When it comes to your sleep, answer these four questions:

1. Do I have trouble falling asleep?
2. Do I have trouble staying asleep?
3. Do I feel rested when I awake?
4. Do I fall asleep easily during the day (when I shouldn’t)?

If your answers are yes to 1 and 2 and no to 3 and 4 - you do not have a sleep issue.

You may be able to improve your sleep quality by falling the recommendations in 'How to Improve Your Sleep'…but feel fortunate and turn your efforts to one of the other pillars.

You will notice that none of the questions here talk of time asleep or amount of deep sleep, REM, or any of the sleep scores you can derive from the variety of sleep trackers.

If you sleep soundly and full of energy, you do not need to track your sleep.

Even if you track your sleep - your answer to these questions is more important than any metric derived from a sleep tracker.

If your answers are not optimal, you will want to improve your sleep habits while assessing yourself for sleep apnea or other sleep disorders.

Use the Wellness Garage Sleep Checklist to assess your Sleep Hygiene and screen yourself for Sleep Apnea.

Aligning our behaviours to our body’s hormonal symphony is relatively straight-forward:  

First, avoid substances that will alter hormones and affect your sleep:

• Alcohol – As a general rule, you should stop all drinking when you aren’t sleeping well. Once your sleep is restful again, you can resume light (one drink per day) alcohol intake.
• Caffeine – if you aren’t sleeping, stop all caffeine. Once your sleep has been restored, it’s OK to have some caffeine but stop after 12 p.m.
• Some medications – check with your doctor whether any of your medications/supplements (or the time you take them) could be affecting your sleep.

Next, optimize your daytime activities:

• Be active during the day as this will drive up adenosine, telling your body it needs rest.
• Get some exercise, but finish at least three hours before bedtime.
• Eat more during the day, avoiding heavy meals late in the evening. Don’t eat anything within two hours of bedtime.
• Get some natural light during the day and avoid bright lights in the evening.

Next, optimize your environment for sleep:

• Keep your bedroom dark – blackout curtains, eyeshades.
• Keep your bedroom quiet – “white noise” can help – humidifiers, fans or “white noise machines.”
• Keep your bedroom cool.
• Create a comfortable sleep environment – invest in your bed, your sheets, your pillow.
• Keep your electronics out of the bedroom.
• Your bed is only for sleeping (once you have re-established your sleep, you can try reading in bed again).

Finally, optimize your sleep ritual:

• Two hours before bedtime, shut down the screens – TVs, computers and phones. The blue light from these devices will suppress your body’s release of melatonin, and the content (especially the news) will often get your mind racing.
• Sixty minutes before your bedtime, begin a process to relax – reading, light yoga, meditation followed by a sauna or hot bath. This ritual will help you wind down from the day, quiet your mind and set your body up for a great sleep.
• Have fun with this – your sleep ritual should be a joy. Think of the rituals we create for our children – playtime after dinner, followed by a bath, a good read in bed and a loving tuck-in. We should all treat ourselves to such a nightly send-off.

Most often, adopting this framework is all it takes to restore sleep.

What do you do if this doesn’t work?

If you have 

• Eliminated substances that harm your sleep
• Optimized your daytime activities
• Optimized your sleep environment, and
• Optimize your sleep ritual

...and you still cannot sleep - it is time for…

Sleep Restructuring

• Go to bed at the same time every night.
• Get up at the same time every morning
• Since you are having trouble sleeping – do not nap.
• Plan for a set amount of sleeping:
• Calculate the total amount you are currently sleeping (albeit broken) and use this to set your new sleep hours.
• So if you are sleeping six hours in a broken fashion, set your wake-up time precisely six hours after the time that you go to bed.
• Then go to bed and wake up at the set times – no exceptions – even if you have had three hours of sleep, you need to get up and start your day. You will be tired during the day but resist all urges to nap; come bedtime, that fatigue will help you get to sleep.
• Once you sleep soundly through that six hours, add 15 minutes to your sleep (go to bed 15 minutes earlier or set the alarm for 15 minutes later).
• When you find that you are sleeping through the night and waking refreshed, your sleep has been restructured. Generally, the total amount of sleep needed will be between seven and eight hours per night. Resist the urge to stay in bed longer than the sleep you require, as this morning-time slumber may result in your sleep deteriorating again.

