Simple habits can establish restful, refreshing sleep       

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Do you have trouble falling asleep? Staying asleep? Feeling rested when you awaken? My guest, Dr. Ioana Amzuta, is an associate professor of medicine specializing in sleep medicine, and she's here to help us get a good night's sleep.

Welcome to "The Informed Patient," Dr. Amzuta.

Ioana Amzuta, MD: Thank you for having me.

Host Amber Smith: I'd like to first ask you why sleep is important. Why do we need to sleep?

Ioana Amzuta, MD: The brain is a highly metabolic organ. In other words, it consumes a lot of our calories, about 20% of what we eat. Our calories are consumed by brain functioning while the brain is awake.

So you can imagine that (with) this very high metabolic rate, there are going to be some byproducts of this very intense metabolism. And one of them is adenosine, a substance that actually helps us fall asleep. So the sleep is necessary to get rid of all the byproducts of the brain metabolism.

But not only that, there are other, more complex functions of the sleep, and I may add that sleep is not a passive mechanism. It's not like the lights are out, and that's it, we fall asleep. The brain is actually actively shutting down some areas and opening up other areas of functioning in order to promote sleep.

And as I said, one of the main functions of sleep is to get rid of the byproducts of the metabolism, especially the adenosine, but also during sleep is when we consolidate memory that we accumulated during the day. We consolidate skills that we learned during the day, such as learning to play the piano or learning to ski or learning a new procedure, for us in the medical field.

Also, during sleep, there is a period of rest for the cardiovascular system, which is very important for the cardiovascular health.

A lack of sleep has a huge impact, not only on how you feel the next day, your ability to stay awake and focus on different tasks, but also on your cardiovascular health, on your immunity, which may be depressed by a lack of sleep. And, unfortunately, we are seeing an increase in the incidence of malignancies with chronic lack of sleep, suggesting that there is, again, something at the immune system level that is not working the way it's supposed to when we are sleep deprived.

Host Amber Smith: So how do we know how many hours of sleep our body needs to do all of that? Those are some important tasks that have to be done every night, it sounds like.

Ioana Amzuta, MD: So we know that for adults, seven to nine hours of sleep are necessary to ensure not only brain health, but cardiovascular health and a strong immune system.

And unfortunately, in the last 10, 15 years, we are dealing not only here in United States, but globally, with an increase in the lack of sleep, so much so that the World Health Organization declared an emergency regarding sleep disorders and especially lack of sleep. Worldwide, apparently 60% of the adults are not getting enough sleep. This is a huge number and with huge social and health implications.

Host Amber Smith: Well, I used the word "night" when I was talking about sleep, but I wonder, does it have to take place at night, or can you get your sleep between 10 p.m. and 6 a.m.?: Is that the same as between 1 a.m. and 9 a.m.?

Does it matter when you're sleeping?

Ioana Amzuta, MD: Well, it all depends on what your chronotype is. In other words, are you an early riser, or are you a night owl? And nowadays there are tools available on the internet where you can determine what type of chronotype you are. And this is very strongly determined geneticially, so not too much that you can do to change that. You are either an early riser or a night owl.

Unfortunately, because of the way the society is structured, the night owls are kind of being punished for their chronotype, because they are forced to go to sleep earlier and wake up earlier than they should. And this has a significant impact on their overall health, because the quality of their sleep is not going to be what it's supposed to be. As an example, if you are someone whose chronotype is such that you would sleep the best going (to bed) at midnight and waking up 8 o'clock in the morning, but you are forced to wake up at 6 o'clock because of your job, you can think that you lost only two hours of sleep, right?

But in fact, you are losing about 60% of your REM (rapid eye movement) sleep. This is the type of sleep where we consolidate most of the memories. And so you are going to be profoundly affected by that lack of sleep in the early morning hours.

So, to answer more concisely to your question, it does matter when you go to sleep, and that's determined by your chronotype.

Host Amber Smith: But the people that chronically are getting, say, six hours of sleep, they're not getting the recommended seven to nine, I guess they're the people that the World Health Organization is concerned about.

