Better Sleep for Mind and Body

Dr. Ong: Thank you so much, Lisa, and welcome everybody. I’m so glad you’re here to join us today for this webinar on Better Sleep for Mind and Body. And if you are here, I imagine that you agree that good sleep is essential for good health and well-being.

So when we’re sleeping well, we’re able to do the things that we enjoy such as exercising and physical activity. But also I realize that there are probably people out there that are doing quite well. When was the last time you heard somebody say something like this, ”Oh, my sleep isn’t good.” Maybe you feel this way yourself. And I know that as a sleep doctor I oftentimes hear people say, “If only I could sleep better. That’s my life.” But what I want to do in today’s webinar is take a step back and think about what actually do we mean by “good sleep”? And the main point I want to try to make today is that good sleep is more than just the number of hours of sleep. There’s actually more to it. So I want to talk about how these dimensions of sleep actually can affect your mental and physical health. But also along the way, provide tips on how you can see better.

And I like to think about the foundation of good sleep with the acronym DTQ. All right, what we mean here is, D is duration, this is the number of hours that you sleep. So what are the number of hours that are appropriate? This is probably what most of you are used to thinking about with sleep health.

Alright, the timing. And here we’re talking about whether or not your sleep is in sync with your circadian rhythm. Circadian rhythms, our biological clock, runs about 24 hours, and “circa diem” is Latin for “about a day”. So the timing of your sleep is really important.

And the third part of this is the quality. Okay, so this has to do with how satisfying your sleep feels, how refreshed you feel when you wake up and whether or not you feel alert during the day.

Alright, now let’s take a deep dive into these different factors. Duration: what happens when you don’t get enough sleep? So this is a worst case scenario that came to me. Let’s see, I remember back when I was living in Chicago. If you’ve been to Chicago O’Hare, you know that this is the L, the train that comes in, and you may have even been at the station at O’Hare Airport. And what happened is in 2014, there was a train conductor who fell asleep as she was approaching the station here and ran up onto the escalator causing over $10 million in damages and injuries to people. But when they did an investigation, they found that she was pulling double shifts, she had only slept a few hours, and was really not in a position to be able to be alert enough to manage a train, and this is what happened. This is an example of a worst case scenario.

Now you don’t have to be a train conductor for this to affect you — even one night of sleep deprivation could actually impair your everyday functioning. So the tasks where they’ve done research and across different studies, they found that the tasks that are most sensitive to sleep loss are the ones that are long and repetitive, ones that involve very little breaks or no breaks. And also ones where you don’t get feedback. It oftentimes affects newly learned tasks. So these are the ones where you’re picking up these novel tasks. And also interesting is that it tends to affect tasks that require performance speed, more so than the accuracy, how quickly you can do something. People who are sleep-deprived can actually still make correct choices, but they oftentimes aren’t able to perform things very quickly.

They’ve also got studies where they looked at type of impairment, and they found that it’s actually quite similar to drinking alcohol. So if you are awake continuously for 18 hours in a row, this is equivalent to being legally intoxicated for a commercial vehicle driver. This is where they find that’s equivalent to a blood alcohol content level of .05. And when they’ve done studies that extend this further, so now you’re 24 hours in a row, if you pulled an all-nighter and stayed up the next day, this is an equivalent impairment to what would happen if you’re legally intoxicated for any driver. Here, we’re talking about a blood alcohol content level of .10. So as you can see, this really affects us.

Now what happens under the hood. We take a look at what our brain looks like when we’re sleep-deprived, and we find that in imaging studies, there’s something called the executive brain. So this is the part of our brain that governs planning, what we do, called the frontal cortex, and here it’s indicated by the green oval.

And there’s another part of the brain called the emotional brain, the amygdala, right, it’s part of processing emotion. So when you’re sleep-deprived, there’s a disconnect between the executive brain and the emotional brain. So it’s emotionally difficult to regulate, and that leads to things like impulsive emotions, inappropriate behavioral response. In some cases, there’s even misreading of social cues. So, remember when we talked about the fact that this looks like what happens when you’re intoxicated. When someone is intoxicated, they also have some of the same behaviors.

