Shaving pubic hair

Pubic hair grooming is a growing phenomenon and is associated with body image and sexual activity. Hair is a distinguishing feature of mammals, though the persistence of visible head, armpit, and pubic hair remains anthropologically unclear. Humans throughout the ages have modified their head and body hair, but aesthetic removal of pubic hair has become the “the ultimate barometer of how fashionable you really are” in the 21st century. Pubic hair was rarely depicted in artistic representations of the nude until the late 19th century ¹. Since the latter half of the 20th century, pubic hair removal also called depilation or epilation, has become an increasingly common grooming practice in the United States and other developed nations ². Pubic hair grooming is increasingly prevalent among men and women in the United States ³.

It is postulated that the current trend of pubic hair removal may be related to the increased accessibility of Internet-based pornography ¹. Vannier et al. ⁴ analyzed pornographic movies and found men are likely to be groomed and most women were likely to have no pubic hair at all, mirroring some pubic hair grooming trends. Anecdotally, pubic hair removal may carry benefits regarding increased sexual sensation and satisfaction though there is no quantative research in this field ¹. Pubic hair removal appears to be an important aspect of expressing one’s sexuality and participation in sexual activity. This practice has an interesting psychosexual basis which, to date, has not yet been fully explored in sexual medicine. Changing beauty ideals are reflected in media sources, such as sexually explicit media or pornographic images ⁵ and have likely contributed to the expansion of this cultural trend. Pubic hair removal has also been associated with various sexual behaviors in women, such as receiving vaginal and clitoral stimulation with fingers ⁶. The role of sexual behavior and pubic hair removal in men is less clear. Several studies have looked at psychological factors contributing to pubic hair removal in men and have found the drive for muscularity, gender role conflicts, and physical appearance social comparisons have been correlated with increasing degrees of body hair removal ⁷. It has been shown that men who have sex with men remove their pubic hair more frequently ⁸.

There are numerous reasons to remove pubic hair; the most commonly reported are focused on sexual activity and sexual expression ⁹. Increasing access to sexually explicit material may also influence grooming motivation and trends ⁴. In a recent study, pubic hair grooming was strongly associated with sexual activity and practices ³. Pubic hair grooming may lead to higher genital satisfaction and sexual function in women ¹⁰ and to greater positive body image in men ⁸. Interestingly, pubic hair–related grooming injuries have increased over the past 10 years, and it has been suggested that anogenital grooming may put one at risk for a sexually transmitted infection (STI) ³. The association between pubic hair grooming, sexual activity, and genital injuries/infections indicate that this is a potentially important but overlooked public health issue.

From a public health perspective, pubic hair removal has been implicated in the spread of certain sexually transmitted infections; however, the evidence has largely been anecdotal or limited to case reports ¹¹, ⁵, ¹². Pubic hair removal has also been associated with a decreased incidence of pubic lice ¹³.

Pubic hair removal can be accomplished by shaving, waxing, trimming with scissors or clippers, and/or tweezing. Herbenick et al. ¹¹ in a cross-sectional Internet-based survey of women aged 18–68 years, found that of those who had removed pubic hair ≥1 time in the previous month, ≤67% used razors, 6% waxed, and 1%–2% had undergone electrolysis or laser hair removal. These rates varied by age group as did the frequency and extent of pubic hair removal. Other studies have reported similar distributions of products used.6 Although the safety of certain personal use depilatory products such as hot wax have been questioned ¹⁴, genital injury from grooming products is largely unstudied. Minor complications, such as painful irritation, erythema, or folliculitis are not uncommon ¹⁵; however, severe complications after pubic hair removal, such as bacterial sepsis ¹⁶, have been reported.

From survey data, partial or complete pubic hair removal has been reported by upward of 70%–88% of young women in the United States ¹⁷. Similar findings have been reported from both Australia ¹⁸, New Zealand ¹⁹ and the United Kingdom ²⁰. The data demonstrated that substantial proportions of both women and men remove body hair from many sites. However, gendered differences remain, and a key dimension of gendered difference appears in the concept of flexible choice around body hair removal or retention. This was seen in the difference between perceived acceptability of having body hair (81% for men, 11% for women). These findings suggest that although men, like women, are now coming under some pressure to remove body hair, there is still a great difference in men and women’s capacity to choose whether to follow it. Investigators have also assessed the prevalence of pubic hair depilation practices in gay and heterosexual men, and 58%–78% reported regular partial or complete pubic hair removal ²¹. Until the 1980s, it was considered normal for women to shave only the bikini zone and armpits, while the latest trend, especially among younger women, is total pubic hair removal ²². Although women’s total removal of their pubic hair has been described as a “new norm,” this study involving 2,451 women ages 18 to 68 years ²² reported a diverse range of pubic hair-grooming practices. Women’s total removal of their pubic hair was associated with younger age, sexual orientation, sexual relationship status, having received cunnilingus in the past 4 weeks, and higher scores on the Female Genital Self-Image Scale and Female Sexual Function Index (with the exception of the orgasm subscale). Findings from that study ²². Although women’s total removal of their pubic hair has been described as a “new norm,” this study involving 2,451 women ages 18 to 68 years ²² suggest that pubic hair styles are diverse and that it is more common than not for women to have at least some pubic hair on their genitals. In addition, total pubic hair removal was associated with younger age, being partnered (rather than single or married), having looked closely at one’s own genitals in the previous month, cunnilingus in the past month, and more positive genital self-image and sexual function. This trend can be observed in magazines like Playboy, which demonstrate a transition from completely hairy pubic areas to different degrees of shaving and, finally, to total pubic hair removal ²³.

Body hair removal practices are potentially influenced by a variety of factors, including sex, age, partner and sexual activity status, sexual orientation, and body image ¹⁷. Not surprisingly, the demographic group largely purported to remove pubic hair—young women—had the greatest injury prevalence. Studies have found that more than one-half of all genitourinary injuries due to pubic hair removal were in women, who also had a younger age distribution, because about one-half were 19–28 years and 21% were ≤18 years old. One report, which surveyed women in a gynecologic clinic, found that >70% of adolescent girls aged 12–20 years routinely shaved or waxed their pubic hair ¹⁷. In an Internet-based survey completed by 2451 women aged 18–68 years, total pubic hair (vs partial) removal was associated with younger age ¹¹. Pubic hair growth in both men and women peaks in the mid-20s and later declines ²⁴. Increased hair growth at these earlier ages may in part explain a greater prevalence of grooming in younger ages.

At-home pubic hair removal is typically accomplished by shaving, waxing, trimming with scissors or clippers, or tweezing. Although minor adverse events, such as rash, folliculitis, pain, or irritation, have been reported after at-home hair removal techniques,10 case reports of subacute complications after pubic hair removal, such as methicillin-resistant Staphylococcus aureus infection ²⁵ or follicular keratosis requiring excision ²⁶, have been reported. Abscess was the primary diagnosis identified in 15.6% of that cohort, with patients typically presenting a various number of days after grooming. Systemic or life-threatening injuries associated with grooming products have been reported in published studies. Dendle et al ¹⁵ described a 20-year-old Australian woman with poorly controlled type 1 diabetes who developed life-threatening sepsis with Streptococcus pyogenes and Herpes simplex after undergoing complete pubic hair removal with hot wax.

Although few published reports have described the effect of grooming practices on external genital injury, the U.S. Consumer Products Safety Commission issued a Hazards Screening Report in 2005 ²⁷, describing injuries related to “personal use” products from 1997 to 2003. Individual product categories included electric grooming devices, unpowered grooming devices, and grooming devices nonspecified, in addition to other categories such as clothing, eye glasses, and shopping carts. An estimated 506,650 injuries due to personal items occurred in 2003, with 5.0% requiring hospitalization and 370 deaths (none related to hair removal devices). Although the hazards report estimated 285.5 million electric grooming products were in use in U.S. households in 2003, it is unknown what portion were hair removal devices. Thus, because genital hair removal is a relatively common practice, the overall injury rate has been very low. Nevertheless, emergency department doctors have found a sharp increase in the number of both men and women who presented to U.S. emergency departments with genitourinary injury in recent years ². In a national stratified probability sample of consumer product-related injuries presenting to U.S. emergency departments, doctors found a modest rate of genitourinary injuries related to grooming product usage (3% of all genitourinary injuries documented). Injuries occurred slightly more often in women (56.7%). When stratified by sex, differences in product type and injury diagnosis were observed. For both sexes, the number of incident cases increased approximately linearly during the study period but was most dramatic among women.

Depilatory practices account for a small portion of genitourinary injuries presenting to U.S. hospital emergency departments. Most injuries are related to nonelectric razors, are minor, and are managed with outpatient treatment. The demographics of patients with genitourinary injuries from grooming products largely parallel observations about cultural changes and grooming practices in the United States. Although hair removal products account for a small proportion of genitourinary injuries, the increasing number of incidents in both men and women is an important concern for healthcare practitioners.

Figure 1. Percentage of grooming injuries stratified by age category

[Source ²]

The proportion of products involved in the injuries is presented in Table 1. Nonelectric razors were involved in 9,600 or 81.9% of the injuries. Electric razors were implicated in 0.7% of the injuries overall and were associated with laceration, rash, or unspecified injury diagnoses. Hot wax was involved in 1.4% of injuries, and a small proportion of these involved the use of both hot wax and a nonelectric razor, which resulted in nonspecific pubic or external genital injury. The proportion of scissors-related injury was greater for men than for women (21.6% vs 6.7%). Furthermore, injury resulting from hair clippers was only reported for men, and injury from shaving cream and hot wax-related injuries was only reported for women. In a small study of depilatory wax burns from the Royal Adelaide Hospital, Australia ¹⁴ found patients with burn injury as a result of using microwave-heated hair removal wax products in a domestic setting.  The pilot study revealed an increase in wax temperature with the number of times the wax was heated. During definitive wax temperature testing, the maximum wax temperature recorded was 227.3 °F (108.5 °C). Seventeen of 60 wax surface temperatures recorded exceeded 194 °F (90 °C), 9 exceeded 212 °F (100°C). Ninety-three percent of the stirred wax temperatures showed an increase in wax temperature with an increase in microwave power output. The results of that study ¹⁴ show that when heating hair removal wax in the microwave according to manufacturer’s instructions, wax temperatures regularly reach unsafe working temperatures. As microwave output power increased, wax temperature also increased. Of the 9 wax temperature measurements that reached over 212 °F (100°C), 8 of them were heated in the 1200-Watts microwave. The results from that study show that the wax heats unevenly, as different areas of the wax surface heated to different temperatures, once mixed the temperature dropped significantly. It was observed that areas of wax at a higher temperature were less viscous with a greater tendency to spill. Given that the majority of burns resulted from wax spillage during removal from the microwave, the packaging of all microwave-heated hair removal wax products should warn that, following heating, the surface wax will become hotter and less viscous than the wax below, and the container may become less rigid and too hot to hold. This should be accompanied by a recommendation that wax is heated on a microwave-safe plate to reduce spillage, and the wax be stirred before use. Heating instructions should include appropriate microwave wattage for heating, an indicator when the wax is too hot for use—for example, a thermometer or color indicator—and detailed instructions for heating and reheating when the container is of varying fullness. Before the most common injury involved the hands (76%), additional safety instructions suggesting that the hot product is removed from the microwave using “oven gloves” might prevent most injuries. Also included should be a warning of the risk of burn injury and simple but appropriate first aid instructions. Most burn injury caused by hair removal wax is preventable, but requires user awareness as well as appropriate warnings and first aid instruction to be provided.

Table 1. Number of product-associated injuries with pubic hair shaving

Men			Women
	Actual	Estimate (%)	Actual	Estimate (%)
Razors (nonelectric)	100	3668 (72.3)	178	5914 (89.2)
Razors (electric)	3	47 (0.9)	2	30 (0.5)
Wax (with razor)	0	0 (0)	2	31 (0.5)
Wax (without razor)	0	0 (0)	2	141 (2.1)
Scissors	25	1097 (21.6)	13	443 (6.7)
Hair clippers	9	262 (5.2)	0	0 (0)
Shaving cream	0	0 (0)	1	71 (1.1)

[Source ²]

The most common site of injury was the external female genitalia ~36.0% (Table 2). Perineal/perianal injury was noted in 7 of the 132 (5%) actual cases of external female genital injury according to a review of narrative reports. External male genitalia constituted 34.5% of all genitourinary injuries, reflecting a scrotal, penile, and genital not otherwise specified injury rate of 21.8%, 11.8%, and 2.0%, respectively. No documentation of urethral or internal genitourinary organ injury was found.

Table 2. Pubic hair removal and shaving injury incidents stratified by genitourinary site

Location	Actual	Estimate (%)
External female genitalia	132	4208 (36.0)
Female pubic not otherwise specified	65	2347 (20.0)
Scrotum	64	2557 (21.8)
Penis	37	1385 (11.8)
Male genitalia not otherwise specified	5	236 (2.0)
Male pubic not otherwise specified	32	972 (8.3)

[Source ²]

Tips for shaving pubic hair

If you are considering shaving or grooming your pubic hair, you should use electric hair clippers instead of nonelectric razor to prevent injury and reduce the risk of microscopic lacerations or abrasions to the skin.

Shaving pubic hair women

Pubic hair removal in women is associated with younger ages, receiving cunnilingus, and a positive genital self-image ¹⁰. Grooming was associated with modestly higher genital satisfaction but this relationship did not persist after multivariable analysis. While female body hair removal is generally practiced according to psychosocial reasons regardless of the body part the hair being removed from, genital hair removal does have health risks because pubic hair has a definite biological purpose as a safety net to protect the vulva from bacterial infections ²⁸. A study based on data from the “National Electronic Injury Surveillance System” showed that the number of emergency room consultations due to genital injuries after shaving increased 5-fold from 2002 to 2010 ²⁹. The authors stated that 81.9% of the injuries were caused by nonelectric shaving methods. The long-term consequences of these injuries are not yet clear ²⁹. Another study gathered data from 1110 college students in the United States, who reported on the complications they experience during genital shaving, namely, pain, rash, cuts, and itching with genital itching as the most common complication of genital hair removal being reported by 80.2% of the participants in this study ³⁰. The Federal Center of Health Education in Germany, with the University of Hamburg, interviewed 160 teenagers aged 16–19 years and found that 94% of the female and 81% of the male participants shaved their pubic hair ³¹. A study at the University of Leipzig in 2009 investigated the shaving patterns of 2,512 young participants aged 18–25. In this study, 88% of female and 67% of male participants admitted to practicing partial or total pubic hair shaving. This trend strongly declined at the beginning of the 31st year of age ³².

Pubic hair removal may be a risk factor for vulvar intraepithelial neoplasia (VIN) or correlated with the increasing incidence of vulvar intraepithelial neoplasia (VIN) ³³. Researchers noticed that the women with vulvar dysplasia or vulvar cancer reported that they completely or partially shave their pubic hair more often and experienced recurrent inflammation. These results are in accordance with those of a previous study ³², which showed that shaving the pubic hair leads to a 4-fold increase in the risk of vulvar dysplasia or cancer.

Complete shaving and shaving only the labia majora were correlated to the occurrence of dysplasia and cancer more frequently than those who did not perform this extent of shaving. The correlation between age and the degree of shaving in our study was similar to that reported by a previous study ³².

Women who completely shave their pubic hair or shave the labia majora show more correlation with developing vulvar dysplasia and cancer. A possible explanation for this may be that shaving the genitals leads to an increased risk of inflammation. This would also account for the higher rates of vulvar intraepithelial neoplasia and cancer in the anterior commissure ³⁴. Other means of removing pubic hair, such as waxing, were not accessible to the participants in the rural area in northwestern Germany where the study was conducted. Therefore, this study could only analyze the impact of shaving and not other forms of hair removal ³⁵.

Vulvar intraepithelial neoplasia was classified by the international society for the study of vulvovaginal disease in 2004 into the following categories ³⁶:

• Classical vulvar intraepithelial neoplasia: including lesions formerly known as vulvar intraepithelial neoplasia II and vulvar intraepithelial neoplasia III, bowenoid, condylomatous, and mixed form
• Differentiated vulvar intraepithelial neoplasia: previously known as vulvar intraepithelial neoplasia of simple type.

Vulvar intraepithelial neoplasia presents clinically as elevated or flat vulvar lesions with a color that varies from white to grey or red to brown or black ³⁷. Vulvar cancer appears as a vulvar lump or mass that might also be ulcerated ³⁸.

Classical vulvar intraepithelial neoplasia is the most common form of vulvar dysplasia with an incidence of 5/100,000 women ³⁹. The common age of patients at presentation is between 30 and 40 years. The progression rate of classical vulvar intraepithelial neoplasia to invasive cancer is 3.3–5.7% within 2.4 to 13.8 years ⁴⁰. Differentiated vulvar intraepithelial neoplasia constitutes only 5–10% of all vulvar preinvasive lesions and is often found associated with lichen sclerosis ³⁹. In 33% of cases, it progresses to vulvar carcinoma ³⁹.

Shaving pubic hair men

Men’s hair removal practices are becoming mainstream, seen as a consequence of changing masculine norms and men’s relationships to their bodies. This is often presented as a straightforward ‘shift’ from men’s ideal bodies as naturally hairy, to increased hairlessness, and the consequence on men’s body concerns as inevitable. Although hairlessness is rapidly becoming a component of the ideal male body, little research has examined men’s concerns about their body hair or their hair removal practices ⁴¹. It is well documented that pubic hair grooming is associated with sexual activity and behavior in women ⁴². This study ⁴³ identifies that the number one motivation for grooming among men of all ages was sex. Certain sexual behaviors, especially receiving and giving oral sex, are associated with grooming. The top three motivations for grooming include sex, hygiene, and routine care. Most men who remove their pubic hair groom the hair above the penis, the scrotum, and the penile shaft. Interestingly, in the multivariate model, higher frequency of sexual activity was not associated with greater odds of grooming. This suggests that, although men might groom for sex, other aspects of sexual behavior beyond frequency might influence grooming. In particular, oral sex seems to be associated with grooming in the current study as well as another study in women ¹⁰. Overall, pubic hair grooming in men is common and grooming is more common in younger men. The prevalence of pubic hair grooming (50.5%) in men reported in a Gaither et al. ⁴³ study is similar to 63.6% men that was reported by Boroughs et al. ⁴⁴.

Grooming may play a role in male body image, as many college males report grooming for a drive of muscularity and physical appearance ⁴⁵. Perceived increase in physical appearance might be a reason that so many men groom for sex. Also, from Figure 2 below, about one in five men report grooming because it makes their penis look longer, which may be another reason that so many men groom for sex. A common reason for grooming in women is concerns about perspiration and odor ⁴⁶. The focus on hygiene as a reason to groom may be a male equivalent of this concern. Whether grooming actually decreases perspiration and odor has not been studied. Pubic hair grooming may also be a reflection of a religious hygienic teaching ⁴⁷.

No difference of self-reported baseline hairiness was found between men who have sex with men (gay men) and men who have sex with women ⁴⁸. Compared with men who have sex with women, men who have sex with men were more likely to groom more than five times per year (42.5% vs. 29.0%), daily (2.4% vs. 1.3%), and to have completely removed all pubic hair more than five times (24.6% vs. 20.7%). Men who have sex with men reported grooming more for sex (76.5% vs. 67.9%) and for vacation (31.9% vs. 20.5%). Men who have sex with men were less likely to prefer their partner to be groomed (42.8% vs. 63.3%). Hair on penile shaft, from penis to navel, scrotum, between scrotum and anus, around anus, and buttocks were areas groomed more often by men who have sex with men ⁴⁸.

Figure 2. Reasons for male grooming by age in a nationally representative sample of U.S. men

[Source ⁴³]

Figure 3. Areas men groom by age in a nationally representative sample of U.S. men

[Source ⁴³]

A nationally representative survey of non-institutionalized adults aged 18 to 65 years residing in the United States was conducted. Four thousand one hundred and ninety-eight men completed the survey. Of these men, 2,120 (50.5%) reported regular pubic hair grooming ⁴³. Samples of gay and heterosexual men completed questionnaires that assessed whether they had ever removed their back, buttock or pubic hair, the frequency with which they did so, the methods used and their self-reported reasons for removing this hair, as well as their level of appearance investment. Results indicated that many gay and heterosexual men remove their back, buttock and pubic hair regularly and that their primary reason for doing so is to maintain or improve their appearance ⁴¹. Of the 4,062 men who completed the survey, 3,176 (78.2%) report having sex with only women, 198 (4.9%) report sex with men, and 688 (16.9%) report not being sexually active. Men who have sex with men are more likely to groom (42.5% vs. 29.0%) and groom more around the anus, scrotum, and penile shaft compared with men who have sex with only women. Men who have sex with men receptive partners groom more often (50.9% vs. 26.9%) and groom more for sex (85.3% vs. 51.9%) compared with men who have sex with men insertive partners.

The prevalence of grooming decreases with age. Adjusting for sexual frequency and sexual orientation, grooming is associated with performing and receiving oral sex. The majority of men report grooming in preparation for sexual activity with a peak prevalence of 73% among men aged 25 to 34 years, followed by hygiene (61%) and routine care (44%) ⁴³. The majority of men who remove their pubic hair groom the hair above the penis (87%), followed by the scrotum (66%) and the penile shaft (57%) ⁴³. Overall, pubic hair grooming is common among men aged 18 to 65 years in the United States ⁴³. Younger ages are associated with greater rates of pubic hair grooming. Many men groom for sex, in particular oral sex, as well as for routine care and hygiene ⁴³.

Table 3. Comparison of demographic characteristics between men groomers and nongroomers

	Groomers, n = 2,120	Nongroomers, n = 2,034
Age	41.1 (40.6-41.6)	48.0 (47.5-48.6)
Race/ethnicity
White	1,416 (66.8)	1,407 (69.2)
Black	215 (10.1)	288 (14.2)
Other, non-Hispanic	84 (4.0)	63 (3.1)
Hispanic	330 (15.6)	214 (10.5)
Mixed races	75 (3.6)	62 (3.1)
Education
Less than high school	110 (5.2)	141 (6.9)
High school graduate	557 (26.3)	648 (31.9)
Some college	610 (28.8)	530 (26.1)
Bachelor’s degree or higher	843 (39.8)	715 (25.2)
Income ($)
<50,000	740 (34.9)	814 (40.0)
50,000-74,999	452 (21.2)	399 (19.6)
75,000-99,999	363 (17.1)	310 (15.2)
>100,000	565 (26.7)	511 (25.1)
Marital status
Married/living with partner	1,391 (65.6)	1,328 (65.3)
Widowed	15 (0.7)	25 (1.2)
Divorced/separated	197 (9.3)	194 (9.5)
Never married	517 (24.4)	487 (23.9)
Location
Northeast	356 (16.8)	354 (17.4)
Midwest	543 (25.6)	517 (25.4)
South	740 (34.9)	711 (35.0)
West	481 (22.7)	452 (22.2)
Other
Baseline hairinessa	3.99 (3.94-4.05)	3.84 (3.78-3.90)
Partner hairinessa	2.26 (2.18-2.33)	2.19 (2.11-2.27)
Genital satisfaction a	4.92 (4.88-4.97)	4.78 (4.74-4.83)

Note: ^aMeasured via Likert-type scales (1-7), genital satisfaction measured using the Index of Male Genital Image.

[Source ⁴³]

Men who have sex with men report more injuries to the anus (7.0% vs. 1.0%), more grooming-related infections (7.0% vs. 1.0%) and abscesses (8.8% vs. 2.5%), as well as lifetime sexually transmitted infections (STIs) ⁴⁸ compared with men who have sex with only women. More receptive partners report grooming at the time of their sexually transmitted infection (52.2% vs. 14.3%) compared with insertive partners. Sexual orientation, and in particular sexual role, may influence male grooming behavior and impact grooming-related injuries and infections. Anogenital grooming may put one at risk for an sexually transmitted infection.

Male injuries constituted a substantial portion of the cohort and were found to increase at a rate that paralleled female grooming injuries. This finding is congruent with contemporary studies that report relatively high pubic hair removal among men ²¹. More men who have sex with men reported never sustaining a grooming injury compared with men who have sex with women (65.9% vs. 79.0%); however, no differences were observed for total lifetime grooming injuries between the two groups. men who have sex with men had more grooming injuries involving scissors (28.6% vs. 12.8%) and reported more injuries to the anus (7.0% vs. 1.0%). men who have sex with men sought more medical treatment for injuries than men who have sex with women (8.8% vs. 1.3%). Infections (7.0% vs. 1.0%) and abscesses (8.8% vs. 2.5%) were more common injury types in men who have sex with men (Table 4).

Table 4. Grooming injuries in men

	Men who have sex with men and women* (n = 198, 4.9%)	Men who have sex with women (n = 3,176, 78.2%)
Experienced grooming injury
Yes	110 (65.9%)	1,652 (79.0%)
Number of grooming injuries	7.24 ± 9.49	6.03 ± 8.73
Instrument used
Nonelectric blade	30 (57.7%)	168 (52.0%)
Electric razor	29 (56.2%)	209 (40.5%)
Scissors	12 (28.6%)	41 (12.8%)
Wax/electrolysis/laser removal	0 (0.0%)	3 (1.0%)
Injury location
Scrotum	29 (50.9%)	296 (56.8%)
Penis	13 (22.8%)	141 (27.1%)
Anus	4 (7.0%)	5 (1.0%)
Perineum	5 (8.8%)	28 (5.4%)
Inner thigh	10 (17.5%)	57 (10.9%)
Pubis	16 (28.1%)	154 (29.6%)
Other	0 (0.0%)	13 (2.5%)
Sought medical treatment
Yes	5 (8.8%)	7 (1.3%)
Injury type
Burn	13 (22.8%)	84 (16.1%)
Rash	20 (35.1%)	155 (29.8%)
Laceration with blood	37 (64.9%)	355 (68.3%)
Injury requiring medical care	0 (0.0%)	4 (0.8%)
Infection	4 (7.0%)	5 (1.0%)
Abscess	5 (8.8%)	13 (2.5%)
Other	7 (12.3%)	43 (8.3%)

[Source ⁴⁸]

Baseline skin infections and abscesses were reported more by men who have sex with men (12.7% vs. 4.7%). More men who have sex with men self-reported being diagnosed with MRSA (4.8%) than men who have sex with women (2.5%). men who have sex with men reported fewer regular sexual partners (64.5% vs. 87.3%), more sexual partners in a year and more sexual partners in a lifetime. The number of lifetime sexually transmitted infections (STIs) was higher in men who have sex with men than men who have sex with women (1.65 vs. 1.45). Compared with men who have sex with women, men who have sex with men report higher prevalence of HIV (20.8% vs. 0.4%), syphilis (23.7% vs. 6.8%), anal warts (9.7% vs. 1.1%) and less prevalence of genital herpes (herpes simplex virus [HSV]) (4.2% vs. 15.5%). No statistical differences were found between groups for chlamydia, human papillomavirus (HPV), gonorrhea or pubic lice. Grooming at the time of an sexually transmitted infection (STI) was more prevalent in men who have sex with men (45.2% vs. 11.5%). men who have sex with men were using more nonelectric blades to groom during the time of an STI (88.2% vs. 54.5%) (Table 5).

Table 5. Infections, number of sexual partners, and sexually transmitted infection (STI)

	Men who have sex with men and women* (n = 198, 4.9%)	Men who have sex with women (n = 3,176, 78.2%)
Previous infections
Skin infections/abscesses	21 (12.7%)	102 (4.7%)
Diagnosed with MRSA	8 (4.8%)	51 (2.4%)
Regular sexual partner
Yes	107 (64.5%)	1,907 (87.3%)
Annual sexual partner (median, IQR)†	2.81, 5.00	1.00, 0.00
Lifetime sexual partners (median, IQR)†	25.00, 65.00	6.00, 12.00
Lifetime # of STI	1.65 ± 0.67	1.45 ± 0.65
Type of STI
HIV	15 (20.8%)	1 (0.4%)
Syphilis	17 (23.7%)	19 (6.8%)
Gonorrhea	31 (43.7%)	124 (44.8%)
Genital herpes (HSV)	3 (4.2%)	43 (15.5%)
Anal warts	7 (9.7%)	3 (1.1%)
Grooming at the time of STI
Yes	28 (45.2%)	22 (11.5%)
Grooming instrument at time of STI
Nonelectric blade	23 (88.2%)	12 (54.5%)
Electric razor	17 (62.1%)	12 (54.5%)
Scissors	7 (25.0%)	4 (18.2%)
Wax/electrolysis/laser removal	0 (0.0%)	0 (0.0%)

Notes: HSV = herpes simplex virus; IQR = interquartile range; MSM = men who have sex with men; MSW = men who have sex with women; STI = sexually transmitted infection; MRSA = Methicillin-resistant Staphylococcus aureus

[Source ⁴⁸]

As seen in Table 5, the majority of injuries for both men who have sex with men and men who have sex with women were to the scrotum, pubis, or penis, which mirrors the results from our previous study, which showed these sites as the most common male genitourinary injury presenting to the emergency department from 2002 to 2010 ⁴⁹. These sites have thin, delicate skin with folds and surfaces that may be hard to visualize and makes these areas more prone to injury. Reserachers found that men who have sex with men had more injuries to the anus as well as more infections and abscesses due to their personal grooming (Table 5). This correlates with the finding that more than double the percentage of men who have sex with men groom the anal region compared with men who have sex with women, suggesting a potential connection between increased grooming frequency and injuries. Further research is required to understand if frequency, grooming instrument, or other mechanism lead to more injury.

