all of the costs of production distribution and consumption are accounted for today. we need you to transition to fairness within and between generations. a transition to peace amongst ourselves and all other creatures great and small. the growing momentum makes clear we are running out of time. soon we won't have anything to transition to. without immediate and substantive and systemic changes, we are not going to have a world that we're proud to give to our children and grandchildren and great grandchildren. a step in the direction of necessary change would be to redouble our support for the federal endangered species act. this would

increasingly favor a few at the cost of many. the degraded condition of our biosphere screams out we redouble our aspects in politics and policy. we must be part of a movement that puts a stop to politicians' disregard for science on matters of great importance like energy policy and human welfare in general. i know and you probably do too that we're imagining a massive mission to affect this great transition. massive missions always require

a mastery of politics. there's no other way to marshal the wreck zit resources. we could more fully master politics, we could more fully ensure a certain transition if more of us showed up to serve in elected office. you may agree that the world is run by those who show up. but you're not the least bit inclined to show up in show in the irrational world of politics. i found that politics is not all that irrational. i have served in the montana legislature for a decade. i sit in the senate. it's an irrational world. it's defined by a bunch of knuckleheads, but they're not irrational. more importantly i have come to believe that at its core our political system favors folks like us. it favors people who believe that facts and knowledge and scholarship and determination matter. why do i believe this? in this age of

hyperpartisanship? because of the way in which our country was founded. during the forive years from 1786 to 187788, they recognized there was with a way to establish a republic that resolved problems related to the rights of the federal government versus the rights of state government. there was no way to resolve the problems related to the rights of women. the rights of native americans, the rights of slaves. at the time of our nation's founding, those problems were insolvable. so our founders created a political system and parties as institutionalized channels for debate. which permitted dissent to be regarded not as treasonable act but as a voice. the genius of the constitution is that it provides a framework for debating questions endlessly

if need be. we will not succeed in ending the extinction crisis. we will not succeed in making renewable energy a foundation of a new energy future. we will not succeed in any efforts to make the world a more peace peaceful, prosperous and just place for all creatures great and small unless we more fully master politics. by winning more debates, by winning more4q!p÷ elections. in 1990, following 27 years of imprisonment, nelson mandela spoke 11 words that ended apartheid. he said we can't win a war but we can win an election. in 1994, he became south

africa's first black president and ended apartheid. similarly, we can pin more elections. by winning enough elections, we can ensure the conservation of the wonderous diverseity of life on earth. that is, of course, a critically important part of the great transition before us. thank you very much. [ applause ] >> hi. i'm have -- we have decided to shift and not do a panel. we don't have enough time in 30 minutes for discussion. i'm going to make a presentation. let me see if i can get this linked up here. yep. there we go. i'm going to give a presentation on how do we -- can we transform our food system to one that can

nourish 9 billion people by 2050 while mitigating and adapting to climate change and restoring the world's ecosystems. that's going to be the focus of my presentation. then these two folks that are here with me we have kate mcbride, who has a local farm here, she's going to speak to us about the beneficial role of livestock in providing nutrition for local communities and we also have brooke la vinvine to talk about some of the things happening on the farm. i'm going inging to start out way presentation. we would like to discuss the issues a lot more. we saw in the trailer some of the major problems that we are dealing with. a lot of people see livestock as part of the solution to climate change. that's a healthy discussion. we would like to invite to you have that with us over lunch. we're not going to get into the debate during this panel -- or

we're not going to have a panel. can we transform our food system? can we solve for this food, water and climate next us these intersecting issues? i believe we can. but we're going to have to talk to b something that makes us very uncomfortable. that is meat. we're in a consumption crisis. i don't want to villainize the animals and say that he are inherently evil as many would maybe -- who advocate for plant-based diets might share that perspective. they certainly play a role in lots of farming systems and have been really critical to the development of our agriculture over time. but we are in a consumption crisis where livestock are a driver of climate change, of fresh water and ocean water pollution. causing water stress and a threat to food security. to put this in perspective, we're raising 70 billion land

based animals a year that have a tremendous environmental cost. while we hear a lot about cattle, which are a really high carbon emitters i would like to point out the scale of chicken, pig and poultry production. because those animals are eating an enormous amount of grain. they take land and produce an enormous amount of waste. as bad as 70 billion animals a year we're raising and slaughtering are, the demand is skyrocketing. by 2050, we're trying to figure out right now how to produce twice the number of animals for consumption. this is actually driven by population growth but more by rising affluence. we wouldn't have a problem with feeding 9 billion people if everybody ate a little bit less meat and less resource intensive food. because the desire of all of these countries that are wonderfully joining us with rising affluence, they are wanting to have the same choices that we have to eat luxurious,

high resource intensive food. so if we want to provide that, the assumption is everyone should have the right to eat these resource intensive foods. everyone should have choice. so we're ramping up animal food production to give people the choices. the problem is is that livestock already dominate human land use globally. about 30% of the ice free surface of the earth is covered with livestock or for food we're growing for livestock. they occupy 75% of our agricultural land. we have about 842 million people that are suffering from hunger. a large percentage of the calories that are being grown on the land that could be fed to humans are fed to animals. we talk -- we heard about water. to put this in perspective this is the water we have on the earth. that's ocean water ice water

and everything. this is the fresh water available to us. this is the available drinking water. 70% of the this middle dot here is used by agriculture. animal foods are way more water intensive than plant-based foods. 32 times for fresh water to produce one calorie of beef than water. sometimes people say that it's six months of six minute showers is the water that it takes to produce one hamburger. that's a lot. i will get more -- there's enormous variability there. i will get into that more in the presentation. basically already 2.5 billion people live in areas that are subject to water stress. by 2025, it's going to be half of humanity. is this really how -- sorry. is this really how we want to use our precious water resources? while we're depleting the water, we are polluting it. livestock are the largest

polluters of fresh and saltwater systems. right now, there's 404 ocean dead zones. this shows the flows of all the nutrients and fertilizers into the ocean. a dead zone is where no aquatic life can live. the rate of dead zones have been doubling every ten years. we're on a tra jeblg torejectory to in increase that rate. this is an affluent pool draining the waste. each dot are cows. this is in texas. i don't show the whole thing. basically, this is surrounded by cattle farm. that's just taking -- draining the aquifer while it's polluting ground water. 80% of the deforest in amazon is used for pasture or feed for livestock. this is an area that's formerly

a forest in brazil. it is a large area providing grain for animals. so while we tend to think of this being directly caused by cows, actually a lot of that grain going to feed pigs and chickens in china. china is the largest purchaser of grain from brazil. the white meats are a major problem when it comes to feed and land to feed them. when you remove an acre of that land in the rain forest, it might have 3,000 or more species living on it. it gets replaced by cattle or by feed for livestock. 30% -- there is a delay up here. my slide show is not clicking through. there we go. 30% of biodiversity lost globally is attributable to livestock. climate change is responsible for 14.5% of all climate change. i know the trailer before said it's the leading cause of

climate change. that's not the case. it's not the leading cause of climate change. but it's a major cause. i think the bigger problem is that it's completely unregulated. we are not monitoring our emissions from our agriculture system. we have no plan in place to do that. also, it presents what i'm going to talk about the potential for mitigation through livestock. we hear a lot about cow parts and climate change. it's a joke. but the process for sheep and goat and all animals with multiple stomachs that digest grass, they emit -- 40% of it does come from that digestive process. we need to understand the system and the story behind this. we have to see that it starts with the clearing of land of forests and grass lands to produce the land to graze the animals and the land to grow the feed, then there's the energy production of the fertilizer,

the gassing from the fertilizer from the waste left on the grasses of the grazing land globally. all way through transportation. if you see the post farm transportation is only 3%. as much as we talk about we want to reduce emissions and eat locally, there's reasons to eat local food. but this is a really small percentage of the whole greenhouse gas pie that is from local foods -- from livestock. sorry. to put this in perspective, 14.5% is equivalent -- that is equivalent to the direct emissions from all of transportation in the world combined. all boats, trains, planes airports cars. so that's a lot of emissions. but it's actually the leading source of non-co2 emissions. nitrous -- there in lies our

opportunity to mitigate through reducing consumption of animal-sourced foods. this shows that if we reduce only co2 emissions or if we reduce only non-co2 emissions, we don't hit our targets. the only way to hit our 2 degree target is to cut both co2 and non-co2 emissions. it's a great opportunity available to us right now. in fact, this study shows a low meat diet cuts the cost of mitigating climate change in half. it's an incredibly economically efficient opportunity. this study here showed that what about took a look at what if we were able to increase productivity? what if we use biogas? and found the only scenario that enables us to meet our target cuts is by swapping out a significant amount of our animal-based calories with plant-based calories. they modelled a flextarian diet.

