This piece continues from the previous installment of Stones in the Body: More Frightening Than Cancer (Yoon Jong-won). The body, figures, and citations follow the manuscript as written.
Lack of Sleep: Save on the Night and the Bone Melts
Mr. Lee falls asleep at 1 a.m. and gets up at 7 a.m. That is 6 hours. The recommended sleep duration is 7 to 9 hours. Every day he is short by 1 to 3 hours.
Why does he not sleep? Because the drama is interesting. Because the game will not end. Because he keeps watching social media. Because there is a lot to do.
The sleep-rhythm collapse dealt with in the primary factors was 'cannot' sleep. It was the case where, because of stress, anxiety, and depression, one cannot sleep even when trying to.
The lack of sleep in the secondary factors is 'will not' sleep. One could sleep if one tried, but does not sleep because of doing other things. It is a matter of choice.
The result is the same.
During sleep at night, growth hormone is secreted. Growth hormone is not needed only by children. It is essential for adults as well. It is involved in tissue repair, muscle maintenance, and bone metabolism.
Growth hormone is secreted mainly during deep sleep (slow-wave sleep). If you cut sleep, especially if deep sleep decreases, growth hormone secretion decreases.
During sleep at night, cortisol drops. Cortisol should be high in the morning and low in the evening. It is the rhythm that gives the strength to get up in the morning and lets one fall asleep in the evening.
If you stay awake until late at night, this rhythm breaks. If cortisol is high at night, sleep does not come. If sleep is insufficient, the next day's cortisol rhythm breaks further. It is a vicious cycle.
Lack of sleep raises inflammatory markers. Inflammatory indicators such as IL-6 and CRP rise. The exact mechanism of why is still under study, but it is clear that sleep plays an important role in immune regulation.
Mr. Lee thinks, "6 hours is enough." Because he has gotten used to it. But the body does not get used to it. A little debt piles up each day.
| Area | Factor | Main trigger | DIAH code | Mechanism summary |
|---|---|---|---|---|
| Movement | Lack of exercise | D(deficiency) + H(hypoxia) | D-PH(physical-stimulus deficiency) + H-CR(circulatory hypoxia) | Bone stimulation halted + circulation lowered (double blow) |
| Movement | Sedentary life | D(deficiency) + H(hypoxia) | D-PH + H-CR | Dangerous if you sit even when you exercise |
| Food | High-salt diet | D(deficiency) | D-NT-2(main) + A-DT-2(conditional) | Calcium excreted along with sodium when sodium is excreted |
| Food | High-sugar diet | I(inflammation) | I-MT-2(main) + A-FN-2(conditional) | Glucotoxicity + AGEs + metabolic inflammation |
| Food | Ultra-processed food | I(inflammation) + D(deficiency) | I-MT-2(main) + D-NT-2(sub) + A-FN-2(conditional) | Inflammation + phosphate + nutrient density↓ |
| Food | Drinking alcohol | A(acidosis) + I(inflammation) + D(deficiency) | A-DT + I-MT + D-NT | Acid metabolism + oxidative stress + reduced absorption |
| Respiration and rhythm | Smoking | H(hypoxia) + I(inflammation) | H-RS(respiratory hypoxia) + I-EN(environmental amplifier) | CO → oxygen transport↓ + chronic airway inflammation |
| Respiration and rhythm | Lack of sleep | H(hypoxia) + I(inflammation) | H-RS + I-ST(stress inflammation) | Growth hormone↓ + cortisol rhythm collapse |
Tertiary Factors: An Acute Event Pushes Through the DIAH Funnel
The primary and secondary factors widen the entrance of the DIAH funnel. Slowly, quietly, unnoticeably. Then one day a tertiary factor comes. Suddenly, without warning. And it pushes through the funnel in one stroke.
To understand the fearsomeness of the tertiary factor, we must compare two people.
A thirty-year-old young man, Mr. A, fell on the stairs. He struck his hip hard. It hurt. He got a bruise. But after resting a few days he was fine. There was not even a crack in the bone.
A seventy-year-old elder, Mr. B, fell on the same stairs. He struck his hip in a similar way. His hip joint broke. He had surgery. He lay in bed. Even after a month passed he could not walk properly. After three months passed he caught pneumonia. One year later, Mr. B passed away.
The same stairs, a similar fall. Why are the results so different?
Mr. A's bones were strong. His muscles were firm too. His immunity was good too. His reserve was sufficient. Even when an impact was applied, there was room to withstand it.
