Insufficient sleep epidemic

Insufficient sleep is a huge public health issue and is becoming an epidemic leading to negative health outcomes. This article tells you the possible negative health outcomes from insufficient sleep, how much sleep you should be getting, and general sleep hygiene tips.

Sleep is increasingly recognized as important to public health, with sleep insufficiency linked to motor vehicle crashes, industrial disasters and medical and other occupational errors. Unintentionally falling asleep, nodding off while driving, and having difficulty performing daily tasks because of sleepiness all may contribute to these hazardous outcomes. People experiencing sleep insufficiency also are more likely to suffer from chronic diseases such as hypertension, diabetes, depression and obesity, as well as from cancer, increased mortality and reduced quality of life and productivity. Sleep insufficiency may be caused by broad scale societal factors such as round-the-clock access to technology and work schedules, but sleep disorders such as insomnia or obstructive sleep apnea also play an important role. An estimated 50 to 70 million U.S. adults have sleep or wakefulness disorder. Notably, snoring is a major indicator of obstructive sleep apnea.

In recognition of the importance of sleep to the nation's health, Centers for Disease Control and Prevention surveillance of sleep-related behaviors has increased in recent years. Additionally, the Institute of Medicine encouraged collaboration between the CDC and the National Center on Sleep Disorders Research to support development and expansion of adequate surveillance of the U.S. population's sleep patterns and associated outcomes. Two new reports on the prevalence of unhealthy sleep behaviors and self-reported sleep-related difficulties among U.S. adults provide further evidence that insufficient sleep is an important public health concern.

Sleep-related unhealthy behaviors

The Behavioral Risk Factor Surveillance System survey included a core question regarding perceived insufficient rest or sleep in 2008 (included since 1995 on the Health Related Quality of Life module) and an optional module of four questions on sleep behavior in 2009. Data from the 2009 survey's Sleep module were used to assess the prevalence of unhealthy sleep behaviors by selected sociodemographic factors and geographic variations in 12 states. The analysis determined that among 74,571 adult respondents in 12 states, 35.3 percent reported fewer than seven hours of sleep during a typical 24-hour period, 48.0 percent reported snoring, 37.9 percent reported unintentionally falling asleep during the day at least once in the preceding month, and 4.7 percent reported nodding off or falling asleep while driving at least once in the preceding month. This is the first CDC surveillance report to include estimates of drowsy driving and unintentionally falling asleep during the day. The National Department of Transportation estimates drowsy driving to be responsible for 1,550 fatalities and 40,000 nonfatal injuries annually in the United States.

Self-reported sleep-related difficulties among adults

The National Health and Nutrition Examination Survey introduced the Sleep Disorders Questionnaire in 2005 for participants 16 years of age and older. This analysis was conducted using data from the last two survey cycles (2005 to 2006 and 2007 to 2008) to include 10,896 respondents aged older than or equal to 20 years. A short sleep duration was found to be more common among adults ages 20 to 39 years (37.0 percent) or 40 to 59 years (40.3 percent) than among adults aged older than or equal to 60 years (32.0 percent), and among non-Hispanic blacks (53.0 percent) compared to non-Hispanic whites (34.5 percent), Mexican-Americans (35.2 percent) or those of other race/ethnicity (41.7 percent). Adults who reported sleeping less than the recommended seven to nine hours per night were more likely to have difficulty performing many daily tasks.

How much sleep do we need? And how much sleep are we getting?

How much sleep we need varies among individuals but generally changes as we age. The National Institutes of Health suggests that school-age children need at least 10 hours of sleep daily, teens need nine to 10 hours, and adults need seven to eight hours. According to data from the National Health Interview Survey, nearly 30 percent of adults reported an average of less than or equal to six hours of sleep per day from 2005 to 2007. In 2009, only 31 percent of high school students reported getting at least eight hours of sleep on an average school night.

Sleep hygiene tips

The promotion of good sleep habits and regular sleep is known as sleep hygiene. The following sleep hygiene tips can be used to improve sleep:

* Go to bed at the same time each night and rise at the same time each morning.