Increased frequency of grooming, in particular removing all pubic hair among men who have sex with men, is associated with increased prevalence of infections and abscesses. Removing pubic hair may lead to microscopic lacerations and abrasions, which could predispose an individual to infection. Although the number of grooming injuries between men who have sex with men and men who have sex with women did not differ, men who have sex with men did seek more medical attention for their injuries. Increased reported infections and abscesses due to pubic hair grooming in men who have sex with men might be a reason for seeking medical advice.

Increased infections and number of sexually transmitted infection in men who have sex with men, particularly HIV, are well documented in the literature ⁵⁰ and study results confirm this. Men who have sex with men had higher rates of HIV, syphilis, and anal warts (Table 5). Receptive partners had higher rates of HIV and syphilis (Table 5). HIV has a high probability of transmission via receptive anal intercourse ⁵⁰ and although higher rates among receptive partners were of borderline significance, it supports this idea. Interestingly, more than four times as many men who have sex with men were grooming at the time of sexually transmitted infection and using nonelectric blades to groom. This could result from the baseline increase in grooming in men who have sex with men that grooming might predicate riskier sexual behavior or that grooming actually increases the likelihood of an sexually transmitted infection. Still, the use of nonelectric blades to groom in men who have sex with men may not be advisable. Going further, three times as many receptive partners reported grooming at the time of sexually transmitted infection. As such, sexual role and grooming together may harbor an environment for an sexually transmitted infection infection; however, given the small sample size, the results are inconclusive. The role of grooming and the risk of acquiring an sexually transmitted infection are still uncertain and require further study with more robust controls with assessment of safe sex behavior. However, electric razors may be safer for anogenital grooming.

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How to sit properly

Low back pain is a major problem for office workers. Individuals adopting poor postures during prolonged sitting have a considerably increased risk of experiencing low back pain. The findings of this study ¹ demonstrate that office workers with chronic low back pain sat significantly more asymmetrically, i.e., sitting with trunk leaning toward either left or right side, than their healthy counterparts in both comfortable and neutral sitting postures. During 1 hour of sitting, both chronic low back pain and healthy workers appeared to assume slumped sitting postures after 20 minutes of sitting, which may partly be explained by increased discomfort experienced in the low back. Healthy workers had significantly more frequent postural shifts than chronic low back pain workers during prolonged sitting, despite chronic low back pain participants reporting significantly greater low back discomfort than their healthy counterparts. Significantly greater asymmetrical sitting posture and more frequent postural shift were found toward the end of the 1-hour sitting period in both chronic low back pain and control groups.

Peak pressure is the maximal pressure around ischial tuberosity. This is calculated between the maximum four adjacent sensors of seat pressure mapping. The peak pressure ratio was calculated by the higher peak pressure side to lower peak pressure side. A higher peak pressure ratio indicates more asymmetrical sitting between left and right sides during sitting. Office workers with chronic low back pain had significantly greater peak pressure ratio, which is an index of asymmetrical sitting posture, than their healthy counterparts in both comfortable and neutral sitting postures. Differences in peak pressure ratio between chronic low back pain and control groups remained throughout the 1-hour sitting period. Patients with chronic low back pain have been shown to demonstrate poorer postural control of the lumbar spine than healthy controls ². Pelvic asymmetry has also been shown to cause higher stress on the lumbar spine in individuals with low back pain ³ and changes in soft tissue tightness ⁴, thus making the spine susceptible to injury. Neutral sitting posture, consisting of sitting with slight lumbar lordosis and a relaxed thorax, has been proposed as an optimal seat posture at work ⁵. Neutral sitting posture was associated with increased internal oblique and transversus abdominis muscles activity compared with slumped sitting posture ⁶. This study ⁷ examined the perceived body discomfort and trunk muscle activity in different prolonged (1 hour) sitting postures, i.e., upright, slumped, and forward leaning sitting postures. The results showed that the highest low back discomfort after 1 hour of sitting occurred with the forward leaning posture, followed by the upright and slumped sitting postures. The forward leaning sitting posture was associated with increased iliocostalis lumborum pars thoracis and superficial lumbar multifidus muscle activity, and the upright sitting posture was associated with increased increased internal oblique/transversus abdominis and iliocostalis lumborum pars thoracis muscle activity. The findings from this study suggest that the upright sitting posture may be an appropriate sitting posture to prevent the development of low back pain in individuals who usually spend a long period of time sitting. Another study ¹ showed that asymmetry in the sitting posture in chronic low back pain participants reduced significantly when they sat in a neutral sitting posture, although it still persisted and was greater than that in healthy participants. The results lend further support to the notion that the neutral sitting posture, which leads to more symmetrical sitting posture, is healthy for the low back.

Figure 1. Sitting postures – (A) Slumped sitting. (B) Upright sitting. (C) Forward leaning sitting

[Source ⁷]

After 20 minutes of sitting, both participants with and without chronic low back pain assumed sitting posture with significantly increased average pressure (AP) at posterior seat, indicating pelvic backward tilting or slumped sitting posture. Average pressure is the total pressure divided by the total sitting contact surface area.Sitting with backward leaning is usually achieved by a backward pelvic rotation, resulting in lumbar kyphosis, and less than 25% of the body weight is transmitted to the floor ⁸. Backward rotation caused by long hours spent at the visual display terminal has been shown to generate load on the lumbar spine and increase intradiskal pressure ⁹. When the seat position is not optimal, more muscular activity may be needed for stabilization resulting in a distinctly larger pressure in the disk ¹⁰. Also, internal oblique and transversus abdominis muscle fatigue was induced by slumped sitting posture after 1 hour of sitting in office workers ¹¹. Patients who habitually adopt passive spinal postures or slump may decondition their lumbar stabilizing muscles ¹², leading to increased passive system loading, injury, and pain ¹³. Sustained stretch of passive lumbar structures in combination with essentially silent muscles may exacerbate low back pain in office workers ¹⁴. One of several identified interventions to reduce the onset and severity of low back pain included periodic rest breaks. Previous studies suggested that frequent, short, rest breaks resulted in short-term decrease in both discomfort and postural immobility ¹⁵.

In terms of postural shift, healthy workers had more frequent postural shifts (the combination of shift in the frontal and sideway planes) than chronic low back pain workers by 43% during 1 hour of sitting. The frequency of postural shift in healthy participants reported in a study (9.6 ± 8.3 times/h) was in line with a previous study (7.8 ± 5.2 times/h) ¹⁶. The results concur with a study by Dunk and Callaghan ¹⁷, who reported less frequent postural shift in individuals with low back pain compared with healthy individuals. Excessive load transmission and tissue deformation associated with prolonged loading in a certain posture may contribute to degenerative change in spinal tissues ¹⁸. Postural shift has been found to increase subcutaneous oxygen saturation, which positively influences tissue viability ¹⁹. Also, postural shifts may alleviate low back discomfort and low back pain during prolonged sitting through alternating activity between different parts of the trunk muscles ²⁰. However, it is interesting to note that despite chronic low back pain workers having significantly greater postural discomfort than healthy workers after 20 minutes of sitting, chronic low back pain workers changed their sitting postures less frequently than their healthy counterparts during 1-hour sitting. The findings shed some light on the notion that sitting characteristics, particularly frequency of postural shift, may partly relate to the cause of low back pain in those required to sit for long periods. Further research should examine the roles of these sitting characteristics on the development of low back pain in workers who are required to sit for long hours.

Why sitting too much is bad for your health

You know you need to be more active, but there is increasing evidence that you also need to spend less time sitting down.

However, there is currently not enough evidence to set a time limit on how much time people should sit each day.

Nevertheless, some countries – such as Australia, the US and Finland – have made recommendations that children limit screen time, such as TV and video games, to just one to two hours a day.

Recent research published in the Lancet 2016 ²¹ has suggested that exercising at least 60 minutes a day can offset the negative effects of sitting too much throughout the day. According to that research, high levels of moderate intensity physical activity (i.e, about 60–75 min per day) seem to eliminate the increased risk of death associated with more than eight hours a day of sitting. However, this high activity level attenuates, but does not eliminate the increased risk associated with high TV-viewing time. These results provide further evidence on the benefits of physical activity, particularly in societies where increasing numbers of people have to sit for long hours for work and may also inform future public health recommendations. Therefore reducing sitting may be an additional health-enhancing strategy on top of physical exercise.

Multiple studies ²² have demonstrated that reducing and replacing sitting with light intensity walking improves glucose control after food consumption. That means glucose levels that do not spike too high, or dip too low. This may be explained by the way working muscles can use up some of the glucose in our system, helping to keep glucose in the optimal range.

Evidence ²³ suggests that when it comes to glucose control, light intensity physical activity spread across the day can be superior to a day in which a single bout of moderate to vigorous exercise is performed in the morning. Even when the total energy expenditure of the light intensity activity is equal to the energy expenditure of the single bout of higher intensity activity.

The link between illness and sitting first emerged in the 1950s, when researchers found London bus drivers were twice as likely to have heart attacks as their bus conductor colleagues. There has been an explosion of research on the ills of sitting in the past few years, prompted by our increasingly sedentary lifestyles.

It is thought excessive sitting slows the metabolism – which affects your ability to regulate blood sugar and blood pressure, and metabolize fat – and may cause weaker muscles and bones.

Essentially, the body is ‘shutting down’ while sitting and there is little muscle activity.

Research on astronauts in the early 70s found life in zero gravity was linked with accelerated bone and muscle loss and ageing.

Sitting for an extended period of time is thought to simulate, albeit to a lesser degree, the effects of weightlessness on astronauts. With the current body of evidence, scientists don’t have a definitive answer to what’s happening.

The research on NASA astronauts suggests that on their return from space, even light walking was effective in overcoming the negative effects of weightlessness.

Breaking up sitting time engages your muscles and bones, and gives all your bodily functions a boost – a bit like revving a car’s engine.

To reduce your risk of ill health from inactivity, you are advised to exercise regularly – at least 150 minutes a week – and reduce sitting time.

Studies ²⁴, ²⁵ have linked excessive sitting with being overweight and obese, type 2 diabetes, some types of cancer, and early death.

Sitting for long periods is thought to slow the metabolism, which affects the body’s ability to regulate blood sugar, blood pressure and break down body fat.

Many adults in the US spend more than seven hours a day sitting or lying, and this typically increases with age to 10 hours or more.

This includes watching TV, using a computer, reading, doing homework, traveling by car, bus or train but does not include sleeping.

High sitting time and brain function

Studies investigating the effects of excessive sitting on brain function have had mixed results. Laboratory studies both support ²⁶ and fail to support ²⁷, the idea that a day of sitting can impair performance on memory related tasks, relative to a day where sitting is interrupted by regular activity breaks.

Other types of studies ²⁸ that track a large number of people over a number of years suggest an association between higher sitting time and impaired brain function. But drawing conclusions from these studies is made difficult by the multitude of different measurements used. Generally, methods that do not rely on the self-reporting of participants are preferred, because self-reporting isn’t always accurate. This isn’t always practical though.

Apart from directly measuring performance on cognitively demanding tasks, another approach is to measure something that would theoretically support improved brain function. For example, researchers at New Mexico Highlands University ²⁹ demonstrated that foot impact during walking sends pressure waves through blood vessels to increase brain blood flow.

Brain blood flow is involved in regulating supply of glucose to the brain, and this likely has implications for brain health over time. For example, scientists know decreases in brain blood flow are associated with a more rapid decline in brain function in those with Alzheimer’s disease ³⁰. For scientists, the way in which sitting is likely to affect brain function poses a research challenge. Based on the available evidence, it’s more likely that reducing sitting would slow cognitive decline, rather than improve cognitive function.

Despite a current lack of conclusive studies linking brain health and sitting, reducing sitting time is already advised to prevent other adverse health outcomes linked to poor glucose control ³¹. With improved glucose control in mind, reducing sitting is especially important after meals.

So take a walk after lunch, wash the dishes by hand after dinner and take an active commute to and from work if possible. There is much opportunity to reduce sitting time throughout the day, and therefore much potential to have a positive impact on health.

Age-specific advice

The recommendations to reduce sitting time apply to all age groups.

Under-5s

In children under five, the advice is to limit the time they spend watching TV, traveling by car, bus or train, or being strapped into a buggy.

There is emerging evidence that sedentary behavior in the early years is associated with overweight and obesity, as well as lower cognitive development.

While this may be a challenge for busy parents, the advice reflects growing awareness that early life experiences and habits impact upon your health as adults.

There is a need to establish healthy patterns of behavior during the early years in order to protect against possible health detriments in the future.

Tips to reduce sitting time:

• reduce time spent in infant carriers, car seats or highchairs
• reduce time spent in walking aids or baby bouncers
• reduce time spent in front of the TV or other screens

Children and young people

Research suggests that children and young people in households with multiple TVs and computers tend to sit more.

For children aged 5 to 18 years, reducing sitting time includes anything that involves moving in and around the home, classroom or community.

Tips to reduce sitting time:

• consider ways for children to “earn” screen time
• agree a family limit to screen time per day
• make bedrooms a TV- and computer-free zone
• set “no screen time” rules to encourage kids to be active
• encourage participation in house chores such as setting the table or taking the bins out
• choose gifts such as a scooter, skateboard, ball or kite to encourage active play

Parents could lead by example by also reducing their TV time and other sitting-based tasks.

Adults

Adults aged 19 to 64 are advised to try to sit down less throughout the day, including at work, when traveling and at home.

Tips to reduce sitting time:

• stand on the train or bus
• take the stairs and walk up escalators
• set a reminder to get up every 30 minutes
• place a laptop on a box or similar to work standing
• stand or walk around while on the phone
• take a walk break every time you take a coffee or tea break
• walk to a co-worker’s desk instead of emailing or calling
• swap some TV time for more active tasks or hobbies

Older adults

Some older adults (aged 65 and over) are known to spend 10 hours or more each day sitting or lying down, making them the most sedentary population group.

It could be partly due to reduced functionality or ill health, but there are also social norms expecting those in later years to ‘slow down’ and rest and that is not helpful.

Older adults should aim to minimize the time they spend in extended periods of sitting each day.

Sitting needs breaking up. Long periods of TV should be avoided, and you should try to do activities that involve light movement and being ‘on your feet’ as much as possible.

Do some tasks standing, like having coffee and chats, or even watching TV.

Tips to reduce sitting time:

• avoid long periods sat in front of a TV or computer
• stand up and move during TV advert breaks
• stand or walk while on the phone
• use the stairs as much as possible
• take up active hobbies such as gardening and DIY
• join in community-based activities, such as dance classes and walking groups
• take up active play with the grandchildren
• do most types of housework

Common posture mistakes and fixes

Here are eight common posture mistakes, and how to correct them with strength and stretching exercises.

If you have back pain, improving your posture is unlikely to address the root cause of your pain, but it may help alleviate muscle tension.

Correcting your posture may feel awkward at first because your body has become so used to sitting and standing in a particular way.

But with a bit of practice, good posture will become second nature and be one step to helping your back in the long term.

1) Slouching in a chair

Slouching doesn’t always cause discomfort, but over time this position can place strain on already sensitised muscles and soft tissues. This strain may increase tension in the muscles, which may in turn cause pain.

Figure 2. Slouching in a chair

Get into the habit of sitting correctly. It may not feel comfortable initially because your muscles have not been conditioned to support you in the correct position.

Exercises to strengthen your core and buttock muscles, and back extensions, will help correct a slouching posture.

Exercises to correct a slumping posture:

• Bridges
• Back extensions
• Plank

Bridges

Target: buttocks and lower back

Start position: Lie on your back with your knees bent and heels close to your bottom. Your feet should be shoulder-width apart and flat on the floor.

Action: Raise your hips to create a straight line from your knees to your shoulders. As you come up, tighten your abdominals and buttocks. Lower yourself gently to the starting position.

Repeat 8 to 10 times.

Tips:

• don’t let your knees point outwards
• keep your chin slightly tucked in
• contract your buttocks, not your hamstrings, as you rise

Figure 3. Bridges

Back extensions

Start position: Lie on your front and rest on your forearms, with your elbows bent at your sides. Look towards the floor and keep your neck straight.

Action: Keeping your neck straight, arch your back up by pushing down on your hands. You should feel a gentle stretch in the stomach muscles. Breathe and hold for 5 to 10 seconds. Return to the starting position.

Repeat 8 to 10 times.

Tips:

• don’t bend your neck backwards
• keep your hips on the floor

Figure 4. Back extensions

Plank

Target: lower back and core muscles

Start position: Lie on your front propped up on your forearms and toes. Keep your legs straight and hips raised to create a straight and rigid line from head to toe.

Action: Your shoulders should be directly above your elbows. Focus on keeping your abs contracted during the exercise. Hold this position for 5 to 10 seconds and repeat 8 to 10 times.

Tips:

• Don’t allow your lower back to sink during the exercise.
• You should be looking at the floor.
• For an easier version, perform the plank with your knees on the floor.

Figure 5. Plank

Side plank

Target: lower back and core muscles

Start position: Lie on your side propped up on an elbow. Your shoulder should be directly above your elbow. Straighten your legs and raise your hips to create a straight and rigid line from head to toe.

Action: Keep your neck long and your shoulders down and away from your ears. Keep your abs contracted during the exercise. Hold this position for 5 to 10 seconds and repeat 8 to 10 times. Repeat the exercise on the other side.

Tips:

• Keep your hips forward during the exercise.
• Don’t let your lower back sink.
• For an easier version, perform the side plank with your knees on the floor.

Figure 6. Side plank

2) Hunched back and ‘text neck’

Figure 7. Text neck and hunched back

Hunching over your keyboard is usually a sign that you have a tight chest and a weak upper back.

Over time, this type of posture can contribute to you developing a rounded upper back, which can cause shoulder and upper back stiffness.

When hunching over a computer, your head may tend to lean forward, which can lead to poor posture. Using a mobile can cause similar problems dubbed “text neck”.

Upper back, neck and rear shoulder strengthening exercises, chest stretches and neck posture drills are recommended to help correct a hunched back.

Exercises to correct a hunched back:

• Gently lengthen your neck upwards as you tuck in your chin
• Seated rows in a gym or pull-ups
• Chest stretches

3) Poking your chin

The poking chin posture can be caused by sitting too low, a screen set too high, a hunched back, or a combination of all three.

Figure 8. Poking chin posture

Correcting a poking chin involves improving your sitting habits and exercises to correct your posture.

How to correct a poking chin:

• Gently lengthen your neck upwards as you tuck in your chin
• Bring your shoulder blades down and back towards your spine
• Pull in your lower tummy muscles to maintain a natural curve in your lower back
• Adjust your seating

4) Cradling your phone

Holding your phone handset between your ear and shoulder places strain on the muscles of the neck, upper back and shoulders.

Figure 9. Cradling your phone

The neck and shoulders are not designed to hold this position for any length of time.

Over time this posture can place strain on the muscles and other soft tissues, and lead to muscle imbalances between the left and right side of your neck.

Try to get into the habit of holding the phone with your hand, or use a hands-free device.

Exercises for neck stiffness and pain:

• Chest stretches (see chest stretches video above)
• Neck stretches: gently lower your left ear towards your left shoulder. Hold for 10-15 deep breaths. Repeat on opposite side.
• Neck rotations: slowly turn your chin towards one shoulder. Hold for 10-15 deep breaths. Repeat on opposite side.

5) Standing with a flat back

A flat back means your pelvis is tucked in and your lower back is straight instead of naturally curved, causing you to stoop forward.

People with a flat back often find it difficult standing for long periods.

This posture is often caused by muscle imbalances, which encourage you to adopt such a position. Spending long periods sitting down can also contribute to a flat back.

A flat back also tends to make you lean your neck and head forwards, which can cause neck and upper back strain.

Figure 10. Standing with a flat back

Exercises to strengthen your core, buttocks, neck and rear shoulder muscles, and back extensions, are recommended to help correct a flat back.

Exercises to correct a flat back:

• Plank
• Side-lying leg raises
• Chest stretches
• Seated rows in a gym or pull-ups
• Back extensions

Side-lying leg raise

Target: buttocks and lower back

Start position: Lie on your right-hand side with your right knee bent at 90 degrees, and your left leg straight and in line with your back.

Action: Press your left fingers into the top of your buttock to keep your left hip slightly tilting forward. Raise your left leg as far as you can without letting your hips tilt back. Slowly lower to the starting position.

Perform 8 to 10 times and repeat on the other side.

Tips:

• raise your leg, keeping it in line with your back
• feel your buttock muscles contracting as you raise your leg
• keep your abdominal muscles contracted throughout the exercise

Figure 11. Side-lying leg raises

6) Sticking your bottom out

If your bottom tends to stick out or you have a pronounced curve in your lower back, you may have hyperlordosis. This is an exaggerated inward curve of the lower back that creates a “Donald Duck” posture.

Wearing high heels, excessive weight around the stomach and pregnancy can all cause this posture.

Figure 12. Sticking your bottom out

Core and buttock strengthening exercises, hip flexor and thigh stretches, and making a conscious effort to correct your standing posture are recommended to help correct a sticking out bottom.

Exercises to correct a “Donald Duck” posture:

• Plank
• Side-lying leg raises
• Hip flexor stretches
• Standing thigh stretch

To help correct your standing posture, imagine a string attached to the top of your head pulling you upwards.

The idea is to keep your body in perfect alignment, maintaining the spine’s natural curvature, with your neck straight and shoulders parallel with the hips.

• Keep your shoulders back and relaxed
• Pull in your abdomen
• Keep your feet about hip distance apart
• Balance your weight evenly on both feet
• Try not to tilt your head forward, backwards or sideways
• Keep your legs straight, but knees relaxed

Watch a video on improving posture.

Hip flexor stretch

Step your left leg forward, keeping both feet pointing straight ahead. Keeping your back leg straight and avoiding sticking your buttock out and arching your back, slowly bend your front leg and push your right buttock forward until you feel a stretch across the front of your right hip joint – hold for 15 seconds. Repeat with the other leg.

Figure 13. Hip flexor stretch

7) Rounded shoulders

One way to tell if you’ve got rounded shoulders is to stand in front of a mirror and let your arms hang naturally by your sides.

If your knuckles face forward, it may indicate that you have a tight chest and a weak upper back, giving the appearance of rounded shoulders.

Figure 14. Rounded shoulders

Rounded shoulders are typically caused by poor posture habits, muscle imbalances and focusing too much on certain exercises, such as too much focus on chest strength while neglecting the upper back.

Exercises to strengthen your core, upper back and chest muscles will help correct rounded shoulders:

• Plank
• Bridges
• Seated rows in a gym or pull-ups
• Chest stretches

8) Leaning on one leg

Leaning more on one leg while standing can feel comfortable, especially if you’ve been standing for a while.

But instead of using your buttocks and core muscles to keep you upright, you place excessive pressure on one side of your lower back and hip.

Over time, you may develop muscle imbalances around the pelvis area, which can cause muscular strain in the lower back and buttocks.

Other causes of uneven hips include carrying heavy backpacks on one shoulder, and mothers carrying toddlers on one hip.

Figure 15. Leaning on one leg

To improve this posture, try to get into the habit of standing with your weight evenly distributed on both legs.

Exercises to strengthen your buttocks and core muscles will help correct uneven hips:

• Plank
• Side-lying leg raises
• Bridges

Good sitting posture

Your spine is strong and stable when you practice healthy posture. But when you slouch or stoop, your muscles and ligaments strain to keep you balanced — which can lead to back pain, headaches and other problems.

Your spine’s curves

A healthy back has three natural curves:

• An inward or forward curve at the neck (cervical curve)
• An outward or backward curve at the upper back (thoracic curve)
• An inward curve at the lower back (lumbar curve)

Good posture helps maintain these natural curves, while poor posture does the opposite — which can stress or pull muscles and cause pain.

Figure 16. Vertebral column

How to sit correctly

Working at a desk is a common cause of back and neck pain, often because you accommodate to your workstation rather than the other way around. For instance, many people strain to see a computer monitor that is too far away, too low, too high, too small or too dim. This compromises good posture. The average human head weighs almost 12 pounds (5.4 kilograms) — the equivalent of a bowling ball! When your neck is bent to 45 degrees, your head exerts nearly 50 pounds (23 kilograms) of force on your neck. In addition to straining joints and muscles in your neck and shoulders, the pressure affects your breathing and mood.

To alleviate this discomfort, redesign your workspace to encourage well-aligned posture. There are many ways to improve the ergonomics — efficiency and comfort level — of a typical workstation. Start by answering these questions.

Is your monitor positioned so that you can see it well without straining?

• Raise or lower the monitor or your chair so your eyes are level with the top of the screen. If you wear bifocals, you may need to lower the monitor another 1 to 2 inches.
• Move the monitor closer or farther away so that you can easily read the screen.
• Increase the font size you use.
• If using a laptop, link to a larger monitor.

Are your mouse and keyboard positioned so that you don’t have to reach up to use them?

• Lower your desk height or raise your chair so that your forearms are parallel to the floor or pointed slightly downward and your wrists are not pointing either upward or downward.

Do you keep frequently used tools within close range to minimize reaching?

• Keep your mouse nearby, and regularly change it from one side of your body to the other.
• Use a headset if you talk on the phone frequently.
• Find shortcut keys you can use while typing.
• Use a document holder so that you don’t have to look down frequently.

Does your chair allow you to maintain the normal curves in your spine, such as the curve in your low back?

• Raise or lower your chair so that you’re not sitting straight up at a 90-degree angle, but rather with a slightly reclined posture of 100 to 110 degrees.
• When you’re seated, do your feet touch the ground?
• Consider using a stool if you’ve elevated your chair and your feet no longer reach the ground.
• Maintain a couple of inches between the back of your knees and the chair.

If your chair has armrests, do they allow your shoulders to relax?

• Consider lowering or getting rid of the armrests so that your neck and shoulders can relax downward.

Correct sitting posture

If your work involves sitting a lot and using a computer, here are some tips to help you sit correctly.

Support your back

You can reduce your risk of back pain by adjusting your chair so your lower back is properly supported.

A correctly adjusted chair will reduce the strain on your back. Get one that is easily adjustable so you can change the height, back position and tilt.

Your knees should be slightly lower than your hips. Use a footrest, if it feels necessary.

Adjust your chair

Adjust your chair height so you can use the keyboard with your wrists and forearms straight and level with the floor. This can help prevent repetitive strain injuries.

Your elbows should be by the side of your body so the arm forms an L-shape at the elbow joint.

Rest your feet on the floor

Place your feet flat on the floor. If they’re not, ask if you can have a footrest, which lets you rest your feet at a level that’s comfortable.

Don’t cross your legs, as this may contribute to posture-related problems.

Place your screen at eye level

Your screen should be directly in front of you. A good guide is to place the monitor about an arm’s length away, with the top of the screen roughly at eye level.

To achieve this, you may need a monitor stand. If the screen is too high or too low, you’ll have to bend your neck, which can be uncomfortable.

Using the keyboard

Place your keyboard in front of you when typing. Leave a gap of about four to six inches (100mm-150mm) at the front of the desk to rest your wrists between bouts of typing.

Keep your arms bent in an L-shape and your elbows by your sides.

Some people like to use a wrist rest to keep their wrists straight and at the same level as the keys.

Keep your mouse close

Position and use the mouse as close to you as possible. A mouse mat with a wrist pad may help keep your wrist straight and avoid awkward bending.

If you’re not using your keyboard, push it to one side to move the mouse closer to you.

Avoid screen reflection

Your screen should be as glare-free as possible. If there’s glare on your screen, hold a mirror in front of the screen so you know what’s causing it.

Position the monitor to avoid reflection from overhead lighting and sunlight. If necessary, pull blinds across the windows.

Adjusting the screen’s brightness or contrast can make it much easier to use.

Working with spectacles

People with bifocal spectacles may find them less than ideal for computer work. It’s important to be able to see the screen easily without having to raise or lower your head.

If you can’t work comfortably with bifocals, you may need a different type of spectacles. Consult your optician if in doubt.

Make objects accessible

Position frequently used objects, such as your telephone or stapler, within easy reach. Avoid repeatedly stretching or twisting to reach things.

Avoid phone strain

If you spend a lot of time on the phone, try exchanging your handset for a headset. Repeatedly cradling the phone between your ear and shoulder can strain the muscles in your neck.

