Max Hirshkowitz, PhD, is chairman of the National Sleep Foundation as it enters its second quarter century with a continued focus on defining and encouraging sleep health.
Sleep Review (SR): As National Sleep Foundation (NSF) chairman, what’s at the top of your agenda?
Max Hirshkowitz, PhD: NSF is working to define sleep health. We are taking on several different initiatives to do this. First, we are conducting rigorous scientific processes to outline the components and facets of sleep health. We are also launching initiatives that further delineate what sleep health is in practice. We are fortunate to live in a time when technology is providing so much information and creating public excitement about sleep. It is our task to stay on top of the groundswell of interest in sleep and health information. Everything NSF does will connect back to understanding and defining sleep health.
SR: I’m familiar with the NSF’s sleep duration recommendations (released earlier this year) and that duration is one component of sleep health. Can you put that into the context of sleep health overall?
Hirshkowitz: Sleep health is more than the lack of sleep disorders. It has to do with well-being and vitality.
So what goes into sleep health? Satisfaction with sleep, quality of sleep, quantity of sleep, and, likely, the timing of sleep. If we ask ourselves where to start of these four components, the obvious place is sleep duration. That’s an easy question to answer because it’s quantitative.
The next step along the pathway is sleep quality, which is more complicated because it is a composite measure and it includes satisfaction with sleep. The NSF has a current project with Maurice M. Ohayon, MD, DSc, PhD, of Stanford, to look at sleep quality. We also have planned for Chuck Czeisler, PhD, MD, FRCP, to look at the timing of sleep.
SR: The NSF recently launched a Sleep Technology Council, whose mission is to support innovations in consumer sleep technology, and it will be hosting its inaugural event, the Sleep Technology Summit & Expo in October. (Editor’s Note: This e-mail and phone interview was conducted in mid-September.) Why is the NSF taking this role of enabling consumer sleep technology?
Hirshkowitz: The Sleep Technology Council is NSF’s first initiative to spur more innovation in sleep products. It’s an exciting time with so many product developers interested in sleep. We want to help these startups and enterprising companies tell their story. NSF partnered with Health 2.0 for the summit as they annually attract 2,000 healthcare leaders to discuss the future of the industry. Emerging consumer sleep technologies have the potential to help tens of millions to better understand sleep and its relation to performance and well-being. So we are working to promote, support, and enable the technology sector with the Sleep Technology Council and the first-of-its-kind industry event.
SR: Sleep medicine professionals seem split on whether consumer sleep devices are friend or foe. What are your thoughts on this?
Hirshkowitz: Healthcare professionals in general, but certainly sleep specialists, should see consumer sleep devices as a friend. As professionals, our goal should always be better health outcomes for patients. Consumer sleep devices are offering the first feedback many people have ever had about their sleep. The explosion in wearables is making sleep tracking ubiquitous. You could compare it to the advent of the bathroom scale. The public now has a pathway to understanding sleep and actionable information that can be used to improve lifestyle and overall wellness. Just as with diet or exercise, consistent self-monitoring is a key to success. In the coming years, consumer sleep devices will create more awareness and importance for sleep health professionals and their work.
SR: To play devil’s advocate, what would you say to sleep professionals who argue consumer devices can’t show medical validity, meaning there are no peer-reviewed studies showing that consumer devices are measuring what they claim to measure?
Hirshkowitz: This is one of the reasons the NSF got involved with the performance standards for these devices.
But you can’t arrive at a destination before you leave. When home blood pressure monitors first came out, they were roundly rejected. And they are now standard of care. If the technology has a value, it will improve.
You are not going to stop technology, and it is very important not to be obstructionist. The thing to do is guide the technology, so it develops in a valuable way with accuracy and standards. It’s not going to be perfect, be it the first version, the second version, the third version, or the fourth version.
On the other hand, the voice of insistence for improvement should be there. We shouldn’t say, “Oh, it’s good enough.”
SR: What about the risk that a person with a sleep disorder buys a consumer device, perhaps makes some sleep hygiene changes based on the device’s suggestions, and then thinks they are OK?
Hirshkowitz: I don’t think we know how often that’s going to happen, but I believe that is a concern. You have to have the appropriate warnings and caveats, such as that the device should not be used as a medical diagnostic tool and that it has not been validated as a medical device. And those caveats are part of the law. Will people break the law? Yes, people do. Does that mean we shouldn’t ever do anything? No.
SR: In 2014, we learned that the NSF and the Consumer Electronics Association (CEA) would be working together to explore technology standards that will aid the development of consumer sleep technology. What is the status of those standards?
Hirshkowitz: We began working with the CEA in May 2014 to bring together consumer sleep technology manufacturers and sleep experts with the goal of advancing consumer sleep technology standards. We have completed the first phase of the project, the development of common sleep terminology based on accepted sleep science, and outlined how the terms are likely to be used in consumer devices. The next phase is to set the minimally acceptable performance standard. It is a delicate process with many companies participating. I am pleased to report that everyone is working to get this right.
SR: The National Sleep Foundation’s professional journal, Sleep Health, launched this year. What, if anything, surprised you about the journal’s launch or its first issue(s)?
Hirshkowitz: I have to admit that I was a little surprised at just how quickly Sleep Health made an impact. But I shouldn’t have been. It was needed. It is unique, from the cover art to the content, and it is already helping to expand the horizons of what constitutes sleep research. By integrating multidisciplinary fields under the banner of sleep, we’re celebrating a wider world than sleep has recognized in the past. Through Sleep Health, researchers are engaging in robust, meaningful dialogues and helping to advance the global sleep health movement. And we’re hearing from our professional members that they love it and find it to be a great resource.
