Constipation is a topic that I really don’t think people talk about enough.

There seems to be a misconception going around, where people think the body “naturally knows what to do” and you should let it move along at its natural pace.

The reality is that our diets have drastically changed over the last hundreds and thousands of years. Our ancestors used to eat up to 100 grams of fiber a day. Today, most people are lucky if they reach 20 grams.

As a doctor, I am biased because I’ve consistently seen the worst of the worst, but I want to give you three examples that really help exemplify my point.

Constipation Can Become an Emergency

Example 1:

I once saw the case of a woman who suffered with chronic constipation and, after having a back injury, was given opioids, which are known to slow down the bowels and cause severe constipation.

She became so impacted that it actually caused a rupture of her intestines, and she nearly died. After emergency surgery and resuscitation, she survived, but now lives with an ostomy.

Example 2:

The next is actually a very common occurrence in the hospital, where there is this phenomenon called delirium.

It is essentially an acute brain injury in older people with vulnerable brains, where they can go from perfectly normal to suddenly completely disoriented, confused, and sometimes incredibly agitated and even a risk to themselves and others. In many cases, the main cause is actually constipation.

You treat the constipation, and they dramatically improve.

Example 3:

Third, hemorrhoids have caused dramatic quality-of-life impairments in many patients I’ve seen, with chronic pain, itching, burning, and discomfort. Chronic constipation with straining and hard stools seems to damage cushions of the anal canal, leading to hemorrhoids.

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Some Lesser-Known Consequences of Constipation

Additionally, here are some lesser-known facts about constipation that people don’t know — to help convince you of the importance of treating it properly.

• Several studies have linked reduced bowel movement frequency with worse cognition.

  • There is even experimental evidence in which giving triathletes magnesium supplementation to induce a bowel movement acutely improves cognitive performance.

Forget online nootropic pills, the first thing you should be doing for your brain is making sure you’re staying healthy and having regular bowel movements.

• Constipation has also been associated with a higher risk of stroke in observational studies.

• In large observational studies, the more fiber people eat, the lower their risk of death.

• Perforation of the bowel from severe fecal impaction has been associated with mortality of around 34%.

• People consistently report worse quality of life when they are chronically constipated.

• Constipation can also cause anal fissures, where hard stools tear the lining of the anus.

• If it gets severe enough, you can get something called fecal impaction, and this actually is not uncommon in the hospital. In some cases where medication won’t work, a healthcare professional may have to manually break it up and pull it out with a gloved finger.

So Many People Are Constipated

I remember throughout medical school and internal medicine residency, I would consistently see abdominal X-rays showing significant stool burden in people in hospital.

Sure, this is a much sicker population if you’re in hospital, but overall, in general, our society does not support optimal gut health.

And I think a lot of people get inadequate advice here.

Even when I was a medical student rotating through different doctors’ offices, the consistent advice being given was quite literally just:

“Eat more fruits and veggies” or “exercise more” or “drink more fluids”

It’s probably partly the result of a busy healthcare system, but this advice is unfortunately lacking.

Despite recommended fiber intake being up to around 38 g a day for men and 25 g a day for women, depending on age, many people don’t even get close to this.

What Is Wrong With “Fruit and Veggies” Advice?

Let’s say people take this advice to heart and start eating more fruits and veggies.

Let’s say they decide to eat an extra apple and a cup of broccoli.

Some apples really only have a few grams of fiber, and you would need to eat many of them to reach your daily recommended amount from apples alone. Not to mention all the extra sugar if these are being added, and not replacing low-fiber foods.

A cup of broccoli, on the other hand, also only has a few grams of fiber.

Go to McDonald’s and get a Big Mac, for example, and there is only about 3 grams of fiber.

So the problem is that even if you add a little extra fiber to your diet, the proportion of fiber relative to the rest of your low-fiber food can still be a challenge for your gut. Ideally, you want each meal to contain at least some fiber to help keep things moving.

The reality is that in an ideal world, people’s diets would be designed to support optimal gut health, but that’s unfortunately not a common reality (and also not practical in the world most of us live in).

Rather than asking you to rebuild your entire diet, here is the practical and easy framework I use (that takes no extra time out of your day):

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During my third year of medical school, I was taking care of a patient recovering from a heart attack. Despite having spent weeks meticulously studying cardiovascular disease, one of my mentors asked me a simple question I couldn’t answer: “Why do some people with plaque have heart attacks while others don’t?”

I thought about it. “Cholesterol? Stress? Inflammation? Genetics?”

“Many people,” he continued, “live their entire lives with significant plaque buildup and never have a heart attack. Others have relatively modest atherosclerosis that suddenly ruptures. We understand several risk factors, but we still can’t fully explain why plaques rupture when they do.”

He paused. “Is there something else we’re missing? Could it even be infectious?”

That conversation stayed with me. Now, a new study published in the Journal of the American Heart Association suggests my mentor might have been onto something.

Researchers found that viridans streptococci—a group of oral bacteria commonly found in your mouth—colonize atherosclerotic plaques as biofilms and may contribute to plaque rupture and heart attacks.

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The Oral Health-Heart Disease Connection Was Already Clear

Before diving into this new study, it’s important to understand that the link between oral health and cardiovascular disease is already well-established. The evidence has been building for decades:

Poor dental health significantly increases cardiovascular disease risk:

• In 1993, periodontal disease was associated with a 25% increased risk of coronary heart disease

• A recent umbrella review identified a 14% to 188% higher risk of cardiovascular disease in those with periodontal disease

Improved oral hygiene is associated with reduced cardiovascular risk:

• One extra daily tooth brushing session is associated with a 9% reduction in the risk of cardiovascular events

• Receiving yearly professional dental cleanings is linked to a 14% risk decrease

• Daily flossing is linked to a 29% reduction in cardiovascular disease prevalence compared to those who do not floss, with each additional day of flossing further lowering risk

What we didn’t know until now was how oral bacteria might be causing heart attacks. This new study provides a potential answer.

What They Found

The research team analyzed atherosclerotic plaques from:

• Sudden cardiac death victims (autopsy)

• Patients undergoing carotid and peripheral artery surgery

Key Findings:

• Viridans streptococcal DNA was detected in approximately 42% of atherosclerotic plaques

• The biofilm was not detected by macrophages of the innate immune system, which are designed to kill the bacteria

  • When the streptococci dispersed from the biofilm, they were detected by macrophages and attacked

• Streptococcal immunopositivity correlated with atherosclerosis severity

How Bacterial Biofilms May Contribute to Plaque Rupture

Here is The Proposed Mechanism:

1. Bacterial Translocation

   • Poor oral hygiene and periodontal disease increase the risk for oral bacteria to enter the bloodstream

   • This can occur during dental procedures, tooth brushing, flossing, or even chewing

   • Viridans streptococci in the bloodstream then enter atherosclerotic plaques

2. Biofilm Formation

   • Viridans streptococci colonize the atheroma as a biofilm

   • The biofilm releases substances that prevent immune recognition

   • Bacteria remain dormant in regions not labeled by immune cell markers

3. Bacterial Dispersal

   • Triggered by unknown factors (possibly respiratory infections, stress, limited nutrition)

   • Virulent bacteria are released from the biofilm

   • These bacteria then become detectable by immune cells

4. Immune Activation

   • Macrophages detect and engulf the dispersed bacteria

   • This triggers an inflammatory reaction in an effort to kill the bacteria

5. Potential Plaque Rupture

   • Inflammatory reactions erode the fibrous cap of atheromas

   • The weakened cap is then more likely to rupture, leading to thrombosis and MI (heart attack)

Limitations

There are a few important limitations worth mentioning:

• Cross-sectional associations cannot prove biofilms cause rupture: temporality and causation remain unclear

• Detection of bacterial DNA and antigens doesn’t definitively confirm viable bacteria or live biofilm architecture

This is hypothesis-generating human tissue evidence that viridans streptococci are present in plaques and may contribute to inflammation and rupture. It does not causally establish that oral bacteria cause heart attacks.

What To Do About This

The evidence is not clear-cut enough to say that brushing and flossing directly prevent heart attacks. But the association is strong, the mechanism is plausible, and better oral hygiene has almost no downside. So why wait for perfect proof?

Here is what I do:

• Brush your teeth at least twice a day

• Floss every day, ideally after every meal (I use dental picks when I am out of the house)

• Schedule dental cleanings annually, ideally twice yearly

  • Listen to your dentist’s recommendations and don’t delay the procedures they suggest (untreated infections may increase bacteremia risk)

Traditional Cardiovascular Prevention Remains Essential:

• Lipid management

• Blood pressure control

• Smoking cessation

• Regular exercise and healthy diet

• Anti-inflammatory strategies are promising but not yet routine

Bottom Line

My mentor’s question from years ago—why do some people have heart attacks while others don’t—may have a partial answer: chronic bacterial infections hiding inside atherosclerotic plaques.

This study provides evidence that oral bacteria may colonize atherosclerotic plaques as biofilms—often escaping detection by immune markers—and intermittently disperse more virulent cells that could drive inflammation and promote plaque rupture. However, confirmation and causal proof will require further studies.

Combined with decades of observational research linking dental disease and increased cardiovascular risk, the connection between your mouth and your heart warrants serious attention.

The good news? Oral hygiene is modifiable. So if you are not on top of your oral health yet, get on it today.

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This newsletter is for educational purposes only. It is not personal medical advice. Always consult your own health-care provider for medical guidance.

But exams, and life, also teach you that it’s important to know the rare signs as well.

Here’s a running list of the most bizarre ways I’ve seen and studied cancer present in people. As a general disclaimer, having one of these does not guarantee that you have cancer, but it may be a warning sign worth checking with your doctor.

Here are some that stuck with me most from my training.

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1. Pain minutes after drinking alcohol

This one almost seems made up, but I’ve seen it myself. In some cases of Hodgkin lymphoma, alcohol can trigger pain at the site of a cancerous lymph node.

The above image is from a real case report involving a 32-year-old man who kept developing chest pain a few minutes after even small amounts of alcohol. About six weeks later, he developed a lesion between his ribs which triggered a workup and he was diagnosed with Hodgkin lymphoma.

The scan above is from his case and shows bulky cancerous mediastinal lymph nodes (top image). Thankfully, they responded to treatment (bottom image).

2. The Leser-Trélat sign

Most people are familiar with seborrheic keratoses, which are classically described as waxy, “stuck-on” skin growths.

In certain gastrointestinal and other cancers, there can be a massive eruption of many of these at once. This is known as the Leser-Trélat sign.

I should note that this one is slightly more controversial these days, but it still shows up in medical textbooks and exams.

3. A positive pregnancy test, in a man

The way pregnancy tests work is by detecting hCG, which is produced by the developing placenta. While it is not normally present at high levels in a male body, certain testicular cancers can actually produce enough hCG to make a pregnancy test positive (this is not the case for all testicular cancers, only certain types).

4. Clubbing

Clubbing is one of medicine’s oldest physical signs, described as far back as Hippocrates.

The fingertips enlarge and the nails become increasingly curved and convex. Why it happens remains not entirely clear.

There are many causes of clubbing, but new unexplained clubbing can be a clue to lung disease, including cancer.

5. A droopy eyelid with a small pupil

Horner syndrome is a classic sign in medicine characterized by three key features: a droopy eyelid, a constricted pupil, and reduced sweating (ptosis, miosis, and anhidrosis) on one half of the face.

This is a sign that the nerve supply to one half of the face is not working properly. Classically, a large cancer growing in the lung, such as a Pancoast tumor, can disrupt this nerve pathway and cause it to malfunction in this pattern. It is also not uncommon for people to have arm and shoulder pain.

6. Peau d’orange

Peau d’orange is French for “orange peel skin.”

In inflammatory breast cancer, cancer cells can block lymphatic drainage from the breast. This essentially causes fluid to back up and can create a characteristic orange-peel appearance of the skin. The breast can also become red, hot, and swollen.

7. Suddenly growing fine “baby hair”

The rapid growth of fine, long, non-pigmented hair can sometimes be a sign of acquired hypertrichosis lanuginosa.

This is very rare, and the exact mechanism is unknown, but it can be a sign of a malignancy that is likely sending hair-growth signals throughout the body.

8. The Sister Mary Joseph nodule

A new lump in the belly button can be a sign of metastatic cancer that has spread from somewhere, often the gastrointestinal or gynecologic system.

This association was actually recognized by Sister Mary Joseph Dempsey, who was working as a surgical assistant and noticed it in patients undergoing abdominal surgery.

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This newsletter is for educational purposes only and is not medical advice. Always seek your own health-care provider for guidance before using this information if you have health conditions.

We’ve all been there. You’re having a good morning. Things are going well and feeling productive. And then you sit down for a quick lunch.

Then like clockwork, your focus starts to slip, eyelids start to feel heavy, head starts to nod, and you start crashing.

Most people blame the blood sugar crash after lunch for this, but that’s only a small part of the picture.

What’s interesting is that this “afternoon slump” is an almost universal phenomenon. Several animals, and even insects, experience the same dip. Even fruit flies have an afternoon siesta.

I was recently interviewed by GQ on why this happens, and what exactly to do about it. You can find the article here. Today I wanted to do even more of a deep-dive, with the exact protocols I have researched and found to be helpful.

The Afternoon Slump Has a Strong Circadian Component

Universally, no matter what people eat, they all still tend to get sleepy in the afternoon (this even tends to happen if people eat nothing and don’t pay attention to the time).

A lot of this seems to boil down to our circadian rhythms. Let’s start with a little bit of physiology. There are two specific processes that determine how awake you tend to feel at a certain time:

• Process S (sleepiness): This is sleep pressure, and essentially continues to build throughout the day, the longer you stay awake.

• Process C (circadian): This is your circadian rhythm, which runs on a ~24-hour cycle that peaks in alertness at different times, no matter how much you’ve slept. That’s why even if you pull an all-nighter, you still get a morning boost in alertness at around the time you typically wake up.

