Poor sleep attached to racial inequities
Disparities jeopardize Black Americans’ health
FORT WORTH, Texas – In every passing person, Tara Robinson saw herself – a potential health crisis wrapped in the guise of someone just going about their daily business.
“Come get your heart checked!” Robinson beckoned to passersby on a cool, sunny morning in Fort Worth, Texas, where the Black Heart Association, the nonprofit she runs with her husband, Fredrick, had stationed the mobile testing unit they call “Cardi V” at a community health festival in the low-income neighborhood where she grew up.
Five years ago, a University of Texas Southwestern Medical Center analysis cited this 76104 ZIP code – which comprises nearly 6 square miles to the south of downtown Fort Worth – as the area with Texas’ lowest life expectancy, at just 66.7 years.
Folks like 64-year-old James Nellums stopped by for heart readings along with tests for glucose, blood pressure and cholesterol levels. Recently diagnosed with diabetes, Nellums said the condition kept him constantly awake, triggering high blood sugar levels or the frequent urge to urinate.
“How much do you sleep?” Robinson asked him.
“About two or three hours a night,” Nellums said.
“Do you nap during the day?” Robinson asked.
“I might doze off for about 45 minutes or an hour,” Nellums said.
“How we sleep, how we manage our stress, how we eat – all that plays a part in our heart health,” Robinson told him.
Poor sleep is linked to a host of health problems, among them some of America’s greatest killers, most of which plague Black Americans. That includes cardiovascular issues – which is why Robinson, a petite
50-year-old exuding uplifting energy, is here. Nearly a decade ago, she suffered a series of heart attacks, seemingly out of nowhere – but looking back over her life, she said, childhood trauma and poverty likely laid the foundation.
“I don’t think I knew what sleep was,” she said. “Coming out of that, I was always trying to figure out my next move. How do I pay the bills? How do I care for my child? You’re stuck in fight or flight.”
The data indicates quality sleep is harder to come by for Black people, with economic, social and environmental factors all playing a role.
“With certain populations, self-care is a luxury,” said Liao Yue, an assistant professor of public health at the University of Texas at Arlington. “You feel you have to give up sleep in favor of working and taking care of your family.”
Links between poor sleep and health issues
Along with heart health, poor sleep is linked with increased risk of hypertension, diabetes and obesity, as well as cognitive issues like Alzheimer’s – all of which disproportionately plague Black communities.
For instance, 47% of Black adults have been diagnosed with cardiovascular disease, compared to 36% of white adults. Black men have a 70% higher risk of heart failure than white men; for Black women, the figure is 50%.
“When we look at cardiovascular health, Black women really stand out,” said Liao, whose research at UT-Arlington examines several factors, including sleep, as part of an ongoing study of cardiovascular disease among Black women. “No matter which metric you look at – incidence, prevalence, mortality – the disparity is there.”
Black adults have the highest incidence of severe obesity, and 59% of Black adults have hypertension, the highest rate among all racial and ethnic groups. Additionally, they are more likely than white adults to have strokes and more likely to die as a result.
Researchers say poor sleep is a major factor. Quality sleep allows the body to reset. The brain clears out toxins. Organs replenish.
As a component of good health practice, sleep has earned increased attention: The American Heart Association recently added sleep health to its “Essential 8” assessments of cardiovascular health; more recently, an editorial in the medical journal The Lancet called for global promotion of sleep as an essential pillar of health.
The chronic health effects linked to sleep loss are usually neither direct nor immediate. Sleep deficiency often exacerbates other risk factors or conditions. But even in the short term – for instance, in the all-nighters pulled by college students, corporate workers, or oncall doctors – loss of sleep takes its toll, researchers say, damaging DNA and preventing cell rejuvenation.
“Sleep is not like a bank account, where if you take out money all you have to do is put it back and all is good,” said Azizi Seixas, associate director of the Center for Translational Sleep and Circadian Sciences at the University of Miami Miller School of Medicine. “We call it social jetlag, and what we have found is that it can cause accelerated aging... You can feel good cognitively if you pull an all-nighter. But you would have put a lot of miles on the car, so to speak, and you cannot reverse the odometer. You’ve just added miles that you didn’t need to.”
