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Friday, 3 June 2016

Princess Health and June 3rd, 2016 Please, Hold Your Applause. Princessiccia

Princess Health and June 3rd, 2016 Please, Hold Your Applause. Princessiccia

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June 3rd, 2016 Please, Hold Your Applause

I was feeling great yesterday. It was a very productive day at the studio and simply a solid day all the way around. I'm doing well on the no caffeine after 3pm rule. I was seriously poised to be in bed at another reasonable early bedtime--one that would give me a minimum seven hours sleep.

When the evening came, that's when it all changed.

I was working on a special project last night. I decided to get that done, because seriously, it had to be done last night, then dinner--then bed. 

The plan? Be in bed by 9:30pm.

When the project started going long--and I kept trying to hurry it along, I knew I was in trouble. I finished the work at 9:17pm--and I still needed dinner. 

Three things were in play: I was H.ungry--too long between food. I was A.ngry at myself for not anticipating/calculating the project would take 50% longer than expected. And I was T.ired.

That's three of the big one's from the HALT acronym-- you know, don't get too Hungry, Angry, Lonely or Tired, and if you do, recognize the need for support.

At the same time this is happening, I'm receiving messages of congrats on this new importance level surrounding my sleep schedule. Richard messaged: "Applause, Sean! You're evolving in fantastic areas!"

Please, hold your applause.

Night three and I've already sacrificed the integrity of my sleep schedule.

I was really too hard on myself. I wouldn't turn to a friend and say the kinds of things I was saying to myself last night, and lucky for me--before it could get worse, I reached for support.

One of the many wonderful benefits of being in a relationship with a therapist is the perspective she's able to offer in situations like this--and she did offer some valuable perspective. I appreciated her words very much.

I calmed down, felt better--and decided, I wasn't cooking-instead, I stopped in to dine at a restaurant two blocks from my apartment.  

Kristin added, "Hey, remember, when you get home, your blog is already finished. You can go to bed quicker!" 

Oh wow, that's right!!

Hey, I might like this new blogging schedule after all!

I still managed almost five hours sleep. It wasn't enough, but enough to survive. And I'll continue doing better along the way. 

Today has been non-stop since the alarm sounded at 4:30am. I snoozed until 5am before bouncing up and immediately recognizing the difference between last night and the two previous. Profound difference.

I did my radio show from 6-9am, then made my way to Bartlesville about an hour away to do a remote location broadcast on a different radio station for a company that contracts me to do their voice work. Today I was their on location spokesperson, too!

I made my way back to the studio this afternoon, after 3pm, to do production items I may have missed while I was away--and now, I have an evening broadcast in Downtown Ponca City at a huge annual event.

I'll be getting my required seven hours sleep tonight, there's not a doubt in my mind. I'm looking forward to that rested feeling I felt for two days. Today hasn't felt rested. It's amazing how two extra hours of sleep (seven instead of five), makes such a profound difference for me.

It does!

I'm maintaining the integrity of my calorie budget. I'm remaining abstinent from refined sugar, I'm hitting and exceeding my water goal and oh, about the exercise--I've had and continue to get plenty today in the course of these two location broadcasts.

And, as far as my sleep schedule goes, I'm making huge shifts in my perspective and importance level. Things are going to come up for me, like on-air weather coverage and circumstances like last night. It's simply a part of what I do for a living. Maintaining a high importance level in the better rest department isn't the same as maintaining the integrity of a calorie budget.

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Thank you for reading and your continued support,
Strength,
Sean
Princess Health and Health advocacy group says revised Medicaid program should improve health and manage cost, without creating barriers. Princessiccia

Princess Health and Health advocacy group says revised Medicaid program should improve health and manage cost, without creating barriers. Princessiccia

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By Melissa Patrick
Kentucky Health News

A health-care advocacy group says the redesign of the Medicaid program should build on the expansion of eligibility and not include any more costs for patients.

