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Param Dedhia, MD - The Power of Sleep: A Key to Addressing Inflammation and Optimizing Health
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Param Dedhia, MD - The Power of Sleep: A Key to Addressing Inflammation and Optimizing Health

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Cleveland HeartLab 2013 Symposium

Cleveland HeartLab 2013 Symposium

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Param Dedhia, MD - The Power of Sleep: A Key to Addressing Inflammation and Optimizing Health Param Dedhia, MD - The Power of Sleep: A Key to Addressing Inflammation and Optimizing Health Presentation Transcript

  • The Power of Sleep a key to addressing inflammation & optimizing health Param Dedhia, MD
  • Disclosures • No third party relationship influences this presentation • I have no financial relationships related to this presentation • No off-label medications or treatments are included in this presentation
  • A Wake Up Call: The Objectives  Present the Power of Sleep as a Key for Optimal Health  Illuminate the Sleep-Inflammation Connection ↓ Sleep → ↑ Inflammation ↑ Inflammation → ↓ Sleep  Offer Tips and Clinical Pearls for Best Sleep
  • The Function of Sleep 10. Pay off sleep debt 9. Replete energy stores 8. Enhance neuroplasticity 7. Regulate ion channels 6. Cool brain and body 5. Optimize physiological repair, growth & function 4. Improve memory formation and consolidation 3. Soothe emotions and mental fatigue 2. Promote endogenous antioxidant defense 1. Reduce inflammatory markers
  • Optimal Sleep  Quantity  Quality
  • Sleep Myths • We all wish that we could sleep like a baby Teenagers are the “best” sleepers • We need less sleep as we get older – Most ALL adults need 7-9 hours… – Sleep changes in adults ↓ Deep Sleep ↑ Arousable ↑ “Cope” with Arousals
  • How much sleep do you need or want? • Studies that paid people to sleep Participants asked to be “well rested” • Definition of “well rested” Not being able to fall asleep in a darkened room mid-day • TAKE HOME POINT Most adults need 7 - 9 hours of sleep
  • GOAL: 7-9 hours of sleep Debate: •All At Once vs. Naps •All At Night = Gold Standard Naps = • Good Option in order to reach 7-9 hours • Consider Power Nap (10 - 30 minutes) • Longer Naps may disrupt night time sleep
  • Stages of Sleep Wake = resting, eyes closed Stage 1 = transitional sleep Stage 2 = typical sleep Stage 3 = “deep” sleep R.E.M. = “dream” sleep
  • Normal Sleep Cycles Awake REM 1 2 3 Hours 8 0 1 2 3 4 5 6 7
  • Disruptors from Consolidated Sleep Arousals & Awakenings • Sleep Apnea/Snoring • Comorbid Conditions • Periodic Leg Movements - Psychiatric, (Depression/ Anxiety) • Bruxism (Teeth Grinding) - Hormonal, Menopausal • Pain & Discomfort - Urological (Bladder*) • Caffeine/ Drugs/ ETOH • Room Environment (light, noise, etc.) - Neurological - Cardiovascular - Autoimmune - Inflammatory
  • Sleep-Inflammation Connection ↓ Sleep → ↑ Inflammation ↑ Inflammation → ↓ Sleep
  • Poor Sleep → Comorbidities Sleep Restriction/ Insufficient Sleep Recovery Chronic Hypoxia &/or Frequent Arousals Stress & Autonomic System Activation ↑ Cortisol, Catecholamines, Blood Pressure, Blood Glucose ↑ Leukocytes, Inflammatory Cytokines, CRP, Oxidative Stress Pro-inflammatory Status & Endothelial Injury Cardiovascular Comorbidities
  • DISORDERED SLEEP MECHANISM RISK FACTORS OUTCOMES • • • • • • • • • • • • Inflammation Metabolic Vascular Hormonal Hypertension Obesity Diabetes Hyperlipidemia CHD & CVD Stroke Dementia Death
