September 18 | American Journal of Health Promotion

 

By Joseph Ojile, M.D. F.C.C.P., D.ABSM

Founder, Chief Executive Officer and Medical Director of Clayton Sleep Institute

President of the Clayton Sleep Research Foundation

In the last 30 years, scientists and physicians have developed an increased understanding of sleep as an intrinsic, universal human biological process that affects the functioning of most—and perhaps all—organ systems.[1] We know now that sleep is the third key player, along with diet and exercise, for an individual’s total well-being.

 

Sleep medicine continues to mature as an interdisciplinary practice, and America’s health care system grows in the ability to recognize, diagnose, and treat all individuals with sleep disorders. Nevertheless, awareness of the pervasiveness of sleep disorders among health care professionals and the general public is relatively low considering an estimated 50-70 million adults in the United States chronically suffer from a sleep or circadian disorder.[2]

 

More than one-third of American adults are not getting enough sleep on a regular basis, and most Americans don’t make the connection between appropriate sleep and personal effectiveness.[3] As American adults struggle to make sleep a priority, health promotion professionals are challenged to define and measure “good” sleep and to make tangible recommendations that propel individuals and the community toward true sleep health.

 

By recognizing the sleep universe is home to treating disorders and disease states as well as manifesting sleep as a vital sign of fundamental well-being, employers and health promotion professionals play a crucial part in advancing sleep health individually, societally, and economically.

 

In this article, we explore (1) sleep as a public health challenge, (2) foremost sleep disorders and treatments, and (3) an opportunity to shift the working perception of sleep from primarily a disease state to a vital sign of life. A reconceptualization of this nature would move us individually and together toward true health.

 

Sleep as a public health challenge

Out of historical necessity, public health efforts, in general, have aimed at treating and preventing large scale threats to population life and health, with attention on disease states as the primary adversary to both. That natural bias is reflected in medical practice and medical specialties—a dominant, almost singular, focus on disease and disorders.

 

Sleep deficiency and untreated sleep disorders are of growing concern to global public health. The 2011 National Institutes of Health Sleep Disorders Research Plan defines sleep deficiency as a “…deficit in the quantity or quality of sleep obtained versus the amount needed for optimal health, performance and well-being; sleep deficiency may result from prolonged wakefulness leading to sleep deprivation, insufficient sleep duration, sleep fragmentation, or a sleep disorder, such as in obstructive sleep apnea, that disrupts sleep and thereby renders sleep non-restorative.”[4]

 

Sleep—like fitness and a well-balanced diet—is billed as essential for health, productivity, and well-being. But despite widespread recognition of the National Sleep Foundation’s sleep duration recommendations, studies indicate a rising proportion of people consistently sleeping less than the recommended hours.[5]

 

Furthermore, and prominent within the purview of public health, studies show sleep deprivation is associated with a higher mortality risk and productivity loss at work. An international study conducted by the RAND Corporation found that individuals from five Organization for Economic Cooperation and Development (OECD) countries who sleep fewer than six hours a night on average have a 13% higher mortality risk than people who sleep at least seven hours.[6]

 

Lifestyle factors such as excessive electronics use, smoking, alcohol consumption and lack of physical activity contribute to low sleep duration. More than 87% of high school adolescents in the U.S. sleep less than the recommended eight-to-nine hours of sleep on school nights despite a physiological need.[7] Short sleep in this age group is associated with suicide risk, obesity, depression and mood problems, low grades and delinquent behavior.[8] Among people of all ages, drowsy driving, a critical byproduct of poor sleep, may be a factor in 20% of all serious motor vehicle crash injuries. More than half of American adult drivers—about 168 million people—report driving drowsy in the past year. Thirty seven percent have fallen asleep at the wheel.[9]

 

On an annual basis, the U.S. loses an equivalent of around 1.2 million working days due to insufficient sleep. This quickly adds up when looking at the total cost of insufficient sleep on an economic level. Findings from the RAND study reveal out of five highly-developed OECD countries, the U.S. sustains by far the highest economic losses—up to $411 billion a year, which is 2.28 percent of the country’s GDP—due to lack of sleep. If individuals who sleep under six hours per night started consistently sleeping six-to-seven hours, their increased productivity could add an estimated $226.4 billion to the U.S. economy.[10]

 

Fortunately, in the last five years, scientists and sleep medicine professionals have worked to develop quantifiable, data-driven measurements that establish a foundation for reliably measuring sleep and sleep disorders in ways that support the best policy development for sleep health.

 

Historically, the National Sleep Foundation (NSF) conducts the annual “Sleep in America®” poll that aims to consistently gather and report sleep behavior trends over time. The poll’s topics and samples vary each year, including analyses on women and sleep; transportation workers’ sleep; and sleep and aging. The “core” questions and ensuing findings from the polls over the past two decades have had limitations, demonstrating the need for a greater focus on key indicators of sleep quality, duration, and target disorders.

