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Sleep and Preventive Health—An Integrative Understanding and Approach 

Sleep and Preventive Health—An Integrative Understanding and Approach
Sleep and Preventive Health—An Integrative Understanding and Approach

Param Dedhia

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date: 16 June 2021


Sleep is essential for health. As with nutrition and physical activity, sleep is among the cornerstones of optimal health and healing. It is the cornerstone of being well in our daily lives and of well-being as it relates to our mental and emotional health. As much as traditional medicine touted the vitality of sleep, contemporary medical education has increasingly embraced this concept. As sleep accounts for approximately one-third of our lives, the appreciation of its role in health and healing has been transparent to modern science only in recent decades. In these recent decades, we are driven to be a part of a nonstop lifestyle in which the quality and quantity of sleep may be casualties.

The role of sleep in the prevention of disease and illness has been extolled in folk remedies throughout the world. Beyond contemporary medicine’s debate regarding the exact role of sleep, the weight of evidence has illuminated both the necessity and the benefits of sleep. The preventative medicine opportunity of sleep has been primarily supported by the observation that insufficient or disordered sleep is associated with serious disease, morbidity, and mortality. Moreover, poor sleep has demonstrated challenges to public health and safety. The perspective of sleep as preventive medicine is furthered by appreciating the two-way impact. By this, it is meant that poor sleep increases the risk of disease and illness, as well as the converse, that disease and illness disrupt sleep. This often creates a vicious cycle in which the accumulative effect is deepened morbidity and mortality. Modern medicine has developed treatments with a focus on pharmacology and interventions that have been helpful. Yet the burden and the growth of sleep challenges will require a frame shift into prevention by which integrative approaches will be the cornerstone.

In this chapter, the healthy obligation and significant opportunity for sleep will become transparent; optimal sleep as a key toward optimal prevention will become clear. To this end, the reader will appreciate the following:

  • Epidemiology of sleep

  • History of sleep and defining sleep in modern medicine

  • Importance of sleep stages and cycles

  • Need for quantity and quality of sleep

  • Common sleep disorders

  • Role of sleep in public safety and performance

  • Association of disrupted or disordered sleep with disease and illness

  • Interventions and treatments for disrupted and disordered sleep

    • Treatment of sleep-related breathing disorder

    • Treatment of Willis-Ekbom disease (formerly restless legs syndrome)

    • Treatment of insomnia

  • Integrative approaches and lifestyle habits for optimal sleep

Epidemiology of Sleep

The interest in sleep can be appreciated from four significant epidemiological perspectives.1 First, sleep disorders negatively impact both short- and the long-term health. The more immediate effects reduce a sense of well-being and performance. Moreover, excessive daytime sleepiness is commonly experienced although not recognized and/or connected to poor sleep. Accumulated effects of disordered sleep include premature mortality, cardiovascular disease, hypertension, obesity, metabolic syndrome, diabetes and impaired glucose tolerance, immunosuppression, inflammation, cancer, cognitive impairment, and psychiatric disorders, such as anxiety and depression.2 Second, there is a high prevalence of sleep problems. Insomnia is the most common specific sleep disorder, such that 30% of adults reports some form of insomnia in the past year3 and 10% acknowledge chronic insomnia.4,5,6 The prevalence of insomnia among women and older adults is even higher.7,8 High prevalence of obstructive sleep apnea, characterized by a reoccurring air flow limitation during sleep, is observed in the general adult population between 5% and 25%, where it is twice as prevalent in women as compared to men.9,10 Third, as the population has been aging and lifespans are longer, it is therefore noteworthy that older adults often take longer to fall asleep, wake more frequently during the night, experience lower sleep efficiency, and self-report poorer quality of sleep,11,12,13,14,15,16 the incidence of sleep problems is increasing. The exponential growth of a 24/7 society providing and catering to day-and-night activities with increased access to mobile phones, media, and Internet has changed our ecosystems and thus has challenged opportunities toward achieving healthy sleep. Patient complaints of sleep have significantly increased over recent years, with increased prevalence of full-time workers experiencing short sleep (defined as less than 6 hours per night).17,18 Shift work continues to expand to staff and service the around-the-clock societies leading to worsening circadian rhythm disorders, which often has a negative impact on health, healing, and performance. It is important to explain the myth that we need less sleep as we get older; it is found that sleep changes as we age such that slow-wave (or deep) sleep decreases and lighter sleep increases while night sleep disruptions and daytime sleepiness worsen, yet there may little insight into this, as it occurs insidiously. Moreover, the pandemic of health concerns such as obesity and the growing incidence of obstructive sleep apnea have had a bidirectional impact that worsens each of the illnesses in both poor and industrial countries.19,20 Fourth, sleep problems are associated with accidents and human errors.21 Thus, in turn, preventable causes of injury and death are unnecessarily promoted (see section “Public Safety and Performance”).

History of Sleep and Defining Sleep in Modern Medicine

Medicine’s interest in and understanding of sleep was minimal until the 1950s. Prior to the scientific innovations in measurements and metrics, it was difficult for many to appreciate sleep. Its importance was minimized as scientific inference was gleaned and based on casual observation. This still can be seen in the definition of “sleep” in the classic medical dictionary by Stedman:

a natural periodic state of rest for the mind and body, in which the eyes usually close and consciousness is completely or partially lost, so that there is a decrease in bodily movement and responsiveness to external stimuli.22

Such a definition is only partially correct, as it omits the full understanding of sleep and health. To begin the appreciation of the vital importance of sleep, it is well to list its key features: (1) natural, (2) recurring, (3) unconsciousness, (4) inactivity of voluntary muscles, (5) reversible, and (6) essential. As observed by the cause and effect of neurotransmitters’ innate response as a circadian rhythm over a 24-hour day, sleep is natural. The ebb and flow of the circadian rhythm’s effect on neurochemistry orchestrates sleep as a recurring process. The total or partial unconsciousness sets the stage for significant internal processing and restoration that is enhanced by limiting the response to external stimuli. The nearly complete inactivity of voluntary muscles promotes physical growth and/or repair. Yet sleep is easily reversible and self-regulating, such that it allows us to engage with our environment as appropriate. In all, sleep is essential for survival. Sleep is no luxury, for it is vital and a key requirement for optimal health.

The key features of sleep are furthered by the emerging concepts and robust data on which Daniel Buysse proposed the “conceptual model of sleep health” (Figure 19.1).23 With this, Buysse poses a helpful definition of sleep by highlighting its role in health and quality of life:

Sleep health is a multidimensional pattern of sleep-wakefulness, adapted to individual, social, and environmental demands, that promotes physical and mental well-being. Good sleep health is characterized by subjective satisfaction, appropriate timing, adequate duration, high efficiency, and sustained alertness during waking hours.23

Figure 19.1 Conceptual model of sleep health. This model, similar to those proposed by many other authors, posits that various dimensions of sleep-wake function can affect distal outcomes of health and function. Intermediate processes may include epigenetic, molecular, and cellular processes that in turn affect systems-level processes. These processes, ranging from inflammation to altered function of neural circuits, are more proximally related to health outcomes. The model also recognizes that the relationships between sleep-wake function and molecular-, cellular-, systems-, and organism-level outcomes are reciprocal; just as sleep affects function and health, so too function and health influence sleep-wake function.

