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Sleep and health POST, UK PARLIAMENT

Dr Sarah Bunn, Lef Apostolakis | POST, UK Parliament

Sleep is as essential to life as food and water. So why don’t we treat it as such? Sleep problems may affect up to a third of the population and most sleep-wake disorders are likely to be underdiagnosed. Research also suggests that long-term sleep problems may be a factor in many physical and mental health conditions.

On the 16th of October 2018, POST in collaboration with the Nuffield Foundation, invited experts from medicine, research, and occupational sectors to highlight the latest research and discuss the implications for policy. On this page you will find a record of the oral presentations from the day, on sleep and health. A second page presents oral presentation on shift work, sleep and health.

professor the lord winston

Professor the Lord Winston, acted as chair and moderator of the panel discussion. Professor the Lord Winston is a world-renowned expert in fertility and genetics, currently Professor of Science and Society at Imperial College London. He has over 300 scientific publications about human reproduction and the early stages of pregnancy to his name and is Chairman of the Genesis Research Trust. In addition he is a passionate science communicator; a BAFTA-winning broadcaster and an author of over 20 titles. He is an active Peer in the House of Lords, and Vice-President of the Royal College of Music.

Professor Russell Foster

Russell is the Head of the Nuffield Laboratory of Ophthalmology, Director of the Sleep and Circadian Research Institute, and a Fellow of Brasenose College, Oxford. His research addresses the neuroscience of circadian rhythms and sleep, and the health consequences of sleep disruption. Russell is a Fellow of the Royal Society and Academy of Medical Sciences and was honoured with a CBE for services to science. He has published over 250 scientific papers, four popular science books and received multiple awards.

The circadian rhythm

The circadian rhythm or body clock fine tunes our physiology and behaviour to the 24 hour day/night cycle. This is demonstrated by patterns in recordings of core body temperature, blood pressure, growth hormone, and cortisol levels during periods of alertness and sleep. The implications of the circadian rhythm on our physiology are profound. For example circadian changes in blood pressure mean that the risk of stroke is increased by 50% between 6.00am and 12.00pm which is significant when planning health services. There is also evidence demonstrating that the timing of some treatments, such as radiotherapy for metastatic brain cancer, has an impact on health outcomes.

The biology of sleep

According to the American Time Use Survey, on average, a person aged 25-54 who is employed and has children will spend 32-36% of their day asleep. When they're not sleeping they spend:

  • 37% of their day working
  • 10.5% of their day doing leisure and sport activities
  • 5% of their day doing household work
  • 4.2% of their day eating and drinking and
  • 6.6% of their day doing other activities

During sleep, critical and complex processes take place involving multiple structures in the brain. These processes include memory consolidation, processing information, and emotional processing. Sleep even promotes problem solving abilities.

With so many processes depending on sleep, it comes as no surprise that the quality of our sleep can define our performance while awake. In turn, sleep quality is influenced by the timing and duration of our sleep, which in turn is determined by the interplay between circadian timing, sleep pressure and societal pressures. For example light detection by the eye influences circadian timing, which is why the drive for wakefulness increases in morning. Likewise, pressure to sleep is driven by the time spent awake and vice versa and finally, societal activities, like the consumption of caffeine can disrupt sleep, as caffeine blocks receptors that mediate sleep pressure.

Consequences of sleep disruption

With sleep playing such a profound role in biological process it should come as no surprise that disruption to sleep and circadian rhythm would have profound effects. For example, short term sleep disruption can lead to loss of attention, high levels of micro-sleeps, failure to process information, memory impairment, and reduced cognition and creativity. Longer term disruption on the other hand can include immune suppression, increased risk for infection and cancer, increased risk of cardiovascular disease and diabetes, and increased propensity for stimulant use. There is also a link to increased vulnerability to mental illness including anxiety, paranoia, and exacerbation of symptoms in those with bipolar disorder and schizophrenia.

Russell says that just in the US approximately 100,000 traffic collisions every year occur in relation to sleepiness, many of which are caused by microsleep. There is a similar association with air accidents.

Today, using brain imaging technologies can help us directly visualise areas of the brain and compare what it looks like when we do tasks well rested, versus when we are sleep deprived.

Image: Roger Mommaerts

While many people may use caffeine to promote alertness, caffeine has a long half-life and may inadvertently make it difficult to sleep in the evening, and can for some people lead to regular use of sleeping tablets or alcohol to promote sleep.

