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Zeo Personal Sleep Coach

 Sleep that knits up the ravelled sleeve of care
The death of each day’s life, sore labour’s bath
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast.   
 -William Shakespeare, Macbeth

Zeo

The company that makes the Zeo Personal Sleep Coach  kindly sent me one of their devices to try out. It’s a nifty little gadget, and if you are a techno geek, you would probably love it. It’s a fascinating toy; but for insomnia, there’s no evidence that it provides any benefit over standard treatment with sleep logs and sleep hygiene advice.

Polysomnography is done overnight in a sleep lab and costs around $1000. It records multiple parameters: EEG, EKG, EMG, breathing, O2, CO2, and limb movements. It is most commonly used to diagnose obstructive sleep apnea (OSA), a serious condition that is linked to hypertension, heart disease, diabetes, metabolic syndrome, stroke, and increased mortality. OSA can be effectively treated with CPAP and other measures. About 50% of snorers have sleep apnea. We typically think of it as a disease of obese, loudly snoring older men, but even young children can have it: snoring is probably never normal in children and should be investigated.

The Zeo is the first sleep monitor available for consumers to use at home. It doesn’t pretend to do what polysomnography does. It can’t diagnose sleep apnea. It is billed as an educational and motivational tool, not intended for the diagnosis or treatment of sleep disorders. A unit that looks sort of like an alarm clock sits on your bedside table and communicates wirelessly with a comfortable soft elastic headband that positions embedded sensors over your forehead to pick up your brain waves.

It provides a graph of the entire night showing when you were awake, in light sleep, deep sleep and REM sleep. It gives a readout of how many minutes you were in each stage and how that compares to your average readings. Most importantly, it gives a ZQ score: a single number that adds the “good sleep” numbers and subtracts the awakenings to provide a single score that you can use to compare your sleep quality from night to night and to compare your sleep to that of the average person of your age.

The information can be uploaded to the Internet and viewed on the company’s website. It is then used to provide individualized coaching.  A lifetime of coaching is included in the purchase price of $349, or you can buy the product without coaching for $249 and can add coaching for $7.95/month or $79.95/year. 

Normal sleep architecture:

  • We should not fall asleep the moment our head hits the pillow: that indicates a sleep deficit. It normally takes 20 minutes or so to get to sleep.
  • REM (Rapid Eye Movement): 20-25% of total sleep time. Normally absent during the first 90 minutes of sleep and then occurs about every 90 minutes. Was thought to be the stage where dreams occur, but now we know dreams occur in every stage of sleep.
  • NREM (Non-Rapid Eye Movement): 75-80% of total sleep time. Includes light sleep and deep sleep.
  • Awakenings during the night are normal and more common as we age. We don’t remember awakenings that last less than a minute. The Zeo registers awakenings that last at least 2 minutes.

According to the manufacturer, two scientifically controlled studies have compared the Zeo’s sleep stage readings to polysomnography readings and found them valid. But how useful is it to know this information? We don’t know what the optimal time in each stage is, and we don’t yet know how to increase REM sleep even if we wanted to. One uncontrolled pre-marketing study found that home users reported significant improvements in the quality of their sleep and better functioning in the daytime, but with no control group these results are uninterpretable.

The ZQ score is an arbitrarily constructed score that has not been validated. If your score goes up 10 points are you really sleeping better? Is it a useful measurement? It is handy in one sense: my husband used to ask me if I slept well, and I would answer “yes” or “no” or “fairly well I guess.” Now I can tell him “68” or “93.” I can see a downside: it would be easy to become psychologically dependent on these numbers and obsess if your score went down. I lent my machine to a friend to try, and immediately found myself missing it. I had come to look forward to seeing my ZQ report every morning.

I chose not to try the online sleep coaching because I thought I could do my own coaching. It’s not hard to read about sleep hygiene measures and apply them, to notice whether the ZQ score goes down if you drink coffee in the evening, etc.

Zeo offers another intriguing service. You can set the alarm and ask it to wake you up to half an hour earlier, picking a time that you are in the stage of sleep that is easiest to awaken from, so you are not violently jolted awake from a deep sleep. I don’t use an alarm (I’m retired and have the luxury of sleeping until I wake naturally) so I didn’t get to try this function out. I don’t know if the benefits of gentle awakening would outweigh the harm of being awakened up to half an hour early and having total sleep time reduced.

