Sleep and Alzheimer's Disease (with Omonigho M. Bubu, MD, MPH, PhD)

Dr. Omonigho M. Bubu is an Assistant Professor of Psychiatry and Population Health at the NYU Grossman School of Medicine, where he studies the connection between sleep and neurodegenerative diseases, as well as social determinants of health as they relate to cognitive health. In this interview, he discusses the importance of sleep, especially for people at higher risk of developing Alzheimer’s disease.

Topics:

• Alzheimer’s disease (AD)
• Associations between sleep and increased AD risk
• Sleep patterns in minoritized communities
• Obstructive sleep apnea
• Dementia and cognitive decline
• Social determinants of health

Cited:

• Obstructive sleep apnea, cognition and Alzheimer's disease: A systematic review integrating three decades of multidisciplinary research (2020)
• Sleep, Cognitive impairment, and Alzheimer’s disease: A Systematic Review and Meta-Analysis (2016)

Visit our website for more information:
https://physicianfocus.nyulangone.org/nyu-langone-insights-on-psychiatry-podcast/

This discussion is for educational purposes and does not substitute for individual clinical judgment or patient care.

Senior Producer: Jon Earle

Transcript

Copy Transcript Copied

NOTE: Transcripts of our episodes are made available as soon as possible. They are not fully edited for grammar or spelling.

[00:00:00] DR. THEA GALLAGHER: Welcome to NYU Langone, Insights on Psychiatry, a clinician's guide to the latest psychiatric research. I'm Dr. Thea Gallagher. Each episode I interview a leading psychiatric researcher about how their work translates into clinical practice. Today I'm speaking with Dr. Michael Bubu. Dr. Bubu is an assistant professor in the departments of psychiatry and population health at the NYU Grossman School of Medicine. His research focuses on the connection between sleep and neurodegenerative diseases. He also studies health disparities and the social determinants of health, as they relate to cognitive health. In our conversation, we explore the importance of sleep, especially for people at higher-risk of developing Alzheimer's disease.

Well, thank you so much for being with us today, Dr. Bubu.

[00:00:42] DR. OMONIGHO M. BUBU: My pleasure.

[00:00:44] DR. THEA GALLAGHER: So, we're just gonna get right into it. Can you give us an overview of your work, particularly on the connection between sleep and neurodegenerative diseases?

[00:00:53] DR. OMONIGHO M. BUBU: Yes. So, um, my research, you know, the big picture just basically looks at, um, the relationship between sleep and neurodegenerative diseases. Right now, uh, our focus is on Alzheimer's disease. However, you know, it is, you know, benchmarked, to a reasonable extent, on three pillars.

And the first is really to examine sleep-wake cycles and activity, or rest activity rhythms, as well as looking at various sleep micro-architectural indices, or macro-architectural indices, as well, and see how they relate to, or are associated with increased AD, Alzheimer's disease risk.

And by Alzheimer's disease, we're looking at the clinical definition of Alzheimer's diseases, as well as the pathogenesis or the pathological processes involved in Alzheimer's disease. And the second prong really ties on the fact that sleep and neurosleep processes, you know, are very much interconnected to various systems, um, more importantly, the cardiovascular system.

[00:02:08] DR. THEA GALLAGHER: Mm-hmm.

[00:02:09] DR. OMONIGHO M. BUBU: So we're also looking at sleep as well as concurrent comorbidities, including vascular risk factors, including neuropsychiatric abnormalities, like depression, all as intricately linked as well to sleep. Um, looking at, uh, things like other chronic comorbidities that can actually, uh, reflect, uh, i- themselves in sleep problems or sleep, you know, possibly is associated with them. Usually they are co-occurring comorbidities and how they together with, uh, either an additive or a synergistic effect, combine to increase AD pathology and risk.

And the third prong really here we're l- we're also trying to look at, you know, how we can use setting sleep metrics to help, in terms of characterizing and identifying people at greater risk of-

[00:03:06] DR. THEA GALLAGHER: Mm-hmm.

[00:03:06] DR. OMONIGHO M. BUBU: ... AD pathology. So it's basically using sleep, uh, metrics or indices as a biomarker, a complementary biomarker or a standalone biomarker, that can predict AD risk, especially with the associations with the pathogenesis of the pathological processes that, uh, is involved in Alzheimer's disease. And um, you know, I would say, you know, just a fo- pillar would be looking at this in the context as well of health disparities.

