Health Inequities in Sleep

Not all populations experience the same access to care and the same health outcomes. Many people are familiar with inequities in rates of diabetes, heart disease, and obesity. But did you know that inequities in sleep health may be linked to these health issues?

Our health and well-being is influenced by our biology, social drivers or determinants of health (SDOH), and health behaviors. Sleep sits right at the intersection of these factors.

As a basic bodily need, sleep has physical, mental, and social dimensions. Sleep can be disturbed by:

• Physical health issues, like apnea
• Your mental state, like stress
• Environmental conditions, like heat or noise

So, the burdens of living with various health conditions, experiencing certain stressors disproportionately, and dealing with challenging living conditions can worsen sleep inequities. And sleep inequities can make those burdens worse too.

What is Healthy Sleep?

Sleep is a biological imperative — we cannot live without it. Although there is a lot about sleep that we still don’t understand, we can define healthy sleep through five dimensions:

• Sleep duration
• Sleep efficiency (ease of falling and staying asleep)
• Timing
• Alertness/sleepiness
• Satisfaction

Some common sleep disorders include insomnia, sleep apnea, narcolepsy, restless leg syndrome, bruxism (teeth grinding), and parasomnias such as sleep-walking.

While people’s sleep needs may vary, most adults need between seven and nine hours of sleep every night. Scientists are still trying to understand all of the functions of sleep. What they do know is that while you sleep, your body is:

• Reenergizing and repairing your cells
• Clearing waste from your brain
• Moving information to memory
• Stimulating your immune system
• Regulating your mood, appetite, and libido

So, it’s no surprise that people who don’t get enough sleep tend to have more health problems than those who do.

The Relationship Between Sleep and Health

Sleep affects every system in a person’s body. The well-documented health effects of insufficient sleep include diabetes, cardiovascular disease, obesity, and depression.

Sleep deprivation may also contribute to neurodegenerative diseases like Alzheimer’s disease. Each of these diseases has a mutually reinforcing relationship with sleep as well as a cascade of other negative health consequences.

In fact, research shows that getting either too little sleep or too much sleep is associated with a higher risk of dying, regardless of the cause of death.

Inequities in Sleep Health

Some populations in the U.S. tend to get less sleep than others. For example, in a study of 429,195 U.S. adults, Black people were significantly less likely than white people to get optimal sleep. The subgroups least likely to get enough sleep were Black women, Black people with middle or high incomes, and young and middle-aged Black adults.

Additional studies show that other traditionally marginalized populations also have a higher risk of sleep problems, including:

• Native Americans and Alaska Natives
• Asian people
• Hispanic or Latino people
• Native Hawaiian and Pacific Islander individuals

To understand this, it’s important to look at the factors that can interfere with getting a good night’s sleep.

Social Determinants of Health

Structural barriers that marginalized individuals face increase the potential for having difficulties getting enough sleep. Neighborhood factors like housing quality and crowding, pollution, ambient noise and light at night, excessive heat, and community violence can all create barriers to healthy sleep routines and interrupt sleep.

In addition, the hours a person works can affect their sleep patterns. For example, shift work can interrupt natural circadian rhythms, which can cause chronic sleep problems.

Cultural and family attitudes about when, why, and how to sleep are important contributors to sleep behaviors. Beliefs that sleep is a luxury or a weakness, caregiving responsibilities, or low awareness about sleep hygiene can interfere with optimal sleep. At the community level, early school start times have been associated with inadequate sleep in adolescents.

Mental Health Factors

We’ve all spent some sleepless nights worrying, but living with chronic stress can seriously affect your sleep health. Stress and anxiety are associated with insomnia and other sleep issues. Chronic insomnia can be related to trauma, tension, pain, or significant life changes. Racial discrimination has been shown to be a significant sources of stress that can impact sleep.

Not getting enough sleep can lead to higher levels of stress and decreased emotional regulation. It can cause a vicious cycle in which stress levels and sleep deprivation both get worse and worse.

Physical Health Factors

Clinically significant excess weight disproportionately affects traditionally marginalized populations due to a variety of factors — including chronic stress and lack of access to fresh, whole foods. And excess weight is linked to obstructive sleep apnea (OSA), a condition in which someone wakes up repeatedly during the night because they’re having trouble breathing due to a blocked upper airway.

In turn, lack of sleep can cause people to compensate by eating more food. Both sleep and food give you energy, so if you’re not getting enough sleep, you’re more likely to be hungry. You’re also less likely to have the energy to exercise. So, in another vicious cycle, poor sleep can contribute to obesity, and obesity can contribute to poor sleep.

Pain has a similar bidirectional relationship. People with chronic pain often suffer from chronic sleep deprivation. Inequities in pain management are well documented and may be another factor in disparities in sleep quality.

Solutions to Insufficient Sleep

You deserve restful sleep. There are various strategies you can use to improve your chances of sleeping well, including sticking to healthy sleep habits, avoiding sleep procrastination, and limiting your exposure to sources of stress.

If none of these strategies do the trick, talk to your doctor. They can help you decide whether treatment is appropriate or refer you to a pulmonologist (lung doctor) or other sleep medicine specialist. If stress is interfering with your sleep, a behavioral health specialist may be able to help.

But do take your need for sleep seriously. Getting enough sleep not only supports your health and well-being; it also gives you the rest and recuperation you need to be your best self for the sake of your loved ones, family, work, and community.

Sleep well.