Sleep affects all areas of our life; it is a fundamental building block of achieving and maintaining good health along with good nutrition and adequate exercise. Yet it is often overlooked and ignored.
Introduction
2.1
Inadequate sleep is prevalent in Australian society with estimates suggesting four in every ten Australians are regularly experiencing inadequate sleep.
2.2
Inadequate sleep can be caused by sleep disorders or by insufficient sleep due to lifestyle factors, such as work patterns, or the use of electronic media. Environmental factors such as noise or light may also contribute to insufficient sleep.
2.3
The impacts of insufficient sleep include: increased risk of chronic diseases, impacts on mental health, impaired judgement, increased risk of accidents and reduced productivity. In 2016-17, the inadequate sleep was estimated to cost the Australian economy $66.3 billion.
Prevalence
2.4
The Royal Australasian College of Physicians (RACP) stated that inadequate sleep is experienced by ‘between 33 and 45 per cent of Australian adults, depending on the methodology used to define inadequate.’ The RACP added that when both adolescents and adults are considered, ‘poor or inadequate sleep affects over 20 per cent of people on a daily or near-daily basis.’
2.5
The National Sleep Foundation in the United States of America recommends that adults have between seven and nine hours of sleep each night. Younger people require more sleep, with the recommended duration for school aged children being between nine and 11 hours each night and for adolescents between eight and ten hours each night.
2.6
In 2017, Deloitte Access Economics (Deloitte) was commissioned by the Sleep Health Foundation to investigate the costs of inadequate sleep and sleep disorders to the Australian economy. Deloitte stated that there was ‘estimated to be 7.4 million Australian adults who did not regularly get the sleep they need.’
2.7
Deloitte estimated that 39.8 per cent of Australian adults experience some form of inadequate sleep. This was further broken down to:
5.8 per cent of adults with excessive daytime sleepiness (EDS) due to sleep disorders;
13.3 per cent of adults with EDS not due to sleep disorders; and
20.7 per cent of adults with subjective insufficient sleep.
2.8
The University of Western Australia Centre for Sleep Science (UWA-CSS) stated that in addition to people experiencing clinical sleep disorders many people were experiencing inadequate sleep due to ‘poor sleep hygiene, poor sleep measures and lifestyle problems.’
2.9
Professor Robert Adams, Professor Gary Wittert, and Dr Sarah Appleton (Adams, Wittert, and Appleton) stated that ‘recent research has found that 12 per cent of adults sleep less than five and a half hours’ a night. Adams, Wittert, and Appleton added that ‘nearly a quarter of adults report that their typical routine does not allow them to get enough sleep, with this figure rising to around 30 per cent in the prime working ages of 18 to 44’ years of age.
2.10
Professor Ron Grunstein stated that there is little evidence that Australians are getting less sleep than previously, stating that data suggests ‘average sleep duration has not changed much in the past two decades.’ Professor Grunstein added, while sleep duration appears to be stable, ‘scientific reports of poor sleep quality ... appear to have increased over the years in Western society.’
2.11
The University of Sydney’s Brain and Mind Centre (USyd-BMC) highlighted that sleep disturbance is also a problem for older people. The USyd-BMC explained that as people age they often experience sleep that is ‘less consolidated, with impaired sleep initiation and maintenance, more awakenings and less deep sleep.’
Prevalence Among Children
2.12
While adult sleep duration has not declined in recent decades, ‘sleep time in certain key groups has been affected, particularly children and young adults.’ The Well Spoken and the Canberra Sleeping Clinic (WS-CSC) added that ‘up to 24 per cent of all children, and 35 per cent of children under two years of age have frequent problems sleeping.’
2.13
The Australian Council on Children and the Media (ACCM) stated that the ‘early establishment of healthy sleep patterns has great benefits for children’s physical and cognitive development.’ The Parenting Research Centre added children’s sleep habits are a primary concern for parents, stating that ‘no other topic tops sleep in the parenting world’ and that parents are ‘desperate for sleep related information.’
2.14
The RACP cited evidence that 70 per cent of South Australian teenagers are getting insufficient sleep every school night. The Adelaide Institute for Sleep Health (AISH) drew attention to similar results from Canadian research which found that 85 per cent of teenagers did not get the recommended sleep duration.
