保健医療科学

2012 Vol.61 No.1 p.35−42

Topic：Sleep health issues in Japan and overseas: from evidence to action<Review>

Global perspectives on sleep and health issues
Ronald R GRUNSTEINNHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS),
University of Sydney and Royal Prince Alfred Hospital, Australia

Abstract
Sleep loss is an important factor in the global burden of disease with collateral effects on cardiovascular and mental healthas well as injury and violent death through human error. This disease burden is poorly recognized due to a range of factors.
The paper argues that improving world-wide sleep health needs to match efforts currently being made in combating obesityand other non-communicable diseases.
Keywords: sleep, non-communicable diseases, sleep loss, sleep disorders(accepted for publication, 20th February 2012)

Ⅰ．Introduction
There is growing awareness that healthy sleep needs
to be integral to qualit y of life in all societies. Sleep
research is a relatively new field of scientific endeavor
and translation of this research has taken place mainly indeveloped economies with clinical management of sleep
disorders such as obstructive sleep apnea and insomnia.
However, t he i ncreasi ng breadt h of sleep resea rch
and the recognition of the growing importance of noncommunciable diseases across all economic strata insociety is highlighting the importance of healthy sleep
globally.
Non- communicable diseases ( NCDs) pose a major
threat to global health and economic development [1].
Internationally around 57 million people died in 2008, and33 million (58%) of these deaths were due to chronic (noncommunicable) diseases (mainly cardiovascular disease,diabetes, cancer and chronic respiratory diseases). It isestimated that they cause 36 million deaths a year of which
one-quarter are premature and 80 per cent occur in lowand middle-income countries. The burden of such diseases
in low-income and middle-income countries is rapidly
increasing and already has major adverse social, economic,
and health effects [2]. Substantial challenges to the healthsystems of such countries as China and Russia have been
identiﬁed as a result of NCDs [3]. There is evidence that
NCDs occur more commonly among the poor and are acommon cause of tipping households into poverty. Poorer
communities tend to develop cardiovascular disease at
much younger ages, leaving destitute dependants.
Mental health problems are an important component of
the burden of non- communicable disease. Neuropsychiatricconditions are the leading cause of disability worldwide,
accounting for 37% of all healthy life years lost from
disease; they are the most disabling conditions even inlow- and middle-income countries, which may be least
able to bear such burdens [4]. T he neuropsychiatricconditions that contribute the most disability-adjusted lifeyears are affective disorders, substance-use and alcoholuse disorders, schizophrenia, and dementia. Limited
capacit y in qualit y data collection possibly results inunderestimation of the burden of disease due to mental
health disorders in many countries.
Road trafﬁc accidents are responsible globally for about
1∙2 million deaths and 10 million permanent disabilities
each year [5]. Three-quarters or more of these deaths are
in developing countries, where numbers of accidents andfatalities have been increasing rapidly. Not surprisingly,
within low-income and middle-income countries, poor

Address for correspondence: Ronald R Grunstein, MB, BS, MD, PhD, FRACPFormer President, World Federation of Sleep Research and Sleep Medicine Societies (2007-11)
Professor of Sleep Medicine
NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), University of Sydney and Royal Prince Alfred Hospital, Sydney, Australia
Tel: +61-2-91140007 Fax: +61-2-91140010
E-mail: ron.grunstein@sydney.edu.au

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Ronald R GRUNSTEIN
people (pedestrians, passengers in buses and trucks, andcyclists) suffer a higher burden of morbidity and mortality
from trafﬁc injuries.

