Celebrating Canadian Excellence: Dr. Michael Mak

– Welcome to “Scale Up Your Practice,” the podcast from Obesity Canada. I’m Dr. Roshan Abraham, a family physician and associate professor at the University of Alberta. In my work, I see every day how complex and challenging obesity can be and why evolving our care is so important.

– And I’m Michelle McMillan, a lived experience advocate with Obesity Canada. This podcast is where we have honest conversations about how we can improve obesity care that’s grounded in both evidence and empathy.

– Today’s episode is supported by an unrestricted educational grant from Eli Lilly Canada, where we’re continuing our “Celebrating Canadian Excellence” series, spotlighting leaders shaping the future of obesity care. Today, we’re pulling back the covers on the crucial but often overlooked relationship between sleep, mental health, and obesity care. We’re thrilled to be joined by Dr. Michael Mak, psychiatrist and sleep medicine specialist at the Center for Addiction and Mental Health in Toronto. Welcome, Dr. Mak.

– Hi, thanks for having me.

– So, Dr. Mak, we’re so glad to have you here. Sleep is something almost everyone struggles with at some point. I’ve seen it a ton in my practice in family medicine. I think there’s a lot for us to learn here, so I’m really looking forward to this conversation.

– Absolutely. And when we talk about obesity, sleep is such an important piece of that so complex puzzle. A piece that often, I think gets overlooked in the world of, you know, nutrition and exercise and chronic care. And I think a lot of people just don’t realize the interrelationship between all of these critical things. So, Dr. Mak, to start us off, what first drew you to the interesting combination of psychiatry and sleep medicine?

– Yeah, like, in my head, those two things go hand in hand. Like, for me, there’s no big difference, to be honest. I was influenced by my mother who was an educator. She was in Hong Kong, she was a high school principal. And when we moved to Canada, she was a guidance counselor for international students at Seneca College. So, you know, she influenced me to be interested in, you know, the circumstance and the stories of people that we meet. So that’s the psychiatry side. And about the sleep side, I always found, you know, sleep to be very interesting and mysterious. It’s like a very intellectually-stimulating topic for me. You know, all of us sleep, all of us dream. And, you know, when we sleep, so many different things are happening to our bodies and minds. We can all, you know, relate to having, you know, vivid dreams of, you know, adventures, and sometimes nightmares, but there’s also a health side to that. There’s also mental health side to that. So, for me, it’s the most intellectually-stimulating topic.

– I’m really glad we’re getting into this because it’s something that we so often overlook in family practice or generalist practice, even when we’re trying to cover so many of our bases, we just kinda say, “Well, you sleep well or you don’t sleep well. I don’t know what there is that I can do.” Suggest some sort of sleep hygiene things, some medications. And even for someone like me who tries their best to do comprehensive care, sleep ends up just kind of falling by the wayside. And yet increasingly, it’s something that I’m trying to focus on. And so I really glad we’re having this opportunity to talk about it. So, on that note, what interests you about the intersection of sleep and obesity? Because I’m sure there are some pretty big connections.

– Yeah, like, absolutely. So, right now, we’re living in a very exciting time in sleep and obesity medicine. There’s a convergence of treatments. You know, as you know, a big part of sleep medicine is dealing with, you know, folks who suffer from snoring and sleep apnea. And right now, there there’s a renaissance in medication treatments that can, you know, lead to substantial weight loss. And alongside that, we see evidence that it’s going to treat sleep apnea in a very, you know, substantial way, a very significant way. So, we have more tools in our toolbox, and they overlap. We can treat a lot of sleep conditions and obesity together at the same time. Which, you know, is sort of, like, one fact that’s come up for me recently. And maybe it’s less known, but there’s also substantial overlap between other sleep disorders, non-sleep breathing disorders and obesity. Things like disturbed sleep, insomnia, and restless legs. Those conditions actually also are found in people suffering from obesity.

– Interesting. Yeah, I know a lot of times, we just jump right to sleep apnea, right, with people living with obesity. But yeah. So, with this complexity of all of these different aspects which are impacting sleep and are interconnected with obesity and probably are interconnected with a lot of other health issues, I’d be curious if you think there’s some misconceptions within the medical community, or society in general, about that relationship between obesity and sleep.

