Sleep epidemiology--a rapidly growing field.

Abstract

The human body has adapted to daily changes in dark and light such that it anticipates periods of sleep and activity. Deviations from this circadian rhythm come with functional consequences. Thus, 17 hours of sustained wakefulness in adults leads to a decrease in performance equivalent to a blood alcohol-level of 0.05%;[1] the legal level for drink driving in many countries.[2] Rats deprived of sleep die after 32 days,[3] and, with longer periods of sleep deprivation, this would also be the case in human beings. Indeed, sleep deprivation is a common form of torture.[4] Given the readily observable effects of sleep in everyday life, it is not surprising that there has been scholarly interest in sleep since the beginning of recorded history.[5] Sleep epidemiology as a subject in its own right has a recognisable history of just over 30 years,[6] with the first modern epidemiological studies of sleep disturbances appearing around 1980.[7;8] Nevertheless, a PubMed search for terms “sleep/insomnia” and “epidemiology” shows that the cumulative number of papers on the subject over the past 10 years is already about 10,000. Although this is less than for standard risk factors, such as obesity (>60,000) and smoking (50,000)(Figure 1), the annual number of papers on sleep epidemiology is rising rapidly (Figure 2). This issue of IJE includes a review[9] of the first comprehensive textbook of Sleep Epidemiology,[10] and the purpose of our Editorial is further to highlight recent developments to give the reader an idea why the coming years are likely to see an increasing interest in sleep studies. Figure 1 Exposures AND Epidemiology 2000–2010 Figure 2 Sleep/insomnia AND Epidemiology by year Why the upsurge in interest? There are several reasons for an increase in interest in sleep from an epidemiological perspective. First, sleep problems are associated with accidents and human errors. It has been estimated that 10–15% of fatal motor-vehicle crashes are due to sleepiness or driver fatigue. Furthermore, by 2020 the number of people killed in motor-vehicle crashes is expected to double to 2.3 million deaths worldwide, of which approximately 230,000–345,000 will be due to sleepiness or fatigue.[11] It has been estimated that nearly 100,000 deaths occur each year in US hospitals due to medical errors and sleep deprivation have been shown to make a significant contribution.[12] Similarly, in a national sample in Sweden of over 50,000 people interviewed over 20 years disturbed sleep almost doubled the risk of a fatal accident at work.[13] Second, sleep problems are common. Population studies show that sleep deprivation and disorders affect many more people worldwide than had been previously thought. A recent study found 20% of 25–45 year-olds slept “90 minutes less than they needed to be in good shape”.[14] Insomnia is the most common specific sleep disorder, with ‘some insomnia problems over the past year’ reported by approximately 30% of adults and chronic insomnia by approximately 10%.[15] Prevalence of obstructive sleep apnoea, characterized by respiratory difficulties during sleep, is also very high with estimates of 9–21% in women and 24–31% in men.[16;17] Third, sleep problems are likely to increase. The rapid advent of the 24/7 society involving round-the-clock activities and increasing night time use of TV, internet and mobile phones mean that adequate sleep durations may become increasingly compromised. Some data suggest a decline in sleep duration of up to 18 minutes per night over the past 30 years.[18;19] Complaints of sleeping problems have increased substantially over the same period, with short sleep (<6 hours/night) in full-time workers becoming more prevalent.[19;20] As more shift work is required to service 24/7 societies the proportion of workers exposed to circadian rhythm disorders, such as shift work sleep disorder, and their effects on health and performance is likely to rise. Sleep architecture is known to change with age; slow-wave (or deep) sleep decreases and lighter sleep increases. Other changes include increases in nocturnal sleep disruption and daytime sleepiness. As the proportion of elderly people in populations across the world increases, these changing sleep patterns will raise the prevalence of sleep disorders. Similarly, the increasing worldwide obesity epidemic and the prevalence of obstructive sleep apnoea, which is over double among the obese, ensure sleep disorders will be of increasing public health importance in lower as well as high income countries.[16;21] Fourth, sleep problems are associated with short and long-term effects on health and well-being. Immediate effects at the individual level relate to well-being, performance, daytime sleepiness and fatigue. Longer term, evidence has accumulated of associations between sleep deprivation and sleep disorders and numerous health outcomes including premature mortality, cardiovascular disease, hypertension, inflammation, obesity, diabetes and impaired glucose tolerance, and psychiatric disorders, such as anxiety and depression. As this evidence represents the core of Sleep Epidemiology, we provide below a snapshot on key findings.