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Supporting Healthy Shift Workers with Audra Starkey

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Supporting Healthy Shift Workers with Audra Starkey

What is the most important thing that we need to do to improve the health of shift workers? 

Shift work has been shown to increase the risk of developing a number of conditions, including obesity, metabolic complications, cardiovascular issues, gastrointestinal problems, and even certain cancers. 

In this episode we are joined by Audra Starkey, from The Healthy Shift Worker Podcast, who not only discusses the various impacts shift work can have on a person but identifies key actions workers can take to help mitigate these risks and be as healthy as possible, emphasising making quality sleep the priority above all else, as well as what to eat and when.

Covered in this episode

[01:00] Welcoming Audra Starkey
[01:39] Defining shift work
[03:17] Discussion on the various health impacts of shift work
[13:40] What can shift workers do to be healthy?
[16:30] Do naps during shift work help or make things worse?
[20:33] Discussing sleep as the #1 priority for shift workers
[27:13] Shift work and increased risk of insulin resistance
[28:30] Chrononutrition: what is it?
[33:58] Eating before bedtime to boost serotonin
[35:36] What to eat on an overnight shift and when
[41:39] Discussing Audra’s book
[43:59] Additional resources
[46:40] Thanking Audra and closing remarks

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Audra Starkey, who's a clinically trained nutritionist, accredited trainer, shift work veteran, and host of "The Healthy Shift Worker" podcast

After more than 20 years in the aviation industry, Audra decided to switch careers and complete a Bachelor of Health Science, majoring in nutritional medicine to gain a better understanding of some of the impacts of circadian rhythm disruption and poor dietary habits, and what they have on our health. Welcome to FX Medicine, Audra. How are you?

Audra: Hi, Andrew. Thanks very much for having me.

Andrew: It's our pleasure. Now, I've got to ask first, we talk about shift work and we think we know exactly what it is, but what exactly is shift work, apart from daytime work?

Audra: Yeah, I think formally it's regarded as anything working outside the hours between 8:00 am and 6:00 pm. But I think a lot of people these days, more and more people are starting to do that kind of work outside the regular 9:00 to 5:00 that we've sort of come to know over the years. 

And of course, it definitely applies to a lot of different industries, manufacturing, transportation, the healthcare industry, it really does form quite a lot of people. And I know that there’s close to, just here in Australia, Andrew, there's almost 2 million people that do actually work shift work. So it's quite a lot of the population, and I know that they're definitely in need of some help and guidance to keep themselves healthy, that's for sure.

Andrew: Absolutely. I mean, being an RN, the thing that really killed me energy-wise was… it wasn't so much shift work, per se, it was the way that the shifts were structured. 

Whereas, for instance, my sister is a psych nurse, and they had...wow, I mean, they had longer shifts, but boy, were they looked after with their energy, ie., with time off. 

So it's really interesting that even within the same overarching profession, there's vast differences in how shifts are managed. 

So I guess the next question is, what are the health impacts of shift working? And it seems obvious, but it's far deeper than what the surface suggests.

Audra: Yeah, and I agree. And just kind of getting back to what you just mentioned then, Andrew, I totally agree with it. Not all shift working workplaces are the same. That is definitely for sure, depending on the occupation, or even it might be the same industry but depends on what state that you're in, amongst the nursing profession, for example. 

Andrew: Yeah.

Audra: So, it can… yeah, it can definitely be vastly, vastly different. But I suppose when it comes to some of the chronic health conditions that shift workers are renowned for, it's because of that circadian disruption and the sleep restriction obviously leads to many metabolic and chronic health conditions, such as insulin resistance, type 2 diabetes, obesity, cardiovascular disease, gastrointestinal complaints, and certain cancers. 

It's certainly not rosy when you dive into the research, but I think it's vitally important that we make shift workers and organisations aware of that. Because I think a lot of corporations just immediately think of “Oh, well, fatigue, you know, we need to help manage the fatigue side of things,” right? But it's way deeper than that, it's not just about fatigue at all.

Andrew: There's also, it’s almost an assumption, when we talk about shift work, and we're thinking about a person having shift work, we're thinking about them in one spot, having the shift work. But even from your experience, you're moving across the world. You're moving through different time zones. So it's not just the time in between working shifts, but it's also the time that that shift starts in a different country, and all of these weird impacts. I mean, there's so much going on there.

Audra: Yeah, absolutely. Although in saying that, Andrew, I didn't fly in the aviation industry, I was based at the airport, so I didn't quite have those...

