Ari Shechter, PhD Assistant Professor of Medical Sciences - PowerPoint Presentation

1. Ari Shechter, PhDAssistant Professor of Medical SciencesColumbia University Irving Medical Centeremail: as4874@cumc.columbia.edutwitter: @ShechterAriSleep Better, Live Healthier!Public Health Conversation Series, UN Division of Healthcare Management and Occupational Safety and Health (DHMOSH)June 9, 2021

2. Kryger, Sleep in Art

3. Kryger, Sleep in Art

4. 3 Pillars of Healthsleepexercisenutrition

5. “Sleep is the intermediate state between wakefulness and death; wakefulness being regarded as the active state of all the animal and intellectual functions, and death as that of their total suspension”Robert MacNish, member of the faculty of physicians and surgeons, Glasgow, in The Philosophy of Sleep, 1834Sleep as passive; inactive state of the brain

6. Sleep is a dynamic and actively produced brain state, with accompanying changes to physiology.Sleep is not static or passive!We do not “turn off” during sleepSome brain regions are more active during sleep than wake (although some are lower)Some hormones (growth hormone, melatonin) are secreted selectively during sleep (although some hormones and systems are reduced)Sleep definition:Neural and physiological

7. Sleep stages and cyclesStage N1: Very light SleepTransition from Wake to SleepDrift in and out of sleep, awaken easilyHypnagogic jerk: Sense of falling followed by sudden muscle contractionsStage N2: Relatively light but maintained sleepBrain activity relatively slowerBreathing and heart rate slowedMaintained sleepStage N3: Deep Sleep (Slow wave sleep)Lower brain activityHigh awakening thresholdRestoration of bodyStage REM: Rapid Eye Movement SleepVery active brain activityDreamsParalyzed bodyImage: Psychology Today

8. Image: University of Minnesota Libraries (open.lib.umn.edu )

9. Sleep quality

10. Circadian rhythm (circa= “about”, dian = “day”) refers to body rhythms that have a roughly 24-hour cycle. Circadian rhythmsImage: Nobelprize.orgThe circadian clock anticipates and adapts our physiology to the different phases of the day. Our biological clock helps to regulate sleep patterns, feeding behavior, hormone release, blood pressure, and body temperature.

11. Circadian rhythms:Melatonin and cortisolMelatonin: The “hormone of darkness”Helps you fall and stay asleepCortisol: A “stress” hormoneHelps you wake up and start the day

12. Lack et al. Sleep Medicine Reviews, 2008Circadian rhythms:Body temperature, Melatonin, and Sleep

13. questions

14. Why do we spend up to one-third of our lives sleeping?Cognitive functionMood and EmotionMemoryVigilance and AlertnessObesity andDiabetesCardio-vascularImmune systemCancer

15. WHO guidelines for sleep duration in children up to 1 year, 2-3 years, and 3-4 years oldAt least 7 hours of sleep per night is recommended to sustain health and safety in adultsToo much sleep??? Beyond duration:daily regularity of sleep duration and timingsleep quality (e.g., frequent awakenings during the night)daytime function: not feeling sleepy even after adequate sleepabsence of sleep disorders (gasping for air/snoring; movement disorders, etc.)

16. DisorderShort sleepInsomniaSDBDiabetes+++Hypertension+NANACHD+NAXStroke+NA+Total CVDX+++: statistically significant positive relationshipX: no statistically significant relationshipNA: no recently reported meta-analyses identifiedAssociations Between Sleep Duration and Disorders and Incident CVD: Summary of Recent Meta-AnalysesShort sleep durationIncreases the risk of diabetes by 30%Increases the risk of hypertension by 23%Increases the risk of CHD by 48%Increases the risk of stroke by 15%

17. blood pressureinflammationdyslipidemiadiet / obesityANS dysfunctionmetabolic functionphysical activity / sedentary behaviorpsychosocial:stress/anxiety/depression

18. Sleep and diabetesShort sleep is associated with diabetesPeople with short sleep duration are ~20-30% higher risk of type 2 diabetes, compared to people who get sufficient sleepLong sleepers are also at a risk Shan et al. 2015, Diabetes Care