Insomnia is a common problem and sleeping pills are not the answer. Insomnia can be treated effectively by cognitive behavioral therapy (CBT): it works to some extent in almost all patients, and has long-term success. It involves counseling in sleep hygiene, cognitive therapy and stimulus control therapy, and when necessary, sleep restriction therapy. It corrects misunderstandings about normal sleep, establishes realistic expectations, and uses simple relaxation techniques and measures like establishing regular sleep hours and a quiet 30-to-60 minute pre-bedtime routine, avoiding caffeine and alcohol, getting out of bed when you can’t sleep, using the bed only for sleep and sex, exercising during the day but not close to bedtime, keeping the bedroom quiet and at a comfortable temperature, banishing pets from the bedroom, addressing stress issues. Patients are instructed to keep a sleep diary, recording how long they slept, how often they woke up during the night, how refreshed they felt in the morning, whether any factors disturbed their sleep, when they exercised, when they drank coffee or alcohol, etc. It’s hard to see how the Zeo could add anything important to this approach except as a crutch to help motivate patients who are not initially cooperative. What I would like to see is a controlled study comparing optimum sleep hygiene and cognitive behavioral therapy to the use of a Zeo and online sleep coaching. One problem would be picking a reliable measure of sleep improvement to assess outcomes.

The Zeo program might turn out to be the best initial approach to insomnia, since it is less expensive than multiple office visits with a provider for CBT. But I wonder if a web-based program providing the same information about sleep hygiene and giving feedback and encouragement might be just as effective without the device. Pending controlled studies, I will have to assume that it is just a gimmick to enlist patients in doing what they should be doing anyway.

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Note: My source for the information about normal sleep, sleep apnea, and treatment of insomnia was a CME course on sleep disorders that I attended in Seattle on Feb. 20, 2010, sponsored by the AAFP in conjunction with the American College of Chest Physicians and presented by a panel of experts in sleep disorders.

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Posted in: Health Fraud

Leave a Comment (21) ↓

21 thoughts on “Zeo Personal Sleep Coach

  1. BillyJoe says:

    Because I am not retired and work long hours and exercise a lot and have a family which demands my time, I am always sleep deprived and, yes, I drop off to sleep as soon as my head hits the pillow. In fact I’m going to be asleep in about ten minutes.

    One thing omitted from the “sleep hygiene” (for some reason I hate that phrase) list is to exercise into a slight sweat before the evening meal and then wear light clothing to cool down during the evening.

  2. LovleAnjel says:

    I’m glad to know it should take me 20 minutes to fall asleep. My insomnia is not as bad as I thought. I do like the idea of the clock waking me up at a nicer time, but I don’t know about paying $399 for an alarm clock that won’t play the CD track I want.

  3. tmac57 says:

    Just as a personal observation, I went through Polysomnography, because of my excessive snoring, and I found the results to be less than reassuring (they said that I did not have OSA), because the environment that you are in, is not conducive to normal sleep. You are put in a room with cameras, hooked up to multiple sensors on your head, face, chest and hand,told “okay, time to go to sleep”,regardless of your normal sleep start time, in a bed that you are unaccustomed to, and you are very aware that someone is watching you try to sleep. I suppose that some people do not have a problem with that scenario, but I felt totally uncomfortable the entire time, and hardly slept at all.

  4. micheleinmichigan says:

    I have periodic bouts of early waking insomnia (wake up at 2:00 or 3:00 am can’t get back to sleep) and went through a period of time where I had waking night sweats. My doctor suggested I keep a sleep log to see if the issue could be related to the hormonal cycle. Unfortunately, my approach to a sleep log is “oh yeah, I’ll write that down when I get a chance” distraction, forget, etc. :) It seems that something like this Zoe could have been useful to me, but the price tag would be way outside my budget.

    Luckily, my doc switched my synthroid dosage due to separate complaints in the same visit and now my sleep issues seems to be gone. (I’m healed!) I suppose it is worth mentioning that a new sleep problem can sometime be a sign of thyroid issues. Although I can’t say it was for certain in my case.

  5. Expat says:

    I always dreamt about an alarm clock that would wake me up in a phase of lighter sleep.

