The Science behind Sleep and its Connection to our Health

Doctors often tell us to get plenty of sleep. But why? Is there science behind our need for shut-eye?  Delve deep into sleep's connection to our health on this episode.  Host Jonathan Fialkow, M.D. welcomes sleep medicine physician Jeremy Tabak, M.D. to talk about sleep health, sleep disorders, sleep medications and more.

For more information about Baptist Health South Florida Sleep Centers please visit BaptistHealth.net/sleep

Transcript

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Announcer:

Doctors often tell us, "Be sure to get plenty of sleep," but why? Is there science behind our need for shuteye? Sleep medicine physician, Dr. Jeremy Tabak, and host, Dr. Jonathan Fialkow, delve deep into sleep on this episode of Baptist HealthTalk.

Dr. Jonathan Fialkow:

Welcome back to Baptist HealthTalk podcast. I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventive cardiologist and lipidologist at the Miami Cardiac & Vascular Institute at Baptist Health South Florida and also chief population health officer at Baptist Health. One of the goals of this podcast is to bring experts in the Baptist community to answer the kinds of questions my colleagues and I are often asked on a daily basis. Lately we've been focused on the corona pandemic and today's topic certainly has a strong connection to that. But it's also one of particular interest to me going back well over 14 years. It's the subject of sleep and the many ways that sleep impacts our health, going beyond its benefit in helping our bodies fight off viruses and infections.

Dr. Jonathan Fialkow:

The average human spends about one-third of their life sleeping or trying to go to sleep. It would seem that this would be incompatible with survival because if we think about it, when you're sleeping, you're not feeding, you're not procreating, and you could be exposed to attack by predators. So why would sleep be important? It must confer some kind of essential benefits in order to outweigh these serious disadvantages. To help guide us through the importance of sleep and how it's a necessity and not a luxury is my guest and colleague, Dr. Jeremy Tabak.

Dr. Jonathan Fialkow:

Dr. Tabak is a physician in the Baptist Health community who specializes in pulmonary disorders and sleep medicine. He's the medical director of the Baptist Sleep Labs. Welcome, Dr. Tabak.

Dr. Jeremy Tabak:

Hi Jonathan. Thank you.

Dr. Jonathan Fialkow:

My pleasure. So first Jerry, let's do a level set. A lot of people think of sleep as just the absence of wakefulness, where you're active, your brain's working, your body's working. That shuts off and now you're asleep. It's not really a passive state where the brain shuts off. So by starting, what is sleep? What is the active process of what's happening when we're asleep?

Dr. Jeremy Tabak:

Well, I mean the bottom line is we still don't know one reason why we sleep, but there appear to be at least several different reasons that we're sleeping. There are several processes going on. The brain metabolism is changed and we're able to consolidate memories during sleep, so it's important for learning, brain function. Sleep has an important cleansing function for the brain where metabolic materials that are built up during the day are cleaned out. In addition, in terms of our overall body, it's important to obtain rest during that period of time so the body can rejuvenate.

Dr. Jonathan Fialkow:

So sleep is important. In fact, a part of torture is when they prevent people from sleeping. So we can recognize, again, the consequences of that. The questions we often get asked are varied and they may not have a specific answer for an individual. Again, we're starting with some of the basics and it's a question we get asked all the time, which is how much sleep does one need? So I'll turn that over to you to answer that broad question.

Dr. Jeremy Tabak:

Well, we've always felt that it's a range. Some people need more, some people need less. But this question has been looked at a lot in recent years and now the American Academy of Sleep Medicine, our professional organization, has put out a position paper based on research that recommends that people get at least seven hours of sleep during the night. There are some people who can get by and do fine with six, but for the majority of people, seven to eight hours is felt to be conducive to good health.

Dr. Jonathan Fialkow:

Are there different ranges or at least recommendations, if you will, for ages? Should a adolescent or a grade school child get seven hours? Does a 75, 80-year-old need seven hours? Is that an across-the-board type of recommendation?

Dr. Jeremy Tabak:

Well, seven hours is for adults. So clearly, children need more, starting with newborns who sleep 14 to 16 hours a day and that gradually decreases over the course of childhood. Teenagers need more than grown adults. Teenagers may need nine to 10 hours in order to function well. That's paradoxical because-

Dr. Jonathan Fialkow:

I'm sorry. Go ahead.

Dr. Jeremy Tabak:

... because with the early rise times for high school and all the activities during the day, teenagers are actually getting by on less sleep when they need more sleep. But over the course of the adult life, our sleep needs are pretty stable. A 60-year-old needs pretty much what a 25-year-old will need.

