The Doctor Weighs In

My son Gil recently took a final exam in nursing  school after cramming the whole night. He did well, thank you. But when he told me about this feat of studiousness, I was wondering: how much is he going to retain one day after the test? I seem to recall from my college days that taking a test after an all-nighter was actually fraught with a lot of fuzzy thinking and faulty memory. Have you ever taken a test, and later asked yourself “how could I make such a stupid mistake”? Or “how could I forget that”?

Perchance to sleep

Sleep is an essential activity in our daily life. Since time immemorial sleep was associated with healing and healthfulness. Lack of sleep was associated with hallucinations and psychic torment. Just ask Lady Macbeth, walking all night, tormented by visions of blood and murder, longing for some blissful rest. Or the captives of state organs, subjected to sleep deprivation in order to wring some information or an admission out of them.

So why is sleep necessary? It has been the subject of lively debate among psychologists and neuroscientists for many years. Still, there is no answer. Some scientists even claimed that it actually is not necessary. One of my colleagues claimed that he never went to sleep for longer than an hour or two a night. But every time I visited him in his office at the university, I found him dozing at his desk. In fact, if sleep were not necessary, it would have been a colossal evolutionary waste; Evolution just doesn’t work that way.

Indeed, recent experiments convincingly demonstrated at least one function.

Brain waves

Human sleep is divided into REM, or rapid eye movement, and NREM, or non-REM, sleep. NREM is further divided into 4 stages, each characterized by typical electrical oscillations seen on an encephalogram, or EEG.

· REM sleep is characterized by theta waves, having oscillations of 4-8 Hz (Herz is a measure of frequency).

· Stage 1 is transitional between wakefulness and sleep, and is therefore characterized by a mixture of wave frequencies.

· Stage 2 is typified by spindle-shaped waves, of 12-14 Hz.

· Stage 3 and 4 are characterized by delta waves , of 1-4 Hz.

· Interwoven in the spindle waves and the delta waves pattern one can discern another oscillatory pattern : extremely slow, less than 1 Hz, wave pattern, called cortical slow oscillations, or slow-wave sleep.

Get smart

Marshall et al. did an ingenious experiment (Marshall et al. Nature, vol.444, pp.610-613, 2006). They wanted to know if any of these sleep phases were associated with consolidation of memory. So they let 13 volunteers memorize 46 word-pairs before going to sleep. Electrodes were then attached to their scalp, and fluctuating electrical potentials were then applied to half the group to induce cortical slow oscillations. The other half received sham stimulation.

The next morning the two groups were tested on the word-pairs they had memorized the night before. Results were quite remarkable. The group that had received the slow-wave stimulation performed better than the sham stimulation group. And they also performed better than they themselves had performed the night before. The effect was absolutely specific to slow-wave stimulation. No effect was shown when the subjects were stimulated with theta waves frequency of REM sleep. Timing of the stimulation was also important: the first 45 minutes of sleep enhanced recall, the last 45 minutes had no effect.

What did we learn?

· First, we now know for certain that sleep is important in consolidating memory.

· We also know that only certain brain waves (slow oscillating) are associated with memory consolidation.

· Finally, we know that if we want to do well on the test the next day, we’ve got to get a minimum of an hour’s sleep. This is when memories are getting embedded in our brain.

Can we enhance memory by artificial means?

Commercial claims notwithstanding (“learn a language while you sleep”), sleep-learning is a pipe dream; it doesn’t work. If you are willing to go to sleep with electrodes attached to your skull, you might be able to recall your Spanish lesson from the day before somewhat better. But those pesky electrodes will probably wake you up throughout the night, and you’ll feel like… (fill in your favorite expression) the next day.

Can this experiment point the way to a ‘memory drug’?

Unfortunately, not. Drugs work on chemicals in the body, not on electrical waves. We don’t know from this experiment which neurotransmitters are associated with the slow-wave oscillations. Acetylcholine, a known neurotransmitter associated with memory retention, has not been tested. Astonishing; they could have nailed it. Maybe they wanted to get another paper out of it. We’ll just have to wait.

Take home lesson

Gil, next time get some sleep; even an hour will ensure a better grade.

