Sleep Hygiene Basics

Sleep Hygiene Basics:
How to Avoid Sleep Debt and Its Consequences

You probably know that getting a good night?s sleep is an important part of a healthy lifestyle. After all, who has not heard that we should all sleep 8 hours each night? You also might understand that when you fail to get enough sleep you are not quite yourself, and you begin to feel run-down. But did you know that getting inadequate sleep can increase your appetite and cravings, especially for carbohydrates?

Long-term, sleep debt or becoming chronically sleep deprived can directly increase your risks for developing the following:

Cardiovascular diseases (CVD):
Heart attack
Heart failure
Diabetes and other disorders of glucose metabolism
Mood disorders:
Cognitive decline:
Poor recall
Slowed thought processing
New research suggests that a large number of people with sleep disorders remain undiagnosed, but that with treatment, people suffering from sleep deprivation and sleep disorders can avoid all of the potential health problems just noted. It is important to take a closer look at sleep disorders and sleep habits now, and decide whether you or a loved one should receive further evaluation for a potential sleep disorder, which might unnecessarily put you or your loved one at risk for multiple chronic diseases, advanced aging, and early death.

Sleep needs
Sleep needs are individual. Some people need more sleep than others, with needs varying according lifestyle and health.

According to the National Sleep Foundation, a general rule of thumb is:

Newborns: 12-18 hours
Infants (3-11 months): 14-15 hours
Toddlers (1-3 years): 12-14 hours
School-aged children: 10-11 hours/night
Teens: 8.5-9.25 hours/night
Adults: 7-9 hours/night
Quality of sleep is just as important as how long you sleep. In most cases of sleep deprivation, it is the deep stages of sleep that are sacrificed.

Deep sleep
The functions of deep sleep include the following:

Growth hormone, essential for growth and development, is produced only during this time
Restorative functions, such as tissue repair and growth, occur and muscles are rested
Blood pressure is lowered, providing rest to the heart and circulatory system
Metabolic processes, including glucose utilization and storage, and the ratio of appetite-controlling hormones are adjusted in an attempt to preserve healthy weight and normal cell and receptor functions
Important functions of the nervous system (nerves), including memory consolidation (improves recall), take place only during this time, and the brain is fueled for the next day
Stress hormone production (cortisol and adrenaline) is decreased to restore balance to the body
Hormones that fuel the immune system are produced, aiding the body in fighting off infection
Daytime effects of sleep loss
Low energy:

Daytime somnolence (extreme sleepiness); frequent napping
Increased risk of accidents (beware of driving)
May become difficult to family
May have difficulty maintaining work and social obligations
Likely not to maintain exercise regimen or other self-care routines
Impaired cognition:

Impaired psychomotor performance; longer periods of sleep loss lead to greater impact on speed of performance
Reduction in performance of reasoning tasks
Impaired short-term memory or recall
Impaired decision making under conditions of uncertainty (worse with age)
Typically affects tasks that are long or monotonous with no feedback or motivation (driving can lead to increased accidents and citations)
Depressed mood:

Irritability, depression, and anxiety
Lack of motivation can interfere with performance of many activities, such as:
Increasing absence from work
Failure to make or carry out plans with friends or family, leading to social isolation
Mood disorders can lead to:
Poor health habits
Missed appointments
Lack of routine care
Further sleep problems
Lack of stamina may lead to the abandonment of one's exercise regimen, which is shown to worsen a depressed mood by altering the balance of 'feel good' hormones produced during exercise
Strong evidence indicates the reversal of all of the effects of sleep loss following recovery from sleep deprivation. Energy improves as fatigue fades. Memory improves via restored brain neurons. Recall and concentration improve. Mood gradually returns to what is normal for the individual. Some of these factors will improve more quickly than others, and each person's experience will differ to some degree.

Insufficient sleep syndrome
Insufficient sleep syndrome can result from:

Decreased/inadequate sleep time
Irregular sleep/wake patterns and poor sleep hygiene
Substance abuse, including overuse of caffeine, alcohol, and nicotine:
Caffeine can affect sleep architecture up to 10-12 hours after consumption, leading to frequent arousals and fragmented sleep, reduced total sleep time, and decreased sleep efficiency
Alcohol causes frequent arousals and is associated with sleep apnea
Shift work (doctors, nurses, truck drivers, and soldiers)
Treatments include:

Adequate sleep time
Good sleep hygiene
Hypnotic medications are not encouraged
Secondary causes of sleep debt
Some common examples of secondary causes of sleep debt include:

Pain from medical conditions:
Arthritis aches
Muscle cramps
Breathing difficulty associated with chronic obstructive pulmonary disease (COPD)
Chest pain (fear vs anxiety)
Post-stroke or myocardial infarction (nervousness)
Psychiatric disorders (anxiety, depression, and 'racing thoughts')

Treatment involves working with your doctors to best manage your diseases and the pain associated with them.