Take regular breaks

Don’t sit in the same position for long periods. Make sure you change your posture as often as is practicable (try to move or stand every 30 minutes).

Frequent short breaks are better for your back than fewer long ones. It gives the muscles a chance to relax while others take the strain.

Best sitting posture

Working at a computer

Arrange your desk, chair and computer to avoid strain on your neck (see Figure 17 below). Have work materials close to you and in easy reach.

• A. Position the top of your screen slightly below eye level and directly in front of you (50-70cm or arm’s length away). There is no single monitor height suitable for everyone. Position the screen to have a comfortable viewing angle to the middle of the screen. Avoid extremes of head and neck bending (upwards or downwards).
• B. Have an adjustable chair so that you can change the height and angle of the back support. Have the chair close to the desk so you do not have to reach for the keyboard or mouse. If possible, rest your forearms on the desktop to ‘unload’ the shoulders.
• C. Desk height should allow sitting with shoulders and arms relaxed with elbows at a 90 degree angle and wrists in a neutral position. Sit with hips and knees at close to 90 degree angles. Feet should be flat on the floor or use a foot stool to achieve a comfortable position.
• D. If working from documents for prolonged periods, these should be placed on a document holder either positioned between the keyboard and monitor or at the same eye level as the screen and close to the monitor. Reading from items placed flat on the desktop may increase the strain on your neck and should be avoided. Books and documents should be elevated onto a sloped surface (e.g. an empty 2-ring folder).
• E. When using the computer mouse, keep the mouse close to the keyboard, use keyboard shortcuts instead of the mouse and alternate which hand uses the mouse.

Current research suggests that spending time standing at work (high set work station) has benefits not only for the neck and back, but also for general health (e.g. by increasing daily activity levels to help maintain healthy body weight). At home and work, try to spend time working in a standing position.

Figure 17. Working at a computer

Some important factors in preventing or reducing the symptoms of computer eye strain have to do with the computer and how it is used. This includes lighting conditions, chair comfort, location of reference materials, position of the monitor, and the use of rest breaks.

Location of computer screen – Most people find it more comfortable to view a computer when the eyes are looking downward. Optimally, the computer screen should be 15 to 20 degrees below eye level (about 4 or 5 inches) as measured from the center of the screen and 20 to 28 inches from the eyes.

Reference materials – These materials should be located above the keyboard and below the monitor. If this is not possible, a document holder can be used beside the monitor. The goal is to position the documents so you do not need to move your head to look from the document to the screen.

Lighting – Position the computer screen to avoid glare, particularly from overhead lighting or windows. Use blinds or drapes on windows and replace the light bulbs in desk lamps with bulbs of lower wattage.

Anti-glare screens – If there is no way to minimize glare from light sources, consider using a screen glare filter. These filters decrease the amount of light reflected from the screen.

Seating position – Chairs should be comfortably padded and conform to the body. Chair height should be adjusted so your feet rest flat on the floor. If your chair has arms, they should be adjusted to provide arm support while you are typing. Your wrists shouldn’t rest on the keyboard when typing.

Rest breaks – To prevent eyestrain, try to rest your eyes when using the computer for long periods. Rest your eyes for 15 minutes after two hours of continuous computer use. Also, for every 20 minutes of computer viewing, look into the distance for 20 seconds to allow your eyes a chance to refocus.

Blinking – To minimize your chances of developing dry eye when using a computer, make an effort to blink frequently. Blinking keeps the front surface of your eye moist. Giving the eyes and body frequent breaks from computer work to reduce eye and muscle fatigue. Since prolonged computer use requires a person to sit in the same position for an extended period, taking time out to stand, stretch and look around will not only help muscles, but will also give the eyes a chance to relax. If the opportunity to get up for full breaks is not frequently available, then “mini” breaks will suffice by looking up from the computer into the distance about every 15 minutes. Frequent blinking or the use of eye drops, too, will keep eyes from drying out and feeling itchy. Dust, too, can irritate eyes as well as accumulate on the computer monitor, which will decrease the sharpness of the screen and may cause eyestrain.

Try these suggestions for creating a work environment that supports good health and posture.

• Set a timer and get up every 30 minutes. Take a walking meeting, stand or exercise during a conference call, or hand-deliver a message when you would normally email it.
• Ask a colleague to take a picture of you at your workstation and check to see if it supports well-aligned posture (eyes looking straight, neck not bent, forearms parallel to the floor, low back in its natural curve). If not, talk to your human resources contact for help if needed.
• Follow the 20/20/20 rule. Every 20 minutes, give your eyes a 20-second break by focusing on something at least 20 feet away.
• Create a standing workstation

Figure 18. Good Posture for computer use

[Source: American Optometric Association ³²] References

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What are hormones

If the body is to function as an integrated whole, its organs must communicate with each other and coordinate their activities. In humans, two such systems are especially prominent—the nervous and endocrine systems, which communicate with neurotransmitters and hormones, respectively. The nervous and endocrine systems act together to coordinate functions of all body systems. The endocrine system is a series of glands that produce and secrete hormones that the body uses for a wide range of functions.

Major hormone-producing endocrine glands are:

• Pineal gland,
• Hypothalamus,
• Pituitary gland (anterior and posterior pituitary),
• Thymus,
• Thyroid gland,
• Parathyroid glands,
• Adrenal glands,
• Pancreas,
• Ovaries (women),
• Testes (men),
• Other hormone-producing cells in several other organs, e.g. stomach, small intestines, heart, placenta, skin, liver and kidneys.

Other hormone-producing cells

Thymosin, produced by the thymus gland, plays an important role in the development of the body’s immune system.

The lining of the stomach, the gastric mucosa, produces a hormone, called gastrin, in response to the presence of food in the stomach. This hormone stimulates the production of hydrochloric acid and the enzyme pepsin, which are used in the digestion of food.

The mucosa of the small intestine secretes the hormones secretin and cholecystokinin. Secreting stimulates the pancreas to produce a bicarbonate-rich fluid that neutralizes the stomach acid. Cholecystokinin stimulates contraction of the gallbladder, which releases bile. It also stimulates the pancreas to secrete digestive enzyme.

The heart also acts as an endocrine organ in addition to its major role of pumping blood. Special cells in the wall of the upper chambers of the heart, called atria, produce a hormone called atrial natriiuretic hormone or atriopeptin.

The placenta develops in the pregnant female as a source of nourishment and gas exchange for the developing fetus. It also serves as a temporary endocrine gland. One of the hormones it secretes is human chorionic gonadotropin, which signals the mother’s ovaries to secrete hormones to maintain the uterine lining so that it does not degenerate and slough off in menstruation.

Skin, Liver, and Kidneys: The skin, liver and kidneys work together to synthesize 1,25-diydroxyvitamin D (calcitriol), the active form of vitamin D, which helps maintain normal levels of calcium and phosphorus in the blood. In the skin, a molecule made from cholesterol is converted to vitamin D by exposure to ultraviolet rays from the sun. Vitamin D undergoes further chemical changes, first in the liver and then in the kidneys, to become calcitriol. Calcitriol acts on the intestine, kidneys, and bones to maintain normal levels of blood calcium and phosphorus.

Figure 1. Endocrine glands and functions

Figure 2. Hormones sources of production and control via the Hypothalamus with feedback control from the Endocrine glands

Note: ACTH= Adrenocorticotropic hormone; TSH= Thyroid stimulating hormone; GH= Growth hormone; PRL= Prolactin; FSH= Follicle-stimulating hormone; LH= Luteinizing hormone; MSH= Melanocyte-stimulating hormones; OXT= Oxytocin; ADH= Antidiuretic hormone (arginine vasopressin)

Hormones, in the strict sense, are chemical (protein) messengers that are transported by the bloodstream and stimulate physiological responses in cells of another tissue or target organ, often a considerable distance away. Certain hormones produced by the pituitary gland in the head, for example, act on organs as far away as the pelvic cavity.

Hormones are produced by the endocrine glands and are sent into the bloodstream to the various tissues in the body. They send signals to those tissues to tell them what they are supposed to do. When the glands do not produce the right amount of hormones, diseases develop that can affect many aspects of life.

Hormones control many different bodily functions, including:

• Respiration
• Heart rate
• Metabolism – digestion, elimination, breathing, blood circulation and maintaining body temperature
• Appetite
• Reproduction
• Sensory perception
• Sleep cycles
• Movement
• Sexual development
• Growth and development
• Mood
• Responses to stress and injury
• Bone and muscle strength

Hormones are powerful. It takes only a tiny amount to cause big changes in cells or even your whole body. That is why too much or too little of a certain hormone can be serious. Laboratory tests can measure the hormone levels in your blood, urine, or saliva. Your health care provider may perform these tests if you have symptoms of a hormone disorder. Home pregnancy tests are similar – they test for pregnancy hormones in your urine.

If your hormone levels are too high or too low, you may have a hormone disorder. Hormone diseases also occur if your body does not respond to hormones the way it is supposed to. Stress, infection and changes in your blood’s fluid and electrolyte balance can also influence hormone levels.

In the United States, the most common endocrine disease is diabetes. There are many others. They are usually treated by controlling how much hormone your body makes. Hormone supplements can help if the problem is too little of a hormone.

Hormones

Growth hormone (GH): Secreted by the anterior lobe of the pituitary gland; promotes general growth of all body tissues, including bone, mainly by stimulating production of insulin-like growth factors.

Insulin-like growth factors (IGFs): Secreted by the liver, bones, and other tissues on stimulation by growth hormone; promotes normal bone growth by
stimulating osteoblasts and by increasing the synthesis of proteins needed to build new bone.

Thyroid hormones (T3 and T4): Secreted by thyroid gland; promote normal bone growth by stimulating osteoblasts.

Insulin: Secreted by the pancreas; promotes normal bone growth by increasing the synthesis of bone proteins.

Sex hormones (estrogens and testosterone): Secreted by the ovaries in women (estrogens) and by the testes in men (testosterone); stimulate osteoblasts and promote the sudden “growth spurt” that occurs during the teenage years; shut down growth at the epiphyseal plates around age 18–21, causing lengthwise growth of bone to end; contribute to bone remodeling during adulthood by slowing bone resorption by osteoclasts and promoting bone deposition by osteoblasts.

Parathyroid hormone (PTH): Secreted by the parathyroid glands; promotes bone resorption by osteoclasts; enhances recovery of calcium ions from urine; promotes formation of the active form of vitamin D (calcitriol).

Calcitonin: Secreted by the thyroid gland; inhibits bone resorption by osteoclasts.

Factors that Affect Endocrine Function

Everyone’s body undergoes changes, some natural and some not, that can affect the way the endocrine system works. Some of the factors that affect endocrine organs include aging, certain diseases and conditions, stress, the environment, and genetics.

Aging

Despite age-related changes, the endocrine system functions well in most older people. However, some changes occur because of damage to cells during the aging process and genetically programmed cellular changes. These changes may alter the following:

• hormone production and secretion
• hormone metabolism (how quickly hormones are broken down and leave the body)
• hormone levels circulating in blood
• target cell or target tissue response to hormones
• rhythms in the body, such as the menstrual cycle

For example, increasing age is thought to be related to the development of type 2 diabetes, especially in people who might be at risk for this disorder. The aging process affects nearly every gland. With increasing age, the pituitary gland can become smaller and may not work as well. For example, production of growth hormone might decrease. Decreased growth hormone levels in older people might lead to problems such as decreased lean muscle, decreased heart function, and osteoporosis. Aging affects a woman’s ovaries and results in menopause, usually between 50 and 55 years of age. In menopause, the ovaries stop making estrogen and progesterone and no longer have a store of eggs. When this happens, menstrual periods stop.

Diseases and Conditions

Chronic diseases and other conditions may affect endocrine system function in several ways. After hormones produce their effects at their target organs, they are broken down (metabolized) into inactive molecules. The liver and kidneys are the main organs that break down hormones. The ability of the body to break down hormones may be decreased in people who have chronic heart, liver, or kidney disease.

Abnormal endocrine function can result from:

• congenital (birth) or genetic defects (see section on Genetics below)
• surgery, radiation, or some cancer treatments
• traumatic injuries
• cancerous and non-cancerous tumors
• infection
• autoimmune destruction (when the immune system turns against the body’s own organs and causes damage)

In general, abnormal endocrine function creates a hormone imbalance typified by too much or too little of a hormone. The underlying problem might be due to and endocrine gland making too much or too little of the hormone, or to a problem breaking down the hormone.

Stress

Physical or mental stressors can trigger a stress response. The stress response is complex and can influence heart, kidney, liver, and endocrine system function. Many factors can start the stress response, but physical stressors are most important. In order for the body to respond to, and cope with, physical stress, the adrenal glands make more cortisol. If the adrenal glands do not respond, this can be a life-threatening problem. Some medically important factors causing a stress response are

• trauma (severe injury) of any type
• severe illness or infection
• intense heat or cold
• surgical procedures
• serious diseases
• allergic reactions

Other types of stress include emotional, social, or economic, but these usually do not require the body to produce high levels of cortisol in order to survive the stress.

Environmental Factors

An environmental endocrine disrupting chemical is a substance outside of the body that may interfere with the normal function of the endocrine system. Some endocrine disrupting chemicals mimic natural hormone binding at the target cell receptor. (Binding occurs when a hormone attaches to a cell receptor, a part of the cell designed to respond to that particular hormone.) Endocrine disrupting chemicals can start the same processes that the natural hormone would start. Other endocrine disrupting chemicals block normal hormone binding and thereby prevent the effects of the natural hormones. Still other endocrine disrupting chemicals can directly interfere with the production, storage, release, transport, or elimination of natural hormones in the body. This can greatly affect the function of certain body systems.

Endocrine disrupting chemicals can affect people in many ways:

• disrupted sexual development
• decreased fertility
• birth defects
• reduced immune response
• neurological and behavioral changes, including reduced ability to handle stress

Genetics

Your endocrine system can be affected by genes. Genes are units of hereditary information passed from parent to child. Genes are contained in chromosomes. The normal number of chromosomes is 46 (23 pairs). Sometimes extra, missing, or damaged chromosomes can result in diseases or conditions that affect hormone production or function. The 23rd pair, for example, is the sex chromosome pair. A mother and father each contribute a sex chromosome to the child. Girls usually have two X chromosomes while boys have one X and one Y chromosome. Sometimes, however, a chromosome or piece of a chromosome may be missing. In Turner syndrome, only one normal X chromosome is present and this can cause poor growth and a problem with how the ovaries function. In another example, a child with Prader-Willi syndrome may be missing all or part of chromosome 15, which affects growth, metabolism, and puberty. Your genes also may place you at increased risk for certain diseases, such as breast cancer. Women who have inherited mutations in the BRCA1 or BRCA2 gene face a much higher risk of developing breast cancer and ovarian cancer compared with the general population.

Endocrine Disrupting Chemicals

Endocrine disrupting chemicals are substances in the environment (air, soil or water supply), food sources, personal care products, and manufactured products that may interfere with the normal function of your body’s endocrine system ¹.

Endocrine disrupting chemicals, a broad category of compounds used in consumer products, electronics and agriculture, have been associated with a diverse array of health issues. These non-natural chemicals or mixtures of chemicals can mimic, block, or interfere with the way the body’s hormones work.

They have been linked to human health issues related to sperm quality, fertility, abnormalities in sex organs, endometriosis, early puberty, nervous system function, immune function, cancers, breathing problems, metabolic issues, obesity, heart health, growth, neurological and learning disabilities, and more.

Exposure to endocrine disrupting chemicals can happen anywhere and come from the air we breathe, the food we eat, and the water we drink. Endocrine disrupting chemicals can also enter the body through the skin and by transfer from mother to fetus (across the placenta) or mother to infant (via breast feeding) if a woman has endocrine disrupting chemicals in her body.

Examples of endocrine disrupting chemicals include bisphenol A (BPA), phthalates, pesticides, and pollutants such as dioxin and polychlorinated biphenyls (PCBs).

Endocrine disrupting chemicals Facts

Endocrine disrupting chemicals often disrupt the endocrine system by mimicking or interfering with a natural hormone. These “hormone mimics” can trick the hormone receptor into thinking the endocrine disrupting chemicals is the hormone, which can trigger abnormal processes in the body. Studies support a link between endocrine disrupting chemicals and harm to human health, but the cause-and-effect relationship is not yet fully understood. Still some endocrine disrupting chemicals are known to pose a threat to people who have excessive exposure to them.

Where are endocrine disrupting chemicals ?

• Industrial chemicals can leach into soil and groundwater and then make their way into the food chain and build up in fish, animals, and people
• Consumer products such as plastics, household chemicals, fabrics treated with flame retardants, cosmetics, lotions, products with fragrance, and anti-bacterial soaps
• Pesticides, fungicides, or industrial chemicals in the workplace The best way to avoid exposure is to check labels and avoid products with known endocrine disrupting chemicals.

Table 1. Some common endocrine disrupting chemicals (EDCs) and their uses include the following:

Common Endocrine Disrupting Chemicals	Used In
Pesticides	Example EDCs: DDT, Chlorpyrifos, Atrazine, 2,4-D, Glyphosate
Children’s Products	Example EDCs: Lead, Phthalates, Cadmium
Industrial Solvents or Lubricants and Their Byproducts	Example EDCs: PCBs and Dioxins
Plastics and Food Storage Materials	Example EDCs: BPA, Phthalates, Phenol
Electronics and Building Materials	Example EDCs: Brominated Flame Retardants, PCBs
Personal Care Products, Medical Tubing	Example EDCs: Phthalates, Parabens, UV Filters
Anti-Bacterials	Example EDCs: Triclosan
Textiles, Clothing	Example EDCs: Perfluorochemicals

[Source ¹]

Where do endocrine disrupting chemicals impact your body ?

More research is needed, but scientists know endocrine disrupting chemicals affect:

Response to stress

• Neurological and behavioral changes
• Reduced ability to handle stress

Metabolism

• Industrial chemicals can interfere with thyroid function

Reproduction

• Virtually all classes of endocrine disrupting chemicals (DDT, BPA, phthalates, PCBs) can mimic or block effects of male and female sex hormones, affecting reproductive health

Growth and development

• Neural development
• Disrupted sexual development
• Weakened immune system

Avoiding endocrine disrupting chemicals

Even if some health effects are not fully proven, taking precautions is wise. Become familiar with endocrine disrupting chemicals to which you and your family may be exposed. Try to avoid unnecessary, preventable exposure to endocrine disrupting chemical-containing consumer products. Experts suggest avoiding microwaving food in plastics to avoid leaching of endocrine disrupting chemicals into food, choosing personal care products and cleaners that are unscented, and replacing older non-stick pans with newer, ceramic-coated ones. These precautions are especially important if you are pregnant or planning a family.

Plastic bottles

At the bottom of your plastic bottle, you’ll find a triangular shape with arrows with a number inside. Those numbers represent the type of plastic used in making the bottle. Plastics with recycling labels #1, #2 & #4 may be safer choices as they do not contain BPA. However, BPA is not the only endocrine disruptor in plastic so just because something is “BPA-free” does not mean that it is endocrine disrupting chemical-free. When possible, avoid disposable plastics.

How to balance hormones naturally

Changing Your Lifestyle

Some of the factors that affect endocrine organs include aging, certain diseases and conditions, stress, the environment, your diet, your body weight and genetics.

Adopting healthy habits — such as regular exercise and adequate sleep along with healthy eating — are important steps in restoring your hormones including the daily cortisol rhythms.

For example, being overweight or obese (too much body fat) can affect your hormones. And with modest weight loss you can improve your health.

If you are living with hormones imbalance, lifestyle is an important part of your treatment. It is very important that you eat a good balance of foods every day and exercise regularly. Managing your hormone imbalance also means taking medicine, if needed.

Healthy Eating

People with hormones imbalance does not require special foods. A healthy, balanced diet can come from everyday foods. Your doctor can refer you to a dietitian who can help you plan meals that taste great and are good for you.

If you have hormones imbalance, you should:

• Consume less than 10 percent of calories per day from added sugars.
• Consume less than 10 percent of calories per day from saturated fats.
• Consume less than 2,300 milligrams (mg) per day of sodium.
• If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and up to two drinks per day for men—and only by adults of legal drinking age.
• Choose foods that are low in fat and salt
• Choose foods that are high in fiber (such as beans, vegetables, and fruit)
• Eat foods from all food groups. The U.S. Department of Agriculture has plenty of information about choosing a balanced diet
• Lose weight if you need to by cutting down on how much you eat.

A healthy diet includes:

• For vitamins, minerals and fiber, eat at least 2 cups of fruits and 2½ cups of vegetables each day.
• Whole grains. Eat at least half of all grains as whole grains each day. Replace refined grains with whole-grain bread, cereal, pasta, brown rice or oats.
• At least two to three servings of fish per week.
• Three servings of low-fat or fat-free dairy products including low-fat or fat-free milk, yogurt or cheese.
• Five to 6 ounces of protein such as lean meat, chicken, turkey, fish, eggs, beans or peas and nuts.
• Two cups of fruits — fresh, frozen or canned without added sugar.
• Two-and-a-half cups of colorful vegetables — fresh, frozen or canned without added salt.
• At least 38 grams of fiber a day for younger men and 30 grams of fiber for women; 30 grams of fiber a day for men and women older than 50.
• Unsaturated fats such as oils, nuts and oil-based salad dressings in place of saturated fats including full-fat dairy foods, butter and high-fat sweets.
• 4,700 milligrams a day of potassium from fruits, vegetables, fish and milk.

For healthy bones and teeth, you need to eat a variety of calcium-rich foods every day. Calcium keeps bones strong and prevents osteoporosis, a bone disease in which the bones become weak and break easily. Some calcium-rich foods include low-fat or fat-free milk, yogurt and cheese, sardines, tofu (if made with calcium sulfate) and calcium-fortified foods including juices and cereals.

Women of childbearing age need to eat enough folic acid to decrease risk of birth defects. The requirement is at least 400 micrograms of folic acid a day. Be sure to consume adequate amounts of folic acid daily from fortified foods or supplements, in addition to food forms of folate from a varied diet. Citrus fruits, leafy greens, beans and peas naturally contain folate. There are many folic acid fortified foods such as cereals, rice and breads.

What and How much Should you Eat ?

For an average adult male who requires 2000 Calories (8368 kilojoules)

Note: 1 Calorie (kilocalories) = 4.184 kilojoules (kJ)

Because how much calories you eat and what food groups you need are highly dependent on your age, sex, and your level of physical activity. For the most accurate way calculate how much food and calories you need to eat per day from each food group >>> Go to the United States Department of Agriculture’s MyPlate Daily Checklist ² >>> https://www.choosemyplate.gov/myplate-daily-checklist-input
Simply enter your age, sex, height, weight, and physical activity level to get a plan that’s right for you. The MyPlate Daily Checklist shows your food group targets – what and how much to eat within your calorie allowance.

Foods that balance hormones

An important part of maintaining a healthy weight and healthy lifestyle is to maintain energy balance is the amount of ENERGY OUT (physical activity) that you do. People who are more physically active burn more calories than those who are not as physically active.

• Vegetables
  • Dark-green vegetables: All fresh, frozen, and canned dark-green leafy vegetables and broccoli, cooked or raw: for example, broccoli; spinach; romaine; kale; collard, turnip, and mustard greens.
  • Red and orange vegetables: All fresh, frozen, and canned red and orange vegetables or juice, cooked or raw: for example, tomatoes, tomato juice, red peppers, carrots, sweet potatoes, winter squash, and pumpkin.
  • Legumes (beans and peas): All cooked from dry or canned beans and peas: for example, kidney beans, white beans, black beans, lentils, chickpeas, pinto beans, split peas, and edamame (green soybeans). Does not include green beans or green peas.
  • Starchy vegetables: All fresh, frozen, and canned starchy vegetables: for example, white potatoes, corn, green peas, green lima beans, plantains, and cassava.
  • Other vegetables: All other fresh, frozen, and canned vegetables, cooked or raw: for example, iceberg lettuce, green beans, onions, cucumbers, cabbage, celery, zucchini, mushrooms, and green peppers.
• Fruits
  • All fresh, frozen, canned, and dried fruits and fruit juices: for example, oranges and orange juice, apples and apple juice, bananas, grapes, melons, berries, and raisins.
• Grains
  • Whole grains: All whole-grain products and whole grains used as ingredients: for example, whole-wheat bread, whole-grain cereals and crackers, oatmeal, quinoa, popcorn, and brown rice.
  • Refined grains: All refined-grain products and refined grains used as ingredients: for example, white breads, refined grain cereals and crackers, pasta, and white rice. Refined grain choices should be enriched.
• Dairy
  • All milk, including lactose-free and lactose-reduced products and fortified soy beverages (soymilk), yogurt, frozen yogurt, dairy desserts, and cheeses. Most choices should be fat-free or low-fat. Cream, sour cream, and cream cheese are not included due to their low calcium content.
• Protein Foods
  • All seafood, meats, poultry, eggs, soy products, nuts, and seeds. Meats and poultry should be lean or low-fat and nuts should be unsalted. Legumes (beans and peas) can be considered part of this group as well as the vegetable group, but should be counted in one group only.

Evidence shows that healthy eating patterns are associated with positive health outcomes. And the evidence base for associations between eating patterns and specific health outcomes continues to grow. Strong evidence shows that healthy eating patterns are associated with a reduced risk of cardiovascular disease. Moderate evidence indicates that healthy eating patterns also are associated with a reduced risk of type 2 diabetes, certain types of cancers (such as colorectal and postmenopausal breast cancers), overweight, and obesity. Emerging evidence also suggests that relationships may exist between eating patterns and some neuro-cognitive disorders and congenital anomalies.

Within this body of evidence, higher intakes of vegetables and fruits consistently have been identified as characteristics of healthy eating patterns; whole grains have been identified as well, although with slightly less consistency. Other characteristics of healthy eating patterns have been identified with less consistency and include fat-free or low-fat dairy, seafood, legumes, and nuts.

Lower intakes of meats, including processed meats; processed poultry; sugar-sweetened foods, particularly beverages; and refined grains have often been identified as characteristics of healthy eating patterns.

A) Vegetables

Healthy intake: Healthy eating patterns include a variety of vegetables from all of the five vegetable subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other. These include all fresh, frozen, canned, and dried options in cooked or raw forms, including vegetable juices. The recommended amount of vegetables in the Healthy U.S.-Style Eating Pattern at the 2,000-calorie level is 2½ cup-equivalents of vegetables per day. In addition, weekly amounts from each vegetable subgroup are recommended to ensure variety and meet nutrient needs.

Key nutrient contributions: Vegetables are important sources of many nutrients, including dietary fiber, potassium, vitamin A, vitamin C, vitamin K, copper, magnesium, vitamin E, vitamin B₆, folate, iron, manganese, thiamin, niacin, and choline. Each of the vegetable subgroups contributes different combinations of nutrients, making it important for individuals to consume vegetables from all the subgroups. For example, dark-green vegetables provide the most vitamin K, red and orange vegetables the most vitamin A, legumes the most dietary fiber, and starchy vegetables the most potassium. Vegetables in the “other” vegetable subgroup provide a wide range of nutrients in varying amounts.

Considerations: To provide all of the nutrients and potential health benefits that vary across different types of vegetables, the Healthy U.S.-Style Eating Pattern includes weekly recommendations for each subgroup. Vegetable choices over time should vary and include many different vegetables. Vegetables should be consumed in a nutrient-dense form, with limited additions such as salt, butter, or creamy sauces. When selecting frozen or canned vegetables, choose those lower in sodium.

B) Fruits

Healthy intake: Healthy eating patterns include fruits, especially whole fruits. The fruits food group includes whole fruits and 100% fruit juice. Whole fruits include fresh, canned, frozen, and dried forms. The recommended amount of fruits in the Healthy U.S.-Style Eating Pattern at the 2,000-calorie level is 2 cup-equivalents per day. One cup of 100% fruit juice counts as 1 cup of fruit. Although fruit juice can be part of healthy eating patterns, it is lower than whole fruit in dietary fiber and when consumed in excess can contribute extra calories. Therefore, at least half of the recommended amount of fruits should come from whole fruits. When juices are consumed, they should be 100% juice, without added sugars. Also, when selecting canned fruit, choose options that are lowest in added sugars. One-half cup of dried fruit counts as one cup-equivalent of fruit. Similar to juice, when consumed in excess, dried fruits can contribute extra calories.

Key nutrient contributions: Among the many nutrients fruits provide are dietary fiber, potassium, and vitamin C.

Considerations: Juices may be partially fruit juice, and only the proportion that is 100% fruit juice counts (e.g., 1 cup of juice that is 50% juice counts as ½ cup of fruit juice). The remainder of the product may contain added sugars. Sweetened juice products with minimal juice content, such as juice drinks, are considered to be sugar-sweetened beverages rather than fruit juice because they are primarily composed of water with added sugars (see the Added Sugars section). The percent of juice in a beverage may be found on the package label, such as “contains 25% juice” or “100% fruit juice.” The amounts of fruit juice allowed in the US Department of Agriculture (USDA) Food Patterns for young children align with the recommendation from the American Academy of Pediatrics that young children consume no more than 4 to 6 fluid ounces of 100% fruit juice per day. Fruits with small amounts of added sugars can be accommodated in the diet as long as calories from added sugars do not exceed 10 percent per day and total calorie intake remains within limits.