[00:03:34] DR. THEA GALLAGHER: Mm-hmm. And looking at sleep problems in the context of health disparities?

[00:03:38] DR. OMONIGHO M. BUBU: Yes.

[00:03:38] DR. THEA GALLAGHER: Mm-hmm. Okay.

[00:03:39] DR. OMONIGHO M. BUBU: Uh, we're doing this because, um, if you look at the data, right, uh, what is does suggest is there are sleep, what we term like sleep health disparities, uh, that reflect themselves, you know, in various differences across racial, ethnic groups in sleep-

[00:03:59] DR. THEA GALLAGHER: Mm-hmm.

[00:03:59] DR. OMONIGHO M. BUBU: ... macro-architecture variables. And by that, I mean look at sleep duration measures. We're seeing that minoritized populations, including Blacks/African Americans or Hispanics, they spend less time in terms of sleep duration, compared to non-Hispanic whites. If we're looking at slow-wave sleep, which is the, um-

[00:04:22] DR. THEA GALLAGHER: Mm-hmm.

[00:04:22] DR. OMONIGHO M. BUBU: ... you know, stage three sleep, um, which is the deepest stage of sleep, we're also seeing, in terms of duration, data showing that Blacks or African Americans spend less time, you know, in slow-wave sleep. We're looking at amplitude as well. And um, even cutting across the Circadian, uh, rhythm, uh, abnormalities or rest activity rhythms, also seeing data that suggests variation in that regard. And so, and all of these metrics, what a reduced slow-wave sleep or slow-wave amplitude or activity, or we're looking at reduced sleep duration, they've all been shown to a reasonable extent to be associated with increased Alzheimer's disease risk.

Also, if we look at sleep disorders, the very, uh, prominent example is obstructive sleep apnea, we also see differences in terms of Blacks or African Americans or Hispanics or min- minoritized population really having a higher burden, carrying a higher burden in terms of OSA severity, or symptom severity presenting with excessive daytime sleepiness. And these again, these various, whether it's OSA itself or the various, uh, whether they're sleepy, excessive daytime sleepiness, you see evidence showing associations with Alzheimer's disease pathology.

And because we understand that, you know, these differences are intricately linked to what we'll call social determinants of health, right-

[00:05:59] DR. THEA GALLAGHER: Mm-hmm.

[00:06:00] DR. OMONIGHO M. BUBU: ... we're investigating this using a health disparities research framework-

[00:06:04] DR. THEA GALLAGHER: Mm-hmm.

[00:06:05] DR. OMONIGHO M. BUBU: ... which race, right, is being treated as a social construct.

[00:06:10] DR. THEA GALLAGHER: Mm-hmm.

[00:06:10] DR. OMONIGHO M. BUBU: Okay? And so, understanding that these differences that we're seeing in race is not because of some kind of inherent problem in a particular racial group, but because there are historical context that, you know, has resulted to a preponderance in terms of the affectation of social determinants of health, right, affecting a, s setting group relative to the other group. Basically, we're seeing, we're investigating what we'll call racism, right-

[00:06:42] DR. THEA GALLAGHER: Mm-hmm.

[00:06:42] DR. OMONIGHO M. BUBU: ... which, uh, ties to whether it is upstream factors in terms of policies and all of that, or midstream factors, or even, you know, that would ultimately have reflected themselves, you know, expressing themselves in this phenotype that we'll begin to see in terms of the differences across, uh, various health, um, indices, or... Whether it's Alzheimer's disease, uh, or whether it's sleep health disparities.

[00:07:11] DR. THEA GALLAGHER: Yeah. And these problems, I mean, they seem very, you know... There's a lot of synergy between them. And at the same time, it's kind of looking at a different aspect of the, of how sleep impacts people on the whole. Um, and why is this such an exciting area of research for you?

