Why Sleep Is So Critical (and What To Do if You're Not Getting Enough ZZZs) with Dr. Nancy Foldvary

Podcast Transcript

Nada Youssef: Hi, thank you for joining us. I'm your host, Nada Youssef. Today we're discussing sleep disorders and taking your questions live. More than 50 million Americans struggle with chronic sleep deficiency. So if bedtime is dreadful for you, we'd like to hear from you. Type in any questions you may have in the comment section below. Our sleep experts today is an acknowledged leader in the field. She's the director of the Sleep Disorder Center here at the Cleveland Clinic, Dr Nancy Foldvary Shaffer, thank you so much for being here.

Nancy Foldvary: Thanks for having me.

Nada Youssef: If you want to just introduce yourself to our viewers.

Nancy Foldvary: Sure. I'm Nancy Foldvary Shaffer. I'm a neurologist and a sleep specialist, and I direct the sleep disorder center at the Cleveland Clinic where we treat people of all ages with sleep and wake disorders.

Nada Youssef: Great. And before we get started, please remember, this is for informational purposes only, and it's not intended to replace your own physician's advice. Sleep is so essential for mind, body, and soul. So I want to discuss very basics first. So let's talk about functions of sleep. Why do we sleep? What does it do to our body? What does it do to our brain?

Nancy Foldvary: Well, years and years ago, we thought that sleep was a passive process and it was something that we could do without, but now we know that sleep is a very active process. There are different stages of sleep. Sleep is critical to restoring our brain and restoring every cell in our body.

Nada Youssef: Sure. Great. And then what happens when you don't sleep enough? How many hours did we really need?

Nancy Foldvary: Well, that's by age. Babies sleep a lot, they sleep 15, 16, 17 hours and that's normal. And as a child grows up, sleep requirements decline to the point where most elementary school students should be sleeping somewhere between nine and 11 hours, teenager is eight to 10 hours, and adult's seven to nine hours. But recent studies show that at least 30%, maybe more of adult Americans are sleeping less than seven hours at night.

Nada Youssef: Wow. So if you're not getting enough sleep, what's happening to my body? Because I'm probably not getting seven or eight hours sleep most of the week, maybe the weekends, but that's it.

Nancy Foldvary: Chronic sleep deprivation is associated with a host of psychological problems, social issues, as well as medical problems. Studies show that if someone's restricting sleep to even four to six hours for a week, that's no different than being awake for 48 hours. And that means that our bodies aren't getting the restoration that is needed.

This leads to a buildup of toxins in our body, it leads to a buildup of inflammatory markers, that we believe underlie the development of chronic diseases like cardiovascular disease and obesity and diabetes.

Nada Youssef: Now, a lot of us aren't really counting how many hours we're sleeping, we just go to bed and wake up. So, what are the signs that I'm like, "Well, you know what? I think I'm sleep deprived." Are there signs?

Nancy Foldvary: And some of this is actually very simple. If you wake up in the morning and you're not refreshed and you're sleepy during the day or you find yourself yawning excessively during the day or you're tired or fatigued, all of these are very common signs of insufficient sleep. And typically, when people come to the sleep disorder center, we look at that first, and sometimes have people keep a sleep diary, Some people will bring in Fitbit's and other sorts of wearable data to the sleep clinic, and it just starts with getting enough sleep.

So we'll ask people to do what they can to extend their sleep before we get concerned that they have something more serious going on.

Nada Youssef:   That sleep diary you speak of, is that just like waking up and talking about if she slept well, how many hours you slept, dreams, nightmares or something like that, or what is that?

Nancy Foldvary: It can be very simple, like a lot of things when we chart them, we become more aware of them. So if you're charting what you're eating every day, you're probably going to be a little bit more aware of avoiding that late night snack that you know is not good for you. So same with sleep, if you chart bedtimes, wake times, and get trends and get a sense for, "Wow, I'm only sleeping four or five hours during the week, but I seem to really make up for that on the weekend."

These are patterns that are useful to evaluate, and they're are good signs that someone's getting not enough sleep.

Nada Youssef:   All week, I'm not sleeping that well. In the weekends, can I catch up on sleep? Does your brain actually catch up?

Nancy Foldvary: So that's a great question. We always thought in the past that it was impossible to catch up, it's something that you lose, that how can you ever catch up? But there is a recent study that showed that folks who slept four, five, six hours during the week and then caught up on the weekends were less likely to die, mortality, than those who remain chronically sleep deprived everyday of the week.

So it does seem that there are some benefits by trying to catch up on the weekend, but certainly better than that is to keep a stable sleep time, bedtime, wake time everyday of the week.

Nada Youssef:   Okay. So you just said two things: First you're saying that if you're not getting enough sleep, you're literally taking years out of your life?

Nancy Foldvary: Right.

Nada Youssef:   And then you can actually catch up on sleep on weekends?

Nancy Foldvary: You could catch up to some degree based on one recent study on the weekends. Better to try to catch up than to not catch up at all.

Nada Youssef:   Well, that's good. How about sleeping too much? A lot of people will maybe sleep in a lot. Is that a good thing or a bad thing? Sometimes I get groggy if I sleep a lot.

Nancy Foldvary: Yes. So actually, oversleeping turns out to have some of the same consequences as under sleeping. There's some data that suggests that people who oversleep, first of all, oversleeping is associated with depression, and depression is associated with a host of other problems as well. But oversleeping can make people feel like they're groggy and cognitively impaired. And there are some studies that suggest that oversleeping may also cause an increased risk of cardiovascular disease, diabetes, obesity as under sleeping. So best is to try to find that sweet violence.

Nada Youssef:   The balance. Can we talk about the stages of sleep? I know REM is one of them, that's all I know. But what are the stages of sleep?

