Revitalize Health With Better Sleep Habits

Audrey Wells, MD

Me, too. Sleep is one of my passions, and I’m happy to get a chance to talk about it.

Laurie Marbas, MD, MBA

Fantastic. Well, let’s dive right in. How would you say sleep directly impacts, for example, blood pressure or other chronic diseases? What are the physiological mechanisms that are involved? Like, what does good sleep do, and maybe what does sleep disruption or difficulty with sleep entail?

Audrey Wells, MD

Yes. I want to first make the point that getting healthy sleep is valuable. It’s something that I think a lot of people discount or negotiate, as they are encountering multiple competitors for their time and their energy. Sometimes sleep gets pinched off, either at night or in the morning, because we are always trying to get more done during the day. But the truth is that healthy sleep means that you can have a more healthy life. One of the major functions of sleep is to enjoy a state of calm. You’re reducing the sympathetic overdrive—that fight or flight response that’s so present and at the ready during the daytime. Sleep is the antidote to that. It’s a parasympathetic state where all of your systems are in relaxed mode. They’re in repair mode. You’re cleaning up the kitchen, restocking the refrigerator, and getting ready for the next day. If you’re not getting healthy sleep, we know that it ends up looking like a disease over the long term. It’s not just feeling tired from day to day. It can contribute to the progression or even the formation of disease.

Laurie Marbas, MD, MBA

What are those exact mechanisms? Would you say that they lead to, for example, something like hypertension? What exactly is it about sleep—the inability to get good sleep or being unable to have regular sleep patterns—that can start that process? Or is it chicken? Like, what came first, the chicken or the egg type of thing?

Audrey Wells, MD

I think there is a little bit of that. Certainly,  there’s a lot of overlap with people who don’t get enough sleep or have a sleep disorder like obstructive sleep apnea, for example. Those folks can have an increased risk of high blood pressure. The opposite is also true. High blood pressure is itself a risk factor for obstructive sleep apnea. There’s a bi-directional response there. One of the causative factors that lead to poor sleep in developing high blood pressure or even other cardiovascular diseases is that there is a loss of nocturnal dipping of blood pressure, and that’s related to this increased sympathetic tone. Your blood pressure is modulated by how much the smooth muscle around your blood vessels is toned, and you lose that dipping where the tone relaxes. Another potential mechanism is that inflammatory mediators are more prominent during loss of sleep or interrupted sleep, probably from a sleep disorder that’s known to increase the risk of cardiovascular disease and overlap with hypertension, diabetes, and other problems. There’s a complex relationship there. But the point I want to drive home is that there is bidirectionality between high blood pressure and impaired sleep.

Laurie Marbas, MD, MBA

Can you speak to some of these sleep disorders? I think many people are aware of, for example, obstructive sleep apnea. But what are some other sleep disorders that someone who has high blood pressure might be dealing with, especially at their fatigue, that they’re like, well, I don’t have sleep apnea? What other things could they be looking for?

Audrey Wells, MD

Yes. A lot of people ask me about insomnia. Is insomnia something that can lead to high blood pressure? The results are a little bit mixed when you look at the research data. It appears that people who experience insomnia, especially if they’re in their midlife years, do have an increased risk for high blood pressure if that insomnia is chronic. Older adults, for some reason, tend not to have that experience. In other words, insomnia that leads to short sleep in the 65-plus age range does not have such a connection to high blood pressure. Interestingly, restless leg syndrome is associated with increased sympathetic tone. There’s an Italian group that does a lot of study with this, and what they show is that the periodic limb movement disorder, which is what’s happening with a lot of folks who have restless leg syndrome, happens during sleep. These little leg movements during sleep, these twitches, are associated with an elevated heart rate, which is transient, and an increase in sympathetic tone. 