Common Causes of Inadequate Sleep
Lifestyle factors
2.15
The Sleep Health Foundation (SHF) stated that a significant cause of inadequate sleep, especially among younger people, is due to ‘work pressures or lifestyle choices that restrict sleep to create more time for work, family, social, and leisure pursuits, including social media.’ The SHF added that some people also conflate achievement with having minimal sleep and stated that ‘the attitude of wearing short sleep as a badge of honour ... needs to change.’
Effect of Electronic Media
2.16
The ACCM was concerned that the use of smartphones and tablets in the evening is negatively affecting children’s sleeping patterns. The ACCM cited a survey which found that almost half of Australian children ‘regularly use screen-based devices at bedtime, with one in four children reporting associated sleep problems.’
2.17
Wellbeing in Schools Australia (WISA), a not-for-profit organisation involved in the training of school staff, stated that:
Students fear the disconnection from their online friends and are keeping their electronic devices switched on [24 hours a day]. The result being they are reporting to teachers of having their sleep regularly interrupted during the night.
2.18
Similarly, the SHF stated ‘children who have, on average, three hours of screen time per day are more likely to have higher rates of poor sleep and poorer educational outcomes than children who spend less time in front of screens.’
2.19
The impact of electronic media on sleep is not limited to children. The AISH commented on a similar pattern among young adults (from 18 to 34 years of age) and stated that ‘the majority [of young adults] do spend time on screens just before bed, and those that do are far more vulnerable to poor sleep and sleep disturbances.’
2.20
SleepFit also commented that we now ‘live in a world of constant digital stimulation and electronic entertainment ... and many of us value alternatives to sleep higher than sleep itself.’ As an example, SleepFit drew attention to the continuous episode programming of streaming TV services which entices viewers to keep watching. SleepFit added that in this situation the ‘perceived payoff for staying up far outweighs the payoff for getting a good night’s sleep.’
Other Lifestyle Factors
2.21
SleepFit suggested that the culture of some workplaces could be detrimental to the sleep health of their employees, stating that ‘there are still some organisations actively glorifying lack of sleep and promoting a culture of late-night work.’
2.22
The Melbourne Sleep Disorders Centre (MSDC) stated that in many industries it can often be seen as a positive trait to function with minimal sleep. The MSDC added that there:
... has to be a society-wide shift [to] not seeing sleep as something that can be traded off as an optional extra, or that we can cheat sleep as much as we can, but [instead seeing sleep] as something that is important.
2.23
Research led by Professor Robert Adams explored the link between working late into the evening and sleeping difficulties. The research found that of the 22 per cent of people doing work ‘in the hour before bed a few nights of the week or more, 69 per cent have two or more sleep problems, significantly more than adults who do not work before bed.’
2.24
Turning Point expressed concern about the effects of drug and alcohol use on sleep health. Turning Point stated that 40 per cent of Australians consume alcohol in the hour prior to bed and suggested that the ‘effects of alcohol on sleep are detrimental to both underlying sleep physiology and health.’
Environmental Factors
2.25
The Institute for Social Science Research (ISSR) emphasised that environmental and social factors can have a significant impact on an individual’s ability to gain adequate sleep. The ISSR added that there was a need for sleep research to be translated into interventions which benefit the broader community, and stated that:
Such interventions may include consideration of built environments (e.g. street lighting and road noise impacts on sleep), policy (e.g. school start times or work shift times), and other aspects of urban and social planning.
2.26
The Public Health Association of Australia described sleep as a ‘key indicator of social wellbeing’ and stated that sleep problems can be caused by factors including ‘poor housing conditions, noise and light pollution, lack of neighbourhood safety, unemployment, insecure work, financial hardship, and other stressors.’
2.27
SleepFit reported that among the 4000 people who had participated in its programs the most common environmental barriers to sleep were: bedrooms that were too hot or cold (37 per cent of participants), interruptions by children (20 per cent), and external noise (17.5 per cent).
2.28
Professor Sarah Blunden, Dr Yaqoot Fatima, Dr Stephanie Yiallourou, and Associate Professor Chris Magee (Blunden, Fatima, Yiallourou and Magee) raised a number of social and environmental factors that may place Aboriginal and Torres Strait Islanders at greater risk of having sleeping difficulties. These issues include: overcrowding in remote communities; ‘the high prevalence of domestic violence’; noise and music late at night; and ‘psychological stressors’ linked to ‘environmental, financial, social, and educational disadvantage.’