Nancy Foldvary: There is Non-REM and there is REM sleep. And sleep, at the beginning of the night, sleep begins at Non-REM, stage one and two are light Non-REM stages. So we pass through those to enter into deeper stages. So deep Non-REM is also called Delta sleep or slow wave sleep. Deep Non-REM sleep is very important for cellular recovery of the body. It's important for growing for kids, growth hormone spikes and Non-REM sleep, so that bones and muscles grow and it's important for immunity. So it protects us from infection.

REM Sleep is the stage that comes after deep Non-REM sleep. And REM sleep is critically important for brain function, particularly learning and memory. So the memories that we build on over the course of the day really get ingrained into the brain in sleep. Also, recent studies show that students who stay up all night really don't do better on tests, even though they've put more hours in because they've deprived themselves of asleep that was needed to really ingrain that memory into the brain.

So you're better off looking at your notes before bed, getting a good night's sleep and you'll more likely remember the material much better than if you just stay up all night.

Nada Youssef:   A lot of people think, when you're sleeping, you're sleeping, nothing's happening. But you're saying that your brain is actually working quite a bit when you are sleeping?

Nancy Foldvary: Yes. Sleep is an active process for the whole body, and REM sleep is closer to wakefulness in terms of brain activity than Non-REM sleep.

Nada Youssef:   Really?

Nancy Foldvary: Mm-hmm (affirmative).

Nada Youssef:   Wow. So REM sleep. Let's talk a little bit about REM sleep. That's rapid eye movement. That's when we're dreaming. And this is when your brain is processing.

Nancy Foldvary: Yes. Brain is very active during REM sleep. There's a lot of vivid imagery that's happening, there's a lot of memory consolidation that's happening. The eyes move, which is why it's called rapid eye movement sleep breathing becomes more irregular, but we are paralyzed. People who happen to wake up out of REM, which can happen in normal state, but it also happens in some sleep disorders, can be very much aware that their bodies are paralyzed, their muscles are paralyzed. This is called sleep paralysis.

Nada Youssef:   I was just going to ask you about that because when I first had my children, I went through this like not sleeping very well.

Nancy Foldvary: You had that?

Nada Youssef:   It was a freaky, like where you actually, you're awake or you think you're awake, but your body's like paralyzed, you are not moving.

Nancy Foldvary: Yeah. And it can take a few minutes to work through, and it can be very frightening. People feel like they're not breathing, but in reality, their critical muscles are working, but skeletal muscles, like our arms and our legs cannot move. It takes a few minutes. And that's because, another interesting concept I think is that wake and REM and Non-REM sleep are not mutually exclusive. There's overlaps between them, and so in some states, like in people with narcolepsy, for example, people with narcolepsy have a very floppy sleep switch, so to speak.

So they're flopping in and out of stages of REM and Non-REM and wakefulness. They can wake up with pieces of them all. Brain's awake, you're pretty sure you're awake, but your body may still be in the state of REM sleep. There can be that dissociation. And while that's an extreme case with narcolepsy, when we are very sleep deprived, normal people can have that same thing happen.

Nada Youssef:   I see. Now, how many REM cycles do you ... What is normal? How many REM cycles should you go through in seven or eight hours sleep?

Nancy Foldvary: Well, we should probably be going through five, six, seven sleep cycles. A sleep cycle begins with wakefulness, and we descend into light Non-REM, deep Non-REM and then REM. And that's a whole cycle. So probably five of those is pretty typical, sometimes six or seven. And what's important is that Non-REM deep sleep is front loaded. We get more of that in the beginning of the sleep period and more of our REM at the end of the sleep period.

So if we are going to bed on time but always wake up at four in the morning because we have depression or because we're cutting sleep short to do other things, chances are we're cutting a few hours of REM out of our sleep cycle.

Nada Youssef:   What messes with REM? I've heard alcohol might mess with REM. It puts you to bed faster, but you don't really get into the REM state? IS that true? Or substance abuse?

Nancy Foldvary: Yes. There are many medications and substances that suppress REM sleep, and then as they withdraw, like alcohol, can actually rebound REM sleep. So there can be abnormalities associated with that. But sleep apnea for example, is particularly likely to present in REM sleep because in REM, again, we're paralyzed. So the muscles of our chest wall that normally would help us breathe and sleep are not working well. And so the airway can collapse more readily and people can have very long sleep apnea episodes where the heart rate changes significantly and oxygen levels really go down.

Nada Youssef:   I'm glad you jumped to sleep apnea, that was going to be my next question. Wildly undiagnosed, what is it and how common is it?

Nancy Foldvary: Sleep apnea is one of the most common reasons why people come to sleep centers. It affects moderate to severe sleep apnea, which means that during sleep, at least 15 times per hour, there's an apnea episode, an episode where the airway is collapsed or partially collapsed, and therefore the brain waves have to wake up to say breathe or oxygen levels drop. 15 times or more an hour occur in about 10 to 17% of men and three to 9% of women are so.

And what's most important is that in this country, we estimate that 85 to 90% of people with sleep apnea don't know they have it. And moderate to severe sleep apnea, those are the statistics just for moderate to severe disease. It's much more common if you consider all ranges of disease, even people with mild sleep apnea may be at risk for some problems particularly daytime sleepiness and poor performance as well as mood changes.

So it's a very common disease and grossly under recognized and very treatable, and it's associated with cardiovascular events, including sudden death and arrhythmias and hypertension as well as diabetes and obesity.

Nada Youssef:   Now, you said that a lot of people don't know they have it, like the mild sleep apnea. What are the signs? Do you know? Don't people wake up gasping for air? Or is that if it's only extreme?

