Pain Doesn’t Belong on a Scale of Zero to 10
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Over the past two years, a simple but baffling request has preceded most of my encounters with medical professionals: “Rate your pain on a scale of zero to 10.”
I trained as a physician and have asked patients the very same question thousands of times, so I think hard about how to quantify the sum of the sore hips, the prickly thighs, and the numbing, itchy pain near my left shoulder blade. I pause and then, mostly arbitrarily, choose a number. “Three or four?” I venture, knowing the real answer is long, complicated, and not measurable in this one-dimensional way.
Pain is a squirrely thing. It’s sometimes burning, sometimes drilling, sometimes a deep-in-the-muscles clenching ache. Mine can depend on my mood or how much attention I afford it and can recede nearly entirely if I’m engrossed in a film or a task. Pain can also be disabling enough to cancel vacations, or so overwhelming that it leads people to opioid addiction. Even 10+ pain can be bearable when it’s endured for good reason, like giving birth to a child. But what’s the purpose of the pains I have now, the lingering effects of a head injury?
The concept of reducing these shades of pain to a single number dates to the 1970s. But the zero-to-10 scale is ubiquitous today because of what was called a “pain revolution” in the ’90s, when intense new attention to addressing pain — primarily with opioids — was framed as progress. Doctors today have a fuller understanding of treating pain, as well as the terrible consequences of prescribing opioids so readily. What they are learning only now is how to better measure pain and treat its many forms.
About 30 years ago, physicians who championed the use of opioids gave robust new life to what had been a niche specialty: pain management. They started pushing the idea that pain should be measured at every appointment as a “fifth vital sign.” The American Pain Society went as far as copyrighting the phrase. But unlike the other vital signs — blood pressure, temperature, heart rate, and breathing rate — pain had no objective scale. How to measure the unmeasurable? The society encouraged doctors and nurses to use the zero-to-10 rating system. Around that time, the FDA approved OxyContin, a slow-release opioid painkiller made by Purdue Pharma. The drugmaker itself encouraged doctors to routinely record and treat pain, and aggressively marketed opioids as an obvious solution.
To be fair, in an era when pain was too often ignored or undertreated, the zero-to-10 rating system could be regarded as an advance. Morphine pumps were not available for those cancer patients I saw in the ’80s, even those in agonizing pain from cancer in their bones; doctors regarded pain as an inevitable part of disease. In the emergency room where I practiced in the early ’90s, prescribing even a few opioid pills was a hassle: It required asking the head nurse to unlock a special prescription pad and making a copy for the state agency that tracked prescribing patterns. Regulators (rightly) worried that handing out narcotics would lead to addiction. As a result, some patients in need of relief likely went without.
After pain doctors and opioid manufacturers campaigned for broader use of opioids — claiming that newer forms were not addictive, or much less so than previous incarnations — prescribing the drugs became far easier and were promoted for all kinds of pain, whether from knee arthritis or back problems. As a young doctor joining the “pain revolution,” I probably asked patients thousands of times to rate their pain on a scale of zero to 10 and wrote many scripts each week for pain medication, as monitoring “the fifth vital sign” quickly became routine in the medical system. In time, a zero-to-10 pain measurement became a necessary box to fill in electronic medical records. The Joint Commission on the Accreditation of Healthcare Organizations made regularly assessing pain a prerequisite for medical centers receiving federal health care dollars. Medical groups added treatment of pain to their list of patient rights, and satisfaction with pain treatment became a component of post-visit patient surveys. (A poor showing could mean lower reimbursement from some insurers.)
But this approach to pain management had clear drawbacks. Studies accumulated showing that measuring patients’ pain didn’t result in better pain control. Doctors showed little interest in or didn’t know how to respond to the recorded answer. And patients’ satisfaction with their doctors’ discussion of pain didn’t necessarily mean they got adequate treatment. At the same time, the drugs were fueling the growing opioid epidemic. Research showed that an estimated 3% to 19% of people who received a prescription for pain medication from a doctor developed an addiction.
