Stay conscious about sleeping: Health risks and misconceptions Special
Sacrificing sleep for other priorities is a common practice but one which causes serious harm. Anyone sleeping seven to nine hours on a daily basis and wonder why they still feel faint, unfocused, anxious or irritable may have an undetected disorder.
Ronald M. Harper Ph.D is a Professor of Neurobiology for the David Geffen Shool of Medicine at UCLA
. Dr. Harper received his doctorate from McMaster University in Ontario, Canada during 1968. Dr. Harper currently has over 250 publications to his name. He now works amongst a team of researchers studying neural mechanisms that underlie the control of breathing and cardiovascular action during sleep. Dr. Harper has been kind enough to provide his insight regarding the steady increase of alarming discoveries between the marriage of brain and cardiovascular functions during a state of sleep. Also included are facts and Dr. Harper's professional opinions regarding undiagnosed or misdiagnosed disorders, sleep supplements and long-term mistreatment.
Dr. Harper, I would first like to thank you for allowing the time for us to discuss this matter. “National sleep awareness week” precedes America’s change to daylight savings time, yet it has received so little attention outside of your professional field. For how many years has this awareness movement been established, and how are you and your peers at the UCLA medical center involving yourselves with raising public awareness in 2011?
As you might imagine, awareness outside the field is a source of significant concern to us. Most pathologies in sleep are considered a joke by the general public- think heavy snoring, sleep walking, extreme nightmares, consuming alerting drugs so that one can drive, drinking excessively so one can sleep, etc., but all of these issues reflect serious concerns in sleep medicine. Researchers within the sleep community made efforts to alert the public, train physicians in the importance of sleep (especially sleep apnea), etc., beginning in the mid-late 1970’s, but the number of investigators was small, and the medical community was extremely conservative. At one meeting I attended in Scotland in the early 1980’s on sleep apnea, one physician stood up in a crowded auditorium and demanded that we study a “real disease”- asthma, where “we can do something about it.” The formation of a clinical arm of sleep researchers has helped to foster recognition of the importance of sleep pathology, but I can relate horror stories that I have encountered only a few months ago, where sleep disordered breathing was unrecognized by an entire range of primary care physicians and specialists in cardiology and endocrinology and diabetes in a patient where even casual observation shrieked “obstructive sleep apnea.” It has been a slow process, but my colleagues and I at UCLA push the issues in medical school teaching, and especially in post-MD training. Fortunately, individuals in charge of pulmonary and neurology specialty training programs have recruited us in those programs. We push sleep-related seminars often, and we pursue private funding which might promote sleep research, especially locally where use of sleep medications results in so many well-publicized premature deaths, or where serious gaps remain in sleep-related care, such as in pediatric care. Both the national basic and clinical sleep societies work very hard in education, and in exposing legislators to the national problems. Both societies have aggressive programs to attract young students to sleep research and practice, and have vigorous training programs; I just came off a 3-year stint with the Sleep Research Society (the basic society) training committee which plans training days and travel support for sleep meetings. Public and physician education is painfully slow, but it is progressing.
What exactly do you mean by your private funding “might” promote sleep research?
Many in the public realize the necessity for sleep, and the consequences of interrupted sleep. They often pay very large sums for medications to ensure that they can have a good night’s sleep. They also realize the importance of research in the field, with the aim of not having to use these medications to avoid enduring the suffering of being unable to sleep well, or their children not being able to sleep well. Some of these people have generously contributed to research efforts.
If your research is accurate, then potentially hundreds-of-thousands lives could be saved over the next 40-years of sleep studies. Considering this, why do you believe there remain so much difficulty convincing general practitioners to recognize disease probabilities based on your data?