Ioana Amzuta, MD: Yes. Yes, and for good reasons, because there were multiple studies showing that sleeping less than seven hours a night is associated with 20% increase in cardiovascular disease, tripling your chance of developing metabolic syndrome, so gaining weight and having high glucose levels, hypertension, and again, there is an increase in the rate of malignancies, once you go below seven hours of sleep.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and my guest is Dr. Ioana Amzuta. She specializes in sleep medicine at Upstate.

So how do you take care of someone who comes to you saying that they're having trouble sleeping?

Ioana Amzuta, MD: First you want to get a very good history of what's happening with that person. Are they not sleeping well because their chronotype does not align with their work schedule? Is this a person who is working shifts and has a hard time going back to a regular sleep schedule in between the night shifts?

Is that someone who is traveling a lot and is affected by jet lag? Is this a person who is not sleeping well because they spent a lot of hours, just before going to bed, checking their mail, checking their social media, being exposed to the blue light from either the phone or a computer or a laptop?

Is this someone who has a drinking problem, and they drink alcohol heavily in the evening hours, and then they cannot have a good quality sleep because of their alcohol consumption? Is that someone who is drinking a lot of coffee until the late evening hours, and again, the sleep is affected by that?

And of course, we are always concerned about the possibility of obstructive sleep apnea, because with the obesity epidemic that we are seeing, obstructive sleep apnea is also a big concern.

Host Amber Smith: At what point would you ever consider a sleep study?

Ioana Amzuta, MD: We do a sleep study when we are concerned that someone may have obstructive sleep apnea.

And in that case, again, we are taking a very detailed history if that person has snoring, has apneic events, meaning that they stop breathing while they are asleep, and usually their bed partners are going to tell them that this is what is happening.

So then we are going to consider doing a sleep study to see if that person has obstructive sleep apnea. And we can do that as a sleep study in our sleep lab, or we can do it as a home sleep study.

Then we do sleep studies for people where we think that they may have a different type of sleep disorder, such as parasomnia, someone who is sleepwalking, for example, or someone who has a disorder related to the REM sleep, such as REM behavior disorder, where people are enacting their dreams. This is a very dramatic disorder.

Host Amber Smith: Let me ask you, is someone who has trouble falling asleep the same as someone who has trouble staying asleep?

Ioana Amzuta, MD: Not really. We used to categorize insomnia into sleep-onset insomnia and sleep-maintenance insomnia. In the last couple of years, the American Academy of Sleep Medicine kind of put everything under the umbrella of insomnia, and again, a very detailed history is necessary, and most of the time will tell you what is keeping awake that person.

I am seeing, at least in my practice, and I think this is pretty much everywhere, that people are excessively using their electronic devices. And that's the reason they cannot fall asleep.

And even if they fall asleep, with their phone in their hand or the laptop on their lap, they find themselves waking up in the middle of the night. And the reason for that is because they're exposed to this blue light that is resetting our circadian rhythm. In other words, our circadian center is fooled by the blue light into thinking that this is daytime. So it's stopping the production of melatonin, which is the trigger for starting sleep.

Host Amber Smith: Do you ever recommend sleeping pills to help someone get to sleep?

Ioana Amzuta, MD: No, and for good reasons. The FDA (Food and Drug Administration) actually approved the hypnotic medications only for short-term treatment, meaning under a month of acute insomnia, so something that has a duration of less than three months.

For the rest of the people, the treatment that is working is cognitive behavior therapy, and it takes time; it's basically retraining yourself to have better sleep hygiene: getting rid of all the distractions, getting rid of drinking coffee later in the evening, or any other caffeinated drinks, reducing the amount of alcohol and, even better, not having any alcoholic drinks in the evening hours, keeping the room at a low temperature, keeping the room quiet.

And again, a big, big part of this is allowing yourself enough sleep time, so don't just go to bed at midnight if you know that you have to wake up at 6 o'clock in the morning. Allow yourself a time in bed of eight hours. And not in bed watching movies or checking social media, but actually sleeping and resting.

Host Amber Smith: Now, what about supplements, or over-the-counter products like melatonin? Do you ever see a reason for people to take those? Do they work?

