Sleep Well

By Michael Breus, PhD, ABSM

There’s more news about complications that can arise from prescription sleep medication: Side effects from a common prescription sleep aid are sending increasing numbers of people to emergency departments.

The number of people seeking emergency medical treatment for the adverse effects of sleep medications containing zolpidem has risen dramatically in recent years, according to a new federal report. Zolpidem is the active ingredient in several of the most commonly prescribed sleep medications, including Ambien, Ambien CR, Edluar, and Zolpimist.

The report was issued by the Substance Abuse and Mental Health Services Administration’s Drug Abuse Action Network (DAWN), which collects information about drug-related visits to emergency departments nationwide. Their analysis included all emergency-department visits that involved adverse effects of zolpidem during the years 2005-2010. During this 5-year period, visits to emergency departments involving adverse effects of zolpidem increased significantly, rising by more than 200%. Women and older adults sought emergency treatment for adverse zolpidem effects in greater numbers overall than men and younger adults. According to the report:

• In 2010, there were 64,175 emergency-department visits involving zolpidem. Of these, 19,487 or 30%–specifically involved adverse reactions to the sleep medication.
• In 2005, there were just 6,111 emergency-room visits involving adverse reactions to the sleep drug. During the period 2005-2010, emergency department visits involving adverse reactions to zolpidem rose almost 220%.

The analysis found women were significantly more likely to seek emergency treatment for problems with zolpidem than men:

• Women accounted for 68% of emergency department visits related to adverse reactions to zolpidem in 2010. The differences between men and women fluctuated during the 5-year period, but overall women made up a greater number of the zolpidem-related emergency visits in every year but 2008.
• The number of emergency-department visits made by women involving adverse effects of zolpidem increased by 274% during the years 2005-2010. Visits by men increased 144%.

Age also was a factor, with greater numbers of cases involving older adults:

• Adults ages 45 and older accounted for 74% of all emergency department visits involving adverse reactions to zolpidem. As a comparison: this same age group accounted for 56% of emergency room visits involving adverse effects of any drug.
• Patients ages 65 and older were the single most common age group to seek emergency treatment for adverse reactions to the sleep medication: 32% of all emergency department visits related to adverse effects of zolpidem were undertaken by people in this age group.
• Patients ages 45-54 were the next largest group, accounting for 22% of all visits.

Other pharmaceutical drugs often were involved in emergency treatments related to zolpidem. Half of the emergency department visits related to adverse effects of zolpidem involved other medications as well:

• Of the total visits to emergency departments related to adverse effects of zolpidem, 40% involved the sleep drug alone.
• In 50% of the cases, one or more additional prescription drugs were involved.
• The most common prescription drugs seen in combination with zolpidem’s adverse effects included narcotic pain relievers, anti-depressants, anti-anxiety medications and other insomnia medications.

The side effects associated with zolpidem can be disorienting, scary, and at times dangerous. These side effects include hallucinations, problems with memory, excessive daytime tiredness, sleepwalking and engaging in other behaviors such as eating and even driving while not fully awake and alert. The adverse effects of zolpidem can be exacerbated when the sleep medication is combined in the body with other common prescription drugs, including narcotic pain relievers, anti-depressants and anti-anxiety medications. Alcohol, too, can have a magnifying effect on the body’s reaction to zolpidem.

Medications containing zolpidem are prescribed to millions of Americans with sleep problems, in numbers that have been rising dramatically in recent years. The SAMHSA report does not discuss reasons for the spike in zolpidem-related emergency department visits, but it’s certainly likely that the rise in the number of prescriptions may play a significant role. For all their frequent usage, we still don’t know a great deal about the health and side effects of zolpidem medications. Stories about strange and erratic behavior associated with these sleep medications have been widely reported, but research into the effects of zolpidem is just starting to accumulate.

In January of this year, the Food and Drug Administration issued a safety alert including changes to its regulations regarding zolpidem. The FDA announced it would require drug makers to cut in half the recommended dosages for women taking zolpidem, and suggested that the recommended dosage for men be lowered as well. The alert also urged medical professionals to warn all patients taking zolpidem about early-in-the-day drowsiness and impairment. The FDA’s action came about as a result of research indicating that patients—especially women—who take zolpidem at night may have concentrations of the medication in their bloodstream high enough to cause impairment in the morning for activities such as driving. The research showed that women’s bodies take significantly longer to metabolize the drug, leaving them particularly vulnerable to excessive drowsiness and impairment in the morning.

Research also has shown that older adults are at greater risk for adverse effects from sleep medications, including those containing zolpidem. The elevated numbers of both women and older adults seeking emergency treatment for problems with zolpidem appears to align with other research suggesting these groups are at elevated risk for complications from these medications. We must continue to learn more about the short-term and long-term effects of zolpidem and other sleep medications on patient safety and health.

Sleep medications containing zolpidem can be an effective short-term treatment for disordered sleep. But these medications must be prescribed with care and caution by doctors, and used correctly by patients. Prescription sleep medications such as those with zolpidem are not intended for long-term use. For most patients with sleep problems, the best long-term prescription for healthy sleep isn’t found in a pill bottle. It’s found in the fundamentals of strong daily sleep habits, and a lifestyle that promotes good sleep hygiene.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

By Michael Breus, PhD, ABSM

Millions of children and adults struggle with symptoms of Attention Deficit Hyperactivity Disorder (ADHD), a condition marked by problems with concentration, impulse control, organization, and memory. It can be a frustrating and difficult condition, stigmatizing and often isolating for those who suffer from it.

But what if some of those who’ve been diagnosed with ADHD are, in fact, suffering from another disorder altogether—a sleep disorder? That’s the provocative and important question posed in this commentary by a practicing psychiatrist with extensive experience treating patients with ADHD.  Dr. Vatsal Thakkar, who is also a clinical assistant professor of psychiatry at NYU Langone Medical Center, makes a powerful argument for the need to consider sleep problems as a possible cause when evaluating patients for ADHD.