The afternoon slump is when process S and process C converge into a sort of perfect combination of sleepiness. While process S has been accumulating for around 8 hours, process C tends to succumb to a natural afternoon dip in alertness before ramping up again in the evening.

So now that we know how it works, let’s go over the evidence on how to combat it.

How to Combat the Afternoon Slump

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We’ve all been taught to wash our hands. They’re in constant contact with germs, dirt, and every surface we touch. One of the main ways we get sick is when we touch our mouth, nose, and eyes with hands that deliver these bugs there for us. So if you think about it, hand washing was never really about the hands. It’s about what the hands reach.

Which raises an important question. The nose and mouth is where most respiratory viruses land first. The common cold, COVID, RSV, they all typically take hold on the mucous membranes of the nose and mouth, sometimes the eyes, and start replicating there before you feel anything.

So if the whole point of washing our hands is to keep viruses out of the nose and mouth, why do we stop at the hands?

Here are some important reasons nasal saline lavage deserves a place beside hand washing.

Colds get shorter and spread less

In a fascinating (but small) randomized trial, adults were instructed to start rinsing and gargling with salt water within 48 hours of a cold. The results were remarkable:

• Colds recovered on average 1.9 days faster

• People used 36% less over-the-counter medications

• Spread of the virus between household contacts was reduced by 35%

The reduced transmission is incredible and makes mechanistic sense. If there’s less virus in your nose, it’s less likely to spread to others and therefore less likely to get others sick. So you’re actually doing other people in your house a favor.

What about long term use?

Another study instructed ~14,000 adults to use nasal sprays when they started to feel a cold coming on or in situations they were likely to get sick. Then they tracked them to monitor the rate of infections. Average total days sick was significantly reduced from ~8.2 days in the usual care group to ~6.4 days on average in the nasal spray group.

So how does it actually work?

1. It physically washes out bad stuff

This is the intuitive mechanism. Rinsing out the nasal passageway removes germs, pollen, and other particles. Even more importantly, you might be washing out inflammatory cells causing problems.

In a study of 30 patients with allergic rhinitis, nasal saline irrigation reduced markers of inflammation as early as 30 minutes. It has been consistently useful for allergies across studies, with one meta-analysis demonstrating an average 28% reduction in symptoms, 62% reduction in medication use, and 28% improvement in quality of life.

2. It might feeds your nose’s own bleach factory

This is one of the most interesting possible mechanisms.

One way your immune cells kill microbes is by producing hypochlorous acid, which is similar to the active compound in household bleach.

A breaking study in 2018 identified that cells in the body are, in fact, able to make hypochlorous acid, which has antiviral properties, and they make more of it when they’re provided with salt.

So the chloride itself from the nasal rinsing may serve as a building block to the body to help fight off viruses. However, it’s worth mentioning that these studies are still from the lab, and we need more experimental human evidence.

3. It speeds up airway clearance

Your airway is lined with cilia, which are microscopic hairs that beat in coordinated waves to sweep mucus and particles out of the lungs.

Illness and inflammation slow it down. Saline seems to speed it back up. In one laboratory study, normal saline improved clearance time by ~24% and hypertonic saline by ~40%. While this might not directly translate to viruses, the mechanism fits.

Faster clearance means less time for a virus sitting in your nose to replicate and spread.

Options to choose from

There are three main ways to use nasal saline rinses:

1. Neti pot/squeeze bottle

   

   1. This is the cheapest and most tried and true method. In a perfect world, I would suggest using this twice a day, but it does take a bit of maintenance. I currently use it mostly when I am sick, have allergies, or know I had an exposure to someone sick.

2. Saline sprays

   

   1. You can also get pre-compressed saline in bottles, or simply a saline spray. I find these really great for traveling or when I’m busy, but they are expensive and don’t clean the entire nasal passage. I usually just keep one in the shower and use it after work to rinse out my nose. I’ve found it has really reduced the amount of times I get sick and my spring allergies.

3. Powered irrigators

   

   1. You can also get electrically powered nasal irrigators if you have the money. I have never been able to justify the cost, and use the other two methods above myself.

In general, I would say start with the compressed spray because it’s very easy. But if you have time, or you’re noticing spring allergies, then an investment into the Neti pot or squeeze bottle would be worth it.

Now here’s the one golden rule of nasal saline lavage: NEVER use tap water. There’s a very low, but real risk that certain organisms can live in tap water, and one woman did die from a brain infection from this. Distilled water is typically very cheap and should be the only thing you ever use.

I hope you found this interesting. Here are some other similar posts:

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This newsletter is for educational purposes only and is not medical advice. Always seek your own health-care provider for guidance before using this information if you have health conditions.

Today’s most popular health tips constantly seem to require people to add even more to their already packed schedules. More exercise, more classes, or even longer, more drawn-out morning routines.

While in general there are few shortcus in life, some health practices truly require minimal time and effort investment compared to the benefits, and in this post I want to cover 10 of them.

1. Stand on one leg when brushing your teeth

Balance is one of the vital signs that we often ignore until we lose it. In a cohort of 1,702 adults aged 51 to 75 (Araujo et al. 2022), those who could not maintain a one-legged stand for 10 seconds had almost a two-fold risk of dying in the following 7 years, irrespective of their age and other risk factors. While this does not imply causation, the importance of maintaining balance cannot be overstated (I can’t even count the number of times I’ve assessed geriatric patients who have fallen and hurt themselves).

To get better balance, practice standing on one leg for 1-2 minutes every day. When starting, feel free to hold the counter for support.

2. Ride the bus or subway without holding the pole

When I first moved to a big city, I was shocked by the amount of balance the subway took. Balance training reduced falls in older adults by 24% according to a Cochrane review (Sherrington et al. 2019).

One easy way to practice balance is on a subway or train (which most people are already taking). Stand with your body unsupported and your feet planted. Make small adjustments to maintain your balance. Hold onto the pole if you sense it is unsafe.

3. Suitcase carry your groceries

Grip strength and longevity have a strong relationship. In a study of almost 140,000 adults, a 5 kg decrease in grip strength was linked with a 16% increase in risk of death, which surpassed the predictive strength of systolic blood pressure (Leong et al. 2015). While the relationship is likely strongly correlative (with grip strength being a marker of overall strength and muscle mass), doing small tasks each day that improve overall strength is likely to add significant benefit.

A “suitcase carry,” holding several grocery bags in one arm, is great for grip and core strength. Alternate sides.

4. Walk for a few minutes after you eat

Blood sugar spikes can be substantially mitigated by walking after each meal (Buffey et al. 2022). Muscles rapidly uptake glucose, blunting the usual spike. Just 2 to 15 minutes after eating is highly effective.

5. Wall sit while you read or scroll

Wall sits are an awesome way to work isometric exercise into your daily routine. Isometric exercises, including wall sits, lower blood pressure more than aerobic or resistance exercises (by about 8/4 mmHg), and wall sits are the most effective of all the isometric exercises (Edwards et al. 2023).

Lean against a wall with your knees bent at 90 degrees. Hold it for as long as you can (and feel free to read or scroll). Aim for two to three rounds.

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By the time I see this pattern, it usually looks the same.

A patient with an addiction comes in exhausted, sleeping poorly, running on caffeine through the day and reaching for something to take the edge off at night.

A glass or three of wine. An edible. A sleeping pill.

They often do not think of themselves as having a problem. They think this is just how life feels now.

What struck me was how often addiction arrived with a body clock already in ruins: no morning anchor, no evening wind-down, and relief chased whenever the craving landed, most often late at night.

At first I assumed the substance was scrambling the clock. But the more I read, the more I started to wonder about the other direction. What if the broken clock was not just a side effect? What if circadian dysfunction was part of what made the addiction so hard to resist in the first place?

I recognized a small version of this in myself. During my internal medicine residency I worked 80 to 100 hour weeks, flipping between day and night shifts until my body had no idea what time it was. I noticed that even when I got a full eight hours of sleep, the more my schedule drifted, the more easily I slid into the easy stuff: scrolling for an hour, eating junk food, chasing whatever made the next hour feel better. Nothing dramatic. But the pull of those little habits got louder exactly when my sleep and routine was most wrecked. The worse the rhythm, the harder it was to stop.

That question, which direction the arrow actually points, is what sent me into the research.

1. Your reward system runs on a clock.

Dopamine is one of the main chemicals behind motivation, reinforcement, and craving. And the body’s clock genes appear to help tune it.

In mice, the core clock proteins control an enzyme that breaks dopamine down. Disrupt the clock gene Per2 and dopamine signaling in the brain’s reward regions shifts (Hampp et al., 2008). In humans, variations in the same PER2 gene have been linked to how much people drink.

The alcohol story is where it gets interesting.

In one landmark study, Per2-mutant mice drank more alcohol, and the reason was not taste, calories, or slower metabolism (Spanagel et al., 2005). The mutation lowered EAAT1, a transporter that normally helps the brain mop up excess glutamate, a key signaling chemical. Less cleanup left more glutamate pooling in reward-related regions, and that hyper-glutamate state seemed to make alcohol more reinforcing. The mice worked harder to get it. A craving medication used in human alcohol treatment, acamprosate, brought both the glutamate and the heavy drinking back down.

It seems that the system that keeps time and the system that drives reward are not separate machines. They share parts.

2. Night owls carry more risk, but it is not destiny.

A 2025 review pooled clinical studies and found that evening types had roughly 55% higher odds of being diagnosed with a substance use disorder than morning types, along with earlier onset and poorer treatment outcomes (Steardo et al., 2025).

In a separate lab study of 144 drinkers, people with later sleep timing got a bigger stimulating buzz from alcohol, the kind of response that tends to predict future problems (Hasler et al., 2019).

Eveningness travels with short sleep, late light, low mood, and more waking hours during the window when self-control is weakest. The problem is unlikely the chronotype in and of itself. The mismatch between the clock and society’s schedule is likely the main contributor.

3. Substances don’t just follow a broken clock. They break it further.

This is where the vicious cycle worsens. Alcohol is the obvious example. It can help you fall asleep faster, and may even make you feel like you slept better, but underneath that illusion, it fragments and worsens sleep. Opioids seem to be worse. In a 2025 study using wrist trackers, adults with opioid use disorder had markedly more irregular sleep-wake rhythms than healthy controls, and that irregularity was tied to a longer history of heroin use and to getting less daylight (Zhang et al., 2025). Autopsy studies of people who died with opioid use disorder show disrupted circadian signaling in the exact reward regions that drive addiction (Puig et al., 2023). We also have good evidence that light at night (e.g., from scrolling, games, shows) can disrupt the clock and make it harder to fall asleep.

And so the cycle continues. A wrecked clock makes the drug more tempting. Then the drug wrecks the clock further.

4. Adolescence is the worst possible timing.

If you wanted to design a brain set up to get hooked, you would build a teenager.

During adolescence, the body clock naturally shifts later and sleep pressure builds more slowly, making it easier for teens to stay up late just as early school start times force them out of bed too soon. That mismatch amplifies reward sensitivity and impulsivity at the same time, creating a peak opportunity for substance use to take hold (Logan et al., 2017). Sleep problems are already the norm here: across 18 studies and more than 120,000 teens, sleep disturbance showed up in about a third of adolescents who used substances (Phiri et al., 2023). The energy drinks they use to cope likely only dig the hole deeper.

5. Fixing the clock seems to help.

In a 2025 pilot study, 41 people in alcohol use disorder treatment were randomized to usual care or a plan that fixed consistent meal, wake, and sleep times (Springer et al., 2025). Over six weeks, about 12% of the structured group relapsed versus roughly 60% of controls: 3 drinking days between them, against 52.

In a 2026 trial, 104 young adults with internet gaming disorder got 14 days of bright light, placebo light, or cognitive training (Li et al., 2026). Bright light beat placebo and matched the training, cutting addiction severity, cravings, and withdrawal, with brain scans showing strengthened reward pathway wiring.

Both of these trials are small, but they both suggest the same thing: protecting the clock, with regular timing or light, can help with addictive behavior (but this is a lever, not a cure).

If you want practical how-to guides behind stabilizing and shifting your clock, I have written it up in detail here:

The bottom line

A few late nights will not give anyone an addiction, and addiction is far too complex to pin on the clock alone.

But the evidence is convincing. Clock genes influence reward systems. Night owls carry more risk. Addicted brains show disrupted rhythms. And steadying those rhythms seems to lower relapse and craving.

The move is not heroic willpower at midnight. It is to stabilize the day before trying to win the night.

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This newsletter is for educational purposes only. It is not personal medical advice. Opinions are my own. Always consult your own health-care provider for medical guidance.

If you spend time on social media, you have probably seen the claims: testosterone levels are crashing, an entire generation of men is being feminized, and the solution is a supplement, injection, or subscription promoted by someone with a discount code.

I have seen the fallout firsthand. Men convinced their fatigue must be “low T.” Men already on testosterone from an online platform without ever having a proper workup. Men with normal levels being sold a hormone they may stay on for years.

But I have also seen the other side: men with genuinely low testosterone whose lives meaningfully improved once they were properly diagnosed and treated under close medical supervision.

The reality is more nuanced than either camp would have you believe. Testosterone is not a scam, but it is not a shortcut every tired man needs. So I went deep into the research to answer the questions I get asked most: Are testosterone levels actually declining? Does it matter? And what can you actually do about it?

Quick primer: Testosterone is the primary male sex hormone, produced by the testes in response to signals from the pituitary gland. It plays a central role in:

• Sexual development and function

• Muscle mass and strength

• Bone density

• Red blood cell production

• Body composition

• Mood and energy

Production peaks in the early morning, declines throughout the day, and gradually decreases with age at a rate that varies depending on genetics, body composition, and overall health.

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Are Testosterone Levels Really Declining?

Maybe, but the story is more complicated than social media would have you believe.

In a landmark US cohort study, researchers tracked men across three waves from 1987 to 2004 and found a ~1% per year decline in total testosterone independent of age, obesity, or smoking. In age-matched comparisons, a man measured in the early 2000s had testosterone about 10% lower than a similar-aged man in the late 1980s. International studies have replicated this finding, with one Israeli study confirming the trend in over 102,000 men within a single healthcare system.