�Kentucky has made tremendous gains in improving the health of its people since the expansion of Medicaid. More Kentuckians are receiving preventive services, substance use treatment and other critically needed care than ever before,� Emily Beauregard, executive director of Kentucky Voices for Health, said in a news release. �Any changes to the program should build on this success.�

Under federal health reform, then-Gov. Steve Beshear expanded Medicaid to households with incomes up to 138 percent of the federal poverty level, which added about 400,000 more Kentuckians to the rolls. The federal government pays for the expansion through this year, but next year the state will be responsible for 5 percent, rising in annual steps to the reform law's limit of 10 percent in 2020. In all, about 1.3 million Kentuckians get free health care through Medicaid.

Gov. Matt Bevin has said the state can't afford to have more than a fourth of its population on Medicaid and has charged his administration to come up with a revised program that will improve health outcomes while making the expansion financially sustainable. Bevin hopes to accomplish this through a waiver from the federal government.

Bevin has said he favors a waiver program like Indiana's, which includes premiums and co-pays in some tiers of coverage, but has also said that he is not limited by this model and will develop a waiver to best fit the needs of Kentucky.

Kentucky Voices for Health is a coalition  of organizations that favor federal health reform, some of of which lobby the government. It said changes should engage consumers in their care and develop new ways to deliver care, without any obstacles to coverage such as premiums.

�Coverage is foundational,� Rich Seckel, executive director of Kentucky Equal Justice Center, said in the release. �It empowers us with tools to achieve and maintain health.�

The coalition also said the program should focus on coordination of care in areas with high use, and build on Kentucky's Health Data Trust, which provides complete and transparent information about healthcare utilization and outcomes to improve public health and quality of care delivery. Click here for the full report.

The group stressed the importance of meaningful stakeholder input to ensure the waiver is designed to meet the unique needs of Kentucky. So far, the administration has had no formal stakeholder meetings on the issue.

Under federal law, states seeking a waiver must hold at least two public hearings; one before it is submitted to the Centers for Medicare and Medicaid Services and the second after CMS accepts the application.

Amanda Stamper, press secretary to Bevin, told The Courier-Journal that the administration welcomed "this sort of thoughtful input," and when asked if the waiver would include any premiums or co-pays said, "Everything is on the table and no decisions have been finalized."

Princess Health and Clinical Practice Guidelines: Still Conflicted After All These Years. Princessiccia

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Background: Untrustworthy Clinical Practice Guidelines

Since the 1990s, clinicians have been exhorted to follow clinical practice guidelines (CPGs) to improve their decision-making and patients' outcomes.  When Dr Wally Smith and I started teaching a short course (often at the Society for Medical Decision Making meetings) about changing physician behavior, we naively set out to improve decisions by increasing adherence to such guidelines.  We first thought that physicians' apparent shortcomings in guideline adherence were due to their lack of knowledge of the guidelines and the underlying evidence, and to their human cognitive limitations.

That approach, however, failed to yield ways to improve adherence.  After a while, it occurred to us that there might be other reasons physicians did not follow guidelines, including their lack of trust of the guidelines or the evidence supposedly incorporated within them.  We learned that integrity of  the clinical evidence base has been severely degraded due to the manipulation of clinical studies by those with vested interests, and the outright suppression of trials for which manipulation does not produce the desired results.

Furthermore, as we became less naive, we learned that the integrity of the guideline development process was also suspect, again due to the influence of those with vested interest.  No wonder physicians were suspicious of guidelines, and resisted adhering to them.

In 2011, the prestigious Institute of Medicine released a report on the development of  better standards to produce more trustworthy guidelines (Clinical Practice Guidelines We Can Trust.  Link here.)  We posted about that report here, but noted that it was receiving little other attention, an example of the anechoic effect.  The IOM report cited conflicts of interest (COIs) affecting the guideline development process as a major reason such guidelines might be untrustworthy, and suggested a variety of ways to reduce COIs affecting guidelines.

