A Culture That Sometimes Touts Sleep Loss Has A Health Problem

BY EARL LANE
WASHINGTON BUREAU

April 13, 2004

BETHESDA, MD -- Chronic sleep loss and untreated sleep disorders have become a serious public health concern, and it is
time for them to be addressed with the same urgency as the campaigns against smoking, drunk driving and obesity,
experts say.

While there is increasing research evidence on the harmful effects of disturbed sleep, getting the word out beyond the
lab has lagged, specialists said at a recent two-day meeting on sleep and sleep disorders at the National Institutes of
Health.

"The people who need the message are the most distant from it," Surgeon General Richard Carmona told the gathering.
"Improving health literacy on sleep disorders is long overdue." Several participants called for a surgeon general's
report on sleep and public health, comparable to the landmark report on smoking and health in 1964 that started to tip
the balance of public opinion on tobacco use.

Carmona said there is no lack of research on the effects of inadequate sleep. But he said the challenge is how to
change a culture in which sleep deprivation sometimes can be a badge of honor. "It's not a sign of weakness to get some
sleep," Carmona said.

According to the conference organizers, 50 million to 70 million Americans suffer health consequences of sleep
disorders, sleep deprivation and excessive daytime sleepiness each year, adding about $15 billion to the nation's
health-care bill and costing industry about $50 billion in lost productivity. Moreover, sleep problems can kill.

"We've got to get over the 'cuteness' of sleepiness and confront the biological danger of sleepiness," said the
University of Pennsylvania's David Dinges, an expert on excessive sleepiness and fatigue. He said that 22 consecutive
hours of wakefulness affect performance on psychomotor tasks the same as if the person had a 0.08 blood-alcohol
concentration.

Sleeping at the wheel

The National Highway Traffic Safety Administration has estimated that 1 percent to 4 percent of highway crashes and 4
percent of fatal crashes are caused by sleepiness, Dinges said. Many sleep researchers think those numbers are too low.
"Sleepiness can kill you quick," Dinges said. A driver who nods off at 60 mph can drift off the highway at a four-
degree angle in less than four seconds, he said.

Drowsy driving represents perhaps the greatest risk to those who have inadequate sleep, Dinges said. Crashes linked to
drowsy driving peak between 3 a.m. and 8 a.m., he said, when the body's neurobiological pacesetter is at a low.

Dr. Charles Czeisler, a Harvard University sleep specialist, noted that the body's strongest drive for waking is in the
evening, just before our usual bedtime, while production of the sleep-inducing hormone melatonin peaks at 4 a.m. to 5
a.m. in the average American.

The groups at risk for sleep-related vehicle crashes, Dinges said, include those who sleep fewer than six hours a day;
young adult males ages 16 to 24; commercial drivers; night-shift workers; those driving after prolonged work hours,
such as medical residents at hospitals, and patients with untreated sleep disorders.

Dangers of sleep disorders

While sleepiness can cause traumatic death in transportation accidents, disordered sleep also can have more subtle
effects. Sleep quality can affect the progression of cardiovascular disease, diabetes and other illnesses, specialists
said.

Dr. Virend Somers, a specialist on cardiovascular diseases at the Mayo Clinic in Rochester, Minn., said there is
compelling data linking obstructive sleep apnea - a disorder marked by abnormal pauses in breathing during sleep - with
changes in arterial blood chemistry and other events that can lead to heart disease. There is increasing data, from
animal studies and human population studies, suggesting an association between sleep-disordered breathing and high
blood pressure. There also are hints that such disordered breathing may be associated with increased risk of stroke,
heart attack and congestive heart failure.

"There has been increasing awareness, in particular from the cardiologists, regarding the potential cardiovascular
implications" of sleep loss, said Dr. Michael Weinstein, director of the sleep disorders center at Winthrop University
Hospital in Mineola. "We see many more referrals from cardiologists," he said in a phone interview.

Some new data suggest that chronic sleep loss also is associated with hormonal changes, including decreased tolerance
for glucose and increased insulin resistance, according to Eve Van Cauter, director of the sleep lab at the University
of Chicago. "Sleep is a major modulator of glucose tolerance," she said.

The severity of diabetes is directly associated with the severity of disturbed sleep, according to the National Sleep
Disorders Research Plan for 2003, a federal roadmap for research on sleep disorders.

Van Cauter said it is possible that sleep loss might represent a risk factor for developing obesity and diabetes. She
said the possible connections between sleep loss and obesity deserve more study, given the increasing problem of
obesity in the American populace.

Insomnia and depression

As to the more familiar sleep-related disorders, researchers have been developing new insights into the causes and
treatment of such problems as insomnia, sleep apnea, narcolepsy and restless legs syndrome. But too often, they said,
the latest findings are not translated quickly enough into useful information for clinicians and patients.

Insomnia has long been viewed as a symptom that can develop as a result of depression. But studies also show there is
feedback in the other direction: Those who have trouble sleeping can develop depression as a result.

"Recent studies show insomnia is a risk factor for depression," said Thomas Roth, a sleep researcher at the Henry Ford
Hospital in Detroit. He cited one study in which those with insomnia had a fivefold increase in risk of depression
compared to those without the sleep problem.

