Monthly Archives: March 2013

Uncle Junior Had Sleep Apnea, and Wasn’t Even Overweight!

I love mob flicks. I always have. The Godfather films: love ’em all. Even the third one. I’ve read all the books (including the ones not written by Mario Puzo), memorized the movies. It’s become a tradition in my family to watch the first Godfather movie at least once per year.

Why? Because these “made” guys live lives that are so incredibly different and far-removed from my own. Because I empathize with them, these complex people that are so ruthless on one hand, but on the other protective and loyal to the death, doing the best they can for themselves and the ones they love. And, perhaps, there’s something seductive about the license they have to just simply . . . uh . . . do things–directly and definitively–about the people that wrong them. Whatever the reason, I find these films very cathartic. They never grow old; indeed, they get better with every viewing.

So imagine my happiness when The Sopranos debuted. Now I could follow the exploits of a New Jersey crime family every week! For years! (1999 to 2007, to be more exact.) I still miss it, now that its run is over.

Remember Junior, Tony Soprano’s notorious uncle? Tony and Uncle Junior had, shall we say, a love/hate relationship, one full of turmoil and, at one point, near-murder. Well, here is a scene in which Tony and Uncle Jun are having a brisk discussion in a CPAP clinic. Junior had just been diagnosed with obstructive sleep apnea!

Warning: anybody who has watched an episode of The Sopranos knows about the harsh language. If you’re new to or unfamiliar with the series, consider yourself warned before you watch the clip above.

Anyway, I distinctly remember this scene when it first aired. It was so strange to watch this mob guy get fitted with a nasal CPAP mask. It made Uncle Junior much more human to me, a little vulnerable. Maybe that was the intent of the producer of the show. That passage has remained stuck in my mind since I first saw it. There are some important points to be made from this scene, however:

1. You do not need to be obese to have sleep apnea. There is this misconception that all sleep apnea sufferers are overweight. This is simply not true. I have an army of patients that are as skinny as can be, including 90-pound ladies that snore like freight trains and gasp and choke all night long without treatment. Your throat and mouth anatomy has much to do with this. There are numerous anatomic characteristics that you may simply be born with, and that can predispose to developing sleep apnea, independent of weight: a large or wide tongue; a high-riding tongue base; a low-hanging soft palate; a large uvula (the dangly thing that hangs down from the soft palate); a “highly arched” hard palate; large tonsils; and “retrognathia,” in which the mandible (lower jaw) is set behind the maxilla (upper jaw). So just because you’re skinny doesn’t mean your snoring and witnessed breathing pauses during sleep should be ignored.

2. The prevalence of sleep apnea increases as one ages, particularly in males. The statistics demonstrate that sleep apnea gradually becomes more common the older we get, even independent of weight.

3. There are many different types of CPAP masks available. The one shown in this clip is clunky and old-fashioned, frankly, though similar masks are still out there for potential use. Now there are numerous new masks that are smaller, less leaky, and more comfortable, and with smaller and better-fitting headgear. CPAP (continuous positive airway pressure) is a primary form of therapy for sleep apnea.

4. Sleep therapists are available to help you through the process of initiating CPAP use. If you undergo an in-lab sleep study to diagnose sleep apnea, you will work with a trained sleep technologist who will help you through the testing and answer questions you may have regarding the diagnosis and treatment of sleep apnea. It seems that Uncle Junior was a bit smitten with his. I don’t know if the man fitting his mask was a physician or a therapist. Usually sleep or respiratory therapists conduct the fitting process of masks following sleep study testing. The actual process of mask fitting is (or at least should be, if the CPAP provider service is worth its salt) substantially more detailed and lengthy than what is shown in this clip: the idea is to find a mask that is comfortable and leak-free, and that means trying on multiple masks, of different types, brands, and sizes, to find the right one. What you see in the clip is simplified for the sake of the show; I suspect the viewing public would become bored with a full-scale demonstration of different CPAP masks.

I love Tony’s sarcastic comment to Uncle Jun at the end of his mask fitting: “How many MIG’s did you shoot down last week?”

Sleep Song #2: “Sleepwalking” by Lyle Lovett

I’ve loved Lyle Lovett‘s music for decades. I met Lyle, quite by chance, in 2006 at the Dallas / Ft. Worth Airport International Airport, my layover between the Bonnaroo and the national sleep medicine meetings. He is the consummate Texas gentleman, pure class both onstage and off. It was an absolute pleasure to get to know him.

