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Opinions of Thursday, 13 July 2017

Columnist: Kojo Essel

Is sleep overrated?

Sleep is a very essential part of healthy living Sleep is a very essential part of healthy living

Many of us continue to have sleepless nights trying to find answers to 1001 questions that we are confronted with daily. Good sleep may not be the answer to all our health challenges but it cer-tainly goes a long way to make us healthier, happier and more productive.

I had the privilege of posing some questions on sleep to Dr. Obo Addy who is a fellow of the American Academy of Sleep Medicine and also American Clinical Neurophysiology Society.
He is also board certified in Sleep Medicine and Psychiatry with years of experience in managing sleep disorders. I am sure we will all benefit immensely from his responses.

1. Do you think we are losing too much sleep over sleep?

If the question is whether we are unnecessarily worrying about sleep, I would answer “No” to that. In fact we are not paying enough attention to sleep and its impact on our health, and our day to day functioning. There are major health consequences of impaired or poorly managed sleep, whether that relates to inadequate duration of sleep, excessively prolonged sleep or disrup-tion of the sleep that we obtain at the night.

But if the question is whether we are losing sleep on sleep, that is not obtaining enough, then it certainly appears we are, especially in our big cities; although the problem is not limited to those settings. In our big cities, with their increasingly heavier traffic, many people are getting up earli-er, in order to leave home early to beat the morning rush hour traffic.

Even young school age children are being forced to be up earlier as well, before they have obtained their requisite amount of sleep, so that their parents can drive them the sometimes long distances to school. More and more people live farther and farther away from where work or school is. Many people are also working longer days, spending long hours at the office, for example. There are still the other things to do in a usual day, including spending time with friends and family. So in addition to getting up earlier in order to beat traffic and get to work on time, many end up staying up late at night, and the result is that they get less than adequate sleep.

We do not have figures for Ghana, but in places where sleep average sleep duration has been tracked over time, there is documentation of definite decrease in that. As an example, a US study reported that in 1913, 8-12 year old school age children (they need more sleep than adults) slept an average of 10.5 hours. By 1964 that average had dropped to 9.2 hours.

2. What in your opinion are the major benefits of proper/restful sleep?

Probably the best way to answer this is to review the evidence on what goes wrong when we don’t get adequate restful sleep. The body’s ability to fight off infection in decreased, risk of heart disease and stroke is higher, one is more likely to become overweight, and also more likely develop diabetes mellitus.

Or addressing it in an affirmative tone, the response may be as follows: Good, adequate restful sleep promotes good health in several respects as well as good level of functioning during the day. Good sleep promotes the body’s resistance to infection, it decreases the risk of becoming overweight, developing diabetes mellitus, and also decreases the risk of heart disease, hyperten-sion and stroke.

Sometimes we are not getting all the sleep we need because we are just not allowing ourselves sufficient time to sleep. But sometimes although we spend enough time in bed sleeping, sleep is still not restful, because there is something going that disrupts the sleep. The most common such factor is snoring, and interruptions in one’s breathing during sleep, although the sleeper himself may not be aware of these occurring. There is a direct correlation between these events and the risk of developing high blood pressure, diabetes or getting a stroke, for example. No, snoring is not a sign of good sleep.
Good sleep promotes a longer, healthier life.

3. Daytime napping has recently been in the news. Some researchers found an association between extended daytime napping and metabolic disease (high blood pressure, diabetes, dyslipidemia, obesity). What is your take on that?

In terms of the ideal or most health sleep duration, what is now established is that too little sleep (consistently averaging less than 7 hours per 24 hour day) as well as too much sleep (longer than 9 hours) are both associated with a higher mortality rate compared to those who obtain 7-9 hours sleep on average.

Some studies have suggested that if one obtains less than adequate duration sleep at night, then a daytime nap that helps to bring the total sleep in that 24 hour period to 7-9, is healthy. But a daytime nap, which may be prolonged, and which makes the total sleep duration for the 24 hour period longer than 9 hours is deleterious.

There is still debate as to why excessive sleep (more than 9 hours per day) has fairly consistently been shown to be associated with higher mortality, or why daytime napping has also at times been noted to be associated with higher mortality risk. But some have suggested that the exces-sive sleep or need for daytime napping, where it is not a cultural norm, may be indicative of some underlying, undiagnosed health problem.

The excessive sleep is then viewed, not as the cause of the increased mortality, but that the underlying health problem causes both the excessive sleep as well as the increased mortality. This may be exemplified by considering obstructive sleep apnea (OSA), in studies which did not specifically rule out OSA as a factor. OSA is often associated with daytime sleepiness. OSA is clearly associated with higher mortality, and associated with metabolic disease.

The authors of one study that reported increased mortality risk with napping, especially if longer than 1 hour, in the British population, suggested that “daytime napping might well be a good surrogate measure of OSA”, and that daytime napping may be potentially im-portant for early detection of OSA in the general population [Leng Y, Wainwright NWJ et al. Daytime napping and the risk of all-cause and cause-specific mortality: a 13-year follow-up of a British population. Am J Epidemiol. 2014 May 1; 179(9):1115-1124].