Nancy Foldvary: That's a sign. Gasping for air, waking up feeling like you're breathless or choking is one sign. Snoring is the most common sign. Now, not all snorers have sleep apnea, but snoring is usually the first symptom. And daytime sleepiness, fatigue, tiredness is another symptom. And then there are many others too, like waking up, feeling ... waking up too many times at night for unclear reasons, waking up and using the bathroom a lot, cognitive impairment, memory problems, even sexual dysfunction in men and in women, morning headaches.

There are many symptoms. I think the challenge is, is that physicians aren't all really well trained in recognizing sleep apnea. Sleep disorders is not something that most of us learned about in medical school. And so, there's a lack of knowledge in the medical community, and it really depends on a bed partner often, like telling the patient that, "You know, you're snoring, you're stopping breathing, it's scary watching you sleep."

We don't often have that. Sometimes bed partners aren't paying attention and not all of us have bed partners. It's something that people, I think forget to bring up when they're at their primary care visit once a year, and so it can go missed for many, many years.

Nada Youssef:   What are the causes? What are the main causes for sleep apnea?

Nancy Foldvary: Well, obstructive sleep apnea as the main type of sleep apnea, by far it's the most common. And this is upper airway collapse in sleep. This is due to floppy muscles in the back of the throat that is most commonly happening in people who are overweight, men more than women, but after menopause, women are equally affected and probably about 25 to 30% of this is genetic. There are folks with obstructive sleep apnea that are not heavy, so you wouldn't really recognize all of them.

Sometimes there is obstruction in the airway, like big tonsils or other kinds of obstruction in the airway. In children, there may be genetic disorders or neurological conditions or some other disorders that might predispose them because of some craniofacial problem. But obesity, increasing age and, at least in middle aged adults, male gender are three of the primary factors.

Nada Youssef:   And if left untreated, how serious does this get?

Nancy Foldvary: If it's moderate or severe sleep apnea, studies, observational studies show that untreated patients have an increased risk of heart attack, stroke, cardiac arrhythmias, obesity, diabetes, sudden death, let alone the cognitive impairment and the daytime sleepiness and the impaired quality of life, and those increased motor vehicle accidents, underachievement in school.

Nada Youssef:   Now, if I have a sleep partner and I'm noticing them starting to snore, what is the advice, what am I supposed to do? Just to let them know or what advice do you do have for them

Nancy Foldvary: Well, snoring folks have a high chance of having sleep apnea. Some snoring is benign, but we don't really know that completely without taking a pretty good sleep history and without doing a sleep test. For people who snore, I would ask them how they feel at the end of a sleep period, are they refreshed? Are they sleepy during the day? Are they waking up unexpectedly at night and not able to fall back to sleep? Do they feel a sense of choking or airway obstruction?

All of those things are important. And sometimes people have no other symptoms but they have a medical disorder that might have been caused by sleep apnea. A younger person with elevated blood pressure or somebody who's gone into atrial fibrillation, a common cardiac arrhythmia, or somebody who has got prediabetes those hemoglobin A1c values are up.

Folks who really want to optimize their health, who snore, really ought to get an evaluation because treating sleep apnea can reverse all of those things I just mentioned. On rare occasion, a patient might come off their blood pressure medication because their high blood pressure really turned out to just be sleep apnea. So sometimes the sleep history helps a lot and other times I'm fooled, I do a sleep study and really don't think this person probably has significant disease and I'm surprised and I've been doing this for over 20 years.

Nada Youssef:   SO the sleep diary sounds like a ... that's exactly when that would help.

Nancy Foldvary: A sleep diary is helpful and then a sleep study. So obstructive sleep apnea is one of several sleep disorders that require a sleep test. And this test can be done in a sleep laboratory or now it can be done at home in certain situations. We do home sleep studies that are meant to confirm the diagnosis of sleep apnea when we really think that patient has it. If we're really not sure what they have, it's much better to sleep in a sleep laboratory because we can put wires on the brain to record the brain waves, wire up other parts of the body to really see what's going on at night.

But there is a subset of people with sleep apnea where we know what we're dealing with. And really, all we've got to do is do a sleep study, it can be done at home with a few sensors, three, four sensors that people could apply on themselves. We can get those results really quickly and start treatment very quickly.

Nada Youssef:   What is the treatment for sleep apnea?

Nancy Foldvary: There are several different treatments. Sometimes, for people with very mild sleep apnea, we may see at a sleep study that the obstruction of the airway only happens when people are sleeping on their back. For a small percentage of people, we just say, "Let's teach you how to sleep on your side with a body pillow or some other mechanism." Some people need to lose some weight and can show that after they've lost weight, their apnea lessens.

And other people use devices like CPAP, Continuous Positive Airway Pressure. So these are the pressurized masks that can be placed inside the nose or over the nose or over the nose and mouth. This is CPAP or positive airway pressure that has been our gold standard treatment for many years. But now we have other alternatives for people who can't tolerate CPAP or where maybe seed pap is not desirable for some reason or another.

There are oral appliances and these are dental devices that really need to be manufactured to meet the needs of an individual by a dentist that help to pull the jaw forward to create space in the back of the throat. And then we've got a newer treatment in the last couple of years, which is a revolutionary treatment, which is hypoglossal nerve stimulation. This is a nerve stimulator made by Inspire and I think we'll see other kinds of devices like this too that allow people to not be tethered to a CPAP machine.

Nada Youssef:   What exactly, what kind of treatment is that? What do they do exactly?

Nancy Foldvary: Hypoglossal nerve is one of the cranial nerves that comes out of the brainstem and it controls the movements of the tongue. When the hypoglossal nerve, a certain part of the hypoglossal nerve is stimulated, the tongue protrudes from the mouth. And so this is a stimulator device that's implanted under the skin in the chest, like a pacemaker would be, and it's wired up to this nerve in the neck. And it also wires down to a space in between the ribs here to sense breathing.

