“Put my head under my pillow, and let the quiet put things where they are supposed to be.”
– Stephen Chbosky
Sleep. It’s such an elegant, yet heavy word. It’s something we crave—almost in a whimsical manner, especially when it eludes—leaving us feeling burdened, bogged-down, entrenched. It is viewed as both a necessity and an extravagance, an essential, biological process and a burden.
When patients do not sleep enough, or deeply enough, this dysfunction can affect their blood pressure, heart rate, mental status, hormones, and immune system,1 and sleep deprivation is known to induce oxidative stress.2 Adults who are short sleepers (less than seven hours) are more likely to report 10 chronic health conditions, including depression, arthritis, diabetes, and asthma.3
What’s more, the shorter the sleep, the shorter the life. In rats, sleep deprivation ultimately leads to death.4 Recent findings suggest that individuals who sleep for less than six hours a night have a 12% increased risk of dying prematurely, relative to those getting six to eight hours a night.5 Over one-third of the US population sleeps less than the recommended seven hours a night,6 and the number of people who report being sleep-deprived has significantly increased over the past few decades. In fact, the National Sleep Foundation’s annual survey found that only 10% of American adults prioritize their sleep over other aspects of daily living such as fitness/nutrition, work, social life, and hobbies/personal interests.7
In recent years, new research has underscored just how important sleep is, and how harmful a lack of sleep can be. A fascinating study in 2018 suggests that sleep loss may causally trigger anxiety, and conversely, sleep may be a novel therapeutic target for the amelioration of anxiety.8 Researchers looked at one night’s loss of sleep on anxiety and emotional regulation in 18 healthy young people. After a night of sleep deprivation, participants reported a 30% rise in anxiety levels compared to how they felt the night prior. People who were allowed a full night’s sleep did not experience anxiety. Brain scans showed that sleep deprivation resulted in amplified reactivity within the amygdala and dorsal anterior cingulate (the brain centers of fear and anxiety), yet marked hypoactivity in the medial prefrontal cortex (emotional reactivity). This suggests that sleep may also help to regulate emotions.8
Sleep can be an emotional topic for many patients. Balancing a life full of work and family dynamics with healthy eating, exercise, and self-care is challenging enough for many, without the added effort of good sleep hygiene. Excessive daytime sleepiness is one of the leading reasons that patients present to sleep clinics.9 As a Functional Medicine clinician, how do you talk to your patients about sleep and give them tools to improve this important lifestyle factor? In the following video, IFM educator Shilpa P. Saxena, MD , offers some tips:
Clinicians themselves need to be cognizant of their sleep balance, especially those who do shift work, as observational studies have highlighted the detrimental health effects of shift work.2 In 2019, a group of researchers evaluated the effects of acute sleep deprivation in clinicians by looking at DNA damage.2 Doctors who had just one night of sleep loss had more breaks in their DNA compared to rested participants. The authors suggest that these molecular changes may help explain why sleep deprivation is also linked to increased risk for cancer, metabolic syndrome,2 and the development of Alzheimer’s disease.10
Relax Into Sleep
“You’re always in a rush, or else you’re too exhausted to have a proper conversation. Soon enough, the long hours, the traveling, the broken sleep have all crept into your being and become part of you, so everyone can see it, in your posture, your gaze, the way you move and talk.” – Kazuo Ishiguro
Any insomniac who has heard the phrase “You need to get more sleep” understands just how frustrating that statement can be. Most people don’t want to go through life half-awake, numb, and burdened by a persistent heaviness of mind and mood. In some cases, it’s a choice—other priorities take precedence—while in other cases, sleep can seem difficult despite our best efforts.
Whatever the reason, people suffering from lack of sleep are often encouraged to engage in nonpharmacological activities that relax the mind and body—from biofeedback to meditation and yoga. But relaxing isn’t sleeping. Can any of these lifestyle interventions actually help propel an individual into sleep?
