What is the best way to sleep?

We all do it. We all need it. But, have you ever considered if you’re doing it “right”? What is the best way to sleep?

Sleep is a crucial part of our day, whether we are aware of it or not; it provides the opportunity for our sympathetic nervous system to recharge and helps regulate vital processes involved in homeostasis including hormone release and blood pressure.

We all are familiar with the short-term effects of not getting a good night’s rest: fogged thinking during the day, fatigue, inability to concentrate. However, we may not all be aware of the long-term effects associated with not getting enough.

Long-term impact of inadequate sleep

Many studies have linked inadequate sleep with various ailments. For instance, it has been shown to increase appetite and thus the risk of obesity. Even our insulin resistance can increase, reducing blood glucose control and contributing to increased risk of type-2 diabetes¹.

Habitual lack of sleep has also been associated with increased risk of cardiovascular disease² and weakened immune function³. Clearly, it is crucial to our long-term health. But what is considered an “adequate” amount?

Ideal sleep duration

The American Academy of Sleep Medicine and the Sleep Research Society have come to the consensus that 7 or more hours each night is the “perfect” amount for adults between ages 18 to 60⁴. This was determined cumulatively from over 1000 scientific studies. Any lower than the 7-hour mark, the risk of developing health disorders has been shown to increase significantly.

One could argue that even if we do get 7 hours, sometimes we do not feel 100% rested when we wake up. What about sleep quality?

Sleep positions

Our positions during sleep can significantly impact how rested we feel, and can even pose a threat to our health. Especially as we age, our selected position becomes more critical; studies have shown that we experience fewer shifts in position during the night with increasing age⁵, making our choice that much more important. This commitment to one position is likely attributed to our age-related decrease in spinal flexibility.  So, which position should we select?

Do you sleep on your stomach?

You might be in the minority here. Stomach sleeping is not a common choice among the general population. There have been numerous studies that have shown that this position is the least liked.

A 2017 study by Skarpsno et al. observed 664 individuals, and found that they spent 12.3% of time in this position, while they spent 54.1% of time sleeping on their side (lateral), and 37.5% of time laying on their back⁶.

Another study looked at the baseline heart rate in 24 infants while sleeping in the front (prone) position versus the back (supine) position. Results showed a significantly higher baseline heart rate in the prone position⁷, likely due to restricted rib cage expansion required for comfortable breathing. Additionally, Pump et al. analyzed the impact of blood flow in 14 adult males in different positions.

The prone position showed significantly increased heart rate and sympathetic nervous activity. It was also associated with decreased stroke volume (the amount of blood pumped out of the left ventricle) and arterial pressure, reducing blood flow⁸. These consequences may actually create circulation issues over time.

Which position gives you more room to breathe?

The prone position may not be the best option for optimal air flow. What about laying on your back?

If you suffer from sleep apnea or snoring, studies have shown that the supine position, where the head, neck, and spine are in line and you are laying on your back, can make the condition worse by obstructing the airway and reducing functional residual capacity in the lungs. Sleep apnea is the stopping and restarting of breathing while asleep.

This position, as opposed to a side position, has been shown to significantly increase the severity of apneic episodes⁹. Even if you do not have sleep apnea, but you feel as though you cannot get enough of a breath while laying on your back, chances are you will have a difficult time sleeping and even feel more tired after a full night’s sleep.

This obstructive effect becomes amplified for those with obesity¹⁰. The most comfortable position for that “big breath” is lateral. But is lateral (side) preferred for all health conditions?

What about pregnancy?

Studies have shown that pregnant women should avoid sleeping in the supine position. One study in particular found that women who slept on their right sides or backs, rather than on their left sides, increased their risk of late stillbirth. Specifically, the absolute risk of late stillbirth for women who slept on their left side was 1.96/1000 births, while right side or supine sleeping posed an absolute risk of 3.93/1000 births¹¹. Another study found that sleeping in the supine position was associated with a 3.7 times increase in stillbirth risk¹². Low birth weight risk also showed an odds ratio of 5.0 when mothers slept in the supine position¹³. These complications are likely due to compression of the inferior vena cava, reducing oxygen supply to the fetus.

What is the best way to sleep if you have heart problems?

A study showed that those with congestive heart failure unconsciously avoided sleeping on their left side significantly more than their right¹⁴. This natural tendency may be to avoid the discomfort of feeling a more prominent heartbeat while sleeping on the left side.

What about acid reflux?

For those who experience acid reflux, it has been recommended to sleep on the left side. One study in particular showed that right-side sleeping was linked to a more acidic esophageal environment (pH <4) than sleep on the back or left side¹⁵. The supine position showed its disadvantages too; more frequent acid reflux episodes, making the left side the most comfortable option.