2.29
Blunden, Fatima, Yiallourou and Magee added that research has found that, Aboriginal and Torres Strait Islander children:
... report poorer sleep quality (e.g. sleep scheduling, sleep fragmentation), decreased sleep duration, worse sleep hygiene, increased sleepiness, and more instability and irregularity in their sleep-wake patterns, particularly in ‘get up’ times.
Artificial Lighting
2.30
An inquiry participant drew attention to the impact artificial light can have on sleep stating that ‘exposure to artificial light, particularly in the blue area of the visual spectrum suppresses melatonin production, and, in turn causes sleep disturbance.’ The inquiry participant added that common sources of ‘blue rich lights are: laptops, televisions, computer monitors, cool white house lights and cool white outdoor lighting, particularly street lighting.’
2.31
Professor Grunstein drew attention to the increasing use of Light Emitting Diode (LED) lights which emit more light in the blue spectrum than traditional incandescent bulbs and are contributing to an annual increase of 2.2 per cent in global light pollution. Professor Grunstein added that while the overall light levels are important, blue ‘light is of the greatest concern as it has more powerful effects on the circadian system.’
2.32
Professor Grunstein suggested that there was a need for building regulators, and engineering and architecture students to have a greater awareness of the negative impacts of excessive light at night. Professor Grunstein also recommended greater use of timers, ‘light shielding techniques, and focused illumination’ to ensure light is only used when and where necessary.
Noise
2.33
Professor Grunstein stated that ‘the burden of disease from environmental noise is the second highest after air pollution.’ Professor Grunstein added that European research had found that:
At least one million healthy years of life are lost every year from traffic-related environmental noise in Western Europe. Sleep disturbance and annoyance, mostly related to road traffic noise, constitute the bulk of this burden.
2.34
The Waubra Foundation suggested that sleep deprivation may be caused by industrial noise sources such as: mining operations; compressors used in heating and cooling; coal, gas, and wind power facilities; and aviation.
2.35
The Waverton Wollstonecraft Rail Noise Action Group (WWRNAG) suggested that noise from passing trains is causing sleep deprivation in members of its community in Sydney. The WWRNAG added that its members reported taking longer than average to fall asleep and also waking between 8 and 11 times during the night.
2.36
Several inquiry participants living in the vicinity of wind power facilities reported that their sleep was being disturbed by noise, including low‑frequency noise, from wind turbines. Ms Melissa Ware attributed noise from the wind farm near her property with symptoms including an ‘inability to get to sleep, poor quality sleep, and waking up tired and not feeling refreshed or restored.’
2.37
The Waubra Foundation stated that some people do not become accustomed to low-frequency noise and vibration, but instead ‘they find they become increasingly sensitive to the sound.’
2.38
In addition to wind turbines, Ms Mikala Mihaljevic and Ms Sumaia Abass attributed similar sleep deprivation symptoms to low-frequency noise emanating from urban areas within Sydney.
2.39
Dr David Hillman of the Sir Charles Gairdner Hospital, who is a member of the Australian Government Independent Scientific Committee on Wind Turbines, advised that the distance that wind farms are required to be set‑back from residential properties varies between the states and territories. In Queensland, for example, the set-back is 1.5 kilometres and Dr Hillman stated at that distance most people ‘simply cannot hear the [wind farms] at all’.
2.40
Dr Hillman also stated that wind farms cause low-frequency vibrations and that if ‘you are right under a wind turbine there is a problem [but] if you are a reasonable distance from it there is not’. Dr Hillman added, however, that there may be individuals:
... with particular sensitivities to low-frequency, inaudible sound. Their needs need to be considered. It is a matter of listening respectfully, measuring, and taking action.
Impacts of Inadequate Sleep
2.41
The RACP outlined the broad range of impacts of inadequate sleep and stated that it:
... impacts full and functioning healthy recovery from existing conditions, work productivity, mental functioning, exposure to accident risk, quality of life, and a range of health conditions. It is also associated with increased all‑cause mortality.
