Category Archives: Health
By Wietse In het Panhuis
We probably all know the good feeling during exercise. Either we are in the gym lifting weights to become stronger, bigger and fitter, or we are running or cycling outside or practicing any performance sport. All of us who are very dedicated to training a lot experience this positive feeling during our training and a feeling of satisfaction afterwards. Exercise makes you feel confident in your body and makes you stress free. For those who train every (other) day of the week probably also know the feeling of not exercising for a couple of days in a row. This gives a feeling of restlessness, perhaps makes you a bit down, while being impatient to train again. For some people not training for three days in a row can be stressful. Is this a sign that exercise may be addictive? It isn’t, because training a lot is healthy, right? If it’s an addiction it’s a healthy addiction , and nothing compared to a substance addiction such as alcohol. It is better than going out, drinking a lot or unhealthy snacking. Of course, these things are much different when they are compared with each other, but does that mean that exercise is not an addiction nonetheless?
What defines addiction?
Like any other term, phenomenon or condition there are countless definitions. Thus, while one definition may refer to addiction, another might not. Therefore it is always difficult to come to a conclusion and reach consensus. However, a distinguishment can be made between dictionary definitions and clinical definitions. Where dictionary definitions shortly and broadly describe something, clinical definitions are elaborate and detailed. Hence, in a clinical situation such definitions are needed to establish whether a certain disease is present or not. Hereby, there may be a difference in what the public refers to as an addiction compared to what a clinician would refer to.
Let’s start off with the following definition regarding addiction by the Cambridge dictionary: “The need or strong desire to do or to have something, or a very strong liking for something”. By means of this definition, exercise could be an addiction. The word addiction has quite a negative undertone, but when looking at this definition, is it really? Is it bad to have a strong desire for and liking of exercise? No, probably not. An exercise addiction in light of this definition seems neither negative nor positive. It’s just a matter of liking.
Another definition states addiction to be “a persistent compulsive use of a substance or action known by the user to be harmful”. Knowing that exercise is beneficial for human health, exercise would not be an addiction according to this definition. This definition mainly implies addiction to substances like drugs.
A medical definition, from the American Society of Addiction Medicine, regarding addiction states the following: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry[…] This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response […]” Note that all of those definitions acknowledge that behaviours, in addition to substances, potentially lead to addiction! Still, only gambling is officially recognized as a behavioural addiction as of yet, though internet and food addiction are vivid areas of research [2,3]. A clinician would hereby be careful to diagnose an excessive exerciser as an addict. Some aspects of this definition – such as the pursue of reward, inability to abstain (or stop) exercising, craving and possibly more – might hold true for exercise, but these are much less severe than when compared to a substance (or gambling) addiction. These aspects translate to a physical or mental dependency on exercise. This would mean that when the use of for example a substance would stop, the addict would suffer physical or mental consequences, also referred to as withdrawal symptoms. So when someone is used to exercising very often and suddenly stops doing this, he or she would probably experience some negative withdrawal symptoms. These are different for every person. While some may not experience these symptoms at all, others might become depressed, and everything within that spectrum.
During exercise, dopamine and many other chemicals such as endorphins are released in the brain. All these hormones and neurotransmitters lead to increased euphoria (happiness), reduction of anxiety and increases in pain threshold. Dopamine and endorphins are the feel-good neurotransmitter that play a role in the reward center of the brain. From eating delicious foods to winning a game and taking certain drugs, dopamine is the chemical that make us want it, and endorphins the one that makes us enjoy it. Without dopamine, you wouldn’t be stimulated to eat dessert after you are already satiated once you finished a two-course meal. Dopamine makes us repeat the actions that lead to its release in order to get the feeling of happiness again. Endorphins inhibit pain signals and could give a feeling of euphoria (a well-known example of this is the runner’s high). Endorphins act on opioid receptors. The opioid receptor works like any other receptor: it is plastic, meaning that it can change. Receptors can adapt to a changing environment by increasing or decreasing in number and also by becoming more or less sensitive, depending on the amount of substrate (in this case endorphins) that is present. We probably all recognize this in caffeine: when you hardly ever drink caffeine, you get very energetic after drinking one cup of coffee, but when you drink it more often you need more cups to get the same effect. This receptor desensitization (becoming less sensitive to stimuli and needing more of a stimuli to reach the same effect) also occurs with the opioid receptor. When one exercises very often, more endorphins are released on a daily basis than without the exercise. One becomes used to these higher levels of endorphins. Suddenly stopping with exercising daily would thereby result in a ‘blue Monday’: a lack of ‘happy hormones’ that makes you feel down. This could cause a physical dependence of exercise.
However, like stated before, an exercise addiction is not the same as an alcohol addiction. Where exercise is healthy for the body, excess alcohol is detrimental. So according to the definitions of liking or dependency as a criterion of addiction exercise can be an addiction, but not according to the clinical definition, nor is exercise harmful to the user. So is any dependency on something by definition an addiction? Are the things that stimulate dopamine and endorphin release in the reward center of the brain addictive? If you love listening to music and would suddenly stop having music in your life, would that be considered an addiction? Probably not. Or if you would have problems with abstaining from the toilet which results in a bit more than minor discomfort… 😉 The same goes for reading a good book, enjoying good company, dancing, fishing, and so on. These are the many simple things in life that we enjoy doing. If we can’t have those simple things we would be disappointed, but that does not mean we are addicted. Like mentioned before, the brain simply functions in this way in order to stimulate behavior that is considered beneficial. These little things make us happy and make us enjoy our lives. Without them, there would be no happiness in this world, therefore we must be allowed to enjoy them. It is only when these things become too important that they bring you physically or mentally out of balance, that it could become a problem.
