Sleep Disturbances and Weight Gain Examining the Evidence
Sleep Disturbances and Weight Gain: Examining the Evidence Eileen Chasens, DSN, RN Assistant Professor November 19, 2009
Obesity Trends* Among U. S. Adults BRFSS, 1990, 1998, 2007 (*BMI 30, or about 30 lbs. overweight for 5’ 4” person) 1998 1990 2007 No Data ≥ 30% <10% 10%– 14% 15%– 19% 20%– 24% 25%– 29% • BRFSS, Behavioral Risk Factor Surveillance System http: //www. cdc. gov/brfss/
Obesity in Children Enlarged Tonsil & Adenoids
A Good Night’s Sleep is when you…
A Bad Night’s Sleep is when you…
What is sleep? n State in which the individual is Unresponsive to the external environment n Is accompanied by stereotypical behavior n n Reversible n Basic need
Mean Hours of Sleep in Adults 7 to 8 hours recommended National Sleep Foundation, 2001 “Sleep in America” Poll of adults
Earth’s rotation on its axis is the fundamental orbital mechanism that underlies endogenous circadian rhythms.
Circadian “Pacemaker” Regulates Timing of Sleep and Wakefulness Output Rhythms Physiology Behavior Light Suprachiasmatic Nuclei (SCN)
Sleep/Wake Restorative Process Balances Sleep and Wakefulness Awake Load Borbely, A. (1982). Neurobiology, 1; 195 -204)
Reticular Activation System
Sleep-Promoting System
Normal Sleep Architecture
Changes in Sleep Architecture Associated with Aging
Normal Changes in Sleep With Age
EEG while Awake
EEG Sleep Stages Awake n Alpha waves (if eyes are closed) n Eyes moving together n High muscle tone
EEG Sleep Stages Stage 1 n Theta waves (3 -7 cycles second) n Rolling eye movements n High muscle tone
EEG Sleep Stages Stage 2 n Sleep spindles (1214 cycles/second) & K complexes n No distinctive eye movement n Lower muscle tone
EEG Sleep Stages 3 & 4 n Delta (slow) waves n n Stage 3: delta < half of epoch Stage 4: delta >half of epoch n No distinguishing eye movement n Low muscle tone
EEG Sleep Stages REM sleep n Fast waves n Rapid eye movements (phasic REM) n Absence of muscle tone
Assessment of Sleep Direct observation n Asking about sleep n Diaries n Use of a Sleep Questionnaire n Actigraphy n Sleep study n
Assessment: Ask your subjects“how’s your sleep? ” Check if any of the following apply: q Sleep less than 7 or more than 9 hours/night q Snore loudly q Stop breathing or gasp during sleep q Excessive daytime sleepiness or doze off q Difficulty 3 or more times a week with insomnia symptoms q Unpleasant feelings in legs when trying to sleep q Interruptions to sleep ü
Self-Report Measures n Sleep diary for bed time, wake time(s), n include daytime activities and meals/beverages
Instruments to Evaluate Sleep n Epworth Sleepiness Scale n n Pittsburgh Sleep Quality Index n n Johns MW (1991) Sleep, 14 (6), 540 -545) Buysse DJ et al. (1989) Psychiatry Res, 28, 193 -213 Functional Outcomes of Sleep Questionaire n . Weaver et al. (1997). Sleep: 835 -43
The Epworth Sleepiness Scale 1. Sitting and reading 2. Watching television 3. Sitting inactive in a public place, or example, a theater or meeting 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing 4. As a passenger in a car for an hour without a break 5. Lying down to rest in the afternoon 6. Sitting and talking to someone 7. Sitting quietly after lunch (when you’ve had no alcohol) 8. In a car, while stopped in traffic
Pittsburgh Sleep Quality Index Buysse DJ et al. (1989) Psychiatry Res, 28, 193 -213 19 items n Generates 7 "component" scores n Sum of scores from 7 components yields one Global Score. n Global PSQI >5 score distinguishes good and poor sleepers n http: //www. sleep. pitt. edu n
Functional Outcomes of Sleep Questionnaire 30 -item questionnaire developed to evaluate areas sensitive to sleep disruption n 5 Factor Design: n n n activity level, vigilance, intimacy and sexual relationships, general productivity, and social outcome areas Short FOSQ 10 -items
Body Movement Monitors Wrist Actigraphy
Actigraphy Examples
Physiological Measures n Polysomnography (PSG) n Multiple Sleep Latency Test (MSLT)
What are the links between sleep and obesity? . . . inadequate sleep duration because of lifestyle factors or insomnia? ? Obesity Insomnia Sleep Lifestyle Factors
INSUFFICENT SLEEP DURATION 2 nd to Lifestyle Factors n n n Caffeine, alcohol and nicotine Exercise, too close to bedtime Excessive naps Irregular sleep schedules Too many demands of daily life!
