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Sleep and the RDN: Incorporating Sleep Education to

Reduce Chronic Disease Risk

This material is based upon work supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, and the Office of Military Family Readiness Policy, U.S. Department of Defense

under Award Numbers 2015-48770-24368 and 2019-48770-30366.

Connecting military family service providers and Cooperative Extension professionals to

research and to each other through engaging online learning opportunities

https://militaryfamilieslearningnetwork.org

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Today’s Presenter

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Robin M. Tucker, PhD, RD, FAND• Assistant Professor• Department of Food Science and

Human Nutrition at Michigan State University

• Researches how sleep affects food choice, body weight, and chronic disease risk.

Disclosures

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Dr. Tucker has received research funding or speaker fees from:– USDA Hatch Funding– Academy of Nutrition and Dietetics/McCormick Science Institute– PepsiCo– Ohio Academy of Nutrition and Dietetics– Michigan Health Endowment Fund

This funding is unrelated to the information presented today.• All photos in this presentation are from pixabay.com and are free for commercial use with no

attribution required.

• After this presentation you should be able to:– Identify at least two ways that insufficient or poor sleep

can contribute to chronic disease risk.– Identify at least two causes of sleep problems.– Describe at least two approaches that dietitians can

share with patients and clients that have been shown to reduce sleep problems.

Objectives

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• Crash course: Sleep 101• Insufficient sleep and chronic disease risk

– Mechanisms• Sleep in the hospital: Stuff of nightmares!• Sleep and performance• Sleep disparities• Recommendations for improving patient sleep outcomes

– Sleep hygiene– Stimulus Control Therapy

Today

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How much sleep did you get last night?A. Less than 6 hoursB. More than 6 but less than 7 hoursC. Between 7 – 9 hoursD. More than 9 hours

Pop Quiz!

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Please respond using the poll pop-up.

Sleep 101: What is sleep?

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What is sleep?

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A period of reduced responsiveness to stimuli, usually associated with immobility, that is reversible.

• Appears to be essential.• No consensus on purpose of sleeping.1

• MANY physiological processes occur during sleep.• Gene expression, muscle repair, removal of toxic

byproducts in the brain, etc.

1. Cirelli & Tononi, PLOS Biology, 2008

How do we fall asleep?

11Image adapted from Nestler et al.: https://neurology.mhmedical.com/data/books/1204/nes003_fig_13-04.png

S = homeostatic sleep drive (sleep debt)C = circadian rhythm (alertness); heavily influenced by light exposure• Point of largest difference promotes sleep• Melatonin works on circadian rhythm

Wake Sleep Wake

S

C

Sleep assessment: Quantity

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1) Quantity: duration of sleep– Recommendation for adults: 7-9 h (National Sleep

Foundation)– Insufficient sleep defined as: < 5, ≤5, < 6, ≤ 6, <7 h in

bed1,2

– Measured using polysomnography (PSG), actigraphy, wearables, self-report

1. Cappuchio et al., Sleep, 2008; 2. Wu et al., Sleep Med, 2014

Sleep recommendations1

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Newborn Infant Toddler Preschool School Age

Teen Young adult

Adult Older adult (65+)

14-17 h 12-15 h 11-14 h 10-13 h 9-11 h 8-10 h 7-9 h 7-9 h 7-8 h

1. Hirshkowitz, Sleep Health, 2015

Sleep assessment: Stages

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Awake

REM

Light

Slow wave

10 p.m. 11 p.m. 12 a.m. …

Takes ~ 90 minutes to complete one sleep cycle.

Restorative sleep; affected by stress, sleep disruption, aging

Dreaming; memory stabilization; emotional control; PTSD; occurs for longer durations at the end of the night; tends to suffer more when not getting enough sleep

Sleep assessment: Quality

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2) Quality: how “well” you sleep– No consensus definition– Quality ≠ quantity

• A variety of self-report instruments –Pittsburgh Sleep Quality Index

(PSQI) – measures sleep quality over the past month

Question Break

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Consequences of insufficient sleep

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• 35% of American adults sleep < 7 h/night.1

• 1910: 9 h; 2003: 7 h2

• Epidemiological evidence3 suggests associations with:

• HTN• CVA• CHD

• DM2• Obesity

1. CDC MMWR 2016 February 19. 2. National Sleep Foundation. Executive summary of the 2003 Sleep in America Poll. Available at: http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.2417365/k.1460/2003_Sleep_in_America_Poll.htm; 3. Luyster et al., Sleep, 2012