this is not at the forefront of every conference. the potential for agriculture to play a role in mitd gating climate change. we need to be moving this even further to the top of the agenda. it's a huge opportunity for individual action and society level shifts. meat is an untouchable. it's a topic that makes us all really uncomfortable. we all have our nutritional philosophy and food philosophies and food ideologies that are die divisive. we need to set these aside so that we can actually talk really honestly about this huge problem. the trailer talked about it being a conspiracy. i don't think there's a conspiracy. i think that it's something that's very socially uncomfortable to talk about. we need to overcome our social discomfort so that we can figure out how to deal with this

problem together as a society. this say topic that we could talk about quite a bit. grass-fed beef produces a lot more methane per gram of protein, more greenhouse gases, which is why the world is ramping up to produce a lot more factory-farmed meat. the scale of that production is actually really scary. i can get into that in the next slide. this shows you the emissions. this is aqua this is white meat and seafood and then you see how much significantly less plant-based foods emit. water is an important issue not just groan house gases. the pigs don't come out so well here per gram of protein when you look at it that way. that's because 1.5 billion pigs a year are raised mostly in these -- this is considered a success story.

this is an efficient factory farm. this is called sustainable intensification. they capture about 50,000 pigs will produce about half a million pounds of urine and feces every day. they capture that and produce energy from it. but this is the way that we're heading in order to feed 9 billion people meat every day. unfortunately, pigs are actually really good at creating meat based on waste. i need to move faster. there's a lot of side effects to this intensification, which is what the antidote is the small local farms doing things differently. we can't just switch to grass-fed beef because it does produce 60% to 07% more greenhouse gas emissions. it requires 80% more land area. so we don't have the space. if we're interested in feeding all the people joining us here on the planet, we cannot feed them all grass-fed meat. it's not an option. actually, when we look admit

gags opportunities in agriculture, this is a new report that came out in january which modelled different potentials. what came out is the number one is shifting dietary trends. if we can shift our eating patterns, it's the greatest potential available to us today to mitigate through agriculture and forest try. switching to a plant-based diet cuts carbon emissions in half. a third study said it's the easiest thing for an individual to do in their every day lives of all the lifestyle choices one could make to reduce their carbon footprint. they compared different energy efficiency and behaviors that one could engage in. dift difficult because they depend on livestock for livelihood. they are trying to get calories to people and meeting our goals is a huge challenge. but there's a lot of room for reduced consumption while still

getting the calories to people who need it. there are benefits to the individual and to the society in reducing animal-sourced foods. i'm going to move quickly through these. there's problems -- challenges to it because of all the enormous subsidies that we pay. you pay out of your tax dollars out of your pocket to keep this machine go to keep meat so cheap that we actually throw it away. we throw away a third of the calories that we produce which then most of that happens at the consumption stage. it's so cheap we don't value it. we throw it away. which creates additional carbon emissions. it's the equivalent as if 28% of our agricultural land is just wasted. it's for nothing. a transformation of agriculture is enormous opportunity. probably one of the biggest challenges that we have in the 21st century. it's not just about individual diets. there's a spectrum of sew sigh

cal level interest vejss from governance, ngo and media. research and also the food industry. bill gates has launched a project called the future of food saying 8% of the world's plant proteins have been explored for human consumption. there's an enormous opportunity. food is ripe for disruption. so this isn't something that's left outside the industry. but it's something we can invite industry into. reducing global meat production is essential. reducing meat consumption globally is an untapped opportunity for climate mitigation. choosing to eat plants is an enormous way for an individual to make a difference. we also need to advocate for societal level intervention. if we want organic food, we need to reduce the amount of animal foods we are reducing. our farms that are doing

integrated sustainable systems. local food is very very important. but to feed 9 billion people, we need to take a look at solutions on a global scale. that's a little bit of the context that i wanted to set. now i would like to shift the stage and share with brooke who has a video to share with us of some of the solutions that he is enacting here in our local community. [ applause ] >> where is the time keeper? i can't see it. i need to see it. what do i get, ten minutes?

thank you. god put animals on the planet for a reason. we just don't flow how to use them or work with them very well. we have lost touch with who they are and who we are and how they work in the system. is meat bad? are cows bad? are pigs bad? look what we do with them. before 1945 or so the world was organic. this country was covered with small-scale farms that distributed network of production and distribution and consumption. as soon as we started shipping things all over the planet from the cheapest source, we started

to mess with the nutrient cycle that keeps us alive. i've got a little video. i'm not going to show my slides. can you -- it's about a minute. we have been -- we got a little gem 35 miles from here. you can hear me okay? can this go longer? my neck is being bent. it will get me? is that good? okay? we have a little gem about 240 acres south of here. i get confused in this valley. but it's down valley. it's outside of carbondale. it's only 90 irrigated. don't start that yet.

about 150 wild, which is an important part of it, too. but on that we have a working ranch and a learning center. we are building soil, and we're growing grass, and we're creating an island of health in a sea of toxins. i think that's what we all need to do even in our homes. but one of the things we're doing is trying more every year, every day to listen to the animals, to the microbes, to the plants and opening up maybe our hearts more as an organ of perception than our brains. and create an environment or

arena for them to do what they need to do best. so nature is waiting for us as pete said just a minute ago, waiting for us to do the right thing. let's run this little video. it's only a minute. this is our compost tea that we spread. i have been a nozzle head, by the way. i'm spraying. if you drive by our place we're spraying. we're spraying this stuff. and it's compost tea. this is an 1,800 magnification. these are the farmers, these are the cultivators, these are what asville as sylvia said we need to protect. but i'm going to find out what they are and i'm going to make t-shirts for them. they are going to become the

next panda and whale or whatever else we need to fall in love with. there is life out there waiting for us to encourage it to do the right thing. if we do it again in a small scale, local system of production distribution and consumption, we can feed the world. look at those. they're like sharks some of those things. see them cruising around? is that it? that's the end. can you run it again? i like to see them. so looking at the whole situation systemically maybe there's not one issue. i mean agriculture is not sustainable.

never has been. it's a 10,000-year-old experiment. but at 7 billion, we're stuck with it. so we need to do it the best we can do with it. maybe we need a good pandemic. nobody wants to talk about that. we're a part of the problem. so i love my cows. and pigs. and chickens. and microbes. and i love all of you. we can do it. build an island of health. thanks. [ applause ] >> can you hear me? okay. i'm kate mcbride. i come to you from a different situation with a different hat. last year i spoke at our day and i spoke about my raw dairy and

why i got into my raw dairy. the reason was any daughter. i have a special needs daughter what has lung disease and no immune system. suddenly, life became all about probiotics antibiotics, anti viral property, enzyme property and oxygen. now my life thanks to my heros that i'm humbly sitting on the opposite side from lester brown and reading his works and various people like courtney white who wrote a book that impressed upon me greatly grass, soils and hope and now my life has changed. it's all about oxygen yes. the raw dairy. but also i have added to that factor carbon. now i'm oxygen and carbon dioxide and i find myself in the right place, i hope.

i see all this stuff on climate and i think, what can i do? oh, boy. i shouldn't be raising meat. but then again maybe i should be. i'm raising -- i run a raw dairy. i raise pigs and lamb. whenever i have a young bull he becomes part of the meat. so then i have beef. i think to myself, what can i do to change the carbon situation? what can i personally do? should i sell my cows? that's not going to do any good. then they will be sold to somebody else. maybe they will be slaughtered and they will die. they will go into the ground or be somewhere else. i started thinking about it. what seems important to me is it's not carbon is bad. it's where is your carbon. that's how i look at it. granted, i'm just a mom that tried to help my daughter.

