Category Archives: Sleep

Control Your Weight And Blood Sugar Through Sleep

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Most people think they gain weight when they lose sleep simply because they have more hours in the day to eat.  This makes sense.  I remember many nights on call as a Resident at St. Louis Children’s Hospital eating large amounts of high-calorie, unhealthy food as quickly as I could.  I got into this eating pattern because I didn’t know if I would be able to eat again all night.  As it turns out, this sort of eating pattern is not the full explanation for the relationship between less sleep and more weight.  There are decades of research on this subject that have shown that good sleep, both in quality and duration, is essential to help control weight and also to prevent type II (adult-onset) diabetes.

Epidemiological (population) research has shown an association between reduced sleep and increased rates of obesity and type II diabetes.  The numbers are surprising.  For example, a study has shown that children with reduced sleep were 89% more likely to be obese.  Adults with reduced sleep were 55% more likely to be obese.  Furthermore, there is a dose relationship.  The shorter the sleep, the greater the risk of obesity.  With regard to type II diabetes, reduced sleep increased the risk of developing this disease by 28%.  For people who have difficulty remaining asleep (fitful sleepers), the risk of developing type II diabetes is increased by 84%. Interestingly, people who had “long sleep” of more than 8-9 hours a night had a 48% increased risk of developing type II diabetes.  To be clear, epidemiological associations do not prove that stimulus X causes effect Y (e.g. decreased sleep causes obesity or diabetes), but that stimulus X is associated with effect Y.  In the case of sleep and obesity or diabetes, the association appears to be very strong.

The main mechanism that appears to link reduced sleep with obesity is the actions of the two hormones, leptin and ghrelin.  These hormones help regulate the feeling of hunger.  Leptin makes people feel full, while ghrelin makes people feel hungry.  Lack of sleep leads to less production in the body of leptin and more production of ghrelin.  Consequently, lack of sleep makes people both feel less full and more hungry.  To put this concept into real-life terms, a meal that would “fill-up” someone getting 7-9 hours of sleep a night (the national recommendations), wouldn’t feel like enough for someone who only gets 5 or 6 hours of sleep a night.

There are other mechanisms whereby reduced sleep can lead to obesity.  Sleep restriction is associated with stimulation of brain regions sensitive to food stimuli.  This suggests that sleep loss may lead to obesity through the selection of high-calorie food (sleep-deprived people are more likely to grab a bag of chips than a bag of carrots, for example).  In addition, there is evidence that restricted sleep can lead to the activation of genes that promote obesity. Supporting this concept is the observation that the inheritability of increased body mass index is increased in people who get little sleep.

Sleep loss also affects how people process glucose (sugar).  Studies have shown that sleep loss leads to decreased sensitivity, of the body, to the hormone, insulin.  This hormone is responsible for helping the body to process glucose and get it out of the blood stream.  If the body detects that there is too much glucose in the blood stream, such as what would happen if there is decreased sensitivity to the effects of insulin, then cells in the pancreas, called beta-cells, respond by making more insulin.  However, in sleep-deprived people the beta-cells do not make enough extra insulin to overcome the decreased sensitivity of the body to insulin. Therefore, sleep-deprived people have decreased glucose tolerance (they cannot get rid of extra glucose in the blood stream as well as they need to) and this leads to increased risk of developing diabetes.

Another reason why sleep-deprived people have decreased glucose tolerance is brain metabolism.  The human brain consumes up to two third of circulating glucose.  However, after sleep deprivation, utilization of glucose by the brain is reduced.  Therefore, sleep deprivation leads to another mechanism whereby blood glucose cannot be processed correctly, increasing the risk for developing diabetes.

Obesity and type II diabetes are metabolic diseases that have a tremendous impact on public health and society.  The role of poor sleep, either in terms of quantity or quantity, or both, is not commonly considered in the management of these conditions.  In clinical practice, it is, therefore, important to consider improving sleep as a therapeutic tool in the management of these obesity and type II diabetes.

For those people who are starting fitness programs, those people who are struggling to reach or maintain a goal healthy weight, or experienced athletes who desire to maintain an ideal body composition, it is important to think about good sleep.  Aside from the main targets of weight control: diet and exercise, good sleep, which is defined as 7-9 hours a night for adults age 18-64, is essential.

Please see my article, “Top 12 Tips To Improve Sleep,” to help you get started.