Figure 19.1 Conceptual model of sleep health. This model, similar to those proposed by many other authors, posits that various dimensions of sleep-wake function can affect distal outcomes of health and function. Intermediate processes may include epigenetic, molecular, and cellular processes that in turn affect systems-level processes. These processes, ranging from inflammation to altered function of neural circuits, are more proximally related to health outcomes. The model also recognizes that the relationships between sleep-wake function and molecular-, cellular-, systems-, and organism-level outcomes are reciprocal; just as sleep affects function and health, so too function and health influence sleep-wake function.

The casual view of sleep, as simply a dormant and passive unconsciousness with suspension of normal bodily activities, shifted as neurology laid the foundation of sleep using electroencephalograph (EEG). Initially, not knowing of all the connections to health and disease, this led many to minimize sleep complaints as only a psychological discussion when patients spoke of their sleep complaints. We know now that the brain is very active during sleep—vital restoration of the mind and body occurs with each night’s rest. Sleep affects our daily functioning and is essential to our physical, mental, and emotional health. William Shakespeare insightfully and aptly described sleep as “nature’s soft nurse.”

The Importance of Sleep Stages and Cycles

Healthy sleep demonstrates repeated oscillations between REM and non-REM stages of sleep through the night to constitute a sleep architecture that follows a repeating cycle approximately every 90 minutes. Healthy and restorative sleep typically consists of approximately five to six cycles of sleep. All stages do not need to be seen in every sleep cycle; however, optimal sleep needs all stages of sleep to occur through the entire sleep. Each sleep stage in any given sleep cycle accomplishes physiological functions to promote health of the body and mind. If sleep is disrupted, fragmented, or missing specific stages over the entire sleep night, then it is more likely for fatigue or daytime sleepiness to be experienced with disregard to whether sufficient amount of sleep was achieved or not.

Non-REM Sleep

Non-REM sleep is composed of a continuum of three separate stages (stage1, stage 2, and stage 3) with each stage progressively “deeper” from a neurophysiological perspective. In non-REM, each “deeper” stage of sleep leads to further reductions in blood pressure and heart rate while rhythmic breathing patterns and heart rate are seen. Stages 1 and 2 are considered to be light sleep, from which we are more readily awakened or briefly aroused when compared to stage 3 sleep, which is referred to as deep sleep. In healthy sleep, stage 1 is the lightest stage and makes up only 5%–10% of the sleep night. Most often, it is the stage that we enter into when we fall asleep. It is often described as twilight sleep, in which we ebb and flow out of conscious awareness. Stage 2 of sleep is the typical sleep that we experience as well as the most common sleep stage, constituting 50% of a healthy sleep night. Stage 3 makes up between 15% and 25% of a healthy night of sleep and is deep sleep, from which it is difficult for us to be aroused or awakened as a result of the reduced receptiveness to external cues. Deep sleep is more likely to occur in the first half of the sleep night.

REM Sleep

Dreams are famously associated with rapid eye movement. The truth is that dreamlike experiences of abstract sounds and images may occur in any stage of sleep. Those which we call dreams are those with a storyline; these are found in REM sleep. Approximately 20%–25% of the sleep night is REM sleep; REM typically starts 90 minutes from the time we fall asleep and then repeatedly occurs every 90 minutes, with each REM episode progressively getting longer. Thus, the relative amount of REM is more likely to be found in the second half of the night.

In REM there is relative atonia of the muscle throughout the body except for the eyes, heart, and diaphragm. A potential negative impact of this is observed in sleep-related breathing disorders, where obstructive sleep apnea may become worsened in REM. An airway obstruction is more challenged when the costal and accessory muscles of ventilation are essentially paralyzed, thereby creating a greater reliance on the diaphragm to drive airflow and ventilation. However, this atonia is of protective benefit to prevent the acting out of dreams that might otherwise harm us and/or our bed partners. The physical body is relatively slowed in REM, yet the brain-wave activity is similar to a brain that is awake, where heart rate is more rapid, blood pressure increases, breathing becomes less regular, and sexual arousal is more common.

Recovery Sleep

All stages of sleep are important, yet there is an opportunity to cultivate stage 3 (deep sleep) and REM (dream) sleep through the adult years. These are the stages that are part of each night’s recovery and they become amplified when sleep is deprived. Such recovery sleep occurs when deep sleep addresses physical repair and restoration. In stage 3 of sleep there is an increased blood supply to muscles as a result, while energy in the form of adenosine triphosphate (ATP) is restored and growth hormone is released to promote growth, development, and repair. There is a progressive reduction in stage 3 throughout adulthood. In REM, the limbic system, which processes emotions, is activated while the frontal cortex, which allows rational thinking, is subdued. This promotes the clearing of emotions.

Sleep patterns change as people age, and sleep disorders become more common. As many as 57% of older adults have reported complaints of poor sleep.24,25,26,27,28 Changes in sleep architecture also occur with aging. In particular, sleep tends toward being less restorative, as older adults spend an increasing percentage of sleep in Stages 1 and 2 and a decreasing percentage of time in deep sleep (stage 3), and dream (REM) sleep.29,30,31 Therefore, it is of great importance to seek opportunities to maintain healthy sleeping given that we have tendency toward less restorative sleep. As a result, awareness of sleep disorders and lifestyle factors that disrupt sleep is vital.

Amount of Sleep Needed

Upon appreciating the importance of sleep stages, the typical follow-up inquiry seeks to know the amount of sleep that is needed. In general, the answer is the sleep time that permits us to be wide awake, alert, and energetic throughout the day. As this is true, it only begins the conversation when optimal sleep time is queried. The vast amount of the adult population requires about 8 hours of sleep, acknowledging that this does vary throughout our life and among people due to genetic predisposition. Without focusing on environmental cues such as light exposure and lifestyle habits, we see the underlying circadian rhythm is 24.2 hours long. This allows us to appreciate why most people are able to able to stay up later rather than seeking an earlier bedtime. This also influences travel across time zones, where we can more readily adjust to travel from West to East and acclimating to a later time. As a result of light exposure and cues from social interaction and environment, we become entrained into a 24-hour period.

As a starting point for the amount of sleep that is needed, the National Sleep Foundation Scientific Advisory Council has recommended sleep ranges for all age groups.32

  • Newborns (0–3 months): Sleep range narrowed to 14–17 hours each day

  • Infants (4–11 months): Sleep range widened 2 hours to 12–15 hours

  • Toddlers (1–2 years): Sleep range widened by 1 hour to 11–14 hours

  • Preschoolers (3–5): Sleep range widened by 1 hour to 10–13 hours

  • School age children (6–13): Sleep range widened by 1 hour to 9–11 hours

  • Teenagers (14–17): Sleep range widened by 1 hour to 8–10 hours

  • Younger adults (18–25): Sleep range is 7–9 hours

  • Adults (26–64): Sleep range did not change and remains 7–9 hours

  • Older adults (65 + ): Sleep range is 7–8 hours

Optimal sleep for an individual varies from person to person and during their lifetime. Moreover, some adults do not fit into the guidelines for optimal sleep. Requiring more than 9 hours of sleep (being a “long sleeper”) or needing less than 6 hours (being a “short sleeper”) does not reflexively diagnose an individual with a sleep disorder. There are genetic predispositions that allow people to be outside of the recommended sleep parameters and have normal and healthy daytime functioning. Approximately 5%–10% of the adult populations are “long sleepers,” and about 5% function well as “short sleepers.”