C) Grains

Healthy Intake: Healthy eating patterns include whole grains and limit the intake of refined grains and products made with refined grains, especially those high in saturated fats, added sugars, and/or sodium, such as cookies, cakes, and some snack foods. The grains food group includes grains as single foods (e.g., rice, oatmeal, and popcorn), as well as products that include grains as an ingredient (e.g., breads, cereals, crackers, and pasta). Grains are either whole or refined. Whole grains (e.g., brown rice, quinoa, and oats) contain the entire kernel, including the endosperm, bran, and germ. Refined grains differ from whole grains in that the grains have been processed to remove the bran and germ, which removes dietary fiber, iron, and other nutrients. The recommended amount of grains in the Healthy U.S.-Style Eating Pattern at the 2,000-calorie level is 6 ounce-equivalents per day. At least half of this amount should be whole grains.

Key nutrient contributions: Whole grains are a source of nutrients, such as dietary fiber, iron, zinc, manganese, folate, magnesium, copper, thiamin, niacin, vitamin B₆, phosphorus, selenium, riboflavin, and vitamin A. Whole grains vary in their dietary fiber content. Most refined grains are enriched, a process that adds back iron and four B vitamins (thiamin, riboflavin, niacin, and folic acid). Because of this process, the term “enriched grains” is often used to describe these refined grains.

Considerations: Individuals who eat refined grains should choose enriched grains. Those who consume all of their grains as whole grains should include some grains, such as some whole-grain ready-to-eat breakfast cereals, that have been fortified with folic acid. This is particularly important for women who are or are capable of becoming pregnant, as folic acid fortification in the United States has been successful in reducing the incidence of neural tube defects during fetal development. Although grain products that are high in added sugars and saturated fats, such as cookies, cakes, and some snack foods, should be limited, as discussed in the Added Sugars and Saturated Fats sections below, grains with some added sugars and saturated fats can fit within healthy eating patterns.

D) Dairy

Healthy intake: Healthy eating patterns include fat-free and low-fat (1%) dairy, including milk, yogurt, cheese, or fortified soy beverages (commonly known as “soymilk”). Soy beverages fortified with calcium, vitamin A, and vitamin D, are included as part of the dairy group because they are similar to milk based on nutrient composition and in their use in meals. Other products sold as “milks” but made from plants (e.g., almond, rice, coconut, and hemp “milks”) may contain calcium and be consumed as a source of calcium, but they are not included as part of the dairy group because their overall nutritional content is not similar to dairy milk and fortified soy beverages (soymilk). The recommended amounts of dairy in the Healthy U.S.-Style Pattern are based on age rather than calorie level and are 2 cup-equivalents per day for children ages 2 to 3 years, 2½ cup-equivalents per day for children ages 4 to 8 years, and 3 cup-equivalents per day for adolescents ages 9 to 18 years and for adults.

Key nutrient contributions: The dairy group contributes many nutrients, including calcium, phosphorus, vitamin A, vitamin D (in products fortified with vitamin D), riboflavin, vitamin B₁₂, protein, potassium, zinc, choline, magnesium, and selenium.

Considerations: Fat-free and low-fat (1%) dairy products provide the same nutrients but less fat (and thus, fewer calories) than higher fat options, such as 2% and whole milk and regular cheese. Fat-free or low-fat milk and yogurt, in comparison to cheese, contain less saturated fats and sodium and more potassium, vitamin A, and vitamin D. Thus, increasing the proportion of dairy intake that is fat-free or low-fat milk or yogurt and decreasing the proportion that is cheese would decrease saturated fats and sodium and increase potassium, vitamin A, and vitamin D provided from the dairy group. Individuals who are lactose intolerant can choose low-lactose and lactose-free dairy products. Those who are unable or choose not to consume dairy products should consume foods that provide the range of nutrients generally obtained from dairy, including protein, calcium, potassium, magnesium, vitamin D, and vitamin A (e.g., fortified soy beverages [soymilk]). Additional sources of potassium, calcium, and vitamin D.

E) Protein Foods

Healthy intake: Healthy eating patterns include a variety of protein foods in nutrient-dense forms. The protein foods group comprises a broad group of foods from both animal and plant sources and includes several subgroups: seafood; meats, poultry, and eggs; and nuts, seeds, and soy products. Legumes (beans and peas) may also be considered part of the protein foods group as well as the vegetables group. Protein also is found in some foods from other food groups (e.g., dairy). The recommendation for protein foods in the Healthy U.S.-Style Eating Pattern at the 2,000-calorie level is 5½ ounce-equivalents of protein foods per day.

Key nutrient contributions: Protein foods are important sources of nutrients in addition to protein, including B vitamins (e.g., niacin, vitamin B₁₂, vitamin B₆, and riboflavin), selenium, choline, phosphorus, zinc, copper, vitamin D, and vitamin E). Nutrients provided by various types of protein foods differ. For example, meats provide the most zinc, while poultry provides the most niacin. Meats, poultry, and seafood provide heme iron, which is more bioavailable than the non-heme iron found in plant sources. Heme iron is especially important for young children and women who are capable of becoming pregnant or who are pregnant. Seafood provides the most vitamin B₁₂ and vitamin D, in addition to almost all of the polyunsaturated omega-3 fatty acids, eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA), in the Patterns. Eggs provide the most choline, and nuts and seeds provide the most vitamin E. Soy products are a source of copper, manganese, and iron, as are legumes.

Considerations: For balance and flexibility within the food group, the Healthy U.S.-Style Eating Pattern includes weekly recommendations for the subgroups: seafood; meats, poultry, and eggs; and nuts, seeds, and soy products. A specific recommendation for at least 8 ounce-equivalents of seafood per week also is included for the 2,000-calorie level. One-half ounce of nuts or seeds counts as 1 ounce-equivalent of protein foods, and because they are high in calories, they should be eaten in small portions and used to replace other protein foods rather than being added to the diet. When selecting protein foods, nuts and seeds should be unsalted, and meats and poultry should be consumed in lean forms. Processed meats and processed poultry are sources of sodium and saturated fats, and intake of these products can be accommodated as long as sodium, saturated fats, added sugars, and total calories are within limits in the resulting eating pattern. The inclusion of protein foods from plants allows vegetarian options to be accommodated.

F) Oils

Healthy intake: Oils are fats that contain a high percentage of monounsaturated and polyunsaturated fats and are liquid at room temperature. Although they are not a food group, oils are emphasized as part of healthy eating patterns because they are the major source of essential fatty acids and vitamin E. Commonly consumed oils extracted from plants include canola, corn, olive, peanut, safflower, soybean, and sunflower oils. Oils also are naturally present in nuts, seeds, seafood, olives, and avocados. The fat in some tropical plants, such as coconut oil, palm kernel oil, and palm oil, are not included in the oils category because they do not resemble other oils in their composition. Specifically, they contain a higher percentage of saturated fats than other oils. The recommendation for oils in the Healthy U.S.-Style Eating Pattern at the 2,000-calorie level is 27 g (about 5 teaspoons) per day.

Key nutrient contributions: Oils provide essential fatty acids and vitamin E.

Considerations: Oils are part of healthy eating patterns, but because they are a concentrated source of calories, the amount consumed should be within the AMDR for total fats without exceeding calorie limits. Oils should replace solid fats rather than being added to the diet.

Foods to Limit

To keep weight in check at any age, you should avoid a lot of excess calories from added sugars, fat and alcohol.

• Limit regular soft drinks, sugar-sweetened beverages, candy, baked goods and fried foods.
• Limit alcohol intake to one drink per day. One drink is equal to 12 ounces of beer, 5 ounces of wine or 1.5 ounces of liquor.
• Opt for low-fat dairy and meat products instead of their full-fat counterparts.

Eat fewer foods that are high in saturated fat — the kind found in fatty meats, sausages, cheese and full-fat dairy products, baked goods and pizza.

Energy Foods

Since men have more muscle and are typically bigger than women, they require more calories throughout the day. Moderately active males should eat 2,000 to 2,800 calories per day. Your energy needs depend on your height, weight and activity level.

For energy, weight management and disease prevention, men should eat whole grains such as whole-grain bread, pasta, cereal, brown rice, oats, barley, fruits and vegetables. These foods are high in fiber, help manage hunger and fullness and help fend off certain cancers, such as prostate and colon.

Beyond Meat

Men are typically meat-eaters because of the perception that more protein equals more muscle mass. That is not the case unless exercise is involved. Men tend to view red meat as more masculine than other proteins; often this leads them to “order the steak.” It’s not the steak that’s unhealthy, it’s skipping the whole grains and vegetables. In addition, excessive meat eating is linked to heart disease and colorectal cancer in men.

Eat red meat less frequently, and, instead, focus on more fruits, vegetables and low-fat dairy products. This will not only help you keep weight off, but it can help keep blood pressure down. Cut down on saturated fat from meat, cheese and fried foods. Instead, opt for foods with unsaturated, heart-healthy fats such as olive oil, canola oil, nuts, seeds and avocadoes.

Weight and Disease Risk

More than women, men gain weight around the middle; that’s due to the male hormone testosterone. If your waist measures more than 40 inches around, it’s time to shed some pounds. This fat around the waist is typically buried deep in the abdomen and increases your risk for diabetes, heart disease and dementia.

Alcohol

If your hormones imbalance is under control and you do not have high blood pressure, your doctor may allow you to drink alcohol in moderation. Keep in mind that if you drink alcohol while taking insulin or other diabetes medication, your risk of having low blood sugar may increase.

If you drink alcohol, limit yourself to one drink a day if you are a woman and two drinks a day if you are a man. Avoid sugary mixed drinks. Never drink alcohol on an empty stomach.

Smoking

Smoking greatly increases your risk of heart disease, eye disease, and blood vessel disease, which are major complications of diabetes. Stopping smoking is the single best thing you can do to lower your chances of developing heart and blood vessel disease.

Exercise For Overall Health

Exercise is an important part of your health. Regular daily exercise helps with weight control, muscle strength and stress management. The American Heart Association ³ recommends the following amounts of physical activity to maintain cardiovascular health:

• At least 30 minutes of moderate-intensity aerobic activity at least 5 days per week for a total of 150 minutes.

OR

• At least 25 minutes of vigorous aerobic activity at least 3 days per week for a total of 75 minutes; or a combination of moderate- and vigorous-intensity aerobic activity.

AND

• Moderate- to high-intensity muscle-strengthening activity at least 2 days per week for additional health benefits.

For Lowering Blood Pressure and Cholesterol

• An average 40 minutes of moderate- to vigorous-intensity aerobic activity 3 or 4 times per week.

Add these activities to your weekly fitness routine to slow down your body’s clock.

• Endurance exercises. Activities such as running, cycling and swimming are the best ways to improve your cardiovascular function and prevent your metabolism from slowing down. Aim to get at least 30 to 60 minutes of moderate-intensity cardio (aerobic) activity most days, for a total of 150 minutes each week.
• Interval training. Instead of a steady-state bout of running or cycling, with high-intensity interval training, you alternate bursts of intense activity (that makes you breathe heavily) with lighter activity. An example workout would include five intervals at a higher intensity (which may mean increasing speed, incline or resistance) for one to two minutes with a one- to two-minute period in between at a slightly lower intensity. An easy way to determine if you’re working hard enough is whether you can talk (or sing) easily. If you can’t, you’re working hard enough during your intervals. Add interval training to your workout routine one or two days each week.
• Strength training. Maintaining muscle mass is very important as you age, since both men and women lose muscle mass as they age and replace it with fat. Skeletal muscle burns more calories at rest compared to fat tissue. It also protects your joints and can help your bones become stronger and maintain their density, which can prevent fractures. Maintaining and increasing muscle mass can also help improve balance and agility, which is crucial as you get older.

Exercise and Physical Activity

Your doctor may have good ideas about types of exercise that would be best for you. Exercise is important for people with hormones imbalance because it:

• Helps insulin work better to lower blood sugar
• Helps keep weight down
• Is good for the heart, blood vessels, and lungs
• Gives you more energy

 

If you have heart disease or risk factors for heart disease, such as high cholesterol, high blood pressure, or poor diabetes control, check with your doctor about whether or not you need a stress test before beginning an exercise program.

If you have nerve damage to your feet, be careful to wear well-fitting shoes and socks to avoid blisters. Talk with your physician and/or podiatrist about your exercise program.

Why is Sleep Important ?

Sleep plays a vital role in good health and well-being throughout your life. Getting enough quality sleep at the right times can help protect your mental health, physical health, quality of life, and safety ⁴.

The way you feel while you’re awake depends in part on what happens while you’re sleeping ⁴. During sleep, your body is working to support healthy brain function and maintain your physical health. In children and teens, sleep also helps support growth and development.

The damage from sleep deficiency can occur in an instant (such as a car crash), or it can harm you over time. For example, ongoing sleep deficiency can raise your risk for some chronic health problems. It also can affect how well you think, react, work, learn, and get along with others.

Healthy Brain Function and Emotional Well-Being

Sleep helps your brain work properly. While you’re sleeping, your brain is preparing for the next day. It’s forming new pathways to help you learn and remember information.

Studies show that a good night’s sleep improves learning ⁴. Whether you’re learning math, how to play the piano, how to perfect your golf swing, or how to drive a car, sleep helps enhance your learning and problem-solving skills. Sleep also helps you pay attention, make decisions, and be creative.

Studies also show that sleep deficiency alters activity in some parts of the brain. If you’re sleep deficient, you may have trouble making decisions, solving problems, controlling your emotions and behavior, and coping with change. Sleep deficiency also has been linked to depression, suicide, and risk-taking behavior ⁴.

Children and teens who are sleep deficient may have problems getting along with others. They may feel angry and impulsive, have mood swings, feel sad or depressed, or lack motivation. They also may have problems paying attention, and they may get lower grades and feel stressed ⁴.

Physical Health

Sleep plays an important role in your physical health. For example, sleep is involved in healing and repair of your heart and blood vessels. Ongoing sleep deficiency is linked to an increased risk of heart disease, kidney disease, high blood pressure, diabetes, and stroke ⁴.

A lack of sleep also puts your body under stress and may trigger the release of more adrenaline, cortisol, and other stress hormones during the day. These hormones keep your blood pressure from dipping during sleep, which increases your risk for heart disease. Lack of sleep also may trigger your body to produce more of certain proteins thought to play a role in heart disease. For example, some studies find that people who repeatedly don’t get enough sleep have higher than normal blood levels of C-reactive protein, a sign of inflammation. High levels of this protein may indicate an increased risk for a condition called atherosclerosis, or hardening of the arteries.

Sleep deficiency also increases the risk of obesity. For example, one study of teenagers showed that with each hour of sleep lost, the odds of becoming obese went up. Sleep deficiency increases the risk of obesity in other age groups as well ⁴.

Sleep helps maintain a healthy balance of the hormones that make you feel hungry (ghrelin) or full (leptin) ⁴. When you don’t get enough sleep, your level of ghrelin goes up and your level of leptin goes down. This makes you feel hungrier than when you’re well-rested ⁴.

Evidence is growing that sleep is a powerful regulator of appetite, energy use, and weight control. During sleep, the body’s production of the appetite suppressor leptin increases and the appetite stimulant grehlin decreases. Studies find that the less people sleep, the more likely they are to be overweight or obese and prefer eating foods that are higher in calories and carbohydrates. People who report an average total sleep time of 5 hours a night, for example, are much more likely to become obese, compared with people who sleep 7–8 hours a night.

Sleep also affects how your body reacts to insulin, the hormone that controls your blood glucose (sugar) level. Sleep deficiency results in a higher than normal blood sugar level, which may increase your risk for diabetes ⁴. One study found that, when healthy young men slept only 4 hours a night for 6 nights in a row, their insulin and blood sugar levels matched those seen in people who were developing diabetes. Another study found that women who slept less than 7 hours a night were more likely to develop diabetes over time than those who slept between 7 and 8 hours a night.

Sleep also supports healthy growth and development ⁴. Deep sleep triggers the body to release the hormone that promotes normal growth in children and teens. This hormone also boosts muscle mass and helps repair cells and tissues in children, teens, and adults. Sleep also plays a role in puberty and fertility.

Your immune system relies on sleep to stay healthy ⁴. This system defends your body against foreign or harmful substances. Ongoing sleep deficiency can change the way in which your immune system responds. For example, if you’re sleep deficient, you may have trouble fighting common infections.

During sleep, your body creates more cytokines—cellular hormones that help the immune system fight various infections. Lack of sleep can reduce your body’s ability to fight off common infections. Research also reveals that a lack of sleep can reduce the body’s response to the flu vaccine. For example, sleep-deprived volunteers given the flu vaccine produced less than half as many flu antibodies as those who were well rested and given the same vaccine.

How Much Sleep Do You Need ?

The amount of sleep you need each day will change over the course of your life, your sleep patterns change as you age. Despite variations in sleep quantity and quality, both related to age and between individuals, studies suggest that the optimal amount of sleep needed to perform adequately, avoid a sleep debt, and not have problem sleepiness during the day is about 7–8 hours for adults and at least 10 hours for school-aged children and adolescents. Similar amounts seem to be necessary to avoid an increased risk of develop­ing obesity, diabetes, or cardiovascular diseases.

Quality of sleep and the timing of sleep are as important as quantity. People whose sleep is frequently interrupted or cut short may not get enough of both non-REM sleep and REM sleep. Both types of sleep appear to be crucial for learning and memory—and perhaps for the restorative benefits of healthy sleep, including the growth and repair of cells.

The table below shows general recommendations for different age groups. This table reflects recent American Academy of Sleep Medicine recommendations that the American Academy of Pediatrics has endorsed.

Table 2. Recommended Amount of Sleep

Age	Recommended Amount of Sleep
Infants aged 4-12 months	12-16 hours a day (including naps)
Children aged 1-2 years	11-14 hours a day (including naps)
Children aged 3-5 years	10-13 hours a day (including naps)
Children aged 6-12 years	9-12 hours a day
Teens aged 13-18 years	8-10 hours a day
Adults aged 18 years or older	7–8 hours a day

[Source ⁴]

Babies initially sleep as much as 16 to 18 hours per day, which may boost growth and development (especially of the brain). School-age children and teens on average need about 9.5 hours of sleep per night. Most adults need 7-9 hours of sleep a night, but after age 60, nighttime sleep tends to be shorter, lighter, and interrupted by multiple awakenings. Elderly people are also more likely to take medications that interfere with sleep.

For example, some older people complain of difficulty falling asleep, early morning awakenings, frequent and long awakenings during the night, daytime sleepiness, and a lack of refreshing sleep. Many sleep problems, however, are not a natural part of sleep in the elderly. Their sleep complaints may be due, in part, to medical conditions, illnesses, or medications they are taking—all of which can disrupt sleep. In fact, one study found that the prevalence of sleep problems is very low in healthy older adults. Other causes of some of older adults’ sleep complaints are sleep apnea, restless legs syndrome, and other sleep disorders that become more common with age. Also, older people are more likely to have their sleep disrupted by the need to urinate during the night.

There is no evidence that indicates older people can get by with less sleep than younger people. There is some evidence showing that the biological clock shifts in older people, so they are more apt to go to sleep earlier at night and wake up earlier in the morning. Poor sleep in older people may result in excessive daytime sleepiness, attention and memory problems, depressed mood, and overuse of sleeping pills.

Across the lifespan, the sleep period tends to advance, namely relative to teenagers; older adults tend to go to bed earlier and wake earlier. The quality—but not necessarily the quantity—of deep, NREM sleep also changes, with a trend toward lighter sleep. The relative percentages of stages of sleep appear to stay mostly constant after infancy. From midlife through late life, people awaken more throughout the night. These sleep disruptions cause older people to lose more and more of stages 1 and 2 non-REM sleep as well as REM sleep.

In general, people are getting less sleep than they need due to longer work hours and the availability of round-the-clock entertainment and other activities ⁵.

If you routinely lose sleep or choose to sleep less than needed, the sleep loss adds up. The total sleep lost is called your sleep debt. For example, if you lose 2 hours of sleep each night, you’ll have a sleep debt of 14 hours after a week. Many people feel they can “catch up” on missed sleep during the weekend but, depending on how sleep-deprived they are, sleeping longer on the weekends may not be adequate ⁵.

Some people nap as a way to deal with sleepiness. Naps may provide a short-term boost in alertness and performance. However, napping doesn’t provide all of the other benefits of night-time sleep. Thus, you can’t really make up for lost sleep.

Some people sleep more on their days off than on work days. They also may go to bed later and get up later on days off.

Sleeping more on days off might be a sign that you aren’t getting enough sleep. Although extra sleep on days off might help you feel better, it can upset your body’s sleep–wake rhythm.

Bad sleep habits and long-term sleep loss will affect your health. If you’re worried about whether you’re getting enough sleep, try using a sleep diary for a couple of weeks.

Sleeping when your body is ready to sleep also is very important. Sleep deficiency can affect people even when they sleep the total number of hours recommended for their age group.

For example, people whose sleep is out of sync with their body clocks (such as shift workers) or routinely interrupted (such as caregivers or emergency responders) might need to pay special attention to their sleep needs.

If your job or daily routine limits your ability to get enough sleep or sleep at the right times, talk with your doctor. You also should talk with your doctor if you sleep more than 8 hours a night, but don’t feel well rested. You may have a sleep disorder or other health problem.

How to get better sleep at night

You can take steps to improve your sleep habits. First, make sure that you allow yourself enough time to sleep. With enough sleep each night, you may find that you’re happier and more productive during the day.

Sleep often is the first thing that busy people squeeze out of their schedules. Making time to sleep will help you protect your health and well-being now and in the future.

Getting enough sleep is good for your health. Here are a few tips to improve your sleep:

• Set a schedule. Go to bed and wake up at the same time every day. For children, have a set bedtime and a bedtime routine. Don’t use the child’s bedroom for timeouts or punishment.
• Try to keep the same sleep schedule on weeknights and weekends. Limit the difference to no more than about an hour. Staying up late and sleeping in late on weekends can disrupt your body clock’s sleep–wake rhythm.
• Use the hour before bed for quiet time. Avoid strenuous exercise and bright artificial light, such as from a TV or computer screen. The light may signal the brain that it’s time to be awake.
• Create a room for sleep – avoid bright lights and loud sounds, keep the room at a comfortable temperature, and don’t watch TV or have a computer in your bedroom.
• Avoid nicotine (for example, cigarettes) and caffeine (including caffeinated soda, coffee, tea, and chocolate). Nicotine and caffeine are stimulants, and both substances can interfere with sleep. The effects of caffeine can last as long as 8 hours. So, a cup of coffee in the late afternoon can make it hard for you to fall asleep at night.
• Avoid heavy and/or large meals within a couple hours of bedtime. (Having a light snack is okay.) Also, avoid alcoholic drinks before bed.
• Exercise 20 to 30 minutes a day but no later than a few hours before going to bed.
• Relax before bed – try a warm bath, reading, or another relaxing routine.
• Don’t lie in bed awake. If you can’t get to sleep, do something else, like reading or listening to music, until you feel tired.
• Spend time outside every day (when possible) and be physically active.
• Keep your bedroom quiet, cool, and dark (a dim night light is fine, if needed).

Napping during the day may provide a boost in alertness and performance. However, if you have trouble falling asleep at night, limit naps or take them earlier in the afternoon. Adults should nap for no more than 20 minutes.

Napping in preschool-aged children is normal and promotes healthy growth and development.

See a doctor if you have a problem sleeping or if you feel unusually tired during the day. Most sleep disorders can be treated effectively.

How to Sleep Better if You Are a Shift Worker

Some people have schedules that conflict with their internal body clocks. For example, shift workers and teens who have early school schedules may have trouble getting enough sleep. This can affect how they feel mentally, physically, and emotionally.

If you’re a shift worker, you may find it helpful to:

• Increase your total amount of sleep by adding naps and lengthening the amount of time you allot for sleep.
• Keep the lights bright at work
• Minimize the number of shift changes so that your body’s biological clock has a longer time to adjust to a nighttime work schedule.
• Limit caffeine use to the first part of your shift to promote alertness at night.
• Remove sound and light distractions in your bedroom during daytime sleep (for example, use light-blocking curtains)

If you’re still not able to fall asleep during the day or have problems adapting to a shift-work schedule, talk with your doctor about other options to help you sleep.

When possible, employers and schools might find it helpful to consider options to address issues related to sleep deficiency.

References

1. Endocrine Disrupting Chemicals (EDCs). Hormone Health Network. http://www.hormone.org/hormones-and-health/endocrine-disrupting-chemicals
2. https://www.choosemyplate.gov/myplate-daily-checklist-input
3. American Heart Association, Go Red for Womens : What Exercise is Right for Me ? – https://www.goredforwomen.org/live-healthy/heart-healthy-exercises/what-exercise-is-right-for-me/
4. Why Is Sleep Important ? National Heart, Lung and Blood Institute. https://www.nhlbi.nih.gov/health/health-topics/topics/sdd/why
5. Brain Basics: Understanding Sleep. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Understanding-Sleep

What sunscreen is safe

Is sunscreen safe ?

Yes according to the American Academy of Dermatology ¹ and the U.S. Food and Drug Administration ² sunscreen is safe to use. No published studies show that sunscreen is toxic to humans or hazardous to human health. Scientific studies actually support using sunscreen. If used properly, regular sunscreen use can reduce risk for skin cancer – reduce melanoma ³; reduce squamous cell carcinoma ⁴ and prevent or delay photoaging of the skin ⁵, ⁶, ⁷. Using sunscreen, seeking shade and wearing protective clothing are all important behaviors to reduce your risk of skin cancer.

Research shows that wearing broad-spectrum sunscreen products that filter both UVB radiation and UVA radiation and that have a sun protection factor (SPF) of at least 15 can:

• Prevent sunburn.
• Reduce your risk of skin cancer and premature aging.

Sunscreen products are regulated as over-the-counter drugs by the U.S. Food and Drug Administration. In 2011, the U.S. Food and Drug Administration (FDA) updated regulations on sunscreen labeling to help consumers select and properly use sunscreens ⁸. The FDA announced that sunscreen products meeting modern standards for effectiveness may be labeled with new information to help consumers find products that reduce the risk of skin cancer and early skin aging, in addition to helping prevent sunburn. The regulation allows sunscreens that pass the FDA’s test for protection against ultraviolet A (UVA) and ultraviolet B (UVB) radiation to be labeled as “broad spectrum.” UVA and UVB radiation contribute to sunburn, skin cancer, and premature skin aging. Sunburn is primarily caused by UVB radiation.

Under the new rules, manufacturers of sunscreens labeled as broad spectrum and SPF 15 or higher may state that the products will help prevent sunburn and reduce the risk of skin cancer and early skin aging. Products that have SPF values between 2 and 14 and pass the FDA’s test may be labeled as broad spectrum, but the manufacturers may not state that these products reduce skin cancer risk or early skin aging.

• Any product that is not broad spectrum, or that is broad spectrum but has an SPF between 2 and 14, must carry a warning stating that the product has not been shown to help prevent skin cancer or early skin aging.

Today on every sunscreen labels, you’ll see whether the sunscreen:

• Is Broad Spectrum, which means the sunscreen protects against UVB and UVA rays and helps prevent skin cancer and sunburn.
• Has an SPF of 30 or higher. While SPF 15 is the FDA’s minimum recommendation for protection against skin cancer and sunburn, the AAD recommends choosing a sunscreen with an SPF of at least 30.
• Has a Skin Cancer/Skin Aging Alert in the Drug Facts section of the label, which means the sunscreen will only prevent sunburn and will NOT reduce the risk of skin cancer and early skin aging
• Is Water Resistant (effective for up to 40 minutes in water) or Very Water Resistant (effective for up to 80 minutes in water). This means the sunscreen provides protection while swimming or sweating up to the time listed on the label.
• Sunscreen manufacturers now are banned from claiming that a sunscreen is “waterproof” or “sweat proof,” as the FDA has determined that those terms are misleading.

Even when using a water-resistant sunscreen, you should reapply after getting out of the water or after sweating.

What is UV radiation ?

Radiation is the emission (sending out) of energy from any source. There are many types of radiation.

Ultraviolet (UV) radiation is a form of electromagnetic radiation. The main source of UV radiation (rays) is the sun, although it can also come from man-made sources such as tanning beds and welding torches.

Radiation exists across a spectrum from very high-energy (high-frequency) radiation – like x-rays and gamma rays – to very low-energy (low-frequency) radiation – like radio waves. UV rays have more energy than visible light, but not as much as x-rays.