Consequences of insufficient sleep

Sleep and weight

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• Experimental1-6 and epidemiological7-9 findings – Associations between insufficient sleep and/or poor sleep

quality have been associated with higher BMI.• Children and adults

1. Fatima et al., Obes Rev, 2015; 2. Magee and Hale, Sleep Med, Rev, 2012; 3. Markwald et al., Proc Natl Acad Sci, 2013; 4. Nedeltcheva et al., Am J Clin Nutr, 2009; 5. Patterson et al., Clin Gerontologist, 2014; 6. St-Onge et al., Am J Clin Nutr, 2011; 7. Cappuccio et al., Sleep, 2008; 8. Chen et al., Obesity, 2008; 9. Wu et al., Sleep Med, 2014

Mechanisms

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Weight gain

Undesirable changes in appetitive

hormones2-5

Increased susceptibility to hedonic aspects of

food7

Increased time

engaged in sedentary behavior6

• Some proposed mechanisms linking insufficient sleep to weight gain

• Sleep deprivation, disruption, or curtailment, even over just 1 or 2 nights results in a variety of maladaptive responses.1

• Not an exhaustive list of mechanisms!

1. Patel & Hu, Obesity, 2008. 2.Nedeltcheva et al, Obesity, 2012; 3. Spiegel et al, Ann Intern Med, 2004. 4. Gonnissen et al, Br J Nutr, 2013. 5. Schmid et al, Sleep Res, 2008. 6. Magee et al, Sleep Med Rev, 2012. 7. Benedict et al., J Clin Endocrinol Metab, 2012.

Observations from our lab

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• First-year university students who reported sleeping less at follow-up experienced the greatest weight gain over the first semester.1

• Food cravings, hunger, portion size, and willingness to work for chocolate increase after a night of curtailed sleep.2

• Preferred sweetness concentration increases after sleep curtailment (hedonics).3,4

1. Ludy et al., Physiol Behav, 2018; 2. Yang et al., Nutrients, 2019; 3. Szyzgiel et al., Nutrients, 2019; 4. Szczygiel et al., Foods, 2019.

Sleep and DM2

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• Meta-analysis observed relationships between short sleep (< or = 5-6 h/night), difficulty falling asleep, difficulty staying asleep and DM2.1

• Insulin sensitivity is decreased; not production.2

• Inflammation is increased after short sleep.3

– CRP, TNF-α, IL-6

– Inflammation à insulin resistance à DM2

1. Cappuchio et al., Sleep, 2008; 2. Buxton et al., Diabetes, 2010; 3. Irwin et al., JAMA, 2006

Sleep and HTN

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Hypertension1

• Insufficient sleep à shorter period of reduced cortisol secretion; impaired clearance of free cortisol

• BP is lowest at night à insufficient time for vascular “recovery”

• Increased activation of sympathetic nervous system

1. Gottlieb et al., Sleep, 2006

Sleep and wound healing

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• Wound healing, muscle repair occurs during SWS/N3 sleep1

– Growth hormone secretion, protein synthesis, cellular division, cellular growth

1. Evans & French, Dimensions Crit Care Nurs, 1995

The hospital: A hostile sleep environment

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• Quantity and quality problems• ICU patients are at highest risk

– Undisturbed rest periods of 50 minutes or less1

• Variety of factors2-4:– Environmental

• Noise, light, ambient temperature, vitals checks, medication administration schedules

– Personal• Pain, medication (side effects, administration), anxiety

1. Evans & French, Dimensions Crit Care Nurs, 1995; 2. Reid, Br J Nurs, 2001; 3. Bartick et al. J Hosp Med, 2010; 4. Dolan et al., Ann Med Surg 2016

The hospital: A hostile sleep environment

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• ICU interventions shown to increase sleep duration and quality1:– Eye masks– Ear plugs– White noise/soothing music– Dimming lights– Reducing overhead paging

1. Kamdar, Am J Med Qual, 2013

Sleep and performance

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• Sleep is part of the US Army’s performance triad

• Designed to promote personal and unit readiness– Extends to families

• Demonstrated improvements in marksmanship1

– Also quicker reaction times

Nutrition

Activity

Sleep

1. The Synergy of the Performance Triad! January 15, 2020 https://p3.amedd.army.mil/what-leaders-need-to-know/what-is-the-performance-triad