And this device can be activated with a magnet by the patient at night, and during the night then, the device stimulates the tongue to protrude out of the mouth creating space in the airway. Now, this treatment can be very effective for treating sleep apnea, but there are clear criteria that must be met for people to meet this. Otherwise, we'd be implanting devices like this knowing that the outcome is probably not going to be superior to CPAP.

So it's important that people go to a center, a sleep center, and be evaluated by an expert who knows ... a team of experts, including an otolaryngologist, usually with a sleep specialist to screen you for this device, which then ends up meaning that only a subset of people with sleep apnea right now are probably eligible for this treatment.

Nada Youssef:   I see. And you said this was called Inspire?

Nancy Foldvary: Inspire is the manufacturer. It's called hypoglossal nerve stimulation.

Nada Youssef:   Wow. Mouthful. All right, so let's jump onto the insomnia. I want to talk about insomnia, what that is and how common insomnia is.

Nancy Foldvary: Oh, insomnia is also very common sleep disorder. We estimate that about 10, maybe 15% of adult Americans at any time in their life have chronic insomnia, which is recurrent nights of sleeplessness for at least three months of a period of time. All of us probably have experienced a sleepless night once in a while. Acute insomnia happens commonly in people who've lost a loved one or lost a job. Sometimes even with travel like jet lag, there might be a period of acclimation back home.

But chronic insomnia, again, 10 to 15% of adults has some of the same consequences as sleep deprivation, as we talked about earlier. Most notably, things like mood disorders, depression, anxiety are very co-connected with chronic insomnia, substance abuse. Sometimes people begin to use substances to help sleep.

Nada Youssef:   Thinking it'll help them sleep.

Nancy Foldvary: Absolutely. But sleep loss from chronic insomnia can clearly cause people to have trouble, struggling at work, and struggling at school, behind the wheel, cognitive issues, depression, and all the other cardiovascular and health effects that come from chronic sleep loss. Women are more likely to be affected than men in contrast to the sleep apnea story.

Again, after menopause, women are equally affected, but generally women outnumber men when it comes to insomnia by two to three to one.

Nada Youssef:   So you're saying you have to have insomnia for three months to be diagnosed with insomnia, is that correct?

Nancy Foldvary: For chronic insomnia.

Nada Youssef:   For chronic insomnia.

Nancy Foldvary: Most sleep disorders officially have symptoms for at least a period of three months of time before they can be diagnosed as chronic sleep disorder.

Nada Youssef:   Do they need like a behavior modification, some melatonin or what kind of treatments do you have for that?

Nancy Foldvary: There are a variety of treatments. Of course, many people now use melatonin, which is really not the best sedative hypnotic. Melatonin is actually very effective for what we call phase shifting, for example, night owls are people who ... some night owls are really genetically wired to sleep the way they do and to not feel sleepy till two in the morning, and that's because their melatonin secretion in their brain is delayed.

So those folks really benefit from a melatonin therapy. There are a host of sedative hypnotics that are prescription drugs. Of course, there are many things people can buy over the counter, but the therapy that works in a more sustained way comparable to sleep aids and in fact superior to, is cognitive behavioral therapy, which is a host of strategies that people can learn in a variety of ways to help them sort of unlearn bad sleep habits and learn good sleep habits.

So there's a cognitive piece and then there are behavioral components of this. And it can be delivered by web, like computerized programs that are available. It can be delivered by a behavioral sleep medicine specialist psychologist, and most medical professionals are beginning to understand some of those aspects. It's a very simple set of tips that that people begin with: Setting asleep time, setting a wake up time, being consistent is really important.

And some of the things we've already talked about: Avoiding alcohol within a few hours of bedtime, avoiding caffeine before bed time, avoiding nicotine. These are all stimulating. Avoid heavy meals within a few hours of bedtime. Avoid exercise within a couple hours of bedtime because all of these things in one way or another, either fragments sleep or cause stimulation.

Nada Youssef:   Now, to ensure a good night's sleep, what is the sleep hygiene, from the sleep expert, what would you say what to do? What not to do? I know sleep in a cold room is a huge one because that affects me big time. What else do you have for me?

Nancy Foldvary: I think it's important to say that we all have an individual need for certain amount of sleep. We're all vulnerable to different things, I think. And so really, you've got to come up with a bedroom and a sleep space that works for you. Some people like it colder, some people like it warmer. Some people aren't bothered by a TV in the room, but for people who really want to optimize sleep, it should be no electronics in the room, it should be no getting in the habit of eating in bed and playing on the phone in bed.

Really, the bed is for sleep, and the lighting needs to be down and we really shouldn't expose ourselves to bright light at night. But probably the most important thing for ensuring chronic good sleep is to set a bedtime and wake time. And more important is the wake time. If we set our wake time to be the same every day, our brains sort of are programmed to know how much sleep we should get, and we might be able to change bedtime a little bit, but if we adhere to a single set wake time, we really can ensure a stable sleep wake period.

Nada Youssef:   That makes sense because even on the weekend, I feel like my body alarm clock is just on exactly the same time everyday, but I can sleep different time.

Nancy Foldvary: Yeah. And think about the people who let themselves sleep in until noon on Sunday. They're going to really struggle to go to bed Sunday night.

Nada Youssef:   And go to work on Monday.

Nancy Foldvary: And then they'll be sleep deprived on the first part of the week there.

Nada Youssef:   How about sleep positions? Is it best to sleep on your back, on your side, on your stomach? I heard you're not supposed to sleep on your stomach. Is that true?

Nancy Foldvary: Well, you're not supposed to sleep on your back if you're at risk for sleep apnea, because when we're on our back, the gravity of the tongue moves forward and then that further collapses the airway. There are folks, as I alluded to, who have sleep apnea only when they're lying on their back or who snore worse when they're on their back. The problem with ... For example, babies, there's this back to sleep campaign where you want babies sleeping on their backs, not on their tummies because of the risk of SIDS.