2.42
Deloitte estimated that, in 2016-17, inadequate sleep and its consequences resulted in 3017 deaths in Australia. Over 77 per cent of these deaths were related to the effects of inadequate sleep on heart conditions, particularly among those people experiencing obstructive sleep apnoea. Almost 10 per cent of the deaths were due to motor vehicle accidents attributed to drowsy driving.
Health Impacts
2.43
The Australasian Sleep Association (ASA) summarised the importance of sleep describing it as a ‘fundamental biological need, which is essential for physical and mental recuperation.’ The ASA added that the impacts of inadequate sleep on health were wide-ranging as ‘the function of every cell in the human body changes when we sleep, so having insufficient or poor quality sleep impairs the function of every cell.’
2.44
The Australasian Epidemiological Association (AEA) stated that ‘studies indicate that poor habitual sleep increases the risk for the development of chronic health conditions by 20 to 40 per cent.’ The ASA described the conditions associated with insufficient or poor quality sleep, stating it results in a:
... greater risk of cardiovascular diseases, including hypertension, stroke, heart attack and arrhythmias; the prevalence of obesity and diabetes is increased; there is a greater risk of dementia and more rapid progression of the disease; and the prevalence of some cancers may be increased.
Physical Health
2.45
Adams, Wittert, and Appleton stated that research has found that among people who slept the recommended seven to eight hours a day at the start of the study, any ‘increase or decrease in sleep duration was associated with an increased mortality risk.’ Adams, Wittert, and Appleton added that ‘a wealth of evidence indicates sleep duration may be a significant determinant of metabolic health, with adverse effects on the levels of glucose, cholesterol, and blood pressure.’
2.46
The AISH described research investigating the impacts of sleep deprivation and stated if you limit the sleep of a person to:
... five hours [of sleep] a night for five nights in a row, and measure their blood glucose on night one and at the end of that five-day period they will have gone from being completely healthy to being in a prediabetic state. Your blood alcohol concentration equivalent is over 0.05 after just five nights in a row at five hours of sleep. If you take a 20-year old male, do that same bout of testing and measure his testosterone at the start and the end of the five days, it is as though he has aged a decade.
2.47
Ms Crystal Grant and Associate Professor Siobhan Banks stated that inadequate sleep ‘is associated with weight gain, which over time leads to obesity, a risk factor for numerous metabolic (including Type 2 Diabetes) and cardiovascular diseases.’ Ms Grant and Associate Professor Banks explained one ‘proposed mechanism for this association’ between inadequate sleep and obesity:
Firstly, short sleep duration leads to increased fatigue, which may result in reduced physical activity (including energy expenditure). Secondly, short sleep duration results in increased wake time and hormonal changes that may affect hunger/appetite, resulting in possible increases to food intake.
2.48
The Charles Perkins Centre stated that inadequate sleep caused by disruptions to the circadian rhythm have been linked to cancer, including ‘pancreatic, colorectal, and lung cancer, and glioma, glioblastoma and melanoma.’ In addition, the Charles Perkins Centre stated that ‘disruptions to circadian rhythm are linked to cancer progression and a worse prognosis.’
Mental Health
2.49
The SHF highlighted the link between poor sleep and mental health by providing the example that ‘poor sleep in young, non-depressed Australian women was found to increase the risk of subsequent depression more than four-fold within a decade.’
2.50
Similarly, the National Mental Health Commission (NMHC) stated that there are ‘clear and compelling reasons that indicate the close link between sleep health and mental health.’ The NMHC explained that ‘sleep deprivation can further contribute to the development of mental illness by lowering an individual’s resilience to respond to mental health problems.’
2.51
The NMHC also drew attention to research indicating a ‘strong correlation between sleep disturbances and suicidal ideation and behaviours.’ The NMHC cited a 2017 study which found that ‘sleep problems worsened suicidal thoughts in the ... days and weeks preceding a suicide attempt or suicide completion.’ The NMHC added that ‘complaints about sleep may serve as a warning sign and key risk factor, while providing an avenue for early intervention and prevention.’