So, this is when you’re talking about acute sleep deprivation, short-term deprivation of one or two nights. But what happens when deprivation is chronic? You know, the first thing is that sleep, when it’s deficient, the body’s out of balance, all right? You know, people don’t often think that sleep is a very active process or that when we’re sleeping things get regulated — hormones, metabolic rate, appetite regulation, even things like pleasure eating. You know, think back to that slide I showed you about emotional regulation. So when we’re sleep-deprived, it really throws your balance out of whack. Things like energy management. And this is one of the reasons why sleep is related to obesity. So this is another study where they looked at different rates of obesity and the hours of sleep across several decades. And this is data from the United States. So as you can see here is a pretty striking pattern that the amounts of sleep people are getting really declined from the 1950s through the early 2000s, from about eight and a half hours to a little over six hours, while the rates of obesity have increased really quite dramatically since the ‘80s and ‘90s, about 30%.

So data like this doesn’t show causation — you can’t say that sleep deprivation causes obesity. I think it shows that there’s a pretty close association here, the lower the amount of sleep and the higher rates of obesity. But as you might know, obesity is often measured by body mass index, or BMI. And one of the things that’s kind of interesting is that, actually, it’s sort of a sweet spot in terms of the amount of sleep that you’re getting that is associated with the lowest body mass index. So getting about seven to eight hours of sleep are the people that actually have a lower body mass index, compared to those who sleep very little, and also to some extent people who sleep more than nine hours or more. So in this case, it looks like BMI is elevated with either too much or too little sleep.

It’s a similar pattern here with diabetes — another health condition that’s associated with obesity, being overweight. Here, the highest risk of obesity are people who sleep less than five hours, and a lower risk are people who sleep seven or eight hours. And you get a little bit of an uptick again, with people who sleep nine hours or more. And so the bottom line here is that when you’re not getting sufficient sleep, it really messes with your blood sugar. Poor glucose management puts you at risk of diabetes.

Finally, another thing that’s highlighted nowadays with the pandemic is with your immune system. So insufficient sleep can also compromise your immune system. And over here on the left, this was a really interesting study where they tracked people’s sleep for a week, and then they actually exposed them to the common cold and they quarantined them, and they measured who had a cold about five days later. And what they found is that of people who slept less than five hours, 45% of those people actually had a cold. And then the more you slept, the lower the percentage of people who had a cold. Those who got at least seven hours of sleep, only about 15, 17 percent of those people had a cold. So this is a pattern that in research we call a dose response curve, it’s usually a pretty compelling signal that close association — in this case, the more sleep you get, the lower your likelihood of getting a cold.

And that also maps on here with the other study, which looked at people who were absent from work due to illness, and they found that people at great risk for being absent due to sickness had little sleep, particularly with four or five hours of sleep. And people who are least likely to be out due to illness, were people who got seven or eight hours of sleep. We also see a little bit of an uptick again here at 10 or 11 hours. In this case, it might be because people are spending more time in bed because they actually are sick. It’s hard to tell if they were sleepy or were bedridden because of illness.

And the last slide here in the section is about mortality. There are studies that have shown that if you’re not getting proper sleep, you’re actually more likely to die. This is something that in research we call “all cause” mortality. That just means death for any cause. And research has shown if you’re sleeping very little, like three or four hours, you have an increased risk of dying, as well as sleeping more than 10 hours here. And, again, that sweet spot, right around seven or eight hours, those are the people with the lowest risk of mortality.

So, I’ve talked a lot about the amount of sleep, what can you do to get the right amount of sleep? And the good news that you could do something about it. But the main thing is to make sleep health a priority. Waking up at the same time every morning is actually something that’s more important than going to bed at the same time. And this is a message that isn’t really clear, in my opinion, with the media. But I’m going to talk more about this when we talk about timing. But getting up at the same time every morning is actually much more important a behavioral and biological component of regulating your sleep than going to bed at the same time.

Another thing you may not be thinking about is being physically active during the day. So when you’re active in the day, if you’re exposed to light, these things help your brain and your body understand when you should be active, so that later on at night, when it’s dark, it can actually help you sleep. This really helps to kind of promote your circadian rhythms.