* Avoid large meals before bedtime.

* Avoid caffeine and alcohol close to bedtime.

* Avoid nicotine.

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The danger of overlooking insomnia

The article details how important it is to get insomnia symptoms checked by a doctor, and discusses what health outcomes could occur from not doing so.

With our busy lives, it can be tempting to shrug off—or ignore altogether—difficulties with sleep. Trouble falling asleep, difficulty staying asleep throughout the night, waking feeling tired and unrefreshed: these are commonly experienced disruptions to sleep for millions of adults. Too often, these sleep problems aren’t taken seriously, or are considered the less-than-ideal price to pay for living full and sometimes hectic lives.

Difficulty falling asleep, waking during the night, waking very early in the morning, and experiencing un-restorative sleep are all symptoms of insomnia, a serious sleep disorder. People may experience these symptoms all at once, or some of them and not others. They may experience them chronically or every so often. They are signs of disrupted, poor quality sleep and they should never be ignored.

New research indicates how high a price we may pay for overlooking signs of insomnia. Scientists at Massachusetts’ Brigham & Women’s Hospital have identified a link between insomnia symptoms and elevated risk of death. Their study, which included more than 23,000 men, found certain symptoms of insomnia associated with higher mortality risk from cardiovascular disease. The men were all participants in the Health Professionals’ Follow-Up Study, a long-term, ongoing research endeavor that investigates issues related to men’s health. In 2004, 23,447 men reported to researchers about their sleep and any insomnia symptoms. Researchers followed up with the men over a period of 6 years, during which time 2,025 of the men died. After adjusting for other mortality-influencing factors including age, lifestyle habits, and other health problems, researchers analyzed data on men’s mortality as related to the presence of the following insomnia symptoms:

• Trouble falling asleep
• Difficulty maintaining sleep
• Waking in the early morning
• Experiencing non-restorative sleep

They found that several symptoms of insomnia were associated with higher rates of cardiovascular death among the men. In particular:

• Men who reported having difficulty falling asleep had a 55% increased risk of death from cardiovascular disease as compared to those men who did not experience this sleep difficulty.
• Men who reported experiencing un-refreshing sleep most of the time were at 32% higher risk for cardiovascular death than men who did not report this symptom.

Poor sleep is well understood to have a serious, negative impact on heart health. Not sleeping well, or enough, raises the risks for a number of cardiovascular problems, including high blood pressure, heart attack, heart failure, and stroke. Protecting the quality of sleep as we age is a critical component of protecting long-term cardiovascular health.

This isn’t the first scientific evidence of a link between poor sleep and increased mortality risk. But the news is particularly worrisome because these symptoms are quite common, particularly as we age. Estimates suggest that 30% or more of American adults experience some insomnia symptoms at least periodically, and for 10-15%, insomnia is chronic. Insomnia grows increasingly common with age: more than half of adults over the age of 65 experience symptoms of insomnia. Women are at higher risk than men for insomnia, due in part to hormonal cycles during childbearing years and to the hormonal changes associated with menopause. This current study included only men, but other research has shown higher risks of mortality associated with poor sleep in both men and women:

• In a number of studies that included both men and women, sleeping fewer than 6 hours and more than 8 hours per night has been associated with increased mortality risk.

• Obstructive sleep apnea in men and in women is linked to significantly highercardiovascular and overall mortality risks. Studies have shown that mortality risks from cardiovascular problems are 2 or more times greater for adults with obstructive sleep apnea. The more severe the obstructive sleep apnea, the greater the mortality risks.

• Research has also linked use of sleeping pills to increased mortality risk. The link between higher rates of mortality and sleeping pill use exists even after factoring out other possible contributors to death risk, including health problems, age, and gender.

