Going even further, what if we moved from a stance of analytics (i.e., here is your past and/or current sleep and here is your past and/or current body weight) to that of forward-looking predictalytics? To explain the term, let me go back to the smoking example. There are efforts to create predictalytics apps that start with you taking a picture of your own face with the camera of your smartphone. The app then asks you how many cigarettes you smoke on average a day. Based on scientific data that understand how smoking quantity impacts outward health features such as bags under your eyes, wrinkles, psoriasis, thinning hair, and yellowed teeth, the app predictively modifies your face on the assumption of your continued smoking, and does so at different future time points: one year, two years, five years, ten years.
The very same approach could be adopted for sleep, but at many different levels: outward appearance as well as inward brain and body health. For example, we could show individuals their increasing risk (albeit non-deterministic) of conditions such as Alzheimer’s disease or certain cancers if they continue sleeping too little. Men could see projections on how much their testicles will shrink or their testosterone level will drop should their sleep neglect continue. Similar risk predictions could be made for gains in body weight, diabetes, or immune impairment and infection.
Another example involves offering individuals a prediction of when they should or should not get their flu shot based on sleep amount in the week prior. You will recall from chapter 8 that getting four to six hours of sleep a night in the week before your flu shot means that you will produce less than half of the normal antibody response required, while seven or more hours of sleep consistently returns a powerful and comprehensive immunization response. The goal would be to unite health-care providers and hospitals with real-time updates on an individual’s sleep, week to week. Through notifications, the software will identify the optimal time for when an individual should get their flu shot to maximize vaccination success.
Not only will this markedly improve an individual’s immunity but also that of the community, through developing more effective “herd immune benefits.” Few people realize that the annual financial cost of the flu in the US is around $100 billion ($10 billion direct and $90 billion in lost work productivity). Even if this software solution decreases flu infection rates by just a small percentage, it will save hundreds of millions of dollars by way of improved immunization efficiency by reducing the cost burden on hospital services, both the inpatient and outpatient service utilization. By avoiding lost productivity through illness and absenteeism during the flu season, businesses and the economy stand to save even more—potentially billions of dollars—and could help subsidize the effort.
We can scale this solution globally: anywhere there is immunization and the opportunity to track an individual’s sleep, there is the chance for marked cost savings to health-care systems, governments, and businesses, all with the motivated goal of trying to help people live healthier lives.
EDUCATIONAL CHANGE
Over the past five weeks, I conducted an informal survey of colleagues, friends, and family in the United States and in my home country of the United Kingdom. I also sampled friends and colleagues from Spain, Greece, Australia, Germany, Israel, Japan, South Korea, and Canada.
I asked about the type of health and wellness education they received at school when they were growing up. Did they receive instruction on diet? Ninety-eight percent of them did, and many still remembered some details (even if those are changing based on current recommendations). Did they receive tutelage on drugs, alcohol, safe sex, and reproductive health? Eighty-seven percent said yes. Was the importance of exercise impressed upon them at some point during their schooling, and/or was the practice of physical education activities mandatory on a weekly basis? Yes—100 percent of people confirmed it was.
This is hardly a scientific data set, but still, some form of dietary, exercise, and health-related schooling appears to be part of a worldwide educational plan that most children in developed nations receive.
When I asked this same diverse set of individuals if they had received any education about sleep, the response was equally universal in the opposite direction: 0 percent received any educational materials or information about sleep. Even in the health and personal wellness education that some individuals described, there was nothing resembling lip service to sleep’s physical or mental health importance. If these individuals are representative, it suggests that sleep holds no place in the education of our children. Generation after generation, our young minds continue to remain unaware of the immediate dangers and protracted health impacts of insufficient sleep, and I for one feel that is wrong.
I would be keen to work with the World Health Organization to develop a simple educational module that can be implemented in schools around the world. It could take many forms, based on age group: an animated short accessible online, a board game in physical or digital form (one that could even be played internationally with sleep “pen pals”), or a virtual environment that helps you explore the secrets of sleep. There are many options, all of them easily translatable across nations and cultures.
The goal would be twofold: change the lives of those children and, by way of raising sleep awareness and better sleep practice, have that child pass on their healthy sleep values to their own children. In this way, we would begin a familial transmission of sleep appreciation from one generation to the next, as we do with things like good manners and morality. Medically, our future generations would not only enjoy a longer life span, but, more importantly, a longer health span, absolved of the mid- and late-life diseases and disorders that we know are caused by (and not simply associated with) chronic short sleep. The cost of delivering such sleep education programs would be a tiny fraction of what we currently pay for our unaddressed global sleep deficit. If you are an organization, a business, or an individual philanthropist interested in helping make this wish and idea a reality, please do reach out to me.
ORGANIZATIONAL CHANGE
Let me offer three rather different examples for how we could achieve sleep reform in the workplace and key industries.