As Dr. Thakkar points out, many of the symptoms of ADHD are very often similar to symptoms of insufficient and disordered sleep, for both children and adults. In children, the symptoms of ADHD and sleep deprivation can be indistinguishable. A diagnosis of ADHD in children frequently comes about after a child exhibits some or all of behavioral symptoms such as these:

Lack of focus: difficulty paying attention, problems listening, forgetfulness, disorganization

Agitated, excitable, impulsive behavior: excessive talking, inability to sit still, difficulty playing quietly, tendency to interrupt, difficulty sharing or waiting for one’s turn

These behaviors associated with ADHD interfere with a child’s social and intellectual development, causing problems with relationships with peers and adults, at school and at home. But what if ADHD isn’t always the underlying cause of these symptoms? Signs of poor quality and insufficient sleep in children can look remarkably like symptoms of ADHD, as a number of recent studies show. There’s particularly strong evidence that children with sleep-disordered breathing exhibit many of the same symptoms—and suffer many of the same behavioral problems—as children who’ve been diagnosed with ADHD.

Sleep-disordered breathing in children has been an area of growing interest among sleep scientists—with good reason. I’ve written about the dangers of sleep-disordered breathing in children, which is linked to a range of developmental and behavioral problems—problems that often mirror those associated with ADHD:

• This study found that children with obstructive sleep apnea had higher rates of behavioral problems including difficulty paying attention, hyperactivity, communication problems, and aggressiveness. These children were also more likely to have learning difficulties and low academic performance than those without sleep-disordered breathing.

• This large-scale study of more than 11,000 children found that those with sleep-disordered breathing were significantly more likely to show signs of hyperactivity, trouble interacting with peers, and conduct issues including aggressiveness and inability to follow rules. The study examined the effects of sleep-disordered breathing on children as young as 6 months. Researchers found that very young children who experienced some form of sleep-disordered breathing were, by the age of 7, 40-100% more likely to have behavioral problems similar to those used to diagnose ADHD.

Many adults being treated for ADHD have symptoms that are difficult to distinguish from the effects of poor quality and insufficient sleep. Difficulty concentrating, trouble completing tasks, problems with organization, and memory lapses are all common struggles for adults who’ve received an ADHD diagnosis. These are also some of the most common problems for adults with sleep problems. I’ve written about the challenges that lack of sleep and disrupted sleep pose to cognitive function in adults, including problems with memory, learning and focus.

Given the similarities of symptoms between ADHD and poor sleep in children and adults, it’s not hard to see how misdiagnosis is possible, even likely. That risk increases when we consider the lack of regular screening that exists for sleep problems. We’ve made great scientific strides in our understanding of sleep in recent years. But we still struggle with a lack of attention paid to sleep problems by both physicians and patients. For both children and adults, sleep problems continue to be significantly under-diagnosed. This study of members of the American Academy of Pediatrics evaluated sleep-screening practices among pediatricians. Researchers found that fewer than 1 in 5 pediatricians surveyed had received any training in sleep disorders, and fewer than 1 in 6 felt confident about their ability to offer guidance to parents about children’s sleep. The study also revealed serious knowledge gaps among pediatricians about sleep, with most unable to answer correctly questions about sleep disorders in children.

The news isn’t any better for adults. An analysis of data from the 2005-2006 National Health and Nutrition Examination Survey found that sleep disorders such as insomnia and sleep apnea remain drastically under-diagnosed. What’s more, though nearly all of the more than 2,000 adults surveyed reported at least one complaint about their sleep, fewer than 1 in 4 of them had talked with physicians about their sleep problems.

More rigorous and effective screening for sleep problems starts with better training for physicians and medical professionals who must make diagnoses every day. As patients and as parents, we also need to be attentive to symptoms of poor sleep in ourselves and in our children. And we need to take these concerns—however mild they may appear—to our physicians.

Another thing we can do? Protect our sleep, and our children’s sleep, by setting sleep-friendly limits against the nonstop, perpetually wired, always “on” culture we live in today. As Dr. Thakkar points out, the escalation of ADHD cases in the 1990s and 2000s coincided with the rise of the digital age, and the widespread use of personal technology that now pervades our daily lives. These devices—our laptops and tablets and cell phones—that enable so much convenience and connection, also threaten the quality and quantity of sleep. The nighttime exposure to light they emit interferes with the body’s release of melatonin, disrupting sleep cycles and diminishing time spent in the deepest, most restorative phases of sleep.  More than ever before in history, we must work to create the darkness that is so essential to sleep. Keeping our bedrooms, and our children’s bedrooms, gadget-free sanctuaries for sleep is one important way to guard against chronic sleep deprivation.

To raise the possibility that some cases of ADHD in children and adults may actually be un-diagnosed sleep disorders does not call into question the seriousness of ADHD, the difficulties it poses, and the importance of effective treatment for this very real disorder. Additional research is critical to determine whether, and how often, sleep disorders are being misdiagnosed as ADHD. The goal is to make the right diagnosis—whether ADHD or sleep problems—and pursue the most effective treatment. All patients, whatever their condition, deserve no less.  Pursuing the question of a link between disrupted sleep and symptoms of ADHD is a matter of public health, one that deserves prompt and sustained attention.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

By Michael Breus, PhD, ABSM

Diabetes is one of the most serious health problems in the United States and around the world. According to Centers for Disease Control estimates, 1 in 10 American adults currently has diabetes. And, if the CDC projections are correct, those numbers will double or even triple over the next 40 years.

There are well-established links between disrupted sleep and risk of type 2 diabetes. But the exact relationship between the two is not fully understood. In the ongoing effort to better understand the causes and risk factors for diabetes, research in recent years has increasingly focused on the role of melatonin. Now, new research indicates that low levels of melatonin are associated with elevated risk for type 2 diabetes. The study, led by researchers at Boston’s Brigham & Women’s Hospital, found that women with the lowest levels of melatonin secretion had more than two times the risk of developing type 2 diabetes as those with higher melatonin levels.