For most other sleep disorders, the body position doesn't matter so much. It's really just for sleep apnea, avoiding the back position.

Nada Youssef:   Okay. I'm going to ask you one more question and I'm going to go to live because we're getting a lot now, but I want to talk about naps because I'm, well, I would say 10 minute power nap, it takes me a half hour to get there, but there's people that sleep for two hour naps. What's normal, isn't normal?

Nancy Foldvary: Well, naps are okay. They should be earlier in the day like before two, three in the afternoon and they probably should be less than an hour. Even better is for people who can power nap for 15, 20 minutes. That's great. When you get into the hour or longer, you risk getting into those deep stages of sleep and then waking up with something we call sleep inertia. That groggy feeling where you don't even know where you are.

Nada Youssef:   Tomorrow or yesterday, and you have no idea.

Nancy Foldvary: Right. And then the net may not even be refreshing and worse yet, probably you slept off some of your sleep debt so you might have trouble sleeping tonight. Because as we wake up in the morning, what happens from wakefulness is that we're creating a debt, and at some point we need to sleep it off. And so if we let ourselves sleep it off too early in the day, we might compromise nighttime sleep and then that could create this variability and wake times and bedtimes, which leads to chronic problems.

Nada Youssef:   So if you take a nap, no longer than an hour.

Nancy Foldvary: Right.

Nada Youssef:   Okay. Great. All right, let's take some live questions. I have AJ. How can one keep their mind calm when trying to sleep and stress about activities and things to come before heading to sleep? That's a good one.

Nancy Foldvary: This is a great question. This is part of the most common chronic insomnia of adulthood, which is an insomnia where people are ruminating at night and you can't turn off your brain. And then eventually what happens is that there is a habit that, "I'm going to ruminate at night and I'm going to be thinking at night." And so people begin to expect that and then can't undo that. And so I think it's important to create sort of a bedtime ritual and that means winding down an hour or two before bed.

That really means, for some people, who are prone to insomnia, that means turning off the electronics, dimming lights, figuring out what your sleep ritual, what do you need to really get comfortable? Is it a bath, is it a glass of milk? we all have different sort of strategies for that. Another tip that our behavioral sleep medicine colleagues will recommend for people who ruminate a lot, will be to keep like a worry journal. Like plan your next day or work through all the things that you worry about every day and do it at a set time of the day so you can sort of put it away and then go to sleep.

Nada Youssef:   Oh, that's a really good idea. I like that one. Okay. And I have David. Can you address the results we get from our Fitbit. If they are accurate, should we talk to our family doctor?

Nancy Foldvary: That's a great question. There are many wearables now that are recording some type of sleep information. The sleep field really doesn't have a lot of scientific information about most of these. There are a few studies that show that there's some correlation between Fitbit sleep activity and what you might get in a sleep laboratory. What I would say, since there's not a lot of information yet on this, is that if you're keeping track of your sleep and you feel that the results of the Fitbit kind of fit with whatever you're feeling, if your Fitbit results say you're getting restful sleep and you feel great during the day and you feel rested in the morning, you're probably a pretty good sleeper.

And maybe that's not a problem. But if your Fitbit is telling you something that sleep is not right and you feel unrefreshed, you need to nap during the day, something's not right, you're not thinking clearly. I think that's appropriate to take to your doctor.

Nada Youssef:   So listen to the signs that your body is giving you?

Nancy Foldvary: Yes.

Nada Youssef:   Because sometimes your Fitbit will tell you every time you go into REM sleep and how many times you went. I wonder if that's accurate as well. Christopher. I often wake up with my heart beating fast and being out of breath. Can snoring be the reason for sleeping bad?

Nancy Foldvary: Well, that sounds like sleep apnea. Snoring is the sound that the muscles in the throat make. It's the vibration sound that the muscles in the throat are making to keep the airway open. When the airway's getting floppy, most snores stop breathing, that's called apnea. And it sounds like you're having more than snoring. That sounds like you're having sleep apnea. So that's definitely something to talk to your doctor about and that's something that would require a sleep test to confirm.

Nada Youssef:   Great. Thank you. Kelly. Any tips for someone who started a third shift position over a year ago and just can't get used to that sleep schedule?

Nancy Foldvary: We hadn't touched on this. Shift workers are at very high risk of being chronically sleep deprived, because our bodies and brain sort of tell us when we should be sleeping, and we should be sleeping at night. This is the circadian rhythm and we should be awake during the day, and shift workers are just forced to do the opposite. Again, some people are very able to adapt to this and others just are more vulnerable to the effects of chronic sleep loss. And so we call this, shift work disorder.

Shift workers who end up getting chronically sleep deprived and then have trouble performing, trouble thinking, are at very high risk for accidents and injuries on the job and driving home from work. There is a medication that's a wake promoting medication that's FDA approved, to help people stay awake when they're shift workers. But that really is sort of treating the symptom, it's not really getting to the root of the problem, which is the chronic lack of sleep of shift workers, which I don't really have a great answer for.

But the literature is showing us that shift workers are at higher risk for the same cardiovascular problems, diabetes, obesity. And this is probably because of this chronic lack of sleep.

Nada Youssef:   Now, it's vacation season, schools out. What do you say about jet lag? Any advice for travelers?

Nancy Foldvary: Well, jet lag is also very individual. Some people manage to not have trouble at all and others have a lot of troubles. When people are traveling more than a couple of times zones away, they may be at risk for jet lag. And we will use melatonin sometimes for jet lag. And there are online like jet lag calculators, so you could actually go online and figure out where you're traveling to, and so what time should you take melatonin. This is a very important point that, depending on which direction you're traveling and how many times zones you're traveling, the timing of melatonin is critical.

