Time for Bed
March 3, 2005
By Jennifer Barrett Ozols, Newsweek

Specialists say millions of Americans have undiagnosed sleep disorders - and millions more have bad habits that are keeping them from a good night's rest

MSNBC -- Joel Friedman says he always had a snoring problem - of the "rafter-rattling, window-breaking" kind. Friends refused to share a hotel room with him on vacation. His nocturnal breathing often kept his wife awake. But he never thought it was a problem until the night his wife noticed a lull in his snoring - and realized he'd stopped breathing too. "She was worried I was going to die in the middle of the night," recalls Friedman. "She told me I had to call the doctor."

The diagnosis: sleep apnea.

That was three years ago. Looking back now, the 53-year-old copywriter figures he probably suffered from the sleep disorder for decades before he was diagnosed. "I would always be tired during the day, I was always falling asleep," says Friedman, who lives outside Chicago. "But I slept eight hours so I never knew why I was tired. I always thought it was because of my diabetes - I assumed my blood-sugar level was off."

Diabetics are indeed at higher risk for developing sleep apnea, a condition that causes people to stop breathing frequently during the night, often for periods of 10 seconds or longer. But Friedman never thought he had a sleep disorder. While sleep apnea is relatively common, affecting as many as 5 percent of all men and half as many women, sufferers are often unaware they have it. They don't usually wake up when they stop breathing; they just feel tired during the day. But that could describe a growing number of Americans these days. And it's one reason why, in an increasingly sleep-deprived society, disorders are often misdiagnosed - or not diagnosed at all.

As many as 50 to 60 million Americans suffer from frequent or chronic insomnia annually - a figure that is expected to nearly double by 2050, according to an analysis by researchers at the University of Toronto). In addition, 28 million have restless legs syndrome, a neurological condition that disrupts sleep; 12 to 15 million have sleep apnea, and more than 140,000 have narcolepsy, a chronic neurological disorder causing unexpected urges to sleep throughout the day. Others suffer from parasomnia disorders, which include sleepwalking, night terrors, sleep-eating syndrome, and (less frequently) sleep violence. But many don't realize it.

"There's a major problem with the underdiagnosis of sleep disorders," says Carl Hunt, the director of the National Center on Sleep Disorders Research, part of the National Institutes of Health, who estimates that as many as 60 to 70 percent of those with these disorders aren't being diagnosed correctly. Part of the problem, he says, is that "as a society, we just don't value sleep." Sleep specialists blame a lack of awareness in the medical community, as well. "Physicians are becoming more aware of sleep disorders, but there's still a ways to go," says Dr. Clete Kushida, an associate professor and director of the Stanford University Center for Human Sleep Research. "Many of these conditions have always been there but they've been misdiagnosed."

Patients also don't realize that a disorder may be to blame for their sleep deprivation. One way to tell: if you have difficulty falling or staying asleep at night or staying awake during the day on a persistent basis, or if you feel like you're getting enough sleep but are still tired each day. In some cases, people don't even recognize that they're not getting enough sleep. "When push comes to shove in our society, sleep is often the first thing to go - either by choice or necessity," says Dr. Hunt. "Many patients will say `Sure, I'm tired - I probably don't get enough sleep. But that's the way life is'."

Dr. Meir Kryger, director of the Sleep Disorders Center at St. Boniface Hospital in Winnipeg, Canada, and coauthor of Principles and Practice of Sleep Medicine (published this month by Elsevier/Saunders), recently saw a woman who had averaged less than five hours of sleep a night for years. By the time Kryger met with the woman, a nurse for more than 20 years, she was so tired she was having trouble staying awake with patients. "What was astounding to me is that she didn't make the connection that when you sleep five hours or less you'll feel sleepy the next day and unable to function," he remembers. "She hadn't felt that great for years and years and it never occurred to her that she could feel better."

Researchers figure that most adults need at least seven to eight hours of sleep a night, and children need even more. But a 2002 poll by the National Sleep Foundation found that 70 percent of American adults get less than eight hours, and 40 percent sleep less than seven hours a night. The poll also found that more than one third of respondents experienced symptoms of insomnia nearly every night. The National Center on Sleep Disorders Research estimates that as many as 70 million people in the United States suffer from sleep problems. And another 30 million Americans suffer from excessive daytime sleepiness caused by inadequate sleep.

