If you want to Improve your Health, Improve your Sleep

EAP Ask the Expert: Sogol Javaheri, MD, MPH, MA – Department of Sleep Medicine, Brigham & Women’s Hospital

Lack of adequate, healthy sleep is widespread and associated with impacts on well-being indicators across the spectrum.

According to Sleephealth.org, sleep-related problems affect 50-70 million people in the US, and account for $16 billion annually in medical costs. Statistics yield:

• 70% of adults reporting insufficient sleep at least once a month
• 11% reporting sub-par sleep every night

Chances are good that our MGB community has sleep issues that are consistent with or even more significant than those in the general population. Healthcare workers have plenty of challenges that represent barriers to optimal sleep:

• Long work hours, night shift or day/night rotations
• Busy lives outside of work
• No shortage of stress

The good news is that there are measures we can all take to achieve better sleep. The EAP partnered with Sogol Javaheri, MD, from the Department of Sleep Medicine, Brigham & Women’s Hospital, to better understand why so many of us have sub-optimal sleep and how we can change that.

Why do so Many People Struggle to achieve Healthy Sleep?

There are several factors that contribute to sleep problems. The U.S. is one of the most sleep deprived countries, in part because of cultural work ethics and the tendency to overfill schedules. We simply don’t allow adequate time to sleep. Here are other potential causes for subpar sleep:

Devices and related offerings

• We can now engage in activities, such as social media or Netflix, at all hours of the day or night. For some, this can represent unhealthy or even addictive behaviors, which can spill over into the sleeping hours
• Blue light generated from screens at night impairs melatonin synthesis and suppresses melatonin secretion. This results in sleep disruption

Sleep disorders

Undiagnosed and untreated sleep disorders can have a significant impact on sleep quality. For example:

• Sleep apnea
• Restless leg syndrome
• Insomnia

Substance use

Each person responds differently to what they put in their bodies. Take note of how some substance use affects you and your sleep:

• Alcohol – although alcohol may initially make you feel relaxed or even sleepy, it can make you feel wide awake and unable to sleep once it wears off. Use of alcohol increases sleep fragmentation and interferes with important REM sleep in the latter part of the night. Avoid using alcohol 3-4 hours before bedtime
• Tobacco can negatively impact sleep, because it’s a stimulant, can affect respiratory function and contributes to sleep apnea
• Caffeine – drinking too much caffeine or drinking it too close to bed can impair ability to fall sleep
• Diet and digestion– it’s generally best to avoid processed or acidic foods and excess sugar. Try not to eat 2-3 hours before bed. Certain gastrointestinal issues such as reflux and gluten allergies might affect sleep

Exercise

• Regular exercise can contribute to healthier sleep. Exercise and ambulating contribute to triggering the homeostatic sleep drive (higher with exercise). On the flip side, being too sedentary can impede sleep because if you are not tired, you may not sleep as well
• Timing of exercise might be important for some. Exercise releases natural endorphins and energy. Exercising early, rather than close to bed, might be more beneficial for some individuals

Sleep cycle

Sleeping “on-cycle” – keeping a routine, consistent schedule (7-8 consecutive hours for most people) is important to sleeping well. Many people mistakenly believe they can make up for lost sleep by sleeping past the planned wake-up time, engaging in ”catch-up sleep” on weekends or napping.

Dr. Javaheri indicates that some people can nap successfully if this does not interfere with the ability to sleep later that night. However, sleeping past the regular wake-up time or engaging in more sleep on the weekends does not reverse metabolic changes and physical effects on blood pressure, heart rate or glucose tolerance levels. When you sleep past your wake-up time, you disrupt the regular sleep cycle pattern for the next night’s sleep. Only consistent sleep can reverse the physiological trends related to unhealthy sleep.

Stress

Stress can affect your ability to fall or stay asleep, contributes to insomnia, and can provide barriers to winding down, especially in the absence of coping strategies.

Medications

Some medications can affect the quality of sleep, perhaps due to impacts on melatonin secretion. Some examples include:

• Amphetamines
• Allergy or cold medications
• Beta blockers

Why does Healthy Sleep Matter?

Sleep overlaps with virtually every system in the body and has a number of impacts on how we feel and function. Healthy sleep allows our bodies to recuperate and thrive. Below are areas affected by sleep quality:

• Blood pressure
• Glucose regulation & diabetes
• Weight maintenance
• Growth hormone production (children)
• Cognition & memory
• Increased cortisol production
• Mood impacts such as anxiety, depression, & stress management
• Alertness & vigilance, which can lead to accidents
• Work productivity

Does Everyone need the Same Amount of Sleep?

No. Different populations require varied amounts of sleep. For example, children (from birth through puberty) typically require more sleep than adults. Within populations, individuals may have different sleep duration thresholds – short, long, or normal (8.1 hours).

Are you really someone who needs less sleep?

Some individuals can legitimately function on less, sleep, without negative impacts, but Dr. Javaheri cautions that this group is smaller than believed. Many short sleepers are unaware of the physiological effects of their subpar sleep. Many of us are resilient and can adjust to certain sleep patterns. However, this does not mean that this is optimal. One way to test this is to check in on your mood, memory, or vital signs (such as blood pressure) before and after changing your sleep routine. You may find that you are more impaired than you think and eventually symptoms can manifest in clinical disease.