2.52
The USyd-BMC advised that research indicates that there is ‘a bidirectional relationship between sleep disturbance and neurodegenerative disease.’ The USyd-BMC added that ‘sleep plays a critical role in clearing the brain of toxins’ and sleep disturbance is associated with ‘more rapid cognitive decline.’ The USyd-BMC elaborated:
... recently there was a system discovered in the brain called the glymphatic system. It is essentially the garbage disposal or sewage system in your brain, but it only opens up properly when you are sleeping well. And so now we have a mechanism of action that explains why it is that people with poor sleep end up developing these systemic brain disorders ... it could be in the long term—it has not yet been confirmed—that if you mess with this glymphatic system you start getting the metabolites build up ... that have been linked strongly with Alzheimer’s.
Economic and Social Costs
2.53
Deloitte estimated that, in 2016-17, the total cost of inadequate sleep in Australia was $66.3 billion. This cost comprised ‘$26.2 billion in financial costs and $40.1 billion in the loss of wellbeing’.
2.54
Deloitte described the financial costs of inadequate sleep as comprising: $17.9 billion in productivity loss; $1.8 billion in health system costs; $0.6 billion in informal costs; and $5.9 billion in other costs, including deadweight costs. The majority of the cost due to lost productivity was related to reduced employment levels ($7.7 billion) and presenteeism ($6.8 billion).
2.55
Deloitte’s estimated lost wellbeing cost of $40.1 billion was calculated by estimating the number of Disability Adjusted Life Years (DALYs) lost due to inadequate sleep. The cost of the lost DALYs was then calculated based on the Australian Government’s ‘official estimate of the value of a statistical life year lost.’
Other Impacts
2.56
Inadequate sleep decreases work performance and productivity and increases the risk of accidents. SleepFit stated that inadequate sleep has been recognised by the insurance industry as a major source of risk due to the fact that ‘tired people make more mistakes’.
Judgement and Mental Functioning
2.57
The RACP described the many ways that inadequate sleep can impair judgement and mental functioning, stating that:
Sleep loss impairs cognition, psychomotor function, and mood. This can result in lapses in attention and clear focus; reduced motivation; compromised problem solving; confusion; irritability, and memory lapses; impaired communication; slowed or faulty information processing and judgement; diminished reaction times; and indifference and loss of empathy.
2.58
Similarly, the WS-CSC stated that when sleep deprived:
... the human body struggles to extract glucose from the blood stream and the brain is unable to think clearly. This then impacts rational thinking, willpower, self-control, productivity, and interactions with colleagues.
2.59
The Appleton Institute stated that ‘21 per cent of men and 13 per cent of women have fallen asleep at work in the last month.’ The Appleton Institute further stated that research in high risk industries indicated that ‘workers who obtain less than five hours sleep prior to work experience almost twice as many errors as those who have slept more.’ In addition, the WS-CSC stated that ‘dangerously, most sleep-impaired individuals believe their ability to perform these tasks is at its usual standards, when tests show it is not.’
Impacts on Children
2.60
The impact of inadequate sleep in children can manifest differently to adults as the ‘effects compound over time and can have a significant influence on children’s growth and development.’ The WS-CSC outlined the physical impacts of inadequate sleep in children as including restricted release of growth hormones, increased risk of obesity, increased cortisol levels making it difficult to ‘wind down, go to sleep or stay asleep’, and weakened immune systems.
2.61
The WS-CSC further stated that for children ‘even small increments of sleep loss (as little as 30 minutes per night) can result in reduced performance on intelligence tests and affect learning in a significant way.’
2.62
The WISA stated that disrupted sleep among students, which it attributed to night time use of digital devices, was resulting in students not being ‘as attentive in class, struggling to remain awake, functioning below their capacity and in some instances not attending school on a regular basis or starting to disengage.’
2.63
In addition, the WS-CSC stated that inadequate sleep interferes with a child’s ‘capacity to regulate behaviour and emotion’, which in turn makes them ‘more likely to be rejected by their peers’. Similarly, Associate Professor Jillian Dorrian, Dr Stephanie Centofani, Dr Amy Reynolds, and Professor Kurt Lushington stated that ‘sleep plays a part in some of the critical issues in schools, including youth mental health and bullying.’
2.64
Blunden, Fatima, Yiallourou and Magee was of the view that although there is limited research regarding the impact of inadequate sleep on Aboriginal and Torres Strait Islander children available, evidence suggested it did impact on school performance and the likelihood of being absent from school. Blunden, Fatima, Yiallourou and Magee added that sleep awareness and education ‘may have potential as another as yet unexplored avenue to increase school attendance and school performance in young [Aboriginal and Torres Strait Islander] populations.’