 

Recognizing that these limitations presented an obstacle for sleep medicine professionals to develop accurate, real-world sleep behavior and health data from the general population, former NSF chairman, Dr. Max Hirshkowitz, and a task force of academics, professional pollsters, sleep clinicians, and researchers, evaluated the poll’s limitations to create a permanent and trend-able index for gauging sleep health. The resulting tool is the Sleep Health Index, a composite, 12-step index of sleep duration, sleep quality, and disordered sleep. Since its inception in 2014, the Sleep Health Index has begun to fill an unmet need in sleep health awareness, showing that Americans consistently fail to prioritize sleep. Measuring sleep quality and satisfaction is now comparable to the scientific rigor used in measuring sleep disorders—a bold step to fill an unmet need in the sleep heath community and increase the public’s knowledge about and respect for sleep.[11] Health promotion practitioners who utilize the Sleep Health Index within their populations can compare their data to nationally representative data gathered each year by the National Sleep Foundation.

 

A similar recent initiative[12] conducted by the Center of Sleep Medicine, Taipei Veterans General Hospital, provides a rigorous scientific view of calibrating the complexities of comorbidities with sleep, specifically sleep apnea (SA), which affects 9%-24% of middle-aged adults in the United States. The longitudinal study included 9853 SA patients (63.59% male) with a mean age of 48.1 years followed for an average of 5.3 years.  SA patients with any comorbidity may experience a higher risk of death compared to those without comorbidity. A total of 42 comorbidities were detailed in the analysis, with an average of 4.4 comorbidities per subject. A Comorbidities of Sleep Apnea (CoSA) index that incorporated age and comorbidities, was then created. Higher CoSA scores were associated with increased mortality, suggesting that an increased number of comorbidities in patients with SA may help stratify risk of death.

 

Prior to the CoSA index scores, the manner in which co-existing diseases such as cardiovascular, diabetes, stroke, and cancers impact mortality in patients, while methodically and deeply investigated, had not been translated into a risk assessment and clinical decision-making tool. Given that 23.5 million Americans have undiagnosed Obstructive Sleep Apnea, its close relationship to common co-existing diseases often provides ingress into diagnosing and treating SA. The CoSA index is a spectacular scientific tool for diagnosticians and clinicians addressing the very large SA patient population.

 

Snapshot: Sleep Disorders & Treatment

Sleep disorders are pervasive in the U.S. Fifty to 70 million Americans chronically suffer from a disorder of sleep and wakefulness. According to the International Classification of Sleep Disorders (ICSD-3), there are 80+ sleep disorders,[13] but the most commonly reported are: Obstructive Sleep Apnea (OSA), Insomnia, Restless Legs Syndrome, Parasomnias/REM Sleep Behavior Disorder, and Narcolepsy. The vast majority, by far, that presents to primary care physicians and frontline care providers comes from OSA and Insomnia. Sleep-disordered breathing including OSA, for example, affects more than 15% of the U.S. population.[14]

 

OSA is a life-threatening illness characterized by repetitive episodes of complete or partial upper airway obstruction occurring during sleep. Approximately 5.9 million American adults are diagnosed with OSA, which is often accompanied by daytime symptoms or comorbid conditions such as hypertension. It is estimated that, in 2015, OSA cost the U.S. economy approximately $149.6 billion.[15]

 

Polysomnography (i.e., sleep studies) is the criterion standard for diagnosing OSA and evaluating the possibility of other sleep disorders that can exist with or without OSA. Ideal candidates for an in-clinic sleep test are patients experiencing sleep-disordered breathing symptoms and specific medical conditions such as atrial fibrillation, chronic heart failure, Parkinson’s, chronic pain syndrome, and pulmonary, cardiovascular, or neuromuscular diseases. Patients with a high risk for moderate-to-severe sleep apnea, with snoring, excessive daytime sleepiness, and obesity are ideal candidates for home sleep apnea tests. There is a range of treatment options for OSA, including oral appliances, ENT intervention, pharyngeal stimulation, positional therapy, and Continuous Positive Air Pressure (CPAP) devices, which significantly reduce both all-cause and cardiovascular events.[16]

 

Chronic insomnia, defined as disrupted sleep that occurs at least three nights per week and lasts at least three months, affects nearly one out of five adults, and is a risk factor for depression, substance abuse, and impaired waking function. Comorbid physical and mental illnesses may be exacerbated by insomnia.[17] The etiology of insomnia is often complex and treatment options for insomnia frequently include the combination of pharmacological and cognitive behavioral therapy strategies.

