At the 2019 Ruth Alston Memorial Lecture, physiologist and sleep therapist Dr Nerina Ramlakhan outlined why it is important occupational health practitioners talk about and promote the importance of good sleep. With this year’s lecture taking place next week (10 March), Nic Paton looks back at her key messages and advice.
It has been estimated by the think-tank Rand Europe that poor sleeping habits cost the UK economy as much as £40bn a year, with tired employees being less productive and more likely to be absent from work. In fact, the UK loses some 200,000 working days a year because of insomnia and poor sleep, it has calculated.
Sleep deprivation is linked to a higher mortality risk, while poor lifestyle habits such as obesity, drinking and smoking and issues such as stress, anxiety and financial or workplace worries can all be connected to sleepless nights. And this is before we get to the potential health effects of shift working or working irregular hours, which can be linked to increased risk of diabetes, cardiovascular ill health and depression, among other conditions.
Yet the question of sleep – either the lack of it or how to attain and sustain “good” sleep – is something that can often be overlooked during an occupational health consultation, given that the focus is more likely to be on whatever specific issue or health concern is being presented. How employees are sleeping and how much, the factors that may be preventing them from getting a refreshed night’s sleep and, crucially, the impact such sleep deprivation may therefore be having on the health issues being presented can go under the radar.
Celebrating best practice within OH
The importance of sleep and how to get better at it was at the heart of last year’s Ruth Alston Memorial Lecture by physiologist and sleep therapist Dr Nerina Ramlakhan. The annual event by iOH, the Association of OH and Wellbeing Professionals, takes place during the Health and Wellbeing at Work show in Birmingham and is designed to promote best practice thinking within OH and celebrate the legacy of OH nurse Ruth Alston.
With this year’s lecture taking place next month (on 10 March) it is therefore an opportune moment to look back at, and reflect upon, what Dr Ramlakhan advised, and how her advice – notably her “five non-negotiables” for good sleep – can be incorporated into the wider day-to-day OH conversation.
Dr Ramlakhan, the author of Tired But Wired: How to Overcome Your Sleep Problems: The Essential Toolkit, structured her lecture in two parts. The first element addressed some of the common myths and assumptions associated with sleep and sleep deprivation, for example the idea that we all need seven to eight hours’ sleep a night (we don’t) or that when we sleep, that’s it, we’re asleep (in fact most of wake on average 10 to 15 times a night).
However, the suggestion that the sleep we get before midnight is more valuable than that after the witching hour was correct, she argued. “We have evolved with a sleep architecture whereby that first hit of sleep before midnight – the 90-minute phase before midnight – is the most powerful phase of sleep. If you’re repeatedly missing out on that phase of sleep, it has an impact. Cognitive impairment is greatest if you’re repeatedly missing out on that phase of sleep. That phase of sleep hits every organ system in the body; and it is anti-ageing.”
The second part of her presentation (after dinner) focused on providing practical tips, some “power tools” as Dr Ramlakhan put it, for better sleep.
“The reason I have become so busy is because insomnia has been around since the beginning of time, since human beings walked the face of the earth. We have always had problems, always had nights when we have not slept that well,” she pointed out.
“But it has become a particular problem at the moment because our world has become so noisy; so speedy, so demanding. We are constantly taking information in. It used to be that we would take breaks during the day; we’d come to work and then have a tea or coffee break in the morning, for example. When I was worked at the Medical Research Council years ago it was in my contract!
“We had a one-hour lunchbreak where we took the card out, and I’m showing my age now. We had a tea or coffee break in the afternoon; we left work at a certain time. And when we left we did not work on the way home or when we got home. So, we had oscillation in our day.”
Impact of technology, screens and globalisation
Now, with technology and screens and globalisation, we’re constantly working to our neurological limits, Dr Ramlakhan argued. “And our physiology still hasn’t quite adapted to that pace. And our sleep is taking the hit.”
Yet in fact, technically, most of us are not sleep deprived. “If you think about a caveman/woman and their mass of leaves, things have really moved on since then; the technology has really advanced. So, we are sleeping, but what we’re getting is a lot of junk sleep. We’re not getting what in Sanskrit or Hindi is called ‘sattvic’, which means pure. We’re not getting enough of that deep sattvic sleep, the real healing, rejuvenating, sleep,” she said.
“You get into bed, put your head on the pillow and then find you’ve got this mad monkey in your brain and you can’t sleep. But it’s not because of something that happened when you put your head on the pillow.