Do you ever feel sore when you wake up?

Lower back pain

There has been association found between habitual sleeping posture and the occurrence of lower back pain. People who sleep on their back have demonstrated an increased risk of developing low back pain by 1.9 times¹⁶. 

Shoulder pain

One study found that of 277 observed individuals, 58.8% experienced shoulder pain while sleeping in the fetal position¹⁷. The fetal position is a variation of the side position, however with the arms and legs curled to the side. In contrast, of those who slept in a log-style side position, only 2.89% experienced pain.

Neck pain

During sleep, we can bend our neck beyond its natural extension and range of motion. Studies suggest that using a small pillow shaped to the crook of the neck can help align the spine to its natural curve, and reduce neck pain¹⁸.

Which is the best position?

So, what is the best way to sleep? According to the health concerns above, a side (lateral) position comes with the lowest risk of developing severe health complications. The lateral sleeping position is actually the most popular overall but is especially more popular in the aging population⁶.

If you are going to sleep on your side, using a pillow between your knees may help keep spinal alignment and prevent joint pain. Sleeping on your left can avoid complications like acid reflux, however, sleeping on your right may alleviate discomfort if you have a heart issue.

Bottom line

Your sleep should be tailored to your own personal health. With some educated adjustments, optimization can improve your overall present and future health.

References

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2. Gottlieb, D.J., et al. (2017). Restless legs syndrome and cardiovascular disease: a research roadmap. Sleep Medicine, 31: 10-17.
3. Watson, N.F. et al. (2017). Transcriptional Signatures of Duration Discordance in Monozygotic Twins. Sleep, 1; 40. Doi: 10.1093/sleep/zsw019.
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8. Pump, B. et al. (2002). Effects of supine, prone, and lateral positions on cardiovascular and renal variables in humans. The American Journal of Physiology – Regulatory, Integrative and Comparative Physiology; 283(1): R174-180. Doi: 10.1152/ajpregu.00619.2001.
9. Oksenberg, A. et al. (2000). Association of Body Position With Severity of Apneic Events in Patients With Severe Non Positional Obstructive Apnea. Chest Journal; 118(4): P1018-1024. Doi: https://doi.org/10.1378/chest.118.4.1018.
10. Shore, E.T., and R. P. Millman. (1984). Abnormalities in the flow-volume loop in obstructive sleep apnoea sitting and supine. Thorax; 39: 775-779. Doi: 10.1136/thx.39.10.775.
11. Stacey, T. et al. (2011). Association between maternal sleep practices and risk of late stillbirth: a case-control study. The British Medical Journal; 342: d3403. Doi: 10.1136/bmj.d3403.
12. McCowan, L. M. E. et al. (2017). Going to sleep in the supine position is a modifiable risk factor for late pregnancy stillbirth; Findings from the New Zealand multicentre stillbirth case-control study. PLoS One; 12(6): e0179396. Doi: 10.1371/journal.pone.0179396.
13. Owusu, J. T. et al. (2013). Association of maternal sleep practices with pre-eclampsia, low birth weight, and stillbirth among Ghanaian women. International Journal of Gynecology & Obstetrics; 121(3): 261-265. Doi: 10.1016/j.ijgo.2013.01.013.
14. Leung, R. S. T. et al. (2003). Avoidance of the left lateral decubitus position during sleep in patients with heart failure: relationship to cardiac size and function. Journal of the American College of Cardiology; 41(2): 227-230. Doi: 10.1016/s0735-1097(02)02717-1.
15. Khoury, R.M. et al. (1999). Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. Official Journal of the American College of Gastroenterology; 94(8): 2069-2073. Doi: 10.1111/j.1572-0241.1999.01279.x.
16. Abanobi, O. A. et al. (2015). Risk-disposing habits of low back pain amongst welders and panel beaters in Owerri, south-east Nigeria. Indian Journal of Public Health Research & Development; 6(3): 332-337.
17. Holdaway, L. A. et al. (2018). Is position associated with glenohumeral shoulder pain and rotator cuff tendinopathy: a cross-sectional study. BMC Musculoskeletal Disorders; 19: 408. Doi: 10.1186/s12891-018-2319-9.
18. Soal, L. J. et al. (2019). Changes in chronic neck pain following the introduction of a visco-elastic polyurethane foam pillow and/or chiropractic treatment. Health SA Gesondheid, Journal of Interdisciplinary Health Sciences; 24: 1099. Doi: 10.4102/hsag.v24i0.1099.
19. Image by StockSnap from Pixabay