First, to employees in the workplace. The giant insurance company Aetna, which has almost fifty thousand employees, has instituted the option of bonuses for getting more sleep, based on verified sleep-tracker data. As Aetna chairman and CEO Mark Bertolini described, “Being present in the workplace and making better decisions has a lot to do with our business fundamentals.” He further noted, “You can’t be prepared if you’re half asleep.” If workers string together twenty seven-hour nights of sleep or more in a row, they receive a twenty-five-dollar-per-night bonus, for a (capped) total of five hundred dollars.
Some may scoff at Bertolini’s incentive system, but developing a new business culture that takes care of the entire life cycle of an employee, night and day, is as economically prudent as it is compassionate. Bertolini seems to know that the net company benefit of a well-slept employee is considerable. The return on the sleep investment in terms of productivity, creativity, work enthusiasm, energy, efficiency—not to mention happiness, leading to people wanting to work at your institution, and stay—is undeniable. Bertolini’s empirically justified wisdom overrides misconceptions about grinding down employees with sixteen- to eighteen-hour workdays, burning them out in a model of disposability and declining productivity, littered with sick days, all the while triggering low morale and high turnover rates.
I wholeheartedly endorse Bertolini’s idea, though I would modify it in the following way. Rather than—or as an alternative to—providing financial bonuses, we could offer added vacation time. Many individuals value time off more than modest financial perks. I would suggest a “sleep credit system,” with sleep time being exchanged for either financial bonuses or extra vacation days. There would be at least one proviso: the sleep credit system would not simply be calculated on total hours clocked during one week or one month. As we have learned, sleep continuity—consistently
getting seven to nine hours of sleep opportunity each night, every night, without running a debt during the week and hoping to pay it off by binge-sleeping at the weekend—is just as important as total sleep time if you are to receive the mental and physical health benefits of sleep. Thus, your “sleep credit score” would be calculated based on a combination of sleep amount and night-to-night sleep continuity.
Those with insomnia need not be penalized. Rather, this method of routine sleep tracking would help them identify this issue, and cognitive behavioral therapy could be provided through their smartphones. Insomnia treatment could be incentivized with the same credit benefits, further improving individual health and productivity, creativity, and business success.
The second change-idea concerns flexible work shifts. Rather than required hours with relatively hard boundaries (i.e., the classic nine to five), businesses need to adapt a far more tapered vision of hours of operation, one that resembles a squished inverted-U shape. Everyone would be present during a core window for key interactions—say, twelve to three p.m. Yet there would be flexible tail ends either side to accommodate all individual chronotypes. Owls could start work late (e.g., noon) and continue into the evening, giving their full force of mental capacity and physical energy to their jobs. Larks can likewise do so with early start and finish times, preventing them from having to coast through the final hours of the “standard” workday with inefficient sleepiness. There are secondary benefits. Take rush-hour traffic as just one example, which would be lessened in both the morning and evening phases. The indirect cost savings of time, money, and stress would not be trivial.
Maybe your workplace claims to offer some version of this. However, in my consulting experience, the opportunity might be suggested but is rarely embraced as acceptable, especially in the eyes of managers and leaders. Dogmas and mind-sets appear to be one of the greatest rate-limiting barriers preventing better (i.e., sleep-smart) business practices.
The third idea for sleep change within industry concerns medicine. As urgent as the need to inject more sleep in residents’ work schedules is the need to radically rethink how sleep factors into patient care. I can illuminate this idea with two concrete examples.
EXAMPLE 1—PAIN
The less sleep you have had, or the more fragmented your sleep, the more sensitive you are to pain of all kinds. The most common place where people experience significant and sustained pain is often the very last place they can find sound sleep: a hospital. If you have been unfortunate enough to spend even a single night in the hospital, you will know this all too well. The problems are especially compounded in the intensive care unit, where the most severely sick (i.e., those most in need of sleep’s help) are cared for. Incessant beeping and buzzing from equipment, sporadic alarms, and frequent tests prevent anything resembling restful or plentiful sleep for the patient.
Occupational health studies of inpatient rooms and wards report a decibel level of sound pollution that is equivalent to that of a noisy restaurant or bar, twenty-four hours as day. As it turns out, 50 to 80 percent of all intensive care alarms are unnecessary or ignorable by staff. Additionally frustrating is that not all tests and patient checkups are time sensitive, yet many are ill-timed with regard to sleep. They occur either during afternoon times when patients would otherwise be enjoying a natural, biphasic-sleep nap, or during early-morning hours when patients are only now settling into solid sleep.