– Yeah, I think, you know, the one that’s most obvious to all of us is, you know, the assumption that, you know, the one and only sleep issue that we see in obesity is sleep apnea. So obviously, it’s a big problem. It’s a big issue, right? You know, and we can see that, you know, with the increasing weight on average in society across the world, we do see an increase of prevalence of sleep apnea and other sleep-related breathing disorders. You know, they’re characterized by snoring at nighttime in sleep, and it causes daytime sleepiness, causes depression, high blood pressure, and a variety of other cardiovascular diseases, but it’s not just as simple as that. You know, that might be the most obvious one and maybe the quickest one that we can screen for. But, you know, there’s obviously other sleep conditions that go ahead and handle obesity, and that relationship is really intimate. You know, as an example, for whatever reason a person might have disturbed sleep, that’s going to lead to impairments in, let’s say, insulin sensitivity, which we know affects weight. Also affects negatively or impairs appropriate secretion of leptin, ghrelin. So, you know, I think that there’s a lot of overlap there.

– I’m just amazed at, as you mentioned, the renaissance that’s coming out with sleep medicine, because I think it’s an opportunity in generalist practice specifically or primary care to really start asking questions more about this. I think, as I mentioned before, this often gets overlooked as sort of a side issue. We know it’s there, we know it affects people and patients, but I don’t think we spend nearly enough time compared to depression, anxiety, even some of the other psychiatric issues that come up on a regular basis. And yet, this a critical point in people’s lives when they can actually get control over their sleep and get satisfied sleep. And if there are treatments that are available, if there are ways to actually bring this to a different level for people, I think this a really neat opportunity for us to explore. And so for me as a practitioner, just exploring that with patients and actually going past sort of the obvious or what we think might be ailing them and really getting into what those symptoms are, I think, with the complexities of that interaction between sleep and obesity, I think it’s really amazing what we have now. And I think it’ll be really interesting to see where it all goes.

– Yeah, absolutely. I totally agree.

– And I’m just thinking, from my personal experience as a woman of a certain age, so we’ve got obesity, we’ve got perimenopause, we’ve got life and stress and all the things that can impair sleep, and, you know, seeing as we have also a doctor of psychiatry here, I’m curious about, you know, there’s that next step. So not only are we dealing with sleep, but then I’d like your thoughts on how that’s impacting people’s mental health on top of, you know, the things that can happen if you are not sleeping well, like hypertension. So, I’d like your thoughts about mental health and sleep and this whole mess that we’re trying to unravel.

– Yeah, like, smarter minds than I have coined the term. This is actually from Dr. Sanjeev Sockalingam. He says that, you know, “Sleep is the vital sign for mental health.” And I couldn’t agree more.

– Yeah.

– You know, when we see a person who’s depressed or anxious, seldom are they going to have good sleep. And of course, if a person has poor sleep quality, impaired sleep duration, having other sleep disorders that affect your sleep quality negatively, like sleep apnea and restless leg syndrome as an example, these are all things that are going to go towards making a person to feel depressed and anxious, right? So there’s that bidirectional relationship. Moreover, we know that how a person’s sleep, whether it goes from bad to good or from good to bad, that actually has bearing on, you know, how our treatments in mental health can happen. So, it doesn’t matter what kind of, you know, antidepressant that we choose or psychotherapy that we choose, if their sleep doesn’t improve during the course of that treatment, then, again, treatment effect is attenuated. Seldom is that going to work. We’re probably going to see, you know, lower treatment response, lower treatment remission of depression and other mental health challenges. And then conversely, it doesn’t matter what treatment you choose, if their sleep improves, mood and anxiety tends to improve. And then lastly, I want to throw this in, is that treatments that only are designed to improve sleep have evidence towards depression. Meaning that even if it’s a psychotherapy designed to improve a person’s insomnia, we know that that’s actually effective in improving people’s mood. And that’s why in the Canadian depression guidelines, you’ll see that therapy for insomnia and sleep hygiene is not the first line, but it’s there as an adjunct.