i found myself on a dairy farm -- raw dairy farm, which is doing miraculous things for my daughter's health. she's no longer living in the hospital and not on house arrest. and i, too, with her immune disorder i had to raise clean food. going back to the cows if you will, because that seems to be a more common scenario, i started thinking about, well, what kind of nutrition am i giving my daughter? i had to be clean. i have organically raised animals. i cannot give them any chemicals, because my daughter can't handle it. same with pigs and sheep. and i started looking at a beef cow. it give u.s. 1,000 pounds of meet. a dairy cow gives you 300,000 pounds of high protein in their lifetime. i think there's two situations here. one, if you look at the big farms, the industrial farms, that's what's causing a lot of

your statements that come, say we should reduce beef in our diet. because most people don't have the opportunity to raise small animals and have small farms. i think of hay. if you put hay on the field and it's eaten by a cow and comes out methane gas that's producing same a.mount as if it's eaten by a rabbit left in the field to rot. i feel that the best process is to return all these farms to small ranches because the small rancher, what they do is they make it viable for the cow to survive. if you -- then the milk or meat it's all very clean. if you don't take care of the animal, you can't return the cycle full cycle. let me start again.

if you don't take care of what the animal is eating that brings us down to the grass. if we don't take care of the grass, then we're all going to find ourselves with the emissions that are produced by cars, everything. it goes into the atmosphere. if we look at other ways to return the carbon from the air back into the soil, one of the number one things you can come upon is resume nants. as a cow or a rabbit eats grasses, there's a root chute ratio. when they eat grass, the chute is shorter. then they drop off part of their root and all the carbon that comes from the oxygen -- from the air in photo synthesis they take the carbon dioxide from the air, photosynthesis, they turn it into liquid carbon, it goes to the roots. an animal eats it, they knock off part of their root and it

becomes into the soil and it feeds the microbes that then they have a relationship. and you return carbon to the soil. if it goes deeper into the ground, you sequester it for long periods of time. carbon storage. but the first way to get there is, same with memory, you can't remember something long-term if it doesn't go into short-term memory. if we can get into the short cycle of getting carbon back into the soil and then get it further, then we're starting to help the picture. so i'm being told i need to close up here. my take home message is i strongly feel that if we can look to other farmers that have done the same thing not just providing the meat but by taking small farms and you distribute

their pool, manure, i'm not sure what i can say over large lots of land urineyou are increasing the soil's viability and you are helping with the plants. the more plants, the bigger the leaf, the more roots, the more carbon you put back into the soil. they did a wonderful project out in california where they took great plots of land and they actually returned dry grass lands back to viable land. they, in turn, found that by putting one year's commercial dairy manure spreading it over the fields, they increased by 40% their carbon return to the soil. so if you find these big

industrial plants i think that the dairies or beef factories, you find that their waste is a huge problem. but if you put that waste -- if it's confined, it's waste. if it's spread out, it becomes a fertilizer. and a good fertilizer. not one that kills microbes but one that helps increase the viability of our soil. so i'm told i'm over. [ applause ] >> we would love to continue this discussion with you. if you would like to join us later at lunch. also with the -- perhaps the panelists from the next panel would like to join us and discuss this transformation of agriculture and what the opportunities are locally and screeri globally. we would love to see you there. thank you guys. >> can we have another round for this panel. with live coverage of the

u.s. house on c-span and the senate on c-span2 we compliment that by showing you congressional hearing. then on weekends, the home to american history tv with programs that tell our nation's story, including six series, the civil war's 150th anniversary american artifacts, touring museums to discover what artifacts reveal about america's past history bookshelf, with the best known american history writers, the presidency, looking at the policies and leg asays of our nation's commanders in chief, lechl turtures in history and our new series, reel america featuring educational films from the 1930s through the '70s. created by the cable tv industry and funded by your local cable or satellite provider. watch us in hd like us on facebook and follow us on twitter.

the national transportation safety administration held a summit last october on the dangers of driving drowsy. sleep specialists, medical doctors, representatives from aaa and vehicle safety advocates look at the prevalence of drowsy driving. the risks associated with sleepiness and driving. and what can be done to address this issue. welcome back, everybody. we're here for our third panel. which mr. bragg is going to lead for us. if you didn't notice we have expanded the audience. sitting in the back there, everybody, is a group from the national organization for youth

safety. noise. [ applause ] there you go. what perfect timing. our next panel is specifically on novice drivers. mr. bragg, whenever you are ready. >> thank you. as a reminder for our panelists sh , push the button on the microphone. when done speaking, turn it off by depressing the button. once again, our panel is on the concern for novice drivers. we have dr. nate lawson, president elect of the american academy of sleep medicine and professor of neurology and co-director of sleep centers at the university of washington. >> thank you. thank you very much for the invitation to speak here today. thank you for making some noise

back there. i'm very excited that high school students are here this morning for my presentation. because i'm going to be talking about why teens are susceptible to driving fatigue and what's happening to them that's making them susceptible. so i'm going to talk about the biology of teen sleep and what's going on during adolescent development in terms of regulating sleep. then teen behaviors that affect sleep as well as societal restrictions. and then what's going on with teen driving and sleep. so the biology of sleep, when we talk about the regulation of sleep biology, we talk about two systems. one is the timing system and the other the sleep/wake system. both systems undergo changes during the adolescent years.

so the timing system just' reminder what we are looking at here in the context of sleep pressure is this 24-hour pattern of higher and lower sleep pressure as a function of the internal biology of our daily clock. what happens to that daily clock during adolescent development? one way of looking at it is asking what is the -- how are you timing your sleep when you don't have anything else going on in the day? so weekend sleep timing if we look at midpoint of that you can see on the vertical axis, the midpoints ranging from about 2:30 a.m. in the 10-year-old and riedz rising to 5:00 a.m. in 20-year-olds. the second decade, the

adolescent phase is where we see a delay in this marker of the biological system. we can also look at it by measuring the biology itself. so by looking at the timing of the hormone that marks the start of the biological night each day. so we have done that and looked at this. it's called the onset phase of melatonin secretion. if you look at it as a function of the stage of puberty so the high school students in the back of the room here are probably at the puberty stage five. the latest progression on this, you can see clearly a pattern that the more mature an adolescent is, the later is the timing of this biological signal. so just a quick summary then. the timing of the rhythms get later across adolescented alesadolescence. as a result, sleep is favored

later in the day. of course, waking up is favored later in the morning as well. but we'll see, there's a problem for adolescents on that end side of the program. the second part of the system is the sleep/wake drive. so the longer you are awake the sleep pressure rises. as we sleep this sleep pressure falls, is dissipated, recovers from being awake. so we have again this pattern that's occurring on a daily basis. although, we alter this significantly many times. we measure this by looking at the type of sleep in a kwaul ;9 ñ taive way just assessing the brain wave patterns. we can also measure and look at this by looking at the slow wave activity. so here is an example of one child who was tanners one,

child-like development the first time she was studied, and a mature adolescent the second time she was studied. you see that the amount of slow wave sleep declined markedly. and the amount of and power of the slow wave activity during sleep also declined markedly. with a didn't change, however was this decay of the sleep pressure across the night. we can look at it in this slide in a different way where model systems are given showing that across puberty this recovery process is not changed. but the rate that sleep pressure builds slows down in the more mature adolescent. we look at that. it jives nicely from some perspective with the circadian processes. we see that recovery process doesn't change. so one interpretation of that is that the need for sleep stays

the same in a 10-year-old and a 17-year-old. but the pressure builds a little slower in the 17-year-old. so it's a little bit easier to stay awake longer. again the result of this is that late nights are favored. here now in a permissive way more than driven as we saw in the circadian system. the key point is the same amount of sleep is needed. so what else is going on with teens? yes, we have the biology. but there's a lot of other stuff that happens during adolescent development. there's psychosocial context. and we could go around the room and everybody could give a point on this. but we see one of the major goals of adolescent development is establishment of autonomy in behaviors and regulating your lives. there are a lot of adolescents who have jobs. a lot of who are using all kinds

of substances, caffeine being a major one, one of my mantras is that no child needs caffeine or should need caffeine. but we see much caffeine used in adolescents. now in the 21st century, screen time at night has become a big deal. social networking is now very highly available and available at night. and, of course, one of the major things that happens during adolescent developments are romantic attachments and the loss of those attachments. there's a ton more things. but one of the key parts of this psychosocial context is the context that society puts on adolescents with the school schedule. so the school start time is a major issue and a major thorn in the side of adolescent sleep. schools in the u.s. start early. in middle schools grade six