Performance Triad

Sleep and performance

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• Exercise performance is impaired with insufficient sleep.1

– Reaction time, accuracy, submax strength, and endurance impaired

• Sleep extension can improve:1

– Reaction time, sprint times, free throw and 3-point accuracy, serve accuracy, swim turns, kick stroke efficiency

1. Vitale, Int J Sports Med, 2019

Sleep and cognition

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• Important relationships for both children1 and adults2

• Kids: sleep duration is positively associated with cognitive performance, including executive function and school performance but not intelligence

• Adults: reaction time and vigilance declines; emotional volatility increases; 24-h without sleep = 0.10% blood alcohol content3

1. Astill et al., Psychol Bull, 2012; 2. Killgore, Prog Brain Res, 2010; 3. Dawson & Reid, Nature, 1997

Sleep and trauma

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• Sleep problems occurring before or shortly after trauma are a risk factor for PTSD, anxiety and mood disorders, suicide, and alcohol and substance use disorders.1-4

• REM sleep appears to play an important role in preventing the development of PTSD.5

– Brain is learning to uncouple the trigger from the dangerous outcome.

• Sleep loss compromises daytime coping mechanisms.5

1. Gehrman et al., Sleep, 2013; 2. Bryant et al., Sleep, 2010; 3. Breslau et al., Biol Psychiatry, 1996; 4. Mellman et al., CNS Sprectr, 2006; 5. Pace-Schott, Biol Mood Anxiety Disorders, 2015

Health disparities; sleep disparities

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• Causes are not well understood1

• Membership in the following groups increases the risk of insufficient or poor quality sleep:– Racial/ethnic minorities, especially African Americans2-5

• Especially African American women6

• Higher levels of discrimination à higher stress7

– High stress3

• Social, occupational, etc.

1. Laposky, Sleep Med, 2016; 2. Tomfhor, Health Psychol, 2016; 3. Kurina, Sleep Health, 2015; 4. Kripke, BMC Psych 2004; 5. Taylor, Sleep, 2005; 6. Ruiter, Sleep Med, 2011; 7. Thomas, Health Psychol, 2006

Health disparities; sleep disparities

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- Food insecure individuals are at higher risk of insufficient sleep, increased time to fall asleep, and other sleep complaints.1-4

• 61% of very food insecure women reported insufficient sleep.1

• Insufficient sleep mediated relationships between food insecurity and obesity.3

- People experiencing mental health concerns (depression, anxiety)

1. Ding, J Nutr, 2015; 2. Liu, Prev Chronic Dis, 2014; 3. Narcisse, Obes, 2018; 4. Grandner, J Clin Sleep Med, 2013; 5. Taylor, Sleep Helath, 2005

Question Break

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Recommendations for clients

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Recommendations for clients

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Recommendations for clients

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• Refer to a sleep physician if a sleep disorder is suspected• Sleep apnea (loud snoring, stops breathing)• Night eating syndrome• REM movement disorder• Restless legs syndrome• Others…

Medication

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• Medication can help• Dependency• “Hangover” side effects• Stops working with time

• Good news: behavioral interventions have been shown to be as effective as medication.1-3

– Gold standard: Cognitive Behavioral Therapy

1. Morin et al., Sleep, 2006; 2. Smith et al., Am J Psych, 2002; 3. Bootzin et al., Ann Rev Clin Psychol, 2011; 4. Ferracioli-Oda, FOCUS, 2018; 5. Li, Front Neuroendocrin, 2019

Melatonin?• Maybe?4, 5

• Effect size is lower than behavioral interventions.

• “Benign” side effects• Efficacy does not appear to

diminish with use

Cognitive Behavioral Therapy for Insomnia (CBTi)

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• Trained therapist to address thoughts/perceptions about sleep– Sleep hygiene training– Stimulus control therapy– Sleep restriction therapy– Relaxation

Sleep hygiene

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• Sleep hygiene:– Describes the behaviors associated with getting good

quality sleep– Some cases of insomnia may be helped with improved sleep

hygiene• Insomnia: 2 main types

–Difficulty falling asleep–Difficulty staying asleep

Sleep Hygiene Index1

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1. I take daytime naps lasting two or more hours.2. I go to bed at different times from day to day.3. I get out of bed at different times from day to day.4. I exercise to the point of sweating within 1 h of going to bed.5. I stay in bed longer than I should two or three times a week.6. I use alcohol, tobacco, or caffeine within 4 h of going to bed or after going to bed.7. I do something that may wake me up before bedtime (ex: play video games, use the internet, clean).8. I go to bed feeling stressed, angry, upset, or nervous.9. I use my bed for things other than sleeping or sex (ex: watch television, read, eat, study).10. I sleep on an uncomfortable bed (ex: poor mattress or pillow, too much/not enough blankets).11. I sleep in an uncomfortable bedroom (ex: too bright, too stuffy, too hot, too cold, too noisy).12. I do important work before bedtime (ex: pay bills, schedule, study).13. I think, plan, or worry when I am in bed.