Dov Michaeli MD, Ph.D.

I am a big fan of the Family Violence Prevention Fund.  They have been on the cutting edge of every issue related to family violence  for years now.  These issues range from helping the criminal justice system respond better to victims to improving the health care system response to family violence.  If there is a way to try to reduce the tragedy of family violence, the Fund is there trying to figure out the best way to do it.

Now, they have a marvelous extension of their efforts -- that is a focus on helping boys learn to respect the women in their lives and to actively disavow activities and attitudes that are at the core of violence against women.  Innovative, yes.  But listen to this.  They have a program that targets coaches, that's right, sports coaches, to engage them as role models to help boys grow into nurturing, supportive boyfriends, husbands, sons, nephews, and friends of girls and women.  What a great idea!

Violence against women is not and never has been simply a "women's' issue."  It is an issue that affects men, women, children, and indeed everyone directly and indirectly related to the victim and the abuser.  Thank heavens an organization like the Family Violence Prevention Fund has taken a broader view of the problem and has begun to address the family violence as an issue that impacts just about everyone.

To learn more about Coaching Boys into Men, check out this site:  CBIM

To help support the Fund as it engages men in their programs, do what I do every year, give the best Father's Day Gift possible, a donation on behalf of your guy to the Founding Fathers program of the Family Violence Prevention Fund.  It is much better than just giving a "thing".  Just ask the men in my life -- Dov, Jason, Kevin, Gili, wouldn't you rather be gifted a Founding Father membership than get one more tie or another pair of socks.  This gift is not just for you -- it is also for your daughters, your wives, your sisters, your mothers and grandmothers and your girlfriends.

Thank you, Family Violence Prevention Fund, you are doing life-changing work.  And for that I say:  Amen.

Pat Salber, MD, MBA

I have been thinking about aging recently. I am not getting any younger, my loved ones are not young either; for heaven's sake--my little kids are in their forties (well, very very early forties). So where do you turn for sage advice? my favorites are the ten commandments. No, not THE Ten Commandments. I am talking about George Carlin's infinite empathy and wisdom-cum- smile. So here they are:

HOW TO STAY YOUNG

by George Carlin

1. Throw out nonessential numbers. This includes age, weight and height. Let the doctor worry about them. That is why you pay him/her.

2. Keep only cheerful friends. The grouches pull you down.

3. Keep learning. Learn more about the computer, crafts, gardening, whatever. Never let the brain idle. " An idle mind is the devil's workshop." And the devil's name is Alzheimer's.

4. Enjoy the simple things.

5. Laugh often, long and loud. Laugh until you gasp for breath.

6. The tears happen. Endure, grieve, and move on. The only person who is with us our entire life, is ourselves. Be ALIVE while you are alive.

7. Surround yourself with what you love, whether it's family, pets, keepsakes, music, plants, hobbies, whatever. Your home is your refuge.

8. Cherish your health: If it is good, preserve it. If it is unstable, improve it. If it is beyond what you can improve, get help.

9. Don't take guilt trips. Take a trip to the mall, to the next county, to a foreign country, but NOT to where the guilt is.

10. Tell the people you love that you love them, at every opportunity.

AND ALWAYS REMEMBER:

Life is not measured by the number of breaths we take, but by the moments that take our breath away.


Woopdeedo, who cares ..

nobody couldn't have said it better.

Thanks, George; I already feel younger.

Dov Michaeli

On January 3, 2006, the New York Times  published an very interesting article by Gina Kolata, an award winning Science reporter, on the intriguing relationship between education (years spent in school) and longevity. This is an extremely complex subject that we will need to come back to it in future postings to try to unravel some of the knotty issues involved.  

But for now, I want to focus on one topic in the article that had little to do with education, rather it dealt with the role of social networks.  Dr. Lisa Berkman , cited in the article, is a professor of public policy at the Harvard School of Public Health. In the 1970’s she worked at a San Francisco health care center that served Chinatown, North Beach (an Italian neighborhood), and the Tenderloin (a district populated with homeless people who lived on the street, mentally ill people, drug addicts and just plain poor people).  She observed that in Chinatown and North Beach people enjoyed tight and extensive social networks, made up of closely-knit families, friends and neighbors who cared for each others. In the Tenderloin people “were sort of dumped”, suffering from almost total isolation.