A 2019 systematic review and meta-analysis of 49 studies covering 4,506 participants found that mind-body therapies like meditation, tai chi, qigong, and yoga can be effective in treating insomnia and improving sleep quality for both healthy individuals and patients.11 The therapies resulted in statistically significant improvement in sleep quality and reduction in insomnia severity. Of note, the researchers found that qigong had a slight advantage over tai chi in the improvement of sleep quality.11
A 2015 randomized clinical trial examining the effects of a mindful awareness practice resulted in improvements in sleep quality, which was superior to a highly structured sleep hygiene education intervention (which targets the modification of day-to-day behavioral and environmental factors that contribute to poor sleep).12 Mindfulness exercises included mindful sitting meditation, mindful eating, appreciation meditation, friendly or loving-kindness meditation, mindful walking, and mindful movement. Participants engaged in a mean of 10 to 30 minutes of mindful experiential practice in each class in addition to the teacher-delivered didactic material and group discussion. The study, published in JAMA, also showed that the mindful awareness practice yielded improvements in sleep-related daytime impairment of depression and fatigue.12
Women with pre-menstrual syndrome (PMS) and perimenopause are known to experience sleep problems, due to the fluctuations in hormone levels. An interesting study in 2018 found that yoga reduced the disturbances of sleep in patients with PMS, which subsequently improved the efficiency of their sleep.13
Sleep disorders are also commonly experienced by cancer survivors; in fact, 51-90% of cancer survivors experience some form of sleep disturbance.14 A 2019 nationwide randomized controlled trial of a yoga therapy program in 410 cancer survivors found improvements in overall sleep quality and reductions in daytime dysfunction.14 Yoga therapy participants also demonstrated a statistical trend for greater reductions in sleep medication use compared to controls.13
Sleep is a complex, active process of restoration for the body, and patients experiencing sleep dysfunction can suffer both from physical and psychological disturbances that greatly affect their quality of life. Talking with patients about their sleep hygiene is the first step in beginning to evaluate how, over the course of their lives, sleep has impacted their overall health. To learn more about the connections between sleep and other biological processes, please see the following IFM-authored articles:
- Rasch B, Born J. About sleep’s role in memory. Physio Rev. 2013;93(2):681-766. doi:1152/physrev.00032.2012
- Cheung V, Yuen VM, Wong GTC, Choi SW. The effect of sleep deprivation and disruption on DNA damage and health of doctors. Anesthesia. 2019;74:434-440. doi:1111/anae.14533
- Centers for Disease Control and Prevention. Sleep and sleep disorders: data & statistics. Published May 2, 2017. Accessed June 5, 2019. https://www.cdc.gov/sleep/data_statistics.html
- Miyazaki S, Liu CY, Hayashi Y. Sleep in vertebrate and invertebrate animals, and insights into the function and evolution of sleep. Neurosci Res. 2017;118:3-12. doi:1016/j.neures.2017.04.017
- Cappuccio FP, D’Elia L, Strazzullo P, Miller MA. Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies. Sleep. 2010;33(5):585-592. doi:1093/sleep/33.5.585
- Adkins EC, DeYonker O, Duffecy J, Hooker SA, Baron KG. Predictors of intervention interest among individuals with short sleep duration. J Clin Sleep Med. 2019;15(8):1143-1148. doi:5664/jcsm.7808
- National Sleep Foundation. National Sleep Foundation’s 2018 Sleep in America Poll shows American’s failing to prioritize sleep. Published March 11, 2018. Accessed September 13, 2019. https://www.sleepfoundation.org/press-release/national-sleep-foundations-2018-sleep-americar-poll-shows-americans-failing
- Simon EB, Walker MP. Under slept and overanxious: the neural correlates of sleep-loss induced anxiety in the human brain. Lecture presented at: Neuroscience 2018; November 4, 2018; Berkeley, CA.
- Khawaja I, Yingling K, Bukamur H, Abusnina W. Vitamin B12 deficiency: a rare cause of excessive daytime sleepiness. J Clin Sleep Med. Published online August 14, 2019. doi:5664/jcsm.7936
- Holth JK, Fritschi SK, Wang C, et al. The sleep-wake cycle regulates brain interstitial fluid tau in mice and CSF tau in humans. Science. 2019;363(6429):880-884. doi:1126/science.aav2546
- Wang X, Li P, Pan C, Dai L, Wu Y, Deng Y. The effect of mind-body therapies on insomnia: a systematic review and meta-analysis. Evid Based Complement Alternat Med. 2019;2019:9359807. doi:1155/2019/9359807
- Black DS, O’Reilly GA, Olmstead R, Breen EC, Irwin MR. Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: a randomized clinical trial. JAMA Intern Med. 2015;175(4):494-501. doi:1001/jamainternmed.2014.8081
- Ghaffarilaleh G, Ghaffarilaleh V, Sanamno Z, Kamalifard M, Alibaf L. Effects of yoga on quality of sleep of women with premenstrual syndrome. Altern Ther Health Med. Published online December 15, 2018.
- Lin PJ, Kleckner IR, Loh KP, et al. Influence of yoga on cancer-related fatigue and on mediational relationships between changes in sleep and cancer-related fatigue: a nationwide, multicenter randomized controlled trial of yoga in cancer survivors. Integr Cancer Ther. 2019;18:1534735419855134. doi:1177/1534735419855134