This is the second part of our SLEEEPSounder series.  Check out these other posts:

• The Importance of Sleep

At Wellness Garage, we are here to support you in your health journey to take control of your health, restore confidence, and optimize your wellness.  We do this through solid evidence-based medicine, personal health coaching and instruction, providing you with the knowledge, skills and support you need to apply healthy habits to your life.

Learn more about how Wellness Garage can help you take control of your health.

(Part of our January series on S3 Weight Management - Systematic, Stratified and Sustainable)
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There are multiple lines of evidence to support that getting a good night's sleep is important in order to be able to lose weight.

From an evolutionary perspective sleep and energy management are intricately linked.

Poor sleep dramatically alters the way the body responds to food.

When you do not get adequate sleep, your hunger hormones send signals to your brain to eat more.

• Ghrelin - a hormone released from the stomach signals that you are hungry, and levels drop off when you are full.  One study showed that those did not get enough sleep had 15% higher ghrelin levels than those that slept more than 7 hrs per night.
• Leptin - is a hormone released from fat cells to suppress hunger and appetite.  The same study showed a 15% decline in leptin for those who were poor sleepers

As a result studies have shown that people who have inadequate sleep consume more calories.

Compounding this,  sleep deprived individuals have been shown to preferentially choose calorie dense foods rich in both fats and carbohydrates.

Inadequate sleep also increases the release of the stress hormone cortisol, which in turn signals the brain to increase appetite via the release of another hormone orexin.  High levels of cortisol may explain why sleep deprivation appears to lead to loss of muscle mass and increased abdominal (visceral) fat.

Independent of its effect on appetite, cortisol also counters the actions of insulin, leading to insulin resistance the result of which can be high levels of insulin.  Insulin is a storage hormone promoting the storage of prompt storage of glucose as glycogen and fats within adipose tissue. 

With high enough levels of insulin, fat will be quickly stored and lipolysis (the breakdown of fat for energy) will be suppressed, resulting in one-way storage in other words "a moment on the lips, forever on the hips"

This cortisol induced insulin resistance can be demonstrated in as little as one week of sleep deprivation.

Other studies have shown that a lack of sleep can

• decrease physical activity
• increased fatigue with physical activity
• decrease resting metabolic rate
• decreased ability to resist temptations

As a result of these effects it is not surprising that inadequate sleep is associated with weight gain.   

Large observational studies, like the Nurses Health Study, following 68,000 nurses, demonstrated that short sleep duration increased the likelihood of obesity by 15%.   Of course, observational research can show associations it cannot prove causation, however shorter term sleep deprivation studies also show weight gain.

The recent PREDIMED Plus study showed that lack of sleep affects weight loss during a trial of the Mediterranean Diet , as overweight people who did not sleep well lost less weight that those without sleep issues.

Finally, sleep apnea one of the most devastating sleep disorders is both associated with and  worsened by weight gain.  This sets up a vicious cycle where poor sleep can lead to weight gain, and potentially sleep apnea and sleep apnea in turn leads to further weight gain.

So we can see from this 

• Lack of sleep leads to powerful physiological changes which leads to weight gain
• Compounding this,  weight gain also leads to powerful physiological changes resulting in decreased sleep

The resulting vicious cycle can set up a progressive deterioration of sleep with a corresponding weight gain.