Dr. Jonathan Fialkow:

And to that point also, the adolescent mind is much more acute in the evening and not so in the morning. So I know there have been some movements towards changing school hours to support the adolescent mind to make sure they get enough sleep. The mind's more acute a little later in the morning. But again, we'll handle that for another podcast. So if the Holy Grail, if you will, is seven hours and clearly there's a variation in that, do we feel as adults in the United States of America, we are getting enough sleep?

Dr. Jeremy Tabak:

Well, clearly as a society we're not getting enough sleep. There was a recent National Sleep Foundation survey which showed that a third of adults get less than seven hours routinely on weeknights. We know that has a significant impact because sleep deprivation affects us in many different ways.

Dr. Jonathan Fialkow:

I do want to address some of the medical aspects of not getting enough sleep. What would be some of the reasons though we're not getting the sleep? What are the things we think that have changed in our society or our lifestyle that are preventing that seven hours that we've been getting for thousands of years?

Dr. Jeremy Tabak:

Well, I mean for a lot of people there's the demands of work. Many people have to work two jobs. People come home from work and have to do household chores and help the children with their homework and so forth. As a society, we have this idea that sleep is not important, not necessary, and that's the one thing that we can give up within impunity. But it's not with impunity. There's consequences that result from that.

Dr. Jonathan Fialkow:

So as you say, and I felt that sometimes, you work a long day, you come home, you may make dinner. By the time you're ready for bed, you feel you've had nothing to your day. So I might make myself watch something on TV a little bit later at night just to have awake time when, in fact, it might be healthy just to say, "Okay, I'll go to sleep and just start again tomorrow." Staying up late for TV programming and various other things might be detrimental as well.

Dr. Jeremy Tabak:

Yeah. People want to watch their show. They want to watch the late night news or watch what would used to be the Johnny Carson Show or equivalent. But then they're not going to get their seven to eight hours of sleep if they have to be up to go to work or take the kids to school.

Dr. Jonathan Fialkow:

So lifestyle things like staying up late, watching TV, playing on the computer, obligations of work and whatnot can certainly decrease our ability to get sleep. How about medical conditions? What kind of medical things? Maybe start by talking about the difference between the quantity of sleep and the quality of sleep. A lot of people may have problems and they say, "But I sleep seven hours," but it might not be a true quality sleep. So maybe start with a little elaboration on quality versus quantity and then move into what are the kinds of medical conditions which might prohibit someone from getting a good quality and quantity of sleep.

Dr. Jeremy Tabak:

Well, there are different reasons people wake up during the night. Some of that is, to a certain extent, age-related. As we get older, we tend to have more arousals during the night. But certainly, for whatever reason, if people are having a fragmented sleep and up frequently during the night, up to urinate, up because they're having back pain or reflux or some other symptoms, then their sleep isn't going to be as refreshing and as rejuvenative as it would otherwise be. Sometimes our habits contribute to that too, medications that we're taking. Some medications are alerting and if you take them at bedtime, it's going to be more fragmented. If you tend to drink alcohol in the evening, that leads to a fragmented sleep, so the sleep is not as restful.

Dr. Jonathan Fialkow:

You have the term fragmented a couple times, which I think is a very important point. Someone can sleep for seven hours straight and they have a certain benefit of the sleep brain. Someone can get a total of seven hours sleep, but with four or five arousals, again, reflux, having to go to the bathroom, dog barking, spouse snoring. That same seven hours might not give them the same rest and benefit of a straight seven hours sleep. Is that fair to say?

Dr. Jeremy Tabak:

To a certain extent that's true. Although on the other hand, a certain number of arousals are expected as people get older. But that's where you wake up briefly sort of having awareness and then you go quickly back to sleep. That may not have the same significance.

Dr. Jonathan Fialkow:

So what would be the indications to someone that they may have a sleep disturbance? Of course, being tired can just be you're not getting enough sleep. But how would we separate someone who just might be tired because of not getting enough sleep versus someone who might have a medical condition which might be contributing towards not getting enough sleep?

Dr. Jeremy Tabak:

Well, when we see someone in the office to evaluate them, we do a sleep history. So the first thing we want to do is get an idea of when did they go to bed, how many times they're up during the night, and when do they wake up in the morning. If someone's tired and sleepy during the day, the first thing we want to do is make sure that they're getting seven and a half or eight hours of sleep at night. Because if you routinely get six hours of sleep at night, you're going to be sleepy either in the morning when you wake up or during the day.

Dr. Jonathan Fialkow:

You said you do a sleep history, which is specific questions that should be asked of patients when they come in for their medical checkups. What are some of the questions you ask them for sleep history beyond how many hours do you sleep? What are the signs that someone might have either, again, not getting enough sleep or a medical component? Fatigue during the day might be one. I know we've talked about falling asleep in front of the TV or driving. What are some of the things that we want to look for?