NHANES data (1999 to 2016) showed lower mean testosterone in later survey cycles among males aged 15 to 39, even after adjusting for BMI. And a 2025 systematic review of over one million men (1971 to 2024) confirmed the global trend, with a key finding: luteinizing hormone (the brain’s signal telling the testes to produce testosterone) is also declining. This points toward something happening at the level of the brain, not just the testes, and cannot be explained by rising obesity rates alone.

But here is where it gets interesting. A 2025 paper in Clinical Chemistry from a Yale research group identified a critical methodological concern with previous data. Between the 2003 to 2004 and 2011 to 2012 survey cycles, NHANES switched from the Roche Elecsys immunoassay to LC-MS/MS (liquid chromatography-tandem mass spectrometry). This is the gold-standard method, but it tends to read lower at the low end of the testosterone range compared to older immunoassays. The widely cited 300 ng/dL diagnostic threshold was originally derived using immunoassay data.

Here is what this means in practice: the percentage of healthy adult men with testosterone below 300 ng/dL appeared to nearly double, from about 12% to 22%, over a decade. But when they applied a lower cutoff of 264 ng/dL (which was specifically developed for modern LC-MS/MS assays), prevalence returned to approximately 11 to 14%, effectively eliminating most of the apparent increase.

Does this mean the decline is fake? Not necessarily. Even in past studies when researchers have held assay methodology constant, testosterone levels still seemed to decline even after accounting for age and body weight.

The bottom line: Testosterone decline appears real, but its magnitude may be overstated, amplified but not completely explained by rising obesity.

What Is Driving the Decline and the Conversation

Rising obesity is a major documented contributor: aromatase in fat increases testosterone-to-estradiol conversion, while adipose-related inflammation and metabolic signals are linked to suppressed gonadotropin output and reduced testicular steroidogenesis, creating a bidirectional cycle where weight gain lowers testosterone and low testosterone can favor further fat gain.

Endocrine-disrupting chemicals remain a concerning but unproven contributor. Phthalates seem to inhibit testosterone synthesis in Leydig cells, and NHANES data link urinary phthalate metabolites to decreased serum testosterone. The concomitant 52% decline in sperm concentration documented among Western men from 1973 to 2011 is consistent with widespread reproductive endocrine disruption, though population-level causation remains unproven.

The opioid epidemic and other medications may have created an under-recognized contributor. Opioid-induced androgen deficiency affects approximately 63% of male chronic opioid users. There is also limited but emerging data that other common medications (e.g., statins, SSRIs) may also be reducing testosterone levels.

Sleep deprivation at a population level matters. CDC data show 35% of US adults sleep fewer than 7 hours, a proportion that has increased over recent decades. As discussed below, just one week of short sleep can reduce testosterone by 10 to 15%.

But the conversation around testosterone has grown far louder than the biology alone would justify. Specifically, social media has amplified this further. A 2026 study in Social Science and Medicine analyzed 46 high-reach Instagram and TikTok posts promoting testosterone tests and treatments. The accounts behind these posts had a combined audience of 6.8 million followers and generated more than 650,000 likes.

None of the posts cited scientific evidence. 85% were published by individuals rather than health organizations, 67% included direct purchase links, and 72% had financial ties to testosterone products.

Why Testosterone Actually Matters

When testosterone is pathologically low and causing symptoms, the consequences are real: reduced libido, erectile dysfunction, muscle loss, low bone density, depressive symptoms, and unexplained anemia. But the Endocrine Society’s clinical practice guideline is clear that a low number on a lab test is not the same as having a disease. Guidelines require both confirmed low levels and consistent symptoms before diagnosing hypogonadism, and routine screening of the general population is explicitly recommended against.

If you get tested, do it right under the supervision of a medical doctor.

Testosterone does more than build muscle and drive libido. It also shapes mood, motivation, and perhaps even how honestly men behave.

Mood and Mental Health

• A meta-analysis of 27 RCTs (1,890 men) found testosterone treatment significantly reduced depressive symptoms, with effects present even in men with normal baseline levels.

• Men with treatment-resistant depression and low testosterone experienced significant improvement when testosterone gel was added to their existing antidepressant regimen.

Honest and Authentic Behavior

• In an RCT of 192 men, a single dose of testosterone eliminated the usual ‘audience effect’ on prosocial behavior, eliminating strategic prosociality when watched and consistent with reduced submission to audience expectations.

• A separate double-blind RCT found testosterone administration significantly reduced lying for financial gain, potentially through effects on pride and self-image.

What Actually Raises Testosterone

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Growing up, most of us were told all sorts of things. Feed a cold, starve a fever. Crack your knuckles and you’ll get arthritis. Don’t swim for an hour after eating. Some of it seemed to work, though it probably would have worked out anyway. Some of it did nothing. And a few of the things we got told are, honestly, bad for you.

Then there’s the small handful that actually hold up.

Home remedies matter to me. People have refined them over generations, they are cheap and usually low-risk, and the good ones genuinely help. So going through medical school, I kept a running list: which of the things we grew up being told have real evidence behind them, and which are just folklore wearing a lab coat.

These are 10 that stood the test of science, with the evidence behind each and the limits worth knowing.

1. Honey for a cough

A Cochrane review of 6 trials in 899 children found honey reduced cough frequency and severity better than no treatment and better than diphenhydramine (Benadryl), with little or no difference compared to the cough syrup dextromethorphan (Oduwole et al. 2018). One or two teaspoons before bed in hot tea is reasonable.

Note: never give honey under 12 months of age. This risks infant botulism.

2. Ginger for nausea

A meta-analysis of 13 trials in 1,174 pregnant women found ginger significantly reduced nausea severity versus placebo, and at least matched vitamin B6 (Hu et al. 2020). A systematic review and meta-analysis of surgical patients found it reduced postoperative nausea severity, vomiting, and rescue antiemetic use versus placebo (Zhu et al. 2021).

The usual dose is about 1 gram a day, split into about four doses.

And unfortunately ginger ale soda does not count. Most brands contain little real ginger and do not reliably deliver the dose studied in trials.

3. Peppermint for an stomach upset

Enteric-coated peppermint oil capsules beat placebo for irritable bowel syndrome (IBS) across 10 trials in 1,030 patients, with a number-needed-to-treat of 4 for overall symptoms and 7 for abdominal pain (Ingrosso et al. 2022).

The catch: it can cause heartburn, and the trials were small.

4. Prunes for constipation

In a head-to-head randomized trial, 50 grams of dried plums twice daily actually outperformed psyllium on the number of complete bowel movements and on stool consistency (Attaluri et al. 2011). The fiber plus sorbitol does the work.

Cheap, palatable, and a sensible first thing to try before laxatives.

5. Cranberry for recurrent UTIs

A 2023 Cochrane review pooled 50 trials and 8,857 people. Cranberry products cut the risk of symptomatic, culture-confirmed UTIs by 26% in women with recurrent infections, 54% in children, and 53% in those at risk of UTIs from an intervention (Williams et al. 2023).

Two cautions: it did not seem to help the elderly, pregnant women, or those with bladder-emptying problems, and it is prevention, not a treatment for an active infection.

6. Chicken noodle soup for a cold

In a lab study, chicken soup appeared to be anti-inflammatory and inhibited the movement of neutrophils (Rennard et al. 2000). However, we don’t have data to show that this translates to actually shortening a cold. What also probably helps is the hot fluid, steam, and salt which eases congestion and keeps you hydrated. But it’s a neat theoretical mechanism for getting better faster.

7. Aloe vera for minor burns

A 2024 meta-analysis of 9 randomized trials found aloe vera healed second-degree burns roughly 3.8 days faster than other topical treatments, with no increase in infection (Huang et al. 2024).

For a small, minor burn, it might be a reasonable option. Anything deep, large, or on the face or hands belongs in a clinic.

8. Oatmeal baths for eczema

In two small single-arm studies, a 1% colloidal oatmeal cream improved itch, eczema severity, skin hydration, and water loss over 14 days (Lisante et al. 2017).

It will not replace prescription treatment for more severe eczema, but for dry, itchy skin, it might be a low-risk add-on worth trying.

9. A warm bath or shower before bed for sleep

A meta-analysis of 13 studies found that a warm bath or shower at 40 to 42.5 degrees Celsius, taken 1 to 2 hours before bed, shortened the time to fall asleep and improved sleep quality (Haghayegh et al. 2019).

The mechanism is counterintuitive: warming the skin pulls heat out of the body’s core afterward, and that core temperature drop is what helps your body sleep better.

10. Vinegar drops for swimmer’s ear

Dilute acetic acid (vinegar) drops were as effective as antibiotic-steroid drops in the first week of acute otitis externa in a Cochrane review (Kaushik et al. 2010).

However, if swimmer’s ear is truly diagnosed, I’d use antibiotic drops because cure rates drop off compared to antibiotics at two and three weeks. Ear infections should be also checked first to make sure the eardrum is intact. In a pinch, I’ve used vinegar drops on vacation for early symptoms with good effect, but pain, discharge, hearing loss, fever, or symptoms that persist need medical care.

11. Salt water gargling for a sore throat

In a small pilot RCT, adults who started hypertonic saline nasal irrigation and gargling within 48 hours of a cold got better about 1.9 days faster, used 36% fewer over-the-counter medications, and had 35% less spread to household contacts (Ramalingam et al. 2019).

This was a small, open-label trial, so I would not call it definitive. But it is cheap, low-risk, and plausible enough that I use it early.

I wrote more about exactly what I do to get over illness faster here:

As medicine advances, it is tempting to dismiss every home remedy as folklore. But that misses the point.

Some are cheap, low-risk, and genuinely helpful. Used well, they can ease symptoms, support recovery, and sometimes reduce the need to reach for medication right away.

Progress in medicine should not make us dismiss time-tested solutions. It should make us more precise about which ones work, who they help, and what their limits are.

Thanks for reading. If this was useful, a like or restack helps others find it.

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This newsletter is for educational purposes only. It is not personal medical advice. Always consult your own health-care provider for medical guidance.

A groundbreaking study published in 2017 asked a simple but critical question: how many people diagnosed with asthma actually have asthma?

Researchers took 613 adults with physician-diagnosed asthma and put them through rigorous objective testing.

Here are some of their striking findings:

• 33% had their asthma diagnosis ruled out - no evidence of airflow obstruction, bronchial hyper-responsiveness, or asthma symptoms after stopping all medications.

• Only 50% had undergone objective testing - despite being given the diagnosis

• 2% had serious conditions misdiagnosed as asthma - ischemic heart disease requiring coronary intervention, subglottic stenosis needing airway procedures, interstitial lung disease, pulmonary hypertension, sarcoidosis, and tracheobronchomalacia.

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Asthma is particularly vulnerable to misdiagnosis:

Symptoms are episodic. You might wheeze during a viral infection but test completely normal weeks later at your appointment. Multiple conditions cause similar symptoms - heart disease, GERD, vocal cord dysfunction. And as the study documented, objective testing often wasn’t performed at initial diagnosis. Half of patients were diagnosed on symptoms and physical exam alone with no further investigation.

This creates the perfect storm for diagnostic error.

Now, this is not to say everything in your chart is wrong. Most diagnoses are correct, and some are more straightforward than others. But this is a good example about the smaller group where uncertainty exists and reassessment can make a meaningful difference.

Additionally, the study couldn’t definitively separate misdiagnosis from remission in all cases. But the association between lack of initial testing and ultimate exclusion of asthma was statistically significant.

Either way (whether misdiagnosis or remission) the finding stands: one-third of recently diagnosed patients with asthma didn’t have current asthma when systematically evaluated, with some serious conditions missed.

The Cognitive Bias Explanation

The study itself did not measure clinician decision-making psychology or anchoring bias. It documented outcomes: which patients did or didn’t have asthma on rigorous testing.

But the pattern suggests cognitive bias may play a role. Here’s how:

Once “asthma” appears in your medical chart, subsequent providers see that label. When you present with shortness of breath and wheeze, anchoring bias - the tendency to rely heavily on the first piece of information encountered - may lead doctors to interpret symptoms through the “asthma” lens rather than reconsidering the diagnosis.

This isn’t proven by the study, but it’s a reasonable psychological explanation for why diagnostic errors persist once made.

The Broader Context: Diagnostic Error Rates

Separate from this asthma study, broader research on diagnostic errors exists.

A synthesis of large observational studies estimated that approximately 5.08% of U.S. adults experience outpatient diagnostic errors each year across all conditions. That’s roughly 1 in 20 patients annually - though this is an estimate from observational studies, not a definitive rate, and it varies widely based on condition type, diagnostic complexity, and clinical setting.

Taking an Active Role in Your Healthcare

You and your doctor are a team, but you’re the one living in your body 24/7.

Your doctor brings medical expertise and pattern recognition from seeing thousands of patients. You bring detailed knowledge of your specific symptoms, how they have changed over time, and what does or doesn’t help.

The best outcomes happen when both perspectives inform diagnosis and treatment.

But there are practical constraints. Time limitations mean your doctor might only have 10-15 minutes per appointment. System fragmentation means records don’t always follow you. And if you don’t actively participate - asking questions, tracking symptoms, following up - critical information can get lost.

And many patients face real barriers: cost of accessing records, language barriers, health literacy challenges, lack of transportation, mental health issues that make advocacy difficult, distrust of medical systems due to past dismissal or discrimination.

Within your means and capabilities, being engaged helps. Even small steps matter.

Here’s a framework for what might help.

Step 1: Gather Your Medical Records Comprehensively

This is critical. Information empowers you and your medical team.

Here’s a stark example of how fragmented some systems still are.

In Canada, provincial health record systems do not communicate across borders. If you move from Ontario to British Columbia, your new physicians have no automatic access to your prior medical records unless you personally provide them.

That means if you arrive in the emergency department after an accident and have a history of anaphylaxis to a medication, your doctors could have no way of knowing and administer it.