Andrew: Right. But relative, for the cabin crew and flight staff, yeah.

Audra: Oh, absolutely, 100%. And it's actually really interesting you bring that up because Qantas, at the moment, are currently undergoing some major research studies, called Project Sunrise, I think, in regards to… they're trying to, fly from Sydney to London kind of direct...

Andrew: Oh, yes.

Audra: Yeah, 19 hours. So they're doing a lot of research at the moment, looking at the light exposure and the timing of when we eat, because those two are very powerful triggers of the circadian rhythm. 

So it's wonderful that they are actually looking at doing that, because even… I was talking to a lady that just flew back out of Thailand the other day, and it was a midnight flight. And she said, "Audra, it was crazy, because we got on the flight at midnight, and within, like, an hour and a half, they're serving us this really big meal, when everyone's really wanting to sleep." 

So yeah, it's not the ideal time to be giving that food out, which is...yeah. So, kudos to Qantas, I have to say, as a previous employer of mine. They really are looking at helping to reduce some of those deleterious effects of jet-lag, which I think every single listener will to relate to.

Andrew: So, let's talk about these major impacts. You mentioned insulin resistance, and that in part would be due to eating at weird hours and things like that. But let's go deeper into that. What are the major health effects that affect shift workers?

Audra: Yeah, so...and I guess, I remember when I was at uni, and I was just so absorbed… so I went to study nutrition, but I was so absorbed into shift work health and well-being, and just reading so many journal articles and clinical trials that had been done on shift work. 

And yeah, these conditions kept coming up, and it almost... And I, to be honest, because this is a bit of a personal thing, I kind of became a little bit emotional about it because I thought “This is crazy. We're not told about this, we're not given this awareness.”

Andrew: No, you are not taught about it.

Audra: Yeah, exactly. Exactly. And I think… So just before going down that track, I wanted to highlight the fact that even just because the clinical trials of shift workers have come up, and they've highlighted these chronic health conditions, I would step back and think, “Well, okay, there is that certain amount that is going to happen between because we're up at what I like to call ‘stupid o’clock…'" I coined the term for one of my clients, which I think is very relevant. 

You know, are these people that they're doing these studies on, have they received any educational support on how to take care of their health that maybe would have altered perhaps the outcomes of a lot of this research? And I firmly believe that yes, that kind of would be the case. 

So I just wanted to kind of put that into kind of play because I guess I'm all about sort of stepping back, and kind of trying to reverse engineer things a little bit to help to mitigate some of these chronic health conditions. 

But yeah, for sure, the insulin resistance, and the pre-diabetes and the type 2 diabetes is very, unfortunately, very prevalent amongst the shift working population, and it can be down to a lot of…a myriad of factors, of course. And the timing of when we eat, which I know we're going to get into more about shortly, definitely plays a big role. But of course, you know, what we're eating, we know…

And Andrew, you would know, yourself being this shift worker, you know that we get stuck in this vicious cycle which is about disruption to our sleep/wake cycle, that we feel so tired all the time, that we don't always make the healthiest dietary choices, you know?

Andrew: Yeah, yeah. Well, I was also very concerned, like I have questioned international flight staff about, has anybody taught them? And indeed, what you say is nobody, ever. 

I was surprised, particularly on one flight, there was one nurse, one teacher, and somebody that had done pre-med. So we're talking about medically trained individuals, and nobody had talked to them about, or had exposed them to any research pertaining to illnesses of shift work, and circadian rhythm disruption, things like that, not at any time. 

It was really interesting, just reading recently how it seems to be now set in stone that there's an increase in, what is it, breast cancer and melanoma, strangely, for flight staff.

Audra: Yeah, I saw that. But even saying that though, Andrew, when we think about it, you know, shift working companies, one of the biggest expenses that they have to endure is high sick leave, right? 

And thus, poor sleep is one of the biggest causes of debilitating our immune system. So if we can actually, again, reverse engineer things a little bit and start teaching people through better sleep and lifestyle habits how to actually improve their sleep. Along with it, of course, needs to be changes within the organisation in regards to rostering. I mean, the R-word is definitely a usually hot topic of debate...

Andrew: Yes.

Audra: But if we can think about if...yes, it will cost that initial financial thing to start educating shift workers, but in the long run, potentially, it's going to save them millions of dollars because it's providing that education and support for people right from the get-go. 

And the sleep thing is a huge thing that actually, in all of my work, I actually put it first before nutrition, because I think… I kind of realised I was getting a bit frustrated there for a while, even working with clients, that there's kind of no point to telling somebody “You should be eating that and you should be doing this, etc., etc.,” if their eyes are hanging out of their heads they're so tired, they're not going to want to do it, you know?