Higher energy UV rays often have enough energy to remove an electron from (ionize) an atom or molecule, making them a form of ionizing radiation. Ionizing radiation can damage DNA in the cells in our body, which in turn may lead to cancer. But because UV rays don’t have enough energy to penetrate deeply into the body, their main effect is on the skin.

Ultraviolet light (lightwaves 200-400nm) from the sun can cause sunburn if your skin is exposed for too long. It is always best to try to avoid excessive sun exposure between the peak hours of 10 a.m. to 4 p.m. – this is when UV rays are the strongest.

Scientists often divide UV radiation into 3 wavelength ranges:

UVA Light (Ultraviolet A):

• UVA rays are the weakest of the UV rays. They can cause skin cells to age and can cause some indirect damage to cells’ DNA. UVA rays are mainly linked to long-term skin damage such as wrinkles, but are also thought to play a role in some skin cancers.
• Ultraviolet A1 (UVA 1) 340-400nm and Ultraviolet A2 (UVA2) 320-340nm
• Levels of UVA is consistent throughout the year regardless of season
• UVA penetrates into the lower dermis of the skin
• Penetrates glass
• 95% of UV is UVA
• Causes tanning of the skin
• Immunosuppressive
• An important contributor to melanoma
• Cause of most aging effects on the skin, such as wrinkling
• Causes many photodermatoses
• Cause of phototoxic reactions to various drugs
• The light that sun-beds mainly use. Remember that there is no such thing as a safe sun tan. The FDA is currently investigating whether suntan beds should be banned for people under the age of 18.

UVB Light (Ultraviolet B):

• UVB rays have slightly more energy than UVA rays. They can damage the DNA in skin cells directly, and are the main rays that cause sunburns. They are also thought to cause most skin cancers.
• 290-320nm
• Levels of UVB light increase during the summer, at noon, and are higher on the equator
• Can only penetrate the surface layer, the epidermis
• Does not go through glass
• SPF of sunscreens are determined by the amount of UVB that it blocks
• More carcinogenic than UVA
• Causes sunburns on the skin
• Required for Vitamin D production

Sunscreens are the first and foremost defence to sun damage. First, you will need to choose the right sunscreen.

UVC Light (Ultraviolet C):

• UVC (200-290nm) rays have more energy than the other types of UV rays. Fortunately, because of this, they react with ozone high in earth’s atmosphere and do not reach the ground. Therefore UVC rays are not normally a risk factor for skin cancer. But they can also come from some man-made sources, such as arc welding torches, mercury lamps, and UV sanitizing bulbs that kill bacteria and other germs (such as in water, air, food, or on surfaces).

The easier way to remember about the UV rays: UVA = Aging = Tanning = Cancer; UVB = Burn = Cancer. Both can damage the skin and increase your risk of developing skin cancer.

Many people believe the UV rays of tanning beds are harmless. This is not true. The best thing to do is not use tanning beds (or booths).

People who may be exposed to artificial sources of UV at their job should follow appropriate safety precautions, including using protective clothing and UV shields and filters.

The Effects of Ultraviolet Light

The skin has evolved to protect us from the harmful effects of ultraviolet light. Sunscreens were first developed to prevent sunburns by blocking UVB; they allowed us to prolong our time in the sun, but that resulted in increased exposure to UVA. Modern sunscreens attempt to block the whole spectrum of UV light, so are called broad spectrum.

Ultraviolet light can be generally categorized as UVA or UVB light, and refer to the different wavelengths, and have varying characteristics.

Ultraviolet Light Short-term negative effects:

• Sunburn/Tan
• Light aggravated conditions
• Photosensitive rashes
• Allergic reactions
• Drug and chemical photo toxicity

Ultraviolet Light Medium-term negative effects:

• Photodamage
• Photo-aging

Ultraviolet Light Long-term effects:

• Skin cancer
• Photo-aging

Can you still get Sun damage on windy, cloudy or cool days ?

YES. You can get sun damage on windy, cloudy and cool days. Sun damage is caused by ultraviolet (UV) radiation, not temperature. A cool or overcast day in summer can have similar UV levels to a warm, sunny day. If it’s windy and you get a red face, it’s likely to be sunburn. There’s no such thing as ‘windburn’.

Sun damage is also possible on cloudy days, as UV radiation can penetrate some clouds, and may even be more intense due to reflection off the clouds.

Does a “fake tan” that darkens the skin, protect your skin from the sun damage ?

NO. Fake tanning lotion does not improve your body’s ability to protect itself from the sun, so you will still need sun protection. Some fake tans have an SPF rating. However, this gives very little protection and should not be relied on for continued protection.

Do people with olive skin not at risk of skin cancer ?

FALSE. People with olive skin can get skin cancer too. Regardless of skin type, exposure to UV radiation from the sun and other artificial sources, such as solariums, can cause skin to be permanently damaged. People with skin types that are less likely to burn can still receive enough UV exposure to risk developing skin cancer. And generally when skin cancers do occur, they are detected at a later, more dangerous stage. Care still needs to be taken in the sun.

If you tan but don’t burn, do you still need to bother with sun protection ?

There’s no such thing as a safe tan. If skin darkens, it is a sign of skin cells in trauma, even if there is no redness or peeling.

Skin darkens as a way of trying to protect itself because the UV rays are damaging living cells. If you tan easily, you are still at risk of skin cancer and need to use sun protection.

Can you still get sun burn in the car through a window ?

You can get burnt through a car window. Untinted glass commonly used in car side windows reduces, but does not completely block transmission of UV radiation.

This means you can still get burnt if you spend a long time in the car next to a untinted side window when the UV is high. More commonly, people are burnt in cars with the windows down, where they can be exposed to high levels of UV radiation.

What is broad spectrum sunscreen ?

FDA meaning:The sunscreen can protect you from the sun’s harmful ultraviolet A (UVA) and ultraviolet B (UVB) rays.

Why you want broad spectrum sunscreen:

It can protect your skin from the sun’s UVA (aging) rays and UVB (burning) rays, which helps prevent:

• Skin cancer
• Early skin aging (premature age spots, wrinkles, and sagging skin)
• Sunburn

About Sunscreen SPF numbers

Another confusing thing about SPF is the number that follows it. This number tells you how much UVB light (the burning rays) a sunscreen can filter out.

To simplify things, you may want to think of the sun protection factor (SPF) as the “sunburn protection factor”.

The sun protection factor (SPF) relates to the amount of time it takes for redness to appear on the skin compared to when no product is used at all. The test is done in a laboratory.

For example, if it takes 10 minutes for unprotected skin to show redness, then an SPF30 sunscreen correctly applied, in theory, will take 30 times longer or 300 minutes to burn. However, it is hard to achieve this level of protection in real life – factors such as skin type, ultraviolet (UV) levels, swimming/drying and how much sunscreen you apply can affect the level of protection. That’s why we always recommend applying liberally every two hours or after swimming, sweating or towel drying. It is also important to apply 15 minutes beforehand before being exposed to UV.

To maximise the protective benefit of sunscreen, apply as directed and whenever possible in conjunction with other sun protection measures such as protective clothing, hats, and sunglasses. When UV levels are at their highest, the most effective protection is to seek shade.

Here’s what the science tells us about how much UVB light different SPF’s can filter out:

• SPF 15: 93% of the sun’s UVB rays
• SPF 30: 97% of the sun’s UVB rays
• SPF 50:  98% of the sun’s UVB rays
• SPF 100: 99% of the sun’s UVB rays.

The American Academy of Dermatology recommends using an SPF 30 or higher.

It’s important to know that no sunscreen can filter out 100% of the sun’s UVB rays. That’s why it’s important to also wear protective clothing and seek shade.

Can you can stay out longer in the sun when you are wearing SPF50+ than you can with SPF30+ ?

NO. No sunscreen is a suit of armor and sunscreen should never be used to extend the amount of time you spend in the sun.

Though it may sound like there is a big difference, SPF50+ only offers marginally better protection from UVB radiation, which causes sunburn and adds to skin cancer risk. SPF30+ sunscreens filter about 96.7% of UV radiation, SPF50+ sunscreens filter 98% of UV. Cancer Council recommends applying a sunscreen that is SPF30 or higher before heading outside, every two hours, after swimming, sweating, or towel drying.

Can you not use Sunscreen when using cosmetics with SPF ?

NO. Unless cosmetics are labelled with an SPF 30 or higher rating, you should wear additional sunscreen under your makeup if you’re going to be in the sun for an extended period.

Foundations and moisturizers that contain sunscreen are fine when outside for short periods, such as a quick trip to the shops at lunchtime. For longer periods of time in the sun, use a separate sunscreen and reapply it every two hours – not just once in the morning. Be aware that most cosmetic products offer either no protection or protection that is much lower than the recommended SPF30.

What is waterproof sunscreen ?

There’s actually no such thing as waterproof sunscreen. Sweat and water wash sunscreen from our skin, so the FDA no longer allows manufacturers to claim that a sunscreen is waterproof. Some sunscreens are water resistant.

What is water resistant sunscreen ?

FDA meaning: How long (either 40 or 80 minutes) the sunscreen will stay on wet skin. The sunscreen must undergo testing before it earns the water resistant designation.

Water resistant:

The sunscreen stays effective for 40 minutes in the water. At that time, you’ll need to reapply.

Very water resistant:

The sunscreen stays effective for 80 minutes in the water. Yes, after 80 minutes, you’ll need to reapply.

Even if your skin remains dry while using a water resistant sunscreen, you’ll need to reapply the sunscreen every 2 hours.

Why reapply sunscreen ?

Once applied, sunscreen only lasts so long on our skin. The sun’s rays break down some sunscreens. Others clump and lose their effectiveness.

To continue protecting our skin from the sun when outdoors, we must reapply sunscreen:

• Every 2 hours
• After toweling off
• When sweating*
• After being in water*

*When using water resistant sunscreen, you’ll need to reapply every 40 to 80 minutes.

The key points are these:

• Wearing sunscreen is an important tool in the fight against melanoma. Research has shown that daily sunscreen use can cut the incidence of melanoma in half.
• The second is that although sunscreen is a critical tool in the fight against skin cancer, it cannot completely ward off the sun’s harmful UV rays. In order to best reduce your risk of skin cancer, it is equally important to seek shade and wear protective clothing in addition to applying sunscreen to all exposed skin.
• For maximum protection, everyone should generously apply a water-resistant, broad-spectrum sunscreen with an SPF of 30 or higher.
• A tan is a sign that your skin has been injured. Whether you’re exposed to the sun’s ultraviolet (UV) rays or visit an indoor tanning salon, every time you tan, your skin is damaged. As this damage builds, you speed up the aging of your skin and increase your risk for all types of skin cancer, including melanoma, the deadliest form of skin cancer.
• Avoid the sun during peak hours. Generally, this is between 10 a.m. and 4 p.m. — regardless of season. These are prime hours for exposure to skin-damaging ultraviolet (UV) radiation from the sun, even on overcast days.
• Unprotected sun exposure is the most preventable risk factor for skin cancer.
• Scientific evidence supports the benefits of using sunscreen to minimize short-term and long-term damage to the skin from the sun’s rays. Preventing skin cancer and sunburn outweigh any unproven claims of toxicity or human health hazard from ingredients in sunscreens.

However, a study the Centers for Disease Control and Prevention ⁹, appeared in the Journal of the American Academy of Dermatology found that the majority of Americans are not using sunscreen regularly to protect their skin from damage caused by the sun’s ultraviolet (UV) rays, according to a new survey. Only about 30 percent of women and less than 15 percent of men regularly use sunscreen on both the face and other exposed areas of skin, the survey suggested ⁹. Women may be more likely to use sunscreen on the face because of the anti-aging benefits, or because many cosmetic products contain sunscreen. However, it is important to protect your whole body from the sun, not just your face. Men may view sunscreen as “nonmasculine, messy, or inconvenient,” the authors wrote, noting that sunscreen advertisements tend to target women more than men. The study also revealed a consistent relationship between sunscreen use and household income. For both men and women in the study, sunscreen use was significantly lower among those with lower household incomes.

Current estimates are that one in five Americans will develop skin cancer in their lifetime ¹⁰, ¹¹. Melanoma, the deadliest form of skin cancer, is now the most common form of cancer for young adults 25-29 years old, and the second most common form of cancer for adolescents and young adults 15-29 years old. In addition, Caucasians and men over 50 years of age are at a higher risk of developing melanoma than the general population.

How to choose sunscreen

Brand matters less than how you use the product. Look for water-resistant, broad-spectrum coverage with an SPF of at least 30. Check the sunscreen’s expiration date. Also, find a sunscreen you like. If you don’t care for the sunscreen, you’re not as likely to use it consistently.

When choosing sunscreen, be sure to read the label before you buy. The US Food and Drug Administration regulations require the labels to follow certain guidelines ¹².

• Choose a sunscreen with “broad spectrum” protection. Sunscreens with this label protect against both UVA and UVB rays. All sunscreen products protect against UVB rays, which are the main cause of sunburn and skin cancers. But UVA rays also contribute to skin cancer and premature aging. Only products that pass a test can be labeled “broad spectrum.” Products that aren’t broad spectrum must carry a warning that they only protect against sunburn, not skin cancer or skin aging.

• Make sure your sunscreen has a sun protection factor (SPF) 30 or higher. The SPF number is the level of protection the sunscreen provides against UVB rays. Higher SPF numbers do mean more protection, but the higher you go, the smaller the difference becomes. SPF 15 sunscreens filter out about 93% of UVB rays, while SPF 30 sunscreens filter out about 97%, SPF 50 sunscreens about 98%, and SPF 100 about 99%. No sunscreen protects you completely.

• The FDA requires any sunscreen with SPF below 15 to carry a warning that it only protects against sunburn, not skin cancer or skin aging.
  “Water resistant” does not mean “waterproof.” No sunscreens are waterproof or “sweatproof,” and manufacturers are not allowed to claim that they are. If a product’s front label makes claims of being water resistant, it must specify whether it lasts for 40 minutes or 80 minutes while swimming or sweating. For best results, reapply sunscreen at least every 2 hours and even more often if you are swimming or sweating. Sunscreen usually rubs off when you towel yourself dry, so you will need to put more on.

• There’s no such thing as waterproof sunscreen ². People should also be aware that no sunscreens are “waterproof.” All sunscreens eventually wash off. Sunscreens labeled “water resistant” are required to be tested according to the required SPF test procedure. The labels are required to state whether the sunscreen remains effective for 40 minutes or 80 minutes when swimming or sweating, and all sunscreens must provide directions on when to reapply.

Consider the pros and cons for different applications, including:

• Creams. If you have dry skin, you might prefer a cream — especially for your face.
• Lotions. Lotions are often preferred for application on large areas. Lotions tend to be thinner and less greasy than creams.
• Gel. Gels work best in hairy areas, such as the scalp and a man’s chest.
• Stick. Sticks are useful when applying sunscreen around the eyes.
• Spray. Parents often prefer sprays because they’re easy to apply on children. Because it’s difficult to know how well you’re applying spray, apply a generous and even coating. Or consider using a gel or cream first and using a spray to reapply sunscreen later. Also, avoid inhaling the product. Don’t apply spray near heat, an open flame or while smoking.

What about the reported health risks associated with some ingredients found in sunscreens ?

The U.S. Food and Drug Administration (FDA) regulates sunscreens. Before an ingredient can be used in sunscreen, the ingredient must be approved by the FDA for this use. Here is the real science behind some of the ingredients now in the news.

Oxybenzone: This is one of the few ingredients in sunscreen that effectively protects our skin from harmful UVA and UVB rays. Here are the facts about oxybenzone ¹³:

• Approved by the FDA in 1978.
• No data shows that oxybenzone causes hormonal problems in humans.
• No data shows that oxybenzone causes any significant health problems.
• FDA approved for use by people 6 months of age and older.

Retinyl palmitate: This ingredient helps protect our skin from premature aging. Here are the facts:

• No study shows that it increases the risk of skin cancer in humans.
• Retinyl palmitate is a form of vitamin A that is found naturally in the skin.
• One form of vitamin A, retinoids, has been used for decades to prevent skin cancer in people who have a high risk of developing skin cancers.

Is nanotechnology safe ?

Before nanotechnology could be used in sunscreens, considerable research was conducted. Sunscreens containing nanoparticle-size ingredients cannot get into the body when applied to healthy or sunburned skin. Your outermost layer of skin prevents nanoparticles from entering into the deeper layers of the skin.

In 2009, environmental activist organisation, Friends of the Earth (FOE), commenced a campaign raising concerns about the possible adverse effects of the nanoparticles used in some sunscreens. They suggested that micronising metal particles such as zinc oxide and titanium dioxide – useful ingredients of sunscreens seeking to protect against UVA and UVB radiation because they reflect the Ultraviolet (UV) radiation – may allow those ingredients to penetrate bodily organs and so increase cancer risk.

A study published in early 2014 exposed human immune cells (called macrophages) to zinc oxide nanoparticles to see how they would respond. The study showed that the human immune system effectively absorbed the nanoparticles and broke them down.

The study did not look at whether the particles are absorbed through the skin and into the bloodstream. So far, the current weight of evidence suggests that titanium dioxide and zinc oxide nanoparticles do not reach living skin cells; rather, they remain on the surface of the skin and in the outer layer of the skin that is composed primarily of dead cells.

Nanoparticles are used in sunscreens to prevent active ingredients from leaving a white residue on the skin. By doing this, you get better UV protection and more even coverage.

In circumstances of scientific uncertainty around public health problems, good quality reliable research is the best way to guide our decisions. Moreover, scientists continue to monitor research and welcome any new research that sheds more light on this topic.

A key concern is whether people reducing their use of sunscreen due to fear would result in more cases of skin cancer. If this is an (inadvertent) outcome of the Friends of the Earth campaign, it would be tragic and a major setback to cancer prevention efforts.

To protect your skin, dermatologists recommend using a sunscreen that offers:

• SPF 30 or greater.
• Broad-spectrum protection.
• Water resistance.

Studies prove that using sunscreen reduces the risk of developing skin cancer. Other things you can do to reduce your risk are to seek shade and wear clothing that protects your skin from the sun.

What’s the difference between a chemical sunscreen and physical sunscreen ?

Each of these protects your skin differently and contains different active ingredients. Here’s a summary of the basic differences:

A chemical sunscreen:

• Protects you by absorbing the sun’s rays
• May contain one or more of many possible active ingredients.
• UV absorbers use ingredients such as Oxybenzone, Octocrylene, 4-Methylbenzylidene camphor and Butyl methoxy dibenzoylmethane.including oxybenzone or avobenzene

A physical sunscreen:

• Protects you by deflecting the sun’s rays
• Contains the active ingredients titanium dioxide and/or zinc oxide

Some sunscreens use both types of active ingredients, so they contain one or more active ingredient found in physical sunscreen and chemical sunscreen.

What causes sunscreen reactions ?

Reactions to sunscreen are rare and can be a result of a sensitivity or allergy to any of the many ingredients used in these products ¹⁴. Some people may have a reaction to a fragrance, preservative, UV absorber or another component of the sunscreen.

Sensitivities to sunscreen are complex and can range from mild to severe. Reactions can be linked to a range of co-factors, including sunlight or other allergens, and can also be caused by or made more severe if sunscreen is used with some medications or other topical creams and lotions.

Some reactions occur soon after applying the sunscreen, while others (e.g. allergic reactions) can develop after a couple of days or even years of using the same product.

Reactions occur in a very low proportion of the population – fewer than 1% of all users – but while uncommon, can be upsetting for those affected.

As with all products, use of sunscreen should cease if an unusual reaction occurs. Individuals or families experiencing reactions should seek a referral to a dermatologist to understand what may have caused the reaction and gain advice on ingredients that should be avoided in the future.

• If you are concerned that you might have a reaction to a new sunscreen, apply some to a small area of skin on the inside of your forearm. If the skin does not react adversely, you should be able to use the sunscreen as directed without concern. This should be adequate assurance in most situations.

What are the different types of reactions ?

Contact dermatitis

The most common sunscreen reaction is called ‘contact dermatitis’ and occurs in people who have a sensitivity to an ingredient found in sunscreen or cosmetics with a sunscreen component. There are two types of contact dermatitis – irritant and allergic.

Irritant contact dermatitis

Irritant contact dermatitis is a reaction that can occur after applying sunscreen and is more common in people who have a history of eczema or sensitive skin. It causes an irritation in the area of the skin where the sunscreen was applied, and can appear as mild redness or as a stinging sensation (without any redness).

Allergic contact dermatitis

Allergic contact dermatitis is the less common type of contact dermatitis and occurs in people who have developed a sensitivity to an ingredient found in the sunscreen or cosmetics with SPF protection. This reaction is the result of an allergy to an ingredient, such as fragrances or preservatives, and can occur even if you have haven’t had a reaction to these ingredients or sunscreens in the past, as allergies can develop over time. An itchy, blistering rash occurs on skin where the product has been applied, and can sometimes also spread to other areas.

Photocontact dermatitis

A rarer type of sunscreen reaction is called ‘photocontact dermatitis’. This type of reaction usually occurs where the product has been applied to the body and exposed to sunlight. In some people, there is an interaction between a sunscreen ingredient and ultraviolet light which leads to a skin reaction. This is usually a result of an allergy to the active ingredients, but it can also be due to a reaction to the fragrances or preservatives in the product. The reaction may look like severe sunburn or eczema, and most commonly occurs on the face, arms, back of hands, chest and lower neck.

How you can avoid having a sunscreen reaction or allergy ?

As sunscreens contain multiple active ingredients, it can be difficult to determine whether you will have a reaction – and, if you do, what component of the sunscreen caused it. For this reason, Cancer Council recommends performing a patch test before applying any sunscreen, where a small amount of the product is applied on the inside of the forearm to check if the skin reacts, prior to applying it to the rest of the body. While the patch test will show whether the skin is sensitive to an ingredient in the sunscreen, it will not indicate an allergy, as this occurs after repeated use of the product.

If you have a known sunscreen allergy, the best way to avoid a problem is to not use any product containing the substances you are sensitive to.

Diagnosis of Contact dermatitis

Patch testing

Your doctor may be able to diagnose contact dermatitis and identify its cause by talking to you about your signs and symptoms, questioning you to uncover clues about the trigger substance, and examining your skin to note the pattern and intensity of your rash.

Your doctor may recommend a patch test to see if you’re allergic to something. This test can be useful if the cause of your rash isn’t apparent or if your rash recurs often.

During a patch test, small amounts of potential allergens are applied to adhesive patches, which are then placed on your skin. The patches remain on your skin for two to three days, during which time you’ll need to keep your back dry.

Skin patch testing can be helpful in determining if you’re allergic to a specific substance. Small amounts of different substances are placed on your skin under an adhesive coating. Your doctor then checks for a skin reaction under the patches and determines whether further testing is needed.

What happens during patch testing ?

If patch testing is recommended, the following will happen:

• Patches containing small amounts of substances to which you may be allergic will be applied to your skin, usually on your back.
• You keep the substances on your skin for a specific amount of time, usually 2 days.
• You return to your doctor’s office so that the doctor can check your skin for reactions.
• You may need to keep some patches on your skin for a longer time and see your doctor again in a few days.

To find out if the allergen is causing your rash, you will need to avoid that substance. For example, if the test shows that you have a nickel allergy, you may need to:

• Stop wearing jewelry and clothing (zippers, fasteners) that contains nickel.
• Cover your cell phone with a case to avoid touching the metal.
• Get a pair of eyeglasses made without nickel.

If your skin clears when you avoid the allergen, it is likely the cause of your rash.

Figure 1. Contact dermatitis – skin patch testing

Contact dermatitis treatment

Treatment is the same for both types of contact dermatitis.

Your doctor may prescribe medications. Examples include:

• Steroid creams or ointments. These topically applied creams or ointments help soothe the rash of contact dermatitis. A topical steroid may be applied one or two times a day for two to four weeks.
• Oral medications. In severe cases, your doctor may prescribe oral corticosteroids to reduce inflammation, antihistamines to relieve itching or antibiotics to fight a bacterial infection.

Avoid what is causing your rash. If avoiding the cause will be difficult, ask your dermatologist for help.

For example, if you are allergic to latex but must wear exam gloves, your dermatologist can recommend another type of glove that you can wear. If you must work outdoors where poison ivy grows, your dermatologist can recommend a protective barrier cream and clothing that can help.

Treat the rash. Once you can avoid the cause, your rash should clear. To relieve your symptoms, a dermatologist may recommend the following:

Mild reaction: Antihistamine pills, moisturizer, and a corticosteroid that you can apply to your skin. Most patients apply the medicine twice a day for 1 week and once a day for 1 to 2 weeks.

Oatmeal baths can relieve discomfort.

Do sunscreens contain endocrine disruptors ?

There is no evidence of any chemicals approved for use in sunscreens disrupting the endocrine system ¹⁵. The endocrine system consists of a number of glands, including the pituitary and thyroid glands, which secrete hormones into the body’s circulation to regulate a number of critical functions such as sleep, metabolism and reproduction. “Endocrine disruptors” describes man made chemicals that affect this system – disrupt activities in the estrogen, androgen, and thyroid hormone systems; exposure to them may result in hormone-related health problems such as obesity and infertility. American sunscreens are regulated by the U.S. Food and Drug Administration (FDA), a government agency that ensures manufacturers use only active ingredients and formulas that are safe and effective. This includes monitoring the latest scientific evidence and adjusting the list of approved ingredients accordingly. Online campaigners based in the US and Europe have expressed concerns that sunscreen may contain endocrine disrupting chemicals, such as oxybenzone and octinoxate. However the FDA reported that there was insufficient evidence to support the claim that chemicals in sunscreen interfere with the endocrine system in humans. Moreover, the endocrine disruption studies were based on the ingestion (swallowing) of the chemicals, rather than their application on the skin, which results in much lower absorption into the body. If some Americans wish to make a personal decision to avoid certain ingredients, there are a variety of sunscreens in the market to choose from. Approximately one in five Americans will be diagnosed with skin cancer by the age of 70. The majority of skin cancers in US are caused by exposure to UV radiation in sunlight. The Cancer Council recommends a combination of sun protection measures to prevent skin cancer. This includes seeking shade when UV levels are high, and wearing sun-protective clothing, sunscreen, a hat and sunglasses.

Do face creams/moisturisers containing sunscreen increase your risk of skin cancer ?

Face creams and moisturisers do not cause skin cancer. If you are going to be indoors for most of the day, with only incidental sun exposure, a cosmetic with SPF30+ is adequate to protect from sunburn, but, like sunscreen, will only be effective for two hours. If you are going to be outdoors in the sun, we recommend you use sunscreen rather than a moisturiser that contains SPF. Use a sunscreen that is SPF 30+, water-resistant and broad spectrum, which means it protects against both UVA and UVB. If you are going to wear sunscreen and moisturisers or cosmetics, it’s best to apply your sunscreen first – on dry, clean skin. This will allow the sunscreen to disperse effectively. Some people mistakenly believe an SPF20 moisturiser and an SPF10 foundation used together form a protection of SPF30. This is not true. You will only be protected to the level of the highest SPF product – in this case, SPF20. Sunscreens on the American market have been approved by the FDA as safe and effective.

Are chemical sunscreens safe to use ?

To minimise the risk of developing skin cancer, sun protection – including but not limited to the use of sunscreen – should be used when UV levels are 3 or above. In America, many people need to rely on sunscreen every day, often over large areas of their body, so it is vital that all sunscreens are safe, effective and good quality. The FDA regulates sunscreens ensuring that only approved ingredients, including chemicals, which have been assessed for quality and safety, are used in each product. Given there has been many rigorous scientific reviews, there is now very strong evidence that the list of commonly used active ingredients used in sunscreen do not pose a concern for human health. Some sunscreens may market themselves as organic or natural – these products often use physical blockers, such as zinc, to help protect against UV. Cancer Council recommends using an SPF30 or higher sunscreen that is broad spectrum, water resistant and FDA approved. As long as your sunscreen meets these requirements, what brand or ingredients you choose is up to you. To check if something is FDA approved, look for the reference to say that the product compiles with FDA. Be wary of products that aren’t FDA approved, aren’t actually a sunscreen or are homemade as these products won’t have been properly tested for effectiveness and may not provide proper sun protection. Sunscreen should not be used as the only line of defence against the sun, be sure to protect yourself in five ways to minimise the risk of skin cancer – slip on sun protective clothing, slop on SPF30+ or higher sunscreen, slap on a broad brim hat, seek shade and slide on sunglasses – when the UV is 3 or above. Those who are worried about sunscreens might choose to primarily rely on other forms of sun protection, including protective clothing.