Short sleep duration more commonly has been recognized for its connection with poor sleep and with poor health, yet both short and long sleep duration require further review, given that both may negatively impact health. Short sleep may be a result of insufficient opportunity to sleep or the result of disordered sleep that limits the ability to maintain sleep once the majority of sleep debt is remedied with some sleep. Long sleep duration may represent fragmented or inefficient sleep, thus requiring a person to establish a greater amount of bedtime to acquire actual sleep time.

An optimal night of quality of sleep necessitates spending enough time in the different stages of sleep—especially deep (stage 3) sleep and dream (REM) sleep. If society were aware of the optimal health and performance that can be promoted by optimal sleep quantity and quality, it would be a most important step toward promoting health via sleep. In clinical practice, it is found that some individuals seem to acclimate and appear well with their sleep despite achieving less than the recommended sleep. It may not be transparent if someone is a short or long sleeper even if they are without daytime complaints. External factors can promote and demand alertness as today’s world is filled and propelled with artificial light and nonstop and increasing sets of imposed expectations and conveniences available 24 hours a day and 7 days a week. It is often surmised that the contemporary world has been actually getting less sleep over the past century. Many adults and teenagers are sleeping at least an hour less on average than 50 or 100 years ago;33 and sleeping less than 6 hours or over 9 hours now accounts for about one-third of adults.34

Insufficient sleep is often termed “sleep deprivation” and leads to sleep debt (also called sleep deficit). This often results in varying expressions of mental, emotional, and physical fatigue. This is observed in difficulties in performing daily activities and those requiring high-level cognitive functions. Similar to the effects of ethanol, two of the effects of sleep deprivation are impaired judgement and reduced insight. Without awareness, or subconsciously denying, this may result in reduced alertness and functionality, which in turn creates serious implications. Although we are aware of our cognitive and physical deficits resulting from sleep debt in the short term, this awareness often fades over repeated nights of poor sleep leading to reduced alertness and functionality with continued sleep deprivation. Beyond reduced alertness and insight, symptoms of sleep deprivation include lapses in attention, poor short-term memory, errors by omission, reduced ability to multitask, irritable mood, aggressive behavior, or daytime sleepiness. Physical manifestations of sleep debt include impaired coordination, impaired reaction time, muscle fatigue, hand tremors, lowered body temperature, increased blood pressure, increased stress hormone levels, and increased heart rate variability. Sleep debt tends to accumulate. About 2 weeks of less than 6 hours sleep per night reduces alertness and performance to a level equivalent to a full 24 hours of sleep deprivation. A week or more of only 4 hours sleep each night creates errors on attention oriented tasks that is equivalent to 2–3 days without any sleep.35

Only sleep reverses the negative effects of sleep deprivation. Recovery from sleep loss depends on the accumulated amount of sleep loss. Following one night of inadequate sleep, the following night of sleep demonstrates the majority of recovery in the first night and essentially complete recovery by the third night of healthy sleep. Longer periods of sleep deprivation require longer periods of recovery. However, the amount of sleep time to recover is less than the total amount of sleep that was lost. This may occur over the period of 1 week if sleep time is given an unlimited opportunity. Recovery sleep is often referred to as rebound sleep, giving attention to the resultant variation in the staging of sleep. On the first night of sleep following a period of sleep deprivation, deep sleep (stage 3) is given priority to restore our physical functions by releasing more growth hormone and repairing the immune system. This is followed by an extension of REM sleep. When overall sleep and/or REM sleep is repeatedly disrupted, then earlier and longer REM is observed in rebound sleep. This is all given an opportunity to rebalance when sufficient quantity and quality of sleep are allowed to occur consistently.

Common Sleep Disorders

Sleep as one of our most essential needs requires both quality and quantity. Sleep disorders reduce the opportunity for optimal quality and quantity required for restful sleep and, as a result, can cause daytime sleepiness and dysfunction. Nearly all of us will experience some kind of sleep disorder during our lifetime. There are over 100 different types of sleep disorders ranging from difficulty sleeping at night to problems with excessive daytime sleepiness. For the purposes of this chapter, we focus on the most common sleep disorders.

“Sleep apnea” mostly commonly refers to obstructive sleep apnea (OSA), yet this may also refer to central sleep apnea (CSA). By far, OSA is the most common type of apnea and it is characterized by complete or partial collapse of the upper airway for 10 seconds or longer repeatedly throughout the night. Although all persons are submitted to relative relaxation of the soft tissues in the airway during sleep, in OSA, these tissues create an obstruction of the upper airway sufficient to limit airflow, and therefore, to disrupt sleep-related breathing. Moreover, when the airway is blocked, the drop in oxygen levels leads to an arousal that wakes us up long enough so we can take a normal breath. These awakenings are often brief, such there may be no awareness that they are occurring during sleep. This repeats during the night, and in severe sleep apnea this leads to 30 or more awakenings per hour over the entire sleep night. Even though the awakenings are usually very short, this fragmenting and interrupting of the sleep along with the reducing of oxygenation has a significant and negative impact on health.

Although snoring is often associated with obstructive sleep apnea, it simply may be a loud sound, as its relevance ranges from being a mild nuisance to a significant disruptor of sleep for a bed partner. It is the result of a partially occluded upper airway in which inhaled air is redirected from the lungs to the mouth. This creates a negative pressure that vibrates in the soft tissues of the palate. Not everybody who snores has OSA, and not everybody who has OSA snores. Snoring is a potential symptom but not a diagnosis of an underlying sleep disorder. In CSA, prolonged breathing pauses lead to both hypoventilation and hypoxemic syndromes. These are due to a dysregulation and lack of cuing from the central nervous system that would otherwise continue involuntary breathing. As a result, there is no drive to initiate and complete a breath for 10 seconds or longer. This fragments sleep quantity and quality similar to OSA, even though the mechanisms are different.

Periodic limb movement disorder (PLMD) is a sleep disorder characterized by rhythmic movements of the limbs that possibly fragments the quantity but more often disrupts the quality of sleep. A type of PLMD is Willis-Ekbom syndrome (previously referred to as restless legs syndrome). This sleep disorder is characterized as sensorimotor discord when resting or lying down to sleep. It is experienced as frequently repeating discomfort, aching, jerking, twitching, tingling, or creeping-crawling sensations, leading to an irresistible urge to move or shift the legs, arms, or torso.

Insomnia is the most common of all sleep complaints. It is a sleep disorder that is characterized by difficulty falling sleep, staying asleep, and/or experiencing restorative sleep for at least 1 month, which leads to daytime dysfunction or disturbance. Etiologies include poor sleep habits, stress, anxiety, depression, health condition(s), medication effect, late night eating, caffeine, nicotine, mental health condition, another medical diagnosis, and/or another sleep disorder.

Circadian rhythm disorders are disruptions to the internal body clock known as the circadian rhythm. This can present as delayed sleep phase disorder, in which the bedtime and wake up time are later, or advanced phase disorder, in which these times are earlier. This is a disorder when it disturbs quality of life as a result of sleep times not aligning with social opportunities or professional pursuits. Jet lag sleep problems are a form of a circadian disruption in which insomnia occurs as a result of change in time zones. Another circadian disruption has increasingly witnessed is shift work sleep disorder, in which sleep timing and opportunity are dysregulated due to working nights or rotating shifts.