through eight, more than half start before 8:00 a.m. high schools looking at different school districts, we see, again, more than half starting before 8:00 a.m. this is a problem when sleep is delayed due to the biology of the system. here is a view of that problem. so this slide is showing that tenth graders, so these are young people on the verge of getting their driving licenses in a school that started at 7:20 in the morning, the kids were sleeping about seven hours a night. we monitored that. we can see when we had them in the lab sleeping that amount of night, and we tested how fast they fall asleep in the morning that at 8:30 a.m., which would be second period in their school, they are falling asleep in under five minutes. some of them were falling asleep

essentially when their head hit the pillow. recently, in august of this year, the american academy of pediatrics actually has now acknowledged that the school start time is a problem in adolescents. i have highlighted here one of the comments and the recommendations of this group was that most school districts middle and high school, should aim for a start time of no earlier than 8:30 a.m. if kids are not getting adequate sleep, there are many consequences. i have highlighted some here from a study showing that the reduction of sleep leads to a number of things that could be thought of as risk taking activities. so you see in these slides from texting while driving to

drinking in excess or drinking at all, i guess at this age in the united states drinking at all is excess. but there are problems and there are consequences for behavior as teens get less and less sleep. we have also seen some data showing that school start time changes have an impact on driving crashes in teens. not necessarily directly attributed to drowsy driving but sort of statistically attributed to the sleep -- the school start change. so lexington, kentucky, one of the first such studies showed that in year after the school district changed their start time from 8:00 a.m. to 9:00 a.m. the crash rate in teenagers went down -- we are going to break away by remarks by the french

president as he addresses the nation following the end of the hostage crisises. >> the next day, a policewoman who was killed in the south of france. and the twin hostage crisis which ended up with four people dead. france has faced the attacks. i would like to express my condolences to the family and those injured but france faced the attacks. it was our nation's duty the murderers were taken off in a printing warehouse and another oh one at the port in the

grocery store. i would like to thank the policemen and all those who took part in those operations for their bravery and confidence. i would like to tell them that we are proud. we are proud of them because when -- to save the human lives of the hostages and neutralize the terrorists who had committed murders. though france has faced up to these tags and that its security forces are composed of courageous men and women france also knows that it is not over yet.

with the threat. and hence i would like to issue a call for vigilance. together with the prime minister, i have strengthened our resources to protect all public places and make sure that we can get on with our lives quietly without being subject to any risks or threats. but we need to be alert. i would also like to make a call for unity. i have said so to the french nation. unity is our weapon. we must show our determination to fight against anything that might divide us and be im

implacable. today this is obviously a hosht antisemitic act committed. not being divided means we should not paint people with a broad brush and we should beware of exaggerations. those who have committed those acts, those fanatics ses have nothing in common with the muslim faith. we must be able to respond to attacks with force when we need to use force. but also with is solidarity and we need to show that solidarity is effective. we are a free nation that does not give in to any pressure that is not afraid. because we carry an idea that is greater than us. and an ideal which we are able to promote.

once again i would like to salute our soldiers who make sure we effectively fight terrorism. governments and heads of governments from across the world have expressed solidaritiment some of them have said they would be present during the mass demonstration on sunday. i will be with them. i would like to call upon all the french people to stand up this day for liberty pluralism, all the values that are so important to us and which europe, in a way, also represents. so that we'll be stronger after this trial. long live the republic. long live france. >> those remarks from the french president hollande courtesy of france-24.

now on c-span3 we go back to a national transportation safety administration summit on the dangers of driving drowsy. i think we get the most traction if we gear our message towards teen boys and young men as the primary target, but clearly we will be addressing driving issues in all teenagers. one of the other things that we need to acknowledge as we try to tackle this problem is the fact that the teenage brain is not yet fully developed. i think anybody here who has a teenager will probably -- this will resonate for them. but we know that through the teenage years, in an area ever the brain called the prefrontal cortex, there's ongoing developmental processes to develop this brain area and this area is really crucial to aspects of judgment, decision making and moderation of social behavior. so if it's not fully developed, then what you have is that teenagers are more apt to not really be able to correctly

assess risk and perhaps engage in more risk taking behavior than adults would. another challenge is the fact that teenagers and young adults are more susceptible and more vulnerable to sleepiness. so here is a study by fitness in 2012. on your left, you can see what they did was they sleep deprived these individuals to five hours the night before a simulated driving task that took two hours. the younger age group had an average age of 23 years. the older age group had an average age of 67 years. you can see that there were substantially more episodes where all four tires would go out of the intended lane in the younger age group than the older age group. this is after the same amount of sleep deprivation. on the right, you can see they were measuring the electro encephalogram. '02 it is a way to measure brain

waves and can indicate if someone is asleep or not. they found, you can see in the younger age group, more what we call power in alpha and theta ranges. really that means a greater propensity to fall asleep and more sleep occurring in the younger age groups. so there is another challenge as we try to address this in the younger group. teenagers are also prone to distraction and risky behaviors, and here on the left is some nhtsa data that showed that for crashes in teenagers that are 15 to 18-year-old drivers, that driver error was the cause in more than 95% of crashes. what i'd like you to appreciate is that, recognition errors, decision errors and performance errors make up most of this. so actually falling asleep only made up 1.2% of critical teen driver errors resulting in

accidents. however, this study did not assess crashes occurring between midnight and 6:00 a.m. which may have artificially reduces that number. recognition errors involving things like distracted driving or inattention. decisional errors involve driving too fast or aggressive driving. those things clearly can be influenced by sleep deprivation and drowsiness. so i think that that's a big issue. on the right, you can see a survey of -- population-based survey of over 500 young licensed drivers showed an increase odds ratio of crash involvement in two conditions. one was being a current smoker. the second was driving drowsy while alone. there's also overlap between drowsy driving and driving while impaired. that's highlighted here. when 11th grade students were surveyed, 13% admitted to driving while impaired at least once in the past 30 days. 24% admitted to riding while impaired, at least once in the

past year. you can see if you look at the odds ratios that the odds are increased over eight-fold of driving while impaired if you were sleepy or drowsy. you can also see that driving after midnight also increased the odds substantially of driving while impaired. not only that, we also have evidence that individuals and teenagers that are using cell phones while they're driving, either texting or on the phone, are more apt to drive while drowsy as well. so i'd like to turn our attention now to the american academy of sleep medicine strategy to try to address this issue. we're going to mostly do this through advocacy and education. we recognize the widespread prevalence of drowsy driving and its association with fatal motor vehicle accidents especially amongst novice drivers. what we're going to be doing is creating a transportation safety task force in order to address this issue. education is a big part of this. we know that it can be

effective. here is a study out of yale from last year which utilized a quick computer-based educational program about risky driving behaviors in emergency rooms and showed that when you assess these individuals one month later, you find that all of these risky driving behaviors were reduced, as well as drowsy driving being reduced by 16%. so at the core of our educational initiative will be efforts to partner with states to promote standardized evidence-based drowsy driving education within the local driver education system. we've done a preliminary assessment and found that at least 17 states currently include drowsy driving education in their curricula. what we have found is that there is high variability in the quality of the content. one exemplar is montana which has power point presentations, videos, and faqs sheets. we'd like to access this space and improve it where we can. we are also looking at state

drivers manuals. we have found that 48 jurisdictions out of 51, including washington, d.c., currently have information about drowsy driving in their drivers manuals. only iowa, south carolina and hawaii do not currently have this. so it is fairly prevalent. however, what we find is that the quality of what's there often can vary quite a bit. some of it is fairly superficial. here's an example of what's in the park arc state drivers manual. we will address this by drafting model language that states can adopt and include in their manuals to equip drivers with more comprehensive information about drowsy driving. we also want to address state driver's license examples and ensure that not only is the content being taught, but it's also being tested. and so here's an example of a practice question from new york.

