Sleep and Weight among Our Veterans

In an article published in this issue of the Journal of Clinical Sleep Medicine, Mayer and colleagues¹ document the prevalence of sleep difficulties and post traumatic stress disorder (PTSD) among veterans referred to a weight-loss program. The study participants were enrolled at their local Veterans Affairs (VA) hospital in a nationally administered program named MOVE! (Managing Overweight Veterans Everywhere). Although a welcome addition to the literature, the results should not be surprising.

Secular trends indicate sleep disorders among US veterans are a growing problem.² The National Veteran Sleep Disorders Study detected a six-fold increase in prevalence between years 2000 and 2010. Advances in trauma care and better body armor ensure that more veteran survive the injuries that they probably would not have in earlier conflicts. Consequently, closed head injuries resulting from proximity to blast explosions have emerged as the signature injury of the wars in Iraq and Afghanistan.³ In traumatic brain injury patients, subjective complaints of daytime sleepiness and poor sleep quality, as well as poorer sleep efficiency and reduced sleep time on polysomnography, are quite common.^4,5 That said, there is evidence that ubiquity of sleep disorders may not be limited to veterans of recent conflicts; in one study, 87% of older veterans, age 55–89, were found to have sleep-disordered breathing.⁶

The relationships between sleep and metabolism are plausibly bidirectional and interwoven.⁷ Several studies have implicated sleep loss and circadian disturbances in increasing the risk for type 2 diabetes⁸ with quite a few “usual suspects”: shift work, cross time zone travel, exposure to artificial light at night, social jet lag, irregular eating behaviors, and reduced exposure to daylight. Controlled studies suggest that sleep curtailment can increase hunger and appetite⁹; conversely, calorie restriction can improve quality of sleep.¹⁰ The impact of sleep and circadian disruption on energy balance and diabetes prompted the National Institute for Diabetes and Digestive and Kidney Diseases to conduct a workshop, at which key principles for research were identified.¹¹

Studies of individual chronotypes indicate that evening chronotype is associated with less healthy lifestyles and increased risk for obesity¹² and risk-taking behaviors.¹³ The good news here is the emerging evidence that morningness/eveningness, hitherto considered a trait, may be amenable to behavioral therapy.¹⁴

Sleep disturbances among veterans seem particularly consequential. An analysis of data from 28,269 veterans enrolled nationally in MOVE! suggested that sleep-disordered breathing is a barrier to successful weight loss.¹⁵ In a multi-center study, 88% of enrolled veterans had clinically significant impaired sleep; the severity of sleep disturbances correlated with PTSD symptom severity; and the improvement in sleep aided by risperidone co-therapy, though modest, correlated with improvement in PTSD symptoms.¹⁶ In a third study, sleep disturbances contributed to the relationship between PTSD and cognitive outcomes among blast-exposed veterans.¹⁷ And in a cohort of 3 million US veterans, incident obstructive sleep apnea was associated with greater mortality, coronary heart disease, stroke, chronic renal disease, and faster kidney function decline.¹⁸

There is further evidence that addressing poor sleep may be a “low-hanging fruit” in enhancing care for veterans. A onetime consultation by a sleep specialist seemed to have durable benefits for veterans in a collaborative primary care model.¹⁹ In a second study of veterans, mere provision of information regarding sleep was beneficial, although, brief behavioral therapy was superior.²⁰ The results echo the call for a step-wise approach to insomnia from a British study in which a single session of cognitive behavioral therapy was sufficiently efficacious for a sizable proportion of those with acute insomnia.²¹

Amidst the nation's ongoing epidemic of prescription drug abuse, notably, a study of 311,400 veterans from Iraq and Afghanistan demonstrated that 8.4% used more than five drugs that act on the central nervous system, and this polypharmacy was associated with overdosage and suicide-related behaviors.²² Another study among veterans of recent conflicts suggested that PTSD symptoms influence pain, and the relationship is exacerbated by problems with sleep and alcohol use,²³ raising the possibility that addressing sleep problems might save lives.

Left untreated, sleep disturbances following trauma may not go away. A recent study of avalanche survivors showed that sleep disturbances were persistent even after 16 years.²⁴ It would be interesting to see if the trajectories are different for those who receive treatment.

With growing data, a pertinent question is whether risk-benefit analysis favors use of benzodiazepines and other hypnotics such as zolpidem in any subset of patients with PTSD. Recent meta-analyses of prazosin in PTSD highlight the gaps in literature,²⁵ but nevertheless support the use of prazosin for sleep disturbances among combat veterans. Unfortunately, early discontinuation and suboptimal dosing of prazosin continue to limit its effectiveness.²⁶ An astute clinician ensures dose optimization by excluding alternative explanations before attributing a side effect to prazosin.

Another question is whether the modest improvement in sleep quality and PTSD severity offered by antipsychotic agents¹⁶ is worth the weight gain and related metabolic changes. Since antipsychotic agents considerably differ in their efficacy and side effect profiles,²⁷ perhaps the risk-benefit analyses favors some, but not other, agents.

Drawbacks of the contemporary treatments make alternative and complementary options appealing. A recent review suggested that meditative movements (tai chi, qi gong, yoga) have beneficial effects for various populations on a range of sleep measures²⁸; however, limitations of the existing studies precluded definite conclusions. In an ongoing randomized trial of 144 military veterans, yoga is being “raced” against delayed treatment comparison group.²⁹ Although back pain-related disability is the primary outcome measure, sleep quality and medication use are among the secondary outcome measures.

In sum, poor sleep is common and contributes to various chronic health problems. Given that it is eminently treatable, clinicians should be educated to screen and refer appropriate patients for specialized care. This is particularly important for veterans who face several additional challenges that contribute to poor sleep. At the same time, research into mechanisms by which poor sleep leads to various metabolic and other health derangements merits sustained investigation, which will potentially lead to mechanism-based interventions and screening strategies, that could, ultimately contribute to better overall outcomes.

DISCLOSURE STATEMENT

The author has indicated no financial conflicts of interest.

CITATION

Jindal RD. Sleep and weight among our veterans. J Clin Sleep Med 2016;12(7):943–945.