If you take it too late, it can give the opposite effect. So this is something that's worth consulting a sleep specialist about. If you're really traveling far and you have problems like this or going online to see if you could figure it out with jet lag calculator.

Nada Youssef:   How long does it take when you consume the pill? Like 45 minutes, 20 minutes?

Nancy Foldvary: Well, there's some sustained release products and some a regular, but really it's about starting to take melatonin several hours before your new bedtime when you travel, and then maintaining that timing of the melatonin at your destination site. And then on your way back, changing it to the time of your return, your bedtime when you return. It's a little confusing and so it's worth looking into that and reading online to think about the timing of it.

Nada Youssef:   Great. And then Jessica. Is it a bad habit to use TV to fall asleep? I can't sleep without the TV on. I know so many people are like that.

Nancy Foldvary: So many people are like that. Really, most people have electronics in their bedroom and for many folks, they've incorporated it into the sleep ritual. It's part of the sleep ritual and it works, so it's hard to argue with that. But, for the 30% or so of Americans who have insomnia or sleep apnea, maybe more than 30%, if you know you've got a sleep disorder or you have symptoms of a sleep disorder, it's only made worse by not really protecting your sleep and adhering to really good sleep hygiene practices.

Another thing I forgot to mention about the insomnia tip is, we have a rule called the 20 minute toss and turn roll. If you're laying in bed for 20 minutes or more and you're tossing and turning, of course, we tell people not to look at the clock, so you've got to figure out how long it has been, but we just don't want to be laying in bed not sleeping. That teaches us that it's okay to lay in bed and not sleep. And some people will tell us who have chronic insomnia that, "I just like to lay there and rest," but that's wrong, that's wrong.

We want to really try to do everything we can to protect the bed for sleep and so having the TV on in the room is generally not advised.

Nada Youssef:   Now, I have a personal question for you. I don't have a TV in my room, but last night, I was tossing and turning probably for hours. So after 20 minutes if I know that I'm not sleeping, I might have to get up. Or sometimes I'm like going to close my eyes and just begin thoughts and-

Nancy Foldvary: Yeah. After 20 minutes you should get up. You should go into a different room. You should do something else, not stimulating, read something that's kind of the newspaper or something that's not going to really get you going. We don't want people like finishing the last chapter of a great novel a two in the morning. I have patients who will iron, boring tasks and really not get back in bed until you feel like your eyelids are droopy and you really feel like I can sleep now.

It doesn't seem right to all insomniacs to do this. And sometimes people will come back to the clinic and say, "I was up and down all night." But part of undoing a longterm bad sleep habit is working through it. And this staying out of bed when you're not asleep is critical for insomniacs.

Nada Youssef:   Great. Thank you. And then I have Ginger. Is there any kind of mouth guard that can be used for sleep apnea? I have seen advertisements recently.

Nancy Foldvary: Yes. There are many different oral appliances. We as sleep experts do not advise that people buy things off the shelf because these oral appliances are meant to really pull the jaw forward. And with that comes the tongue and some of the muscles in the back of the throat to create space in the back of the throat. These potentially can cause some problems with dentition and TMJ joint pain. And so really these ought to be done under the guidance of a dentist and dentists can make these, can manufacture these devices that are specifically for your mouth with your dentition.

And that's probably the safer strategy for using an oral appliance than buying something off the shelf.

Nada Youssef:   What about teeth grinding?

Nancy Foldvary: Teeth grinding is common and most of the time it's not associated with any other sleep disorder. And when dentists say that you're wearing down the surface of your teeth, they may recommend sort of an off the shelf sort of appliance, just to protect the surface of the teeth. But that's not something that's going to treat sleep apnea.

Nada Youssef:   Right. And now, teeth grinding, it's really hard to tell if you're doing it. I feel like you'd have to ... I started hearing my kids grinding their teeth during vacation when I let them sleep in my room. But other than that, I had no idea it was happening.

Nancy Foldvary: Yes. I think that's common that a dentist will say the child's teeth are wearing down and so they must be grinding. Some people seem to know it, they seem to recognize it and feel some pain in their muscles and in their cheeks and their jaw. But yeah, I think more often, we see it on a sleep study and we just happened to see it and people really don't recognize that they've been doing it.

Nada Youssef:   Okay. Sue. I'm on a sleep apnea machine, and every morning I have trouble breathing. Why is that?

Nancy Foldvary: Well, you're getting blown away with pressure. Based on a sleep study, it need 18 centimeters of water pressure blowing constantly through your machine to keep your airway open, but some folks can't tolerate that. It could lead to swallowing of air, and it can lead to worsening sleep apnea. So the C in CPAP stands for continuous. Continuous positive airway pressure means that that machine is blowing 18 centimeters of water pressure in constantly. It may be fine when you're breathing in, but then your body and your chest wall has to breathe out against that positive pressure.

If you're having problems with how you feel in the morning after being on a machine with that high of a setting, even though it might've been medically appropriate, there are alternative modes of PAP therapy, like an automatic titrating device and something called bi-level path, that allows you to set multiple settings. Two settings, one during inhalation, one during exhalation. So it makes it easier to breathe out all that positive pressure. So that is definitely worth bringing back to your sleep doctor.

Nada Youssef:   There you go. Thank you. "Chris. I've been diagnosed with obstructive sleep apnea, but I have difficulty wearing the mask. Are there any remedies to the mask?"

Nancy Foldvary: Well, there are lots of ways we salvage sleep apnea masks. Many times when people come to the clinic and they have problems with CPAP, we find that they have the wrong size mask, they're on machine that's not the ideal mode as I was saying a moment ago. And some folks just can't tolerate CPAP, but there are lots of ways to salvage it. So before you give up, I'd highly suggest that you see a sleep expert to think through really what your available options are.