Mr. B's bones were already weakened. Over decades, through the primary factors (stress, lack of sleep) and the secondary factors (lack of exercise, nutritional imbalance), the gates of the DIAH funnel had widened. Calcium had been leaking out of the bones little by little. Muscle had wasted away too. Immunity had dropped too. His reserve had run dry.
For Mr. A, the fall was an 'event.' A painful but recoverable event.
For Mr. B, the fall was a 'trigger.' It touched the first piece of an already leaning row of dominoes.
This is the essence of the tertiary factor. The tertiary factor itself often cannot be avoided. Falling, getting infected, undergoing surgery. They are part of life. The problem is when the tertiary factor is applied to an 'already weakened body.' The same impact produces a completely different result.
Scene, Falls and Fractures: Failing to Get Up Is the Problem, Not Falling
We saw it earlier in the case of Mr. Jeong. He fell and his hip joint broke. The surgery was successful. But what came after was the problem.
Because there was pain, he did not want to move. He was afraid he might fall again. So he stayed lying down. A week, a month, three months.
What happened while he lay there?
Stimulation to the bone disappeared. D-PH(physical-stimulus deficiency) opened. The muscle pump stopped. H-CR(circulatory hypoxia) opened. Two gates opened wide at the same time.
According to the LeBlanc study, one week of bed rest decreases bone density by 1%. A month means 4%. For Mr. B, who already had osteoporosis, 4% is fatal.
At the same time, when you lie down, lung function declines. As the direction of gravity changes, secretions pool in the lower part of the lungs. It is hard to cough them out. It becomes a good environment for bacteria to grow. The risk of pneumonia rises.
When you lie down, blood flow stagnates. Especially in the legs. Blood pools in the veins, and a clot can form. If the clot breaks off and goes to the lungs, it is a pulmonary embolism. It can cause sudden death.
There is a study showing that the one-year mortality rate of hip fracture reaches 20 to 30%. It is the result of a meta-analysis by the Haentjens research team. The fracture itself is not the cause of death. The 'immobile state (不動)' caused by the fracture is the cause of death. When you lie down, pneumonia, blood clots, bedsores, muscle loss, and bone loss occur in a chain.
For Mr. Jeong, the real danger was not the falling. The failing to get up was the real danger.
Acute Infection: The Inflammation Explosion Burns Calcium
Mr. Choi, a sixty-five-year-old man, was usually healthy. One day he caught a cold. He thought it was nothing. A few days of rest and it will heal.
But the fever did not go down. The cough got worse. His breathing became short. When he went to the hospital it was pneumonia. He was admitted. He received antibiotics. He was discharged after a week.
After discharge, Mr. Choi was listless. He had originally been an active person, but he had no energy to do anything. Even after a month passed, he did not return to his former condition.
Why is that? Let us look at what happened during the acute infection.
Pneumonia bacteria invaded the lungs. The immune system was mobilized in full. White blood cells rushed to the lungs. Inflammatory cytokines poured out. IL-1, IL-6, TNF-α. A fever arose. The body became a battlefield.
Calcium is mobilized for this war. For immune cells to be activated, an intracellular calcium signal is needed. Calcium is used in large quantities to fight the infection.
At the same time, inflammatory cytokines directly affect the bone. IL-1 and TNF-α activate osteoclasts. The cells that dissolve bone suddenly become active. The more severe the inflammation, the greater the bone loss.
Acute infection opens I-AC(acute infection). It opens intensely in a short time. A week of hospitalization can cause several months' worth of bone loss.
This is the reason Mr. Choi had no energy even after a month passed. He won against the infection, but in that process the body's reserve was exhausted.
Surgery and Hospitalization: Treatment Creates a New Problem
Surgery is treatment. It is done to cure disease. But the surgery itself is a stress on the body. Treatment can create a new problem.
Ms. Kim, a sixty-year-old woman, had knee artificial-joint surgery. Her knee hurt so much that walking was hard. They said that if she had the surgery she could walk again.
The surgery was successful. But after the surgery several things overlapped.
There was the stress of the surgery itself. Anesthesia, incision, bleeding, suturing. The body perceives this as trauma. Stress hormones are secreted. Cortisol rises. I-ST(stress inflammation) opens.
Bed rest was needed. One must lie down until the surgical site recovers. It is not complete immobility, but the amount of activity sharply decreases. D-PH(physical-stimulus deficiency) and H-CR(circulatory hypoxia) open.