If you follow a general practitioner around for a day, you would be impressed if they would have the time or the opportunity to follow what is happening in the sleep field. Most physicians are allotted about 15 minutes per patient to detect current problems, relate those problems relative to the entire patient history, and decide on an intervention. I am always astonished at the work load they carry. Even determining a sleep history is difficult- remember that an obstructive sleep apnea patient does not recognize that he is obstructing (although the spouse may hear the snoring, the patient does not; he only might say that he sleeps badly and is sleeping during the day, but the spouse or sleeping partner typically is not present with the patient). The other problem is that sleep issues usually are not a major component of a medical school curriculum. It is rare to find an hour lecture on sleep, largely because there are so many other issues in a four-year medical school program, with usually only two years for formal basic lectures. That deficit is slowly being remedied and now some post-MD training programs (e.g., specialty training in neurology) require exposure to sleep issues. It is important to realize how long it takes to bring new concepts into the medical field, with the history of ulcer diagnosis and treatment perhaps being a good example. When I was young, ulcers was a stress-related disease, treated by antacids and diet, bland foods, and rest. That view was current for all of recent medical history. In 1982, two Australians showed that a bacterium, Helicobacter pylori, caused ulcers, not stress or diet, with the appropriate intervention being an antibiotic. It was not until 1997 that the Center for Disease Control started an education campaign to disseminate this information to physicians. Of course, transfer of this information was not immediate, and I remember arguing the issue with a health care professional in 2002! The problem with sleep disorders is much more difficult- unlike ulcers, there is no single bacterium causing the different problems, and many of the solutions are still being determined.
Do you believe it would be easier to push physicians into considering such an approach by raising public awareness, or do you believe that if physicians continue to down-play your research that public awareness will remain “painfully slow?”
I certainly don’t believe that physicians actively down-play new information on sleep research. However, the first commandment in medicine is “Do no harm.” There is always the possibility that new approaches can do harm, and we can point to a large number of interventions that have done just that- think prefrontal lobotomy for psychiatric illnesses, for example, which won a Nobel prize for one surgeon, became an office procedure here in the U.S., and destroyed many patients. There is a very difficult balance between innovation and conventional practice. I think the solution is progressive, replicated research, with continuing educational efforts.
What sort of obstacles have you encountered from pharmaceutical companies which manufacture medication for behavioral and sleep related issues as your studies have progressed?
I have not personally encountered such obstacles from pharmaceutical companies. I have heard anecdotes from colleagues that would suggest that the companies often do not pursue avenues that would be very helpful for the field, and certainly helpful for fiscal reasons to the companies. However, I am not privy to their decision-making processes, which surely are dependent on financial responsibilities to their stockholders, and may follow paths that I might not consider.
The newest report from the centers for disease control and prevention (CDC) claims that an estimated 50 to 70 million Americans suffer from chronic sleep deprivation; what is the extent of your involvement with the CDC, and do you support this estimation as being accurate?
I have no involvement with the CDC. I have testified before inquiries for the National Academy of Science, and have co-organized a workshop on glycemic control and sleep for the National Institutes of Health, and sit on a review panel for the latter agency, but I am not a government employee. My perspective is that the CDC has very carefully put together this report. I believe their numbers; their estimates are similar to other estimates collected with smaller samples and extrapolated. We are, as a country, confronted with a very serious health problem.
Over the past few years reports have continued to surface regarding sleeping disorders being an underlying cause for many behavioral conditions. Now they have also been linked as a cause for more threatening diseases such as diabetes, hypertension and obesity. Would you please explain how this is possible and who is most at risk for such drastic consequences?
The relationship between obstructive sleep apnea (OSA) - stopped breathing episodes during sleep from a block airway - and high blood pressure is extremely disturbing; even moderate levels of OSA results in three times the risk for hypertension. Similarly, the incidence of diabetes in those with OSA is very high - greater than 75%, depending on how it’s measured - and vice versa. Obesity is a classic risk factor for OSA. The concern is also great for children, especially with the recent obesity epidemic in that age group. Since obesity enhances the potential for OSA, and there may be an interaction between OSA and diabetes. The obvious question is “What is the mechanism underlying these interactions?” If we can assume that the interaction stems from obstructive events in OSA, mechanisms are a little easier to understand; airway obstruction is accompanied by extreme changes in the part of the nervous system that innervates the heart, the blood vessels, and, together with a separate part, the pancreas. From this perspective, OSA could lead to these other diseases. However, a different scenario may emerge. The commonality of obesity and OSA, as well as the cardiovascular issues may stem from some common hypothalamic injury or characteristic. The jury is still out on those mechanisms, but it is a problem we are very interested in following.
In your opinion, should there be more of a concern on which diseases sleep deprivation may cause or which diseases are causing sleep deprivation, such as obesity, which has long been a severe problem in America?