Safe sunscreen ingredients

Here is a list of FDA approved sunscreen active ingredients ¹⁶:

• 2-ethylhexyl-4-phenylbenzophenone-2-carboxylic acid
• allantoin (with aminobenzoic acid)
• amiloxate (isoamyl p-methoxycinnamate)
• aminobenzoic acid (PABA)
• avobenzone
• bemotrizinol
• bisoctrizole
• bornelone (5-(3,3-dimethyl-2-norbornyliden)3-pentene-2-one)
• camphor
• cinoxate
• diethylhexyl butamido triazone
• digalloyl trioleate
• diolamine methoxycinnamate (diethanolamine methoxycinnamate)
• dioxybenzone
• dipropylene glycol salicylate
• drometrizole trisiloxane
• ecamsule
• ensulizole (phenylbenzimidazole sulfonic acid)
• enzacamene (4-methylbenzylidene camphor)
• ethyl 4-[bis(hydroxypropyl)] aminobenzoate (roxadimate)
• glyceryl aminobenzoate (lisadimate, glyceryl PABA)
• homosalate
• lawsone (w/ dihydroxyacetone)
• meradimate (menthyl anthranilate)
• octinoxate (octyl methoxycinnamate; ethylhexyl methoxycinnamate)
• octisalate (octyl salicylate; ethylhexyl salicylate)
• octyl triazone (ethylhexyl triazone)
• oxybenzone (benzophenone-3)
• padimate a (5 percent or higher)
• padimate a (up to 5 percent)
• red petrolatum
• sodium 3, 4-dimethylphenyl-glyoxylate
• sulisobenzone
• titanium dioxide
• trolamine salicylate
• zinc oxide
• zinc phenol sulfonate

What sunscreens can be used by people with sunscreen allergies ?

Sunscreen ingredients are similar across all brands, and sensitivities to sunscreen are complex, so simply changing the brand of sunscreen may not eliminate a reaction.

• A dermatologist is best placed to diagnose any reaction and help determine which ingredients should be avoided in the future.

Sunscreens that use ingredients that reflect UV away from the skin, such as zinc oxide and titanium dioxide, have not been reported to cause contact allergy. However some people do not like to use products with these ingredients as they tend to be heavier creams that do not absorb well into the skin. Others may like to try a sunscreen that has been specially formulated for sensitive skin. A dermatologist will be able to provide product advice.

What does the term “sensitive skin” mean on sunscreen ?

The FDA does not define this term for sunscreen.

In general, if a sunscreen label says “sensitive skin,” it often means that the sunscreen:

• Contains one or both of these active ingredients — titanium dioxide and zinc oxide
• Does NOT contain fragrance, oils, PABA (aminobenzoic acid), or active ingredients found in chemical sunscreens, which can irritate sensitive skin
• Is hypoallergenic.

What does the word “sports” mean on sunscreen ?

The FDA has NOT defined this term for sunscreen.

When you see the word “sports” on sunscreen, it usually means that the sunscreen will stay on wet skin for either 40 or 80 minutes. To be sure, check the label. You may also see the words “water resistant” or “very water resistant.”

To protect your skin, you’ll need to reapply sports sunscreen:

• When sweating (every 40 or 80 minutes)
• After toweling off
• After getting out of the water (or every 40 or 80 minutes)
• Every 2 hours (when not sweating or in the water)

Is it best to use sunscreen that contains insect repellant ?

If a sunscreen label says it contains insect repellant, the American Academy of Dermatology recommends looking for another sunscreen.

While both products provide important protection, the American Academy of Dermatology recommends buying separate products because:

• Sunscreen should be applied liberally and often
• Insect repellant should be applied sparingly and less often than sunscreen.

Are spray sunscreens safe ?

The FDA continues to evaluate the safety and effectiveness of spray sunscreens. The challenge in using sprays is that it is difficult to know if you have used enough sunscreen to cover all sun-exposed areas of the body, which may result in inadequate coverage. When using spray sunscreen, make sure to spray an adequate amount and rub it in to ensure even coverage.

To avoid inhaling spray sunscreen, never spray it around or near the face or mouth. Spraying the sunscreen into your hands and then applying it can help you avoid inhalation while also ensuring adequate coverage. When applying spray sunscreens on children, be aware of the direction of the wind to avoid inhalation.

What does the word “baby” mean on sunscreen ?

Like the word “sports,” the FDA has not defined this term for sunscreen.

In general, when you see the term “baby” on sunscreen, it means the sunscreen contains only these active ingredients:

• Titanium dioxide
• Zinc oxide

These ingredients are less likely to irritate a baby’s sensitive skin.

Should You Put Sunscreen on Infants ?

According to the U.S. Food and Drug Administration, applying sunscreen on infants aged 6 months and younger isn’t a good idea ¹⁷.

Chemicals used in sunscreen can harm newborns, instead babies and infants under 6 months of age should avoid the sun altogether. Young babies can’t regulate body temperature properly, making them especially prone to overheating and dehydration, the FDA says.

The FDA recommends:

• Keep infants out of the sun as much as possible.
• If infants do go outside, avoid the sun when ultraviolet rays are strongest, between the hours of 10 a.m. and 3 p.m.
• Create a canopy over baby’s carrier or stroller.
• Dress baby in lightweight, tight-weave long pants; a long-sleeve shirt and wide-brimmed hat.
• Watch baby carefully for signs of overheating and dehydration.
• Give baby breast milk or formula regularly.
• If baby develops a sunburn, get out of the sun immediately and apply a cold compress as soon as possible.

Children 6 months of age and older ¹⁸:

• Use a sunscreen that contains zinc oxide or titanium dioxide, which is most appropriate for the sensitive skin of infants and toddlers ¹⁹.
• Even when using sunscreen, keep children in the shade and dress them in clothing that will protect their skin from the sun, i.e., long-sleeved shirts, pants, and wide-brimmed hats.

How to apply and store sunscreen

Apply 30 minutes before you go outside. This allows the sunscreen (of SPF 15 or higher) to have enough time to provide the maximum benefit.
Use enough to cover your entire face and body (avoiding the eyes and mouth). An average-sized adult or child needs at least one ounce of sunscreen (about the amount it takes to fill a shot glass) to evenly cover the body from head to toe.

Frequently forgotten spots:

• Ears
• Nose
• Lips
• Back of neck
• Hands
• Tops of feet
• Along the hairline
• Areas of the head exposed by balding or thinning hair

Know your skin. Fair-skinned people are likely to absorb more solar energy than dark-skinned people under the same conditions.

Reapply at least every two hours, and more often if you’re swimming or sweating.

• Limit time in the sun, especially between the hours of 10 a.m. and 2 p.m., when the sun’s rays are most intense.
• Wear clothing to cover skin exposed to the sun, such as long-sleeved shirts, pants, sunglasses, and broad-brimmed hats.
• Use broad spectrum sunscreens with SPF values of 15 or higher regularly and as directed.
• Reapply sunscreen at least every two hours, and more often if you’re sweating or jumping in and out of the water.

Storing your sunscreen

To keep your sunscreen in good condition, the FDA recommends that sunscreen containers should not be exposed to direct sun. Protect the sunscreen by wrapping the containers in towels or keeping them in the shade. Sunscreen containers can also be kept in coolers while outside in the heat for long periods of time. This is why all sunscreen labels must say: “Protect the product in this container from excessive heat and direct sun.”

Can you still use the sunscreen you bought last summer, or do you need to purchase a new bottle each year? Does it lose its strength?

Dermatologists recommend using sunscreen every day when you are outside, not just during the summer. If you are using sunscreen every day and in the correct amount, a bottle should not last long. If you find a bottle of sunscreen that you have not used for some time, here are some guidelines you can follow:

• The FDA requires that all sunscreens retain their original strength for at least three years.
• Some sunscreens include an expiration date. If the expiration date has passed, throw out the sunscreen.
• If you buy a sunscreen that does not have an expiration date, write the date you bought the sunscreen on the bottle. That way, you’ll know when to throw it out.
• You also can look for visible signs that the sunscreen may no longer be good. Any obvious changes in the color or consistency of the product mean it’s time to purchase a new bottle.

Prevent skin cancer

Follow these tips to protect your skin from the damaging effects of sun exposure and reduce your risk of skin cancer:

• Apply broad-spectrum SPF 30 or higher sunscreen with water resistance. A sunscreen that offers the above helps to protect your skin from sunburn, early skin aging and skin cancer ²⁰. When you are going to be outside, even on cloudy days, apply sunscreen to all skin that will not be covered by clothing. Apply sunscreen to dry skin 15 minutes BEFORE going outdoors. Reapply approximately every two hours, or after swimming or sweating. Use a broad-spectrum, water-resistant sunscreen that protects the skin against both UVA and UVB rays and that has an SPF of at least 30. Learn how to apply sunscreen.

• Use one ounce of sunscreen, an amount that is about equal to the size of your palm – “1 ounce, enough to fill a shot glass”. Thoroughly rub the product into the skin. Don’t forget the top of your feet, your neck, ears, and the top of your head.

• Seek shade. Remember that the sun’s rays are strongest between 10 a.m. and 2 p.m. If your shadow is shorter than you are, seek shade.

• Protect your skin with clothing. When going outside wear a long‐sleeved shirt, pants, a wide‐brimmed hat and sunglasses.

• Use extra caution near water, sand or snow as they reflect and intensify the damaging rays of the sun, which can increase your chances of sunburn.

• Get vitamin D safely. Eat a healthy diet that includes foods naturally rich in vitamin D, or take vitamin D supplements. Many people can get the vitamin D they need from foods and/or vitamin supplements. This approach gives you the vitamin D you need without increasing your risk for skin cancer. Do not seek the sun. If you are concerned that you are not getting enough vitamin D, you should discuss your options for getting vitamin D with your doctor.

• If you want to look tan, consider using a self-tanning product, but continue to use sunscreen with it. Don’t use tanning beds. Just like the sun, UV light from tanning beds can cause wrinkling and age spots and can lead to skin cancer. The United States Department of Health & Human Services and the World Health Organization’s International Agency of Research on Cancer have declared UV radiation from the sun and artificial sources, such as tanning beds and sun lamps, as a known carcinogen (cancer-causing substance) ²¹.

• Check your skin for signs of skin cancer. Your birthday is a great time to check your birthday suit. Checking your skin and knowing your moles are key to detecting skin cancer in its earliest, most treatable stages.

If you spot anything changing, growing or bleeding, see your dermatologist.

How do you treat a sunburn ?

It’s important to begin treating a sunburn as soon as possible. In addition to stopping further UV exposure, dermatologists recommend treating a sunburn with:

• Cool baths to reduce the heat.
• Moisturizer to help ease the discomfort caused by dryness. As soon as you get out of the bathtub, gently pat yourself dry, but leave a little water on your skin. Then apply a moisturizer to trap the water in your skin.
• Hydrocortisone cream that you can buy without a prescription to help ease discomfort.
• Aspirin or ibuprofen. This can help reduce the swelling, redness and discomfort.
• Drinking extra water. A sunburn draws fluid to the skin surface and away from the rest of the body. Drinking extra water prevents dehydration.

Do not treat sunburns with “-caine” products (such as benzocaine).

If your skin blisters, you have a second-degree sunburn. Dermatologists recommend that you:

• Allow the blisters to heal untouched. Blisters form to help your skin heal and protect you from infection.
• If the blisters cover a large area, such as the entire back, or you have chills, a headache or a fever, seek immediate medical care.

With any sunburn, you should avoid the sun while your skin heals. Be sure to cover the sunburn every time you head outdoors.

Although it may seem like a temporary condition, sunburn—a result of skin receiving too much exposure from the sun’s ultraviolet (UV) rays—can cause long-lasting damage to the skin. This damage increases a person’s risk for getting skin cancer, making it critical to protect the skin from the sun.

References

1. Sunscreen remains a safe, effective form of sun protection. American Academy of Dermatology. https://www.aad.org/media/news-releases/sunscreen-remains-a-safe-effective-form-of-sun-protection
2. Sunscreen: How to Help Protect Your Skin from the Sun. U.S. Food and Drug Administration. https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/understandingover-the-countermedicines/ucm239463.htm
3. Reduced melanoma after regular sunscreen use: randomized trial follow-up. Green AC, Williams GM, Logan V, Strutton GM. J Clin Oncol. 2011 Jan 20; 29(3):257-63. https://www.ncbi.nlm.nih.gov/pubmed/21135266/
4. Prolonged prevention of squamous cell carcinoma of the skin by regular sunscreen use. van der Pols JC, Williams GM, Pandeya N, Logan V, Green AC. Cancer Epidemiol Biomarkers Prev. 2006 Dec; 15(12):2546-8. http://cebp.aacrjournals.org/content/15/12/2546.long
5. Mechanisms of photoaging and chronological skin aging. Fisher GJ, Kang S, Varani J, Bata-Csorgo Z, Wan Y, Datta S, Voorhees JJ. Arch Dermatol. 2002 Nov; 138(11):1462-70. https://jamanetwork.com/journals/jamadermatology/article-abstract/479061
6. Wlaschek M, Tantcheva-Poor I, Naderi L, Ma W, Schneider LA, Razi-Wolf Z, et al. Solar UV irradiation and dermal photoaging. J Photochem Photobiol B. 2001;63(1–3):41–51. https://www.ncbi.nlm.nih.gov/pubmed/11684450
7. Hughes MC, Williams GM, Baker P, Green AC. Sunscreen and prevention of skin aging: a randomized trial. Ann Intern Med. 2013;158(11):781–790. https://www.ncbi.nlm.nih.gov/pubmed/23732711
8. Sunscreen Drug Products for Over-the-Counter Human Use; Final Rules and Proposed Rules. U.S. Food and Drug Administration 21 CFR Parts 201, 310, and 352. https://www.gpo.gov/fdsys/pkg/FR-2011-06-17/pdf/2011-14766.pdf
9. Holman DM, Berkowitz Z, Guy GP, Hawkins NA, Saraiya M, Watson M. Patterns of Sunscreen Use on the Face and Other Exposed Skin among US Adults. Journal of the American Academy of Dermatology. 2015;73(1):83-92.e1. doi:10.1016/j.jaad.2015.02.1112. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4475428/
10. Stern RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol. 2010 Mar;146(3):279-82.
11. Robinson JK. Sun Exposure, Sun Protection, and Vitamin D. JAMA 2005; 294: 1541-43.
12. Sunscreen: How to Help Protect Your Skin from the Sun. U.S. Food and Drug Administration. https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/ucm239463.htm
13. Is sunscreen safe? American Academy of Dermatology. https://www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/prevent/is-sunsceen-safe
14. Sunscreen reactions. Cancer Council of Australia. http://www.cancer.org.au/preventing-cancer/sun-protection/sunscreen-reactions.html
15. Endocrine Disruptor Knowledge Base. U.S. Food and Drug Administration. https://www.fda.gov/scienceresearch/bioinformaticstools/endocrinedisruptorknowledgebase/default.htm
16. OTC Active Ingredients. U.S. Food and Drug Administration. https://www.fda.gov/downloads/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/CDER/UCM135691.pdf
17. Should You Put Sunscreen on Infants? Not Usually. U.S. Food and Drug Administration. https://www.fda.gov/forconsumers/consumerupdates/ucm309136.htm
18. How to decode sunscreen lingo. American Academy of Dermatology. https://www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/prevent/sunscreen-labels/how-to-decode-sunscreen-lingo
19. Paller, AS et al. New Insights About Infant and Toddler Skin: Implications for Sun Protection. Pediatrics. 2011 July; 128 (1): 92-102.
20. Hughes MC, Williams GC, Baker P, Green AC; “Sunscreen and Prevention of Skin Aging, a Randomized Trial”. Annals of Internal Medicine. 2013; 158(11):781-790.
21. Report on Carcinogens, Eleventh Edition (Ultraviolet Radiation Related Exposures); U.S. Department of Health and Human Services, Public Health Service, National Toxicology Program.

What is sleep ?

Sleep can be defined as a temporary state of unconsciousness from which (in contrast to coma) one can awaken when stimulated. Sleep is an active state of unconsciousness produced by the body where the brain is in a relative state of rest and is reactive primarily to internal stimulus ¹. Sleep is one of many bodily functions that occur in cycles called circadian rhythms, so named because they are marked by events that reoccur at intervals of about 24 hours. Sleep is characterized by a stereotyped posture (usually lying down with the eyes closed) and inhibition of muscular activity (sleep paralysis). It superficially resembles other states of prolonged unconsciousness such as coma and animal hibernation, except that individuals cannot be aroused from those states by sensory stimulation.

However, the exact purpose of sleep has not been fully elucidated ¹. There are several prominent theories currently which have explored the brain and attempt to identify a purpose for why you sleep which includes the Inactivity theory, Energy conservation theory, Restoration theory, and the Brain plasticity theory.

Inactivity theory is based on the concept of evolutionary pressure where creatures that were inactive at night were less likely to die from the predation of injury in the dark, thus creating an evolutionary and reproductive benefit to be inactive at night.

Energy conservation theory posits that the main function of sleep is to reduce a person’s energy demand during part of the day and night when it is least efficient to hunt for food. This theory is supported by the fact that the body has decreased metabolism of up to 10% during sleep.

The restorative theory states that sleep allows for the body to repair and replete cellular components necessary for biological functions that become depleted throughout an awake day. This is backed by the findings many functions in the body such as muscle repair, tissue growth, protein synthesis, and release of many of the important hormones for growth occur primarily during sleep.

Brain plasticity theory is that sleep is necessary for neural reorganization and growth of the brain’s structure and function. It is clear that sleep plays a role in the development of the brain in infants and children and explains why it is necessary that infants sleep upwards of 14 hours per day.

These theories are not exhaustive or all-inclusive of the prevalent ideas; rather, they serve to frame the concept that scientists do not fully understand sleep yet. It is more accepted that no single theory explains it all, and a combination of these ideas is more likely to hold the key to sleep ¹.

Although sleep is essential to the normal functioning of the body, the exact functions of sleep are still unclear. Studies have shown that sleep deprivation impairs attention, memory, performance, and immunity; if the lack of sleep lasts long enough, it can lead to mood swings, hallucinations, and even death.

There has been considerable debate in the scientific community about the importance of sleep, but some proposed functions of sleep are widely accepted:

1. Restoration, providing time for the body to repair itself;
2. Consolidation of memories;
3. Enhancement of immune system function; and
4. Maturation of the brain.

Sleep deprivation impairs attention, learning, and performance.

Why is Sleep Important ?

Sleep plays a vital role in good health and well-being throughout your life. Getting enough quality sleep at the right times can help protect your mental health, physical health, quality of life, and safety ².

The way you feel while you’re awake depends in part on what happens while you’re sleeping ². During sleep, your body is working to support healthy brain function and maintain your physical health. In children and teens, sleep also helps support growth and development.

The damage from sleep deficiency can occur in an instant (such as a car crash), or it can harm you over time. For example, ongoing sleep deficiency can raise your risk for some chronic health problems. It also can affect how well you think, react, work, learn, and get along with others.

Healthy Brain Function and Emotional Well-Being

Sleep helps your brain work properly. While you’re sleeping, your brain is preparing for the next day. It’s forming new pathways to help you learn and remember information.

Studies show that a good night’s sleep improves learning ². Whether you’re learning math, how to play the piano, how to perfect your golf swing, or how to drive a car, sleep helps enhance your learning and problem-solving skills. Sleep also helps you pay attention, make decisions, and be creative.

Studies also show that sleep deficiency alters activity in some parts of the brain. If you’re sleep deficient, you may have trouble making decisions, solving problems, controlling your emotions and behavior, and coping with change. Sleep deficiency also has been linked to depression, suicide, and risk-taking behavior ².

Children and teens who are sleep deficient may have problems getting along with others. They may feel angry and impulsive, have mood swings, feel sad or depressed, or lack motivation. They also may have problems paying attention, and they may get lower grades and feel stressed ².

Physical Health

Sleep plays an important role in your physical health. For example, sleep is involved in healing and repair of your heart and blood vessels. Ongoing sleep deficiency is linked to an increased risk of heart disease, kidney disease, high blood pressure, diabetes, and stroke ².

A lack of sleep also puts your body under stress and may trigger the release of more adrenaline, cortisol, and other stress hormones during the day. These hormones keep your blood pressure from dipping during sleep, which increases your risk for heart disease. Lack of sleep also may trigger your body to produce more of certain proteins thought to play a role in heart disease. For example, some studies find that people who repeatedly don’t get enough sleep have higher than normal blood levels of C-reactive protein, a sign of inflammation. High levels of this protein may indicate an increased risk for a condition called atherosclerosis, or hardening of the arteries.

Sleep deficiency also increases the risk of obesity. For example, one study of teenagers showed that with each hour of sleep lost, the odds of becoming obese went up. Sleep deficiency increases the risk of obesity in other age groups as well ².

Sleep helps maintain a healthy balance of the hormones that make you feel hungry (ghrelin) or full (leptin) ². When you don’t get enough sleep, your level of ghrelin goes up and your level of leptin goes down. This makes you feel hungrier than when you’re well-rested ².

Evidence is growing that sleep is a powerful regulator of appetite, energy use, and weight control. During sleep, the body’s production of the appetite suppressor leptin increases and the appetite stimulant grehlin decreases. Studies find that the less people sleep, the more likely they are to be overweight or obese and prefer eating foods that are higher in calories and carbohydrates. People who report an average total sleep time of 5 hours a night, for example, are much more likely to become obese, compared with people who sleep 7–8 hours a night.

Sleep also affects how your body reacts to insulin, the hormone that controls your blood glucose (sugar) level. Sleep deficiency results in a higher than normal blood sugar level, which may increase your risk for diabetes ². One study found that, when healthy young men slept only 4 hours a night for 6 nights in a row, their insulin and blood sugar levels matched those seen in people who were developing diabetes. Another study found that women who slept less than 7 hours a night were more likely to develop diabetes over time than those who slept between 7 and 8 hours a night.

Sleep also supports healthy growth and development ². Deep sleep triggers the body to release the hormone that promotes normal growth in children and teens. This hormone also boosts muscle mass and helps repair cells and tissues in children, teens, and adults. Sleep also plays a role in puberty and fertility.

Your immune system relies on sleep to stay healthy ². This system defends your body against foreign or harmful substances. Ongoing sleep deficiency can change the way in which your immune system responds. For example, if you’re sleep deficient, you may have trouble fighting common infections.

During sleep, your body creates more cytokines—cellular hormones that help the immune system fight various infections. Lack of sleep can reduce your body’s ability to fight off common infections. Research also reveals that a lack of sleep can reduce the body’s response to the flu vaccine. For example, sleep-deprived volunteers given the flu vaccine produced less than half as many flu antibodies as those who were well rested and given the same vaccine.

Daytime Performance and Safety

Getting enough quality sleep at the right times helps you function well throughout the day. People who are sleep deficient are less productive at work and school ². They take longer to finish tasks, have a slower reaction time, and make more mistakes.

After several nights of losing sleep—even a loss of just 1–2 hours per night—your ability to function suffers as if you haven’t slept at all for a day or two.

Lack of sleep also may lead to microsleep ². Microsleep refers to brief moments of sleep that occur when you’re normally awake.

You can’t control microsleep and you might not be aware of it ². For example, have you ever driven somewhere and then not remembered part of the trip ? If so, you may have experienced microsleep.

Even if you’re not driving, microsleep can affect how you function. If you’re listening to a lecture, for example, you might miss some of the information or feel like you don’t understand the point. In reality, though, you may have slept through part of the lecture and not been aware of it.

Some people aren’t aware of the risks of sleep deficiency. In fact, they may not even realize that they’re sleep deficient. Even with limited or poor-quality sleep, they may still think that they can function well.

Several studies show that lack of sleep causes thinking processes to slow down. Lack of sleep also makes it harder to focus and pay attention. Lack of sleep can make you more easily confused. Studies also find that a lack of sleep leads to faulty decision making and more risk taking. A lack of sleep slows down your reaction time, which is particularly important to driving and other tasks that require quick response. When people who lack sleep are tested on a driving simulator, they perform just as poorly as people who are drunk.

For example, drowsy drivers may feel capable of driving. Yet, studies show that sleep deficiency harms your driving ability as much as, or more than, being drunk. It’s estimated that driver sleepiness is a factor in about 100,000 car accidents each year, resulting in about 1,500 deaths ².

Drivers aren’t the only ones affected by sleep deficiency. It can affect people in all lines of work, including health care workers, pilots, students, lawyers, mechanics, and assembly line workers.

As a result, sleep deficiency is not only harmful on a personal level, but it also can cause large-scale damage. For example, sleep deficiency has played a role in human errors linked to tragic accidents, such as nuclear reactor meltdowns, grounding of large ships, and aviation accidents.

Regulation of sleep-wake cycles

Humans sleep and awaken in a 24-hour cycle called a circadian rhythm that is established by the suprachiasmatic nucleus of the hypothalamus (see Figure 1). A person who is awake is in a state of readiness and is able to react consciously to various stimuli. EEG (electroencephalogram, a test that detects electrical activity in your brain using small, flat metal discs (electrodes) attached to your scalp) recordings show that the cerebral cortex is very active during wakefulness; fewer impulses arise during most stages of sleep.

How does your nervous system make the transition between these sleep-wake states ?

Because stimulation of some parts of the brain and the nervous system increases activity of the cerebral cortex, a portion of the reticular formation known as the reticular activating system (RAS) (see Figure 3), when the reticular activating system (RAS) area is active, many nerve impulses are transmitted to widespread areas of the cerebral cortex, both directly and via the thalamus. The effect is a generalized increase in cortical activity.

Arousal, or awakening from sleep, also involves increased activity in the reticular activating system (RAS). For arousal to occur, the RAS must be stimulated. Many sensory stimuli can activate the RAS: painful stimuli detected by nociceptors, touch and pressure on the skin, movement of the limbs, bright light, or the buzz of an alarm clock. Once the RAS is activated, the cerebral cortex is also activated, and arousal occurs. The result is a state of wakefulness called consciousness. Notice in Figure 3 that even though the reticular activating system (RAS) receives input from somatic sensory receptors, the eyes, and the ears, there is no input from olfactory receptors; even strong odors may fail to cause arousal. People who die in house fires usually succumb to smoke inhalation without awakening. For this reason, all sleeping areas should have a nearby smoke detector that emits a loud alarm. A vibrating pillow or flashing light can serve the same purpose for those who are hearing impaired.

Acting with other brain regions, the hypothalamus helps regulate the complex phenomenon of sleep. The suprachiasmatic nucleus (Figure 1) is the body’s biological clock. It generates the daily circadian rhythms and synchronizes these cycles in response to dark-light information sensed via the optic nerve. In response to such signals, the preoptic nucleus induces sleep. Other hypothalamic nuclei near the mammillary body mediate arousal from sleep. Under the influence of the hypothalamus, the pineal gland secretes the hormone melatonin, which signals the body to prepare for the nighttime stage of the sleep-wake cycle. The pineal gland (pineal body) is a small, pine cone-shaped structure at the end of a short stalk on the roof of the diencephalon (epithalamus) (see Figure 2). During the darkness of night, the suprachiasmatic nucleus of the hypothalamus responds to a lack of visual input from the retina by sending signals to the preganglionic sympathetic neurons in the upper thoracic spinal cord. The signals then go to postganglionic neurons in the superior cervical ganglion, whose axons run on the internal carotid artery to stimulate the pineal gland to secrete melatonin. Increased melatonin levels promote sleepiness.

Elevated melatonin levels get the body ready for sleep. The timing of the rise in melatonin levels changes during a lifetime. In youth and childhood, melatonin levels rise in the early evening hours, and thus young children tire early in the night. In adolescence, the time at which melatonin levels rise shifts to much later in the night. As a result, teenagers are not sleepy until quite late in the night. This physiological shift makes it difficult for teenagers to fall asleep at a reasonable hour. The sleep deficit is compounded by the fact that most secondary schools start early in the morning. A few school systems have recognized this biological constraint and have changed the start of high school to later in the morning, allowing their students to get their needed sleep.

The reticular activating system (RAS) that is located mainly in the medial nuclear group of the pons and medulla in the brain stem also functions in sleep and in
arousal from sleep (see Figure 3). Axons from all the major ascending sensory nerve tracts synapse on reticular activating system (RAS) neurons, keeping these reticular neurons active and enhancing their arousing effect on the cerebrum. The fact that visual, auditory, and touch stimuli keep people awake and mentally alert explains why many students like to study in a crowded room: they are stimulated by the bustle of such an environment. General anesthesia, alcohol, tranquilizers, and sleep-inducing drugs depress the RAS and lead to a loss of alertness or consciousness. Severe injury to the RAS is a cause of coma.

Descending pathways of the reticular formation send axons to the spinal cord via the reticulospinal tracts. Certain descending pathways from the reticular formation influence somatic motor neurons to postural muscles. Others diminish muscle tone by inhibiting motor neurons, as when the person is sleeping. Axons from the reticular formation influence the autonomic neurons that regulate visceral functions such as heart rate, blood pressure, and respiration. Another group of descending fibers from the reticular fromation influence our perception of pain by inhibiting the transmission of pain impulses.

