Good sleep may very well be the Holy Grail of health. It is the tide that raises all ships, so to speak, and is a topic that is so vast that to summarize it in a single article seems unworthy of its importance. Alas, even an outline would be a daunting feat, but here we go...
Sleep is the most anabolic activity that we undergo. It is the single most important factor when it comes to recovering from illness and injury. While it may seem prosaic and passive, it is one of the most busy and complex physiological events that we undergo. The metaphor of a duck swimming on the surface of a pond comes to mind. Everything seems placid above, but under the water there is a frenzy of activity.
In this article we will learn about why sleep is so important, how it gets disrupted, and what we can do about it. Try to keep your eyes open for this one.
The Importance of Sleep
All animals require sleep to function. What that sleep looks like across the entire animal kingdom varies greatly. Humans and most other mammals have distinct periods of rapid eye movement (REM) sleep and non-REM sleep, whereas marine mammals, reptiles, and most birds don't tend to have much REM. Marine mammals like whales and dolphins as well as migratory bird species (like ducks ;-P), exhibit a unique adaptation called unihemispheric sleep in which they shut down half of their brain for sleep, while the awake half still runs the body's functions
In humans, the stages of sleep have been well studied. There are three levels of non-REM sleep (N1-N3). N3 is known as 'deep sleep' and is critically important for cleaning out protein and other metabolites that build up in the brain, as well as repairing the body. During REM sleep, memory is consolidated and the brain restructures its neural connections. Most people's sleep cycles range from 90-120 minute and include a period of deep sleep followed by a period of REM. Most people function best with 4-5 such cycles, but there is a small number of people who can function normally on fewer.
If we are unable to meet our sleep requirements (which typically decrease as we age) then problems can arise. The most extreme examples of sleep deprivation can actually cause organ failure and death. Acute deprivation usually is self-correcting, as you know if you have ever pulled an all-nighter, but chronic deprivation is more insidious and much more common.
Sleep Disturbances
50 to 70 million Americans are reported to have ongoing difficulties with sleep, but the actual number is most likely higher. It is a well documented fact that the average hours of sleep have decreased since the Industrial Revolution and the invention of the electric lightbulb. Before that time, circadian rhythms were largely constrained by the length of the day, but modern advances have disrupted that natural rhythm.
Sleep deprivation can lead to hormonal dysregulation, memory issues, and weight gain. In a sleep study with college-aged subjects, a single night of sleep deprivation produced insulin resistance that matched that of pre-diabetic patients. You can imagine the effects on older, less metabolically healthy people who routinely get under 7 hours of sleep each night. It is little wonder that the rise in type 2 diabetes parallels the decrease in sleep time, but there is also the issue of sleep quality.
Sleep quality has become increasingly mainstream thanks to devices called 'wearables,' including Fitbit, Whoop, Garmin, and Oura Ring. These attempt to approximate time spent in each phase of sleep by measuring heartrate and movement during the night, and while they can be useful starting place for some people, they are not fool-proof. A better metric for how well you sleep is how easily you can wake up in the morning and how much energy you maintain throughout the day. If you are groggy in the morning, rely on caffeine to stay awake, and find yourself napping in the afternoon, then something might be off with your nighttime sleep. But what exactly?
There are numerous types of sleep disorders which we won't detail fully here. A small percentage are genetic in nature or caused by issues in with the central nervous system (i.e. Central Sleep Apnea, Narcolepsy). These need more in-depth treatment modalities that are beyond the scope of this article. Fortunately, the majority of sleep issues are behavioral, structural, or psychological in nature and can benefit greatly from lifestyle intervention.
Obstructive Sleep Apnea (OSA)
OSA is by far the most common type of diagnosable sleep disorder and is estimated to affect close to 25 million Americans. The two most common causes of OSA are obesity and chronic stress. People with OSA often snore during the night and have frequent wake events that go undetected by the person sleeping. These small interruptions disrupt the sleep phases and result in decreased overall sleep quality.
Chronic Insomnia
Over 30 million Americans suffer from un-differentiated chronic insomnia, meaning that they either have difficulty falling asleep or staying asleep, or both. The exact causes of insomnia vary depending on the person, but shifts in hormones during menopause, psychological stress, disruptions in circadian rhythm, and chronic pain are a few of the regular culprits. Insomnia can also be caused by certain medications, alcohol, and drugs.