Andrew: Yeah, no...yeah.

Audra: So we've kind of got to work...I always kind of felt, when I was working in nutrition at first, I felt like I was putting the cart before the horse. So I thought "I'm going to need to flip this around a little bit.” When I'm working with my clients, I need to focus on their sleep first because I know if I can improve their sleep, they're more likely to eat better, which you know, has that flow-on effect to everything. 

It used to ponder me, or used to fascinate me a little bit, Andrew, because you know, when somebody works 9:00 to 5:00, they say...or even if they've worked, they've finished at 6:00 at night, they actually don't come back to work until about 16 hours later, and that they've already had a really nice bit of sleep. Yet, some of the shift workers have these eight-hour minimum turnarounds, you know, even ten is not enough in my book. 

Andrew: Yes.

Audra: But that's like asking someone who works 9:00 to 5:00, say, if they finish work at 6:00, asking them to come back at 2:00 or 3:00 in the morning.

Andrew: Yes.

Audra: Like, it just would not happen. So I never have understood where this small minimum turnaround comes into play, when we're attacking those that are the most vulnerable with sleep, and you’re making it worse.

Andrew: Yes, and a flow-on for that with, say, the medical staff, when you're talking about doing a late shift which ends at 11:00, and then you're on an early shift which starts at 7:00, that's an eight-hour break. 

And as you say, within that eight hours, you have to clock off, get home, wind down, get ready for bed, get into bed, go to sleep. Then wake up, get ready for work, go to work. So there's...you don't get eight hours sleep, you'll get five, or four. And when you think about the flow-on effects of that, well, that's the patients.

Audra: Absolutely. Yeah, so it's a kind of crazy, crazy world. And I guess that’s why I'm sort of doing this, I am trying to raise some much-needed awareness for both. It's a 50/50 responsibility of the employee and the employer. We've got to start doing things differently because, given it’s... The underlying factor is that that circadian rhythm disruption, the sleep deprivation and its impact on our immune system, our mental health and well-being. As I alluded to you before, we're more likely to face cardiovascular diseases and stuff. It's not just about fatigue anymore, it's big.

Andrew: No. Far deeper. So, can shift workers indeed be healthy? And then, what do they have to do to be that?

Audra: Ah...that's the million-dollar question, isn't it? Oh, my goodness. Yeah, well I suppose...of course, I do believe it. And this is kind of why I do what I do, but a caveat there is, of course, and we alluded to before, Andrew, it really...it depends a lot on the actual job, what you do, where you work, who you work for, even from the local management perspective of how open they are to actually taking care of their staff health. 

I think if you are in that environment from the get-go, then obviously you've got a lot better chance of being a healthy shift worker. But as I said before, to me, absolutely everything comes back to education. And I can say, just myself over 20 years of working in shift work, what frustrated me a little bit over the time is that each time I would perhaps go and see a healthcare practitioner, the words that I would always hear back is “Well, you should just quit your job.” And that kind of frustrated me, you know? 

And even though I'm now a health practitioner and I get it, I understand why they're saying it, but it's kind of not helpful. And also, I loved my job. And I know that there are a lot of people out there in industries, whether it's police, nursing, paramedic, veterinary, they absolutely love their jobs. 

So just give us some guidance on how to stay healthy, or to at least mitigate some of those chronic health conditions that I alluded to before. And I've really lost count now of how many people who have actually come up to me after I've delivered a seminar and said to me, "Audra, where were you 20 years ago, when I needed you?"

Andrew: Right. Yeah.

Audra: Or I even had a lady say to me, "Where were you 40 years ago, when I needed you?"

Andrew: Oh, wow.

Audra: I had to say, "Well, I was probably only about five years old, so I wouldn't have been so helpful."

Andrew: I've got to say to that point that you made about a health practitioner saying “Just quit your job,” it doesn't solve the problem because there's another person who will take that job.

Audra: But we need shift workers, too. Like, you know, we need people. The world would literally stop spinning if we didn't have shift workers.

Andrew: Absolutely.

Audra: And we need somebody to be able to call at 2:00 in the morning if we've got an emergency, which I hope will never happen to anyone listening. But we need somebody there, and I think because of that we need to be doing whatever we physically, possibly can to help them take care of their own health. Because yeah, a lot of them are also in the healthcare setting themselves.

Andrew: And forgive me for concentrating a little bit on the healthcare setting, because it is...perhaps a little bit of a penchant that I have. But the ability, in some instances, to get at least some rest... 

