As March is World Sleep Month and March 19 is World Sleep Day, Dr Sibasish Dey, Head – Medical Affairs, Asia and Latin America, ResMed rues the lack of sleep awareness in India. He makes a case for the evolving sleep diagnosis market in the country, the use of digital health technologies for the treatment of sleep disorders
This March marks approximately a year since the COVID-19 pandemic and associated lockdowns took over our lives. What are the key changes in our sleep cycles/patterns due to the pandemic?
The COVID–19 outbreak in 2020 brought lockdown to most of the nations, altering schedules and lifestyle. People have been experiencing sleepless nights due to fears of getting the virus supplemented by financial and economic worries and the pressures of schooling children while working from home. the COVID-19pandemic has undoubtedly led many of us to experience a good deal of stress and poor sleep. A study in the Indian journal of Psychiatry has shown that sleeping patterns have significantly been influenced because of the pandemic, with a reduction in night-time sleep duration and an increase in daytime sleeping. The changes can be primarily attributed to:
• Due to the pandemic, people no longer had to get up early and travel to work, as was the case in the pre pandemic era. Since they are now confined to their homes, they tend to wake up only a few minutes before office hours and get straight to work.
• The entire circadian rhythm has been impacted and people are forced to rely on external sources of melatonin that can help them get a peaceful sleep. Studies in the US and other west have shown that there has been a 40-50 per cent increase in prescription medicines for sleep.
• Shorter sleep duration at night can also be associated with increased proportion of longer sleep onset latency and depression after lockdown. Stress and anxiety have taken over and people are finding it difficult to sleep.
• A study led by AIIMS Rishikesh has highlighted that 79.4 per cent people used to fall asleep in less than 30 minutes before COVID-19 which is now reduced to 56.6 per cent after lockdown. In another major finding, 3.8 per cent people used to take more than 60 minutes to fall asleep which increased to 16.99 per cent after the lockdown.
• Additionally, there is less or almost no exposure to sunlight. Sunlight induces the generation of melatonin in the brain – a primary hormone that helps us sleep. Low exposure to sunlight is also a culprit to sleepless nights.
• COVID–19 has also impacted the sleep quality in multiple ways. There are increasing number of complaints with regards to sleep quality which could also be worsening due to pre-existing conditions.
What were the key triggers pre-pandemic, like the increasing use of light emitting gadgets, etc to evolving sleep cycles?
Unhealthy sleep hygiene relates to various diseases and health problems, including mental health, blood pressure and cardiovascular diseases. Most of these sleeping issues are directly associated with certain unfavourable lifestyle habits worsened by the pandemic and can be treated via specific lifestyle changes. The key triggers to consider are:
• Gadgets – one of the primary triggers for worsening sleep quality, especially in millennials, is the increased use of gadgets and social media. The constant stream of information and the blue light emitting from our devices keeps our mind alert and prevents a proper “shut down” of our systems. The phone light also confuses our body to take it for daylight, halting melatonin production and effecting a natural sleep-inducing process of our body.
• The competitive environment and long working hours – people today, especially millennials and the organised working population, tend to sleep much later at night, most likely due to the prominence and structure of sleep being utterly dependent on their professional requirements. Additionally, the increasing competition eating into our rest and sleep time again hinders people’s sleep cycle.
• Stress and anxiety – today’s generation, especially the working-class people, have been reported to have maximum levels of stress and anxiety. This is because of the standard of living, increased workplace demands in the modern world, and an unprecedentedly competitive environment.
• Poor lifestyle habits – stress that most people experience leads to poor coping behaviours, such as poor diet and overconsumption of alcohol or caffeine, all of which wreaks havoc on a sleep cycle.
Are there any trends specific to countries, age groups, professions, gender-related?
A good night’s sleep is essential for your overall health and well-being. Conserving energy, healing the body, consolidating memories, and regulating emotions are some of the key reasons why we sleep.