And my third point here is, pay attention to what I’m calling workaholic pattern. What I mean by this is that some people feel that they would be more productive if they could just get away with very little sleep. If I could sleep for just a few hours a night, then there’s so much more I could get done. But I just showed you a lot of data that suggests that if you sleep that little, you’re really putting yourself at risk for some serious health consequences, so I really encourage you to pay attention to that. Basically, make sleep health a priority by really setting aside sufficient time to allow your body to rest and recover.

Now, one question often comes up is, how do I know I’m getting the proper amount of sleep? And what I tell people is to pay attention to sleepiness throughout the day. And what I mean by sleepiness is, how likely are you to fall asleep when given the opportunity? For example, if you’re just going to lay down for a couple minutes, would you actually fall asleep? The answer is yes, if you fall asleep quickly, you’re probably pretty sleepy. And you probably need more sleep. Your sleepiness is really your body’s cue that it needs sleep. That’s like how hunger is your body’s cue that you need food. That’s what sleepiness does from a sleep standpoint. By asking yourself: Are you alert? Are you putting forth effort to stay awake? Okay, yes, that might be a sign that you’re sleepy.

And it’s important to pay attention to different substances, caffeine and stimulants. Because these can actually mask sleepiness, they can cover it up. You may not know that if you keep drinking coffee, you’re taking a lot of stimulants.

And people oftentimes ask, what is the sweet spot? You’ve seen my earlier slides for adults, it’s generally between seven to nine hours, this is a chart that comes from the National Sleep Foundation, you can easily Google this. I think it’s a nice way to think about it because the dark blue was really what they considered the recommended amount of sleep. And it does vary across the different ages, obviously, like babies and children need a lot more sleep than adults. Then the light blue is an area that might be appropriate, the research is more mixed. And, as we talked about, it’s little sleep like six hours or a lot of sleep, like 10 or 11 hours. But beyond that, these orange areas, that’s not recommended because those are areas that are associated with significant health consequences. So, figure out where your sweet spot is and try to stay in that range.

Alright, so there might be people that say, “Well, hey, I’m following everything that you’re saying, but every time I get in the bed, this happens.” And this is really the picture of someone who has insomnia. So as most of you know, insomnia is difficulty falling asleep, could be difficulty staying asleep, could also be waking up early and being unable to fall back asleep. Okay, so those are the nighttime symptoms. Now, insomnia is more than just that. It will also affect you during the day. So you can be very fatigued or sleepy during the day. All right, that’s sleepiness. What I mean by fatigue here, more like feeling lethargic, feeling tired, it’s not having energy, but you wouldn’t necessarily fall asleep. In the case of insomnia, most people are more fatigued than they are sleepy.

It can also affect concentration, your attention, you might have difficulty focusing on tasks, it can affect your mood, you might feel irritable, maybe even depressed. So the good news is that we can get help for insomnia and there are good treatments. So if you think you’re struggling with insomnia or you’re not sure, it’s important to talk to a health care provider, that’s what we mean by HCP. And you can get an evaluation or you might actually go to a specialist. And one thing I like to tell people is that in the case of insomnia, it doesn’t necessarily involve taking a sleep test. This is where you go into the lab, you get hooked up, and you look like Frankenstein, it can be very scary but it’s not. But insomnia doesn’t involve going through a test like that. It’s actually very easy, they can just ask a few questions to figure out if you have insomnia.

Well, the good news is that insomnia can be effectively treated. So we have something that we call CBT-I, which stands for cognitive behavioral therapy for insomnia. And you can see down here, actually, some different components, more than just sleep hygiene, these are do’s and don’ts that everybody hears about, but it actually involves a very customized or very personalized schedule, especially what to do when you can’t sleep, things that are grounded in the science of sleep. It’s much more than just tips here and there. I’m giving you some tips today, but CBT-I goes way above and beyond that. And the main thing is that CBT-I is both effective, and it’s safe. That’s why I recommended it as a first line treatment.