Appetite, involving the hormones leptin and ghrelin, is also affected by sleep disruption. Leptin is made by adipose tissue and suppresses food intake, whereas ghrelin is made in the stomach and promotes hunger. Sleep disruption increases ghrelin levels and leads to a fall in leptin levels. This suggest sleep deprivation can affect obesity prevalence, particularly childhood obesity.

There is also a significant link between psychiatric illness and sleep disruption. For example, 80% of psychiatric inpatients experience clinically significant insomnia. Sleep disruption can be an early signal for mental illness and is also a therapeutic target.

Interventions

For those at risk of sleep disruption either at home or in the workplace, there are several approaches that could be adopted.

Higher frequency health checks: Individuals at risk of sleep disruption, such as long-term shift workers, are at increased risk for cardiovascular disease, cancer, obesity, type 2 diabetes, metabolic syndrome, and gastro-intestinal problems. Therefore early screening would benefit this group, particularly for cancer, where the five year survival rate improves if cancer is detected early.

Lighting: according to some studies, brighter lighting in nursing homes improves residents’ sleep-wake timing, increases cognition, slows cognitive decline, reduces levels of depression and improves capacity for daily living. So lighting could be a promising intervention.

More than half of trainee doctors have had an accident or near miss on their way home after a night shift due to sleep deprivation

Vigilance technology: technological solution that improve alertness, such as drowsiness detection technologies in driving could be significant. For example, one study showed that more than half of trainee doctors have had an accident or near miss on their way home after a night shift due to sleep deprivation. Should there be a duty of care on employers to provide such technologies?

Appropriate nutrition: shift workers are at increased risk of cardiovascular disease, obesity, risk of type 2 diabetes, metabolic syndrome, and gastro-intestinal problems. However, food provision for shift-workers is poor, and largely based on high fat, sugar and salt foods.

Sleep education: educating the public about sleep is key, particularly when it cme to adolescents. The TeenSleep project brings together knowledge about the science of sleep, sleep hygiene, and stress management techniques. This has been developed int oeight information sessions that can be delivered by teachers to children over eight sessions. Data shows that this programme can improve sleep quality in teenagers. However, sleep education could also play a potentially important role in helping the public get better sleep and helping people monitor and understand negative changes in their partners' behaviour. For example, shift work couples with children under 19 years old are six times more likely to divorce if one of the spouses worked between midnight and 8am as compared with those working daytime hours.

Digital devices: there is a variety of technologies available that claim to improve sleep. However, caution is needed since many are not clinically validated, and some are misleading and can actually cause stress, for example by creating anxiety about not getting enough sleep.

Professor John Stradling

John directed the respiratory sleep service at Oxford from 1985 to 2013. Research concentrated on obstructive sleep apnoea (OSA) and its cardiovascular consequences. He is concerned to raise awareness of OSA, particularly in HGV and coach drivers. He has over 300 original publications, recently receiving awards from the American Association of Sleep Medicine, the British Thoracic Society, an honorary doctorate from Grenoble University, and was a recent keynote speaker at the American Thoracic Society

Obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is the failure of the upper airway to stay open when its muscles relax during sleep. This repeatedly disrupts normal breathing during the night – often hundreds of times a night – causing a person to briefly wake up to restore normal breathing. These repeated awakenings, often paired with loud snoring, usually go unnoticed by the sufferer. This means that OSA is under-diagnosed, and that often diagnosis only occurs when a sufferer's partner notices the symptoms.

Severe OSA, when daytime sleepiness is usually present, is called OSA Syndrome (OSAS). The main result of OSA is excessive daytime sleepiness, which increases the likelihood of falling asleep, especially while driving. Interventions mainly aim at treating the sleepiness.

The prevalence of OSA is difficult to quantify as there ins't a single definitions. In the UK, approximately 1% to 2% of adults have severe OSA worthy of Continuous Positive Airway Pressure (CPAP) treatment. The Oxford sleep clinic has over 11,000 patients on CPAP treatment. In the UK, approximately 5% to 10% of heavy goods vehicle (HGV) drivers have significant OSA likely to be increasing their degree of sleepiness.