Published April 4, 2015

References:

Copinschi G, Leproult R, Spiegel K. The important role of sleep in metabolism. Front Horm Res. 2014;42:59-72.

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Morselli LL, Guyon A, and Spiegel K. Sleep and metabolic function.  Pflugers Arch. 2012 Jan;463(1):139-160.

Morselli L, Leproult R, Balbo M, et al. Role of sleep duration in the regulation of glucose metabolism and appetite. Best Pract Res Clin Endocrinol Metab. 2010 Oct;24(5):687-702.

 

 

Top 12 Tips To Improve Sleep

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The importance of sleep cannot be overstated.  Here are some tips to help you get the quality sleep you need:

  1. Maintain a consistent sleep schedule with the same bedtime and wake-up time every day, even on weekends  This helps to regulate your body’s clock.
  2. Stick to a relaxing bedtime ritual that you do every night before bedtime.  This is best done away from bright lights.  This ritual helps separate your sleep time from your stressful or exciting daytime activities.
  3. If you have trouble sleeping, avoid naps, especially later in the day.  If you have trouble falling asleep, try to eliminate all naps.
  4. Exercise daily.  Vigorous exercise is best.  If you exercise late in the day give yourself enough time to relax and let your core body temperature drop before trying to sleep.
  5. Evaluate your room. Your room is for sleeping, not for work or entertainment. Remove work materials, computers, and televisions.  Your room should be cool, between 60 and 67 degrees, and free from any noise and light that can disturb your sleep.  Consider using blackout curtains, eye shades, ear plugs, and white noise machines.  Don’t forget that your restless or snoring sleeping partner can be a big disturbance to you, too.
  6. Sleep on a comfortable mattress and pillows.  Most mattresses need to be replaced after 9-10 years.
  7. Use bright light to help you manage your circadian rhythms.  For example, avoid bright light in the evening and expose yourself to bright light (ideally natural light) in the morning.
  8. Avoid alcohol, caffeine, and nicotine late in the evening, since all three of these substances can disrupt sleep.  Of course, please avoid all nicotine in general for a variety of health reasons.
  9. Remember that indigestion affects sleep.  Avoid large meals and spicy meals close to bedtime.  Ideally, give 2-3 hours between the last full meal and bedtime.  Small snacks can be okay, but try to stick to liquids.
  10. Avoid electronics before bedtime.  The screens on devices such as tablets and laptops emanate light that can be activating to the brain.
  11. If you cannot sleep, go to a different room and engage in a relaxing activity until you are ready to sleep.  This helps you to associate your bedroom with successful sleep and not frustration.
  12. If you have allergies or asthma, ask your physician for help to keep these conditions under control.  These conditions are common causes of disrupted sleep.

Modified from Healthy Sleep Tips from the National Sleep Foundation.

Image: Panneau – dormir.

Please check out the other articles on this blog about sleep and other interesting topics.

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Maximize Sleep To Improve Athletic Performance

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This is part 4 of a series about the importance of sleep to athletes.  Part 1 was “Improve Athletic Performance By Taking A Nap.”  Part 2 was “Reduced Quality Of Sleep In Athletes.” Part 3 was “The Effect Of Sleep Deprivation On Athletic Performance.” Please subscribe to this blog for future installments and other interesting content.

My wife, Jessica, is an Ultramarathoner (you run an ultra, you get a capital “U”).  I have always been amazed at her powers of recovery. She ran a couple marathons last year as training exercises for a 50 mile race. She can run for hours on one day, then wake up the next day and do it again.  What is her secret?  Aside from being naturally gifted and very determined, she gets a lot of sleep; much more than me.  Is she on to something?  There is some research, in fact, that does demonstrate that extended sleep enhances athletic performance.

