Maggie McKay (Host): Welcome to Total Health Talks, your Cook County Health Podcast, where we empower your journey to better health. I'm your host, Maggie McKay. And today, we're going to talk with Dr. Aiman Tulaimat, Chair of Pulmonary Critical Care and Sleep Medicine. Today, we're going to focus mainly on the sleep part, because that's something that affects us all. Thank you so much for being here today.

Aiman Tulaimat, MD: Thank you. Thank you, Maggie, for having me. It's a pleasure.

Host: So, let's start with why does sleep exist, and what is your brain doing while you're asleep?

Aiman Tulaimat, MD: Well, if you think about it from an, evolution perspective, sleep sounds like a really scary situation to be in. Imagine in the wilderness, during sleep, you cannot defend yourself. You cannot find food. You cannot protect your wellbeing, your family. So, there must be a very strong reason for us to spend a third of our life in this state.

And what really happens during sleep is at that time, the brain cleans itself. That's one of the main functions that happen during sleep, is the brain has to get rid of the waste it accumulates throughout the day. And the best time to do this is when the rest of the body shuts down.

There are many other functions for sleep. Sleep is important for learning, of course. Without adequate sleep, our memory suffers tremendously. So, just by thinking about it from these two perspective, that's enough. We know from animal studies that if an animal doesn't sleep enough—and these are animals that have short lifespans—the animals develop significant organ failure and actually die. So, it is a very, very important function for our survival. And when we are asleep, the brain is not shut down. The brain continues to work. We might look asleep to the rest of the world. But actually, inside, the brain is tidying up, cleaning, and taking care of itself, getting ready for the next day.

Host: How does sleep help clear toxins from the brain? How does that work?

Aiman Tulaimat, MD: In the last few years, we've learned a lot about this aspect of brain function. The brain has something called a glymphatic system. It's these little channels throughout the brain where the brain swims. When we sleep, the neurons, which are the building blocks of our brain, kind of shrink a little bit, and there's more space for that fluid to flow around. And during sleep, the flow of that fluid is about 10 times what it is when we are awake.

Now, why do we think there is so much waste in the brain? Well, the brain is the organ that consumes the largest amount of oxygen for its weight. The brain, when we are awake, consumes about 20% of the energy the body produces. The brain doesn't occupy 20% of our size, but it consumes 20% of the energy of the body. And it has to come out. And during the day is probably not the time, I guess, our physiology tells us. So when we sleep, the body washes out that waste.

And there is one important element in that waste that there is a lot of buzz about right now, which is amyloid proteins. Amyloid proteins are part of the waste. And if it's not excreted, we think it contributes to cognitive decline with age, or dementia is another way of thinking about it. So, when we are awake, we produce a lot of waste. And when we sleep, we need to double up the cleaning activity during the eight hours to clean all that waste to get us ready for the next day.

Host: This might be naive, but where does that waste go? Does your body reabsorb it, or…?

Aiman Tulaimat, MD: Yeah, it goes to the circulation and the body destroys it. It just leaves the brain. It leaves the brain.

Host: Okay. Naps, are they helpful or harmful?

Aiman Tulaimat, MD: Well, it is about 3:00 PM, and I should have already had my nap today. Unfortunately, U couldn't. But if I could, I would've taken a 10-minute nap. And naps are useful tools, and we should think of them strategically. A 10-minute nap can be immediately refreshing. And if you're struggling with concentration, you feel tired, taking a 10-minute nap will give you a boost and you'll get going again. A 30-minute nap is probably even better. A 30-minute nap not only will give you energy, but will have a longer effect of the energy, not just for the next hour, maybe two hours or three hours, you'll have a higher performance and will improve your learning for that particular day. So, your memory will be more effective that day after a 30-minute nap. The problem with a 30-minute nap is when you wake up from the nap, you're not fully awake. It takes you time. There's grogginess after the nap. You don't have that with a 10-minute nap. With a 30-minute nap, you start to have grogginess.

Now, longer naps, maybe a 60-minute nap. The thing with a 60-minute nap is it'll definitely wake you up, but the grogginess will be very long. It'll be also probably up to 60 minutes after that. So, it depends how you utilize the nap during the day, depending on your needs that day.

Host: When you say a 10-minute nap, I mean it takes me like 20 minutes just to fall asleep. Do you have to actually be asleep during naps or just resting?

Aiman Tulaimat, MD: A nap is really a sleep. I mean, that's how I would think about it, falling asleep. There's nothing wrong with laying down to clear your mind to do some relaxation exercise. That all has good effects. But for example, you're on the road and tired, it might be a good idea to stop and take a 10-minute nap if you can. That will give you some energy get to your destination. That's something that is useful. It increases your alertness. It's probably better than drinking coffee, for example, when you're driving. A 10-minute nap will give you a boost of focus and concentration for another hour or so that probably coffee would not be as good.