Researchers used data from the Nurses’ Health Study, a long-term, large-scale project investigating a broad array of women’s health issues. Since its inception in 1976, the Nurses’ Health Study has collected information from more than 200,000 female nurses. For this study, researchers used information from women who provided blood and urine samples in 2000. First, researchers selected the women without diabetes, and monitored their health for the next 12 years. During the period of 2000-2012, 370 of the women developed diabetes. Using this sub-group, researchers analyzed melatonin levels. In their analysis, they controlled for other risk factors for type 2 diabetes, including body mass index, family history, high blood pressure, and lifestyle habits. They found:

• Lower melatonin levels associated with higher risk of diabetes
• Those with the very lowest levels of melatonin secretion had 2.17 times the risk for diabetes than those with the highest levels of melatonin
• Women with the highest levels of melatonin developed diabetes at a rate of 4.27 cases per 1,000. For women with the lowest levels of melatonin, the incidence of diabetes was 9.27 cases per 1,000.

This is the latest in a series of research breakthroughs that suggest melatonin plays an important role in metabolic functions and risk of diabetes. I wrote recently about studies that have found that mutations to the body’s melatonin receptor gene are associated with significantly heightened risk for type 2 diabetes. Other research has also found evidence of a relationship between melatonin levels on the onset of diabetes:

• Several studies involving mice and other animals have found melatonin secretion has an effect on insulin sensitivity and other markers of diabetes. This study showed improvements to insulin sensitivity and glucose tolerance in mice given supplemental melatonin. And in this study, blood pressure and blood glucose levels dropped in hamsters given melatonin. On the other hand, mice deprived of melatonin experienced diminished ability to metabolized glucose, likely as a result of increased resistance to insulin.
• Studies involving people have also shown links between insulin resistance and melatonin. This study of patients with metabolic syndrome found a strong association between melatonin levels and insulin levels in the human body. Many people with metabolic syndrome very often go on to develop diabetes.

How does melatonin work in the body to influence the onset of diabetes? We don’t yet have a definitive answer to that question. The current study, and other studies of melatonin and diabetes, have not identified the mechanism by which melatonin influences the development of diabetes. In discussing their results, researchers indicate that they believe evidence points strongly to melatonin’s role in the secretion of insulin.

Melatonin, best known as “the sleep hormone,” is critical to regulating the body’s 24-hour biological clock and sleep-wake cycle. Melatonin release is triggered by the absence of light. As night approaches, melatonin levels rise, preparing the body for sleep. Melatonin levels fall back as daytime arrives, and the body becomes alert and prepared for a waking day. Over years of scientific inquiry, our understanding of melatonin’s role in the body has broadened. We’re still learning about the range of melatonin’s influence. But the hormone is now recognized as having influence in several important biological functions, including the immune system and metabolic system.

So, does this mean people at risk for type 2 diabetes should start taking melatonin supplements? Definitely not.

We don’t know enough yet about melatonin as a factor in diabetes. Studies such as this latest one strongly point to a relationship, but it’s one that is not yet well understood. These and other research findings do not indicate that an increase of melatonin through supplements would work effectively to reduce the risk of type 2 diabetes. And supplemental melatonin comes with its own set of possible complications. Our bodies are expert at creating and regulating melatonin naturally. Introducing supplementation of the hormone into the body at an inappropriate dose, or at the wrong time of day, can interfere with the proper functioning of the body’s circadian clock. Melatonin should only be used when specifically recommended by a doctor after careful determination that it is an appropriate treatment.

That said, these results are yet another step forward in our understanding of the importance of melatonin, and in particular, its relationship to diabetes risk. Building on discoveries such as this may lead to new and more effective treatment and prevention strategies to combat this dangerous and all-too-common disease.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

By Michael Breus, PhD, ABSM

We all know exercise is good for us. Good for our health, good for our waistlines, good for stress and for our clarity of mind. Exercise is also very—very—good for sleep. Research has shown that exercise can improve sleep, including for people with sleep disorders and other sleep-related illnesses. And now there’s even more evidence of the sleep benefits that can come with regular physical activity.

The National Sleep Foundation devoted its annual Sleep in America poll to exploring the relationship between exercise and sleep. Their results found that people who exercise regularly experience better quality and more consistent sleep than those who do not. People who exercise are also significantly less likely to feel sleepy during the day, and to experience symptoms of sleep disorders such as insomnia and obstructive sleep apnea. And the news gets better: while more vigorous exercise is best, people participating in light exercise—as little as 10 minutes of walking a day—reported substantially better sleep than non-exercisers.

The NSF interviewed a nationally representative sample of 1,000 adults between the ages of 23-60. Participants were asked to report on their physical activity in the past week, providing details on the frequency, duration, and intensity of their exercise. They also were asked to report on the quantity and quality of their sleep, as well as sleep problems including symptoms of disordered sleep and daytime drowsiness. Participants provided information about their overall health, and personal habits including alcohol and smoking.

Based on the reports of physical activity, respondents were divided into four categories, according to their exercise habits:

1. Vigorous: These people participated in activities like running, biking, swimming, and other pursuits that require significant physical exertion.
2. Moderate: Respondents in this category spent time doing activities that included higher-than-normal levels of physical exertion, including yoga and weight training.
3. Light: People in this category were physical active at normal levels of exertion, getting their exercise primarily by walking.
4. No activity: The respondents in this category did not engage in exercise.

The results were striking. All respondents—from vigorous exercisers to non-exercisers—reported getting roughly the same amount of sleep on a nightly basis, an average of 6 hours and 51 minutes on workdays, and 7 hours and 37 minutes on non-workdays. All groups also reported needing about the same amount of sleep to meet the demands of their daily lives: an average of 7 hours and 17 minutes. But exercisers at all levels reported sleeping substantially better than those who did not exercise:

• More than half of exercisers (56-67%) reported getting a good night’s sleep every night or almost every night, compared to 39% of non-exercisers.
• Exercisers at all levels also reported higher quality of sleep than non-exercisers. More than three-quarters (76-83%) said their sleep was “very good” or “fairly good,” compared to 56% of non-exercisers.
• More than half of exercisers at all levels also reported feeling their quality of sleep improve on days they engaged in physical activity.