Thirty years later, after studying another group, Seventh-Day Adventists, well-known for their social cohesiveness as well as prolonged life span, she came to the conclusion that social isolation is associated with twofold to fivefold (i.e. 200% to 500%!) increases in mortality rates. This correlation has been corroborated in many other studies and in many other countries. Such a ‘hazard ratio’ (a term used in epidemiological studies, meaning the hazard of dying in the experimental group over the hazard in the general population) is so compelling that even one who insists on biochemical/molecular evidence of causality must sit up and take notice.

And indeed, it reminded me of the Okinawan people who are one of the longest-living society on earth. Their active lifestyle and healthy diet still don’t completely account for their outsized longevity. The distinguishing feature in their culture is the extremely close-knit family, the active role that grandparents and great grandparents take in the daily chores of the family, and the unusual respect and reverence they are being treated with.

And then there is the well-known observation that married men live significantly longer than single men. Or the statistic that societies that regard the care of older people as a societal obligation, such as Holland and the Scandinavian countries, also have some of the lowest mortality rates of the industrialized countries.

Is there a biological explanation?

In insect societies, a bee or a wasp separated from her nest will simply curl up and die within a day or two. Solitary wasps, on the other hand, live happily their full life span without ‘feeling’ the need for social contact. If you had a chance to observe bees’ behavior in their hive you’d be struck by the constant touching and stroking of each other with their antennae. Part of it is a form of transmission of information through pheromones, including and ‘I.D. scent’ that says “you belong”.

But is it possible that such pheromones evolved to occupy such a central role in the bee’s physiology as to make life without it impossible? If so, this would be an extreme case of ‘enforced socialization’, essentially saying “socialize or die”! Another intriguing possibility: the touching and stroking with the antennae could be the equivalent of grooming in primates. Monkeys that don’t get their daily dose of touching, stroking and grooming become depressed. So do human infants. Could it be that bees require the same tactile sensation?

What could be the biological mechanism that would curtail the lifespan of a bee separated from her hive? I don’t think we know. But there must be one.

What about us, humans?

It is known that social isolation is a stressful state, and conversely, social support reduces stress. Put in a biological context -- stress is expressed biologically by chronically elevated levels of the stress hormones cortisol and epinephrine (aka adrenaline). We know that these hormones are pro-inflammatory. The inflammatory response has been associated with coronary heart disease, autoimmune diseases, and cancer. In fact, we now know in precise molecular detail how this happens.

The stress hormones cause the release of peptides from white blood cells that are called interleukins. These peptides allow cells to ‘talk’ to each other and thus coordinate the inflammatory response and the immune response. A certain amount of the stress hormones is actually normal, and it results in the production of normal physiological levels of interleukins. This allows us to have an appropriate levels of inflammation and immune function necessary to protect us from foreign invaders and, in some cases, cancer. But when stress hormones are chronically elevated, over months and years, the protective function of the inflammatory and immune responses is turned into a pathological process that causes a variety of diseases, and death.

Mind you, this is speculation. All I did here is connect the dots of isolated biological and medical studies, most of them in the test tube or in animals. But what I wanted to demonstrate is that a biological basis for something as ‘social’ as social isolation and longevity most probably does exist.

Should we wait for the ultimate proof?

Absolutely not! Social policy should be based on solid evidence, and the hazard ratios of social isolation are so compelling as to make them an appropriate basis for policy. The cost of social isolation in human and economic terms is very high. We should take it very seriously now, as a huge wave of aging boomers is upon us.

by Dov Michaeli, MD, PhD

Here is Dov Michaeli on transfats and honeybees:

One of the greatest accomplishments of the “public health advocacy” was the almost total banning of cigarette smoking in every public space. The campaign to ban smoking has now spread worldwide including, believe it or not, France. Anybody who ever visited a restaurant in France knows how revolutionary this change is.