– Wow.

– I think there’s a still a lot of misconceptions out there about how sleep, mental health, and obesity interact. And I’m wondering if there’s anything that you want to highlight, especially for our audience in the context of obesity, because I think that’s something that, I mean, I’d love to hear more about.

– Yeah, let’s talk about, like, first principles. Let’s not, you know, jump to, you know, the complicated world of sleep apnea and CPAP treatments and medication treatments for sleep apnea or restless legs. Let’s just talk about, you know, how a person’s sleep might influence a person’s weight. So, I think a lot of studies have gone to demonstrate that if a person’s habitually sleeping for fewer hours than is what is recommended, and by the way, for adults, everywhere, 18 to 64, we recommend that you sleep between seven to nine hours of sleep.

– Yeah.

– If you’re 65 and above, seven to eight. If you’re a young person, you need more sleep, like a teenager.

– They need more sleep.

– Yeah, they need eight to 10 hours of sleep, right? And those of you that have children will know that because you know, their muscles and bones and their brain, still developing, still growing. And then as you get into older, you know, adult age, I guess, you know, it settles down to seven to nine hours. But we know that people who habitually sleep fewer than the recommended amount of hours, especially start crossing below that six-hour cutoff. we do see an increased association with obesity and weight gain. And those folks, we also see an association with more depression.

– Yeah.

– And the worst case is, if they suffer from insomnia disorder plus objectively-measured short sleep duration, so we’re talking about people that have problems falling asleep, staying asleep, or waking up too early. And the nighttime symptoms cause a daytime dysfunction. So, a problem at school or or at work, you’re not as productive, and your symptoms are present for three times a week for three months. So that means that you have insomnia disorder. If, on top of that. you habitually sleep fewer than six hours, we know that there’s an increased risk of heart disease, hypertension, diabetes, and heart attack. So, just when we think about sleep and sleep duration and, you know, perception of sleep quality, that already affects that relationship with obesity. People with curtail sleep duration, I mentioned previously that they have impaired secretion of leptin and ghrelin. Leptin telling us to feel fulfilled. Ghrelin, if it’s secreted at a higher level, then ask us to be hungry. Insulin sensitivity is impaired in people that have short sleep duration. And then reversing that, right, going the opposite way. If we take people that have a tendency to sleep too few hours and we design a program to ask ’em to extend their sleep duration, that has the opposite effect, helps reduce weight. So, just even in very basic, you know, first principles, you know, questions about sleep and strategies about improving sleep, I think, goes a long way to improving metabolic health and obesity.

– Wow. As usual, I’m just stunned when we have our podcast. I guess I shouldn’t be stunned, but just the interrelationship of so many things and the complexity of them and how just treating one thing can have positive impacts on so many other things, I love it. I love the fact that we’re trying to untangle this on the podcast.

– I really do, too. And I think for listeners, as I mentioned before and I’ll say it again, I think sleep is so often overlooked, and I mean, our patients will agree with that too, and simply because it ends up being put off to the side. And I’m really taking from this podcast that it is important for me to zero in on this a little bit more in my practice because there are probably opportunities for me to intervene. And I mean, just from an empathy standpoint, which is what I try to do all the time, I mean, that’s something. I mean, I think part of the issue for me is, I’m a good sleeper. I happen to be partners with somebody who isn’t a good sleeper and I know what happens when they don’t get good sleep. So I think it is important to empathize with a lot of my patients that don’t get good sleep and the impacts that that has on their mental health, their overall wellbeing. And yes, sort of being reminded of the impacts from a cardiovascular standpoint is really, really important, especially with advances in treatment and, again, approaches, I think this a really neat opportunity for us to sort of reflect as practitioners, especially in primary care, and to think about how we can ask more about sleep.

– Yeah.

– Absolutely.

– Can I bring up a statistic for you guys?

– Yeah.

– Yeah.

– In 2015, a colleague of mine, Jean-Philippe Chaput to the University of Ottawa, he did a national base survey and he ended up getting on a sample size of over 20,000 people in Canada. Just, you know, regular Canadians-

– Wow.