Doctors who wanted to treat pain had few other options, though. “We had a good sense that these drugs weren’t the only way to manage pain,” Linda Porter, director of the National Institutes of Health’s Office of Pain Policy and Planning, told me. “But we didn’t have a good understanding of the complexity or alternatives.” The enthusiasm for narcotics left many varietals of pain underexplored and undertreated for years. Only in 2018, a year when nearly 50,000 Americans died of an overdose, did Congress start funding a program — the Early Phase Pain Investigation Clinical Network, or EPPIC-Net — designed to explore types of pain and find better solutions. The network connects specialists at 12 academic specialized clinical centers and is meant to jump-start new research in the field and find bespoke solutions for different kinds of pain.
A zero-to-10 scale may make sense in certain situations, such as when a nurse uses it to adjust a medication dose for a patient hospitalized after surgery or an accident. And researchers and pain specialists have tried to create better rating tools — dozens, in fact, none of which was adequate to capture pain’s complexity, a European panel of experts concluded. The Veterans Health Administration, for instance, created one that had supplemental questions and visual prompts: A rating of 5 correlated with a frown and a pain level that “interrupts some activities.” The survey took much longer to administer and produced results that were no better than the zero-to-10 system. By the 2010s, many medical organizations, including the American Medical Association and the American Academy of Family Physicians, were rejecting not just the zero-to-10 scale but the entire notion that pain could be meaningfully self-reported numerically by a patient.
In the years that opioids had dominated pain remedies, a few drugs — such as gabapentin and pregabalin for neuropathy, and lidocaine patches and creams for musculoskeletal aches — had become available. “There was a growing awareness of the incredible complexity of pain — that you would have to find the right drugs for the right patients,” Rebecca Hommer, EPPIC-Net’s interim director, told me. Researchers are now looking for biomarkers associated with different kinds of pain so that drug studies can use more objective measures to assess the medications’ effect. A better understanding of the neural pathways and neurotransmitters that create different types of pain could also help researchers design drugs to interrupt and tame them.
Any treatments that come out of this research are unlikely to be blockbusters like opioids; by design, they will be useful to fewer people. That also makes them less appealing prospects to drug companies. So EPPIC-Net is helping small drug companies, academics, and even individual doctors design and conduct early-stage trials to test the safety and efficacy of promising pain-taming molecules. That information will be handed over to drug manufacturers for late-stage trials, all with the aim of getting new drugs approved by the FDA more quickly.
The first EPPIC-Net trials are just getting underway. Finding better treatments will be no easy task, because the nervous system is a largely unexplored universe of molecules, cells, and electronic connections that interact in countless ways. The 2021 Nobel Prize in Physiology or Medicine went to scientists who discovered the mechanisms that allow us to feel the most basic sensations: cold and hot. In comparison, pain is a hydra. A simple number might feel definitive. But it’s not helping anyone make the pain go away.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News’ free Morning Briefing.
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Junk Food Turns Public Villain as Power Shifts in Washington
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The new Trump administration could be coming for your snacks.
For years, the federal government has steered clear of regulating junk food, fast food, and ultra-processed food.
Now attitudes are changing. Some members of President-elect Donald Trump’s inner circle are gearing up to battle “Big Food,” or the companies that make most of the food and beverages consumed in the United States. Nominees for top health agencies are taking aim at ultra-processed foods that account for an estimated 70% of the nation’s food supply. Based on recent statements, a variety of potential politically charged policy options to regulate ultra-processed food may land on the Trump team menu, including warning labels, changes to agribusiness subsidies, and limits on which products consumers can buy with government food aid.
The push to reform the American diet is being driven largely by conservatives who have taken up the cause that has long been a darling of the left. Trump supporters such as Robert F. Kennedy Jr., whose controversial nomination to lead the Department of Health and Human Services still faces Senate confirmation, are embracing a concept that champions natural foods and alternative medicine. It’s a movement they’ve dubbed “MAHA,” or Make America Healthy Again. Their interest has created momentum because their goals have fairly broad bipartisan support even amid a bitterly divided Congress in which lawmakers from both sides of the aisle focused on the issue last year.
It’s likely to be a pitched battle because the food industry wields immense political influence and has successfully thwarted previous efforts to regulate its products or marketing. The category of “food processing and sales companies,” which includes Tyson Foods and Nestle SA, tallied $26.7 million in spending on lobbying in 2024, according to OpenSecrets. That’s up from almost $10 million in 1998.
