From our collaborators at Johns Hopkins Medicine International | Six keys to raise your Sleep Health IQ

1. Recognize the gender differences in sleep disorder symptoms and abnormal sleep patterns

A 2016-2017 Canadian health measures survey found over 6% of respondents had been diagnosed with sleep apnea. Interestingly significant differences in the risk factors and symptoms of sleep apnea were noted between genders, shedding light on how diagnostic accuracy and timing can be improved with greater awareness of the differences between the sexes.

For instance, Canadian obstructive sleep apnea (OSA) male sufferers were more likely to be the loud “window rattling” snorers who can be heard through closed doors as opposed to female OSA sufferers. Canadian female OSA suffers are more likely to suffer from fatigue and insomnia as a result of their OSA and twice as likely to have an elevated BMI as compared to their male OSA counterparts.

Both male and female OSA sufferers reported higher rates of diabetes, hypertension, heart disease and mood disorders than non OSA sufferers, however, female OSA sufferers reported even higher rates of hypertension than their male OSA counterparts. These findings support previous studies that females with OSA are more likely to experience more subtle symptoms that could delay diagnosis, while at the same time suffer greater health consequences if left untreated.(4)

Another 2018 study evaluating over 21,000 Canadians, aged 6-79 years, found that as many as 42% of the adult respondents experienced insomnia symptoms with many suffering with sleep difficulties for well over a year. Older adults, women and those suffering from other health or quality of life setbacks seemed to be the most vulnerable.

2. The strong relationship between sleep and mood

Sleep and restfulness are universally associated with positive images of calm, serenity and peacefulness resulting in positive images of next day vitality, enthusiasm and happiness. On the contrary, the sleep deprived individual is typically depicted as one who is cranky, ill-tempered, moody, uninspired and lethargic. Science has provided neurobiological data to back up these images and associations. In fact , mounting evidence shows a strong association between sleep patterns and individual moods and behaviors.(6)

For instance, sleep (or lack thereof) can be a potential trigger or risk factor for both depression and anxiety disorders. Concurrent sleep deprivation can also reduce the overall effectiveness of treatment for mood disorders or increase the likelihood of relapse of symptoms if the sleep complaints are not addressed. Aside from its impact on mood, poor sleep patterns have also been linked with increased likelihood of an individual choosing to participate in risk behaviors ranging from gambling practices, substance abuse, and even reckless driving maneuvers.(7)

Thus mounting evidence suggests that sleep can represent both a personal and public health benefit when it comes to our moods and our actions.

3. Beware of over-the-counter sleep aides

The increase in sleep awareness has also resulted in an economic boom in nonprescription sleep aides and supplements. Most nonprescription sleep aides include one or a combination of the following:

  • Antihistamine
  • Alcohol
  • Melatonin
  • Tryptophan
  • Magnesium

All of the above substances have been associated with inducing sleep, however, in most cases the amount of the active ingredient is not regulated and therefore can vary from brand to brand or even pill to pill. Moreover, even in cases where the supplement does contain the substance as labeled, all of the aforementioned substances can be associated with side effects that can include daytime grogginess, mental slowness and even significant drug reactions. As a result, even greater caution is required when considering use in older individuals.

A recent report from the journal Drugs and Aging (8) based on risk-benefit analysis made the following recommendation for the use of common OTC sleep aides in the elderly population:

  • Benzodiazepines should not be used routinely for sleep in the elderly
  • Melatonin shows a slight improvement in sleep timing and duration but calls for caution due to variability in effectiveness and quality
  • Tryptophan shows a slight improvement in sleep but calls for caution due to limited research of use in the elderly
  • Valerian root appears safe with unclear evidence of sleep benefit

Therefore, any of these over-the-counter sleep aides or supplements should not be taken without discussing with your physician. In order to avoid the possible unwanted risk that comes from synthetic sleep supplements, increasing attention is now turning to natural sources of sleep-inducing substances. A small number of well-controlled studies have found sleep promoting benefits from the following foods:

  • Tart cherry juice (melatonin rich)
  • Parmesan cheese (tryptophan rich)
  • Soy (tryptophan rich)
  • Pumpkin seeds (magnesium rich)
  • Salmon (melatonin, tryptophan, and magnesium rich)

4. Sleep-tracking devices: Recognize the strengths and limitations

The growing awareness of sleep health has also brought an expanding inventory of consumer tracking devices. Sleep tracking devices now include wearables, sleep apps, portable devices and even smart mattresses to provide real time feedback on the features of your sleep quality. Although research is slowly being reported regarding the agreement and correlation of these device outputs with the more conventional methods to monitor sleep, consumers should remain cautious about making any conclusions about the presence or absence of a sleep disorder based on these devices.

