Healthier Sleep: The Wellness Issue

Healthier Sleep Magazine

A publication of World Sleep Society

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Contributing Writers

Célyne H. Bastien, PhD

Diego Z. Carvalho, MD

Gina Dewink

Brendan Duffy, RPSGT, CCSH

Karen Kilpatrick

Sharon Moore

Rosei Skipper, MD

Jessica Thomas, MPH

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Healthier Sleep is published up to five times per year by World Sleep Society, 3270 19th Street NW, Suite 109, Rochester, MN 55901 and distributed to sleep medicine and research professionals as well as the public. No part of this publication may be reprinted or reproduced without written permission.

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World Sleep Society/Healthier Sleep Magazine does not provide or offer medical advice. All content within the magazine, such as text, graphics, information obtained from sleep experts, and other material, is for informational purposes only. The content is not intended to be a substitute for medical diagnosis, advice or treatment. Relying on information provided by World Sleep Society and/or any of its employees, experts within the material, or other writers is solely at your own risk.

About the Wellness Issue

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Sleep Is Essential for Health

By Jessica Thomas, MPH

On an intuitive level, we all know that good sleep is vital for our health. However, if we scratch the surface of this understanding a little bit, problems can start to emerge. Do we know what good sleep truly is? Many people think it can be defined by the number of hours we sleep or whether we have problems like sleep apnea.

The truth, though, is far more complex. Good sleep has more to do with the quality of our sleep rather than the number of hours that we sleep. And just because you don’t have a sleep disorder or other significant problem, that doesn’t mean you get good sleep.

Defining Good Sleep Health

There are many ways to define what good sleep health is, but there is no consensus about the right or wrong way to go about this. As a result, it remains an area of active debate in the scientific and medical community.

At its simplest, good sleep health leaves you feeling energetic and able to take on your daily tasks. On the other hand, a lack of good sleep health may leave you feeling exhausted, dragging, and struggling to function. Completing even simple tasks can be arduous. This lack of good sleep health can affect both your physical and mental health.

The Link Between Poor Sleep Health and Poor Overall Health

Not surprisingly, if good sleep health can be linked to good health outcomes, poor sleep health can also be linked to poorer overall health and health outcomes for impacted people.

The United States’ National Institutes of Health (NIH) has conducted extensive research into the negative impacts of poor sleep on health and has found myriad consequences. Some of these effects are logical and expected, and some are less well-known (although research continues into these less well-known risks).

Perhaps the most well-known links are among poor sleep patterns, poor sleep health, and cardiovascular health. Poor sleep can lead to high blood pressure, which is also linked to heart disease and an elevated risk of stroke.

Research has also shown that poor sleep health causes late-night eating and increased caloric consumption, which can increase the risk of a person developing obesity. Obesity is a standalone problem. However, it’s also associated with an elevated risk for other diseases, such as type 2 diabetes, which can negatively impact a person’s quality of life, as well as their life expectancy.

Poor sleep health not only impacts a person’s physical health, but it also affects their mental health. For example, insomnia can skyrocket a person’s risk of depression almost ten times. Many people who are dealing with poor sleep also highlight how this has led to an uptick in their anxiety. However, it is important to note that the relationship between sleep and mental health is complex. Existing mental health problems can also drive sleep issues. There is an element of circularity here.

Assessing Our Sleep

In a seminal article published in 2014, Dr. Daniel Buysse highlighted traditional weaknesses in the sleep study field. As Buysse noted, sleep medicine has tended to focus on problems that can be identified and treated. Unfortunately, this approach overlooks many aspects of sleep and minimizes the link between sleep and health.

Buysse notes that one of the most important things that can be done is transforming the language we use to talk about sleep. Instead of focusing on the terminology of sleep problems, such as sleep apnea and narcolepsy, it’s critical that we move towards discussing sleep health. Assessing sleep health requires input from the person who is trying to sleep. One way to do this is with the RU-SATED questionnaire. RU-SATED attempts to give people insight into their sleep health with six simple and straightforward questions, only one of which is focused on how much time a person sleeps. The questionnaire also assesses regularity of sleep times, satisfaction with sleep, alertness during the day, timing of sleep, and efficiency of falling asleep. A higher score out of 12 indicates that a person has better or good sleep health. On the other hand, a score near zero should raise alarms about sleep and the person’s health.

Moving Forward

Throughout the world, many people are plagued by poor sleep, ranging from sleep deprivation (not getting enough hours of sleep each night) to getting poor quality and disrupted sleep that negatively impacts their day-to-day functioning. Part of addressing poor sleep is transitioning the conversation both in the general public and in the medical community from poor sleep and the number of hours slept each night to good sleep health and the quality of sleep.

Once this transition happens, it’s crucial for both sleepers and the scientific community that studies them to understand that there is a fundamental link between good sleep health and good overall health. Without good sleep health, people are at risk of developing a wide range of physical and mental health problems.

World Sleep Day: Celebrating Awareness

In recent years, there has been a rise in global awareness that good sleep is essential to a person’s overall physical and mental health. To celebrate this awareness and continue building momentum, a wide range of stakeholders, including sleep researchers, medical doctors, and impacted patients, join together to acknowledge World Sleep Day on the Friday before Spring Vernal Equinox of each year. To learn more visit worldsleepday.org

*Citations available on healthiersleepmag.com

Jessica Thomas is a public health professional, health & wellness writer, and entrepreneur. She enjoys learning about and educating others on healthy living and observing how technology is changing the healthcare space.

Things to Know about Sleep & Stress

By Célyne H. Bastien, PhD

Understanding the relationship between stress and sleep has been essential during the unprecedented times that we have lived in since 2020. The pandemic had a devastating effect on sleep, especially because of the stress caused by situations like isolation, loneliness, financial hardship, fear, and disrupted home routines.

