Preventing Weight Gain in Residency

This is the time of year when 4th year medical students are winding down and preparing for the “big move” into internship.  Our 4th year students take a special 3 week course to get them ready – a wonderful mix of small groups on professionalism, ACLS training, first night on call beeper emergencies…etc, etc.  It ends with a small group of senior faculty who talk about making the transition to residency.  I wish we’d recorded the talks – they were all really wonderful.  In addition to giving wonderful professional advice,  all of the faculty included advice on taking care of yourself.  It struck me that one of the specific issues that each of them mentioned (well, four out of five) was how much weight they had gained in their internship and residency.

Losing weight is not easy for those that struggle with this issue – but preventing weight gain is not as hard – and should be a goal for every intern and resident!   It’s not hard – you need to increase your activity (a little) and watch out for stupid food choices.   Here’s the “rules” I wish someone had given me before I started my residency (if you have rules you would add, please send a comment!)

1.  No junk food (doughnuts, pizza, hamburgers, etc)

2.  Take healthy food with you to work – especially for call nights.  Keep emergency healthy food in your locker i.e. high quality energy bars, dried fruit/nuts (in appropriate small portions).

3.  Make sure you get an hour of real exercise on days when you are not in the hospital

4.  Take the stairs instead of the elevators.

JAMA. 2010 Mar 24;303(12):1173-9.

Physical activity and weight gain prevention.

Lee IM, Djoussé L, Sesso HD, Wang L, Buring JE.

Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA. ilee@rics.bwh.harvard.edu

CONTEXT: The amount of physical activity needed to prevent long-term weight gain is unclear. In 2008, federal guidelines recommended at least 150 minutes per week (7.5 metabolic equivalent [MET] hours per week) of moderate-intensity activity for “substantial health benefits.”

OBJECTIVE: To examine the association of different amounts of physical activity with long-term weight changes among women consuming a usual diet.

DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study involving 34,079 healthy US women (mean age, 54.2 years) from 1992-2007. At baseline and months 36, 72, 96, 120, 144, and 156, women reported their physical activity and body weight. Women were classified as expending less than 7.5, 7.5 to less than 21, and 21 or more MET hours per week of activity at each time. Repeated-measures regression prospectively examined physical activity and weight change over intervals averaging 3 years.

MAIN OUTCOME MEASURE: Change in weight.

RESULTS: Women gained a mean of 2.6 kg throughout the study. A multivariate analysis comparing women expending 21 or more MET hours per week with those expending from 7.5 to less than 21 MET hours per week showed that the latter group gained a mean (SD) 0.11 kg (0.04 kg; P = .003) over a mean interval of 3 years, and those expending less than 7.5 MET hours per week gained 0.12 kg (0.04; P = .002). There was a significant interaction with body mass index (BMI), such that there was an inverse dose-response relation between activity levels and weight gain among women with a BMI of less than 25 (P for trend < .001) but no relation among women with a BMI from 25 to 29.9 (P for trend = .56) or with a BMI of 30.0 or higher (P for trend = .50). A total of 4540 women (13.3%) with a BMI lower than 25 at study start successfully maintained their weight by gaining less than 2.3 kg throughout. Their mean activity level over the study was 21.5 MET hours per week (approximately 60 minutes a day of moderate-intensity activity).

CONCLUSIONS: Among women consuming a usual diet, physical activity was associated with less weight gain only among women whose BMI was lower than 25. Women successful in maintaining normal weight and gaining fewer than 2.3 kg over 13 years averaged approximately 60 minutes a day of moderate-intensity activity throughout the study.

PMID: 20332403 [PubMed – indexed for MEDLINE]

Post Call Recovery

I’m on call this weekend.  As we started rounds this morning, the conversation turned to one of our superstar residents who (uncharacteristically) was late to rounds.  He was up all night and overslept after falling asleep in the wee hours of the morning.  What struck me was what he told us… “I knew something was wrong when I woke up feeling good.”  Being on call, and being up all night is part of medical training (and practice).  And it’s not just an occasional event – we often have to do it every three or four days.  It’s essentially iatrogenic jet-lag and it takes some time to learn how to manage this kind of fatigue.

Photo credit

 

Being tired after call takes two major forms:  with sleep and without sleep.  Depending on the type of call, the recovery is different.  If you have been inundated with work, but were able to sleep, you will be physically (somewhat) and emotionally (a lot) tired.  The treatment for this is play.  You need to spend some time doing something that is not related to work, preferably in the company of friends.  You need time to process what you have just seen and done, but, more importantly, you need to feel like you are still connected to the world outside of work.  Physical activity is essential.  Even if you get home late, do something to stretch and use your body.  Even a 15 minute walk outside followed by 5 minutes of stretching will do the trick.  If you live with a significant other, make sure you have dinner together and really talk.  Put on some nice music.  Call a friend.  Go out to eat.  Whatever you do, don’t “numb out” by drinking a beer in front of the TV set.

Being tired without sleep is a physiologically abnormal state for human beings.  No matter how much the culture says you should be “tough enough” to go without sleep, it’s crazy.  We are designed to sleep 7-9 hours every night and, when we don’t, we don’t function as well.  There is an amazing amount of literature on the effect of sleep deprivation on performance, competence and health.  Suffice it to say that we all realize we don’t want the pilot of our plane to have been up for 24 hours prior to our flight.  It’s no different for a doctors.