You see here medications, and what I mean here are things that you might be seeing, like Ambien, Lunesta — those are common sleep medications — that’s considered a second line treatment. That’s because there’s a lot of risk with adverse events and side effects. That’s problematic. But CBT-I doesn’t have that. So just so you know, we do have effective treatment. And at SleepCharge, we use CBT-I as a first line treatment.

Okay, so let’s talk about the T, timing. What happens when sleep is not timed to your schedule? So some people, you might not be working the daytime nine to five shift, if you’re a night worker. This is a study where they looked at what happens when you work one week of night shifts. And what we’re showing you here are different melatonin levels. And as you might know, melatonin is a hormone that’s released, usually at nighttime, and it regulates your night and day cycles. It shuts down the wakefulness that keeps the body active. And after just one week of working night shifts, you can see the timing of melatonin’s release, this is over here on the right, it’s all over the place. So you can see how when you work at night it really confuses your natural internal clock. That’s the main reason why people with night shifts have a lot of trouble with sleep.

Now, you might not be shiftworker. But all of us go through this with daylight saving, right? It was last weekend. And I want to show you some data from a study. So these folks went and took some data from motor vehicle accidents, car crashes, before and after daylight saving in spring and fall. And what they found is that in spring — so this is what we just went through when we lost an hour — there was actually an increase in car crashes the day after the spring shift. Okay, well, we lost an hour, you can see that here on the left, see a big spike here. Then in the fall, when we actually gain an hour, there’s actually a slight drop here in the number of accidents. But to be fair, this is much smaller, and it does rebound after a week back to baseline levels. But I think what this data shows us is that our bodies are quite sensitive, and even one hour of sleep loss or sleep gain can make a difference in how you’re functioning and also even lead to car crashes. What can you do then to properly time your sleep?

First of all be aware of your timing cues and how it can affect sleep. Getting up at the same time every morning. And the reason is because that is actually what your brain uses as an anchor, to regulate and to guide your circadian rhythms. And along with that, bright light in the morning is really helpful because that light is what really helped me understand oh, okay, it’s time to get going. Alright, so I need light to turn my brain to keep me active and get me going.

By the same token, in the evening, if you avoid bright light, this is what helps to allow your brain to release melatonin. Okay, and so the melatonin as I mentioned helps prepare our brain to be sleeping, and so if you avoid bright light before bedtime, that will help work with your melatonin, helps it get released on time.

Okay, let’s say your circadian rhythm is off track, say you’re either a shift worker or other things like jet lag. What can you do to try to get your circadian rhythm back in place? Are there ways you time naps to actually help you be able to maintain your performance or alertness if you’re at work, etc.? There’s also a way to plan physical activity and meals. Now, a lot of this could be done in conjunction with a sleep specialist because it’s a very personalized, very customized thing, but I just want people to know that there are actually ways to help reset your circadian rhythm without using medication. You can do this through timing of these different activities.

Alright, now let’s talk about the third and final dimension, this is quality, that happens when sleep is not satisfying. So I’m going to show you a visual of what this looks like. And at the top here, this is called a hypnogram. Alright, these are the different stages people go through when they’re asleep. You don’t need to be a specialist. But if you look at the top of the hypnogram, you can see that we go through these cycles, there’s a little bit of an awakening here. And then later on, you know, we have more REM sleep and a little bit less deep sleep, this is a typical progression of sleep states.

Down here, the second one looks really complicated. Hey, there’s lines going everywhere. And you can see, there’s very, very little deep sleep. But my point here is that fragmented sleep looks like this bottom one to a sleep doctor. It’s very light, it’s very choppy. And in fact, this is somebody with sleep apnea. And sleep apnea, for those who don’t know, is a disorder with frequent pauses in breathing, and that’s what causes people to either wake up obviously or indicates that the brain has a little arousal that causes you to work harder.

So the symptoms of apnea are snoring, choking or gasping during sleep, having unrefreshed sleep, again having poor sleep quality and also having a dry or sore throat or headache upon awakening. And people who have sleep apnea are very sleepy, or they may even fall asleep during the day. But one thing that’s a little different than insomnia, where people are more fatigued, people with sleep apnea are more sleep-deprived.

