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Rochelle Goldberg, MD, FAASM, FCCP, DABSM Associated Professor, Internal Medicine,
Sidney Kimmel Medical College Thomas Jefferson University, Philadelphia, PA
Director, Sleep Medicine Services, MLHS
I like to sleep.
No other conflicts related to this presentation.
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Define normal sleep needs
Explain sleep-wake control concepts
Define insufficient sleep
Discuss world wide implications of sleep loss
List health and functional consequences of sleep loss
Sleep needs change with age ◦ Age 5-1010-11h/n; age 11-17 8.5-9.5h/n;
adult 7-9h/n http://www.sleepfoundation.org/article/how-sleep-works
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◦ Homeostatic requirement (Process S)
Increased pressure for sleep the longer the duration of wake thru the day
◦ Circadian rhythm (Process C)
24 hour cycle controlled in suprachiasmatic nucleus in brain stem (sleep pacemaker), light-dark external influences
◦ Sleep inertia (Process W)
Cirelli, Nature Rev Neurosci 2010
Opponent process model
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Diagnostic criteria: ◦ Complaint of excessive sleepiness; ◦ Habitual sleep period (by hx, logs or actigraphy)
is shorter than age-adjusted normative data; ◦ Longer sleep time on weekends, vacations; ◦ PSG: latency <10 min, S Eff >90%; ◦ MSLT: generally short latency (<8min), w or w/o
SOREMPs; ◦ Sleepiness cannot be attributed to other sleep,
medical, neurologic, psychiatric disorders; or medications or substance abuse.
ICSD, second edition
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What is this compound?
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Question 1:
Joe Smythe is a 75 year old man. Prior to retirement he went to bed at 9pm and got up at 5am for work. Since his retirement 10 years ago, he usually goes to bed at midnight, and continues to get up at 5am.
Which of the following is most correct about Joe’s current sleep situation?
A. He should be fine, as he doesn’t need as much sleep now.
B. He should be fine, as long as he maintains the same schedule throughout the week.
C. He is likely to have increased insulin resistance.
D. He is likely to lose weight over time.
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National Health Interview Survey ◦ 30% adults
report <6 hrs/n
◦ 31% HS students reported >8 hrs/school night
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Insufficient rest or sleep among US adults
Shankar A, Syamala S, Kalidindi S (2010) Insufficient Rest or Sleep and Its Relation to Cardiovascular Disease, Diabetes and
Obesity in a National, Multiethnic Sample. PLoS ONE 5(11): e14189. doi:10.1371/journal.pone.0014189
IS prevalence (Finnish Twin Cohort) ◦ 1990 24.4% (16.2%
men, 23.9% women) ◦ 44% with IS in 1981,
still with IS 1990 ◦ In multivariate
analysis, 2/3 factors non-genetic
Hublin C. The Finnish Two Cohort. Sleep 2001; 24(4):392
CDC survey
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Drowsy driving is an acknowledged risk of IS ◦ 1,550 fatalities, 40,000 non-fatal injuries
annually National Department of Transportation
Correlation of drunk and drowsy driving ◦ 17-19 hours w/o sleep > BAC of 0.05%
Response speeds, accuracy measures (different tests)
◦ Longer hours w/o sleep = BAC of 0.1% Williamson AM. Moderate sleep deprivation produces impairments in cognitive and
motor performance equivalent to legally prescribed levels of alcohol intoxication. OccupEnvironMed 2000;57:649
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Microsleeps Errors (lapses, incorrect responses)
Cognitive slowing in subject based tasks Psychomotor responses Short term and working memory
Divergent thinking Compensatory effort to behavioral
effectiveness Performance w increased task duration
Situational awareness neglect “nonessentials”
Derived from: Goel N, Rao H.Neurocognitive Consequences of Sleep Deprivation. Semin Neurol 2009;
29(4): 320-339
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Which of the following has NOT (yet??) been associated with insufficient sleep?
A. Nicotine addiction
B. Weight gain
C. Increased C-reactive protein
D. Memory loss
E. Heart disease risk
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Weight gain/ Obesity
Diabetes
Hypertension
Cardiovascular Disorders
Stroke
Metabolic Syndrome
Dementia
Combination of medical conditions that increase the risk for: ◦ Heart disease ◦ Stroke ◦ Type 2 diabetes.
Conditions: ◦ increased blood pressure
high blood sugar ◦ excess body fat around the
waist ◦ abnormal cholesterol or
triglyceride levels.
KnutsonKL.The metabolic consequences of sleep deprivation.Sleep Med Rev 2007; 11(3):163
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Appetite/hunger responses with sleep deprivation
Healthy normal BMI subjects
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Insufficient rest/sleep and obesity
Odds ratios (95% confidence interval) of diabetes incidence over the follow-up period by sleep duration at baseline
Hours of Sleep Model 1 Model 2 Model 3 ≤ 5 1.91 1.57 1.47
(1.37-2.67) (1.11-2.22) (1.03-2.09) 6 1.25 1.19 1.08
(0.94-1.70) (0.88-1.60) (0.80-1.47) 7 1.00 1.00 1.00 8 1.16 1.09 1.09
(0.89-1.51) (0.84-1.43) (0.83-1.43) ≥ 9 1.85 1.57 1.52
(1.32-2.60) (1.10-2.24) (1.06-2.17)
Model 1 – Unadjusted. Model 2 – Adjusted for physical activity, depression, alcohol consumption,
ethnicity, education, marital status, and age. Model 3 – Adjusted for the variables in Model 2 plus overweight/obesity and hypertension.