She had to eat hospital food. Hospital food tries to balance nutrition, but it is less tasty than home cooking. With no appetite, she does not eat well. Protein intake decreases. D-NT(nutritional deficiency) can open.
There was infection risk. The hospital is a place where sick people gather. There are also antibiotic-resistant bacteria. Surgical-site infection, pneumonia, urinary tract infection. I-CH(chronic infection) can open.
Ms. Kim had the surgery to fix her knee. The knee got better. But during the 2 weeks of hospitalization, muscle wasted away. After discharge, rehabilitation took longer than expected.
If surgery is needed, it must be done. But you must know that surgery is not 'free.' Raising physical strength as much as possible before surgery, and moving as soon as possible after surgery, is important.
4. Why Tertiary Factors Are Especially Dangerous: The Problem of Reserve
Let us summarize.
The tertiary factor itself often cannot be avoided. No matter how careful you are, you can fall. No matter how much you wash your hands, you can get infected. If disease arises, you may have to undergo surgery.
The problem is when the tertiary factor is applied to an 'already weakened body.'
For a young and healthy person, a person with sufficient reserve, the tertiary factor is a 'recoverable event.' Even if they fall, they get up. Even if they are infected, they overcome it. Even if they have surgery, they recover quickly.
For a person whose gates have already widened through the primary and secondary factors, a person whose reserve is exhausted, the tertiary factor is a 'decisive blow.' If they fall, they cannot get up. If they are infected, they are sick for a long time. If they have surgery, complications arise.
So the focus of prevention is not avoiding the tertiary factor. The tertiary factor cannot be avoided. The focus of prevention is blocking the primary and secondary factors. It is keeping the gates narrow. It is preserving the reserve.
If you manage the primary and secondary factors well, then even when the same tertiary factor comes, a different result comes out.
| Tertiary factor | Main trigger | DIAH code | Mechanism summary |
|---|---|---|---|
| Fall and fracture | D(deficiency) + H(hypoxia) | D-PH(physical-stimulus deficiency)-3 + H-CR(circulatory hypoxia)-3 | Bedridden → bone stimulation halted + circulation lowered |
| Acute infection | I(inflammation) | I-AC(acute infection)-3 | Inflammation explosion → calcium mobilized for immunity + osteoclast activation |
| Surgery and hospitalization | D(deficiency) + H(hypoxia) + I(inflammation) | D-PH-3 + H-CR-3 + I-CH(chronic infection)-3 | Bed rest + lowered circulation + infection risk |
| Acute hemorrhage | H(hypoxia) | H-CR-3 | Blood volume decrease → tissue hypoxia |
| Traffic accident | D(deficiency) + H(hypoxia) | D-PH-3 + H-CR-3 | Trauma + immobility + circulatory disturbance |
It is not that you don't fall because you are lucky. Blocking the primary and secondary factors and having the 'reserve' that keeps you from breaking even when you fall is the real luck.
The Door That Drugs Open [Table] ⚠️ Safety Gate
| Caution |
|---|
| This section is not a criticism of prescriptions. Medicines are prescribed because they are needed. It is because the benefit is greater than the harm. It is only that we should know that some medicines can 'incidentally' widen the DIAH funnel, and manage it by consulting with the attending physician. Never stop a medicine you are taking on your own. Consult your attending physician from the perspective of 'bone, falls, nutrition.' |
Ms. Han, a sixty-two-year-old woman, has been taking steroids for ten years for rheumatoid arthritis. The joint pain has improved a lot. Without the steroids, her joints would have been ruined and she would not have been able to use her hands.
But in a recent bone density test she was diagnosed with osteoporosis. The doctor said it was "a side effect of long-term steroid use."
Ms. Han was confused. The medicine weakened her bones? Then should she stop the medicine?
No. She must not stop the medicine. If rheumatoid arthritis is not controlled, the joints are destroyed. The 'benefit' of the steroid is greater than the 'harm.'
But it is a fact that steroids affect the bones. You must know this and prepare for it. Supplement calcium and vitamin D, exercise, measure bone density regularly, and if necessary add an osteoporosis medication.
Knowing that a medicine can widen the DIAH funnel and stopping the medicine are completely different matters.
1. Scene, Glucocorticoid (Steroid): The Drug That Opens All Four Trigger Gates
Steroids are powerful anti-inflammatory drugs. They are prescribed to suppress inflammation in autoimmune diseases such as rheumatoid arthritis, asthma, Crohn's disease, and lupus. They are also used to prevent rejection after organ transplantation. Sometimes they are life-saving drugs.