Hypersomnia, or excessive sleepiness, is a condition when there is trouble staying awake during the day. A specific form of daytime sleepiness is narcolepsy, which is a neurological dysfunction controlling the sleep and wakefulness.

REM sleep behavior disorder (RBD) occurs when there is incomplete or absent paralysis that typically occurs during REM sleep. This may result in a person acting out a dream and thus is potentially harmful to the person sleeping or the bed partner.

Parasomnias are disruptive sleep disorders that can occur during arousals from REM sleep or partial arousals from non-REM sleep. Parasomnias include nightmares, night terrors, sleepwalking, and confusional arousals.

Public Safety and Performance

Sleep disorders impact individuals as well as the public at large. In recent decades, the burden of a nonstop 24-hours-a-day/7-days-a-week world has negatively impacted sleep as shift work continues to expand. Shift work often creates highly irregular sleep-wake schedules, and this has been found to contribute to poor health. Chronic exposure to shift work represents a serious challenge to health and healing by its connection with increased risk of obesity, metabolic syndrome, and type 2 diabetes36,37,38,39—shift workers and students also often show day-to-day variability in their sleep patterns. Young adults tend to have later bedtimes, but spend more time in bed for sleep on nonwork days compared to work days.40 Similarly, following the transition to retirement, the older adult typically goes to bed later and sleeps longer than when they were working.41 The impact of the difference in sleep timing between work days and free days is associated with increased body mass index, fat mass, and insulin resistance.42,43,44 Hence, irregular sleep-wake timing may impact health, even in individuals who have never worked a night shift.45

Insomnia and poor sleep are major contributors to both unintentional fatal injuries in general as well as fatal motor vehicle injuries.46 The lack of sleep is a factor in manmade errors and many accidents each year. The sleep debt is associated with an increased risk of accidents and injuries. In recent decades, the news headlines have reported industrial and transportation accidents that occurred at night or with limited amount of sleep. Culprit errors were found during the Chernobyl tragedy that occurred at 12:28 a.m., and the Three Mile Island accident was initiated at 4 a.m. The Exxon Valdez captain was not drunk but he had only slept 6 hours in the previous 48 hours. According to the National Transportation Safety Board, fatigue is a factor in 57% of deaths of truck drivers. The Libby Zion case brought national attention to the concerns with work hours of medical trainees and hospital-related errors.47

There is a higher risk of preventable injuries and accidents occurring on night shifts than on day shifts. This risk increases with the length of the work shift and the number of back-to-back night shifts worked. Traffic accidents are also more likely during nighttime hours. This surges around 2–3 a.m., when there is the greatest peak in sleep drive within circadian rhythm. The second surge in auto accidents coincides with the next-largest peak in sleep drive, which occurs in the midafternoon. An estimated 20% of all traffic accidents are, in part, due to drowsiness. A small shift, such as 1 hour less of sleep that is likely to occur with daylight-saving time each spring, has been associated with a 20% increase in motor vehicle accidents on the following Monday.

Association of Disrupted or Disordered Sleep with Disease and Illness

Building on the appreciation of the underlying physiology of sleep and its inherent opportunities, the importance of sleep connects to not only the health of the public but also to vital opportunities of individuals for personal health and wellness. Sleep is associated with health and healing, whereas disrupted and disordered sleep is associated with disease and illness. The majority of medical literature has drawn the associations between premature all-cause mortality and both shorter (less than 7 hours) and longer sleep (more than 8 hours).48,49,50 Research connects health and sleep by demonstrating the impact of sleep spanning the continuum of cellular health to organ systems. Moreover, sleep impacts health and healing at not only on the physical but also the mental and emotional level.

Cardiovascular Health and Sleep

Atherosclerotic cardiovascular disease (ASCVD) is one of the most common diseases in industrial nations. Even with improved ability to diagnose and treat, ASCVD and its consequences are important contributors to morbidity and mortality. Therefore, it is necessary to go beyond the management of traditional ASCVD risk factors and seek other factors and comorbidities that might contribute to its development and progression. One such factor is sleep—and the focus on both poor quantity and quality of sleep.51, 52 Once healthy sleep became a significant factor in heart health, the importance of sleep was firmly established in modern medicine. For this reason, we highlight the connections and correlations between sleep and ASCVD.

Decreased sleep time is associated with developing of cardiovascular diseases by way of endothelial dysfunction53,54,55,56,57,58 leading to increased risk of inflammation, metabolic dysregulation of blood glucose, hypertension, stroke, coronary events, and sudden cardiac death.59,60,61 And ASCVD, such as coronary heart disease, peripheral vascular disease, and stroke, is highly prevalent in obstructive sleep apnea.62

The underlying mechanisms that provoke ASCVD include hypoxemia, reoxygenation, hypercapnia, sympathetic activation, metabolic dysregulation, endothelial dysfunction, systemic inflammation, left atrial enlargement, acute cardiac stretch and diastolic dysfunction, left and right ventricular dilation, and hypercoagulability. As a result, sleep apnea—especially OSA, is associated with nocturnal nondipping of blood pressure, systemic hypertension, pulmonary hypertension, heart failure, arrhythmias, diabetes mellitus, renal disease, stroke, cardiac fibrosis through repeated remodeling, myocardial infarction, and sudden cardiac death.63,64,65,66,67,68

Inflammation significantly increases the risk of endothelial dysfunction and developing plaque in ASCVD.69 Obstructive sleep apnea has been shown to increase inflammatory markers.70 Moreover, OSA is a common condition in patients with ASCVD.71,72,73,74 Obstructive sleep apnea with oxygen desaturation index ≥ 5 (number of oxygen desaturation events of 4% per hour) is independently associated with increased inflammatory activity in nonobese patients with coronary artery disease. The intermittent hypoxemia, as opposed to the number of apneas and hypopneas, is associated with enhanced inflammation.75

Patients with acute myocardial infarction and sleep-related breathing events have prolonged myocardial ischemia, less salvaged myocardium, and impaired left and right ventricular remodeling compared with those without sleep-related breathing events, all of which predispose to heart failure.76 Several studies have identified that patients with acute myocardial infarctions have a high likelihood of OSA, with estimates ranging from 50% to 66%.76,77,78,79,80,81

Participants with untreated severe sleep-disordered breathing (defined as a apnea-hypopnea index > 30 breathing events per hour) were two-and-half times more likely to have an incident coronary heart disease or heart failure compared to those without sleep-disordered breathing.82 Obstructive sleep apnea is highly prevalent in patients with cardiovascular disease, particularly heart failure. Approximately 35% to 60% of patients with heart failure have OSA,83,84,85,86,87 and the presence of comorbid sleep apnea is associated with adverse outcomes including increased hospitalizations, morbidity, and mortality.88,89,90

There is a strong association between OSA and cardioembolic stroke. Cardioembolic strokes are more common in patients with OSA, even after adjusting for atrial fibrillation. There is a high incidence of paroxysmal atrial fibrillation in those with OSA.91 Obstructive sleep apnea is 30% more common in people who have a stroke and is an independent risk factor for ischemic stroke.92,93 Men with moderate to severe OSA are at a threefold higher risk of stroke.94