Ioana Amzuta, MD: First of all, here in United States, none of the melatonin products are FDA approved. As a result of that, they go under nutritional supplements, and so the dose of melatonin in this product is not checked, so you don't know for sure even if you are getting any melatonin in the supplement.

In Europe, the doses are standardized, and they are considered a medication, so they are checked. They ensure that you have a certain number of milligrams in the melatonin supplements.

The only reason to take melatonin would be for jet lag. Why is that? Because the melatonin is actually not helping you stay asleep. The melatonin is just a trigger for sleep. So, if you can imagine a race, the melatonin is the person who shoots the gun in the beginning of the race, that's all. It's giving a signal that the race has started, but it's not helping you stay asleep during the night.

Now, in order for people to have a healthy dose of melatonin before they go to bed, they have to be exposed to natural light in the early morning hours. And this is a signal for the brain that you have to start producing the substance, the melatonin, which will reach a peak around 9 to 10 p.m. for most of us. And again, if you travel somewhere and you have jet lag, melatonin is helpful, because it's kind of resetting this circadian rhythm along with other things, such as the light exposure, and the time of the meals, which is another very good timekeeper -- zeitgeber (time cue) -- for your circadian clock.

But other than this, melatonin is not really helpful to give you a good night's sleep.

Host Amber Smith: Well, I wanted to ask you about some things people can do to optimize their chances of getting a good night's sleep. You've already talked about a lot of them, about avoiding the caffeine, avoiding alcohol. Does a bath or a shower before bed help your body realize that it's time to sleep?

Ioana Amzuta, MD: Yes, definitely. And the reason for that is because just before going to sleep, there is a drop in the internal body temperature, OK? And that's a signal for your brain that this is the time to go to sleep. This is something that is controlled by your circadian rhythm.

You can trick your body into thinking that this is the time to go to sleep by taking a hot bath. Now you are going to say, how come, because this is hot and you are telling me the body temperature has to drop.

But when you take a hot bath, what happens is that you have vessel dilation. So you are going to see how your skin is becoming red. That's because the vessels are dilating, and so when that happens, you are going to lose a lot of heat through all these dilated vessels, not during the bath itself, but immediately after that. And you can do that also with a prolonged shower, or you can use a sauna just before going to bed. It will create the same effect.

So this vessel dilation that will help your body get rid of some of the internal heat, that will drop your core body temperature, and it'll transition you very nicely to sleep.

Host Amber Smith: What about the temperature of the air in the room? What should that be set at?

Ioana Amzuta, MD: So there were studies looking into this, and it looks like the ideal temperature should be around 65 degrees.

Now, of course, different people have different levels of comfort. For me, 65 is far too cold. My level of comfort is probably around 75, not 65, but keep in mind that you have to keep your room on the colder side.

And again, 65 looks like it's the magic number.

Host Amber Smith: Is it better to sleep in the dark, or does that matter?

Ioana Amzuta, MD: That matters very much, and it matters, again, to create a more robust circadian rhythm. You need that darkness at nighttime and the light exposure in the morning to have robust production of melatonin.

And so I recommend blinds or blackout curtains; especially if you are someone who is working shifts, and you have to achieve your sleep during the day, that becomes extremely important.

Host Amber Smith: If you work out or exercise right before bed, will that help you tire yourself out so that you'll sleep better?

Ioana Amzuta, MD: You shouldn't exercise just before going to bed, and the reason for that is because the exercise is going to increase your internal body temperature. And this goes against what we were talking about before, that your body has to cool down before going to bed. But exercise is an extremely important way of getting a good night's sleep, so if you are exercising, try to stop exercising about two hours before going to sleep. And keep in mind that 30 minutes minimum of aerobic exercise daily will ensure a very good quality sleep.

Now there were people looking into what kind of aerobic exercise is better. Is running better than cycling, for example, and it looks like yes, there is a little bit better evidence for cycling, for spinning, for creating that good quality night's sleep.