But taking steroids for a long time affects the bones. Steroids are the only drug that can open all four gates of DIAH.
It opens the D(deficiency) trigger gate. Steroids decrease calcium absorption in the intestine. Even if you eat calcium, it is not absorbed. At the same time, they increase calcium excretion in the kidney. They reduce the calcium coming in and increase the calcium going out.
It opens the I(inflammation) trigger gate. It sounds paradoxical, but while steroids suppress inflammation, they simultaneously activate the inflammatory pathway of the bone. They directly suppress osteoblasts. The cells that make bone cannot do their work. They extend the lifespan of osteoclasts. The cells that dissolve bone live longer.
It opens the A(acidosis) trigger gate. Steroids disturb metabolism. Blood sugar rises, fat distribution changes, and they can affect the acid-base balance.
It opens the H(hypoxia) trigger gate. Steroids can damage the microvessels. In particular, if the microvessels of the femoral head (the head of the thigh bone) are affected, avascular necrosis can occur. It is when the blood flow to the bone is cut off and the bone dies.
The FDA warns of osteoporosis risk with long-term steroid use. It is the drug with the highest level of evidence.
If you are taking the medicine: do not stop it. Consult your attending physician and discuss calcium and vitamin D supplementation, exercise, bone density monitoring, and if necessary the addition of an osteoporosis medication.
2. Proton Pump Inhibitor (PPI): Suppress Gastric Acid and Calcium Will Not Dissolve
Omeprazole, esomeprazole, lansoprazole. They are drugs that suppress gastric acid secretion. They are widely prescribed for gastroesophageal reflux disease, gastric ulcer, and indigestion. Some can be bought at the pharmacy without a prescription.
PPIs suppress gastric acid. Because if there is too much gastric acid, the mucosa of the esophagus or stomach is damaged. But gastric acid has another role too. The role of dissolving calcium.
Calcium is an alkaline substance. It dissolves well in an acidic environment. The gastric acid secreted in the stomach dissolves calcium and makes it into an absorbable form. But if you suppress gastric acid with a PPI, calcium does not dissolve well. Undissolved calcium simply passes through the intestine and is excreted.
Taking a PPI long term can decrease calcium absorption. In particular, the effect can be large for people with insufficient calcium intake and people with insufficient vitamin D.
The connecting code is D-NT. Evidence level ★★.
If you are taking the medicine: consult your attending physician so that you take it only for the necessary period. If long-term use is needed, discuss calcium and vitamin D supplementation.
3. Other Drugs to Watch
Loop diuretic (furosemide): used for heart failure, edema, and hypertension. It increases calcium excretion in the kidney. D-NT. Evidence level ★★★.
Anticonvulsant (phenytoin, phenobarbital): used for epilepsy. It promotes vitamin D breakdown in the liver. When vitamin D decreases, calcium absorption decreases. D-NT. Evidence level ★★★.
Aromatase inhibitor (letrozole, anastrozole): used for breast cancer. It suppresses estrogen. When estrogen decreases, bones weaken. D-HR. Evidence level ★★★.
Fall-risk-increasing drugs (benzodiazepines, sleeping pills, opioids): they do not directly affect the bones. But they cause dizziness or drowsiness.
You become prone to falling. A fall is a tertiary factor. It indirectly pushes through the DIAH funnel.
| Drug group | Representative drug | DIAH code | Mechanism | Evidence |
|---|---|---|---|---|
| Glucocorticoid | Prednisolone | D+I+A+H | All four gates | ★★★ |
| PPI | Omeprazole | D-NT | Gastric acid suppression → calcium solubility↓ | ★★ |
| Loop diuretic | Furosemide | D-NT | Kidney calcium excretion↑ | ★★★ |
| Anticonvulsant (enzyme-inducing) | Phenytoin | D-NT | Promotes vitamin D breakdown | ★★★ |
| Aromatase inhibitor | Letrozole | D-HR | Estrogen suppression | ★★★ |
| Fall-risk drug | Benzodiazepine | Indirect | Fall risk↑ → triggers tertiary factor | ★★ |
The Chain of Aging and Chronic Disease Factors: One Calls the Next
The four gates of the DIAH triggers are not separate from one another. They are connected to each other.
When one opens, another becomes prone to opening along with it. This is the reason chronic diseases do not come 'alone.'