“They have been absolutely instrumental and highly, highly successful at delaying any regulatory effectiveness in America,” said Laura Schmidt, a health policy professor at the University of California-San Francisco. “It really does feel like there needs to be a moment of reckoning here where people start asking the question, ‘Why do we have to live like this?’”
“Ultra-processed food” is a widely used term that means different things to different people and is used to describe items ranging from sodas to many frozen meals. These products often contain added fats, starches, and sugars, among other things. Researchers say consumption of ultra-processed foods is linked — in varying levels of intensity — to chronic conditions like diabetes, cancer, mental health problems, and early death.
Nutrition and health leaders are optimistic that a reckoning is already underway. Kennedy has pledged to remove processed foods from school lunches, restrict certain food additives such as dyes in cereal, and shift federal agricultural subsidies away from commodity crops widely used in ultra-processed foods.
The intensifying focus in Washington has triggered a new level of interest on the legal front as lawyers explore cases to take on major foodmakers for selling products they say result in chronic disease.
Bryce Martinez, now 18, filed a lawsuit in December against almost a dozen foodmakers such as Kraft Heinz, The Coca-Cola Co., and Nestle USA. He developed diabetes and non-alcoholic fatty liver disease by age 16, and is seeking to hold them accountable for his illnesses. According to the suit, filed in the Philadelphia Court of Common Pleas, the companies knew or should have known ultra-processed foods were harmful and addictive.
The lawsuit noted that Martinez grew up eating heavily advertised, brand-name foods that are staples of the American diet — sugary soft drinks, Cheerios and Lucky Charms, Skittles and Snickers, frozen and packaged dinners, just to name a few.
Nestle, Coca-Cola, and Kraft Heinz didn’t return emails seeking comment for this article. The Consumer Brands Association, a trade association for makers of consumer packaged goods, disputed the allegations.
“Attempting to classify foods as unhealthy simply because they are processed, or demonizing food by ignoring its full nutrient content, misleads consumers and exacerbates health disparities,” said Sarah Gallo, senior vice president of product policy, in a statement.
Other law firms are on the hunt for children or adults who believe they were harmed by consuming ultra-processed foods, increasing the likelihood of lawsuits.
One Indiana personal injury firm says on its website that “we are actively investigating ultra processed food (UPF) cases.” Trial attorneys in Texas also are looking into possible legal action against the federal regulators they say have failed to police ultra-processed foods.
“If you or your child have suffered health problems that your doctor has linked directly to the consumption of ultra-processed foods, we want to hear your story,” they say on their website.
Meanwhile, the FDA on Jan. 14 announced it is proposing to require a front-of-package label to appear on most packaged foods to make information about a food’s saturated fat, sodium, and added sugar content easily visible to consumers.
And on Capitol Hill, Sens. Bernie Sanders (I-Vt.), Ron Johnson (R-Wis.), and Cory Booker (D-N.J.) are sounding the alarm over ultra-processed food. Sanders introduced legislation in 2024 that could lead to a federal ban on junk food advertising to children, a national education campaign, and labels on ultra-processed foods that say the products aren’t recommended for children. Booker cosigned the legislation along with Sens. Peter Welch (D-Vt.) and John Hickenlooper (D-Colo.).
The Senate Committee on Health, Education, Labor and Pensions held a December hearing examining links between ultra-processed food and chronic disease during which FDA Commissioner Robert Califf called for more funding for research.
Food companies have tapped into “the same neural circuits that are involved in opioid addiction,” Califf said at the hearing.
Sanders, who presided over the hearing, said there’s “growing evidence” that “these foods are deliberately designed to be addictive,” and he asserted that ultra-processed foods have driven epidemics of diabetes and obesity, and hundreds of billions of dollars in medical expenses.
Research on food and addiction “has accumulated to the point where it’s reached a critical mass,” said Kelly Brownell, an emeritus professor at Stanford who is one of the editors of a scholarly handbook on the subject.
Attacks from three sides — lawyers, Congress, and the incoming Trump administration, all seemingly interested in taking up the fight — could lead to enough pressure to challenge Big Food and possibly spur better health outcomes in the U.S., which has the lowest life expectancy among high-income countries.
