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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.

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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

slide3

Obesity Trends* Among U.S. AdultsBRFSS,1990, 1998, 2007

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

1998

1990

2007

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  • BRFSS, Behavioral Risk Factor Surveillance System http: //www.cdc.gov/brfss/
obesity in children
Obesity in Children

Enlarged Tonsil & Adenoids

what is sleep
What is sleep?
  • State in which the individual is
    • Unresponsive to the external environment
    • Is accompanied by stereotypical behavior
  • Reversible
  • Basic need
mean hours of sleep in adults
Mean Hours of Sleep in Adults

7 to 8 hours recommended

National Sleep Foundation, 2001 “Sleep in America” Poll of adults

slide9
Earth’s rotation on its axis is the fundamental orbital mechanism that underlies endogenous circadian rhythms.
slide10

Light

Circadian “Pacemaker”Regulates Timing of Sleep and Wakefulness

  • Output Rhythms
  • Physiology
  • Behavior

Suprachiasmatic Nuclei (SCN)

sleep wake restorative process balances sleep and wakefulness
Sleep/Wake Restorative ProcessBalances Sleep and Wakefulness

Awake Load

Borbely, A. (1982). Neurobiology, 1; 195-204)

eeg sleep stages
Awake

Alpha waves (if eyes are closed)

Eyes moving together

High muscle tone

EEG Sleep Stages
eeg sleep stages1
EEG Sleep Stages

Stage 1

Theta waves (3-7cycles second)

Rolling eye movements

High muscle tone

eeg sleep stages2
EEG Sleep Stages

Stage 2

Sleep spindles (12-14 cycles/second) & K complexes

No distinctive eye movement

Lower muscle tone

eeg sleep stages3
EEG Sleep Stages

Stages 3 & 4

Delta (slow) waves

Stage 3: delta < half of epoch

Stage 4: delta >half of epoch

No distinguishing eye movement

Low muscle tone

eeg sleep stages4
EEG Sleep Stages

REM sleep

Fast waves

Rapid eye movements(phasic REM)

Absence of muscle tone

assessment of sleep
Assessment of Sleep
  • Direct observation
  • Asking about sleep
  • Diaries
  • Use of a Sleep Questionnaire
  • Actigraphy
  • Sleep study
assessment ask your subjects how s your sleep
Assessment: Ask your subjects“how’s your sleep?”
  • Check if any of the following apply:
  • Sleep less than 7 or more than 9 hours/night
  • Snore loudly
  • Stop breathing or gasp during sleep
  • Excessive daytime sleepiness or doze off
  • Difficulty 3 or more times a week with insomnia symptoms
  • Unpleasant feelings in legs when trying to sleep
  • Interruptions to sleep
self report measures
Self-Report Measures
  • Sleep diary for bed time, wake time(s),
    • include daytime activities and meals/beverages
instruments to evaluate sleep
Instruments to Evaluate Sleep
  • Epworth Sleepiness Scale
    • Johns MW (1991) Sleep, 14 (6),540-545)
  • Pittsburgh Sleep Quality Index
    • Buysse DJ et al. (1989) Psychiatry Res, 28, 193-213
  • Functional Outcomes of Sleep Questionaire
    • Weaver et al. (1997). Sleep:835-43

.

slide27

The Epworth Sleepiness Scale

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

pittsburgh sleep quality index buysse dj et al 1989 psychiatry res 28 193 213
Pittsburgh Sleep Quality IndexBuysse DJ et al. (1989) Psychiatry Res, 28, 193-213
  • 19 items
  • Generates 7 "component" scores
  • Sum of scores from 7 components yields one Global Score.
  • Global PSQI >5 score distinguishes good and poor sleepers
  • http://www.sleep.pitt.edu
functional outcomes of sleep questionnaire
Functional Outcomes of Sleep Questionnaire
  • 30-item questionnaire developed to evaluate areas sensitive to sleep disruption
  • 5 Factor Design:
    • activity level, vigilance, intimacy and sexual relationships, general productivity, and social outcome areas
  • Short FOSQ 10-items
body movement monitors
Body Movement Monitors

Wrist Actigraphy

physiological measures
Physiological Measures

Polysomnography (PSG)

Multiple Sleep Latency Test (MSLT)

slide34
What are the links between sleep and obesity?... inadequate sleep duration because of lifestyle factors or insomnia??

Obesity

Insomnia

Lifestyle

Factors

Sleep

insufficent sleep duration 2 nd to lifestyle factors
INSUFFICENT SLEEP DURATION 2nd to Lifestyle Factors
  • Caffeine, alcohol and nicotine
  • Exercise, too close to bedtime
  • Excessive naps
  • Irregular sleep schedules
  • Too many demands of daily life!
insomnia
What is it?

Difficulty getting to sleep

Difficulty staying asleep

Awakening too early from sleep

Hyper-vigilant at night/ Tired & fatigued during the day?