‘A disproportionate burden’
But while the National Sleep Foundation recommends seven to eight hours of quality sleep a night, more than a third of U.S. adults (35.4%) say they get less than that on average, according to an analysis of data published by the American Heart Association in January 2022.
The numbers are more pronounced among low-income people and people of color – and in particular, Black Americans. An analysis of 2018 data collected by the Centers for Disease Control and Prevention found that 45.4% of Black adults reported getting less than seven hours of sleep compared to 33.2% of non-Hispanic white adults.
Further data published by the CDC in 2020 showed short sleep duration highest among Native Hawaiians and Pacific Islanders (47%), with Black Americans next at 43.5%.
In addition to physical health, sleep deficiency affects mental health, aggravating anxiety and depression. It can also harm one’s livelihood, diminishing work or academic performance, risking safety and hampering social relationships.
Seixas said racial and ethnic minorities not only sleep less than white adults; they have less quality sleep, are more likely to toss and turn, and are more prone to disorders like sleep apnea.
“When a disproportionate burden of poor sleep health is experienced by certain groups, what we end up seeing is disproportionate consequences of that burden,” he said.
Many people know their sleep habits could be better. Desiree Carmichael, a 42-year-old Black single mom and utility firm administrator in Birmingham, Alabama, said after her boys clock out, she’s tempted to do the same.
“Instead, what ends up happening is that once they’re down, I’m doing things around the house that I don’t have time for during the day,” said Carmichael, who averages six hours of sleep nightly. “Chores, bills, laundry. It’s like, let me just throw these dishes in the dishwasher.”
Others feel they have little choice given economic challenges. Precious Abed, a 38-year-old Black single mom and part-time hair stylist in Dallas who juggles night shifts at supermarkets or restaurants, says her hours spent away from work are split between caring for her three kids – including an infant daughter – and filling out applications for more full-time employment.
“I feel fatigued, overwhelmed and very stressed,” said Abed, who’s usually in bed at midnight and up at 5:30. “Being a single mom, I feel I always have to make sure I’m looking for a job, something to bring money into the house.”
Additionally, societal and environmental factors like racism and noise- or crime-ridden neighborhoods play a role, making sleep a mechanism that both reinforces and reflects ongoing social and health inequities.
“The social factors that you need to sleep well are inequitably distributed across society,” said Connor Sheehan, an assistant professor of sociology at Arizona State University in Tempe. “You need time – and if you’re working two jobs, or you have a two- or three-hour commute to get to your job, you don’t have time to sleep. Time is not equitably distributed across society; it’s distributed in a manner that reflects broader social inequality.”
Do disparities start at early age?
Poor sleep patterns aren’t unique to adults – and they might even start in childhood, according to a yearslong study of children in central Pennsylvania led by Julio Fernandez-Mendoza, a professor of psychiatry and behavioral health who studies behavioral sleep medicine at Penn State Health’s sleep research and treatment center in Hershey, Pennsylvania.
Researchers interviewed parents of 700 kids, ages 5 to 12, about whether their children had trouble falling or staying asleep, then followed up with families about seven years later.
More than half of the 400 children whose families participated in the follow-up interview continued to experience insomnia symptoms in adolescence, while about 30% found their symptoms had gone away.
The researchers found that non-Hispanic white kids of low socioeconomic status were 2 1⁄2 times less likely to develop good sleep patterns than white kids of higher economic status. Meanwhile, Black children were seven times less likely than non-Hispanic white children to do the same – with just 10% of those kids developing good sleep habits, regardless of socioeconomic status.
“How do we interpret this?” Fernandez-Mendoza said. “We believe it’s racism. Even if you have good socioeconomic status, you still experience stress and racial discrimination…. Children already experience the structural determinants that lead them to sleep poorly at night. You basically go to bed stressed.”
Fernandez-Mendoza and his team hope to soon publish the results of their most recent follow-up with the cohort, 15 years after the first. But what he said they’ve found is that childhood insomnia persists, becoming chronic among racial and ethnic minorities.