  • OSA and Inflammation Control Mild OSA Severe OSA BMI 28.3 ± 1.3 27.9 ± 1.0 28.1 ± 0.06 AHI 3.3 ± 0.6 11.0 ± 0.9 48.4 ± 0.04 Low SaO2 95.2 ± 2.6 83.7 ± 1.7 75.7 ± 2.1 CRP (mg/L) 0.90 ± 0.2 1.5 ± 0.3 2.8 ± 0.4 IL-6 (pg/mL) 0.91 ± 0.15 1.23 ± 0.14 2.25 ± 0.28 IL-18 (pg/mL) 181.9 ± 20.3 209.7 ± 27.0 273.5 ± 16.8 Minoguichi, Am J Respir Crit Care Med 2005 OSA = Obstructive Sleep Apnea
  • Sleep Duration & Inflammation • Elevated hs-CRP & IL-6 – U Shaped Impact • Short Sleep Duration < 5 hours • Long Sleep Duration > 9 hours – Stronger correlation in women than men Miller, Sleep 2009 Rohde, Am J Cardiol 1999 Sesso, Hypertension 2007
  • Sleep Duration & Adipokines Each hour of reduced sleep time • 6 % increase in leptin (p = 0.01) • ↑ Leptin • Potential furthering of leptin resistance 14 % increase in visfatin (p = 0.02) Each hour of reduced REM • 15 % increase in leptin (p = 0.01) • 31 % increase in visfatin (p = 0.05) ↑ Visfastin • Competitive inhibition of insulin receptor binding Other studies note increased IL-6, TNF α, & adiponectin Hayes, Sleep 2011
  • Glucose and Sleep Advanced Glycation End-Products (AGE) Insulin Resistance → AGE High Caloric, High Saturated Fat → AGE Oxidative Injury from Sleep Apnea → AGE Tan, Sleep 2006 Veasey, Sleep 2006 Wautier, Am J Physiol Endo Metab 2001
  • Sleep & Hypertension • Sleep-related Breathing Disorders promote non-dipping of nocturnal blood pressure • Even mild OSA associated with increased risk of developing hypertension in 4 years – (OR 1.42: [1.13-1.78]) • Moderate to Severe even greater risk – (OR 2.9: [1.5- 5.6]) Wisconsin Sleep Cohort, Sleep 2008
  • Syndrome X → “Syndrome Z” • “Syndrome Z”: Syndrome X + Sleep Disturbance – Proposed Model Fit with Syndrome X – Sleep Disturbance: Model Fit (0.82 ± 0.03; p < 0.01) greater model fit than • Insulin Resistance (0.67 ± 0.05; p < 0.01) • Hypertension (0.64 ± 0.04; p < 0.01) • Dyslipidemia (0.60 ± 0.05; p < 0.01) – Obesity: Model Fit (0.85 ± 0.02; p < 0.01) Nook, Sleep 2011
  • Sleep Duration & Pneumonia • Both Short and Long Duration promote Pneumonia Risk in Women – U Shaped Impact • Short Sleep Duration < 5 hours – (RR 1.39: [1.06-1.82]) • Long Sleep Duration > 9 hours – (RR 1.38: [1.04–1.84]) – Perceived Insufficient Sleep – (RR 1.50: [1.29-1.74]) Patel, Sleep 2012
  • Sleep Duration and Immunity • Short Sleep Duration (< 6 hours) Negative effect in vivo antibody response to novel antigen – Hepatitis B Vaccination – Influenza Vaccination – Possible explanation for poor sleep with increased susceptibility to infectious disease Prather, Sleep 2012
  • Sleep Duration & Mortality • Both Short and Long Duration associated with increased all-cause mortality – U Shaped Impact • Short Sleep Duration < 6 hours – (RR 1.12: [1.06-1.18]) • Long Sleep Duration > 9 hours – (RR 1.38: [1.22–1.38]) Cappuccio, Sleep 2010
  • Insomnia • Prevalence of insomnia 21.4 % (18 to 65 years) • Adjusted OR 2.2 in setting of medical disorders • Heart Disease (1.6: [1.2-23]) • Migraine (1.8: [1.5-2.1]) • Hypertension (1.5: [12-18]) • Asthma (1.6: [1.3-2.0]) • Diabetes (1.4: [20-105]) • COPD (1.9: [1.5-2.5]) • Gastric Ulcers (2.1: [1.6-2.7]) • Neurological (2.0: [1.5-2.7]) • Arthritis (1.8: [1.5-2.2]) • Menstrual (1.7: [1.3-2.1]) Budhiraja, Sleep 2011
  • Sleepy U.S. • National Sleep Foundation Survey, 2005 – 21 % think they have “sleep problems” • Of these, 75% have some problem – Only 45% would ask their doctor about it
  • Sleepiness doesn't kill but Sleep Apnea does OPEN AIRWAY COLLAPSED AIRWAY ABCs of Life Airway Breathing Circulation
  • Sleep Apnea & the Heart Very High Mortality Similar risk as smoking > 50% increase in cardiovascular events 2 - 3 times increased risk for myocardial infarction Higher Risk of Major Medical Conditions – – – – Arrhythmia Sudden Cardiac Death Hypertension Stroke − Dementia − Elevated Blood Sugar − Depression − Traumatic Injury