Ready for some good news? While sleep problems left untreated may shorten longevity, improving sleep can have powerful positive health benefits. A study conducted recently in the Netherlands found that a regular routine of 7-8 hours of sleep may have as significant an impact on risk for cardiovascular death as not smoking.Regular, sufficient amounts of high-quality sleep have also been linked to reduced riskfor type 2 diabetes, largely because of the positive effect that sleep can have on improving insulin sensitivity.

If you have symptoms of insomnia, don’t ignore them. Share them with your doctor. Make an honest assessment of your sleep habits and make a commitment to taking simple steps to improve your sleep routine and your overall sleep hygiene. Taking steps to improve the quality and quantity of your sleep is one important way to protect your cardiovascular and overall health for the duration of your life. And sleeping well may actually help you extend that duration.

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How caffeine disrupts your sleep

New research looks into the specifics of how late-in-the-day caffeine can disrupt your sleep at night.

You hear it all the time when it comes to sleep: Don't drink caffeine too late in the day. It's among the most common sleep tips -- and it's a good one. Caffeine, with its stimulant effects, is disruptive to good sleep. And these days, with the popularity of energy drinks and other caffeine-laden beverages and snacks, it's not difficult to wind up consuming caffeine throughout the day, even if you've set your coffee cup aside. The negative health consequences of too much caffeine also extend beyond sleep problems. Research shows that caffeine may contribute to cardiovascular problems. A recent large-scale study also suggeststhat heavy caffeine consumption -- more than four 8-ounce cups of coffee per day on a daily basis -- is linked to higher mortality rates in men and women.

But how late in the day is too late in the day to be consuming caffeine? Despite consensus about caffeine's sleep-disrupting effects, recommendations about the timing of caffeine consumption -- and when it's best to stop for the day -- can vary widely. Though an abundance of research has been conducted to establish caffeine's negative effects on sleep, very little attention has been paid to the specific timing of caffeine consumption relative to bedtime.

A new study attempts to fill in some of these important specifics about the effects of late-afternoon and early-evening caffeine consumption on nightly sleep. Researchers at Michigan's Henry Ford Hospital's Sleep Disorders & Research Center and Wayne State College of Medicine analyzed the sleep-disruptive effects of caffeine consumption at different lengths of time before bedtime. They found that caffeine consumed even six hours before bedtime resulted in significantly diminished sleep quality and sleep quantity. This is believed to be the first study to investigate directly the effects of caffeine at specific times before nightly sleep.

The study included 12 adult men and women, all of whom were healthy and were normal sleepers who in their regular lives were moderate consumers of caffeine. During the study period volunteers kept up their normal sleep routines, which included bedtimes between 9 p.m. and 1 a.m. and wake times between 6 a.m. and 9 a.m. Participants' total nightly sleep duration fell somewhere in the range of 6.5 to 9 hours per night, with no regular habit of napping during the day. Throughout the study researchers tracked sleep by having participants keep sleep diaries and by using at-home sleep monitors. Participants were given doses of caffeine in pill form as well as placebo pills, on a schedule that enabled researchers to measure the sleep-disruptive effects of caffeine taken at three different points: at bedtime, three hours before bedtime, and six hours before bed. They found significant disruptions to sleep as a result of caffeine taken at all three points:

• Caffeine consumed zero, three, and six hours before bedtime significantly reduced total sleep time. Even caffeine consumed six hours before bed reduced total nightly sleep amounts by more than one hour.
• Caffeine consumed at all three points diminished sleep quality. Caffeine taken three and six hours before bedtime, as well as caffeine consumed at bedtime, significantly increased the amount of time spent awake during the night.
• Disruptions to sleep as a result of caffeine were perceived by volunteers (as recorded in sleep diaries) for caffeine consumed at bedtime and three hours before bed, but were not reported for caffeine taken six hours before bed. However, sleep monitors measuring total sleep time, and sleep efficiency (time spent sleeping relative to total time spent in bed) showed that caffeine consumed six hours before bedtime had significant detrimental effects to both.