So there was on some nights, depending on the work and how heavy the workload was, obviously, that's going to depend entirely on which ward you're on, what type of work you're doing, but there would be the time to catch a nap. Is this a benefit or does it actually create more problems, these little mini naps?

Audra: Oh, yeah, definitely the benefit is always...is there, but is it practical in most workplaces? That's kind of the thing. I know the likes of Google and Apple, they have these napping pods that they've brought into the workplace for their staff to literally have somewhere where they can actually nap, and it's very well done. It's very well designed to block out all light, noise...it's even got a timer on it for about 20 minutes so that after 20 minutes, that they have to kind of get up. And if it was me, I would love to see a napping pod place in every shift working workplace everywhere. 

But again, it sort of depends on the workplace. I was doing some work for some 24/7 veterinary clinics just fairly recently, and for them it's not practical because, again, I suppose this comes back to a staffing issue really, doesn't it? 

Andrew: Yeah.

Audra: If they then needed to be awake and alert and observant of their patients.

Andrew: That's right.

Audra: Yeah, that's where it gets a little bit... But hey, if they could get a bit of a rotating roster of at least one person... It just kind of tops up that sleep tank basically. Because you're experiencing that…

You've got those two things that's happening with sleep: your sleep drive and your sleep rhythm are both mixed up. Because you've got the sleep drive, where you've got that build-up of adenosine in the brain to help put you to sleep, but then if you're awake at 3:00 in the morning, you've got that circadian misalignment, so you've got those two things attacking at the same time. But at least by having that little bit of a nap, you're doing what the body instinctively wants to do, is sleep during the night. But not too long, of course, otherwise you wake up drowsy.

Andrew: Yeah. Is there any length of time that's best for a siesta? And is there any research showing what long-term effects of having a siesta is?

Audra: Yeah, I think what I've found when I've done a lot of the research, Andrew, is that nothing has really specifically, necessarily been done on shift workers.

Andrew: Right.

Audra: You know what I mean? Which is really crazy because they're the ones that are the most vulnerable to that. But I do know that some of the studies that have been done down in Adelaide and through Monash University and that, in the sleep labs down there, is that they have looked at the different timings and so forth of, I think it was people in United States, in the train industry I think, about different types of links and so forth. 

But the thing is, you don't want to go too deep, as I said before, because you end up going deeper and deeper into that sleep cycle, which is around 90 minutes. Ideally, even a 90-minute nap would prove to be more beneficial because you're going through that whole sleep cycle. But if you're taking it too much longer, and then you're waking up in the middle of the sleep cycle, then you end up being more drowsy, and it takes a little bit to kind of come out of that...yeah, that sort of drowsiness, which is...you know, alertness is key, particularly if you're driving equipment, and taking care of patients and so forth.

Andrew: So when you're prioritising your management plan, your care of patients who come in, what do you focus on first?

Audra: Sleep, 100%.

Andrew: Just sleep.

Audra: Well, not just sleep, but it's where I start.

Andrew: Yeah.

Audra: There's so much in the health and well-being space and it's all about nutrition and exercise, and nutrition and exercise, and nutrition and exercise. Which is wonderful and it's all very relevant, but sleep is even more important. 

And interestingly, even earlier in this year, the Australian government actually released a report ironically called "Bedtime Reading." They did research into sleep health awareness within Australia. It was a 171-page document, so it's bound to put anybody who's listening to sleep. If you're wanting to find a sleep-inducing strategy, get them to read the actual document. 

But they just released a lot of the findings that we are not only a world that is... I think even the World Health Organization has stated we are living in a world obesity epidemic, a type 2 diabetes epidemic, but we're also living in a world sleep loss epidemic. 

We can't last long without air, we can't much longer without water. And then really, sleep kind of comes in next in the ladder, because.… My best way to describe this is that if you were to go without eating for two or three days,  which I'm not recommending as a new diet for 2020, that's for sure…

Andrew: No.

Audra: …but if we weren't to eat for two to three days, after that time we would feel tired, lethargic, we'd lose a bit of muscle mass, but generally speaking, you know what, Andrew, you know that you’re going to feel okay. 

But if we were to not sleep for two to three days, we would barely be able to function, and we'd begin to hallucinate. So that really gives us a huge clue as to just how critically important sleep is when it comes to our health and well-being. And we know with shift workers, as we've already said, they do, they experience that sleep deprivation, that sleep disruption, and so forth. 