If your sleep apnea is mild, there might be alternative options. If you meet criteria for the hypoglossal nerve stimulation, that might be a great option. And then if you meet criteria for an oral appliance, that too can allow you to not use CPAP. There are many alternatives and sometimes, it takes a long time for people to get back to a sleep center to really explore those. I wouldn't give up on CPAP, until you go back to your sleep doctor and see if you qualify for any of those other remedies.

Nada Youssef:   Great. "I'm Scott. I've lost 160 pounds. Is it possible I don't need my CPAP anymore?"

Nancy Foldvary: Yeah. Good for you, Scott. Yes, it is. Now, not everybody, even after extreme amounts of weight loss normalizes their sleep apnea. So we see people routinely who are going for bariatric surgery, various types of weight loss surgery and sometimes they come back to the sleep clinic disappointed because we repeat a study after they've lost 100 pounds and they still have sleep apnea. Usually the sleep apnea is milder and if it's milder, that often means that the pressure settings on the CPAP can go down.

And on occasion, it means that maybe there's an alternative therapy to CPAP, but then there are many people who lose a lot of weight and we'll retest them in the sleep lab and find that their apnea is gone or virtually gone. And so they can be relieved of their CPAP machine. So that warrants a new sleep study.

Nada Youssef:   So Scott needs to go back and get a new sleep study in his case?

Nancy Foldvary: Yeah.

Nada Youssef:   Great. Cheryl, "Do people with shallow breathing qualify for CPAP?"

Nancy Foldvary: Oh, that's very difficult. People who qualify for CPAP are people who have sleep apnea, which means that you got at least five times per hour where you obstruct your airway on a sleep study and you have some symptoms from it or you obstruct your airway 15 times per hour. And rarely, we use these machines, not CPAP, but another kind of PAP for people who have low oxygen levels, but not simply for shallow breathing. I'm not sure what ... Shallow breathing can happen from a number of causes like chest wall diseases and neuromuscular problems.

That's probably worth undergoing a sleep study to see if you in fact may have sleep apnea, because some people with sleep apnea wake up and just feel that breathlessness and sort of assume that they've been breathing in a shallow way.

Nada Youssef:   Interesting. All right. And then I have Linda, "How do you handle legs and arms that just keep moving? Is that restless leg syndrome?"

Nancy Foldvary: Restless legs is also a very common sleep disorder. 10, 12% of the adult Caucasian population in the United States, a little less in African-Americans, but this is also a common disorder. And this is a disorder characterized by an urge to move the body. It's called restless legs because it was first described as legs, but some people have restless arms and some people have restless bodies. The key thing is it's an urge to move the body that is relieved with movement that happens when you're at rest and at night.

Many people with restless legs have low brain iron levels and so we do a blood level of a protein product that carries iron, and sometimes the treatment is simply iron replacement, but if my restless leg requires those additional features, not just the movements and the movements at night, but the urge to move before bedtime, that's relieved by movement.

Nada Youssef:   Okay. Speaking of movements, I remember the question that I have for you, sleepwalking, is that normal? Because I know some people that sleepwalk and what to do when you notice someone's sleep walking.

Nancy Foldvary: Yeah. Sleep walking is not uncommon in children, but it's a genetic disorder we believe. It tends to run in families. Most childhood sleepwalkers are going to go in remission, meaning it's going to go away as they get older, but sometimes it doesn't go away and sometimes it recurs in adulthood, usually under situations of extreme stress or sleep deprivation, but there are a host of medicines on the market, including some of the drugs that are prescribed for sleep disorders like Zolpidem, a drug that is commonly used for insomnia that can activate sleepwalking.

And so sometimes we'll hear about sleep walkers, sleep drivers-

Nada Youssef:   It'll activate the sleep walking?

Nancy Foldvary: Yes. It can cause episodes of sleep walking in somebody who's not otherwise genetically predisposed to sleep walk. Fortunately, most of the time sleep walking is a rather benign thing but some people walk routinely to the kitchen and eat and sleep, eat-

Nada Youssef:   And eat, wow.

Nancy Foldvary: And there are folks who can sleep drive and so, these kinds of behaviors can get people into trouble. What's really important is to ensure that you're getting enough sleep, not letting yourself get sleep deprived and managing stress because those are the two things that tend to activate in sleep walkers.

Nada Youssef:   What are those chemicals doing to our brain that are making us sleep walk or do things that we are not aware that we're doing?

Nancy Foldvary: Well, sleep walking is one of the Non-REM sleep, deep Non-REM sleep disorders of arousal. So there is a faulty arousal system that causes an arousal out of a deep stage of sleep that is followed by automatic behavior. Behaviors that we can do during wakefulness but normally wouldn't do during sleep. That is abnormal. Again, there's probably some genetic predisposition for those kinds of arousals. Sometimes children will have night terrors, screaming, inconsolable screaming in sleep, and sometimes we will see what we call confusional arousals, which are faulty, this dysfunctional arousal from sleep that causes people to sort of look around and appear confused.

Can happen in children, can happen in elderly people, and those folks might not get out of bed. So there's the spectrum of confusion in bed, but I stay in bed to screaming, to walking, and eating and doing other things. And this is all thought to be genetically due to some faulty arousal system out of deep Non-REM sleep.

Nada Youssef:   Now, if you see like my daughter sleep walking right now, what do I do? Do I wake her up? Do I just let her go? She might hurt herself. What do you do with that?

Nancy Foldvary: Yes. The best thing to do is first of all, if you know you've got a sleep walker in the house, is to protect the environment. And so for people who are sleeping on the second story and have to be, you can put some sort of a bell or something on the door, something to wake other people up in a household. Make sure that windows are locked and so the people can't jump out of windows and fall downstairs, some of that kind of stuff. What we typically instruct on is not to like shake a patient awake because this person's in deep Non-REM sleep.