INSOMNIA What is it? n n Difficulty getting to sleep Difficulty staying asleep Awakening too early from sleep Hyper-vigilant at night/ Tired & fatigued during the day?
Insomnia n n n Transient - less than 2 weeks Chronic - continuing difficulty with sleep for at least 6 months Etiology: n Medical n Psychiatric n Pharmacologic n Primary Sleep Disorder n Genetic n Tobacco / Alcohol
Short Sleep Duration & BMI In the Wisconsin Sleep Cohort 33 32 Adjusted BMI (adj. for age, 31 gender) 30 (N=1, 024) 6 7 8 9 Average Nightly Sleep (Hrs. ) Taheri S, et al. PLo. S Med. 2004
Hrs. Slept / Day (incl. Naps) Abundant data indicates that we live in a sleep-restricted society Ancillary study of the CARDIA Study (n=668; age: 38 -50) Lauderdale DS, et al. Am. J. Epi. 2006
Percentage of adults with < 6 hrs sleep per night Guo, et al. (2002). American J. Clinical Nutrition: 76: 653 -8. )
Potential mechanisms where sleep loss is associated with weight gain Taherei, S. et al. (2006). Archives in diseases in Children: 81 881 -884)
Effects of Sleep Restriction (6 d) vs. Extension: Young, Healthy Men 3 h 48’ Sleep 9 h 03’ Sleep CHO Breakfast Glucose (mg/dl) Insulin (ml. U/L) HOMA (Io x Go/22. 5) (BMI: ~23) Spiegel K, et al. J. Clin. Endocr. Metab. 2004
Sleep Duration: Leptin, Ghrelin, Hunger and Appetite in Healthy Young Men After 2 days of 4 hrs. sleep After 2 days of 10 hrs. sleep Spiegel K, et. al. Ann. Int. Med. 2004
What are the links between sleep and obesity? . . . sleep fragmentation 2 o to Circadian Rhythm Disturbances Type 2 Diabetes Circadian Rhythm Disturbances Insomnia Sleep Lifestyle Factors
Shift Work Sleep Disorder Sleep disorder that affects people who frequently rotate shifts or work at night n The most common symptoms of SWSD are insomnia and excessive sleepiness. n Other symptoms of SWSD include: n n Difficulty concentrating Headaches Lack of energy
What are the consequences of SWSD? Increased accidents n Increased work-related errors n Increased sick leave n Increased irritability, mood problems, etc. n WEIGHT GAIN! n
Work-shift period and Weight Gain (Geliebter, A. (2000). Nutrition ) n n Survey about weight gain since starting shift work 85 Respondents, 36 on Days, 49 on Late shift
A longitudinal study on the effect of shift work on weight gain in male Japanese workers. Suwazono Y. (2008) Obesity: 18877 -1893.
What are the links between sleep and type 2 diabetes? . . . sleep fragmentation 2 o to Restless Leg Syndrome Type 2 Diabetes Restless Leg Syndrome Circadian Rhythm Disturbances Insomnia Sleep Lifestyle Factors
Restless Legs Syndrome & Sleep Fragmentation n n Unpleasant, creeping feeling in legs Irresistible urge to move Associated with other medical conditions Periodic Leg Movements during sleep require evaluation
Odds Ratio (OR, 95% CI) of RLS according to BMI from Nurses Health Study & Health Professionals Follow-Up Study Gao, X. et al. (2009) Neurology, 72: 1255 -61.
