The Science of Slumber

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Most doctors probably have an idea of where they might end up in the medical field. They train for a specialty, whether it’s cardiology or anesthesiology, and stay put. For sleep medicine, that’s not always true.

“There are lung doctors because of sleep apnea, there are neurologists, there are pediatricians,” says Conrad Iber, M.D., a professor of medicine at the University of Minnesota, as he lists off authors on a National Institute of Health journal article on the history of sleep medicine.

Doctors and an array of other professionals like psychiatrists and scientists have historically found their way into sleep medicine through curiosity and medical practices that intersect with sleep. That’s not an unusual path when you consider that sleep medicine didn’t become a nationally recognized specialty until 2004.

Dr. Iber stumbled into sleep medicine in the early 1980s, when he was studying why people started and stopped breathing during sleep. One thing led to another and, after years of working in lung and critical care, Dr. Iber is now primarily a sleep doctor for Fairview Health Services and operates out of the University of Minnesota. Iber is also a professor of medicine at the university.

Now his specialty is booming, with a third of Americans facing sleep-related illnesses. So how did this modern sleep revolution come about?

trends of sleep awareness

A Sleepy History

Major discoveries in sleep medicine took off in 1953 when University of Chicago professor Dr. Nathaniel Kleitman and his graduate student Eugene Aserinsky discovered Rapid Eye Movement (REM) sleep. The first sleep disorder center was established at Stanford University in 1964. By 1975, sleep centers were popping up around the country. In 1989, Allan Rechtschaffen, M.D., released his findings from his now-classic study that proved sleep deprivation in rats could be deadly within two to three weeks.

Though this might sound like steady progress, the truth isn’t that straightforward. While researchers agreed that a lack of sleep could have serious and even life-threatening health consequences, sleep experts couldn’t fully explain why sleep was imperative to our survival until as late as 2003.

Still, Dr. Iber says research boomed between the years of 2000 and 2009. Today, he estimates that nearly 1 million studies have been conducted at over roughly 2,500 sleep centers across the country.

Dr. Iber and his team came together while they resided at the American Academy of Sleep Medicine in 2003. Iber was the president at the time, and he and the board at the AASM worked over the next year to propose sleep medicine as a new medical specialty to the Accreditation Council for Graduate Medical Education (ACGME). “It was already there, we just needed to name it,” Iber says.

To become a medical specialty, sleep medicine needed to prove it affected all ages in both men and women. National institutes needed to be doing funded sleep research. Sleep medicine needed to prove that sleep affects every organ system in the body.

The ACGME granted their proposal on the first pass in 2004. Since the approval, individual medical professionals can be certified to practice sleep medicine and sleep centers can be properly accredited nationally.

Thomas Hurwitz, M.D., an assistant professor of psychiatry at the University of Minnesota, was on the other end of this process as a part of the exam writing committee for the national exam and a board member of the American Board of Sleep Medicine. “The goal was for the field to mature,” Dr. Hurwitz says.

Dr. Hurwitz, like most now in the field of sleep, came from another line of work. He now mostly works at the Minneapolis VA Medical Center, but started as a psychiatrist at Hennepin County Medical Center in downtown Minneapolis a few years after the Minnesota Regional Sleep Disorders Center was founded in 1977. Hurwitz says every Tuesday he and his coworkers within the center would swap what they were learning from their patients.

The American Board of Sleep Medicine and several other sleep oriented medical groups gave the first test to certify the next generation of sleep specialists in 2007. The test was designed in compliance with the ACGME approval of the specialty, and places like the Minnesota Regional Sleep Disorders Center now have fellowships for aspiring sleep specialists. Training has become less about “learning by doing” as Hurwitz and many others had done in the past, and more of a streamlined
educational process.

 

Waking Up To Sleep Science

Americans themselves are learning rtrends of sleep graphight along with doctors and scientists about sleep’s importance to daily life. But that doesn’t mean we’ve always followed the doctors’ orders.