Accidents
2.65
The WS-CSC stated that:
... even small amounts of sleep deprivation degrade a person’s abilities and increase the risk of micro sleeps—a dangerous state to be in while driving a car, wielding a scalpel or operating machinery ... unsurprisingly, a lack of sleep has been linked to motor vehicles crashes, industrial disasters, and medical and other occupational errors.
2.66
The AISH stated that ‘fatigue and sleepiness kill more people on the road than drugs and alcohol combined.’ Associate Professor Mark Howard and Associate Professor Clare Anderson elaborated that drowsiness is ‘the underlying cause of 20 to 30 per cent of road crashes’ in Australia.
2.67
The Queensland Government stated that ‘on average 31 people are killed and 462 seriously injured each year on Queensland roads as a result of crashes where fatigue played a part.’ The Queensland Government added, however, that these figures may underestimate the impact of fatigue as ‘it can be difficult to know if fatigue contributed to a crash.’
2.68
Research led by Professor Adams found that ‘drowsiness while driving is common’ in Australia, with 29 per cent of survey participants reporting driving while drowsy in the at least monthly. In addition, one-fifth of adults reported having dozed off while driving and five per cent reported having a ‘motor vehicle accident in the past year because they dozed off or were too tired.’
Concluding Comment
2.69
Sleep is a fundamental biological need, and (along with exercise and nutrition) it forms the foundation of health and wellbeing. Yet, as the Royal Australasian College of Physicians stated, the importance of sleep is often overlooked. It is concerning that four in every ten Australians are not getting adequate sleep and this indicates there is a need for a greater focus to be placed on sleep health.
2.70
The Committee was particularly concerned to hear about the impact that smartphones and other forms of electronic and digital devices may be having on the sleep health of children. The Committee heard that the majority of teenagers are getting insufficient sleep on most school nights, in part due to continual disruptions from their digital devices. Over time consistently insufficient sleep can influence children’s growth and development as well as impact their performance at school, and also increase the likelihood of the development of negative behavioural patterns.
2.71
Adults are also risking their health by not prioritising sleep in their daily lives. As with children, many adults are using digital media in the late evening and night, which may have a detrimental impact on their sleep. In addition, a culture of ‘burning the candle at both ends’, which encourages people to work late into the evening can also result in reduced sleep. Individuals may believe that they are able to cope with a lifestyle involving regular insufficient sleep without experiencing any serious health effects. Unfortunately the evidence suggests that this is not the case.
2.72
The Australasian Sleep Association stated that insufficient sleep affects the functioning of every cell in the human body. While there is a need for further research on the health impacts of sleep, available evidence suggests that insufficient sleep increases the risk of many serious health conditions including: obesity, diabetes, cardiovascular conditions, and cancer.
2.73
In addition, insufficient sleep has been associated with a range of mental health issues. Sleep deprivation restricts people’s resilience to deal with mental health issues and is associated with an increased risk of depression. Insufficient sleep is also linked with cognitive decline in older people. While the research is at an early stage, recent work has focussed on the role of sleep in clearing the brain of toxins and the possible links this may have to the development of Alzheimer’s Disease.
2.74
As well as having direct health impacts, insufficient sleep can impair judgement and mental functioning. In 2016-17, the impact that this had on productivity alone was estimated to cost Australia $17.9 billion. Including the effects on health and wellbeing, the overall cost of inadequate sleep is estimated to be $66.3 billion.
2.75
Insufficient sleep also leads to fatigue which is a major contributing factor to road accidents. Fatigue kills more people on the road than alcohol and drugs combined. One-fifth of adults have reported dozing off while driving.
2.76
As individuals, there are few lifestyle changes that can be made that are as simple as prioritising sleep and yet have such widespread positive impacts. Improving the duration and quality of sleep can reduce the risk of developing chronic health conditions, enhance mental wellbeing, and improve productivity and mental functioning.
2.77
The Committee recommends that the Australian Government prioritise sleep health as a national priority and recognise its importance to health and wellbeing alongside fitness and nutrition.