People who get less than 6 hours of sleep per night on a chronic basis are also at risk for high blood pressure and even refractory hypertension, meaning they take three or more medications to control their blood pressure. Unfortunately, this has been prominent, especially in the last 50 years. People, specifically Americans, report sleeping 2 hours less than they did in the 1960s and early 70s. As a nation, we’re not moving in a great direction when it comes to preserving not only our sleep quantity but our sleep quality as well.

Laurie Marbas, MD, MBA

This gets to the point that we hear that people should be sleeping 7 to 8 hours of restorative sleep. How do you know that you’re getting so many people to say, Oh, I’m going to bed at ten, but maybe they’re waking up and then they’re waking up early? Or, like, how do we understand that we’re getting the number, the amount, and the quality of sleep that we should be having? Are there any tools or anything that we should be doing to evaluate that we can do at home? Or do we need to be tested in a lab-type setting?

Audrey Wells, MD

It’s a good question. I think a lot of people come upon this decision point about recognizing that their sleep isn’t as good as they want it to be and they’re trying to decide if they need to seek specialty care from a sleep medicine doctor like myself. Not getting restful sleep is one piece of evidence that your sleep may not be as healthy as it could be. That tends to manifest as problems with daytime sleepiness or fatigue. Running out of energy before your day is through. But it can also be subtle, like problems with mood, irritability, impatience, feeling like you do not have the social patience to deal with relationships, and such, which can be manifestations of poor sleep quality. Another thing to consider is that I hear from a lot of people that they assess how well they sleep right when they wake up in the morning. That’s just a little bit off. You should wait an hour to assess the night before, because when you first wake up in the morning, your circadian rhythm and that cortisol burst that you get, not as anything pathologic but just as a function of the circadian timing, are not fully online yet. Wait an hour to look back on your sleep the night before and say, Was that my best sleep or is there room to improve? For most people who enjoy an overnight sleep schedule, assessing alertness in the late morning hours, typically between 10am and 11 a.m.—that’s the day when you should feel alert and awake, productive, and socially fluid.

Then there’s another increase in alertness around the seven or eight p.m. mark. If you have a bedtime, that’s around ten or 11:00. Looking at those periods when you should feel alert is one way to assess your sleep quality. Something else I’ll mention is that some people have risk factors for sleep problems that have nothing to do with symptoms. Here, I’m talking about age. More people who are older have sleep disorders. Weight, people who are experiencing obesity, regardless of whether it’s associated with another condition, can sleep more poorly. Metabolic issues like diabetes tend to interfere with sleep quality. If you have some of those conditions, my advice would be to get on high alert to see if sleep is problematic and even potentially contributing to the conditions I just mentioned.

Laurie Marbas, MD, MBA

I do want to ask about some things, like what do you think about the risk and the different types of technology that we can use, like the WHOOP, for example? It’s structured around heart rate variability and looking at whether or not you had decent sleep and how much you should be exerting yourself the next day. Is there any scientific evidence showing that it is beneficial and we should be making decisions based on the information?

Audrey Wells, MD

I think there is, but it’s a little bit with a grain of salt at this point. Now, consumer wearable devices are getting better and better over time. I think for right now, what I would say is that most consumer wearables are good at determining when you went to sleep and when you woke up. A lot of them, including the OURA Ring that I’m wearing, will guesstimate what the space in between them looks like. It tells me how much slow, wave-deep sleep I have. It tells me how much REM sleep I have. But as a sleep medicine physician, I can tell you that at best it’s an educated guess right now. However, what I like about it is that when I wake up in the morning, I want to see what my ring report is. It’s elevated into my consciousness and can affect my decision-making. I think for people who are interested in these sleep trackers, that’s an important thing to recognize because it may change behavior. I think any time you’re looking at positive behavioral changes, that tracker has value.

Laurie Marbas, MD, MBA

I think yes. That’s what I found outside of even just using something like the WHOOP or a continuous glucose monitor for diabetes; it makes them make better decisions because it’s immediate, it’s objective data. It’s not someone telling them an opinion or anything. I think 100%. But speaking about behaviors, what type of behaviors should we be doing throughout the day or early evening to set ourselves up for the best sleep possible? What are the things that we can do regularly to improve our sleep?