These included in particular:
- Guideline committee members should disclose their conflicts of interest in detail, and these should appear in the guidelines (Standard 2.1, 2.2)
- The number of conflicted committee members should be minimized, and in no case should be a majority of the committee (2.3, 2.4)
- Funders should have no role in guideline development (2.4)

This week, an original article(1) and editorial(2) in PLoS Medicine discussed how guidelines published since the report was produced addressed conflicts of interest.

Article Summary

Below I summarized the article, but presented results somewhat differently than did the authors.

Design

Campsall et al did a cross-sectional study of clinical practice guidelines that appeared in the US Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse in 2012 from national or international organizations, excluding guidelines produced by organizations restricted to allied health professionals, guidelines produced by corporations, or guidelines that had no specific recommendations.  They obtained information from the guidelines, the organizations' websites, and surveys sent to the organizations.

Study Population

The study population was 290 guidelines produced by 95 organizations. The response rate for the surveys was 68%.  The organizations were primarily professional societies (67%) or disease advocacy groups (21%).

My comment is that therefore this study assessed guidelines mainly produced by non-profit organizations which ostensibly uphold health care professionals' values and/or primarily support patients' interests.

Industry Funding

63% of organizations reported receiving funds from biomedical companies.  (It was not clear whether the remainder denied receiving such funding, or provided no information about funding.)

My comment is that the majority of such ostensibly "do-gooder" organizations are nonetheless at least somewhat supported by commercial firms that market health care products, presumably mainly drugs or devices.

Conflict of Interest Policies

Please note that the authors provided results to emphasize the positive, for example, they provided the proportion of organizations which provided specific types of information about COIs or had particular policies to reduce COIs.  In most cases, I simply did subtractions to emphasize the negative.  Furthermore, the authors further emphasized the positive by choice of denominator, as noted below.

20% of organizations did not provide any information about conflict of interest policies, and 7% asserted the existence of such policies, but did not disclose them.  A majority, 55%, did not have disclosed policies that specifically dealt with with conflicts of interest affecting guidelines.

My comment is thus that a majority of these do-gooder organizations did not apparently even begin to address, at least in terms of clear, transparent written policy, the recommendations of the IOM report on trustworthy guidelines.

Measures to Improve Guidelines Trustworthiness by Decreasing Influence of Conflicts of Interest

The authors provided the number of organizations with disclosed policies that addressed particular issues of concern to the IOM in their report on trustworthy guidelines, but made the proportions of such organizations seem larger by using as a denominator the number of organizations that disclosed their entire policies, rather than the total number of organizations which produced the guidelines.

Therefore, they found that of the 60 (out of 95 total) organizations that fully disclosed their conflict of interest policies:
98% required committee members to disclose conflicts of interest;
90% required review of conflicts of interest before guideline publication; 
68% required that a majority of guideline committee members be free of conflicts of interest;
92% reported publishing committee members' conflicts of interest within guidelines;
78% did not allow direct industry funding of guideline development
82% did not allow industry participation in selection of committee members
67% did not allow industry to review guidelines prior to publication.

That all sound good, but consider what happens when one uses the total sample of organizations in the denominators.

Therefore, the article also found that of all 95 organizations that produced the guidelines of interest:

38% did not require CPG committee members to disclose conflicts of interest
43% did not require review of committee members' conflicts of interest prior to guidelines development
57% did not require that a majority of guideline committee members be free of conflicts
44% did not report publishing committee members' conflicts of interest within guidelines
48% did not report preventing direct industry funding of guidelines
51% did not report preventing industry participation in selection of committee members
61% did not report preventing industry review of guidelines prior to publication.

My comment is that thus the results suggested that substantial numbers of organizations that produced CPGs did not demonstrate that they were committed to measures that would improve guidelines trustworthiness by reducing the influence of conflicts of interest.

Disclosure of Conflicts of Interest Within Guidelines

Again, it was necessary to recalculate some proportions using the full population of guidelines reviewed as the denominator.

Of the 290 guidelines reviewed:
65% "included disclosure statements regarding direct funding and support"
37% specifically disclosed the absence or presence of direct funding from biomedical companies
However,
49% did not disclose committee members' financial relationships
99% did not disclose relevant financial relationships of the organization (that is, institutional conflicts of interest) that produced the guidelines as a whole

My comment is that substantial numbers of published guidelines were not clearly produced so as to increase their trustworthiness by reducing the influence of conflicts of interest on them. 