4. Is this new trend worth adopting? Some companies have started teaching their staff to sleep properly in addition to encouraging naps during work hours. Will this boost produc-tivity the long run?

There is a good way to take a nap, and a not so good way to do so. There is a natural or physio-logical dip in level of alertness in the middle of the day. A nap is most helpful or healthy when it occurs during this part of the day. It is generally between about 12 noon and 3 pm.
The second parameter of a good nap is that it should be relatively short, generally no more than 1 hour.

Some studies have shown a half hour nap to be more beneficial than a 1 hour nap. A short daytime nap may indeed improve level of alertness and productivity during the second half of the day. This may not be critical for most people. But in patients with narcolepsy, a condition in which the person may have irresistible daytime sleep, scheduled short daytime naps may be part of the prescribed treatment. The short nap often helps improve alertness and level of functioning in the hours after the nap.

It is however important to point out that if one is already obtaining good adequate nighttime sleep, then a daytime nap, particularly if prolonged, may be more harmful in the long term than helpful. So the emphasis should be on obtaining good sleep at night, and taking necessary steps to diagnose and treat any identified sleep disorders.

5. Many people facing sleep challenges tend to rush to alcohol and medications (e.g. diaze-pam). What will you advise?

Using alcohol to try promote sleep is certainly not a good idea. Good refreshing sleep is one that is organized a certain way, and which follows a particular cyclical pattern throughout the night. Alcohol may be viewed in this context as the great deceiver.

It clearly often causes one to fall asleep quicker, so if one is worried about how long it takes them to fall asleep, they may perceive the alcohol as solving their problem. But as noted above there is more to goo sleep than just how fast you fall asleep. Alcohol causes disorganization of the normal cycle of sleep, and the poorer quality sleep is less refreshing.

Moreover later in the night, when the alcohol wears off, the brain reacts to that, there is a withdrawal effect, further disrupting sleep. There is also a risk of de-pendence. The brain becomes so used to falling asleep with alcohol on board that, after a while, it may loses the ability to fall asleep without it, and secondary alcohol induced insomnia develops.

There is another factor that makes alcohol at night inadvisable. Alcohol has a mild relaxing effect on the throat muscles involved in breathing. Especially for those who snore, and who may have interrupted breathing during sleep (called obstructive sleep apnea), without necessarily being aware of that, night time alcohol tends to worsen the snoring and the interrupted breathing.

The same effects can be produced by medications such as Diazepam. When one has episodes of ob-structive sleep apnea (OSA) during sleep, the brain tends to awaken the person repeatedly in or-der to breathe and to bring their oxygen level up, if it dropping.

Alcohol and these medications impair the brain’s ability to detect these breathing interruptions or drops in oxygen level prompt-ly, so the episodes may last longer, with associated lower oxygen levels, making the condition more dangerous. OSA contributes to major health problems, including high blood pressure, dia-betes mellitus and stroke, as well as depression and cognitive difficulties.

Sleeping pills and anxiety relieving medications such as Diazepam have their place in the treat-ment of sleep problems, but one needs to first determine what is causing the sleep difficulties, before administering medications. Without that diagnostic step, the use of the medication can actually worsen the patient’s condition.

6. Is there any relationship between gender, age and quality of sleep and adequate duration of sleep?

The characteristics of sleep change over the life span. We all know that babies spend a lot of time sleeping, 50% or more in the 24 hour day cycle. As the child grows, this decreases steadily, with 9-10 hours being needed during later childhood, and about 9-9 1/4 in the teenage years. The ade-quate amount for adults is 7-9 hours. The percentages of the different stages of sleep also change with age, so determining whether the sleep one is getting is the best for them or not depends to a large degree on what the person’s age is. Some sleep disturbances are clearly age related, with some conditions more likely to occur in teenagers, while others are almost completely confined to the geriatric age group.

There are no major gender differences in the normal characteristics of sleep. But there clearly are gender differences in the occurrences of some sleep disorders. Snoring and obstructive sleep ap-nea, the most common conditions seen at specialized sleep clinics, are clearly more frequent in men than in women. They also occur more frequently with advancing age.

7. What are your final words on sleep, and where in Ghana can one get professional help?

Sleep problems are not necessarily caused by or related to stress, although these may be major contributing factors. Disorders of sleep range from difficulty falling sleep or maintaining sleep (insomnia), to problems of excessive daytime sleepiness (hypersomnia).

Snoring can be a sign of a major sleep disorder, obstructive sleep apnea (OSA), which has major health consequences if left untreated. These include diabetes, high blood pressure, heart disease and stroke, as well as impairment of cognitive functioning and depression. The effect on thinking processes may contribute to academic difficulties in some children who snore and have OSA.
We need to pay more attention to sleep problems.

If any should have sleep difficulties or problems, as with all health issues, it is generally best to first seek help from your own physician or the clinic where you get your usual care. But addition-al specialist care, testing and specific sleep disorders treatment may be needed.