but what we'll propose to do is write questions and then offer them to states to include in their driver's license examples related to the perils of drowsy driving. another approach that we plan to take will be to engage with another important stakeholder which is the insurance industry. and what we see is that when we've looked at this space, that there is some things being done, particularly by state farm, to try to address this issue with their celebrate my drive and steer clear discount program, if young drivers go through these modules, they can actually save money on their insurance rates. and so we're going to seek to partner with auto insurers to make drowsy driving education a part of their existing discount programs or collaborate and

develop new discount programs that address drowsy driving. as part of our national healthy sleep awareness project we'll have a public safety campaign and we have to be mindful that if we want to get some traction with teenage drivers that we have to have messaging that is going to resonate with them. these are some examples of messaging that is from the utah teen driving safety task force that we think will resonate with younger drivers and be compelling and be something that might motivate behavior change. so this forum is happening at a very advantageous time. it is actually teen driver safety week 2014. transportation safety is really an issue that can unite a diverse coalition of interest groups from both the public and private sectors. the academy's transportation safety task force and our healthy sleep project will seek to develop strategic partnerships with a variety of stakeholders, including federal and state agencies, safety foundations, medical institutions, professional societies, insurers, driving educators, and the auto industry. i want to finish with an example of success. this is the state graduated

driver's license laws that are out there. this shows how strategy and targeted initiatives can lead significant improvements in driver safety. so all states and the district of columbia have a three-stage gdl system which really gives young drivers the opportunity to develop the expertise and competency to drive while keeping them away from situations that would be unsafe. one of the major tenets is limiting driving hours so they are not driving at night. also limit being the number of passengers that can be in the car and whether or not they can have their cell phones with them when they are in the car. and this initiative has been tremendously successful. you can see here on the right that the change in per capita fatal crash rates by driver age has reduced substantially, over 70%, in the 16-year-old age group. so this is a true example of success. however, we have to be mindful that there's work still to be done.

the overall teen crash rates remain elevated compared to middle aged drivers. so in summary, what the academy is going to be doing is convening the aasm transportation safety task force. we're going to be assessing driver's education curricula, drowsy driving material for examples. we want to ensure there is accuracy and consistency in the content of the materials. we'll develop and insure a discount program. some elements of a drowsy driving campaign being targeted to the novice driver. research without action is merely an academic pursuit. thank you.

>> thank you, dr. watson. dr. watson touched on this briefly and we have young people here so i'd like to expand on it. would you discuss how prolonged chronic sleep deprivation affects the cognitive development of adolescents. >> how it affects their cognitive development? >> yes. >> well, there's not a lot of data on how it affects the development but it is clear that sleep deprivation affects thinking in a lot of different ways. it also affects learning and the ability to learn. you think about it on three levels we have it now. if you're too sleepy, you have trouble with the acquisition phase of learning. paying attention, not being distracted, being motivated to get the information in. so we hear education, education, education. well, if you're too sleepy, you're not going to be absorbing the education. secondly, sleepiness is going to impact how one retrieves the information. so you can acquire the information, but then you have to be able to use it.

so if you're too sleepy, too tired, distracted, unmotivated, that's a problem as well. and the third factor, in the last decade or so we've learned a huge amount about, is that sleep itself helps to substantiate those things you learn during the daytime. it actually improves learning. so the students who get plenty of sleep get a bonus in their learning purely from having a good night's sleep. and one of the things particularly maybe related to driving is the motor skills learning is particularly advantaged by having a good night's sleep. and a lot of what we do when we drive is sort of repeated motor skills. oh, you press this pedal, and you do this turn and you turn that.

so, the -- the quality and quantity of sleep are affecting the learning and the ability to perform at a number of different levels. >> i ask that question briefly, too. i think that there's some research out there in animal models that show that sleep deprivation can affect cells in the brain which are involved in mielinating the axons. getting back to frontal lobe development it would be a possibility i suppose is yet unproven that there could be some effect there, as well. and we also know that you know, sleep is important for many things, clearly, but, that sleep is a time when the by-products of neurotransmission get cleared out of the brain, and so if you're not sleeping, that's not happening, and there's some suggestions that that can create some issues with the protein deposition in the brain. >> thank you.

are adolescents as likely to become aware that they are becoming drowsy as adults in >> no. the short answer is no. you know, the adolescent brain is just wired differently, as has already been alluded to. and the part that's turned on seems fully functional is the emotional part. and it's that executive part that's not turned on, and not helping to gauge situations, and keep you aware of what's going on. one of my colleagues has alluded to this situation in adolescent as, since we're at a driving forum, as the accelerator is fully engaged, but the brake is not.

and so, you have this part of adolescent brain development where all of the emotional regulate -- all the emotional activity is there but the regulation of that activity, the foresight, the controls, are not fully engaged yet. >> another comment i'd like to make, so we do something in sleep medicine called the maintenance of wakefulness test which tests a person's ability to stay awake in an environment where they may be prone to fall asleep. and what researchers have shown that if you ask individuals to press a button, and younger individuals to press a button, as they get drowsier, as they feel sleep is imminent, that 60% of the time they fall asleep without pressing the button. and even if you incentivize it, you still get a substantial percentage of individuals that just fall asleep without érá. so i think that quite often

people -- they cannot judge how sleepy they are. they cannot judge that sleep is imminent. and obviously that has implications for transportation safety. >> okay dr. lawson as a parent of a child that by some measures is now an adult, when i think back to how he was learning to drive and i try to do all these things to make him safe it never really occurred to me to think about drowsy driving. my question is, are we doing enough to teach parents about sleep health so we can convey that to the children? >> i would argue we're not doing enough to teach parents about sleep health. i think sleep iq in this country is low right now and i think that, you know, that's one of our great challenges, is to get people to reprioritize sleep in their lives, in a forum such as this is one way to get the message out. because really ultimately, you know, the sleep habits that

these children develop when they're in homes with their parents are going to be the ones that are going to carry throughout their lives. in some sense having parents that enforce bedtimes, that get technology out of the bedroom, you know, that limit caffeine use parental involvement is crucial to good sleep health and good sleep habits in the youth of this country. you know, sleep education is not only limited to the general public, but unfortunately it's also limited within the medical schools of our country at the academy we've been trying for years to increase sleep education but haven't had a lot of success because curricula are already stuffed with so many other things. but we find that many medical schools only have two or three hours worth of sleep medicine education, and unfortunately we end up with many physicians out in the world that never think of sleep illness, or sleep problems when their patients come to see them. that's also a problem.

>> i think one of the really nice points of the american academy of pediatrics comments on school start time was also advice to pediatricians to get involved in this issue of adequate sleep for teenagers. it's the pediatricians who can help empower the parents to help guide and put limits on the sleep and the electronic activities of teenagers. and younger children, as well. >> thank you, have nothing else. >> fascinating presentations as a mom of a middle schooler i'm listening very carefully. so speaking of parents, and because we have a lot of youth

leaders in our audience today, dr. carskadon you mentioned the concept of school start times and i'd like to know if you have any advice or suggestion to people who may be trying to advocate for later school start times? any kind of words of wisdom for those individuals? >> it's a challenge. in the united states, there are thousands of school districts. every town, every, you know, village, has its own school district. and every school district has its own organizational style, and own, you know catchment area for students. some may have a commute of five minutes. some may have a commute of an hour or more. so, the challenges are individual for each district. there are things to help, though. those who are advocating. there are actually some nice

websites now that have, where parents have put together materials that are useful. the national sleep foundation also has modules on how to go about advocating for later school start times. and i think one of the big flags that thank you can be waved, since august 25th, 2014, is that advice from the american academy of pediatrics, which is backed up by another paper, which includes the data that supports this move. so it's a hard task but what's always fascinated me has been in school districts that make the change, the commitment that they show to the health and well-being of the teenagers in their schools is just staggering to me. i mean, it really is so impressive that what they do, how they arrange it, the steps that they take to bolster the situation, are just so impressive. and that tells me that it really does take a commitment in a big way to the health, the safety, and the educational needs of teenagers for schools to make this kind of change. >> you know, i'm in seattle, and

