Miles to go before I sleep: America is becoming a culture of sleeplessness

Surveys show most adults get less sleep than their bodies need, which can result in exacerbation of health risks.

By Stephanie Stapleton, amednews staff. Feb. 19, 2001.

It's 8 a.m., rush hour at almost every Starbucks. People with bleary eyes fight back yawns as they wait in line for the jolt that will help them start the day. They'll likely need another one in the midafternoon, just to get over the hump.

The pressures of life, work and leisure have triggered an expansion in the productive hours on the clock. As a result, people are more and more tired. Whether it is a medical resident pulling long shifts, a dot-com entrepreneur whose workdays stretch well into the night or a parent struggling to balance the demands of work and family, there simply do not seem to be enough hours in the day. And sleep is one of the first things sacrificed.

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Indeed, America is becoming a culture of sleeplessness. Just as this trend is on the upswing, scientists are uncovering evidence of the serious health implications that may follow.

The result: Doctors and patients face challenges completely different from fighting off the sandman. First, both are coming to realize that adequate rest ranks as high as nutrition and exercise in terms of behaviors that are central to maintaining good health. In addition, physicians and patients need to become more aware that sleep difficulties are health problems that can be addressed.

The Center for the Advancement of Health, a Washington, D.C.-based organization that promotes recognition of how psychological, social, behavioral and environmental factors influence health, describes sleep as "a dynamic behavior during which important physiological changes take place, both in the brain and in the body." It affects mental and physical well-being -- the ability to think and function.

Still, most American adults get less sleep than they need, according to the National Sleep Foundation's 2000 Omnibus Sleep in America Poll. Based on these findings, adults on average sleep six hours and 54 minutes, about an hour less than the eight hours recommended by sleep experts. In addition, about one-third of adults said they slept less than six and a half hours per night. And 45% of those surveyed said they were willing to sleep less to get more work done.

"A lot of people live like this week after week," said Robert Doekel Jr., MD, the medical director of HealthSouth's Sleep Disorders Center in Birmingham, Ala.

And just as society seems to be pushing people to squeeze more out of every day, the science highlighting this lifestyle's detrimental effects is advancing. Researchers are quick to admit that what is currently known represents a preliminary snapshot -- a patchwork of data that leave critical questions unanswered but also raise red flags.

For instance, in a 1999 study published in the Lancet, researchers restricted their subjects' sleep to only four hours a night for six nights. The results showed marked changes in metabolic and endocrine functions. Blood samples taken from study subjects -- 11 healthy young men -- reflected impaired glucose tolerance similar to a prediabetic state. The sleep debt also reduced the secretion of growth hormone and cortisol. Overall, the effects were similar to those seen in the aging process. Therefore, researchers concluded that sleep debt may increase the severity of age-related chronic conditions.

To sleep, perchance to heal

More studies indicate a critical relationship between sleep and immune system response. According to the CAH, an investigation of elderly widows and widowers whose sleep was disrupted due to bereavement-related depression experienced decreased levels of natural killer cells, indicating a weakened immune system. In addition, laboratory animals' ability to survive bacterial infection has been linked to the amount of deep sleep the animal gets during the first 12 hours of infection. Other studies have shown that when lab rats were totally deprived of sleep for four weeks, they died of opportunistic infection.

But these studies offer only parts of the puzzle. The definitive scientific evidence of the interworkings -- the precise explanations -- remains elusive. "If you are ill, your doctor will tell you to get a good night's sleep," said Michael Twery, PhD, a program officer for sleep research at the National Institutes of Health's National Heart, Lung and Blood Institute. "He just can't tell you why [it helps]."

Efforts to elucidate this relationship are still in the beginning stages. The research has surged forward in recent years -- sped along by genetics and the development of new tools that allow very careful measurement of neurochemical elements of the brain, neurophysiological relationships and the neurocircuitry that regulates sleep, Dr. Twery said. But data from these investigations and the longitudinal studies required to prove the connections between sleep and good health as well as sleep deprivation and negative outcomes are still far in the future.

Some of the conclusions, however, can be advanced on the basis of common sense. "There's all sorts of evidence that sleep is an important thing," said James Krueger, PhD, a neurobiology professor at Washington State University in Pullman, who studies the biochemistry of sleep and the brain's responses to sleep and wakefulness. "From what we know, what we can tell from the pathologies, we're better off getting sleep."

This assumption does not alter the underlying reality. Most people do not get adequate rest -- either because of their lifestyle choices or because they have a sleep disorder. And while science struggles to piece together the biochemical rationale and impact, it is left to patients and physicians to work through the day-to-day consequences of sleep deprivation.

According to the omnibus sleep survey, 62% of adults experience a sleep problem a few nights per week or more. Still, a separate NSF survey released in January found that most primary care physicians are not comfortable with patient issues related to sleep and don't ask patients about their sleep habits or whether they experience sleep difficulties.