Furthermore, Willis-Ekbom disease (formerly restless legs syndrome) is independently associated with diastolic blood pressure.95 Most epidemiologic studies,96,97,98 though not all, have demonstrated that Willis-Ekbom disease is associated with cardiovascular disease, with higher risk among those who have frequent symptoms98 and diagnosis for more than 3 years.99, 100, 101

Sleep and Obesity

Today, we are witnessing two pandemics: increasing obesity102 and increasing sleep disorders.103 Obesity is reaching epidemic proportions throughout the developed world and is attributed largely to industrialization with reduced acute disease, increased food consumption,104 and lowered levels of physical activity.105 The role of sleep in obesity is becoming increasingly understood. Sleep deprivation and disorders have been hypothesized to contribute toward obesity by decreasing leptin, increasing ghrelin, and compromising insulin sensitivity.106 There is a negative relationship between sleep duration and central adiposity. This has been recognized as a significant risk factor in the pathophysiology of OSA in adults. Furthermore, OSA is associated with increased body mass index.107

Sleep and Metabolic Syndrome

Obesity is a major risk factor not only for sleep apnea but also for cardiovascular and metabolic diseases. Metabolic syndrome is a cluster of risk factors that include central obesity, insulin resistance, hypertension, elevated triglyceride levels, and low high-density lipoprotein cholesterol levels,108 and is associated with an increased risk for diabetes, cardiovascular events, and mortality in the general population.108,109,110

There is an independent association of OSA with the different components of metabolic syndrome, particularly insulin resistance, hypertension, and abnormal lipid metabolism.111 The common association between OSA and obesity makes it difficult to separate the role each one plays in their metabolic consequences.112,113 Nevertheless, OSA is associated with metabolic syndrome independently of central obesity with metabolic profile progressively worsened with increasing severity of OSA.114 Sleep-disordered breathing and concurrent metabolic syndrome are synergistically associated with worse endothelial function. Individuals with both of these conditions appear to be at a significantly higher risk for cardiovascular disease complications.115

Sleep and Diabetes

In recent decades, type 2 diabetes has also reached epidemic proportions worldwide. The increasing prevalence of type 2 diabetes can be attributed to dramatic lifestyle changes in response to the industrialization of modern society that may not be limited to changes in our diet and physical activity.116 As with cardiovascular disease, one such factor strongly associated with development and progression of type 2 diabetes is sleep. Although short sleep duration is more commonly observed than long sleep duration, both are noteworthy in regard to regulating blood glucose. Population studies have observed a U-shaped relationship between sleep duration and type 2 diabetes risk; those who self-report habitually sleeping less than 7 hours or more than 8 hours are at increased risk.117 Decreased insulin sensitivity due to short sleep duration is observed among patients118,119,120,121 and in laboratory studies.122,123,124,125,126,127 Furthermore, when sleep time is extended in short sleepers, insulin sensitivity improves.128 Strongly linked to the presence of obesity, the OSA syndrome is an independent risk factor for abnormalities of glucose metabolism ranging from simple impaired glucose tolerance to frank type 2 diabetes.129

Sleep and Immunology

Poor immune status or increased inflammation is related to poor quantity or quality of sleep. Inflammation may be observed when the immune system gets increasingly triggered. It is appropriate for the immune system to be turned on in the setting of infection or illness. It is increasingly appreciated that lifestyle practices, especially poor sleep, directly play a pivotal role in both inflammation and immunocompetence.130,131,132

Several studies have shown insufficient sleep may enhance the susceptibility to infection.133,134,135 Shorter sleep duration prior to viral exposure was associated with increased susceptibility to the common cold.136 Short sleep duration (less than 6 hours per night) and poor sleep continuity are associated with immunosuppression leading to chronic illnesses,137,138,139,140 susceptibility to acute infectious illness,141,142,143 and premature mortality.144,145,146,147 Sleep deprivation results in diminished T cell proliferation,148 shifts in T helper cell cytokine responses,149,150 decreases in natural killer cell cytotoxicity,151,152 and increased activation of proinflammatory pathways.153,154,155,156 Furthermore, sleep deprivation and disorders have been found to induce increases in circulating levels of inflammatory markers, such as tumor necrosis factor-α‎ (TNF-α‎),153 C-reactive protein (CRP),155 and interleukin-6 (IL-6),157 with significant elevations occurring after only 1 night of sleep loss. Patients with both sleep apnea and nonapnea sleep disorders were associated with a higher risk for developing autoimmune diseases.158 This results from chronic pattern of inflammation found in sleep disorders.159,160 Brain health requires restorative function of sleep as focused on the glymphatic immune system, especially during REM sleep, as part of the restorative function of sleep is the removal of potentially neurotoxic waste that accumulates in the central nervous system during awake hours.161

As vaccinations have been a cornerstone of preventive medicine, it is therefore important to draw the connections between sleep and vaccinations. Sleep promotes antiviral immunity by supporting the adaptive immune response,162 with evidence that experimental and naturalistic sleep loss is associated with poorer immunological memory after a vaccination.163,164,165 One may not achieve the full benefit of the hepatitis B series or the hepatitis A and influenza vaccination followed by less than 6 hours of overnight sleep.

Sleep and Cancer

Emerging evidence links OSA with increased cancer incidence and worse cancer outcomes.166,167,168,169 North American and European data sets suggest malignancy is more likely to occur in subjects with severe sleep-disordered breathing,167,168 while animal models suggest that the mechanism is linked to intermittent hypoxia promoting tumor progression and metastasis.170,171 The mechanisms underlying these adverse outcomes include chronic systemic inflammation, oxidative stress, and immune dysfunction.

Patients with OSA have significantly reduced levels of circulating invariant natural killer T (iNKT) cells, and hypoxia leads to impaired iNKT cell function. This may be helpful to explain the increased cancer risk reported in patients with OSA.172 The iNKT cells are a select subset of innate T cells with a direct impact on cancer biology and autoimmune diseases.173, 174 Moreover, iNKT cells have an anticancer response in the prevention of tumors and in the clearing of tumors,175 by directly lysing cancer cells.176 Furthermore, the number and function of circulating iNKT cells are reduced in cancer patients,177,178 and therapeutic strategies aimed at restoring iNKT cell number and function have shown significant promise in the context of cancer immunotherapy.179,180,181,182,183 Among these opportunities includes quantity and quality of sleep.

