Continuing education

Phyllis Berryman, RN, MBA, COHN-S/CM, FAAOHN

Eileen Lukes, PhD, RN, COHN-S, CCM, FAAOHN

The Costs of Short Sleep

by Kathleen K. Ohlmann, RN, MSN, COHN-S, and Mary I. O’Sullivan, MS

abstract
Sleep plays an important role in workers’ lives, allowing them to relax, restore, and revitalize their bodies, minds, and
emotions every 24 hours. Sleep repairs the physical body to improve and maintain general health, consolidate learn-
ing and memory, and recharge the psychological batteries to maintain emotional balance and well-being. Quality sleep
is as important as nutrition or exercise in maintaining overall health. A nutritious diet provides vitamins and minerals to
maintain body functions and generate adequate energy to perform daily tasks. Regular exercise keeps muscles toned,
improves cardiovascular activity, and reduces stress. However, neither diet nor exercise replaces the need for sleep. With
prolonged inadequate sleep, humans do not function well. They become accident prone, are less productive, and experi-
ence increased fatigue and health problems. This article discusses the importance of sleep, sleep events, health risks
associated with inadequate sleep, and health care professionals’ role in protecting employees and companies.

D
o coworkers complain about difficulty sleeping?
Many workers do; in fact, more than 70 million
Americans suffer from sleep problems (www.
sleepfoundation.org). Fatigue and sleep loss cost the na-
tion billions of dollars each year, according to the Wash-
ington, DC-based National Sleep Foundation (www.
sleepfoundation.org), which regularly conducts sleep re-
search and disseminates the latest sleep information. Why
is this important to occupational health professionals?
Although occupational health nurses cannot “make” em-
ployees sleep, they can explain the value of sleep through
About the Authors
Ms. Ohlmann is President, Work Place Solutions, Inc.; and Ms. O’Sullivan
is President, Quanta Dynamics, Inc., Louisville, KY.
The authors disclose that they have no significant financial interests in any
product or class of products discussed directly or indirectly in this activity,
including research support.
Ms. Berryman is Senior Consultant, Medical Management, Integrated Dis-
ability Management Department, FinCor Solutions, Lansing, MI. Dr. Lukes
is Health Services Southern Regional Manager, The Boeing Company,
Mesa, AZ.
education to improve worker health, performance, and
safety.
In this article, the authors present four key ideas: the
importance of sleep, sleep events, health risks associated
with inadequate sleep, and the health care professional’s
role in protecting employees and companies.
The Value of Sleep
Sleep plays an important role in workers’ lives, al-
lowing them to relax, restore, and revitalize their bodies,
minds, and emotions every 24 hours. Sleep repairs the
physical body to improve and maintain general health,
consolidate learning and memory, and recharge the psy-
chological batteries to maintain emotional balance and
well-being.
Quality sleep is as important as nutrition or exercise
in maintaining overall health. A nutritious diet provides
vitamins and minerals to maintain body functions and
generate adequate energy to perform daily tasks. Regu-
lar exercise keeps muscles toned, improves cardiovas-
cular activity, and reduces stress. However, neither diet

