Social, cultural disparities affect sleep and sleep medicine

Often unnoticed or unaddressed, sleep medicine is hobbled by disparities. Sleep disruptions that have been documented in people with disabilities, in racial and ethnic minorities, and in women can often be associated with factors in their social and cultural environments, and there is a need for further research and potential corrective strategies to better serve these individuals.

“Sleep disparities in disabled people is not usually discussed and is highly important,” said Diwakar Balachandran, MD, FCCP, Professor of Sleep and Pulmonary Medicine, and Sleep Center Director, The University of Texas MD Anderson Cancer Center.

“Talking about sleep in people with disabilities gets to what we define as ‘normal.’ In medicine, we tend to view disability as patient-focused, something we need to fix. We should be moving to a more social model of disability as barriers that prevent people from getting the care they need. We should be looking at ways to address those barriers and social determinants of disease so people can get the care and the sleep they need to live complete lives.”

Dr. Balachandran discussed sleep disorders in individuals with spinal cord injuries (SCI) and sight impairment during the CHEST 2021 session, Disparities in Sleep Medicine.

Sleep disorders can have as much, if not more, to do with social, cultural, and environmental factors as clinical factors, he explained.

Sleep disorders are common in people with SCI. Some disorders are affected by physical determinants such as the location of injury. Injuries at C3 and above result in complete paralysis of all respiratory muscles.

Lower injuries typically result in less severe breathing dysfunction, but patients still encounter external barriers such as bed positioning, bladder management, the need for assistance in donning and removing a positive air pressure mask, medications, pain, and anxiety that disrupt sleep.

Blindness can affect circadian rhythm, leading to out-of-phase sleep when the suprachiasmatic nucleus is no longer stimulated by light/dark periods. Light therapy may help patients with residual light perception regain a 24-hour sleep cycle. Melatonin and melatonin agonists may help individuals without light perception.

“We have a lot we can offer, but we need to address the barriers,” Dr. Balachandran said. “We can do a lot more to help our patients than just provide medication.”

Multiple studies have identified racial and ethnic disparities in sleep, with Blacks/African Americans typically reporting less and lower quality sleep compared with Caucasians and other groups. Many studies identify race as a risk factor for disturbed sleep.

“Race is not a risk factor,” said Chandra L. Jackson, MS, PhD, Earl Stadtman Investigator, Epidemiology Branch, National Institute of Environmental Health Disparities, National Institute on Minority Health and Health Disparities. “Race is a social construct, a proxy for relative disadvantage and advantage based on phenotype. Racism, not race, is the risk factor.”

Physical, cultural, social, and psychological environments are all important determinants of health and disease, including sleep. Sleep and other behaviors are strongly influenced by external factors, such as demands for rotating shift work, which adversely affect circadian rhythm and sleep. Social factors can funnel individuals into jobs or neighborhoods with more sleep disturbance elements, including pollution from industrial and agricultural sources that can directly affect sleep.

“There is a need to consider social and environmental factors in sleep recommendations,” Dr. Jackson said. “Sleep medicine can include social determinants of health in clinical decisions, better meet patient needs with more flexible sleep clinic hours, and provide incentives to attract more sleep specialists to low-income communities.”

Sex and sex hormones play important roles in sleep in women. Estrogen replacement in menopausal women can decrease sleep latency and increase REM sleep, while progesterone increases NREM sleep and raises the core body temperature. Prolactin increases slow wave sleep and the menstrual cycle, which features abrupt drops in sex hormones, affecting sleep in many women. Fatigue and insomnia are more common in adolescent girls than boys.

“Sleep complaints are common in pregnancy,” said Nancy H. Stewart, DO, MS, Assistant Professor of Pulmonary, Critical Care, and Sleep Medicine at the University of Kansas Medical Center. “There are risk factors for sleep apnea in pregnancy that correspond to the general population, including increased BMI and increased neck circumference.”

Sex-based differences in sleep continue through the postpartum period, menopause, and beyond, Dr. Stewart added.

“Women have different sleep symptoms, risks, and consequences than men,” she said.”

Women also have different risks in medicine than men, including sleep medicine. A study of gender bias in health care found that male providers are more often associated with surgery and female providers with family medicine. Similarly, a retrospective look at 14 awards given by 11 medical societies in seven specialties over 72 years found just nine awards given to women.

“Gender stereotypes also operate in R01 peer review,” Dr. Stewart said. “Reviewers more easily view male researchers as scientific leaders and score their applications more competitively, which can contribute to sex-based differences in R01 awards. Being aware of implicit bias is the first step in understanding and addressing it.”

Bias is similarly evident in sleep medicine. The American Academy of Sleep Medicine (AASM) membership is 61% male, Dr. Stewart noted. And while female membership is increasing, AASM leadership is 55% male, and 81% of AASM fellows are male.

“There is an underrepresentation of women in medicine and across leadership, which leaves room for improvement,” she said.