Sleep is the single most underrated variable in adult health. It quietly drives cardiovascular risk, metabolic health, cognitive performance, mood, and immune function in ways that often don't show up on routine labs. When I sit down with a patient who's tired, gaining weight, struggling with blood pressure, or not thinking clearly, sleep is usually on the short list of things I want to understand before we talk about anything else.
The CDC's number is that about a third of American adults don't get enough sleep. Among the high-performing patients I see, the fraction is higher. People run on six hours for years and normalize it. It isn't normal, and the long-term cost is real.
TL;DR
- Sleep silently drives cardiovascular risk, metabolic health, cognition, mood, and immune function
- Most adults need 7 to 9 hours of continuous sleep; quality matters as much as duration
- The 3 most common problems: insomnia (usually responds better to CBT-I than meds), obstructive sleep apnea (most under-diagnosed; high-impact when treated), restless legs and circadian disorders
- Sleep hygiene basics that fix most complaints with no meds: consistent schedule, cool/dark/quiet bedroom, 30-60 min wind-down, caffeine cutoff at noon, alcohol reality check, no large meals before bed
- For executives specifically, sleep apnea is often the missed driver of difficult-to-control BP, weight, and cognitive complaints. (The executive-specific deep dive.)
- To reach the practice: call 561-468-6981
What sleep actually does
Sleep isn't a single state. You cycle through stages: light sleep, deep sleep (physical restoration, growth hormone release, tissue repair), and REM sleep (memory consolidation, emotional processing). You need all of them, and you need to cycle through them without being interrupted. Duration matters; most adults need 7 to 9 hours. But quality matters at least as much. Seven hours of fragmented sleep is not the same as seven hours of continuous sleep.
What it costs you to sleep badly
The consequences show up across systems.
Cardiovascular. Sleeping less than six hours is associated with a measurable increase in heart attack risk. Sleep apnea (which I'll come back to) drives hypertension, atrial fibrillation, and stroke. Poor sleep raises inflammatory markers and resting blood pressure.
Metabolic. Even a few nights of short sleep reduces insulin sensitivity and disrupts the hormones that control hunger (ghrelin up, leptin down). The result is higher fasting glucose, worse A1C trajectories, and more difficulty managing weight.
Cognitive. Memory consolidation happens in sleep. Decision-making, reaction time, and sustained attention all degrade quickly with sleep debt. People don't notice the degradation because impaired sleep also impairs your insight into how impaired you are.
Mood and mental health. The relationship runs both directions. Bad sleep makes depression and anxiety worse, and depression and anxiety make sleep worse. For patients who come in with mood changes, I always ask about sleep first.
Immune function. Your body does a lot of immune work during deep sleep. Chronically undersleeping makes you more susceptible to infection and slows recovery from illness.
The sleep problems I see most often
Insomnia
Difficulty falling asleep, staying asleep, or waking too early. Contributing factors I look for: stress and anxiety (by far the most common), caffeine or alcohol timing, evening screen exposure, inconsistent schedule, underlying medical conditions, medications that disrupt sleep architecture, and shift work or jet lag.
For most patients with insomnia, the answer is not a sleep medication. It's addressing the contributing factors and, when needed, cognitive behavioral therapy for insomnia (CBT-I). The evidence for CBT-I is strong and it outperforms medication for durable improvement. Medication has a role for short stretches, not as a long-term solution.
Obstructive sleep apnea
This is the one that gets missed most often. Classic picture: loud snoring, witnessed pauses in breathing, morning headaches, daytime sleepiness, difficult-to-control hypertension or A1C, and a neck circumference above 17 inches in men or 16 in women. Risk factors include excess weight, older age, male sex, and family history, but it's not only heavy patients who have it.
Undiagnosed sleep apnea drives cardiovascular disease, stroke, diabetes, and cognitive decline. The diagnostic workup is a sleep study (home or in-lab). Treatment is usually CPAP, sometimes an oral appliance, sometimes weight loss or positional therapy, rarely surgery. Treated sleep apnea changes the long-term trajectory of a patient more than almost any other intervention I can offer.
If you snore loudly, wake up unrefreshed, and have blood pressure or weight that won't behave, get evaluated. (Why this gets missed in executives specifically and what modern testing looks like.)
Restless legs and circadian disorders
Less common, still worth naming. Restless legs syndrome (uncomfortable leg sensations, urge to move, worse at night) has both lifestyle and medical causes, including iron deficiency, which is straightforward to check. Circadian rhythm disorders affect shift workers, frequent travelers, and people with delayed or advanced sleep phase patterns. These often respond to light-timing strategies, melatonin used properly, and schedule changes more than to sleep medication.
What actually helps most patients
The boring answer is usually right. The following covers most sleep complaints I see without any medication or workup:
A consistent schedule. Same bedtime, same wake time, seven days a week. Weekends included. Your circadian rhythm doesn't observe weekends.
A cool, dark, quiet bedroom. 65 to 68 degrees, blackout curtains or a sleep mask, earplugs or a white-noise source if your environment isn't quiet. The bedroom should be for sleep and intimacy only. Move the TV out.