“Once again, Black children are much more likely to have a persistent trajectory of insomnia symptoms,” Fernandez-Mendoza said. “But where do those come from? Are they chronic? Did they happen before? Yes, they have happened since childhood. This not only shows the disparity but that the disparity is long-term – and it travels with them throughout their lives.”
Researchers have found that sleep disparities persist among adults, even as income and education levels rise. Studies conducted by Sheehan, of Arizona State, showed Black and Hispanic people with higher education enjoying muted benefits of higher education compared to their white counterparts – or even suffering reversed benefits.
“Black adults with more education actually sleep worse than their peers with lower levels of education,” Sheehan said. “We speculate that it’s greater exposure to white spaces and more awareness of discrimination, which requires more coping resources.”
‘No idea they had poor sleep’
One reason so many Americans are notoriously sleep-deprived is an ethic that prizes work and productivity over all else – including sleep.
“There is this grind culture that is accepted in the U.S.,” said Rashon Lane, a senior health equity scientist for the division of sleep medicine at Brigham and Women’s Hospital in Boston. “There has not been a culture of valuing rest and prioritizing sleep. If you’re living with chronic conditions like diabetes, obesity and heart disease, sleep health may not be something that automatically rises to the top of mind – but it impacts all of those things.”
Seixas, of the University of Miami, concurred.
“People have this fear of missing out, where they are voluntarily depriving themselves of sleep,” he said. “But another driver is revenge sleep, where people believe they’ve gone through a difficult day, and the only time they can have alone time is at night. We are so starved for peace and tranquility that we would rather compromise on our sleep just to have those moments.”
Unawareness of healthy sleep patterns could be another issue, some say.
“The overwhelming majority of Black Americans in my study had no idea that they had poor sleep,” said Karen Lincoln, director of the Center for Environmental Health Disparities Research at the University of California, Irvine.
“It was the way everyone around them slept. It was fascinating, sadly so – we’d have rooms of people saying, ‘Me too,’ not even realizing it was a problem. Whose doctor talks to them about sleep? But it’s related to everything.”
Lincoln suggested the issue in Black communities may have deep and dark roots, a vestige of American slavery when slave owners discouraged sleep in favor of labor.
“They were packed into the bellies of ships where sleep was absolutely impossible,” Lincoln said. “Then they were forced to live in sheer brutality, and the expectation was that most of the day would be spent working. They were starting in the dark and finishing after dark. Sleep was a luxury. Their sole purpose was to work and to breed.”
While sleep patterns might seem disconnected from such historical and social factors, Lincoln said, those factors remain reinforced by social interaction with a world still rife with problematic stimuli.
‘Stuff starts to keep you up’
Recent years have brought added stress for Black and Hispanic individuals, who are more likely to be saddled with student loans – another source of stress and disrupted sleep – after the U.S. Supreme Court’s rejection of President Joe Biden’s proposed debt forgiveness plan last June.
Black and Hispanic workers were also more likely to be low-wage, essential workers during the pandemic and/ or to have a close friend or family member die from COVID-19 complications, while images of brutality and civil unrest surrounding the deaths of George Floyd and Breonna Taylor at the hands of police exacerbated the mental turmoil.
“All of that happened at the height of the pandemic,” said Dayna Johnson, an assistant professor of epidemiology at Emory University. “So you have anxiety and stress, and these experiences of vicarious discrimination, and it had a more detrimental effect on Black people.”
Robinson, of the Black Heart Association, said she’s heard similar stories from community members in her nonprofit’s outreach.
“All that stuff starts to keep you up at night,” she said. “Imagine all the moms who heard him (Floyd) call for his mother. That’s triggering.”
Mercedes Carnethon, a professor of preventive medicine at Northwestern University’s Feinberg School of Medicine in Chicago, said research now needs to go more than skin-deep to determine what is driving the disparities.
“The reasons are not the color of one’s skin,” Carnethon said. “They’re socioeconomic factors, household characteristics, and cultural values around sleep. They’re the occupations that people hold. It’s not race as biology but race as social factor, and by identifying the social factors, we can think of strategies to address them.”