19. Sleep and diabetesShort or poor quality sleep leads to reduced insulin sensitivity (increased insulin resistance)Reutrakul and Van Cauter, 2018, Metab Clin Exp

20. Short sleepers gain more weight over timePatel al. 2006, Am J Epidemiol

21. Energy balanceObesity is the product of energy imbalance At energy balance, intake = expenditure and weight remains unchanged At energy imbalance, intake ≠ expenditure and weight changes In positive energy balance, calories IN exceed calories OUT, and body weight gain resultsIn negative energy balance, calories OUT exceed calories IN, and body weight loss results

22. Sleep and ObesityShort sleep can lead to obesitymodified from Reutrakul and Van Cauter, 2018, Metab Clin Exp

23. Sleep restriction increases hormonal drive for appetite/food intakeIntakesShort SleepHabitual SleepP valueAll (n = 26)Energy, kcal2813.6 ± 116.3 2517.7 ± 116.30.02Fat, g112.2 ± 6.8 91.5 ± 6.8 0.01Saturated fat, g36.8 ± 3.528.1 ± 3.5 0.04Carbohydrates, g402.1 ± 32.6344.2 ± 32.6 0.19Protein, g98.0 ± 4.1 88.1 ± 4.1 0.08Spiegel et al. 2004, Annals Int MedSt-Onge et al. 2011, Am J Clin Nutr

24. Sleep affects the brain’s response to foodSt-Onge et al., 2012, Am J Clin NutrFood stimuli compared to non-food stimuli increased regional brain activity in the orbitofrontal cortex, insula, and regions of the basal ganglia and limbic system after restricted sleep. (regions involved in reward processing and decision making) Restricted sleep induces a state of greater responsiveness to food stimuli and heightened awareness of the rewarding properties of food

25. worksleepSleep is normally initiated during the rising phase of the melatonin curve and the declining phase of the core-body temperature curveSHIFT WORK and DAYTIME SLEEP

26. Sleep is normally initiated during the rising phase of the melatonin curve and the declining phase of the core-body temperature curveShift work and jet lag involve “going against” the endogenous 24-h circadian clock and its physiologyShift workers often attempt to sleep during the rising phase of the core-body temperature curve and during a time when melatonin secretion is minimalAlso, attempt to work during times when alertness levels are lowSHIFT WORKworksleep

27. Sleep:Aging related changesOhayon et al. 2004, Sleep

28. Young adult vs 60 y.o.WHO

29. Circadian rhythms:Aging related changesCircadian rhythms become less robust and slightly phase advanced with old age. Hood and Amir, 2017 J Clin Investigtion

30. Sleep hygiene: practices and habits that are necessary to have good nighttime sleep quality and full daytime alertness.Maintain regular sleep schedule Go to bed and get up around the same time every day (even weekends and vacation)Limit naps close to bedtime (recall: sleep homeostasis); early afternoon betterSleep environmentBedroom quiet, dark, relaxing, comfortable, cool temperatureEliminate light from electronic devices, lamps, etcBlackout curtains, eye shades, ear plugs, white noise machines, fans, etc. to make environment relaxing and sleep conducive

31. Sleep hygiene: practices and habits that are necessary to have good nighttime sleep quality and full daytime alertness.Pre-sleep routineRelaxing pre-bedtime routine to help wind down: Warm bath/shower (thermophysiological cascade)Quiet activities (e.g., reading, music)Low lightsAvoid electronic devices and short-wavelength (“blue”) light before bed. (change settings, brightness on devices)Try to avoid emotionally upsetting conversations and activities before attempting to sleep (news, social media)Limit other stimulating activitiesCaffeine/Nicotine: stimulantsAlcohol: Can help fall asleep but quality disturbedFood: Heavy or rich foods, fatty or fried meals, spicy dishes, citrus fruits, and carbonated drinks can trigger indigestion/heartburn for some people; limit close to sleepReduce your fluid intake before bedtime.