While all exercisers reported significantly better sleep, the highest quality sleep was reported by those who engaged in the most vigorous physical activity. Vigorous exercisers reported the highest sleep quality, and the most robust daytime energy levels. And they were least likely to have problems with their sleep:

• 26% of vigorous exercisers said their quality of sleep was “very good,” compared to 16% of light exercisers.
• 66% of vigorous exercisers said they got more sleep than they needed, compared to 53% of moderate and light exercisers.
• Vigorous exercisers had fewer sleep problems than moderate and light exercisers, including less difficulty falling asleep and staying asleep, waking too early and not being able to fall back asleep. All exercisers reported fewer of these problems than people who did not exercise at all.
• 50% of vigorous exercisers said they had no problems maintaining enthusiasm for the demands of their daily lives, compared to 40% of moderate and light exercisers and 33% of non-exercisers.

People who engaged in no exercise didn’t just report lower quality sleep, they also reported in greater numbers a range of difficulties with their health and their daily lives:

• Non-exercisers were significantly more likely to say they experienced “very bad” sleep than exercisers. Fourteen percent of non-exercisers categorized their sleep as very bad, compared to 3-4% of exercisers.
• More than half—61%–of non-exercisers reported “rarely” or “never” getting a good night’s sleep on workdays, compared to 29% of vigorous exercisers.
• Non-exercisers were more likely to feel sleepy during the day. Nearly twice as many non-exercisers reported daytime sleepiness as exercisers.
• Daytime sleepiness interfered with non-exercisers daily activities and their safety more often than for those who exercised. 14% of non-exercisers reported having trouble staying awake while driving, eating, or engaging in social activity 1 or more times in the previous two weeks, compared to 4-6% of exercisers.
• Non-exercisers were significantly more likely to have symptoms of sleep disorders including obstructive sleep apnea. Forty-four percent of non-exercisers demonstrated a moderate risk for sleep apnea, based on standard clinical indications for the sleep disorder. This number was more than twice as high as for vigorous exercisers, only 19% of whom indicated a moderate risk of sleep apnea.

The message here is clear: put some time every day toward exercise, and when bedtime comes around you’ll sleep better. For those trying to juggle a regular exercise routine amid busy schedules, there’s some more good news in these poll results. The survey found that exercise at any time of day was good for sleep, including within 4 hours of bedtime. It’s been a common recommendation—including from the National Sleep Foundation itself—to avoid exercise during the final 4 hours of the waking day, in order to prevent physical exertion from interfering with sleep. Based on these results, the NSF has revised its recommendation, and encourages normal sleepers to exercise at any time of day, provided that their exercise does not interfere with their sleep. People with insomnia and other sleep disorders should continue to schedule their exercise earlier in the day. And anyone who finds their sleep diminished by late-day exercise should do the same.

So, where do you fit in the sleep-exercise picture that these survey results illustrate? Are you sleeping as much, and as well, as you need? If you’re looking for ways to improve your sleep, your daily exercise routine is a great place to start.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

By Michael Breus, PhD, ABSM

Insomnia and disturbed sleep are common among people with depression and other mental health problems. Research indicates that people with depression are significantly more likely to experience insomnia symptoms. Insomnia also has been linked to an elevated risk for suicide. A recent study offers new details about the relationship between insomnia and suicidal thoughts among people with depression.

Researchers at Georgia Regents University examined the possible influence of insomnia and disturbed sleep among patients with a history of depression and suicide. Their analysis revealed that the connection between insomnia and suicidal thoughts may be influenced by nightmares, and also by the presence of negative attitudes and beliefs about sleep in patients who are suffering from depression.

Their study included 50 patients between the ages 20-84. All had received treatment for depression either as inpatients or outpatients, or in the emergency room. Seventy-two percent of the participants were women, and a majority—56%–had attempted suicide at least once. Researchers measured levels of depression and insomnia, feelings of hopelessness, as well as the presence and severity of nightmares and attitudes and beliefs about sleep.

• Participants experienced moderate insomnia, on average
• As expected, their analysis showed an association between the presence and severity of insomnia and suicidal thoughts
• Researchers also analyzed data to examine the possible relationship between nightmares and attitudes about sleep with suicidal thoughts, and found significant associations. When these additional sleep problems were included in the analysis, insomnia itself was no longer directly associated with suicidal thoughts. This suggests that insomnia may have an indirect effect on suicidal thoughts, through the presence of these other symptoms, in patients who are depressed.
• Among people with depression, insomnia contributes to a sense of hopelessness about sleep, according to researchers. These negative feelings about sleep, as well as nightmares experienced by people with depression and insomnia, may be critical predictors for suicidal thoughts.

This is important new information in our understanding of the link between insomnia and suicide. The presence of these symptoms—nightmares and feelings of hopelessness about sleep—may be a more specific predictor of suicide risk among people with depression than insomnia in general.

Earlier work by some of the same researchers explored the relationship between insomnia and suicide. Their study included 60 patients between the ages 18-70. Two thirds were women, and all suffered from major depression and insomnia symptoms. Researchers found that the severity of insomnia among these patients was linked to degree of suicidal thoughts. More severe insomnia was associated with higher intensity of suicidal thoughts. In their analysis, researchers isolated insomnia from other symptoms of depression, such as low mood and inability to experience pleasure. They determined that insomnia is an independent predictor of suicidal thinking. This latest study built on those findings, looking with greater depth and specificity at how insomnia and related attitudes and behaviors of disrupted sleep may influence suicidal thoughts.