One might say that in general something is not an addiction as long as there are no negative consequences. Does this mean that as long as one just exercises frequently without any adverse mental or physical effects, exercise is not an addiction? We already know that clinically speaking, exercise is probably not an addiction. However, if at any point exercise has adverse mental of physical effects, can it be considered a sort of addiction or compulsive behavior? One review that looked at people who are exercise dependent found that compulsive exercise is associated with eating disorder pathology, perfectionism, neuroticism, narcissism, and obsessive compulsive traits. This doesn’t mean that anyone who exercises a lot will get these problems or traits, but it means that these problems or traits occur more often in an exercise dependent person that in an exercise independent person. It might be that people who are more likely to get these traits become exercise dependent more often than other people. It might also be that an extreme form of exercise triggers these problems or traits. However, this topic of research is still behind, due to the lack of research and methodological problems. If these problems or traits are not present we probably tend to conclude that exercise is not harmful, but is that true? Would there be a realistic situation that could occur in any of us where an exercise dependency becomes harmful?
When the consequences of exercise become negative
There seems one possible and logical situation where exercise dependency has negative consequences: when one is not able to exercise anymore, of which injuries are the most common cause.
There are two problems regarding injuries with exercising a lot. First of all, exercising a lot could lead to training too much and thereby an increased risk of overuse injuries. Knowing how to train safe and smart could help a great deal with injury prevention, but there is always a chance on an accident. Secondly, exercise dependency makes one want to train often without skipping a training. It is therefore difficult to get enough rest to recover and to rehabilitate steadily without overtraining. One study that nicely illustrates this looked at interviews with physiotherapists, who had treated injured people with an exercise dependency . These therapists stated that the largest problem in treating these people was the low compliance when they asked them to exercise less. In other words, recovery from their injuries was hampered by the fact that they were not able to abstain from exercising.
Mainly this last aspect complicates the whole injury situation. Rationally one knows to take it easy in order to recover, but often this is too difficult. One ends up doing too much, resulting in a worsening of the injury, leaving you at the end and beginning of a vicious circle. One could stay within this circle for quite a while during which the situation keeps spiraling downward, until one finally realizes: it can’t go on like this. Meanwhile, the situation has hit rock bottom, where exercising (daily) has become impossible. In addition, daily life has become a struggle: walking, standing, even sitting causes pain. The feeling of missing a normal training becomes stronger and stronger. The body starts to become weaker and less muscular, stress increases, and one misses its most important outlet. Feelings of stress, anxiety and depression increase. At this point one wonders how much he would give to get out of this situation. Looking jealously how others are exercising like ever before, wondering why they can while you can’t. At this point you realize: I show signs of addiction. Which is just like what happened to me.
My personal experience
I wrote this article because I found out for myself how addicted I was to exercise while I had been injured for a very long time. I suffered from a back injury for three years. The paragraph above roughly describes the development of my injury. I was in this downward spiral where I tried to train, ending up worsening the injury and the situation, after which the circle started again from the beginning. I quickly started to notice the injury in my daily life. I couldn’t walk for 20 minutes without noticing it, the same went for sitting. Standing was even worse. It caused me stress. There were moments I felt depressed (depression is a condition from which I did not suffer and I don’t want to speak lightly of it, but you get the point). I couldn’t enjoy the simple things anymore, because I was too distracted by the injury. I had been to six different physiotherapists. All of them were able to help me in the beginning, but after ending up in another downward spiral, they did not succeed in lifting me up from it again. At one point, it was so bad I couldn’t even go to the supermarket and do groceries anymore. It was the first year of my master, and it started halfway the first year of my bachelor. At this point I was often thinking about doing an internship in the next year, requiring 9 to 5 attendance. How would that on earth be possible, when I was laying down in bed half of the day? Let alone getting a job after my internship?
In the meantime I had been to so many physiotherapists, I started losing something much more important than my strength, fitness and muscle mass I had been working on for years. I started losing hope. I always thought at some point in my life I must recover from the injury, naturally. It made sense that this was a temporary thing and that it must go over at some point, but now I started to lose that confidence. If it had to end at some point, it first should be preceded by change or improvement, but improvement was not coming. Therefore, I gained the mentality to try anything that would give a slight chance of improvement. Someone recommended a physiotherapist who had helped him before. I did not have much confidence that it would help, but I went anyway.
At the beginning of every first session with a physiotherapist, the therapist will ask you to explain the situation and the symptoms of the injury. Like any other time, I explained in a mere 10 minutes what was going on. To explain the whole situation I would need about a day or write a whole book, but I did the best I could to give a good depiction of the situation. I told about all the advice I had been given by previous therapists and that I took all their advice to heart by doing all the required exercises, stretches, and any other possible beneficial action on a daily basis. Somewhere in the middle of my story he interrupted me and said “what exactly is the problem? You are not in great pain, your back can make all movements without problems, nothing seems to be wrong with your back. All you seem to have is some feeling in your back. You know, I think all those physiotherapists have driven you crazy: “Pay attention to this, pay attention to that, keep this straight, don’t forget that”. Just let it go. Just move on.” And so his speech continued for a while. Within half an hour I stood outside of his practice. After three years I found out that the problem had grown in my head. I was so intensely focused on my injury that anything I felt in my back caused me anxiety. Any stimulus would tell me something was wrong, that I was exhausting my back, that I had to lay down. This pattern had caused me to become so inactive and not used to moving, that it made sense that any movement would result in some feeling in my back. It made sense that when I would walk for 20 minutes I would start feeling my back, because I was not used to it anymore. I misinterpreted the stimuli since I didn’t know the reaction of my own body anymore. The day prior to the visit to this therapist I was not able to go to the supermarket and do groceries. This day I went cycling and walked for over half an hour. The week after I started exercising. I could again go out on a trip, visit family, go on a weekend trip. All things I couldn’t do before without having stress and anxiety, without enjoying them, I could now do again. It felt like my life has stood still for three years and I could start living again. Nowadays I am no more limited by my injury and I am doing my internship from 9 to 5.