The key to reversing this cycle is to prioritize sleep​:

• avoid substances that will alter hormones and affect your sleep - alcohol, caffeine, some medications
• optimize your daytime activities - get outside and be active, but not too close to bedtime
• optimize your environment for sleep - dark, cool, quiet and comfortable (no electronics)
• optimize your sleep ritual - give yourself a 8-9 hour window to sleep, start your wind-down 60-90 min before bed

Along the way, pay close attention and investigate any warning signs:

• Restless sleep
• Awakening with choking, gasping, or smothering
• Morning headaches, dry mouth, or sore throat
• Waking up to urinate more than once per night 
• Feeling unrested and groggy in the morning - “brain fog”
• Fatigue, low energy, memory challenges with difficulty concentrating

For more on this,  see some of the previous blog posts on sleep

• Sleep Advice - for Seniors (or anyone for that matter)
• 22 Practical Steps For Better Sleep
• Sleep Apnea - What you need to know
• Sleep

For other posts in our foundational behaviours for weight managemetn series:

• S3 Weight Management - A systematic, stratified and sustainable approach
• Taking the First Step
• Eat Real Food
• Hydration without calories
• Go 12 hours a day without eating
• Get lots of fibre (from real foods)
• Get 150 minutes of exercise

On January 29th- we will launch a new group program - fully covered by MSP (for those with a BMI >30 or a BMI between 27 and 30 and a weight related diagnosis).

During the month of January - we will be posting about the foundational behaviours for sustainable weight management - stay tuned.
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If you would like to learn more about the S3 program and whether you are eligible please check out our Sustainable Weight Management program page.

What are the symptoms?
The main symptoms of OSA are 

• loud snoring,
• fatigue, and 
• daytime sleepiness. 

However, some people have no symptoms or may not recognize that they have symptoms.

Other symptoms may include one or more of the following:

• Restless sleep
• Awakening with choking, gasping, or smothering
• Morning headaches, dry mouth, or sore throat
• Waking up to urinate more than once per night 
• Feeling unrested and groggy in the morning - “brain fog”
• Fatigue, low energy, memory challenges with difficulty concentrating

Perhaps the best way to determine risk is the use of the STOP-BANG questionnaire which uses a series of questions and results of physical measurements to calculate the risk for sleep apnea in adults aged 18 and older.
Snoring – Do you snore loudly (loud enough to be heard through closed doors)?
Tired – Do you often feel tired, fatigued or sleepy during the daytime?
Observed – Has anyone observed you stop breathing or choking/gasping during your sleep?
Pressure – Do you have or are being treated for high blood pressure?
Body mass index (BMI) – Body mass index more than 35kg/m2?
Age – Age older than 50?
Neck circumference – Neck size 17 inches or larger for males or 16 inches or larger for females?
Gender – Male?
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Positive answers to the above questions are then used to determine risk:
Low risk – Yes to 0 to 2 questions
Intermediate risk – Yes to 3 to 4 questions
High risk – Yes to 5 to 8 questions

• OR yes to 2 or more of 4 STOP questions + male gender
• OR yes to 2 or more of 4 STOP questions + BMI > 35kg/m2
• OR yes to 2 or more of 4 STOP questions + neck circumference ≥ 17 inches for males or ≥ 16 inches for females

How common is it?
In 2017, 6.4% of Canadians self-reported a diagnosis of sleep apnea through the Canadian Health Measures Survey (CHMS) - this was more than double the rate reported in 2009.
In the US, using the broadest criteria is estimated that 20-30% of men and 10-15% of women have sleep apnea.   
In all likelihood, sleep apnea is under-diagnosed - using the STOP-BANG risk tool, the CHMS found that nearly one-third (30%) of Canadian adults were considered to be at intermediate or high risk for sleep apnea - 15% were high risk and 15% were moderate risk.

Rates are increasing along with the rates of obesity.

What are the risk factors?