Sleep and Memory

Cognitive impairment and dementia together constitute a growing public health concern. Sleep disruption and excessive daytime sleepiness contribute to cognitive impairment as well as neurodegeneration184,185,186,187,188,189,190

The association between sleep and cognitive function in older adults has been established.191,192,193 One key mechanism is nocturnal hypoxia, which in turn, decreases frontal lobe neuronal viability, and decreases hippocampal membrane turnover.194 Another key mechanism includes sleep fragmentation, with more time in stage 1 sleep and less time in REM sleep. Both nocturnal hypoxia and sleep fragmentation in older adults are associated with incident Alzheimer’s dementia and the rate of cognitive decline.195,196 Specifically, sleep loss impairs cognitive functions ranging from attention and learning ability to verbal fluency and inhibitory control.197,198

Quantity of sleep is essential for memory, in part, by allowing for a healthy representation of all sleep stages—especially recovery sleep. Recovery sleep is also important for memory. In general, non-REM sleep, especially stage 3, is associated with improved episodic and declarative (factual) memory that was encoded during wakefulness,199,200,201,202,203,204,205 while REM sleep is associated with gains in semantic and emotional memory.206,207,208 As a result, non-REM sleep may function to consolidate specific memories, whereas REM sleep integrates these experiences into networks of generalized knowledge.209,210

Sleep and Pain

Prevalence studies indicate high rates of comorbid chronic pain and insomnia in the aging population. Osteoarthritis, which affects approximately half of all persons age 65 years or older, is one of the most common comorbidities associated with poor sleep in the aging population.211 In the general population, a majority of arthritis sufferers report pain during the night,212 and pain secondary to arthritis is one of the most common factors predicting sleep disturbance.213,214 Both insomnia and pain adversely affect physical function, mood, and cognition.215,216 As poor sleep is associated with reduced pain thresholds and next-day pain reports,217,218,219,220 interventions for both sleep and pain are necessary to improve both outcomes.221

Mental and Emotional Health

The World Health Organization has stated that mental illnesses are the leading causes of disability worldwide and account for over 30% of healthy years lost from noncommunicable diseases.222 Depression alone is expected to be responsible for one-third of health years lost to disability from mental illness.223 Impaired sleep occurring during psychiatric or medical disorders has a bidirectional and interactive relationship with and coexisting medical and psychiatric illnesses.224,225

Sleep disturbances—short sleep duration, long sleep duration, insomnia, poor sleep quality, alterations in sleep architecture and OSA—often precede, co-occur with, or result from the onset of depression.226,227,228,229,230,231,232,233 More than 90% of patients with depression report some type of sleep disturbance234,235 and those with OSA have nearly double the odds of depression compared to those without OSA.236 There is a bidirectional relationship between Willis-Ekbom disease and a wide array of psychiatric conditions.237 Sleep disturbances impair daytime functioning and quality of life, which in turn decreases adherence to treatments of the mental health conditions.238 The importance of considering sleep disturbances in the context of mood disorders is highlighted by the fact that sleep disturbances are a risk factor for onset, exacerbation, and relapse of mood disorders.239

Interventions and Treatments for Disrupted and Disordered Sleep

Given the impact of disrupted and disorder sleep, the need for interventions and treatments is significant and important. Essentially the focus has been to address underlying etiologies and focus on improving outcomes. Modern medicine has made progress in treating some of the common sleep disorder: sleep-related breathing disorders, periodic limb movement disorders, and insomnia.

Treatment of Sleep-Related Breathing Disorders

Given the significant challenges to morbidity and mortality as well as to quality of life, treatment of sleep apnea needs to be detailed and personalized. First and foremost, both a thorough clinical evaluation with an interdisciplinary team and sleep testing are required so a patient can be directed to appropriate and best treatment options. Proper patient selection increases the success of nonsurgical and surgical approaches.240


Nonsurgical approaches for OSA begin with treating underlying medical conditions, positional therapy, and lifestyle modifications with focus on nutrition and exercise. Pharmacotherapy directed toward underlying allergic rhinitis or hypothyroidism may be helpful in combination with other therapies.241,242 For CSA, narcotic medications may be a culprit cause, and thus it is necessary to review medications for alternative regimens. Depending on the results of the polysomnogram, positional therapy such as avoiding the supine sleep position can be efficacious.243,244,245,246,247 Such an approach may improve snoring but also may either resolve or reduce the severity of sleep apnea. Typically, helpful lifestyle discussion prioritizes healthy body weight and judicious intake and timing of alcohol.

Nasal dilators and mandibular advancement devices demonstrate best results for mild and positional sleep apnea. Nasal dilators are for patients suffering from uncomplicated snoring and nasal obstruction. Mandibular advancing devices contract the genioglossus, and anteriorly forward both the mandible and hyoid bone to increase the oral airway during sleep.248 Positive airway pressure (PAP) is the treatment of choice for moderate and severe sleep-disordered breathing including OSA, CSA, and sleep-related hypoventilation. The most common form—continuous positive airway pressure (CPAP)—maintains a continuous level of PAP in a spontaneously breathing patient. Other forms that provide noninvasive positive pressure ventilation include autoadjusting PAP (autoPAP), bilevel positive airway pressure (bilevel PAP), adaptive servoventilation (ASV), and volume-assured pressure support (VAPS).249

Continuous PAP uses a nearly continuous air pressure to promote an open airway during both inspiration and expiration. Autoadjusting PAP adjusts the pressure based on respiratory events while delivering the adjusted pressure throughout the respiratory cycle. An advantage of autoPAP is for those who require higher pressures in REM sleep or the supine position, but cannot tolerate the higher pressure through the entire night.250 Bilevel PAP provides a higher pressure during inspiration and lower pressure during expiration, which may provide improved ventilation and ultimately greater tolerance and compliance, as high pressures may be difficult to tolerate. Some bilevel PAP devices provide a backup rate to address either weak or absent respiratory effort. Adaptive servoventilation is also a bilevel system during both inspiration and expiration, but it has the added sophistication of continuously changing the inspiratory pressure support on a breath-by-breath basis in order to achieve a target ventilation or flow for a more constant breathing pattern. This is especially important in the treatment of periodic breathing or Cheyne–Stokes respiration. An important contraindication of ASV therapy is regarding patients with symptomatic, chronic heart failure (New York Heart Association class 2-4) with reduced left ventricular ejection fraction ≤ 45% and moderate to severe predominant CSA.251 Finally, VAPS is a variable form of bilevel PAP that allows for more control of respiration by targeting volume or ventilation to be programmed. Indications for VAPS are those with combined periodic breathing and hypoventilation or patients with REM-related hypoventilation related to conditions like chronic obstructive pulmonary disease (COPD), neuromuscular disorders, or obesity, who may need different pressure support levels at different times.252


The ultimate goal of surgical intervention for sleep-related breathing events is either to bypass upper airway obstruction or to increase the upper airway anatomical dimensions. Although not appropriate for all patients, surgical outcomes improve with site-specific surgery after detailed anatomical review.253,254,255,256,257,258,259,260,261 Regardless of the chosen surgical approach to manage sleep apnea, constant reevaluation is necessary.

Surgery for moderate to severe OSA is an option for those who have failed CPAP. Surgical may not be definitive therapy but it may be a step toward reducing CPAP pressures to allow for compliance. To allow effective patient selection and site-specific surgery, drug-induced sedation endoscopy (DISE) is increasingly becoming the preferred and optimal evaluation.262,263,264 Although a procedure at a single anatomical site can resolve symptoms, an increasing number of patients display multilevel obstruction and therefore require careful assessment and treatment.