First of all, the reported studies that are well-controlled and independent are usually based on studying a very small number of individuals who are typically young, healthy and without any major sleep or medical conditions at the time of their enrollment in the study. Therefore, the results regarding the reliability of these devices cannot necessarily be applied to older individuals or those with medical or sleep conditions.

With that said, after factoring in the potential limitations that these devices carry, they can still be a useful tool if it helps the individual to be more in tune to their sleep habits and helps promote prioritization of sleep healthy behavior.

5. Adopt the following sleep-conducive environment features:

  • Keep the bedroom clean, uncluttered at all times
  • Keep the bed made when not sleeping, and use the bed only for sleep, sex or sickness
  • Keep TVs, computers, smart phones, and smart pads out of the bedroom
  • Keep the bedroom temperature between 67-73 degrees Fahrenheit
  • Keep the bedroom dark during your sleep period with the aid of black out curtains and ventilated sleep masks as necessary and as safety permits
  • Keep the bedroom well-lit during waking hours with maximal natural light if possible
  • Keep the room lit at night with diffusing downward (shaded) light and minimal overhead and LED light sources
  • Develop a relaxation ritual before bed (for example, yoga, meditation, light reading)
  • Keep your wake time regimented regardless of weekday, weekend or holidays (this should not deviate more than 30 minutes, even on weekends and holidays)

6. Know when to seek help

The three most common sleep disorders worldwide are insomnia (inability to fall asleep or stay asleep), chronic insufficient sleep, and sleep apnea (breathing difficulty while sleeping, often associated with snoring, gasping or choking while sleeping). Recognize that men and women, as well as adults and children can have different symptoms and consequences for their sleep loss.

Finally, take some time to self-reflect on your sleep habits and overall function and consider the potential link and impact between the two. This may require some self-experimentation in terms of tweaking the various facets to identify your ideal bedtime, wake time and bedroom environment components and how it may factor into your ability to function at “your best” the following day. Consider taking a step back to ponder the following questions:

• Do I routinely allow myself more or less than 7-9 hours of sleep opportunity?
• Do I feel more agitated and irritable with my family, friends, and workmates?
• Do I fall asleep in work meetings, at the dinner table or while watching a movie in the evening with family?
• Do I have more difficulty concentrating and focusing on routine tasks recently i.e., making change, doing simple arithmetic?
• Do I routinely snore loud enough for others to hear me in another room?
• Do I have a new diagnosis of high blood pressure or diabetes?
• Do I have uncontrolled high blood pressure or diabetes?
• Do I nod off while driving an average of once a month ?
If you said yes to any of the above questions, you might want to consider getting a formal sleep evaluation.

Dr. Charlene Gamaldo is the Medical Director of the Johns Hopkins Center for Sleep

References
1. Chang VC, Chaput JP, Roberts KC, Jayaraman G, Do MT. Factors associated with sleep duration across life stages: results from the Canadian Health Measures Survey https://doi.org/10.24095/hpcdp.38.11.02
2. Hui SA and Grandner MA. Trouble Sleeping Associated with Lower Work Performance and Greater Health Care CostsLongitudinal Data from Kansas State Employee Wellness Program. JOEM Volume 57, Number 10, October 2015.
3. Gariepy G et al., More than just sleeping in: a late timing of sleep is associated with health problems and unhealthy behaviors in adolescents, Sleep Medicine, https://doi.org/10.1016/j.sleep.2018.10.029.
4. Public Health Agency of Canada. 2013; What is the Impact of Sleep Apnea on Canadians? Fast Facts from the 2009 Canadian Community Health Survey – Sleep Apnea Rapid Response; https://www.canada.ca/en/public- health/services/chronic-diseases/sleep-apnea/what-impact-sleep-apnea-on-canadians.html. (accessed: May 14, 2018).
5. Chaput JP, Yau J, Rao DP and Morin CM. Health Reports, Vol. 29, no. 12, pp. 16-20, December 2018 • Statistics Canada, Catalogue no. 82-003-X Prevalence of insomnia for Canadians aged 6 to 79 • Health Brief Prevalence of insomnia for Canadians aged 6 to 79
6. Palagini L, Domschke K, Benedetti F, Foster RG, Wulff K, Riemann D. Developmental pathways towards mood disorders in adult life: Is there a role for sleep disturbances? Journal of Affective Disorders 243 (2019) 121–132.
7. Gariepy G, Dore I, Whitehead RD, Elgar FJ. More than just sleeping in: a late timing of sleep is associated with health problems and unhealthy behaviours in adolescents, Sleep Medicine, https://doi.org/10.1016/j.sleep.2018.10.029
8. Abad VC and Guilleminault C. Insomnia in Elderly Patients: Recommendations for Pharmacological Managmenet. Drugs & Aging 35(9): 791-817, 2018.

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