[00:07:31] DR. OMONIGHO M. BUBU: Yeah. So, I'd say, during, um, my graduate school at Emory, you know, this is where I began to investigate sleep and neurodegeneration, again, in particular Alzheimer's disease risk. I began to develop empirical evidence with respect to that and in my doctoral level training as well. Uh, I was able to consolidate that with mentors. And then looking at the biologic plausibility between sleep and Alzheimer's disease and looking at, you know, the disparities as well that exists between Alzheimer's disease burden and sleep health disparities burden, knowing as well, you know, the relationship between sleep and AD, based on the literature. When you look at that, you're noticing that in Alzheimer's disease, you have sleep problems.

[00:08:26] DR. THEA GALLAGHER: Mm-hmm.

[00:08:26] DR. OMONIGHO M. BUBU: And these sleep problems would normally, you know, accentuate themselves relative to the severity of the disease. You will also see, you know, new evidence showing that sleep can possibly precede the onset of AD. So if you look at the physiology and you look at the ascending arousal system, which is a system that regulates, you know, sleep-wake cycles, you're seeing that various anatomical elements in the ascending arousal system are affected in AD as well. You know, when you look at, uh, the neurons in the brainstem, the locus coeruleus, and other, the tegmentum pontine, um, uh, nuclei, and all of these various nuclei, uh, are affected as well in AD, deregulates sleep wake cycles, and part of the ascending arousal system.

We're seeing that 45% of Alzheimer's disease individuals have sleep problems. and there was, coming to see as well, like I said, the sleep problems can't possibly precede the onset. We, um, we look at the, uh, slow wave sleep. We've seen evidence that shows association with, you know, glymphatic clearance. And this is clearance of, um, the, the various abnormal proteins, right, that we've seen Alzheimer's disease, like amyloid plaque or tangles. Or we've seen sleep, you know, related to the glymphatic system helping in fact in terms of regulation of the glymphatic system. So all of this evidence, right, you know, drew my interest to looking at sleep and AD risk-

[00:10:08] DR. THEA GALLAGHER: Mm-hmm.

[00:10:08] DR. OMONIGHO M. BUBU: And for, as a positive personal motivation, there's my grandmother, actually, when I was eight years old, and saw her very vibrant, uh, and, and active. And then in her later life... Now she lived up to 99 years old. But in her later life, you know, she became very distant, you know, from what I now know, right, to, to be dementia symptomatology, uh, most likely of AD type. And, um, you know, she deteriorated badly, um, before she passed. And, you know, at that young age, I had that interest to, you know, become a physician and understand what would have occurred or transpired to make her deteriorate that bad. And, and so that's how my background, you know, even my background-

[00:10:59] DR. THEA GALLAGHER: Mm-hmm.

[00:11:00] DR. OMONIGHO M. BUBU: ... training includes medicine, you know, uh, fellowship, postdoctoral training in neurology, neuropsychiatry, as well as population and public health. So I have, you know, I see, I look at this in a broad, multifaceted perspective, uh, employing various multidisciplinary, um, techniques and skills as well.

[00:11:22] DR. THEA GALLAGHER: So is your idea that, you know, sleep problems are a causal factor with Alzheimer's or that sleep problems are an indication that somebody is at risk for developing Alzheimer's?

[00:11:34] DR. OMONIGHO M. BUBU: Yeah. So, um, I think both scenarios are possible and there's evidence to that fact.

[00:11:40] DR. THEA GALLAGHER: Mm-hmm.

[00:11:40] DR. OMONIGHO M. BUBU: You know? So, the first thing is, well, we'll look at an association between exposure and outcome, right? Exposure now being sleep, and the outcome being Alzheimer's disease. We do see an association. So cross sectionally and in a cross-sectional manner, you're, you know, assessing both exposure and outcome at the same time point, just a snapshot. But that doesn't tell us which one comes first, right?

[00:12:07] DR. THEA GALLAGHER: Mm-hmm.

[00:12:08] DR. OMONIGHO M. BUBU: And then... So we do have that cross-sectional associations that we see, where sleep duration measures, sometimes fragmentation measures and disorders like insomnia, circadian activity rhythms, as well as obstructive sleep apnea, you know, have been associated with dementia risk. Uh, but then to be able to tease out, right, to tell whether one comes before the other, you want to see design, uh, lo- prospective or longitudinal study, and there are a few out there that have actually shown that sleep problems can possibly precede the onset of Alzheimer's disease. Right?