Even hospitals, specialist clinics, and family practices often operate on different electronic record systems that do not interface with one another.

How to gather everything:

Request records from every provider you’ve seen:

• After appointments, and with your primary care provider, ask for copies of specialist reports, imaging and lab results, etc.

• Sign up for patient access portals. Many hospitals allow you to sign up and see all of your records and test results

What to specifically request:

• Consultation reports and progress notes from specialists

• Diagnostic test results (bloodwork, imaging, pulmonary function tests, cardiac tests)

• Operative reports if you’ve had surgery

• Emergency room reports

• Hospital discharge summaries

Organize everything chronologically:

• Create a folder (physical or digital) sorted by date

• Keep a master list of all diagnoses with dates they were made

• Keep a master medication list with start/stop dates and reasons (including sick day instructions if relevant)

• Document all surgeries and procedures with dates

Create a one-page medical summary:

• Active diagnoses

• Current medications with doses

• Drug allergies with specific reactions

• Major surgeries/procedures with dates

• Key test results (like baseline lung function if you have respiratory disease)

• Emergency contacts

• Names and contact info of your doctors

This can all easily be compiled into a folder on your computer and tracked on an excel sheet.

Step 2: How to Use AI to Help Understand Your Diagnoses

I am an advocate of people using AI-tools to help people educate themselves — but this is never a replacement for medical care. AI tools cannot diagnose or treat you, and their outputs commonly contain inaccurate or outdated information. Always verify with healthcare professionals and trusted medical sources. Many times physicians will be able to direct you to helpful vetted resources.

Most patients don’t fully understand their diagnoses. A doctor says “you have asthma” and people nod, but do they actually know what that means? What the diagnostic criteria are? What tests should have been done?

AI tools can be starting points for learning, but they have significant limitations.

Some important warnings:

• AI can hallucinate - generate plausible-sounding but completely false information

• AI can cite outdated medical information - guidelines change frequently

• AI training data may not represent all populations equally - recommendations might not apply to your specific demographic

• AI cannot assess your individual situation - it doesn’t know your complete medical history

• Never make treatment decisions based solely on AI output

• AI is not confidential - do not enter sensitive personal, medical, or identifying information that you would not be comfortable being made public.

However, they can be a helpful tool for answering questions and learning the basics in many circumstances, which you can then verify with your doctor and other resources.

Here are some prompts to start with:

“I’ve been diagnosed with [condition]. Can you explain in simple terms what this condition is, what causes it, and how it’s typically diagnosed?”

“What are the standard diagnostic tests for [condition]? What objective findings confirm this diagnosis?”

“Here are my [lab results and imaging reports]. Can you explain what these findings mean in simple terms, which results are normal or abnormal, and how they support or change a diagnosis of [condition]?”

“What other conditions can mimic or be mistaken for [condition]? What are the key differences?”

“What lifestyle factors or behaviors worsen or improve this condition?”

“I’m on [medication]. What is this medication, how does it work, what are common side effects, and what are serious side effects I should watch for?”

After getting AI responses, verify with:

• Your healthcare provider directly at your next visit and

• Major medical organizations’ patient education materials (e.g., American Heart Association, American Lung Association, etc.)

How to use these tools responsibly:

Use them to educate yourself and generate good questions, not to diagnose or treat yourself

Bring questions from your research to your doctor: “I read that [X] can also cause these symptoms. Have we ruled that out?” or “what do you think of the evidence behind this diet for [X condition]”?

Never stop or change medications based on information you find online without discussing with your healthcare provider first

Be explicit with your doctor that you’re researching: “I’ve been reading about my condition to better understand it. Can we discuss what I found?”

Example of good use:

You have “asthma.” You research: “What objective tests confirm an asthma diagnosis?” or “What is the guideline-based criteria for judging asthma severity”

You learn about spirometry with bronchodilator response, bronchial challenge testing, peak flow variability from reliable sources.

You check your records. You’ve never had these tests. You were diagnosed based on symptoms alone.

Next appointment: “I’ve been reading about the diagnostic criteria for asthma. Would it be reasonable to confirm my diagnosis with objective testing, such as spirometry with bronchodilator testing?”

Step 3: Advocate During Appointments

Many diagnostic errors happen because of incomplete communication and information (especially when pieces of your medical record are missing). Both parties make assumptions. Critical information gets missed.

This isn’t about being combative. It’s about being a collaborative partner in your care.

At every appointment where a diagnosis is made or treatment changed, here are five key questions to make sure you know the answers to:

1. “What exactly is the diagnosis, and how certain are you?”

Ask for a full explanation of the disease and why they think you have it.

If your doctor isn’t certain, that’s valuable information. “I’m treating this empirically as asthma and we’ll reassess” is very different from “objective testing confirms asthma.”

2. “What is the treatment plan, and why did you choose this specific approach?”

Understand not just what you’re taking, but what the expected outcomes are.

“This is a corticosteroid inhaler. It reduces airway inflammation. We’re starting with a low dose and will reassess in 6 weeks to see if you have less shortness of breath and wheeze”

That’s informed treatment. You know what to expect, when to follow up, what success looks like.

3. “What’s the backup plan if this treatment doesn’t work?”

It’s helpful to think ahead. If the first treatment fails, what’s next?

This also reveals diagnostic certainty. If they say “if the asthma medications don’t help, we’ll reconsider the diagnosis, try something else, and explore further testing for other conditions,” that tells you they’re keeping an open mind and what else you can expect.

4. “What other diagnoses could explain my symptoms?”

This is a question that encourages broader diagnostic thinking without being confrontational.

It invites your doctor to share their thought processes so you can better understand their reasoning.

“I’ve read several conditions can cause symptoms similar to asthma. Can you walk me through how we determined asthma was the most likely diagnosis in my case?” This prompts them to explain their reasoning and what findings would make them reconsider, and also what else you should look out for should symptoms change.

5. “What should I do if my symptoms worsen, I get sick, or I have an emergency?”

Ask your clinician to spell out a clear action plan.

Helpful follow-up questions include:

• “What changes in my symptoms should prompt me to call the clinic?”

• “Are there medications I should adjust or start if I get sick?”

• “What symptoms mean I should seek urgent or emergency care?”

• “How often is too often to use my usual rescue or as-needed treatments?”

This moves the plan from vague reassurance to specific, actionable guidance and helps you respond appropriately when things change.

Write down the answers to all five questions. Review them at home. Follow up if something doesn’t make sense.

Most doctors appreciate engaged patients who ask thoughtful questions. You’re helping them do their job better.

Step 4: Consider a Second Opinion

You’re not trapped with one doctor. If you don’t feel heard, if treatments aren’t working, if something doesn’t sit right - getting another perspective is reasonable.

How to approach it:

Be direct and polite with your current doctor: “I’d like to get a second opinion to confirm the diagnosis and treatment approach. Could you please refer me to another physician for this?”

Most doctors won’t be offended. They understand the value of fresh perspectives.

Bring all your organized medical records (see Step 1)

Come with specific questions (see Step 2)

Be open about why you’re seeking the second opinion - “treatments haven’t worked” or “I want to confirm this diagnosis”

The asthma study functioned as a systematic “second opinion” for all participants. That comprehensive re-evaluation found serious conditions that had been labeled as asthma - including heart disease requiring intervention and airway problems requiring procedures.

Step 5: Acknowledging the Bigger Picture: Systemic Issues Need Fixing Too

The healthcare system has structural problems that contribute to diagnostic errors:

Time constraints: 15-minute appointments aren’t enough for complex cases

Fragmented records: Lack of interoperability between systems and even doctors

Financial barriers: Some testing and specialist visits cost money and time many patients don’t have

Workforce shortages: Not enough specialists in many areas

These need policy-level fixes. Better EMR integration. More time per appointment. Better diagnostic support tools

You advocating for yourself helps you individually. But we also need systemic change to reduce diagnostic errors for everyone

What you can practically do:

• Share experiences to raise awareness among peers and patient communities

• Support and engage with patient advocacy organizations

• Write to local representatives or health ministries about access, poor experiences, wait times, and record interoperability

• Participate in surveys, public consultations, or advisory panels when available

• Vote and advocate with healthcare access and quality in mind

You Have More Power Than You Think

Your doctor wants to help you. Most of us went into medicine because we care. We work hard, we agonize over complex cases, we want you to get better. And most of the time doctors get things right.

But medicine is hard. The human body is complex. Time is limited. Information is imperfect. Even with excellent training and good intentions, we miss things.

That’s where you come in.

You’re not a passive recipient of care. You’re the most important member of your healthcare team.

You’re the only person who experiences your symptoms 24/7. You’re the only one who knows exactly how treatments affect you. You’re the only constant as you move between doctors and systems.

That knowledge is power.

When you track symptoms and keep organized records, you give your doctor data they might not get any other way. When you ask questions, you help them think more thoroughly. When you speak up about treatments not working, you provide crucial feedback.

This isn’t being difficult. This is communication.

The asthma study proved it matters. Systematic reevaluation ruled out asthma in one-third of patients and caught serious conditions in 2% that needed completely different treatment.

The system has flaws. Doctors are human. Errors happen. Patients should not have to carry that burden alone, but being organized and engaged can add another layer of protection

Start today. Request your medical records. Write down questions for your next appointment.

Your doctor has medical expertise. You have lived experience and motivation. Together, that’s powerful.

But you need to show up as an active partner.

Your health is the most important investment you will ever make.

Thanks for reading. If you found this helpful, a like or restack means a lot and helps others discover it.

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This newsletter is for educational purposes only. It is not personal medical advice. Opinions are my own. Always consult your own health-care provider for medical guidance.

For most of my teenage years and early twenties, my mornings followed the same script: alarm, snooze, snooze, phone, and 30 minutes disappearing into a half-awake scroll before I had even left bed.

Then coffee.

Then out the door without daylight, movement, or anything resembling a real breakfast.

I told myself I was a night person. The truth was simpler: I was letting my morning routine set the state of my brain before the day had even started.

When I finally needed to pull myself in medical school, I rebuilt the first hour from scratch — and the gap between a good morning and a bad one is not subtle.

Here are the habits that worked wonders for me:

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1. Don’t touch your phone for the first 30 to 60 minutes after waking.

My old morning routine was not “waking up.” It was, like many others, handing the first 30 minutes of my attention to an algorithm.

Dopamine helps the brain decide what is worth paying attention to. The problem with checking your phone first thing is that it gives you rapid, effortless rewards before you have done anything difficult: a notification, a message, a headline, a funny clip, another scroll.

That teaches the morning brain to expect stimulation without effort.

A 2025 RCT used an app to block all mobile internet on participants’ smartphones for 2 weeks. The intervention improved mental health, subjective well-being, and objectively measured sustained attention. 91% of participants improved on at least one of these outcomes (Castelo et al., 2025). They also spent more time socializing in person, exercising, and being in nature.

I keep my phone in another room. I don’t check it until I have had light, water, movement, and coffee. For a deeper dive into how phones hijack attention and what to do about it, I wrote more about building a healthier relationship with your phone here.

2. Bright light, within minutes of waking.

This is the habit where I noticed the biggest immediate difference: I feel more awake in the morning, less foggy through the day, and more ready to sleep that night.

Light hitting the back of your eye suppresses melatonin and tells your master clock the day has started.

In a randomised trial in night owls, a morning routine built around earlier sleep-wake timing, morning bright light, fixed meals, caffeine timing, and exercise timing produced a ~2-hour phase advance in sleep timing, reduced self-reported depression and stress, lowered morning sleepiness, and improved simple measures of cognitive and physical performance, including reaction time and grip strength (Facer-Childs et al., 2019). It was bundled, so we can’t isolate light alone, but morning light is one of the strongest signals telling your body that the day has started, helping suppress melatonin and reinforce the natural cortisol rise that makes you feel awake.

Outdoor light beats any indoor light, even on a cloudy day. If you can’t get outside, or it is still dark when you wake up, a 10,000-lux lamp helps. More on the optimal morning light strategies here.

3. Wake up at the same time every single day.

Your wake time is the foundation everything else stacks on. Drift it by 90 minutes on the weekend and you spend Monday morning paying for it.

In a 30-day study of college students, more regular sleep-wake patterns were associated with higher GPA. The irregular sleepers also had delayed melatonin timing and a delayed sleep-propensity rhythm, roughly equivalent to shifting their biology 2 to 3 time zones later. The effect was not simply because they slept less; sleep duration was not significantly correlated with GPA (Phillips et al., 2017).

In another study of college students, simply regularizing sleep-wake schedules reduced daytime sleepiness and produced greater, longer-lasting improvements in alertness than giving students a sleep-duration target alone, even when both groups were told to sleep at least 7.5 hours (Manber et al., 1996).

Protocol: Pick a wake time you can keep. Hold it within 30 to 60 minutes, including weekends.

4. Don’t let mild dehydration ruin your morning.

You have just spent 7 to 9 hours fasting and losing water through breath and skin. Dehydration can quietly affect how you feel in the morning.

In an RCT of 64 young adults, after 12 hours of water restriction, 500 mL of water improved working memory, while 200 mL was enough to reduce anger, fatigue, and total mood disturbance (Zhang et al., 2020). Cheapest cognitive intervention on this list.

In healthy young women, losing just 1.36% of body mass from dehydration was enough to make concentration feel 45% worse, tasks feel 58% harder, fatigue rise 17%, and headaches become about twice as common (Armstrong et al., 2012).

I drink a glass of water every morning after my coffee.

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A few years ago, I got a sinus infection that would not quit. I tried to wait it out, gave it a few days, did everything conservative I could. Eventually, I needed antibiotics.

Antibiotics were nothing new to me. I prescribe them constantly, sometimes dozens of times in a single day, and I mean it when I say they are one of the most important tools in medicine.

But being on the other side of the prescription made the tradeoff feel personal. Because I also know the rest of the story. Antibiotics can wreak havoc on the gut in ways we are still working to understand. And I have watched C. difficile, an infection that can follow a course of antibiotics, take people’s lives.

The usual advice is simple: take a probiotic.

