Optimal Self-Care for Surgeons: Sleep, Diet, and Exercise

The physiology and metabolism of the brain and body are distinct entities that operate in tandem. The cognitive brain may want to complete a half-marathon or shed 15 unwanted pounds, but the body has no interest in such goals. The primary concern of the latter is survival, irrespective of an individual’s stated ambition.

The concept of “pregnenolone steal” is a hypothesis that illustrates this dichotomy.¹ Pregnenolone, the precursor of all other steroid hormones, plays a pivotal role in enhancing memory, elevating mood, and combatting stress.² In times of stress that jeopardize survival, pregnenolone metabolism follows a specific hierarchy, prioritizing the synthesis of stress hormones, particularly cortisol. When the stress stimulus abates then the cortisol levels decrease to allow repair and the production of reproductive.

Cortisol mobilizes the body’s nutritional resources as part of the “fight or flight” stress response. Stores of carbohydrates and fats are mobilized, and proteins are converted to glucose. This process gives the body compounds that are easily converted to energy to effectively respond to immediate threats.

In evolutionary terms, the “fight or flight” response was typically a short-lived reaction. For instance, when a predator threatened a primitive humanoid, the stress response would trigger an increase in cortisol production to aid in immediate survival. Once the danger from the predator was avoided and the individual was safe, cortisol levels would naturally decrease, allowing the body to return to a state of equilibrium.

Today, the stress takes the form of a demanding job, especially among surgeons who deal with complicated operations and emergency situations. Sleep deprivation and poor nutrition compound the state of chronic stress. Pregnenolone steal becomes the chronic state, with the prolonged over synthesis of stress hormones and reduced secretion of repair and sex hormones. The result is undesired weight gain, loss of lean muscle mass, and a weakened immune system. The individual is more susceptible to injury and illness and has a decline in overall health.

The strategy relies on quality sleep, proper nutrition, and regular exercise. The priority of self-care therefore is to mitigate the metabolic state of chronic stress. Once free from the physiological and hormonal equivalent of a threat to survival, purposeful stress of a half-marathon or weight loss becomes achievable.

Sleep has the most significant impact on physical well-being. Proper sleep is the cornerstone for optimal self-care. Three consecutive nights of less than 6 hours of sleep can triple the cortisol levels in the body, consistent with the level of stress induced.³

The quality and duration of sleep allow the body vital recovery time, as most restorative processes occur during sleep. Human growth hormone (HGH) is produced during specific sleep cycles. Uninterrupted sleep enhances HGH production for optimal recovery and regeneration.

Achieving quality sleep presents both physiological and psychological challenges. Physiologically, a 1-2° drop in body temperature signals sleep initiation as part of the circadian rhythm.⁴ Psychologically, a calm, unburdened mind is essential for quality sleep. Electronic devices such as smartphones and computers in the bedroom, even if unplugged and turned off, can disrupt sleep by keeping the brain active and reminding individuals of work obligations.⁵

Inadequate sleep carries significant health repercussions. Sleep loss is associated with obesity and type 2 diabetes.⁶ The human body regulates various hormones during sleep, including ghrelin and leptin. Lack of sleep increases ghrelin and decreases leptin levels, resulting in excess hunger and overeating. Carbohydrate and insulin metabolism is thus impacted, with an increase in serum glucose levels.

Blood pressure decreases during sleep. Insufficient sleep thereby elevates daily average blood pressure with increased risk of heart disease and stroke. Long-term sleep deprivation elevates inflammatory indices that may contribute to chronic medical conditions.

Inadequate sleep profoundly affects cognitive performance and recovery. Poor sleep diminishes concentration, creativity, and learning abilities. Prolonged wakefulness impairs driving skills comparable to alcohol intoxication. Driving skills after being awake for 24 hours are equivalent to a blood alcohol concentration level of 0.10%.⁷

The foundation of good sleep hygiene is to establish consistent patterns that signal to the brain that sleep is about to come. To enhance sleep quality and duration, a consistent sleep schedule is essential, with a routine bedtime and wake up time each day, including weekends.

Alcohol and caffeine interfere with sleep, especially in the hours before bedtime. While alcohol can initially promote sleepiness, it inhibits deep stages of sleep. The half-life of caffeine ranges from 1.5 to 9.5 hours, so the intake of caffeine-containing drinks in the early evening and afternoon interferes with sleep.⁸ Digestion of large meals places physiological and metabolic demands that are counterproductive to restful sleep.