1. Mastin et al., J Behav Med, 2006

Responses: always, frequently, sometimes, rarely, never

Tips for clients: Sleep hygiene

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• Sleep hygiene1:– Environmental

• Make sure the sleeping area is comfortable

– Comfortable bedding and pillow

• Reserve bed and bedroom for sleep– Avoid TV, reading, etc. in bed

1. Adapted from the Sleep Hygiene Practice Scale, Lin et al., Sleep, 2007

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• Sleep hygiene1:Temperature– Is the room set to a comfortable temperature?– One of the body’s signals to sleep is a drop in core body

temperature. • A warm bath or shower about an hour before bedtime can help this

drop in temperature to occur. • While your core body temperature falls before sleep, the temperature

in your hands and feet increases. – Wearing socks or a warm foot bath can trigger this response, leading to falling

asleep faster.1-3

1. Ko & Lee, J Physiol Anthropol, 2018; 2. Krauchi et al., Nature, 1999; 3. Liao et al., Int J Nurs Stud, 2005

Tips for clients: Sleep hygiene

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• Sleep hygiene1:– Noise and lighting

• Avoid falling asleep with the TV or music on• Using ear plugs or white noise can minimize

disruptions• Light at night disrupts the circadian rhythm by

suppressing melatonin production2

– Use red night lights for illumination3

1. Adapted from the Sleep Hygiene Practice Scale, Lin et al., Sleep, 2007; Boivin et al., Nature, 1996; 3. Brainard et al; Ann NY Acad Sci, 1985

Tips for clients: Sleep hygiene

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Tips for clients: Sleep hygiene

• Sleep hygiene1:– Scheduling

• Consistent bedtimes and wake times– Avoid sleeping in on the weekend– Do not nap for more than one hour/day (science suggests sweet spot is <

30 minutes2)

• Outdoor exposure to light and exercise promote sleep– Avoid vigorous exercise 2 hours before sleep

• Give yourself time to relax/unwind before bedtime

1. Adapted from the Sleep Hygiene Practice Scale, Lin et al., Sleep, 2007; 2. Milner and Cote, J Sleep Res, 2009

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Tips for clients: Sleep hygiene

• Sleep hygiene1:– Feeding

• Avoid going to bed hungry BUT!• Avoid eating or drinking a lot an hour before bedtime• Avoid caffeine at least 4 hours before bedtime• Avoid nicotine and/or alcohol 2 hours before bedtime

– What about warm milk, chamomile tea, etc. to promote sleep?• Limited evidence2

1. Adapted from the Sleep Hygiene Practice Scale, Lin et al., Sleep, 2007; 2. Peuhkeri et al., Sleep Research, 2012

Tips for clients: Stimulus Control Therapy

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• Stimulus Control Therapy– 1. Go to bed only when sleepy.– 2. If you do not fall asleep within 10 minutes, get up and do

something else. Repeat as necessary.– 3. Get up at the same time every morning - no matter how much

sleep you got the night before (strengthens homeostatic sleep drive).– 4. Do not nap.– 5. Do not use the bed for any other activities besides sleep or sex.

1. Bootzin and Epstein, Ann Rev Clin Psychol, 2011.

One of the most effective single-component interventions for insomnia.1

Tips for clients: Relaxation

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• Yoga1

• Tai chi2

• Mindfulness meditation3

• Progressive muscle relaxation4

– https://alzheimers.med.umich.edu/wellness-initiative/ – Click on the “Meditations” tab for short (~5 min) and longer guided

meditations

1. Manjunath, Indian J Med Res, 2005; 2. Irwin, Sleep, 2008; 3. Black, JAMA Int Med, 2015; 4. Borkovec, Behav Therapy, 1975

Summary

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• Compelling evidence suggests link between sleep and chronic disease risk

• Behavioral recommendations can be as effective as medications

• Not all recommendations make sense to everyone; tailor to problematic behaviors

• It can take time (weeks) to see results, but results can be achieved

Questions?

