Sleep Studies

With a good night's rest increasingly losing out to the Internet, e-mail, late-night cable and other distractions of modern life, a growing body of scientific evidence suggests that too little or erratic sleep may be taking an unappreciated toll on Americans' health, Washington Post staff writer Rob Stein reports in Sunday's Post.

Read the full story: Scientists Finding Out What Losing Sleep Does to a Body (Post, Oct. 9)

Lawrence Epstein, regional medical director of Sleep HealthCenters, was online Tuesday, Oct. 11, at 2:30 p.m. ET to discuss how lack of sleep affects Americans' health.

Sleep HealthCenters is a Sleep Medicine specialty group in the Boston area that provides consultative, diagnostic and therapeutic services to patients with sleep disorders.

Epstein is a graduate of the University of California at Los Angeles (UCLA, 1979) and the George Washington University School of Medicine and Health Sciences (1985). He is currently board certified in Internal Medicine, Pulmonary Diseases, Critical Care Medicine and Sleep Medicine. After training he completed a tour of duty in the U.S. Air Force, serving as Medical Director of the Sleep Disorders Center at Wilford Hall Medical Center and as Military Consultant to the Air Force Surgeon General for Sleep Disorders. He then spent 5 years developing a Sleep Medicine program at the West Roxbury VA Medical Center before joining Sleep HealthCenters in 2000.

Epstein is also an Instructor in Medicine at Harvard Medical School. He serves as faculty for the Sleep Medicine fellowship training program at Brigham and Women's Hospital. His research interests include methods of diagnosis and treatment of obstructive sleep apnea and he is currently involved in a large multi-center National Institutes of Health study evaluating the neurocognitive benefits of treating sleep apnea with continuous positive airway pressure. Epstein is the president-elect of the American Academy of Sleep Medicine and is on the Governing Council for the World Federation of Sleep Reseach and Sleep Medicine Societies. He is also on the Editorial Board of the Journal of Clinical Sleep Medicine.

A transcript follows.

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Lawrence Epstein, M.D.: Good afternoon, this is Dr. Epstein. I am glad to see we are addressing the topic of sleep. Sleep is a basic drive, like eating and drinking and the body will let you know when you are not getting enough. In order to get adequate sleep you need to make it a priority. If you are allowing yourself enough time to sleep and still have problems, that is the time to consider a sleep disorder. I will try to answer some of you questions about how to get a good night's sleep.

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Fairfax, Va.: My boyfriend has disturbed sleeping patterns, and most likely sleep apnea, from what I can tell listening to him snore/choke/gasp all night long. However, he also does not have health insurance, and cannot afford to pay out of pocket. I know from previous research that the average cost of a sleep clinic study is about $1500. Are there any lower-cost options for low-income patients with no health insurance?

Lawrence Epstein, M.D.: The first place to start is with your doctor, who can do a complete evaluation and decide how likely you are to have a problem like sleep apnea. There are specially trained sleep specialists who can go over all the ways to diagnose and treat your problem. The gold standard is still a laboratory based sleep study and most insurances require this test. However, there are some modified tests that can be done in the home that might be easier for you. You can check the Web site of the American Academy of Sleep Medicine, at www.sleepeducation.com for information on sleep and the location of the nearest sleep center

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Dreamland: Thanks for holding this chat. Does the presence or absence of dreams have anything to do with the quality of sleep? My husband doesn't remember his dreams (or doesn't have them) and I have very vivid dreams almost every night. Who's sleeping better and what can we do to improve our sleep?

Lawrence Epstein, M.D.: You are welcome. Everybody has multiple dream episodes each night. Whether or not you remember them is determined by when you wake up in relation to the dream. If you wake up during or just after a dream you will remember it, otherwise you don't. So remembering dreams is less a function of sleep quality than timing of awakening. The best way to improve sleep is to make sure you get enough to meet your needs and to keep a regular routine about sleep.

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Bethesda, Md.: I did an online article on bipolar disorder, and I found in my research that there is a definite link between sleep deprivation and mania through the enzyme protein kinase C (PKC). This also raises in type II diabetes. I'm starting to think that many cases of bipolar disorder may be environmentally caused or strongly triggered upon weak susceptibility thanks to the chaotic sleeping schedules of America.

Research also indicates that the number one cause of ADHD and hyperactivity in kids seems to be sleep problems. I have a major concern about how the brain is being hurt through those vulnerable years. Kids need a lot of sleep, yet they're wired not to want to sleep if there's something going on they can learn about. With all the stimuli out there... What would be your advice to parents who suspect a sleep disorder in their children?

Lawrence Epstein, M.D.: The more we look the more we find a relationship between sleep and general health. Sleep deprivation is associated with weight gain, heart disease, elevated blood pressure and reduced survival. Clearly the longer you have a sleep problem the bigger the effect. So detecting problems in childhood is important. Whereas adults who are sleep deprived are usually sleepy, children can present with a variety of problems from sleepiness to irritability to hyperactivity to poor school performance and behavior. The place to start is with your doctor. If you suspect a sleep problem there are pediatric sleep specialists as well.