Here are four things to keep in mind as we consider the importance of healthy sleep even during uncertain times.

1.) It is normal in a stressing period to feel that our sleep is not of good quality or has deteriorated. We can take longer to fall asleep, wake up more often during the night, or even wake up in the early hours of the morning without being able to return to sleep. When we experience sleep difficulties, we may start to worry about our sleep and then get anxious about the fact that we are not getting enough sleep. From there, our health might deteriorate because of the lack of sleep.

2.) Sleep can help stress. By sleeping, your body is relaxing, and your mind is at peace (besides the occasional bad dreams which could be punctually disturbing). Thus, if you get a good night’s sleep, your body and your mind is better “equipped” to face stressing situations: your stress coping mechanisms are more effective.

3.) Lighten the mood to lessen the stress. There are many things you can do, and they relate mostly to sleep hygiene and general health hygiene: have a nice sleeping environment, make sure you have plenty of time to recuperate, learn something new (cooking, language, etc.), talk to family members and friends to release some of the stress, exercise (but no later than four hours before going to bed), watch funny movies, do not use any electronics in your bedroom, attend some relaxation/meditation/mindfulness/yoga classes, and eat well to lighten your mental load and mindset.

4.) Stress during the day, instead of at night. One other recommendation is to reserve 30 to 60 minutes during the day to sit down and take the time to write what stresses you. It will not only give you the opportunity to find solutions to what is stressing you, it will also allow you to say “this is my time to worry and to think about all my problems.” This reserved time to “worry” is may help to avoid these feelings while in bed trying to sleep, empowering you to think to yourself “I have already spent my time and energy thinking about this, and there is nothing else to do at this moment about it.” There is no single fix to de-stress and sleep better, but it is important to recognize how sleep and stress interact. Many resources are now available online to help you and offer sleep tips for sleeping better. For example, you can visit sleeponit.ca to find some of these tips

Dr. Bastien of the School of Psychology at Laval University in Quebec City, Canada has been working in the field of sleep for more than 30 years.

We can get ourselves into a kind of vicious circle where stress induces sleep difficulties and then sleep difficulties increase stress. Sleep deprivation is associated with emotion dysregulation. Feeling irritated, more depressed, more anxious, lacking concentration and attention are common consequences of sleep deprivation.

Taking Charge of Your Child's Sleep

Creating a Sleep Sanctuary

By Sharon Moore

When looking for solutions for sleep problems, it’s tempting to turn straight to an expert. But the fact is that you know your kid best. As a parent, you are in the prime seat. You are there when your kids are born and for their first cry and first smile. You are there when they take their first steps, speak their first words, and eat their first solid foods. You are there when they get sick, have a tantrum in the supermarket, or crawl into your bed at some ungodly hour. No one will make your children’s future and best interests a priority as much as you. This puts you in the perfect position to take charge of your child’s sleep.

How can you do it?

Setting your child’s bedroom up as a sleep sanctuary is a simple yet effective way to start. Creating a lovely sleep environment helps to set positive associations with sleep. When these positive associations become the norm, then they become triggers for sleep. In other words, by creating a range of environmental signals, you can train the body and mind to know instinctively that it is time to sleep. It’s a positive self-reinforcing spiral. Here are some tips on how you can create a sleep sanctuary for your kids.

Get the light right

Light in your environment can assist or disrupt sleep cycles. If your internal clock does not register light cues, you may experience irregular or drifting circadian rhythms and either delayed or advanced sleep phase disorders.

Electronic screens should be kept outside the bedroom. The wrong kind of light, such as that emitted by electronic screens, will lower melatonin levels, disrupting sleep onset. Darkness signals the release of melatonin.

To address this, ensure you and your kids are not exposed to any bright lights or screens for at least an hour before bedtime. If you are able to dim the lights throughout the house, start turning them down an hour before bed.

Ideally, your child’s bedroom will be dark or have very soft lighting. If your child needs a nightlight, a small one in a rosy color light will be best. You could use a small soft lamp on a timer, which fades slowly to complete darkness as your child drifts off to sleep.

Keep the sound down

Harsh or stimulating sounds can keep us awake or rouse us from sleep. These include sounds from a TV, iPad or phone, family members talking loudly (or fighting), household noises like washing dishes, noisy neighbors, dogs barking, cars, wind, storms, and music.

The best strategy is to lower any household noise levels you can control. Start your dishwasher earlier or later; move socializing and conversations to far-away parts of the house.

For all those sounds you can’t control, do what you can to soundproof your child’s room. Soft furnishings like rugs and curtains go a long way in absorbing noise.

Some soft sounds can, however, ease children (and adults) into sleep. Consider using quiet, gentle classical music, white noise machines, or ambient nature noises like waves and running water.

These soft sounds can mask other household and neighborhood noise and set the scene for restful sleep. However, avoid relaxation tracks with irregular sounds like gongs or chimes, as these can rouse your child as they try to drift off.

Once you have the physical environment set up along with great consistent bedtime routines, you’ll start to see a clearer picture of your child’s true sleep quality and quantity.

>Sleep Sanctuary continued from page 9

Become air aware

Air quality in the bedroom is vital for sleep health. Air quality can also have a big impact on your child. Is there a problem with mold, dust, or any other funny scent? Do what you need to eradicate it.

Air temperature also needs to be just right. The ideal sleep temperature is about 18 degrees Celsius or 64 degrees Fahrenheit. Warmer or cooler temperatures can contribute to sleep deprivation, stress, and parasomnias.