Interestingly, the campaign to ban smoking gathered unstoppable momentum only after it was demonstrated conclusively that second hand smoking is as harmful as the first hand variety. Arguments of personal freedom, free choice, equal rights-all paled against the realization that smoking is injurious to the smoker and to the innocent bystander alike. Opposition to the ban didn’t quite disappear voluntarily, but in the face of overwhelming public demand the laws were passed in all fifty states.   From a biological perspective this episode was a quintessential case of enforced altruism.

New York City’s ban on using trans fats in restaurants can be viewed in the same light. And as in the smoking case, it created a heated debate pitting civil libertarians, free marketeers, civil rights advocates and French fries aficionados against public health advocates.

When confronted with fraught issues that touch on human behavior, societal mores, conventions and taboos-it is always instructive to examine what Biology has to say about it.

What make us tick?

Recent research in genetics, neurobiology, and evolutionary psychology reveals that a large component of our behavior is genetically determined. All we do with our thin veneer of civilized behavior is modulate, modify, tinker around the edges-the core is hard wired!

What can we learn from social insects?

In a previous post we looked at the fascinating society of the honeybee. In that society there is a queen whose sole function is to lay eggs, a few males (with the unsexy appellation of ‘drones’) whose function is to fertilize the female, and a vast majority of females, whose sole function it is to do the work. Mind you, these workers have functioning ovaries and are potentially fertile.

How do the bees do it? And why?

It has been known for a long time that social insects have a peculiar genetic system called haplodiploidy, which makes full sisters in ants, bees and wasps related by ¾.  This is 50% more than the standard value of ½ of other animals, including us.

The evolutionary theory to explain this unusual phenomenon is called the ‘kin selection theory’ and was first proposed by W.D. Hamilton in 1964 (Journal of Theoretical Biology, vol. 7, pp. 1-52, 1964). Basically, the theory posits that workers evolved to create a closer genetic kinship in order to altruistically forgo reproduction because they can pass on more of their genes by raising siblings.

Implicit in this theory is that kinship encourages altruistic behavior. Indeed, there is a great deal of evidence to support it, but we really don’t need to go to the scholarly literature; just think of the altruistic behavior of 1^st degree relatives, like parents toward their offspring, the somewhat less altruism shown by first cousins, and even less so by 3^rd and 4^th degree relatives. We ascribe it to love, devotion or loyalty-but at its most fundamental level it is evolution’s way of making sure we maximize the chances of our DNA’s survival.

Is that all there is to it?

Well, not quite. Comparative studies of several bee, wasp and ant species (all social insects) show that genetics is not all. In a fascinating paper titled “Enforced Altruism in Insect Societies (Nature, vol.444, p. 50, 2006) Tom Wenseleers and Francis Ratnieks of the University of Leuven in Belgium show that altruism is modulated more by constraints on worker reproduction than by relatedness. Yes, relatedness does play a role, but more workers are fully committed to work rather than lay eggs when policing by others is most effective. The rules against workers engaging in the sin of egg laying are enforced by workers, and sometimes the queen herself, eating the eggs of those ‘rebellious’ workers.

Fascinating indeed, but is there a parallel here to human affairs?

I think so. Genetic relatedness works in humans, as I alluded to above. To wit, mothers are more likely supporters of the campaign to ban trans fats than supporting the free choice camp. The campaign for healthy foods in fast food restaurants and supermarkets is spearheaded by parents of young children.

On the other hand, people who have no genetic relationship to children are more likely to oppose such “heavy handed” regulation. They just don’t want to give up their cherished individual rights for the greater good of the community. Stated differently, they refuse to be altruistic.

So what is a society to do?

Enforce altruism through regulation, and punishment if need be. Sounds so illiberal, but sorry, it is purely biological.

One more thought on enforcement. The punishment meted out to the law-breakers is not designed to inflict pain, or ‘eliminate’ them. Rather, it is designed to make breaking the law pointless, unrewarding. The enforcers simply eat the eggs!

Does punishment work the same way with humans?

We’ll address this question next time. Stay tuned.