What are the links between sleep and obesity? . . . Obstructive Sleep Apnea Type 2 Diabetes OSA Restless Leg Syndrome Circadian Rhythm Disturbances Insomnia Sleep Lifestyle Factors
Obstructive Sleep Apnea Repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction during sleep n n This interruption in breathing can take place just a few times or up to hundreds of times over the course of a night n. Airflow cessations or reductions produce: Arousals n Fragmented sleep n Reductions in blood oxygen saturation n Fluctuations in blood pressure and heart rate n
Obstructive Sleep Apnea Anatomy of a blocked airway n. Possible obstruction sites The upper airway excess tissue, large tonsils, a large tongue, and usually includes the airway muscles relaxing and collapsing when asleep n The nasal passages n Structure of the jaw and airway can be a factor in sleep apnea n
Risk Factors for OSA n Risk Factors n Male gender n Increased age n Obesity n Recessed mandible n Comorbid Medical Conditions
Outcomes Associated with Untreated OSA n n n n Hypertension Stroke Heart Attack Atrial fibrillation Depression Functional Impairments Performance Impairments DIABETES n Increased Mortality n
Intermittent Hypoxia Induces Insulin Resistance in Obese Mice HOMA (mean ± SEM) Adapted from: Polotsky VY, et al. J. Physiol. 2003
Odds Ratio for Diabetes Mellitus & Impaired Glucose Tolerance By Self. Report Usual Sleep Time in Older Population {SHHS} (age: 53 -93 yrs. ) Adj. Odds Ratio (referent to 7 - 8 hrs. sleep) Adj. for: age, gender, race/ethnicity, AHI, waist circ. , field site Adapted from: Gottlieb DJ, et al. Arch. Int. Med. 2005
Sleep Duration & Relative Risk for Incident Diabetes: Massachusetts Male Aging Cohort Self-Report Hours of Sleep/Day <5 6 7 8 >8 2. 6 (1. 28– 5. 27) 1. 93 (1. 06– 3. 5) 1 1. 40 (0. 78 -2. 53) 3. 63 (1. 79– 7. 38) 1. 95 (0. 95– 4. 01) 1. 95 (1. 06– 3. 58) 1 1. 41 (0. 78 -2. 55) 3. 12 (1. 53– 6. 37) Age-adj. relative risk Multivariate model * *Adjusted for 10 -year age-group, hypertension, current smoking, self-rated health status, waist circumference, education (all covariates measured at baseline). Yaggi HK, et al. Diab. Care 2006
Sleep Duration & Relative Risk for Incident DM: Nurse’s Health Study Hours of sleep per day 5 6 7 8 9+ 122 576 731 422 118 Ageadjusted relative risk 1. 57 (1. 28– 1. 92) 1. 27 (1. 12– 1. 44) 0. 98 (0. 87– 1. 11) 1 1. 47 (1. 19– 1. 80) Multivar. model incl BMI * 1. 18 (0. 96– 1. 44) 1. 10 (0. 97– 1. 25) 1. 02 (0. 91– 1. 16) 1 1. 29 (1. 05– 1. 59) n *Adj. : shift work, hypercholesterolemia, HTN, smoking, snoring, exercise, alcohol, depression, postmenopausal hormone, Ayas NT, et al. Diab. Care 2002 family hx diabetes
OSA Associated with DM in Hypertensive Men OSA Obese OSA Non-Obese Prevalence Of Diabetes N=2, 668; Obese = BMI >27; OSA = AHI >20 Non-OSA Obese Non-OSA Non-Obese Elmasry A, et al. , J. Int. Med 2001
What is the evidence that sleep disturbances are associated with type 2 diabetes? Sleep AHEAD study recruited from Look AHEAD n Exclusion criteria for Sleep AHEAD were previous treatment for OSA. n Efforts were made to enroll individuals with undiagnosed OSA using a symptom questionnaire n Because almost all of the first 80 participants had OSA upon PSG, the symptom screen was dropped n
Data from Sleep AHEAD Study (N=305) Foster et al. (2009). Diabetes Care, 1017 -1 -19.
Conclusions from Sleep AHEAD n n Exceedingly high prevalence of undiagnosed OSA among obese patients with type 2 diabetes Unequivocally high prevalence of moderate-tosevere OSA Results do not appear to be secondary to a selection bias Possibility that some of the morbidity and mortality associated with type 2 diabetes may be attributable to undiagnosed OSA? !