The National Sleep Foundation’s Sleep in America Polls have been conducted for the past 20 years. They show that the number of Americans getting less than six hours o
f sleep increased 4 percent from 1998 to 2005, totaling about 16 percent. Americans getting a solid eight hours fell from 35 to 26 percent during that same period.

The hours of sleep reported on the polls aren’t encouraging, but that doesn’t mean the information is falling on deaf ears. Since 2000, Americans have become more educated about sleep’s benefits. Thirty percent of the respondents of the 2005 poll stated they felt best after eight hours of sleep per night. In 2002, 40 percent of respondents reported a good night’s sleep most nights. That number rose to 49 percent in 2005. This awareness of sleep’s benefits on adults’ and children’s well-being exponentially rose in 2014’s Sleep in The Modern Family poll, where 63 percent of adults found sleep extremely important to their own well-being. That value on quality sleep rose 3 percent when it came to their children.

 

This increased awareness is especially notable in terms of how children are affected.  The ongoing debate on high school start times is the most apparent example of parents’ concerns over their children’s sleep.

In 2009, Fairfax County, Virginia—the thirteenth largest school district in the country— commissioned a massive study that looked at three key factors: how many students were feeling hopeless, thoughts about suicide, and attempted suicide. They measured these factors by the amount of sleep per school night reported by almost 28,000 eighth, tenth, and twelfth graders.

Fairfax high school students reported around six and a half hours of sleep per school night on average, three hours shy of the recommended nine and a half. Most children in the U.S. average about eight. The difference of one hour less of sleep was dramatic.

For children who slept a solid nine hours: 19.2 percent reported feeling hopeless, 8.1 percent reported thinking about suicide and 1.8 percent had attempted suicide. The bottom end of the spectrum was children sleeping four hours or less per night. Over half reported feeling hopeless, 31.5 percent considered suicide, and 13.3 percent reported actually attempting to take their lives.

The Fairfax school system has taken action and moved its start time nearly an hour later to 8:10 a.m. starting this year.

 

New Breakthroughs

This increasing clarity of the benefits of sleep is riding a wave of science that has given us more concrete reasons why we need sleep. But Dr. Iber says there are three key findings that have come about since the science surrounding sleep has advanced. One is sleep’s key role in neuroplasticity, the process of the brain’s synapses making connections as we go about our day-to-day lives. In short, our brain makes many new connections each and everyday, but you can’t keep expanding something in a closed container. So, in a sense, our brains take out the trash every night when you sleep.

“While you’re asleep there’s a pruning process,” says Dr. Iber. “All the unnecessary connections that don’t have an emotional tag on it are pruned off.”

The second key finding is that our brain uses sleep to commit things to memory. So if you practice piano for a few hours and come back later the same day, sure you’ll be good. But Dr. Iber says if you sleep on it, “you’ll be better.”

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Although the research has only been done on animals, the third finding looks at how sleep flushes out daily-accumulated neurotoxins. “There is no reason to think it doesn’t apply to humans,” says Dr. Iber. “We don’t have a lymphatic system in our brain and so we can’t really evacuate the toxins. So there’s a flushing mechanism. The clearance of neurotoxins only occurs under two circumstances, one is general anesthesia and the other is sleep. So if you want to clear out neurotoxins, you have to sleep.”

Despite these advances, sleep medicine faces a lack of trained sleep professionals to treat common sleep illnesses such as sleep apnea, restless leg syndrome, and insomnia which taken together affect 10 to 15 percent of the U.S. population. “When you think of the population of Minnesota, that’s a lot of people,” says Dr. Iber. “Especially since I have only about 10 psychologists that can handle insomnia and are specifically trained in sleep medicine.”

Shift workers have also become an uphill battle for sleep docs. Between 12 and 15 million people in this country work outside the nine-to-five routine, some of whom are police, bus drivers and laborers working with heavy machinery. “These people are really ill from doing their shift work,” says Dr. Iber. “And they’re making mistakes and it’s not good.”

Sleep affects not just shift workers. We may be more aware, but as the data indicates, a large portion of America isn’t taking that to heart. Sleep science is not just headed toward more research and scientific reasoning, but also looking down the barrel of how to treat what we’ve discovered.