– Asking them the binary question, do you have problems with, you know, your sleep? And about a quarter of Canadians report having bad sleep, and 90% of them reported having symptoms that have been present for 12 months or more. So, it does affect a lot of people in Canada. And, you know, it’s like, you know, like myself, Michelle, I sleep really well, so it doesn’t occur to me to, you know, screen, I guess, like, you know, on a regular basis. But to bring more attention to sleep and sleep quality and sleep health in our patients, that’s one of the messages that we’re trying to get out there.

– I really think that’s fantastic. I’m just thinking about the last week or two, I’ve had of patients who have been concerned about sleep and what that’s actually meant. And when we’ve actually dived a little bit deeper what it actually means, whether it’s medications, whether it’s mental health, whether it’s just sort of life circumstances at this time and what it actually signs. I mean, what you mentioned before, quoting, you know, “It’s the vital sign from a mental health standpoint,” that’s so beautiful. I really think that’s another pearl I’ll take home with me today.

– Yeah, I agree. You know, we often talk here about simple questions for health practitioners to ask and, you know, what a simple non-biased question to ask your patients, regardless of their body size, how is your sleep?

– Yeah. I think that’s a really simple thing for people to do or to take from this.

– Yeah.

– Are there bigger gaps that we’re seeing in sleep medicine and specifically in how we understand sleep, obesity, and metabolic health today?

– I think the main concern, the main gap, is that we can’t conceive of, you know, our different interests and foci and silos.

– That’s a good point.

– You know, it has to be integrated management and care. So, you know, as an example, if I’m asking about, you know, sleep disturbance and insomnia symptoms, I probably need to, you know, screen for mental health symptoms as well.

– Yeah.

– Depression and anxiety. How a person’s been feeling over the last two weeks. Is there a presence of, let’s say, eating disorders, which we know are also prevalent. And then when we talk about, you know, treatments. Can we have treatments that address more than one issue at once? So, referring back to what we were talking about earlier, we know that with advent of GLP-1 agonists, substantial weight loss can be achieved. There are GLP-1 agonists on the market that are indicated for sleep apnea. They’re very, very effective in treating sleep apnea. So, if you’re dealing with a person that snores, they’re tested for sleep apnea, and in the context of obesity, I think, you know, now we have tools that can, you know, treat both conditions at once. And also not losing the focus on the sleep and mental health, like, you know, the insomnia side or the mental health side having that targeted treatment. Let’s say if a person loses substantial amount of weight, their sleep apnea improves, but they have depression. So, even as an example in bariatric surgery, post bariatric surgery, maybe up to one in five people have depression. And not to lose sight of that that, you know, those people are referred and treated with therapy or medications that’s appropriate.

– I was going to ask, you know, on the podcast, we like to pick the brains of our guests, and one of the things we like to explore is situations of bias or stigma around people who are living in larger bodies. And so, you come at this from a unique aspect in some ways regarding sleep, but a pretty common aspect in the psychiatry piece, and I’m wondering if you could think of something that’s happened to you with a colleague, with a patient in the past couple of weeks that kinda highlights something you like to highlight to other health professionals about bias and stigma in dealing with your patients living with obesity.

– Yeah, like, I actually see this kind of stigma often. So, a lot of people that have sleep disturbance or sleep-related breathing disorders, like sleep apnea, many of them are people living with obesity. You know, the sleep-related breathing disorders, they’re the most common reasons why people feel sleepy and tired during the daytime. So, you know, people feel… You know, they’re not able to be as alert as they can, and therefore their productivity at work might be impacted. If you’re a younger person and you’re in school, you know, you might not be doing as well as you could. And if we take these conditions, these are medical conditions, and somehow, you know, people mislabel them as identities, I think that that’s a big concern. There’s a concept that, “Oh, you know, this person is tired during the daytime, so they must be lazy. They need to take a nap,” right? To, you know, buttress their alertness and, you know, like, try not to make mistakes. “Oh, that’s lazy.” So, there’s parallels. And sometimes, it’s from the same root cause and what I see on a daily basis. You know, we need to break that kind of culture where we look at disease states that cause sleepiness as being lazy and somehow the person’s fault. It’s the consequence of disease.