“Maybe getting rid of highly processed foods in some things could actually flip the switch pretty quickly in changing the percentage of the American public that are obese,” said Robert Redfield, a virologist who led the Centers for Disease Control and Prevention during the previous Trump administration, in remarks at a December event hosted by the Heritage Foundation, a conservative think tank.
Claims that Big Food knowingly manufactured and sold addictive and harmful products resemble the claims leveled against Big Tobacco before the landmark $206 billion settlement was reached in 1998.
“These companies allegedly use the tobacco industry’s playbook to target children, especially Black and Hispanic children, with integrated marketing tie-ins with cartoons, toys, and games, along with social media advertising,” Rene Rocha, one of the lawyers at Morgan & Morgan representing Martinez, told KFF Health News.
The 148-page Martinez lawsuit against foodmakers draws from documents made public in litigation against tobacco companies that owned some of the biggest brands in the food industry.
Similar allegations were made against opioid manufacturers, distributors, and retailers before they agreed to pay tens of billions of dollars in a 2021 settlement with states.
The FDA ultimately put restrictions on the labeling and marketing of tobacco, and the opioid epidemic led to legislation that increased access to lifesaving medications to treat addiction.
But the Trump administration’s zeal in taking on Big Food may face unique challenges.
The ability of the FDA to impose regulation is hampered in part by funding. While the agency’s drug division collects industry user fees, its division of food relies on a more limited budget determined by Congress.
Change can take time because the agency moves at what some critics call a glacial pace. Last year, the FDA revoked a regulation allowing brominated vegetable oil in food products. The agency determined in 1970 that the additive was not generally recognized as safe.
Efforts to curtail the marketing of ultra-processed food could spur lawsuits alleging that any restrictions violate commercial speech protected by the First Amendment. And Kennedy — if he is confirmed as HHS secretary — may struggle to get support from a Republican-led Congress that champions less federal regulation and a president-elect who during his previous term served fast food in the White House.
“The question is, will RFK be able to make a difference?” said David L. Katz, a doctor who founded True Health Initiative, a nonprofit group that combats public health misinformation. “No prior administration has done much in this space, and RFK is linked to a particularly anti-regulatory administration.”
Meanwhile, the U.S. population is recognized as among the most obese in the world and has the highest rate of people with multiple chronic conditions among high-income countries.
“There is a big grassroots effort out there because of how sick we are,” said Jerold Mande, who served as deputy undersecretary for food safety at the Department of Agriculture from 2009 to 2011. “A big part of it is people shouldn’t be this sick this young in their lives. You’re lucky if you get to 18 without a chronic disease. It’s remarkable.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Subscribe to KFF Health News’ free Morning Briefing.
This article first appeared on KFF Health News and is republished here under a Creative Commons license.
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The Calorie Myth – by Jonathan Bailor
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First we’ll mention: the author is not a doctor, but the book is endorsed by assorted well-known doctors in the field, and the science described is consistent with current scientific consensus (and, for that matter, consistent with what we wrote in our mythbusting feature: Are You A Calorie-Burning Machine?).
It’s often (correctly) said that “not all calories are created equal”, but how should we quantify them? He proposes his “SANE solution”, which is based around the ideas of:
- Satiety: how quickly calories fill us up
- Aggression: how likely calories are to be stored as fat
- Nutrition: how many micronutrients calories bring with them, and how much
- Efficiency: how easily calories are converted
To this end, he recommends a diet high in foods that score well on his “SANE” factors, and provides such things as recipes, meal plans etc to help, as well principles for exercising more usefully in the context of metabolic base rate, and moving (rather than fighting) one’s “set point”, which is usually associated with one’s weight but it really has more to do with metabolic base rate. In fact, Bailor recommends throwing out the bathroom scale and focusing on pursuing good health itself, rather than obsessing over changing one’s relationship with the Earth’s gravitational field.
Yes, it says “lose weight” in the subtitle, but the idea is that this will be a by-product rather than the thing actively pursued. After all, we can control our actions, so that input variable is where we should put our focus, not the output variable of the numbers on the scale which can often be misleading (muscle weighing more than fat, tendency to water weight fluctuations, etc).
