BMJ: How to get a better sleep if you work night shifts

From Optimising sleep for night shifts by Helen McKenna and Matt Wilkes 3rd March 2018

Night shift work happens when your body would rather be asleep. Alertness, cognitive function, psychomotor co-ordination and mood all reach their lowest point between 3am and 5am.

After a night shift is over, the worker has to try to sleep when the body would prefer to be awake. This shift away from the circadian phase compounds the fatigue and can lead to chronic  sleep disturbance. There is  more likelihood of occupational accidents, obesity, type 2 diabetes, heart disease and breast, prostate and colorectal cancers. Psychological and physical well being is affected and accidents or near misses when travelling home are much more likely to occur.

Performance on the night shift gets worse as people get older and it takes longer to recover from a night on.

On average most people sleep about 8 hours a night.  Some people cope with sleep deprivation better than others. Performance will be impaired after two hours of sleep deprivation and gets worse as sleep debt accumulates. Therefore before starting a set of night shifts it is wise to sleep in the morning before, avoid caffeine that day,  and if you can take a nap in the afternoon between 2pm and 6pm.  For a nap to be most effective you need 60-90 minutes asleep.

When you start the shift, try to fit in a nap of about 30 minutes if this is the sort of job that allows this, but have a coffee immediately before the nap, and don’t have any more caffeine after the nap.  Sleeping longer than 30 minutes can make you feel groggy as you move into deep sleep and are the roused from it. Caffeine can help performance but you also want to try to sleep the next morning. Avoid it for the 3-6 hours before you plan to go to sleep in the morning. If you are doing critical tasks especially between 3-5am it is wise to build in more checks to your work.

Working in bright light can perk you up on the night shift.

When it comes to eating you are probably best to eat your main meal immediately before the night shift then eat just enough to feel comfortable as the shift goes on.

Jet lag improves at the rate of one day for every hour you are out of phase.  Circadian adaptation is therefore impossible during short term rotating shift work. Therefore you have to do your best to optimise your sleep between the shifts so as to keep the sleep debt minimal.

If you can possibly arrange lifts home or travelling home on public transport after a night shift, do so.

You can try to improve the situation by wearing sunglasses in daylight on the way home, avoiding electronic device screens, using blackout blinds, ear plugs and eye masks or even white noise generators.  A warm bath and then sleeping in a not cold but cool room and wearing woollen nightwear may help. Melatonin taken in the morning after a night shift has been shown to improve sleep duration by up to 24 minutes. Avoid alcohol and caffeine as these won’t help. Drugs such as Zopiclone can improve sleep if taken during the day but it can be addictive and needs a prescription.

After a run of night shift work you may get into the swing of your regular routine by having a 90 or 180 minute sleep, as this is one or two sleep cycles,  or sleeping in to noon and then getting up and getting outside for some exercise in bright light. Do your best to include meals at the usual times and socialise a little.  You will also need to pay attention to paying back your sleep debt by going to bed earlier than usual and sleeping in later than usual for a few days. It is best to avoid day time naps during the recovery from shift phase.

The path to sleep optimisation is an individual thing. Feel free to experiment.

Obesity makes asthma particularly difficult to control

From British Thoracic Society Winter Scientific Meeting December 2017 London

Researchers have demonstrated that diet induced obesity leads to the development of airways hyper-reactivity through the interplay of an immunological and metabolic pathway.

Resultant asthma can affect children as well as adults. Unfortunately obesity associated asthma responds poorly to standard asthma medications including steroids and can result in more hospitalisation and a reduced quality of life.

The most effective obesity treatment is probably bariatric surgery to achieve sustained weight loss. In contrast dietary management and drugs are far less effective.

Gestational diabetics seven times more likely to get type two diabetes

From RCGP Brian McMillan et al

Reducing risk of type 2 diabetes after gestational diabetes: a qualitative study to explore the potential of technology in primary care.

April 2018

Although women who have experienced gestational diabetes have are seven times more likely to develop type two diabetes than other pregnant women, there is as yet no formal testing arrangement in primary care.