So, uh, but the general consensus in the field are a reciprocal relationship-

[00:12:54] DR. THEA GALLAGHER: Mm-hmm.

[00:12:54] DR. OMONIGHO M. BUBU: ... where there's a possibility that the sleep problems can possibly precede the onset of AD. And then, there's also a very strong evidence that shows that in AD, because you're having neurodegenerative processes going on that affects all these various sleep-wake nuclei in the ascending arousal system, you do have a, a preponderance of sleep problems as well, even affecting, you know, circadian rhythms, uh, as the disease progresses. So, you know, the answer to that will be absolutely in AD or in dementia, because of the anatomical elements in the brain that are affected in AD, including elements in the ascending arousal system that regulates sleep wake cycle, there are sleep problems. So, neurodegenerative processes can worsen sleep problems and can present that way as well. And usually, the sleep problems would worsen as the disease worsens.

[00:14:01] DR. THEA GALLAGHER: Mm-hmm.

[00:14:02] DR. OMONIGHO M. BUBU: There is also evidence and that's where our work is, trying to look at, you know, sleep as a marker of AD pathology and looking at various sleep processes. There is evidence showing, and some of, uh, evidence has shown, especially if you look at obstructive sleep apnea, that it can proceed, you know, in terms of prospective studies. You know. We do need more of that, though. Uh, but we're seeing that it, it definitely can precede the onset of Alzheimer's disease, or seen evidence that it is related to the pathology, so have shown, uh, we have evidence that obstructive sleep apnea, for example, is related to longitudinal or prospective changes in amyloid burden. And we're getting new evidence with respect to tau pathology as well, was also seen, you know, an interactive or synergistic effect between OSA and AD analogy, like amyloid beta, you know, and how that impacts, you know, progression or time to progressing to Alzheimer's disease.

So, sleep can possibly precede the onset of AD. And AD patients definitely will have sleep problems because of the neurodegenerative processes that's going on. So that's, that's how we can... For now, that's the evidence that is there, that sleep can actually be a risk factor of Alzheimer's disease.

[00:15:31] DR. THEA GALLAGHER: And it looks like in some of the public health research, they found that maybe up to 15% of AD could be prevented with interventions that will help reduce sleep problems and disorders.

[00:15:42] DR. OMONIGHO M. BUBU: Yeah, absolutely.

[00:15:43] DR. THEA GALLAGHER: Pretty powerful, right?

[00:15:44] DR. OMONIGHO M. BUBU: Correct. So this is a meta analysis. And a meta analysis would normally, you know, look at evidence from various kinds of studies. Uh, this is a meta analysis that, you know, I led, you know, looking at sleep problems that included sleep macro-architecture ver- rhythms, the duration and fragmentation measures, uh, that also included disorders, insomnia, circadian activity rhythms, abnormalities, or, say, altogether, it's, it's a really broad definition of sleep problems that included all of those, uh, stuff that I just talked about, and then looking at AD risk.

And so, you know, we're able to conduct a meta analysis that actually provided, you know, a measure of association or measure of estimate, an estimate, or, you know, estimated the magnitude of the effect of how sleep problems can impact AD risk. Okay? And so, the conclusion that was, we did see that sleep increases Alzheimer's disease risk. And then the other thing was to look at what you call the population attributable risk, in which you're trying to see the contributory effect of this particular exposure, which is sleep problems themselves, and how they impact Alzheimer's disease risk. Now what we did see was that 15% of sleep problems, of Alzheimer's disease rather, you know, can be attributable to sleep problems.

[00:17:20] DR. THEA GALLAGHER: Mm-hmm.

[00:17:20] DR. OMONIGHO M. BUBU: And again, sleep problems, broad definition, including duration, fragmentation indices, hypoxia indices, or disorders. And what that tells us in an epidemiological fashion clinically, really, is that if we can eliminate sleep problems, we may be able to reduce 15%, right-

[00:17:41] DR. THEA GALLAGHER: Mm-hmm.