Other research has shown a strong association between insomnia and disrupted sleep and suicide for people with depression and other psychiatric disorders:

• This study examined the relationship of nighttime sleep disturbances—including insomnia and nightmares—and the risk of suicide among psychiatric outpatients. Researchers found that both insomnia and nightmares were linked to an elevated risk of suicide.

• This study also investigated sleep disturbances and nightmares as risk factors for suicide. Rather than including only participants with depression or other psychiatric disorders, Hungarian researchers used a broad sample of data, representative of the general population of Hungary. They found that sleep disturbances and nightmares elevated the risk of suicide by as much as 4 times among men, and as much as 3 times among women. In this study, frequent nightmares and sleep disorders were associated with a higher risk of suicide than depression.

• Sleep problems have been shown to be strong predictors of suicidal behavior for adolescents. This research reported that sleep problems in early adolescence (ages 12-14) were a significant predictor of suicidal thoughts and self-harming behaviors by later adolescence (ages 15-17). And this study of young adults in the military revealed sleep problems to be a stronger predictor of suicidal thinking than depression or feelings of hopelessness.

• In addition to risks for young adults, there also appear to be particular risks for older adults, in the connection between suicide and insomnia and disrupted sleep. This research showed that older adults with sleep problems were at greater risk for suicide than those in their age group who maintained healthy sleep patterns.

Understanding how insomnia and other sleep problems contribute to hopelessness and thoughts of suicide can provide important new options for suicide prevention and treatment of depression and suicidal thoughts. By identifying nightmares and dysfunctional, negative attitudes about sleep as important predictors of suicidal thinking in people with depression, we may be better able to identify those who are at greater risk for self-harm.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

By Michael Breus, PhD, ABSM

Insufficient sleep is related to a range of health problems, from diabetes and cardiovascular disease to depression, poor immune function, and cognitive decline, particularly in later years. For all that we know about the health risks associated with lack of sleep, we actually don’t know a lot about exactly how poor sleep contributes to poor health. The mechanics of the relationship between sleep and disease remain little understood.

New research may offer some important insight into how sleep affects heath. A new study indicates that poor sleep can significantly disrupt and inhibit normal gene activity, in hundreds of genes. The genes affected help to govern broad and important biological functions, including stress, the immune system, inflammation, metabolism, and circadian rhythms. A team of researchers led by scientists at England’s University of Surrey examined the influence of sleep on gene function, and found that a week of low sleep altered the activity of more than 700 genes. The study was collaborative effort among specialists in sleep science, genomics, physiology, and bioinformatics.

The study included 26 adults whose sleep was monitored for two weeks. During the first week, participants sleep slightly fewer than 6 hours per night, less than the recommended 7-8 hours. During the second week, they slept 8.5 hours nightly. After the conclusion of each week, researchers took blood samples and analyzed them to identify any changes in genetic activity. After controlling for other factors, including exposure to light, activity levels, and food, the results showed that a single week of insufficient sleep had a dramatic effect on gene activity:

• Low sleep altered the activity of 711 genes
• The total number of genes affected by sleep increased by 7 times after one week of sleep deprivation
• Many of our genes rise and fall in activity in accordance with our body’s 24-hour circadian clock. A week of insufficient sleep reduced the total number of genes that rise and fall in line with circadian rhythms from 1,855 to 1,481.
• Sleep deprivation also diminished the amplitude of the rise and fall of some of these circadian-aligned genes.

The genes affected by sleep deprivation help govern circadian rhythms, metabolic functions, and sleep homeostasis—the regulation of sleep itself. These are genes connected to immune system functioning, inflammation levels, and stress responses. Previous research has shown that disrupted sleep is indeed strongly associated with health problems related to these biological functions:

Circadian rhythms. In recent years we’ve learned a great deal about the importance of our circadian rhythms to health. Sleep itself is one of the many essential biological functions governed by our 24-hour circadian clock. Disruptions to circadian function are associated with a range of health problems, including psychiatric disorders, dementia, metabolic disorders such as diabetes, autoimmune disorders such as rheumatoid arthritis, and cancer.

Metabolism. Disrupted sleep is also strongly associated with metabolic diseases, including obesity, metabolic syndrome, and diabetes. Studies have shown that sleep problems can predict the future development of metabolic syndrome, a disorder that is associated with higher risk for diabetes and cardiovascular disease. Sleep is a critical factor in healthy weight control, and sleep deprivation is strongly linked to obesity. And there is a great deal of research to indicate that poor sleep increases the risk of diabetes, perhaps by contributing to insulin resistance.

Inflammation. Inflammation in the body is linked to a long list of health problems, including cardiovascular disease, chronic pain, diabetes, and cancer. Insufficient sleep has been linked to an increase in inflammation. This study showed people who slept 6 or fewer hours per night had higher levels of inflammation than those who slept between 6-9 hours nightly.

Immune system. Research has also shown that sleep plays a role in immune system functioning. Numerous studies in recent years indicate that disrupted sleep, as well as too little sleep, may compromise healthy immune activity. This recent research found poor sleep to be as damaging to the immune system as stress.

Stress. Stress response is another biological process affected by the gene disruption found in this latest study. The relationship between sleep and stress is complicated. Stress can interfere with both the quantity and quality of sleep, as this study shows. And insufficient sleep can have negative effects on the way we respond to stress. Research shows that low sleep is linked to hormonal changes that can affect stress response. Studies also show that healthy sleep works to ease the emotional sting of difficult memories. Lack of sleep may inhibit our ability to process difficult emotional experiences, prolonging periods of stress and anxiety.

There’s an abundance of scientific evidence linking sleep to these and other health problems. But we’re just scratching the surface of understanding the underlying pathways by which sleep influences health. Understanding more about how sleep affects genetic function holds great promise in illuminating these pathways, and could open important new avenues for both treatment and prevention of illness and disease.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

By Michael Breus, PhD, ABSM

Moderation and variety are two important keys to eating well for health. Eating a wide range of foods in moderate amounts are hallmarks of a diet in balance, and great ways to help achieve and maintain a healthy weight. Sleep is also an important component of overall health and weight regulation. How do sleep and diet work together? That’s the subject of a new study, which indicates that people who sleep less than 7-8 hours a night may consume more daily calories and eat a less varied diet.