The style is a little flashy and salesy for this reviewer’s personal taste (a lot of references to his own businesses and neologisms associated with such), but it doesn’t take away from the quality of the content, and in terms of science, study references come at a rate of about one per page on average.
Bottom line: if you’d like to rethink your relationship with calories, then this book can help give you a much more practical angle.
Click here to check out The Calorie Myth, and take control of your metabolic base rate!
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Everything You Need To Know About The Menopause – by Kate Muir
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Kate Muir has made a career out of fighting for peri-menopausal health to be taken seriously. Because… it’s actually far more serious than most people know.
What people usually know:
- No more periods
- Hot flushes
- “I dunno, some annoying facial hairs maybe”
The reality encompasses a lot more, and Muir covers topics including:
- Workplace struggles (completely unnecessary ones)
- Changes to our sex life (not usually good ones, by default!)
- Relationship between menopause and breast cancer
- Relationship between menopause and Alzheimer’s
“Wait”, you say, “correlation is not causation, that last one’s just an age thing”, and that’d be true if it weren’t for the fact that receiving Hormone Replacement Therapy (HRT) or not is strongly correlated with avoiding Alzheimer’s or not.
The breast cancer thing is not to be downplayed either. Taking estrogen comes with a stated risk of breast cancer… But what they don’t tell you, is that for many people, not taking it comes with a higher risk of breast cancer (but that’s not the doctor’s problem, in that case). It’s one of those situations where fear of litigation can easily overrule good science.
This kind of thing, and much more, makes up a lot of the meat of this book.
Hormonal treatment for the menopause is often framed in the wider world as a whimsical luxury, not a serious matter of health…. If you’ve ever wondered whether you might want something different, something better, as part of your general menopause plan (you have a plan for this important stage of your life, right?), this is a powerful handbook for you.
Additionally, if (like many!) you justifiably fear your doctor may brush you off (or in the case of mood disorders, may try to satisfy you with antidepressants to treat the symptom, rather than HRT to treat the cause), this book will arm you as necessary to help you get what you need.
Grab your copy of “Everything You Need To Know About The Menopause” from Amazon today!
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Hazelnuts vs Pistachios – Which is Healthier?
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Our Verdict
When comparing hazelnuts to pistachios, we picked the hazelnuts.
Why?
An argument could be made for either, depending on what we prioritize! So there was really no wrong answer here today, but it is good to know what each nut’s strengths are:
In terms of macros, pistachios have more fiber, carbs, protein, and (mostly healthy) fat. That does make them the “more food per food” option, but it’s worth noting that while hazelnuts have more fiber, they also have a higher margin of difference when it comes to their greater carb count, and resultantly, hazelnuts do have the lower glycemic index. That said, they’re still both low-GI foods, so we’ll call this section a win for pistachios overall.
When it comes to vitamins, hazelnuts have more of vitamins B3, B5, B9, C, E, K, and choline, while pistachios have more of vitamins A, B1, B2, and B6. So, a fair 7:4 win for hazelnuts here.
In the category of minerals, hazelnuts have more calcium, copper, iron, magnesium, manganese, and zinc, while pistachios have more phosphorus, potassium, and selenium. A clear 6:3 win for hazelnuts.
In short, both are good sources of many nutrients, so choose according to what you want to prioritize, or better yet, enjoy both.
Want to learn more?
You might like to read:
Why You Should Diversify Your Nuts
Take care!
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Heart Attack: His & Hers (Be Prepared!)
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Heart attack symptoms vary by sex. This is governed by hormones, so if you are for example a postmenopausal woman and not on HRT, your symptoms might be nearer that of men.
The following symptom list is intended as a rough “most likely” guide. You may not get all of the symptoms you “should”. You could get symptoms from the “wrong” category. So don’t sweat the minutiae, but do be aware of…
Symptoms for everyone:
- Jaw, neck, and/or back pain
- Nausea and/or vomiting
- Shortness of breath
- Feeling of impending doom ← heart attack survivors assure us that you’ll know this one if you experience it
Additional symptoms (mostly) just for men:
- Pressure and/or pain in the upper chest
- Discomfort and/or tingling in the arms
- Sudden cold sweat
Additional symptoms (mostly) just for women:
- Pressure and/or pain in the lower chest and/or abdomen
- Feeling of fullness and/or indigestion
- Fatigue, dizziness, possibly fainting
In the event of experiencing symptoms…
Call 911 or your local equivalent.This is not the time to wait to see if it goes away by itself. If unsure, call. Better safe than sorry/dead.