[00:17:41] DR. OMONIGHO M. BUBU: ... of AD risk burden in the population. So that's, that's the... And this, this is very significant, because it is very similar to the kind of population attributable risk for very well established and known risk factors for Alzheimer's disease, like the vascular risk factors like hypertension, as well as, you know, lack of physical activity and all of that. So, we do see that the population attributable risk is, is impactful, yes. So 15% of AD can be prevented if we're able to deal with sleep problems. That's what the data shows.

[00:18:18] DR. THEA GALLAGHER: Yeah. And that's, um, you know, that's something that clinicians can take and utilize, whether it's with medication or treatment modalities, correct?

[00:18:28] DR. OMONIGHO M. BUBU: Yeah, absolutely. The good news is that sleep problems can, you know... They're effective treatment modalities for sleep problems. All right? Whether disorders, in particular, the clinical application as it is, them the evidence is, is, is very early, though, you know, because we need trials-

[00:18:48] DR. THEA GALLAGHER: Mm-hmm.

[00:18:48] DR. OMONIGHO M. BUBU: ... to begin to show that we can affect or impact sleep, and then we can see differences in terms of AD risk or reduction in the risk, or we can see the AD pathology being affected, uh, in terms of getting better. So that's that, th- those are studies that are o- o- ongoing. But I think with respect to disorders, first of all, I think it will be important for clinicians, right, to, when, when you're treating someone with obstructive sleep apnea, right, especially in an individual that has a sleepiness phenotype.

[00:19:28] DR. THEA GALLAGHER: Mm-hmm.

[00:19:29] DR. OMONIGHO M. BUBU: So, obstructive sleep apnea with excessive daytime sleepiness, or other endo types, it will be important to have in, in that clinician's mind, you know, to be able to counsel them about the possibility of cognitive decline or cognitive-

[00:19:45] DR. THEA GALLAGHER: Mm-hmm.

[00:19:45] DR. OMONIGHO M. BUBU: ... associations with, uh, OSA and the importance of, you know, ensuring that they adhere to treatment modalities that are being prescribed for them. For... And same with insomnia, you know, or comorbid, uh, insomnia with OSA, that phenotype as well. You know, it's important, you know, as well to look at individuals, like what the data is showing with OSA and vascular risk factors co-occurring and having a synergistic effect on progression to AD for individuals, uh, in terms of time to progression or affecting, you know, changes in the pathology in terms of the markers. So it will be important, you know, to, uh, aggressively, right, screen for OSA as well as co-occurring hypertension in various at-risk patient populations, and, and intervene early to, to, you know, prevent cognitive issues. There's strong evidence, you know, linking some of these conditions with cognitive outcomes, whether it's performance in terms of executive function problems, processing problems, attentional issues. So, these are ways that, um, I think clinicians need to be alerted and, and be hypervigilant in terms of-

[00:21:05] DR. THEA GALLAGHER: Mm-hmm.

[00:21:06] DR. OMONIGHO M. BUBU: ... uh, their interactions with patients.

[00:21:08] DR. THEA GALLAGHER: And it might adjust kind of the, um, the focus for treatment. If sleep problems are a factor, they shouldn't maybe be secondary, they should be primary in some ways.

[00:21:19] DR. OMONIGHO M. BUBU: I mean, it, it... Not necessarily, like, primary. Right? But it should be considered as a whole.

[00:21:25] DR. THEA GALLAGHER: Mm-hmm.

[00:21:25] DR. OMONIGHO M. BUBU: Right?

[00:21:26] DR. THEA GALLAGHER: Yeah.

[00:21:26] DR. OMONIGHO M. BUBU: So, we're looking at... We're trying to treat the whole person and it should come, be considered as, as an important, a vital factor that can play a significant role in terms of cognitive outcomes, and decline and potential, right, for AD risk or AD development in the future. Alzheimer's disease is a disease in which the pathogenesis is very protracted. The pathogenesis from the data out there tells us that, you know, you can have earlier signs as much as 15 to 20 years back before you basically begin to see onset of symptoms or clinical-

[00:22:07] DR. THEA GALLAGHER: Wow.

[00:22:07] DR. OMONIGHO M. BUBU: ... symptomatology. So it just tells us that we need to catch it early-

[00:22:11] DR. THEA GALLAGHER: Mm-hmm.