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Among Lyle Lovett’s many great songs is “Sleepwalking,” from his 1998 album, Step Inside This House. As humorous as this song is (see the lyrics below), Lyle sings with substantial clinical accuracy regarding the mysterious phenomenon of sleepwalking, also known as somnambulism.

Sleepwalking represents a series of complex behaviors that tend to arise from arousals from non-REM sleep. Sleepwalkers walk about in an altered state of consciousness, often appearing confused or “glassy-eyed.” Judgment appears impaired. There can be variable degrees of interaction with their surroundings and with other people. Sometimes interactions with others can be inappropriate above and beyond the apparent confusion; agitation or even violence may occur in this setting. In the morning, upon awakening, they are usually partially or completely amnestic of the previous night’s sleepwalking event.

Because sleepwalking and other related parasomnias (the clinical spectrum of unusual movements or behaviors that occur during or out of sleep) tend to occur following abrupt arousals from deep forms of non-REM sleep (called “slow wave sleep“), it stands to reason that people who have lots of deep sleep at night may be particularly prone to sleepwalking. As such, those who are sleep-deprived or who have preceding insomnia (such as the protagonist in Lyle’s song) can be predisoposed to sleepwalking. Other factors that may increase a person’s risk for sleepwalking would include alcohol use; certain medications; previous head injury and other neurologic disorders; travel or sleeping in unfamiliar environments; and stress. In addition to avoiding these predisposing factors, it’s important for sleepwalkers to do what they can to get proper amounts of sleep each night–thus preventing or minimizing sleep deprivation, which leads to increased slow wave sleep–and keep their sleep schedules regular.

Here, now, are the lyrics to this great song. Enjoy!

Sleepwalking
(Willis Alan Ramsey)

Last night you know I couldn’t sleep
I was tossing, turning, and counting sheep
To tell the truth
The next thing I knew
I woke up on the outside
In the middle of the avenue

A policeman spied me in traffic there
In my t-shirt and my underwear
He said, “Son, Son
It sure don’t look good
The way you’ve been calling for your baby
All over the neighborhood”

It seems I was sleepwalking
Again last night
The way I was sweet-talking
It must have caused a terrible fright
Last night, you know when I was sleepwalking

Someone saw me at a doughnut shop
I was sitting and crying on a tabletop
It was not a pretty sight
I was out of control
The way that I was carrying on
About my sweet jelly roll

I said, “Officer please
My baby’s got me down on my knees
Lying in bed
Late at night
Sometimes I just go out of my head
At night
And I go out sleepwalking”

Later on, down at the jail cell
I was hoping things would turn out well
Because I don’t recall
That masquerade ball
And I sure don’t remember nothing y’all
About that blown up rubber doll

It seems I was sleepwalking
Again last night
The way I was sweet talking
It must have caused a terrible fright
Last night, you know when I was sleepwalking

So lately I’ve stopped going anywhere
And I’ve taken to sleeping with a teddy bear
It’s a very full and rich
Imaginary life
And it’s sure enough better than dreaming y’all
About any imaginary wife

No more sleepwalking
No more dreamtalking
No more sleepwalking
No more sleeptalking

Is Daytime Sleepiness a Problem?

 

The answer, of course, is yes.  However, it may not necessary feel like a problem to the sleepy person.  Why?  Because if you’re used to feeling a certain way during the day for years, and if there’s no pain or other immediately negative consequence involved, then that way feels tolerable for years and thus becomes normal–to you–because what feels normal is simply what you experience regularly and every day.