These women may benefit from annual Hbaic and ongoing dietary and advice on weight management.

If these women have a HbA1c of more than 42 they can become eligible for the National Diabetes Prevention Programme. Otherwise not.

Women in this situation were interviewed and told researchers that they would welcome advice regarding diet and the help of other women in the same situation. They said they would value technology to give them the information to enable personalised self management.

Diabetes awareness mama: managing mood changes in your type 1 child

This article is from the mother of a type one son who has recently started school. She discusses ways to help other parents of children in the same situation in her blog.

https://diabetesawarenessmama.com/2017/07/05/managing-mood-changes/

Managing mood changes
July 5, 2017
Hannah Foreman-Wenneker
Today I would like to open the doors on what goes on behind the scenes of a T1D child. What do they feel that we parents cannot see? What do they want to tell us but are too young to possess the vocabulary or verbalise their emotions? These, and many more questions, often race through my mind. Taking on the full time job of a pancreas isn’t just about calculating carbohydrates, night time blood tests or insulin pump therapy; it is equally as important to understand the side effects this disease has on your child’s brain and subsequently, personality.
It all starts with the physiology of diabetes. I will never be able to fully appreciate what our son physically and mentally feels when he experiences a hypo or hyper, I can only describe to you what I have been told. According to the experts: diabetics, when a child is having a hypo they feel weak, dizzy, confused and shaky. This fantastic 3 minute video of four woman describing how they physically feel and mentally react during a hypo is well worth your time.
It is quite common for a T1D to suffer from ‘hypo-unawareness‘, particularly in young children who are naturally less aware of their body and how it functions. Hypo-unawareness is physically dangerous, but it is also a mental battle for the patient and for those who care for them. When our son Noah, is feeling these symptoms his insulin pump will give me a warning alarm (caveat: there is a 20 minute, give or take, communication delay between his body and the pump) and I can treat the hypo for its physical effects.

There is no medical treatment for the mental effects of a hypo. In our experience, Noah morphs from an adorable kitten to a roaring lion in a nano-second. He goes from “Mummy I love you to the universe and back” to a vein-popping, red faced animal screaming inaudible words that make no sense anyway. Unlike typical child-like tantrums (which he naturally has too, yey! these appear as is if from nowhere.

Sometimes his behaviour is quicker to burst forth than the pump’s warning alarm and we can tell he is having a hypo simply from his monumental meltdown over inconsequential nothingness. Even though I know his diabetes is just ‘having a conversation with me’, I confess, I sometimes feel embarrassed when we are out in public. There are occasions when I have been in the supermarket or walking down the street and Noah’s diabetes wants to have another ‘chat’ with me. Millions of parents know the look you get from strangers on the street; you know the one, it appears that you cannot control your own child. I get those same looks but sometimes I just want to scream ‘you have no idea what he battles with inside!‘

Noah can also become confused during a hypo and he finds it difficult to concentrate. Whilst these are less fiery side-effects they cause me more long-term concern than the tantrum-style behaviour. I know the meltdowns will become easier as he gets older but he has already started school and now I find myself wondering how hypos will affect him in the future. How will Noah cope with T1D together with his education? Will it impact his academic ability? How can we help him now to learn to overcome these issues down the line?
According to this scholarly article we are already using the best possible therapy to support Noah’s mood and behaviour. ‘Continuous subcutaneous insulin infusion’ or insulin pump therapy has been very effective in reducing the frequency of hypos in T1Ds and the results show improved mood and behaviour changes in young children. So is that all that we have at hand to help? My answer to this is: I don’t think so.

Whilst it is notoriously difficult to measure neurological impact of T1D and, from what I can gather, is something that experts vary in opinion on, frequently the following cognitive elements are reported to be affected by T1D: intelligence (general ability), attention, processing speed, memory, and executive skills. I am not a scientist and I haven’t done any research into this, I am also only two years in as a T1D carer but my firm belief today is that all of these cognitive domains can also be greatly influenced by the parents, teachers, siblings, social circles, mentors and extended family etc. who surround the child.
And what about hypers? Someone once described to me that a hyper is like having a massive hangover, but without the nausea part. The patient is very thirsty, has severe headaches and lethargy. It isn’t rocket science to realise that these are not attributable feelings to a productive day at school or work.