Hunt and other researchers blame the country's swelling sleep debt on a combination of factors from increasing life pressures to the Internet, which allows users to shop, surf the Web, or e-mail any time of the day or night. "A lot of this has to do with the way our society has evolved," says Dr. David M. Rapoport, medical director of the Sleep Disorders Center at New York University. "We are a very sleep-deprived society."

That's not just a personal issue, but a public-health one, too. Researchers at Columbia University's Mailman School of Public Health and the Obesity Research Center found last year that the less participants slept each night, the more likely they were to become obese. Subjects between the ages of 32 and 59 who slept four hours or less per night, for example, were 73 percent more likely to be obese than those who slept between seven and nine hours each night. Researchers now believe that shortened sleep cycles are associated with decreased secretion of the hunger-suppressing hormone leptin, which can prompt the sleep-deprived to consume as many as 1,000 calories more per day (particularly sweets and salty carbohydrates). People who sleep less also produce less insulin, which helps moderate blood-sugar levels, according to the National Center on Sleep Disorders Research.

"There's still a lack of insight as to how clinically impaired people can be when they are sleep deprived," says Dr. James Herdegen, medical director of the Center for Sleep and Ventilatory Disorders at the University of Illinois Medical Center in Chicago. "Fifty years ago, no one even talked about sleep. It's still a relatively young field."

To be sure, anyone who's stayed out late on a work night knows that a lack of sleep can make it harder to focus and function the next day. But research has shown that sleep deprivation can also affect memory, emotional stability, learning and even immunity to other diseases. It's also been associated with high blood pressure, heart problems, diabetes and depression. "There is just no substitute for getting a good night's sleep," says Hunt. "Sleep is as important as diet and exercise to our overall good health."

A lack of sleep can also endanger others. Approximately 100,000 traffic accidents (1,500 of them fatal) a year are sleep related. The government estimates that sleep-related problems also add $16 billion to the nation's health-care bill, including medications and health-care services. And U.S. consumers are spending an estimated $84 million or more per year on over-the-counter medication, according to an analysis published in the journal Sleep and Breathing in 2002.

Nor is it likely to get better as the population gets older and fatter - both risk factors for sleep apnea and other sleep disorders.

Hunt is hoping the trend will reverse with better awareness and treatment options. "The good news for people who have symptoms is that there is an increasing array of effective prescription medicines," says Hunt. Short-term sleeping aids like Sonata and Ambien have fewer side effects than past pills, and they aren't nearly as addictive. The Food and Drug Administration also recently approved Lunesta, a new sleep-disorder drug by Sepracor, for long-term treatment of insomnia. And there are more drugs on the way. Sanofi-Aventis, which makes Ambien, is working on a continuous-release version of the drug that could be approved as early as this summer. And Merck and Pfizer also have sleep-disorder drugs in the pipeline.

Drugs aren't the only solution. Most sufferers of sleep apnea can be treated immediately with a bilevel positive air pressure (Bi-PAP) or a continuous positive airway pressure (CPAP) machine, both of which force air into the nose and mouth at varying pressures (though more serious apnea cases may require surgery). The CPAP made "a huge and instantaneous difference" for Friedman. "My life changed," he says. "I won't sleep without it, even when I travel." Friedman later discovered that the machine also evened out his glucose levels - a big benefit for a diabetic - when he participated in a recent study. (See Latest Research).

For chronic insomniacs there's also cognitive behavior therapy, or CBT, a technique that includes changing a patient's routine, behavior and thoughts related to sleep, which has been gaining popularity. In a recent Harvard-led, head-to-head study published last fall in the Archives of Internal Medicine, researchers concluded that patients with insomnia could derive "significantly greater benefits" in both the short and long term from CBT than from sleeping pills and recommended that CBT be considered first in treating chronic insomnia.

Many of those without sleep disorders could also benefit from some behavioral changes, like establishing a bedtime routine, incorporating relaxation techniques like meditation and warm baths before bed and avoiding exercise or stressful activities late at night. "A lot of it is common sense," says Kryger. "The first step is just making sleep a priority."