Self-help for Disrupted Sleep

General Tips

• Dim lights a half hour to an hour before bedtime
• Sleep in a cool, dark, quiet environment
• Use a noise machine/white noise or relaxing music if you can’t avoid background noise
• Avoid alcohol, caffeine, and unhealthy foods in large amounts or close to bed (See above for a full explanation)
• Don’t look at the clock – this can cause stress and promotes cycles of sleep trouble
• If you or your partner snores, get evaluated for this
• Avoid sleeping with pets if they disrupt your sleep
• Try to limit screen distractions such as TV or phones. Some people may find devices helpful. This is Ok if they provide stress relief and do not impact your ability to sleep well. If you are unsure, eliminate an activity for 2 weeks and see if your sleep improves
• Try to keep a consistent sleep schedule (based on the number of hours you require)
• It’s most important to have a consistent wake-up time, regardless of when you go to sleep
  – Waking up late effects sleep for the next night

People without a regular night sleeping schedule

Sometimes work or life stage can interfere with keeping a standard sleep schedule

• Night shift – many healthcare workers have variable shifts or work at night. Dr. Javaheri recommends trying to get some consistency by always sleeping days (even on your off days) while on the night shift. Avoid shifting back and forth
• New parents – Those with a new baby just do the best they can, especially for the first few months. Sleep whenever possible, or when the baby sleeps. Every baby’s sleep cycle is different. If possible, split the responsibility with your partner. Feeding time is an important bonding opportunity for parents. However, if lack of sleep affects mood or functioning, it might be helpful to seek temporary help from family members or even a night nurse

Allow time to wind down before bed

It’s best not to go from “on” to “off” immediately. Even 10 – 15 minutes can help you to transition. Consider some of these options for decompressing:

• Reading
• Listening to Audibles or books on tape
• Exploring Mindfulness and meditation

Tracking sleep

Sleep diaries and sleep apps can be beneficial to get a “slice in time” view of patterns and evaluate factors that impact sleep, particularly if you are trying to eliminate negative habits or introduce positive ones. For example, you may want to try 2 – 4 weeks with and without alcohol in the evening to see how it affects your sleep.

Dr. Javaheri cautions against focusing too much on numbers and details, or tracking sleep indefinitely. This can lead to worrying about sleep, which can be detrimental and lead to more sleep issues. Pay less attention to hours and more on how you feel:

• Do you feel rested when you wake up?
• Are you able to concentrate?
• Can you focus?
• Are you productive at work?

Using Medications or supplements for sleep

Are over-the-counter medications or CBD/Marijuana products recommended?
In general, the American Academy of Sleep Medicine does not recommend any over-the- counter medications for sleep.

• Avoiding substances to help you sleep is preferable, but not always feasible. If you are suffering, use something sparingly and on an as needed basis, so you don’t become dependent or tolerant
  – If you use a substance too frequently, it may not be as effective for sleep, and you will need to increase the dosage or switch to a different medication
  – A trial-and-error process is advisable as everyone’s body metabolizes supplements differently and has unique sensitivities
• Be careful with substances that are not FDA regulated as they may have undeclared added ingredients
  – FDA screening of various melatonin formulations found a variety of unregulated substances in them, including Viagra, Benadryl, and Diphenhydramine
• Marijuana: Be careful what you are taking and how much. Different strains of marijuana have different effects
• Vitamins: It’s OK to use vitamins in small doses if helpful and you experience no adverse health effects

Professional Help for Sleep Problems

Sleep medicine experts can treat things such as:

• Sleep apnea
• Restless leg syndrome
• Insomnia

Many people hesitate to seek help for insomnia, despite the fact that it’s a legitimate condition and the most common (and also untreated and unrecognized) sleep disorder in the country.
Alternatively, people self-medicate or use over the counter supplements because they think sleep is not something they should be discussing with their doctor. Sleep is one of the pillars of our health and needs to be addressed. As discussed above, chronic, or untreated sleep disorders lead to significant physical and mental health issues and diminished life satisfaction.

Consider seeking clinical expertise and intervention if:

• Sleep challenges are impairing your daily function or affecting your mood
• There is an impact on your ability to concentrate or complete tasks
• You experience significant daytime sleepiness or drowsy driving
• Lack of sleep is a major source of stress

What to expect when you see a sleep medicine expert

• You will discuss your concerns about sleep
• The doctor may prescribe a medication
• Your doctor may order a sleep study

Sleep studies are usually done to rule out conditions (such as sleep apnea) which contribute to insomnia. Sleep apnea and insomnia (COMISA) commonly co-occur in as many as 50% of patients.

There are 2 types of sleep studies:

Home sleep tests

• Useful for straightforward cases of “yes or no” for sleep apnea
• Not evaluative for other sleep disorders
• More cost effective
• Insurance may not cover the in-lab test for all cases
• Use three connections to monitor air flow, oxygen level and contraction of the diaphragm
• More convenient and you might sleep better with this type of test

In-lab tests

• More informative and provide more data about your sleep
  – EEG, EMG, and EKG
  – Details on stages of sleep
• Utilize more probes
• Make sense if you don’t sleep well at home

Resources

• The National Sleep Foundation
• HMS – Division of Sleep Medicine – Sleep & Health Education Gateway
• Sleep Foundation – Myths and Facts About Sleep

MGB Sleep Clinics

• BWH & BWF
• MGH
• NWH
• Salem

Help from the EAP

The Mass General Brigham EAP offers free and confidential services for employees and immediate household family members. EAP records are separate from medical and HR records. Contact the EAP at 866-724-4327 or request an appointment via our online form for confidential assistance.