On July 1, Charles Czeisler, PhD, MD, FRCP, began his term as the National Sleep Foundation’s highest elected volunteer post. As chairman, he’ll promote public sleep health and safety through initiatives such as a journal launch, updated sleep time recommendations, and continuing education to primary care physicians.
Sleep Review: As National Sleep Foundation (NSF) chairman, what’s at the top of your agenda?
Charles Czeisler, PhD, MD, FRCP: The NSF is the voice of sleep health and safety. The aim is to advocate and educate people about the relationship between sleep and health, and that’s really at the top of my own agenda. All of our activities and programs are intended to advance that mission of sleep health.
One activity I’m really excited about is the launch of our journal, Sleep Health. Sleep Health will create a unified place for a wide range of research regarding the health benefits of sleep.
SR: What are agenda items #2 and #3?
Czeisler: Our other major initiatives include ramping up our educational program and updating our sleep time recommendations.
The NSF has convened a Sleep Time Recommendations Expert Panel (STREP) to update recommendations for appropriate sleep times at every life stage. One of the most common questions people ask is “how much sleep do I need?” We’re gathering a multidisciplinary team of experts in sleep and other scientific disciplines to formulate updated recommendations for age-specific sleep needs. We’re pleased that a wide range of organizations are represented on this expert panel, which includes the American Academy of Pediatrics, American College of Chest Physicians, American Association of Anatomists, American Congress of Obstetricians and Gynecologists, American Geriatrics Society, American Neurological Association, American Physiological Society, American Psychiatric Association, American Public Health Association, Gerontological Society of America, and the Human Anatomy and Physiology Society.
Across the board, the NSF is increasing the academic rigor of the activities that have been happening over the past 25 years. That’s why we have assembled an expert panel, instead of relying on one study or another. It’s a systematic review across all of the research that has been conducted, so the recommendations will be grounded in sleep science.
We anticipate the recommendations from the expert panel will be released in January 2015.
Another top initiative is the NSF partnering with the Consumer Electronics Association to develop technology standards for wearable sleep electronics. There are a lot of devices and apps out there that claim to be measuring sleep. The NSF is committed to helping companies create more innovative sleep products that promote sleep health, but we want to make sure there are standards for those wearable products.
SR: Before you were chairman, what was your role with the NSF?
Czeisler: I was a member of the NSF’s first board of directors when the organization was founded 25 years ago. It was a privilege to be on the first board.
During the ensuing decades, I’ve remained active in many of the advocacy and educational activities, including its drowsy driving initiative. I’ve also been active in numerous Sleep in America polls and conferences and committees. I chaired the Sleep Health & Safety Conference 3 years ago. Throughout the past year, I’ve served as vice chairman of the board.
SR: What can we expect from the NSF on Capitol Hill?
Czeisler: The NSF is pressing for changes on a wide variety of issues, including asking Congress for studies to explore how the military is managing sleep in our military and our veterans.
We’ve also been working hard to prevent legislation that interferes in the screening of truck drivers, pilots, and railroad workers for sleep disorders. Various federal agencies have initiated plans, like the National Highway Traffic Safety Administration, trying to issue regulations pertaining to the screening of commercial drivers for sleep apnea, but then legislation passed that delayed that effort. That was a setback. We will do our best to make sure that Congress understands the importance of that kind of regulatory activity.
We’re very concerned with Senate Bill 1941. This would prevent the Federal Aviation Administration from implementing new policies designed to screen for untreated sleep apnea among airline pilots. The NSF believes strongly there should be policies in place that help detect sleep apnea and other sleep disorders among high-risk populations, particularly the transportation industry.
Regarding our advocacy efforts, we host the annual Washington Sleep Leaders Summit, which will happen in April 2015. The first summit was very successful. Participants advocated for sleep health for the military, veterans, and older adults, and we will continue to advocate for sleep health among these populations and other populations throughout the year.
SR: Most cases of obstructive sleep apnea (OSA) remain undiagnosed. Does the NSF have plans for a public awareness campaign?
Czeisler: The NSF awareness media strategy routinely addresses the underdiagnosis of OSA. Our website, sleepfoundation.org, helps connect patients with professionals and with laboratories.
This is a very important issue, and the underdiagnosis of OSA is a challenge we need to address in the sleep field. We have to engage primary care physicians to identify patients at high risk of OSA and ensure they are diagnosed and treated.
To put it in perspective, there are 209,000 actively practicing primary care physicians in the United States. That compares with 9,000 board-certified sleep specialists, not all of whom are practicing. We need to enlist those 209,000 primary care physicians if we are going to be successful in diagnosing and treating the 50 to 70 million Americans who have sleep disorders.
SR: There are primary care physicians who don’t know or care about sleep disorders. What will the NSF do so more primary care physicians understand the importance of sleep?
Czeisler: The NSF has a two-pronged educational approach that’s aimed at both the public and primary care physicians and other healthcare professionals. We’ve identified primary care physicians as often being the first line of care for people suffering from sleep issues or sleep disorders. We have a dedicated continuing medical education (CME) program devoted to teaching them about the clinical and basic science of sleep medicine.
Through attendance in our programs, we expect to see physicians being better able to recognize risk factors and symptoms of sleep disorders and sleep-related problems. We also expect primary care physicians to be able to effectively counsel patients by providing the physicians with tools and strategies so they can have an open dialogue with every patient they see about sleep. Overall, we hope primary care physicians adopt the idea of sleep as a vital sign for health.