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Insufficient rest/sleep and diabetes mellitus
Shankar A, Syamala S, Kalidindi S (2010) Insufficient Rest or Sleep and Its Relation to Cardiovascular Disease, Diabetes and
Obesity in a National, Multiethnic Sample. PLoS ONE 5(11): e14189. doi:10.1371/journal.pone.0014189
Potential process for insufficient sleep and increased risk for diabetes
Knutson KL. The metabolic consequences of sleep deprivation. Sleep Med Rev 2007; qq(3):163-178.
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Insufficient rest/sleep and any cardiovascular disease (CVD)
Weekday vs weekend sleep >2 hours
Mean age 72.1
Ideal Cardiovascular Health (ICH) ◦ AHA 2020
Higher obesity and hypertension in IS group
Age, race adjusted still poorer ICH
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Insufficient rest/sleep and coronary heart disease (CHD)
Shankar A, Syamala S, Kalidindi S (2010) Insufficient Rest or Sleep and Its Relation to Cardiovascular Disease, Diabetes and
Obesity in a National, Multiethnic Sample. PLoS ONE 5(11): e14189. doi:10.1371/journal.pone.0014189
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Insufficient rest/sleep and stroke.
Shankar A, Syamala S, Kalidindi S (2010) Insufficient Rest or Sleep and Its Relation to Cardiovascular Disease, Diabetes and
Obesity in a National, Multiethnic Sample. PLoS ONE 5(11): e14189. doi:10.1371/journal.pone.0014189
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Pain perception (bidirectional)
Premature aging
Altered immune response with increased systemic inflammation
Workplace productivity
The ICU patient
Adolescents/teens-technology; driving risk
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Self-treat issues
Global business ◦ Coffee consumption increased 5% in 2013 ◦ 83% of Americans drink coffee
From Trade publication: NCDT 2013
See Addendum
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Suzie Doe is a 44 year old woman presenting with fatigue and sleepiness. She goes to bed at midnight and gets up for work at 6am. She is most concerned about recent weight gain. Which of the following factors, regarding her insufficient sleep, is most likely mechanism for the weight change?
A. She has decreased appetite for non-carbs.
B. She has increased ghrelin levels.
C. She has reduced insulin resistance.
D. She has increased leptin levels.
E. She drinks too many energy drinks.
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Epidemic: No one is exempt Basic RX: Sleep more ◦ “If you DON’T snooze, you lose!”
“Sleep deficiency contributes to the risk for several of modern societies’ medical epidemics, including CVD, diabetes, obesity and cancer.”
“[This is an]…opportunity for individuals, institutions and communities to promote good health…”
Coffee and tea (8-ounce) caffeine (mg)
Coffee, Drip 115-175
Coffee, Brewed 80-135
Coffee, Espresso (2oz) 100
B&J Coffee Fudge Fr.Yog 85
Coffee, Instant 65-100
Tea, iced 47
Tea, brewed, imported 60 (avg)
Tea, brewed, US brands 40 (avg)
Tea, instant 30
Tea, green 15
Hot cocoa 14
Coffee, Decaf, brewed 3-4
Coffee, Decaf, instant 2-3
Dark chocolate (1 oz) 20
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The Light Weights-Sodas Caffeine (mg)
Diet Rite Cola 0
Sprite 0
7-Up 0
Mug Root Beer 0
Diet Barq's Root Beer 0
Sundrop Orange 0
Minute Maid Orange 0
A&W Root Beer 0
Slice 0
Sierra Mist 0
Fresca 0
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Soft drinks (12-ounce) caffeine (mg)
Red Bull (8.2 oz) 80.0
Jolt 71.2
Mountain Dew / Diet 55.0
Kick Citrus 54.0
Mellow Yellow 52.8
Surge 51.0
Tab 46.8
Shasta Colas 44.4
RC Cola /Diet 43.0
Dr. Pepper / Diet 41.0
Mr. Pibb / Sugar Free 40.0
Red Flash 40.0
Sunkist Orange/ Diet 40.0-41.0
Slim-Fast Cappuccino
Delight 40.0
Ruby Red 39.0
Storm 38.0
Big Red 38.0
Pepsi-Twist,Jazz,Diet,Cherry/ Diet/ One 36.0-38.0/ 55.5
Aspen 36.0
Coke products / Diet 34.0 / 45.6
Snapple Flavored Teas (Reg /Diet) 31.5
Canada Dry Cola / Diet 30.0 / 1.2
A&W Creme Soda / Diet 29.0 / 22.0
Nestea Sweet Iced Tea 26.5
Nestea Unsweetened Iced Tea 26.0
Barq's Root Beer 23.0
Slim-Fast Chocolate Flavors 20.0
Snapple Sweet Tea 12.0
Lipton Brisk, All Varieties 9
Canada Dry Diet Cola 1.2