[00:22:11] DR. OMONIGHO M. BUBU: Right? And then the, and the, there is a multiplicity of risk factors, uh, with respect to cognition or dementia or Alzheimer's disease, as we know. And sleep is, I think, a very important aspect that should be considered together with those factors.

[00:22:29] DR. THEA GALLAGHER: Mm-hmm.

[00:22:30] DR. OMONIGHO M. BUBU: Primarily, again, because effective treatments, you know, and prevention, even modalities, right, exist for, for sleep problems, and, um, could be as easy as, you know, ensuring the environment where one sleeps is okay, having a regular routine, change of schedule. You know? Timing in bed and timing spent. But there's so many things that are, that may not necessarily, right, require medications, if we're just talking of arranging your time to be able to spend the recommended hours of, uh, uh, of sleep time. Right? So that's easy. Then when you do have sleep disorders, right, uh, ensuring that doctors are looking out for all of these and be able to treat them promptly, and encourage patients to be adherent, um, explaining to them the possibilities or the importance, right, of being treated and, and being on top of the issues so that, 'cause there's a possibility you're mitigating, um, adverse health outcomes that could occur way down the lane, especially in terms of cognitive problems and Alzheimer's disease in particular.

[00:23:38] DR. THEA GALLAGHER: And are you saying and, even if you can see some of these factors 15 to 20 years prior, that there's a way to maybe slow down the process?

[00:23:47] DR. OMONIGHO M. BUBU: Yeah. So that's what, this, what the field is trying to do right now, because most of the trials for Alzheimer's disease focused on the disease itself when it has occurred, but then there were failures upon failures upon failures. Right now, there are issues, you know, debate about the pathology, the pathogenesis, which one is more important, is it amyloid, is it tau that we target or what have you. Irrespective of that, we do know, right, based on the biological definition that's pos- proposed that the presence of amyloid plaques is indicative that someone has AD type pathology. Now, only plaques would be there. And then over time, you have tau deposition occurring, which corresponds more to symptom onset or, you know, the clinical symptomatology, uh, presentations that we see in, in neurodegenerative processes, Alzheimer's disease in particular.

And so now even the drugs that have been, um, approved, you know, whether it's ad- Aduhelm or Aducanumab, or the recent one that's been approved, they are targeting early stages of the disease, right, uh, you know, with evidence of pathology. So, why? Because maybe... And that's... And they've seen some effects there. So I think that prevention will be key, right? And prevention is key, really, to many disease processes. And early detection is also key. So with respect to AD, right, since we're identifying some of these risk factors, and we know, in an early stage, in cognitively normal people, this is... Um, our research is mainly on cognitively normal people. So these are people that are clinically normal in terms of cognitive performance. Right? We're seeing these associations between sleep problems and AD pathology itself. So we're saying if we can identify setting markers, or in our case where we're looking at sleep and look at sleep as a marker of AD pathology, we can determine early in the process and catch this early, and then, you know, intervene on sleep. Right? And because we intervene on sleep, the, the, the hypothesis will be based on causal mechanisms with respect to AD pathology. And if we intervene on sleep, that would slow down possibly the neurodegenerative process that occurs over time.

[00:26:22] DR. THEA GALLAGHER: Yeah. That's really exciting. And when you're looking at biomarkers, are you looking at biomarkers of sleep problems or biomarkers of Alzheimer's disease?

[00:26:30] DR. OMONIGHO M. BUBU: Yeah. So we look into both.

[00:26:31] DR. THEA GALLAGHER: Mm-hmm.

[00:26:32] DR. OMONIGHO M. BUBU: So there are biomarkers that are being even looked at with respect to, you know, the circadian science field and sleep field that employs what we'll call metabolomics, transcriptomics. They are on that side. Or, uh, vo- there are research looking at, again, microarchitectural indices, local sleep processes-

[00:26:54] DR. THEA GALLAGHER: Mm-hmm.

[00:26:54] DR. OMONIGHO M. BUBU: ... as they, you know, relate to various brain regions. And there is research on the AD side, right, uh, which looks at different biomarkers as well. And, early stage biomarkers, late, mid-stage biomarkers, and new biomarkers, uh, are being investigated as well. Because the goal of that, the biomarker, is to be able to catch that disease early. Because the biomarker is expected to tell you, it's a marker that tells you, "Okay. There's an ongoing disease process," and then it changes as the disease process progresses. So, it's biomarkers on both sides. And then you try to relate those markers together and see if, if there's an association or if there's any kind of potential causal relationship between them.