Host: So, how does exercise or the lack of it affect sleep?

Aiman Tulaimat, MD: Exercise. Daily exercise improves nighttime sleep for sure, absolutely. We know that very well. And as long as exercise happens three or four hours or more before sleep, it has a sleep-enhancing effect. And it has no detrimental effect on sleep. In fact, sleep gets deeper, sleep becomes more continuous, and what we call sleep latency—time to fall asleep—gets shorter, so it becomes a better experience.

The problem is the closer exercise gets to sleep or the more intense exercise, then it really starts to affect sleep. It delays sleep onset. It makes our sleep shorter. And in fact, when people do intense exercise and are able to fall asleep, the heart rate stays up when they're asleep, which really tells us that the nervous system is not fully rested, it's not fully down.

So, I advise my patients all the time, avoid exercise in the three hours before going to bed. I prefer exercising in the morning. Wake up, exercise. And I get to do two things this way. I improve my sleep at night, and I get my exercise out of the way. Because what happens, your stamina and your energy will kind of weaken as the day goes down, and too many things compete for your time. So, I advise my patients for metabolic health, for cardiac health, and for sleep health, try to exercise in the morning. You get all the benefits together.

Host: And what are the physical and mental consequences of not getting enough sleep? Because, for years, I did an overnight shift. And I have to tell you, I never felt rested.

Aiman Tulaimat, MD: And that's a big problem. And I can approach this from aspects. The challenge you're bringing attention to, which is night shift or shift work. Fifteen percent of the workforce works night. Healthcare, policing, airports, all transportation, all of this works 24/7 and 15% of the workforce works nights. And night work is very disruptive. And there has to be focus on the quality of alertness and rest actually during the night shift. And then, a lot of attention when people go home after a night shift. The environment at home has to be calm, has to be at a good temperature, no light, no distractions, et cetera, to allow the opportunity to sleep. And many people actually continue to struggle with sleep problems even when they're no longer working night shift. There is a residual effect. The sleep-wake cycle just gets chronically disrupted.

Now, sleep deprivation in people who just sleep regular time at nighttime and work daytime has a lot of effects, and I can give you a few examples. As a pulmonologist also, we see a lot of respiratory infection. And sleep deprivation upsets our immunity. So, think about it this way, there was an experiment where they had individuals sleep more or less than seven hours and they exposed them to the cold virus to see if lack of sleep increases you developing cold if you're exposed to the virus. And indeed, if you are sleep-deprived, you catch the virus more easily and develop a cold, which really tells us that our ability to deal with viruses and microbes declines. Patients with insomnia, for example, are more likely to get COVID and influenza during the winter season.

So, all of these tell us that sleep deprivation has significant effects on immunity. Lack of sleep is associated with higher death rate. Lack of sleep is associated with developing diabetes. It's associated with higher risk of diabetes, even in people who eat healthy food. So, eating healthy and sleeping more doesn't protect you from the increased risk of diabetes.

So, sleep deprivation has so many effects on our metabolism, not to mention, of course, its effects on memory, on learning, on cognitive function, whether it is dealing with mathematics, solving problems, language problems. It has a broad effect on everything we do every day.

Host: What's a reasonable threshold for how many times waking up at night is "too many"?

Aiman Tulaimat, MD: Now, our sleep happens in cycles. So when we fall asleep, we go through light sleep, deep sleep, dream sleep, and then the cycle repeats multiple times. And sometimes in the transitions of these cycles, we wake up, especially when we get into the lighter sleep. And that's fine.

The problem with waking up from sleep is our inability to go back to sleep. So if you are unable to go back to sleep in 20 minutes, that becomes problematic. And if this happens two or three times a night, that is definitely problematic. So for an individual who wakes up two or three times a night and it takes them 20 minutes to go to sleep, that's technically insomnia, and it has to be addressed by a sleep professional.

Host: Can you explain sleep apnea in simple terms? Because we hear so much about it.

Aiman Tulaimat, MD: Okay. Sleep apnea is extremely common. It's hard to pinpoint a number, but at least 10 to 15% of adult population have it. And what it is, breathing during sleep becomes irregular. We fluctuate between having small breaths and large breaths, small breaths and sometimes no breath, and then go back to large breath, and that continues through the night.

And as we go through this irregular breathing, a few things happen. Our body recognizes the low oxygen, that is alarming. Our body feels the air is not coming in. It alarms the brain and causes awakenings. And these sudden awakenings stimulate our stress hormones. And these are the stress hormones that ultimately lead to things like high blood pressure in patients with sleep apnea. And I can give you a very simple example, or two simple examples.

