCP encouraged him to see a dietitian. • 5’10”, 198# (previously 183#), BMI 28.4 Nothing has really changed with how I eat. If anything, I eat less now than I used to. In the morning I have coffee and a slice of toast. Most days I’m in the field visiting clients so I don’t have time for lunch. When I get home, I have dinner with the family. The kids like ice cream for dessert so I’ll have a couple bites with them. Sometimes I have a beer or two before bed.

37. 93 women with overweight/obesity Sedentary lifestyles; asked to keep baseline Randomized to a diet intervention for 12 weeks Eat Dinner Like a King…. Calories early in day Calories late in day Jakubowicz et al. 2013

38. Jakubowicz et al. 2013

39. Intermittent Fasting • Alternate-day fasting alternates days of zero calories with days of unrestricted calories • Modified fasting allows 20-25% of estimated caloric needs on fasting days and unrestricted intake on non-fasting days (5:2 diet) • Time-restricting feeding requires a prolonged nighttime fast

40. IF versus Continuous Restriction 88 women randomized to 1 of 4 arms for 8 weeks: • IF70, an IF diet at 70% energy needs (weekly) • IF100, an IF diet at 100% energy needs (weekly) • DR70, a continuous restriction at 70% energy needs (daily) • Control, 100% energy needs daily IF groups fasted for 24 hours after breakfast on 3 nonconsecutive days/week Hutchison et al 2018

41. Hutchison et al 2018

42. UAB 2017

43. IF vs Continuous Restriction • 137 adults with type 2 diabetes • 5:2 fasting plan (500-600 calories) vs continuous restriction (1200-1500 calories) for 12 months • No significant differences between groups Carter, Clifton & Keogh 2018

44. AHA Statement February 2017 Circulation St.-Onge et al. 2017

45. St.-Onge et al. 2017

46. Applying the Research While intermittent fasting is certainly a strategy that works for some, as with any diet, the question a person need ask to determine if it's right for them is, "could I enjoy living this way forever," and if the answer's "no," then intermittent fasting isn't going to be their panacea. Yoni Freedhoff, MD Bachert A, 2018

47. What Should We Tell Pat?

48. Two years later, Pat is back He was laid off from his job as an insurance agent and has started a new job as a night shift dock worker for a long-haul freight company. Has maintained his weight since he last saw you (198#, BMI 28.4).

49. Shift Work

50. Shift Work • 15% of US workforce has non-traditional schedule • Misalignment between internal clock and external environment; level of disruption can vary based on chronotype • On average, shift workers sleep 2-4 hours less per 24-hour period than people with traditional schedule American Academy of Sleep Medicine 2018; National Sleep Foundation 2018