Sleep is so important that we spend one third of our lives doing it.
Many of us are chronically under slept however, and if you experience fatigue throughout the day, that is an indicator you are not achieving adequate rest. 7 to 9 hours of sleep is considered optimal in adulthood. Additional signs of healthy sleep include falling asleep within 15-20 minutes, staying asleep easily and feeling rested upon waking. [i] Unfortunately, on a societal level, we are chronically sleep deprived, with estimates that 35% of us are not getting the recommended 7+ hours of sleep per night.[ii] Fortunately, there are a number of strategies to help improve sleep duration and quality.
There are far reaching health and societal consequences for our lack of sleep. According to the Center for Disease Control (CDC), an estimated 1 in 25 adult drivers report having fallen asleep while driving in the previous 30 days. Recent estimates indicate that drowsy driving cause up to 72,000 crashes, 44,000 injuries and 800 deaths[iii]. It is suspected that even these numbers are underestimated, and that likely closer to 6,000 fatal crashes each year are caused by drowsy drivers.[iv]
The health consequences of lack of sleep appear to affect all aspects of our well-being, including physical and mental health. Adults and children are more likely to be obese with the less sleep.[v] After a poor night’s sleep, you crave more carbohydrates for the following days and tend to consume more calories. In one study, there was an average of 2 pounds of weight gain after 1 week of only 5 hours of sleep per night.[vi] I am sure you can think of a time when you have not achieved enough sleep, and then craved poorer quality foods (e.g., carbohydrates) to give you quick access to energy. Down the road, from middle age to older adulthood, people who report not getting enough sleep are twice as likely to be diagnosed with type 2 diabetes.[vii] Finally, short sleepers (less than 7 hours) have an estimated 12% increased risk of all-cause mortality (the death rate from all causes of death). [viii]
Why Do We Sleep?
Sleeping has many purposes, including allowing our body a time to rest and repair. A recent discovery in neuroscience is that during sleep, our brain is given an opportunity to clean itself. Specifically, fluid moves between our neurons (i.e., brain cells), which operates like a waste disposal system by clearing out the waste products generated during performance of normal day-to-day tasks.[ix] There may be a connection between the lack of cleaning that happens if you do not achieve adequate hours of sleep, and the development of age related disorders (e.g., Alzheimer’s Disease).
Common Barriers to Sleep in 2020:
- Screen time
- E-readers, iPads, cellphones, TVs as well as bright over head lights have all been shown to reduce sleep latency, duration, and quality. My recommendation is to discontinue screen time at least 1 hour before bed. The blue light emitted from these devices suppresses our production of melatonin. Melatonin is a hormone that regulates our circadian rhythms, which help regulate our sleep-wake cycle in a 24 hour period. In one study, one hour of iPad reading before bed, versus one hour of reading in dim light with a paper book, the iPad readers had a 50 percent reduction in the release of melatonin. The iPad readers also lost a significant amount of REM sleep. Furthermore, there was an aftereffect, and for several days after the iPad use ceased, there was a 90-minute lag in their evening rise of melatonin.[x]
- A common misconception I hear about is that sleep quality is enhanced with alcohol. When we look at sleep data after someone has consumed alcohol, we see that there is an increase in the fragmentation of sleep – i.e., increasing number of wakings throughout the night. These wakings are very brief, meaning the individual often does not recall that they occurred. Alcohol inhibits REM sleep, also known as dream sleep, which is the time when memory integration and association happens. The best advice is to abstain from alcohol due to its harmful effects on sleep quality.