Now, there is a good treatment for sleep apnea, as well, called positive airway pressure — PAP. Some people might have heard it as CPAP, which stands for continuous positive airway pressure; it’s sort of a version of PAP. This involves wearing a mask that blows air — that’s not oxygen. People think it’s oxygen but it blows air and, basically, it keeps your air passageway open with continuous airway pressure. Sometimes it can be a little bit hard to get used to or adapt to. The good news is that there are good techniques to use to help people get used to it to help simplify it. And so you know, we are very good at helping people stay on top of their CPAP use. So that’s built into our program that we use here at Nox Health.

But taking you on this journey, I want to go through a few quick take-home points. But the first one is that good sleep can be yours by following healthy sleep habits. This is something that’s under your control. And remember that good sleep includes more than just the duration of your sleep. It also includes the timing of your sleep and the quality of your sleep. And those of you who might have a sleep disorder or think you may have a sleep disorder, please do seek help because effective treatments are available whether that’s for insomnia or sleep apnea, the most common sleep disorders. But we also have very effective measures for other types of sleep disorders. And I think if you do all of these things, you’ll be able to live a healthier, happier and more productive life everyday.

Moderator: Thank you so much, Dr. Ong, for all that wonderful information. So don’t forget to take your Sleep Checkup by visiting sleepcharge.com/sleep-checkup. If you have more questions, we are happy to help, just give us a call or email us. Don’t forget to subscribe to our Sound Sleeper e-newsletter — this will provide you quarterly updates on sleep health topics.

Moderator: Dr. Ong, you talked about sleep DTQ (duration, timing and quality). How do I know if my sleep DTQ is good?

Dr. Ong: The main way to know is to see how you feel during the day. Are you sleepy? I mentioned that sleepiness feels like it takes a lot of effort to stay awake — that’s probably a sign that you’re getting insufficient sleep. Now, again, it might be the number of hours, it might be the timing of your sleep or the quality, it could be one of those dimensions. But that’s probably the main way to know for yourself. Now, if you want to try to get more specific, as you mentioned, we do have our Sleep Checkup, a way to give you a score for your DTQ that can break it down into these different dimensions. So, I think just paying attention to sleepiness, how you feel, maybe using a Sleep Checkup, if you have access to that, can help give you a way to get started to figure it out. And if you really can’t figure out for yourself, I think the best thing to do is talk to a health care provider.

Moderator: I think a lot of us might be guilty of this: I wake up in the middle of the night, and I can’t get back to sleep. Sometimes I turn the TV on. Are there any other suggestions that you have?

Dr. Ong: So this goes to somebody who has insomnia. And, you know, I imagine the person who’s asking this, and others, have probably heard it’s best to get out of bed. I think that’s particularly important if you have chronic insomnia, meaning this is a persistent problem for you. And then this is part of what we cover in CBT-I, so I’ll just try to give you a little bit of a flavor. It is helpful to get out of bed. One of the important things that people don’t realize is there are actually different things that you can do. But the most important thing is to not try to fall back to sleep.

Okay, I realize it’s a lot easier said than done. But sleep effort is one of the main things that causes people to ramp up. And when you do ramp up, it’s your fight or flight system, basically, it kicks into gear and your brain thinks, oh, I need to be awake, because I need to be on guard for something out in the environment. And so the main thing is, do something that you enjoy. Now it shouldn’t be too activating. So I give people more liberties, whether it be TV or reading, whatnot. But the idea is you do it until you feel sleepy. And that’s really when you should be going back to bed. It’s not based on how much time you’re out or if you know what you need to do the next day. You’re really not going to be able to fall asleep until you feel sleepy. So you really need to wait for that. And over time, you will probably start to get sleepy sooner and sooner. And hopefully at some point, you won’t even wake up. So it really is a process. So it’s not something that you can just kind of nip in the bud in one night. But if you do these types of techniques over and over, they slowly start to help your brain understand that, hey, I don’t need to be on guard in the middle of the night. And that fight or flight system will slowly come down.

