Sleep Debt: The Hidden Costs

Everyone has a sleep bank. Each night your accounts get credited with 7-8 hours of the physical and mental benefits of sleep and each day the accounts pay out those benefits in the form of emotional, intellectual and physical energy. Just like in any bank account, withdrawals can’t exceed deposits without incurring debt. Sleep debt, though, is easy to ignore because physical activity keeps alertness high. As long as you move around instead of reading or watching TV, you won’t nod off and you can keep thinking that 5 or 6 hours of sleep a night meets your needs. But covering the debt with activity is like keeping a bank balance out of the red by borrowing money and paying interest. Sleep debt exacts a toll on the body that goes beyond depressed mood, irritability and lack of ability to concentrate and learn, not to mention the potential for causing motor vehicle accidents.

The biological clock

As sleep debt mounts, the body’s biologic clock goes awry. This clock, located deep in the brain, controls circadian rhythms – regular ups and downs in behavior, body temperature, appetite, hormone production, alerting mechanisms, and the urge to sleep. When the clock malfunctions chronically, the results show up in the form of weight gain, high blood pressure, diabetes and diminished immunity to infection.

Setting the clock

Regular periods of darkness are required to set the brain’s internal clock to keep the body in synch with the 24-hour day set by the sun. Sleep researchers have shown that, when living in a research setting where there are no external clues about time of day or night, subjects’ internal clocks actually work on a 25-hour cycle. Normal peaks of sleepiness and alertness work themselves into the wrong time of the  24-hour day and night outside the sleep lab, producing weeks of daytime sleepiness and nighttime insomnia in the research subjects. Over time, the peaks cycle back into synchrony with day and night producing several weeks of normal daytime alertness and nighttime sleepiness.

Laboratory settings may exaggerate these patterns, but most people know that during some weeks they simply perform better during the day and sleep better at night  than during other weeks, indicating that in the modern, artificially lit world, the 24-hour day is more like a 24-25 hour day as far as the body’s natural rhythms are concerned. This clock drift is very sometimes very evident. Cyclical insomnia and daytime sleepiness are in common in blind people, in people at very high latitudes where the summer sun circles the sky for almost 24 hours, and in shift workers who are up all night in brightly lit environments. These problems, while distressing, respond to maintaining regular sleeping schedules and closing out all light during sleep periods, which resets the clock.

Why the clock matters

The internal clock is easily disrupted by one or two day episodes of sleep deprivation that people experience for reasons as varied as extra work loads, exams, brief periods of emotional upheaval, or any of the other myriad problems that keep people awake, but studies have repeatedly demonstrated that a few days of “catching up” on sleep restore the body to normal rhythms, contributing to a widely held impression that sleep deprivation, while responsible for serious accidents, doesn’t cause real health problems.
However, bigger problems do come from disturbing circadian rhythms more chronically. In recent years research attention has shifted from short term sleep deprivation to the chronic, partial sleep deprivation that is so common in our modern society, where nodding off during monotonous and sedentary activities like reading or watching TV are almost expected. Many people think they need no more than 5-7 hours of sleep at night, but while a few truly short sleepers exist, most people require around 8 hours of sleep each night to achieve maximal alertness throughout the day. Chronically shortchanging sleep by even an hour a day changes the timing and levels of multiple hormones, causing other metabolic changes and weakening the immune system.

Lack of sleep wreaks havoc on hormones

One of the first hormonal changes produced by chronic short sleep involves cortisol, the stress hormone produced by the adrenal gland. Normally cortisol levels decline during late evening hours, but without enough sleep, production continues unabated, Cortisol then begins to contribute to immune stress and to insulin resistance, which leads to diabetes and fat deposition. A second contributor to insulin resistance is a change in growth hormone secretion from one large burst during sleep to two, smaller bursts before and after sleep. A third change comes from failure of the pituitary gland to produce its normal night-time rise in thyroid stimulating hormone, the stimulus for the thyroid gland to produce more thyroid hormone. All of these changes are consistent with the fact that as little as one week of 4 hour sleeping nights can convert healthy young people to a pre-diabetic state. Observational studies do show higher rates of diabetes in chronically sleep-deprived women.

Lack of sleep and obesity

If these hormone changes are not enough to convince a short sleeper to turn out the lights earlier, studies on the appetite influencing hormones leptin and ghrelin, produced by fat tissue and the stomach respectively, might help. Leptin, which signals when to stop eating, diminishes markedly after 6 days of four- hour sleeping nights, despite no change in caloric intake. Ghrelin, which stimulates appetite, particularly for high carbohydrate foods, goes up when sleep is short.

Sleep debt is all around you

    All of these hormonal factors are significant in society where people lead overscheduled lives in stimulating, loud and bright environments without regard to natural day and night. We do not need sleep studies to tell us that we are in an age of significant sleep debt – just count the number of people, including children, asleep on planes and buses, over books and newspapers, and on couches in front of TVs. If you fall asleep regularly under these circumstances, you are in chronic sleep debt. Given the increase in obesity and diabetes over the last few decades, sleep is another potential therapeutic avenue – a fruitful and inexpensive area of health over which we have considerable control.

Managing the sleep budget: factors under your control

1. Take the television out of the bedroom.
2.Darken the room completely, or wear a comfortable, opaque eye mask.
3. If noise is a problem were soft ear plugs.
4. Keep the temperature low at night and invest in a comfortable mattress that does not move.