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nor exercise replaces the need for sleep. With prolonged
inadequate sleep, humans do not function well. They be-
come accident prone, are less productive, and experience
increased fatigue and health problems.
So why do so many workers experience too little
sleep? The recommended amount of sleep is 7 to 8 hours
per night or 1 hour of sleep for every 2 hours awake, al-
though the current average sleep time has decreased to
about 6.7 hours per night in the United States, according
to the National Sleep Foundation’s “2008 Sleep in Amer-
ica Poll” (www.sleepfoundation.org). The 24/7 American
lifestyle is a main culprit limiting sleep time, and for many
sleep is considered a luxury. Today’s economy mandates
that Americans work more and sleep less. Messages such
as, “Business can’t wait!” “Time is money!” and “If you
snooze, you lose!” describe the ongoing pressure workers
feel.
How do health care providers know if workers are
sleep deprived? Some indicators are:
l Being dependent on an alarm clock.
l Feeling sleepy while driving.
l Being addicted to caffeine and other stimulants.
l Making mistakes.
l Forgetting.
l Feeling depressed or “uptight.”
l Getting sick frequently.
The National Sleep Foundation, in its 2009 “Sleep
in America Poll,” asked respondents how they cope with
sleepiness (www.sleepfoundation.org). Their responses
were:
l 84% just accept it and keep going.
l 58% consume caffeinated beverages.
l 38% choose foods high in sugar and carbohydrates.
l 37% nap.
l 5% take alerting medications.
What happens during sleep that makes sleep so
important? The basic physiology of sleep provides an-
swers.
The Basic Physiology of Sleep
Using modern technology, recent research in the field
of sleep medicine has provided vital information about
sleep. One area is a new understanding of the body’s bi-
ological clock and its significance to circadian rhythms
and the sleep process (Moore-Ede & Levert, 1998).
The Biological Clock Regulates Circadian Rhythms
The biological clock serves as a personal timekeeper,
and individuals unconsciously rely on it each day. Locat-
ed in the hypothalamus of the brain, the biological clock,
called the suprachiasmatic nucleus, acts like a pacemaker
governing important body cycles. It regulates the body’s
circadian rhythms, 24-hour cycles of the body, including
the sleep/wake cycle, the release of hormones, and the
regulation of body temperature and alertness levels.
The Sleep/Wake Cycle
The natural sleep/wake cycle is stimulated by chemi-
cals released in response to daylight and darkness. In the
early morning hours, the hormone cortisol and the neu-
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rotransmitter serotonin are released. Cortisol naturally
stimulates humans to awaken, and serotonin, when ac-
tivated by bright light, helps humans wake in an upbeat
mood.
Conversely, as nighttime approaches, cortisol and
serotonin are suppressed and melatonin, the hormone
responsible for the onset of sleep, is released (Hauri &
Linde, 1996).
Sleepiness, Body Temperature, and Circadian
Rhythms
Body temperature is lowest between 4 a.m. and 6
a.m. and steadily rises during the day, reaching its peak
between 7 p.m. and 8 p.m. Then, as evening progresses,
temperature falls, reaching its low point again in the ear-
ly morning hours. The onset of sleepiness is linked with
body temperature and circadian rhythms. The higher the
body temperature, within normal limits, the more alert
humans are. When body temperature decreases in the
evening and early morning hours, humans feel sleepy
and less alert. Even for those who work at night, this
natural process does not change, although it can be suc-
cessfully managed by some night shift workers, who
probably fight sleepiness in the early morning hours
(O’Sullivan, 2003).
When circadian rhythms are disrupted or changed,
they affect how well individuals feel physically, mentally,
and emotionally. For instance, if lifestyles include re-
maining awake late at night, working at night, or traveling
extensively, biological clocks become confused and cause
sleep problems. Because sleep/wake cycles are naturally
programmed to respond to daylight, darkness, and body
temperature, it is not easy to switch sleep time on and off
at any time of the day or night.
The Sleep Process or Architecture of
Sleep
Sleep is a diverse and complex process that includes
non-rapid eye movement (NREM) or quiet sleep, and
rapid eye movement (REM) or active sleep. Each of these
sleep states has different outcomes, but both are impor-
tant for alert daytime functioning (Maas, 1998).
NREM
Quiet sleep consists of light sleep and deep sleep.
During deep sleep, the body is restored through the re-
lease of hormones that promote tissue growth and repair.
When individuals are stressed, their bodies do not experi-
ence deep sleep. Instead, they spend much of their sleep
time in light sleep and often awaken feeling tired instead
of rested.
REM
Dream sleep restores workers mentally and emo-
tionally. During REM sleep, the active brain completes
complex tasks, such as organizing information, process-
ing new learning, and storing long-term memories. REM
sleep also is busy organizing ideas into neural networks
of associated ideas, facilitating problem-solving and de-
cision-making abilities. Dreams enhance emotional sta-
AAOHN Journal