All of the most current research on this subject is from one institution, Stanford.  There are some limitations to the study designs and to the accessibility of the data, which will be discussed later.  One study has been published as a full peer-reviewed manuscript and will be the focus of most of this article.  In this study, 11 members of Stanford’s varsity men’s basketball team maintained their usual sleep-wake schedules for 2-4 weeks, then extended their sleep for 5-7 weeks.  During the period of sleep extension, the participants were to obtain as much nocturnal sleep as possible with a minimum goal of 10 hours in bed each night.  Per journal entries, the participants’ sleep increased from a baseline average of 470.0 minutes per night to 624.2 minutes per night during the study period.  Per actigraphy measures, baseline and study measures were 400.7 minutes and 507.6 minutes, respectively.  To translate this information into hours, during the study period the participants were in bed for 10.4 hours and actually slept 8.46 hours. Incidentally, at baseline the participants were sleeping less than 7 hours a night, which is not atypical, but less than national recommendations for sleep (7-9 hours per night). Variables measured included timed sprints (the participants ran a back-and-forth shuttle across the basketball court), shooting accuracy, reaction time, levels of daytime sleepiness, and mood.  At the end of the period of sleep extension, compared with baseline, participants demonstrated a faster sprint time (15.5 seconds vs 16.2 seconds), an increase in free throw shooting accuracy of 9%, an increase in 3-point field goal shooting accuracy by 9.2%, faster reaction time, decreased sleepiness sales, and improved mood, including, during practices and games, improved overall ratings of physical and mental well-being. Incidentally, this improved speed, shooting, and mood did not lead to a better record for the men’s basketball team.  Their record in the 2005-2006 season was 16-14, while it was 18-13 in the previous and subsequent seasons.  There are hundreds of variables that go into the performance of a basketball team over a season, so these results are merely interesting, not instructive.

These Stanford researchers also did very similar studies in varsity swimmers, football players, and tennis players.  The results have only been reported so far in abstract form, and, so, are not available for a great deal of scrutiny.  These studies appeared to show similar results to the basketball players.  For example, swimmers decreased their 15 meter sprint swim times from 6.98 to 6.47 seconds, decreased their reaction times from 0.88 to 0.73 seconds, decreased their turn times from 1.10 seconds to 1.00 seconds, and increased their kick strokes from 26.2  to 31.2, after the period of sleep extension.   The football players decreased their 40 yard dash times from 4.71 seconds to 4.61 seconds, after the period of sleep extension.

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There are important limitations to these research findings, however.  The most obvious limitation is the lack of a control group in these studies. It is reasonable to expect that well-coached collegiate athletes will improve their performances over 5-7 weeks and it is unknown if these athletes would have improved, to some degree, regardless of their sleep schedules. My impression, however, is that shooting accuracy and reaction times are unlikely to change so significantly just from coaching and training over 5-7 weeks.  Indeed, the concern for many athletes is fatigue over the course of an athletic season.  These athletes did not appear to experience this fatigue.  Another limitation is the fact that the researchers have not published three of their abstracts, dated 2008, 2009, and 2010, as full manuscripts.  This suggests that their data may have other weaknesses that have led to rejections by medical journals over the past seven years. For busy athletes, however, the most important weakness is the difficulty of applying these results to real life.  Not many people have the flexibility and freedom to be in bed for 10.4 hours every night for an athletic season.

In spite of the limitations of the research presented, it does appear that extended periods of increased sleep do lead to important enhancements in athletic performance.  This effect appears to be applicable to both skills and endurance and to both team and individual sports.

Just like eating right, practicing skills, and training endurance, maximizing sleep can let an athlete reach his or her full potential.

Published March 24, 2015

References:

Mah CD, Mah KE, Dement WC. Extended sleep and the effects on mood and athletic performance in collegiate swimmers. Journal of Sleep and Sleep Disorders Research. 2008;31(Suppl.):0384.

Mah CD, Mah KE, Dement WC. Athletic performance improvements and sleep extension in collegiate tennis players. Journal of Sleep and Sleep Disorders Research. 2009;32(Suppl.):0469.

Mah CD, Mah KE, Dement WC. Sleep extension and athletic performance in collegiate football.  Journal of Sleep and Sleep Disorders Research. 2010;33(Suppl.):0304.

Mah CD, Mah KE, Kezirian EJ, et al. The effects of sleep extension on the athletic performance of collegiate basketball players.  Sleep. 2011;34:943-950.

 

 

The Effect Of Sleep Deprivation On Athletic Performance

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This is part 3 of a series about the importance of sleep to athletes.  Part 1 was “Improve Athletic Performance By Taking A Nap.”  Part 2 was “Reduced Quality Of Sleep In Athletes.” Please subscribe to this blog for future installments and other interesting content.

We all miss sleep before important athletic events.  There has been research on the effect of partial and total sleep deprivation on aerobic and anaerobic exercise performance.  This information is important to all athletes, but especially to ultra-endurance athletes who, as a part of competitions become sleep deprived.

