The Role of Self-Regulation and Shift Schedule in Countering the Slow Violence of Shiftwork: Notes from the

Front Line

Ruhi Snyder, RPSGT, CCSH Sleep Disorders Lab

Kingston Health Sciences Centre, Kingston, Canada rsnyder7@gmail.com

Structure of the Talk:

• AbriefintroductiontoCircadianRhythms•  ImportantHormones•  Chronotypes•  ShiftWorkTolerance

• ConsequencesofCircadianDisruption•  Metabolic•  Cognitive

• RoleofSelfRegulationandShiftSchedule–MyCaseStudy•  Results•  Conclusion•  ClosingStatement

What is shift work?

• Atypicalworkschedulesthatextendbeyonda9-5workday,suchas•  Earlyworkstarts•  Compressedworkweeks•  Eveningwork•  Nightwork

… observed the harmfulness of shift work, in particular night work: such as bakers who work at night, so when others sleep

they stay awake, while trying to sleep during the day like animals who escape the light: hence in the same town, there

are men living an antithetic life in comparison with others

BernadinoRamazzini.DeMorbisArtificumDiatriba.1713.

“Slow Violence” is the term coined by Rob Nixon to describe the catastrophic effects of

environmental deterioration and its invisible trauma on human beings.

As shift-workers, we commit

the slow violence against ourselves.

Nixon,Rob.SlowViolenceandtheEnvironmentalismofPoor(2011).HarvardUniversityPress.

The Slow Violence of Shift Work

• CircadianRhythmDisorders• MetabolicDisorders•  SleepDisorders• MoodDisorders• Cognitivedysfunction• Cancer

Normal circadian rhythm

•  Theapproximately24hourbiologicalclock–keepstherhythmandsynchronicityofvariousphysiologicalaspectsincluding:

•  Hormones•  Bloodsugar•  Sleep/wake•  Metabolism

•  It’ssynchronicityisfundamentaltovariousaspectsofwellbeing.•  Itallowsorganismstoadjusttheirphysiologybyanticipatingdailyenvironmentalchanges,ratherthanmerelyrespondingtotheminareactivemanner.

Krygeretal.PriniciplesandPractiseofSleepMedicine5thedition.

The Master Clock

ImagefromGoogleImagesonMasterClock

The Human Circadian Clock

• Hasaninherentrhythmthatislongerthan24hours

•  Itrequiresresettingorentraining.

•  Themostpowerfulcueorsynchronizerislight(465nm).

Appleman,K.SleepMedicine2013(14)456-461

Regulation of the Central Pacemaker

Int.J.Mol.Sci.2014,15,23448-23500.J.PinealRes.2012;52:1-11

Melatonin - Darkness Hormone

•  Oneofthemostwellknowncircadianoutputsignal,othersbeingthecentralnervoussystemandthecorebodytemperature

•  Consideredtobegoldstandard•  Suppressedbylightduringthedaytime.

• markerforcircadiansystem•  Releasedbythepinealgland.•  Hasantioxidativepropertiesthatcombatsfreeradicaldamage

J.PinealRes2012(52)1-11;AnnClinBiochem200643:344-353

Long-term effects of Chronodisruption:

Circadianrhythmdisruption• Behavioralchanges,•  Sleepdisorders,• Alteredhormoneandmetabolicdysregulation

Leadingto:

Krygeretal.PrincipleandpracticeofSleepMedicine5thed.2011Karatsoreosaetal.ProcNatAcadSciences.2011;108:1657–1662

•  Mooddisorders•  Cognitiveimpairment•  Obesity•  Diabetes

•  Hypertension•  Cardiovasculardisease•  Cancer

Chronotypes

•  Twotypes:•  Eveningtype“theowl”•  Morningtype“thelark”

• Chronotypecanvarywithageandgender• Chronotypemodulatesshiftworker:

•  Sleepduration•  Sleepquality•  Socialjetlag(internaldys-synchronization)

• MunichChronoTypeQuestionnaire(MCQTshift)

Judaetal.JBiolRhythms2013;28(2):141-51BiologicalRhythmsRes2010;(6):415-413

Tolerance of shift work (SWT) studies

AIM:determineindividualdifferenceofshiftworktolerancebyevaluationofsleep,sleepiness,fatigue,socialfunctioning,physicalandmentalhealthAcohortof2,059Norwegiannurses(38%responserate)weresentquestionnaires,remindersFindings:•  VariablesveryimportanttoSWT:well-beingandphysicalhealth•  Shiftworktolerancedefinitionshouldnotonlyincludeinsomnia,fatigue,anxietyanddepression,butalsomentalhealthandsocialfunctioningvariables

.

IntArchOccupEnvironHealth2004;71,121-129BiologicalRhythmsResearch2015:46,No.257-264

Saksvik-lehouillieretal.IndustrialHealth2015;53:69-77

Tolerance of shift work (SWT) studies

AnotherstudyonDutchPoliceofficersFindings:•  SWTwasdirectlyrelatedtoqualityofsleep.• Womenweremoreintolerantbecauseofaddedresponsibilitiesoutsideofwork.•  Ofteninshiftworkerssleepisshortenedto4.8–5.5hourswhichoftenleadstochronicsleepdeprivation.

