Sleep Disorders: Overlooked Lifestyle Factors that Clinicians Should Consider

Mark G. Goetting, MD, Associate Professor in the Department of Pediatric and Adolescent Medicine, Department of Medicine Center for Clinical Research, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, has an extensive interest in sleep disorders along with the impact of lifestyle behaviors on sleep. Board certified in sleep medicine, neurology, pediatrics, obesity medicine, lifestyle medicine and behavioral sleep medicine, he is an expert regarding the lifestyle factors that may promote or hinder sleep. In this column, Dr. Goetting shares important steps for sleep preparation, factors that clinicians may overlook in their conversations with patients, and what it takes to achieve sound sleep.

Q: How important is regular sound sleep for our health and well-being?

Mark G. Goetting, MD: The average adult does best with about seven hours of sleep nightly. This is linked with optimal alertness, cognitive and mood health, and longevity. But this is only the average. There is a broad variability in total sleep needed, the timing of the sleep, whether it is segmented or continuous, and the sleep staging. Recommending a sleep pattern contrary to the genetic propensity leads to frustration and is counterproductive. Diversity in sleep is important, perhaps essential, for the survival of a group of humans. The sentinel hypothesis purports that the safety of a village requires that someone be alert 24 hours a day, every day. Studies show that current simple agrarian societies as well as modern industrial cultures contain individuals with a broad range of sleep diversity. Much of it is in our DNA.

We aim to do a paradoxical task: sacrifice from our waking life to improve our sleeping one. But in those moments with head on the pillow in which one cannot fall asleep, the harder one tries the less likely they will succeed. A wise person sets the stage during the day to achieve sound sleep at night.

Q: What are some of the major obstacles that clinicians face when trying to help people with sleep disorders such as insomnia, for example, and what should the focus be?

Dr. Goetting: Often we read of or are asked for a great sleep tip. The best tip is that tips don't usually work. Even solid teaching given to bright people usually fails to change behavior that could have helped sleep. Optimal sleep usually requires serial “experiments” or interventions, reassessments, and coaching.

The term sleep hygiene is acceptable but does have the negative connotation that something must be dirty and needs cleaning. It also focuses on simple measures implemented in the evening or later. The American Academy of Sleep Medicine says this about sleep hygiene in those with insomnia: “our analysis shows that it does not produce clinically significant improvements in insomnia symptoms when used as a single-component therapy.” ¹

Sleep preparation is a more appropriate term. While sleep is a preparation for the wake period, in turn, the wake period is preparation for sleep. This opens many behavioral opportunities as tools.

Q: What are the important lifestyle factors that may be overlooked during clinical conversations with patients addressing sleep disorders?

Dr. Goetting: The basic ingredients for the likelihood of sleep are:

Opportunity: the space and time to safely sleep.

Environment: quiet, comfortable, warm and dark.

Sleep pressure: enough sleep deprivation to be sleepy.

Circadian alignment: the drop in the normal alertness drive.

Appropriate lighting.

When all are aligned, sleep may occur but is not guaranteed. Let's look at each of these more closely.

A. Opportunity seems the most straightforward, but it requires foresight. Some can rely on waiting until becoming sleepy before preparing for bed, but often this doesn't work. A winding down pattern can evoke the sense of sleepiness when done habitually. In some, setting a “sleep alarm” (opposite of a wake alarm for mornings) on their phone can signal it's time to abandon awake activities and go through the rituals that precede sleep. Disturbances such as text alarms and pets on the bed should be minimized. Stability in the timing of this opportunity is important. Picking a “sleep alarm” time and sticking with it improves time to sleep and sleep duration, and it can even modestly shift circadian physiology.

B. An appropriate environment is more complex. Generally, we sleep better in a comfortably cool environment with warm bedding. The background sound is personal preference but should be devoid of anything distracting such as audiobooks and radio. The two common disruptors are a crying baby and a snorer. The latter is important to address, not only for the health of the snorer but for the bystander. So called “second- hand snoring” has health implications, including fibromyalgia symptoms and depression. ^2,3 Temperature change is a zeitgeber. Humans evolved with greater external body temperatures during the day and with activity. Replicating this in modernity can be helpful to shift or reinforce a circadian rhythm.

C. Sleep pressure builds with every minute of wakefulness. Yet sleepiness may not be perceived until night due to the circadian alertness pressure. Naps may reduce nighttime sleep pressure and cause difficulties in sleep onset, sleep maintenance, or both. But the inherent circadian rhythm of the person may not allow sleepiness until much later than average or may program for middle of the night awakenings. These should be considered as genetic possibilities of circadian alertness variants.

D. The circadian tendency is in general, genetically determined but can be swayed by certain influences. These are very helpful tools in improving sleep. The two C's of circadian manipulation are consistency and contrast.

E. Lighting is important. It is best to mimic the pattern of the outside. That is, light should gradually fade as bedtime approaches. That does not mean programmable dimmers, but the progressive avoidance of brightness before the “sleep alarm” goes off. People have variable sensitivity to light exposure having an effect on sleep. Blue light may have an influence. In one study it delayed sleep time but not melatonin release. ⁴ A recent meta-analysis on blue light exposure and sleep showed inconsistent evidence that it has a serious effect on the circadian rhythm. ⁵ The effects of screen exposure incorporate the constellation of both light and blue light as well as cognitive arousal. An early study showed adolescents who were randomized to watching a rather sedate documentary, “The March of the Penguins,” or playing a violent video game for comparable times just before going to bed had only a modest difference in sleep onset times. ⁶ More recently, active screen time had significantly more deleterious effects than passive screens. ⁷ This may explain why cell phone activity delays sleep onset.