Moderator: I think that this is going to pertain to a lot of us that are coming back to the office. And this question is: I’ve been working from my home during the pandemic. And now we have to go back into the office. I’m worried about having to get back to my old schedule and having to get up earlier for my commute. Do you have any advice about how to make this a lot easier?

Dr. Ong: Yeah, the first one is, see if you can continue to telecommute. But if you can’t do that, in all seriousness, this is where the time you set does get a little more personalized and customized. Depending on how big that gap is, what we usually do is slowly have people advance their sleep. You know, for example, if you’re waking up now at 9 am and let’s say you need to wake up at 7 am to go back to the office, what I usually suggest in these cases is slowly get up about 30 minutes earlier, maybe every few days. You could do it in bigger chunks and say, okay, I’m going to go an hour earlier. If you’re going to do that, I would probably recommend staying at that an hour earlier for about four or five days, and then try to go another hour earlier and just realize it’s a process.

So you’ll probably have to deal with a little bit of sleep deprivation as you do this. But this would be a way of basically adjusting to a different time zone — that’s sort of what it’s like when you have these adjustments. So imagine if I’m in the Central Time Zone, something like this would be like moving two hours ahead. So it wouldn’t be the East Coast but one time zone ahead of that. If I’m gonna adjust to that, then I usually try to start a couple of weeks ahead of time. So if you can plan it that way, that will be the easiest way to minimize sleep loss.

You can do it in one chunk. If you’re going to do that, then when you wake up, I recommend getting exposure to bright light as much as possible and doing some of the things that we talked about in terms of that regularity, even on the weekends. Okay, that’s the other important thing. Once you get adjusted, then it’ll be easier. Alright, so there’s sort of a fast paced way, that might be a little more of a shock to the system and sort of an easy way into it, if you can plan it out ahead.

Moderator: Is using a sleep aid to fall asleep good or bad? I can’t sleep the entire night without a sleep aid.

Dr. Ong: So by sleep aid, I’m assuming we’re talking about sleep medication. So I’ll sort of take it in a couple ways, let’s say first, prescription sleep medication. So as I mentioned, it’s really not considered a first line treatment. This was, I think, about four or five years ago, when the American College of Physicians, the group that regulates the guidelines for primary care physicians, recommended that CBT-I be the first line treatment. So if you’re going to take medication, well, it might help you in the short term. Usually the recommendation is to try to get off of it. Once your sleep has stabilized, if you can, you can use some CBT-I as part of that. So just realize that when you do that, you might run some risk of withdrawal effects as you’re getting off the sleep medication. So the nice thing about CBT-I is it’s very doable with or without medication. I’ve worked with many people who are on medication, and we do some CBT-I to help them get off of it. So you know, just coming back to prescription medication, it can be useful, but just know it comes with some baggage. And that’s the main reason why it’s no longer the first line treatment.
If it’s over the counter, the problem is that it’s not as regulated as prescription medication. Over-the-counter melatonin is a very common one, when they’ve done studies that look at the purity, and it really varies quite a bit. So you don’t really know exactly what dose you’re getting. And the problem there is that it’s not so much a safety concern, but it may not be effective. So, yeah, I would say over-the-counter stuff you can take with a grain of salt.

But in general, what I would also say is that when people take medication and try to fall asleep, it’s that sleep effort. And, again, as I mentioned earlier, that’s usually the biggest thing that works against you in the case of insomnia, because your body thinks, hey, I need to put forth effort to do something. And it’s kind of like performance anxiety, the more you try to do it, the less likely it’s going to happen. So anything that your brain thinks you’re trying to put more effort into, it’s going to try to work harder and in the case of sleep, it’s going to work against you. So that’s why CBT-I really is the first line treatment. And that’s something I would recommend, even if you’re using medication.

Jason C. Ong, PhD

Dr. Ong, Director of Behavioral Sleep Medicine at Nox Health, is a clinical psychologist with 17+ years of experience in behavioral sleep medicine. Dr. Ong is responsible for proven behavioral approaches to improve sleep health for those in the SleepCharge program. Dr. Ong is a former professor at the Center of Circadian and Sleep Medicine at Northwestern University. He has received more than $10 million in research support and is credited in 100+ publications.