The brain stem, at the base of the brain, communicates with the hypothalamus to control the transitions between wake and sleep. (The brain stem includes structures called the pons, medulla, and midbrain.) Sleep-promoting cells within the hypothalamus and the brain stem produce a brain chemical called GABA, which acts to reduce the activity of arousal centers in the hypothalamus and the brain stem. The brain stem (especially the pons and medulla) also plays a special role in rapid eye movement (REM) sleep; it sends signals to relax muscles essential for body posture and limb movements, so that we don’t act out our dreams.

The basal forebrain, near the front and bottom of the brain, also promotes sleep and wakefulness, while part of the midbrain acts as an arousal system. Release of adenosine (a chemical by-product of cellular energy consumption) from cells in the basal forebrain and probably other regions supports your sleep drive. Caffeine counteracts sleepiness by blocking the actions of adenosine.

In addition, two related brain neuropeptides called orexins act as an important “sleep switch.” Produced by the hypothalamus, orexins stimulate increased activity in neurons of the reticular formation, leading to arousal and waking. Blocking orexin receptors induces sleep. Orexins are absent or at low levels in a disorder called narcolepsy, in which a person experiences excessive daytime sleepiness and fatigue and may often fall asleep at work or school, with abnormally quick onset of REM sleep. Narcolepsy seems to be an autoimmune disease caused by antibody-mediated destruction of the orexin-producing neurons.

What about melatonin ?

Your body produces this hormone that may cause some drowsiness and cues the brain and body that it is time to fall asleep. Melatonin builds up in your body during the early evening and into the first 2 hours of your sleep period, and then its release stops in the middle of the night.

Melatonin is available as an over-the-counter supplement. Because melatonin is considered safe when used over a period of days or weeks and seems to help people feel sleepy, it has been suggested as a treatment for jet lag. But melatonin’s effectiveness is controversial, and its safety when used over a prolonged period is unclear. Some studies find that taking melatonin supplements before bedtime for several days after arrival in a new time zone can make it easier to fall asleep at the proper time. Other studies find that melatonin does not help relieve jet lag.

Figure 1. Hypothalamus (suprachiasmatic nucleus) – regulation of sleep-wake cycles

Figure 2. Pineal gland

Figure 3. Reticular activating system & Reticular formation- regulation of sleep-wake cycles

Sleep mechanisms

Two internal biological mechanisms–circadian rhythm and homeostasis–work together to regulate when you are awake and sleep.

The mechanism through which sleep is generated and maintained is more of a balance between two systems located within the brain: the homeostatic processes which are functionally the body’s “need for sleep” center and the circadian rhythm which is an internal clock for the sleep-wake cycle ¹.

Sleep Generation is initiated within the ventrolateral preoptic nucleus (VLPO) of the anterior hypothalamus and acts to inhibit the arousal regions of the brain including the tuberomammillary nucleus, lateral hypothalamus, locus coeruleus, dorsal raphe, laterodorsal tegmental nucleus, and pedunculopontine tegmental nucleus. Hypocretin (orexin) neurons in the lateral hypothalamus help to facilitate this process in a synergistic effect.

Non-rapid eye movement (NREM) sleep is a functional disconnection between the brain stem and the thalamus and cortex maintained with hyperpolarizing GABA neurons in the reticular activating center of the thalamus and the cortex. Corticothalamic neurons signal the thalamus which causes hyperpolarization of the thalamic reticular neurons. This process produces delta waves from both thalamic reticular and cortical pyramidal sources. Thus correlating with the varying stages 1 to 3 of non-rapid eye movement (NREM).

Rapid eye movement (REM) sleep is generated by “REM-on neurons” in the mesencephalic and pontine cholinergic neurons. The pedunculopontine tegmental nucleus and the lateral dorsal tegmental neurons trigger desynchronized cortical waveforms. The tonic component of rapid eye movement (REM) sleep is parasympathetically medicated, and the phasic component is sympathetically mediated.

Circadian rhythms

Circadian rhythm regulates sleep, which tends to change over the course of human lives ³. Circadian rhythms direct a wide variety of functions from daily fluctuations in wakefulness to body temperature, metabolism, and the release of hormones. They control your timing of sleep and cause you to be sleepy at night and your tendency to wake in the morning without an alarm. Your body’s biological clock, which is based on a roughly 24-hour day, controls most circadian rhythms. Circadian rhythms synchronize with environmental cues (light, temperature) about the actual time of day, but they continue even in the absence of cues.

Newborns spend about 50% of their total sleep in REM sleep, usually directly entering REM sleep. Newborns also tend to initially sleep in short intervals, obtaining around 12 to 18 hours of sleep. As children reach 5 to 10 years of age, their sleep demand decreases to 10 hours. The demand further decreases as teenagers require 8 to 9 hours and adults need 7 to 8 hours. Your circadian rhythm also controls the nocturnal release of adrenocorticotropic hormone (ACTH), prolactin, melatonin, and norepinephrine, which are all essentials hormones for normal body functioning ⁴.

Circadian rhythm is the body’s cyclical nature for the desire for sleep. The hypothalamus controls it via the suprachiasmatic nucleus with sensory input from the retinohypothalamic tract based on light levels detected from the retina ¹. The circadian rhythm is approximately 24.2 hours per cycle ¹. Melatonin, produced in the pineal gland, has also been shown to be a modulator of the circadian rhythm that has concentrations varied based on light level. Melatonin levels are greatest in the night and decreased during the daytime. Finally, body temperature has been associated as part of the circadian rhythm. The exact set point varies among different people, but it is expected to have generally lower temperatures in the morning and higher temperatures in the evening ¹.

Sleep-wake homeostasis

Sleep-wake homeostasis keeps track of your need for sleep. The homeostatic sleep drive reminds the body to sleep after a certain time and regulates sleep intensity. This sleep drive gets stronger every hour you are awake and causes you to sleep longer and more deeply after a period of sleep deprivation.

Factors that influence your sleep-wake needs include medical conditions, medications, stress, sleep environment, and what you eat and drink. Perhaps the greatest influence is the exposure to light. Specialized cells in the retinas of your eyes process light and tell the brain whether it is day or night and can advance or delay our sleep-wake cycle. Exposure to light can make it difficult to fall asleep and return to sleep when awakened.

Night shift workers often have trouble falling asleep when they go to bed, and also have trouble staying awake at work because their natural circadian rhythm and sleep-wake cycle is disrupted. In the case of jet lag, circadian rhythms become out of sync with the time of day when people fly to a different time zone, creating a mismatch between their internal clock and the actual clock.

Sleep functions

Sleep functions in a relatively predictable cyclical pattern between 2 major phases: Non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep ¹. Non-rapid eye movement (NREM) sleep is subdivided into several stages numbered 1 to 3. Each phase and stage represents the relative depth of sleep and offers unique characteristics in the brain wave, muscle tones, and eye movement patterns. As the name implies, non-rapid eye movement (NREM) is characterized by an absence of eye movements and REM (rapid eye movement) is characterized by rapid eye movements.

Sleep begins with a short NREM stage 1 phase, followed by NREM stage 2, then NREM stage 3, then finally into REM sleep. NREM accounts for approximately 75% to 80% of total sleep and REM accounts for the remaining 20% to 25% of sleep ¹. This progression through the stages of sleep occurs in this order of events on repeat throughout the night for varying lengths of time. The initial cycle lasts 70 to 100 minutes to complete fully. However, the remaining cycles last 90 to 120 minutes each. The amount of REM in each cycle progresses throughout the night from being minimal on initiation of sleep, but eventually is up to 30% of the cycle later in the night. A total of 4 to 5 cycles through this progression is typical in a night.

NREM stage 1 is the shallow stage of sleep where a person is still easily awoken. It lasts 1 to 7 minutes. Rhythmical alpha waves characterize electroencephalogram (EEG) at a frequency of 8 to 13 cycles per second.

NREM stage 2 lasts approximately 10 to 25 minutes in the initial cycle of sleep but progresses to consume 50% of the total sleep cycle later in the night. Stage 2 is a much deeper sleep state than stage 1, but individuals are still awoken with heavy stimulation. Brainwave activity on EEG is low voltage “sleep spindles and K-complexes.” Current theories suggest that memory consolidation occurs primarily during this stage.

NREM stage 3 lasts about 20 to 40 minutes, initially. EEG characterized by high-voltage, slow wave frequency.

REM is the phase of sleep responsible for dreaming. It is characterized by total body voluntary muscle paralysis (except for the extraocular muscles). This paralysis is thought to be a mechanism to prevent neural stimulus from dreams to manifest in actual muscular impulses during sleep. EEG in REM is “Sawtooth waveforms,” theta waves, and slow, alpha waves in a desynchronized pattern set.

Sleep Stages

Sleep is broken down into 5 distinct stages recognizable from changes in the EEG: Wake (Stage W), NREM stage 1, NREM stage 2, NREM stage 3, and REM sleep ³. In the first 30 to 45 minutes, the EEG waves drop in frequency but increase in amplitude as one passes through five sleep stages. Non-rapid eye movement (NREM) stages 1 to 3 are considered non-rapid eye movement sleep, each progressively going into deeper sleep. Sleep is staged in sequential 30-second epochs, and each of these epochs is assigned a specific sleep stage. The majority of sleep is spent in the NREM stage 2 ⁵. During sleep, your body cycles through 4 different stages consisting of both rapid-eye-movement (REM) and non-rapid eye movement (NREM) sleep. Your body usually cycles through these stages on average 4 to 6 times, averaging 90 minutes in each stage. As the night progresses, fewer NREM stages occur, and the duration of REM sleep episodes increase ⁶.

Wake (Stage W)

Stage 1 is the wake stage or stage W, which further depends on whether the eyes are open or closed. During eye-open wakefulness, there are alpha and beta waves present, predominantly beta. As individuals become drowsy, and the eyes close, the alpha rhythm is the predominant pattern. An epoch is considered stage W if it contains greater than 50% alpha waves and eye movements associated with wakefulness ⁷.

Stage W is a transition stage between wakefulness and sleep that normally lasts 1–7 minutes. One feels drowsy, closes the eyes, and begins to relax. Thoughts come and go, often accompanied by a drifting sensation. One awakens easily if stimulated. The EEG is dominated by alpha waves. People awakened during this stage often say they have not been sleeping.

NREM Stage 1 (N1)

This is the lightest stage of sleep and starts when more than 50% of the alpha waves are replaced with low-amplitude mixed-frequency (LAMF) activity. There is muscle tone present in the skeletal muscle and breathing tends to occur at a regular rate. This stage tends to last 1 to 5 minutes, consisting of around 5% of the total cycle.

One passes into light sleep (first stage of “true sleep”). The EEG declines in frequency but increases in amplitude. Occasionally it exhibits 1 or 2 seconds of sleep spindles, high spikes resulting from interactions between neurons of the thalamus and cerebral cortex. In it, a person is easy to awaken. Fragments of dreams may be experienced and the eyes may slowly roll from side to side.

NREM Stage 2 (N2)

This stage represents deeper sleep as your heart rate and body temperate drop. It is characterized by the presence of sleep spindles, K-complexes or both. These sleep spindles will activate the superior temporal gyri, anterior cingulate, insular cortices and the thalamus. The K-complexes show a transition into deeper sleep. They are single, long delta waves only lasting for a second. As deeper sleep ensues and the individual moves into N3. All of their waves will be replaced with delta waves. Stage 2 sleep lasts around 25 minutes in the initial cycle and lengthens with each successive cycle, eventually consisting of about 50% of total sleep.

This is moderate to deep sleep, typically beginning about 20 minutes after stage 1. Sleep spindles occur less often, and theta and delta waves appear. The muscles relax, and the vital signs (body temperature, blood pressure, and heart and respiratory rates) fall.

NREM Stage 3 (N3)

This is considered the deepest stage of sleep, also called slow-wave sleep (SWS), because the EEG is characterized by a much slower frequency with high amplitude signals known as delta waves. The muscles are now very relaxed, vital signs are at their lowest levels, brain metabolism decreases significantly and body temperature drops slightly at this time and most reflexes are intact. During this stage, it is the most difficult to awaken from, and for some people, even loud noises (over 100 decibels) will not awaken them. As people get older, they tend to spend less time in this slow, delta wave sleep and more time stage N2 sleep. Although this stage has the greatest arousal threshold, if someone is awoken during this stage, they will have a transient phase of mental fogginess. This is known as sleep inertia. Cognitive testing shows that individuals awoken during this stage tend to have mental performance moderately impaired for 30 minutes to an hour. This is the stage when the body repairs and regrows its tissues, builds bone and muscle and strengthens the immune system.

REM Sleep

This is the stage associated with dreaming. Interestingly, the EEG is similar to an awake individual, but the skeletal muscles are atonic and without movement. The exception is the eye and diaphragmatic breathing muscles, which remain active. The breathing rate is altered though, being more erratic and irregular. This stage usually starts 90 minutes after you fall asleep, and each of your REM cycles gets longer throughout the night. The first period typically lasts 10 minutes, and the final one can last up to an hour ⁸.

Sleep studies

Your health care provider may recommend a polysomnogram or other test to diagnose a sleep disorder. A polysomnogram typically involves spending the night at a sleep lab or sleep center. It records your breathing, oxygen levels, eye movements, muscle movement of chin and legs, nasal pressure and airflow, chest and thorax movement, and pulse oximetry, heart rate, and EEG (brain waves) throughout the night. Your sleep is also video and audio recorded. These tests are performed overnight and usually require a minimum of 6 hours of monitoring. The data can help a sleep specialist determine if you are reaching and proceeding properly through the various sleep stages. Results may be used to develop a treatment plan or determine if further tests are needed.

Figure 4. Electroencephalogram (EEG)

Normal sleep consists of two components:

1. Non-rapid eye movement (NREM) sleep and
2. Rapid eye movement (REM) sleep.

Several physiological changes occur during non-rapid eye movement (NREM) sleep. There are decreases in heart rate, respiratory rate, and blood pressure. Muscle tone also decreases, out only slightly. As a result, there is a moderate amount of muscle tone during NREM sleep, which allows the sleeping person to shift body positions while in bed.

Dreaming sometimes takes place during NREM sleep but only occasionally. However, most dreaming occurs during rapid eye movement (REM) sleep. When dreaming does occur during NREM sleep, the dreams are usually less vivid, less emotional, and more logical than REM dreams. Most nightmares, however, occur during NREM sleep.

During rapid eye movement (REM) sleep, the eyes move rapidly back and forth under closed eyelids. REM sleep is also known as paradoxical sleep because electroencephalography (EEG) readings taken during this time show high-frequency, small amplitude waves, which are similar to those of a person who is awake. Surprisingly, neuronal activity is high during REM sleep—brain blood flow and oxygen use are actually higher during REM sleep than during intense mental or physical activity while awake!

In spite of this high amount of neuronal activity, it is even more difficult to awaken a person during REM sleep than during any of the stages of NREM sleep.

Rapid eye movement (REM) sleep is associated with several physiological changes. For example, heart rate, respiratory rate, and blood pressure increase during REM sleep. In addition, most somatic motor neurons are inhibited during REM sleep, which causes a significant decrease in muscle tone and even paralyzes the skeletal muscles. The main exceptions to this inhibition are those somatic motor neurons that govern breathing and eye movements. REM sleep is also the period when most dreaming occurs.

Brain imaging studies on people going through REM sleep reveal that there is increased activity in both the visual association area (which is involved in recognition of visual images) and limbic system (which plays a major role in generation of emotions) and decreased activity in the prefrontal cortex (which is concerned with reasoning). These studies help to explain why dreams during REM sleep are often full of vivid imagery, emotional responses, and situations that may be illogical or even bizarre. Erection of the penis and enlargement of the clitoris may also occur during REM sleep, even when dream content is not sexual. The presence of penile erections during REM sleep in a man with erectile dysfunction (inability to attain an erection while awake) indicates that his problem has a psychological, rather than a physical cause.

Intervals of NREM and REM sleep alternate throughout the night. Initially, a person falls asleep by sequentially going through the stages of NREM sleep (from stage 1 to stage 4) in about 45 minutes. Then the person goes through the stages of NREM sleep in reverse order (from stage 4 to stage 1) in about the same amount of time before entering a period of REM sleep. Afterward, the person again descends through the stages of NREM sleep, and then ascends back through the stages of NREM sleep to enter another period of REM sleep. During a typical 8-hour sleep period, there are four or five of these NREM-to-REM cycles. The first episode of REM sleep lasts 10–20 minutes. REM periods, which occur approximately every 90 minutes, gradually lengthen, with the final one lasting about 50 minutes. In adults, REM sleep totals 90–120 minutes during a typical 8-hour sleep period. As a person ages, the average total time spent sleeping decreases, and the percentage of REM sleep declines. As much as 50% of an infant’s sleep is REM sleep, as opposed to 35% for 2-year-olds and 25% for adults.

Figure 5. Sleep stages and brain activity – one sleep cycle

Figure 6. Sleep stages and brain activity – 8 hour sleep cycle

Although we do not yet understand the function of REM sleep, the high percentage of REM sleep in infants and children is thought to be important for the maturation of the brain.

Different parts of the brain mediate NREM and REM sleep. NREM sleep is induced by NREM sleep centers in the hypothalamus and basal forebrain, whereas REM sleep is promoted by a REM sleep center in the pons and midbrain. Several lines of evidence suggest the existence of sleep-inducing chemicals in the brain. One apparent sleep-inducer is adenosine, which accumulates during periods of high usage of ATP (adenosine triphosphate) by the nervous system. Adenosine inhibits neurons of the RAS that participate in arousal. Adenosine binds to specific receptors, called A1 receptors and inhibits certain cholinergic (acetylcholine-releasing) neurons of the RAS that participate in arousal. Thus, activity in the RAS during sleep is low due to the inhibitory effect of adenosine.

Caffeine (in coffee or chocolate) and theophylline (in tea)—substances known for their ability to maintain wakefulness—bind to and block the A1 receptors, preventing adenosine from binding and inducing sleep.

The Role of Genes and Neurotransmitters

Chemical signals to sleep

Clusters of sleep-promoting neurons in many parts of the brain become more active as we get ready for bed. Nerve-signaling chemicals called neurotransmitters can “switch off” or dampen the activity of cells that signal arousal or relaxation. GABA is associated with sleep, muscle relaxation, and sedation. Norepinephrine and orexin (also called hypocretin) keep some parts of the brain active while we are awake. Other neurotransmitters that shape sleep and wakefulness include acetylcholine, histamine, adrenaline, cortisol, and serotonin.

Genes and sleep

Genes may play a significant role in how much sleep we need. Scientists have identified several genes involved with sleep and sleep disorders, including genes that control the excitability of neurons, and “clock” genes such as Per, tim, and Cry that influence our circadian rhythms and the timing of sleep. Genome-wide association studies have identified sites on various chromosomes that increase our susceptibility to sleep disorders. Also, different genes have been identified with such sleep disorders as familial advanced sleep-phase disorder, narcolepsy, and restless legs syndrome. Some of the genes expressed in the cerebral cortex and other brain areas change their level of expression between sleep and wake. Several genetic models–including the worm, fruit fly, and zebrafish–are helping scientists to identify molecular mechanisms and genetic variants involved in normal sleep and sleep disorders. Additional research will provide better understand of inherited sleep patterns and risks of circadian and sleep disorders.

How Much Sleep Do You Need ?

The amount of sleep you need each day will change over the course of your life, your sleep patterns change as you age. Despite variations in sleep quantity and quality, both related to age and between individuals, studies suggest that the optimal amount of sleep needed to perform adequately, avoid a sleep debt, and not have problem sleepiness during the day is about 7–8 hours for adults and at least 10 hours for school-aged children and adolescents. Similar amounts seem to be necessary to avoid an increased risk of develop­ing obesity, diabetes, or cardiovascular diseases.

Quality of sleep and the timing of sleep are as important as quantity. People whose sleep is frequently interrupted or cut short may not get enough of both non-REM sleep and REM sleep. Both types of sleep appear to be crucial for learning and memory—and perhaps for the restorative benefits of healthy sleep, including the growth and repair of cells.

The table below shows general recommendations for different age groups. This table reflects recent American Academy of Sleep Medicine recommendations that the American Academy of Pediatrics has endorsed.

Table 1. Recommended Amount of Sleep

Age	Recommended Amount of Sleep
Infants aged 4-12 months	12-16 hours a day (including naps)
Children aged 1-2 years	11-14 hours a day (including naps)
Children aged 3-5 years	10-13 hours a day (including naps)
Children aged 6-12 years	9-12 hours a day
Teens aged 13-18 years	8-10 hours a day
Adults aged 18 years or older	7–8 hours a day

[Source ²]

Babies initially sleep as much as 16 to 18 hours per day, which may boost growth and development (especially of the brain). School-age children and teens on average need about 9.5 hours of sleep per night. Most adults need 7-9 hours of sleep a night, but after age 60, nighttime sleep tends to be shorter, lighter, and interrupted by multiple awakenings. Elderly people are also more likely to take medications that interfere with sleep.

For example, some older people complain of difficulty falling asleep, early morning awakenings, frequent and long awakenings during the night, daytime sleepiness, and a lack of refreshing sleep. Many sleep problems, however, are not a natural part of sleep in the elderly. Their sleep complaints may be due, in part, to medical conditions, illnesses, or medications they are taking—all of which can disrupt sleep. In fact, one study found that the prevalence of sleep problems is very low in healthy older adults. Other causes of some of older adults’ sleep complaints are sleep apnea, restless legs syndrome, and other sleep disorders that become more common with age. Also, older people are more likely to have their sleep disrupted by the need to urinate during the night.

There is no evidence that indicates older people can get by with less sleep than younger people. There is some evidence showing that the biological clock shifts in older people, so they are more apt to go to sleep earlier at night and wake up earlier in the morning. Poor sleep in older people may result in excessive daytime sleepiness, attention and memory problems, depressed mood, and overuse of sleeping pills.

Across the lifespan, the sleep period tends to advance, namely relative to teenagers; older adults tend to go to bed earlier and wake earlier. The quality—but not necessarily the quantity—of deep, NREM sleep also changes, with a trend toward lighter sleep. The relative percentages of stages of sleep appear to stay mostly constant after infancy. From midlife through late life, people awaken more throughout the night. These sleep disruptions cause older people to lose more and more of stages 1 and 2 non-REM sleep as well as REM sleep.

In general, people are getting less sleep than they need due to longer work hours and the availability of round-the-clock entertainment and other activities ⁹.

If you routinely lose sleep or choose to sleep less than needed, the sleep loss adds up. The total sleep lost is called your sleep debt. For example, if you lose 2 hours of sleep each night, you’ll have a sleep debt of 14 hours after a week. Many people feel they can “catch up” on missed sleep during the weekend but, depending on how sleep-deprived they are, sleeping longer on the weekends may not be adequate ⁹.

Some people nap as a way to deal with sleepiness. Naps may provide a short-term boost in alertness and performance. However, napping doesn’t provide all of the other benefits of night-time sleep. Thus, you can’t really make up for lost sleep.

Some people sleep more on their days off than on work days. They also may go to bed later and get up later on days off.

Sleeping more on days off might be a sign that you aren’t getting enough sleep. Although extra sleep on days off might help you feel better, it can upset your body’s sleep–wake rhythm.

Bad sleep habits and long-term sleep loss will affect your health. If you’re worried about whether you’re getting enough sleep, try using a sleep diary for a couple of weeks.

Sleeping when your body is ready to sleep also is very important. Sleep deficiency can affect people even when they sleep the total number of hours recommended for their age group.

For example, people whose sleep is out of sync with their body clocks (such as shift workers) or routinely interrupted (such as caregivers or emergency responders) might need to pay special attention to their sleep needs.

If your job or daily routine limits your ability to get enough sleep or sleep at the right times, talk with your doctor. You also should talk with your doctor if you sleep more than 8 hours a night, but don’t feel well rested. You may have a sleep disorder or other health problem.

Who Is at Risk for Sleep Deprivation and Deficiency ?

Sleep deficiency, which includes sleep deprivation, affects people of all ages, races, and ethnicities. Certain groups of people may be more likely to be sleep deficient. Examples include people who:

• Have limited time available for sleep, such as caregivers or people working long hours or more than one job
• Have schedules that conflict with their internal body clocks, such as shift workers, first responders, teens who have early school schedules, or people who must travel for work
• Make lifestyle choices that prevent them from getting enough sleep, such as taking medicine to stay awake, abusing alcohol or drugs, or not leaving enough time for sleep
• Have undiagnosed or untreated medical problems, such as stress, anxiety, or sleep disorders
• Have medical conditions or take medicines that interfere with sleep

Certain medical conditions have been linked to sleep disorders. These conditions include heart failure, heart disease, obesity, diabetes, high blood pressure, stroke or transient ischemic attack (mini-stroke), depression, and attention-deficit hyperactivity disorder (ADHD).

If you have or have had one of these conditions, ask your doctor whether you might benefit from a sleep study.

A sleep study allows your doctor to measure how much and how well you sleep. It also helps show whether you have sleep problems and how severe they are.

If you have a child who is overweight, talk with the doctor about your child’s sleep habits.

What Are the Signs and Symptoms of Problem Sleepiness ?

Sleep deficiency can cause you to feel very tired during the day. You may not feel refreshed and alert when you wake up. Sleep deficiency also can interfere with work, school, driving, and social functioning.

How sleepy you feel during the day can help you figure out whether you’re having symptoms of problem sleepiness. You might be sleep deficient if you often feel like you could doze off while:

• Sitting and reading or watching TV
• Sitting still in a public place, such as a movie theater, meeting, or classroom
• Riding in a car for an hour without stopping
• Sitting and talking to someone
• Sitting quietly after lunch
• Sitting in traffic for a few minutes

Sleep deficiency can cause problems with learning, focusing, and reacting. You may have trouble making decisions, solving problems, remembering things, controlling your emotions and behavior, and coping with change. You may take longer to finish tasks, have a slower reaction time, and make more mistakes.

The signs and symptoms of sleep deficiency may differ between children and adults. Children who are sleep deficient might be overly active and have problems paying attention. They also might misbehave, and their school performance can suffer.

Sleep-deficient children may feel angry and impulsive, have mood swings, feel sad or depressed, or lack motivation.

You may not notice how sleep deficiency affects your daily routine. A common myth is that people can learn to get by on little sleep with no negative effects. However, research shows that getting enough quality sleep at the right times is vital for mental health, physical health, quality of life, and safety.

To find out whether you’re sleep deficient, try keeping a sleep diary for a couple of weeks. Write down how much you sleep each night, how alert and rested you feel in the morning, and how sleepy you feel during the day.

Compare the amount of time you sleep each day with the average amount of sleep recommended for your age group, as shown in Table 1. Recommended Amount of Sleep (see above).

Many people try to make up for lost sleep during the week by sleeping more on the weekends. But if you have lost too much sleep, sleeping in on a weekend does not completely erase your sleep debt. Certainly, sleeping more at the end of a week won’t make up for any poor performance you had earlier in that week. Just one night of inadequate sleep can negatively affect your functioning and mood during at least the next day.

Daytime naps are another strategy some people use to make up for lost sleep during the night. Some evidence shows that short naps (up to an hour) can make up, at least partially, for the sleep missed on the previous night and improve alertness,mood, and work performance. But naps don’t substitute for a good night’s sleep. One study found that a daytime nap after a lack of sleep at night did not fully restore levels of blood sugar to the pattern seen with adequate nighttime sleep. If a nap lasts longer than 20 minutes, you may have a hard time waking up fully. In addition, late afternoon naps can make falling asleep at night more difficult.

If you often feel very sleepy, and efforts to increase your sleep don’t help, see your doctor.

How to get better sleep at night

You can take steps to improve your sleep habits. First, make sure that you allow yourself enough time to sleep. With enough sleep each night, you may find that you’re happier and more productive during the day.

Sleep often is the first thing that busy people squeeze out of their schedules. Making time to sleep will help you protect your health and well-being now and in the future.

Getting enough sleep is good for your health. Here are a few tips to improve your sleep:

• Set a schedule. Go to bed and wake up at the same time every day. For children, have a set bedtime and a bedtime routine. Don’t use the child’s bedroom for timeouts or punishment.
• Try to keep the same sleep schedule on weeknights and weekends. Limit the difference to no more than about an hour. Staying up late and sleeping in late on weekends can disrupt your body clock’s sleep–wake rhythm.
• Use the hour before bed for quiet time. Avoid strenuous exercise and bright artificial light, such as from a TV or computer screen. The light may signal the brain that it’s time to be awake.
• Create a room for sleep – avoid bright lights and loud sounds, keep the room at a comfortable temperature, and don’t watch TV or have a computer in your bedroom.
• Avoid nicotine (for example, cigarettes) and caffeine (including caffeinated soda, coffee, tea, and chocolate). Nicotine and caffeine are stimulants, and both substances can interfere with sleep. The effects of caffeine can last as long as 8 hours. So, a cup of coffee in the late afternoon can make it hard for you to fall asleep at night.
• Avoid heavy and/or large meals within a couple hours of bedtime. (Having a light snack is okay.) Also, avoid alcoholic drinks before bed.
• Exercise 20 to 30 minutes a day but no later than a few hours before going to bed.
• Relax before bed – try a warm bath, reading, or another relaxing routine.
• Don’t lie in bed awake. If you can’t get to sleep, do something else, like reading or listening to music, until you feel tired.
• Spend time outside every day (when possible) and be physically active.
• Keep your bedroom quiet, cool, and dark (a dim night light is fine, if needed).