And sometimes these disorders happen out of REM sleep, where there can be active dreaming and someone can be dreaming about being chased by a murderer or something like that. And so you really don't want to abruptly shake people awake, they may act out against you. Best is to sort of coax a sleepwalker back to sleep, gently coax them.

Nada Youssef:   Great information. Thank you. Jake, "Any suggestions for those with Takayasu’s, aortic arch syndrome, lower vascular narrowing, who experience right leg restlessness, leg pain, like pins and needles. One idea circulated is to use a cold compress, which is a cool damp towel. And thanks for your thoughts.

Nancy Foldvary: Oh my gosh, that's a hard question, but yeah.

Nada Youssef:   It's loaded.

Nancy Foldvary: That's a hard question. It is loaded. Any cardiovascular disease, folks who have any kind of sleep complaints and have cardiovascular disease like valvular disease, really ought to be evaluated carefully for some type of sleep disordered breathing, some type of sleep apnea, because there's treatments. And those treatments can reduce vascular events and can protect heart function and allow the heart to rest at night. There are also people who have restlessness or restless leg syndrome associated with sleep apnea and simply treating the sleep apnea makes that restlessness go away. And so that's something to consider as well.

For restless leg syndrome, there is a device on the market that's a vibration pad essentially, because one of the things that seems to really work for restless legs is that counter stimulation, the rubbing, massage, that kind of stuff. And so there is a vibration pad that RLS patients will use as well, that sort of provides that counter stimulation so people feel less of an urge to move at night.

Nada Youssef:   Okay. And now Christopher said he heard that there is a ring that helps stop snoring and would you recommend it?

Nancy Foldvary: There are devices that work on snoring. There are a number of things that can expand the space in the nose and that can create space in the back of the throat by plugging in the nose. And these things can be effective for primary snores. Primary snores are folks who snore and it's a nuisance, but there is no evidence of sleep apnea. That requires a sleep study to know that. Other treatments for primary snores would be addressing things like nasal congestion. Sometimes people only snore when they're stuffy and they have a cold, chronic allergies and things like that are also useful to get evaluated if you're a snorer.

Nada Youssef:   Let's jump on to like people that have nightmares from let's say, PTSD or some kind of depression or something that they went through. Is there any recommendation for nightmares?

Nancy Foldvary: Well, nightmare is actually can be associated with PTSD. They very often happen in people with PTSD, but nightmares are a manifestation of REM sleep, and there are a number of REM sleep disorders as well. And so if you think about it more globally, we're interested in making sure that REM sleep disorders are not present. There is a medication that can be very effective for nightmares. There is also forms of behavioral therapy where people could sort of rehearse dreams and sort of change the ending.

And this is done with behavioral sleep medicine psychologists and even non sleep train psychologists who treat people with PTSD. A combination of those two things, I believe is very effective for nightmares.

Nada Youssef:   Okay. And then Jody wants to know, "Everybody's tired. How do I know I have a problem?" That's a very good question.

Nancy Foldvary: Well, I guess stress is fatiguing. Stress is really difficult on brain function, but everyone shouldn't be tired, if everyone were getting seven, eight hours of sleep. I think sleep deprivation is an epidemic in this country and most of us are not paying attention to it. I would challenge you first to keep track of your sleep, see if you really are getting at least eight hours of sleep and if you are tired and you're getting eight hours of sleep, you may actually have a sleep wake disorder and that might be worth evaluating. There are many scientific studies now that focus on tiredness and the effects of sleep deprivation.

We know that just being awake for 16, 17, 18 hours, which is how we are in the evening, leads us to have motor performance and cognitive performance comparable to having a blood alcohol level of .08, which is legal intoxication in some states. We need sleep, we need seven, eight hours of sleep at night. And if we're getting that, but we're only getting that once in a while, we're chronically sleep deprived and that really is the most common cause for sleepiness and tiredness in our society.

Nada Youssef:   That's crazy, what a good sleep can do.

Nancy Foldvary: Yes.

Nada Youssef:   Okay. One last thing for you before I let you go. I'm a very light sleeper. Since I became a mom, I'm a very, very light sleeper. I can hear every little thing, any recommendation? Without drugs, without melatonin, without any of these sleep aids. What do I do?

Nancy Foldvary: Well, people use earplugs now. It's really the environ ... There's so much environmental noise and stuff happening anymore. We don't really protect our night times anymore for quiet time. Some people who are light sleepers really benefit by making sure that window treatments are covering the whole window. So light's not coming through, that sounds are quiet, keep pets out of the room. And probably earplugs-

Nada Youssef:   Keep pets and children out of the room.

Nancy Foldvary: Yes. Pets and children.

Nada Youssef:   All right, well, that's all the time that we have for today. Is there anything that you want to kind of close with?

Nancy Foldvary: Well, I just want to say that sleep is as important as diet and exercise, and we really spend a lot of time focusing on how we eat and how we move during the day. A recent study actually, the National Sleep Foundation came out with a poll earlier this year that showed that only 10% of people prioritize and value sleep over all of these other things we do, our hobbies, our diet, and our exercise. So if you just think of it as one of those critical things you need to manage like diet and exercise, I think we'd all be a little bit better off.

Nada Youssef:   This information is critical. Thank you so much for being here today.

Nancy Foldvary: You're welcome. It was fun.

Nada Youssef:   Thank you. And as far as our next Facebook Live, we'll be back next Wednesday at 12:00 PM Eastern standard time. We will have on Chef Jim Perko from the Wellness Institute, as he prepares a dish you can cook up for Father's day. He will be making [ground 00:54:05] salmon and pasta with green beans, a recipe that you will love and that will love you back. And for more health tips and information, please follow us on Facebook, Twitter, Snapchat, and Instagram @Clevelandclinic, one word. We'll see you again next time. Thank you.