32. Sleep hygiene: practices and habits that are necessary to have good nighttime sleep quality and full daytime alertness.Adequate daytime light exposureTogether with limited nighttime light exposure, sufficient daytime light helps maintains proper expression and timing of the circadian system and sleep-wake cycle regulationExerciseEven10 minutes of aerobic exercise (e.g., walking or cycling) can improve nighttime sleep quality.

33. Psychological & behavioral approaches for insomniaStimulus controlSet of instructions designed to reinforce the association between bed/bedroom with sleep, and to re-establish a consistent sleep-wake scheduleTossing/turning/anxiety about sleep can cause bedtime to become a conditioned stimulus to trigger a negative response and further exacerbate poor sleepGoal is to (re-) establish a positive association of bed with sleep at night. Bed for sleep!Limit the practice of other activities such as eating, reading, watching television, studying, work, hobbies especially stressful things in bedGo to bed only when sleepy (will associated rapid sleep initiation with bed)If you cannot fall asleep, or you wake up in the night and cannot fall back asleep, get out of bed and go to a dimly lit area and do a relaxing activity (read a book, but not something overly rewarding or fun – don’t want to reinforce being awake)

34. Psychological & behavioral approaches for insomniaSleep restrictionRestrict time in bed (the sleep window) to narrower range, thereby increasing the homeostatic drive (i.e., accumulated sleep debt will fall asleep faster).Gradually increase window over days/weeks until optimal sleep duration is achieved and individual able to initiate and maintain sufficient sleepRelaxation trainingRelax both your mind and your body. This helps you to reduce any anxiety or tension that keeps you awake in bed. Procedures like meditation, progressive muscle relaxation, etc. to reduce autonomic arousal, intrusive thoughts, tension interfering with sleep

35. https://drcraigcanapari.com/harnessing-sleep-drive-for-a-better-bedtime/

36. Sleep as a social determinant of health / sleep disparities researchCOVID-19 and sleepSleep and neurodegeneration / Alzheimer’s diseaseWearable devices and monitoring of sleep outside the laboratoryCircadian medicineTiming of behaviors (time restricted eating, etc)

37. InsomniaSymptomsDifficulty falling asleep Difficulty staying asleep Waking up too earlyFeeling that sleep is unrefreshingAssociated with feelings of daytime sleepiness, fatigue, difficulty concentrating, irritable moodPrevalenceAffects 30-45% of adults in a given year.10-15% of adults report chronic (persistent) insomnia.Becomes more common with aging

38. Genetic vulnerabilityPhysical and psychological arousal (being “revved up”)Psychological factors: depression, stress, anxietyInsomniaThere are many different causes of insomniaMedical or neurological conditionsBehaviors and environment: work shifts, screen time, light exposure Substances: Caffeine, alcohol, medications

39.

40. Sleep hygiene: practices and habits that are necessary to have good nighttime sleep quality and full daytime alertness.

41. Psychological & behavioral approaches for insomniaStimulus controlSet of instructions designed to reinforce the association between bed/bedroom with sleep, and to re-establish a consistent sleep-wake scheduleTossing/turning/anxiety about sleep can cause bedtime to become a conditioned stimulus to trigger a negative response and further exacerbate poor sleepGoal is to (re-) establish a positive association of bed with sleep at night. Bed for sleep!Limit the practice of other activities such as eating, reading, watching television, studying, work, hobbies especially stressful things in bedGo to bed only when sleepy (will associated rapid sleep initiation with bed)If you cannot fall asleep, or you wake up in the night and cannot fall back asleep, get out of bed and go to a dimly lit area and do a relaxing activity (read a book, but not something overly rewarding or fun – don’t want to reinforce being awake)

42. Psychological & behavioral approaches for insomniaSleep restrictionRestrict time in bed (the sleep window) to narrower range, thereby increasing the homeostatic drive (i.e., accumulated sleep debt will fall asleep faster).Gradually increase window over days/weeks until optimal sleep duration is achieved and individual able to initiate and maintain sufficient sleepRelaxation trainingRelax both your mind and your body. This helps you to reduce any anxiety or tension that keeps you awake in bed. Procedures like meditation, progressive muscle relaxation, etc. to reduce autonomic arousal, intrusive thoughts, tension interfering with sleep