SR: As we touched on earlier, at the beginning of this year, the NSF released its updated recommendations for appropriate sleep durations for children and adults. What impact have these updated recommendations had on the public at large since their release?
Hirshkowitz: NSF knew from the frequency of our website search history that updated sleep duration recommendations were a necessity for the public. I had the honor of leading the panel that included experts in sleep, physiology, anatomy, pediatrics, gerontology, neurology, and gynecology, to come to a consensus on the recommendations. It was all done through an exhaustive review of the existing sleep duration literature. The public needed a standard and the response has been fantastic. A quick Google search will demonstrate how desired information on “how much sleep do I really need?” is. We had so much interest in our updated recommendations that David Letterman even created a “Top 10” list out of them. NSF will regularly review and will update these guidelines, and the literature, as researchers unravel more of the mysteries of sleep.
SR: What can we expect from the NSF on Capitol Hill?
Hirshkowitz: NSF has an active agenda on Capitol Hill. Our Sleep Health & Safety conference (November 6, 2015) brings together automobile manufacturers, sleep experts, and policy makers to discuss new autonomous driving technology and the future safety of America’s roadways. We’ve worked with Senate staff to get language in the Department of Defense Appropriations Act of 2016 acknowledging that sleep disorders are increasingly prevalent among service members, and that sleep disruptions have been associated with diverse mental and physical disorders, including traumatic brain injury and posttraumatic stress. Our goal is to get the Department of Defense to support basic translational and clinical research on how the disruption of normal sleep and circadian biological rhythms adversely affects the health, safety, performance, and productivity of our military and civilian populations. NSF is also pushing to have Congress direct the Secretary of the Health and Human Services department to issue a report on the state of sleep health in America’s older adult population. We’ll host our annual Sleep Leadership Summit in February 2016, where we will work the halls of Congress to advocate sleep health change.
SR: When I interviewed then-chairman Dr Czeisler last year, he mentioned that the NSF had developed a robust CME programming plan that will expand the types of educational activities offered in the coming year, specifically incorporating online videos, case methods, activities, and more, in addition to annual live CME activity. Did that CME programming plan come to fruition? Will there be any significant updates to CME courses during your tenure as chairman?
Hirshkowitz: As our work with the Sleep Technology Summit and Sleep Health & Safety conference should indicate, NSF is working to be at the cutting edge of professional education. We are working on new CME programming that will reflect not only the latest in sleep health science, but also our standing as innovators in sleep. We’ll be making some announcements in the coming months, so keep an ear out.
SR: The 2015 NSF Sleep in America Poll focused on pain and sleep, finding that pain is a key factor in the gap between the amount of sleep Americans say they need and the amount they’re getting. What clinical significance, if any, is there to the poll findings?
Hirshkowitz: The poll confirmed the high bidirectional relationship between pain and sleep. If clinicians can work with patients to manage pain and sleep together, they are likely to have better outcomes for both. We also issued our first-ever Sleep Health Index in the past year. The Sleep Health Index is our new, annual general population poll to track Americans’ sleep behaviors and trends. It provided significant numbers around sleep. For instance, we found that 45% of the public said that poor or insufficient sleep affected their daily activities at least once in the past week. So we have our work cut out for us improving sleep health.
SR: Regarding the new Sleep Health Index, will you be repeating the same questions every year for the Index so you have an apples-to-apples comparison?
Hirshkowitz: I was intimately involved in the Sleep Health Index. I felt it was important to split off the questions we’d ask yearly about sleep and not load them onto another poll that wouldn’t necessarily have a representative or probabilistic sample.
The initial poll was given and it performed pretty well. We got involved with a high level group that does polling analysis and they’ve done an incredibly detailed analysis, and I’ll be writing an article for the Sleep Health journal to detail how well the poll performed.
The analysis also showed some of the questions we had weren’t contributing much, so we are going to probably drop some of those questions and may add a few new ones. There is a core of about 12 questions that will be repeated yearly, so that we’ll have a true index.
SR: The NSF brings sleep awareness to the general public. Of what sleep-related public appearance are you the most proud?
Hirshkowitz: I am very proud of our new Bright Schools program for middle school students that we’re running this school year. The Bright Schools Competition is a learning experience that will help students, their parents, and teachers better understand the link between light, sleep, and student health and performance. We convened an expert review panel that included our own Chuck Czeisler, Mark Rea, PhD, from Rensselaer Polytechnic Institute & the Lighting Research Center, George C. Brainard, PhD, from Thomas Jefferson University, and Jonathan S. Emens, MD, DABSM, of Oregon Health & Science University to create the learning criteria. Then we partnered with the National Science Teachers Association to create the actual lesson plans. Projects are due at the end of January and we’ll be announcing the winners in April 2016. People can check out brightschools.org to see what we’re doing. It’s an ambitious program that I hope will seed the next generation of sleep thought leaders.
Hirshkowitz is consulting professor at Stanford University School of Public Health and retired full professor at Baylor College of Medicine Department of Medicine. He was the founder and director of the Sleep Disorders and Research Center at the Michael E. DeBakey Veteran Affairs Medical Center and training director of the Baylor Sleep Medicine Fellowship Training Program. This is his third time earning the cover of Sleep Review.
As chair, Hirshkowitz leads the NSF’s board of directors, comprised of physicians, scientists, and business professionals.
Sree Roy is editor of Sleep Review. CONTACT [email protected]