INSOMNIA
insomnia1
Insomnia
  • Transient - less than 2 weeks
  • Chronic - continuing difficulty with sleep for at least 6 months
  • Etiology:
    • Medical
    • Psychiatric
    • Pharmacologic
    • Primary Sleep Disorder
    • Genetic
    • Tobacco / Alcohol
slide38

33

32

31

30

6

7

8

9

Average Nightly Sleep (Hrs.)

Short Sleep Duration & BMI In the Wisconsin Sleep Cohort

Adjusted BMI(adj. for age, gender)

(N=1,024)

Taheri S, et al. PLoS Med. 2004

abundant data indicates that we live in a sleep restricted society

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
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
Potential mechanisms where sleep loss is associated with weight gain

Taherei, S. et al. (2006). Archives in diseases in Children: 81 881-884)

slide42

3h 48’ Sleep

9h 03’ Sleep

 CHO Breakfast

Effects of Sleep Restriction (6 d) vs. Extension: Young, Healthy Men

Glucose(mg/dl)

Insulin(mlU/L)

HOMA(Io x Go/22.5)

(BMI: ~23)

Spiegel K, et al. J. Clin. Endocr. Metab. 2004

slide43

After 2 days of 4hrs. sleep

After 2 days of 10hrs. sleep

Sleep Duration: Leptin, Ghrelin, Hunger and Appetite in Healthy Young Men

Spiegel K, et. al. Ann. Int. Med. 2004

slide44
What are the links between sleep and obesity?... sleep fragmentation 2o to Circadian Rhythm Disturbances

Type 2 Diabetes

Circadian Rhythm

Disturbances

Insomnia

Lifestyle

Factors

Sleep

shift work sleep disorder
Shift Work Sleep Disorder
  • Sleep disorder that affects people who frequently rotate shifts or work at night
  • The most common symptoms of SWSD are insomnia and excessive sleepiness.
  • Other symptoms of SWSD include:
    • Difficulty concentrating
    • Headaches
    • Lack of energy
what are the consequences of swsd
What are the consequences of SWSD?
  • Increased accidents
  • Increased work-related errors
  • Increased sick leave
  • Increased irritability, mood problems, etc.
  • WEIGHT GAIN!
work shift period and weight gain geliebter a 2000 nutrition
Work-shift period and Weight Gain (Geliebter, A. (2000). Nutrition )

Survey about weight gain since starting shift work

85 Respondents, 36 on Days, 49 on Late shift

slide48
A longitudinal study on the effect of shift work on weight gain in male Japanese workers.Suwazono Y. (2008) Obesity: 18877-1893.
slide49
What are the links between sleep and type 2 diabetes?... sleep fragmentation 2o to Restless Leg Syndrome

Type 2 Diabetes

Restless Leg

Syndrome

Circadian Rhythm

Disturbances

Insomnia

Lifestyle

Factors

Sleep

restless legs syndrome sleep fragmentation
Restless Legs Syndrome & Sleep Fragmentation

Unpleasant, creeping feeling in legs

Irresistible urge to move

Associated with other medical conditions

Periodic Leg Movements during sleep require evaluation

slide51
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
What are the links between sleep and obesity?... Obstructive Sleep Apnea

Type 2 Diabetes

OSA

Restless Leg

Syndrome

Circadian Rhythm

Disturbances

Insomnia

Lifestyle

Factors

Sleep

obstructive sleep apnea
Obstructive Sleep Apnea
  • Repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction during sleep
      • This interruption in breathing can take place just a few times or up to hundreds of times over the course of a night
  • Airflow cessations or reductions produce:
      • Arousals
      • Fragmented sleep
      • Reductions in blood oxygen saturation
      • Fluctuations in blood pressure and heart rate
obstructive sleep apnea1
Obstructive Sleep Apnea

Anatomy of a blocked airway

  • Possible obstruction sites
    • The upper airway excess tissue, large tonsils, a large tongue, and usually includes the airway muscles relaxing and collapsing when asleep
    • The nasal passages
    • Structure of the jaw and airway can be a factor in sleep apnea
risk factors for osa
Risk Factors for OSA

Risk Factors

Male gender

Increased age

Obesity

Recessed mandible

Comorbid Medical Conditions

outcomes associated with untreated osa
DIABETES

Increased Mortality

Hypertension

Stroke

Heart Attack

Atrial fibrillation

Depression

Functional Impairments

Performance Impairments

Outcomes Associated with Untreated OSA
slide57

Intermittent Hypoxia Induces Insulin Resistance in Obese Mice

HOMA

(mean ± SEM)

Adapted from: Polotsky VY, et al. J. Physiol. 2003

slide58

Adj. Odds Ratio(referent to 7- 8 hrs. sleep)

Odds Ratio for Diabetes Mellitus & Impaired Glucose Tolerance By Self-Report Usual Sleep Time in Older Population {SHHS} (age: 53-93 yrs.)

