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Duration, timing and quality of sleep are each vital for health, performance and safety

Published:January 13, 2015DOI:https://doi.org/10.1016/j.sleh.2014.12.008
Duration, timing and quality of sleep are each vital for health, performance and safety
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More than 30 years ago, Rechtschaffen et al
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Physiological correlates of prolonged sleep deprivation in rats.
Science. 1983; 221: 182-184
demonstrated that sleep is just as necessary as food for bodily survival. Yet, as recently as 2005, Hobson
  • Hobson J.A.
Sleep is of the brain, by the brain and for the brain.
Nature. 2005; 437: 1254-1256
has argued that “sleep is of the brain, by the brain, and for the brain.” In 2007, systems biologist Van Savage and theoretical physicist Geoffrey West concluded that the reason why small mammals with a high metabolic rate like the mouse sleep so much longer, approximately 14 hours per day, than large mammals with a low metabolic rate like the elephant, which sleeps only 3.5 hours per day, is that the core function of sleep is to repair, reorganize, and maintain the brain's neurons, which burn more energy per unit mass than any other tissue.
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  • West G.B.
A quantitative, theoretical framework for understanding mammalian sleep.
Proc Natl Acad Sci U S A. 2007; 104: 1051-1056
The landmark discovery that sleep facilitates the clearance of toxic metabolic debris, including amyloid β, that is generated by neural activity and accumulates during wakefulness, supports and extends that theory.
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Neuroscience. Garbage truck of the brain.
Science. 2013; 340: 1529-1530
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Sleep drives metabolite clearance from the adult brain.
Science. 2013; 342: 373-377
Evidence of the crucial role that sleep plays in brain development, synaptic pruning, plasticity, rehearsal, memory consolidation, learning, and insight further supports the conclusion that sleep is critical for brain functioning,
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Ontogenetic development of the human sleep-dream cycle.
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Sleep-dependent memory triage: evolving generalization through selective processing.
Nat Neurosci. 2013; 16: 139-145
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Sleep and developmental plasticity not just for kids.
Prog Brain Res. 2011; 193: 221-232
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Sleep and the price of plasticity: from synaptic and cellular homeostasis to memory consolidation and integration.
Neuron. 2014; 81: 12-34
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Biasing the content of hippocampal replay during sleep.
Nat Neurosci. 2012; 15: 1439-1444
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Sleep and memory in mammals, birds and invertebrates.
Neurosci Biobehav Rev. 2014; ([Epub ahead of print])https://doi.org/10.1016/j.neubiorev.2014.09.020
rather than simply serving to keep us out of trouble at night.
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Sleep viewed as a state of adaptive inactivity.
Nat Rev Neurosci. 2009; 10: 747-753
Moreover, in the 15 years since Eve Van Cauter and her colleagues at the University of Chicago discovered that sleep deficiency adversely impacts metabolic and endocrine functions,
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Impact of sleep debt on metabolic and endocrine function.
Lancet. 1999; 354: 1435-1439
it has been demonstrated unequivocally that the duration, timing, and quality of sleep also critically affect physical health, mental health, performance, and safety.
Committee on Sleep Medicine Research Board on Health Sciences Policy.
in: Sleep disorders and sleep deprivation. An Unmet Public Health Problem. Institute of Medicine of the National Academies; The National Academies Press, Washington, D.C.2006
Thus, it is clear that sleep is critical not just for optimal brain functioning but also for optimal functioning of the body as well.