• India is the second most sleep-deprived country globally with an average of 7 hours 1 min of sleep, behind the Japanese with 6 hours and 47 min of sleep.
• Additionally, many studies have revealed that Indians are the least active, with only 6533 steps a day on average, nearly 3600 steps lesser than the most active country, Hong Kong.
• In India, a cross-section of studies conducted across various subpopulations reported a sleep apnea prevalence of 13.7 per cent among adults and 7.5 per cent among urban middle-aged men.
• Although there are slight differences in sleep apnea symptoms for men and women, the risks are more significant for women. Firstly, because their symptoms are not as overt, they are late or never diagnosed with OSA. Secondly, according to a study published in the European Respiratory Journal, women suffering from acute obstructive sleep apnea are at a two to three-fold higher risk of cancer. Additionally, as per a recent ResMed study for the US market, 35 per cent of women reported worse sleep quality in 2020 than just 26 per cent of men.
• Although snoring is one of the earliest obstructive sleep apnea symptoms, it is often the most ignored. As a result, many cases of obstructive sleep apnea go undetected or untreated. According to an estimate, a minuscule 2 per cent of people suffering from obstructive sleep apnea consult a physician.
• Chronic sleep deprivation has been seen to be life threatening, and the consequences are mostly observed in night shift workers, frequent travellers, and truck drivers. Additionally, due to the pandemic and the pressure built on the healthcare community, they have also been exposed to an extremely unhealthy sleep cycle.
What are the awareness levels in the general population in India and globally, on the harm caused by erratic sleep cycles?
Today, millions of Indians suffer from sleeping disorders, with majority of them being undetected. Over 28 million Indians suffer from moderate to severe sleep apnea alone, according to a 2019 Lancet Respiratory Medicine study. Sleeping disorders left untreated have detrimental consequences on our mental and physical well-being, including increased risk of heart attacks, diabetes, depression, amongst others, making it imperative to raise awareness on sleeping disorders.
According to a survey conducted by ResMed, 72 per cent of the surveyed population who snore are not concerned that snoring could be related to underlying health conditions. This statistic shows that awareness around sleep disorders, symptoms, and consequences is low globally. In the same survey, 46 per cent of respondents indicated their doctor had not asked them about their sleep quality, signifying a significant gap in the medical fraternity around awareness of sleep disorders and the importance of healthy sleep hygiene.
In India, over 80 per cent of sleep apnea cases go undiagnosed and untreated, majorly due to snoring being considered a sign of deep, peaceful sleep. Moreover, there are not more than 500 sleep labs in a country of 1.3 billion people, single-handedly showcasing that we as a country are not aware of the repercussions of a bad sleep cycle even though with the advent of technology, people are becoming actively aware and considerate of their physical health.
At ResMed, we understand that the level of discourse on sleep awareness continues to be low in India. We are continuously investing in education and awareness initiatives to underscore the importance of sleep and associated disorders. We recently launched a campaign – #WakeUpToGoodSleep, to raise awareness amongst consumers and doctors in India about the health benefits and importance of good sleep. As part of the campaign, we launched a short educational film that showcases sleep apnea, a relatively unknown sleep disorder, and its effects, such as fatigue, mental stress, irritability, and even traffic accidents, to reiterate the importance of a good night’s sleep.
What are the long term clinical impacts of these changes on overall health?
Sleep has co-relations with almost all chronic diseases, and a healthy sleep cycle goes a long way in the overall wellbeing of an individual, both physically and mentally. People with a healthy sleep cycle tend to have higher concentration levels and are more productive at work.