 

The broad coverage in scholarly research of the under-diagnosis and under-treatment of sleep disorders and comorbidities presents a challenge to objectively measuring and treating sleep disorders. They often co-occur, making it difficult to know if one morbidity started before the other or to infer causality. For example:

• Restless legs syndrome affects over one 1 out of 20 adults, and causes difficulty sleeping and subsequent daytime sleepiness.[18]
• REM sleep behavior disorder may affect 1 out of 250 adults and may cause patients to injure themselves or others while asleep. Recent findings associate this disorder with an increased risk of Parkinson’s disease and other neurogenerative conditions.[19]
• Narcolepsy/cataplexy and other forms of hypersomnia affect 1 in 200 people disturbing sleep and producing excessive daytime sleepiness that profoundly reduces quality of life and performance at work and in school.[20]
• Nearly one in five pre-dialysis patients with Chronic kidney disease (CKD) do not get the optimal amount of sleep, which is associated with poorer quality-of-life outcomes.[21]
• Individuals with early Lyme disease (LD) and post-treatment Lyme disease syndrome (PTLDS) experience poor sleep quality, which is associated with typical LD symptoms of pain and fatigue.[22]

 

Shifting the Sleep Paradigm

 

Our “daytrip” through the landscape of sleep disorders, comorbidities, and treatments showcases countless opportunities for public health professionals to recognize the impact of the disorders themselves, as well as the critical nature of sleep duration and sleep quality for ideal sleep health. Along with the figures, tables, research, and tools noted here, there are abundant resources available to professionals and individuals, among them key initiatives from the National Sleep Foundation:

• org: patient-facing consumer information
• Sleep Health: an award-winning scholarly journal featuring the best thinking in sleep from international scientists, researchers, and clinicians
• Sleep Awareness Week: an annual media campaign to showcase consumer topics in sleep and feature results from the Sleep Health Index®

 

And in particular for public health professionals:

• Foundations of Sleep Health™: Currently in development, this first sleep health textbook, aimed toward public health practitioners, will advance sleep theories and practices to key movers in individual and community health practices and programs.

 

Other credible resources in the community of sleep professionals are:

• American Academy of Sleep Medicine
• Sleep Research Societies
• American Academy of Dental Sleep Medicine
• American Association of Sleep Technologists
• American Association for Respiratory Care
• Sleep disorder patient associations and support groups

 

Though organizations in the sleep ecosystem tend to converge on sleep medicine and sleep research, they also share a vision for sleep health that extends far beyond the absence of pathology. Sleep professionals are slowly moving the needle from a singular focus on sleep deficits and disorders to sleep as a universal benefactor of good health and a frontline defender against chronic disease.

 

Operating with knowledge of the disorders and comorbidities associated with poor sleep will empower public health practitioners to elevate their professional application of sleep medicine to the benefit of the individuals and communities they serve. Now, we in the professional sleep community call upon public health professionals to join us in the front lines for sleep advocacy:

• To promote sleep as a vital sign for health, where the daily quality and quantity of sleep is every bit as critical as an indicator of health as pulse rate, respiration rate, blood pressure and body temperature, and
• To promote sleep as a priority for a truly healthy life.

 

When patients come to sleep medicine professionals, they are motivated: These are people that want to sleep! For everyone else…oh, if only “Get better sleep!” were a glamorous message! Like most truths, it is plain, and like common sense, it is uncommonly true. We ask you to strive for awareness, prioritization, and incremental change. As you embark as ambassadors for sleep health, here is a going-forth gift—some simple tactics for better sleep that, in my experience, patients actually hear and sometimes do:

 

• Keep a consistent bedtime, even on weekends.
• Remove cell phones (tablets, TVs) in the bedroom.
• Avoid caffeine after 4:00 pm.
• Don’t have nicotine or alcohol within two hours of bedtime.
• Limit daytime naps to 20-30 minutes.
• Consume only a very light snack before bed.
• Get early morning sunlight.

We in the sleep community look forward to the contributions of public health professionals as pivotal players in increasing awareness of sleep as a health non-negotiable and as a top priority in daily life.

—

References

[1] Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK19948/

[2] Institute of Medicine (US) Committee on Sleep Medicine and Research; Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK19948/

[3] National Sleep Foundation, Sleep in America Poll 2018. Sleep & Effectiveness are Linked, but Few Plan Their Sleep. 2018. https://sleepfoundation.org/sites/default/files/Sleep%20in%20America%202018_prioritizing%20sleep.pdf. Accessed May 11, 2018.

[4] National Center on Sleep Disorder Research. National Institutes of Health Sleep Disorders Research Plan. Bethesda: National Institutes of Health; 2011. https://www.nhlbi.nih.gov/files/docs/ncsdr/201101011NationalSleepDisordersResearchPlanDHHSPublication11-7820.pdf. Accessed May 11, 2018.