1. Keep the biologic clock in sync with the sun by getting outside regularly.
2. Get regular exercise like walking, but avoid exercise in the last 3-4 hours before bedtime.
3. Keep naps short – 45 minutes or so – and confined to early afternoon hours.
4. Avoid heavy meals and alcohol in the last 4 hours before sleep.
5. Aim for the same bedtime every night, well before midnight, and develop a quiet bedtime ritual

Internal factors
1. Empty your bladder right before getting in bed.
2. Seek medical treatment for heartburn if causes frequent awakening. Ditto for urination.
3. Evaluation for sleep apnea is a must for someone who snores and suffers from daytime sleepiness.
4. Treatment of arthritis with exercise, physical therapy and medications, if necessary.
5. Try to get weight down to normal: sleep apnea, heartburn, and arthritis pain all benefit

Mind-Body Medicine

If the mind, that rules the body, ever so far forgets itself as to trample on its slave, the slave is never generous enough to forgive the injury, but will rise and smite the oppressor.  Henry Wadsworth Longfellow

In the 1600s, philosopher René Descartes gave the world the concept of mind-body dualism. The body was composed of physical substance, visible, weighable and measurable. The mind was something else. Over the next three centuries, as scientists deconstructed the body to discover its secrets, the mind reclaimed its place as an inseparable part of the body. (Soul is another matter, not open to scientific inquiry.) Some rudimentary examples of the mind-body connection are the blush of embarrassment, the adrenaline rush following a near miss accident or the receipt of bad news, and the cotton mouth that accompanies emotional distress. The mind perceives and the body reacts. The mind decides  and the body acts.  Not only are mind and body inseparable, but most often the body responds to a vast subconscious system rather than to the aware part of the mind known as consciousness.

The powerful subconscious mind

In Sigmund Freud’s (1856-1939) introductory rendering, the unconscious mind was a cauldron of seething resentments that gave rise to neurotic behaviors and bad dreams. Modern research softened this view and today the unconscious mind seems more like an executive secretary who relieves the boss of routine work.  It sorts through incoming information, keeps track of the environment and runs the motor system that operates the body, all with such subtlety that much of the time you, the boss, think you are in charge. But if you have an electrode placed in your brain recording the action of the nerve cells that put your arm in motion, the recording will show activation of those cells before you are consciously aware of your decision to reach for that candy bar. Before you “know” it, the choice has been made in your subconscious mind.  But this doesn’t mean we are automatons – after all, you can still decide not to eat the candy.

The neuropeptide network: connection of mind to body

The subconscious mind may have even more power than we suspect.  The same chemicals that transmit information in the brain are found in virtually every organ of the body. This neuropeptide network, discovered around 1980, bridges the gap between the brain and the body, making a psycho(mind)somatic(body) connection.  Since the time of Freud, the word psychosomatic has a bad reputation, often synonymous with “hysterical” or “without physical cause.”   All symptoms, however, are technically psychosomatic because they arise in the body and are perceived in the mind. The discovery of the chemical interplay between brain and other body organs forces us to consider whether the flow of information goes the other way too.  Can the mind cause diseases to happen? Can it help heal disease?

Placebo effect

Eastern medical practices have always regarded the body/mind as one entity.  Since the 1950s, Western medicine has acknowledged the mind’s influence over the body by taking into account the placebo effect in studies of new treatments.  The placebo effect is the relief that happens when a patient believes he has received a real treatment, despite the treatment being a sham.  The phenomenon may reflect the power of belief or it may reflect the fact that many disease processes get better on their own – the only way to tell is to add a third, no-treatment group to each study.  The fact that the placebo effect occurs in more than 30% of patients in many studies demonstrates the mind’s significant role in disease and health.

Conventional medicine takes a look at the alternatives

Western medicine’s gradual acceptance the mind/body connection culminated in the establishment of a National Center for Complementary and Alternative Medicine (NCCAM) within the National Institute of Health ( in 1991. The center conducts controlled studies on subjects such as the effect of regular meditation on chronic pain, anxiety, high blood pressure, cholesterol, health care use, substance abuse, post-traumatic stress syndrome in Vietnam veterans.  It offers objective descriptions of Eastern medical theories which for which science has no proof.  Part of the NCCAM’s mission is also to educate the public to become discerning customers within the vast alternative care and wellness industries that capitalize on the tantalizing possibility that good health may be a byproduct the “right” frame of mind.

The alternative and the conventional medical industries operate side-by-side, sometimes, but not always complementing each other.  Conventional medicine is increasingly fragmented, with care delivered on an organ by organ basis. The whole person and his mind- body relationship can get lost in the process; unwanted side effects occur, and sometimes treatments hurt more than they help.  But conventional methods save many lives and provide much needed comfort.  Alternative practices that teach wellness via mind-body wholeness also do much good, mostly in preventing disease by emphasizing the back- to- basics factors: nutrition, sleep, exercise, relaxation, relationships and environment.  Importantly, most of them do no harm except if they keep patients from seeking conventional help when necessary.

The importance of habits

In this century, the commercial spotlight is trained on the role of the mind in sickness and in health, which may obscure an important fact: most of the mind’s effects on health are subconscious, embedded in long years of mental and physical habits and not amenable to conscious adjustment over short periods of time.  The right thinking and attitudes will help only insofar as they can work their way into the subconscious underpinnings of the mind by the diligent practice that leads to habit formation.  Whether the mind-body practices are called meditation, yoga, Tai-chi, guided imagery, art and music therapy, biofeedback or acupuncture,  they should be undertaken as long term projects  requiring persistence,  just like all those other low-tech habits that promote good health. The mind may be the body’s master, but it cannot change the laws of nature that govern all biologic systems. There are no quick and easy fixes.


Interesting Reading

Blink: The Power of Thinking Without Thinking, Malcolm Gladwell, Little Brown, Boston, 2005

Anatomy of an Illness as Perceived by the Patient, Norman Cousins and Rene Dubos, W.W. Norton & Co., NY, 1979.



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