Despite difficulties to quantify prevalence, we know of several factors that are associated with OSA. Obesity, and snoring are positively correlated with OSA. It is also more common in men than women, with middle-aged men havign the highest risk of presenting OSA symptoms. Occupational factors can also play a significant role: commercial drivers are more likely to have OSA due to their sedentary lifestyle. Irregular shift patterns exacerbate the sleepiness.

Symptoms of OSA other than snoring, include difficulty concentrating, falling asleep when watching TV and in meetings, and drowsiness while driving. However, not all of those with OSA are sleepy and it is not clear why.

If left untreated, sleepiness due to OSA can severely impair driving, with affected drivers being three to nine times likelier of being in an accident. Accidents are also likely to be more severe due to failure to correct errors quickly, with accidents involving HGVs tending to be particularly serious.

Health, treatment, and policy

Beyond daytime sleepiness, OSA is linked to increased risk of high blood pressure, heart problems, and stroke and is associated with depression and type 2 diabetes. Furthermore, it has a major impact on quality of life. It is thought to reduce life expectancy by 20%, although this is difficult to prove. However, patients who comply with treatment can expect to lead a normal life and drive as safely as any other driver.

Indeed, when treated, patients report feeling as if they have a new lease of life; they feel more refreshed and suggest their relationships improve as sleep patterns normalise. Overall health gains lead to fewer sick days taken, improve concentration and motivation at work, as well as safety behind the wheel. The most common and effective treatment is CPAP, which is approved by the National Institute for Health and Care Excellence (NICE). It gives rapid results, often after the first treatment. Still, it can be difficult to get patients to give it a go, and depends on having highly skilled sleep clinic staff.

OSA is very common in middle aged, overweight men and is over-represented among heavy goods drivers. Yet, this group is less likely to come forward with symptoms as they perceive a risk of losing their livelihoods. However, they are more likely to seek help if they have guaranteed and rapid access to treatment. Addressing this is the Four Week Wait campaign, an initiative trying to improve treatment access for professional drivers. A NICE clinical knowledge summary for GPs advises them to fast track drivers. The Newcastle Freeman Hospital has run a pilot demonstrating that a fast track programme is possible. The Driver and Vehicle Licensing Agency (DVLA) has changed its requirements following representations from the OSA Partnership Group in order to be more driver friendly. NICE Clinical Guidelines and Practice Standards are in progress but will not be available for at least two years.

Professor Colin Espie

Colin is Professor of Sleep Medicine, Director of Experimental and Clinical Sleep Medicine research, and Fellow of Somerville College, Oxford. He is also Emeritus Professor, College of Medical, Veterinary and Life Sciences, University of Glasgow. Colin has published over 250 research papers, mostly on the assessment and treatment of insomnia. He is CoFounder and Chief Medical Officer of Big Health, whose award-winning digital programme, Sleepio, is now being made available in parts of the NHS.

Insomnia

Insomnia is a common disorder. It is estimated that 30% of the population regularly experience symptoms as such difficulty in falling or staying asleep and early awakening and 10-12% of the population is affected by chronic (long-term) insomnia. During the daytime, symptoms can include fatigue, low mood, poor concentration and reduced productivity. Insomnia is also considered the most common expression of mental ill health and a risk factor for illnesses.

Despite its prevalence, insomnia is generally poorly managed in clinical practice. In fact it is often trivialised, with patients often encouraged to treat their symptoms with a plethora of marketed 'treatments' that have not been validated in clinical studies and do not work. These include wrist bands, special beds, mattresses and pillows, crystals, magnets and homeopathies, aromatherapies, pseudo-neuroscientific practices, sleep apps, and over-the-counter products.

Within this cacophony of false remedies, some evidence based approaches to treat insomnia are being developed. Furthermore, some of these approaches can be scaled up to be delivered at a population level. The first such approach that comes to mind is medications, which are affordable, evidence-based (to an extent), and can be standardised and indeed NHS England issues twelve to 14 million prescriptions for sleeping tablets each year. However medications have limited effectiveness, which is why the recommended first line of treatment is often Cognitive Behavioural Therapy for Insomnia (CBT-I). This type of therapy has been endorsed in practice guidelines from the American College of Physicians and in a European guideline. Patients who do not respond to CBT-I are then prescribed pharmacological solutions.