[00:27:42] DR. THEA GALLAGHER: Yeah, it sounds like you're covering all your bases, trying to understand how all of this works together. And, you know, this third prong that you're talking about, the social determinants, uh, that affect sleep quality, can you get into that a little bit more? Like, what should clinicians know about this? I know that we've been talking a lot in the last few years about social determinants, especially, you know, with a variety of conditions and problems. With this specifically, you know, what should we know about this?

[00:28:09] DR. OMONIGHO M. BUBU: Yeah, I think, uh, it's important to understand the role of social determinants of health as they relate to health outcomes. So, they are what they are, social determinants of health. They determine health outcomes. Right? And I think the very first thing is to appreciate the role that they play. Second thing will be to... So, irrespective of race, right, uh, low educated, poor, white person, versus a low educated, uh, or, or a low educated Black person or Hispanic person would have poor health outcomes compared to their counterparts, meaning rich, educated white person or rich, educated Black person. Right? Um, I think that's important to understand.

The second thing is to also understand that there are different... Again, because of the historical context in the United States and other countries, like the United States, that have, uh, a history of racism or, or slavery and all that kind of stuff over time, right, that there are particular racial, ethnic groups, right, that are much more affected by the social determinants of health. And these other things that are responsible for the variations in the outcome, they're, you know, to a large extent, responsible for many of the disparities that we see. And so, it is important as well when a patient is sitting in front of you, to look at that context, not just the biomedical context, which focuses on the individual and is usually tied to behaviors. You know?

If you're going to tell somebody to exercise, right, and lose weight and that kind of stuff, and the individual goes back to their community where there's no access to parks, no access to gyms, and there's a food desert, there's no way the individual will ever come out, you know, achieve the goal that you're trying to set for that person. So understanding that and, you know, might help to direct... You know. Whether it's social support or social services that could help at least make things a little bit better. There's so much... There's not, not much the, you know, one to one physician can do about that. But it can help the person become a more empathetic doctor, you know, understanding some of the challenges that can affect health outcomes-

[00:30:39] DR. THEA GALLAGHER: Mm-hmm.

[00:30:39] DR. OMONIGHO M. BUBU: ... whether it's, it's stress, and all of that kind of stuff. I think that's important. On the research side, what we're doing, right, is making these known because, so that they can impact and affect policy changes when you understand that the fact that there are food deserts in certain communities, there's so much noise that can affect people's sleep. Uh, there's no green space, all that kind of stuff. Uh, you know, you can influence policies and to understand that, okay, this is what's really affecting the indices that we have in the United States, where u- US spends the highest amount in health care, but they're, like 19, to 20, right, when you compare them to other developed world. And I'm sure they want to do better. And so to do better, then you have to change, have a, you know, a reimagining of policies. And, and, and this is where health equity comes in, to provide resources that an individual would need tailored to that individual that will be able to equip the individual to be successful.

So, I think that mindset brought into the clinic is important to see outcomes. Otherwise, we'll just be dishing out prescriptions. And then, people are coming back, and there's no effect. Either because they can't afford it, there's no health care access, or they can't exercise or they, their access to food is wrong, you know, or they live in an environment, in our case, sleep, that affects their sleep. Right/ They're in stressful situations, their work does not allow them... You know. Shift work and all of that stuff. So there are many things that can impact health as well. And these are usually the mediators. And by mediators, I mean, they explain the differences that we see in these health outcomes.

[00:32:29] DR. THEA GALLAGHER: And you hope for... It sounds like you hope for some policy changes with maybe some external factors. But, um, uh, uh, do you also think there could be some policy changes with regard to, like, sleep hygiene education or things of that nature as well?

[00:32:43] DR. OMONIGHO M. BUBU: Yeah, absolutely. You know, I mean, there's been sleep field, there are many things that, uh, sleep researchers are fighting for, right, whether, uh, with, with children in terms of, uh, related to early school start times, right-

[00:32:57] DR. THEA GALLAGHER: Mm-hmm. Mm-hmm.

