What’s keeping you wide awake?

How did you sleep last night? Did you binge-watch Slow Horses? Woke up groggy, tired and irritable? Does your bed resemble a war zone? You are in the majority. 

Several studies have shown that over 60 per cent of Indians are grappling with sleeplessness. Extended wakefulness is an epidemic, say experts. Yet, sleep is not a priority for most of us. A 2024 Local Circles study says that 61 per cent of Indians surveyed get less than six hours of uninterrupted sleep. Insomnia has ensconced itself into an oblivious society. Wakefulness is ruining lives. A chronic lack of sleep increases levels of beta-amyloid and tau proteins, associated with Alzheimer's and dementia, by around 25-30 per cent, demolishes immune systems, doubles the risk of cancer and increases the incidence of lifestyle diseases.  

Sleep scientist and author Dr Matthew Walker warns, “Sleep is the single most effective thing we can do to reset our brain and body’s health each day.” Instead, we are wishing it away in complete disregard. Globally too, sleep is the big story today with the melatonin supplements market set to cross $10 million by 2033 and the sleep aids market to hit $455 million by 2029.

How deep is your slumber?

Dr Manvir Bhatia, leading sleep medicine expert, Neurology, Sleep Centre and ex-prof AIIMS, Delhi, explains, “When we sleep, the brain activates a clean-up system, especially at night. Cerebrospinal fluid wipes and clears out the junk. If sleep-deprived, proteins accumulate in the brain — amyloid and tau — the culprits for dementia which then aggregates, destroying brain cells. Sleep should be non-negotiable. Our habits and behaviour are the culprits that impair this crucial cleanup.” 

Dr D V Seshagiri, associate professor, Department of Neurology, Nimhans, say most people do not seek help. “Our cities never sleep, the abject lack of awareness is acerbated as many don’t know whom to consult. Detecting sleep arousal is key to diagnosing disorders,” he says. Disorders such as insomnia, sleep-disordered breathing, periodic limb movements in sleep, restless leg syndrome, excessive sleepiness, and REM sleep behaviour disorders are becoming more commonplace.

“In India, almost 20 to 30 per cent are chronically sleep deprived. Youth sleep patterns have completely changed and the lack of sleep medicine specialists is a big concern," says Dr Bindu Kutty, senior professor at the Department of Neurophysiology, and person-in-charge of the Centre for Consciousness Studies (CCS). 

Screens are established killers of sleep. As social media, doomscrolling, binge-watching, shift work and the urge for instant gratification bombard lives, how does the body recover? Screen time, Dr Sheshagiri feels, is making, “Our beds into stimuli-absorbing machines, instead of it being a stimulus for sleep.”

Luke Coutinho, integrative lifestyle expert, stresses, “During sleep, DNA repair occurs, inflammation is controlled, gut microbiome rebalances, brain detoxifies, and muscle recovery occurs. It’s time to put sleep at the centre of your wellness journey.”

Our day determines our night

“People do not understand or accept this main tenet — one’s night is determined by one’s day. That is the thumb rule, ” avers Dr Bhatia. During the pandemic, Dr Gulshan, a post-doc fellow at CCS, conducted a 2020 study on sleep, emotions and dreams, finding a direct relationship between quality of sleep and bad dreams. Notably, women are likely to be more affected by sleep and emotional compromise.

In The Sleep Solution, authored by Dr Manvir Bhatia, sleep debt is defined as, “When the body gets less sleep than what is required.” Busting the myth that we can make up for the lack of sleep on weekends, she adds, “People think recovery sleep can help. However, it is not just hours missed, what is required is thrice the amount of hours missed (10X3 =30).”

Experts stress that even one hour of sleep deprivation is detrimental, which over time can lead to various co-morbidities.

What do sleep labs do?

There are two stages of sleep structure — Rapid Eye Movement (REM) and Non-Rapid Eye Movement (NREM) — with 80 per cent constituting NREM, and 20-25 per cent, REM. This 75-80 percent NREM includes light and deep sleep states with NREM deep sleep at 25-30 percent (for healthy individuals).

“The sleep cycle and structure has to be recorded over a night to find out anomalies,” says Dr Kutty. Sleep labs explore these stages through Polysomnography (PSG), collecting data in multidimensional timelines — electroencephalogram, electromyography, electrocardiography, electrooculography, blood oxygen saturation level, respiratory airflow, and respiratory movement.

With no blanket treatment, each individual is data analysed before embarking on the sleep restoration process. Collecting and centralising sleep and circadian data is crucial in India as is education to promote sleep health. Sleep data will drive the implementation of sleep health policies at the government level.

The inflammation connection

Sleep has anti-inflammatory properties, explains Dr Bhatia. As inflammation is the first sign of infection, “there are cells in our body, which, akin to an army getting ready for any attack, spring into action.” Lack of sleep accentuates the pro-inflammatory factors. Dr Arun Sasidharan, a neuroscientist at CCS elaborates: “Our immune system has this memory, a consortium which recognises and responds quickly and effectively to pathogens encountered before. These immune cells have a memory recouping during sleep. When adequate sleep is elusive, flu-like symptoms are exaggerated, and immune responses are high. During extended wakefulness, the brain’s autonomic functioning gets disturbed and cells get altered. This activates inflammation further eventually leading to the individual becoming immuno-compromised."

