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Over the last two decades, researchers and policymakers have been paying more and more attention to how everything from housing to racism to pollution influences health — and how these social determinants contribute to health disparities.
But newer research is finding that one thing has been missing from that list: sleep.
“Sleep is absolutely a determinant of health,” said Dr. Rachel Widome, an associate professor in epidemiology and community health at the University of Minnesota. “Sleep has an impact on a whole host of health outcomes from physical to mental.”
Sleep can be seen as a resource, Widome said, one that Black and brown people have less access to, which exacerbates health inequities. People who don’t sleep as well appear to be at a higher risk for a slew of negative health outcomes, including cancer, cardiovascular disease, diabetes, hypertension, obesity, and even death.
Dr. Ivan Wu, an assistant professor at the University of Minnesota’s School of Public Health who researches the connection between sleep, obesity, and cancer, said that poor sleep perpetuates ongoing health disparities. “Not getting enough sleep is related to all these terrible things,” he said.
Until recently, most research in sleep disparities focused on documenting the problem. But now, Wu and others are beginning the process of finding solutions.
Identifying the problem
The picture that has emerged from a decade of research is a familiar one: Black and brown Americans are much more likely to sleep poorly than white Americans. And the darker a person’s skin color is, the worse their sleep tends to be, said Dr. Dayna A. Johnson, a sleep epidemiologist at Emory University.
“The theory is that racial minorities experience a stress that is unique and chronic and additive to the general stressors that all people experience,” said Johnson, who was one of the first researchers to work on sleep disparities. “We all experience stress, but there are added stressors for certain groups. For certain populations, racism fits into that category.”
People who experience racism and ruminate about it at night may have problems falling asleep, according to a study Johnson led published in the journal Sleep. And people who anticipate racism may experience interference with their sleep-wake cycle, she said, since their body may be in a heightened state of arousal, with higher blood pressure and variability of heart rate.
Structural racism is also a fundamental contributor to sleep disparities, Johnson said. For example, people of color are still more likely to live in neighborhoods that are not conducive to sleep, areas experts sometimes refer to as “sleep deserts.” Air pollution can cause inflammation and contribute to sleep apnea. Places with higher pollution are often close to highways and have fewer trees and sidewalks–attributes that allow people to exercise safely.
Noisier nights, whether from traffic or thin walls between apartments, hinder sleep. The sense of safety can also cause sleepless nights.
The longer a foreign-born person lives in the U.S., the worse their sleep becomes, Johnson said. She suspects this phenomenon could stem from the built-up stress of language barriers, for example, or worsening dietary habits.
The National Institutes of Health has funded more research on sleep disparities in the last several years, and it is now considered a priority area, Johnson said. But developing ways to solve the issue is in its infancy.
Working toward sleep equity
Wu, a clinical psychologist, began researching sleep inequities while working at the University of Texas MD Anderson Cancer Center, in Houston. There, he realized that the subject of sleep was often missing from research on obesity and cancer risk.
Since moving to Minneapolis last fall, Wu is hoping to extend the work he started in Houston. A pilot study he began there involves evaluating whether the risk of cancer and obesity can be lessened through sleep interventions. Through individual counseling sessions over the course of a month, Wu adapts established cognitive behavior therapy for insomnia to the population of Black adults he’s working with. He’s found that the practice works as long as neighborhood-related stressors, such as loud traffic, don’t interfere.
The participants in Houston were recruited through relationships with Black churches there. Now, he’s looking to build relationships with local churches to expand that research in Minneapolis.
Wu is also teaming up with a friend he met during graduate school at Michigan State, Dr. Abdifatah Ali, on a cancer prevention initiative with the Twin Cities’ East African community funded by the Masonic Cancer Center. In the first phase of that project, researchers will talk to community members about their beliefs, attitudes and knowledge around cancer screenings, physical activity, diet and sleep, said Abdifatah, now an assistant professor at the U of M’s Carlson School of Management.
Eventually, the pair hopes to be able to train community health workers to disseminate information and correct disinformation on cancer-prevention strategies, including healthy sleep.
Individual “fixes,” such as using mindfulness and yoga to create a calmer state of mind before sleep or Wu’s cognitive behavior sleep therapy program, often work. But there are often external factors, such as pollution, that are beyond an individual’s control. So both Johnson and Wu believe that sleep equity solutions need to be community oriented in order to effect substantial and sustainable change. “It’s not the individual; it’s the context in which they live,” Johnson said.
That means solutions need to be developed across an array of contexts. At the policy level, adjusting school start times could foster better sleep for kids, for example. In doctor’s clinics, physicians could talk about sleep health. In the public health sphere, knowledge around sleep and local customs could be disseminated through healthy sleep campaigns.
One example: In many Somali homes in the Twin Cities, smoke detectors with low batteries beep around the clock. Many believe the devices beep when they’re working properly, Abdifatah said, or that it’s the landlord’s responsibility to “fix” them. Such misinformation could be corrected with a community-wide effort.
Widome pointed out that sleep is often viewed as “garbage” or “throwaway” time.
“If you’re getting the right amount of sleep, you’re spending a third of your life sleeping,” she said. “How much time do we spend thinking about our health in the other two-thirds of the day — what we do in our leisure time, how physically active we are, what we eat?”