But I do know from working with clients that the shift workers, they're not always prioritising their sleep. Incredibly, they're not prioritising their sleep, and also they might be either knowingly or unknowingly doing self-sabotaging behaviours that is making their sleep disruption even worse. 

Andrew: Yes.

Audra: And I think we need to attack that first. I remember... you know, I’m really reluctant to prescribe a client with magnesium if I know that they are staying awake to 11:00 at night on their iPad. You're throwing away that hard-earned cash on supplements if you're not doing this as well. 

So I suppose that's where I come at that sort of approach from all angles to kind of get the best patient outcomes. But absolutely, sleep is foremost. I've even kind of developed a better sleep program for shift workers for that very reason, because it's critically important. We know that we feel so much better and we function much better when we've had a better night's sleep.

Andrew: And restful sleep. So my next question has got to do with how people are fearful of getting sleep, therefore it prevents sleep. How often is this the major factor, the worry of sleeplessness, the worry of not getting rest?

Audra: Oh, I think it's a huge one. Yeah, they get stuck in that sort of anxiety-insomnia feedback loop, where they know that they've got to get up at 3:00 in the morning or whatever, but they're panicking because they're counting back the clock, thinking "Oh, my gosh, it's five hours to go. I've only got four hours to go.” It is huge. 

And I'm glad that you mentioned that really, Andrew, because I think that really is one of the big drivers for most people in this crazy, stressful world that we live in. A lot of people have so much on their plate that they are going to bed feeling very anxious and wired, you know? 

We're tired and wired, and our nervous systems are just still on high alert, which is definitely going to prevent anybody from being able to sleep. Because if our brain is getting that signal, feeling that we're not safe, then it's not going to be able to start to wind down and produce melatonin and so forth, to enable the body to be able to sleep. 

So yeah, the anxiety thing is huge. But again, I guess that's where we need, as practitioners, to really start kind of digging deeper as to what's the cause of the anxiety? What is it specifically that they are worrying about? And obviously refer on if required to those that deal or specialise in this area because it's very big. It's a very real thing.

Andrew: And what about with sleep deficit, once we're in that horrible quandary? How long does it take to be able to pay back the sleep deficit?

Audra: Oh, actually it's interesting because I just recently heard about a study where they were working on adolescents that were having a lot of trouble sleeping, and that were staying up, like couldn't fall asleep 'til about 1:00 in the morning and so forth. But what they ended up doing is they actually ended up taking them camping for two weeks. So, of course...

Andrew: Right…night time.

Audra: Yeah. So, well obviously putting them in that natural cycle, where they're not on their iPads, they're not being exposed to the blue light, which adolescents do. They were forced into the environment where they were governed by the light and the darkness, and so then they were finding that they were getting sleepy by 9:00 pm, and they were waking up at around 6:00. So...

Andrew: That's really interesting.

Audra: Yeah. So, it can be done. But the thing is, in today's world, we are not living in that perfect camping environment, are we? We've got this light toxicity going on, light at the wrong time, and not enough light at the right times and so forth, which is messing with their circadian rhythms. 

But talking about the one night of sleep deprivation, there was recently a study that showed...well, it's not that recent, but it was showing that just one night of sleep deprivation causes a 40% reduction in our ability to handle glucose.

Andrew: Wow.

Audra: Yeah. And I remember reading this, thinking, “Oh, my Lord,” like, just having all these epiphany moments. So okay, well shift workers are prone to, as we said before, the pre-diabetes, insulin resistance and stuff. Why is this? What's going on? 

And when you kind of read research like that, it makes sense, doesn't it? If that's happening, and then we're putting it on top of, you know, eating the lollies and the chips and the pizza and that at 3:00 in the morning, it's no wonder...

Andrew: Double whammy.

Audra: ...it's no wonder that over time, shift workers can be prone to developing those chronic conditions. So I think we need to… We've got to get out there and tell people this, so at least arm them with the knowledge so that they can then make better choices and decisions around what they're doing instead of just them not knowing it, you know? We're adults, we should be able to make our own decisions. But without that knowledge behind us, we're not likely to change our behaviour.

Andrew: With regards to eating, you mentioned that 40% reduction in glucose handling, and how we tend to eat the wrong things at the wrong time. So chrononutrition, what is this? And how do we best handle this, particularly when you've got those extremely powerful urges of hunger driving you?

Audra: At 2:00 in the morning?

Andrew: Yes, at the wrong time.

Audra: Yeah. Well, chrononutrition kind of falls under the area of science called chronobiology, which is all about timings and cycles, or rhythms. So certain things like our body temperature and melatonin are all designed to get released at certain times of the day and night. Which is a good thing because if it all happened at once, it would be chaos.