If you are not alone, or if it is someone with you who is having the suspected heart attack, it may be quicker to go to the Emergency Room by car, than wait for an ambulance.
Even if you choose to do that, you should still call 911 anyway, as the responder will be able to instruct you in real-time, not something we can do in a newsletter.
Note that if available, this means three people in the car is ideal:
Driver, patient, and third person on the phone giving information and following instructions.
Emergency situations rarely go entirely by-the-book, but with a little foreknowledge and at least one person with a calm head, preventable deaths can be avoided.
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Sleep Tracking, For Five Million Nights
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5 Sleep Phenotypes, By Actual Science
You probably know people can be broadly divided into “early birds” and “night owls”:
Early Bird Or Night Owl? Genes vs Environment
…and then the term “hummingbird” gets used for a person who flits between the two.
That’s three animals so far. If you read a book we reviewed recently, specifically this one:
The Power of When – by Dr. Michael Breus
…then you may have used the guide within to self-diagnose your circadian rhythm type (chronotype) according to Dr. Breus’s system, which divides people into bears, lions, wolves, and dolphins.
That’s another four animals. If you have a FitBit, it can “diagnose” you with being those and/or a menagerie of others, such as giraffe, hedgehog, parrot, and tortoise:
How Fitbit Developed the Sleep Profile Experience (Part 2 – Sleep Animals)
Five million nights
A team of researchers recently took a step away from this veritable zoo of 11 different animals and counting, and used a sophisticated modelling system to create a spatial-temporal map of people’s sleep habits, and this map created five main “islands” that people’s sleep habits could settle on, or sometimes move from island to island.
Those “five million nights” by the way? It was actually 5,095,798 nights! You might notice that would take from the 2020s to the 15970s to complete, so this was rather a matter of monitoring 33,152 individuals between January and October of the same year. Between them, they got those 5,095,798 nights of sleep (or in some cases, nights of little or no sleep, but still, they were there for the nights).
The five main phenotypes that the researchers found were:
- What we think of as “normal” sleep. In this phenotype, people get about eight hours of uninterrupted sleep for at least six days in a row.
- As above for half the nights, but they only sleep for short periods of time in bouts of less than three hours the other half.
- As per normal sleep, but with one interrupted night per week, consisting of a 5 hour sleep period and then broken sleep for a few more hours.
- As per normal sleep generally, but with occasional nights in which long bouts of sleep are separated by a mid-sleep waking.
- Sleeping for very short periods of time every night. This phenotype was the rarest the researchers found, and represents extremely disrupted sleep.
As you might suspect, phenotype 1 is healthier than phenotype 5. But that’s not hugely informational, as the correlation between getting good sleep and having good health is well-established. So, what did the study teach us?
❝We found that little changes in sleep quality helped us identify health risks. Those little changes wouldn’t show up on an average night, or on a questionnaire, so it really shows how wearables help us detect risks that would otherwise be missed.❞
More specifically,
❝We found that the little differences in how sleep disruptions occur can tell us a lot. Even if these instances are rare, their frequency is also telling. So it’s not just whether you sleep well or not – it’s the patterns of sleep over time where the key info hides❞
…and, which gets to the absolute point,
❝If you imagine there’s a landscape of sleep types, then it’s less about where you tend to live on that landscape, and more about how often you leave that area❞
In other words: if your sleep pattern is not ideal, that’s one thing and it’d probably be good to address it, by improving your sleep. However, if your sleep pattern changes phenotype without an obvious known reason why, this may be considered an alarm bell warning of something else that needs addressing, which may be an underlying illness or condition—meaning it can be worthwhile being a little extra vigilant when it comes to regular health screenings, in case something new has appeared.
Want to read more?
You can read the paper in full here:
Five million nights: temporal dynamics in human sleep phenotypes
Take care!
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