The Role of Sleep in Health Disparities
A good night’s sleep is a luxury for all of us, but according Dr. Carmela Alcántara’s research, it is even less attainable for minority populations, which in turn places them at greater risk for poor health.
With advances in sleep science, today’s wellness gurus are constantly preaching the benefits of a good night’s sleep. Even in New York City, which is known for being the city that never sleeps, sleep evangelist Arianna Huffington warns her fellow “sleepless overachievers” that the downside is severe burnout.
That’s a condition that Columbia University sleep scholar Carmela Alcántara understands very well. “The culture in New York City is all about maximizing efficiency, productivity, and options, which is what makes it so vibrant and dynamic,” she says. “However, this quest for optimization is often achieved at the expense of one’s sleep.”
But the interesting thing about Alcántara’s research is that she is not so interested in the city’s privileged residents—though she will be the first to tell a Columbia student not to pull an all-nighter—as in those for whom poor sleep habits are almost unavoidable due to sub-standard living and working conditions.
The impact of sleep on mind and body
From a family that migrated from the Dominican Republic to Suffolk County, Long Island, when she was only six, Alcántara earned an undergraduate degree in psychology and sociology with a concentration in Latina/o studies at Cornell University. She did an M.A. and Ph.D. in clinical psychology at the University of Michigan, and her post-doctoral research took place at Harvard’s T.H. Chan School of Public Health. By the time she arrived in New York City, Alcántara was determined to make a good night’s sleep available to all, regardless of race, ethnicity, or socioeconomic background.
By then she had also tested her assumption that sleep could be an entry point for finding out about an individual’s overall health. Before joining our School in 2015, she worked as a psychotherapist at New York University-Bellevue Hospital Center, where she was struck by how often people who are reticent about mental health will speak freely about how well they are sleeping. “Patients are much more willing to talk about sleep than about depression or anxiety,” she says, “because sleep is inherently less stigmatized in today’s society. Sleep functions as an important and powerful entry point to facilitate conversations with patients about their mental and physical health.”
At Columbia, Alcántara started up the Sleep, Mind & Health Research Program with a team that includes colleagues from the Columbia University Irving Medical Center. They have been testing various ideas about the link between sleep patterns and physical health. One of their most interesting findings is a correlation between healthy sleep and the recovery, even the survival, of people who suffer major adverse cardiac events such as heart attacks.
“Specifically, we found that those who slept less than seven hours a night regularly fared much worse in terms of their risk of having another heart attack, becoming hospitalized, or dying, than those who slept seven hours or more,” she explains. These findings were published in the International Journal of Cardiology in 2014.
The connection between sleep and cardiovascular health
We asked Alcántara to explain in layperson’s terms how sleep affects cardiovascular health.
“The truth is that we don’t quite know, and it’s complicated,” she tells us. “But it involves the interaction of biological pathways and behaviors. Several studies show that when people don’t get sufficient sleep, there’s an increase in cortisol, which is a hormone that’s a marker of stress, and also an increase in inflammation, which is an important driver in atherosclerosis, or the buildup of plaque in your arteries, which in turn leads to cardiovascular disease.”
Moreover, poor sleep affects hormones that regulate appetite and weight gain. “For example,” Alcántara says, “if you’re not sleeping much, and you’re eating at times when you should be sleeping, you’re eating out of synch with your body’s clock.” Those who eat during the night are less likely to make healthy food choices, and their bodies will find it more difficult to metabolize food. Such behavior can lead to obesity, an established marker for diabetes and cardiovascular disease.
Conversely, following the body’s normal circadian rhythm, which is synchronized with the day/night cycle, leads to healthy eating patterns. It also helps to regulate one’s blood pressure, insulin sensitivity, and heart rate—all key components of cardiovascular health.
Healthy sleep habits
Alcántara’s research is taking place at a time when the fashion for being sleep-deprived, even in the city that never sleeps, has been waning, and word is gradually spreading that there is such a thing as good sleep hygiene. Alcántara notes that the Centers for Disease Control has prioritized sleep health in their campaigns to improve the health of all people in the United States (sleep health is a 2020 objective and also appears in CDC’s proposal for 2030).
According to common consensus, the tenets of good sleep hygiene include
● not taking naps
● going to bed and waking up at the same time each day
● turning off lights and TV
● using the bed only for sleep and sex, not for reading or other activities.
For those suffering from sleeplessness, sleep experts recommend Cognitive Behavioral Therapy for Insomnia, often called CBT-I. Sedatives such as Ambien are not high on anyone’s list, Alcántara notes, since patients tend to deplore its side effects, not to mention its addictive properties.
Health is determined in part by access to social and economic opportunities, along with the resources and supports available in our homes, neighborhoods, and communities. Bearing in mind such factors, Alcántara and her team are sensitive to conditions that could make it daunting for certain individuals to embrace the above sleep regimen. They are discovering that members of racial and ethnic minorities are less likely than whites to get six or seven hours of sleep every night, thereby putting themselves at greater risk of obesity, cardiovascular disease, diabetes, and mortality. Their findings were published last year in the Journal of the American College of Cardiologists.
Alcántara lists a few of the factors that contribute to these disparities, beginning with an individual’s sleeping arrangements in their home. “How many people are living in the house?” Alcántara asks. “Do they have their own room? Do they feel safe?”
Then there is the neighborhood itself: “Light pollution, noise pollution, crime and safety. These are all factors that can directly affect sleep or indirectly affect sleep through their impact on other health behaviors,” she says.
Employment status is another huge factor that can contribute to poor sleep health. “Does the person have a demanding job or care-giving responsibilities that make it hard to keep a steady schedule? Do they face discrimination or other stressors that impact their nightly sleep?” she asks, going on to point out that that some are compelled to work at night as drivers or engage in other types of shift work because of the limited opportunities available to them, while others must work rotating shifts that throw off their circadian rhythms, and still others are permanently or temporarily unemployed.
Alcántara was the lead author of a study published in the January 2019 issue of Sleep, suggesting that Latinx people searching for work may also be dealing with “acculturation stress”—figuring out how to adapt to a new culture.
“The impact of acculturation stress on insomnia is stronger among Latina/os who aren’t working,” Alcántara says. “They may spend more time in bed and ruminate, or take more naps during the day.” And they may engage in maladaptive thought patterns that cast the lack of sleep as an insurmountable problem, turning the problem into a vicious cycle.
Need for more targeted sleep education
How can this situation be remedied? One of the biggest problems Alcántara and her team face is that most sleep educational campaigns are not trying to reach populations with special needs, such as Latinx people and other minorities, nor are interventions being designed to meet those needs.
Alcántara says her team is working hard to make up for this neglect. “How can we get these campaigns and interventions to folks who don’t speak English, for example?” she says. “And we don’t have enough providers or specialists who are adequately trained to treat sleep problems, not to mention providers who speak languages other than English.”
Mobile platforms offer one possible solution. Alcántara is the principal investigator of a project, funded by the Agency for Healthcare Research and Quality, to test e-health methods for expanding access to cognitive behavioral therapy for Latinx people dealing with insomnia.
“There’s a lot of room to grow,” she points out. “In some cases, such as insomnia, we know what works and works really well, but we need to adapt interventions, develop them, test them, and, if they’re effective, get them out to people who have traditionally been left out of clinical trials.”
SOCIAL WORK LIVE: Carmela Alcántara and the Health Impact of Sleep (12/18/2018)
Related external link:
Sleep Education, a resource provide by the American Association of Sleep Medicine (AASM)