Dr. Jeremy Tabak:

Well, we want to, as you said, go through their medical problems, see what things might be affecting them. Do they have prostate problems that are waking them during the night to urinate? Is a woman going through hormonal changes and having hot flashes? Insomnia becomes much more common in women as they approach the menopause. And then the things that we do during the day, how much coffee are you drinking? What time are you having your coffee? Are you having more than a couple of drinks with dinner but drinking into the evening, alcohol? Or are you drinking a lot of water in the evening and waking up because your bladder is full?

Dr. Jonathan Fialkow:

So that moves into the concept of sleep hygiene, good sleep habits or preparation for sleep habits. Maybe we can touch on those a little bit. You mentioned a couple, not having a lot of fluid in a couple of hours before you go to sleep, maybe not exercising right before bed, decreasing caffeine in the evening. What about light? Do you recommend that patients kind of dim the lights or don't look at bright screens right before bed?

Dr. Jeremy Tabak:

Yeah. Well, that's very important. Nowadays many people have a screen. They're going to bed with their phone or their iPad and that light from the screen is alerting to the brain and naturally shuts off our melatonin. Melatonin is a natural hormone that signals to the brain that it's nighttime and time to go to sleep. But once the brain is exposed to bright light through the eye, that shuts off our melatonin production. So the use of screens and bright light, including TV or having bright lights in the room, it can be very detrimental to sleep.

Dr. Jeremy Tabak:

When we talk about good sleep habits and sleep hygiene, we want to first focus on the bedroom. Is the bedroom dark? Is the bedroom cool enough? Is the bedroom quiet? Are the children coming in and out? Are the dogs coming in and out of the bedroom? Is the animal sleeping in the bed with the person? Is the mattress comfortable? All of these things are important. The sleep environment is very important.

Dr. Jonathan Fialkow:

I appreciate that. People really can pay a little attention towards what they may be doing that may inhibit a good night's sleep, and with some small changes they may find some big benefits. So sleep hygiene becomes important. Let's talk a little bit about sleep apnea, obstructive sleep apnea. You can bring in some other components. It's very prevalent. That was when I first became involved as a preventive cardiologist and sleep medicine, seeing the confluence of cardiovascular disorders with obstructive sleep apnea.

Dr. Jonathan Fialkow:

Can we speak a little bit about how someone may know if they have sleep apnea? What are the kinds of signs, what they should do if they think they do, or if their doctor thinks they do? Can you elaborate on sleep apnea a little bit?

Dr. Jeremy Tabak:

Well, in terms of symptoms, snoring is very common as a symptom. It can be loud. It can be disruptive to the partner's sleep. So one common reason people come into the office is because their bed partner can't sleep because the patient is snoring. So snoring and very often the partner can hear apnea, so periods where the breathing stops. Someone who has sleep apnea may have a very restless sleep, so they're all over the bed. They may wake up in the morning with a headache. They may feel tired in the morning when they wake up at night. They may have more acid reflux because reflux is made worse. They have more waking up to urinate or nocturia because that's more common in people who have severe sleep apnea.

Dr. Jonathan Fialkow:

Yeah. I think that's, again from a clinical standpoint very, very important because, again, those are things that people will go to a gastroenterologist for or urologist for. Of course, it should be through the primary, which we know. But when you have that increased pressure to open up your airway, it puts pressure on the bladder and pressure on your stomach to push acid up. So reflux and going to the bathroom at night can be sleep apnea. When someone may have sleep apnea, what's the usual medical evaluation?

Dr. Jeremy Tabak:

Well, we talk to them to find out what other medical problems they have that might go along with sleep apnea, high blood pressure, diabetes, heart disease. We examine them. We want to know what their weight is because the majority, 80% or so, patients with sleep apnea are overweight. We look at their neck circumference because there's a strong correlation between the neck circumference in inches and whether or not they have sleep apnea. We look in the mouth to see whether there's crowding in the mouth, which is a sign of sleep apnea. So we do a physical exam.

Dr. Jeremy Tabak:

We do some questioning in the office in terms of how sleepy they are. We have standardized measures of sleepiness that we go through with people. And then in order to confirm our impression or get an idea of how severe the apnea is, we have to do a sleep test either in lab or sometimes at home, in appropriate situations, to confirm the diagnosis and, again, to get us a measure of the severity and indicate what the proper treatment might be.

Dr. Jonathan Fialkow:

And what would some of those treatments be if someone were found to have sleep apnea?

Dr. Jeremy Tabak:

Well, when someone has moderate to severe sleep apnea or even if they have mild sleep apnea and they're symptomatic with sleepiness, we usually will talk about C-PAP or continuous positive airway pressure, which is a small mask that fits over the nose that puts a little pressure on the throat to keep your tissues open during the night. So the person has a normal breathing pattern and more restful sleep. A lot of people get started on it, feel much better, but also have improvement in some of the cardiovascular risks that are associated with untreated severe sleep apnea.

