Unhealthy Sleep-related Behaviors — 12 States, 2009

LR McKnight-Eily, PhD; Y Liu, MS, MPH; AG Wheaton, PhD; JB Croft, PhD; GS Perry, DrPH; CA Okoro, MS; T Strine, PhD


Morbidity and Mortality Weekly Report. 2011;60(8):233-238. 

In This Article

Editorial Note

This report is the first to present estimates of the prevalence of unhealthy sleep-related behaviors based on responses to questions added to BRFSS in 2009. The results highlight two prevalences of self-reported sleep-related behaviors with potentially dangerous consequences: 37.9% of adults in 12 states reported unintentionally falling asleep during the day at least 1 day in the preceding 30 days, and 4.7% reported nodding off or falling asleep while driving during the same period. The sleep module, consisting of questions derived from surveillance-system and clinically validated sleep surveys, was developed by CDC and the National Sleep Awareness Roundtable†† in response to an Institute of Medicine recommendation to expand surveillance and monitoring of sleep loss and sleep disorders and to increase public awareness of unhealthy sleep behaviors.[1]

Nationwide surveillance has not previously assessed the prevalence of either unintentionally falling asleep during the day or nodding off or falling asleep while driving. Drowsy driving, one of the most lethal consequences of inadequate sleep, has been responsible for an estimated 1,550 fatalities and 40,000 nonfatal injuries annually in the United States.[4] In the analysis summarized in this report, the prevalence of falling asleep while driving ranged from 2.0% among persons aged ≥65 years to 7.2% among persons aged 25–34 years. Populations previously found at greatest risk included persons aged 16–29 years (particularly males), those with untreated sleep apnea syndrome or narcolepsy, and those who work shifts, particularly night shifts or extended shifts.[4] Sleepiness reduces vigilance while driving, slowing reaction time, and leading to deficits in information processing, which can result in crashes.[4] Differences among adults in the 12 states in the prevalence of nodding off or falling asleep while driving were substantial (range: 3.0% in Illinois to 6.4% in Hawaii and Texas) and might result from differences in the prevalence of populations at greater risk or differences in the use of safety measures, such as road rumble strips, an evidenced-based intervention that alerts inattentive drivers through vibration and sound.§§

Unintentionally falling asleep during the day can be indicative of narcolepsy or hypersomnia and has been associated with obstructive sleep apnea, which, in turn, has been associated with hypertension, cardiovascular disease, stroke, diabetes, and obesity.[1] Falling asleep on the job can result in productivity losses for employers and dismissal for workers. In addition, depending on circumstances and level of responsibility, unintentionally falling asleep during the day can have dangerous consequences (e.g., while child caretaking, lifeguarding, or operating heavy equipment). To assess the potential impact of unintentionally falling asleep during the day, additional inquiry regarding the circumstances of this behavior is required.

Snoring, reported by 48.0% of participating adults, is a symptom of increased upper airway resistance during sleep and generally considered a marker for obstructive sleep apnea;[1,5] pregnant women who snore can be at risk for preeclampsia.[5] The finding in this report regarding average hours slept per 24-hour period is similar to findings in other reports. In this analysis, 35.3% of U.S. adults in 12 states reported having <7 hours of sleep on average during a 24-hour period, compared with approximately 29% in the 2004–2006 National Health Interview Survey,[6] and compared with 37.1% in the 2005–2008 National Health and Nutrition Examination Survey who said they had <7 hours of sleep on workday and weekday nights.[7]

Differences in prevalence by sociodemographic characteristics and state were observed for all four sleep-related behaviors. Adults in Hawaii had the highest prevalences for all four behaviors. The reasons for higher prevalences in Hawaii and other variations are unclear and might be subjects for further examination.

The findings in this report are subject to at least three limitations. First, the increase in the number of households with cellular telephones only and the increase in telephone number portability continue to decrease BRFSS response rates, reducing the precision of state estimates and potentially introducing bias. Although in 2009 all states conducted BRFSS surveys for cellular-only households in addition to households with landline telephones, cellular telephone data were not included for the sleep module and other optional modules. Second, institutionalized persons and persons residing in households without landline telephones are not included in the survey, nor are adults from all 50 states and U.S. territories, thereby limiting the generalizability of these findings. Finally, all estimates were based on self-report rather than physiologic measures of sleep behaviors with actigraphy (use of a movement-detection device with software that uses movement patterns to diagnose sleep disorders)[1] or polysomnography.

Substantial increases in the percentage of U.S. adults reporting an average of <7 hours of sleep per 24-hour period were observed from 1985 to 2004¶¶ and can be attributed in part to broad societal changes, including increases in technology use and shift work.[1] Sleep disorders are common health concerns that can be evaluated and treated. However, many health-care professionals might have only limited training in somnology and sleep medicine, impeding their ability to recognize, diagnose, and treat sleep disorders or promote sleep health to their patients.[1] The results described in this report indicate that a large percentage of adults in 12 states reported unhealthy sleep behaviors that can be related to disease comorbidity (e.g., obstructive sleep apnea and obesity), including nearly one in 20 persons who reported nodding off or falling asleep while driving in the preceding 30 days. Expanded surveillance is needed to understand and address the public health burden of sleep loss and disorders[1] and their associations with health problems and chronic diseases among adults in all 50 states and U.S. territories, which will enable further assessment of state and nationwide trends.

Healthy People 2020 includes a sleep health section, with four objectives: increase the proportion of persons with symptoms of obstructive sleep apnea who seek medical evaluation, reduce the rate of vehicular crashes per 100 million miles traveled that are caused by drowsy driving, increase the proportion of students in grades 9–12 who get sufficient sleep, and increase the proportion of adults who get sufficient sleep.*** Promoting sleep health, including optimal sleep durations, and reducing the prevalence and impact of sleep disorders will require a multifaceted approach. This approach should consider 1) sleep environments (i.e., living conditions and proximity to noise); 2) type, scheduling, and duration of work;[8] 3) associated health-risk behaviors such as smoking, physical inactivity, and heavy drinking;[1,9] 4) chronic conditions such as obesity and depression and other comorbid mental disorders;[1,5] 5) stress and socioeconomic status;[8] and 6) validation of new and existing therapeutic technologies.[1] Drowsy driving also should be addressed, and additional effective interventions developed and implemented. As a first step, greater public awareness of sleep health and sleeping disorders is needed.

** The National Sleep Foundation suggests that adults need 7–9 hours of sleep per night. Additional information available at http://www.sleepfoundation.org/article/how-sleep-works/how-much-sleep-do-we-really-need.
†† Additional information available at http://www.nsart.org.
§§ Additional information available at http://drowsydriving.org/2009/07/countermeasures-rumble-strips.
¶¶ Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5437a7.htm.
*** Available at http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=38.


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