Cognitive Behavioural Therapy for Insomnia

CBT-I describes a system of therapies that operate through cognitive control and restructuring, promoting relaxation, sleep hygiene education, and behavioural changes to establish sleep needs, manipulate sleep pressure, and timing. Traditionally, CBT has been delivered face-to-face in healthcare settings, either individually or in group settings. With millions of people suffering from insomnia, delivering CBT-I face-to-face may be challenging, but delivering the underlying psychology could be scalable. The concepts, constructs and procedures associate with psychological practice are not limited to in-person communication and can be translated into an evidence-based digital medicine approach which is scalable, affordable, evidence-based, and standardised.

There are several examples of CBT-I, including SHUT-I (Sleep Healthy Using the Internet), sleepcare and Sleepio, the effectiveness of which have been validated in several randomised controlled trials, with effects comparable to face-to-face CBT. This evidence based mobile approach is called digital CBT (dCBT). Recent papers in Lancet Psychiatry and JAMA Psychiatry showed that dCBT-I is effective in reducing mental health symptoms and preventing depressive episodes. Therefore sleep interventions can be used to improve mental health and wellbeing.

CBT-I is effective and offers a choice of evidence-based treatment to all patients. This means we might soon be seeing clinical guidelines suggesting CBT-I be offered as a first line treatment for insomnia. Implementation and commissioning pathways in the NHS are already being developed, with Sleepio available in London, Oxfordshire, Buckinghamshire and Berkshire, through implementation funded from Innovate UK and NHSE initiatives.

Still there is a need to regulate digital medicine. The non-profit organisation Digital Therapeutics Alliance was established in 2017 and is working to optimise and integrate digital therapeutic solutions into healthcare to improve health outcomes. It is important that developers of such technologies undertake appropriate research including pre-registered trials, subject to thorough analysis and independent scrutiny to ensure that the public is well served.

Dr David Crepaz-Keay

David has led the development, delivery, and evaluation of self-management and peer support projects across England and Wales. He has been a technical adviser to the World Health Organization on empowerment issues, and has spoken and written widely on involvement, empowerment, self-management, and peer support. In addition to his work with PHE, David is also Head of Empowerment and Social Inclusion at the Mental Health Foundation, where he has promoted the inclusion of mental health voices in public health.

Public health messages

Public Health England has developed a new mental health campaign, which aims at raising awareness about sleep, among other areas of interest. Every Mind Matters, is a preventive population-level campaign aiming at enabling people to manage their mental health. Through the development and delivery of a range of engaging content, it aims at promoting the personal understanding of mental health as a way of driving self-care actions, in all groups regardless of their mental health status.The campaign consists of four main themes: anxiety, low mood, stress, and sleep.

Sleep

Every Mind Matters places information about sleep in a broader public and mental health context. The campaign brings together a range of content, from informative video, to action plans, and sleep hygiene tips, that form a clearly signposted path leading to f support resources. Integral to the campaign is the message that sleep is fundamental and the belief that we can’t have the best possible mental health without the best possible sleep, which is why trying to improve the population’s mental health are and sleep are two tasks that go hand in hand.

Image: Employer Toolkit

Messaging challenges

When it comes to talking about mental health, David admits that it can sometimes be difficult, so he often drops the word "mental". He believes that anything that an individual does to improve their health will also inadvertently improve their mental health. He finds it easier to engage about mental health by addressing other factors that are easier to talk about such as sleep, the quality of which can have a profound effect on mental health. If we can get sleep right, then other positive consequences will follow from that.

The main focus of the Every Mind Matters campaign is to highlight what people can do for themselves, by helping them model action plans and offering advice. The challenge for a campaign like this is to get people’s attention, therefore content has been designed specifically with a need to drive engagement in mind. So far, the campaign is reaching a good segment of the population, with 3.8 million people having engaged with the content just within the first three days of the campaign's launch. The impact of the programme will be evaluated at a future point.

Image: Employer Toolkit

Beyond this campaign, Public Health England has produced other resources on sleep, including an Employer Toolkit, which was developed in collaboration with Business in the Community. Other current public-facing resources are the Rise Above campaign (focused on teenagers) and the One You campaign (focused on adults). Resources hosted elsewhere that offer support for people seeking help include NHS Choices (Public Health England is part of the review group) and a Minded training module on sleep in adolescence for parents, teachers and youth workers.

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Lef Apostolakis
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