I experienced for myself the huge impact of restraining from training after exercise dependence. From physically feeling down and stressed to mentally seeing everything I worked for disappear. If I would have to answer the question “Is exercise addictive?” I would say that it can be considered a small addiction, even though clinically it is not recognized as an addiction. However, the purpose of the article was not to quarrel about definitions or only show scientific articles, but I wanted to show the human perspective, hence I called this an opinion article. I would say that if exercise would be considered addictive, it doesn’t have to be a problem. Like anything or any activity that brings us joy, exercise can brighten our lives as long as it doesn’t get out of proportion. If your whole world does not evolve around exercise, it wouldn’t be unbearable when suddenly exercising wouldn’t be possible anymore.
I would just advise to sometimes stand still and think about the transience of life. One day we will be old and our exercise performance will decline, so it should not happen that we lose our happiness when we get older. Realizing this from time to time will bring us perspective on what is important in life. Similarly, something detrimental could happen to us at any moment in life. When we are aware of this, we will be prepared and able to deal with it when it happens.
Always wanting to lift more weight, to get stronger, to be fitter, to look better is something you strive for when you are training passionately. However, at some point we must be satisfied with where we are. Enjoying what we have without always wanting more is an undervalued capacity nowadays. When we think in light of this about the endorphin story again, we know that exposure to more endorphins desensitizes the receptor. Always wanting more does therefore not work. When you get more, the next time you need even more to stay happy. Finally you would end up drinking 10 cups of coffee a day. A man who wins the lottery is thrilled of excitement one day, but this effect slowly wears off and in the end the money didn’t buy long-lasting happiness. It becomes boring. Similarly, this can be compared to a phenomenon called muscle dysmorphia (or in bro terms ‘bigorexia’), during which people feel like they are not muscular or can only see their shortcomings, even though these people are very ripped. It’s programmed in our brains and society to want more, but wanting more is not possible every single day. Happiness without sadness doesn’t give happiness. You can’t be happy every moment of the day during every day of the year. In our current society we have the idea that we should always be happy and when this doesn’t happen we are afraid that we don’t enjoy our lives.
Maybe our opioid receptors need a day off every now and then. Just once in awhile, a single day to not experience much joy. To stay inactive. To rest and sensitize. So the next time they get a glimpse of happiness, they take the opportunity to enjoy it to the fullest. And maybe so should we.
 ASAM Board of Directors, American Society of Addiction Medicine. (2011, April 19). Retrieved December 08, 2017, from https://www.asam.org/resources/definition-of-addiction
 O’Brien, Charles. “Addiction and dependence in DSM-V.” Addiction 106: 866–867 (2011): 10.1111/j.1360-0443.2010.03144.x
 Potenza, Marc N. “Non-Substance Addictive Behaviors in the Context of DSM-5.” Addictive behaviors 39.1 (2014): 10.1016/j.addbeh.2013.09.004. PMC. Web. 8 Dec. 2017.
 Lichtenstein, Mia Beck et al. “Compulsive Exercise: Links, Risks and Challenges Faced.” Psychology Research and Behavior Management 10 (2017): 10.2147/PRBM.S113093. 85–95. PMC. Web. 8 Dec. 2017.
 Adams, J., & Kirkby, R. (1997). Exercise dependence: A problem for sports physiotherapists. Australian journal of physiotherapy, 43(1), 53-58.
By Wietse In het Panhuis
Probably everyone recognizes this situation: You have had a busy work week, waking up early at 7 am every morning, and going to bed at 11 pm. On Friday, you feel tired and you have the feeling that you should catch up on sleep, but you also want to go to bed later, since it’s weekend. Therefore, you decide not to set your alarm clock on Saturday and Sunday. You stay up late on Friday and Saturday, and you wake up at 11 am on Saturday and Sunday morning. Is this a good idea? Does sleeping in really help to catch up on sleep, rest and recover?
As mentioned before in my other article on sleep and rest, there is not an optimal sleep duration that works for all people (if you missed the previous article, you can read it here: https://wageningenbeasts.com/2016/12/04/optimizing-your-sleep-and-biological-rhythm/). Some people need much sleep, others need less. The reason for this is differences in habit, but also differences in genetics (and of course differences in age, but this can be neglected since the readers of this article are probably all students). Therefore, no solid recommendations can be done on how long you should sleep.
If you get less sleep than you need, sleep deprivation (the need for sleep) will accumulate. Often when you have one bad night of sleep, you will still feel fine the next day, but when this happens for a few nights in a row you will start to notice the effects of sleep deprivation. Of course I don’t have to explain to you that (chronic) sleep deprivation is bad for you and can have serious health consequences. That is probably also the reason you want to sleep late during the weekends, to get some more rest. In theory, it is true that the body needs to catch up on sleep when it is sleep deprived, so in that respect you are right. There are however other factors that play a role.