Adding a relaxing scent into the air can have a positive effect for some children. Choose scents associated with love and safety or essential oils that soothe and relax, like lavender or rose. Using a specific scent can help your child develop an association between that smell and sleep, making it easier for them to fall asleep. Most importantly, if there are allergens, they may impact the way your child can breathe well for sleep.

Reduce the clutter

Bedrooms should be a space for sleep, but many children’s bedrooms are also play areas, cluttered with toys, games, electronics, and other stimulating items. If you can, create a play area outside of the bedroom for all of these items. If this isn’t possible, packing everything up for sleep can be part of the bedtime routine.

Aim for comfort and safety

Kids need to feel safe, secure, and comfortable in their physical environment to get to sleep easily.

Children who experience regular nightmares can find bedtime to be very stressful. You can help them feel safe in their rooms by doing a safety check on the windows and doors or even “sweeping the room” with an “invisible light saber” to keep imaginary monsters away.

Happy photos next to the bed (cuddly, warm, smiling photos of loved ones, or photos of great holidays) can help kids feel safe and connected even while alone in their bed.

Choosing pajamas and blankets with soft, hypoallergenic material can also help soothe kids. Look for pajamas with no seams for sensitive kids, or pajamas and blankets with added scent for kids who respond to soft scents.

Setting the scene for further investigations

Once you have the physical environment set up along with great consistent bedtime routines, you’ll start to see a clearer picture of your child’s true sleep quality and quantity. Sometimes families are so busy that they need help with this too.

If you suspect that your child has sleep problems that run more deeply, then creating a sleep sanctuary will help you to investigate this more clearly. You’ll be able to distinguish between

environmental factors, over which you have control, and the potential behavior, physical, or medical issues that may need further investigation and expert help. IF they need this, don’t wait! Bring your observations to your primary care provider for discussion.

Bedtime Reads

Looking to learn even more? Each issue, we highlight a book about sleep.

Sharon Moore is an author, speaker, sleep health advocate and speech pathologist and runs Well Spoken Clinic in Canberra, Australia. She treats patients of all ages referred by medical and dental specialists for disorders of function of the upper airway that impact breathing, eating, and communication. Her book Sleep-Wrecked Kids is full of information and practical help for parents and is available through any online book retailer.

Sleep-Wrecked Kids: Helping Parents Raise Happy, Healthy Kids, One Sleep at a Time

by Sharon Moore

In her book, author and speech pathologist/ myofunctional practitioner with 40 years of clinical experience, Sharon Moore explains:

• The importance of sleep for kids

• The good sleep formula

• 7 tailored assessments to target sleep red flags

• Simple environment and routine changes

• How to address sleep disordered breathing, even before your kids are born

• 20+ specialists who can help your kids sleep

The Four Stages of Sleep

By Karen Kilpatrick

Each night as you drift off to sleep, your brain begins a series of sleep stages. These stages combine to form a sleep cycle, but it doesn’t end there. You go through several sleep cycles each night. What happens during those stages, and do we really need them all? We spoke with Dr. Kin Yuen, a sleep medicine specialist at the University of California San Francisco, to learn more.

You may have heard of rapid eye movement (REM), which takes up 20% to 25% of each night, but that’s only one stage. There are three other

stages of non-REM sleep: stage one, when you feel drowsy and start falling asleep; stage two, often referred to as light sleep; and stage three, called deep sleep.

The sleep stages and cycle change throughout the night, and each stage is significant for different reasons.

Let’s take a look at each of the four stages.

1 2 3 4

Stage 1: Falling Asleep

The first stage of sleep happens as you close your eyes and move from being awake to sleeping. According to Dr. Yuen, this stage usually only lasts a few minutes, but most people go through it several times each night. It takes about 5% to 10% of total sleep time.

During this stage, both brain and body activity slow down, but it’s easy to wake up. This is also when “hypnic jerks” happen – those involuntary contractions of muscles that sometimes feel like you’re falling.

Stage 2: Light Sleep

As you move into stage two, your breathing and heart rate slow down. This stage is referred to as “light sleep,” but that doesn’t mean it’s not needed. “Light sleep has an important role,” says Dr. Yuen. “This stage is necessary for memory formation and consolidation.”

Dr. Yuen explains that stage two is characterized by certain spikes in the electrical activity of the brain – called "sleep spindles" and "K complexes" by sleep scientists – which relate to how we encode and store information learned during the earlier day. This stage lasts between 10 to 25 minutes of each cycle, but it accounts for about half of the total sleep time.

Stage 3: Deep Sleep

Stage three is called “deep sleep” or “slow wave” sleep. In this stage, brainwaves slow down. Muscle tone, heart rate, and breathing rate all decrease. It’s hard to wake up from this stage, and when you do, you’re likely to feel pretty groggy.

This stage helps to restore the body and boosts the immune system, creativity, and memory. About 15% to 20% of the night is spent in deep sleep. Dr. Yuen says this stage mostly takes place in the first part of the night.

Stage 4: REM Sleep

In REM sleep, brain activity increases to levels that appear similar to wakefulness. Your eyes move rapidly even though they are closed. Dreams can happen in any stage, but they are especially vivid in REM sleep.

While the breathing muscles and the eye muscles stay active, the rest of your body’s muscles enter a state called “atonia,” which is like a temporary paralysis. Your breathing and heart rate become slightly irregular. Dr. Yuen notes that our bodies do not have temperature regulation in REM sleep. “In REM, we take on our ambient temperature. If the room temperature is set to 68 degrees, you are going to cool down substantially. A lot of people wake up because they feel chilly,” Dr. Yuen adds.

The REM sleep stage gets longer as the night goes on. The first sleep cycle of the night might only have a few minutes of REM, but by the end of the night, it’s likely to be closer to an hour.

