Sleep as a determinant of health

Sleep as a determinant of health

When Robert Thomas, MD, began his sleep medicine training in the 1990s, many physicians viewed it as a niche specialty with little influence on the health of the population.

The mindset was: Sleep Medicine? Who cares? It’s such a small thing, recalls Thomas. It has evolved in interest and importance over the past 25 years.

Although sleep is a basic human need fine-tuned over millions of years of evolution to allow for nearly everything in the body’s daily functioning, modern life is pretty bad for sleep, says Thomas, a professor of medicine at Harvard Medical School. co-directs the Sleep Disorders Center. at Beth Israel Deaconess Medical Center in Boston.

Electricity, computers, smartphones, night and irregular shift work, and the ability to travel and communicate across time zones, as well as mental and physical health issues have disrupted the natural course of sleep for an estimated 50-70 million people in the United States alone. according to the National Heart, Lung, and Blood Institute. And poor sleep is linked to chronic health problems, including heart disease, kidney disease, high blood pressure, diabetes, stroke, obesity and depression. It is also linked to accidents that can lead to injury or death.

Many people suffer from poor sleep routines and experience both short- and long-term health effects, but some people are even less likely to get enough sleep, especially Black and Latino people, people of low socioeconomic status and people who work overnight or irregular shifts for long periods.

And while research and understanding of sleep and its importance to health is increasing, the medical field has yet to catch up with the needs for screening, diagnosing and treating sleep disorders, says Thomas.

So far, sleep [disorders have] considered something unusual to be addressed directly in common general or specialist practice, he says. Patients are best served by sleep assessment being an integral and standardized part of most areas of medicine, such as neurology, cardiology, pulmonology and psychiatry.

The science of sleep

The human body and brain are wired to function on a 24-hour cycle, during which biological mechanisms known as circadian rhythms drive fluctuations in wakefulness, body temperature, metabolism, hormone release, gene expression, and more. These rhythms are heavily influenced by light and dark, which signals the brain when it’s time to be awake and when it’s time to wind down for sleep.

Sleep involves repeatedly going through two stages: non-REM (rapid eye movement) sleep, during which your body temperature drops and your heart rate, respiration, and brainwaves exhibit complex combinations of slow and fast patterns; and REM sleep, when the body is paralyzed as brain waves, breathing, and heart rate accelerate, and when dreams occur. Adequate amount, quality, and timing of both types of sleep have complementary roles in brain and body health, Thomas explains.

Researchers believe that the brain can eliminate toxins, analyze and store memories, and regulate immune processes, among other essential tasks, during sleep.

Scientists also observed the effects of lack of sleep: decreased attention and cognitive processing, increased risk of automobile accidents, high blood pressure, memory loss, increased risk of mental illness, and increased risk of several chronic conditions. including heart disease and diabetes. .

There’s a lot of literature showing that sleep is critical to biological, psychological, and behavioral processes, says Ze Wang, PhD, a professor at the University of Maryland School of Medicine in Baltimore.

Wang leads a research team that is looking at how insufficient sleep affects the mental and behavioral health of children and adolescents using data obtained over a 10-year period. After studying data collected from the children over a two-year period, the team found that getting insufficient sleep (less than 9 hours a night) was associated with less gray matter in the brain, worse cognition scores and severe behavioral problems.

Factors that can contribute to insufficient sleep can be environmental, family [conflict]socioeconomic, social media [use]AND [lack of] physical activity, among others, says Wang.

He adds that school policies that require children to wake up early or stay up late doing homework, as well as increased smartphone use among children, may be major contributing factors to the shortages.

While he emphasizes that the study is observational, it suggests the far-reaching impact that poor sleep can have, starting in early childhood, and how powerful a person’s environment can have on their well-being.

Iniquity of sleep

With growing recognition of the impact of social determinants of health on a person’s well-being, many in the medical field are familiar with how issues such as food insecurity, poor quality housing and lack of access to education can interact with a person’s ability to prevent and treat health problems. But fewer people think about including adequate sleep in the equation for social determinants of health.

When the National Institute on Minority Health and Health Disparities was formed in 2000, it was primarily examining racial disparities in the incidence and outcomes of cancer, HIV, and heart disease, says Girardin Jean-Louis, PhD, a professor in the Departments of Psychiatry and Neurology at Miller School of Medicine, University of Miami Florida.

