Waking Up to the Importance of Sleep: Need for a National Sleep Health Policy

'Mr. A, a 50-year-old male, presented to the emergency department after meeting an accident in a car. In the accident, three passengers were killed. He reported that he had an accident in the morning around 10:00 a.m. because he fell asleep at the wheel despite sleeping 8 h. He was taking medication for high blood pressure and diabetes, which were marginally controlled. He was advised to have a sleep study 3 years ago by a sleep specialist, but he did not pay attention to it. Sleep is ubiquitous, and all living beings are known to spend time in it. The human species spends nearly one-third of its life in sleep, and no wonder, nature has provided us with sleep for a reason. Scientific data suggest that sleep is important for restoration, repair, growth, and providing rest to body organs. Besides this, sleep plays an important role in the regulation of metabolism in the body. It reduces blood sugar and prevents the rise of bad cholesterol. Restorative sleep protects the brain by cleaning the waste products that accumulate during wakefulness and helps in memory consolidation.[1] Changes in quality, quantity and timing of sleep can result from modifiable factors, for example, exposure to environmental factors such as intensity of noise, presence of light, crowding and air pollution. Similarly, sleep disorders such as insufficient sleep syndrome, insomnia, obstructive sleep apnoea (OSA), and restless leg syndrome, are also modifiable factors that prevent the occurrence of restorative sleep. These factors interact with the genetic factors (non-modifiable at present) and regulate the course and severity of sleep disorders and their consequences. The most recent National Family Health Survey of India-5 reported that one-fourth of the adult Indian population is obese, one out of seven adults has diabetes, and every fifth Indian adult suffers from high blood pressure.[2] High blood pressure, heart attack, stroke and diabetes, which were considered disorders of the population above 50 years old, have now been reported amongst young adults as young as 25 years old. While the sedentary lifestyle has been blamed for these disorders, it alone does not provide the complete picture. Another important factor contributing to this huge health burden is dysregulated sleep and sleep disorders. Scientific experiments have shown that even after 1–2 nights of insufficient sleep, blood sugar rises because the body becomes resistant to the effects of insulin, a hormone that helps the muscles absorb sugar from the blood. Similarly, sleep deprivation has been found to increase the risk of obesity.[3] Scientific data collected by sleep researchers indicates that a significant proportion of the Indian population, irrespective of age, has non-restorative sleep. Insomnia has been reported in nearly 10% of Indian adults; OSA in 8% of adults and 5% of children; and sleep deprivation in nearly half of the adults and one-fourth of children.[4,5] No wonder we are a grossly unhealthy nation, with a great proportion of the population suffering from diabetes and high blood pressure. Unfortunately, these ill effects are not limited to adults but also affect children. This is a sorry state of affairs, as it will lead to a grossly unhealthy country and increase the burden on the already burdened healthcare system. Besides having a personalised effect on health, medical disorders also pose a huge economic burden. International data suggest that the cost of untreated sleep disorders, for example, insomnia and OSA, amounts to billions of dollars annually (US$100 billion for insomnia and US$150 billion for OSA).[6,7] These economic effects result not only from expenditure on the management of sleep disorders and their health consequences but also from work absenteeism, reduced productivity and accidents. Work absenteeism and reduced productivity have large deleterious effects on the economy of a country at large, especially a country like India, which is an emerging economic power. In the USA, work absenteeism and reduced productivity cost approximately US$ 67 billion for insomnia and US$ 90 billion because of OSA annually, which affects not only the economy of the nation at large but also family income.[6,7] The economic effects of sleep deprivation and sleep disorders are further compounded by industrial and road traffic accidents. Accidents result in monetary loss and loss of instrumental resources, which create impediments to growth in addition to resulting in disability, reduced productivity and increased expenditure on medical care. According to the Sleep Foundation, major industrial accidents that have been attributed to sleep deprivation and sleep disorders include the Three Mile Island nuclear accident, the explosion of the Challenger spaceship, the Exxon Valdez oil spill and the Chernobyl tragedy.[8] Besides these major industrial accidents, traffic accidents-road, air and railway-have been attributed to disordered sleep. These include the Air India plane crash in 2010 in Mangalore, India, where 158 passengers lost their lives[9] and the American Airlines Flight 1420 crash in Arkansas, where 10 passengers were killed and over 100 were injured.[10] Both pilots on Jaipur-Mumbai flight IC-612 fell asleep during the flight, resulting in the plane overshooting halfway to Goa.[11] Similar incidents have been reported by Ethiopian Airlines in 2022 as well.[12] A study by the Safety Matters Foundation amongst Indian pilots in 2022 reported that nearly two-thirds of pilots doze off in the cockpit.[13] Similarly, in the USA, the Metro North train crash[14] and the Hoboken train crash[15] have been linked to undiagnosed OSA amongst train drivers. Unfortunately, similar data from India are not available, but the absence of data does not indicate the absence of a problem. It is not uncommon to find news of road traffic accidents that have been attributed to disordered sleep in the Indian media. The Central Road Research Institute has found that 40% of road traffic accidents on the Agra–Lucknow highways are caused by sleep deprivation.