Dr. Daniel Buysse, a University of Pittsburgh psychiatrist, said it is time for physicians to stop regarding insomnia
as "a nuisance symptom." It is a disorder with real consequences, he said, including increased absenteeism at work,
higher risk of being involved in a motor vehicle accident and increased risk of cognitive decline in later years.

Buysee said the good news is that behavioral techniques have proved successful in treating insomnia. He said the basic
treatment includes such guidelines as: restrict time in bed; establish a regular wakeup time; go to bed only when
sleepy; stay in bed only when asleep; and avoid practices that can hurt sleep, such as drinking caffeine or alcohol in
the hours before bedtime.

Dr. Emmanuel Mignot, a Stanford University sleep specialist, said there has been much progress in understanding
narcolepsy, a disorder characterized by excessive sleepiness accompanied by episodes of muscle limpness known as
cataplexy. The prevalence of narcoplesy-catalepsy is about 1 in 2,000 persons, according to Mignot, and it has been
tightly associated with the presence of a particular surface protein on the white blood cells as well as a deficiency
in a hormone called hypocretin. "We think it is an autoimmune disease," Mignot said, in which the narcoleptic's own
body defenses target hypocretin-containing cells in the hypothalmus.

It is possible to diagnose the disorder by measuring hypocretin-1 levels in the cerebrospinal fluid. Only two or three
labs do the test, Mignot said, and "it needs to become much more available" to clinicians.

Mignot also noted that there are effective medications that can be used to treat the disorder, including several that
are approved for other uses but can be prescribed "off label" for narcolepsy as well. "Most people in general practice
have no clue they should be used for narcolepsy," Mignot said.

Similarly, Dr. Mark Mahowald, director of a regional sleep disorders center at Hennepin County Medical Center in
Minneapolis, said that there are off-label treatments available for restless legs syndrome. The syndrome, marked by an
irresistible need to keep the legs in motion during sleep, is one of the more prevalent and readily treatable causes of
severe insomnia, Mahowald said. The syndrome usually responds dramatically to some of the newer dopamine agents
developed for Parkinson's disease such as pramipexole or ropinirole. But Mahowald said many practitioners have never
even heard of restless legs syndrome, a situation he attributed in part to the lack of courses on sleep-related
disorders in many medical schools. He said that about one-third of medical schools do not have sleep medicine in their
curriculum.

Test your sleep IQ

This quiz was prepared by the National Heart, Lung, and Blood Institute.

Answer true or false to each question.

1. Sleep is a time when your body and brain shut down for rest and relaxation.

2. If you regularly doze off unintentionally during the

day, you may need more than just a good night's sleep.

3. If you snore loudly and persistently at night and are sleepy during the day, you may have a sleep disorder.

4. Opening the car window or turning up the radio will keep a drowsy driver awake.

5. Narcolepsy is a sleep disorder marked by "sleep attacks."

6. The primary cause of insomnia is worry.

7. One cause of not getting enough sleep is restless legs syndrome.

8. The body has a natural ability to adjust quickly to different sleep schedules such as working different shifts or
traveling through multiple time zones.

9. People need less sleep as they grow older.

10. More people doze off at the wheel in early morning or midafternoon than at night.

ANSWERS

1. False. Although it is a time when your body

rests and restores its

energy levels, sleep is an active state that affects your physical and mental well-being. Adequate restful sleep is
critical to good health. Insufficient restful sleep can result in mental and physical health problems and possibly
premature death.

2. True. Many people doze off unintentionally during the day despite getting their usual night of sleep. This could be
a sign of a sleep disorder.

3. True. Persistent loud snoring at night and daytime sleepiness are the main symptoms of sleep apnea, a common and
serious sleep disorder.

4. False. Opening the car window or turning the radio up may arouse a drowsy driver briefly, but this won't keep that
person alert.

5. True. People with narcolepsy fall asleep uncontrollably regardless of the amount of sleep the night before.

6. False. Insomnia has many causes, including physical and mental conditions and stress. It is important to get it
diagnosed and treated if it persists for more than a month.

7. True. Restless legs syndrome is distinguished by tingling sensations in the legs and sometimes the arms - while
sitting or lying still, especially at bedtime. A person with RLS has difficulty falling asleep or staying asleep and
usually feels extremely sleepy and unable to function fully during the day.

8. False. The human body's biological clock programs each person to feel sleepy during the nighttime hours and to be
active during daylight. People working the night shift are constantly fighting their biological clocks. Sleeping during
the day in a dark, quiet bedroom and getting exposure to sufficient bright light at the right time can help.

9. False. As we get older, we don't need less sleep, but we often get less sleep. Our ability to sleep for long periods
of time and to get into the deep restful stages of sleep decreases with age.

10. True. Our bodies are programmed by our biological clock to experience two natural periods of sleepiness during the
24-hour day. The primary period is between about midnight and 7 a.m. A second period of less intense sleepiness is
between about 1 and 3 p.m. This means that we are more at risk of falling asleep at the wheel at these times -
especially if we haven't had enough sleep.

SOURCE: New York Newsday, United States
http://tinyurl.com/29hcy

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