Audrey Wells, MD

I want to point out something insightful in your question, which is that the way you sleep at night starts with how you spend your day. It’s not just the last hour before you get into bed that makes a difference in your sleep quality. When you wake up in the morning, your brain is getting signals that will affect how you sleep the following night. Some easy things are to get bright light, meaning sunlight, preferably into your eyes as early as you can when you wake up in the morning. Now, up here in Minnesota, in the wintertime especially, it’s dark when I wake up, and it’s dark for several hours after I wake up. I use an artificial light source in the morning, which is going to tell my brain that in about 16 hours it should get ready to sleep. Not only does it help me feel more awake, but it also sets a little timer that makes getting to sleep at night more likely and more reliable. I like that. 

Another thing you can do is exercise. getting your heart rate up, creating a contrast with sleep. Weight training exercises, balance exercises, and cardiovascular exercises. All of this signals to your brain that it’s time to be awake. I like to make a little analogy with the pendulum here. If you swing the pendulum on one side with exercise, meal timing, social connection, and light exposure, the stronger the signals you have, the more that pendulum is going to swing in the other direction at night with better sleep quality, more reliable sleep, staying asleep longer throughout the night, or having shorter nighttime awakenings.

Laurie Marbas, MD, MBA

That’s perfect. Well, I think this is a good place to pause for just a moment. I want to thank you so much for joining us today. I hope you found this conversation very insightful and engaging. If you’re a summit purchaser, stay right here, because we’re about to dive even deeper into a very interesting discussion. I have some good questions coming up here. But if you’re not, it’s okay. You can click on the button below or go to the site and get access to the rest of the conversation. If you’re watching this, thank you for being a valuable member of our community, and let’s continue this conversation. We were just speaking about the behaviors early in the day, and I love that analogy of the pendulum. The more you do during the day, swings better into the night. You mentioned having better sleep quality and duration. Many people fall asleep okay. But then they wake up in the middle of the night, like 2 to 4 somewhere in there, and they struggle to go back to sleep. What are those? Why do we do that? Are there any other insightful things that we can be doing outside of what you mentioned before to improve the duration of our sleep with less nighttime waking?

Audrey Wells, MD

I want to tell you that this question is one that I get all the time. If I had a magic wand and could wave it over everybody who had problematic nighttime awakenings, I would because this is a challenge. For historical context, in the past, before we had artificial lights or electric lights, it was pretty common for people to go to sleep at sunset when the sun went down or an hour or two thereafter wake up in the middle of the night, spend two or three hours awake, and then fall back asleep for a second period when and then awaken again when the sun came up. If you look in the literature, you’ll see references to the second sleep and also nighttime activities where people would tell stories, talk, have sexual relations, play with their kids, and stuff. I think recognizing that a nighttime awakening does not have to be problematic is step one. A lot of people think I should not wake up during the night, and when they do, they think this is not right, and they start doing calculations with the clock, and they get very agitated, which only makes it more difficult to get back to sleep.

I want to tell you that it takes 3 to 5 minutes of awakening to remember that awakening. If I had EEG sensors on my head, I would see between five and 20 arousals from sleep across the course of the night. Well, we just don’t remember all of these because we don’t; it doesn’t come to consciousness in a way that’s stored in our memory. I want to just normalize the fact that it’s okay to wake up in the middle of the night, give yourself a few minutes, and you will probably go back to sleep. If you’re having long nighttime awakenings, however, a lot of times people are stuck in their brains, having a monkey mind or a pinball effect, or they’re agitated in their bodies. They don’t feel comfortable. Their body feels like they can’t settle down. I have specific ways of working with people on that. But just to give you a little tip with the mind question, usually, if you can’t go back to sleep and your mind is circulating, it’s because there’s something that’s not enough, not safe, or not congruent. Meaning, it’s out of integrity. 