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Silver Spring, Md.: Like so many overworked Americans, I'm probably not getting the sleep I need. I hear about cases like Bill Clinton or Margaret Thatcher needing only 4 hours or so a night. Is that real? And is it possible to "train" your body to get by on less sleep -- or is the amount you need fixed by biology? Thanks!

Lawrence Epstein, M.D.: Unfortunately it is not possible to train your body to get used to doing without sleep. You can try to manage the effects of sleep deprivation such as using caffeinated drinks or taking short catnaps. However,studies have shown no limit to the worsening of performance with prolonged sleep deprivation. The longer you are sleep deprived the more impaired you become. If you listen to your body you will know when you are getting enough sleep. If you are sleepy during the day, nod off watching TV, need coffee to function, then you are not getting enough sleep.

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Sleepless in Silver Spring, Md.: Posting early, since I've been up since 3:30 AM: What's the best way to get sleep patterns back on track? Awake at 4 AM, either toss and turn for an hour and a half before sleeping another hour or so or just give up and get up. Coffee in morning only, exercise in morning. Tired by mid-afternoon,nap some days, falling asleep frequently when in front of TV, in bed by 11:30. Is this to be expected entering senior citizenship?

Lawrence Epstein, M.D.: There are several steps to re-establishing your sleep pattern. First is to regularize your routine. The most important part is the wake up time. Get out of bed at the same time every day, weekend and weekday. Count back how long you sleep and go to bed at the same time each night. Expose your self to light in the morning, this helps set the body's internal clock. Avoid daytime sleeping, which interferes with your ability to sleep at night. Avoid things that interfere with sleep such as caffeine and alcohol. If you still have problems then go to see your doctor.

There are changes that accompany getting older. Your sleep tends to more fragmented and the body's clock shifts to going to bed earlier and getting up earlier. However, you still need to get about the same amount of sleep, you're just not as efficient at it.

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Guilford, Vt.: Can you suggest a good book with basic material about the science of sleep?

Lawrence Epstein, M.D.: Forgive the shameless plug, but I am the Editor of the Harvard Medical School Special Health Report titled: Improving Sleep, A Guide To A Good Night's Rest. You can get information on it at www.health.harvard.edu

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Dupont Circle, Washington, D.C.: Good Morning,

I basically get at least 7 hours of sleep each night but wake exhausted. I have been told that I snore (quite loudly sometimes). I am 43, exercise and eat fairly well. I work full time, am a single parent of a teenager and go to school more than half time. Could it be that I just need a new mattress? I have had my current one for at least 10 years. Any research on replacing mattresses? I have found that when I sleep elsewhere, say a relative or hotel, I don't wake up as exhausted. Could it be psychological? Thanks for any direction you can give me.

Lawrence Epstein, M.D.: Snoring and daytime sleepiness are symptoms of a sleep and breathing disorder called sleep apnea. The airway blocks off multiple times a night and you have to wake up briefly in order to breath. These awakenings are so short you are not aware of them but they can disrupt sleep making sleep nonrestful and causing daytime sleepiness. If this sounds like you then you should talk with your doctor who can advise you on next steps.

Anything that either fragments sleep or causes you not to get enough sleep can cause daytime sleepiness. If your mattress wakes you up a lot it could contribute to how you feel. However very little work has been done looking at the benefits of various mattress types.

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Washington, D.C.: In light of the recent information on the medical necessity of sleep, and as a good friend of a medical school student, I am astonished at the hours she is required to put in! She regularly gets off call around midnight, only to have to be back at the hospital for rounds mere hours later. Shouldn't the medical community be setting an example for us?

Lawrence Epstein, M.D.: I agree. In recognition of this the body that governs medical school training, the Accreditation Council for Graduate Medical Education, recently imposed limits to how long trainees can work consecutively and over the course of the week. They may not work more than 24 consecutive hours and not more than 80 hours/week. Still a lot of work but an improvement over what was previously happening.

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Washington, D.C.: Dr. Epstein, Do you believe that there are "morning people" and "night owls?" I am a self-diagnosed night owl. I am always exhausted in the morning and can almost never make it to work before 9:30. But when I'm home at night, cleaning up or watching TV or spending time with my husband - I'm not tired. I hardly ever go to sleep before midnight. How can I break this pattern when I'm not tired at a "reasonable" hour?

Lawrence Epstein, M.D.: There are definitely different sleep types, what we call morning larks and night owls. This has to do with variation in control of the sleep/wake cycle by the internal clock. The best way to cope with this is to adapt your life and work schedule to accommodate your own internal clock. If you cannot there are a variety of techniques involving behavior modification, light therapy and medication that can be used. These should be done with the help of your doctor.

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Washington, D.C.: Does this study mean that taking a nap in the middle of the day is a bad thing? Also just as a commentary, it seems like many other factors like eating, exercise, and overall healthy living, not just sleep cause the ailments found in this study. I mean come on cancer, diabetes, obesity, heart disease all can't solely be based on poor sleeping habits.