Researchers at the Perelman School of Medicine at the University of Pennsylvania examined the dietary differences among people with different sleep patterns, and found that people who reported sleeping the recommended 7-8 hours per night consumed fewer calories than those who reported sleeping 5-6 hours per night. People who slept between 7-8 hours nightly also had more diverse diets than those who slept both less and more than this recommended nightly amount. Eating a wide range of foods is considered an indicator of a healthy diet.

Researchers used data from the National Health and Nutrition Survey (NHANES), a population-based survey of the health and nutrition habits of adults and children in the US, conducted annually by the Centers for Disease Control. As part of the survey, participants report their nightly sleep amounts. Researchers used this information to create four sleep categories:

Very short sleep: Those who slept fewer than 5 hours per night

Short sleep: People who slept 5-6 hours nightly

Standard sleep: Those who slept 7-8 hours per night

Long sleep: People who slept for 9 or more hours nightly

The NHANES data also included detailed information about participants’ daily eating habits. Using this information, researchers analyzed how the diets of short and long sleepers differed from standard sleepers, in terms of the range of foods and nutrients, and also calorie intake. They found that calorie consumption differed among the four groups:

• Short sleepers, those who slept between 5-6 hours nightly, consumed more calories than any other group.
• Short sleepers were followed by standard sleepers, very short sleepers, and long sleepers, in the overall amount of calories consumed daily.

Researchers also found differences in the makeup and quality of diets across the four groups:

• Standard sleepers, those who slept 7-8 hours, had the most broadly varied diet of all the groups.
• Very short sleep was associated with lower consumption of tap water, as well as carbohydrates and lycopene, a nutrient found in red and orange vegetables such as tomatoes. Lycopene is an antioxidant, and may protect against cancer and heart disease.
• Short sleep was associated with lower amounts of Vitamin C, tap water, and selenium, a mineral found in fish, meat, and nuts. Selenium helps to protect heart health, and may reduce the risk of some cancers.
• Long sleep was linked to lower carbohydrate consumption, as well as lesser amounts of theobromine. Theobromine is a stimulant, similar to caffeine but much weaker, which is found in chocolate and tea. Theobromide also has relaxing effects, and may help to lower blood pressure. Long sleep was also associated with greater alcohol consumption.

We don’t know from this study whether diet is influencing sleep or sleep is influencing food choice, or both. But the evidence is abundant that these two pillars of health—sleep and diet—affect each other in a number of ways. We’ve seen a great deal of research that diet and weight control are strongly influenced by sleep, and that too little sleep can make eating healthfully more challenging:

• Sleep deprivation disrupts hormones that regulate appetite, according to a number of recent studies. Being low on sleep increases feelings of hunger, a result of imbalances to the levels of hormones ghrelin and leptin, which work to regulate appetite.
• Being short on sleep can also compromise our ability to select healthy foods. Changes to brain chemistry brought about by insufficient sleep affect impulse control and judgment, resulting in poor food choices. And short sleep has also been shown to activate the reward centers of the brain, making junk food appear even more enticing.
• Other research has also shown that too little sleep is linked to increased calorie intake, and to eating more high-fat foods. This study found that men who were sleep deprived consumed an average of an additional 263 calories daily, compared to men who got sufficient sleep. Women who were sleep deprived consumed an average 329 extra calories daily. Both men and women also ate greater proportions of high-fat and high-protein foods. And this study concluded that people short on sleep were more likely to consume more of their overall calories from snacks, with higher carbohydrate amounts.

Sleep has a powerful effect on diet and weight control. There is also evidence that diet can help or hinder sleep, depending on what foods you choose:

• A high-fat diet may contribute to disrupted sleep and excessive daytime tiredness, according to studies like this one.
• On the other hand, a vitamin and mineral-rich diet can both keep weight in check and promote healthy, restful sleep. Foods rich in magnesium and potassium—including many fruits, vegetables, grains, and nuts—improve circulation, and relax the muscles of the body. Research has shown that the gene that regulates potassium in the body may also be responsible for generating slow-wave sleep, the deepest and most restorative phase of sleep. Foods with calcium aid in the body’s production of melatonin, a hormone critical to maintaining a healthy sleep-wake cycle.
• And it’s not just what you eat, but when: the timing of meals and snacks relative to sleep can also have an effect on the quality of your eating and sleeping. People who have later bedtimes and eat more of their calories later in the day sleep less, consume more calories, and have less healthful diets, according to this research.

Want your diet and your sleep to work together, each strengthening the other? Adopt a varied, nutrient-rich diet and a sleep routine that allows for 7-8 hours of nightly rest. Now that’s a recipe for long-term health.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

By Michael Breus, PhD, ABSM

All too often, snoring is regarded as a nuisance rather than a real health problem. People who snore—and the partners who must listen to their snoring at night—usually have no problem acknowledging that snoring is disruptive and uncomfortable. But most don’t look for actual treatment for their snoring, particularly if it is not accompanied by obstructive sleep apnea, a serious sleep disorder that is characterized by interruptions to breathing during sleep.

Snoring—with or without sleep apnea—is a very real health concern. Snoring is a sign of disrupted sleep, which can lead to many health problems. And new research suggests that snoring itself may increase the risk of cardiovascular disease.

Researchers at Detroit’s Henry Ford Hospital investigated the possible effects of snoring on the cardiovascular system. They found that snoring is associated with a thickening of the inner walls of the carotid arteries. The carotid arteries are responsible for carrying blood to the brain. This thickening of the arterial wall is an early sign of carotid artery disease, a narrowing or blocking of the arteries that increases the risk of stroke. Researchers also found that people who snore were more likely to suffer from this arterial thickening than others with more widely known risk factors for cardiovascular disease, including smokers, people who are overweight, and those with high blood pressure and high cholesterol.