One, in the earlier studies in animals that we simulated sleep apnea, these happen mostly in dogs, a dog can develop hypertension in 14 days of having sleep apnea, like a medically-induced sleep apnea that is very rapid to get hypertension. So, that confirms the relationship that sleep apnea is a cause of hypertension. And more recently, we've seen that the treatment of sleep apnea improves blood pressure control. That seals the evidence that sleep apnea causes hypertension and treatment of sleep apnea improves the control of hypertension.

So, it's common. It manifests as irregular breathing, frequently snoring, but not always. And the main consequence that we look at metabolically or cardiovascularly is hypertension.

Host: And is sleep apnea common in children? When should parents seek professional help if so?

Aiman Tulaimat, MD: Sleep apnea affects about 1% of children. And in some communities, it's up to 5%. That's one in 20 children. And the manifestation in children is different. In adults when we don't sleep well, we're usually tired and sleepy, children become hyperactive. And frequently, that is mistaken for ADHD. And it would become more devastating when this ADHD from sleep apnea gets treated with medications.

In children, the main treatment sleep apnea, especially if they're younger children, is by removing their tonsils, because it's the narrowing of the airway from the large tonsils that gives them sleep apnea most frequently. But in children other than hyperactivity, you can see the children having, of course, snoring, having restless sleep, turning and moving a lot, sleeping in odd positions.

These are all things that parents can notice and they should bring up this matter with a pediatrician because all it takes is a sleep test. And if it's the tonsils, the tonsils are removed, and the child activity gets improved. In fact, I was just in a meeting with a pediatric sleep specialist. And in his practice and he's had a lengthy career in sleep medicine, he said ADHD should never be diagnosed in a child unless sleep disorders are ruled out first, because the hyperactive behavior is one of the main manifestations of sleep disorders in children.

Host: That's so interesting. I've never heard that. What sleep disorders affect children the most?

Aiman Tulaimat, MD: Well, in addition to sleep apnea IN children, you can see sleepwalking. There are night terrors where the child wakes up looking scared. They don't remember any of these behaviors. Children can also have insomnia. Children can have a lot of behavioral problems where they negotiate, they don't want to go to sleep. And these are all things that some are just normal behaviors that we have to coach the parents how to deal with, they're not consequentials.

Teenagers can get narcolepsy, which is a condition in which the child is extremely sleepy, they fall asleep anytime. And it's due to a loss of hormone in the brain that helps them stay awake. Many of those children are usually labeled as lazy And they go through life labeled as lazy until they're diagnosed at an early age. But if a 17 or 18-year-old is falling asleep constantly and they sleep well at home, this deserves investigation. Narcolepsy is not rare, but it is extremely underdiagnosed.

Host: What about tips for unplugging from phones and devices before bed? Good idea?

Aiman Tulaimat, MD: Well, there's been a lot of talk about the light from the phone and its effect on our brain, and it's a big controversy. What we know for sure is what is most stressful is the psychological stimulation from the device more than the light. We've talked a lot about the light. But what gets us more stimulated and takes us away from sleeping is getting psychologically stimulated, angry, upset from what is on social media.

I think that is what we should be more cognizant of, not necessarily having the phone. I look at my phone sometimes at night, checking on friends, looking at pictures sent by my sister or my mother. That's okay. It is the engagement with social media that can sometimes be very stressful is what it probably affects sleep.

Host: So, why do people feel wide awake at night, but they struggle to wake up in the morning? Like, do you have any tips for people who work night shifts or have irregular schedules? Because some people work in the day, and then they got called in to do overnights. And then, the next day they work in the evening, and the next day in the morning. So, your body must just be going crazy.

Aiman Tulaimat, MD: Yeah, your body and your mind. These are very stressful situations. And I'll try to divide this into different categories. So, there is what we call delayed sleep phase. These are individuals who are wired to go to bed very late. These are the night owls. They go to sleep 3:00 AM, 4:00 AM, and then they sleep normally until noon. And they wake up feeling refreshed and they do this day on, day off. And that's how their body is programmed. So if they don't have any early morning commitments, they don't struggle. It's not an issue. It's a situation they would live with.

The problem is when these individuals with delayed sleep phase have to wake up in the morning to go to school or have to wake up in the morning to go to work or have to drive a car under these conditions, that becomes a problem. Now, there are interventions we can do to shift the sleep to an earlier time. It takes time. This is a very challenging situation. But we have methods of helping the patients what we call advance their sleep to a schedule that works well for their life.

Now, shift workers is a very different situation. Shift workers, let's say they go to work at 11:00 PM and they stay there and then they get home and they struggled to sleep. That has to do with two things. The first, sometimes night shift workers consume large amounts of caffeine to maintain focus at work, which when they get home, caffeine is still in the bloodstream and they're unable to go to sleep. So, that becomes a problem.