Now, why that is, we don't know, and the difference is not huge, so whatever type of aerobic exercise, meaning that you have to increase your heart rate. And exercise for 30 minutes at the rate where you are sweating, and you are not able to utter more than two, three words at a time. It's extremely important to have a good night's sleep.

Host Amber Smith: Is reading a good way to wind down?

Ioana Amzuta, MD: Reading is a very good way of relaxing. But keep in mind that if you have a very bright light by your bed, so you can read, maybe that's not a good idea.

I truly encourage patients to keep the bed and the bedroom just for sleep. In other words, if you want to read in a different room, try to kind of wind down for the nighttime, definitely do it.

But then when you go to bed, try to keep the bed only for sleep.

Host Amber Smith: Now, some people like to read their books on a tablet that's backlit with that blue light ...

Ioana Amzuta, MD: Uh-huh.

Host Amber Smith: ... that you've already told us about. Is that not recommended in the evening?

Ioana Amzuta, MD: Fortunately, there are settings nowadays on the tablets, where you can adjust the light. You can put a black and gray scale on the tablet that will minimize the exposure to light, and a lot of them have specific nighttime settings.

Host Amber Smith: Now, how do you feel about if someone is struggling to get a good night's sleep, and they're feeling tired during the day? How do you feel about naps?

Ioana Amzuta, MD: What will happen if you take a nap during the day? Remember we were talking about that byproduct, adenosine, that builds up in the brain as we are staying awake. If you take a nap, some of that byproduct, the adenosine, is going to be reduced. So by the time you go to bed in the night, you are not going to have such a powerful drive to fall asleep and stay asleep.

For most people, I would say avoid naps during the day. There are some professions where you kind of have to tell people to take a short nap. I'm talking about airplane pilots, long-distance drivers, physicians, nurses, where they don't have a choice, they have to work at different hours during the day, and they may become so sleepy that they cannot function. In that case, yes, you have to take a nap. I am telling everybody to try to limit the nap to about 30 minutes to avoid that post-nap drowsiness.

There was an interesting study done a couple of years ago, at UC (University of California)-Berkeley, where actually they did something called an "espresso nap." In other words, you have a shot of espresso, and then you take a nap, and when you wake up from that nap, you have enough time to absorb the caffeine, so you feel refreshed, both because of the caffeine and because you took that short nap. Again, not something that I would recommend for, usual circumstances. This is mostly for people who have to work shifts or have to work long hours, and they need to be awake and alert, for their job.

Host Amber Smith: Do you have any special advice for teenagers, who seem to need a lot more sleep during the teen years and are forced to get up early to go to school? Some of them are the night owls that wish they could stay up later and sleep later, but they can't because of school. Do you have any advice for them?

Ioana Amzuta, MD: I would have advice for the school system, not for the teenagers, because what is happening to them is very natural.

During the teenage years, there is a delay in your circadian rhythm. In other words, you are forced to fall asleep later during the night and sleep later during the day. This is physiological. It happens to all the teenagers. And this is extremely important for the brain to mature.

During this time, they have the highest concentration of REM sleep as well. And there were beautifully designed studies that showed that limiting the REM sleep during the teenage years by waking them up early in the morning is leading to depression, to personality disorders, to problems with attention during the day and concentration.

So, if anything, I would advocate for the schools to have later start times for the teenagers because it's really horrible what we are doing to them by waking them up so early in the morning, especially for the teenagers that are involved with sports.

Host Amber Smith: Any special advice for seniors who develop sleeping difficulties as they age?

Ioana Amzuta, MD: For seniors, it is very important to get light exposure during the day. This will ensure that you have a healthy melatonin production. And again, exercise is the best cure for having problems sleeping, so maintaining a healthy level of exercise, 30 minutes of aerobic exercise five times a week, and in addition to that, some weight training, twice a week. That was proven to have amazing health benefits and improve the quality of sleep.

Host Amber Smith: Well, Dr. Amzuta, thank you so much for making time for this interview. I appreciate it.

Ioana Amzuta, MD: My pleasure.

Host Amber Smith: My guest has been Dr. Ioana Amzuta. She specializes in sleep medicine, and she's an associate professor of medicine at Upstate.

The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

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