For example, not enough can look like, I don’t feel like I did a good presentation at my job today. I’m ruminating about that and feeling like I could have done better. That can keep you up. Getting up out of bed, writing down all of your thoughts, and just evacuating your brain can help you feel seen and soothed. Then you go back to bed, having purged all of that negativity out. Similarly, with not being safe, people can be worried about a medical test that they got and fixate on that during the night. It makes sense because, at night, our brain is biased toward the negative. Pointing that out and helping people understand they don’t need to trust those thoughts so much can help them fall back to sleep. These are a few of the cognitive tricks that I use to help people relax and fall asleep again. But I want to point out that it’s always tougher in the middle of the night because you’ve already satisfied some of your sleep needs in the first few hours that you’ve been asleep.

Laurie Marbas, MD, MBA

Question: Could you explain what you mean by our brains being biased toward negativity at night?

Audrey Wells, MD

Yes, there’s been studies done on this. People have more catastrophe thoughts at night. There is more of a sense of aloneness. People have more risk for things like suicidality in the middle of the night. It’s a little bit like your frontal lobes. The logical part of your brain is the most fragile part when it comes to sleep. Do you remember when I talked about the timer that was set for 16 hours over the day? That is your frontal lobe expiration time. At night, the part of your brain that inhibits your emotional center, which is biased toward the negative, goes offline, and in the middle of the night, it’s not functioning appropriately. Those negative emotions can come out and drive the bus. Evolutionarily, we were geared to look for threats in our environment, and that’s what’s being expressed. It makes sense that in the middle of the night, you’re going to be more fearful, more prone to characterize things negatively, do black-and-white thinking, and just have maladaptive coping mechanisms.

Laurie Marbas, MD, MBA

Excellent. You also spoke about the things that we should be doing, such as the early bright light to set the stage for the cascade of events to help us fall asleep 16 hours later and some different exercises. What are some of the things that maybe we should avoid in our final question? Just to get people to look, these are the bucket things I need to do, and these are things that maybe I need to avoid.

Audrey Wells, MD

Yes, I have three big ones that I’d like to put out there as, like, actionable steps. The first one is not going to buy me any fans. I understand that totally, but I need to give it to you guys straight. That is a short wavelength. The blue light from an electronic screen is not helping you at night. Your dreams are not on this device, and a lot of people are under the misguided notion that it helps them go to sleep. The truth is, that is going to cause sleep disruption. That’s point one. Point two is to please avoid eating three hours before you go to sleep. Now, a lot of people have weight loss or weight management on their minds, and this is totally in line with that goal. When you eat too close to bedtime or even during the night, your digestive system and the hormones that regulate appetite and satiety are not optimal. You can end up overeating. You tend to have cravings that are more in line with unhealthy snack foods, and there’s more of a propensity to put on fat, which is problematic. But you also need to consider that acid reflux is a real problem, and that can be experienced in the middle of the night too. I talked about light exposure. I talked about food. I think the third thing I’d recommend is avoiding too much sedentary activity during the day. You may have heard the term or the phrase sitting is the new smoking, and I think that’s true entirely. We’re at our desks sitting down too much, and it’s important to get up and get active. Not only is that good for your vasculature, including your cardiovascular health, but it also helps that pendulum, again, to swing up for a bigger arc. Exercise is associated with daytime and alertness, and being still, in the dark, and relaxed is associated with sleep.

Laurie Marbas, MD, MBA

Now, I agree. I have. There’s a point of not getting enough exercise that I notice. My sleep quality is deprived versus the opposite. fantastic. Well, thank you, Dr. Wells, for joining us today at Reversing Your Hypertension Summit. We are thankful for you, for people like you, and for sharing your knowledge and wisdom with us today.

Audrey Wells, MD

It was a pleasure. Great to see you.