Ⅱ．Adequate Sleep ‒ A Basic Need and Right
In considering what is important globally for health we
consider the importance of adequate nutrition and water(amount and safety from infection). Even with respect
to nutrition, global health agencies recognise that overnutrition may be as important in the world as undernutrition. Nevertheless, the right to food and water are
fundamental human needs.
Can we advocate that there is basic right for adequate
sleep? Sleep is a biological necessity but different to foodand water in a fundamental way. We obtain food andwater from our own environment – humans (and animals)cannot produce their own food and hydration. However
humans need to generate their own sleep – with total sleep
deprivation, the innate drive to sleep builds up internallyand becomes dominant and unless generated, leads toincreasing sleepiness and then sudden sleep episodes torecover lost sleep. Even with shortened bursts of sleepthat are inadequate for proper homeostasis, the sleepinessand sleep attacks may be more subtle but ever presentrisks to health and safety. We cannot hunt for sleep likeanimals to do for food, we cannot “buy” sleep (despite theefforts of the pharma industry!) – sleep is an innate needthat we must provide time for its “production”. In thatsense, we need the right environment to generate sleep.
This environment needs to be safe and free of disturbing
noise or light or temperature extremes. Therefore ability
to provide good quality shelter/housing is fundamental togood sleep. However to maximise sleep also requires low
level of mental stress as well as low environment stress.
Conditions such as urbanisation with crowding, long work
schedules, shift work and especially night work are allcontributors to potential sleep loss [6].
T he term sleep loss is all encompassing including
voluntary and involuntary short sleep hours, insomnia andother sleep disorders that result in the attenuation of the
beneﬁts of sleep. However preventing or managing sleep
loss is rarely considered part of the global health agenda.
It does not get the attention of world health agencies andeven national organisations. Progress is often made in
wealthier countries by consumer or more often industry
driven action groups or professional groups with focus on
funding of high end diagnostic and treatment services.
However, despite the greater attention being paid to NCDs,
it is fair to say the right to good quality sleep is not on theagenda.

36

Ⅲ．Sleep Health and the Burden of NonCommunicable Disease
When considering the rise of NCDs, focus has beenplaced on the change in diets in economically developing
societies (more processed foods high in sugar, saturated
fats and salt) and reduced work-related physical activity
with urbanisation and change in work practices andtransport methods. Appropriately, road accident reduction
has focused on interventions such as helmets and seatbelts.
However, an argument can be made for increasing
attention to sleep health in reducing the global burden of
NCDs. Inadequate hours or fragmented sleep contribute toworsening atherosclerosis, hard cardiovascular endpoints,
hypertension, diabetes and premature mortality [7-11].
Similar disruption of normal sleep patterns results in lossof alertness, cognitive dysfunction, neurobehavioural
failure and increased catastrophic events such as motor
vehicle crashes, marine disasters and other catastrophic
events [12-16]. Lack of sleep or insomnia are associatedw it h development of ma ny ment a l hea lt h disorders[17-19]. Sleep disturbances may be early markers ofneurodegenerative disorders proving a way of selecting
those who may benefit from neuroprotective therapies[20].
While, there is growing evidence that lack of sleep andsleep disorders exacerbate many of the non-communicablediseases that are of concern to groups such as WHO, there
is inertia to change the agenda. There are several reasons –ﬁrstly, the view that sleep problems are problems of wealthiercountries and not an issue to economically disadvantaged
people. Often sleep disorders are seen as a problem of theneurotic “worried well” and not as fundamental as other
health concerns. Another reason is the silo mentality ofmany medical disciplines. Organisations will argue that“cardiovascular diseases” or “depression” are the issue
and not consider disorders that may contribute to these
problems. Sleep crosses all organ-based and other healthspecialties and as such requires inter-disciplinary researchand clinical care. The final reasons probably emanate fromthe sleep health field. The global sleep research agenda isyoung and we may not have the data or research systems inplace to advocate the importance of global sleep health topolicymakers. We need hard data to convince policymakers
that sleep health is actually a health issue not just a problemsof the “worried well” confined to highly rated economic
societies. Finally, as a field our organisational structures
are inadequate – there is only a very slowly emerging global
presence for sleep professionals often hamstrung by the needto function locally as a priority and lacking in global vision.

J．Natl．Inst．Public Health，61（1）：2012Global Perspectives on Sleep and Health Issues
In the next section, the impact of sleep on human healthis briefly summarised and a future agenda to deal with
global sleep health is discussed.

problem of sleep loss and mental health and other healthissues related to sleep loss.