"Physicians are not discussing sleep with patients because they don't know what it is -- or how to deal with it short of giving a sleeping pill," Dr. Twery said.

About 69% of primary care physicians believe they should raise issues about sleep with patients, but nearly all say the discussion is most likely to occur if it is initiated by the patient.

"What struck me about these numbers is that doctors believe this is something they should check up on," said Dr. Meir Kryger, a member of the NSF board of directors and director of the Sleep Disorders Centre at the University of Manitoba's St. Boniface General Hospital Research Centre. But frequently, the subject does not come up.

One reason is that sleep information is not usually covered as part of regular patient histories. "If these questions aren't asked, the information will never lead to a diagnosis," Dr. Kryger said. "I don't know one doctor who won't ask about chest pains." But few ask about snoring. Still, it is likely that 4% of the male population and 2% of the female population have sleep apnea. This is the same magnitude as asthma.

Dr. Kryger extrapolated the numbers: If a physician's practice has 1,000 male patients, it is likely that 40 have sleep apnea. "If you're not seeing them, you're missing them," he said.

Meanwhile, these patients are two times more likely than the general population to have hypertension, three times more likely to have a heart attack, four times more likely to have a stroke and five times more likely to be involved in a car crash, Dr. Doekel said.

And sleep apnea is just one of the disorders that frequently slips through the cracks. The short list also includes narcolepsy, restless leg syndrome and insomnia.

Time is a major factor that prevents physicians from these diagnoses. Nearly three-quarters of those surveyed said discussing sleep takes time away from other medical problems. But doctors also have an information gap; 80% said they are not as knowledgeable about sleep problems as they should be. And fewer than half of the doctors surveyed reported that they usually consult with a sleep medicine specialist.

The difficulties appear to stem from core values, experiences and conditioning.

Doctor of sleeplessness

On one hand, medicine itself has a subculture of sleeplessness -- both in terms of the rigors involved in the training years and the reality that health care is a business that operates around the clock.

Dr. Doekel remembers the early days of his career. "I was on 36 hours, off 12 and proud of it. It was a badge of honor pulling that kind of schedule." More and more, though, such patterns are considered "risky business," he said.

At the same time, patients exist in a world where being tired is often viewed as a sign of weakness or laziness, of underachieving. Thus, it may not be considered to be a legitimate complaint.

"Sleepiness is pervasive in society," said the NIH's Dr. Twery. "We grow up with it. Whether it is a physician who works an 18-hour day, a truck driver or an airplane pilot, you just feel the sleepiness is normal and go with it."

And from that circumstance comes the disconnect.

"Patients come to the doctor and say they are experiencing fatigue, that they are run down, even crabby or irritable, that they wake up with headaches," Dr. Twery continued. "They don't say they are sleepy." And at the same time, physicians don't ask.

But he believes that if the recognition of sleep disorders is increased, it could make a big difference to the overall health of society. Obese patients, for instance, often have hypertension and receive medication to control it. At the same time, a percentage of these patients also will have sleep apnea. But this disorder often will go untreated.

One current research question being explored is whether there is a causal relationship between the two conditions. Ultimately, sleep experts hope to determine if treating the sleep disorder can help ease the hypertension. In addition, they hope to identify the types of patients most likely to have the most benefit from treatment.

This kind of hope also spills over into speculation about the treatment of other serious illnesses. One line of sleep investigation involves the concept that deprivation results in a loss of brain cells.

If this is true, then some experts maintain that the absence of sleep speeds the progression of neurodegenerative and muscular-degenerative diseases. Therefore, the presence of sleep could slow it down.

"Right now, medical science cannot cure Alzheimer's or Parkinson's," Dr. Twery said.

However, if a subset of these patients also has sleep disorders, treating the latter could stall the progression of the more serious condition. Even if the idea holds true only 10% of the time, he added, it would be "a huge contribution."

ADDITIONAL INFORMATION:

Are you sleeping?

Here is a sampling of questions doctors can ask patients to find out about sleep problems. Does the patient:

Snore most nights and how loudly? Ever been told that he or she gasps for breath or stops breathing during sleep?
Ever fall asleep while driving or while at work? Feel sleepy during the day or fall asleep when reading or watching TV?
Have difficulty falling asleep or staying asleep? Wake up feeling tired?
Keep a regular sleep schedule? How many hours of sleep per night? Is he or she a shift worker?
Take sleeping pills or other treatments to improve sleep? Take any medications or supplements at all?
Smoke or drink alcohol? Drink caffeine products? At what time of day does he or she exercise or eat the evening meal?
Experience nighttime heartburn or pain or frequently need to go to the bathroom?
Suffer from stress or has he or she recently experienced lifestyle changes?

Source: National Sleep Foundation