    I noticed that sometimes I get up and I’m fine, and other times I just feel like crap.

    I heard it’s about REM or deep sleep, is that truly science-based?

  6. mcook says:

    There is an iPhone app that claims to do the same thing if you put it under your sheet. I’m not sure how well this would work either, but it’s much cheaper. Reviews have been mixed, but I wonder what people think of the method: http://www.lexwarelabs.com/sleepcycle/

  7. Harriet Hall says:

    One of my daughters went to a sleep lab for polysomnography and they told her they couldn’t interpret the data because she wasn’t asleep long enough!

    My other daughter tried the Zeo, got a good ZQ score, and decided that the machine lies, because she had not slept well and she still felt tired and sleepy.

  8. Geekoid says:

    I have always wanted to try a system that wakes me when I am not in the deepest sleep.

    During my regular sleeping routine, some morning are a lot harder to wake up to then others and I have always wondered if that was do to the stage of sleep I was in at the time the alarm sounded.

  9. Jojo says:

    @micheleinmichigan: If my synthroid levels are to high I also suffer from early wake-up insomnia. In fact, it’s the most obvious signal that I need to see my endocrinologist.

    I don’t think the Zeo would be much help with my current sleep problems unless it can keep my three year old from waking in the middle of the night.

  10. micheleinmichigan says:

    # Jojo

    “@micheleinmichigan: If my synthroid levels are to high I also suffer from early wake-up insomnia. In fact, it’s the most obvious signal that I need to see my endocrinologist.”

    Yes. In this case my levels were low, which I’m told typically means sleeping more, so the connection wasn’t an obvious one.

  11. clgood says:

    If you own an iPhone 3Gs and want to experiment with that early wake-up idea, you can get the Sleep Cycle app. It uses the accelerometers in the iPhone (which turn out to be quite sensitive) to monitor how much you move around when you sleep. This may be a decent proxy for sleep states, and you get a cool graph in the morning.

    In case you’re wondering, the phone just gets set on the corner of the mattress by the pillow. You don’t have to strap the phone to yourself or anything.

    My anecdotal n-of-1 experience probably isn’t relevant, as I have some sort of fatigue problem that I’m still trying to beat. But there are plenty of positive anecdotes in their feedback on the App Store.

  12. antipodean says:

    It looks like something between a toy and a device to cause insomnia in susceptible people. None of that information is in any way useful.

    Tmac57: don’t worry about the PSG for your snoring. It’s not designed to measure your sleep quality. We know it’s not great sleeping in the lab. They just need a 2-3 hours or more of you asleep to see whether your snoring is actually a whole lot of apnea. If they didn’t get you asleep for long enough they’d get you back to have another go. (which is what they should do with your daughter, Harriet, if they are testing for OSA)

    If they said your sleep study was normal then you can feel reassured. If anything PSG is too sensitive, so if you test negative you’re probably just fine.

    Harriet. The cost of PSG is massively inflated in the USA. It’s much cheaper elsewhere.

  13. tmac57 says:

    antipodean- Thanks for the response. I hope you are right. I would hate to go through that again. I do wonder if I really slept even 2-3 hours though, because They turned the lights out at 10pm, and I remember being awake at 1am , then having to get up to use the bathroom ( that was quite the hassle with all of those wires still attached), and then they woke me up to put a CPAP on me for some period of time, and then woke me up about 5am and told me they were done and to go home. Not a lot of room in there for anything like normal sleep. I really felt like they were going through the motions to just collect they insurance payment. I had a similar experience with a physical therapy clinic that was just pushing people through the door, and racking up insurance payments, without much effort to really help the clients. But thats a topic for another day.

  14. antipodean says:

    If they put you on CPAP that means you were undergoing what’s called a split-night diagnosis and titration.

    So what should have happened is that the first half of the night they established you had a bad case of sleep apnea and the second half of the night they spent trying to get the CPAP pressure right to fix it. You must have slept more than 2-3 hours. The problem is that humans are utterly rubbish at guessing how much sleep they are getting- especially when anxious in sleep labs.

    In order for them to claim insurance they would have had to fulfill a number of criteria deemed sufficient to get both parts of the split night adequately described. They should have passed this information on to the sleep physician who ordered the PSG for your follow-up.