Ⅴ．Sleep Health and Disadvantage
Ⅳ．Sleep Across the Globe
Sleep problems cannot be seen in isolation from societal
change. This is not to say that sleep was perfect in agrariansocieties hundreds or thousands of years ago but a numberof modern trends have contributed to the problem widening
from a poor physical environment to sleep to broader issues.
Sleep health issues affect many different countries withdiffering levels of economic development both rural andurban and in niche areas as diverse from call centres inIndia, to industrial workers in China and to military forces.
I ncreasing urba nisat ion results in crowding w ith
increasing noise from transport, pollution ( light andparticulate), stress and longer commute times as cities
get bigger. This provides a poorer physical and mental
environment for sleep. With “globalization” and the 24
hour society, workforces never stop and the cost is people
working at times their biology is programmed to sleep.
This provides a challenge to safety as it increases therisk of crucial periods of vigilance failure [21]. In turn,this is exacerbated by workforces (formerly from highly
regulated high income countries) being outsourced to
low and middle income countries with different and lessregulated labour laws affecting work and sleep hours. The
argument that less attention to sleep and safety will mean
increased costs due to human error is rarely raised.
Many in the global workforce are active during thenight hours. Busy mega-cities cannot afford to close theirinfrastructure during daylight hours, so road or otherrepairs are undertaken at night by often huge workforces.
Society may respond to the challenge to sleep in strange
ways - caffeine is now the world’s most popular psychoactive
substance in large part due to its temporary alerting effectand cultural acceptability [22].
One of the problems is capturing the impact of thesechanges. Some argue that there is evidence of reduced
sleep hours in society over the past century or even in
the past 20 years – others question this. It is likely thatthe proportions of extreme short and long sleepers are
increasing [23,24]. We know even less about sleep qualitychanges over time but evidence is certainly increasing of
the occupational risks of sleep loss [25].
In high-income countries, societal changes contributing
to sleep loss particularly impact on adolescents and young
adults. Technology such as the internet and mobile phones
can contribute to the problem [26]. As these technologies
become cheaper, they will contribute globally to theIncreasing dat a suppor ts the v iew that pover t y isindependently associated with poorer sleep health [2729]. T he f indings are robust and consistent across adiverse range of societies. These include studies fromthe USA (Figure 1) [27] showing clear-cut adjusted sleep
differences between poor white and racial controls. In theUK, data from the British Psychiatric Morbidity Survey
2000, (n= 8578 men and women aged 16–74) found strong
independent associations between sleep problems andfour measures of socio-economic status (SES) - householdincome, educational qualiﬁcations, living in rented housing
and not being in paid employment [28]. SES inequalities
played a major part in accounting for gender differencesin sleep problems and the direction and adjustment of thedata indicated that disrupted sleep may be a mechanism
through which low SES is linked to poor health. Other
studies from developing countries highlight the diverse
way sleep loss can impact on health. In a population-based
cohort study in Sri Lanka sleeping < 8 hours per day was
associated with impaired gestational weight gain after
adjustment for confounders [29]. In Nigeria, insomnia
rates appear similar to European and North American
prevalence with higher rates in women and those withgreater poverty [30].
A community based study of elderly slum dwellers in
Mumbai found high rates of depression in the elderlywith 62% of those depressed having sleep problems [31].

Figure 1 In a cross-sectional survey of 9,714 randomly
selected subjects, social disadvantage in UnitedStates was associated with impaired sleep quality.
Holding the odds-ration for poor sleep quality for
non-poor whites at 1.0, other racial and economic
groups with the most marked problems in poor whites(adapted from Patel et al [27])J．Natl．Inst．Public Health，61（1）
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37

Ronald R GRUNSTEIN
It is interesting to ref lect that it not just the “worriedwell” of wealthier countries that express concern about
sleep problems. Interesting data on the health domain of
sleep/energy has been obtained from African and Asian
centres (n=46,269) in the WHO Health and Demographic
S u r vei l l a nc e S yst em ( H DS S ) [3 2]. T hes e su r veys
invest igat ing di f ferences in socio - demographic andeconomic characteristics related to self-reported healthhave shown a great deal of variability in the 8 domainsof health complaints between different countries andgenders. Sleep problems were rated highly in self-reported
health in Ghana, Vietnam, South A frica and Kenya in
men and Ghana, Vietnam, South A frica but not Kenya
in women. In Indonesia, Bangladesh and India the sleep
domain was less predominant. These data highlight thatsleep problems are not insigniﬁcant issues to people livingin these countries.
L ower SES is linked to higher rates of obstructive
sleep apnea in adults and children [33]. Moreover withgrowing world problems with overnutrition and increasing
rates of obesity, future higher rates of sleep apnea will
be expected. This would be magnified in those Asian
countries such as India, China and Korea where racialdifferences in cranio-facial morphology predispose to thedevelopment of OSA [34]. High rates of OSA are likely tobe linked with higher rates of diabetes and hypertension.
There are many diverse ways that social disadvantage
and sleep loss inter-relate to contribute to ill-health. Someof these concepts are listed in Figure 2.