Here is a not-uncommon scenario in my clinic.  A man and his wife walk in.  I ask the gentleman if he feels sleepy during the day.  “Not at all,” he may tell me, or he may reply with a more vague “not any more than usual” or “not any more than anyone else.”  Does he tend to doze off if he’s in front of the TV, for example, I ask, or while reading at home?  “No, never,” he replies casually.  This is when the silent eye-rolling from his wife, who cajoled him for months into this visit, changes to an exasperated gasp.  The frustration now is just too much for her.  “He falls asleep all the time,” she tells me, much to the man’s annoyance.  “No I don’t!,” he exclaims, challenging her angrily with his eyes.  “You fall asleep at the dinner table!,” she returns.  “Every night!  Even when we have company!”  The exchange continues in its escalation, both voices now raised to the point in which they can be heard outside the clinic room.  There have been times in which I’ve had to intervene in a mounting spousal fight over this question of sleepiness.  It’s not like he thinks she’s deliberately lying.  He may believe she’s exaggerating, and may accuse her of being prone to exaggeration during this visit.  But the primary problem here is more inscrutable:  the manifestations of daytime sleepiness just don’t seem to be a problem to him like they are for her–what’s wrong with napping when you’re bored, after all–and therefore he doesn’t believe it signals the presence of a medical issue or something that needs to be acted upon or repaired.

There are several problems with this logic.  First, the tendency to drowse and fall asleep by accident, though not necessarily painful in and of itself, can in fact lead to things that are painful, like fall-asleep car crashes.  According to the National Highway Traffic Safety Administration, about 100,000 police-reported car accidents occur in the United States annually due to or associated with driver fatigue or sleepiness.  I’ve seen patients who admitted to me that they’ve fallen asleep behind the wheel of their 18-wheelers, or while driving their motorcycles on the freeway.  Tell me how this is not a dangerous problem.  Secondly, the idea that it’s normal to fall asleep by accident just because you’re sedentary or bored is not based on fact.  If you get proper amounts of sleep regularly and if there are no sleep disorders, you generally shouldn’t be falling asleep easily during the day, even if you’re bored.  Finally, and importantly, the tendency to struggle to stay awake is a symptom of something, not necessarily the problem itself but an indicator that something is wrong, wrong with the quantity of your sleep, the quality of your sleep, or both.

Excessive daytime sleepiness is an incredibly prevalent problem with far-reaching implications.  In 2008 the National Sleep Foundation conducted a survey (called The 2008 Sleep in America Poll).  Of its respondents, 36% nodded off behind the wheel during the previous year; 29% fell asleep at work or drowsed substantially at work; 20% had sex less often or lost interest in sex due to sleepiness; 14% missed family events, work functions, and leisure activities because they were too sleepy or had sleep problems.

The most common cause of daytime sleepiness is simple sleep deprivation.  The vast majority of human adults require between 7.5 and 8 hours of sleep per night regularly to feel awake and alert consistently during the day.  However, as you are probably well aware, many of us tend to get less than that, and often much less than that.  In addition, there are many medical sleep disorders, ranging from obstructive sleep apnea and periodic limb movement disorder to narcolepsy and idiopathic hypersomnia, for which daytime somnolence is an important clinical feature.  If you are struggling to stay awake during the day despite proper amounts of sleep each night, perhaps a sleep disorder needs to be uncovered and managed.

Bottom line:  daytime sleepiness is in fact a real problem, one that can directly and indirectly impact your quality of life.  Consider doing something about it.

Have a great week, everybody!  Cheers!

 

Turn the Clock Forward Tonight!

 

A week from tomorrow is “Selection Sunday,” the day in which the National College Athletic Association (NCAA) announces the participating teams in the annual national college basketball tournament, and the ways in which those teams will match up and “seed.”  Much less exciting, however, is what will happen tomorrow, which is that this year’s Daylight Saving Time (DST) will begin.  In most parts of the United States, clocks will be moved forward in time by one hour, starting from 2 a.m. overnight.  Some portions of the U.S. remain on “standard” time all year ’round:  Hawaii, some parts of Arizona, and U.S. territories of Guam, the American Virgin Islands, American Samoa, and Puerto Rico.  The idea is that advancing clocks forward a bit will provide us with more light in the evening and less light in the morning.

What this means is that the vast majority of Americans will feel tonight like we’ve “lost” an hour of time this weekend.  This one-hour shift does not truly represent a loss, of course, because we “gained” an hour in November 2012 (and will gain it again in November of this year).  But it can feel that way.  DST can be potentially disruptive to computers, various forms of equipment, medical devices, and other electronics, but it can also disrupt some people’s sleep, though usually mildly.

Adults are typically able to handle up to one hour’s worth of “shift change” in sleep scheduling per day (a critical concept in the understanding of jet leg, for example).  Everybody’s different, though, and everybody has different thresholds for feeling effects of changes in bed schedules and work schedules.  Making the change Saturday night into Sunday morning further allows for maximal societal flexibility in absorbing this time change in time for the beginning of most people’s typical work or school weeks.