Common primary sleep disorders
Common primary sleep disorders include:

Insomnia - the inability to fall asleep or remain asleep
Restless legs syndrome (RLS) - unpleasant feelings in the legs like creepy, crawly, or tingly feelings at night with an urge to move upon lying down to sleep
Narcolepsy - a neurological disorder caused by the brain's inability to regulate normal sleep-wake cycles:
Daytime features include excessive daytime sleepiness (EDS), cataplexy (sudden muscle weakness, especially in the legs but also the face and neck, that is brought on by strong emotion, especially laughing), and sudden sleep attacks
Nighttime features include insomnia, dreamlike hallucinations, and sleep paralysis
Obstructive sleep apnea syndrome (OSAS)
Treatments include:

Meditation and other relaxation methods
Cognitive behavioral therapy
Good sleep hygiene
Medications as warranted
Obstructive sleep apnea
By far the most common sleep disorder is obstructive sleep apnea (OSA). OSA is a sleep disorder characterized by pauses, known as apneas, in breathing during sleep because of upper airway collapse or shallow breathing. These episodes occur repeatedly throughout sleep, leading to disturbance of normal sleep patterns, known as sleep architecture, which is important for health. Snoring is the most obvious sign of sleep apnea, although not all people who snore have sleep apnea. There are several ways that a physician may identify patients at risk for OSA, but a true diagnosis requires a polysomnogram, which entails an overnight study in a controlled sleep laboratory.

The consequences of untreated OSA are known collectively as obstructive sleep apnea syndrome (OSAS).Considerable data supports OSAS as an independent risk factor for CVD, including hypertension, stroke, heart failure, and cardiac sudden death, as well as the metabolic syndrome (syndrome X). In addition, it is now theorized that OSAS is independently associated with glucose intolerance, type 2 diabetes, and possibly insulin resistance.

Treatment options for OSA may include one or more of the following:

Weight control
Continuous positive airway pressure (CPAP)/bilevel positive airway pressure (BiPAP) therapy - the gold standard
Surgical interventions
Dental/oral appliances
Positional therapy
Data indicates that compliance with CPAP therapy may provide a protective effect against OSAS and appears to improve the diseases associated with it, as well as the risk of death from CVD. Similarly, surgical weight-loss methods are very successful in treating OSA and its associated conditions.

Sleep restriction
In general, sleep restriction may increase appetite and food cravings by altering levels of unique hormones in the body. Chronic sleep deprivation results from long-term inadequate sleep quantity and/or quality, ultimately leading to weight gain, insulin resistance or glucose intolerance, and increased fatigue. This begins a forward-moving cycle of increased hunger, coupled with decreased physical activity that is almost certain to result in weight gain. This cycle is shown to cause metabolic syndrome, CVD, and diabetes in previously healthy people.

The impact of sleep deprivation appears to affect so many systems that many experts predict that sleep hygiene will appear along with diet, exercise, and smoking as a major modifiable risk factor for a number of chronic diseases in the foreseeable future.

The consequences of sleep debt
Try these suggestions to promote sleep hygiene and avoid sleep debt and its consequences:

Keep a regular bedtime and wake-up times, even on the weekends
Try not to nap during the day, but if you do, limit naps to brief periods (10-15 minutes)
Ensure bedroom conditions are conducive to sleep (dark, quiet, comfortable temperature, and comfortable pillow and mattress; use earplugs or eyeshades if necessary)
Restrict caffeine to before 10 am or ideally, give it up altogether
Do not smoke during the evening hours, if you must smoke at all
Limit alcohol to light consumption (it can fragment sleep architecture, leading to frequent waking)
Limit food and beverage intake 3 hours prior to bedtime
Remember regular exercise is a must, but finish at least 4-6 hours prior to bedtime:
Exception: Light exercise before bedtime may help individuals with anxiety to relax
Get at least 30 minutes of exposure to sunlight in the morning hours, and avoid bright lights in the evenings, including computer and television screens in the hours prior to bedtime (bright lights suppress melatonin production)
Keep the bedroom as a place for quiet or rest:
Do not bring business or homework into the bedroom
Do not watch television
Recreational reading is OK
Practice stress management techniques as necessary or appropriate
Keep a bedside diary to record problems, plans, etc, so they do not remain in your mind and prevent sleep
Avoid reading or watching news about troubling events just before bed
Try taking a warm bath 1-2 hours prior to bedtime to help promote sleep, this works for many people
Have a warm glass of milk before bed, this helps many people

References and recommended readings
Dept of Health and Human Services, Centers for Disease Control and Prevention. Sleep and chronic disease. Available at: Accessed December 8, 2010.

Dept of Health and Human Services, Centers for Disease Control and Prevention. Sleep hygiene tips. Available at: Accessed December 8, 2010.

Morselli L, Leproult R, Balbo M, Spiegel K. Role of sleep duration in the regulation of glucose metabolism and appetite. Best Pract Res Clin Endocrinol Metab. 2010;24:687-702.

National Sleep Foundation. How much sleep do we really need? Available at: Accessed December 8, 2010.

National Sleep Foundation. Sleep hygiene. Available at: Accessed December 8, 2010.

University of Maryland Medical Center. Sleep Disorders Center?sleep hygiene: helpful hints to help you sleep. Available at: Accessed December 8, 2010.

Van Cauter E, Knutson KL. Sleep and the epidemic of obesity in children and adults. Eur J Endocrinol. 2008;159(suppl 1):S59-S66.

Review Date 1/11