While it would be very unusual to not sleep at all before important competitions, it is commonplace to have reduced or disrupted sleep.  The studies that have investigated the effects of such reduced sleep on performance have, surprisingly, not demonstrated a large decrement.  For example, one study described the effects of one night of restricted sleep on athletes and found no change in gross motor function such as muscle strength and endurance running.  Another similar study in females showed similar results with less of an effect upon gross motor functions than tasks that required rapid reaction times.  In a study of eight swimmers, the effect of 2.5 hours of sleep for four consecutive nights was studied and no effect was observed in back and grip strength lung function, or swimming performance.  However, mood state was altered with increases in measures of depression, tension, confusion, fatigue, and anger.  With regard to anaerobic performance, a study examined the effects of a single night of 2.5 hours of sleep in a group of sedentary women and found no change in muscle strength.  However, an effect on anaerobic performance appears to become more apparent after several nights of restricted sleep.  This was demonstrated in a study of the effect of partial sleep loss (3 hours of sleep per night for 3 consecutive nights) on muscle strength. In this study, there was a decrease in maximal bench press, leg press, and deadlift, but not maximal bicep curl.  Interestingly, however, sub-maximal efforts were significantly negatively affected for all four tasks to a greater degree than the maximal efforts. Furthermore, the largest impairments were found later in the protocol, which suggests that there is an accumulative effect of muscle fatigue from sleep loss.  This last study may be of particular interest to long-course triathletes, who rely on muscular endurance, particularly in the cycling leg of races.

In the case of prolonged periods of no sleep, there are some interesting studies that have shown a large effect on performance.  For example, 30 hours without sleep has been demonstrated to lead to decreased running performance  This was shown in a trial in which participants ran, self-paced, on a treadmill for 30 minutes either after normal sleep or after 30 hours without sleep.  The sleep-deprived performances were clearly inferior, with the participants covering an average of 6224 meters after normal sleep and 6037 meters after no sleep.  Interestingly, the sleep-deprived participants had a similar perception of their effort in both performances.  This suggests that sleep deprivation may lead to decreased running performances because of impaired perception of effort.  In another study with similar results, there were significant decreases in average and total sprint time after 30 hours without sleep.  In terms of anaerobic performance, a study of 24 hours of sleep deprivation in weightlifters showed no differences in the tasks measured, including snatch, clean and jerk, front squat, total volume load, and training intensity.  However, the mood state of sleep-deprived participants was significantly negatively affected, including increased confusion.  At 30 hours of sleep deprivation, however there does appear to be an effect on muscle strength.  This was demonstrated in a study that showed decreased knee extension and flexion peak torque after no sleep for 30 hours, as compared to after normal sleep.  The importance of the difference between 24 hours without sleep and longer durations of time without sleep was demonstrated, again, in another study that showed that anaerobic performances were unaffected after 24 hours of wakefulness but were impaired after 36 hours of wakefulness.

So, don’t worry about a single night of reduced sleep before a race.  It does not appear to have a meaningful effect upon athletic performance.  In contrast, a number of consecutive nights of reduced sleep does appear to affect muscle strength, especially sub-maximal strength, but does not appear to affect swimming performance.  With regard to no sleep at all before exercise, 24 hours without sleep has not been shown to affect performance, but 30 hours or more without sleep has been shown to affect both aerobic and anaerobic performance.  For those people who participate in overnight endurance races, either as a solo athlete or as part of a relay team, this information may be particularly important.  Performance in such as situation is impaired and, as described above, an athlete may be unable to perceive this impairment aside from feeling grouchy.

Published March 22, 2015.

References:

Bambaeichi E, Reilly T, Cable NT, et al. Influence of time of day and partial sleep loss on muscle strength in eumenorrheic females.  Ergonomics. 2005 Sep 15-Nov 15;48(11-14):1499-1511.

Blumert P, Crum AJ, Ernsting M, et al. The acute effects of twenty-four hours of sleep loss on the performance of national-caliber male collegiate weightlifters. J Strength Cond Res. 2007;21:1146-1154.

Bulbulian R, Heaney JH, Leake CN, et al. The effect of sleep deprivation and exercise load on isokinetic leg strength and endurance. Eur J Appl Physiol Occup Physiol. 1996;73:273-277.

Oliver SJ, Costa RJ, Laing SJ, et al. One night of sleep deprivation decreases treadmill endurance performance.  Eur J Appl Physiol. 2009 Sep;107(2):155-161.