Stages continued on page 16 >

>Stages continued from page 15

Putting It All Together

Over the course of a night, most people will have 4 to 6 sleep cycles. The first cycle of the night typically lasts about 70 to 100 minutes, and the cycles tend to get longer throughout the night. Dr. Yuen says that stage three (deep sleep) is usually the longest stage in the beginning of the night. As the night goes on, REM sleep increases in length while deep sleep decreases.

Not only are all the stages needed, but they also work together to accomplish different tasks during the night. “We know that for the first two sleep cycles, we actually need alternating stage two, slow wave sleep, and REM sleep for most of our memories to be consolidated,” says Dr. Yuen. “Declarative memory is more likely to be consolidated in stage two, then other parts like procedural skills are more likely to be consolidated during REM sleep. We need the alternation of the stages.” This means if you don’t get two full cycles of sleep in a night, any learning from that day might not be cemented in your memory.

According to Dr. Yuen, the stages don’t always go in the same order. It’s possible, for example, to go from stage two (light sleep) directly into REM sleep, skipping stage three (deep sleep). “It’s more likely to happen in the latter part of the night, going from stage two to REM,” says Dr. Yuen. “You might not have any slow wave sleep left by then.”

Keep In Mind

There are a lot of factors that can influence your sleep cycles. Sleep stages and cycles change as we age; the sleep cycles for an infant are very different from those of an adult, for example. “If you’re sick with a cold, that might influence sleep stages,” says Dr. Yuen. “If you’re in an environment you’re not familiar with, these stages might shift.” Other factors include exercise, alcohol, prescription medications, jet lag, and shift working.

Our innate biological rhythms, or circadian rhythms, also influence the sleep cycles. As Dr. Yuen said, “If you’re a night owl and you have to get to a meeting at 8 in the morning, you’re not going to get all of these sleep stages.”

If you’re using a sleep-tracking device, it’s important to remember that while current technology tries to capture sleep stages, the device may be less accurate than inpatient sleep studies. Dr. Yuen notes that these devices tend to overestimate the times you wake up during the night.

Everyone is different and has unique sleep patterns that change from night to night. It’s normal to have a night or two when things feel a little off and you don’t feel refreshed, but if it seems like you’re consistently missing out on that important, restorative sleep, it’s a good idea to talk with your doctor

Dr. Kin Yuen is an assistant professor at the University of California San Francisco and an adjunct assistant professor at Stanford University. Her research interests include cardiac arrhythmia, medical devices, and health economic evaluations in sleep disorders.

Not only are all the stages needed, but they also work together to accomplish different tasks during the night.

Dr. Kin Yuen | University of California San Francisco

The Sleep Secret That Experts Prioritize

And Why You Should Too

By World Sleep Society Staff

leep is one of the three pillars of good health, along with a balanced diet and regular exercise.

The world’s leading sleep experts have hectic daily agendas, often directing a sleep center or university department while also conducting and publishing research and managing personal lives. In a time when business leaders are proudly proclaiming they only sleep a few hours per night, what are leading sleep experts doing? Are they only sleeping four hours a night to get ahead?

World Sleep Society interviewed five internationally renowned sleep experts who all understand that success does not have to come at the price of sleep deprivation. The real secret?

Make time in a busy life for adequate sleep.

>Sleep Secret continued from page 17

Liborio Parrino, MD (Italy)

“Sleep is a non-negotiable condition that warrants wellness and prevents diseases” states Dr. Parrino, an Associate Professor of Neurology at Parma University, Italy. “Unfortunately, sleep is generally considered a time-wasting duty by many.”

Dr. Parrino began his sleep career by studying the recovery of sleep in comatose patients. Thirty-five years later, his current sleep research centers around the overlap between insomnia and sleep apnea syndrome. Dr. Parrino is industrious and successful. But does he make time for sleep? “In accordance with the recommended indications, I try to respect the range of 7–8 hours of sleep per night,” he relays. “No matter the content of my day, after 9:00pm, I start to slow down in order to welcome sleep in a relaxed and peaceful background.”

Clete Kushida, MD, PhD (United States)

Dr. Kushida of Stanford University researches treatment effectiveness for patients with obstructive sleep apnea, as well as new therapies for sleep apnea, restless legs syndrome, and narcolepsy. Dr. Kushida states, “I average 7 to 8 hours of sleep per night and I do this by consistently setting a standard sleep routine, and going to bed and waking up about the same time." Sleep is so important — not only for health, but also for maintaining optimal alertness in job performance, particularly in occupations where public safety is at risk.

Maree Barnes, MBBS (Australia)

“On an individual level,” begins Dr. Barnes of the Institute for Breathing and Sleep, Austin Hospital in Melbourne, “sleep is essential to good physical, emotional and psychological health. On a societal level, inadequate or poor sleep is a significant financial cost to our community.” Sleep disorders cost the Australian economy more than $5.1 billion each year in healthcare and indirect costs. Reduction in life quality caused by sleep disorders in Australia has a further cost equivalent of $31.4 billion per year.

“Personally,” Dr. Barnes explains, “I try to average 8 hours sleep each night. There are some nights when this is not possible, so I sleep in when I can. I don’t nap during the day. I make this possible in two ways,” she continued. “Firstly, by making sure I have at least 8 hours reserved every night, and secondly, by ensuring my bedtime behaviors promote good sleep.” Dr. Barnes creates the right sleep environment by making sure the bedroom is dark, quiet and comfortable, avoiding caffeine, alcohol or exercise for at least one hour prior to bed, and leaving electronics out of the bedroom.

"We must all remember," Dr. Barnes adds, "that without adequate sleep, we are at risk of accidents on the road, at work and in the home, as well as cardiovascular and metabolic illnesses.”