The biological clock
Like mentioned before in my previous article, the biological clock is a mechanism that (a.o.) informs the body about time: the sensation of day and night. The biological clock is a complex system, because it can be influenced by many factors (think of light, psychological factors, activity, food intake). The complexity is also the reason why the biological clock does not adapt easily to changes in the daily routine. A jet-lag is a perfect example for this. After traveling it takes some time to adjust the sleep rhythm to the new time zone. However, it takes even longer before you are fully adapted to the new time (e.g. when you don’t need an alarm clock to wake up at a certain time). A rule of thumb is: don’t mess with your biological clock! It is best for the biological clock to have a regular pattern in sleep (most important), but also in things like food intake. Big changes in these patterns disturb the clock, which could result in sleeping problems, fatigue, changes in mood, concentration, study performance and metabolism, and in more severe cases (like chronic shift-work) in diseases like diabetes, cardiovascular disease and obesity, and even mortality[1-6]. A stable clock is therefore a healthy clock.
When you wake up early during the week and late in the weekend, this is confusing for the biological clock, especially when there is a great difference between the times of waking up. For each day you go to bed and wake up at a different time, the biological clock has to adapt. When sleeping in during the weekend and waking up early on Monday again, the biological clock keeps adapting back and forth. In this way, the body does not fully get used to waking up early during the week. This could possibly be the explanation why you are feeling tired during the week.
What I personally notice, is when I am not used to waking up early, and I wake up early even though I get my hours of sleep, I am still tired. This is because the biological clock is not used to waking up at a different hour, and not because the body did not get enough sleep. When sleeping in during the weekend, the body is not well-adapted to waking up early during the week, and this can cause the sensation of fatigue.
Thus, when you are tired after waking up early for a week, the likely cause of this is that your rhythm during the weekend is different, and not because you don’t get enough sleep. The latter is of course still a possibility, and in that case you could try to go to bed earlier to see if that helps. The answer to the question: ‘Is sleeping in during the weekend beneficial?’ is therefore: No, the benefits of some extra sleep do not outweigh the disadvantage of a disturbed biological clock. If you still want some extra sleep during the weekend, the best thing to do is to go to bed earlier.
Of course this is not a very attractive message. When it is Friday, we want to enjoy our weekend by staying up late and do fun things. This message discourages that. You might accept and implement this message by enjoying your weekend in the morning instead of late in the evening, but I can imagine that you don’t want to give up your nights out. Alternatively, when you go out partying, it might be better to still wake up early (maybe one hour later than on a weekday). In this way, you will have some sleep deprivation, but you can solve this by taking a power nap during the day or by going to sleep earlier in the evening. The upside of this, is that your biological rhythm will be more stable, which will be more beneficial in the long run.
 Åkerstedt, T., Kecklund, G., & Johansson, S. E. (2004). Shift work and mortality. Chronobiology international, 21(6), 1055-1061.
 Ramin, C., Devore, E. E., Wang, W., Pierre-Paul, J., Wegrzyn, L. R., & Schernhammer, E. S. (2015). Night shift work at specific age ranges and chronic disease risk factors. Occup Environ Med, 72(2), 100-107.
 Antunes, L. C., Levandovski, R., Dantas, G., Caumo, W., & Hidalgo, M. P. (2010). Obesity and shift work: chronobiological aspects. Nutrition research reviews, 23(01), 155-168.
 Li, Y., Sato, Y., & Yamaguchi, N. (2011). Shift work and the risk of metabolic syndrome: a nested case-control study. International journal of occupational and environmental health, 17(2), 154-160.
 Trockel, M. T., Barnes, M. D., & Egget, D. L. (2000). Health-related variables and academic performance among first-year college students: implications for sleep and other behaviors. Journal of American college health, 49(3), 125-131.
 Wolfson, A. R., & Carskadon, M. A. (1998). Sleep schedules and daytime functioning in adolescents. Child development, 69(4), 875-887.
By Wietse In het Panhuis
“What is healthy?”
You have probably heard this question, asked this question, or answered this question very often. It is a topic that everyone has an opinion about, and therefore a topic of discussion. People often tend to disagree, and argumentation between persons differs frequently. There are countless so called ‘experts’ who have written a book about nutrition, and countless subdivisions of groups of people, all with their own visions and way of living healthy. Nutrition and health can almost be called a religion. With so much diversity in opinion and belief, how do we know what is healthy? And what does ‘healthy’ even mean?
Let’s start with some definitions of health.
According to the World Health Organization (WHO), health can be defined as: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. This definition has been established in 1948. A more recent definition states: “Health is the ability of individuals or communities to adapt and self-manage when facing physical, mental or social changes”.
Health has a lot of different meanings. It can say something about the physical and mental status of a person, but also about the lifestyle in which nutrition, physical activity and habits are included. In this article I will mainly talk about health in relation to nutrition, as nutrition can have a great impact on both good and bad health.
From an economical perspective, a population is healthy if health care costs and unemployment due to disease will be low. So in other words, health would be defined as merely the absence of disease. From an environmental point of view, health would be defined as having a dietary pattern that is good for the body, which mainly includes sustainable and environmentally friendly foods. From a cultural perspective, health is simply eating the foods of your own culture. You are healthy if you eat the foods of your (eating) culture. Your own culture’s foods would contribute to a good physical and mental well-being. These three examples show that the meaning of health is determined by perspective, and there are many more perspectives than just these three; to each his own perspective towards life. There is not a single truth.