Reilly T and Deykin T., Effects of partial sleep loss on subjective states, psychomotor and physical performance tests.  J Human Mov Stud. 1983;9:157-170.

Reilly T and Hales A., Effects of partial sleep deprivation on performance measures in females. Contemporary Ergonomics. Taylor and Francis. ED McGraw (London) 1988:509-513.

Reilly T and Piercy M. The effect of partial sleep deprivation on weight-lifting performance. Ergonomics. 1994;37:107-115.

Sinnerton S, and Reilly T. Effects of sleep loss and time of day in swimmers.  Biomechanics and Medicine in Swimming: Swimming Science IV. Maclaren D, Reilly T, and Lees A. Spon Press (London) 1992:399-405.

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Skein M, Duffield R, Edge J, et al. Intermittent-spring performance and muscle glycogen after 30 h of sleep deprivation. Med Sci Sports Exerc. 2011;43:1301-1311.

Soussi N, Sesboue B, Gauthier A, et al. Effects of one night’s sleep deprivation on anaerobic performance the following day. Eur J  Appl Physiol. 2003;89:359-366.

Reduced Quality Of Sleep In Athletes

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This is part 2 of a series about the importance of sleep to athletes.  Part 1 was “Improve Athletic Performance By Taking A Nap.”  Please stay tuned (subscribe to this blog) for future installments and other interesting content.

Athletes commonly have reduced quality of sleep.  While the National Sleep Foundation recommends 7-9 hours of sleep per night for adults age 18-64, most of us, including athletes, don’t get this much.  For example, elite athletes in a recent study only obtained an average of 6.8 hours of sleep per night.  In another study of elite athletes, their total time in bed was 8.6 hours, but their sleep quality was poor with a total time asleep of only 6.9 hours.  Studies have been published that examine some aspects of the poor quality of sleep that many athletes experience.

One study explored whether the duration of exercise affects sleep.  In this study, 8 male athletes, age 23-42 years, had their sleep studied on four separate occasions.  The four occasions were as follows: after a day with no specific exercise, after a day of a 15 km run, after a day of a 42.2 km run (this is a marathon, folks), and after a day in which the athletes participated in an ultra-triathlon.  The athletes showed similar sleep patterns the first three days, but, after the ultra-triathlon, had significantly increased wakefulness and decreased rapid eye movement (REM) sleep.  So, in these very fit endurance athletes, sustained exercise to the extent of running a marathon did not affect sleep, but an ultra-triathlon did affect sleep.

Another study, of 13 elite male cyclists (average age 23.9 years), investigated a possible mechanism for decreased REM sleep in athletes.  Each subject was studied during training after (not before) a race competition and in a recovery period in which there was no training or racing. Compared to levels during the recovery period, nighttime and daytime excretion of epinephrine and norepinephrine (catecholamines) was significantly elevated after exercise. Correlated with increased catecholamines, REM onset latency was significantly increased in the athletes during training.  The investigators concluded that the catecholamines that were produced in excess during intense exercise led to the alteration in sleep architecture.

Other studies have looked at the potential effects of the anxiety associated with competition on quality of sleep in athletes.  For example, a group of 632 German athletes were surveyed about the quality of their sleep before important competitions.  62.3% reported having poor sleep the night before an important competition over the prior 12 months.  The main difficulty was falling asleep and this was related to thoughts about the competition and nervousness.  Athletes in individual sports reported more difficulties than athletes in team sports.  In a similar study with largely similar results, a group of 283 elite Australian athletes (129 male, 157 female, average age 24 years) were surveyed about the quality of their sleep before important competitions. 64.0% reported worse sleep on at least one occasion in the nights prior to an important competition over the prior 12 months.  82.1% reported that their main problem with sleep was falling asleep.  The athletes thought that their difficulty falling asleep was related to thoughts about the competition and nervousness.  Interestingly, 59.1% of team-sport athletes and 32.7% of individual-sport athletes reported having no strategy to overcome poor sleep, such as relaxation and reading.

Aside from these reports, there are a lot of other common reasons for disrupted sleep in athletes, especially before competitions.  These include challenging travel schedules, meals at odd times or that take unusually large amounts of time (in a busy restaurant, for example), obligations with sponsors, extra preparation of gear before competitions (numerous times, I’ve reassembled my bike after shipping it in pieces in a bike box), noisy or uncomfortable hotel rooms, and family obligations.  It may be fair to say that it is difficult to NOT have disrupted sleep before competitions.