In summary, humans evolved with a light-dark cycle in which our genes create our circadian rhythm for sleep-wake, whatever that rhythm might be for the individual. Artificial light and social or virtual engagement may push the rhythm back and delay sleep onset. It is important to have a consistent light-dark cycle day to day, as much as possible. Also, the contrast between peak light and full dark should be profound.

Q: What are some other important sleep promoters that clinicians should consider when talking with patients?

Dr. Goetting: There are many other factors that affect sleep. Meal timing, for example, is important to consider. The timing, volume and content of meals affect the circadian rhythm. A reasonable starting point is the traditional breakfast, lunch and dinner times—the more consistent, the better. The contrast factor is to not eat between meals. Optimally for most, there is at least a three-hour break between dinner and sleep. Exercise is another well-known factor that can affect sleep. Exercise raises body temperature, is alerting, and leads to a drop in temperature at the end. It is often stated that moderate or more intense exercise should not be performed in the evening. If done as a routine, this appears to not be the case. In fact, in a recent controlled trial, subjects fell asleep faster with evening exercise. ⁸ It may be because it was habitual, and a signal embedded in sleep preparation. Also, it is speculated that the subsequent more dramatic fall in temperature was the needed component.

Sleep tracking is the creation of the sleep-wake pattern, generally over a month or more for the sake of confidence. Paper sleep logs are inexpensive and useful. This technique provides a subjective sense of how long it took to sleep, how many awakenings there were and how long, and when rise time for the day happened. The patient fills the events of the night out upon awakening, which takes about a minute. These logs can be downloaded for free (https://sleepeducation.org/resources/sleep-diary/). Alternatively, wrist worn actigraphy devices are widely available and built into many smart watches. Smart phones applications can also work. These applications give an objective assessment of sleep based on activity and complement the subjective measure by sleep logs. Most patients will not tolerate radical changes to their sleep preparation behaviors. Tracking permits making one adjustment at a time and determining success or failure. Some changes the patient may do easily and without hesitancy. Tracking is most important when testing the difficult ones.

A potential adverse consequence of tracking is orthosomnia. ⁹ This is the unhealthy and counterproductive obsession with getting perfect sleep. It mostly is associated with compulsive sleep tracking and dissatisfaction with the imperfect control of sleep. In some, therapy is needed to reverse the anxiety promoted by this disorder. ¹⁰

To Contact Dr. Mark G. Goetting

Mark G. Goetting, MD

Associate Professor, Department of Pediatric and Adolescent Medicine, Department of Medicine Center for Clinical Research, Western Michigan University Homer Stryker M.D. School of Medicine

Kalamazoo, Michigan, USA

E-mail: mark.goetting@wmed.edu

Other sleep promoters include mindfulness/meditation—both of these interventions have been shown to improve sleep. ¹¹ Several dietary approaches are known to affect sleep. Added sugar as a sole factor and an ultraprocessed food diet are associated with poor sleep and appear causative. ^12,13 The DASH, Mediterranean, and plant-based diets improve sleep. ^{14 –16} Caffeine is complicated because many people are rapid metabolizers, but some will be served best by eliminating caffeine 10 hours before bedtime. Bedroom sounds are highly personalized. There is support that music can facilitate sleep, presumably by inducing relaxation, distracting from arousing thoughts, and masking environmental sounds. Bedpartners can affect sleep. Restless sleep and snoring obviously threatens the sleep of the bedpartner. These can be addressed and are usually amenable to therapy. But if not, a “sleep divorce” should be considered. On the positive side, habitual affectionate touching preceding sleep and upon awakening improves sleep. ¹⁷ Sexual activity also enhances sleep. ¹⁸

Like it or not, alcohol is a toxin and is harmful when used habitually in even modest amounts. While it can help induce sleep, it worsens sleep architecture and continuity, resulting in non-restorative sleep. ¹⁹ Exposure to greenspace and abundant plants, whether it means a walk in the woods, living in a tree-dense suburbia, or being surrounded by houseplants improves sleep as well as alertness and overall mood. ²⁰

Social isolation with or without loneliness is associated with a poorer quality of sleep and overall sense of wellbeing. ²¹ Those without a strong sense of purpose and usefulness are at risk for many health issues, sleeplessness being one of them. ²² Practice of the basic principles of positive psychology improves overall quality of life and sleep specifically for our purposes. ²³

Melatonin has two influences on sleep. First, it can shift the circadian rhythm, which is its more powerful effect. Second, it is a mild hypnotic. Commercial melatonin is notoriously variable in content and contaminants. A recent analysis showed concentrations ranging from −83% to +478% of the labelled content. There was up to more than a 400% variation batch to batch with the same brand. ²⁴ Care is needed to assure the supplement recommended and/or purchased meets quality standards. It can be used to influence circadian patterns when taken at the same time each night chronically. In general, to shift an earlier sleep time, it is given about four to five hours before the intended new sleep time at a dose of no more than 1 mg. ²⁵ It should not be given on an as needed basis. This can result in the feelings of jet lag.

Q: What are your final thoughts regarding clinicians promoting healthy sleep habits and lifestyle behaviors?

Dr. Goetting: Many patients have concerns about their sleep timing and continuity. Traditional sleep hygiene is usually not a powerful tool. This may be due to the general public being aware of these guidelines and have tried them or are not willing to. Sleep preparation begins with an assessment of sleep patterns and a review of “low hanging fruit” such as looking at alcohol use, caffeine use or environmental disturbance issues. The interventions mentioned above can be viewed as a menu of choices to begin with. A two-to-four-week trial with review of the new sleep tracking data helps keep successes and delete failures. This process takes time but can produce a helpful sleep preparation pattern for a lifetime.▪