For the last year, Noah experiences an (as yet) unresolved hyper every morning after his breakfast. His glucose levels soar, sometimes triple the amount of a non-T1D and try hard as we might, we haven’t yet fixed this ‘bug’ in his daily routine. Nevertheless, off he marches every morning to school, feeling like he drank himself under the table the night before. For now, I simply admire his strength but I worry about when he becomes a teenager, how will he find the will to keep concentrating on math, or history or grammar when he mentally becomes aware that he has a choice?
And speaking of teenagers, puberty is a notoriously challenging period for many diabetics, but I will leave this topic for another day, another year even. The underlying point here is that T1D presents enormous challenges both physically and mentally. Both require a bachelor degree level of understanding to deliver optimal short and long term care. Both take place behind the scenes and in front of a crowd but T1D is so massively misunderstood by many (including me before my son’s diagnosis) that raising awareness and understanding is a monumental challenge, but one that many can be proud to be passionate about.
#weneedacure

 

Polycystic ovary syndrome is linked to autism in offspring

Cambridge University Autism Research Centre has found that compared to women who do not have polycystic ovary syndrome, women who do have this have about double the risk of having a child with autism.  The risk was slightly higher in male children compared to female children.

Cherskov A et al. Polycystic ovary syndrome and autism: At test of the prenatal sex steroid theory. Transl Psychiatry. Aug 1 2018. doi:10.1038/s41398-018-01867.

The UK and US are the only western countries where life expectancy is falling

Researchers looked at 17 high income countries to evaluate trends in national mortality.

In the UK there has been a drop of a few months in life expectancy for both men and women over the age of 65. Degenerative diseases were the main cause such as respiratory disease, circulatory disease, Alzheimer’s disease, nervous system disease and mental disorders.

In the USA drug overdoses were responsible for the decline in life expectancy.

The study looked at mortality between 2014 and 2015. A sixty five year old in the UK at that time would have been born in 1950, after the start of the NHS.

We will need to wait to see if this trend will reverse or not.

British Medical Journal. UK life expectancy drops while other western countries improve. National Health Services. 2018 August 16.

Younger age at diagnosis predicts earlier death in type one diabetes (on standard treatment)

Researchers in Sweden have found that the earlier children are diagnosed with type one diabetes, the less their life expectancy is. Matters are worse for women than men. They think that adults diagnosed in childhood need increased input to deal with cardiovascular risk factors as they get older. Currently age of onset is ignored when it comes to stratifying risk.

Those diagnosed under the age of 10 had 4 times the hazard ratio for all cause mortality, over 7 times the risk of cardiovascular disease, 4 times the risk for non cardiovascular mortality,  over 11 times the risk of cardiovascular disease, 31 times the risk of having a myocardial infarction, over 6 times the risk for stroke, 13 times the risk of heart failure, but almost the same risk as controls for atrial fibrillation.

There is a better outlook for those diagnosed in their late twenties. The risk was almost 3 times the background rate for total mortality and the most prominent risk was again for cardiovascular mortality coming in at 6 times the background rate.

What this means is that if you are a girl diagnosed with type one under the age of ten, you may expect to live almost 18 years fewer than your classmates and if you are a boy, 14 years fewer.

My comment: More effort could also be given to youngsters on diagnosis achieving normal blood sugars by advising parents about the easiest ways to control blood sugars such as the adoption of a low carb diet and advanced insulin techniques. Although these statistics are shocking to see, it doesn’t have to be like this at all. Many diabetics have changed their life expectancy around and reverse some complications by adopting practices that improve glycaemic control and metabolic factors such as we describe on this site.

Rawshani A et al. Excess mortality and cardiovascular disease in young adults with type 1 diabetes in relation to age at onset: a nationwide, register-based cohort study. Lancet 2018;392:477-86;doi:10.1016/S0140-6736(18)31506-X