But the moment you look closer, it gets complicated.

Which probiotic? Which strain? What dose? Taken when? To prevent diarrhea, C. diff, microbiome disruption, or all of the above? And where does diet fit in?

So I went into the literature and talked to experts looking for a practical answer.

It was messier than I expected. But this is the framework I landed on.

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Antibiotics do real damage to your gut

Antibiotics do not aim. They indiscriminately kill the bug causing your infection along with a large share of your normal gut bacteria.

This study caught my attention: healthy men given a 4-day course of broad-spectrum antibiotics initially saw massive disruptions in their gut microbiome. It largely bounced back within six weeks, but 9 common species were still missing six months later (Palleja et al., 2018).

This loss weakens colonization resistance, your gut community’s ability to keep invaders out. What most doctors are familiar with is this allowing a dangerous pathogen, C. difficile, to take over and cause severe, sometimes deadly colitis. C. diff is far more common in people who are older, hospitalized, on long or repeated antibiotics, or who have had it before. About 462,000 Americans got it in 2017, and thousands die from it each year (Guh et al., 2020). For a healthy adult on a short course, the baseline odds are low, but not zero.

Why I care about my gut microbiome

Your gut does not just affect your gut. Gut bacteria help train immune defenses far beyond the intestine, including in the lungs. In animal studies, wiping out the gut microbiome worsens responses to bacterial and viral respiratory infections (Budden et al., 2017).

That is why I worry most about people who catch infection after infection and take antibiotic after antibiotic. Each course leaves a dent, and some people may be stacking those dents faster than they can recover.

There is good evidence that a probiotic reduces antibiotic-associated diarrhea (Goodman et al., 2021), and newer evidence that it may modestly lower the risk of C. difficile (Esmaeilinezhad et al., 2025). That C. diff benefit is small, but C. diff can be devastating, and to me a small cut in that risk is well worth it.

What I take, and how to do it well

I take two things, for two different jobs.

For the diarrhea itself: Saccharomyces boulardii has the strongest adult evidence here, cutting antibiotic diarrhea from roughly 17% to 8% in pooled trials (Szajewska and Kołodziej, 2015), and as a yeast it is unaffected by antibiotics. Lactobacillus rhamnosus GG is another simpler single-product option.

For the wider microbiome: a multi-species probiotic or synbiotic (probiotic + prebiotics). In a recent randomized trial, healthy adults who took a 24-strain synbiotic plus a pomegranate-derived prebiotic during and after antibiotics (ciprofloxacin and metronidazole) regained microbiome diversity faster and made more butyrate, acetate, and barrier-supporting metabolites than placebo (Napier et al., 2026). This was an early, industry-funded study measuring lab markers, not diarrhea, so I treat it as promising, not proven. I always ensure I pair probiotics with prebiotics and a high fiber diet.

The Protocol:

• Start on day one, not after you feel sick. Earlier is linked to more benefit.

• Take probiotics a couple of hours apart from the antibiotic to reduce exposure to peak antibiotic concentrations. S. boulardii does not require this separation because it is a yeast and is not affected by antibacterial drugs.

• Ask your doctor first if you are immunocompromised, critically ill, since rare bloodstream infections have occurred.

To help guide your decision on which brand to buy, probioticchart.ca (Canada) and usprobioticguide.com are helpful resources.

What I eat

Diet is the other half of the equation. Food helps create the recovery environment. In a Stanford randomized trial, a diet rich in fermented foods increased microbiome diversity and lowered inflammatory markers, while a high-fiber diet changed microbiome function and appeared to work best in people who already had more microbial diversity (Wastyk et al., 2021).

So my approach is simple: add helpful microbes, then feed them.

The protocol:

• Fermented foods, several servings a day. In the above study, yogurt and vegetable-brine drinks tracked closest with the diversity gain.

  • Aim for live-culture yogurt and kefir, kimchi and other fermented vegetables, sauerkraut, miso, tempeh, and kombucha. Buy refrigerated, not shelf-stable, so the cultures are alive.

• Fiber, building toward at least 30 to 40 grams a day from food: legumes, whole grains, oats, nuts, seeds, vegetables, fruit, and berries. Psyllium is a great supplement to add here.

• Resistant starch when tolerated: cooled potatoes or rice, legumes, slightly green bananas.

• Ramp both up slowly. Your gut needs time to adapt, and too much too fast can cause discomfort. In this trial, higher fiber intake was linked to more carbohydrate in stool, suggesting the microbiome was not fully processing it yet.

• Separate dairy, calcium, iron, and zinc from a fluoroquinolone or tetracycline, which they can bind and weaken.

The bottom line

Probiotics with antibiotics are neither a scam nor a miracle.

For me, this is about trying to optimize the odds. I know most healthy people on a short course of antibiotics will do just fine. But I have also seen what happens when someone is the unlucky one. C. diff can derail a life, and in rare cases, end one.

So my reasoning is simple. Antibiotics can severely disrupt the microbiome. That disrupted state is linked to a long list of bad outcomes. Probiotics and diet are imperfect tools, but both have evidence of benefit. For a cheap, low-risk add-on, that is a trade I will take.

If you are healthy and taking a short course, either taking a studied probiotic or skipping it and watching for symptoms is reasonable. But when I take antibiotics, this is the strategy I follow.

Thanks for reading. If you found this helpful, a like or restack helps others discover it.

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This newsletter is for educational purposes only. It is not personal medical advice. Opinions are my own. Always consult your own health-care provider for medical guidance.

One of my favorite parts of having an online presence is getting to connect with interesting people from around the world and, somewhat selfishly, getting to ask them all the questions that have been rattling around in my head.

I’ve become more serious about running over the past few years, and also more curious about the physiology behind it: Zone 2, VO2 max, threshold training, fueling, shoes, injury prevention, and why some runners keep improving while others plateau.

So I asked Brady Holmer, exercise physiologist, 2:24 marathoner, and author of the popular Physiologically Speaking newsletter.

He’s one of the rare people who can explain the science and actually live it himself.

I came in with my full list of burning questions. He answered every one, and he did not disappoint.

Here’s Brady:

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A lot of runners hear that most of their training should be in Zone 2. In practice, how should recreational runners identify Zone 2, and how reliable are methods like chest straps vs. wrist-based heart rate sensors, perceived effort, and the “can you hold a conversation?” test?

• The best (and simplest) way identify zone 2 is using the talk test. If you were exercising with a friend or spouse and can hold a conversation, then you can be somewhat sure that’s an intensity that roughly corresponds to zone 2 intensity. For people who want to be a bit more accurate, heart rate is a good guide, but make sure you’re using a chest strap if you want the most accurate measurement. Wrist-based heart rate is ok for resting and light activity but accuracy tends to go down if you’re moving more vigorously. I’m also a HUGE fan of perceived effort, and there are plenty of studies showing that it reliably correlates with lactate/VO2 max intensities compared to methods like heart rate and lactate. For zone 2, target a 3–5/10 effort level.

My ranking:

• Lactate measures

• (Chest) heart rate

• Wrist or arm band heart rate

• Talk test

• Perceived effort

Once someone has a reasonable sense of their Zone 2 intensity, what percentage of their training do you think should actually be in Zone 2? Does this change depending on how much someone runs each week or what their goals are?

• Despite what you might hear about the “80/20” rule, there really no single law on how someone should distribute their training across zones in a given week—it will be highly dependent on total volume, life demands, etc. That being said, the 80/20 rule isn’t necessarily wrong and it’s a good framework once people know what it actually means: it means making 80% of your total weekly sessions lower intensity and 20% of them higher intensity. It does NOT refer to time distribution. For example, if someone runs 5x per week, then 4 of those sessions should be easier and 1 should be harder. For 6–7 sessions per week, 2 sessions can be higher intensity. But if someone is not devoting a lot of time to running—maybe 1–3 hours per week, I think nudging up the intensity on each run allows for better adaptations. Zone 2 combined with low volume may not be enough stimulus to really improve much.

• Here’s generally my recommendation: below 5–6 hours per week, don’t be afraid to do an extra run at a slightly more uptempo pace. Above 6 hours, 80/20 rule becomes a bit more valid for injury prevention.

For someone like me who runs consistently, around 15-25 miles per week across 4-5 runs, what would a realistic training week look like if the goal is to improve fitness and race performance without making running take over their life? How would you split that week between easy runs, a long run, tempo or threshold work, strides, hills, intervals, or anything else?

• 3 runs: easy “zone 2” base building runs (3–6 miles each). You can add strides or uphill repeats to the end of 1–2 of these runs (e.g., 6x20–30” strides or uphill strides with full walk recovery).

• Workout: tempo run, intervals, threshold work (3–5 miles total)

• Long run: 7–10 miles

What would you tell someone whose VO₂ max has plateaued after months or years of consistent training? How should they think through whether the limiting factor is training volume, intensity, threshold work, recovery, or simply how VO₂ max is being estimated?

• The easy way to determine whether volume or intensity is the limiter would be to add both (independently). Take your current workload and add easy volume. If you see VO2 max moving or trending up, maybe volume was your limiter. More often than not, if someone has been training a long time and hit a plateau, intensity will be the limiter. But you want to increase gradually. Start adding a few extra intervals or 10–25% more time to your interval session each week, rather than add an entire session.

• Recovery could be an issue if someone is training very hard and seeing no progress (that’s one definition of “overtraining”). For many full-time professionals, lack of recovery could just mean life’s demands are high in addition to training. But for most people this likely isn’t the main cause of a plateau.

• A lack of an improvement could very likely be due to measurement, and if you’re relying on a smartwatch estimated number, please be careful. That value can be deflated by a run where heart rate is artificially elevated (due to heat, stress, humidity, etc.), which automatically penalizes you. I’d say if someone knows they’re training hard VO2 max isn’t budging (watch), it’s probably a measurement error versus true non-response. My advice here—do a field test (some watches have them built in) like a 12-minute run test. If that improves, it’ll track pretty well with fitness/VO2 max (you can even put your score into a calculator online).

If someone has a very busy week and cannot train normally, what is the minimum amount of running they should do to maintain their fitness? For example, what would your “weekend warrior” or “bare minimum maintenance” protocol look like, and which types of runs should they prioritize?

• 3 runs MINIMUM — but that means frequency without respect to time. Just get out/get moving for as long as you’re able on those runs. Ideal protocol for 3 runs: 1 slow and easy, 1 hard run (tempo, intervals) and 1 run that’s ~2x distance if your long and slow run. Keep this easy.

Running shoes have become increasingly complicated: daily trainers, plated shoes, shoe rotation, and mileage limits. What does the evidence actually suggest runners should care about, and what is mostly marketing?

• Comfort is #1. I truly mean that. Every brand nowadays has a good daily trainer, and most of the special features from brand to brand are marketing. Test a couple different brands and models of a non-plated trainer and pick the one that’s most fun to run in for you. And most comfortable.

• Rotation is important but you don’t need 10 pairs. I’d suggest 2 trainers you can rotate throughout the week (“resting” a shoe can help its lifespan). I also think everyone should have 1 “super shoe” or plated shoe for long runs and workouts, but you shouldn’t be wearing these daily! 1–2 times per week, or maybe 25% if your runs.

• The evidence on “motion control” stuff is not really there. Unless you’ve got a severe orthopedic issue, a “neutral” shoe with moderate cushion is the best choice.

What is the simplest strength-training plan you would recommend for recreational runners who want to get faster, stay healthy, and prevent injury?

• 2–3 times per week “full body circuit” that hits 2–3 upper body/core exercises and 1–2 leg exercises. For injury prevention, you can stick to lighter dumbbells or body weight, but for performance enhancement experimenting with squats/deadlift/more advanced lifts could be helpful.

• For getting faster, plyometrics are underutilized. Jump, drop jump, skip, high knees… explosive (unweighted) movement WILL make you faster even without strength training. Primarily by enhancing neuromuscular efficiency/power output.

What are the biggest mistakes recreational runners make that lead to injury? Are there any early warning signs that someone should reduce load before they get sidelined?

• Increasing single-run mileage too fast. Studies show that this correlates strongly to running related injuries, rather than the “total weekly mileage.” Try to refrain from increasing the distance of your longest run by more than 10–15% of the distance of your previous longest run. Don’t add speed to rapidly either. Strides are a good bridge from easy running to formal speed workouts.

• If you have something bothering you that doesn’t go away after 2–3 days of complete rest, that’s a good sign of an “injury” versus just a “pain.”

What do runners most often get wrong about fueling, especially for long runs, half marathons, and marathons? How should people think about carbs before, during, and after running? What about hydration?

• That you NEED to fuel every training run. Don’t need to, but you can. My recommendation is usually 90 minutes or longer unless you’re running hard.

• Biggest mistake is doing something foreign or new on race day before testing in training. That means no gels, which many people end up doing because they use what the race provides to them. Bring your own or research what your goal race has available and use it in training.

• Next is trying to fuel more than you’re ready for. The gut can be trained to tolerate higher carbs, but jumping from 50 in training to 70–90 on race day is a recipe for disaster.

• Same with hydration—I’d bet many runners underfuel and over hydrate during races. Especially those who are spending more time on the course.

• Fueling after: don’t delay carbs! Protein can wait (doesn’t have to), but having a carb-containing meal or snack within 30 minutes of a training run speeds up glycogen replenishment and helps you adapt better.

Warm-ups are another area where advice seems all over the place. For most recreational runners, is starting with a slow easy run enough, or should they be doing drills, dynamic movements, or other warm up routines before certain sessions?

• Easy running and some light dynamic drills is enough. But if it’s an easy run, the first few miles can just be the “warmup.” If you’re going to run hard, easy miles followed by strides and even a “practice repetition” slower than goal pace will help you reduce inertia and perform better on the first interval.

How should runners think about mobility and stretching? What is actually useful, how much should people do each week, and what routines are most beneficial?

• The evidence here is SPARSE. My answer is do what you think you need. Extra tightness or notable lack of mobility could require attention. But nobody needs a daily 30-minute “stretching routine” just because.