There is  literature on this problem, but these are studies that doctors don’t often review.  A sleepless call night is basically a shift in your body clock i.e. jet-lag. The big difference is that the light cues are the same after call (unlike when you fly to Europe).  So what have business executives and airline pilots learned about dealing with this kind of time shift?

  • Stay hydrated.  It may sound silly, but paying attention to drinking enough water will make a big difference.  How much is enough?  Enough to keep your urine clear.  It is amazing how, during a busy day, you can forget to drink water.  Start looking for the drinking fountains and stop for a drink when you see them.  Carry a water bottle in your on-call bag and pull it out when you are doing sign outs, or taking a break.  Having a bag of cut up lemons helps, too.  A tall glass of ice water with fresh lemon in it is a fabulous treat in the middle of a busy night.  Mild dehydration will increase your level of fatigue.  Watch out for soft drinks and tea – the caffeine may give you a little kick (and there is nothing wrong with that from time to time) but, if you drink a lot of caffeine,  it will really mess up your sleep cycle when you do get to sleep.  Also, tea and coffee act as a diuretic, so your net hydration may be negative.  Water is by far the best choice.
  • Don’t skip meals.  Most importantly, don’t skip breakfast.  Most students and residents have to get up really early to get to work. And, most people just don’t feel like eating a big breakfast at 5:30 in the morning.  Eat something before you leave the house (a cereal bar or piece of fruit, for example) and then take something more substantial for later in the morning.  Even if it’s only an energy bar in the pocket of your white coat – take something and then eat it!
  • Don’t go too long without food during a long shift.  You need to eat something every 3-4 hours if you are working hard.  You should carry at least one snack in your coat pocket such as a small bag of nuts, an energy bar, some raisins, or some dried fruit.

Probably the worst mistake people make in recovering from call is what they do once they leave the hospital.  You can really help your recovery, enjoy your time off more, and return to work ready if you realize one fact:   You have shifted your biologic clock by staying awake all night.  If you go home the next morning (or afternoon) and sleep for 8-10 hours, you will have shifted it even more.   So how do you best recover?

  • No matter how tired you are, your first stop should be the gym, a park, or someplace you can work out.  This does not have to be (and shouldn’t be) a hard workout.  This should be a “work out the stress” workout.  Don’t push yourself hard, but work up a little sweat.  Even if it’s just 20 minutes of walking in a park, you will feel better.
  • Treat yourself well.  Take a nice long shower when you get home.  Make yourself a nice meal, but not junk food.  Eating a lot of protein and fat will put you in a fatigue tail-spin.
  • Take a nap, but make yourself get up so you can sleep that night.  3-4 hours is usually about right.  Make arrangements to have dinner with friends, if you live alone.  If you have a significant other, make plans to do something together in the evening.  If you want to have a glass of wine, or one beer, do so – but don’t have more than that.  It will mess up your sleep and it’s not worth it.
  • Don’t drink caffeine after the morning.   Even though you will be sluggish in the afternoon, don’t sabotage your night time sleep with caffeine.
  • Go to sleep early.  In addition to being sleep deprived, you will also feel socially deprived.  It’s natural to want to go out with friends when you feel this way.  However, they are not as sleep deprived as you are, and they don’t have to do this again in a few days.  If you’ve had a hard call, with very little sleep, you should plan to get 10-12 hours of sleep the next night.  You have to get at least 8 hours.  In other words, if you have to be up at 6, you should be in bed no later than 10 pm, but, as crazy as it sounds, if you can get to sleep at 8, it will be better.

Energy for Call

Food is fuel.  It’s also solice if you are stressed, and face it – it’s fun to eat. Other professions that deal with stress and physical labor have learned the lesson about not paying attention to nutrition.  The culture of medicine demands a “selflessness” that borders on the absurd.  It is often a badge of honor that you can go all day without eating.  But, when you consider the consequences of such behavior, it is really crazy.  There is no benefit to the patients, and clear harm to the doctor.

Eat often and eat well

When you are physically and intellectually busy (an average day on call in the hospital) you need to plan to eat every 3-4 hours.  In general, you will have one “meal” (i.e lunch) in the middle of the day and two snacks.  It’s not always going to possible to stop for lunch at lunchtime, but you should be able to find 10 minutes at some point in between 11 and 4 to eat a meal.  Different rotations have different demands, and you can certainly take this into account when planning your meals.  A peanut butter and jelly sandwich on whole wheat requires no preparation, and no refrigeration (it can even go in the pocket of your white coat).  Alternatively, buy a loaf of whole wheat bread every week, and put the bread, a jar of peanut butter and a jar of jelly in your locker. It takes 2 minutes to make a sandwich to put into your pocket on the way to a conference or a brief break.  Bring leftovers from the previous night’s dinner to reheat and have for lunch.  You need to plan to include fruits and vegetables as part of every meal and your snacks.  Buy a bag of apples once a week and put them in your locker.. and then make sure you eat the entire bag every week.  The snacks don’t need to be elaborate, but you do need to watch the clock and eat them – even if you are not hungry!

Examples of easy snacks for the hospital

  • “Meal replacement bars” (power bars, Luna bars, Kind bars etc)
  • “Meal replacement drinks” (Ensure, Boost, etc)
  • Skim milk with either graham crackers/peanut butter or a banana
  • Cheese stick and an apple
  • Melba toast or other crackers with sliced cheese plus some fruit
  • Yogurt