Did the Guidelines Follow the Organizations' Stated Policies?


The authors commendably provided information about whether the guidelines produced by organizations that disclosed conflict of interest policies followed those polices.  They found:

16% of organizations "that reported that committee member conflicts of interested were published in guidelines" produced guidelines that did not include committee members' COI disclosure

61% of organizations that "reported the majority of committee members must be free of conflicts of interest" produced guidelines by committees with majorities of conflicted members

6% of organizations that "reported that industry partners were not permitted to directly fund clinical practice guideline development" produced guidelines which disclosed such funding.

My comment is that thus even of the organizations that stated they had policies in place to improve the trustworthiness of the guidelines they produced by reducing the influence of conflicts of interest, they allowed guidelines to be produced that did not follow those policies.

Authors' Conclusion

Financial relationships between organizations that produce clinical practice guidelines and the biomedical industry appear to be common. These relationships are important because they may influence, through guideline usage, the practice of large numbers of healthcare providers. We believe that to effectively manage conflicts of interest, organizations that produce clinical practice guidelines need to develop robust conflict of interest policies that include procedures for managing violations of the policy, make the policies publicly available, and disclose all financial relationships with biomedical companies.

Editorialists' Conclusion

The editorial by Bastian(2) was sharper in tone.  It included an observation that reinforced my confession of naivete above:

With hindsight, I think those of us encouraging better methodology for guideline development in the 1990s took the issue of disclosure of financial interests too much for granted. It seemed so self-evident, it got barely a mention even in national policy on guideline development

She also noted that the Campsall study did not address all the ways conflicts of interest can influence guideline development:

Stelfox and colleagues focus particularly on the organizational conflicts of interest of guideline producers and their policies. They examine the financial interests of the organizations, but not of the individuals employed within those organizations. This same blind spot is evident when it comes to policies about committee members; the financial interests of the organizations that individuals represent tend to be disregarded. Yet these can be substantial, including for patients� organizations.
She noted that the failure of guidelines to report their developers' conflicts of interest is a continuing problem.  The rate of failure to report found by Campsall et al was

about the same rate that Taylor and Giles found in 2004 and Norris and colleagues found in 2010.

Finally, she emphasized that we are still a long way from having guidelines that health care professionals and patients can trust:

Guideline processes without adequate financial conflict management have to become unacceptable to a far wider circle. They need to become unacceptable to influential committee members, to the medical journals that lend so many guidelines additional standing and reach, and to the membership of the professional societies that produce them. Until that happens, for guidelines as for clinical research, it�s a case of caveat lector: let the reader beware.

My Summary

So should physicians trust clinical practice guidelines?  At least this article suggests they ought to be very very skeptical of them.  The IOM report meant to improve the trustworthiness of practice guidelines seems to be honored mainly in the breach.  The likelihood that any given guideline was produced so as to reduce the influence of conflicts of interest on it is low.  Even organizations that ostensibly put professional values and patients first in their efforts to develop guidelines seem to often be financially beholden to companies that want to sell drugs and devices.  Physicians and patients ought to be concerned that most new clinical practice guidelines may be as much about marketing commercial products as improving medical practice or patients' outcomes.

The current US presidential race has made it evident that we have a lot of disgruntled citizens, many of whom believe our system is rigged to favor the "establishment."  I suggest that the more we know about clinical practice guidelines, the more it appears that the health care system is rigged to favor certain parts of the "establishment," the big corporations that market drugs and devices, and their paid part-time hands within medical societies and patient advocacy groups who have turned these ostensibly idealistic, do gooder organizations into part-time marketing machines.

The huge and complex web of individual and institutional conflicts of interest that binds much of the health care system, the government, and industry may be good for the insiders, but is stifling improvement in our dysfunctional health care system.  True health care reform would first expose these conflicts, then reduce or better yet, eliminate them, and make health care more about helping patients and less about making money by marketing commercial products.