“Every choice you make, from the minute you wake up until the time you get into bed, every single choice that you make, informs how you are going to sleep. When I talk to people about ‘sleeping well’ really what I am talking about is about living well. Or loving well. Because the more we love, the more we trust; and sleep is an act of faith. We sleep when we feel safe. And when we feel safe we can let go of whatever is happening out there and we can sleep,” she added.
This brought Dr Ramlakhan on to her “five non-negotiables” of good sleep, five things that, she argued, people can do to change their nervous system and, in turn, generate the mental, physical and emotional environment that can encourage, and sustain, a better night’s sleep; that all-important sattvic sleep. And the non-negotiable element of this was important, she emphasised.
“My waiting list for one-to-one work is three to four weeks. But when people come to see me unless they do these five things for 7-10 days I do not see them for a second one-to-one. Because I know if they haven’t done these things, we can’t change their relationship with sleep,” she said.
The five non-negotiables
1) Eat breakfast within half an hour of rising. “If you eat breakfast within half an hour, it is telling the hunter/gatherer physiology that you’re living in a safe environment,” said Dr Ramlakhan.
“This is the one thing that makes a huge difference to my clients who are waking up in the morning tired but wired, pressing the snooze button, exhausted, eeking out every last second of sleep. But the stomach is knotted; they can’t eat; they’ve got no appetite. So eat breakfast, even if it is as small as eight almonds and two dates. A lot of my clients can’t eat because they’re not used to eating breakfast.”
2) Don’t use caffeine in place of food. “Eat, then have your cup of tea or coffee. This isn’t just about sleeping; it is about getting amazing sleep, sattvic sleep, so that you wake up with the energy for life, the energy for the best bits of your life.
“So many people miss out on those best bits because they get through the door at the end of the day, but they’ve got no energy. What I have noticed is when my clients and patients are doing the five non-negotiables, they have more energy at the end of the day. They’re living more within the safe part of their nervous system, in the parasympathetic. So, cut back on caffeine. Ideally no caffeine after 4pm, especially if you’re a sensitive sleeper.”
3) Drink a litre to a litre-and-a-half of water. “Hydration over a period of time, hydrating the brain, so that your sleep bio-chemistry works more effectively and efficiently,” advised Dr Ramlakhan, though as it was an evening lecture she added the caveat: “If you don’t drink much water, please don’t start now, as you’ll be cursing me during the night.”
4) Be earlier to bed, three or four nights a week. “This doesn’t mean getting into bed at 9pm fast asleep. It is what I call ‘rest entrainment’,” she said. “With my patients and clients who are really not sleeping well or who have adrenal issues, thyroid issues, fibromyalgia, chronic fatigue, women with menopausal issues getting huge night sweats, just getting them to go to bed earlier and rest makes a big difference,” she said. But it was also closely linked to her fifth, and final, non-negotiable.
5) Rest in an environment that is free of technology. “So resting without electronics in the bedroom; no phones, iPads, screens, tablets. Reading on a book (remember that?) rather than a Kindle,” Dr Ramlakhan said.
“If you go to bed tonight and you think you’re not going to sleep well, don’t use the word ‘sleep’, use the word ‘rest’ and stop checking the time during the night. We know it is normal to wake during the night. What is not normal is to check the time and then, once you’ve done that, do a calculation and subtract. What you’ve done is a risk assessment of what is the likely impact of not getting that sleep. So, then you are wide awake and fretting. Turn your clock away so you don’t check the time during the night.
“But be earlier to bed. Getting into bed, resting, reading a book, meditating; training the body to receive rest earlier, three or four nights a week. This has such an impact on the physiology, such an impact on the recalibration of the sympathetic, parasympathetic nervous system,” she added.
So, what can this all achieve? Dr Ramlakhan emphasised the results, if you genuinely stick at it and sustain these lifestyle change, can be significant. “I have noticed that, when people apply these five non-negotiables of good sleep, something about their relationship with sleep changes. They might come back two weeks later and say, ‘well the sleep’s still not brilliant, but I feel good, my energy is good’.
“Even though they might be waking up a lot, whatever sleep they’re getting, somehow it’s deeper and their energy levels are better. They are less caffeinated. Their blood sugar levels are more stable. They’re well-hydrated. They’re not constantly on their devices.”
The lecture finished with Dr Ramlakhan outlining a few practical, meditative exercises that she argued can help to create the right state of mind for sleep. For example, take time out to pause, reflect and think about your day, in particular all the good things that have happened, the things you can be grateful for.
“Think about the day you’ve had so far, from the time you woke up to now. Go through your day and think about as many things that have happened that you are grateful for. You might even want to keep a gratitude journal, a special notebook and pen, where you write things down before you go to sleep,” she said.