[16] The effects of sleep deprivation are most apparent on straight roads, which promote dozing off amongst sleepy drivers. According to a report of the Ministry of Road Transport and Highways, Government of India, for 2021, more than 50% of accidents occurred on straight roads.[17] Unfortunately, amongst the causes of accidents, sleep disorders and sleep deprivation have not been included. This is a sorry situation in India, where the management of sleep disorders is not yet included in the schemes of insurance companies or government schemes. Not only is the treatment cost of sleep disorders to be borne by individuals but also the availability of sleep physicians and well-organised sleep laboratories in India is limited to a few centres, thus further reducing the opportunities for optimal management of sleep disorders. Considering these issues, there is an urgent need to pay attention to sleep deprivation and sleep disorders in India and develop a national policy on sleep health [Figure 1]. This policy should have multiple components that focus on awareness, promoting healthy sleep as a primordial preventive measure, recognising and optimally managing sleep disorders as a secondary preventive measure, screening drivers and pilots for sleep disorders and lastly, investing in sleep research in India.Figure 1: Consequences of absence and the benefits of having a national sleep health policyIncreasing awareness of sleep disorders amongst the masses may be done using conventional measures utilised for various other health issues, for example, tuberculosis, malaria and HIV. Since disordered sleep affects the development of children, it is imperative that they should be informed about the concept of sleep health from the very beginning by including it in their science curriculum. Several research papers from India reported that Indian medical doctors are ill-informed about sleep and sleep disorders,[18,19] which can be addressed by the inclusion of sleep disorders in the medical curriculum and the recognition of sleep medicine as a separate speciality. For the recognition and management of sleep disorders, it is important that sleep disorder units having multi-speciality teams including psychiatrists, pulmonologists, paediatricians, general physicians, ENT surgeons, dentists, oro-maxillofacial surgeons and physiologists be established at least at the level of medical colleges, along with the requisite high-quality diagnostic and treatment facilities. This team will function not only as a human resource for the adequate management of sleep disorders but also to impart knowledge amongst medical graduates and post-graduates. Such centres may also become hubs for getting connected to various centres in their geographical area to provide care to patients using telemedicine. These centres may be connected to highly specialised sleep disorder centres that invest only in the field of sleep medicine for the transfer of knowledge. Sleep Disorders centres with a multi-speciality team may be established in all institutes of national importance, providing medical care to developing human resources (sleep physicians, sleep surgeons, and sleep technologists) in the field of sleep medicine. For this reason, there is a need to recognise sleep medicine as a separate and independent speciality. These centres may be developed as two-way referral centres using a hub-and-spoke model with the sleep disorders units of medical colleges in their geographical locations. In addition, for common sleep disorders like insomnia, which affect nearly 10% of Indian adults, short-term online training programmes may be run to equip in-service doctors about the recognition and management of insomnia. One of the authors of this article has conducted three such programmes, which were found beneficial by the participants. This may be replicated on a larger scale. Diagnosis and management of sleep disorders should be included in government health schemes like Ayushman Bharat to reduce the burden on the patient's pocket. One of the major issues is the treatment of OSA, which requires a device known as positive airway pressure (PAP) for management in most cases. This is a costly device, and in addition, being an external device, its use by patients with OSA cannot be ensured. A model of Medicare from the USA may be used to make it available to the masses at a reduced cost. Most PAP devices these days come with in-built mechanisms where their daily use may be monitored remotely. If any patient is found not using the device, it may be taken back from him and given to another person in need. To prevent accidents, workers engaged in the operation of heavy machinery, commercial drivers, and pilots should be screened for disordered sleep before they are given a license and periodically, although randomly. Devices may be developed that ring alarms before such a person starts dozing off on the wheel, and these may be installed in vehicles. Last but not least, funding agencies should invest in sleep research in India, as data from Caucasian and other populations may not be extrapolated to the Indian population because of genetic and anatomical differences. In conclusion, if we are able to pay attention to and promote sleep health in the Indian population, we can look forward to a better and healthier population. This will translate into increased productivity and economic growth for a country in the long term. Economic growth will come not only from increased productivity and the reduction of work-absenteeism but also from reduced expenditure on healthcare, as it is said that 'money saved is money earned'. Declaration of generative of AI and AI-assisted technologies in the writing process During the preparation of this work, the author(s) used QuillBot, a paraphrasing tool in order to check the grammatical mistakes. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.