there have been a group of concerned parents, and professionals, that have been working to try to get a later school start time now for about a year and a half. and as, you know, observing that process, i think that what i've seen is like dr. carskadon is saying, it's really about education. and you need to educate the school board about the issue. and what we find is that once you begin to do that, i mean the argument that you make is so strong that, because you're talking about their well-being, you're talking about their being prepared to learn when they show up to school, that it's really hard to be opposed to it once you understand the issue. >> thank you. that's very helpful. my final question is just a bit of a curiosity thing. i read recently this term that i thought was very interesting, it was social jet lag and the concept being that even people who aren't using, you know, going on long-distance air travel can have circadian

disruption or dysrhythmia just by their lifestyles. it strikes me adolescents, even well intentioned adolescents on school nights might have very different schedules on weekends. i wondered if you observed that in your work and if you can comment on that. >> it's really a huge issue especially for adolescents because there's this biological pressure for them to stay up later. so it's almost as if they are jet lagged all week long, and then on the weekend, they can sleep at their biologically appropriate time. another way to think of it is we're also making them into shift workers. getting them up a totally inappropriate biological time and having them at school when their brain is really biologically prepared to be on the pillow at home. so social jet lag is a major,

major issue in adolescents who are sleeping at one time during the week, and then a totally different time on the weekend. and it isn't good for them. >> thank you both. dr. malloy? >> and as a father of a young man in high school, whose county is actually considering moving the start time back an hour, which i would like when i'm waking my son up to get him ready. unfortunately the cost has made it somewhat the school board would like it, the cost is too great.

are there any studies that look at the costs associated with not moving the school time? that the -- we've seen the crash rates are higher, learning -- you've mentioned learning. is there anything that can quantify that? >> there's one paper that comes to mind that was written in a -- the psychological economics journal about comparing improvements in middle schoolers' test performance by changing the school start times an hour later, the cost of that, versus getting the same improvements in their test taking by reducing the class size. and it was a 7 to 1 difference. so it costs 7 times more to get the same, you know, bang for your buck in terms of the performance outcomes by reducing class sizes, as by changing the school start time. so, yes, there are economic costs, but there are also ways to work around it. and you know, it is a complex situation, and a complex issue. but part of what's gone on is we've decided that the little

children can't ride on the same buses as the big children. which, i was at one forum where some high school students said, but those are our little brothers and sisters. what's the problem? and i think, you know, there are some -- some interesting thinking on these things that maybe need to be readjusted. >> i think when you consider costs, you know, similar question was asked of dr. flowers in his panel, and you know, i'm just thinking in a similar way to him that, you know, this is really a social issue. and how do you figure up the cost of the, you know, the safety of our children, their learning preparedness, their mental health, you know, all these things that are at stake here.

i think cost is obviously an important argument, but i think that there are many elements of this that clearly go beyond the cost assessment. >> dr. rosekind. >> thank you. i'd have three questions i'd like a comment from each of you, so we'll try to stay focused. starting in the last panel, even before that, there's been a lot of discussion about culture, and a lot of need for changing attitudes and behaviors. it seems a lot of, since it's education, education, education here, not just about drowsy driving but all these issues, seems like there's a real generational opportunity here by focusing on teenagers. and dr. watson you started on that a little bit but i'd like each of you to kind of comment. if we want 2015 to be the year there's no more sleep problems, it's not going to happen. it's going to take us awhile. and it seems like this focus on teenagers may be driving is part of the hook gives us this generational opportunity to really see some of the cultural

change that we keep talking about. could both of you make a comment about that? >> well, dr. rosekind, what was most exciting for me today was to see these youth leaders in the audience here. and i think, you know, we can, as grown-ups, can talk till we're blue in the face, and talk at these young people, but it's the leaders of the, i think, who really have the opportunity to get these messages across to their fellow teenagers. and to really have some impact. i think, you know, if we can convince those young people that get their parents on board, get the pediatricians on board, get

the school districts on board, and really shift the mind-set to where sleep is no longer the forgotten country, but part of our health behaviors, it's going to take work, it's going to take time, as you say, i've been trying to send this message for decades now, and it really seems like our society may be at a point where the commitment is there to do the things that will push this message forward. and the younger we can get it into the family life, the better we will all be. to start at teenagers, i think, is hard for many parents. if they haven't started in their 9 and 10-year-olds, and keep the bedtime setting, and keep, you know, thinking about planning for sleep. not just letting sleep be the last thing in the day, it's so much easier to keep that going, as the kids get a little older. >> you know, i think deliberate or not, there are some powerful interests that don't want us to sleep in this country. there's some that i refer to as the caffeine industrial complex out there. and i'm from seattle. but, you know, if you look at

what the stock has done on starbucks, you don't have to look very far to see that when there's a need for caffeine, that there's an economic benefit that's out there. you know, you also can't consume things when you're sleeping. so, you know, i think that we have to acknowledge these challenges that we have. but yet you know, we also have to also propose the -- you know, what the value of sleep is to teenagers. and you know, i mean they're pretty savvy, and i think they'll hear the message. you know, when we let them know that there's a lot of experimental and epidemiological studies showing an association

between sleep deprivation and obesity those kinds of things will get their attention. hat we also see in teenagers is obviously they're embracing technology, and there's lots of sleep health focused technology that's out there that i think is a real opportunity in order to engage people. what that tells me is that people are interested in their sleep. they want to know more about their sleep. and i think if we could just take it a step further, you know, to say -- to encourage them to get more of it, then we'll definitely be making progress. so, you know, i think it's going to be an educational effort. i think, you know, we need to convince people on a case by case basis to prioritize their sleep and see how they feel. i do that in clinic all the time. and it's a simple experiment you can do on yourself by prioritizing sleep for a few weeks. and you know, going to bed when you're sleepy and waking up spontaneously when you're rested. and then gauge how you feel during the day. and compare that. and you know, get people to focus on the quality of their wakefulness experience rather than the quantity of their wakefulness experience. and if we keep trying to get those messages out there i think eventually they'll resonate. >> thank you both. just briefly, you have one

bullet dr. carskadon on screen time. but if each of you could make a brief comment about technology. it seems to be part of creating the risk, and maybe part of the solution. but if you could just sort of give us a little bit more about the role of technology again, both as part of the problem, but also maybe in helping us out. >> well, part of the problem, there's a paper i have in my bag now that just came out showing that if you block the light from a technology in the evening, you actually will have better melatonin onset phase so the signal of night time is established better. but you know, the problems with technology, i think all of us can commonsense those. well, if you're using your technology, you're not asleep. if you have it in bed with you, and your phone is ringing, or pinging, you're not going to be able to sleep as well. so that's very clear.

to the extent that apps are made, or you know -- well my fantasy for technology was always a rolling blackout of the internet. for people whose brains are of a certain age. and you know, that's obviously not going to happen anymore. it's something we have to live with, and something we have to begin to understand better, and begin to use thoughtfully, and not -- and not use it so much so late to avoid sleeping. >> yeah. you know, this is a really difficult issue. because like you say, is it the solution, or is it the problem? i mean, technology has been interfering with sleep ever since the invention of the alarm clock. so, in my ideal world nobody --

everybody wakes up spontaneously now. that's clearly not the world that we live in. but, you know, i do think that, you know, as a sleep medicine practitioner that it's really important to have good sleep hygiene and a part of that is to have, you know, regular habits, and have a wind-down period of time where you're, you know, you allow your body to prepare for sleep. and you know, i think we have problems when people view sleep as something that they need to do. those are the people that have trouble. the people that sleep well are the ones that let it happen in the right circumstances. and so in generally speaking i think we need to keep technology out of the bedroom, and really kind of preserve the bedroom environment for sleep. >> so this is the last issue i'd like both of you to address, and that is, when you think of the conversation around start time

of schools, a lot of that is about learning. dr. sizeler's done a lot of work with medical interns and residents and that's around hours of work for learning. and yet in both situations, we can also focus on the car crashes. so we're here at the national transportation safety board, health well-being, but we're all about safety. and we're focused on this because lives get lost and people injured. and it seems that that piece, and you showed the data that when you change the start time of schools, crashes go down, safety improves, and i'm just wondering how much, again there's been a lot of health and well-being especially focused on the learning part, but really one of the, at least equally important hook here is the safety for all of these individuals at any level of our educational system, and for all