Andrew: Yes.

Audra: But the term, it's good that it's really starting to get more and more, I guess, awareness around it. But the term was originally coined by a French doctor back in the mid-1980s, called Dr Alain Delabos, and it is based around the body's biological clock, or our rhythms. 

And so the more we are in alignment with our circadian rhythms, the healthier we will be. Really, it comes down to that. Chrononutrition, though, applies to not so much what we're eating, but when we're eating. 

Just to put this into context a little bit, Andrew, this is how I kind of stumbled on this even myself. I was in my last year at studying nutrition up here in Brisbane, at Endeavour College. And each time we had a client coming in, we had to get them to fill out the food diary, what they're eating for breakfast, lunch and dinner and stuff. And I would have clients that were actually eating fairly reasonably well, but they were still struggling with their weight. So I decided to kind of mix things up a little bit, and I started to ask them a different question: when they were eating.

Andrew: Right.

Audra: And that opened a whole different Pandora's box for me, I suppose, and what really led me down the path to dive deeply into this area of chrononutrition. Because it's not so much relevant for people that work Monday to Friday, 9:00 to 5:00, that eat at the same time and so forth. But for shift workers, this is crucial. Absolutely crucial. 

Even, for example, your postprandial glucose response is actually much worse when you're eating, say, at 3:00 am than if you'd been having that same meal during the day. So basically, when we eat during the night versus the day, and how we metabolise it, it is drastically different. 

So this is, again, this is why it's crucial that shift workers are aware and have an understanding of what is a circadian rhythm. What is it? What happens when I eat at this particular time? Because we know our appetite-regulating hormones you were alluding to before, Andrew, about having that sugar craving at 2:00 in the morning, it's usually because our appetite-regulating hormones are totally being skewed all over the place. 

Now we know, the studies have shown that leptin can drop by about 20%, which is that signal that tells us that we're feeling full, versus ghrelin increases, which can make us overeat, and...

Andrew: Hungry, yeah.

Audra: ...and overeat on all the wrong things. So to help answer your original question of “How do you stop the starving hunger cravings?” Well, what I firstly do recommend for my clients straightaway is to have a glass - again, I'm getting back to really basics, here - but having that glass of water first, because a lot of the time that hunger and thirst really confuses it. 

Have a glass of water first, and then have something that contains proteins and healthy fats so that it's going to help to stabilise your blood sugar, increase that satiety, that feeling of fullness so that you're less likely to want to go for the doughnut. Which is obviously the highly refined and processed sugars which your brain is needing, but we know that that's certainly not going to be good for your health and well-being. 

And as I said, what we were alluding to before about the body's ability to handle glucose, our pancreas, incredibly, that beta-cell function is completely different at night. Like, the pancreas does not function in the same capacity as it does during the daytime. 

And again, and I keep harping on this, just when I was reading it, thinking “This is so important, I wish somebody had told me about this many years ago because it could have changed my eating behaviour.” And maybe...again, what I'm trying to do is to help people not eventually develop the chronic health conditions of type 2 diabetes. 

Because I know I've had patients that have. And I just think, if they'd just been given this advice and recommendations and education beforehand, could I even potentially help one person? Well, great. But I think we can do a much bigger job on that by getting it more out to, flowing into the workplaces, and in...yeah, nursing degree training, being built into the curriculum. 

Andrew: Yeah.

Audra: Yeah, it's so important.

Andrew: Audra, what about this theory of taking a small amount of carbohydrates just before going to bed to boost serotonin?

Audra: Yes. Yeah, yeah, yeah, that's true. That's because there's...

Andrew: One would have to be careful about the type of carbs, I would imagine? You mentioned the doughnut before.

Audra: That's it, 100%. Yeah, 100%. Yeah, how much, exactly when. But that's a good point to raise because I've found that a lot of my night shifting clients, a lot of them would...they do their night shift, and they would just go home and have a shower and go straight to bed. Which I totally get it, that's all we feel like doing, but they would not have anything to eat. 

But that can then lead to that disruption of their blood sugar to a point where blood sugar drops so much that it fires off our stress response, and it can be enough to wake people up. So what we want to do is to help increase and improve that sleep by having that little snack or meal beforehand, just before sleep.  

 So for example, let's say instead of a plain bowl of porridge, which is pure carbohydrate, it's going to give you that high sugar spike on its own. But I get my clients to just chuck things on it like chia seeds, Greek yogurt, some healthy fats and protein that will help to stabilise that blood sugar. And it makes a huge difference to their sleep. Huge.