Last week, Medscape posted my web video editorial about the food industry using advertising imbedded in video games as a way of marketing some of their less healthy products to children. You can watch it by clicking on this link, be sure your sound is turned on. Or you can read my post about the same topic from earlier this year (reprinted here for your convenience). This one will make your blood boil (or something like that). A recent report from the Kaiser Family Foundation, “It’s Child Play: Advergaming and the Online Marketing of Food to Children,” is a comprehensive look at this new type of advertising. Haven’t heard of it? You will. According to the report, Price Waterhouse Coopers estimates a five-fold increase in spending on this type of advertising by 2009. Advergaming (a contraction of advertising and gaming) is the use of online video games with embedded brand messages to engage your target audience. It is specifically designed to blur the boundary between advertising and entertainment. This report looks at advergaming that targets kids. Advergaming is a good deal for food marketers. It is cheap compared to TV advertising ($2 per thousand users compared with $7 to $30 per thousand viewers).

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I did not eat celery sticks before Thanksgiving dinner. I ate fresh French bread that I "dipped" in spinach dip made from mayonnaise and sour cream (OMG! Thank you, Amy, it was delicious). I did not drink sparkling water. (I drank Edna Valley Chardonney-heck, I live in California). Then, I ate alot of turkey--mainly dark meat... a bit of stuffing, a few scoops of mashed potatoes and gravy, a big spoonful of sweet potatoes topped with coconut ( thank you, Karen) and some home-made apple pie (Karen, these calories are from you too, thanks an awful lot). I didn't bother with the green beans or the salad. This was a night of serious carb-loading. Quite a few of my loved ones felt compelled to remind me of my pre-Thanksgiving blog. "Hey, why are you eating brie instead of celery sticks?" "That looks like wine, not sparking water." How could they say these things to me right when I am enjoying the "cocktail" hour? The morning after the Thanksgiving feast, the scale proclaimed that I had gained 3 pounds. I am not sure these are "real pounds," if you know what I mean. At least not yet---real pounds are the ones that just keep hanging around even if you starve, starve, starve yourself for the next two to three days. I think of these initial pounds as indulgence pounds...the type of pounds that pile on just when you are having some fun.

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Thanksgiving is one of my favorite holidays. The whole family travels from all over the country to our house in Larkspur, California. There are adult children, their children, cousins, cousin-in-laws, parents, parents-in-laws, and friends and friends’ friends. It is a big gathering for the Michaeli-Salber clan. It is also, hands down, the biggest eating day of the year. Let’s take a quick inventory of the typical (when you are really honest) adult Thanksgiving plate:

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Rick Botelho is a family doc who really cares about health promotion and disease prevention. He understands that many people have a strong desire to help family members improve their health habits. But all too often good intentions are perceived by the recipient as nagging or worse, a criticism of who they are as human beings. Rick has written a guidebook, Motivate Healthy Habits: Stepping Stones to Lasting change to help families make lasting improvements in their health habits. Here is a summary: Improving Your Family’s Health Habits: Change Yourself before Helping Others By Rick Botelho www.motivatehealthyhabits.com Does giving information and advice to family members help them to change their unhealthy habits work? Then, you’re the lucky one. Despite knowing what to do, most family members do not change their behavior. Giving information and advice addresses only surface change. Knowledge alone seldom changes behavior. For most people, behavior change is a challenge.

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Rick Botelho is a family doc who really cares about health promotion and disease prevention. Unlike a lot of doctors who glibly tell patients “loses weight” or “stop drinking,” Dr. Botelho really understands how hard it is to make lifestyle changes. He has written a guidebook, “My Healthy Habits” and a companion workbook, “My Healthy Habits Journal, to help individuals find the motivation to change. He advocates moving beyond “health information, advice and self-management supports,” to “motivational approaches to behavior change.” The book takes you through a step-by-step approach that is designed to move you from an unmotivated state to being ready to make the changes and then actually making the changes. The book uses check lists and journaling to help you understand your current readiness to change and to explore barriers to change, including emotional barriers. In his chapter on “Understanding Change,” Dr. Botelho describes the “Force for Change” model. The model is based on the idea that both internal and external factors are involved in determining whether we will make changes in our health habits. The internal factors include understanding where you are at on a scale of “readiness to change.” Readiness to change stages are as follows:

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