By Veronique Hauschild, MPH, U.S. Army Public Health CenterMarch 22, 2017
FORT RUCKER, Ala. (March 22, 2017) - Because losing is not an option and the cost of poor performance is high, the Army continuously strives to find ways to improve the mental and physical capacity of its Soldiers.
So why isn't the Army doing a better job managing Soldiers' sleep?
Fatigue refers to the mental and physical deficiencies that result from lack of sleep; excessive physical, mental and/or emotional stress; illness; medications; or a combination of these conditions.
Even with enhancements to Army programs that improve physical fitness and nutrition to optimize Soldier capabilities, studies show that the military culture has yet to give the proper value to sleep.
Poor sleep has been associated with impaired reaction time, poor judgment, accidents and low morale. Recent analysis of 2014 Army data, revealed that fatigue was a contributing factor in 628 Army accidents and 32 deaths.
Sleep loss results in decreased performance effectiveness and poses safety risks. Despite this, health officials believe the military has historically accepted, if not prided itself on, functioning on suboptimal amounts of sleep.
Remember the Army slogan, "We get more done by 9 o'clock than most people do all day?" The perception that a lack of sleep is the "Army way" still prevails. However, some leaders and Soldiers are starting to recognize that operationalizing warfighter management strategies to minimize fatigue is an untapped source for optimizing force strength.
Brain deactivation, especially in the parts of the brain that support judgment, thinking skills and alertness, are characteristics of fatigue from a lack of sleep. All Soldiers experience conditions that contribute to sleep debt (see Figure 1). The average military member gets just over six hours of sleep per night, instead of a more optimal seven to eight hours.
Short-term consequences of sleep loss are attention deficits, slowed reaction times, reduced alertness, impaired problem solving and reduced motivation, according to Lt. Col. Ingrid Lim, sleep lead and Office of the Surgeon General Performance Triad TRADOC coordinator, System for Health Directorate, deputy chief of staff for public health.
"Less than five hours of sleep five days a week can result in a 20 percent decrease in thinking performance," Lim said.
"Routinely, getting five to six hours of sleep per night is like performing with a blood alcohol level of 0.08 percent, which is like being drunk on duty. Clearly, the Army is not functioning at its best when Soldiers are regularly deprived of sleep."
Figure 1. Sleep Debt Experienced by U.S Army Soldiers (See attachment)
Poorer performance and quality of life studies conclude that inadequate sleep results in poor health, safety and readiness. Physical abilities, a core element of force strength, may reduce when a Soldier is tired.
Impairment to mental sharpness and the ability to judge and evaluate information are especially of concern to health officials.
Lim said sleep deprivation impacts to tedious and sedentary tasks that require mental focus such as guard duty and monitoring equipment are even more of a concern than simple physical task duties.
"Deeply concerning is when mental fatigue affects those in leadership positions," she said. "This is an area that we need to focus more attention as unit leaders tend to get the least amount of sleep. During training center rotations, as one goes up in the hierarchy of leadership, they tend to obtain less sleep."
In addition to the real-time impacts during military operations and training, studies have shown there are an increasing number of sleep disorders among service members. Officials acknowledge this is a serious public health concern.
In 2014, approximately 14 percent of Soldiers across the Army received a sleeping disorder diagnosis. Soldiers with inadequate sleep suffer from chronic diseases such as hypertension, diabetes, depression, obesity and cancer. They also have higher mortality rates, lower quality of life and overall less productivity.
How can the Army balance the need to condition Soldiers while improving sleep?
Table 1 (attached) summarizes several sleep management strategies that are available for use by the Army. A reverse physical training schedule is a strategy currently under consideration.
Reverse PT includes starting the Soldier's duty day later and having PT in the afternoon.
This may be beneficial because a "zero dark thirty" wake-up call tends to result in less morning sleep for young adults and teenagers and it may affect the quality of sleep because it is not in alignment with a Soldier's natural circadian rhythm of sleep, which is from 11 p.m. through 7 a.m.
Circadian rhythms can influence sleep-wake cycles, hormone release, body temperature and other important bodily functions. Consequently, they are associated with various sleep disorders such as insomnia and linked to obesity, diabetes, depression, bipolar disorder and seasonal affective disorder.
An initial evaluation study in an active duty unit-training environment suggests that even a short-term (seven- to 10-day) reverse PT schedule used with sleep banking (see Table 1) can improve military performance.
During the recent study, this sleeping strategy increased a unit's average sleep from five to six hours to over eight hours a night, 10 days prior a field training exercise. The study found improved performance, measured as gunnery scores, as well as better moods, greater motivation and more energy in the Soldiers.
The leadership reported higher morale and there were no accidents or injuries reported.
Soldiers indicated a preference for conducting PT in the afternoon because they were sleeping better, had improved family time, ate better breakfasts and were less irritable and less stressed overall.
However, leaders reported difficulty with a reverse PT schedule as the rest time conflicted with other work duties and meetings.
Leaders need to walk the walk and sleep the sleep
Lim said commanders and leaders are responsible for implementing means to improve health, wellness, performance and the quality of life of Soldiers both at home and work.
"Commanders must put as much emphasis on sleep as they give to physical fitness if we expect optimal performance," she said. "When in garrison, the priority should be to ensure eight hours on (duty) and 12 hours off so Soldiers can be fully rested in preparation for field training exercises and deployments."
Lim added that doing so could improve Soldiers' health resilience to emotional injuries. Additionally, she said that leaders must train and implement deliberate sleep management strategies so it becomes routine practice, and they should encourage sleep banking when able.
Though data is still limited, sleep banking appears to be one example of a strategy that could help Soldiers be more receptive to new information and feedback, grasp information easier and tackle tasks more efficiently.
"To fully optimize the potential that is lost to fatigue, the Army culture must shift leaders' mindsets to walk the walk and sleep the sleep," Lim said. "We need to be an example for our Soldiers."
Table 1. Sleep management strategies for the Army (See attachment)
Table 2. Army caffeine dosing schedule (per ATP 6-22.5) (See attachment)
This article is based on an interview with Lt. Col. Ingrid Lim sho shared information provided by members of the 1st Armored Brigade Combat Team 1st Infantry Division assisted with a pilot P3 evaluation of sleep banking. Special appreciation to Capt. Brad Jones, Company Commander for Charlie Company, 3-66AR Battalion, Capt. Jordan Thornburg, Physician Assistant for 3-66AR Battalion, Maj. Amy Thompson, Brigade Surgeon.