Everyone Sleeps!—(Poorly) or Not Enough: Sleep as a Priority and Vital Sign

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.” ³

Sleep—like fitness and a well-balanced diet—is billed as essential for health, productivity, and well-being. But despite widespread recognition of the NSF’s sleep duration recommendations (Figure 1), studies indicate a rising proportion of people consistently sleeping less than the recommended hours. ⁴

OPEN IN VIEWER

Figure 1.

Sleep duration recommendations by the National Sleep Foundation.

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 5 Organization for Economic Cooperation and Development (OECD) countries who sleep fewer than 6 hours a night on average have a 13% higher mortality risk than people who sleep at least 7 hours. ⁴

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 United States sleep less than the recommended 8 to 9 hours of sleep on school nights despite a physiological need. ⁵ Short sleep in this age-group is associated with suicide risk, obesity, depression and mood problems, low grades, and delinquent behavior. ⁶ 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. ⁷

On an annual basis, the United States 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 5 highly developed OECD countries, the United States sustains by far the highest economic losses—up to $411 billion a year, which is 2.28% of the country’s GDP—due to lack of sleep. If individuals who sleep under 6 hours per night started consistently sleeping 6 to 7 hours, their increased productivity could add an estimated $226.4 billion to the US economy. ⁴

Fortunately, in the last 5 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 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 2 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 trendable 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. ⁸ 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 NSF.

A similar recent initiative ⁹ 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 SA, which affects 9% to 24% of middle-aged adults in the United States. The longitudinal study included 9853 patients with SA (63.59% male) with a mean age of 48.1 years followed for an average of 5.3 years. As shown in Figure 2, patients with SA 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 patient. A Comorbidities of Sleep Apnea (CoSA) index that incorporated age and comorbidities was then created (see Table 1). 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.

OPEN IN VIEWER

Figure 2.

The comorbidome of sleep apnea. AA indicates aortic aneurysm; Af, atrial fibrillation; BPH, benign prostate hypertrophy; CAD, coronary artery disease; CLD, chronic liver disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; ESRD, end-stage renal disease; GERD, gastroesophageal reflux disease; HF, heart failure; PUD, peptic ulcer disease.

OPEN IN VIEWER

Table 1.

Predictors for Increased Risk of Mortality by Cox Regression Analysis and Point Assignment for CoSA Index Scoring System.

	Prevalence (%)	Hazard Ratio (95% CI)	P Value	Point Assignment
Hypertension	37.41	1.58 (1.16-2.15)	.004	2
COPD	27.73	1.46 (1.13-1.89)	.004	1
Diabetes mellitus	16.90	1.40 (1.08-1.82)	.012	1
Age ≥65 years	14.46	3.72 (2.74-5.05)	<.001	3
Ischemic stroke	6.70	1.75 (1.30-2.35)	<.001	2
Malignancy	6.52	2.91 (2.20-3.85)	<.001	3
Heart failure	4.48	1.57 (1.11-2.20)	.010	2
Dementia	1.93	1.79 (1.17-2.73)	.008	2
Atrial fibrillation	1.26	1.79 (1.02-3.15)	.044	2
ESRD	0.5	8.40 (4.61-15.29)	<.001	6
Aortic aneurysm	0.27	3.37 (1.30-8.69)	.012	3

Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; CoSA index, comorbidities of Sleep Apnea Index; ESRD, end-stage renal disease.

Prior to the CoSA index scores, the manner in which coexisting 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 SA, its close relationship to common coexisting 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 and Treatment

Sleep disorders are pervasive in the United States. 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, ¹⁰ but the most commonly reported are Obstructive Sleep Apnea (OSA), insomnia, restless legs syndrome, parasomnias/rapid eye movement (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 US population. ¹¹

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 (Figure 3). It is estimated that, in 2015, OSA costs the US economy approximately $149.6 billion. ¹²

OPEN IN VIEWER

Figure 3.

Prevalence of obstructive sleep apnea in cardiovascular disease *Note: The Apnea Hypopnea Index (AHI) reflects the severity of obstructive sleep apnea and represents the number of apneas or hypopneas a person experiences per hour of sleep.

Polysomnography (ie, 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 SA, with snoring, excessive daytime sleepiness, and obesity are ideal candidates for home SA tests. There is a range of treatment options for OSA, including oral appliances, ear, nose, and throat (ENT) intervention, pharyngeal stimulation, positional therapy, and continuous positive air pressure devices, which significantly reduce both all-cause and cardiovascular events. ¹³

Chronic insomnia, defined as disrupted sleep that occurs at least 3 nights per week and lasts at least 3 months, affects nearly 1 out of 5 adults and is a risk factor for depression, substance abuse, and impaired waking function. Comorbid physical and mental illnesses may be exacerbated by insomnia. ¹⁴ The etiology of insomnia is often complex and treatment options for insomnia frequently include the combination of pharmacological and cognitive behavioral therapy (CBT) strategies.

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

Restless legs syndrome affects over 1 out of 20 adults and causes difficulty sleeping and subsequent daytime sleepiness. ³

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 NSF:

Sleep.org: patient-facing consumer information

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

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

When patients come to sleep medicine professionals, they are motivated: These are people who 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.

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.