Lawrence Epstein, M.D.: You are right. The study does not mean that only sleep is involved in determining your health. What the study showed was that when you remove, or control, for all these other factors, there is still an association between how much sleep you get and the likelihood of developing obesity and other medical problems. Sleep deprivation is one of the factors contributing to the likelihood of gaining weight. But it is one of the easiest to eliminate. Get more sleep and you are more likely to be healthy.

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Washington, D.C.: Good afternoon. I was diagnosed with severe sleep apnea -- waking up on average of every 45 seconds with oxygen levels below 70 percent -- and have started using a CPAP machine. I feel rejuvenated and have the energy to start working out again and combined with a smart diet have started losing a lot of the weight that may be a major cause of the apnea. My question is if I continue to lose weight at what point do I go for another study to determine if the CPAP machine should be adjusted to a lower level due to improved air flow, or do I leave it at the original level that was determined in my earlier studies?

Lawrence Epstein, M.D.: I am glad to hear you are making such significant changes. It can be hard to do but the payback will be great.

Weight loss always reduces apnea. Whether or not it goes away depends on how much weight you lose and the shape of your airway. I recommend to my patients who are following your course to get to their target weight then come back to see me and we will reevaluate the need for CPAP.

Good Luck

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Washington, D.C.: Dr. Epstein,

Thank you for taking my question. I was fascinated to hear about the link between sleeplessness and health problems like obesity and diabetes. Did the researchers determine that losing sleep CAUSES these other problems, or are they only correlated? As someone who has struggled with insomnia for years and was recently diagnosed with diabetes, I've found that I tend to get into an unhealthy spiral. It starts when I sleep poorly, then snack more to keep myself going at work, or else eat while I'm awake in the middle of the night (for example, a bowl of cereal to help me get back to sleep). The unhealthy eating then makes it hard for me to sleep all night, ad infinitum. I'm working to break this cycle with help from my doctors. I'm just wondering what your thoughts are about correlation vs. causation in this situation.

Lawrence Epstein, M.D.: The study showed they were correlated, a finding suggesting but not proving causality. However there have been several other studies showing a similar link and suggesting how it might happen. Sleep deprivation leads to changes in the body chemicals that regulate appetite and weight in a way that promotes weight gain. Your history is common and shows the difficulty of managing this problem.

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Arlington, Va.: When should you be tested for sleep apnia, and how is clinical apnia different than just having bad sleep habits (erratic schedule, etc.). I know I snore, and even when I get a full night's sleep, I often wake up feeling exhausted.

Lawrence Epstein, M.D.: If you are suspected of having sleep apnea you should be tested. Symptoms include daytime sleepiness even when you get enough sleep, loud snoring, stopping breathing episodes at night and gasping at night. The breathing problems fragment sleep, causing sleep to be nonrestful and leading to daytime sleepiness. Tell your doctor your symptoms and then you can decide on further steps.

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Alexandria, Va.: What is normal sleep? For instance, I usually get about 7 hours a night but I don't think ever as an adult I have slept the whole night without waking up at least once? Is that normal?

Lawrence Epstein, M.D.: The amount of sleep you need varies from person to person, but most people need about 7 1/2 to 8 hours to feel fully rested. The best way to find out what you need is to take a week or two (such as while on vacation) sleep as much as possible and see how much you need not to be tired during the daytime.

Everyone wakes up multiple times each night. Usually you go back to sleep so quickly you don't remember it. As you get older there are more awakenings. This is not abnormal unless there is something waking you up such as a sleep disorder. If you wake up a few times each night, get back to sleep easily and feel rested during the day you are unlikely to be having a problem.

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Alexandria, Va.: My brother has mild sleep apnea, diagnosed by a sleep study.

The ENT recommended surgery. We did some research on pubmed and found the surgery has a very low rate of success and a high risk of adverse events (voice change).

Do you think surgery is overprescribed for sleep apnea? Should CPAP be the gold standard? The only standard?

Lawrence Epstein, M.D.: CPAP is the gold standard for treating sleep apnea. It has a 100% success rate. However, it is a treatment rather than a cure meaning you have to wear it for it to work and people often don't wear it enough. There are other treatments including dental appliances and surgery. The oral appliances are good for mild to moderate sleep apnea with a 50-70% success rate. Weight loss is the ultimate cure for those who are overweight. Surgery can be curative but has a lower success rate. There are multiple surgeries that can be done. The least invasive have a 40-45% success rate. The most invasive, requiring jaw reconstruction surgery, can have up to 90% cure rates. I suggest having a discussion with a board certified sleep specialist, who can give you a complete evaluation and a thorough assessment of your options.

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Lawrence Epstein, M.D.: I am afraid I have to go now. I enjoyed hearing from all of you. I apologize for not being able to answer all of your questions. For more information check out the Web site: www.sleepeducation.com.

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washingtonpost.com: This concludes today's discussion with Lawrence Epstein, M.D. Thank you for your questions.

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Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.