Dr. Julio Fernandez-Mendoza: Heart health and sleep

[0:00:19]

JULIO FERNANDEZ-MENDOZA: Hi, I’m Julio Fernandez-Mendoza, and I’m a scientist clinician, which means that I’m a professor at the Penn State College of Medicine devoting most of my time to sleep research, but I’m also a clinician. I’m a psychologist that cares for patients at the Penn State Health Sleep Research and Treatment Center. So, part of my work focuses on understanding how and why insufficient and poor sleep is associated with heart health outcomes.

[0:00:58]

JULIO FERNANDEZ-MENDOZA: We do have a lot of data that has backed up an expert consensus that adults who report getting about seven to eight hours of sleep are those that have the best health in general. So, for that reason, the recommendation is that adults should be getting about seven to eight hours of sleep. Now, of course, that recommendation changes with age. Older adults may need more like six to seven hours of sleep. And of course, as you mentioned, youth, they get more sleep than adults, so the recommended amount of sleep for youth, including teens, is to get at least nine hours of sleep.

[0:01:47]

JULIO FERNANDEZ-MENDOZA: We do have quite solid evidence, both from population-based studies—which is these are studies that we do in the general community, like surveys or sometimes even including biological measures, but also sleep lab studies—showing that poor, insufficient sleep is a risk factor for heart problems being high blood pressure, the first sign before people develop full-blown heart disease. Actually, in our team, we were the first ones to show that among those who complain of insomnia—difficulty falling or staying asleep—those who did not get enough sleep were the ones who were at risk of heart problems. And we found this in both teens and adults. And the mechanism by why insomnia and short sleep may impact heart problems is through things such as having elevated stress, hormone levels, elevated inflammation. So, these type of or cardiac problems that are subclinical, that they show up before you develop heart disease, and those are involved in this relationship much more than the known coexistence, for example, of sleep problems with depression or anxiety and the like. We know that those do play a role in poor sleep but are not necessarily the connection with heart problems.

[0:03:22]

JULIO FERNANDEZ-MENDOZA: We do have, as a field, actually, and most people are familiar with good sleep hygiene habits, such as: you need to cut down caffeine and alcohol, quit smoking, exercise regularly, eat at adequate times, and adequate quantities. And of course, these basic lifestyle habits are essential for good sleep and good sleep health actually, and also good heart health in general. However, most people who want to get better and sufficient sleep is because they actually suffer a problem that has become persistent, and in those cases, these lifestyle changes do not help as much. The good news is that multiple studies, a lot of scientific studies, have backed up specific behavioral changes that can improve sleep. And these can be kind of like summarized into six rules that we like to provide to people who have persistent sleep problems. And of course, these rules can be followed at the short term, very firmly, and then down the road, people can adapt them to their own lifestyle and way of sleeping. But these rules are number one: rise, get up at the same time no matter what. No matter how much sleep you get. This will serve as an anchor to your sleep/wake cycle, your circadian rhythm. Some people may have heard about this term.

Second, do not use your bed for anything else except sleep and sexual activity. Third, simply do not lay in bed awake. Get out of bed. Go into another room if you can, and do an activity that is enjoyable or relaxing, and go back to bed only if you feel sleepy enough to sleep. Fourth, get going with your daily activities even after a poor night’s sleep. In other words, do not compensate for a sleep loss. Don’t try to sleep in, nap, or doze during the day or evening if you had a poor night’s sleep, and do not cancel errands, obligations, work, school, social dates because you had to sleep, get going. Fifth, go to bed only when you feel actually sleepy enough to fall asleep, even if that means going to bed at the time that you’re currently falling asleep. And actually, that is better at the short term to improve your sleep quality. And then finally, six plan to be in bed the amount of time that pertains to the amount of sleep that you’re currently getting and then increase it weekly by 15 minutes if you’re sleeping better. So, if these rules do not work for you, for anyone in the public, then do seek a clinical provider who can then give you the best advice on who can help you and with what interventions. But these are six rules that are typically not disseminated to the public, that are evidence-based, which means that they are tracked by science, and that go above and beyond simple sleep hygiene habits.