Charles Samuels, MD (Canada)

Dr. Samuels is the Medical Director of the Centre for Sleep and Human Performance as well as a Clinical Assistant Professor at Cummings School of Medicine, University of Calgary. “The general public needs to know that sleep is important, has a purpose and we should all make it a priority,” Dr. Samuels declares. “I aim for an 8-hour window at night, usually from 11:00pm to 7:00am,” he says of his sleeping habits. “If I have to get up early, napping is a key part of my strategy. If I get 6 hours of sleep, I nap during the day for 15–20 minutes.”

But Dr. Samuels wasn’t always able to balance his schedule around sleep. During prolonged work hours as a rural physician, sleep debt impacted his behavior with his young family, his performance as a physician and almost cost him his life. “Two incidents cemented why sleep should be priority number one in my health,” Dr. Samuels relays. “First, while on-call, I rolled my car in the middle of winter while driving to the emergency room from my house at midnight. I was clearly not fit to drive, and I was very lucky. Another more dramatic incident occurred one summer night driving home from the emergency department around 2:00am. I drove by my house, continuing on a country road and ended up at the shore of a lake, having fallen asleep driving. I woke up scared to death. I had no idea where I was, and it took me an hour to find my house.”

After these incidences, Dr. Samuels began researching the science of sleep. He also learned how to organize his day and night around sleep. When following his routine, he has the energy to work, train, and enjoy the weekends.

Nesreen Elsayed Morsy, MD (Egypt)

“When I was starting a pulmonology career eleven years ago,” begins Dr. Nesreen Elsayed Morsy of Mansoura University in Egypt, “sleep medicine was a mysterious area to me. I was excited to explore it. Especially in Egypt, it was a new field in the medical practice.” Currently, Dr. Morsy is researching the relationship between obstructive sleep apnea and venous thromboembolic diseases (blood clots, veins and circulation). “Although daily I have a lot to do, I am eager to have 6 to 7 sleep hours for workdays, and increase it to 9 hours on weekends,” Dr. Morsy states. “I am careful to get enough continuous sleep in a suitable place.”

Dr. Morsy believes more individuals should be aware of how optimal sleep is important for the body’s health. “Our sleep period is a time of growth hormone release and body repair, essential for learning and memory,” she describes. “Sleep loss can impair immune response, increase hunger, elevate cardiovascular diseases mortality and impair neurocognitive performance. We must all place sleep at the highest of importance.”

The professionals in this article represent the many leaders belonging to World Sleep Society’s membership, committed to advancing sleep medicine and research worldwide. For more information visit worldsleepsociety.org.

How to Improve Your Sleep with Better Nutrition

By Diego Z. Carvalho, MD

The relationship between nutrition and sleep is far from being completely clarified. However, the available scientific evidence supports a few tips that can improve your sleep.

1) Cut down on coffee and caffeinated products (soft drinks, tea, chocolate); and restrict them to the morning. Caffeine has stimulating effects and can make it difficult to fall asleep. For those who can sleep after a cup of coffee, it can lead to reduced sleep duration, more awakenings, reduced deep sleep, and worsened subjective sleep quality. Caffeine doses equivalent to two 8oz cups of coffee in the morning have been shown to reduce deep sleep at night.

2) Reduce or eliminate alcoholic beverages before bedtime. Although alcohol has sedative properties and can make you sleep more quickly, it comes at a high cost. In the second half of the night, you are more likely to experience increased sleep disruption with more awakenings and less deep sleep, which can make you feel less refreshed in the morning. Alcohol can also give rise to or worsen obstructive sleep apnea and reduce your oxygen levels at night.

3) Swap out sugary and starchy foods, for vegetables and fruits. A high glycemic index diet, which is associated with foods with high amount of simple carbohydrates such as potatoes, white rice and white bread, can quickly increase blood sugar. Although high glycemic meals were shown to help healthy volunteers fall asleep in experimental conditions, higher intakes of dietary added sugars, starch, and nonwhole/refined grains have been associated with a higher risk of developing insomnia over time. By contrast, higher non-juice fruit and vegetable intakes were significantly associated with lower chances of developing insomnia.

4) Eat more fiber and less saturated fats. Avoid food choices with high amount of saturated fat (butter, red meat, chicken skin, whole dairy products) and focus on eating more fibers. An experimental study has found that higher percentage of energy from saturated fat was associated with more arousals and less deep sleep while greater fiber intake was associated with more deep sleep.

5) Avoid heavy meals prior to bedtime. Eating a large amount before bed can delay your sleep onset time and cause more awakenings. On the other hand, significant food restriction can cause more difficulty falling asleep and reduce the amount of deep sleep

*Citations available on healthiersleepmag.com

Dr. Carvalho is with the Center for Sleep Medicine at Mayo Clinic in Rochester, Minnesota.

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When Does Your Workout Training Day Start?

How good sleep impacts your exercise and training results.

By Brendan Duffy, RPSGT, CCSH

If you were to ask athletes when their training day begins, many would likely say it starts when they get to the gym. Early morning joggers might say their training begins after a healthy breakfast. However, if you were to ask elite athletes American football legend Tom Brady, superstar basketball player LeBron James, Olympic track speedster Usain Bolt, or basketball star Caitlin Clark, they all would tell you unequivocally that their training starts the night before!

It starts with a good night’s sleep. These four elite athletes are part of a growing trend of athletes who are believers in sleep, emphasizing quality sleep routines as crucial parts of their

performance and recovery protocol. They embrace the growing science that points to sleep as perhaps the best mode of recovery available to any athlete. Sufficient rest is as important to these athletes as the nutrition they select to fuel their bodies and their minds.

Sufficient rest is as important to these athletes as the nutrition they select to fuel their bodies and their minds.