Sleep duration and health

Recent data indicate that 28% of Americans report obtaining insufficient sleep on most nights, and only 31% of Americans report consistently obtaining sufficient sleep.
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Perceived insufficient rest or sleep among adults—United States, 2008.
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In fact, 30% of civilian workers and 44% of night shift workers in the United States are sleeping less than 6 hours per night,
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Short sleep duration among workers—United States, 2010.
MMWR Morb Mortal Wkly Rep. 2012; 61: 281-285
and this fraction is only likely to rise.
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Perspective: casting light on sleep deficiency.
Nature. 2013; 497: S13
Rigorous physiological studies have demonstrated that just a week or two of sleep curtailment increases appetite and food intake,
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Brief Communication: Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels and increased hunger and appetite.
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Impact of insufficient sleep on total daily energy expenditure, food intake, and weight gain.
Proc Natl Acad Sci U S A. 2013; 10: 5695-5700
decreases insulin sensitivity and glucose tolerance
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  • Van Cauter E.
Impact of sleep debt on metabolic and endocrine function.
Lancet. 1999; 354: 1435-1439
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Impact of sleep and sleep loss on neuroendocrine and metabolic function.
Horm Res. 2007; 67: 2-9
—even in adipose tissue removed from sleep-deprived participants,
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  • Brady M.J.
Impaired insulin signaling in human adipocytes after experimental sleep restriction: a randomized crossover study.
Ann Intern Med. 2012; 157: 549-557
impairs the immune response to vaccination,
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  • Van Cauter E.
Effect of sleep deprivation on response to immunization.
J Am Med Assoc. 2002; 288: 1471-1472
degrades the ability to resist infection,
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  • Turner R.B.
Sleep habits and susceptibility to the common cold.
Arch Intern Med. 2009; 169: 62-67
disturbs mood,
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Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night.
Sleep. 1997; 20: 267-277
increases the vulnerability to attentional failures,
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  • Pack F.
  • Williams K.
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  • Powell J.W.
  • Ott G.E.
  • et al.
Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night.
Sleep. 1997; 20: 267-277
, 
  • Van Dongen H.P.A.
  • Maislin G.
  • Mullington J.M.
  • Dinges D.F.
The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation.
Sleep. 2003; 26: 117-126
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Patterns of performance degradation and restoration during sleep restriction and subsequent recovery: a sleep dose-response study.
J Sleep Res. 2003; 12: 1-12
and, when combined with prior chronic circadian disruption, impairs pancreatic β-cell responsiveness.
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  • Porter J.H.
  • Duffy J.F.
  • Wang W.
  • et al.
Adverse metabolic consequences in humans of prolonged sleep restriction combined with circadian disruption.
Sci Transl Med. 2012; 4: 129ra143
Concurrently, epidemiologic studies have revealed that habitually short sleepers have an increased prevalence of obesity;
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Meta-analysis of short sleep duration and obesity in children and adults.
Sleep. 2008; 31: 619-626
that short sleep duration in young children confers an increased risk of obesity in older children
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Short sleep duration in infancy and risk of childhood overweight.
Arch Pediatr Adolesc Med. 2008; 162: 305-311
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  • Williams S.M.
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Longitudinal analysis of sleep in relation to BMI and body fat in children: the FLAME study.
BMJ. 2011; 342: d2712
and adults;
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Childhood sleep time and long-term risk for obesity: a 32-year prospective birth cohort study.
Pediatrics. 2008; 122: 955-960
and that habitually short and habitually long sleepers are at increased risk for incident calcification of the coronary arteries,
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Short sleep duration and incident coronary artery calcification.
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incident coronary heart disease,
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Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies.
Eur Heart J. 2011; 32: 1484-1492
incident type 2 diabetes,
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Sleep duration as a risk factor for the development of type 2 diabetes.
Diabetes Care. 2006; 29: 657-661
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Association between sleep duration and diabetes in black and white adults.
Diabetes Care. 2013; 36: 3557-3565
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  • Miller M.A.
Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis.
Diabetes Care. 2010; 33: 414-420
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Short sleep duration is associated with risk of future diabetes but not cardiovascular disease: a prospective study and meta-analysis.
PLoS One. 2013; 8: e82305
incident stroke,
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Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis.
Diabetes Care. 2010; 33: 414-420
and death.
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Mortality associated with short sleep duration: the evidence, the possible mechanisms, and the future.
Sleep Med Rev. 2010; 14: 191-203
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Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies.
Sleep. 2010; 33: 585-592