Adj. for: age, gender, race/ethnicity, AHI, waist circ., field site

Adapted from: Gottlieb DJ, et al. Arch. Int. Med. 2005

slide59

Self-Report Hours of Sleep/Day

Sleep Duration & Relative Risk for Incident Diabetes: Massachusetts Male Aging Cohort

*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

slide60

Hours of sleep per day

Sleep Duration & Relative Risk for Incident DM: Nurse’s Health Study

*Adj.: shift work, hypercholesterolemia, HTN, smoking, snoring, exercise, alcohol, depression, postmenopausal hormone, family hx diabetes

Ayas NT, et al. Diab. Care 2002

slide61

OSA

Obese

OSA

Non-Obese

Non-OSA

Obese

Non-OSA

Non-Obese

OSA Associated with DM in Hypertensive Men

Prevalence

Of

Diabetes

N=2,668; Obese = BMI >27; OSA = AHI >20

Elmasry A, et al., J. Int. Med 2001

what is the evidence that sleep disturbances are associated with type 2 diabetes
What is the evidence that sleep disturbances are associated with type 2 diabetes?
  • Sleep AHEAD study recruited from Look AHEAD
  • Exclusion criteria for Sleep AHEAD were previous treatment for OSA.
  • Efforts were made to enroll individuals

with undiagnosed OSA using a symptom questionnaire

  • Because almost all of the first 80 participants had OSA upon PSG, the symptom

screen was dropped

data from sleep ahead study
Data from Sleep AHEAD Study

(N=305)

Foster et al. (2009). Diabetes Care, 1017-1-19.

conclusions from sleep ahead
Conclusions from Sleep AHEAD
  • Exceedingly high prevalence of undiagnosed OSA among obese patients with type 2 diabetes
  • Unequivocally high prevalence of moderate-to-severe 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
Obstructive Sleep ApneaPrevalence
  • At least 15–18 million with OSA
    • 1 in 5 adults has at least mild OSA
    • 1 in 15 adults has at least moderate OSA
    • 80–90% OSA cases undiagnosed
    • Doctors usually can't detect the condition during routine office visits
    • No blood tests for the condition
treatment options
Treatment Options

Mild OSA

  • Losing weight
    • Positional therapy
    • Avoidance of central nervous system (CNS) depressants
  • Oral mouth devices (keep the airway open)
    • Can bring the jaw forward, elevate the soft palate, and retain the tongue (from falling back in the airway and blocking breathing)
  • Possibly requires continuous positive airway pressure (CPAP)

Moderate to severe OSA

  • First-line treatment for the underlying obstruction is typically continuous positive airway pressure (CPAP)
  • Surgery of the airway may be required in certain cases
obstructive sleep apnea overview
Obstructive Sleep Apnea Overview

Normal Airway

CPAP Airway

69

treatment of sleep apnea
Treatment of Sleep Apnea
  • CPAP (Continuous Positive Airway Pressure)
    • Need for increased adherence to all night/every night
    • Need to bring to hospital if admitted, especially if surgical patient
slide70
CPAP only works if it is worn all night, every night. OSA: Residual Sleepiness and Functional Impairment With CPAP with suboptimal use*

*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.

After Three Months of CPAP Treatment*

70

70

65%

60

60

50

50

43%

40

40

34%

Patients With ES (%)

Patients With Impairment (%)

30

30

20

20

10

10

0

0

Objective Sleepiness

(MSLT <7.5)

n=85

Subjective Sleepiness (ESS >10)

n=106

Functional Impairment

(FOSQ <17.9)

n=120

hours of cpap use and outcomes on fosq ess and mslt
Hours of CPAP use and Outcomes on FOSQ, ESS, and MSLT

Weaver et al. (2007) Sleep. 30: 711-719.

cpap treatment glucose control
CPAP Treatment & Glucose Control

p = 0.02

p = 0.06

83 +/- 50 days

(N=25/ 17 with A1c>7%)

Babu AR, et al. Arch. Intern. Med. 2005

adherence to cpap determines its efficacy
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

slide74

p = 0.001

p = 0.003

p = 0.001

(No  BMI)

Not a RCT

(n = 13)

(n = 18)

CPAP Therapy Improves Insulin Sensitivity

Harsch IA, et al. AJRCCM 2004

vigilance and sleep restriction
Vigilance and Sleep Restriction

Van Dongen H., et al:.

Sleep 2003;26:117-126.)

cognitive abilities and mood are affected by sleep deprivation
Cognitive abilities and mood are affected by sleep deprivation.
  • 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
Diabetes and Depression
  • Research linking depression and diabetes is compelling
  • Bi-directional association between sleep disorders and depression
  • 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
incidence of clinical depression with insomnia
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
The Experience Of Being Sleepy While Managing Type 2 Diabetes.
  • 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
Summary
  • Sleep is a physiological necessity.
  • Sleep disruption is due to either
    • 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.
slide82
Is sleep important for improving health outcomes in persons at risk for weight gain or who are overweight or obese, you be the judge!