- Caffeine is the most widely used stimulant around the world. It is effective at blocking our feeling of sleepiness. A chemical called adenosine accumulates in our brain the longer we are awake, and contributes to our need to sleep by building “sleep pressure”. Caffeine works by blocking adenosine, and thus reducing our sleep pressure. With caffeine, we also see changes in the quality of sleep; specifically in the amount of deep sleep we can achieve. [xi] The half-life of caffeine is 6 hours, meaning that after 6 hours, half of the amount of caffeine you have in your body is still present. For example, if you have approximately 320 mg of caffeine at 8 a.m. and 42 mg at 12 p.m., by 10 p.m. you still have approximately 76 mg of caffeine in your system. Typically, 1 cup (250 ml) of coffee is around 100-250 mg of caffeine, but will vary on how the coffee is prepared. 1 tall cup (12 ounces) of Pike Place Roast from Starbucks has 235 mg of caffeine in it.[xii] My recommendation when there are sleep challenges, is to not have any caffeine within 12 hours of your sleep time.
Foundations for Restful & Restorative Sleep
- Avoid screens for 1 hour before bed.
- Consistent bedtime and wake up time; avoid naps after 3 p.m.
- Keep room cool – approximately 18 degrees Celsius is ideal.
- Dark room – consider black out blinds.
- Quiet – use ear plugs if needed, or if your partner’s sleep disrupts you, consider sleeping in separate rooms.
- No snacking or eating after dinner.
- Avoid alcohol and nicotine, while minimizing caffeine use 12 hours before bed.
- Dim the house lights approximately 2 hours before bedtime.
- Consider having a warm bath or shower before bed.
- Bed is for sleep and intimacy only.
What if optimizing foundations for sleep isn’t enough?
After optimizing sleep hygiene – for example trying suggestions from the list of foundations for sleep above – you can then explore other options for supporting sleep. As much as possible, I recommend avoiding sleeping medications. Sleep medications are sedatives and do not improve sleep quality, yet they give you a false sense that you have had a good night’s sleep.
A variety of symptoms can impact your sleep quality including hot flashes, restless legs, muscle cramps, sleep apnea, anxiety and frequent urination. I recommend discussing possible treatment options with your primary care provider and possibly getting a referral for a sleep study. There is a link at the end of the article to an at-home screening questionnaire for sleep apnea.
Cognitive behavioural therapy for insomnia, known as CBT-I, helps you optimize your foundations for sleep and associate your actions and behaviours during the daytime with your sleep quality. It has the most evidence behind it for improving sleep quality and quantity. A 2015 meta-analysis reviewed 20 randomized trials for chronic insomnia in 1100 participants. They found that CBT-I improved sleep across a variety of outcome measures, including sleep onset latency (improved by 19 minutes), wake time after sleep onset (decreased by 26 minutes) and sleep efficiency, which is the ratio of time people spent in bed versus time asleep (improved by 10 percent). [xiii] There are a variety of online options for CBT-I, many of which are free. Links to resources for this are at the end of the article.
Some supportive options that I often discuss with patients include:
- Meditation before bed. Consider trying one of the widely available apps (e.g., Insight Timer, Calm). Mindfulness based meditation programs have been shown to improve sleep quality. [xiv] There are many mindfulness-based meditation programs available in Victoria, outlined through BCalm (bcalm.ca).
- Melatonin is a hormone that is naturally produced by our pineal gland in our brain to help regulate our circadian rhythms (our internal clock), and initiate sleep. Our production of melatonin reduces as we age. It can be helpful in managing jet lag and transitioning sleep/wake times in shift workers. [xv], [xvi]
- Magnesium is an important nutrient that many of us are not getting enough of because our soil is less rich in magnesium nowadays, and our diets are higher in refined foods. [xvii] Magnesium functions as a muscle relaxant, and in some people it can be helpful for improving sleep, particularly older adults. I recommend magnesium glycinate as it has superior absorption and is gentle on the bowels. [xviii]
- Botanical medicine can be supportive in some, and there are a variety of options for this including chamomile, kava, and valerian; all with varying degrees of effectiveness and side effect profiles.[xix] I recommend speaking with your Naturopathic Doctor or primary care provider prior to experimenting with over the counter herbals.