bility by allowing individuals to process feelings and re-
solve personal issues. Normally, workers spend about 2
hours of the 7 to 8 hours of sleep time in REM, but if they
limit their sleep time to 6 hours or less, they also limit
their REM sleep, thus affecting their high performance
functioning and productivity levels.
The Sleep Process
An analysis of a normal 8-hour sleep period shows
that as workers begin to sleep, they gradually descend into
deep sleep and then periodically ascend into lighter sleep
and then dream sleep. As sleep progresses, humans spend
less time in deep sleep and more time in active or dream
sleep with the longest dream sleep period occurring in the
early morning hours, lasting 30 to 60 minutes.
Recent studies confirm that older workers spend
more time awake in bed or in light sleep, particularly af-
ter the age of 50 (O’Sullivan, 2003). They also engage
in less deep sleep and REM sleep, both of which are im-
portant to physical, mental, and emotional restoration and
renewal. Workers can improve their sleep by practicing
health-promoting habits and engaging in daily exercise.
Exercise strengthens the body and consolidates sleep pat-
terns, so workers spend less time awake and experience
better sleep quality.
Sleep Deprivation and Health Risks
Current research indicates a direct relationship be-
tween sleep deprivation and health risks (Institute of
Medicine, 2006). Although primary care issues are pri-
vate and not open to employers, business and industry are
experiencing the consequences of employees’ poor life-
style choices and poor health. Ignoring employee health
is like an ostrich with its head in the sand. The issues
are still there and are being paid for by health insurance,
workers’ compensation insurance, and absenteeism and
presenteeism.
To assist occupational health nurses in becoming
aware of the connections, examples of how sleep depri-
vation affects the human body and its ability to function
properly in the work setting follow.
Chronic Sleep Deprivation and Cardiovascular
Diseases
Renewal of cardiovascular tissues occurs during
deep sleep. Interruption in deep sleep can cause damage
to organs that do not receive the rejuvenating time for
healing and repair while the body is in a state of rest and
relieved of any outside demands (O’Sullivan, 2003). In
addition, circadian rhythms are out of sync with external
rhythm regulators—light and dark. Researchers at the
Peter Munk Cardiac Center of Toronto General Hospital
discovered that chronic sleep disruption can cause car-
diac and kidney disease. Major outcomes included car-
diomyopathy and significant scarring of kidney tubules
due to epithelial inflammation (Marino et al., 2008).
Mayo Clinic researchers believe the combination of
oxygen deprivation and extremely high nighttime blood
pressure caused by obstructive sleep apnea may be re-
sponsible for endothelial damage observed in their study.
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Because treatment of high blood pressure has been shown
to improve endothelial function, it is likely that by elimi-
nating nightly blood pressure spikes and oxygen short-
ages caused by obstructive sleep apnea, the condition will
improve. Researchers also find that they cannot control
blood pressure until they resolve or correct the sleep con-
dition (Somers, 2008).
Weight Gain and Sleep
Participants in a study conducted by Patel, Malhotra,
White, Gottlieb, and Hu (2006) found that when they
spent less than 4 hours in bed sleeping, their leptin lev-
els were 18% lower on average and ghrelin levels were
27% higher than among those who slept 7 to 8 hours.
Short-term sleep restriction lowers levels of the satiety-
promoting hormone leptin and increases levels of the ap-
petite-promoting hormone ghrelin, thus increasing sub-
jective appetite and hunger. It seems that sleep-deprived
individuals have an interruption in leptin levels and thus
tend to be hungrier. In this study, the reciprocal changes
in leptin and ghrelin observed in response to sleep re-
striction were associated with a 24% increase in hunger
and a 23% increase in appetite. Most of the participants
preferred calorie-dense high-carbohydrate foods such as
sweets, salty snacks, and starchy foods, with an increased
intake of 33% to 45%. It is believed that limited sleep is
the body’s chemical trigger to compensate for lack of en-
ergy and lack of sleep (Patel, Malhotra, White, Gottlieb,
& Hu, 2006).
Diabetes and Sleep
It was postulated in a study at the University of Chi-
cago that loss of deep sleep may increase the risk of Type
II diabetes (Tasali, 2007). After three consecutive nights,
participants’ insulin sensitivity decreased 25% and was
especially pronounced among those with the least deep
sleep. Short sleep duration (5 hours or less vs. 7 hours)
has also been shown to be correlated with diabetes inci-
dence. Sleep deprivation decreases glucose tolerance and
compromises insulin sensitivity by increasing sympathet-
ic nervous system activity, raising evening cortisol levels,
and decreasing use of cerebral glucose.
Memory and Sleep
Abnormal insulin levels may increase the risk of cer-
tain neurodegenerative disorders. Increased glucose lev-
els in the blood increase the acid level and cause inflam-
mation (Okereke, Hankison, Hu, & Goodstein, 2005).
Normally, insulin acts on the brain to provide learning