Obstructive Sleep Apnea Prevalence n. At least 15– 18 million with OSA 1 in 5 adults has at least mild OSA n 1 in 15 adults has at least moderate OSA n n 80– 90% OSA cases undiagnosed Doctors usually can't detect the condition during routine office visits n No blood tests for the condition n
Treatment Options Mild OSA n Losing weight n n Positional therapy Avoidance of central nervous system (CNS) depressants n Oral mouth devices (keep the airway open) n Can bring the jaw forward, elevate the soft palate, and retain the tongue (from falling back in the airway and blocking breathing) n Possibly requires continuous positive airway pressure (CPAP) Moderate to severe OSA n First-line treatment for the underlying obstruction is typically continuous positive airway pressure (CPAP) n Surgery of the airway may be required in certain cases
Obstructive Sleep Apnea Overview Normal Airway CPAP Airway 69
Treatment of Sleep Apnea n CPAP (Continuous Positive Airway Pressure) n n Need for increased adherence to all night/every night Need to bring to hospital if admitted, especially if surgical patient
CPAP only works if it is worn all night, every night. OSA: Residual Sleepiness and Functional Impairment With CPAP with suboptimal use* After Three Months of CPAP Treatment* 70 65% Patients With ES (%) 60 50 40 34% 30 20 10 0 Patients With Impairment (%) 70 60 50 43% 40 30 20 10 0 Objective Sleepiness (MSLT <7. 5) n=85 Subjective Sleepiness (ESS >10) n=106 Functional Impairment (FOSQ <17. 9) n=120 *Average CPAP use over 3 months was 4. 7 hours per night, which is consistent with other studies of CPAP adherence. Data presented as mean. 29. Weaver TE. Sleep. 2007; 30: 711 -719.
Hours of CPAP use and Outcomes on FOSQ, ESS, and MSLT Weaver et al. (2007) Sleep. 30: 711 -719.
CPAP Treatment & Glucose Control 83 +/- 50 days p = 0. 02 p = 0. 06 (N=25/ 17 with A 1 c>7%) Babu AR, et al. Arch. Intern. Med. 2005
Adherence to CPAP Determines its Efficacy Patients Using PAP Avg. >4 Hrs. /Day Patients Using PAP Avg. <4 Hrs. /Day Babu AR, et al. Arch. Intern. Med. 2005
CPAP Therapy Improves Insulin Sensitivity p = 0. 001 p = 0. 003 (No BMI) Not a RCT (n = 13) (n = 18) Harsch IA, et al. AJRCCM 2004
Vigilance and Sleep Restriction Van Dongen H. , et al: . Sleep 2003; 26: 117126. )
Cognitive abilities and mood are affected by sleep deprivation. n n Memory is impaired when sleep is not consolidated Paying attention to and completing tasks is compromised Mood is impaired Over ½ of adults report that sleepiness makes it hard to concentrate, solve problems and make decisions at work
Diabetes and Depression Research linking depression and diabetes is compelling n Bi-directional association between sleep disorders and depression n Results in people having a difficult time following a diabetes treatment plan, which in turn places them at risk for otherwise avoidable complications of diabetes n
Symptom of depression, of a sleep disorder, or of both?
Incidence of Clinical Depression with Insomnia Chang, P. , et al. (1997). Am J. Epidemiol; 146: 105 -114)
The Experience Of Being Sleepy While Managing Type 2 Diabetes. n n Sleepiness described as a burden that one must force oneself to combat Difficulty in going beyond the minimum required to manage one’s life A lack of structure exacerbates difficulties Expressed feeling lazy, crazy and misunderstood because of chronic sleepiness Chasens ER, Olshansky E. JAPNA (2006); 12(5): 272 -8.
Summary n Sleep is a physiological necessity. n Sleep disruption is due to either n n Insufficient sleep and lifestyle issues, or Fragmented sleep and health problems Primary sleep disorders such as OSA, RLS, or insomnia Sleep loss can have serious physical, personal and social consequences.
Is sleep important for improving health outcomes in persons at risk for weight gain or who are overweight or obese, you be the judge!
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