  15. BillyJoe says:

    “In order for them to claim insurance they would have had to fulfill a number of criteria ”

    This is another negative with health in the American.
    The domination by insurance companies. Insurance companies in effect telling doctors how to treat people.

    And it’s happening in Australia as well. The TAC (transport accidents) and WorkCover insurers will not pay for procedures they have not first approved, meaning they can veto the recommendation of the patient’s specialist. The paperwork has become so onerous that many have opted out of treating patients with transport or work injuries. And, for the first time, a medical indemnity insurer has published guidelines for doctors to follow in the diagnosis of melanoma (there are 52 boxes to tick off!)

  16. Ian says:

    I was pretty much sold after seeing the graph. :) I think it would just be interesting to see if that dream you just woke up from was in REM or light sleep. I guess I’m one of those techno geeks mentioned in the first paragraph. This is exactly the sort of technology that is now possible due to everyone having wireless.

    (that said $400 is a bit much…)

    Given all the comments in this blog about the stress of sleeping sleep labs, maybe the professional sleep labs should look at technology like this. Even if it gives them less detailed data it might be worth it to have a full week or month of data to look at.

  17. Harriet Hall says:

    Correction:

    I wrote that ” 6 months of coaching is included in the purchase price of $399, and it can be extended for another 6 months for $99.” I took that from more than one source on the Internet.

    An e-mail from Zeo this morning informed me that this is not the current pricing.

    “The Zeo with the coaching program is actually $349 and includes a lifetime of coaching. If someone buys the product without the coaching at $249 they can add the coaching element for $7.95/month or $79.95/year.”

    I will corrent the post to reflect this.

  18. antipodean says:

    Ian

    This technology tell you nothing that is useful for testing for the sleep disorders that sleep labs test for.

    Sleep labs are not necessarily stressful places to sleep if designed properly.

    Having said that enourmous resources are being put into refining home diagnostics, just as you suggest.

    BillyJoe

    I said “In order for them to claim insurance they would have had to fulfill a number of criteria ”

    This was perhaps not as clear as it should have been. I was referring to the quality and quantity of the data being collected being sufficiently good information to guide clinical care. This is a good thing.

  19. BillyJoe says:

    “I was referring to the quality and quantity of the data being collected being sufficiently good information to guide clinical care.”

    The question is: who should be providing the guidelines for good clinical care, the insurance companies or the specialist colleges?
    (I think you know my answer)

  20. micheleinmichigan says:

    BillyJoe, what you mentioned is certainly a problem in the U.S. (Grrr). But, I think antipodean is saying basically, if a lab does shoddy work, the insurance company will not pay for it. This is supposed to motivate the lab to do good work. The insurance companies are supposed to use standards of care from research and doctors to set the criteria for “good work”.

    For example, I once had my shoulder X-rayed for impingement. The doctor was appalled at the quality of X-ray, but doesn’t really have the ability to say “That ain’t good enough, you’re not getting paid” The insurance company does. Of course, the problem is, then the patient gets billed for what the insurance company doesn’t pay. Then the patient is left with the choice of fighting the charges (without medical knowledge), fighting the insurance company, paying the bill or having a strike on your credit. So, not a great system.

    Also sometimes the insurance companies do not use standards of care or look at individual circumstances. (I won’t hazard a guess as to how often.)They look for loop holes in how they can use science to increase their profit margin. And, like you said, that is a big problem and a complete waste, since it generates untold amount of clerical costs.

    (I’m no expert, only a health care consumer who deals with hospital charges and insurance companies a reasonable amount.)

  21. Basiorana says:

    I doubt it would tell a layperson that much, but could it be brought in to a sleep therapist as a more accurate reading of how you sleep at home? Or maybe the tech could be developed into such a tool? My fiance snores so bad he actually stops breathing, but he can’t go into a sleep lab because his anxiety prevents him from falling asleep with the monitors. This despite the Ativan and Geodon he takes each night. They tried it several times when he was a teen and each time he simply stayed awake all night– he didn’t even dose, and this was with the maximum safe dose of sedatives they could give him. Without the drugs, he will never sleep– the last time he didn’t take them he went five days before he was hospitalized for hallucinations.

    I want to try this to compare how I sleep on trazodone to how I sleep without it. I still can’t tell if it actually does anything more than trap me in nightmares.

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