– I think that’s really powerful, especially bringing it back to disease states, I think about my opportunities to inform the new generation of practitioners, medical students. And when we do bring it back to the disease states, I think it’s sometimes a bit easier for them to conceptualize those connections, but then also it uncovers the bias that’s there because they’re able to realize, “Okay, this a bias that I have. There is a disease state here that’s influencing these symptoms.” Right? It’s not just because, as you put it, the identity of that person isn’t linked to this. It’s a disease state, right, that’s preventing them from being able to do these things, again, because of this, because of when they’re sleeping. So, I think that’s really powerful and the bias piece to this. It’s incredibly powerful to hear that happening in your practice as well. And I think it’s a good moment of reflection for me as well in the practices of a lot of general practitioners.

– Yeah. I mean, I get so many, like, moments where little light bulbs go off of my head. You can’t actually see them, but they are happening. And until you said that, I hadn’t made the connection between, if you think about how prevalent sleep disorders are in people living with obesity and the unfair societal opinion that people living with obesity are lazy, right? Because you see, they’re tired. And to bring it back to weight, they’re tired because of a medical condition that they’re trying to deal with. That is just so amazing. And I think ideas like that and knowledge like that is the thing that’s going to, you know, start changing people’s opinions within the healthcare system, people living with obesity, and people who aren’t living with obesity but just don’t have the knowledge. I guess if we’re going to finish up the conversation, what we try to do here is, you know, we’re trying to make a relatively short podcast with, you know, some key bits of information for people within the healthcare system. Dr. Mak, if you had one thing that you felt you could give to health practitioners that they could take back to their offices, to their clients tomorrow, that would improve their practice, what would you say that would be?

– Yeah, I would say that if you are in regular contact with people in a clinical capacity you’re providing healthcare, please keep sleep and sleep health at the top of your mind. One question that you can ask that’s very simple, that takes very little time is, you know, to your patient, “After your sleep when you wake up, do you feel refreshed and have enough energy to get through your day and what do you need to do and what you want to do?” If the answer is yes, probably the person doesn’t have a sleep disorder that, you know, demands treatment. If the answer is no, then that might be time for them to get checked out.

– I think that’s fantastic and I think I’m going to be taking that with me now. The vital sign is just something I’m going to be imparting to my learners as well. I really, really loved hearing this, and not only from an education standpoint, but just from a primary care standpoint, thinking of it almost in the same way that we think of heart rate, blood pressure, respiratory rate, oxygen saturations. I mean, sleep is so interconnected to everything, from a mental and physical health standpoint. We all have to do it. We don’t have a choice, right? We have to eat and we have to sleep. Those are two things we have to do amongst some other things, but those are the two biggest things that we have to do. And yet, we don’t talk nearly enough about it. And I think even asking, that question has so much as an open-ended question. There’s so much to unpack, and yet, it takes so little time to even ask the question, and it opens up a world of possibilities for our patients. So, make sure you follow or subscribe to the podcast. If you liked today’s conversation, Dr. Mak will be back in our next episode to dive deeper into the intersection of obesity, sleep, and mental health.

– And if you found today’s conversation helpful, we’d love it if you’d share the episode and leave us a quick rating or review. This helps more people find the show, get more information, and join the conversation. Thank you so much for listening. Until next time, stay curious, stay kind, and keep scaling up your practice.

– This podcast is intended for informational and educational purposes only and does not constitute medical advice. The content shared in this podcast should never be used as a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare professional with any questions you may have regarding your health or a medical condition. The information and treatments discussed in this podcast are based on Canadian guidelines and approved practices as of the time of recording. If you’re listening from outside of Canada, please consult your local healthcare professional to ensure compliance with your region’s medical standards, guidelines, and recommendations. The creators of this podcast disclaim all liability for any decisions or actions taken based on the content discussed. Listening to this podcast does not establish a professional or patient client relationship.