[5] Hafner M, Stepanek M, Taylor J, Troxel WM, van Stolk C. Why sleep matters – the economic costs of insufficient sleep: A cross-country comparative. RAND Corporation. https://www.rand.org/pubs/research_reports/RR1791.html. Published November 30, 2016. Accessed May 11, 2018.

[6] Hafner M, Stepanek M, Taylor J, Troxel WM, van Stolk C. Why sleep matters – the economic costs of insufficient sleep: Across-country comparative. RAND Corporation. https://www.rand.org/pubs/research_reports/RR1791.html. Published November 30, 2016. Accessed May 11, 2018.

[7] National Sleep Foundation. 2006 Sleep in America Poll. https://sleepfoundation.org/sites/default/files/2006_summary_of_findings.pdf. Accessed May 11, 2018.

[8] Eaton D, Kann L, Kinchen S, et al. Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Surveillance — United States, 2009. Morbidity and Mortality Weekly Report. 2010; 59(SS05);1-142.

[9] National Sleep Foundation. 2005 Sleep in America Poll. https://sleepfoundation.org/sites/default/files/2005_summary_of_findings.pdf. Published March 29, 2015. Accessed May 11, 2018.

[10] Hafner M, Stepanek M, Taylor J, Troxel WM, van Stolk C. Why sleep matters – the economic costs of insufficient sleep: A cross-country comparative. RAND Corporation. https://www.rand.org/pubs/research_reports/RR1791.html. Published November 30, 2016. Accessed May 11, 2018.

[11] Hirshkowitz M. Indexing America’s sleep health. Sleep Health. 2017;3(4):232-233. doi:https://doi.org/10.1016/j.sleh.2017.06.001.

[12] Chiang C-L, Chen Y-T, Wang K-L, et al. Comorbidities and risk of mortality in patients with sleep apnea. Annals of Medicine. 2017;49(5):377-383. doi:https://doi.org/10.1080/07853890.2017.1282167.

[13] Phillips K. What are the Types of Sleep Disorders? A Full List of Sleep Disorders. Alaska Sleep Clinic. http://www.alaskasleep.com/blog/types-of-sleep-disorders-list-of-sleep-disorders. Published February 4, 2015.

[14] Institute of Medicine. Sleep disorders and sleep deprivation: An unmet public health problem. Colten HR, Alteveogt BM, editors. ISBN:0-309-66012-2, 1–500. 2006. Washington, D.C., National Academies Press.

[15] Frost & Sullivan. Darien, IL: American Academy of Sleep Medicine; 2016. In an age of constant activity, the solution to improving the nation’s health may lie in helping it sleep better. What benefits do patients experience in treating their obstructive sleep apnea? Available from: http://www.aasmnet.org/sleep-apnea-economic-impact.aspx.

[16] Fu Y, Xia Y, Yi H, Xu H, Guan J, Yin S. Meta-analysis of all-cause and cardiovascular mortality in obstructive sleep apnea with or without continuous positive airway pressure treatment. Sleep and Breathing. 2017;21(1):181-189. doi:https://doi.org/10.1007/s11325-016-1393-1.

[17] Insomnia costing U.S. workforce $63.2 billion a year in lost productivity, study shows. September 2011. https://aasm.org/insomnia-costing-u-s-workforce-63-2-billion-a-year-in-lost-productivity-study-shows/. Accessed May 11, 2018.

[18] National Center on Sleep Disorder Research. National Institutes of Health Sleep Disorders Research Plan. Bethesda: National Institutes of Health; 2011. https://www.nhlbi.nih.gov/files/docs/ncsdr/201101011NationalSleepDisordersResearchPlanDHHSPublication11-7820.pdf. Accessed May 11, 2018

[19] National Center on Sleep Disorder Research. National Institutes of Health Sleep Disorders Research Plan. Bethesda: National Institutes of Health; 2011. https://www.nhlbi.nih.gov/files/docs/ncsdr/201101011NationalSleepDisordersResearchPlanDHHSPublication11-7820.pdf. Accessed May 11, 2018

[20] National Center on Sleep Disorder Research. National Institutes of Health Sleep Disorders Research Plan. Bethesda: National Institutes of Health; 2011. https://www.nhlbi.nih.gov/files/docs/ncsdr/201101011NationalSleepDisordersResearchPlanDHHSPublication11-7820.pdf. Accessed May 11, 2018

[21] Minerd J. Poor Sleep Common in CKD Under- and over-sleeping linked with poor quality of life in pre-dialysis patients. MedPage Today. https://www.medpagetoday.com/nephrology/generalnephrology/72686. Published May 3, 2018.

[22] Weinstein ER, Rebman AW, Aucott JN, Johnson-Greene D, Bechtold KT. Sleep quality in well-defined Lyme disease: a clinical cohort study in Maryland. SLEEP. 2018;41(5). doi:https://doi.org/10.1093/sleep/zsy035.