This last finding is especially important, because it suggests that people can't -- and shouldn't -- rely entirely on their own perceptions of how much or little caffeine affects their sleep, especially caffeine consumed in the afternoon. Even if you don't feel that late-afternoon cup of coffee has a negative impact on your sleep, this study suggests that it is likely to be interfering nonetheless. This is one reason that I have long recommended a 2 p.m. cut off time for caffeine consumption.

Remember, limiting caffeine doesn't mean removing it entirely from your daily routine. A moderate amount of caffeine, consumed at the right times, can be useful and evenhealthful, stimulating alertness and energy. These new findings provide us with some really important specifics about just how significantly late-in-the-day caffeine can undermine a good night's sleep. Want to enjoy your coffee without wrecking your sleep? Follow these basic suggestions for consuming caffeine in a sleep-friendly way:

Stick to a 2 o'clock cut off. As this current study shows, late-afternoon caffeine can cause problems for your sleep, even if you aren't aware of it. To avoid sleep disruption, restrict your caffeine consumption primarily to the morning hours. If you do have a midday cup of coffee, make sure to drink it before 2 p.m.

Taper caffeine as the day progresses. Start your day with your most highly caffeinated beverage and ease up on the caffeine as the morning goes on. First thing in the morning is likely when you'll crave caffeine the most, and when it can do you the most good in terms of boosting energy and shaking off the effects of a night's sleep. Switch over to tea or decaffeinated coffee as the morning continues, to keep overall daily caffeine amounts moderate and be comfortably caffeine-free by mid-afternoon.

Avoid jumbo drinks. These days, everything seems to be "super-sized" -- and caffeinated drinks are no exception. From a 20-plus-ounce latte or soda to a caffeine-packed energy drink, a lot of caffeine products deliver way more of the stimulant than is healthful. Stick to something much closer to the old-fashioned 8-ounce cup, and savor it.

Don't ignore your sleep problems. Being tired makes us more likely to feel the need for caffeine, and that extra consumption can in turn make sleep problems worse. Avoid this sleep-disruptive cycle by making sleep a daily priority. Practice good sleep hygiene and talk to your doctor about how you are sleeping, particularly about any problems that arise.

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Insomnia increases risk of death

A study finds a link between insomnia and increased mortality risk.

Insomnia, the most common sleep disorder, affects up to one-third of the population in the United States. In new findings, researchers from Brigham and Women's Hospital (BWH) have found that some insomnia symptoms are associated with an increased risk of mortality in men. These findings are published online in Circulation and will appear in an upcoming print issue.

"Insomnia is a common health issue, particularly in older adults, but the link between this common sleep disorder and its impact on the risk of death has been unclear," said Yanping Li, PhD, a research fellow in the Channing Division of Network Medicine at BWH and lead author of the paper. "Our research shows that among men who experience specific symptoms of insomnia, there is a modest increase risk in death from cardiovascular-related issues."

Specifically, researchers report that difficulty falling sleep and non-restorative sleep were both associated with a higher risk of mortality, particularly mortality related to cardiovascular disease.

Researchers followed more than 23,000 men in the Health Professionals Follow-Up Study who self-reported insomnia symptoms for a period of six years. Beginning in 2004 through 2010, researchers documented 2025 deaths using information from government and family sources. After adjusting for lifestyle factors, age and other chronic conditions, researchers found that men who reported difficulty initiating sleep and non-restorative sleep had a 55 percent and 32 percent increased risk of CVD-related mortality over the six year follow up, respectively, when compared to men who did not report these insomnia-related symptoms.

"We know that sleep is important for cardiovascular health and many studies have linked poor or insufficient sleep with increased risk factors for cardiovascular-related diseases," said Xiang Gao, MD, PhD, a researcher in the Channing Division of Network Medicine at BWH and Harvard School of Public Health and senior author of this study. "Now we know that not only can poor sleep impact disease risk, but it may also impact our longevity. While further research is necessary to confirm these findings, there is overwhelming evidence that practicing good sleep hygiene and prioritizing sufficient and restful sleep is an often overlooked but important modifiable risk factor in overall health."

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