  • Who Gets Apnea?  Large neck: >17” men & >16” women  Nasal congestion or fracture  Small chin  Family History  Alcohol or sedatives  Men of all ages and Women after menopause
  • Signs & Symptoms of Apnea  Mouth Breathing and/or Airway Crowding  Morning Complaint of Dry Mouth or Headache  Sleepy, Tired, Irritable, Poor Performance  Hypertension (requiring >1 meds)  Arrhythmia (atrial fibrillation; repeat cardioversion)
  • Crowded Airway: Sleep Apnea • • • • Class I Class II Class III Class IV View Soft Palate, Fauces, Uvula, Tonsillar Pillars View Soft Palate and Fauces, Uvula Tip Obscured View Soft Palate View Hard Palate Only
  • Tonsils: Sleep Apnea Narrowing of Lateral Airway
  • Treatment for Sleep Apnea Sleep Position (Side vs. Back) CPAP Treat Stuffy Nose Dental Device Surgery Provent Alcohol Weight Loss (Timing at Night) GOLD STANDARD
  • Consequences of Poor Sleep: Sleepiness !
  • It is NOT “normal” to: • Fall asleep if reading quietly in the afternoon • “Drift off” at afternoon meetings • Sleep on airplanes • Fall asleep watching TV in the early evenings • Sleep when you are a passenger in a car • “Drift off” while waiting at red lights
  • Chronic Sleep Deprivation 16 14 12 10 8 6 4 2 0 Time In Bed 0h TIB 4h TIB 6h TIB 8h TIB 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Number of Errors 14 days of sleep restriction days of sleep restriciton Van Dongen HP. Sleep 2003
  • Alcohol General rule: per drink 1 hour of sedation… followed by 1 hour of arousal/withdrawal
  • Sleep Interference • Caffeine: – The biggest one: – Half life =7 hours, i.e. ¼ of am coffee still there at 10 PM 8 AM 3 PM Full Half 10 PM Quarter
  • Steps to Better Sleep • Appreciate Sleep as Time Well Spent • Reduce Body Activity and Temperature • Slow Down a Busy Brain • Make the Bedroom a Sanctuary • Create Rituals
  • Tip for Better Sleep • Appreciate Sleep as Time Well Spent As much setting aside “Me Time” is vital, sleep is of top priority– it will provide better ‘Me Time” If sleeping were a pill, its label would list: - antioxidant - anti-inflammatory - antidepressant - libido enhancement - heart smart
  • Tip for Better Sleep • Reduce Body Activity and Temperature The act of cooling down the core body temperature promotes the transition to DEEP sleep - Warm Shower - Exercise Earlier in the day up a 3 hours before bed time - Cool (not cold) room yet, extremities need to be warm
  • Tip for Better Sleep • Slow Down a Busy Brain Advice to think of nothing rarely works The brain is a “factory of thoughts” Stream of consciousness is default mode Seek a recitation– this creates stillness of mind & body -Recite a poem, prayer or hymn -Count or watch breaths -Progressive muscle relaxation
  • Tip for Better Sleep • Make the Bedroom a Sanctuary Sight – Lighting Smell – Aromatherapy Sound – Quiet or White Noise Touch – Temperature & Comfort The bed is only for: (1)Intimacy (2)Sleep NOT for work, worry, or problem solving
  • Tip for Better Sleep • Create Rituals Start winding down 1-2 hours before bed Dim the lights & turn off the screens Time the liquids before bed - water - alcohol - caffeine
  • Tip for Better Sleep • Create Rituals Enjoy reading, stretch or gentle yoga Warm shower Set wake up time
  • Tip for Better Sleep • Create Rituals If cannot get to sleep or get back to sleep in 20 minutes… GET OUT OF BED -Avoid TV and Computer -Recite poem, prayer or hymn -Count breaths -Progressive relaxation -Read -Stretch -Gentle Yoga
  • Prescription for Optimal Health Param Dedhia, MD Internal Medicine dN oo G A p lee S t’s igh
  • THANK YOU Param Dedhia, MD pdedhia@gmail.com