[00:32:57] DR. OMONIGHO M. BUBU: ... to maybe, you know, uh, so that kids can sleep, have the necessary recommended amount of sleep that they should have. Right? Um, things like, even, you know, the daylight saving time and how that impacts sleep health, or... You know. And, and so there are policy changes that, uh, I think are necessary, but we on our side need to provide the evidence and guide the policymakers on what they need to do, right, to make these changes.

However, it's important that there's an educational aspect that is important also for the masses, right? So we as researchers, or scientists, or physicians should be able to educate with our patients, the population we serve, you know, regarding sleep, and sleep health, sleep hygiene, and how that impacts their health, whether it is cognitive health or cardiovascular health or any other aspects of their health, because this is very important for them to understand. So education is key as well, providing resources is key as well. Ultimately, you know, the upstream factors can be driven by us providing data that can drive this policy changes.

[00:34:11] DR. THEA GALLAGHER: Yeah. And, and, you know, it sounds like you're doing a lot of the broad strokes work. And then the granular work on the research side, for those listening that are psychiatrists, clinicians working with patients today, what do you want them to take from your research that they can implement into their clinical practice today?

[00:34:30] DR. OMONIGHO M. BUBU: Yeah. I think it's important to understand the role of sleep in health outcomes, especially neuropsychiatric illnesses. I think many psychiatrists, neurologists and physicians, primary care physicians know that, uh, made... Uh, even depression. You know. You have associations with sleep problems there, whether it's anxiety issues or, you know, with psychotic problems. So, you know, there is a very strong association between sleep problems and these neuropsychiatric symptomatology. So I think it's important to, uh, as, as they, as physicians or, we relate with patients. Uh, it's important to also understand the role of sleep in these, um, neuropsychiatric symptomatology, whether it's their onset or, as you know, co-occurrence within the disease process itself, uh, and be able to provide, you know, educational measures or whether interventions as well that could help to treat that aspect of it.

I think it's also important, like I indicated earlier, to consider the, the fact of social determinants of health, whether it's the environment where the person is, how that can impact sleep as well, how that can impact stress, how that can impact, ultimately, their biology or phenotypic expression in terms of disease. And it's important to basically treat the whole person and not just focus on, you know, the individual and put in an in- individual behavior, but also looking beyond that and looking at factors that can as well affect health outcomes.

Oh, a- and... So be more empathetic, right, and be more understanding of the role of sleep in neuropsychiatric symptomatology or disease processes, and making a very conscientious effort to educate patients on sleep, to intervene when necessary as well, you know, understanding the role that sleep plays in all of these, uh, processes.

[00:36:43] DR. THEA GALLAGHER: Yeah. And it sounds like understanding the importance that, of the role of sleep, and then also making sure it's a priority in, in the clinical work that one is doing, whether it's at the evaluation level, um, making sure that's a priority in your evaluation to specifically ask about sleep, which I think historically hasn't been a priority maybe in a psychiatric evaluation, but making sure you're getting, you know, detailed information about sleep and then making it, um, the part of the puzzle with regard to, you know, the treatment interventions that you're utilizing.

[00:37:15] DR. OMONIGHO M. BUBU: Absolutely. But th- that's it. You hit the nail on the head. So, absolutely. So, again, taking sleep as a very important aspect of all of the evaluation is important. Getting a good sleep history is important. And being able to unders- uh, uh, tie that also to, uh, in management plan. Absolutely.

[00:37:36] DR. THEA GALLAGHER: Yeah. I think that'll, um, inspire a lot of clinicians to, again, make sure that this is an important part of, uh, their evaluation and the work that they're doing with patients. So, thank you so much for connecting your research in a practical way to the work that psychiatrists and clinicians are engaging with. I really appreciate all the work that you're doing, and can't wait to hear more.

[00:37:57] DR. OMONIGHO M. BUBU: Okay, great. I'm very happy for the opportunity to discuss this as well.

[00:38:03] DR. THEA GALLAGHER: Thanks so much again for that conversation, Dr. Bubu. If you enjoyed this episode, be sure to rate and subscribe to NYU Langone Insights on Psychiatry on your podcast app. For the Department of Psychiatry at NYU Langone, I'm Dr. Thea Gallagher. See you next time.