For those who are particularly sensitive to effects of sleep schedule shift changes, my suggestion would be go to bed just a little bit earlier tonight (Saturday) than usual, say 15-30 minutes.  Then tomorrow night (Sunday), go to bed slightly earlier than you did tonight.  This exercise is not very taxing, and should allow you to absorb easily the time change internally in time for work or school come Monday morning.

Many basketball teams are playing their end-of-regular-season games today, so there will undoubtedly be some “bubble” teams (and their fans) that won’t be sleeping all that well tonight if they lose, independent of DST.  Most people, however, will sleep well and will find the shift change pretty easy to handle, though many (like myself) will grumble a little about the subjective sensation of the time “loss.”

Enjoy the weekend nonetheless, everybody!

How Do You Make Time For Sleep?

 

A high school classmate of mine recently asked me about how to find time for sleeping.  This is a vitally important question that bears discussion.

You probably have heard phrases like “sleep is for sissies” or “I’ll sleep when I’m dead.”  Well, regardless of the motivations one may have for saying such things, the fact is that sleep is essential, and you function best if you get as much sleep as your body and brain need.  An important concept is that your body will somehow, eventually, force you to find the time to sleep.  To those who do not believe this (take it from me, there are some people who honestly do not), a simple experiment would be to stay awake, day and night, for as long as you can.  See how long you can stay awake before you eventually fall asleep.  There comes a point in which the urge to sleep becomes overwhelming and completely irresistible, forcing even the most sleep-deprived people and the most hardcore insomniacs to yield to its power.

A less dramatic example from everyday life is the concept of “sleeping in.”  Most everybody has slept in, such as on weekends, on occasion during their lives.  Unless there is some complicating circumstance like certain medical illnesses, medications, or substances (like alcohol or drugs), your body won’t let you sleep more than what it needs, so sleeping in is your body’s way of telling you that it’s needing more sleep on other nights than what you’re granting it.

The vast majority of adults require around 7.5 to 8 hours of sleep per night regularly to feel fully rested and awake during the day.  However, today’s American society often makes it difficult to get that much sleep every night.  Think about the challenges we face.  Many of us work hard, spending long hours working, networking, and commuting.  We play hard too, engaging in numerous activities that make us happy and fulfilled.  Our lifestyle has evolved based on a combination of individual drive and capabilities and the culture and expectations of the society in which we live.  There are many additional factors that also play roles, of course.  If you have children, for example, you know well the challenges of coordinating your life with your kids’ schooling and activities.  The availability of different activities and entertainment has also grown exponentially in the past several decades; choices of things to do to occupy your time have now become virtually limitless.  Finally, there is technology, that ubiquitous fun, instructive, helpful, time-sucking presence that virtually defines our modern lifestyle.

These components are inevitable and inescapable in our collective lives.  There are still only 24 hours in a day.  But because there is always so much going on and because we’re always so busy, there are times in which something’s gotta give, and often that thing is sleep.  As a result, many of us sacrifice sleep, getting 4, 5, 6 hours per night for nights on end.  The problem is, there are well-known shortterm and longterm consequences of missing out on sleep, ranging from depression to fall-asleep car crashes.

Most of us have the common-sense knowledge that daytime fatigue and sleepiness result from missing out on proper amounts of sleep.  The clinical consequences of chronic sleep deprivation and the concept of sleep debt will be topics of future blog entries.  The purpose of today’s entry, however, is to outline a program to help a chronically sleepy, sleep-deprived person make more time for sleep.  Here are some simple but important steps.

1.  Buy into the notion that you need your sleep.  You need to own this one to get more sleep; as with anything else in life, fixing a problem starts with understanding the problem and acknowledging  the need to change.  This concept will be a recurring theme here at the Sleep Help Desk.  There’s nothing you can do about your intrinsic sleep needs:  you need sleep, and without enough of it inevitable consequences arise, such as daytime sleepiness, health problems, and decreased work productivity.  You’re human; it’s not macho to sacrifice your sleep to prove to everybody that you can go longer and further than everybody else.  A pot of coffee per day may make you feel more alert temporarily, but it doesn’t address the underlying cause of chronic sleepiness.