Instead of caffeine, as I had mentioned earlier, a nap in the middle of the shift can really boost attention and performance. And that's something I think employers should pay more and more attention to, that night shift workers need to rest for them to perform their duties at the best they can And that when they go home, they're able to rest instead of relying on caffeine that will take away their sleep when they get home.

Another thing that might be important is the home environment when we get home. One of the strongest ants for our brain is light. So, I do advise my patients who have, who work night shift, that when they go home, especially if the sun is up, is to wear sunglasses to reduce the light exposure on the way home. And when they get home, they have to use blackout curtains. And they might need to use earplugs to reduce noise. Any stimulus has to be avoided to allow them to get the sleep.

Now, many times shift workers are unable to get a long period of sleep. Let's say they get home at 8:00 and they're able to sleep four hours. What many shift workers do—and I think this is reasonable—is that they would wake up, take care of some activities, and then they would take another nap before they go to the shift again. So this way, combined together, the first session of sleep and then the second period of sleep, add to a total of reasonable sleep that will give them good energy when they're at the night shift.

Host: So for day workers, should they rely on caffeine to stay awake during the day, like eight-to-five job?

Aiman Tulaimat, MD: I drink caffeine every day. There are coffee or tea. And there's evidence that the consumption of coffee or tea has other health benefits, but we have to remember two things. Coffee might take away our sense of fatigue. That doesn't necessarily make us more effective cognitively.

So, I use coffee for enjoyment. Maybe it can take away my sense of fatigue, but that's all. And we have to remember two things. Coffee, especially in older people like myself, stays longer in the body. So if I drink coffee at 2:00 PM, it is in my bloodstream at 10:00 PM, it hasn't left.

And the other thing is, as we get older, we get more sensitive to caffeine. So, it becomes more disruptive of our sleep. So, my son, 24, drinks coffee at 6:00 PM, 7:00 PM He goes to sleep. I drink a cup of coffee at 2:00. I'm awake until 1:00 AM. For the combination of these two effects, that it stays probably longer in my bloodstream, and then probably my brain is more sensitive to it now. So, it disrupts my sleep.

Host: For children. Any thoughts on melatonin gummies?

Aiman Tulaimat, MD: Melatonin is a large problem. And as you've probably been aware from the news, there have been increased incidences of melatonin ingestion by children in large quantities. And most of these cases go without harm. But we do not know what large doses in the long run can do for children. And that is the worry here.

Ingesting a large quantity of melatonin here and there is probably not going to cause immediate negative effects, but we have no information about long-term effects. And the problem is that the companies that are making those supplements are putting superphysiologic amounts of melatonin. So if a child ingests melatonin that the parent is using, these are doses in the 5-10 milligrams. Some adults are using 20 milligrams, which is extremely high dose. The therapeutic dose of melatonin is half a milligram to one milligram. And then, when you see on the shelves and supplement stores and in pharmacies, doses of 5 and 10 milligrams that are extremely high, and then you put them in gummies and it's in all sorts of supplements.

So, the amount of melatonin floating around us, it is really large. And children will easily pick them up and take them. And so, it is concerning how much melatonin is out there. I don't think it is immediately harmful, but I don't think also we know the long-term effects of these large doses of melatonin.

Host: So in closing, is there anything else you've learned in researching sleep that people should know?

Aiman Tulaimat, MD: It's not from researching sleep. It's from taking care of thousands of patients. Everything in our life competes for our sleep. Our work competes for our sleep. Entertainment competes for our sleep. Our children competes for our sleep. The TV competes for our sleep, our neighbors. Everything is encroaching on our sleep and we should really protect it.

This is a sacred time for our body to relax, to get ready for the next day, and we should be aware of this competition for our rest. Because if we are not rested, we cannot take care of anybody else. We cannot take care of ourselves. We cannot take care of our children. We cannot be good drivers. We cannot be good students. We cannot be good doctors.

For us to do everything during the day, it is very important for us to protect our sleep or our nights. So, That is the message I try to tell my patients, is that protect your sleep from the rest of the world, and you'll be a better person.

Host: So true. Well, this has been so informative and helpful. Thank you so much for sharing your expertise and for taking the time.

Aiman Tulaimat, MD: Oh, you're welcome. Anytime.

Host: Again, that's Dr. Aiman Tulaimat. As we wrap up another insightful episode of Total Health Talks, make sure to visit cook county health.org/podcast. And subscribe to our podcast, share and connect with us on social media. Stay tuned for more engaging discussions. This is Maggie McKay signing off from Total Health Talks. Stay well.