What if health is defined as happiness? That in turn raises the question: What is happiness? Happiness could be defined as living the way you want to live, not worrying about what you can and can’t eat for example. You can eat only healthy foods, but you may still be unhappy. Being unhappy can be physically unhealthy for you. Just doing whatever you want might make you happy (and therefore healthy), but it might have consequences for the duration of your life. For some people this is a trade-off. Happiness can also be defined as the absence of disease: being sick can decrease your quality of life significantly. Therefore, the absence of disease might be a prerequisite to being happy and healthy.
In conclusion, the definition of health is different for everyone.
Why do these definitions matter?
Why would it matter to have different definitions of health? Isn’t living a lifestyle that is supposed to be healthy beneficial for everyone in general? Of course, exercising, eating healthy, not smoking, not drinking, etcetera can be beneficial for everyone. However, as there are so many definitions of health, there is not a lifestyle that fits all of these definitions. Everyone has their own definition of health, and therefore there might be different ways to approach this. What can be seen as healthy, could not be as healthy or important for another person. Some examples below will illustrate this.
Think of a person suffering from anorexia nervosa (an eating disorder). This person has a mental problem that is causing the inability to eat. When such a person eats, this provokes feelings of fear. For this person it is extremely important to tackle this mental issue and learning to eat again, while proper nutrition and exercise are less important.
Another example: the elderly. It is well-known that muscle mass and functionality decrease with aging. This often results in immobility, such as not being able to rise from a chair, walk the stairs, do groceries, etcetera. Eventually, this will lead to a loss of independence, meaning that elderly can’t take care of themselves anymore. So for elderly the focus could be on maintaining their muscle mass and functionality. This goal requires different dietary factors than what is generally considered to contribute to health. To optimize muscle mass and functionality, one should engage in physical activity (partly cardio, partly strength training) and have sufficient protein intake and total energy intake. A high protein and energy intake are not considered to be good for general health outcomes, such as good organ functionality, healthy aging, absence of disease, etc. Eating vegetables for example is not important for the goal of optimizing muscle mass and functionality.
As was mentioned earlier, happiness and thereby healthiness can be determined by living a lifestyle where you just do what you want to do. There is scientific consensus on the fact that it is best to not drink alcohol, and limit red meat intake[4,5]. For persons who value unhealthy habits this might seem irrelevant, because alcohol and red meat might be important contributors to their happiness.
Everyone has their own definition of health, based on what would be best for their situation or on their view on life. This can depend on age, mental well-being, physical well-being, the presence or absence of disease, the differences in risk people have of getting a disease, and so on. Therefore, health should be seen as a relative concept, and thereby there should also be different ways to approach it. There is not a ‘one-size-fits-all-solution’.
Should you give the same lifestyle recommendations to an anorexic girl of 14 years old and a frail man aged 85? Or to a young woman suffering from depression, a man with terminal cancer who has 1 year to live, or a grandmother with dementia that doesn’t even recognize her own husband anymore? No! They all have different priorities in live. The anorexic girl needs to survive: she has to prevent starving to death by working on her mental issues. The frail man needs to improve his mobility, by exercising and having a high energy high protein diet. The young woman with depression might eat healthy in order to keep her body healthy, but when you suffer from depression this can also make you physically unhealthy, let alone the fact that she is not happy. Mental health is much more important for this woman than physical health. The man with terminal cancer should try to make most of his life that he has left. Should he eat his fruits and vegetables every day in order to be healthy? He is going to die anyway, why not eat the foods he likes and spend time with his family on the couch? Also, why would you keep the grandmother with dementia alive? She does not recognize her family anymore, she doesn’t know where she is, her quality of life has tremendously decreased. Would you want her to eat fruits and vegetables in order to be physically healthy when mentally she is already long gone? In these cases it might seem more humane if death comes soon naturally after years of suffering…
This article might have had a bit of a philosophical approach instead of some clear answers on what is healthy, which is probably what you hoped for when you started reading this article. However, this article might set you thinking about what is important for you. What do you need in your life that makes you happy? What should you emphasize in your life? After all, being happy is more important than being healthy. It is just nice if these two can fit together in your life.
Find your priorities in life, live accordingly and pursue happiness.
 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
 Huber, M., Knottnerus, J. A., Green, L., van der Horst, H., Jadad, A. R., Kromhout, D., … & Schnabel, P. (2011). How should we define health?. Bmj, 343.
 Aoyagi, Y., & Shephard, R. J. (1992). Aging and muscle function. Sports Medicine, 14(6), 376-396.
 International Agency for Research on Cancer. (2015). IARC Monographs evaluate consumption of red meat and processed meat. press release, (240).
 Alcohol. World Health Organization. Retrieved January 29, 2017, from http://www.who.int/topics/alcohol_drinking/en/
By Wietse In het Panhuis
Do you have trouble falling asleep? Are you sleeping long, but are you still feeling tired? Do you have a disturbed sleep rhythm and do you want to change it? I addressed these questions and many others in my recent lecture on sleep and rest. For members there is an opportunity to watch the lecture online (it is posted in our Facebook group under videos) in case you missed the lecture. Nonetheless, I will summarize my lecture in this article. First, I will provide some background information on sleep and rest, and afterwards I will give some tips on how to change sleep rhythm and improve sleep.