IntArchOccupEnvironHealth2004;71,121-129BiologicalRhythmsResearch2015:46,No.257-264

Saksvik-lehouillieretal.IndustrialHealth2015;53:69-77

Metabolic consequences of sleep loss

Sleepdeprivationisassociatedwith:•  Neuroendocrineregulationofappetite-decreasedLEPTINlevelandincreasedGHRELIN

•  Increasedenergyintakethroughhigh-caloriefood,snacks•  Insulinresistanceleadingtodiabetes•  Activationofgenesthatpromoteobesity

Sleepdebthassimilarimpactasagingonriskofchronicdisorders

Spiegeletal.JApplPhysiol2005;99(5):2008-2019.VanCauteretal.SleepMed.2008Sept;9(1):S23–S28.

Copinschietal.FrontHormRes2014;42:59-72.

Chronic effect of shift work (SW) on cognition

Prospectivelongitudinalstudy•  Cohortof3,232employees/retiredemployees:1,484shiftworkers•  Clinicalexamsandquestionnairesatbaseline,5years,10years•  Measuredtestsofspeedandmemory

Findings•  Shiftworkassociatedwithchronicallyimpairedcognition•  StrongerforexposuretoSW>10y•  AfterstoppingSW,recoveryofcognitivefunctiontookatleast5years

Marquieetal.OccupEnvironMed2015;72:258-265.

Verylittleresearchintohealthofshiftworkersthatcombinesinterventionsbaseduponlifestylefactors.

Asshiftworkers,•  wedealwithmultiplevariables

•  wehaveverylittlecontrolofourenvironmentandit’simpactonourphysiology

Case Study

Snyder,Ruhi(2015).

Foundation of Case Study

•  TimingandTypeofExercise

•  TimingandTypeofDiet

•  ShiftSchedules

•  Intermittentfasting

•  Meditation

•  BlueBlockingSunglasses

Methods

•  Asleeptechnologistworking12-hournightskeptadetailedlogofshiftschedule,sickdays,burnoutdays,exerciseandfoodintakeduringnightshiftsanddaysoffworkandcreatedaselfregulationprogramthatevolvedoveraperiodofthreeyears.

•  Aself-regulationprogramwasimplementedafterthefirstyearandinvolvedmodifying:

•  thetimingandtypeofexercise,•  timingandcompositionofdiet•  Intermittentfastingandmeditation•  shiftschedulesduringthenexttwoyearsand•  Addedblueblockingglassesafterfinishingnightshiftasashieldfromthemorninglight.

Exercise Related Benefits

•  Exerciseimproves:•  Sleep•  Mood•  Stresslevel•  executivefunction•  Cognition•  Neuroplasticity•  regulatesmetabolism•  Increasesmusclemass

VanReethetal.AmPhysiolSoc1994;E964-74Spark:TheRevolutionaryNewScienceofExerciseandCognition2008

JournalofScienceandMedicineinSport2014;(17)51-55

Benefits of Nocturnal Exercise

•  Onlyahandfulofstudieshavebeenconductedoneffectsofnocturnalexercise•  NocturnalExercise(HighIntensityIntervalTraining)phasedelaysCircadianRhythmsofMelatonin

•  Regularexercisecancreatesubstantialphasedelays•  Acceleratesre-entrainmentofthehumansleep-wakecycle

EuropeanJofAppliedPhysio(2007)99:331-341

J.PinealRes.(2012)52:1-11JournalOfCircadianRhythms201614(1):2,1-8

Sample Journal Entry- 2012 2weeksoffworkApproximatelysleptfor11-12hours.Inbedby1:30amWokeupfirstaround10:30amandwentbacktobedat11:00amandthenwokeupagainat1:00pm.Hadabagelcreamcheeseforbreakfastandasingleshotlattewithacupofmilk.Mildheadacheandtook1Advil(200mg).Hadpastawithcheese,peasandcornat6:30followedbyathirdlatte.Arrivedatworkafterbeingofffor12days.

Mood:fairlygood.Attitude:goodExercise:at11:30Stretching:2minutesStairs:1:54Rest:0.1Pushupsandabs:1:29@20eachStairs:2:22Pushupsandabs:.30Stretching:7minutesHadadifficulttimeduringthesecondsetofstairclimbing-pacerelativelyslowgoingdownandatthelowestafterclimbing50stairs.Continuedtorunupatarelativelylowpaceforthenext50stairs.

Levelofenergy:highFocus:highAttitude:positiveConcentration:goodAnalyzed1studyandconducted3diagnosticstudies.Moreenergyandwanttodomorephysicalactivity-recordedat2:18am.anothersetofpullupsat12:30amMeal@1:00amcontainingbeefandabeansoup.Teaat2:00am.Energylevelat4:00-moderate,yawningpresent.Physicallyalert.Mentally-mildlyfoggy.