Napping during the day may provide a boost in alertness and performance. However, if you have trouble falling asleep at night, limit naps or take them earlier in the afternoon. Adults should nap for no more than 20 minutes.

Napping in preschool-aged children is normal and promotes healthy growth and development.

See a doctor if you have a problem sleeping or if you feel unusually tired during the day. Most sleep disorders can be treated effectively.

How to Sleep Better if You Are a Shift Worker

Some people have schedules that conflict with their internal body clocks. For example, shift workers and teens who have early school schedules may have trouble getting enough sleep. This can affect how they feel mentally, physically, and emotionally.

If you’re a shift worker, you may find it helpful to:

• Increase your total amount of sleep by adding naps and lengthening the amount of time you allot for sleep.
• Keep the lights bright at work
• Minimize the number of shift changes so that your body’s biological clock has a longer time to adjust to a nighttime work schedule.
• Limit caffeine use to the first part of your shift to promote alertness at night.
• Remove sound and light distractions in your bedroom during daytime sleep (for example, use light-blocking curtains)

If you’re still not able to fall asleep during the day or have problems adapting to a shift-work schedule, talk with your doctor about other options to help you sleep.

When possible, employers and schools might find it helpful to consider options to address issues related to sleep deficiency.

Here are some potentially life-saving tips for avoiding drowsy driving

• Be well rested before hitting the road. If you have several nights in a row of fewer than 7–8 hours of sleep, your reaction time slows. Restoring that reaction time to normal can take more than one night of good sleep, because a sleep debt accumulates after each night you lose sleep. It may take several nights of being well rested to repay that sleep debt and make you ready for driving on a long road trip.
• Avoid driving between midnight and 7 a.m. Unless you are accustomed to being awake then, this period of time is when we are naturally the least alert and most tired.
• Don’t drive alone. A companion who can keep you engaged in conversation might help you stay awake while driving.
• Schedule frequent breaks on long road trips. If you feel sleepy while driving, pull off the road and take a nap for 15–20 minutes.
• Don’t drink alcohol. Just one beer when you are sleep deprived will affect you as much as two or three beers when you are well rested.
• Don’t count on caffeine or other tricks. Although drinking a cola or a cup of coffee might help keep you awake for a short time, it won’t over come extreme sleepiness or relieve a sleep debt.

Top 10 Sleep Myths

• Myth 1: Sleep is a time when your body and brain shut down for rest and relaxation.

No evidence shows that any major organ (including the brain) or regulatory system in the body shuts down during sleep. Some physiological processes actually become more active while you sleep. For example, secretion of certain hormones is boosted, and activity of the pathways in the brain linked to learning and memory increases.

• Myth 2: Getting just 1 hour less sleep per night than needed will not have any effect on your daytime functioning.

This lack of sleep may not make you noticeably sleepy during the day. But even slightly less sleep can affect your ability to think properly and respond quickly, and it can impair your cardiovascular health and energy balance as well as your body’s ability to fight infections, particularly if lack of sleep continues. If you consistently do not get enough sleep, a sleep debt builds up that you can never repay. This sleep debt affects your health and quality of life and makes you feel tired during the day.

• Myth 3: Your body adjusts quickly to different sleep schedules.

Your biological clock makes you most alert during the daytime and least alert at night. Thus, even if you work the night shift, you will naturally feel sleepy when nighttime comes. Most people can reset their biological clock, but only by appropriately timed cues—and even then, by 1–2 hours per day at best. Consequently, it can take more than a week to adjust to a substantial change in your sleep–wake cycle—for example, when traveling across several time zones or switching from working the day shift to the night shift.

• Myth 4: People need less sleep as they get older.

Older people don’t need less sleep, but they may get less sleep or find their sleep less refreshing. That’s because as people age, the quality of their sleep changes. Older people are also more likely to have insomnia or other medical conditions that disrupt their sleep.

• Myth 5: Extra sleep for one night can cure you of problems with excessive daytime fatigue.

Not only is the quantity of sleep important, but also the quality of sleep. Some people sleep 8 or 9 hours a night but don’t feel well rested when they wake up because the quality of their sleep is poor. A number of sleep disorders and other medical conditions affect the quality of sleep. Sleeping more won’t lessen the daytime sleepiness these disorders or conditions cause. However, many of these disorders or conditions can be treated effectively with changes in behavior or with medical therapies. Additionally, one night of increased sleep may not correct multiple nights of inadequate sleep.

• Myth 6: You can make up for lost sleep during the week by sleeping more on the weekends.

Although this sleeping pattern will help you feel more rested, it will not completely make up for the lack of sleep or correct your sleep debt. This pattern also will not necessarily make up for impaired performance during the week or the physical problems that can result from not sleeping enough. Furthermore, sleeping later on the weekends can affect your biological clock, making it much harder to go to sleep at the right time on Sunday nights and get up early on Monday mornings.

• Myth 7: Naps are a waste of time.

Although naps are no substitute for a good night’s sleep, they can be restorative and help counter some of the effects of not getting enough sleep at night. Naps can actually help you learn how to do certain tasks quicker. But avoid taking naps later than 3 p.m., particularly if you have trouble falling asleep at night, as late naps can make it harder for you to fall asleep when you go to bed. Also, limit your naps to no longer than 20 minutes, because longer naps will make it harder to wake up and get back in the swing of things. If you take more than one or two planned or unplanned naps during the day, you may have a sleep disorder that should be treated.

• Myth 8: Snoring is a normal part of sleep.

Snoring during sleep is common, particularly as a person gets older. Evidence is growing that snoring on a regular basis can make you sleepy during the day and increase your risk for diabetes and heart disease. In addition, some studies link frequent snoring to problem behavior and poorer school achievement in children. Loud, frequent snoring also can be a sign of sleep apnea, a serious sleep disorder that should be evaluated and treated.

• Myth 9: Children who don’t get enough sleep at night will show signs of sleepiness during the day.

Unlike adults, children who don’t get enough sleep at night typically become hyperactive, irritable, and inattentive during the day. They also have increased risk of injury and more behavior problems, and their growth rate may be impaired. Sleep debt appears to be quite common during childhood and may be misdiagnosed as attention-deficit hyperactivity disorder.

• Myth 10: The main cause of insomnia is worry.

Although worry or stress can cause a short bout of insomnia, a persistent inability to fall asleep or stay asleep at night can be caused by a number of other factors. Certain medications and sleep disorders can keep you up at night. Other common causes of insomnia are depression, anxiety disorders, and asthma, arthritis, or other medical conditions with symptoms that tend to be troublesome at night. Some people who have chronic insomnia also appear to be more “revved up” than normal, so it is harder for them to fall asleep.

References

1. Brinkman JE, Sharma S. Physiology, Sleep. [Updated 2018 Dec 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482512
2. Why Is Sleep Important ? National Heart, Lung and Blood Institute. https://www.nhlbi.nih.gov/health/health-topics/topics/sdd/why
3. Patel AK, Araujo JF. Physiology, Sleep Stages. [Updated 2018 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526132
4. Zajac A, Skowronek-Bała B, Wesołowska E, Kaciński M. [Sleep paroxysmal events in children in video/polysomnography]. Prz. Lek. 2010;67(9):762-9
5. Malik J, Lo YL, Wu HT. Sleep-wake classification via quantifying heart rate variability by convolutional neural network. Physiol Meas. 2018 Aug 20;39(8):085004.
6. Memar P, Faradji F. A Novel Multi-Class EEG-Based Sleep Stage Classification System. IEEE Trans Neural Syst Rehabil Eng. 2018 Jan;26(1):84-95.
7. Varga B, Gergely A, Galambos Á, Kis A. Heart Rate and Heart Rate Variability during Sleep in Family Dogs (Canis familiaris). Moderate Effect of Pre-Sleep Emotions. Animals (Basel). 2018 Jul 02;8, 7
8. Della Monica C, Johnsen S, Atzori G, Groeger JA, Dijk DJ. Rapid Eye Movement Sleep, Sleep Continuity and Slow Wave Sleep as Predictors of Cognition, Mood, and Subjective Sleep Quality in Healthy Men and Women, Aged 20-84 Years. Front Psychiatry. 2018;9:255.
9. Brain Basics: Understanding Sleep. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Understanding-Sleep

What is a Healthy Lifestyle

Healthy Lifestyle means the aggregation of decisions by individuals which affect their health, and over which they more or less have control. Being physically active and eating a healthy diet are keys to a healthy lifestyle. However, a healthy lifestyle is more than just diet and exercise. It is the steps, actions and strategies one puts in place to achieve optimum health. Today we go over the components of leading a healthy lifestyle and how it’s important to lead a balanced life.

The study involving 55,685 participants at Massachusetts General Hospital in Boston and colleagues recently showed that living a healthy lifestyle makes it possible to outsmart your genes and significantly reduce the number of heart attacks and other heart issues. Among participants at high genetic risk, a favorable lifestyle was associated with a nearly 50% lower relative risk of coronary artery disease than was an unfavorable lifestyle ¹. Healthcare providers have long preached the importance of healthy lifestyle habits to improve heart health, especially for those with a family history of heart disease. But until now there has never been a systematic evaluation of how – or even if – genetic risk and lifestyle interact to impact a person’s overall risk. Although the study examined only heart disease, improving lifestyle may have other benefits. The study authors added that their findings would likely prove relevant for cutting risk for diabetes, cancer and other chronic diseases as well.

 

By living a healthy lifestyle, you can help keep your blood pressure, cholesterol, and sugar normal and lower your risk for heart disease and heart attack ². A healthy lifestyle includes the following:

• Eating a healthy diet.
• Maintaining a healthy weight.
• Getting enough physical activity.
• Not smoking or using other forms of tobacco.
• Limiting alcohol use.

In general, most would agree that a healthy person doesn’t smoke, is at a healthy weight, eats a balanced healthy diet, thinks positively, feels relaxed, exercises regularly, has good relationships, and benefits from a good life balance. So in addition to healthy eating foods, a healthy lifestyle also includes:

• Healthy Diet

Choosing healthful meal and snack options can help you avoid heart disease and its complications. Be sure to eat plenty of fresh fruits and vegetables and fewer processed foods.

Eating foods low in saturated fats, trans fat, and cholesterol and high in fiber can help prevent high cholesterol ³. Limiting salt (sodium) in your diet also can lower your blood pressure. Limiting sugar in your diet can lower you blood sugar level to prevent or help control diabetes.

+ Eat less saturated fats, which comes from animal products (like cheese, fatty meats, and dairy desserts) and tropical oils (like palm oil).
+ Stay away from trans fats, which may be in baked goods (like cookies and cake), snack foods (like microwave popcorn), fried foods, and margarines.
+ Limit foods that are high in cholesterol, including fatty meats and organ meat (like liver and kidney).
+ Choose low-fat or fat-free milk, cheese, and yogurt.
+ Eat more foods that are high in fiber, like oatmeal, oat bran, beans, and lentils.
+ Eat a heart-healthy diet that includes plenty of vegetables and fruits and is low in salt and sugar.

• Healthy Weight

Being overweight or obese increases your risk for heart disease, weight-related diseases and other health issues. To determine if your weight is in a healthy range, doctors often calculate your body mass index (BMI) and measure your waist-hip-ratio. If you know your weight and height, you can calculate your BMI. Doctors sometimes also use waist and hip measurements to calculate excess body fat. BMI and waist circumference are two measures that can be used as screening tools to estimate weight status in relation to potential disease risk. A trained healthcare provider should perform other health assessments in order to evaluate disease risk and diagnose disease status.

Excessive abdominal fat may be serious because it places you at greater risk for developing obesity-related conditions, such as Type 2 Diabetes, high blood pressure, and coronary artery disease. Your waistline may be telling you that you have a higher risk of developing obesity-related conditions if you are ⁴:

+ A man whose waist circumference is more than 40 inches
+ A non-pregnant woman whose waist circumference is more than 35 inches

• Physical Activity

Physical activity can help you maintain a healthy weight and lower your blood pressure, cholesterol, and sugar levels. For adults, the Surgeon General recommends 2 hours and 30 minutes of moderate-intensity exercise, like brisk walking or bicycling, every week. Children and adolescents should get 1 hour of physical activity every day.

• No Smoking

Cigarette smoking greatly increases your risk for heart disease. If you don’t smoke, don’t start. If you do smoke, quitting will lower your risk for heart disease. Your doctor can suggest ways to help you quit.

• Limited Alcohol

Avoid drinking too much alcohol, which can raise your blood pressure. Men should have no more than 2 drinks per day, and women only 1.

A Healthy Lifestyle Protects you against Heart Disease

It’s no secret that healthy living can reduce your risk for developing heart disease ⁵.

But ever wonder how much it may help ? Up to 92%, suggests a study published Jan. 6, 2015, in the Journal of the American College of Cardiology. It evaluated health habits of 90,000 young and middle-aged women nurses during a 20-year period (from 1991 to 2011).

The healthy lifestyle habits included:

• not smoking;
• exercising for at least 2.5 hours each week;
• watching TV for fewer than seven hours a week;
• consuming a diet rich in vegetables, legumes, and whole grains but low in red meat, refined grains, and sugar;
• consuming no more than one alcoholic drink daily;
• and having a body mass index in the normal range.

Only around 5 percent of the women studied fit into this category at any one time. Compared with 95 percent of women who had none of those healthy habits.

About 45 percent of the women developed one of these risk factors (cardiac disease like diabetes, high cholesterol and high blood pressure), during the 20-year study period.

For women who had diabetes, hypertension or high cholesterol and who also adhered to a healthy lifestyle had a much lower risk of subsequently developing heart disease — i.e. having a heart attack — compared to women who did not adhere to a healthy lifestyle.

The study found that women who followed six healthy living recommendations — such as eating a healthy diet and getting regular exercise — dropped their odds of heart disease about 92 percent over 20 years, compared to women living the unhealthiest lifestyles.

“Adopting or maintaining a healthy lifestyle can substantially reduce the incidence of diabetes, hypertension and high cholesterol, as well as reduce the incidence of coronary artery disease in young women,” said the study’s lead author, Andrea Chomistek, an assistant professor of epidemiology and biostatistics at Indiana University Bloomington.

Furthermore, a healthy lifestyle was also associated with a significantly reduced risk of developing heart disease among women who had already developed a cardiovascular risk factor like diabetes, hypertension or high cholesterol.

The researchers also estimated that unhealthy lifestyles were responsible for almost 75 percent of heart disease cases in younger and middle-aged women.

Why do those habits provide so much protection against heart disease? Limiting TV watching frees up time for exercise, and the other activities are known to reduce blood pressure, LDL cholesterol, and blood sugar, which reduce the three major risk factors for heart disease—hypertension, high levels of cholesterol and triglycerides, and diabetes. And even though the study involved young and middle-aged women, its a remainder to you that it’s never too late to adopt a healthy lifestyle.

Would these findings be similar in men ?

“There is unequivocal evidence that a healthy eating pattern, being physically active, maintaining an ideal body weight and not smoking are strongly related to reduced risk of heart disease,” said Donna Arnett, chair of epidemiology at University of Alabama at Birmingham School of Public Health and past president of the American Heart Association. Who wrote a commentary accompanying the study.

A Healthy Lifestyle may help you prevent Alzheimer’s Disease

Alzheimer’s disease, the most common form of dementia, is characterized by the accumulation of two types of protein in the brain: tangles (tau) and plaques (amyloid-beta). Eventually, Alzheimer’s disease kills brain cells and takes people’s lives.

What causes Alzheimer’s ? We still aren’t sure. For about 99% of all cases, amyloid and tau are closely associated with Alzheimer’s disease, but many things may contribute to the development of symptoms, such as inflammation in the brain, vascular risk factors, and lifestyle ⁶.

So far, evidence suggests that several healthy lifestyle habits may help ward off Alzheimer’s disease.

What you should do:

• Exercise. The most convincing evidence is that physical exercise helps prevent the development of Alzheimer’s disease or slow the progression in people who have symptoms. The recommendation is 30 minutes of moderately vigorous aerobic exercise, three to four days per week.

• Eat a Mediterranean diet. This has been shown to help thwart Alzheimer’s disease or slow its progression. A recent study showed that even partial adherence to such a diet is better than nothing, which is relevant to people who may find it difficult to fully adhere to a new diet. The diet includes fresh vegetables and fruits; whole grains; olive oil; nuts; legumes; fish; moderate amounts of poultry, eggs, and dairy; moderate amounts of red wine; and red meat only sparingly.

• Getting enough sleep. Growing evidence suggests that improved sleep can help prevent Alzheimer’s disease and is linked to greater amyloid clearance from the brain. Aim for seven to eight hours per night.

Even though the authors don’t have enough evidence that all healthy lifestyle choices prevent Alzheimer’s disease, the authors do know healthy lifestyle can prevent other chronic problems. For example, limiting alcohol intake can help reduce the risk for certain cancers, such as breast cancer. So it’s wise to make as many healthy lifestyle choices as you can. “They’re all beneficial, and if they wind up helping you avoid Alzheimer’s, all the better,” says Dr. Marshall ⁷.

But don’t feel like you need to rush into a ramped-up routine of living a healthier lifestyle. All it takes if one small change at a time, such as:

• exercising an extra day per week (try adding 15 minutes more to your exercise routine)
• getting rid of one unhealthy food from your diet
• going to bed half an hour earlier, or shutting off electronic gadgets half an hour earlier than normal, to help you wind down
• listening to a new kind of music, or listening to a podcast about a topic you’re unfamiliar with
• or having lunch with a friend you haven’t seen in a while.

A Healthy Lifestyle may help you prevent Cancer

Cancer is a leading cause of death in the United States and most cancers are not inevitable. Genes are important, but diet and lifestyle are even more important in most cases ⁸.

In a study involving 89,571 women and 46,399 men white population, published online May 19, 2016, in JAMA Oncology, Dr. Giovannucci and fellow researcher ⁹ found that a healthy lifestyle can prevent 40% of cancer cases and 50% of cancer deaths in the United States amongst the white population. The researchers examined the lifestyles of about 136,000 white men and women and found that four healthy habits were associated with preventing lung, colon, breast, pancreatic, and kidney cancer. The habits: 150 minutes of moderate-intensity exercise per week, maintaining a body mass index between 18.5 and 27.5, no smoking, and drinking only in moderation (up to one drink per day for women, two for men). The authors suggested about 20 percent to 40 percent of cancer cases and about half of cancer deaths could potentially be prevented through modifications to adopt the healthy lifestyle pattern of the low-risk group. These findings reinforce the predominate importance of lifestyle factors in determining cancer risk. The takeaway message for you: you can lower cancer risk, and it’s never too late to start benefiting from healthy lifestyle changes ⁸.

Healthy Lifestyle interventions provide benefits to Women with Gestational Diabetes (or Diabetes in Pregnancy) and their Babies

Gestational diabetes or diabetes in pregnancy, is a glucose intolerance leading to high blood glucose levels that is first recognised during pregnancy and which usually normalises after giving birth. Diabetes during pregnancy has been linked to many short-term and long-term health problems for the mother and her baby. The main way to treat diabetes in pregnancy is through lifestyle changes such as diet, exercise and checking blood glucose levels ¹⁰.

Women with gestational diabetes have an increased risk of developing high blood pressure during pregnancy (pre-eclampsia) and are more likely to have their labour induced. The babies of women with Gestational diabetes are more likely to be large when born and this can be linked to babies having birth trauma (bones broken or nerves damaged during the birth) and the need for giving birth by caesarean section.

Lifestyle interventions that include two or more components of dietary advice, physical activity, education, and self-monitoring of blood glucose are the first-line treatment for most women diagnosed with gestational diabetes. Interventions such as healthy eating and physical activity aim to help women maintain their blood glucose levels within a target range and to improve health outcomes for the mother and baby.

From a review involving fifteen randomised controlled trials (45 publications), involving 4501 women and 3768 infants. It was concluded that pregnant mothers who received receiving lifestyle interventions  (healthy eating, physical activity and self-monitoring of blood glucose concentrations) were less likely to have postnatal depression and were more likely to achieve postpartum weight goals. Exposure to lifestyle interventions was associated with a decreased risk of the baby being born large (defined as a newborn’s weight, length, or head circumference that lies above the 90th percentile for that gestational age) and decreased neonatal adiposity.

The contribution of individual components of lifestyle interventions could not be assessed. Ten per cent of participants also received some form of pharmacological therapy.

Physical (For The Body)

• Good Nutrition, Eating Right
• Getting Physically Fit, Beneficial Exercise,
• Adequate Rest and Sleep,
• Proper Stress Management.

Relationships

• Build The Love relationship you want with your spouse and loved ones

Emotional Wellness (For The Mind)

• Self Love (you are nature’s greatest miracle, you are unique, rare and you are valuable).
• Self Forgiveness,
• Gratitude,
• Self-Supportive Attitudes,
• Positive Thoughts and Viewpoints,
• Positive Self-Image.

Spiritual Wellness

• Inner Calmness,
• Openness to Your Creativity,
• Trust in Your Inner Knowing.

You Also Need to Give and Receive

• Forgiveness,
• Love and Compassion,
• Practice Mindfulness,
• You Need to Laugh and Experience Happiness,
• You Need Joyful Relationships With Yourself and Others.

Understand that:

All Suffering Arises From Self Centered Thinking.

You End Suffering By Looking at the Truth.

Only You have a choice to either live your life in a Beautiful State or a Stressful State.

You can’t always control the things that happen outside of you. Most of the time you can, but not always. But you can ALWAYS control your inner experience. Anything that goes on inside you that is immobilizing, stops you, gets in your way, or keeps you from reaching your goals – ANYTHNG that happens inside: YOU CHOOSE. It’s Yours and YOU own it all.

The Power of Your Choice

No matter what conditions we are faced with:

• You can choose your attitude toward your health and fitness (which is the single most important choice),
• You can choose to feel valued and appreciated,
• You can choose what to eat,
• You can choose what to drink,
• You can choose whether to exercise or not,
• You can choose how much weight to lose,
• You can choose to be self-disciplined,
• You can choose to have the high energy you need to do what you want,
• You can choose to wake up with enthusiasm every day,
• You can choose how to handle adversity,
• You can choose to appreciate others and let them know it,
• You can choose to handle your emotions,
• You can choose to mold and develop yourself,
• You can choose to confidently find solutions for the challenges in your life,
• You can choose to laugh easily and often, especially at yourself,
• You can choose to have a circle of warm, caring friends,
• You can choose your own purpose in life.

Do the choices you make every day get you what you want ?   

Each one of these choices happens INSIDE and is not controlled by ANYONE but you. Everyone has the ability to control and choose these things. Just think of the difference the right choices in these areas can make for you.

If there’s something you don’t like about yourself — if you are anxious, shy, fat, unhappy, if you hate your job, if you’re stressed out — YOU HAVE CHOSEN IT. Your choices got you here. And you can change almost anything in your lives if you are aware of your choices and your desire is strong enough.

Is Your Life Based on TRUTH or FICTION ? Figure our your Truth – Live It and Share It.

The Key is Your Life Purpose and Life Vision – life without a Vision and Purpose is meaningless, directionless and your life will go astray and fall apart over time.

The Wheel of Life

1. Your HEALTH and FITNESS Life. Define exactly What you want, WHY you want it and what you need To Do to get it. e.g. healthy eating, regular exercise, proper sleeping pattern
2. Your EMOTIONAL Life. Explore the nature of emotions and discover how you can further develop your emotional intelligence. Make your emotions work for you, instead of living in reaction mode. Sharing your feelings and thoughts with your loved ones.
3. Your INTELLECTUAL Life. It’s time to think about thinking ! Your intellectual life holds the power to move you quickly and forcefully towards your life’s goals.
4. Your CHARACTER. This is the foundational category that affects every other area of your life. Define the person you need to become in order to achieve the life you desire. Learn how to consciously choose the character traits you want to build into your life and develop a strategy for accomplishing that. The sky is the limit in this category, so have fun!
5. Your LOVE RELATIONSHIP with your spouse, family and loved ones. Dig deep to define the values and expectations for your love life. You’ll achieve clarity on what you really want in this area of your life and identify what steps you can take to create and nurture an extraordinary love relationship.
6. Your SOCIAL Life. Thoughtfully evaluate your relationships with friends and extended family. You’ll come to understand which relationships contribute positively to your life and which ones drain you. You’ll learn what actions you can take to strengthen your most important relationships and what you can do let unhealthy relationships go.
7. Your TIME.
8. Your PARENTING Vision and Life.
9. Your CAREER. Explore the meaning and rewards of a great career. Discover the foundational pillars upon which a successful, fulfilling career is based. Learn new strategies to take any career to a higher level and make more money in the process !
10. Your FINANCIAL Life. Deeply explore the true nature of money – what it is, where it comes from and how wealth is actually created. From this process of self-discovery, you’ll come to view yourself and your financial life in an entirely new way.
11. Your CONTRIBUTIONS to society.
12. Your SPIRITUAL Life. Journey into your spirituality to examine, define and document your deepest beliefs about life, the world, and your place in it. Discover a strength deep within and gain a valuable new perspective on the purpose and meaning of your life.
13. Your QUALITY OF LIFE.
14. Your LIFE VISION – take an in-depth look and openly thought through your entire life using the above life categories as a guide, one category at a time. Now, you’re going to EXPERIENCE the life you intend to create. Using a deep, visualizations exercise, take a journey to your future… So you can see, feel, touch, and taste it… Experience your life 5 years from now – crystal clear, vivid and compelling. After this exercise, you’ll have a newfound clarity for how you will live from this day forward. The next step is to take massive action to build and manifest the life you want ! Remove all the barriers between you and your Life Vision.

Your future is in your amazing and wonderful mind. It contains everything you want out of life and all the strategies you need to get there. You are holding your life vision in your hands. Without a Life Vision – you’re not clear on exactly what you want in every important area of your life.

Everything in Life requires a focused and inspired actions in order for you to attain the goals you set out to achieve. Your Love Life and your health also require the time, the energy and the rituals (daily, weekly, monthly and yearly) with constant review to make them better. Greet each day with Love in your heart. This is the greatest secret of success in all life ventures. Failure will never overtake you if you form good habits and you are determination to succeed is strong enough.

To be active every day is a step towards better health and a healthy body weight. It is recommended that adults accumulate at least 2 ½ hours of moderate to vigorous physical activity each week and that children and youth accumulate at least 60 minutes per day. You don’t have to do it all at once. Choose a variety of activities spread throughout the week.
Start slowly and build up.

References

1. The New England Journal of Medicine December 15, 2016, N Engl J Med 2016; 375:2349-2358 – Genetic Risk, Adherence to a Healthy Lifestyle, and Coronary Disease – http://www.nejm.org/doi/full/10.1056/NEJMoa1605086
2. Centers for Disease Control and Prevention. – Preventing Heart Disease: Healthy Living Habits – https://www.cdc.gov/heartdisease/healthy_living.htm
3. Centers for Disease Control and Prevention. – Preventing or Managing High Cholesterol: Healthy Living Habits – https://www.cdc.gov/cholesterol/healthy_living.htm
4. National Institute of Health, National Heart, Lung and Blood Institute – The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults. – https://www.nhlbi.nih.gov/files/docs/guidelines/prctgd_c.pdf
5. Harvard University, Harvard Health Publications. – Healthy lifestyle protects women against heart disease – http://www.health.harvard.edu/womens-health/healthy-lifestyle-protects-women-against-heart-disease
6. Harvard University, Harvard Health Publications. – A healthy lifestyle may help you sidestep Alzheimer’s – http://www.health.harvard.edu/blog/a-healthy-lifestyle-may-help-you-sidestep-alzheimers-2017010910955
7. Harvard University, Harvard Health Publications. – A healthy lifestyle may help you sidestep Alzheimer’s Disease – http://www.health.harvard.edu/blog/a-healthy-lifestyle-may-help-you-sidestep-alzheimers-2017010910955
8. Harvard University, Harvard Health Publications. – More evidence that a healthy lifestyle might help prevent cancer – http://www.health.harvard.edu/staying-healthy/more-evidence-that-a-healthy-lifestyle-might-help-prevent-cancer
9. http://media.jamanetwork.com/news-item/can-a-healthy-lifestyle-prevent-cancer/
10. Cochrane Review 4 May 2017 – Lifestyle interventions for treating women with gestational diabetes (or diabetes in pregnancy) – http://www.cochrane.org/CD011970/PREG_lifestyle-interventions-treating-women-gestational-diabetes-or-diabetes-pregnancy