Little surprise that across cardiac, medical, and surgical intensive care units, studies consistently demonstrate uniformly bad sleep in all patients. Upset by the noisy, unfamiliar ICU environment, sleep takes longer to initiate, is littered with awakenings, is shallower in depth, and contains less overall REM sleep. Worse still, doctors and nurses consistently overestimate the amount of sleep they think patients obtain in intensive care units, relative to objectively measured sleep in these individuals. All told, the sleep environment, and thus sleep amount, of a patient in this hospital environment is entirely antithetical to their convalescence.
We can solve this. It should be possible to design a system of medical care that places sleep at the center of patient care, or very close to it. In one of my own research studies, we have discovered that pain-related centers within the human brain are 42 percent more sensitive to unpleasant thermal stimulation (non-damaging, of course) following a night of sleep deprivation, relative to a full, healthy eight-hour night of sleep. It is interesting to note that these pain-related brain regions are the same areas that narcotic medications, such as morphine, act upon. Sleep appears to be a natural analgesic, and without it, pain is perceived more acutely by the brain, and, most importantly, felt more powerfully by the individual. Morphine is not a desirable medication, by the way. It has serious safety issues related to the cessation of breathing, dependency, and withdrawal, together with terribly unpleasant side effects. These include nausea, loss of appetite, cold sweats, itchy skin, and urinary and bowel issues, not to mention a form of sedation that prevents natural sleep. Morphine also alters the action of other medications, resulting in problematic interaction effects.
Extrapolating from a now extensive set of scientific research, we should be able to reduce the dose of narcotic drugs on our hospital wards by improving sleep conditions. In turn, this would lessen safety risks, reduce the severity of side effects, and decrease the potential for drug interactions.
Improving sleep conditions for patients would not only reduce drug doses, it would also boost their immune system. Inpatients could therefore mount a far more effective battle against infection and accelerate postoperative wound healing. With hastened recovery rates would come shorter inpatient stays, reducing health-care costs and health insurance rates. Nobody wants to be in the hospital any longer than is absolutely necessary. Hospital administrators feel likewise. Sleep can help.
The sleep solutions need not be complicated. Some are simple and inexpensive, and the benefits should be immediate. We can start by removing any equipment and alarms that are not necessary for any one patient. Next, we must educate doctors, nurses, and hospital administrations on the scientific health benefits of sound sleep, helping them realize the premium we must place on patients’ slumber. We can also ask patients about their regular sleep schedules on the standard hospital admission form, and then structure assessments and tests around their habitual sleep-wake rhythms as much as possible. When I’m recovering from an appendicitis operation, I certainly don’t want to be woken up at 6:30 a.m. when my natural rise time is 7:45 a.m.
Other simple practices? Supply all patients with earplugs and a face mask when they first come onto a ward, just like the complimentary air travel bag you are given on long-haul flights. Use dim, non-LED lighting at night and bright lighting during the day. This will help maintain strong circadian rhythms in patients, and thus a strong sleep-wake pattern. None of these is especially costly; most of them could happen tomorrow, all of them to the significant benefit of a patient’s sleep, I’m certain.
EXAMPLE 2—NEONATES
To keep a preterm baby alive and healthy is a perilous challenge. Instability of body temperature, respiratory stress, weight loss, and high rates of infection can lead to cardiac instability, neurodevelopment impairments, and death. At this premature stage of life, infants should be sleeping the vast majority of the time, both day and night. However, in most neonatal intensive care units, strong lighting will often remain on throughout the night, while harsh electric overhead light assaults the thin eyelids of these infants during the day. Imagine trying to sleep in constant light for twenty-four hours a day. Unsurprisingly, infants do not sleep normally under these conditions. It is worth reiterating that which we learned in the chapter on the effects of sleep deprivation in humans and rats: a loss in the ability to maintain core body temperature, cardiovascular stress, respiratory suppression, and a collapse of the immune system.
Why are we not designing NICUs and their care systems to foster the very highest sleep amounts, thereby using sleep
as the lifesaving tool that Mother Nature has perfected it to be? In just the last few months, we have preliminary research findings from several NICUs that have implemented dim-lighting conditions during the day and near-blackout conditions at night. Under these conditions, infant sleep stability, time, and quality all improved. Consequentially, 50 to 60 percent improvements in neonate weight gain and significantly higher oxygen saturation levels in blood were observed, relative to those preterms who did not have their sleep prioritized and thus regularized. Better still, these well-slept preterm babies were also discharged from the hospital five weeks earlier!
We can also implement this strategy in underdeveloped countries without the need for costly lighting changes by simply placing a darkening piece of plastic—a light-diffusing shroud, if you will—over neonatal cots. The cost is less than $1, but will have a significant, lux-reducing benefit, stabilizing and enhancing sleep. Even something as simple as bathing a young child at the right time before bed (rather than in the middle of the night, as I’ve seen occur) would help foster, rather than perturb, good sleep. Both are globally viable methods.
I must add that there is nothing stopping us from prioritizing sleep in similarly powerful ways across all pediatric units for all children in all countries.
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