How does sleep impact exercise?

Sleep is an often overlooked but crucial component of athletic performance and recovery. Whether you are an elite athlete or a weekend warrior, quality sleep can greatly improve your physical and mental performance via several pathways – and not only does your sleep influence your exercise, but exercise can increase your sleep quality. Exercising is important for our overall health and weight management. Through better sleep, our hormones work efficiently to manage our caloric intake. Lack of sleep causes several growth and metabolic functions to be out of balance. This may stifle many exercise benefits. Proper sleep opportunity aids in boosting our immune system, keeps our heart healthy, improves mood, and helps in several other physical and mental aspects of a healthy lifestyle.

What else does a good night’s sleep do to enhance your exercise?

Body Restoration & Repair

When you sleep sufficiently, you repair, strengthen, and sculpt your muscles. Daily exercise causes microscopic muscle fiber damage to be rebuilt stronger via restorative sleep. Various hormones such as growth hormone and testosterone are released during sleep. They are essential in muscle repair and growth. In addition, our appetites are regulated in part by nocturnal sleep via hormones such as leptin and ghrelin. Ensure your exercise schedules include sufficient sleep and recovery time to achieve your desired weight loss or other training goals.

Performance

Quality sleep can also help you to improve your performance and your accuracy skills. It enhances your ability to stay on task and retain information. This is important when learning a new game strategy or perhaps a new exercise routine. In one research study at Stanford University, basketball players who increased their sleep time were able to improve their foul shot accuracy and 3-point shooting by 9%! In another study, tennis players increased their serve accuracy from 36% to 42%!

Mental Health

Exercise is a wonderful way to reduce stress and improve your mood. Sleep also has a positive effect on mood and emotional wellness. You probably can easily recall how “out of sorts” you felt after suffering a bad night’s sleep. An important part of our nightly sleep is an emotional reset. When sleep time is insufficient, you do not allow time to completely reset mentally for the next day’s stressors. If sleep deficiency continues, it may contribute to mental distress. A lack of sufficient sleep and increased negative feelings are bidirectional. In other words, the less sleep, the more mentally troubled you may feel. An increasing emotional burden can then lead to even more sleep issues. It is wise to seek help if you are experiencing overwhelming stress or sleep issues to avoid this scenario.

So... when does a good workout and training day start?

It starts the night before! Train well, sleep well! Exercise will improve your nights, and good nights will improve your exercise!

Brendan Duffy, RPSGT, CCSH is the Director of Catholic Health Sleep Services on Long Island, NY and also works with several athletes and NCAA teams on sleep P.R.O. skills and strategies (Performance, Recovery, and Optimization). He can be contacted via email at sleepcoachz@gmail.com or via his LinkedIn page, linkedin.com/in/brendan-duffy-08622049

Sleep Tracking Devices

By Jessica Thomas, MPH

In recent years, there has been a dramatic increase in the purchase of devices that monitor sleep quality and quantity. This is driven by increased marketing efforts and a heightened understanding by consumers of the importance of sleep for overall health. To gain more knowledge on these devices, we spoke with Dr. Timothy Morgenthaler, the Director of the Center for Sleep Medicine at Mayo Clinic in Rochester, Minnesota. Drawing on his 25 years of professional experience, he enlightens us on wearables and "nearables" and their role in sleep medicine.

Wearables and Nearables: Understanding What They Are

No matter what type of device a person decides to buy, it’s important to remember that all devices have the same fundamental goal: to collect information and offer insight into the amount of sleep a person gets and the quality of their sleep.

Wearables are the category of devices that you are likely most familiar with. They come into direct contact or touch with the person using

them. Think of devices like Apple Watches and FitBits. Many devices commonly considered smartwatches and activity trackers now include sleep tracking technology.

"Nearables" are devices that come near a user without directly touching them. For example, these devices could use sensors or pads placed directly under a person’s mattress. While some devices are clearly placed very near to the user, Dr. Morgenthaler cautions to not emphasize the "near" part of nearables. He notes that as technology improves, these devices can likely be placed farther and farther from the individual.

Not All Products Are Created Equally

There has been an explosion of new products

available in the wearable and nearable markets in recent years. Many consumers struggle to separate the good devices from the not-sogood. Dr. Morgenthaler notes that this could be challenging even for medical providers since there is a lack of peer-reviewed studies that compare products. Even when studies do exist, they are often based on earlier, less relevant generations of the device since technology is evolving so quickly.

Numerous factors may explain the quality differences between devices. One driving factor is that different devices use different technologies to collect patient data. For example, Dr. Morgenthaler notes that wrist-based wearables tend to focus on activity as their

baseline. Algorithms then use the information to create conclusions. However, these algorithms may vary dramatically from company to company, which can also play a role in quality differences.

Next Generation Data Collection Offers More Information

Movement-based measurements are typical in many wearables. Newer models, however, also collect other information, such as heart rate. Changes in heart rate and/or pulse rate can give insight into whether a person’s sleep is disrupted or not. It can also provide information, at least to a limited degree, on which sleep stage a person is in.

Nearables also collect data based on a person’s movement. For example, sensors placed under a person’s mattress can measure whether a person is tossing and turning during the night based on subtle pressure changes in the mattress. This tossing and turning can be a sign of disrupted or low-quality sleep. The sensors in under-mattress nearables are usually finely calibrated and can detect even slight pressure changes, such as those that could result from snoring.

Not all nearables collect information based on movement or activity, though. Some nearables use infrasonic sound waves to collect information about heart rate and breathing rate, as well as other physiological data. Other, simpler nearables use a microphone to detect sounds during the night, including snoring.

No matter what type of device a person decides to buy, it’s important to remember that all devices have the same fundamental goal: to collect information and offer insight into the amount of sleep a patient gets and the quality of their sleep.