I think it is important to get at the basic mechanisms underlying any disease that is of major concern for maintaining national health. We all accept that obesity is probably the single characteristic that interferes with an extraordinarily wide range of health issues, including diabetes, cardiovascular disease, arthritis, mobility, and a range of emotion-related illnesses. Obviously eating too much underlies obesity, but the real issue is why are the brain mechanisms underlying eating not shutting off excessive food intake? We know the body has mechanisms to shut food intake off, otherwise everybody would be grossly obese. We even know some of the neural signals involved in such shut-off processes. We know now that interrupted sleep, time-shifted sleep, known as in shift work, or short sleep leads to excessive food consumption, over-indulgence in comfort foods, etc. Thus, determining the brain processes operating during interrupted sleep that modify food intake regulation should directly attack a mechanism operating in obesity. It is the case that we do not know how short sleep durations or interrupted sleep interferes with the “shut off” mechanism, but those processes should be high on the list for determining mechanisms underlying obesity.
Though you have merely scratched the surface of this mechanism, it is possible that obesity is caused by sleep apnea and its link to this tendency to over-eat rather than the deceleration of one’s metabolism due to sleep deprivation?
I could speculate on a scenario which starts with sleep apnea, which exaggerates activity in two components of the autonomic nervous system to alter outflow of those systems during apnea periods. The organs that regulate food-regulatory hormones and pancreatic processes that modify glucose are modified by the autonomic nervous system. So, the answer is yes, it is possible that mechanisms triggered by sleep apnea could lead to obesity; however, those mechanisms are speculative.
Do you believe that in children and adults alike many psychological disorders, such as attention deficit disorders, are often misdiagnosed? How does long-term treatment for such psychological disorders present further danger to a patient when the actual issue is a sleeping disorder?
I have a story for this question. While at a national meeting, I went up to a booth for hyperactive children support, manned by an exceptional lady who responded to my question of sleep-related breathing in these children. She described how she had a son who she followed around carrying his bowl of cereal in the morning, because he was so hyperactive. After tonsillectomy for his loud snoring and sleep apnea, this little boy became another child, sitting at the breakfast table, eating normally like “normal” children, with school performance improving remarkably. We forget what happens when children become very sleepy- they become hyperactive, as anyone who has had to put a tired child to sleep can testify. Children with OSA are very tired. The consequences to classroom performance of placing a child fatigued from waking hundreds of times during a night to arouse from sleep are of course obvious, and the long term effects, with significant brain injury resulting from sleep apnea, including injury to areas involved with depression, anxiety, memory, and depression should be worrying.
How do these potential brain injuries extend beyond the development of psychological disorders? Are there direct relations between sleep apnea and severe brain trauma?
It is apparent now that sleep apnea leads to significant brain injury. We first showed the injury some time ago (2002), and have replicated these findings with multiple groups of patients and with different types of measures both for gray matter in the brain and for interconnecting fibers which allow communication between brain areas. The damage appears as loss of tissue (the volume of mammillary bodies, important structures for memory, are sometimes reduced by half, for example), and as loss of nerve fibers. Some of the damage occurs in brain areas found injured in other psychological conditions (that do not have sleep apnea), conditions such as depression and anxiety. It appears that nearly half of OSA patients are depressed, so injury in those areas is not surprising. Similarly, over a third of OSA patients show excessive anxiety, with excessive injury in those anxiety areas of OSA subjects with that condition. Those conditions are long-term problems, and recovering or retraining affected brain areas is a formidable problem.
Regularly failing to receive at least seven hours of sleep per day can provide brief instances of “dozing off” while performing daily functions such as driving and working. Similarly, these symptoms can indicate potential epilepsy, which some doctors treat for without consideration to sleep. Do you believe that nervous disorders such as epilepsy should not be diagnosed or treated, unless substantial evidence is available, before testing for sleeping disorders?
At UCLA, certain epilepsy patients are brought in for evaluation for potential surgery to relieve the condition. Often, such patients when under close attention do not have a seizure, which makes evaluation difficult. Everyone knows, however, that if one wants to see seizures, simply sleep-deprive the patient. Some seizure patterns preferentially occur in some sleep states over others, which is why epilepsy evaluation typically includes a sleep recording. Sleep and epilepsy are so closely related that such evaluation is mandatory.