For readers who want to learn more about running science, endurance training, and performance, where should they follow your work? Could you also tell us a bit about your newsletter and what you cover there?

• Substack is the best place—I write a weekly newsletter on a study I found interesting and worth sharing, and I publish my own training quite often as well (I shared my entire training log leading up to last year’s Boston marathon). I also share a lot of science and personal advice on X (@brady_h).

This newsletter is for educational purposes only. It is not personal medical advice. Opinions are my own. Always consult your own health-care provider for medical guidance.

You know this one. You’re dredging through a tough day, finally have some down time at 3 PM, so you lie down for a quick nap. You wake up an hour later groggier than before. The fog clears around 6, just in time to ruin your sleep that night. You toss until 1 AM, wake up exhausted, and need another nap tomorrow.

Welcome to the vicious cycle of improper napping. Many people get stuck in it. Long, late naps wreck the afternoon and steal the night.

A good nap is the opposite. Short, early, and engineered, it melts away fatigue and gives you hours of heightened alertness without touching your sleep that night.

Here is a recipe for the perfect nap.

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First, what do naps actually do?

A quick tour of the benefits:

• Possibly bigger brains. A 2023 Mendelian randomization study of nearly 380,000 UK Biobank participants linked habitual daytime napping to about 15 cm³ more total brain volume (Paz, Dashti & Garfield, 2023).

• Hours of alertness from just a 10-minute nap. A 2006 Sleep trial showed that a 10-minute afternoon nap produced immediate improvements in alertness, fatigue, vigor, and cognitive performance, with benefits lasting up to 155 minutes (Brooks & Lack, 2006).

• Learning that rivals a full night. A landmark Nature Neuroscience study found that a 60-to-90 minute afternoon nap containing both slow-wave and REM sleep produced learning gains on a perceptual task (texture discrimination) equivalent to a full 8-hour night of sleep (Mednick, Nakayama & Stickgold, 2003).

• Better mood and less sleepiness for four hours. A 2023 polysomnography trial found that naps of several durations all improved mood and reduced sleepiness for up to 240 minutes post-nap (Leong et al., 2023).

Now to the protocols.

How long should I actually nap?

In general, for fast afternoon alertness: 10 to 20 minutes. For learning or recovery, usually 30 minutes, with a buffer.

When you fall asleep, you move through progressively deeper stages. Deep sleep becomes more likely as the nap gets longer, and it is the heaviest, hardest-to-wake stage. Wonderful at night. A disaster when your alarm is about to yank you out of it in the middle of the afternoon.

The trick is to stay in light sleep. A 10-to-20-minute nap clears some sleep pressure, and most people stay in light sleep the whole time. You wake up feeling roughly like yourself.

A 30-to-60-minute nap is the borderline. Some people stay in light sleep through it and feel great. Others slip into deep sleep right at the end and pay for it.

This is the logic behind the famous “NASA nap.” In a NASA aviation study, long-haul pilots were given a 40-minute rest opportunity, producing about 26 minutes of actual sleep on average. Compared with no-nap crews, they showed better alertness and performance.

The Protocol:

• Default: set a 25-40 minute timer. That covers 5 to 10 minutes of sleep latency plus a 15-30 minute nap.

• If you fall asleep fast, 20 minutes is usually enough.

• If you want a memory nap before/after studying or learning, use the longer end of the range.

• If you wake up groggy, the nap was probably too long, not useless. Shorten it next time.

Why do long naps make me feel worse?

It’s called sleep inertia. It happens when you wake out of slow-wave sleep, which typically appears 20-60 minutes after falling asleep during the day. Abrupt awakening from slow-wave sleep produces the most severe inertia, and it gets worse the more sleep-deprived you were going in (Tassi & Muzet, 2000).

This is why one-hour naps feel terrible without a recovery window. The fix is not avoiding longer naps. The fix is matching the nap to the goal.

When during the day should I nap?

Early afternoon. For most people, between 1:00 and 3:00 PM.

In the early afternoon, sleep pressure has been building for hours while your circadian alerting signal often dips, making a short nap easier to fall into, less likely to disrupt sleep that night, and where you’ll get the most benefit. Most nap research targeting normal daytime alertness uses an early-afternoon window for exactly this reason.

The Protocol:

• Aim for 1:00 to 3:00 PM.

• Avoid naps within about 6 hours of bedtime.

• If you have active insomnia, be cautious. If you have trouble falling asleep at night, sometimes it is helpful to make sure you are as tired as possible when bedtime rolls around.

This is the end of the free preview.

Next, I’ll show you the highest-leverage nap protocol I use: the “Nappuccino.”

You’ll also learn:

• How to maximize the benefits of a nap

• How to wake up with less grogginess and improved cognitive performance

• When a longer nap is actually the right move

• What to do if you cannot fall asleep at all

Read more

But a small number of symptoms are different.

They are the warning signs doctors learn to take seriously because catching them early can change the outcome.

These are 10 symptoms I tell people not to ignore. Some I have seen dozens, even hundreds, of times. Others only a few. But every one of them is the kind of symptom worth recognizing before it is dismissed.

This is not meant to make you anxious about every ache, cough, or headache.

It is meant to help you know when your body may be telling you something that deserves attention.

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1. The “Worst Headache of Your Life”

A “thunderclap” headache, one that goes from zero to maximum in under a minute, is the classic warning sign of a subarachnoid hemorrhage: bleeding around the brain from a ruptured aneurysm. It kills up to 60% of people, and the risk of a fatal re-bleed is highest in the first hours. Speed to peak is the giveaway.

A headache that hits maximum intensity in under a minute, especially if unlike any you have had before, is a 911 call. Don’t drive yourself or brush it off.

2. Intractable Hiccups

If someone walks into a doctor’s office with hiccups that have gone on non-stop for days, that’s an immediate red flag. I once saw a patient with persistent hiccups who turned out to have a brain tumor. Most hiccups are harmless, but hiccups lasting more than 48 hours can signal trouble in the brain, chest, or gut. The hiccup reflex passes through the brainstem, so a stroke or tumor there can set them off. The list of causes is extensive, but others include reflux, certain medications, kidney failure, electrolyte abnormalities, and masses in the chest or abdomen.

Hiccups lasting more than 48 hours need a doctor, not another folk remedy.

3. Repeated Spells of Low Blood Sugar

A few years back I saw a young man with the classic Whipple’s triad: episodes of sweating, shaking, and confusion that consistently resolved with food. His spells had been chalked up to anxiety for weeks. After finally coming into the ER, we caught it. It was an insulinoma, a very rare cancer, and only the second one I have seen. He was treated and surgically cured within days.

Whipple’s triad is the pattern that points to true low blood sugar: symptoms of hypoglycemia (sweating, tremor, palpitations, confusion, slurred speech, or even loss of consciousness), a measured low glucose during the episode, and resolution once the glucose is corrected. In someone without diabetes, this combination can signal an insulinoma: a rare insulin-secreting tumor of the pancreas. Episodes can be brushed off as anxiety or panic attacks. Many insulinomas are benign and can be cured with surgery. If untreated, severe hypoglycemia can be very dangerous, leading to seizures or even death in rare cases.

If you have repeated episodes of sweating, shakiness, confusion, or fainting that consistently resolve with food or juice, try to check a glucose level during an episode and talk with your doctor. If an episode causes loss of consciousness, a seizure, or you are unable to safely treat it yourself, call 911 immediately.

4. New One-Sided Calf Pain or Swelling

A new painful, swollen, warm, or red calf, especially on one side, can be a deep vein thrombosis (DVT): a clot in the deep veins of the leg. The danger is that part of the clot can break loose, travel to the lungs, and become a pulmonary embolism. I’ve seen a lot of these, often after immobility, long travel, surgery, hospitalization, pregnancy, cancer, or estrogen-containing medications. Caught early, blood thinners can prevent the clot from growing or travelling to the lungs.

New one-sided calf swelling, warmth, tenderness, or redness, especially after a long flight, surgery, or hospitalization, needs urgent evaluation. With shortness of breath, chest pain, or lightheadedness, call 911.

5. Visible Blood in Urine, Even Once

Pink, red, or cola-colored urine, especially when painless, can be a warning sign of bladder cancer or another serious urinary tract problem. People often dismiss it because it may happen once and then disappear. Sometimes the cause is infection, kidney stones, or an inflammatory or autoimmune condition. But visible blood in the urine is never something to ignore. Even one episode deserves evaluation, because the cause needs to be found, and cancers caught early, for example while still confined to the bladder lining, are far more treatable.

Even one episode of visible blood in your urine, painful or painless, deserves urgent evaluation. The fact that it stopped does not mean it was nothing.

6. Bleeding After Menopause, Even Once

Any vaginal bleeding more than a year after your last period is considered postmenopausal bleeding and should never be ignored. The most common causes are benign, particularly thinning of the vaginal or uterine lining, but bleeding can also be the first sign of endometrial cancer (cancer of the uterine lining). About 9% of women with postmenopausal bleeding are ultimately diagnosed with endometrial cancer. The good news is that when it is caught while still confined to the uterus, outcomes are generally very good. Once it has spread beyond the uterus, survival drops sharply.

Any bleeding after menopause, even spotting, even once, warrants a call to your doctor and usually a transvaginal ultrasound and possibly a biopsy. It is rarely an emergency, but it is never normal.

7. Morning Headaches and Loud Snoring

Loud snoring, pauses in breathing, morning headaches, and daytime sleepiness are classic clues for obstructive sleep apnea. You may think you are sleeping, but your brain may be waking up over and over starving for oxygen just to restart breathing. Treatment can meaningfully improve energy, sleepiness, quality of life, blood pressure, and risk of serious disease. I have OSA myself; I wrote about my diagnosis here and why I chose to treat it, even though it was mild.

If you snore loudly, have witnessed pauses in your breathing, or wake up with headaches and are falling asleep throughout the day, ask your doctor about a sleep study.

8. Yellow Eyes

Yellow discolouration of the whites of the eyes (jaundice) means bilirubin is building up in the blood. Bilirubin is a yellow pigment produced when red blood cells are broken down, and the liver normally clears it. Yellow eyes can signal several broad categories of trouble: liver disease, red blood cells being destroyed too quickly, or a blockage of bile flow. Sometimes the cause is something readily treatable, like a gallstone. Other times it is a sign of a serious underlying disease, including cancer, infection, or autoimmune disease.

New yellow discoloration of the eyes, especially when painless or progressive, deserves urgent evaluation. Don’t wait to see if it goes away.

9. Constitutional Symptoms

Unexplained fevers, drenching night sweats that soak the sheets, and unintentional weight loss are often called “B symptoms.” Sometimes the cause is something benign, but together they can point to a serious inflammatory process in the body. That can include cancer, classically lymphoma, but also autoimmune disease or chronic infections like tuberculosis, endocarditis, or HIV. Some cancers like lymphoma can present this way and can be highly curable when caught early. The danger is that young, otherwise healthy people can carry these symptoms for months before anyone takes them seriously.

A combination of unexplained fevers, drenching night sweats, and unintentional weight loss lasting more than a few weeks deserves a workup. Don’t write it off as stress.

10. New Floaters, Flashes, or a Curtain Over Vision

A sudden shower of new floaters, flashes of light, or a dark curtain moving across your vision can be a warning sign of a retinal tear or detachment. As we age, the gel inside the eye gradually shrinks and pulls away from the retina. Most of the time this is harmless, but sometimes it creates a tear that allows fluid to slip underneath and lift the retina away from the back of the eye. The longer a retinal detachment goes untreated, the greater the risk of permanent vision loss. Outcomes are best when it is recognized and treated early.

A dark curtain or shadow moving across your vision is an eye emergency. A sudden shower of new floaters or flashes, especially with any loss of vision, should also be assessed urgently.

Most of the time, these symptoms will not turn out to be the worst-case scenario.

But that is exactly the point.

You do not need to panic over every symptom. You just need to know the handful that deserve attention.

Because in medicine, timing matters.

The body often whispers before it screams. Listening early can change everything.

Thanks for reading. If you found this helpful, a like or restack means a lot and helps others find it.

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This newsletter is for educational purposes only. It is not personal medical advice. Opinions are my own. Always consult your own health-care provider for medical guidance.

Through medical school and residency, I saw sleep apnea all the time.

I reviewed sleep studies. I explained AHIs. I counseled patients on CPAP.

I just never thought to apply it to myself.

I was exhausted for years and blamed training, call shifts, and stress. My wife told me I snored loudly. My mother has severe sleep apnea. I still brushed it off.

Doctors really are the worst patients.

Eventually, I got tested. The result: mild OSA overall, but strongly REM-predominant.

At first, some people might think: “Great, now I have to treat this too”.

But I saw it differently: “I get to treat this”.

Sleep is one of the biggest levers for energy, mood, health, and performance. This gave me something measurable I could optimize.

Most people know sleep apnea matters. But here’s why I treated mine seriously, even though the overall result was only “mild.”

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Treating Mild OSA Improves Quality of Life

The strongest evidence is the MERGE trial (2020). Over 300 patients with mild OSA were randomized to CPAP or standard care for 3 months (Wimms et al., 2020).

• More energy: CPAP improved a measure of vitality by 10/100 points, a meaningful boost in day-to-day energy.

• Less daytime sleepiness: Patients felt more awake and alert during the day.

• Less fatigue: CPAP helped reduce that drained, low-energy feeling.

• Better mood: Depression symptoms improved.

• Better sleep quality: Insomnia symptoms also improved.

The takeaway: even in mild OSA, CPAP can meaningfully improve how people feel, especially energy, sleepiness, fatigue, mood, and sleep quality.

It should be noted that this study was funded by ResMed (a CPAP manufacturer).

Blood Pressure Drops

A meta-analysis pooling 51 randomized trials on sleep apnea found:

• CPAP reduced systolic BP by about 2.5 mmHg and diastolic by about 2.0 mmHg

• Each extra hour of nightly use → about 1.5 mmHg more systolic reduction

• Oral appliances showed comparable BP effects (Bratton et al., 2015)

Modest, real, dose-dependent.