Other Sleep Disorders
There is a group of sleep disorders called parasomnia that includes sleep walking, dream paralysis, and other REM related disorders. Restless Leg Syndrome (RLS) is another source of chronic sleep issues.
Common Western Sleep Treatments
Before prescribing any treatments for sleep, most physicians will order a sleep study be conducted. The gold standard sleep study is done in a laboratory setting with the patient hooked up to both a pulse oximeter to measure blood oxygen saturation and a electroencephalogram (EEG) to measure brain activity. While important for spotting abnormal brain activity, their findings need to be taken with a grain of salt because these studies are often one-time tests of a person who is sleeping in an unfamiliar environment. Because of the cost and non-normal setting of sleep studies, at home sleep apnea tests are becoming more common and involve wearing a pulse oximeter and some kind of movement tracker in the comfort of your own bed.
For cases of mild to severe sleep apnea, doctors will typically prescribe the use of a positive airway pressure (PAP) device. These vary in complexity, from simply adding supplemental oxygen through the nose to using an automated device that adjusts real-time to the person's breathing patterns. They often involve the use of a mask, which limits the comfort and thus the compliance of usage. That being said, for people who suffer from severe apnea, the use of these devices can be profound.
Prescription medications for chronic insomnia are generally matched to the underlying cause of the sleep disorder. From hormonally related insomnia, often times bioidentical hormones are prescribed. For insomnia related to anxiety, benzodiazepines, anti-depressants, and barbiturates are often used. For circadian related disorders, melatonin receptor agonist and dual orexin receptor antagonist are commonly prescribed. Gabapentin is being used for Restless Leg Syndrome.
For intractable insomnia, GABA Receptor Agonists like Lunesta, Ambien, and Sonata are used. These drugs have a particularly interesting side effect profile which includes increased rates of parasomnia and disruptions to REM sleep. Thus, these drugs affect sleep quality by altering the natural progression of sleep stages. They can also be highly addictive and difficult for patients to quit.
There is a long list of supplements and over-the-counter sleep aids: L-theanine, GABA, melatonin, magnesium, anti-histamines, etc. While these can work great, they should not be relied on independent of larger sleep strategy. There are no quick fixes for chronic problems.
Sleep in Chinese Medicine
As a time of rest and restoration, sleep is categorized in Chinese Medicine (CM) as being primarily yin in nature. Nighttime is when the energy of yin is at its highest, and ideally the mind and body are ready to slow down and enter into the calm of sleep. If a person has a deficiency of yin or, its child, blood, then sleep will be difficult. Yin and blood deficiencies are more common in older patients, peri-menopausal women, and anyone who is undergoing chronic illness or stress. Being unable to get quality sleep creates a vicious cycle in these groups, because they can never seem to get ahead.
Heat is another source of insomnia in CM. Heat is created when yin and blood are deficient, but also can be caused by pathogenic factors like acute infections and fever, as well as excessive qi and blood stagnation. Stress, lack of physical activity, and poor diet can all lead to stagnation. Disturbance of the shen (spirit/mind) can also result in bad sleep. Shen disturbance is typically anything that is psychological in nature like mania, bipolar, depression, anxiety, etc.
Common treatment strategies for improving sleep revolve around clearing heat, moving stagnation, tonifying yin and blood, and/or calming the shen. A combination of acupuncture, herbs, diet, and lifestyle intervention is often necessary to correct sleep issues. Chinese Medicine, when applied appropriately, is a powerful tool for correcting even the hardest patterns of dysfunction.
Conclusion
To re-echo the introduction, sleep is the most important activity that we undergo each and every day. It sets the foundation for functioning well during the day and without it we would die. While the collective consciousness is shifting to embrace more care to be taken towards sleep, we are still far from having a healthy sleeping population in this nation, especially when you consider the number of medically diagnosed cases of insomnia.
Bridging the gap between Eastern concepts and Western diagnoses like sleep apnea and chronic insomnia, involves a holistic approach. There is typically an ample amount of low-hanging fruit to be seized upon. Improvements in diet, weight loss, and exercise regimen, reduction of drug, caffeine, and alcohol use, stress management, sleep hygiene, and restoring circadian rhythmicity can all increase the quantity and quality of sleep. Teaming up with a healthcare provider to help address sleep issues can be incredibly beneficial in getting the rest that you deserve. For more information please reach out to our clinic.
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