Optimizing sleep necessitates creating an ideal sleep environment. The bedroom should serve as a “sleep sanctuary,” free from work-related activities and distractions like electronic devices. Effective blackout curtains can ensure darkness. A cool room (temperature 60-67 F) promotes the natural decline in body temperature required for sleep.

The body inherently seeks nutritional homeostasis to promote essential metabolic and physiological functions. Macronutrients (carbohydrates, protein, and fat) are indispensable for overall health and performance. Decreasing or eliminating them to lose weight may yield short-term losses, but sustained deprivation as a diet strategy typically fails. Both undereating and overeating can have detrimental effects on health.

More success at weight loss is achieved by focusing on the quality of food rather than the macronutrient itself. One example is fried foods. They are not bad for one’s health because they have high amounts of carbohydrates; they are bad for one’s health because of the way they are prepared. Low-carb-diets eliminate unhealthy food choices in favor of more nutritious alternatives.

Nutrient timing is a critical concept where the body is fueled during its most active periods. A front-loaded approach to calorie consumption corresponds to the demands of today’s lifestyle and workplaces. A substantial, nutritious breakfast is therefore a priority, with the goal of consuming at least 60% of total daily caloric intake by lunch.

The concept was tested in a crossover study where subjects first ate a small breakfast (11% of total calories) and a large dinner (69% of total calories); then, the caloric proportions switched to a large breakfast and small dinner. Despite identical total calorie consumption, a larger breakfast led to 2.5 times higher diet-induced thermogenesis and better blood glucose and insulin concentrations than a large dinner.⁹

Avoiding prolonged periods without eating is equally important. Fasting promotes the hoarding of fat (due to its higher calorie concentration) and the metabolism of lean muscle mass for energy. A study of elite gymnasts and runners who abstained from eating or snacking for 3 hours or longer at any point during the day had higher body fat percentages, regardless of caloric balance.¹⁰

In summary, nourish the body according to its needs, providing the right macronutrients to meet specific demands. Carbohydrates, vital during exercise, are to be avoided during sedentary activities.

Exercise fads are typically malaligned with human evolution. Humans have evolved to excel in prolonged, low-intensity activities. Humans are endurance movers capable of maintaining a slow, steady pace over extended periods. Our bodies inherently respond favorably to programs that maximize endurance.

Granted that humans will never overtake cheetahs that are adapted to fast burst at high-energy, high-intensity workouts offer significant benefits in appropriate dosages. The stress of exercise increases cortisol levels and promotes the breakdown of muscle. Its benefit become manifest only when recovery allows tissues to repair and strengthen. A proper exercise program begins at one’s current fitness level then builds over time. Unrealistic goals only lead to failure, such as jumping from inactivity to intense workouts, leading only to sore muscles and joints that make movement impossible. Strength training as a primary activity of an exercise regimen often ends in frustration and abandonment of the regimen.

The goal of exercise is to maximize adaptation. Effective adaptation occurs when one exercises within current fitness levels and respects human evolutionary biology. Approximately 80% of exercise time is therefore devoted to low-intensity aerobic activities, maintaining a heart rate below 60%-65% of maximum. A good guideline is that conversation during exercise remains effortless. The remaining 20% can be more challenging but in small doses at a time.

One may think, “I only have a few hours per week to exercise, so I need to make most of that exercise hard to maximize the bang for my buck.” Research indicates that the 80/20 training principle remains effective even with less than 4 hours of weekly exercise.¹¹ Even when exercising only 30-45 minutes daily, devoting 80% of the time in easy exertion is the best strategy toward adaptation.

Exercise during a fasted state promotes fat loss, a widely stated goal for exercise. Timing also plays a role, especially for those targeting fat loss. Fat oxidation during 30 minutes of exercise on a stationary bike is 70% higher when fasted compared to a fed state.¹²

Optimal self-care has a structured sequence for sleep, meals, and exercise regimens. A sustainable routine for each step should be attained before moving to the next. People often start with exercise, increasing the demand for calories that can interfere with proper nutrition. The imbalance promotes pregnenolone steal, burnout, and early abandonment of the self-care strategy. Addressing each component step-by-step and mastering each one before proceeding to the next is a reasonable approach to improve health and quality of life.