Dr. Jonathan Fialkow:

Right. Hypertension is very much correlated with sleep apnea and, of course, the risk for heart attack and stroke, as we mentioned before. So it's more than just being tired. There really are medical consequences from untreated sleep apnea. Going back to a point you made before we move on to the end section, if your spouse has apneic episodes, if you're listening to your spouse snore and you hear them stop breathing for eight, 10 seconds, should you wake them up or should you just let them get through it and then make sure they see a doctor for follow-up on sleep apnea?

Dr. Jeremy Tabak:

Well, I mean I know people get worried and they want to shake the person, sort of rouse them out of it. But this is something that in people with severe sleep apnea is going on throughout the night many, many times. We see people who stop breathing 20, 30, 40, 50 times per hour. So the spouse isn't really going to be able to treat that by just watching them and shaking them. But if there is a concern, they should definitely discuss it with their doctor so that it can be evaluated.

Dr. Jonathan Fialkow:

So I think for the listeners, if you hear that, tell you stop say, "Hey listen, we got to get you checked out." But your fear that they won't start breathing again, they will start breathing again. They cycle in and out of this. As you said, it could be every 30, 60 seconds for real severe cases. So I think that's something we get asked quite a bit. Last section before we let you go back to your busy day. Let's talk a little bit about medications. You mentioned melatonin, natural-occurring substance in the brain that prepares the brain for sleep.

Dr. Jonathan Fialkow:

I always tell people it's like twilight, the sun slowly goes down and you start releasing melatonin. And then the sun goes down and now you fall asleep, again, going back to a couple of hundred generations ago. Does taking melatonin help people fall asleep if they have any kind of sleep disorders?

Dr. Jeremy Tabak:

Well, it's not going to compensate for a sleep disorder, like sleep apnea or restless leg syndrome. But if someone has simple problems falling asleep, it can help them sleep. We certainly would focus on their sleep habits first and the things they can do with their daily routine. But I would certainly rather have someone try melatonin than to try a prescription sleeping pill. Because with prescription sleeping pills, there's a concern about what kind of side effects they have, how they affect people during the day.

Dr. Jeremy Tabak:

We know that people, especially older people who take prescription sleeping pills, have a greater incidence of falling during the day and all the consequences from that. They begin to develop memory problems over the years. So for insomnia, we focus on other treatments other than taking medications to sleep.

Dr. Jonathan Fialkow:

I can tell you in practice, and I'm sure it's much more frequent in your practice, I can't tell you how many times we've seen elderly people not infrequently brought in by family members that they're forgetting things and they think they're having neurological disorders, and with a good history finding out they're taking sleep aid medications. By stopping those, they recover and do much better. So both the falling and the memory is real.

Dr. Jonathan Fialkow:

If someone takes a medication to help them sleep, does the amount of time they're sleeping have the same recovery benefit as if they fell asleep naturally? Or is it kind of a false lack of consciousness?

Dr. Jeremy Tabak:

Well, I mean it certainly if someone is sleeping very poorly, taking a mild sleeping pill to get their six to eight hours is better than being awake all night. But it's just not a good long-term solution is what I'm trying to say. There are techniques now that we use, something called cognitive behavioral therapy, that within a few weeks can get people sleeping better without the use of long-term sleeping pills.

Dr. Jonathan Fialkow:

Well, I appreciate all the information, Jerry. It's a phenomenally important topic that many people don't think about. They know when they're suffering, that they need more sleep when they're tired, but they don't really think about what may be driving that poor sleep and then, of course, when it becomes a medical condition that warrants more intense evaluation. Any final comments? Any points you'd like to make that that we didn't get to before we end?

Dr. Jeremy Tabak:

Yeah. I'd just like to bring up in this time when we're all fighting the COVID epidemic, that the importance of sleep is especially there. Getting a good night's rest, getting some sleep is very important to our immune function and how we're able to fight off an infection. Of course, it's during a stressful time and may be difficult to get to sleep well. So it's important to address that anyway and do some of the things that we can do to sleep better during the night. It has important health benefits for us.

Dr. Jonathan Fialkow:

It's an extremely important concept and maybe the pandemic will drive people to pay a little more attention to their sleep. If it is a motivator, the fact that it can enhance their immune system towards getting a better night's sleep, then I think, from an education standpoint, it will be of benefit. Well, thank you very much, Dr. Tabak, a colleague and a great resource within the Baptist Health System.

Dr. Jonathan Fialkow:

Once again, podcast listeners, if you have any thoughts or topics for future podcasts, please send us an email at baptisthealthtalk@baptisthealth.net. Stay safe and stay home.

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