Sleep disorders are underdiagnosed and fewer are even treated. This means that your patients could be spending night after night with poor sleep.

Obesity and sleep loss are two separate but often interconnected health concerns, each with its own set of risks.

“It is well known that obesity increases the risk of heart disease, type 2 diabetes, and high blood pressure, but obesity can also lead to structural changes in the body that make breathing more difficult and therefore contribute to sleep disorders such as obstructive sleep apnea,” explained Fariha Abbasi-Feinberg, MD, medical director of sleep medicine at Millennium Physician Group in Fort Myers, Florida. “In fact, even a 10% weight gain can increase [sleep apnea] risk by up to sixfold.”

In addition, she noted how the relationship is bidirectional: Obstructive sleep apnea (OSA) “can impair sleep quality, affect metabolism and hormone levels, making it harder to maintain or lose weight.” Sleep loss may also interfere with the body’s natural hunger and satiety signals.

One potential explanation for patients’ prolonged sleep deprivation and chronic poor sleep could be, of course, by sleep apnea. In contrast to topics like diet, physical activity, or blood pressure, there are limited campaigns around identifying symptoms of sleep disorders.

To raise awareness, the US Office of Disease Prevention and Health Promotion’s Healthy People 2030 has set a goal to increase the proportion of adults with sleep apnea symptoms who get assessed by a healthcare provider. As a primary care doctor, you can help by encouraging your patients to “self-screen” by charting and monitoring their sleep quality.

Why Patient Engagement Is Recommended

In an ideal world, a review of sleep health would be part of a patient’s regular annual physical, said Michael Perlis, PhD, associate professor of psychology in the Department of Psychiatry, and director of the Behavioral Sleep Medicine Program, Perelman School of Medicine, University of Pennsylvania in Philadelphia.

“For decades it has been argued that primary care is the single best place to screen for, if not diagnose and treat, sleep disorders. Part of this is due to the ubiquity of sleep disorders in primary care,” Perlis said. “It is estimated that [more than] 50% of primary care patients have sleep disorders complaints.”

Even though there’s a prevalence of sleeping disorders, discussing sleep disorders with patients can be overlooked and unaddressed and “this scenario is further compounded by patients’ disinclination to talk about their sleep health,” he said.

Insomnia and sleep-related concerns are a very common primary care complaint, said Joseph R. Teel, MD, professor of clinical family medicine and community health at the Perelman School of Medicine, and chief of regional primary care at the Penn Medicine Medical Group in Philadelphia. “I believe the real deficit is in case identification when people don’t mention anything. Most people are not being screened,” Teel said.

According to Perlis, patients may be hesitant for several reasons, including:

• The tendency to minimize sleep problems or feel that they can be self-managed.
• They don’t have a means to “self-assess.”
• They may be afraid to be diagnosed with OSA, which may seem to be the default.
• They are anxious about possibly having to use a continuous positive airway pressure (PAP)/PAP.

The net result is that most primary care providers (PCPs) don’t raise questions about sleep health, and most patients don’t tell PCPs, said Perlis.

“Because of this, sleep disorders are woefully underdiagnosed, and fewer still are treated. This not only means people are living with poor sleep health, but they are also at increased risk for the psychiatric and medical health disorders that arise from, or are complicated by, persistent poor sleep,” he said.

One way to resolve this situation is to encourage patients to conduct self-assessments.

“In the past, this was not easily done as most patient-friendly screeners were specific to particular disorders. These days, comprehensive self-screening is only a click or QR code away. It is available at no cost, it was created by (and is maintained by) a small group of clinician-scientists, and the initiative is supported by unrestricted funds from industry sponsors,” Perlis said.

The screener itself, accessible online at sleephealthscreen.com, only takes 3-5 minutes.

“The results are clear, and the information is the individual’s to use as they see fit. If the respondent chooses to, they can send PDFs of their completed survey and a report to themselves or to their healthcare provider,” he said.

Additional Ways to Encourage Patient Self-Advocacy

While there are benefits for patients to use tools or technology to self-screen their sleep health, it’s vital that diagnosis for a sleep disorder comes from an accredited sleep specialist, said Anita V. Shelgikar, MD, sleep medicine specialist and clinical professor of neurology at the University of Michigan School of Medicine in Ann Arbor, Michigan, and spokesperson for the American Academy of Sleep Medicine.

It’s important that doctors ask the patient about their sleep habits, she said.

“By creating an open dialogue, PCPs open the door for patients to understand sleep as a vital aspect of their physical and mental health and that concerns can be addressed by a medical provider,” said Shelgikar.

Shelgikar provided mechanisms and directives to suggest to patients to participate in monitoring sleep patterns and challenges: 

Keep a sleep diary. Encourage patients to log bedtime, wake time, sleep latency, nocturnal awakenings, total sleep time, naps, and subjective sleep quality for 1-2 weeks prior to their appointment.

“Sleep diaries reveal patterns that distinguish between insomnia subtypes, circadian rhythm disorders, and insufficient sleep syndrome while providing objective behavioral data for calculating sleep efficiency,” she said. This longitudinal data establishes baseline metrics essential for differential diagnosis and guides cognitive behavioral therapy for insomnia protocols, particularly sleep restriction therapy titration, said Shelgikar.

Check in with a bed partner. Encourage patients to have their bed partner systematically document witnessed apneas, snoring characteristics, gasping episodes, periodic limb movements, and unusual nocturnal behaviors over at least 1 week.

“History from bed partners provides critical observational data for conditions patients cannot self-report, significantly increasing diagnostic sensitivity for obstructive sleep apnea, periodic limb movement disorder, and REM [rapid eye movement] behavior disorder,” she explained. Witnessed apneas combined with daytime sleepiness create high pretest probability for OSA, helping justify to insurers the need for polysomnography or home sleep apnea testing and guiding appropriate diagnostic pathways.

Evaluate how diet affects sleep quality and quantity. Have patients track how often and when they drink caffeine, as well as alcohol intake, evening meal composition and timing, and any foods that triggers reflux. “Correlating dietary patterns with sleep diary data helps distinguish primary sleep disorders from lifestyle-related disturbances, and persistent insomnia despite optimal sleep hygiene strengthens the case for formal diagnostic evaluation,” she said.

Evaluate how exercise affects sleep quality and quantity. Ask patients to log exercise timing, duration, intensity, and type for 1-2 weeks alongside their sleep diary, and to note the relationship between physical activity and sleep quality. “Regular moderate-intensity exercise improves sleep consolidation and increases slow-wave sleep, though vigorous exercise within 2-3 hours of bedtime can delay sleep onset due to elevated core temperature and sympathetic activation,” Shelgikar said. “Documenting the exercise-sleep relationship identifies whether inadequate physical activity or poor exercise timing contributes to sleep complaints and informs prescriptive exercise programs that may reduce need for hypnotic medications.”

Perlis and Shelgikar reported having no disclosures.