Andrew: So making it like, it might have the carbohydrate content, but it's a low glycemic index load.

Audra: Exactly, yeah.

Andrew: Great...okay. Two scenarios I want to pose to you, and the first one is when you've got regular but inverted shift work, ie., you work nights all the time, do you change their chrononutrition so that their daytime eating is actually during the hours of nighttime? 

And then nighttime behaviour, their sleep, which has to happen at some time, is during the daytime? Or do you still use the Earth's sun and nighttime as the sort of gauge of the biological clock?

Audra: Yeah, so I remember hearing once that...I think somebody was recommending while I was at uni, to recommend to a shift working client just to flip their meals, you know? So having their big meal at midnight, for example, as if they were having the reverse at the same time...

Andrew: It's never sat right with me.

Audra: Exactly. I so agree, 1,000%, Andrew. And when I heard that I went, “No that just does not sit with me,” as well, and I suppose it's kind of what led me down to the path. 

No, I will always just try, and as I alluded to before, the more we are in alignment with our circadian rhythms, the healthier we will be. So we know that we need to be training those peripheral tissue clocks, the clock genes in our peripheral tissues, which is really our gastrointestinal tract to coincide it with our circadian...sorry, SCN, suprachiasmatic nucleus in the brain to kind of make sure everything is as close and in sync as how it should be. 

Now, as shift workers, we are out of sync to our circadian rhythms. But where we can, we need to be basically trying to do things to recalibrate those circadian rhythms. So what I do is, I recommend them to just eat as closely... 

So for example, a night shift person would be to have their main meal, dinner or what they would normally be doing before they go into their night shift because it's going to be usually big enough that...you know, you've got your proteins, your healthy fats and complex carbohydrates that will give you enough energy to kind of get through your shift, help you to stabilise that blood sugar so that you're less likely to get the cravings. 

I'm not saying that you won't get the cravings at 2:00 in the morning, but it's going to sustain you for much longer. And then when you come home from night shift, as I said, have that small something to eat just before bed, again to help you to be able to sleep all the way through. 

Actually, and I might digress slightly there, Andrew. You just reminded me of something, that there was a study that was actually, eventually published in the Nurses and Midwifery Journal. Actually you probably did see it, where they looked at driver alertness of somebody that was doing a night shift...

Andrew: Was it...yeah, basically it was .08 or something...it had the equivalent of .08 alcohol, is that right?

Audra: Oh no, that was... No, no, it was...what they were doing is that they were assessing driver alertness from somebody. They looked at eating during the night. So what they got people to do is either have a big meal during the night, a small, like a snack during the night...

Andrew: Oh...right.

Audra: ...or not eat at all. And then after doing that night shift, they put them in a 40-minute driving simulator, and they got them to… and so they just looked at their driving. And what they found is that those that have the larger meal during the night had more aggressive driving behaviour.

Andrew: Oh, really?

Audra: They're more likely to swerve into different lanes, they were just not making better decisions. Whereas those that had the snack, so just something small during the night, their alertness was much more prevalent. And even not eating was better than the big meal. And I think it's important for people to know that.

Andrew: Yeah. It sort of smacks of an inverted intermittent fasting.

Audra: Yeah. Yeah.

Andrew: Which of course is healthy, it's just that they're doing it the wrong way around. But it's really interesting. 

So what about things like favouring, say, soups, which are usually - not always - but usually more nutrient-dense, calorie-poor over the higher caloric type foods? Any work being done on that? What's your opinion?

Audra: My number one recommendation to night shifters is actually to have soups during the night because you're getting that liquid nutrition. It's reduced load on the gastrointestinal tract immediately. So and again, we know that shift workers are prone to a lot of gastrointestinal complaints, peptic ulcer diseases and so forth over the long term, so having something small and nourishing, as you said, they're usually quite nutrient-dense but less taxing on the gut. 

And also, our body temperature naturally drops around 2:00 and 4:00 in the morning based on our circadian cycle, and you would probably remember those times in the...working during the night, and you get that cold chill.

Andrew: Yes. You'd just put a jumper on, yeah.

Audra: Yeah, yeah. Well, that's the body doing what it's naturally designed to do. And it does that, actually drops the body temperature to help keep you asleep. Which is wonderful if you're actually sleeping, not so much when you're at work. So again, that's where a soup can actually be a great thing to have because you're addressing both of those two things. 

