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

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Cleveland HeartLab 2013 Symposium

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

  1. 1. The Power of Sleep a key to addressing inflammation & optimizing health Param Dedhia, MD
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. Optimal Sleep  Quantity  Quality
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. Stages of Sleep Wake = resting, eyes closed Stage 1 = transitional sleep Stage 2 = typical sleep Stage 3 = “deep” sleep R.E.M. = “dream” sleep
  10. 10. Normal Sleep Cycles Awake REM 1 2 3 Hours 8 0 1 2 3 4 5 6 7
  11. 11. 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
  12. 12. Sleep-Inflammation Connection ↓ Sleep → ↑ Inflammation ↑ Inflammation → ↓ Sleep
  13. 13. 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
  14. 14. DISORDERED SLEEP MECHANISM RISK FACTORS OUTCOMES • • • • • • • • • • • • Inflammation Metabolic Vascular Hormonal Hypertension Obesity Diabetes Hyperlipidemia CHD & CVD Stroke Dementia Death
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. Sleepiness doesn't kill but Sleep Apnea does OPEN AIRWAY COLLAPSED AIRWAY ABCs of Life Airway Breathing Circulation
  27. 27. 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
  28. 28. 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
  29. 29. 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)
  30. 30. 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
  31. 31. Tonsils: Sleep Apnea Narrowing of Lateral Airway
  32. 32. 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
  33. 33. Consequences of Poor Sleep: Sleepiness !
  34. 34. 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
  35. 35. 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
  36. 36. Alcohol General rule: per drink 1 hour of sedation… followed by 1 hour of arousal/withdrawal
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. Tip for Better Sleep • Create Rituals Enjoy reading, stretch or gentle yoga Warm shower Set wake up time
  45. 45. 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
  46. 46. Prescription for Optimal Health Param Dedhia, MD Internal Medicine dN oo G A p lee S t’s igh
  47. 47. THANK YOU Param Dedhia, MD pdedhia@gmail.com

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