>Devices continued from page 25

The Challenges of Nearables and Wearables

While nearables offer invaluable information about sleep quality and quantity, they are not perfect. For example, they may detect noises that another person in the room (not the device user) is making. They may also pick up background noise that is entirely unrelated to a person’s sleep. It’s a careful balancing act to get the sensitivity of sensors precisely right.

There are also potential problems that affect the quality of information from wearables. Some wearables may have too sensitive of a threshold that records everything as a movement, even if it is not really a movement. At the same time, other wearables may lack sufficient sensitivity and movement may be missed.

Problems also occur when the algorithms for the collected information incorrectly evaluate the data. Many companies have worked to improve their algorithms and correct the errors, but it’s not always perfect. Updating algorithms can also take extensive time. Some companies seem to be better at this process than others, based on Dr. Morgenthaler’s evaluation.

Final Words of Wisdom from Dr. Morgenthaler

When asked for his conclusions

The good news is that most devices available on the market do a relatively good job of estimating how much a person is sleeping each night and when they are falling asleep. Information about the total amount of sleep is one of the most important pieces of evidence that a provider may need to start treating sleep disturbances. The information generated from these at-home devices often closely mirrors what doctors find from inpatient sleep studies. Currently, though, overnight tests, such as sleep studies, are undoubtedly more scientifically rigorous

Consider This Cautionary Note

Dr. Morgenthaler emphasizes that wearables are much less accurate at determining sleep stages. For instance, some users might be concerned when their wearable tells them that they are not getting enough REM sleep. It’s important to consider that this conclusion may not be correct since it hinges on differentiating heart rate variability from stage to stage.

Reassuringly though, sleep stage information is frequently not integral in driving treatment protocols, according to Dr. Morgenthaler. However, it may be challenging to communicate this limitation to wearable users, who are often quite attached to the data they receive from their devices.

about

wearable and nearable devices, Dr. Morgenthaler describes them as the ultimate double-edged sword for both medical providers and users. People who use these devices often come to doctors with lots of data from their devices. Although this data can be helpful in starting conversations, it can also take time to sort out what information is truly meaningful.

The most important thing that Dr. Morgenthaler wants wearable and nearable users to know is that these devices can be great starting points. At this point, however, they should never replace a thorough clinical evaluation from a skilled sleep practitioner. He also cautions that buyers need to carefully sort through the large variety of available options and focus (when possible) on buying a device that has been independently scientifically tested

Dr. Timothy Morgenthaler

Jessica Thomas is a public health professional, health & wellness writer, and entrepreneur. She enjoys learning about and educating others on healthy living and observing how technology is changing the healthcare space.

Relaxation Techniques for Better Sleep

By Gina Dewink

Whether a short situational bout or a chronic issue, difficulty falling or staying asleep can affect quality of life. Next time you’re staring at the clock, consider trying a relaxation technique to calm and quiet your body and mind.

Reduce Sleep Anxiety

Progressive muscle relaxation (PMR) is the practice of tensing and relaxing specific muscle groups in your body and is often used in meditation. Place yourself in a comfortable position (lying down or seated). Beginning with feet and move up the body, tighten and hold each muscle group for 5 to 10 seconds then exhale with the release. Breathe deeply and move slowly from one group to the next. In just 10 to 20 minutes per day, this technique can easily be done before bed.

Seek Sunlight

Though it may seem counterintuitive, daytime exposure to sunlight has been linked to improving circadian rhythms, the signals from your body to sleep. Try taking a walk or simply sitting in the sun (even through a window) just before sunset. Sunlight causes melatonin levels to decrease, promoting wakefulness. Later, your dark bedroom should also help cue your body to increase melatonin and cause sleepiness.

Breathe Like a Singer

Beyond supporting voice and offering less strain on vocal chords, diaphragmatic breathing (DB) is also useful for relaxation. Consciously using your diaphragm muscle by trying to inhale into your stomach, breathing becomes a focus, giving the mind a task. The method is best done lying down—making it a good addition to a bedtime routine. Place one hand on the stomach, just below the rib cage before breathing in totally and slowly through the nose. With the other hand on your chest, focus on making the stomach rise and the chest remain still.

View Calming Imagery

If stress is a factor in your insomnia or you find it hard to relax at night, setting up a visual toolkit is an effective method of slowing down. First, find images that bring you peace—nature scenes, sleeping animals, repeated patterns or clouds. Next, find a peaceful place and set a time to view the pictures. Use your imagination to immerse yourself in the sensory aspects—touch the leaves, feel the wind, hear the crackle of a fire. After practice, simply viewing the calming imagery will decrease tension.

Practice Peace

A breathing technique known as 4-7-8 has gained popularity for its calming properties. With its origin in yogic practice, it gets easier with practice. Begin by placing the tongue against the gumline behind the upper front teeth and let it remain there for the entirety of the practice. Exhale completely through the mouth. Next, inhale through the nose for the count of four. Hold the breath to the count of seven. Exhale through the mouth again for a full count of eight. Usually, this is done for four cycles. Beginners may not be able to hold breath for the full count at first.

Sleep Matters by Chuan

Chuan Spa offers you bespoke breathing techniques, which are based in the principles of Traditional Chinese Medicine, to calm your breathing, balance your elements, and relax your body for a better sleep.

Start by identifying your element through Chuan Spa’s “Find Your Element” questionnaire and then practice the exercise described in our 5 Elements Breathing Technique guide.

Gina Dewink has been working and writing for nonprofit health organizations since 2004. With a degree in communications, her career history includes the American Academy of Neurology and World Sleep Society.

Circadian Rhythms

Can our bodies keep track of time?