of us generally, to be focusing on how the safety element of this needs to be as included as health, well-being or learning anything else we want to be talking about here. >> well, you know, i think that we're really going to enact change through education here. you know, i -- you know i listen to the radio. i commute by ferry. i listen to the radio quite a bit. i hear so many public health announcements from nhtsa in regards to distracted driving and impaired driving. i'd like to hear some about drowsy driving. you know, i think that, you know, the academy through its national healthy sleep awareness project is going to be getting the word out but i think that, you know, we -- there's going to come a point where everyone will be aware of this. i don't think we're there yet. but we have to keep knocking on the door, in order to get our message heard. >> i think that there has to be a way to incentivize young people to get better sleep for their health and for their safety. and for the safety of their friends. and people they don't know on

the roads. one of the first stories i ever heard about a teen fall-asleep crash is you know is a tragedy that is repeated many, many times in this country. and we just -- we aren't hearing them. we're not listening to them. we're not telling our children about them. this first crash is a young man who was, you know, well on his way to college, he had gone to visit a college that he wanted to attend. he had stayed up late. he had driven too early in the morning. and he fell asleep, his car drifted, and crashed head-on with a car of another teenager, killing both of them. i mean, it's just that kind of story, and that kind of, you know, again, it's the let's wake them up by telling them the worst that can happen. because they're not hearing that. they're not seeing that. and they're not, you know, it's just not part of what is the

message that they're getting. that might help implement some change. >> great. thank you both for a great panel. mr. bragg your leadership, with just keeping at this high quality level of excellence here. to all of our safety leaders in the back. dr. carskadon didn't know you were coming but you made her day. if you didn't notice she was talking to all of you directly basically. so we're hoping you not only got some information to be educated but we may have saved the life and prevented an injury there with our folks that are here. we're about to break for lunch. i'm just going to take a little prerogative. i was reminded of something. i took it out of my opening remarks but i'm going to do it now. one of the things you just heard about dr. carskadon discuss was a sleep latency test which was objective physiological way to measure how sleepy people are. took two stanford professors to figure that out. i mention this because i was her first post-doc out of graduate school, first one when she moved to brown, and it means do i know sleepiness alertness to that

test, i know it extremely well. i mention this because part of my career was working at nasa and running something called the fatigue countermeasures program. the first call was from dr. carskadon saying mark what's this fatigue stuff? nobody knows sleep alertness better than you do. i'm bringing this up because our conversation was around specifically how people talk about sleepiness, alertness, drowsiness, fatigue, et cetera. so i notice fatigue was in your title of your talk today. and the doctor was going to include this. you're going to hear a lot of words today, fatigue, drowsiness, sleepiness, alertness. we're all talking about the same thing. we do not want to get pulled into a semantic discussion because we're really talking about the same thing. but we've already heard those words used differently through the day and i just want to highlight whether it's fatigue, sleepiness, drowsiness, they're all dangerous and they're all part of this we're talking about now. we're going to adjourn for lunch. we will see you back here starting at 1:15.

welcome back everybody. we are going to begin our fourth panel of the day. the chair of that is dr. mary pat mckay. whenever you're ready. as a reminder for the panel when you push the button on the microphone a green light will indicate the microphone is on. when speaking bring your microphone close to you and when finished please turn off the mic. in this panel, we'll discuss health issues. our panelists are dr. maurice ohayon, chief of mental health and population sciences at stanford university. dr. indira gurubhagavatula, associate professor in the division of sleep medicine at the university of pennsylvania and the director of the sleep disorders clinic at the philadelphia veterans

administration medical center. and finally dr. ronald farkas, lead medical officer in the division of neurology products at the u.s. food and drug administration. dr. ohayon. >> member rosekind, thank you very much to have invited me to this forum. so i will speak today about drowsy drivers in our generic population. so this data is coming from the survey that was realized in 2013. this study is very recent, and i am trying -- i will try to present you what are the results we found about the drowsy driver and a link with the sleep

disorder, the mental disorder, and also the medical condition. so, in fact, from where we are coming a number on drowsiness and accidents. generally speaking, they are coming from police reports transportation and safety agency. from insurance report. from clinical study for specific disease. all with numbers that are focusing on accidents, also sleepiness, but generally speaking with few number inside, and rarely from population studies. the way to collect the data is the correlation with the death toll are higher because, in

fact, we find, for example in the general population only the people that are alive and for just reason. the population survey representative of the general population are difficult to do, but are one of the best way to assess sleepiness at wheel without any consequences with the police, or with any kind of physical implication. the people are spontaneously reporting what is happening, and like that, we can see the impact on traffic accidents marginally. so the present study is based on a large representative sample of the american general population. i will go very fast on it. this study has two main objective to determine how many individuals experience sleepiness while at the wheel. of the motor vehicle. to identify what are the characteristics of this individual in term of sociodemographic characteristics

of their medical condition. secondly the treatment that are very important for these people sleepy at wheel. so the sample, the size of the sample is more than 19,000 people. we have a participation rate, i give the participation rate only to say how much could be the results that we are presenting, 83.2% participation rate. the age range is between 18 and 100 years. the location, 15 states. we took 15 states and for each state we are representative according to the -- office of census of usa. we have 13,300 individuals reporting driving motor vehicles at the moment.

so it is 83.8% of the sample, and the results that we present you will see are for these people in majority. when it will be an exception, i will tell you. only to put the program with sleeping at wheel let me say that according to all the general population study, the american population is sleeping around 6 hour 45. this number that repetitively found inside of the population. so comparatively the duration of sleep in europe is around 7 hours. with one exception in uk where we found a number around 6 hour 50 minutes. 28% of the general population of america is experiencing daytime sleepiness. these results are presented.

everyone is really a big number putting sleepiness as the first reason to have an accident. but also, something that is concerning the social relationship, familial at work, et cetera. so the consequence of all of that is that in our study we were needing to collect more information about the sleepiness, we have a sleep disorder diagnosis, according to the icsd-2, organic diseases and psych tro pick consumption. sleepiness at wheel by age and gender. i think that i have no pointer

unfortunately but i can tell you that the difference between men and women is important at any kind of age. and generally speaking, we find 10% of the general population for the men, that is concerned when for the women is practically half. the traffic accident by age and gender, i don't say sleep at wheel. i am saying only traffic accident by age and gender, and you see that for the category of age between 18 and 24, we have the highest prevalence as the previous speaker was saying. we have after -- and peak at 35, 24, for the rest is comparable is no significant difference between all the group. the traffic accident with or without sleeping at the wheel in the past year, as you see in red, i have sleeping at wheel.

in gray, i have without sleeping at wheel. if you look at our -- our graph, you have inside the men and the women, and you see that the men have more traffic accidents in the past year than the women. and you see that without sleeping at the wheel, so in red is sleeping at the wheel you see that we are practically for the men around 15%, and we go with the women, around 10%, and you have comparatively the accident without sleeping at the wheel. sleeping at the wheel by the time of the accident, very interesting thing inside of the general population of america you see the number are for night time. like the previous speaker was saying, night time is really the

biggest problem. and i must add that we found that the early morning is practically concerned. i have not put the bar here but we will come back on the next slides. the sleeping at wheel by night time sleep duration that is something that everyone have said i will go very fast on this saying that less -- more you sleep, less you have sleeping at the wheel. so, this is very interesting thing, is only a confirmation that what the previous speaker was saying. sleeping at the wheel -- sleepy at the wheel by fatigue severity, this is more interesting, and you see that we have many significant difference between the group, and you see

we have mild, we have moderate, and we have severe, and you see that we have a lot of people that are concerned, around 15%. the prevalence of sleeping at the wheel, and accident by automatic vehicle -- automatic vehicle we mean that the people are driving without taking care of anything, they are in automatic pilot. they are going totally lucky for computer was going there. but is the responsible for a lot of accidents like you can see. we have there the frequency of the people that are concerned by that. you see 15% for the people that are sleepy. and we have the car so accident

in gray. so you see that sleepiness is not totally recovering the car accidents. we have practically something like i would say half more of sleepy people inside of the general population, and these people are driving. they are not all accidents. so to appreciate the -- the frequency, and the prevalence of sleeping at wheel, you must keep that in your mind. everyone have not an accident is why the police can be only under estimate. excuse me. the prevalence of sleepiness at the wheel by sleep disorder, and here is very interesting, because we have sleep apnea with

great strength, and you see we have always the same kind of design for the bar in red the presence of the disorder. the absence of disorder when you have sleep apnea, you see you have around 18% that are concerned, and you see on the side in gray, without sleep apnea. and you have the same for insomnia. and you see that insomnia is less powerful than sleep apnea to give sleeping at the wheel. surprisingly is doing more problem of sleepiness that insomnia inside of this sample but here the difference is not significant. the prevalence of sleepiness at the wheel by mental disorder. and you see that the disorder is exiting, and exiting in comparison of the people without sleeping disorder, bipolar disorder is also coming.