Case study – exercise and shift schedule Year ExerciseOnNights ExerciseonDaysoff ShiftSchedule

2011-2012 Variabletiming-Running,yoga,cardio11:30pm-4:00am

Variabletiming-Running,yoga,cardioNoon-7:30pm

4nights/wk3nights/wkIntermittentdayshift

2012-2013 Variabletiming–highintensitytraining12–2:30am

Controlled–martialarts7-9pm2x/wk12-1:301x/wk

4nights/wk3nights/wkIntermittentdayshift

2013-2014 Controlledtiming-highintensitytraining,yogaandmeditation2:00-2:45am

Highlycontrolled12-1:302x/wk–martialartsAfternoon–runningPostexercise-meditation

3nights/wkto3nights/wkandadayshift(fixeddays)

2014-2015 Controlledtiming-highintensitytraining,yogaandmeditation2:00-2:45am

Controlledandflexible12-1:301x/wk–martialartsAfternoon2x/wk–running,hiking,andrecoveryperiods.Postexercise–yogaandmeditation

2nights/weekor2nightsaweekwithaflexibledayshiftFixedschedule

Year DietonNights DietonDaysOff

2011-2012 VariableandunrestrictedAllfoodgroups,somesweets,caffeineanytime,occasionalalcohol

VariableAllfoodgroups,somesweets,caffeineanytime,occasionalalcohol

2012-2013 Eveningmeal6pm-Halfaportionofmealcontainingleanprotein,carbs,two-threevegetablesandasaladSnacks11pm-12ampmfruitsmoothieswithproteinpowder,nutsandvarious1hourpriortoworkout:fruits/vegetablesPostworkoutmealtheotherhalfoftheeveningmeal

BLS-bigmeal7-9:30pmafterworkoutifapplicableSnacks–fruits,nuts,smoothies

2013-2014 Stricttimingofintakeofmealsandcoffee,noprocessedfoodorsugarMeal1hourpriortoshiftMeal1-1/2hourpostworkoutduringtheshiftPreworkout-fruit,wholegraincrackersandnutsNocaffeineafter1pmNofoodintakeafter4am.

Wholegrainsonly;eliminatedalcoholandprocessedsugarS-6:30-8pmStarted12hourfasting

2014-2015 Continuesame Continuesame;occasionalalcohol

Case study – diet type and timing

Results

• AfterimplementationoftheSelfRegulationProgramandchangestoshiftschedule,thefollowingqualitativeandquantitativeobservationsweremade:

• Mental-improvementofmood,tolerance,patience,self-efficacy,senseofempowerment

•  Physical-improvementinstrength,endurance,sleepqualityandenergylevel;lesspronetoinjuryandfatigue

•  Sick–significantreductioninsickdaysandtimeoffforburnout(eg.preSRP:8sickdays/year;SRP:0sickdayspastyear)

•  Productivity–improvementinfocus;increasedworkoutput;improvedinteractionswithpatientandimprovementinwork-lifeintegration.

Shift Schedule

Ruhi Snyder ©2018

Ruhi Snyder ©2018

Shift Schedule

Ruhi Snyder ©2018

Shift Schedule

Ruhi Snyder ©2018

Evolution of Self-Regulation and Impact on Work

Conclusion

•  Theauthor’sself-regulationprograminvolvinglifestylefactorshadnumerouspersonalandemployeebenefits

• Regularconsecutivenightshiftsfollowedbyatleast4daysoffandaflexibledayshiftonatwoweekcycle,reinforcedwithselfregulationasperdailytimedexerciseandmeals,anda12hourfast,meditation,wearingblueblockingsunglasses…ledto,bettermentalandphysicalhealth,reducedsickdays,andincreasedproductivityandimprovedworklifeintegration.

Closing statement

Thecasestudyiscomplexasitisembeddedinreal-lifewithmultiplevariablesthatshiftedconstantly.It,therefore,requiredamulti-layered,constantly-evolvingapproach.Itrequiredaprocessofselfawarenessofmyownrhythms,awillingnesstochangeandaltercoursewhenneeded,anopendialoguewithmyorganizationandacompletecollaborationandunderstandingfrommyfamily.Italsorequiredanunderstandingofpersonaleconomy(goingfromfulltimewithbenefitstopermanentparttimewithnobenefits).Asa24-hoursociety,shiftworkisarealityformany(Bluecollarorwhitecollar)andasareit’simplicationsonone’swell-beingandoncommunityandthesociety.Weneedamorecollaborativeandreallifeapproachtoshiftworkforthereisnoonemodelfitsallsolution,forhumanbeingsaredynamicandconstantlychangingsystemswithvariablesthatarechangingfrommomenttomoment.

RuhiSnyder2018

Acknowledgements:

KimSnyder,LucasSnyder,SaruGill-Bajwa,ArzoiBajwa,Dr.HelenDriver,ShelaghFreedman,Dr.KarenSchultz,LaurieAnderson,CynthiaDawson,TabathaKnight,KatherineQuarterman,KrisMarks,Dr.MichaelFitzpatrick,GillianBlekkenhorst,JenniferSnyder,Dr.NicolleDomnik,Dr.MalaJoneja,Dr.ManojDias-Abbey,TallackMartialArts,BenRobinson