Overall, chronic sleep loss has co-relations with:
o Hypertension – long-term sleep deprivation has been associated with increased blood pressure and increased heart rates. Sleep helps our bodies regulate hormones that can cause stress, and the lack of sound sleep can further amplify the effects of stress on the body.
o Strokes – many studies have proved that sleep impacts our brain activity and may hamper parts of the brain that control the circulatory system or cause inflammation that makes the development of a blood clot more likely. Lack of sleep can cause a greater instance of fatal cardiovascular problems, such as heart attacks and stroke.
o Obesity – sleep deprivation is related to higher cortisol levels, the stress hormone, resulting in anxiety, stress, and frustration, which often contributes to emotional eating and poor nutritional habits. Another hormone, called ghrelin, is produced in the stomach and has been associated with long-term sleep deprivation, and an excess of ghrelin can make people feel hungrier.
o Decreased fertility – In our brain, a section that controls the body’s circadian rhythm also contains reproductive hormones. Regularly getting fewer than 7 hours of quality sleep can lead to lower testosterone levels and the hormones that trigger ovulation, making conception even more difficult.
o Memory loss – Sleep helps the brain form memories, gives it time to organise itself, especially to commit information from STM (Short Term Memory) to LTM (Long Term Memory), making sleep an essential element contributing factor for memory recall.
o Traffic accidents – Long term sleep deprivation may also cause road and traffic accidents, primarily observed in commercial truck drivers. India is home to over 11 per cent of road accidents globally, which is an alarming indication of the economic cost of sleep deprivation in the country.
Sleep patterns are habit-forming and very individualised, so how can these changes be diagnosed early and corrected?
Early diagnosis of sleep disorders is crucial for the general health of the population. Although sleep patterns are habit-forming and significantly individualised, multiple common symptoms indicate a sleep disorder, so patients must watch those. Patients experiencing morning headaches, daytime sleepiness, tiredness even after a 7–8-hour long sleep, snoring, etc., must consult a sleep specialist immediately and get themselves tested.
The advent of digital and home care technologies have enabled detailed process such as sleep testing to go from laboratories to our bedrooms. Now, it is possible to analyse sleep quality by simple wearable devices such as onesleeptest by Ectosense. These technologies have made sleep testing accessible for everyone to enable early diagnosis. People experiencing even mild symptoms must consider taking a home sleep test to rule out a sleep disorder and associated diseases.
Are such devices, services affordable and accessible, and convenient for a country like India?
Sleep testing has evolved and has gone from sleep labs to bedrooms powered by the evolution of cloud connected technologies. ResMed provides remote and self-monitoring software solutions that help maximise patient adherence and health outcomes, plus optimise clinicians’ patient management efficiencies.
ResMed has also introduced a sleep coach assistant service, consisting of a team of coaches who remotely guide patients through every step of their journey to better sleep. We are providing services including sleep apnea detection via a home sleep test, helping patients diagnosed with sleep apnea understand the treatment options available such as a CPAP (continuous positive airway pressure), and even guiding patients through the hassle-free installation of devices and providing the best possible offers on devices, including EMI schemes for devices for a cost sensitive market like India.
As changing sleep cycles are a public health concern, what can governments and policy experts, NGOs, do to encourage healthy sleep hygiene?
The Ministry of Health and Family Welfare, Government of India, has implemented policies regarding various non-communicable diseases over the years, such as diabetes and is effectively contributing to encouraging the efforts to use telehealth and telemonitoring services. However, awareness about the importance of sleep in India is still at a nascent stage, making it essential for different stakeholders to build on the efforts and increase investment to undertake initiatives to raise awareness about the importance of sleep. The industry should focus on:
• Accelerating research and innovation promotes public and private partnerships to streamline research infrastructure while also improving industry-academia collaboration and establishing a robust innovation ecosystem.
• Achieving equitable and sustainable healthcare – increased acceptability of digital technologies can improve overall healthcare delivery, including access to India’s rural market. Hence, enabling teleconsulting and focusing on preventive healthcare are some of the areas that should receive continued investment for expansion by the industry, government, and other healthcare sector stakeholders.
• To improve access to devices and treatment options, the government should adopt various global best practices to increase awareness and adoption of chronic diseases in India and ultimately reduce the economic burden.