Rural Appalachian adults face growing sleep crisis

In the field of modern medicine, sleep is increasingly recognized as a pillar of health. However, a recent study published in JAMA Network Open reveals that for many Americans living in rural Appalachia, this pillar is crumbling. In this study, a team of researchers led by Mairead E. Moloney, Ph.D., from the Miller School of Medicine at the University of Miami, found that adults in rural Appalachia have significantly higher rates of insomnia, obstructive sleep apnea (OSA) risk, and insufficient sleep durations when compared to the rest of the United States

Rural Appalachia has long been recognized as one of the most economically depressed regions in the United States. For comparison, the median household income rate in Appalachia is approximately $64,500, which is close to $14,000 less than the national average.

To understand the sleep patterns of this population, Moloney’s team analyzed data from 327 participants across 12 economically distressed counties in Eastern Kentucky. The average age of participants was 45. The cohort was also predominantly White (97%) and female (76%). The team used previously collected data from the Researching Equitable Sleep Time in Kentucky Communities (REST-KY) project, an initiative designed to identify why certain geographic populations suffer from poor sleep.

While insomnia affects roughly 10% of the general U.S. population, Moloney and her team found that 65% of Appalachian adults met the clinical criteria for the disorder.

“Insomnia was significantly associated with female sex, non–full-time employment, living alone, cigarette use, poor diet quality, lower social support, poor self-rated health, polypharmacy, trauma history, moderate to severe anxiety or depression and high stress,” Moloney and her team write.

Furthermore, the risk of OSA, which is a dangerous condition where breathing repeatedly stops during the night, was present in 51% of the group, compared to 38% nationally. Insufficient sleep duration (less than 7 hours) was also more common, affecting 45% of participants.

“Elevated OSA risk was significantly associated with older age, being male, cigarette use, higher body mass index, poor self-rated health, polypharmacy, and trauma history. Insufficient sleep was significantly associated with lower social support,” Moloney and her colleagues continued.

These numbers suggest that nearly two-thirds of the population in this region is operating under a state of chronic sleep debt, which can impair cognitive function, increase the risk of workplace accidents and weaken the immune system.

The study also documented a correlation between low income and poor sleep.

“Insomnia prevalence varied significantly by income, declining from 82.9% (34 of 41 participants) among participants earning less than $20,000 annually to 44.4% (16 of 36 participants) among those earning more than $100,000, demonstrating a clear socioeconomic gradient,” Moloney and her team write in the study.

Sleep disorders also coincided with other significant health burdens, including obesity, polypharmacy and trauma.

Just over half (55%) of the cohort was classified as obese, which is a primary risk for OSA.

Even more (71%) participants reported taking at least five prescription medications. This "polypharmacy" can create a vicious cycle, as many medications for chronic pain or metabolic issues have side effects that disrupt natural sleep cycles.

Trauma rates were also very high, with 67% of participants reporting a history of it. The psychological toll of trauma is known to trigger hyperarousal, making it difficult for the body to enter the deep, restorative stages of sleep.