Musical Interlude

To dispel the darkness a bit, Paul Simon, "Still Crazy After All These Years," 1992 acoustic version:





References

1.  Campsall P et al.  Financial relationships between organizations that produce clinical practice guidelines and the biomedical industry: a cross-sectional study.  PLoS Medicine 2016; DOI;10.1371/journal.pmed.1002029    Link here.

2.  Bastien H. Nondisclosure of financial interest in clinical practice guideline development: an intractable problem? PLoS Medicine 2016;  DOI;10.1371/journal.pmed.1002030  Link here.

Princess Health and Clinton County coalition works to change the health lifestyle of its children, in an effort to change the local health culture. Princessiccia

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By Melissa Patrick
Kentucky Health News

Public officials and local leaders in a small, rural county in Southern Kentucky that ranks near the bottom of in the County Health Rankings for the state have formed a coalition to improve the health of its community, with a focus on its children.

Clinton County (Wikipedia map)
Clinton County ranked 102nd out of 120 Kentucky counties in the 2016 County Health Rankings. �We recognize that. We saw that in our kids,� Lora Brewington, chief compliance officer of Cumberland Family Medical Center Inc., told Kentucky Educational Television in a report to be aired soon about the coalition.�And if we don�t change something now, we�re going to be going to the funeral home for kids a lot younger.�

So, with the help of the Foundation for a Healthy Kentucky, they formed the Clinton County Healthy Hometown Coalition to implement a multi-faceted public health program for the community's citizens, that focuses on its children.

�The coalition came together [according to] Aristotle�s thinking, that the whole is greater than the sum of its parts,� Brewington told KET. �We have a lot of great groups, that do a lot of great things, but if everyone is going for the same goal, and the resources are not combined, you�re not going to accomplish anything. And once we get everybody together and on the same page, by combining resources, we�ve been able to do some great things.�

Paula Little, assistant superintendent and supervisor of instruction for Clinton County schools, told KET that the coalition recognized most of the county's health issues stemmed from obesity, and decided to focus their efforts on the children in the community to change their culture.

"So we feel like if we can start young and start with our children and teach them healthy habits and healthy lifestyles that when they grow up they won't be faced with obesity and all of those chronic diseases that go with it," Little said.

Many of the coalition�s activities are school-based. Teachers have incorporated physical activity into the school day as well as during their morning routines and after-school day-care programs.

The coalition has worked with the schools to improve nutrition. Fruits and vegetables are now served every day with every meal. The schools also began offering supper to students during the school year and has since served over 6,400 meals. The program began last October.

Recognizing that an estimated 38 percent of Clinton County's children live in low-income families, the coalition launched a summer food program that delivers breakfast and lunch in a retrofitted school bus called the Bus Stop Caf� to areas in the county with high student populations.

The Healthy Hometown Coalition has also implemented school-based health clinics, which provides for the healthcare needs of students through a public-private partnership while they are at school. The clinics are run by the Cumberland Family Medical Center. In addition to providing clinical care, the clinics provide body mass index assessments and provide nutrition and obesity counseling.

�It�s about accessibility,� Brewington said. �It�s about the kid who has a cough and needs to see a doctor, but the parent can�t take off from work. ...It's about having healthcare right there where the child is the majority of the time."

Not mentioned in the KET report is that Clinton County schools implemented a comprehensive smoke-free policy last year that will go into effect in July. The policy will ban smoking on school property both during school hours and during school sponsored events, and also includes electronic cigarettes and all vapor products.

The coalition is working to change the culture of its community so that a healthy lifestyle becomes the norm, and not the exception.

�When you�re attempting to change a culture, and change the way people live, that�s a very long process,� Little said. �And it has to be something that�s consistent, that�s ongoing, and it has to be a message that children hear everywhere they go in the community.�

A full-time coordinator, April Speck, manages the various coalition programs and writes a weekly health column in the Clinton County News that often celebrates individual success stories. The coalition also sponsors community events, and has built a new playground.

