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Waking up about sleep: A public health need, overlooked

Back to school lunacy is upon us.  Parents with kids in tow will raid retail outlets, snatching up the latest gadgets, backpacks, brand name clothes, and sneakers.  Many will schedule every minute of their child's day for the next nine months. Kids will be signed up for soccer, gymnastics, instrument lessons, play dates, and academic enrichment work.  What most likely won't be a highlight on kids' harried calendars: enough time for healthy sleep.

In 2014, the American Academy of Pediatrics published, "Let them Sleep," a report that recommended among other things delaying start times for middle and high school students to 8:30am, at the earliest.   Later start times would align the natural rhythms of children and adolescents, and hopefully afford them with 8.5-9.5 hours of necessary sleep.

Sleep deprivation among kids and adolescents increases risks associated with obesity, depression, cognitive performance and driving.  Sleep should be considered alongside nutrition. Would school boards ever approve of serving cheese fries, Twinkies, and Coke for lunch? That menu is essentially analogous to a 7am start time. It is downright unhealthy.

The scientific data are in, so why haven't things changed? Because we live in a culture where sleep has been hyper-moralized.  Like obesity, addiction, and depression, the need for sleep is understood as a vicious moral weakness rather than what it actually is— a critical physiological process required for maintaining overall health and well-being. The need for sleep is highly stigmatized and sleep disorders often cluster around mental illness, obesity, and other ethically fraught health conditions.

Historically, sleep has generally not been considered alongside other serious public health issues. In the US, sleep is generally considered to be a quotidian and habitual part of everyday life that wastes precious time.  Sleep apnea, for example, is a serious medical condition that has only recently been recognized by mainstream medicine and primary care providers.   Despite calls from the Institute of Medicine, very few medical schools include even a modest number of hours on sleep disorders in their curricula. This lack of physician training has led to over 40 million Americans undiagnosed, misdiagnosed, and untreated for sleep disorders.

An attitude of indifference toward sleep health defines high performance jobs, where toughness, stamina, and grit are considered basic qualifications. In the presidential election, sleep deprivation has been cast as heroic, while a purported need for sleep is weak.  Branches of the military, for example, embrace an ethos of performance enhancement through controlled sleep deprivation. Pilots have long been issued amphetamines and modafinil –drugs used to allow soldiers to stay awake sometimes for days at a time.  It remains unclear what the long-term impact of sleep deprivation, modafinil and other anti-sleep interventions have had on the health of soldiers and veterans, but it is unlikely to be good.  Mental illnesses such as posttraumatic stress disorder, depression, and anxiety are more common among veterans who have experienced disturbed sleep and report symptoms of insomnia and sleep deprivation.

Similarly, the culture of medicine is anti-sleep. The structure of medical education is built upon a presumption that trainees will be sleep deprived for years, especially during residency.  It is true that things have improved as work hours have been reduced, but oftentimes, overworked residents are left with no other option than to fudge the numbers so that their training programs remain in compliance with the 2011 duty hour regulations put forth by the Accreditation Council for Graduate Medical Education.  Work hour restrictions are mostly aimed at enhancing patient safety and overlook the health concerns of young doctors.  However, sleep schedules that result from periodic and often random night swings have been shown to have long-term adverse consequences.

In traditional corporate settings, the idea of "nap rooms" seems ridiculous— to get ahead there is simply no time for sleep.  The Society for Human Resource Management found in 2013 that only 6% of companies had employee nap rooms.  Progressive businesses are recognizing the fact that they and their employees simply cannot afford sleep deprivation.    Companies like Google, Nike, Proctor and Gamble, and Huffington Post all provide the time and space for employees to nap.  Some even use "energy pods" – futuristic white capsules where employees can lay back and catch a power nap during the day.  These companies see the bottom line value in investing in well-rested and refreshed employees.

The economic impact of sleep deprivation is staggering.  A 2011 study found that insomnia costs the U.S. workforce $63.2 billion in productivity losses in a given year, not to mention increased health care spending from individuals with sleep loss. Sleep loss results in cognitive impairments, including deficits in attention, vigilance, and memory, and chronic sleep deprivation is associated with poorer mental health status, resulting in depression and anxiety.

Poverty and sleep deprivation are also connected.  A 2011 study by Patel and others found that sleep health was significantly reduced in the poor.  It is difficult to determine causation: does poverty mediate poor sleep quality, or does poor sleep quality lead to poverty? Probably both.  Regardless, it is clear that without intervention, sleep deprivation has an enormous impact on one's health, well-being, and ability to successfully build a stable life above the poverty line.

Despite the facts, sleep is still viewed as a luxury or a sign of laziness rather than being akin to potable water and nutrition— the basic public health necessity that it truly is.    While there has been some progress, there is still a long way to go to elevate the importance of sleep in both policy and practice. In the 1990's, smoking bans seemed novel, but now smoke free public spaces are normal.  That process required a slow but steady effort to change the public's attitude. Likewise, attitudes about sleep must be transformed through education and public policies that encourage healthy sleep.

But to make real headway in rationalizing our nation's attitude toward sleep, we need to start with our kids.  Let's not continue to subject them to the insidiously destructive structure of ridiculously early school start times.    It is time to think creatively about providing the necessary hours of sleep to our kids, to provide them with immediate benefits and to engender healthy sleep habits for adulthood.

Dominic Sisti is Director of the Scattergood Program for Applied Ethics of Behavioral Health Care and Assistant Professor of Medical Ethics and Health Policy at Penn. Andrea Segal is a research coordinator and MPH candidate at Penn.

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