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Robin M. Tucker, PhD, RD, FANDDepartment of Food Science and Human NutritionMichigan State Universitytucker98@msu.edu

References

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• Cirelli & Tononi, PLOS Biology, 2008• Cappuchio et al., Sleep, 2008• Wu et al., Sleep Med, 2014• Hirshkowitz, Sleep Health, 2015• CDC MMWR 2016 February 19• National Sleep Foundation. Executive summary of the 2003 Sleep in America Poll. Available at:

http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.2417365/k.1460/2003_Sleep_in_America_Poll.htm• Luyster et al., Sleep, 2012• Cappucchio et al., Sleep, 2008• Fatima et al., Obes Rev, 2015• Magee and Hale, Sleep Med, Rev, 2012• Markwald et al., Proc Natl Acad Sci, 2013• Nedeltcheva et al., Am J Clin Nutr, 2009• Patterson et al., Clin Gerontologist, 2014• St-Onge et al., Am J Clin Nutr, 2011• Cappuccio et al., Sleep, 2008• Chen et al., Obesity, 2008• Wu et al., Sleep Med, 2014• Patel & Hu, Obesity, 2008• Nedeltcheva et al, Obesity, 2012• Spiegel et al, Ann Intern Med, 2004• Gonnissen et al, Br J Nutr, 2013• Schmid et al, Sleep Res, 2008• Magee et al, Sleep Med Rev, 2012• Benedict et al., J Clin Endocrinol Metab, 2012

References

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• Ludy et al., Physiol Behav, 2018• Yang et al., Nutrients, 2019• Szyzgiel et al., Nutrients, 2019• Szczygiel et al., Foods, 2019• Buxton et al., Diabetes, 2010• Irwin et al., JAMA, 2006• Gottlieb et al., Sleep, 2006• Evans & French, Dimensions Crit Care Nurs, 1995• Reid, Br J Nurs, 2001• Bartick et al. J Hosp Med, 2010• Dolan et al., Ann Med Surg 2016• Kamdar, Am J Med Qual, 2013• The Synergy of the Performance Triad! January 15, 2020 https://p3.amedd.army.mil/what-leaders-need-to-know/what-is-the-performance-triad• Vitale, Int J Sports Med, 2019• Astill et al., Psychol Bull, 2012• Gehrman et al., Sleep, 2013• Bryant et al., Sleep, 2010• Breslau et al., Biol Psychiatry, 1996• Mellman et al., CNS Sprectr, 2006• Killgore, Prog Brain Res, 2010• Dawson & Reid, Nature, 1997• Laposky, Sleep Med, 2016• Tomfhor, Health Psychol, 2016• Kurina, Sleep Health, 2015• Kripke, BMC Psych 2004

References

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• Taylor, Sleep, 2005• Ruiter, Sleep Med, 2011• Thomas, Health Psychol, 2006• Ding, J Nutr, 2015• Liu, Prev Chronic Dis, 2014;• Narcisse, Obes, 2018• Grandner, J Clin Sleep Med, 2013• Morin et al., Sleep, 2006• Smith et al., Am J Psych, 2002• Bootzin et al., Ann Rev Clin Psychol, 2011• Ferracioli-Oda, FOCUS, 2018• Li, Front Neuroendocrin, 2019• Mastin et al., J Behav Med, 2006• Lin et al., Sleep, 2007• Ko & Lee, J Physiol Anthropol, 2018• Krauchi et al., Nature, 1999• Liao et al., Int J Nurs Stud, 2005• Boivin et al., Nature, 1996• Brainard et al; Ann NY Acad Sci, 1985• Milner and Cote, J Sleep Res, 2009• Peuhkeri et al., Sleep Research, 2012• Bootzin and Epstein, Ann Rev Clin Psychol, 2011• Manjunath, Indian J Med Res, 2005• Irwin, Sleep, 2008• Black, JAMA Int Med, 2015• Borkovec, Behav Therapy, 1975

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FODMAPS & Athletes: Current Research & Strategies

Thursday, April 16, 202011:00 a.m. – 12:00 p.m. EST

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This webinar presents the current research on FODMAP consumption by athletes and the use of low-FODMAP nutritional strategies for reducing exercise-induced gastrointestinal symptoms.

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