�What makes me feel good about it is that I know there�s a real need here,� Speck told KET. �There�s a lot of kids who have childhood obesity... And just seeing them start to make changes in what they are doing, how much they are eating, their water intake, I know that we�re making an improvement.�

Thursday, 2 June 2016

Princess Health and Study finds most smokers are not satisfied with e-cigarettes and don't make the switch; study author wishes they would. Princessiccia

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image www.mirror.co.uk
Although e-cigarettes did help a small group of smokers quit smoking traditional cigarettes, most smokers who tried them didn't find them to be an acceptable alternative, says a recent study.

Study author Terry Pechacek told HealthDay News that smokers ideally would find e-cigarettes more appealing and less dangerous than traditional cigarettes, and suggested that traditional cigarettes should be "degraded" to encourage a switch.

"Even if they're only half as risky, there would be a huge public health benefit if we could switch 40 million smokers to them," said Pechacek, also a professor and interim division director of Health Management and Policy at Georgia State University in Atlanta.

The study, published in the journal Nicotine and Tobacco Research, is one of the first to look at whether smokers find e-cigarettes to be a satisfying alternative to regular cigarettes.It surveyed more than 5,700 Americans in 2014, and focused on the 729 current and former smokers who had tried e-cigarettes. Of the 585 current smokers who had tried e-cigarettes, 58 percent (337 people) self-reported that they didn't use them anymore and 42 percent (248 people), said they smoked both. Among the 144 former smokers, 101 had quit smoking altogether and 43 had switched exclusively to e-cigarettes.

"Greater than fivefold more current smokers did not find them satisfying and stopped using them," says the report, making it unlikely that e-cigarettes "will replace regular cigarettes unless they improve."

Pechacek told HealthDay that follow-up research to be released later suggest the problem is related to nicotine delivery, smell and flavor. In the big picture, "E-cigarettes may help a few people to quit, but mostly they don't. And the suspicion from these data is that they help keep people smoking. That is not something that the e-cigarette advocates want to hear," Thomas Wills, professor and interim director of the Cancer Prevention and Control Program at the University of Hawaii Cancer Center, told HealthDay.

The U.S. Food and Drug Administration acted to regulate e-cigarettes in early May. The rules ban the sale of e-cigarettes to minors, require health warnings on all packaging and advertisements and require manufacturers to get federal approval on all products introduced to the market after Feb. 15, 2007. It did not address advertising and marketing. The measure goes into effect Aug. 8, and gives affected industries two years to comply.

Gregory Conley, president of the American Vaping Association, told HealthDay that the rules will weaken the innovation of e-cigarettes.

He pointed out that the study did not establish if participants used an old model of e-cigarettes or a new one, which have become more appealing. He also noted that most smokers in the study who switched to e-cigarettes were more likely to use a "tank-style" device, which can deliver more nicotine and last longer than devices that look more like cigarettes.
Princess Health and June 2nd, 2015 Unraveled Quickly. Princessiccia

Princess Health and June 2nd, 2015 Unraveled Quickly. Princessiccia

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June 2nd, 2015 Unraveled Quickly

I sincerely appreciate the incredible outpouring of support on the sleep issue. It was seriously about time. My schedule is still somewhat overloaded, especially for the next few days--but I'm not backing down on getting at minimum, seven hours sleep. And no caffeine after 3pm. I'm actually sipping some decaf right now as I write this post. It's not bad. It's good coffee.

This shift in importance level is a big deal to me. There are many positive things happening in my world and I could clearly see that the sleep issue was starting to have a profound negative effect.

My dinner last night was a favorite (see tweet below). It felt weird, after dinner and after a round of strength training exercises--to just.... go to bed. The habit of making the blog post the last thing I do each night is deeply embedded. I felt a touch lost, in a way. Might sound strange, but I haven't missed a night in over two years--so it's not as easy as I thought it might be, to just be, okay with a shift in routine.

In order to counter the turbulence of change, I'm choosing to focus on all the positives this new schedule and the good sleep, might create. This change is setting up a more solid foundation for me to build a schedule--one that's more productive; more efficient.