Sleep timing and health

During that same time interval, emerging evidence that chronic exposure to recurrent disruption of sleep and circadian timing induced by night shift work increases the risk of breast cancer,
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Nested case-control study of night shift work and breast cancer risk among women in the Danish military.
Occup Environ Med. 2012; 69: 551-556
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Circadian disrupting exposures and breast cancer risk: a meta-analysis.
Int Arch Occup Environ Health. 2014; ([Epub ahead of print])
endometrial cancer,
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Night shift work and the risk of endometrial cancer.
Cancer Res. 2007; 67: 10618-10622
colorectal cancer,
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Night-shift work and risk of colorectal cancer in the nurses' health study.
J Natl Cancer Inst. 2003; 95: 825-828
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0058 Colorectal cancer risk and shift work in a population-based case-control study in Spain (MCC-Spain).
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and prostate cancer
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Prospective cohort study of the risk of prostate cancer among rotating-shift workers: findings from the Japan collaborative cohort study.
Am J Epidemiol. 2006; 164: 549-555
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  • Fall K.
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Circadian disruption, sleep loss, and prostate cancer risk: a systematic review of epidemiologic studies.
Cancer Epidemiol Biomarkers Prev. 2012; 21: 1002-1011
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Night shift work, chronotype and prostate cancer risk in the MCC-Spain case-control study.
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has led the World Health Organization to classify night shift work as a probable carcinogen.
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Painting, firefighting and shiftwork.
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Moreover, extended duration (>24 hours) work shifts have been associated with poorer performance on clinical tasks
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Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns.
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Sleep loss and performance in residents and nonphysicians: a meta-analytic examination.
Sleep. 2005; 28: 1392-1402
and increased risks of serious medical errors, preventable adverse events, self-inflicted percutaneous injuries, and motor vehicle crashes among resident physicians;
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The Gordon Wilson Lecture: work hours, sleep and patient safety in residency training.
Trans Am Clin Climatol Assoc. 2006; 117: 159-189
and 12-hour shifts and frequent overtime are associated with an increased risk of making an error
  • Rogers A.E.
The effects of fatigue and sleepiness on nurse performance and patient safety.
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and having an occupational injury.
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Occup Environ Med. 2005; 62: 588-597
Laboratory studies have demonstrated that misalignment between the timing of the sleep-wake cycle and endogenous circadian rhythmicity disturbs energy metabolism;
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Impact of circadian misalignment on energy metabolism during simulated nightshift work.
Proc Natl Acad Sci U S A. 2014; 111: 17302-17307
adversely affects both glucose metabolism and cardiovascular regulation;
  • Buxton O.M.
  • Cain S.W.
  • O'Connor S.P.
  • Porter J.H.
  • Duffy J.F.
  • Wang W.
  • et al.
Adverse metabolic consequences in humans of prolonged sleep restriction combined with circadian disruption.
Sci Transl Med. 2012; 4: 129ra143
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  • Hilton M.F.
  • Mantzoros C.S.
  • Shea S.A.
Adverse metabolic and cardiovascular consequences of circadian misalignment.
Proc Natl Acad Sci U S A. 2009; 106: 4453-4458
and impairs attention, neurobehavioral performance, mood, and cognition.
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  • Horowitz T.S.
  • Duffy J.F.
  • Czeisler C.A.
Acute sleep deprivation and circadian misalignment associated with transition onto the first night of work impairs visual selective attention.
PLoS One. 2007; 2: e1233
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Complex interaction of the sleep-wake cycle and circadian phase modulates mood in healthy subjects.
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Sleep and wakefulness out of phase with internal biological time impairs learning in humans.
J Cogn Neurosci. 2006; 18: 508-521
Epidemiologic studies reveal that night shift work is associated with increased odds of obesity;
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Night shift work at specific age ranges and chronic disease risk factors.
Occup Environ Med. 2015; 72: 100-107
a 5-fold increase in the risk of progressing from impaired glucose tolerance to diabetes;
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  • Satoh J.
Psychosocial factors are independent risk factors for the development of type 2 diabetes in Japanese workers with impaired fasting glucose and/or impaired glucose tolerance.
Diabet Med. 2008; 25: 1211-1217
an increased risk of blood pressure elevation;
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Shift work is a risk factor for increased blood pressure in Japanese men: a 14-year historical cohort study.
Hypertension. 2008; 52: 581-586
incident hypertension;
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  • Nogawa K.
The relationship between shift work and the onset of hypertension in male Japanese workers.
J Occup Environ Med. 2003; 45: 1002-1006
incident coronary heart disease, including fatal and nonfatal myocardial infarctions;
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Prospective study of shift work and risk of coronary heart disease in women.
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and that a decade of exposure to shift work chronically impairs cognition.
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Chronic effects of shift work on cognition: findings from the VISAT longitudinal study.
Occup Environ Med. 2014; ([Epub ahead of print])
It has even been reported that 5 years of exposure to recurrent transmeridian travel (jet lag) produces atrophy of the brain's temporal lobe.
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Chronic “jet lag” produces temporal lobe atrophy and spatial cognitive deficits.
Nat Neurosci. 2001; 4: 567-568