The biological clock is a ‘system’ in the brain that regulates the daily rhythm of +/- 24 hours. As most of you might know, the biological clock plays an important role in the sleep rhythm. In humans (and many other animals), this rhythm is not exactly 24 hours. This system, also called the suprachiasmatic nucleus (SCN), which is located in the hypothalamus of the brain, is set like a stopwatch: every day it counts down 24.2 hours. This would mean that after one month of such a rhythm, your rhythm will have shifted 6 hours (30 times 0.2 hours per day). Luckily, this system (or stopwatch) is able to adapt in such a way that this clock becomes 24 hours exactly. This adaption (or entrainment) can happen because the body is able to register signals from the surrounding environment. These signals (or stimuli) tell us something about the time of the day, and are therefore also referred to as ‘zeitgebers’ (=time-givers). The most important zeitgeber is light. The SCN is able to register light, which will result in a signal of ‘day’. In the absence of light, the SCN will interpret this as ‘night’. This adaptation of the biological clock, also called the pathway of light entrainment, is displayed simplistically on the picture on the right (retrieved from: https://www.nigms.nih.gov/education/pages/factsheet_circadianrhythms.aspx). Here you see that light travels to the SCN through the eyes, which will result in a message of ‘day’ in the brain.
Most of you probably have also heard of melatonin. This hormone is released in the brain (in the pineal gland (hypofyse in Dutch)) during the evening, and levels peak during the middle of the night (and are low to zero during the day). Melatonin makes you feel tired and stimulates the body to fall asleep. Therefore, melatonin plays an important role in the sleep rhythm. Melatonin is also involved in the pathway of light entrainment (which was described above). During the day, the light will tell the SCN that it is ‘day’. The SCN in turn will inhibit or block the pineal gland, which will prevent the pineal gland from releasing melatonin. During the evening, the absence of light will allow this inhibition to stop: melatonin will be slowly released, and you will become tired.
The eyes are especially sensitive to blue light, which means that of all colors of the light spectrum, blue light has the greatest impact on the SCN. This means that blue light gives the strongest signal to the brain that it is day. Blue light is highly present in televisions, laptops, smartphones, etcetera. You might imagine, that when the eyes are exposed to a lot of blue light during the evening, this will inhibit melatonin to be released, and will result in problems falling asleep. So if you use these devices a lot during the evening, this can lead to sleeping problems.
Sleep and training
The main function of sleep Is cognitive recovery; to give the brain rest, and to store the memories that are made during the day. Of course the body also rests and recovers during sleep, but recovery from training also occurs during the day (when you are sitting or lying down). In addition, sleep duration does not seem to be associated to heavy exercise: top athletes do not need more sleep than non-athletes[5,6]. Thus, sleeping more is not essential in recovering from training. However: sleep deprivation can hamper recovery. Thus, make sure to get your hours of sleep, but you do not need more than that. This will probably raise the question: how many hours do we need?
How many hours of sleep do we need, and how is this determined?
Age is the most important determinant of how much sleep one needs. Newborns need most sleep, and elderly least. However, within the same age groups, there are large differences in how much one sleeps. How much sleep you (as an average adult) need is determined by mainly two factors: genetics and habit. It is not exactly known how important the genetic factor is, in other words: how great the difference in required hours of sleep is between persons solely due to genetic differences. However, it is known that habit can cause great differences and that the role of genetics in sleep duration is probably small. All in all, no clear conclusions can be drawn on how much sleep an individual actually needs. So… now you still don’t have an answer to the question: how much sleep do you need?
Even though differences in individual sleep requirements are not known yet, one study looked at the average hours of sleep and the corresponding mortality ratio in a group of over 1.000.000 people. The mortality ratio tells something about the relative chance of death, compared between groups (if you do not understand it: it can be interpreted as an indication of how healthy someone is). These mortality ratios can be seen in the figures below (retrieved from Youngstedth et al 2004).
The first thing that can be concluded from these graphs is that there are hardly any differences between women and men in the mortality ratios of each group with different sleep durations. The figure also shows that people who sleep between 6.5 and 7.5 hours per night have the lowest mortality ratio and can therefore be seen as most healthy. The figure also shows that the mortality ratio increases with less than 6.5 hours of sleep, but what’s striking, is that the mortality ratio increases even more if people sleep longer than 7.5 hours of sleep. Also, on average, sleeping more than 9.5 hours a night is worse than sleeping 2.5-3.5 hours a night. Of course this is only one study, but it gives a good indication for the general population (side note: the study did adjust for lifestyle, physical activity and dietary factors).
Now there are some people who sleep 9 or even more hours a night, and if they sleep less, they are tired and not functioning. As you read before, genetics play a small role in differences in sleep duration, so this is a good example of habit. The body gets used to the amount of hours you sleep (Small intermezzo to illustrate this. Polyphasic sleep regimens are sleeping patterns during which you sleep (the most extreme example) only 2 hours per 24 hours. Every 4 hours you sleep 20 minutes. Within these 2 hours you rest as much as during a normal 8-hour night, since this sleep solely consists of deep sleep which has a higher restorative capacity. Anyone can get used to such a sleep pattern, but it takes a very long time to get used to. These polyphasic sleep regimens are a perfect example that shows that sleep is mainly determined by habit). If one would sleep 6 hours every night for many(!) nights in a row, the body will adjust the restorative capacity of sleep: one would have more restful sleep (more deep sleep, as deep sleep is most important in recovery). If one would sleep 9 or 10 hours for many nights in a row, the sleep rhythm will adjust to that: one would have relatively more light sleep (light sleep is not very important in recovery). In conclusion, even though there might be some genetic differences in how much sleep one needs, habit probably explains the large differences in sleep duration between people. Therefore, one can also change their habits and thus change their total sleep duration, which will result in more (productive) hours during the day.