Nasal surgery, including septoplasty, turbinate reduction, sinus surgery, and/or nasal valve surgery, can be efficacious for simple snorers and in facilitation of CPAP usage by reducing pressure requirements along with patient discomfort.265,266,267,268

Palatal surgery has been the most common surgery performed for sleep-related breathing disorders. This approach addresses the anatomy of the soft palate by removing excess tissue (e.g., uvula, soft palate, redundant pharyngeal mucosa, tonsils). Uvulopalatopharyngoplasty was developed by Fujita in the 1980s, but has significant associated morbidity and has fallen out of favor, as success rates for OSA are low.269,270 In pediatric sleep apnea, adenotonsillectomy has been shown to improve apnea-hypopnea index and quality of life.271,272,273

Tracheostomy is rarely required, but remains the definitive treatment for OSA, as the upper airway is bypassed. Aside from tracheostomy, the highest success rates have been achieved by maxillo-mandibular advancement, which increases retropalatal and retroglossal dimensions.274,275 Bariatric surgery may improve OSA, but typically does not resolve OSA or snoring.276,277 A newer approach entails the surgical implantation of a hypoglossal nerve stimulator that is synchronized with inspiration when reduced upper airway muscle activity is the underlying etiology of OSA.278,279

Treatment of Periodic Limb Movements (Willis-Ekbom Disease)

Therapeutic options for Willis-Ekbom disease, a neurosensorimotor disorder (better known by its previous name, restless legs syndrome) are contingent on the underlying etiology. The challenge lies within the varied causes that include both genetics and biochemical factors. Willis-Ekbom disease is a continuous spectrum with a major genetic contribution at one end and a major environmental or comorbid disease contribution at the other. It is suggested that the involved genes are significantly expressed in the primary form of the disease (idiopathic) but also are involved in the comorbidities that are the roots of the secondary forms of the disease.280 In up to two-thirds of cases, genetic factors are considered to contribute to the etiology of Willis-Ekbom Disease.281

Whereas the most common secondary forms are linked to the biochemistry of iron deficiency, pregnancy, Parkinson’s disease, and end-stage renal disease,282 the list of associations include relative magnesium deficiency, B vitamin deficiencies, thyroid disorders, cardiovascular disease, arterial hypertension, diabetes, neuropathy, erectile dysfunction, arthritis, rheumatic illnesses, multiple sclerosis, migraine, fibromyalgia, depression, anxiety, mood disorder, attention-deficit hyperactivity disorder, liver disease, obesity, narcolepsy, and other sleep disorders.283 Ultimately, most presentations of Willis-Ekbom disease are treated with pharmacology (dopamine agonists, gabapentin, or low-potency opioids).284 Additional options seek to reduce the excessive periodic limb movement and their arousals by treating an accompanying sleep disorder, if present. A recently introduced approach enhances peripheral circulation with pneumatic compression or applies counterstimulation with vibration.285

Treatment of Insomnia

Although more than half of primary care patients may experience insomnia, only about one-third report this problem to their physicians286 and only 5% seek treatment.287 The vast majority of persons with insomnia remain untreated.288 Given the fast pace of primary care visits and the time needed to understand underlying etiology, it is not a surprise to know that two-thirds of patients with insomnia report a poor understanding of treatment options, and many turn to alcohol (28%) or untested over-the-counter remedies (23%).289

In this setting, the approaches may rely on use of prescribing pharmacology, resulting from the relatively short periods of time afforded to medical clinics to discuss underlying issues causing insomnia and patients living full lives with limited resources to delve deeper into root causes of insomnia. Nonbenzodiazapine receptor agonists such as eszopiclone and zolpidem, and the orexin antagonist suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known. Benzodiazepine hypnotics, melatonin agonists, and antidepressants in general populations and for most pharmacologic interventions in older adults may be helpful for select individuals but are without insufficient data to be widely helpful. In general, pharmacotherapy is intended for short-term use. Hypnotics may be associated with dementia, fractures, and major injury. The Food and Drug Administration warns about cognitive and behavioral changes, iatrogenic illness, or accidents including driving impairment, and other harms, and advises lower doses for females and older adults.290,291

Araújo and colleagues offer a framework to better address insomnia and its treatment. They categorize the issues as (1) experience of insomnia, (2) management of insomnia and (3) medicalization of insomnia. The main findings indicate that (1) insomnia is often experienced as a 24-hour problem and is perceived to affect several domains of life; (2) a sense of frustration and misunderstanding is very common among insomnia patients, which is possibly due to a mismatch between patients’ and healthcare professionals’ perspectives on insomnia and its treatment; (3) healthcare professionals pay more attention to sleep hygiene education and medication therapies and less to the patient’s subjective experience of insomnia; and (4) healthcare professionals are often unaware of nonpharmacological interventions other than sleep hygiene education.292

The paradigm of therapy starts with etiology: comorbid insomnia due to another sleep disorder or a medical disorder that requires treatment of the underlying process; the more common psychophysiological insomnia requires cognitive and behavioral approaches. Herein is the opportunity to use cognitive-behavioral therapy for insomnia (CBT-I), which was been well-established as an evidence-based, efficacious treatment for insomnia.293,294,295,296 Cognitive-behavioral therapy is commonly prescribed for depression, but clinical trials have shown it is also the most effective long-term solution for those with insomnia.

Positive effects of CBT-I on sleep quality are robust over time.297,298 The treatment has been found to be efficacious in populations with a variety of comorbid medical conditions, including persons with comorbid insomnia,299 comorbid psychiatric conditions,300 and chronic pain.301,302,303,304,305

Also, CBT-I helps identify the negative attitudes and beliefs that hinder sleep, and replaces them with positive thoughts, effectively “unlearning” the negative beliefs.306 The behavioral aspect of CBT focuses on helpful sleep habits and avoids unhelpful sleep behaviors. Behavioral techniques that may be recommended include stimulus control,307 sleep restriction,308 systemic desensitization,309 sleep hygiene, sleep environment improvements, relaxation training,310 parodoxical intention,311hypnosis,312 and biofeeback.313 Over a period of six to eight weekly sessions,314,315,316 for most adults in either individualized or group-based administration, CBT-I has been shown to be effective317,318,319 yet greatly underused in comparison to pharmacological approaches.

Integrative and Preventative Approaches

First and foremost, the awareness and continued appreciation of the importance of sleep are essential for best health. Such awareness is the key to prevention. In our ever-expanding lives, we seek to expand the hours of day and as result, sleep is treated as a mere luxury. Sleep needs to be prioritized. Educating the public and our patients as to the fundamental need for quantity and quality of sleep cannot be overstated. As much as nutrition and exercise are appropriately highlighted for both health and healing, restorative sleep is prerequisite for optimal health and healing. In addition to positively impacting the physical body, sleep also promotes mental and emotional health. Furthermore, it is helpful to note that healthy sleep supports healthy eating and physical activity. Therefore, sleep both directly and indirectly benefits health. Conversely, disrupted and disordered sleep negatively impacts health and healing opportunities. In this chapter, we have presented sleep and its connection with both public health and personal wellness. Sleep is strongly correlated with cardiovascular disease, obesity, metabolic syndrome, diabetes, immune status, cancer, memory, pain control, mental health, and emotional health. It would be excessive to state that sleep is a single factor preventing these illnesses. Instead it is more helpful to urge the public and our patients to prioritize restorative sleep to reduce either the development or the progression of these diseases.

It is important to think of sleep beyond the time spent in bed. Thus, it is necessary to view the impact of the 24 hours of the day on sleep. By this, it is meant that our daytime lives impact our ability to get to sleep, stay asleep, and awake refreshed for the new day. The focus on lifestyle toward best health also can be applied toward best sleep. There are preventable causes of disrupted sleep when focusing on lifestyle: caffeine, alcohol, tobacco, eating patterns and food choices, light exposure, and exercise.