[0:06:53]

JULIO FERNANDEZ-MENDOZA: Adolescence is a very unique developmental period, and I think that all of us adults who have been adolescents before, we know that it was a different stage in our life. And there is not just because there are obvious physical and emotional and behavioral changes that occur during adolescence, but also our sleeping brain changes during puberty and development. One of the things that happened is that adolescents internal clock changes in a way that their sleep schedule shifts to later hours. So, while it’s true that adolescents get engaged behaviorally more into things at night and so forth because of their psychosocial relationships, we do know that there is biology behind it, that their internal clocks have shifted. So, it’s not just simply choice. So, for many of them, still, the school start times are at odds with that biological shift in their sleep schedule, which leads them to not get enough sleep during the school days, which and that becomes a problem. We know that impacts performance in school and the like. So, we need first—not just the adolescent themselves or parents—we need overall policy school changes that align with scientific knowledge on child development. So, we cannot continue having school systems and states that put adolescents at risk by having them wake up at a time that is completely at odds with what we know with from biological scientific knowledge. Now, of course, also parents can identify whether their adolescent’s sleep is way too shifted or is shifting excessively that they are falling asleep very late and having difficulty waking up in the morning. Some parents may say, My kid actually just cannot go to school. It’s impossible to wake them up in the morning because they fell asleep very late. And they can actually help them sometimes.

And here I would recommend first to go to see a clinical provider in that case, but there are two basic things that they can do to help their kid. One of them is to help them plan their evening behaviors to an earlier time to allow their brain prepare for an earlier sleep. But then also, and this is very important, they can help their kid by advancing their wake up time, starting on weekends, for example, on after two weekends of letting them sleep in, and they can then plan to wake them up little by little, 30 minutes earlier during several days, even if it means school days until the desire wake up time, whatever is desired or needed for schooling and other activities. But the recommendation here is, do not and never wake them up just simply early and attempt to get them re-shifted. That actually would not work, and this is a mistake that sometimes the field has given or a misunderstanding that, oh, what you need to do with an adolescent that is not waking up in the morning is wake them up at 5am in the morning and as if it was the military, and they will see. They will not get used to it. You’re going at odds with their internal clock. We need—you need to do that little by little. So, in that sense, I will tell parents, try that, and if it does not work, consult with the clinical provider. And we have very effective methods to get adolescents to get good and better, and sufficient sleep.

[0:10:43]

JULIO FERNANDEZ-MENDOZA: People should consult with a sleep provider if they feel they sleep poorly, if they feel unrefreshed, sleepy, or fatigued during the day, or have behaviors or move too much while asleep, or snore, or grind their teeth. All these things should be paid attention to, not only whether I’m getting enough sleep or not. Now, sleep science has grown tremendously, and sleep medicine and behavioral sleep medicine are specialties that include evidence-backed interventions. And these are not just drugs. Most people may think, Oh yeah, most sleep providers are going to recommend me taking this prescription medication that is very expensive. That is not true. We have behavioral, non-drug-based treatments that work. In fact, for example, cognitive behavioral therapy for insomnia is the first-line guideline-recommended treatment for insomnia, and insomnia affects about 10% of adults, and about another 30% of adults would have insomnia symptoms, so not the disorder. So, there are a lot of behavioral, non-drug based interventions that are first line treatment for many sleep disorders, also when I mean non-drug, it involves light therapies and behavioral sleep medicine specialists are the ones that are best at mixing behavior change and sleep behavior change with light therapies. And then, of course, there are medications that work some people do—may need drugs, or some people may need devices, such as positive airway pressure therapy for sleep apnea, or, for example, surgeries nowadays that are performed for people with mild sleep apnea, and even FDA just recently approved medications for a sleep apnea that help you lose weight, like the GLP-1s and other type of medications that go, that go to the cause of obstructive sleep apnea, which is the metabolic changes. So, there is a lot nowadays in the sleep medicine and behavioral sleep medicine that is available to the public, and sometimes the individuals need to, kind of, like push to get referred to a sleep provider. And I highly recommend it.