and memory. Insulin resistance may cause brain inflam-
mation, a key process in the development of Alzheimer’s
disease (Tasali, 2007). Studies also show learning is en-
hanced if it is immediately followed by restorative sleep
(Abel, Graves, Pack, & Heler, 2003).
Depression and Sleep
Individuals with insomnia are four times more likely
to develop major depression. They experience disruptions
in sleep architecture and rapid onset of irregular REM
sleep patterns. Their depression may be related to dys-
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IN S U M M ARY
The Costs of Short Sleep
Ohlmann, K. K., & O’Sullivan, M. I.
AAOHN Journal 2009; 57(9), 381-385.
1 Quality sleep is as important as diet and exer-
cise in maintaining good health.
2 Humans’ biological clock regulates four circadian
rhythms related to sleep—the sleep/wake cycle,
the release of hormones, the regulation of body
temperature, and alertness levels.
3 The sleep process includes non-rapid eye
movement, which allows physical repair of the
body, and rapid eye movement, which restores
individuals mentally and emotionally.
4 Chronic sleep deprivation is linked to several
common health problems, many related to meta-
bolic syndrome, such as cardiovascular diseas-
es, weight gain, Type II diabetes, poor memory,
depression, digestive problems, and cancer.
5 Occupational health nurses must educate em-
ployees about sleep, conducting proper follow-
up when necessary and treating these issues
promptly when they arise.
regulation of neurotransmitters such as serotonin, norepi-
nephrine, and dopamine, which regulate the sleep/wake
cycle. Sleep loss or interruption is also likely to cause
mood impairment (Roth, 1999).
Digestive Problems and Sleep
The link between sleep-disordered breathing and
gastroesophageal reflux disease is unclear. It appears
that when either is treated, they both improve. Corti-
sol levels may affect the gastric system, especially for
shift workers. As previously mentioned, cortisol levels
generally increase in the morning and decrease in the
evening. However, with ongoing stress, these levels re-
main high.
Metabolic Syndrome
Also known as insulin resistance, metabolic syn-
drome includes a variety of conditions that combine to
cause synergistic effects. By definition, individuals who
have three or more of the following risk factors may be
diagnosed with metabolic syndrome: overweight or a
large waist, hyperglycemia, hypertension, hyperlipid-
emia, depression, and stress. It has been found that the
brain system controlling the sleep/wake cycle might also
play a role in regulating appetite and metabolism (Van-
Cauter, Knutson, Leproult, & Speigel, 2005).
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Cancer and Sleep
The International Agency for Research of Cancer
states that night shift work has been classified as a “prob-
able carcinogen,” a primary health concern for occupa-
tional health professionals. Although shift work is already
known to affect health, work performance, and social life,
research regarding cancer and shift work is ongoing and a
conclusive link between the two has not been established
(Straif et al., 2007).
As noted in a white paper from Circadian Technolo-
gies (Aguirre & Moore-Ede, 2007), cancer is caused by
abnormalities in a cell’s DNA. Substances that can cause
abnormalities and lead to cancer are called carcinogens.
For an individual, the risk of developing cancer depends on
many factors, including length and intensity of exposure
to the carcinogen and the individual’s genetic makeup.
The classification of shift work as a probable carcinogen
was based on laboratory and epidemiological studies that
provided “sufficient evidence for the carcinogenicity of
light during the biological night” (Aguirre & Moore-Ede,
p. 2). The International Agency for Research of Cancer
noted there are six of eight epidemiological studies that
found a modest increased risk of breast cancer in women
who had worked night shifts for a long time, compared to
women who did not work nights.
The Health Care Professional’s Role
These previous studies are but a few with results
suggesting sleep is an essential part of the health system
and should be considered as important as nutrition and
exercise in promoting health. Short sleep does have a
direct negative impact on companies’ bottom line by af-
fecting employee health, performance, and safety. The
Institute of Medicine (2006) estimated that “hundreds
of billions of dollars a year are spent on direct medical
costs related to sleep disorders, such as doctor’s visits,
hospital services, prescriptions, and over the counter
medications. Sleep problems can have serious conse-
quences” (p. 1). According to the National Highway
Traffic Safety Administration, drowsy driving claims
more than 1,500 lives and causes at least 100,000 motor
vehicle crashes each year (National Technical Informa-
tion Service, 1999).
The role of occupational health nurses is to educate
and protect employees and companies, with the intent to
limit the risk and liability for all involved. As dedicat-
ed health care professionals, occupational health nurses
can assist workers through education and referral. Many
workers do not understand the significance of sleep.
Nurses can be the change agent needed to promote total
well-being of employees.
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