Caffeine is a common part of the lives of many, as witnessed by rituals of morning coffee or tea as well as the surge in energy drinks among younger adults. Unfortunately, caffeine has discernible impact on sleep that challenges opportunities for restorative sleep.320 Caffeine blocks the adenosine receptor in the central nervous system, which is involved in sleep induction and the regulation of deep sleep. Caffeine has a half-life ranging from 3 to 7 hours depending on an individual’s expression of the cytochrome p450 1A2 genotype. As much as coffee and tea are appropriately touted for their antioxidant benefits, the scheduling and quantity of caffeine is significant as it relates to timing and quality of sleep. According to the 2001 Sleep in America poll by the National Sleep Foundation, 43% of Americans are “very likely” to use caffeinated beverages to combat daytime sleepiness. This, in turn, creates a vicious cycle of poor sleep leading to daytime sleepiness, which leads to increased caffeine consumption. The opportunity is to focus on the timing and quantity of caffeine in our daily lives so that it can be helpful and not disrupt our best sleep.

Alcohol is commonly used around the world as a sleep aide.321 Regrettably, this is neither helpful nor recommended based on its effects on sleep. Whereas in the short term, it helps induce sleep, this effect tapers in a series of days and weeks depending on the individual’s hepatic clearance. The impact of ethanol on sleep staging demonstrates a reduction of quality of sleep in the second half of the sleep night. Alcohol has physiological effects on sleep such as airway relaxation and narrowing; hence, this negatively impacts sleep-related breathing such as OSA. There is a dose effect with ethanol on both its impact on sleep staging and the physiology of breathing during sleep. As with caffeine, the opportunity is to balance the timing and quantity of ethanol in our daily lives so that it does not interfere with healthy sleep.

Tobacco has multiple hazards toward optimal health. In particular, nicotine is usually discussed because of its addictive quality. However, it has significant effects that reduce the quantity and quality of sleep. Nicotine shifts the circadian rhythm by altering the expression of clock genes.322 People who smoke tobacco are two and half times more like to have OSA. The limitation of airflow is in part due to the inflammatory effect on the nasal and oral airway.323 Tobacco use leads to difficulty initiating sleep due to its stimulant and withdrawal effects.324 Those who smoke tobacco are more likely to experience nonrestorative sleep due to more time spent in the light sleep stages as opposed to the deep and REM sleep stages.325 It is appreciated that tobacco cessation is important for the health of the public as well as for individuals. Hence, the encouragement to be a former tobacco user can be furthered by appreciating its negative impact on sleep.

Eating patterns and food choices influence overall health as well as sleep health. Individuals consuming excessive numbers of calories report short sleep time and quality.326 Concentrated carbohydrates such as sugars act as stimulants on the body and influence a wide range of neurotransmitter shifting that hinders the ability to fall asleep and stay asleep.327 Individual variance in food tolerance, such as spicy foods and dairy, also impacts the ability to physically be soothed to be able to sleep. Large meals eaten close to bedtime typically disrupt sleep onset and/or sleep quality. As discussed earlier, poor sleep creates the hormonal and neurochemical basis for food cravings. Again, we see the vicious cycle of poor sleep leading to both overconsumption and poor food choices, which limits restorative sleep. The opportunity to support healthy nutrition also supports healthy sleep.

The world as we know it has expanded with artificial light and electronics. However, it has been at cost of sleep quantity and quality. Exposure to light, and especially blue light, acts on several non-image-forming (NIF) functions of the visual system. They impact sleep by directly acting on the sleep-wake cycle but also indirectly by influencing body temperature, hormonal balance, alertness, and cognitive processing—these, in turn, have a negative impact on sleep.328 The NIF functions are maximally sensitive to blue wavelengths (460–480 nm), which in turn are involved in melatonin suppression, vigilance, and stimulating mental activity.329,330 Blue light exposure 1–2 hours before bed reduces sleep onset, REM, and overall perception of sleep quality. Sources of blue light include artificial lighting and digital screens (televisions, computers, tablets, and phones). Herein lies the opportunity to honor the benefits that lighting and electronics have added to our lives, but there is a new opportunity to schedule the exposure to light so that healthy sleep can be promoted.

National Sleep Foundation’s 2013 Sleep in America poll highlighted the association between exercise and better sleep. It is thought that a physically robust daytime uses our ATP resources such that the cleaving of the phosphate bonds results in a higher amount of adenosine by bedtime. Again, adenosine promotes sleep induction and deep sleep stages. Exercisers compared to nonexercisers are more likely to report restorative sleep. Poor sleep makes us less likely to exercise, which in turn leads to relative difficulty falling asleep, falling back asleep in the middle of the sleep night, and waking up too early.331,332,333 Thus, there is a vicious cycle of reduced physical activity and reduced sleep. Although the timing of exercise has been widely debated, it is likely to be based on individual experience. Promoting daily physical activity also promotes nightly rest by way of healthy sleep.334

Integrative medical approaches ultimately bring together the best of modern medicine and traditional wisdom of lifestyle medicine. It is appreciated that the public is seeking quantity and quality of life—lifestyle medicine with appreciation of quantity and quality of sleep are essential toward this pursuit. The time-honored teaching of best medicine is rooted in taking a thorough and deep history and then aligning investigations and therapeutic offerings that are individualized to persons partnering with us. Whereas the histories are not always transparent toward the underlying challenge toward best sleep, investigations such as sleep studies are ripe with information but need to be applied to the context of a person’s life. As some patients approach sleep via the modern medicinals and others via the proactive lifestyle route, the opportunity for integrative medicine is to educate and offer all persons as to the full spectrum of both opportunities toward best sleep. As medications are commonly prescribed or bought over-the-counter to promote sleep, they can be helpful for some in the short term. However, their benefits often wane over time. Moreover, pharmacology is only one approach and does not address the full spectrum of opportunities for best sleep. In addition to teaching or prescribing healthy lifestyle toward optimal sleep, integrative medicine is already positioned to translate this within the realms of modern medicine, which has adopted CBT with a focus on sleep hygiene as well as tests such as polysomnogram. Therefore this platform allows for understanding both underlying the lifestyle habits and medical conditions that influence an individual’s sleep. On this platform, we can be build preventative approaches. Such preventative approaches can align toward maintaining optimal sleep as well as early detection of sleep disorders so that resulting medical ailments can be reduced or prevented. Again, sleep is no luxury for it is vital and a key factor for optimal health.


Healthy sleep is a cornerstone of healthy lifestyle and preventative medicine. Sleep that is healthy has both quantity of sleep and quality of sleep—this allows sleep to both physically reparative and emotionally restorative. To connect this sleep into both sick care and healthcare is to appreciate that there is a two-way impact: poor sleep increases the risk of disease and illness, and disease and illness disrupt and disorder sleep. This translates into a vicious cycle that creates both morbidity and mortality. Today’s medicinal approaches to improve sleep primarily uses pharmacology and interventions. As much as these have been helpful, it is not comprehensive, and therefore it is not enough. If our patients and our communities were aware of the benefits of optimal sleep, it would be a most important step toward promoting health via sleep. Lifestyle and behavioral approaches for healthy sleep are a must, especially in our nonstop, expanding lives. With best sleep, we promote our best health.


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