Practitioner Perspective: Sleep Strategies for Optimal Health and Wellness

A healthy diet, physical activity, and good mental health are all essential to promoting a healthy mind and body, but according to Shane Creado, MD, without quality sleep, it’s impossible to achieve optimal health outcomes.

In his new book, Peak Sleep Performance for Athletes, Creado, a board-certified psychiatrist and integrative sleep medicine physician, details his framework for helping athletes leverage sleep to optimize their sport performance. The framework includes a three-tiered pyramid that works to help patients avoid sleep disturbances, improve their sleep quality, and achieve their true potential. And while the book is geared towards athletes, Creado said his Pyramid of Peak Performance can be applied to any patient.

“I wanted to provide a framework, the same framework that I use with my professional athletes, for everyone to have access to because sleep problems are usually a symptom of multiple underlying factors,” said Creado. “Our duty is to identify as many contributing factors as we can and mitigate those as much as possible.”

Climbing the Pyramid of Optimal Sleep

When working with patients, Creado likes to stress the difference between poor sleep quality and inadequate sleep. When someone gets enough sleep, it’s still possible for them to show symptoms of sleep deprivation, he explained. “The strategies listed in the pyramid are for anybody to not just normalize, but truly optimize sleep.”

Level One

The first tier of Creado’s sleep optimization framework addresses what he calls "sleep saboteurs," or the obstacles getting in the way of quality sleep. 

"At this stage, we are going to work on eliminating those things and establishing general sleep practices,” said Creado. “I may also use cognitive behavioral therapy for insomnia, the gold standard treatment. Not Ambien, not psychedelics.”

According to Creado, disruptions to sleep come in many forms, each requiring different levels of treatment. For example, patients struggling to sleep due to conditions like post-traumatic stress disorder (PTSD) or sleep apnea should be referred to a specialist for longer, more intensive care. Other saboteurs are more minor and in the patient’s control.

Seemingly insignificant, things like bright lights, watching TV before bed, a snoring partner, and discomfort are known to compromise sleep. Creado explained that treating these saboteurs with simple lifestyle interventions and changes to a patient’s sleeping environment can make a significant difference in sleep quality.

"Look at sleep as your mini-vacation," said Creado. “Consider a cooling weighted blanket, weighted eye mask, or blackout blinds.”

For the best results, Creado said weighted blankets should be 10 percent of a patient’s body weight. He also suggests earplugs for light sleepers and instructs patients to avoid sleeping with restless or noisy partners and pets.

Level Two

The second level of the pyramid involves tracking patients’ sleep metrics. To gain insights into patients' baseline condition, Creado suggests measuring testosterone levels and inflammatory markers before starting personalized sleep protocols. In addition, Creado said he sometimes uses rating scales to track a patient's levels of depression, anxiety, and daytime sleepiness. Then, throughout treatment, he will continue to track these metrics and watch for improvements or identify when a protocol isn’t working and intervene.

When evaluating patients, Creado said it’s also important that patients differentiate feelings of sleepiness from fatigue, which is a separate diagnosis. To do this, Creado suggests using the Epworth Sleepiness Scale, which asks patients to rate their level of tiredness during periods of low activity like watching TV or sitting in a car. Then, based on their answers, the test can help determine the extent of their problem.

For normal levels of sleepiness, Creado suggests using his framework; however, if their problems continue to persist, patients should be evaluated by a sleep doctor for sleep disorders such as narcolepsy and sleep apnea.

Level Three

In the third and final stage of the peak sleep pyramid, Creado incorporates specific optimization strategies into his patients' routines. This usually involves taking a deeper look at a patient's circadian rhythm, training times, and travel. Interventions in this phase may include techniques like exposure to bright light in the morning and light blocking at night.

One of Creado’s favorite sleep strategies is called sleep extension. For this intervention, patients are asked to slightly increase their amount of sleep with the intention of increasing alertness during the day. According to Creado, multiple studies out of Stanford University increased athletes’ amount of sleep by just 30 minutes a night and found that the extra sleep had significant impacts on their performance. One investigation on basketball players showed that after sleep extension, participants demonstrated faster-timed sprints, and their shooting accuracy increased by nine percent.

Creado also likes using strategic napping to help normalize and maintain patients’ sleeping schedules. For instance, if a patient is traveling to a different time zone, Creado may instruct them to nap at a specific time for a specific length of time upon arrival. This, he said, can help patients avoid sleep deprivation while also adjusting to the time zone.

“Strategic napping and sleep extension are some of my favorite optimization strategies to apply once we get the foundational things right,” said Creado.

Addressing Sleep in Everyday Patients

In his book, Creado discusses the benefits of sleep as it relates to athletic performance, but he said the impact of sleep on the body does not stop there. Sleep affects all aspects of overall health, he explained, and just as it’s overlooked in sports, the importance of sleep is also downplayed in healthcare settings. Especially with holistic, integrative care, Creado said it’s essential that practitioners address their patients’ sleeping habits for optimal health outcomes.

“It's incredibly important for integrative practitioners to focus on sleep as a cornerstone of integrative health. Sleep problems impact 711 genes, and if you're not getting proper sleep, over 300 of those genes are upregulated, which result in increased risk of cancers, immune problems, heart attacks, and strokes,” said Creado. “And over 300 of those genes are downregulated and suppressed, which can lead to reduced immune function and increased inflammation."

According to Creado, sleep problems have been linked to an increased risk of diabetes, obesity, cancer, and accelerated aging. To prevent chronic illness and premature death, Creado strongly believes that sleep screenings should be included in annual screenings.

When sleep problems are detected, Creado suggests practitioners remedy them with the gold standard of insomnia treatment. This, he said, includes cognitive behavioral therapy for insomnia combined with an integrative approach to correcting any deficiencies in ingredients needed for neurotransmitters, imbalances in hormones, and other factors that sabotage sleep.

“If we are not addressing sleep in a personalized way for an individual,” said Creado, “we're doing them an injustice, and we're failing a Hippocratic Oath.