This year, we’ve developed a robust CME programming plan that will expand the types of educational activities we offer in the coming year. Specifically, we plan to offer online videos, case methods, activities, and more, in addition to our annual live CME activity.
SR: Is home sleep testing (HST) a boon or a bust to consumers? What about to sleep professionals?
Czeisler: Around 2005, when I was asked by the Institute of Medicine during an expert panel on how sleep should be organized in academic medical centers, the chairman asked me if we could record the sleep of astronauts in space, then do we really still need everyone to go into a sleep lab or could they be recorded at home? My answer was it should be possible to diagnose sleep disorders in the home.
In the ensuing decade, we’re seeing a transition to more and more routine diagnostic testing being done in the home. And it’s the only way because there aren’t enough sleep labs or centers to diagnose the Americans who have sleep disorders. It’s a great thing that home sleep testing is available on a widespread basis.
SR: Any advice for sleep centers who fear low HST reimbursements?
Czeisler: There will always be a role for in-laboratory diagnostic testing. Given that 85% of patients with sleep apnea are undiagnosed and untreated, we could actually reach out to that larger population, instead of dealing only with a fraction of the population who have sleep disorders. We’re not providing the penetrance that is necessary to really achieve success in terms of diagnosing the larger population who has sleep disorders. In order to achieve that penetrance, there have to be some changes.
If the field could achieve a much higher rate of testing via HST, then there would be so many patients identified who have complex comorbidities that require in-lab testing that a successful program should actually see an increase, or certainly not a decrease, in in-lab testing.
My recommendation is outreach, working with people in other medical specialties, getting to primary care physicians, and integrating sleep health into the managed trade of American medicine.
Let me give an analogy. When brain scans were first introduced, only neurologists could order and interpret them. Obviously, that has changed in the ensuing decades. So, many more imaging studies are being ordered because primary care physicians, emergency department specialists, and others are ordering the tests. That has not eliminated the need for neurologists. It’s only increased the demand for specialists to address the more complicated cases as primary care physicians are caring for the routine cases. The same evolution needs to happen as the sleep field matures.
SR: In the news is the truck driver who was allegedly awake for 24 hours before causing a crash that left actor Tracy Morgan in the hospital. Any thoughts?
Czeisler: With all of these accidents, it’s a tragedy and, sadly, a preventable tragedy. In so many of these instances, the information in these media reports may not be accurate. We shy away from speaking directly about the reports since we don’t know whether they have been substantiated.
Instead, we use it as an opportunity to educate the public about the dangers of sleep deprivation. Certainly being awake for 24 hours without sleep induces an impairment of neurobehavioral performance that is the equivalent to being legally drunk. Even if you remain awake, reaction time is delayed threefold to fourfold, so it takes three to four times the time to step on the brake. It is hazardous.
SR: What will be the tipping point when the public will understand that sleepiness can be the equivalent of being drunk (in terms of cognitive impairment)?
Czeisler: We’re really beginning to reach that tipping point. We’ve already achieved significant public awareness surrounding this issue. Much of that is due to the NSF Sleep in America poll, which started in 1991. This year, we’re developing even more rigorous methodologies to ensure our research continues to add value to the sleep community and the general public. Through efforts like the Sleep in America poll and Drowsy Driving Awareness Week, people are really beginning to understand that sleep should be a priority.
SR: Speaking of the Sleep in America poll, is it realistic to expect that the public will ever unplug electronic devices in the bedroom?
Czeisler: It’s certainly a challenge to make people aware of the disruptive nature of electronic devices in their sleep environment. Seventy percent of Americans report that they regularly obtain insufficient sleep, and most are not aware of the role of electronic devices in contributing to sleep deprivation. There is a need for further research that will demonstrate that.
The NSF is working this issue from numerous angles, including awareness of shutting down at night. We’re also looking at ways to limit light exposure, particularly the short wavelength light among common devices that can be especially disruptive to sleep. An important thing that people should be aware of is the availability of free software called f.lux, which can be installed on computers and helps reduce the exposure to short wavelength light (the most active in suppressing melatonin).
SR: You attended SLEEP 2014. What was your biggest takeaway from the conference?
Czeisler: Every year it’s amazing for me to see how the sleep field has flourished since I began doing research on sleep and its disorders. The first meeting had only 60 participants. They met in one room, and we had a single track. I was a graduate student at the time. Now there are two orders of magnitude more people at the meeting.
This year’s conference was exciting and an interesting collaboration of sleep professionals and research scientists. It’s always fun to be part of learning about what’s new and exciting in the field. It never ceases to amaze me how many different avenues of sleep medicine there are and exciting findings from the Sleep Research Society (SRS) and the American Academy of Sleep Medicine. The work by scientists at the SRS looking at comorbidities associated with sleep disorders, such as cardiovascular disease, diabetes, the impact on the immune system, and so on is stunning and amazing to me.
SR: Of what sleep-related public appearance are you the most proud?
Czeisler: I was invited to walk with the Boston Red Sox in the 2013 World Series victory duck boat parade. That was very exciting. And I was stunned this past month when the Boston Red Sox presented me with the 2013 World Series Championship ring.
SR: Finally, are there any NSF events you urge sleep professionals to attend?
Czeisler: The NSF Sleep Health & Safety conference is an annual event in which the NSF explores sleep topics from the public health and safety perspective. It will take place November 7, 2014 in Washington, DC.
Sree Roy is editor of Sleep Review. E-mail questions and comments to [email protected]
Watch Czeisler’s TEDxCambridge 2011 Talk “A Sleep Epidemic.”