• Age – sleep apnea is more common as you age
• Obesity - the link between excess weight and sleep apnea is well established. People who are overweight are more likely to have extra tissue in the back of their throat, which can fall down over the airway and block the flow of air into the lungs while they sleep.
• Male sex – men are twice as likely as women to have sleep apnea
• Having a large neck size (greater than 17” in men; 16” in women
• Drugs and/or Alcohol – increases the risk of sleep apnea as you may not awaken to open the airway
• Airway abnormalities - large tonsils, large tongue, deviated septum

What happens if it is left untreated?
The initial consequences of untreated sleep apnea are daytime sleepiness and difficulty concentrating results in increased errors and accidents.  People with severe sleep apnea are two to three times more likely to have a motor vehicle accident - this represents an impact on morbidity and mortality that is similar to the cardiovascular sequelae of OSA.

Over time untreated sleep apnea increase risk for cardiovascular disease, high blood pressure, abnormal heart rhythms, heart attack and stroke.

People with OSA have higher rates Insulin resistance and Type II Diabetes.  This association is partly manifested by the shared risk factor of obesity, but also appears to be independent.  In one study, patients with severe OSA had a 30% higher risk of diabetes even after controlling for age, obesity, pre-existing cardiovascular disease. 
The physiological mechanisms underlying this risk are likely related to the increase in oxidative stress caused by lack of oxygen as well as activation of the sympathetic nervous system (with the insulin resistance effects of adrenaline and cortisol).

For patients with existing metabolic syndrome - OSA is associated with poorer metabolic biomarkers: increased glucose, triglycerides, inflammatory markers, and overall increased cardiovascular risk.

Nonalcoholic fatty liver disease (NAFLD) - given the increased risk of metabolic syndrome with OSA and the shared risk factors between NAFLD and metabolic dysfunction -   OSA appears to contribute to the development and severity of nonalcoholic fatty liver disease (NAFLD), independent of shared risk factors such as obesity.

Mortality - Severe OSA increases the risk of death by 2-3 time independent of other risk factors - interestingly an increased risk of mortality does not appear to be present for untreated mild OSA.  What isn’t completely clear is how treatment of severe OSA affects the risk of mortality.

Diagnosis:
Once suspected due to witnessed apneic episodes, loud snoring, daytime sleepiness, resistant hypertension, or ineffective sleep - the next step is to get a sleep assessment.

The gold standard is the polysomnogram - done overnight in a sleep lab (and requiring a referral from your physician), it measures  breathing effort and airflow, blood oxygen level, heart rate and rhythm, duration of the various stages of sleep, body position, and movement of the arms/legs.

A more accessible alternative not requiring physician referral is a Level III sleep study - using portable devices that can be used at home.

Is it reversible?
This depends primarily on the underlying cause of the sleep apnea - if the primary cause is obesity then weight loss can improve symptoms and lead to a cure.  

Brain damage caused by severe sleep apnea is reversible.  A 2017 neuroimaging study is the first to show that white matter damage caused by severe obstructive sleep apnea can be reversed by continuous positive airway pressure therapy.

There is high quality evidence that in most adults positive airway pressure therapy reduces the frequency of respiratory events during sleep, decreases daytime sleepiness, improves systemic blood pressure (BP), lowers the risk of crashes, improves erectile dysfunction, and improves quality of life across a range of disease severities.

Unfortunately to date there have been no studies that have demonstrated that treatment improves mortality.

What are the treatments?