Let us follow the story of Mr. Oh, a fifty-five-year-old man. Let us look at what happened in his body over 10 years.
1. The Chain That Began from D(Deficiency)
Mr. Oh was promoted to manager at work. His responsibilities increased, and time was short. He made do with lunch carelessly. A roll of gimbap at a snack bar near the office, or a convenience store lunchbox. Dinner was either a company dinner or a drinking gathering. There was no time for a proper meal.
His nutritional state worsened. In particular, calcium and vitamin D were lacking. Because there was no time even to see the sunlight. D-NT(nutritional deficiency) opened.
When nutrition is lacking, immune cells weaken. Immune cells are, after all, cells. They need nutrition to be made, maintained, and to function. Protein, zinc, vitamin C, vitamin D. When these are lacking, immunity drops.
Mr. Oh caught colds often. He was sick once each time the season changed. At the office too he heard people say, "Why does Manager Oh live with a cold hanging on him like this?"
He thought a mere cold was nothing to worry about. But a cold is also inflammation. When an infection arises, an immune response occurs, and inflammation arises. When the body recovers, the inflammation subsides. But when you get infected often, inflammation arises often.
Moreover, in a State Where Immunity Is Weakened by Nutritional Deficiency, Infections Drag On. A Cold, Instead of in One Week,
does not heal but goes on for 2 weeks, 3 weeks. The inflammation persists for a long time.
Starting from D-NT, it led to I-CH(chronic infection).
When inflammation persists, metabolic waste accumulates. As immune cells act, they produce waste. Breakdown products come out of the damaged tissue. Most of this waste is acidic.
Lactic acid builds up. Uric acid builds up. Ketone bodies can build up. The acid load on the body increases.
Mr. Oh was told at a health checkup that his uric acid level was high. They said, "Be careful of gout." There was no gout attack yet, but it was a sign that the body was tilting toward acidity.
Starting from I(inflammation), it led to A-FN(functional acidosis).
The body must neutralize acid. When acid builds up, enzymes do not work properly. Cell function collapses. It must be neutralized.
To neutralize, alkali is needed. Where is the largest alkali storehouse? It is the bone. The calcium of the bone is stored in the form of hydroxyapatite. When this dissolves, an alkaline substance is released along with calcium ions.
Calcium leaked out of Mr. Oh's bones little by little. In order to neutralize the acid. Over 10 years, little by little, little by little.
Starting from A, D-NT worsened further. At first D opened because of nutritional deficiency, but now D(deficiency) opens because of acid neutralization as well. It is a vicious cycle.
2. Lack of Exercise Worsens the Situation
Mr. Oh was busy and had no time to exercise. A life of going to work at 7 a.m. and leaving at 10 p.m. On weekends he was tired and had to rest. Exercise was always something to do 'later.'
When you do not exercise, D-PH(physical-stimulus deficiency) opens. Since there is no stimulation to the bone, there is no reason to maintain the bone.
When you do not exercise, H-CR(circulatory hypoxia) opens. Since the muscle pump does not work, blood flow stagnates. The oxygen supply to peripheral tissues decreases.
When tissue lacks oxygen, it is damaged. Cells die. The dead cells must be cleared away and repaired. An inflammatory response occurs.
In particular, ischemia-reperfusion injury is a problem. When oxygen is supplied again to tissue that was damaged by a lack of oxygen, paradoxically greater damage occurs.
Reactive oxygen species are generated explosively. The tissue is damaged further. The inflammation becomes more severe.
Starting from H(hypoxia), I(inflammation) became more severe. Inflammation arises because of hypoxia, acid builds up because of inflammation, bone dissolves because of acid, there is no stimulation to the bone because of not exercising, and hypoxia arises because blood does not circulate...
3. The Vicious Cycle That Turns in a Circle
If we summarize Mr. Oh's 10 years, it is like this.
It is a circle. There is no starting point and no ending point. Once it begins to turn, it keeps turning while reinforcing one another.
[Figure 6-4] The Trigger Chain Loop (circular diagram)
| Connection | Direction | Mechanism explanation |
|---|---|---|
| D(deficiency) → I(inflammation) | D→I | "nutrition↓ → immunity↓" |
| I(inflammation) → H(hypoxia) | I→H | "hypoxia → inflammation explosion" |
| H(hypoxia) → A(acidosis) | H→A | "inflammation persists → metabolic waste" |
| A(acidosis) → D(deficiency) | A→D | "bone mobilized to neutralize acid" |