Ⅵ．Sleep Health, Inflammation and Vascular
DiseaseSleep loss appears to favour the development of a proinﬂ ammatory state with increased risk of vascular damage
and consequences of stoke, myocardial infarction andoverall mortality. Epidemiological studies such as theW hitehall study [35] have shown intriguing links not
only between long working hours and sleep disturbance
but also sleep loss and increased mortality. Redline andFoody [36] argue to that sleep loss should be added tothe top 10 potentially modiﬁ able risk factors for vasculardisease in addition to established factors such as tobaccosmok i ng, over weight , dysl ipidem ia , hy p er t ension,
physical inactivity, poor diet, and psychosocial factors.
This is based on research over the last decade provides
linking short sleep hours, insomnia and sleep apnea tothe development of vascular pro-inﬂ ammatory factors andsubsequent heart disease. Even use of a simple question(after robust adjustment for confounders), “Have you had
difficulties falling asleep in the last month?” identified agroup of individuals at a significantly increased relativerisk of experiencing a subsequent myocardial infarction
with the more disturbed sleep, the greater the cardiac risk
[7]. In the Coronary Artery Disease In Young Adults Study(CARDIA), the 5-year incidence rate of coronary artery
calcium was inversely associated with sleep duration
measured at an early time point [9]. In the MONICA
Ausberg study of nearly 7,000 adults followed for a meanof 10 years, an almost 3-fold increased incidence of AMI
was observed in women who reported sleeping <=5 hours
compared with those sleeping 8 hours per night [37].
Longitudinal studies have associated obstructive sleep
apnea with increased mortality and observational cohort
studies of CPAP treatment support risk reduction from
CPAP therapy [36]. There is even data linking restlesslegs syndrome/periodic limb movement disorder withincreased cardiovascular risk [38].

Ⅶ． No Mental Health without Sleep Health

Figure 2 Interdependent mechanistic processes related tosleep loss in poorer urban areas38

A recent publication in Lancet strongly argued thatmental health awareness needs to be integrated into all
aspects of health and social policy, health-system planning,and delivery of primary and secondary general healthcare. The article was entitled “No Health without Mental
Health” [4]. Given the strong links between sleep loss andworse mental health it could be argued that reduction insleep loss may be an important underpinning of bettermental health globally. This can be demonstrated across a
range of mental health disorders.

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For ex a mple, depres sion is t he lead i ng c ause of
disability in both women and men in the United States
and worldwide and one of the 10 leading disorders for
global disease burden. Major depression commonly cooccurs with symptoms of insomnia and the close link
between insomnia and depression [17-19] suggests that theconditions are not just randomly associated. Insomnia is
now considered not only a symptom of but also a possible
predictor of depression. Meta-analysis [39] has shownthat non-depressed subjects with insomnia have double
the risk of developing depression compared to people withno sleep difficulties. In people with no sleep difficulties,
the incidence of depression is much lower as compared to
the general population. The different age-groups showedthat the ef fect of insomnia in predicting subsequent
depression is si m i la r i n ch i ld ren a nd adoles cent s ,working-age individuals, and elderly individuals. Whilesome epidemiologic studies have indicated that longwork hours/overtime work is an important risk factor for
depression, recent work has suggested that this may be a
confound of associated short sleep hours and perception of
insufﬁcient sleep. Certainly the concept of “work burnout”
is associated with sleeping problems.
The combination of short sleep or insufﬁcient sleep withlong work hours has a synergistic effect on depression[40] In the Whitehall II cohort study [41] working morethan 55 hours per week, compared with working 35 to 40
hours per week, was associated with 1.98 times higher
odds for shortened sleep hours (< 7 hours per day) while
repeated exposure to long work hours was associatedwith up to 3.24 times higher odds for shortened sleep. In
a Wisconsin-based prospective cohort study, shortened
sleep (< 334 minutes per night) was associated with
3.18 times higher odds of depression as compared withsleeping 409 minutes per night [42]. Disturbed sleep andcircadian rhythms are important features of mental healthdisorders [43].
T here are high rates of depression in people with
obstructive sleep apnea (OSA) in both community andclinical populations. A large community study reported
a rate of 17% and reports for sleep clinic samples range
bet ween 21% and 41% . Both conditions share similar
symptom clusters and confounders (eg obesit y) andintervention trials are very limited [44].
If insomnia is indeed a predictor for depression, early
and adequate treatment of insomnia might contribute to
the prevention of the future development of depression[45,46]. This view seems to be supported by some studies
showing that adding cognitive-behavior treatment for
insomnia (CBT-I) is efﬁcacious also in patients with both
symptoms of insomnia and depression and guarantees abetter treatment outcome in this population than standard
antidepressant treatment alone.