Are you saying that it is possible for these so called “black out seizures,” which may last only seconds, may likely be a cause of long-term sleep deprivation and not necessarily a serious epileptic condition?
No. What I suggest is that sleep deprivation establishes conditions that lead to seizures. Sleep deprivation enhances the potential for seizure onset.
Should this notion be highly considered if the sleep recording results are inconclusive?
No. A great many conditions can lead to seizure discharge. Seizures may preferentially occur in rapid eye movement sleep, for example, which may not be present in a conventional short epilepsy-screening sleep test.
How many children would you estimate are misdiagnosed and improperly treated for attention deficit and behavioral disorders?
Predicting a number is very difficult, unless a specific disorder is outlined. Sleep behavior should always be part of the assessment in any consideration of behavioral disorder.
Has there been an argument presented by those in your profession as to why physicians may prescribe behavioral medication to children while only being encouraged, but not necessarily required, to monitor cardiovascular functionality on a regular basis, but never to test for sleep disorders prior to distributing medication?
Those issues of ruling out sleep disorder involvement in some of these pediatric disorders are a constant source of discussion in my field.
What testing and treatment process would you suggest to parents concerned about their young children having attention deficit or behavioral disorders?
Part of any parental assessment is careful observation and tabulation of the child’s sleeping patterns before any behavioral assessment is considered. That assessment should pay special attention to snoring, excessive movement during sleep; note whether bedding is severely disturbed, difficulty falling asleep, difficulty arousing, multiple arousals for any reason at night. Those indictors should indicate to any well-trained behavioral specialist.
So, parents should preemptively observe their child’s sleep patterns prior to presenting it to their doctor in order to increase the chances of an accurate diagnosis?
Yes. The physician will have his 15 minutes to try to determine what is wrong with the child, and the more ready information he has, the better.
Roughly, how many fatalities cause by traffic accidents are related to sleep deprivation?
The National Highway Traffic Safety Administration suggests that fatigue or drowsiness is the major cause of 100,000 reported passenger vehicle crashes per year. Those crashes result in a minimum of 1,500 deaths, and many crashes are unreported. Patients with SDB have variously been shown to have a fifteen-fold risk of vehicular accidents. There is a substantial literature supporting these high estimates.
What is SDB?
Sorry- SDB is sleep disordered breathing. It includes both obstructive sleep apnea (OSA), and central apnea, or Hypopnea.
How many fatigue related crashes would you be able to estimate going unreported each year?
I do not have data on that issue, but one could guess that the many other crashes go unreported out of embarrassment, fear of prosecution, etc.
What are the dangers that people face when frequently substituting the recommended amount of sleep with the increasingly popular energy drinks? Is there a greater potential for health risks by frequently consuming energy drinks as opposed to simple caffeinated drinks, such as coffee and soda?
A “sleep debt” is incurred, even if sleep can be diverted for a few hours. One of the problems is that the arousal provided by energy drinks may momentarily switch to what is termed “micro sleeps” at inopportune times, or lead to excitation of brain areas which result in poor choices in decision-making – think; aggression, short-term advances over longer term appropriate behavior, etc. In my youth, the technique of choice for staying awake was amphetamines, which were heavily used by truckers, etc. A friend described to me how, after consuming amphetamines for a cross-country drive, he became increasingly frightened that cars behind him were focused on driving him off the road, and how it took some time to realize that it was drug-induced paranoia. There are costs, measured both in neural and cardiovascular effects, associated with pushing arousal processes to extremes, and that includes heavy use of energy drinks.
Besides paranoia, what are some of the other causes related to the use of energy drinks and other aids for sleep diversion?
Poor decision making - the irritability introduced by high-caffeine or similar agents leads to short-circuiting of decision processes, so that choices are made based on speed, reducing irritation, or other reasons unrelated to appropriate choices.
How long would you estimate the recovery period necessary for a typical adult’s body after missing an entire night of sleep; say 36 to 40 hours without sleep?
A single night loss can probably be recovered over the next three days. The timing differs if one sleeps only say, four hours per night for several nights, and there may be substantial individual variability.
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