Sleep

Is Your Lifestyle Helping or Hurting?

 By Paul E. Lemanski, MD, MS, FACP

Medicines are a mainstay of American life and the healthcare system not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death.

In the first 107 installments of the Non-Medicated Life, certain dietary practices and a healthy lifestyle have been shown to accomplish naturally for the majority of individuals most of the benefits of medications in the prevention and treatment of chronic medical conditions such as obesity, hypertension, high cholesterol, and diabetes that increase the risk for cardiovascular disease and death.

What is not generally appreciated is that certain dietary practices and a healthy lifestyle can also significantly improve our ability to get a good night’s sleep. This is important not only because the over reliance on prescription and over-the-counter sleeping pills encourages a dependency with inherent risk, but also because achieving a naturally arrived at good night’s sleep improves overall health in multiple ways.

Most all of us are aware of the benefits of a good night’s sleep because of the way it makes us feel: refreshed, energetic, mood enhanced, and restored. Lack of sleep or poor sleep makes us feel just the opposite. However, apart from how it makes us feel, chronic loss of sleep or poor sleep may worsen medical conditions and in the extreme manifestation called sleep apnea may cause hypertension, arrhythmia, heart failure, and even death. To understand why this is so, let’s first address the questions, what is sleep and what makes for a healthy night’s sleep?

Sleep – both what occurs while we are sleeping and why it occurs – has been a mystery since humans achieved conscious awareness. It is characterized by a decrease in responsiveness, muscular activity, and metabolic rate occurring typically for eight out of 24 hours. It is a nearly universal process occurring in all animal species in some form. This suggests an evolutionary origin related most probably to exposure to day/night cycles. The purpose of sleep is not well understood, but it has been suggested that conservation of energy, restoration and repair of tissues and body structure, and memory consolidation and problem solving may all play a part.

Sleep from a medical and scientific standpoint is best described with the use of a polysomnogram or sleep study. The sleep study in its most rigorous form measures brain waves via an electroencephalogram (EEG), and sensors for eye movements, muscle activity, respiratory rate, heart rate, oxygen saturation, and leg movements. With this approach, sleep may be shown to be made up of rapid eye movement (REM) sleep and non-REM (NREM) sleep. It may be further categorized into discreet stages, occurring four or five times during the night, making up what is referred to as an individual’s sleep architecture.

Initially, most individuals enter sleep through non-REM, which has three stages: 1) stage N1 (or light sleep) accounting for five-to-10% of sleep time begins with a fall in respiratory rate and heart rate; 2) stage N2 accounting for 45-55% of sleep time is characterized by further slowing of pulse and respiration and a decrease in body temperature; and, 3) stage N3 (or deep sleep) accounting for 10-20% of sleep time is characterized by repair of tissues and body structures, strengthening of immune function, the restoration of energy stores and the release of hormones such as testosterone. REM sleep or stage R is characterized by changes in EEG, eye movements that are rapid and darting and a marked reduction in muscle activity and muscle tone. Stage R is also associated with vivid dreaming and may be a time of memory consolidation and the processing of the day’s emotions and sensory input.

Each stage may be altered both positively and negatively by medications, drugs or alcohol, but also by certain behaviors. For example, stage R may be delayed or suppressed by alcohol, sedatives, tricyclic antidepressants, and antidepressants known as selective serotonin reuptake inhibitors or selective serotonin reuptake inhibitors (SSRIs), which are a widely used type of antidepressant medication. 

Heavy alcoholic use is associated with an increased risk of REM sleep behavior disorder, a condition in which the usual muscle paralysis during dreaming does not occur, resulting in a flailing of arms and legs during REM. Choosing to go to bed late and awakening early by alarm may decrease REM because the longest periods of REM typically occur at the end of the sleep cycle. Although further studies are needed to confirm the risks of decreased REM, a retrospective 2020 study published in JAMA Neurology, suggested that every 5% decrease in REM sleep was associated with a 13% greater risk of dying from all causes over the subsequent 20 years.

Moreover, several sleep disorders are related to abnormalities of sleep stage. For example, narcolepsy may occur in those who have Stage R very early in their sleep architecture. Hypoxia or low oxygen levels in the blood may occur in those with emphysema when the intercostal muscle and the diaphragm contraction is reduced during Stage R. Finally, the most dangerous sleep disorder, obstructive sleep apnea is exacerbated by the muscular relaxation and decreased tone that occurs in the throat during REM. 

In the case of sleep apnea, snoring which represents partial obstruction of the airway, may progress to complete obstruction and apnea or a cessation of breathing. During the apneic period oxygen in the blood falls and carbon dioxide rises and the individual is forced to avoid the deeper more restorative stages of sleep. The result is an increase in hypertension, heart arrhythmia, and heart failure, which may be life threatening. Moreover, sedatives – including prescription sleeping pills – may significantly worsen sleep apnea and their use is actually contraindicated.

Avoiding such abnormalities of sleep stage may be aided by relatively simple dietary and behavioral lifestyle choices. First, it is important to practice good “sleep hygiene.” Retiring and awakening at the same time will help regularize sleep stages. A consistent meal schedule may help as well. Avoiding alcohol and stimulants such as caffeine and nicotine, especially in the latter half of the day is important to preserving adequate REM sleep. Avoiding blue light from computers and cell phone screens for at least two hours prior to retiring may significantly aid falling to sleep. Moreover, a cool, dark room in which to sleep and exposure to bright sunlight upon awakening will further help regularize sleep stages. Finally, losing weight if overweight or obese can effectively improve apneic periods.

In summary, dietary practices and behavioral lifestyle choices can help correct sleep stage abnormalities including sleep disorders such as sleep apnea. Avoidance of alcohol and stimulants and a recognition of the adverse effects of some medications on sleep stage abnormalities may suggest the use of alternative medications or medication discontinuation, as appropriate. In this way a healthy diet and lifestyle may improve sleep with both an enhanced sense of well-being and objective health benefit.

Paul E. Lemanski, MD, MS, FACP (plemanski3@gmail.com) is a board-certified internist practicing internal medicine and lifestyle medicine in Albany. Paul has a master’s degree in human nutrition, he’s an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.