A wind-down window. 30 to 60 minutes before bed with dim lights, no screens, and a low-stimulation activity. Reading, a shower, light stretching, whatever.
Caffeine cutoff. Nothing after noon if you're sleep-sensitive. Caffeine's half-life is long and variable; by evening you don't feel it but your brain still does.
Alcohol reality check. A glass of wine feels sedating. It fragments the back half of your night and suppresses REM. If you're troubleshooting sleep, drop alcohol for two weeks and see what changes.
Exercise, but not right before bed. Regular physical activity improves sleep. High-intensity exercise in the two hours before sleep can make it harder to fall asleep for some people.
No large meals in the hour before bed. Reflux in bed wakes people up.
When to get evaluated
Most sleep complaints are worth a conversation with a physician if they've lasted more than three weeks, are affecting your daytime function, or come with specific red flags: loud snoring with witnessed pauses, leg discomfort disrupting sleep, excessive daytime sleepiness, new difficulty focusing or remembering. Some are straightforward fixes. Some need a sleep study. Either way, they shouldn't be ignored.
How I approach sleep in my practice
Sleep is on every annual-visit checklist. I ask about duration, quality, snoring, partner observations, daytime energy, and any medication or substance that affects sleep. For patients with signs of sleep apnea, I arrange a home sleep study and handle the follow-through. For insomnia, I talk through the contributing factors first and refer to CBT-I when it's the right answer; medication comes up when it's appropriate and stays brief. For patients on medications that impair sleep, I review whether a different choice is available.
This is the kind of work that requires time. (What an actual annual physical includes when sleep gets the time it deserves.) Most of it isn't dramatic; it's methodical. Done over time with a physician who knows your history, sleep is one of the most improvable variables in adult health.
Frequently Asked Questions
How much sleep do I actually need?
Most adults need 7 to 9 hours. There's individual variation but it's narrower than people assume; if you're consistently sleeping less than 7 and not falling asleep within 20 minutes of an opportunity to nap, you're probably under-slept. The "I only need 5 hours" people are almost always wrong about themselves; objective testing usually shows the impairment they don't perceive.
Are sleep trackers (Oura, Whoop, Apple Watch) useful?
For most people, yes, with caveats. They're reasonably good at tracking duration and reasonably bad at distinguishing sleep stages. The most useful signals are: consistency of bedtime/wake time, total sleep time, and resting heart rate trends (a chronically elevated resting HR overnight often points to alcohol, late meals, illness, or stress). Don't chase the deep-sleep number; chase the fundamentals.
Is melatonin safe and does it work?
Useful for jet lag and circadian shifts; less useful as a "sleep aid" for ordinary insomnia. The doses sold OTC (5 mg or higher) are typically much higher than physiological; lower doses (0.3 to 1 mg) often work better. Quality control of OTC supplements is variable. Talk to your physician before using regularly, especially if you're on other medications or have a sleep disorder being worked up.
What about prescription sleep medications (Ambien, trazodone, etc.)?
Have a role for short stretches. Not a good long-term answer for most patients. Z-drugs (Ambien, Lunesta) carry risks for older adults including falls and cognitive effects. Trazodone is often used at low doses for sleep maintenance and is generally better tolerated long-term. Bottom line: don't stay on sleep medications by default; the work is to figure out why sleep is bad and address that.
How do I know if I have sleep apnea?
Classic clues: loud habitual snoring, witnessed pauses in breathing or gasping, morning headaches, daytime sleepiness despite "enough" hours, blood pressure or A1C that won't behave despite treatment, neck circumference greater than 17 inches in men or 16 in women, and the partner who tells you to "do something about your snoring." Any combination of these warrants a sleep study, which is now usually a home test.
Can sleep apnea be treated without CPAP?
Sometimes, depending on severity and anatomy. Mild cases may respond to weight loss, positional therapy (preventing back-sleep), or a custom oral appliance. Severe cases almost always need CPAP. Newer CPAP machines are quiet and substantially more comfortable than older models, and for patients who can't tolerate CPAP, surgical options including hypoglossal nerve stimulators are evolving. The point is that "I won't tolerate CPAP" isn't a reason to leave apnea untreated; there are alternatives.
How to evaluate any practice for serious sleep work
The criterion is whether sleep gets real time during your annual visit and whether the practice will arrange and follow up on a sleep study, not just hand you a referral. Panel size below 300 is a reasonable proxy for the time required. (Full criteria for evaluating any concierge practice.)
About the Author
Dr. Ben Soffer, DO is a board-certified physician practicing concierge primary care in Boca Raton, Florida. He caps his practice at 50 patients, which makes the kind of methodical sleep work described above part of normal care rather than a referral-and-hope.
If you're struggling with sleep and want to think it through properly
A no-obligation conversation about your specific situation, including any sleep concerns you've been pushing through.
- Call: 561-468-6981
- Email: info@drbensoffer.com
- Or reach out through the contact form