Ⅷ．Sleep Loss, Human Error and Violent Death
The links between sleep loss and injury and death are
well established [12-16]. Sleep loss results in sleepiness,
impaired judgement, risk taking and loss of alertness
cumulating in human error that can result in individual or
large-scale death. A number of disasters have in part orwholly been attributed to human error due to sleep loss.
These range from exhausted shift workers at Chernobyl,
over worked crew in A laska with the Exxon Valdez to
one driver over-using the internet at night with the Selby
train disaster. There are huge economic consequencesof sleep loss resulting in single or systems human error.
Problems are exacerbated in societies where there arelimited systems regulating works hours and rest for those
involved in sustained operations. Often investigationsof such catastrophic events in developing countries arelimited and little attention paid to sleep loss compared withinvestigations by NTSB in US or transport in higher socioeconomic countries where sleep loss is more frequently
considered in investigations. Sleep disorders such as sleep
apnea contribute to fall asleep crashes and human error[47]. Even on Canadian farms those who sleep less than 6hours per night during the peak agricultural season hasheightened work anxiety and stress and injury risk due tothis sleep loss [48].

Ⅸ．The Global Sleep Health Agenda Moving
Ahead
The only way to properly prioritise sleep health in the
global health agenda is to continue on the pathway oflarge scale sleep and circadian research. This research
agenda needs to extend to world regions that are not
traditionally centres of sleep research. The involvementof such regions requires training and investment locallyin research infrastructure not an easy task in times ofworldwide economic difﬁculties. Such research is crucial
to better engage international health agencies who, at
this stage, have limited engagement with sleep health andprofessional organisations involved in the ﬁeld. This paper
has highlighted some of the growing evidence that lackof sleep and sleep disorders influence the developmentof and or worsening of non- communicable diseases/
disorders. These sleep health issues are not confined to
wealthier countries. However in poorer socio-economic
countries the focus will be on simpler diagnostic tools
and interventions that can be delivered at the population

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Ronald R GRUNSTEIN
level eg. Targeted investigation of sleep disorders in highrisk groups, prevention of accidents in transport industry
through health promotion, focused easily deliverable
behavioural interventions to improve sleep health.
K ey f a c t or s i n t h is a genda a re ou r p rofe s s iona lorganisations that can through expertise and advocacy
influence policy. The World Sleep Federation ( WSF), is
an international organization that was founded in 1988
and is currently comprised of seven Charter members(A merican Academy of Sleep Medicine, Asian Sleep
Resea rch S ociet y, A ust ra lasia n Sleep A ssociat ion,
Canadian Sleep Society, European Sleep Research Society,Federation of Latin American Sleep Societies, and Sleep
Research Society) representing about 53 sleep societies
and organizations, and over 12,000 individual members.
At our recent Congress in Kyoto, The WSF committed tobuilding this global agenda for improving sleep health.
We have seen similarly structured groupings such as theInternational Association for the Study of Obesity (IASO)
achieve important outcomes in global ways of dealing witha major public health problem through research, powerfuladvocacy and policy change. Like obesity, sleep healthcrosses all organ-based and other health specialties andas such requires inter-disciplinary research and clinicalcare. This sometimes provides a challenge locally andespecially when dealing with organisations internationally.
The WSF’s role in improving informatics and connectivity
between world organisations will be crucial in addressing
the global sleep health agenda.

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