Sleep Disturbances and Weight Gain: Examining

the Evidence

Eileen Chasens, DSN, RNAssistant ProfessorNovember 19, 2009

1998

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

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

2007

1990

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

Enlarged Tonsil & Adenoids

A Good Night’s Sleepis when you…

A Bad Night’s Sleep is when you…

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

6.4

6.6

6.8

7

7.2

7.4

7.6

7.8

8

Hours

Week Days Week Ends

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

7 to 8 hours recommended

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

Circadian “Pacemaker”Regulates Timing of Sleep and Wakefulness

Suprachiasmatic Nuclei (SCN)

Light

Output Rhythms

Physiology Behavior

Sleep/Wake Restorative ProcessBalances Sleep and Wakefulness

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

Awake Load

Reticular Activation System

Sleep-Promoting System

Normal Sleep Architecture

Changes in Sleep Architecture Associated with Aging

Normal Changes in Sleep With Age

EEG while Awake

EEG Sleep StagesAwake Alpha waves (if

eyes are closed)

Eyes moving together

High muscle tone

EEG Sleep Stages Stage 1 Theta waves

(3-7cycles second)

Rolling eye movements

High muscle tone

EEG Sleep StagesStage 2 Sleep spindles (12-

14 cycles/second) & K complexes

No distinctive eye movement

Lower muscle tone

EEG Sleep StagesStages 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 Stages

REM sleep Fast waves

Rapid eye movements (phasic REM)

Absence of muscle tone

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?”

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 Sleep diary for bed time, wake time(s),

include daytime activities and meals/beverages

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

.

The Epworth Sleepiness Scale 1. Sitting and reading

2. Watching television

3. Sitting inactive in a public place, or example, a theater or meeting

4. As a passenger in a car for an hour without a break

5. Lying down to rest in the afternoon

6. Sitting and talking to someone

7. Sitting quietly after lunch (when you’ve had no alcohol)

8. In a car, while stopped in traffic

0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

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

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

Wrist Actigraphy

Actigraphy Examples

Physiological Measures

Polysomnography (PSG)

Multiple Sleep Latency Test (MSLT)

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

Insomnia

Obesity

LifestyleFactorsSleep

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 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

Adjusted BMI

(adj. for age, gender)

Taheri S, et al. PLoS Med. 2004

Short Sleep Duration & BMI In the Wisconsin Sleep Cohort

Average Nightly Sleep (Hrs.)

6 7 8 930

31

32

33

(N=1,024)

Abundant data indicates that we live in a sleep-restricted society

5.256.216.25

6.666.13

012345678

All Cauc.Women

Cauc.Men

BlackWomen

Black Men

Hrs

. S

lep

t /

Day

(in

cl.

Nap

s)

Lauderdale DS, et al. Am. J. Epi. 2006

Ancillary study of the CARDIA Study (n=668; age: 38-50)

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

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

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

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)

3h 48’ Sleep 9h 03’ Sleep CHO Breakfast

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

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

After 2 days of 4 hrs.

sleep

After 2 days

of 10 hrs. sleep

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

Sleep

Type 2 Diabetes

LifestyleFactors

Insomnia

Circadian Rhythm Disturbances

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?

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 )

Survey about weight gain since starting shift work

85 Respondents, 36 on Days, 49 on Late shift

A longitudinal study on the effect of shift work on weight gain in male Japanese workers. Suwazono Y. (2008) Obesity: 18877-1893.

What are the links between sleep and type 2 diabetes?... sleep fragmentation 2o to Restless Leg Syndrome

Sleep

Type 2 Diabetes

LifestyleFactors

Insomnia

Circadian Rhythm Disturbances

Restless LegSyndrome

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

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

Sleep

Type 2 Diabetes

LifestyleFactors

Insomnia

Circadian Rhythm Disturbances

Restless LegSyndrome

OSA

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 Apnea

Anatomy of a blocked airwayPossible 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 passagesStructure of the jaw and airway can be a factor in sleep apnea

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

Intermittent Hypoxia Induces Insulin Resistance in Obese Mice

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

HOMA

(mean ± SEM)