And while a 2 to 3 mmHg drop may sound small, blood pressure is one of those variables where small changes can compound over time. Lower BP means less chronic strain on the heart, brain, kidneys, and blood vessels and preventing high blood pressure reduces risk of heart attack and stroke.

I wrote a full evidence-based protocol on how I’d lower blood pressure without medication here:

Why REM-Predominant OSA Caught My Eye

Some people see “mild” on a sleep study and shrug it off. The number that caught my attention was my REM-specific AHI, and it changed how I interpreted the result.

The problem: REM is only about 20-25% of total sleep. If your apneas cluster there, your overall AHI averages them out across the whole night and makes the picture look milder than it actually is.

The associations from observational studies are highly concerning:

• Higher REM-AHI independently predicts morning hypertensive blood pressure, even after accounting for non-REM events, BMI, and age (Falla et al., 2023)

• Higher REM-AHI was linked to roughly a 7-fold increase in odds of metabolic syndrome (Koo et al., 2020)

• REM-OSA is associated with worse insomnia symptoms, with a stronger signal in women (Hoshino et al., 2020)

• Higher REM-AHI may matter for the brain too: in older adults at higher Alzheimer’s risk, REM sleep apnea severity was linked to worse verbal memory (Lui et al., 2024)

REM is one of the most important stages of sleep. It’s where memory consolidates, where mood gets regulated, where the brain does some of its most important recovery work.

That’s exactly where my events clustered.

Even with a “mild” overall label, choking or obstructing every few minutes during the stage of sleep that mattered most was not something I could shrug off. That’s what made me personally keen to treat.

Why I Chose CPAP

Here were my options:

• CPAP: best evidence base. My choice.

• Oral appliance therapy: May provide comparable symptom improvement in mild OSA for some patients, but it is expensive and did not seem ideal for me given my history of TMJ issues.

• Surgery: can be effective for the right anatomy, but I avoided it.

• Medications: there is emerging evidence for certain pharmacologic approaches in select patients with OSA. But I am not overweight, and for me personally, I would prefer to avoid exposing myself to potential long-term medication side effects when an effective non-pharmacologic option existed.

In medical school, I saw a previously very healthy young person nearly die from a post-tonsillectomy bleed. What should have been a routine recovery turned into a bedside emergency. They survived, but it shook me. I’m not anti-surgery, but after that experience, my own bar for surgical options, especially for something I could manage non-invasively, is very high.

What Actually Changed

Before CPAP, I was sleeping a solid 8 hours most nights and still waking up tired. I didn’t actually realize how tired I was, because it had become my baseline. My body was getting the time. It just wasn’t getting the recovery.

After about a week on CPAP, I started noticing something strange: I could go to bed an hour later, sleep for 7 hours, and wake up more refreshed than I had on 8.

I also started using it for naps when I could fit them in. A nap with the mask on left me feeling sharper than longer naps without it. Same input, much better output.

However, it didn’t fix everything. I still get the typical afternoon dip in energy, which is a normal circadian phenomenon, not a sleep apnea problem. CPAP is not going to upend your day. But my mornings and evenings are dramatically better, and that’s where most of my fatigue used to hit.

The label was mild. The fatigue was not.

When to Ask Your Doctor About a Sleep Study

Most sleep apnea is undiagnosed. Don’t wait for it to become obvious.

Classic symptoms (any of these is worth raising):

• Loud habitual snoring

• Witnessed apneas, gasping, or choking during sleep

• Unexplained daytime sleepiness (the symptom most responsive to treatment)

• Unrefreshing sleep or fatigue not explained by anything else

• Frequent nighttime awakenings

• Nocturia (waking repeatedly to pee)

• Morning headaches

Sleep apnea also travels with conditions that often quietly coexist with it: high blood pressure, atrial fibrillation, heart failure, pulmonary hypertension, diabetes, metabolic syndrome, or excess weight. Having one of these doesn’t mean you have OSA. But if you also snore, wake gasping, feel unrefreshed, or struggle with daytime sleepiness, it’s a conversation worth having with your doctor about a sleep study.

Final Thoughts

I could have dismissed my own diagnosis and kept going at the same pace. I didn’t realize how tired I’d been until I wasn’t anymore.

I’m glad I didn’t.

If something about your sleep feels off, the snoring, the fatigue, the morning fog that won’t lift, take it seriously enough to ask. The cost of getting tested is small. The upside, if you’re anything like me, is an extra hour of more productive life every day.

The downside of ignoring it is also real: higher long-term risks of hypertension, atrial fibrillation, stroke, and cardiovascular disease. You feel the fatigue today. The rest accumulates quietly.

Don’t be the patient (or doctor) who waits.

Thanks for reading. If you found this helpful, a like or restack means a lot and helps others discover it.

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This newsletter is for educational purposes only. It is not personal medical advice. Opinions are my own. Always consult your own health-care provider for medical guidance.

I first tried creatine in my early twenties. A friend from the gym convinced me.

Within weeks, the difference was obvious. My bench, squat, and deadlift all jumped. Recovery felt easier. I put on visible muscle without changing anything else.

Like most people, I filed it away as a great strength supplement and didn’t think much beyond that.

Then medical residency happened.

Overnight shifts. 26-hour calls. Cognitive demands on almost no sleep. I started digging into the research on how to optimize my brain under sleep-deprived conditions, and creatine kept showing up. The findings shocked me. It wasn’t just a gym supplement.

I wrote about it in Creatine for the Sleep-Deprived Brain. But the deeper I kept digging, the more applications appeared. Blood sugar. Mood. Bone. Vascular function. Some are well-established. Others are early signals worth watching. All of them sit on top of one of the cheapest, most-studied supplements available.

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How it works (30 seconds)

Your body uses ATP for energy. Creatine helps regenerate ATP through the phosphocreatine system, especially in tissues with high demand like muscle and brain. You make about 1 gram a day and get most from meat. Supplementation tops off the tank and provides more available rapid energy.

1. More muscle and strength

This is one of the most studied and beneficial supplement for muscle and strength gains.

Two large reviews cover the basics. One pooled 60 trials on lower-body lifts and found consistent gains in squat, leg press, and overall quadriceps strength (Lanhers et al., 2015). The other pooled 53 trials on upper-body lifts and found the same for bench press and chest press (Lanhers et al., 2017). The effect held across age, sex, training status, dose, and duration.

Creatine plus resistance training added about 1.1 kg more lean body mass than placebo plus lifting, with the benefit consistent across young, middle-aged, and older adults (Delpino et al., 2022).

If you lift, creatine works. Very few supplements have this level of evidence.

2. Protects the brain under sleep deprivation

In an incredible study, a single high dose of creatine (0.35 g/kg, about 25g for a 70kg adult) didn’t just blunt the cognitive toll of sleep deprivation. Some measures actually exceeded the well-rested baseline.

Word memory improved by 10%. Processing speed jumped across the board: 29% on language tasks, 24% on numeric tasks, and 16% on logic tasks. Brain energy metabolites and cognitive performance stayed elevated for up to 7.5 hours (Gordji-Nejad et al., 2024).

Sleep is still the actual intervention. But under metabolic stress, creatine seems to help buffer brain energy demand.

I did a deep dive on creatine and sleep deprivation as a guest on the Psychiatry and Psychotherapy Podcast, and helped put together the comprehensive show notes here:

3. Improves memory and processing speed

A 2024 review pooled 16 trials and roughly 500 participants on creatine and cognition. There was consistent evidence for improved memory, attention, and information processing speed (Xu et al., 2024).

The effect sizes are modest, not transformative. But for a supplement this cheap, safe, and easy to take daily, even small gains are worth it. Compounded over years, they add up.

4. Preserves muscle during immobilization

A small 2009 study put young men in arm casts for a week. The creatine group lost only 4% of strength compared to 22% in the placebo group, and 10% of endurance compared to 43% (Johnston et al., 2009).

This is my go-to recommendation when a friend or family member gets injured. It’s cheap, low-risk, and may help preserve strength while they heal.

The findings haven’t been replicated in larger trials. But for many healthy adults, creatine is low-cost, generally well-tolerated, and reasonable to consider given minimal other options.

5. Improves blood sugar in type 2 diabetes

In a 12-week trial, adults with type 2 diabetes on metformin who added creatine to their exercise routine dropped their HbA1c from 7.4% to 6.4%. This is a huge change and rivals first-line medications (Gualano et al., 2011).

Important caveat: this was creatine plus exercise, not creatine alone. It works as an add-on to training, not a replacement for it. I wrote a full deep dive on this here:

6. Enhances depression treatment

In a trial of 52 women with major depression already taking an SSRI, adding creatine led to faster and greater improvement by week 2, sustained through week 8 (Lyoo et al., 2012).

This is add-on territory, not standalone treatment. People with a bipolar history should not self-start creatine for mood without talking to their clinician first.

7. May support bone health

In one 12-week trial, older men who did resistance training plus creatine gained 3.2% in arm bone density. The placebo group lost 1% (Chilibeck et al., 2005).

A longer 12-month follow-up trial in older men didn’t replicate the density gains. There was no overall difference between creatine and placebo, though a trend toward improved femoral neck strength favored creatine (p = 0.061) (Candow et al., 2021).

Evidence is mixed, but still some signal of benefit. Given the strong safety profile and the other reasons to take it, bone health is a reasonable possible bonus.

8. Emerging signal for vascular and metabolic health

A small 12-person randomized crossover pilot in sedentary older adults found that 4 weeks of creatine improved several vascular markers, including flow-mediated dilation and a ~62% increase in microvascular reperfusion rate, along with reductions in fasting glucose and triglycerides (Clarke et al., 2024).

Too early to draw firm conclusions, but the data is intriguing.

9. Excellent safety profile

Creatine has one of the strongest safety records of any supplement studied. The International Society of Sports Nutrition reports that doses up to 30g/day for up to 5 years have been safe and well-tolerated in healthy individuals (Kreider et al., 2017).

But if you have kidney disease, are pregnant or breastfeeding, have other medical conditions, or are on prescription medications, talk to your doctor first.

The bottom line

Creatine is one of the most extensively studied and best-supported supplements out there. The strength and muscle evidence is overwhelming. The cognitive, metabolic, mood, and vascular signals are intriguing and getting stronger.

How to take creatine: the practical guide

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Nothing prepared me for what I would see in medical training.

What shocked me most wasn’t necessarily the dramatic stuff. It was how often a person’s catastrophe traces back to something completely ordinary. The things most people do every day without a second thought.

These are not common dangers. Most are rare, and statistically unlikely to happen to you.

But they are medically real. They are the kinds of cases doctors see, hear about, read about, and never forget.

This article is not meant to scare you. It is meant to make a few ordinary risks easier to recognize before they become potentially catastrophic in an unlucky few.

Here are 10 I never expected to learn.

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1. Feather pillows and duvets

A classic respirology presentation: a non-smoker with months of worsening cough and breathlessness. By the time a doctor sees them, they can't get dressed in the morning without stopping to catch their breath. Some need supplemental oxygen. A CT scan of their chest shows hazy "ground-glass" patches scattered across the lungs, the imaging pattern of widespread inflammation. The trigger was the feather duvet on their bed (Liu-Shiu-Cheong et al., 2019). Tiny down particles can drive an immune lung reaction called hypersensitivity pneumonitis; continued exposure can scar the lungs permanently.

2. Hantavirus from cleaning a cabin

A 44-year-old man cleaned a heavy infestation of rodent droppings out of an old camper van, then went camping. Two weeks later: sore throat, cough, breathlessness, fevers. Hantavirus pulmonary syndrome (Yap et al., 2016). The virus is shed in rodent urine, droppings, and saliva, and inhaled when contaminated dust is stirred up. HPS kills roughly 35% of those infected (de St Maurice et al., 2017).

3. Showerheads

Another classic respirology presentation: a woman with months of a stubborn cough that brings up tons of green phlegm, weight loss, and fatigue. Imaging of the chest shows small nodules and inflamed airways in one part of the lung. Her sputum grows Mycobacterium avium, genetically identical to the slimy biofilm inside her own showerhead (Falkinham et al., 2008). A 2009 study found similar bacteria enriched over 100-fold above tap-water levels in showerheads, aerosolizing into the airway with every shower (Feazel et al., 2009). In some cases, infection can lead to bronchiectasis: permanent airway scarring that can leave people with an ongoing productive cough, repeated chest infections, and worsening breathlessness.

Tip: Replace plastic showerheads and tubing every year, clean them with vinegar regularly, and keep your bathroom dehumidified.

4. Popping a pimple in the “triangle of danger”

A 22-year-old woman squeezed a pimple on her nose. A week later, the left side of her face was swollen and red. Within days, she was septic and short of breath: chest CT showed findings concerning for septic pulmonary emboli (chunks of infection that had broken off and travelled to her lungs), and brain imaging revealed a clot in her cavernous sinus extending down her jugular vein. She survived after weeks of IV antibiotics and blood thinners (Restrepo Vanegas et al., 2023). The veins between eyebrows and upper lip drain backward into the cavernous sinus, deep inside the skull, with few valves to stop infection from spreading the wrong way.

Tip: Never squeeze pimples in this zone.

5. Bad contact lens hygiene

A 57-year-old man came to the ED with eye pain and severe vision loss in both eyes after wearing the same soft contacts day and night for two weeks without daily cleaning. He could only perceive light from his right eye and hand movement from his left. His right cornea had perforated; the left had pus pooling inside the eye. A corneal transplant saved the right eye; the left healed with a permanent scar across his central vision (Cope et al., 2018). Sleeping in contacts raises infection risk 6 to 8-fold.

Tip: Never sleep, swim, or shower in contacts, or rinse them with tap water.

6. Cotton swabs in the ear

A healthy 31-year-old man developed seizures after worsening left ear pain and discharge. Brain imaging showed pockets of pus near the left temporal lobe of his brain. The cause? A cotton bud lodged deep in his ear canal, triggering necrotising otitis externa, skull base osteomyelitis, and subdural abscesses (Charlton et al., 2019). An estimated 263,000 US children have been treated in EDs for cotton-tip ear injuries; a quarter had a perforated eardrum (Ameen et al., 2017).