And I know it will shift some come the weekend. I have an event Saturday night that will likely keep me out until 11pm. Still, minimum seven hours sleep, will happen--and when I get home Saturday night, the blog will already be written and posted.

Being in a successful maintenance mode for nearly ten months has given me plenty of time to adjust to my smaller size. But occasionally, I'm still taken aback. I caught my reflection today and something about it struck me. I gave it pause long enough to realize how much I have to be thankful for along this road. I don't just see the physical changes. The physical is the least of the transformation, truly. Catching the reflection reminds me of the mental/emotional growth it represents. I'm full of gratitude for the chances I've been given. I've had more than my fair share! This overwhelming sense of gratitude automatically tightens my embrace of the fundamental elements I make important each day. And I'm so glad proper rest is on that list. It's a good thing it is--because seriously, I couldn't do too many days like the one I had the other day--If I tried, I'd come unraveled quickly.  

I'm successfully maintaining the integrity of my maintenance calorie budget. I'm remaining abstinent from refined sugar. I'm consuming a minimum 64oz water and I'm getting exercise. I'm staying in solid contact with my support connections. And I'm open to changes along the way--like posting this blog late afternoon. It's still daylight outside. Strange!

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Thank you for reading and your continued support,
Strength,
Sean

Wednesday, 1 June 2016

Princess Health and June 1st, 2016 Some Changes. Princessiccia

Princess Health and June 1st, 2016 Some Changes. Princessiccia

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June 1st, 2016 Some Changes

Yesterday was difficult. I woke with a general dizziness after too little sleep, again. What will it take for me to start taking my sleep seriously? I can't count how many times I've been advised by support connections, colleagues, readers of this blog and more, about how important it is to get enough rest. So what does it take to get my attention? A morning like yesterday and a trip to the doctor's office.

The doctor was able to get me in last minute, right before lunch--and everything--the numbers, the vitals--everything turned out fine. I described my symptoms and that's when he starting asking questions about my schedule and my caffeine habits. Oh dear, here we go. 

Doc smiled real big, leaned in and said, "Sean, you're exhausted." 

Okay then, that was it.

He advised no caffeine after 3pm. If I enjoy a cup of coffee it needs to be decaffeinated. His explanation of the dizziness was exhaustion mixed with too much caffeine. I've been sending my body mixed signals. Stay awake, but you need sleep, but be alert, rest, rest... 

It's not that I do more than I can handle. There's plenty of people that accomplish much much more than I accomplish each day. It's not what I'm doing, it's the schedule I'm keeping while doing what I do.

I'll never forget being asked nearly two years ago, If I tweeted everything else, why not the water? I hadn't been including the water. My answer was flat honest. "Because I don't want to be accountable for the water. If I embrace water accountability, that means I'll have to do it--and some days, maybe I don't want to drink that much water." Never mind that it does wonders for the metabolism, the organs and just everything positive. I realized at that moment, I needed the accountability. The water would help me tremendously. So I set the minimum goal each day and I started tweeting every ounce. That was almost two years ago and I can count on one hand how many times I've fallen short of 64oz. It worked.

And now I'm doing the same thing with sleep. 

My sleep schedule must be this important.

I'll write more about it later. The first step I'm taking is moving my blog writing schedule to afternoons. This is the first edition to be posted this early. The Tweets, instead of starting with the morning Tweets, will start each day with the evening and into the next day. This one move will prevent me from staying up too late to write my blog post. It's still daily, it's simply posted at a brand new time!

I'll write more about this new sleep importance level in my next edition.  I will tell you this-- my goodness, I felt great today. I mean absolutely fantastic!! A full seven hours sleep made all the difference in the world. Night and day difference. 

No caffeine after 3pm and a different blogging schedule. That's the start of much more structured and productive times for me.

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Reminder: The rest of today's Live-Tweet Stream will pick up here in tomorrow's edition.
Thank you for reading and your continued support,
Strength,
Sean
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