We weren’t thinking about sleep, necessarily, he explains.

Over the past 23 years, however, research on the importance of sleep health, including its research on racial and ethnic disparities in the diagnosis and access to treatment of sleep disorders, has highlighted how intimately sleep affects sleep equity. Health.

That was the attitude [in the medical field] was that if you have a heart problem, you have to take care of it. If you have high blood pressure or diabetes, that needs to be treated, but if you say you can’t sleep, it won’t kill anyone. Well, that’s not really true.

Girardin Jean-Louis, PhD
Miller School of Medicine, University of Miami

Blacks and Hispanics are more likely to report getting fewer than six hours of sleep each night than the recommended seven to eight hours than whites, and blacks are less likely than whites to be diagnosed and treated for a sleep disorder, such as sleep apnea. A 2018 study found that although sleep apnea (when a person stops and starts breathing during sleep) is far more common in blacks than whites, as many as 95 percent of blacks with sleep apnea go undiagnosed.

Jean-Louis says the reasons behind this underdiagnosis and treatment of sleep disorders in the Black community echo the same reasons they are undertreated for other health issues like cancer.

People who face barriers to accessing health care, such as having experienced racism in a health care setting, lack of insurance coverage, unable to time off work, or lack of child care or transportation, have less likely to take the additional steps needed to seek help for a sleep disorder, she says.

When sleep clinics are based in hospitals, which some in minority communities distrust, or when they are made up primarily of white people or people who cannot communicate effectively with a person entering the clinic, they create barriers to diagnosis and treatment says Jean-Louis.

The key, he says, is making interventions accessible to the communities that need them most. This work is still in its early stages, but some researchers are developing models to better engage underserved communities with sleep health education, implementing sleep screening for high-risk individuals during hospitalizations, using telehealth, and enabling primary care and other health professionals to stay well-educated about sleep health and sleep disorders.

That was the attitude [in the medical field] was that if you have a heart problem, you have to take care of it. If you have high blood pressure or diabetes, that needs to be treated, but if you say you can’t sleep, it won’t kill anyone. Well, that’s not really true, says Jean-Louis. More and more people are becoming aware now that sleep is important.

Sleeping in medical school curricula

Not only is raising awareness of the impact of sleep on health essential to improving health care for patients, it is also an important goal for many clinicians, especially those in training both professionally and personally.

Rachel Salas, MD, a sleep medicine specialist and assistant medical director of the Johns Hopkins Center for Sleep and Wellness in Baltimore, Maryland, says part of the problem is that sleep medicine receives little attention in medical education. This reinforces the idea that sleep is unimportant and perpetuates poor sleep habits for medical trainees themselves, who often work schedules that make it difficult to maintain regular, good sleep.

Many people think they’re special and don’t need much sleep, says Salas.

He has worked to change that by creating a sleep medicine curriculum housed within the Johns Hopkins University School of Medicine department of neurology and providing guidance to other training programs on how to improve their curriculum. In recent years, she has noticed an increase in attention to sleep health in the academic medical field.

Ten years ago, medical students only received an average of 02 hours of sleep education, Salas says. [Now]many national education organizations are coming together to make sure they include sleep in education, whatever the specialty.

She hopes the additional education will not only help the next generation of doctors better serve their patients, but also encourage doctors to take better care of their sleep.

Sleep is one of those things that cuts across all fields. It is a basic human need.

Rachel Salas, MD
Johns Hopkins Center for Sleep and Wellness

Laura Barger, PhD, a part-time assistant professor of medicine at Harvard Medical School, is leading an ongoing study that evaluated data for first-year medical residents during various periods over the past 20 years. She found that long shifts are associated with an increase in significant medical errors and adverse events.

The study influenced a temporary change in regulation that limited first-year residents to 16-hour shifts, but that regulation has since been lifted, Barger says. Her team is currently analyzing data collected from 2020 to this year.

Salas says today’s medical students are very interested in learning about sleep medicine because they have heard and witnessed the effects of poor sleep on themselves and their communities.

Sleep disturbances are so common that they have seen them in their own pupils and students, in their families, he says. Sleep is one of those things that cuts across all fields. It is a basic human need.

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