Researchers examined data from 913 patients who sought treatment at Henry Ford Hospital’s sleep clinic. All the participants were between the ages of 18-50, and none of them had obstructive sleep apnea. Of this group, 54 men and women completed a survey about their snoring histories. They also received ultrasounds to measure the thickness of the intima-media of the carotid artery wall. Intima-media thickness is a measurement of the two innermost layers of the carotid artery wall. Thickening of the intima-media layers is considered a sign of elevated risk for cardiovascular disease.

People who snored had greater levels of intima-media thickness than those who did not snore, according to the study results. Snoring was alone among risk factors that associated with this abnormality to the carotid arteries. Researchers found no increase in intima-media thickness among people with other standard risk factors for cardiovascular risk factors, including obesity, smoking, diabetes, high blood pressure and high cholesterol.

This study is one of the first to show evidence of an increased risk to cardiovascular health from snoring. There is abundant evidence that obstructive sleep apnea is associated with increased risk of cardiovascular disease. Obstructive sleep apnea is also associated with a growing array of other health problems, including diabetes, cancer and sexual dysfunction in both men and women. Snoring is a frequent symptom of obstructive sleep apnea—but not everyone who snores has sleep apnea. Overall, much less attention has been paid to the possible health problems of snoring when it is not accompanied by sleep apnea. The research that has been done in this area has returned conflicting evidence regarding the health risks associated with snoring.

• A limited amount of research has indicated that snoring does not pose risk to cardiovascular health. Australian researchers conducted a long-term study of nearly 400 adults and found no increased risk of cardiovascular disease or death from snoring.

• Other studies have suggested that snoring is associated with other risk factors for cardiovascular disease, but that there is no direct relationship between snoring and cardiovascular problems. Among these risk factors are obesity, smoking, and alcohol consumption.

• Still other research indicates a more direct link between snoring and cardiovascular disease. This study conducted in Hungary found increased risk of cardiovascular disorders among men and women who snore. Researchers in this study adjusted for other common risk factors, such as obesity, in order to isolate the effect of snoring on cardiovascular health.

The latest research appears to offer new evidence of a direct connection between snoring and the development of cardiovascular problems. Researchers indicate that they intend to follow this work with another study to investigate a possible association between snoring and cardiovascular events, such as heart attack and stroke.

It is important to take snoring seriously as a health problem. While we wait for science to develop a greater understanding of the ways that snoring may negatively affect health, there are things we all can do to diminish the risk of snoring:

Maintain a healthy weight. Snoring appears to be closely associated with excess weight. Keeping your weight in check through regular exercise and healthy diet is one way to prevent, reduce and even eliminate snoring.

Drink moderately. Alcohol relaxes the muscles in the throat, and makes snoring more likely. Keep your alcohol consumption moderate, and drink no closer than 3 hours before bedtime, to avoid having alcohol interfere with your sleep and increase your risk of snoring.

Don’t smoke. Smoking irritates and inflames the tissues of the upper airway, and increases the likelihood of snoring. Improving your sleep and reducing your snoring is another very good reason to quit.

Talk to your doctor. It is important to let your physician know if you snore, no matter how mild you believe your snoring to be. Your doctor can advise you on the best strategies for treatment, including mouth guards and dental devices that can help keep your airway open during sleep. Your doctor can also monitor your condition in the event it progresses to obstructive sleep apnea.

Just because snoring is common doesn’t mean it’s harmless. Protect your health and take your snoring seriously.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

By Michael Breus, PhD, ABSM

It is one of the most common struggles that couples face: over the life of a relationship, partners can lose a sense of appreciation for one another. Holding on to a sense of gratitude for each other is one of the hallmarks of couples who stay content in their relationships over the course of many years. On the other hand, loss of gratitude and appreciation between partners can jeopardize a relationship’s long-term success.

A new study suggests that poor sleep may contribute to a lack of appreciation between romantic partners. Researchers at the University of California, Berkeley conducted a multi-part study to examine how sleep may affect people’s feelings of gratitude, and the ability to value and appreciate romantic partners. The study was presented recently at the annual conference of the Society for Personality and Social Psychology. The study included more than 60 heterosexual couples between the ages 18-56. They participated in three separate exercises designed to measure how sleep affects individual levels of gratitude, and sense of appreciation between partners:

• After a night of sleep, people were asked to make a list of 5 things for which they were grateful. Those with poor sleep demonstrated less of a sense of appreciation than those with better sleep quality and sleep quantity.
• Participants were asked to keep a daily record for two weeks of both their sleep and their feelings of gratitude—and lack thereof. Researchers identified a decline in levels of gratitude that was associated with poor sleep. People were more likely to report feelings of selfishness after a night of sleeping poorly.
• The third section of the study looked specifically at how sleep affects the dynamic of gratitude and appreciation between couples. Their results showed that people tended to feel less appreciated by their partners if either they or their partner slept poorly.

The last finding is particularly interesting. A lack of sleep by one person in the relationship resulted in greater likelihood of diminished feelings of appreciation by both partners. This suggests just how deeply sleep can influence the emotional dynamic of a relationship.

Sleep can pose a number of challenges to relationships. Poor sleep can make for difficult sleeping conditions for couples. The tossing and turning of insomnia and the noisy, disrupted sleep of snoring and sleep apnea don’t just diminish the quality of sleep for the individuals with the disorder. They also rob partners of restful sleep. Night owls and larks who share a bed may also have difficulty marrying their sleep schedules. If you’re an early-to-bed, early-to-rise type, having a partner who likes to read or watch television late into the night can interfere with sleep.