- Acupuncture – a review of research on acupuncture for treatment of insomnia demonstrated improvements in sleep quality.[xx]
Many of the sleep tracking devices (e.g., Apple Watch, Fit Bit, Oura Ring, and Whoop) have limitations in determining actual sleep quality/quantity; however, some people do find the information they obtain from these devices to be beneficial in terms of optimizing their sleep.
Cognitive Behavioural Therapy for Insomnia https://mysleepwell.ca/cbti/
At home sleep apnea questionnaire – http://www.stopbang.ca/osa/screening.php
Highly recommend reading the book ‘Why We Sleep” by Matthew Walker
[i] Stepanski, E. J., & Wyatt, J. K. (2003). Use of sleep hygiene in the treatment of insomnia. Sleep medicine reviews, 7(3), 215-225
[v] Cappuccio, F. P., Taggart, F. M., Kandala, N. B., Currie, A., Peile, E., Stranges, S., & Miller, M. A. (2008). Meta-analysis of short sleep duration and obesity in children and adults. Sleep, 31(5), 619-626.
[vi] Markwald, R. R., Melanson, E. L., Smith, M. R., Higgins, J., Perreault, L., Eckel, R. H., & Wright, K. P. (2013). Impact of insufficient sleep on total daily energy expenditure, food intake, and weight gain. Proceedings of the National Academy of Sciences, 110(14), 5695-5700.
[vii] Mesarwi, O., Polak, J., Jun, J., & Polotsky, V. Y. (2013). Sleep disorders and the development of insulin resistance and obesity. Endocrinology and Metabolism Clinics, 42(3), 617-634.
[viii] Cappuccio, F. P., Taggart, F. M., Kandala, N. B., Currie, A., Peile, E., Stranges, S., & Miller, M. A. (2008). Meta-analysis of short sleep duration and obesity in children and adults. Sleep, 31(5), 619-626.
[ix] Benveniste, H., Liu, X., Koundal, S., Sanggaard, S., Lee, H., & Wardlaw, J. (2019). The glymphatic system and waste clearance with brain aging: a review. Gerontology, 65(2), 106-119.
[x] Chang, A. M., Aeschbach, D., Duffy, J. F., & Czeisler, C. A. (2015). Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proceedings of the National Academy of Sciences, 112(4), 1232-1237.
[xi] O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk management and healthcare policy, 11, 263.
[xiii] Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M., & Cunnington, D. (2015). Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Annals of internal medicine, 163(3), 191-204.
[xiv] Black, D. S., O’Reilly, G. A., Olmstead, R., Breen, E. C., & Irwin, M. R. (2015). Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: a randomized clinical trial. JAMA internal medicine, 175(4), 494-501.
[xv] Sharkey, K. M., Fogg, L. F., & Eastman, C. I. (2001). Effects of melatonin administration on daytime sleep after simulated night shift work. Journal of sleep research, 10(3), 181-192.
[xvi] Herxheimer, A., & Petrie, K. J. (2002). Melatonin for the prevention and treatment of jet lag. Cochrane Database of Systematic Reviews, (2).
[xvii] Guo, W., Nazim, H., Liang, Z., & Yang, D. (2016). Magnesium deficiency in plants: an urgent problem. The Crop Journal, 4(2), 83-91.
[xviii] Abbasi, B., Kimiagar, M., Sadeghniiat, K., Shirazi, M. M., Hedayati, M., & Rashidkhani, B. (2012). The effect of magnesium supplementation on primary insomnia in elderly: A double-blind placebo-controlled clinical trial. Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences, 17(12), 1161.
[xix] Leach, M. J., & Page, A. T. (2015). Herbal medicine for insomnia: A systematic review and meta-analysis. Sleep medicine reviews, 24, 1-12.
[xx] Shergis, J. L., Ni, X., Jackson, M. L., Zhang, A. L., Guo, X., Li, Y., … & Xue, C. C. (2016). A systematic review of acupuncture for sleep quality in people with insomnia. Complementary therapies in medicine, 26, 11-20.