It was all about stopping and really slowing things down, she added. “Close your eyes. Imagine someone standing in front of you; they could be alive or no longer alive. Ideally this person is someone you like immensely or, preferably, love.
“Take a deep breath in, breath out, relax. Allow yourself to sink into the chair and imagine this person standing in front of you. And then imagine looking into their eyes; really take the time to imagine their eyes, to really look into their eyes. And say, ‘thank you so much for being in my life; I’m so grateful to you, thank you’. Imagine reaching over to them and holding them in your arms, enveloping them in your arms. Imagine the feel of that hug. Imagine the feel of them. What does it feel like to touch them, to hold them? Take a deep breath in and breath out. Imagine, while you’re hugging them, saying ‘thank you so much for being in my life, I love you, I love you. I’m so grateful to you’. And now gently disengage, step away and when you’re ready open your eyes and come back into the room.”
She also outlined a meditation approach that can help get you back to sleep if you wake in the night. “Repeat these words softly and silently to yourself, as if putting a baby to sleep. I love my right foot. I love my right big toe. I love my right little toe. I love all the toes of my right foot. I love the top of my right foot. I love the bottom of my right foot. I love my left foot. And so on.
“Doing this exercise, you will lose your train of thought because you’re falling asleep. This is a really powerful exercise particularly if you’re one of these people who thinks, ‘ah I was awake all night’. Because the more you do this exercise, the more you become aware of, actually, how much deeper down you are in the stages of consciousness than you thought you were.
“Now when I do that exercise it acts almost like a switch. ‘I love my right foot’ and I’m gone. The more times you use that exercise, the more it works. As soon as you lose the train of thought you go back to the starting point. You literally bore yourself to sleep by loving yourself to sleep.”
Dr Ramlakhan concluded her lecture with a call to arms for us all to work harder at getting better at what we too often just assume comes naturally: sleep.
“There is a reason why I’m busy at the moment, not just with people like yourselves and adults, but also in schools. I think if we can give ourselves a good night’s sleep, we stand a better chance of showing our children how to do it.
“Because, after all, sleeping well isn’t just about sleeping well. It is about living well. And living well is about loving well. If we can love ourselves, we can teach our children, and they can sleep, and we’ll be all happy. And I’ll be out of a job,” Dr Ramlakhan added.
You can find out more about Dr Ramlakhan’s work at http://www.drnerina.com/
The 2020 Ruth Alston Memorial Lecture
The 2020 Ruth Alston Memorial Lecture, by iOH The Association of Occupational Health and Wellbeing Professionals, will be held on the evening of Tuesday 10 March after the first day of the Health and Wellbeing at Work conference and exhibition.
The lecture will celebrate 28 years of RAML and will be on the subject of “occupational health, making or breaking your business?”. While the full speaker line-up is still being finalised, the first speaker of the evening will be Charlene Gay, University of Derby graduand and winner of the 2019 iOH Ruth Alston Memorial Award for Excellence in OH Nursing, whilst studying for her SCPHN OH qualification.
Charlene will talk about the unexpected secondary effects of hearing loss (mental health and dementia) and her work on improving compliance with hearing protection, particularly among workers for whom English is not their first language.
Earlybird tickets are priced at £45 for iOH members and £60 for non-members/guests. For more details go to https://ioh.life/raml-2020/
Further tips and advice
In its report, Why Sleep Matters: quantifying the economic costs of insufficient sleep, Rand Europe set out three recommendations that it argued could help tackle the issue of poor sleep.
- Individuals could: set consistent wake-up times, limit the use of electronic items before bedtime, and exercise.
- Employers could: recognise the importance of sleep and the employer’s role in its promotion, design and build brighter workspaces, combat workplace psychosocial risks, and discourage the extended use of electronic devices.
- Public authorities could: support health professionals in providing sleep-related help, encourage employers to pay attention to sleep issues, and introduce later school starting times.
“Why Sleep Matters: quantifying the economic costs of insufficient sleep”, Rand Europe, https://www.rand.org/randeurope/research/projects/the-value-of-the-sleep-economy.html
“Shift workers more likely to report ill health”, NHS, https://www.nhs.uk/news/lifestyle-and-exercise/shift-workers-more-likely-to-report-poor-health/
‘Occupational health models: Ruth Alston’s legacy and influence’, Occupational Health & Wellbeing, August 2017, https://www.personneltoday.com/hr/roccupational-health-models-ruth-alstons-legacy-and-influence/