2.  Regulate your sleep schedules.  I recommend awakening around the same time every day, regardless of whether or not you need to awaken for work or some other activity.  This helps you obey your body clock’s hardwired need for regularity, allows you to get more consistent, predictable amounts of sleep at night, and ultimately increases your levels of wakefulness and alertness during the day.  If you have frequently irregular sleep schedules, you can still experience daytime sleepiness even if you get proper total amounts of sleep most nights.

3.  Change your bedtime scheduling little by little.  My recommendation is to slowly, gradually go to bed earlier, such as by 10-15 minute increments every 2-3 days.  If you know you’re sleep-deprived, tonight go to bed 15 minutes earlier than your usual.  Continue to go to bed around that time for several days.  Then, go to bed 15 minutes earlier than that.  Repeat this until you eventually get your 8 hours of bedtime per night.  This way, your body clock will easily absorb the changes you’re making in your sleep scheduling (thus avoiding a “jet-lagging” effect); if you suddenly go to bed two hours earlier than you usually do, for example, insomnia may well result, even if you’re sleep-deprived.  More importantly, however, you are more likely to be able to adhere easily to the changes you’re making for yourself if the changes are slow, deliberate, and gradual.  Why is this important?  Because we humans are creatures of habit.  If you’re used to staying up until midnight watching the late-night talk shows, for example, when you know you need to awaken early for work, though you know you will be sleep-deprived, the tendency to still stay up late watching TV remains, simply out of habit.  It’s what feels familiar and normal to you.  Successfully making something new familiar takes time.

4.  Reprioritize your and your family’s evening activities.  I know this is hard.  It took me some time to achieve this myself.  But if you really scrutinize what you and your loved ones do after work or school, it often becomes apparent that there are periods of time that could be either spent doing more essential activities or resheduled to another time of the day or week to allow for more sleep.  Try sitting down with your family and drawing out a weekly activity chart to determine what activities are most important in the evening, what activities can be stopped or rescheduled, and what down time there really is for you and your family to wind down from your day and prepare for adequate sleep.

5.  Stick with it.  Like restarting smoking, falling off the wagon and regularly getting less sleep than your body needs can eventually feel “normal” again because it returns to your daily routine.  Avoid the temptation.  Keeping striving to allow yourself proper amounts of sleep.  Often the tiredness you feel when you are now used to feeling more awake and alert during the day may be incentive enough to keep getting proper amounts of sleep each night.

Our crazy modern world doesn’t allow us to get our 8 hours every single night.  I recognize that, being a fellow member of our society, there are times in which there is no choice but to be sleep deprived from time to time.  March Madness is usually such a time for me, depending on how deep the Jayhawks get in the NCAA tournament (hopefully going all the way this year!).  Your body is usually able to handle a night or two of sleep deprivation from time to time, and make up for the sleep at a later time with minimal consequence.  Chronic sleep deprivation is an entirely different matter, however.

So the pearl for today:  be good to yourself and give your body the sleep it needs and deserves.  You eat and drink to provide your body with nutrition; don’t deny yourself the amount of sleep your body needs.

“Speed and Sleep:” My Interview With Kristin Hersh

The early nineties were a turbulent period for me: uneasy, scary, and fascinating, one of huge new responsibilities and intense personal and geographic exploration. And through it all, as has always been the case, music was there, providing stimulation, comfort, and light during an uncertain and often dark time.

My home state of Kansas has always been a classic rock, Zeppelin-n-Stones kind of place, but I was always able to find music not heard on Wichita radio. For years, alternative rock to me was electronic (Depeche Mode, Kraftwerk), gothic (The Mission U.K., Sisters of Mercy), or flannel (Pearl Jam, Nirvana). Then one day—I forget where or how—I came upon “Not Too Soon” by a Rhode Island band called Throwing Muses. I found their music totally different and completely compelling: dreamlike lyrics, edgy, unconventional guitar chord structures, tempo changes out of nowhere. Later, in 1994, when Throwing Muses’ cofounder, guitarist and singer, Kristin Hersh, released her first solo album, Hips and Makers, I was smitten. Even now, “Beestung” and “Your Ghost” transport me instantly back to my training days in New England, their delicate, dark acoustic melodies beautifully reflecting the shadows and quiet chaos I lived in at the time.