Sleep quality and health

Sleep disruption caused by a variety of sleep disorders has been associated with adverse consequences on health, performance, and safety. Chronic insomnia, which affects approximately one-tenth of the US population,
  • Depner C.M.
  • Stothard E.R.
  • Wright Jr., K.P.
Metabolic consequences of sleep and circadian disorders.
Curr Diab Rep. 2014; 14: 507
is both a symptom of and a risk factor for anxiety and depression.
  • Neckelmann D.
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  • Dahl A.A.
Chronic insomnia as a risk factor for developing anxiety and depression.
Sleep. 2007; 30: 873-880
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  • Nissen C.
  • Riemann D.
Clinical implications of the causal relationship between insomnia and depression: how individually tailored treatment of sleeping difficulties could prevent the onset of depression.
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Difficulty initiating or maintaining sleep is associated with an increased risk of incident type 2 diabetes
  • Cappuccio F.P.
  • D'Elia L.
  • Strazzullo P.
  • Miller M.A.
Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis.
Diabetes Care. 2010; 33: 414-420
and incident prostate cancer, including advanced prostate cancer.
  • Sigurdardottir L.G.
  • Valdimarsdottir U.A.
  • Mucci L.A.
  • Fall K.
  • Rider J.R.
  • Schernhammer E.
  • et al.
Sleep disruption among older men and risk of prostate cancer.
Cancer Epidemiol Biomarkers Prev. 2013; 22: 872-879
Chronic insomnia is associated with an increased risk of developing or dying of cardiovascular disease.
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  • Cesari F.
  • Casini A.
  • Macchi C.
  • Abbate R.
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Insomnia and risk of cardiovascular disease: a meta-analysis.
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In a prospective 20-year follow-up study, Parthasarathy et al
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Persistent insomnia is associated with mortality risk.
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recently found that participants with persistent insomnia had higher serum C-reactive protein levels and were more likely to die than participants without insomnia.
Now that the definition of obstructive sleep apnea (OSA) has been corrected such that it no longer requires a concomitant complaint of excessive daytime sleepiness, it is recognized that the prevalence of OSA is much higher than the oft-quoted underestimate of 4% of men and 2% of women that was based on that erroneously restrictive definition.
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  • Weber S.
  • Badr S.
The occurrence of sleep-disordered breathing among middle-aged adults.
N Engl J Med. 1993; 328: 1230-1235
Moreover, over the past 20 years, the prevalence of OSA (Apnea-Hypopnea Index, AHI >5) with or without the complaint of daytime sleepiness has risen from 24% of men and 9% of women to 34% of men and 17% of women, with 13% of adult men and 6% of adult women in the United States having moderate-to-severe OSA,
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The occurrence of sleep-disordered breathing among middle-aged adults.
N Engl J Med. 1993; 328: 1230-1235
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  • Palta M.
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Increased prevalence of sleep-disordered breathing in adults.
Am J Epidemiol. 2013; 177: 1006-1014
which can have serious health and safety consequences. In children, OSA is associated with attention deficit hyperactivity disorder and poorer academic performance.
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Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: a meta-analysis.
Sleep Med Rev. 2014; 18: 349-356
In adults, OSA is associated with disturbed glycemic regulation and an increased risk of diabetes,
  • Depner C.M.
  • Stothard E.R.
  • Wright Jr., K.P.
Metabolic consequences of sleep and circadian disorders.
Curr Diab Rep. 2014; 14: 507
increased risk of incident nonalcoholic fatty liver disease and liver fibrosis,
  • Sookoian S.
  • Pirola C.J.
Obstructive sleep apnea is associated with fatty liver and abnormal liver enzymes: a meta-analysis.
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Association of obstructive sleep apnoeawith the presence and severity of non-alcoholic fatty liver disease. A systematic review and meta-analysis.
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incident ventricular arrhythmias,
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A systematic review of the association between obstructive sleep apnea and ventricular arrhythmias.
J Clin Sleep Med. 2014; 10: 1155-1160
incident cardiovascular risk,
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Obstructive sleep apnea and cardiovascular risk: meta-analysis of prospective cohort studies.
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risk of motor vehicle crashes,
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Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis.
J Clin Sleep Med. 2009; 5: 573-581
stroke,
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Obstructive sleep apnea as a risk factor for stroke and death.
N Engl J Med. 2005; 353: 2034-2041
and all-cause mortality.
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Remarkably, in an 18-year follow-up to their landmark 1993 OSA population prevalence study, Young et al
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Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort.
Sleep. 2008; 31: 1071-1078
found that, among participants in their cohort, who had an average age of 48 years in 1988, only 58% with severe OSA (AHI, ≥30) were still alive 18 years later as compared with 94% of those without OSA (AHI, <5), reflecting 3.8-fold greater adjusted hazard ratio for all-cause mortality and a 5.2-fold greater adjusted hazard ratio for cardiovascular mortality.
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Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort.
Sleep. 2008; 31: 1071-1078
Recent data suggest that OSA may even play a causal role in Alzheimer disease.
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Can sleep apnea cause Alzheimer's disease?.
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Drowsy driving symptomatic of pervasive sleep deficiency