Tip: Never put anything in your ear canal. Oil drops are safer.

7. Tampons left in too long

Sepsis is a common serious reason for people to end up in hospital. It’s basically your immune system overreacting to an infection, and instead of just fighting the bug, it starts attacking your own body.

One tragic case: a 17-year-old girl died of tampon-related toxic shock syndrome while she was on her period. Swabs from her vagina grew a bacteria called Staphylococcus aureus that was making a toxin which sets the immune system off all at once (Tang et al., 2010).

Tip: Tampons should never be left in place for more than 8 hours

8. Phone charging on the bed or under a pillow

A 39-year-old man’s lithium-ion foot warmer caught fire while he was wearing it. Full-thickness burns through skin and muscle required weeks of surgery to repair (Cole-Price et al., 2024). Lithium-ion batteries and chargers can overheat or fail, and bedding can trap heat or ignite if something goes wrong (Duff et al., 2024).

Tip: Charge devices on a hard surface, never under a pillow or blanket.

9. Black licorice

A 54-year-old man collapsed in a fast-food restaurant after eating licorice-flavored candy daily for three weeks. His heart went into ventricular fibrillation, a chaotic rhythm where the heart quivers instead of pumping. His potassium had dropped to 2.0 mmol/L (normal is 3.4 to 5.0), low enough to throw the heart’s electrical signals into chaos. He died 32 hours after arriving at the hospital (Edelman et al., 2020).

The active compound in real black licorice (glycyrrhizin) blocks an enzyme in the kidney that normally keeps cortisol in check. With that brake gone, cortisol drives the kidney to flush out potassium, and levels fall fast.

This does not mean you can never eat black licorice. This case involved an extreme intake: he had reportedly been eating roughly 1 to 2 large bags daily for weeks. But it is an important reminder that dose matters.

10. Too Much Tylenol

Tylenol (acetaminophen) is one of those drugs that’s completely safe in proper doses, but it doesn’t take much to overdose. The recommended daily max for adults is 4 grams. Take more than that for a short while, and your liver can fail.

Another tragic case: A 22-year-old pregnant woman with severe dental pain took 8 to 9 grams of acetaminophen daily for about two weeks. She developed acute liver failure, needed a liver transplant, and her fetus unfortunately passed away two weeks after the operation (Thornton & Minns, 2012).

One of the most common ways people accidentally overdose is by taking acetaminophen from several products at once: a cold medicine, a sleep aid, and a prescription painkiller, all quietly stacking the same drug.

Tip: Read every label for “acetaminophen” and don’t combine multiple products. Check the correct dose with your doctor if you have medical conditions. And if you ever think you might have taken too much, please come to the ER right away. It doesn’t take much to overdose, but it’s incredibly easy to treat if caught early.

Thanks for reading. If you found this helpful, a like or restack means a lot and helps others discover it.

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This newsletter is for educational purposes only. It is not personal medical advice. Opinions are my own. Always consult your own health-care provider for medical guidance.

There is a strange moment before every high-pressure performance.

You are still technically the same person. Same brain. Same body. Same notes. Same slides. Same playbook. But sometimes you need to become someone slightly different. The person who can walk into the room and start the talk. The person who can step to the line and take the shot. The person who can speak clearly to their boss while their heart is trying to escape their chest.

Watch any video of Ronnie Coleman (8-time Mr. Olympia champion and bodybuilding legend) approaching a heavy lift and you will often hear the same cue: “Light weight, baby.” Watch Rafael Nadal before any serve and you will see the same small sequence of movements every time. Tug of the shorts. Wipe of the nose. Tuck of the hair behind each ear. It looks superstitious. It is not. Most elite performers have some version of this, and the same idea translates straight into clinical performance, public speaking, exams, and any other moment that demands you show up at your best.

Most people try to solve this by thinking harder. They reread. They rehearse. They over-caffeinate. They catastrophize. But performance is not just a knowledge problem. It is a state problem.

Your brain is constantly asking: who am I right now, and what would a person like me do next? That question gets answered by your mindset, your clothes, your posture, your music, your breath, your environment, the opening line you say to yourself. Not because cues are magic, but because they tell your brain which version of you is showing up.

Here is the system I actually use to cross that bridge.

1. Harness your adrenaline

Anxiety and excitement feel almost identical in your body. Racing heart. Tight chest. Heightened alertness. The difference is the story your brain attaches. Anxiety says danger. Excitement says opportunity. Trying to “calm down” usually fails because the arousal is already there.

A 2024 review pooled 44 randomized trials of stress reappraisal. People who briefly reframed their nerves as useful energy performed better than those who tried to suppress it (Bosshard and Gomez, 2024).

In one study, students preparing for the GRE were given a brief message before a practice test telling them that stress did not mean they were going to perform poorly. Instead, they were told this arousal could be their body mobilizing energy to help improve performance. These students scored higher on the actual math GRE, taken weeks later, than a control group (Jamieson et al., 2010).

Protocol:

• Reframe your feelings of stress as “I’m excited,” not “I’m anxious.”

• Avoid telling yourself to “calm down.” It often backfires.

• Frame your racing heart as fuel, not failure.

• Use a one-line script: “This is my body getting ready.”

2. Use a cue phrase, not a pep talk

Most people’s default self-talk is vague and hostile. Don’t mess this up. You always choke. Why are you like this? That is not honesty. It is a bad pre-game speech. Your brain needs a reliable switch.

That is what Ronnie Coleman’s “Light weight baby” actually was. Not motivation. Not bravado. A two-word command that told his nervous system how to interpret 800 pounds before he ever touched the bar. The weight did not change. The story attached to it did. And the story is what your brain uses to decide how much of itself to commit.

A meta-analysis of 32 studies found that self-talk consistently improved sport performance, with the strongest effects for fine-motor tasks and tasks people had not practiced before. Trained self-talk worked better than whatever people happened to mutter on their own (Hatzigeorgiadis et al., 2011).

In a separate cycling study, 24 athletes who practiced motivational self-talk for two weeks lasted 18% longer on a time-to-exhaustion test than controls, with reduced perceived effort at the same workload (Blanchfield et al., 2014).

Protocol:

• Pick four key cue phrases that motivate and are specific to you. Two for the early-mid phase (”feeling good,” “smooth and steady”). Two for the hard part near the end (”push through this,” “you’ve got this”).

• Make them specific. Running: “Feeling good.” High-pressure moment: “One breath, then go.” Presenting: “Slow is smooth.”

• Rehearse them during normal training before relying on them under pressure. Drop the ones that feel flat. Replace them with phrases that actually land with you.

• Use them during the task, especially for effort-dependent tasks, not just before. The above athletes deployed their cues mid-effort, when the urge to quit peaked.

3. Borrow an identity

“I am about to give a presentation” is fragile. Your brain can argue with it. Are you, though? You’re nervous. You haven’t rehearsed enough. “I am a presenter” or “I am the best candidate” is harder to argue with. When you take on a role, your brain stops asking whether you can do the task and starts asking what someone like you would do next. Action becomes a consequence of identity instead of a battle of motivation.

In one study, children who took on a role like Batman before a boring task persevered longer than children who simply tried to focus, with the strongest benefit for those who fully imagined being the character (Shachnai et al., 2022; White et al., 2017). The adult version is less about pretending and more about choosing the identity before the task: writer, runner, doctor, presenter.

Protocol:

• Before the task, name your role confidently: “I am the presenter walking into the room” or “I am the best candidate.”

• Ask what that person would do for the next 5 minutes.

• Pick a role that already feels true. Not aspirational fantasy.

• Pair the role with the right outfit (see #4 below). The cue is stronger when your brain has both signals.

This is the end of the free preview.

The first three tools are enough to start: aim the adrenaline, use a coaching cue, and step into the role.

Below: four more evidence-based strategies that build the rest of the system, plus the 5-minute performance routine I use right before high-stakes moments.

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You are not lazy. You are probably just bad at transitioning.

During residency, I would work 80 to 100 hour weeks. On my evenings off, I’d walk in, sit down “for five minutes,” and suddenly it was 9:47 PM.

Sometimes I was genuinely tired. But often I was just stuck in work mode: brain still on, body still, phone in hand.

The first 20 minutes after you get home decide what kind of evening you’ll have. Here are 10 evidence-based ways to make it swing your way.

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1. Change into your “evening uniform”

The first thing I do when I get home is shower (cold as you will see below), then change clothes. The shower is optional. The change is not.

Clothing carries symbolic meaning. In the original “enclothed cognition” experiments, wearing a lab coat improved selective attention (Adam and Galinsky, 2012). Your work clothes say keep performing. Your evening clothes should say you are home now.

Protocol: Before you sit, change into what you want the evening to be. Workout shorts and walking shoes if you want to move. Sweats if you want to read. Not work clothes.

2. Use cold water as a hard reset

A short cold shower is one of the few tools that genuinely shocks me out of work mode. The acute physiology backs this up: in an immersion study, 14°C water for one hour raised noradrenaline about 530% and dopamine about 250% (Šrámek et al., 2000).

Protocol: When you get home, take a cold shower. To make it tolerable, keep the shower warm and end with 30 to 60 seconds of cold. If even that feels like too much, just splash cold on your face. Cold face exposure alone dampens stress responses (Richer et al., 2022).

3. Put your phone in another room

Even when you aren’t using it, your brain knows it’s there.

Several experiments have discovered that the mere presence of one’s phone reduced cognitive capacity even when ignored; performance was best when it was in another room (Ward et al., 2017).

The effect extends to people too: having a phone visible on the table reduced self-reported emotional closeness, trust, and partner empathy, with the strongest effects during personally meaningful conversations (Przybylski and Weinstein, 2013).

Protocol: When you walk in, put your phone in another room. Not nearby, not in your pocket. More on this here.

4. Drink water before you diagnose yourself as exhausted

Sometimes “I’m dead after work” is dehydration plus a nervous system still running on work stress.

In an RCT after 12 hours of water restriction, 64 young adults received 500, 200, 100, or 0 mL. Even 200 mL reduced thirst, anger, and fatigue; 500 mL improved working memory (Zhang et al., 2020).

A separate study found only mild dehydration (1.36% body mass) worsened mood, raised perceived task difficulty, and lowered concentration (Armstrong et al., 2012).

Protocol: Instead of caffeine, snacks, or the couch, drink a few glasses of water.

5. Move before you sit

The couch is a behavioral black hole. The longer you sit on it, the harder it is to do something productive.

It takes shockingly little to have huge health benefits. For example, just 3-min bodyweight breaks every 30 min across a 4-hour evening extended that night’s sleep by about 29 minutes versus uninterrupted sitting (Gale et al., 2024).

Protocol: If you’re planning a workout, do it right away. If you do nothing else, while dinner cooks or Netflix plays, do 3 min of some sort of body weight exercise every 30 mins.

6. Walk for 10 minutes after dinner

Post-meal glucose responses get worse across the day, with the dinner spike usually the largest, and post-meal fatigue often hits hardest in the evening too.

In a randomized crossover trial of adults with type 2 diabetes, walking for 10 minutes after each meal lowered post-meal glucose more than one 30-minute walk, with the strongest effect after dinner (Reynolds et al., 2016).

Protocol: After dinner, walk for 10 minutes. Outside if possible.

7. Try cyclic sighing (or box breathing)

When I get home and am wired, a few minutes of breathing exercises or meditation does more for the rest of the evening than almost anything else I could do at that moment.

A randomized trial compared three breathing techniques (cyclic sighing, box breathing, cyclic hyperventilation) versus mindfulness, 5 min/day for one month. All three improved mood; cyclic sighing produced the largest mood improvement and biggest drop in respiratory rate (Balban et al., 2023).

Protocol:

• Cyclic sighing: inhale through your nose, add a small second inhale, then a long slow exhale.

• If that feels weird, box breathing works too: 4 in, 4 hold, 4 out, 4 hold.

8. Use binaural beats for mental fatigue

This sounds like nonsense, but there’s actually remarkable studies to back this up..

In one trial, participants finished a 90-min cognitive task, then 12 minutes of either 14 Hz binaural beats or quiet rest. The binaural beats group held their sustained attention performance. The quiet rest group’s scores collapsed from 49% to 18% on a standard attention test (Axelsen et al., 2020). Twelve minutes is shorter than most commutes home.

Protocol: Headphones, 10-12 min, beta-range track (14 Hz). More on this here:

9. Use creatine and chewing gum for “calm energy”

Late caffeine is a recipe for ruined sleep. For a non-stimulant alternative, creatine has the strongest evidence with benefits for memory, attention, and processing speed (Xu et al., 2024). I take 5-10 g daily; I notice a subjective lift on evenings I take it or an extra dose later in the day, which fits with trials on sleep deprivation.

Another low-effort option is gum. A meta-analysis of 21 papers found mastication produces a small but significant improvement in sustained attention (Miquel et al., 2019).

Protocol: 5-10 g creatine monohydrate daily. Sugar-free gum nearby.

10. Brain dump before bed

Working memory hates open loops. Unfinished work tasks keep firing in the background, even when you’ve left the office. Writing them down offloads them so your brain can drop the thread.

In a polysomnography study, those who wrote a 5-minute to-do list at bedtime fell asleep faster than those who journaled about completed activities; the more specific the list, the faster they fell asleep (Scullin et al., 2018).

Protocol: If work is still on your mind, grab a pen and write tomorrow’s list. Be specific: not “email Mike,” but “email Mike about the Q3 numbers.”

The bottom line

The goal isn’t a perfect evening. It’s to stop letting inertia from work dominate it.

You are not lazy. You are not broken. You just need a better off-ramp from work.

Thanks for reading. If you found this helpful, a like or restack means a lot and helps others discover it.

Subscribe now

This newsletter is for educational purposes only. It is not personal medical advice. Opinions are my own. Always consult your own health-care provider for medical guidance.