and anxiety disorder could be there. but again, what is really without any discussion is a depressive disorder. the prevalence of sleepiness at the wheel by alcohol consumption, and here you see, if you take -- with the number of drinks that the people are taking you will say, oh, i see six drinks is not so much difference, is because in my opinion, they are in the bed and they are not moving anymore. if you look at the category, it's small that we have. for the prevalence of sleepiness at the wheel by medication. and here, some big surprise, anti-arrhythmic agents are exiting strongly, and the anti-psychotic also and something very surprising but not so surprising i suppose for

the people of the fda is otc drugs because of the presence of anti- -- inside the project i verify is really this project that are responsible of that. the antidepressant you see, they have a participation, but, not so high. so what is the best predictor of sleepiness at wheel for men 35 years old? you see, here we have the fact to take daily alcohol, the fact that you are fatigued, and the fact that you have sleep apnea. this is explaining 47% of the variance. when we are taking the best predictor for the people, the men more than 35, here you find a lot of explanation, so the

sleep disorder are there. they are ordered by frequency, and this is explaining 48% of the variance. to respect the time, i must go faster. best predictor of sleepiness at wheel for women, and you see that also there, we have for example something that is more present for the women, the otc, and this is explaining all this four factors are explaining, 46% of the variance. we have for the best predictor for the women, more than 35 and here also we have sleep apnea that is exiting with 45% of the variance. again sleep apnea has a big presence in all these best predictors that we can find for this population. the best predictor of traffic accident, that is interesting, i

hope, so sleep you have, again, sleep apnea, and you see that 41.8% of the variance is explained. again this predictor are very strong. variances is explained. the predictor is very strong. the best predictor of traffic accidents for a man of more than 35 years of age. i will go through the confusion to finish. so while it's affecting 9% of men and 4% of the women, representing and that is a big number 13.4 million of american drivers. the sleepy individual at the wheel have nearly two times more chances to be involved in a traffic accident than in the past year and that clearly is a defector associated with sleepiness at the wheel of sleep

deprivation of insomnia and sleep apnea, depression alcohol, and medication. thank you very much. >> thank you. dr. g? >> doctors price and mckay, thank you for the invitation. i appreciate the opportunity to be here. so i'm going to be talking about this health conditions that lead to daytime sleepiness and the process by which was illustrated so beautifully in her talk. what determines how alert we are at any given 24-hour period. it fluctuates over the course of the day and determined by two different processes. one is called the homeio static process and that is indicated by the downward pointing arrows at

the top of the slide. that said the longer we are awake the greater the drive to fall asleep. the longer we have been asleep and the less our drive to continue to sleep. that process is counter balanced by another process which is an alerting process that is driven by a pacemaker. that has us be the most alert late in the day and early in the evening. there is a dip that is our siesta time but that drives they incredible sleepiness we feel in the early morning hours. of course our behavioral capability to operate a motor vehicle varies according to the level of sleepiness. in real life things are never this clean and easy. there other factors that modify our alertness that can be external or internal. whether we feel stressed or anxious or whether it's urgent or highly motivated, we will be

more alert and if we consumed alcohol or taken medications, or for being sedentary, we may be less alert. the disorders that cause sleepiness can impact any of the processes. disorders increase the amount of time we are awake. patients with insomnia will have a hard time. are ri gene issues using devices early in the day. sir kadian sis orders like jet lag and a group that directly impact the duration and quality of sleep. that includes sleep apnea and restless legs. certain medical disorders such as heart failure or gasping or breathing difficulties at night and psychiatric disorders or ocd where people have a hard time staying asleep.

i will focus today on sleep apnea and the epidemiology and as shown in slide after slide, it has an important association with drowsiness while we drive. i will cover what is it what is the usual symptoms and the consequencecons consequences and can it be treat and does treatment help? does it make sense economically? let's go. i have 11 minutes. here we have a picture of an airway. it is air moving through the nose and mouth and down the wind pipe and into the lungs. when we, awake this is plenty of air. sleep apnea does not happen or only happens when we are asleep. the air collapses and blocks the progressive air into the throat and down into the lungs. why does that happen? what's different? people with sleep apnea can have

an airway that is narrowed. it can be narrowed because of fatty tissue built up in the upper airway and obesity is the strongest risk factor. not saying all patients are obese, but it is one of the strongest risk factors we know of. airways can be crowded with large tonsils or a large tongue or if the jaw is recessed and set back like dotn knots instead of jay leno. everything gets floppier as we get older and the airway is no exception. women after menopause. nasal congestion can contribute. we would have to suck harder to get the air in to suck the airway shut. alcohol and sleeping pills can block the nerves and make it easier for the muscles to

collapse. what happens when the walls collapse is they start to vibrate and that's when the bed partner tells you to sleep on the couch. they hear the snoring. the other times the air can be blocked completely. that is known as an apnea. some air gets in but not the full flow. that is what happens when this goes. the amount of oxygen in the blood drops. the brain has a sensor and it sends a signal for the muscles to wake up just enough to open the airway. that is a burst of adrenaline which we know is a stress hormone. during the few seconds when the airway is closed it's not like a part of the brain takes a break and works for someone else, they continue to work, but they are doing it without oxygen. that alerting signal, the adrenaline causes the muscles to reopen and airflow to get restoebre reestablished. the coast is clear and you can go back to sleep. as soon as we do it happens

again. this can continue like this all night. when i ask how do you think you feel the next day after spending a night like this the response is the way i feel right now. the most important thing for them to know at that point is when you feel like that, the most dangerous thing you can do is operate a motor vehicle. there 18 studies in car drivers as well as truck drivers who reported this analysis that was commissioned that showed that the odds of a crash with people with sleep apnea were from 1.21 to 4.89, a 21% chance higher of having a crash up to a 4.9 fold increase. so what happens at night in a person with sleep apnea is they may snore or choke or gasp and may have to get up and europe 18 frequently because of the pressure swings in the chest that fools the body into fluid

imbalances and increasedation. they are not aware they are doing any of this and told by a bed partner. these events with surges of a dlen rin. this can contribute to hypertension and heart disease and stroke and prediabetes and death. each of these is terminated by arousals. that can lead to increased sleepiness and crash risk and lead to mood disturbances irritability and sadness and forgetfulness and difficulty with focusing and difficult we sustaining attention and with executive decision making that the doctor referenced. reaction time if somewhere were to cut them off can take longer. they can often experience more headaches and impotence and studies linking it to reduced productivity. all of this gets worse as people gain weight. as a country, we are facing a huge obesity epidemic and a

recent analysis looked at what happened at current prevalence. 9% of men and 4% of women had at least moderate to severe apnea in 1994. the data were applied to current rates of obeseityobesity, the numbers almost tripled. the way we identify this disorder was traditionally by using the inlab sleep study that required patients to come in and get hooked up and they would have wires taped to the head that measured brain waves and eye movement and shin and muscle activities and all of that taken together told us were they asleep or not. we used chest bells to measure breathing and airflow and snoring sensors to tell us is the airflow decreasing or is it completely absent even though there is ongoing effort and did the oxygen level drop by using a finger clip? with this technology, we know 85% of cases remain undiagnosed.

what's really encouraging is the development recently of portable sleep studies and there is no eeg monitor and we use the chest and abdominal effort bells and airflow snoring and oxygen sensors. there variations to this model. the beautiful advantage of this type of device is that a patient can assemble it themselves in their own home. they are much more convenient for those who shift away from home a lot. once it is diagnosed, can we treat it? i my patients think of your airway like a tire. when you were a kid and you had a flat tire, you blow it up with air. we had this device called a continuous positive airway pressure machine that we don't need to bring patients back in and to repeat the sleep study to repeat the pressure