By Rosei Skipper, MD

Have you ever wondered why it’s so hard to sleep after the clocks change, or why you feel so sluggish on dark winter days? Or why after working an overnight shift or traveling overseas you experienced the difficulty of “resetting” to a new time? Perhaps you’ve noticed the natural ebb and flow of your appetite during the day—or even noticed that you feel colder at certain times. All of these processes and more are controlled by what are known as circadian rhythms—the natural cycles of our bodies that occur about every 24 hours. When our body isn’t in sync with the outside world, things can get out of whack.

Is there a clock inside of us?

Kristen Knutson, PhD is an Associate Professor in the Center for Circadian

synchronizing these inner clocks to the outside world, and light exposure is the most important cue. Dr. Knutson highlights that “the timing of our clocks can be changed by exposure to light.”

Modern life can throw off our clocks

and

Sleep Medicine in the Department of Neurology at Northwestern University. Her research focuses on the associations between sleep, circadian rhythms and chronic diseases. Dr. Knutson explains that each cell in our bodies has a tiny molecular clock that dictates when to do various activities, like release hormones and process energy. These tiny clocks are controlled by one central clock, sometimes known as the conductor, which is located in the hypothalamus area of the brain. When everything is working well, all of the clocks are synchronized to the same time, and the conductor directs them all, much like a maestro leading an orchestra. Together the system tells us when to eat, sleep, and wake up. The body is constantly

There are a lot of challenges to maintaining a normal circadian rhythm these days, especially during a pandemic. Our bodies didn’t evolve to live with today's technology, and our brains can’t always tell the difference between daylight and artificial light. Using a screen at night can confuse our brains by giving us the “daytime” signal when it’s actually time for bed. Conversely, not getting enough light during the day can make us feel sluggish and sleepy. With school and work now often occurring from home, the routines of our lives may be very different. Shift workers may particularly have difficulty getting on track, especially if their work hours change frequently. How can we help our bodies feel on schedule, especially now that the nights are long and many of us are working from home? As Dr. Knutson emphasizes, now it’s more important than ever to keep your rhythms on track

Rosei Skipper, MD completed her Psychiatry residency and fellowship at the Mayo Clinic in Rochester, MN. She is currently pursuing further training in psychoanalytic therapy.

Try and maintain the same sleep/wake times each day—even on the weekends. Your body will feel best when you wake up and go to bed on a regular schedule.

Dr. Knutson’s Tips to Keep Your Clock Consistent

Kristen Knutson, PhD is an Associate Professor in the Center for Circadian and Sleep Medicine in the Department of Neurology at Northwestern University.

Make sure to get some light in the morning, especially if you’ve had a tough time waking up. This could mean taking a brisk walk outside or just choosing a sunny window to sit by for your morning coffee.

Avoid bright light in the evening—especially if you have trouble falling asleep. You may want to choose a paper book at night and to make your bedroom as dark as possible. If you must use a screen at night, try turning down the brightness.

Keep your daily schedule as consistent as possible. In addition to maintaining a routine sleep schedule, make sure to eat at regular intervals throughout the day. If possible, avoid large meals at night as they can disrupt sleep.

Exercise can help keep your body on track, and it doesn’t have to be intense. Something as simple as regular family walks can benefit everyone’s mood and health, including your four-legged family members.

Have you noticed that you and your pets don’t share the same sleep patterns? That’s because our circadian rhythms are different. So if your cat is pouncing on your head at 3am, it may be time for banishment from the bedroom!

Strategies to Sleep with a Snorer

By Jessica Thomas, MPH

Sleeping with a snorer can undoubtedly leave one sleep-deprived and crabby the next day. The good news, though, is that there are some strategies that can be used to help the non-snorer get more sleep.

Strategy 1 Stop the Source

Snoring is often exacerbated by sleeping on one’s back, so think of ways to adjust the snorer’s position. One widely suggested method is to tape or sew a tennis ball to the back of the snorer’s pajamas, preventing the snorer from sleeping on their back. If your snoring bed partner is a committed back sleeper, then consider ways to elevate their neck and head while sleeping – like using a pillow specially designed to provide elevated support.

Strategy 2 Block the Noise

Along with stopping the source, try to limit or otherwise control the sound in your bedroom. Snoring in an otherwise quiet space can simply hold your attention and eventually build feelings of frustration. Listening to self-selected white noise can help cover and “compete” with the noise of the snoring, allowing you to focus less on the snoring. Noisecanceling headphones or other ear coverings are an option, too, but can also become more bothersome to a sleeper.

Strategy 3 Change the Space

Sleeping and waking alongside a partner gives us a sense of intimacy, comfort, and security. However, sometimes a shared bed or bedroom is simply no longer tenable. If able, consider sleeping in another bed or room to simply get away from the noise. This may seem like an extreme option, but every person has the right to a sound sleep.

Popularly called a “sleep divorce,” this strategy is simple and obvious but not easy or available to all. This strategy helps us see how bothersome snoring is not just a singular problem but one that involves both bed partners. Sleeping with a snorer takes maturity and commitment from both partners to truly address the issue.

You Deserve Good Sleep

Snoring can negatively impact the sleep of both the snorer and their bed partner. When snoring starts to disturb the other person’s sleep, take the issue seriously – and sympathetically – and start working on strategies to solve it. If your bed partner’s snoring frustrates you, remember that you deserve a good night’s sleep, and it’s a conversation worth having.

Finally, remember that not all snoring is necessarily related to a medical issue. Sometimes people just snore, or they are congested for any number of reasons. However, take note if your bed partner seems to have moments when they stop breathing or gasp. These may indicate a deeper issue with your partner’s breathing during sleep, so raise these observations with your partner and primary care provider.