But again, I would always be recommending not a big meal, but just something small to tide them over. And I know that you would relate to this, and my sister's a nurse, so I'm very much aware of what goes on in those nursing wards at midnight. You know, the takeaway pizzas get brought in, the Uber Eats and so forth, the comfort food...

Andrew: Chocolates, yeah. You got it.

Audra: Yeah, it's a very real thing. And I get it, and I'm not saying to never do it again because night shift is hard, and it kind of makes it a bit of fun. But just over the long-term, it can be very problematic, obviously.

Andrew: Now, you've written a book about this. Is all that we've talked about, all of these support measures for your patients, and indeed, practitioners' patients, is all of this advice covered in your book?

Audra: Yeah. So, my book is obviously designed for shift workers to read. It's a very holistic take on shift work, health, and well-being. 

So what I do is I talk about, really, the five biggest struggles that we face, working shift work, is that sleep deprivation which is a key driver behind the fatigue, the weight fluctuations, the stress, the anxiety, depression, a poor immune system, and also some of the impacts that it has on our relationships. 

So, I have a very holistic take on health, I suppose. And it's written very much in an easy to read style because not every shift worker has a science background. For me, myself, I didn't start reading journal articles until I started studying, but being in aviation I had no need or desire to read a journal article. So I know that I needed to make sure that… the people who are reading it are tired, and a lot of us, we start reading a book and then we get shiny object syndrome, and head off onto another kind of thing. 

But I wanted to make sure that people who pick up and read this book read it from start to finish. Because everything in it is so vitally important. It's not, as I said, it's not really in-depth because I want… Because I do share my story right at the beginning as to give a bit of a backstory as to some of the challenges I faced. 

But also to, I suppose, be that little bit of a big hug for them, to give them a bit of a sense of hope that there are things that they can do. Which is why it works beautifully, I suppose, as a complement for health practitioners, just as something extra to give their clients as opposed to an addition to the prescription that they will be giving to their client. 

But it's a book that I wish somebody had given me 20 years ago. And I know that there's none around there, there's nothing out there to support the shift worker. And so I suppose that’s really why I wrote it.

Andrew: So with regards to support references, if you like, for practitioners to look up to be able to show their shift work patients, “Look, this is a real issue,” what sort of things do you suggest? There was a couple I found, ohsrep.org.au was an Australian one which described the issues of shift workers. What ones do you recommend?

Audra: Oh, I've got over 100 references.

Andrew: Oh, okay...well, we won't list those right now.

Audra: Yeah. So...yeah, yeah, yeah. So, it's very well-referenced because, you know, we're evidence-based practitioners. That's kind of what we do, you know? 

There's sort of a mixture, but it all… all the references have to do with, as I was saying before, is that sleep, the weight fluctuations, chrononutrition, why eating during the night is… Or chrononutrition, why this is just vitally important that we get it out there, and let people be aware of it. 

But even, I also delve off into something slightly different because shift workers, we are prone to having relationship breakdowns, marital stress and all that kind of stuff. And a lot of that stems from the fact that...and has been shown in studies, where the less sleep we have, it reduces our empathy and we're more likely to say and do things that we wouldn't ordinarily say.

Andrew: Salient point. Well done, yes.

Audra: Yeah. So again, having that awareness, or letting somebody know that. Because occasionally that's fine, but over time, that chronic… you know, saying and doing things that you wouldn't ordinarily say, that's obviously to our family members that we know and love, but also our workmates as well.

Andrew: Yes.

Audra: But at least having that awareness, okay, when you get home or whatever, maybe I won't get into this conversation, I'll have a sleep first. And then we'll take up this conversation after I've had a good night...after I've had a good, sleep to sort of top up my sleep tank a bit. 

Because yeah, I just...I suppose, as I've sort of highlighted before, it's a very personal thing, and I generally am concerned about the shift workers of the world. Because I get it, I know it, I've lived it, I've breathed it. And it's just to kind of give them a resource out there, that there is hope.

Andrew: Maybe that's where the ancestral saying came from, about "Let me sleep on it." We'll certainly put up some relevant references, and some of the references from your book so that practitioners can get a taste of the book, up on the FX Medicine website. 

But thank you so much, Audra, for taking us through this real issue, not just on some discomfort and some tiredness, fatigue, but we're talking about major health illnesses that are facing us on an economic level here. So, thank you so much for taking us through these important issues today on FX Medicine.

Audra: You're welcome, Andrew. Thank you so much for having me. It was lovely chatting.

Andrew: This is FX Medicine. I'm Andrew-Whitfield Cook.


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