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So it is with some delight that I can say that in recent years I have become friends with Kristin Hersh. She is as lovely and intriguing as her music. Self-described as shy, she absolutely tears it up onstage. She lives and records music in New Orleans. She is a wife, mom, bandleader, touring artist, and author. She is also an insomniac of long standing.

Kristin’s difficulties with sleep are thoroughly chronicled in her excellent memoir, Rat Girl. On the very first page, introducing her 1985 self to us and upon finding a place to crash for the night: “So I park myself under a sad crucifix and watch tiny blue, green, red and orange bulbs blink on and off. Insomniacs like to waste time.”

Rat Girl‘s depiction of Kristin’s concept of musical creation demonstrates an altogether higher plane of creativity.  She has the gift of synesthesia, in which senses interplay and stimulate one another.  She sees music and melodies in colors; songs are born, and she is their pained, sometimes even reluctant, conduit. Her description of the sensation of sleeplessness is in many ways similar to that of her perception of music: colorful, raw, graphic, desperate, vivid almost to the point of shocking. “Sleep stopped coming, days stopped ending—now sleep doesn’t come and days don’t end. Sleeping pills slow my thinking, but they can’t shut down my red-hot brain. If I do manage to drop off, wild dreams wake me up. So I’m different now; my thinking is liquid and quick, I can function at all hours. My songs are different, too, and when I play them, I become them: evil, charged.”

People with psychophysiologic insomnia (a clinical form of insomnia, associated with excessive worry and frustration from not sleeping well) can easily relate to this portrayal of the sleepless mind. The urgency of her music further exacerbates her problems when birthed at night: “If I fall asleep, the song wakes me up, whispering, chanting and shouting, suggesting bass lines and backing vocals, piano parts and guitar solos. It’s that—the clattering noise of the thing, louder and louder, first whispering, then gasping with its own impact—that’s so upsetting, so overwhelming. A sickening frenzy.” Finally, conjoined with her insomnia, Kristin’s diagnosed bipolar disorder is also an important, recurring theme in her book; compromised sleep, particularly in the “manic” phase, is in fact a hallmark clinical feature of bipolar affective disorder and a primary contributor to the “red-hot brain.”

I checked in with Kristin recently and asked her some questions regarding her long struggle with insomnia.

MC: How long have you had your insomnia, Kristin? How has it changed or evolved over the years?

KH: I stopped being able to sleep reliably when I was a teenager and experienced my first manic episode. I could no longer fall asleep at night and songs came to me at 4 a.m., so I was only sleeping about fifteen minutes at a time. After that, life on the road, sandwiched between four pregnancies and subsequent sleep disruption due to nursing babies, was difficult to distinguish from that caused by manic and depressive episodes or even blood sugar imbalances.

MC: How has your insomnia affected your life? Like your thoughts, your songwriting, your relationships with others?

KH: It is the number one problem in my life (and in my husband’s life, though he has never experienced it himself!). Not only is it caused by bipolar imbalances, it also can trigger them. It reduces immune function and is so isolating that it imbues my worldview with a sharp loneliness that is very difficult for me to shake. I think my songs would be a lot less melancholy if I were healthier.

MC: How does the insomnia change, if at all, when you’re on tour?

KH: Crossing time zones shakes up any healthy pattern I’ve been able to implement but it also offers a handy scapegoat when I’m already out of balance! Sometimes it actually allows me to start over and clean up my sleep act. Additionally, playing music every night is such a release, there is very little tension or mind chatter left to keep me awake. That said, living without a schedule is difficult. The availability of meals and beds and showers and exercise is unpredictable at best.

MC: Have you found anything specific that has reliably helped you?

KH: Acupuncture helps immensely, but sleep medication doesn’t seem to work; it makes my brain more buzzy. Exercise helps and adhering to a strict schedule and diet help. 5-HTP and melatonin when I’m crossing time zones help temporarily.

A huge thank-you goes to Kristin for helping raise the awareness of insomnia and the effect it has on people’s lives.

I’ll conclude with Kristin’s perfect description of Throwing Muses music from Rat Girl, a book I recommend without reservation for its wit, honesty, and importance in the world of modern music. “Some music is healthy, anyway. I know a lot of bands who’re candy. Or beer. Fun and bad for you in a way that makes you feel good. For a minute. My band is . . . spinach, I guess. We’re ragged and bitter. But I swear to god, we’re good for you.”