65.9

204.7

58.944.9

0

50

100

150

200

250

300

Intermittent Hypoxia Intermittent Air

Day 0

Day 5

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

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

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

<5 6 7 8 >8

 

 Age-adj. relative risk

2.6(1.28–5.27)

1.93 (1.06–3.5)

1 1.40(0.78-2.53)

3.63 (1.79–7.38)

 Multivariate model *

1.95 (0.95–4.01)

1.95 (1.06–3.58)

1 1.41(0.78-2.55)

3.12 (1.53–6.37)

Sleep Duration & Relative Risk for Incident Diabetes: Massachusetts Male

Aging Cohort

Yaggi HK, et al. Diab. Care 2006

Self-Report Hours of Sleep/Day

*Adjusted for 10-year age-group, hypertension, current smoking, self-rated health status, waist circumference, education (all covariates measured at baseline).

5 6 7 8 9+

 n 122 576 731 422 118

 Age-adjusted relative risk

1.57 (1.28–1.92)

1.27 (1.12–1.44)

0.98 (0.87–1.11)

1 1.47 (1.19–1.80)

 Multivar. model incl BMI *

1.18 (0.96–1.44)

1.10 (0.97–1.25)

1.02 (0.91–1.16)

1 1.29 (1.05–1.59)

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

Ayas NT, et al. Diab. Care 2002

Hours of sleep per day

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

OSA Associated with DM in Hypertensive Men

OSA Associated with DM in Hypertensive Men

N=2,668; Obese = BMI >27; OSA = AHI >20 N=2,668; Obese = BMI >27; OSA = AHI >20 Elmasry A, et al., J. Int. Med 2001Elmasry A, et al., J. Int. Med 2001Elmasry A, et al., J. Int. Med 2001Elmasry A, et al., J. Int. Med 2001

PrevalenceOf

Diabetes

PrevalenceOf

DiabetesNon-OSA

Non-Obese

Non-OSAObese

OSANon-Obese

OSAObese

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 StudyPresence and Severity of OSA in Patients with

T2DM

None14%

Mild32%

Moderate31%

Severe23%

None

Mild

Moderate

Severe

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

(N=305)

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 ApneaPrevalence

At least 15–18 million with OSA1 in 5 adults has at least mild OSA1 in 15 adults has at least moderate OSA80–90% OSA cases undiagnosedDoctors usually can't detect the condition during routine office visitsNo blood tests for the condition

Treatment OptionsMild 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

69

Normal Airway

CPAP Airway

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

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*

34%

65%

Pati

en

ts W

ith

ES

(%

)

43%

0

10

20

30

40

50

60

70

Objective Sleepiness

(MSLT <7.5)n=85

Subjective Sleepiness (ESS >10)

n=106

Functional Impairment(FOSQ <17.9)

n=120P

ati

en

ts W

ith

Im

pair

men

t

(%)

0

10

20

30

40

50

60

70

Hours of CPAP use and Outcomes on FOSQ, ESS, and MSLT

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

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

p = 0.02

p = 0.06

CPAP Treatment & Glucose Control

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

83 +/- 50 days

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

Patients Using PAP Avg. >4 Hrs./Day

Patients Using PAP Avg. <4 Hrs./Day

Adherence to CPAP Determines its Efficacy

CPAP Therapy Improves Insulin SensitivityCPAP Therapy Improves Insulin Sensitivity

Harsch IA, et al. AJRCCM 2004

Harsch IA, et al. AJRCCM 2004

0

24

68

1012

1416

18

BMI <30 BMI >30

Ins

uli

n S

en

sit

ivit

y I

nd

ex

BL

2 Days CPAP

3 Mon. CPAPp = 0.001p = 0.001

p = 0.001p = 0.001

p = 0.003p = 0.003

(n = 13) (n = 18)

Not a RCT

(No BMI)

Vigilance and Sleep Restriction

Van Dongen H., et al:.

Sleep 2003;26:117-126.)

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 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

Symptom of depression, of a sleep disorder, or of both?

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. 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 sleepinessChasens ER, Olshansky E.

JAPNA (2006);12(5):272-8.

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.

Is sleep important for improving health outcomes in persons at risk for weight gain or who are overweight or obese, you be the judge!