Despite these recent advances in understanding the health, performance and safety impacts of sleep loss, sleep deficiency—a deficit in the quantity or quality of sleep obtained vs the amount needed for optimal health, performance, and well-being—is increasing in our society. As noted in the 2011 National Institutes of Health Sleep Disorders Research Plan, “sleep deficiency may result from prolonged wakefulness leading to sleep deprivation, insufficient sleep duration, sleep fragmentation or a sleep disorder, such as in OSA, that disrupts sleep and thereby renders sleep nonrestorative.”
  • National Center on Sleep Disorders Research
National Institutes of Health Sleep Disorders Research Plan.
in: National Institutes of Health, Bethesda, MD2011
Unfortunately, as noted above, sleep deficiency from each of those causes is on the rise. Although some contrarians continue to argue that health concerns about sleep deficiency are overrated,
  • Horne J.
Is there a sleep debt?.
Sleep. 2004; 27: 1047-1049
the fact that an estimated 58.8 million of America's licensed drivers report driving while drowsy each month
  • National Sleep Foundation
Sleep in America Poll: summary of findings.
in: 2009
and that 7.5 million of them lose that struggle and fall asleep at the wheel each month,
  • Royal D.
National survey of distracted and drowsy driving attitudes and behavior: 2002.
in: vol. DOT HS 809 566. National Highway Traffic Safety Administration, Washington, D.C.2003: 1-61
causing more than 50,000 debilitating injuries and 6400 traffic fatalities annually,
Committee on Sleep Medicine Research Board on Health Sciences Policy.
in: Sleep disorders and sleep deprivation. An Unmet Public Health Problem. Institute of Medicine of the National Academies; The National Academies Press, Washington, D.C.2006
, 
https://www.aaafoundation.org/sites/default/files/AAAFoundation-DrowsyDriving-Nov2014.pdf
demonstrates that many Americans are not even obtaining the sleep that they need to conduct routine daily functions like driving, let alone maintain optimal mental and physical fitness.
Compelling evidence thus reveals that sleep is vital for both the brain and the body. For this reason, the National Sleep Foundation has launched Sleep Health, a new journal dedicated to ensuring that research addressing the broader public health implications of the epidemic of sleep deficiency has a permanent home.

Disclosure

Dr Czeisler has received consulting fees from or served as a paid member of scientific advisory boards for the following: Bose Corporation; Boston Celtics; Boston Red Sox; Columbia River Bar Pilots; Citgo Inc; Cleveland Browns; Merck; Novartis; Purdue Pharma LP; Quest Diagnostics, Inc; Teva Pharmaceuticals Industries Ltd; Valero Inc; and Vanda Pharmaceuticals, Inc; Dr Czeisler currently owns an equity interest in Lifetrac, Inc; Somnus Therapeutics, Inc; Vanda Pharmaceuticals, Inc; Dr Czeisler received royalties from McGraw Hill; Penguin Press/Houghton Mifflin Harcourt; and Philips Respironics, Inc and has received grants and research support from Cephalon Inc; National Football League Charities; Philips Respironics; ResMed Foundation; San Francisco Bar Pilots; and Sysco. Dr Czeisler is the incumbent of an endowed professorship provided to Harvard University by Cephalon, Inc and holds a number of process patents in the field of sleep/circadian rhythms (eg, photic resetting of the human circadian pacemaker). Since 1985, Dr Czeisler has also served as an expert witness on various legal cases related to sleep and/or circadian rhythms, including matters involving Bombardier, Inc; Delta Airlines; FedEx; Greyhound; Michael Jackson's mother and children; Purdue Pharma, LP; United Parcel Service; and the United States of America.

Acknowledgments

Supported in part by the following grants: NIH/NHLBI-HL095472, NIH/NHLBI-HL94654, NIH/NHLBI-U01-HL111478 from the National Heart Lung and Blood Institute; NIH/NIA-P01-AG009975 from the National Institute on Aging; NIH/NIGMS R01 GM105018 from the National Institute of General Medical Sciences; NASA NCC9-119, NASA NNX10AF47G and NASA Cooperative Agreement NCC 9-58 from the National Aeronautics and Space Administration; NSBRI-HFP02801 and NSBRI-HFP02802 from the National Space Biomedical Research Institute; FEMA EMW-2010-FP-00521 from the Federal Emergency Management Agency; and GAMS-839 from the National Football League Charities.

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Article info

Publication history

Published online: January 13, 2015

Identification

DOI: https://doi.org/10.1016/j.sleh.2014.12.008

Copyright

© 2015 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.

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