• Weight loss — Weight loss may be helpful for obese or overweight patients.
• Avoid alcohol and other sedatives — Alcohol can worsen sleepiness, potentially increasing the risk of accidents or injury. People with OSA are often counseled to drink little to no alcohol, even during the daytime. Similarly, people who take anti-anxiety medications or sedatives to sleep should speak with their healthcare provider about the safety of these medications.
• Stop Smoking
• Adjust sleep position — Adjusting sleep position to stay off the back may help improve sleep quality in people with sleep apnea, but this is difficult to maintain and is rarely an adequate solution.
• Continuous positive airway pressure (CPAP) — The most effective treatment for sleep apnea uses air pressure from a mechanical device to keep the upper airway open during sleep. A CPAP device (figure 3) uses an air-tight attachment to the nose, typically a mask, connected to a tube and a blower which generates the pressure [3]. Devices that fit comfortably into the nasal opening, rather than over the nose, are also available. CPAP should be used any time the person sleeps (day or night).  Continued follow up with a healthcare provider helps to ensure that the treatment is effective and comfortable. “The best CPAP device is the one you’re going to use.”
• Dental devices — A dental device, called an oral appliance or mandibular advancement device, can reposition the jaw (mandible), bringing the tongue and soft palate forward as well. This may relieve obstruction in some people [4].  This treatment is excellent for reducing snoring, although the effect on OSA is sometimes more limited [4]. As a result, dental devices are best used for mild cases of OSA when relief of snoring is the main goal. Failure to tolerate and accept CPAP is another indication for dental devices. While dental devices are not as effective as CPAP for OSA, some patients prefer a dental device to CPAP. Side effects of dental devices are generally minor but may include changes to the bite with prolonged use.
• Surgical treatment — Surgery is an alternative therapy for patients who cannot tolerate or do not improve with nonsurgical treatments such as CPAP or oral devices.  The most common surgical procedures for sleep apnea:
  • ​​Nasal surgery: Correction of nasal problems such as a deviated septum.
  • Uvulopalatopharyngoplasty (UPPP): A procedure that removes soft tissue on the back of the throat and palate, increasing the width of the airway at the opening of the throat. UPPP alone has limited success rates (less than 50 percent) and people can relapse
  • ​Mandibular maxillomandibular advancement surgery: Surgery to correct certain facial problems or throat obstructions that contribute to sleep apnea. MMA may have a higher success rate, particularly in people with abnormal jaw (maxilla and mandible) anatomy, but it is the most complicated procedure.

References:
https://www.uptodate.com/contents/sleep-apnea-in-adults-beyond-the-basics?search=sleep%20apnea&topicRef=7683&source=see_link
https://open.alberta.ca/publications/level-i-and-level-iii-sleep-studies
Canadian Thoracic Society Guidelines: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3070752/pdf/crj18025.pdf
American Academy of Sleep Science: http://jcsm.aasm.org/ViewAbstract.aspx?pid=31513

https://www.health.harvard.edu/blog/weight-loss-breathing-devices-still-best-for-treating-obstructive-sleep-apnea-201310026713

https://aasm.org/brain-damage-caused-by-severe-sleep-apnea-is-reversible/

https://www.webmd.com/sleep-disorders/sleep-apnea/sleep-apnea
STOP-Bang Questionnaire. Property of University Health Network, for further info: www.stopbang.ca modified from Chung F., et al. Anesthesiology. 2008. Vol. 108: 812-821; Chung F., et al. British Journal of Anaesthesia. 2012. Vol. 108:768-75; Chung F., et al. Obesity Surgery. 2013. Vol. 23: 2050-2057; Chung F., et al. Journal of Clinical Sleep Medicine. 2014.

(This post originally appeared in the Peace Arch News)

I am a 78-year-old woman and my husband died last year. I’m getting used to living alone and have wonderful friends and a very supportive family. My only problem is that I’m having trouble sleeping at night. I can’t seem to fall asleep and then I wake up a number of times during the night. I don’t want to take sleeping pills but wondered if there is anything else I can do to improve my sleeping.

I’m glad that you’re doing so well adjusting to living alone and I think I can help you with your sleep. You are very wise to avoid sleeping pills as they frequently cause more problems than they solve.
Your problem sleeping is shared by many; lack of sleep has become epidemic in our society and is increasingly common as we age. There are many causes for poor sleep, some of which need medical assessment, but mostly our ability to sleep well is within our control. Without knowing more about your physical and emotional health, here is a safe and proven framework for sleep. If you are not sleeping well after implementing this, a visit with your physician is warranted.

A good night’s sleep is all about optimizing your behaviours and environment to fit your body’s natural rhythm.