“Studies show that a lack of sleep makes one 20 per cent more prone to a common cold as the pathways to memory cell formation are affected,” adds Dr Kutty. Overeating causes GERD, and its reflexes cause insomnia, which often many do not connect to a lack of sleep.

Dr Bhatia speaks of many patients, who sleep at 5 am, awake at 2 pm, unable to hold jobs, with haywire food habits, GI systems in disarray, and health parameters affected. “We guide and motivate them to move cycles gradually, one hour per week, and follow stringent guidelines,” he adds, worried at how India’s sleep deprivation is catapulting.

Are you losing sleep over sleep?

If you are looking for sleep clinics, make sure to check their accreditation and ensure they have a qualified sleep technician and sleep medicine specialist on board. Expenses have a wide range — anything between Rs 1,000 to Rs 35,000 depending on the centre you choose and the extent of treatment. While gadgets and technology come in handy, Dr Bhatia advises prudence. "Unbridled worry about sleep is called orthosomnia and that has become a disorder by itself!

What's the deal with melatonin?

Sleep labs today measure melatonin levels, the sleep-inducing hormone that indicates sleep onset with blood tests. “These are variable — not a one-time measurement like blood sugar, but measured through the night, to gauge peaks, which helps estimate one’s sleep onset,” explains Dr Bhatia.

Self-medicating with over-the-counter melatonin is rampant. Available in gummies, or tablets, most are synthetic versions of the natural hormone produced by the body’s pineal gland. Dr Manvir cautions, “We have no idea about the content or potency of these gummies. These are better prescribed by a sleep medicine specialist, and only for a short period. Popping a gummy won’t address underlying causes.”

Dr Kutty is also concerned about such quick fixes. “Simply taking melatonin might help you sleep, but self-medication is not advisable. We don’t medicate, or prescribe unless required. It is important to correct one's maladaptive behaviour and sleep habits first.”

Sleep hygiene protocols

1. Stick to a fixed sleep timing. Even if you sleep only six hours, do it at the same time every night. 

2. Eat nutritious food (and not junk) before sunset, in small quantities. 

3. Ensure you sleep in a comfortable, dark room, clear of stimulation. Try to keep the temperature cool. 

4. Get sunlight in the morning. Light changes the circadian rhythm, and is akin to a switch off for the night hormone melatonin. 

5. Try to not consume caffeine after late afternoon as it lingers in the blood for six to eight hours and blocks sleep receptors.

6. Any strenuous exercise must be done at least two to three hours before you sleep and light activity closer to bedtime. 

7. Monitor how you feel when you get up. If sleepy and tired, you are probably waking up in the middle of a deep sleep cycle. Use a wearable device and readjust time to wake up during the NREM (Non-Rapid Eye Movement) phase. In other words, restful sleep.

8. Unable to sleep? Don’t spend time in bed. Take a walk, read, listen to music, do breathwork, or meditate.

9. Clear out your emotional clutter before you sleep. Keep a check on screen time. 

10. You can measure your sleep quality with the Stop-Bang Scoring Model, the Epworth Sleepiness Scale or the Pittsburgh Sleep Quality Index. Those who suffer from sleep apnea must consult a clinician who can alleviate symptoms with CPAP (Continuous Positive Airway Pressure) machines and other methods. 

What you eat is how you sleep

1. There are a few soporific foods that promote sleep. These include yoghurt, banana, milk, oats, peanuts, almonds, honey, chamomile, etc. Foods to avoid in the night include anything with caffeine, alcohol, tomato-based products (may cause acid reflux and heartburn), cured meats and aged cheese. 

2. And avoid popping that pill! Dr Bhatia terms it a "dreadful habit", an addiction to which the body quickly develops tolerance and thus demands an incremental increase of the substance in question. Most sleeping pills work by enhancing the effect of Gaba, a neurotransmitter that dampens the impulses of the nervous system and causes a 'hangover' effect. The pills also come with the danger of rebound insomnia (once you stop taking them) and subsequent withdrawal symptoms. 

How much sleep is enough?

1. Naps are good if they are short. A short nap after lunch — say about 15-20 minutes — helps. Not a three-hour conk-off in the afternoon. 

2. In general, adults need anything between 7 to 9 hours of sleep. However, this differs considerably according to each individual's requirements and circumstances. For instance, those who work in shifts have a disturbed body clock. The American Academy of Sleep Medicine classifies this as 'Shift Work Disorder' and advises sufferers to structure their day with big chunks of sleep (since they are awake in the night), meals, exercise and relaxation time. 

3. As we age, deep sleep is qualitatively and quantitatively affected. The elderly spend a higher percentage on light sleep and this can effectively reduce the deep sleep time by 15 per cent or more. If not tackled, this can up the risks for neurodegenerative disorders. Doctors recommend avoiding sleeping during the day, reducing caffeine intake, moderate exercise and a balanced diet.