How to change the sleep rhythm?
Now, how can one change his sleep rhythm? You might want to change your rhythm in case you go to bed late and wake up late, and you want to advance these times, or when you want to reduce your sleep duration in case you are sleeping 9-10 hours a night, as mentioned in the last paragraph. To help you with this, I have some tips:
- Be consistent! The biological clock is a complex mechanism, which is why it adapts very slowly to changes in your daily rhythm. Thus, be consistent in the time you go to bed and when you wake up. Sleeping late during the weekend with the intention to catch up sleep actually disturbs your rhythm, as this is a sudden, large change for your rhythm. Also, when you want to change (advance) your sleep rhythm, try to go to bed and wake up 5-15 minutes earlier every single day.
- When step 1 does not really work for you, since you are having problems with falling asleep earlier than usual, you might cold turkey your rhythm. Just set your alarm clock 1-2 hours earlier than you are used to and stick to it: wake up every day at this time. Your biological clock will have a harder time to adapt and will be disturbed due to the large change, but your body and brain will be more tired during the evening, which will aid in falling asleep. Doing this is more exhausting than option 1, as you will experience tiredness until your biological clock has adapted. Adapting completely might even take a few weeks! One important side note: when doing this, you will probably be more prone to fall asleep during the day. However, it is important you do not take daytime naps, as this will hinder sleep onset at night!
- A third option that might help is melatonin. As mentioned before, melatonin is a hormone that is produced by the pineal gland in the brain and is released (secreted) during the evening. Melatonin causes the typical feeling of being tired when it is getting darker outside. This hormone is also available in supplement-form. Taking low dosages of melatonin supplements a few hours before going to sleep can stimulate and advance the melatonin production of the body. This helps you fall asleep earlier and thus advance your sleeping rhythm. One important side note: do not use this chronically, and do not use high dosages. Chronic use or high dosages of melatonin can hamper the melatonin production of the body, and will result in melatonin-resistance: your body needs more melatonin to experience the same effects (due to receptor insensitivity, which basically happens when you administer any kind of drug).
How to improve sleep?
If you want to improve sleep (e.g. when you have trouble falling asleep or in case you are experiencing restless sleep such as frequent awakenings during the night) I also have some tips for you. Do mind, that not all of these tips are practical or feasible, but from a theoretical point of view to optimize sleep.
- Increasing zeitgeber strength can make the biological rhythm stronger and the sleep cycle better. This means, that when differences between day and night are greater, the body will have a stronger perception of day and night (zeitgebers). This can be done by:
- Decreasing the amount of light during the evening (dim the lights of the lamps and the television).
- Downloading a blue light filter on laptops and smartphones. As mentioned before, blue light exposure during the evening can inhibit melatonin release. This application filters most of the blue light from the screen, which will diminish inhibition of melatonin release.
- Limiting light from entering the room during the night, by having good curtains, and switching off all the lights.
- Spending the day in the light. Sunlight exposure can help, but also switching on lights inside the house when it is cloudy outside, will keep the light signals (zeitgeber strength) high.
- Avoid drugs (or psychostimulants). Pretty obvious, but that doesn’t make it less important. Avoiding substances such as hard drugs (MDMA, speed, etc.), but also limitation or elimination of smoking (nicotine), caffeine[14,15] and alcohol will help in order to optimize the nights rest. Consumption of these substances are all related to a decrease in sleep quality. A little side note for caffeine: there are large differences between persons in their sensitivity to caffeine (due to genetics and habit). This explains why some people can drink coffee during the evening without having difficulties falling asleep, while others have these difficulties when they drink coffee at 3 pm. Therefore, there are no clear conclusions about this yet, but as a general rule of thumb it is wise to avoid caffeine consumption (coffee, energy drinks) 6 hours prior to bedtime, and limit consumption of tea and soft drinks throughout the day[14,15].
- Limit stress. Stress can have a great impact on sleep: falling asleep is more difficult, sleep quality is less, and it will cause feelings of fatigue during the day. Limiting stress is therefore essential for optimizing sleep. However, this is easier said than done. Terminating stress from daily life can be achieved by looking at the stressor: what causes the stress? Are you able to eliminate this from your life? If it is not possible to change this stressor, it is better to change your attitude and how you perceive this stressor. Now this is quite an extensive topic, which is why we will discuss it more thoroughly in another article. For now, I can recommend meditation or yoga. A lot of people are not into this, but before dismissing it, you could give it a try. It takes some practice, but then it can be really beneficial and enjoyable. If you don’t want to try this, you might try a quick, easy tip: 4-7-8 breathing. This can be done when lying in bed when attempting to fall asleep. It is a special way of breathing that allows your mind and body to fully relax. With this technique you breathe in for 4 seconds, hold this for 7 seconds, and breathe out for 8 seconds. Do this very slowly, breathe deep into your belly and not your ribcage, and try to relax all your (facial) muscles. Doing this lowers the heart rate, relaxes the muscles, and lets the mind focus on the body instead of thoughts and will thereby help you to fall asleep more easily (this actually is the basic principle of meditation). You can look up 4-7-8 breathing on YouTube or Google for a more detailed explanation.