Quality sleep is an important aspect of an athlete’s preparation.  Because of lengthy competition and training, the increased excretion of catecholamines, anxiety associated with competitions, and the complexity of preparing for competitions, most athletes achieve less-than-optimal sleep at least part of the time.

When suffering on a race course it is helpful to remember that everybody else is suffering, too. Perhaps it would also be helpful to remember that we are also not alone in being sleep-deprived athletes.

Published March 18, 2015

References:

Driver HS, Rogers GG, MItchell D, et al. Prolonged endurance exercise and sleep disruption. Med Sci Sports Exerc. 1994 Jul;26(7):903-907.

Erlacher D, Ehrlenspiel F, Adegbesan OA, et al. Sleep habits in German athletes before important competitions or games. J Sports Sci. 2011 May:29(8):859-866.

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Juliff LE, Halson SL, and Peiffer JJ. Understanding sleep disturbance in athletes prior to important competitions. J Sci Med Sport. 2015 Jan;18(1):13-18.

Lastella M, Roach GD, Halson SL, et al. Sleep/wake behaviours of elite athletes from individual and team sports.  Eur J Sport Sci. 2015 Mar;15(2):94-100.

Leeder J, Glaister M, Pizzoferro K, et al. Sleep duration and quality in elite athletes measures using wristwatch actigraphy. J Sports Sci. 2012;30(6):541-545.

Netzer NC, Kristo D, Steinle H, et al. REM sleep and catecholamine excretion: a study in elite athletes. Eur J Appl Physiol. 2001 Jun;84(6):521-526.

Improve Athletic Performance By Taking A Nap

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The National Sleep Foundation recommends 7-9 hours of sleep per night for adults age 18-64. Unfortunately, most of us don’t get this much sleep.  This is also true for athletes.  For example, elite athletes in a recent study only obtained an average of 6.8 hours of sleep per night.  In another study of elite athletes, their total time in bed was 8.6 hours, but their sleep quality was poor with a total time asleep of only 6.9 hours.   With travel to events or, simply, pre-race jitters, many athletes experience serious disruptions to their already-inadequate sleep schedules.  These disruptions can affect athletic performance.  The good news, however, is that there is a small study which has shown that sleep-deprived athletes perform better after short naps.

This study involved 10 healthy males with mean age 23.3 years who either napped or sat quietly from 1 PM to 1:30 PM after a night of shortened sleep (they slept from 11 PM to 3 AM).  Thirty minutes after the nap or quiet sitting, a number of parameters were measured, including alertness, short-term memory, intra-aural temperature, heart rate, choice reaction time, grip strength, and times for 2 meter and 20 meter sprints. The participants who took afternoon naps had lowered heart rate, lowered intra-aural temperature, and improvements in alertness, sleepiness, short-term memory, and accuracy at the choice reaction time test.  Mean reaction times and grip strength were unaffected.  Interestingly, sprint times were also significantly improved, with mean time for 2 meter sprints falling from 1.060 seconds to 1.019 seconds and mean time for 20 meter sprints falling from 3.971 seconds to 3.878 seconds. Please note, again, that these numerous improvements were after only a 30 minute nap.

The practical implications of these findings vary with an athlete’s individual situation.  For example, a triathlete with a 7 AM race-start is hardly going to have an opportunity for a nap. However, a triathlete in a large multi-wave event (like the Transamerica Chicago Triathlon or USAT Nationals) can go back to his or her hotel room after setting up transition and take a short nap.  Athletes in events played later in the day, which includes most professional team sports, can also practically include naps in their schedules.  These scheduled naps can be relatively brief, since this study demonstrated that naps of only 30 minutes can lead to enhancements in performance.

So, have a nice nap and come back and race or train better!

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Published March 15, 2015

References:

Lastella M, Roach GD, Halson SL, et al. Sleep/wake behaviours of elite athletes from individual and team sports.  Eur J Sport Sci. 2015 Mar;15(2):94-100

Leeder J, Glaister M, Pizzoferro K, et al. Sleep duration and quality in elite athletes measures using wristwatch actigraphy. J Sports Sci. 2012;30(6):541-545.

Waterhouse J, Atkinson G, Edwards B, et al. The role of a short post-lunch nap in improving cognitive, motor, and sprint performance in participants with partial sleep deprivation. J Sports Sci. 2007 Dec;25(14):1557-1566.