These may be among the reasons why an increasing number of couples are choosing to sleep in separate beds. Research shows as many as 25% of couples are sleeping separately, and this is a number that’s been rising for years. The separate-bed strategy may seem like an attractive option for couples struggling to sleep together well. But it’s important to consider what might be lost in this choice. I’m talking about the intimacy created by sharing a bed. And I’m not only talking about sexual intimacy, although that’s certainly a risk of sharing separate beds. (At the very least, couples are much less likely to have spontaneous sex if they’re not sleeping together.) I’m also talking about the sense of togetherness and emotional connection that comes from sleeping together.

What’s more, sleeping together can actually reinforce good sleep habits. Partners who sleep together can be a positive influence when it comes to keeping reasonable bedtimes, and not falling asleep to the television. Studies have shown that sleep apnea patients who use CPAP therapy are 60% more likely to stick with the treatment if their partners continue to share a bed, rather than sleeping separately.

This latest research makes sense given what we know about how sleep affects mood and outlook, as well as emotional and mental health. Poor quality sleep and insufficient sleep can negatively affect mood and judgment, making us cranky and less apt to greet the inevitable ups and downs of life with perspective and an even keel. Research shows that poor sleep increases the likelihood of depression and anxiety, conditions that themselves can interfere with sleep. So it’s not surprising that gratitude might diminish when we’re short on sleep, and that the people closest to us—our partners—might bear the brunt of this diminished sense of appreciation.

I’d like to see more studies like this—both for the specific knowledge and insights they provide us about the functions of sleep, but also for the way they highlight the very central role that sleep plays in the quality of our waking lives, and the lives of those we love.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com

By Michael Breus, PhD, ABSM

Does your child snore? Does he breathe through his mouth when he sleeps? Do you ever notice pauses in your child’s breathing while she’s asleep? If you’ve answered yes to any of these questions, your child may be suffering from sleep-disordered breathing.

Sleep-disordered breathing in children is disruptive to their nightly rest, which can result in other health problems. Scientists are still working to get a sense of how prevalent the disorder is among children. We’re also still learning about the risk factors that contribute to sleep-disordered breathing in children, as well as the health consequences for kids who suffer from it. Increasingly, it appears that both the risks and the health effects of sleep-disordered breathing are different in children than they are in adults. A new study examines both the prevalence of sleep disordered breathing in children, and the particular risk factors they face.

Researchers in Finland examined sleep-disordered breathing in 491 children ages 6-8. Their study, which was part of a larger research project on child health, analyzed the prevalence of sleep-disordered breathing among the children. The study also examined risk factors that might contribute to the sleep disorder, including tonsil size, jaw position, and facial proportions. For the purpose of this study, sleep-disordered breathing was defined as frequent or loud snoring, mouth breathing during sleep, and sleep apnea.

Here are some important highlights of their results:

• 9.9% of children had some type of sleep-disordered breathing. This rate was the same for both boys and girls in the study
• Average body-fat percentage was 20.6 for girls and 15.0 for boys
• 11.4% of boys and 15.6% of girls were overweight or obese
• Body fat was not associated with an increased risk of sleep-disordered breathing. Sleep-disordered breathing was no more frequent among obese and overweight children in this study than among children at normal weight

Several craniofacial features were associated with elevated risk for sleep-disordered breathing:

• Children with enlarged tonsils were 3.7 times as likely to experience symptoms of sleep-disordered breathing
• Children with cross bite were 3.3 times a likely to have sleep-disordered breathing. Cross bite is a dental condition where teeth are out of alignment with corresponding teeth above or below.
• Children with convex facial profiles were 2.6 times as likely to suffer from sleep-disordered breathing as children with other facial types. Convex facial features include prominent forehead and brow line and receding chin.

These results suggest that the risk factors for sleep-disordered breathing in children may be very different than those for adults. The most significant risk factor of sleep-disordered breathing in adults is excess body weight. Research indicates that 70% of people who are morbidly obese have obstructive sleep apnea. This study indicates that excess weight may not be a risk factor for children. For them, features of the head, neck and throat, as well as certain dental conditions, may be more significant indicators of risk for sleep-disordered breathing.

The health problems for children who develop sleep-disordered breathing also appear to be different than those for adults. A growing body of research indicates that children who experience sleep-disordered breathing are at greater risk for problems with behavioral, emotional, and cognitive development:

• This large-scale study of more than 11,000 children found that kids with sleep-disordered breathing were significantly more likely to exhibit behavioral and emotional problems, including hyperactivity, anxiety, depression, social issues with peers, and conduct problems including aggressiveness.
• Children who exhibit aggressive and bullying behavior in school were twice as likely to have some form of sleep-disordered breathing, according to this research
• Children with sleep-disordered breathing demonstrated lower intellectual abilities than those without, in this study. This cognitive impairment existed regardless of the degree of severity of the sleep disorder. Even children with mild forms of sleep-disordered breathing experienced cognitive difficulties.

A recent large-scale study in the United States examined the prevalence for sleep disordered breathing among children. Researchers evaluated more than 12,000 children between the ages 6 months and 6.75 years, and found:

• 1-2% of children across all ages suffer from chronic sleep apnea
• As many as 21% of children in this age range snore habitually
• Children ages 1.5-2.5 years are especially vulnerable to snoring: researchers found a significant increase in rates of snoring among children at this age
• By the age of six, 25% of children are mouth breathing during sleep

These latest results from Finnish scientists add to the body of research that indicates how significant an issue sleep-disordered breathing is for children. We need to know more about the prevalence of the disorder among children, as well as the risk factors and health consequences. We also need to further explore how the risks to children may differ from adults.

To avoid the behavioral, cognitive and emotional problems associated with sleep-disordered breathing, we also need to get better at identifying the problem. Early intervention can help avoid more serious problems that can occur if the disorder is left untreated. The most effective treatment strategy will involve the cooperation among doctors and dentists. But the process starts with parents. Paying attention to your child’s breathing during sleep, and bringing attention to any signs of irregular breathing, is the first and critical step.

Sweet Dreams,

Michael J. Breus, PhD

The Sleep Doctor™

www.thesleepdoctor.com