- My last and most important tip, is to think positively. The mind and body are closely connected. People who suffer from depression are feeling physically sick and people who are happy are physically healthier than when they wouldn’t be happy. Besides this, the mind also plays a crucial role in sleep. When you think you had a good night of sleep, you will feel energetic. When you think you had a bad night of sleep, you will feel tired. Your perception of sleep influences how tired or energetic you are. A good illustration of this, is a study that looked at elderly insomniacs: elderly people who suffer from chronic sleeping problems. From all possible non-pharmacological interventions that improve sleep, Cognitive Behavioral Treatment (CBT) seemed most effective in improving sleep in these insomniacs[18,19,20]. This treatment is normally applied for patients suffering from depression, as it helps to change unhelpful thinking and behavior. Thus, CBT, which helps in thinking more positively, seems to be most effective in improving sleep and energy levels during the day. This example shows how important mindset is in sleep. My message to you: don’t worry if you have one bad night of sleep. You will be fine! Your body is well able to deal with a little less sleep every now and then. Don’t let this influence how you feel! The same goes for those people who sleep 9-10 hours a night: you don’t need this, 8 hours will be fine. It is just a matter of mindset and habituation.
I hope these tips will help you, they sure have helped me improve my sleep. Good night all!
 Breedlove, S.M.W., N.V. , Biological Psychology: An Introduction to Behavioral, Cognitive, and Clinical Neuroscience. 7th ed. 2013, Sunderland, Massachusetts: Sinauer Associates Inc. 633.
 Reiter, R.J., Melatonin: the chemical expression of darkness. Molecular and cellular endocrinology, 1991. 79(1): p. C153-C158.
 Gooley, J.J., et al., Spectral responses of the human circadian system depend on the irradiance and duration of exposure to light. Science translational medicine, 2010. 2(31): p. 31ra33-31ra33.
 Phillips, S. M., Tipton, K. D., Aarsland, A. S. L. E., Wolf, S. E., & Wolfe, R. R. (1997). Mixed muscle protein synthesis and breakdown after resistance exercise in humans. American Journal of Physiology-Endocrinology And Metabolism, 273(1), E99-E107.
 Brand, S., Gerber, M., Beck, J., Hatzinger, M., Pühse, U., & Holsboer-Trachsler, E. (2010). High exercise levels are related to favorable sleep patterns and psychological functioning in adolescents: a comparison of athletes and controls. Journal of Adolescent Health, 46(2), 133-141.
 Leeder, J., Glaister, M., Pizzoferro, K., Dawson, J., & Pedlar, C. (2012). Sleep duration and quality in elite athletes measured using wristwatch actigraphy. Journal of sports sciences, 30(6), 541-545.
 Reilly, T., & Piercy, M. (1994). The effect of partial sleep deprivation on weight-lifting performance. Ergonomics, 37(1), 107-115.
 Barclay, N. L., Eley, T. C., Buysse, D. J., Rijsdijk, F. V., & Gregory, A. M. (2010). Genetic and environmental influences on different components of the Pittsburgh Sleep Quality Index and their overlap. Sleep, 33(5), 659-668.
 Youngstedth, S.D., & Kripke, D.F. (2004). Long sleep and mortality: rationale for sleep restriction. Sleep medicine reviews, 8(3), 159-174.
 Sánchez-Barceló, E. J., Mediavilla, M. D., & Reiter, R. J. (2011). Clinical uses of melatonin in pediatrics. International journal of pediatrics, 2011.
 Kramer, A., Merrow, M., Circadian Clocks. Handbook of Experimental Pharmacology. Vol. 217. 2013, Berlin Heidelberg: Springer-Verlag 417.
 McCann, U. D., & Ricaurte, G. A. (2007). Effects of (±) 3, 4-methylenedioxymethamphetamine (MDMA) on sleep and circadian rhythms. The Scientific World Journal, 7, 231-238.
 Sabanayagam, C. and A. Shankar, The association between active smoking, smokeless tobacco, second-hand smoke exposure and insufficient sleep. Sleep Medicine, 2011. 12(1): p. 7-11.
 Clark, I. and H.P. Landolt, Coffee, caffeine, and sleep: A systematic review of epidemiological studies and randomized controlled trials. Sleep Medicine Reviews, 2016.
 Drake, C., et al., Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med, 2013. 9(11): p. 1195-1200.
 Kamel, N.S. and J.K. Gammack, Insomnia in the Elderly: Cause, Approach, and Treatment. The American Journal of Medicine. 119(6): p. 463-469.
 Âkerstedt, T. (2006). Psychosocial stress and impaired sleep. Scandinavian journal of work, environment & health, 493-501.
 Irwin, M.R., J.C. Cole, and P.M. Nicassio, Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychology, 2006. 25(1): p. 3.
 Okajima, I., Y. Komada, and Y. Inoue, A meta‐analysis on the treatment effectiveness of cognitive behavioral therapy for primary insomnia. Sleep and Biological Rhythms, 2011. 9(1): p. 24-34.
 Trauer, J.M., et al., Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Annals of internal medicine, 2015. 163(3): p. 191-204.
By Wietse In het Panhuis
Everyone probably knows someone who has or has had the terrible disease called “cancer”. Cancer has not only affected their life tremendously, but also the life of their parents, their children, their brothers and sisters, their partners, their friends, their acquaintances, and you. Cancer is a scary disease because it silently develops over decades until at some moment you find out that you have cancer, and by then it may be already too late. But what can we do to prevent this? What is in our own hands?
Ask yourself: Which dietary or lifestyle factors will increase the risk of getting cancer? And which factors will decrease that risk?
What factors could you come up with? The answer of an average consumer would be: “E-numbers, coloring agents, sweeteners, hormones, sugar, and dairy products increase your risk of getting cancer and superfoods decrease your risk of getting cancer”. Read the rest of this entry