Mandy Withers was in her late 20s when she first realized she was more than tired.
Then, a young mom of three, just out of graduate school, and training for her new position as a pulmonary and sleep medicine nurse practitioner, she thought falling asleep after dinner and foggy mornings were just the price of doing business.
But as she stood in the corner of the exam room, and listened to her new boss screen patient after patient for sleep apnea, she silently checked “yes” to most of the symptoms. She wasn’t just busy, she was chronically unrested. A sleep study proved as much. And with the addition of a CPAP machine, she suddenly found she could finish a movie with her family after a day at work.
That was 15 years ago, and better sleep changed Withers’ life. “But if I hadn’t been working in sleep medicine, I would have had no idea,” Withers said.
Sleeplessness is a fixture of Eastern Kentucky, where Whiters and her family live. A groundbreaking study in 2015 revealed that Appalachia has some of the highest rates of insufficient sleep in the country, and Eastern Kentucky counties fared the worst. But the reasons for the region’s chronic unrest have been severely understudied.
Now, new research reveals rates of poor sleep are more widespread than first believed. The new study published in JAMA Open Network found that 65% of participants reported clinically significant insomnia, compared to a national average of 10%. And for those living below the poverty line, rates of insomnia surged even higher to 80%.
“That is a massive rate of insomnia prevalence,” said Mairead Moloney, lead author on the study. “It’s a huge alarm bell that something is going on in this population that needs addressing immediately.”
Because sleep is not isolated. Sleep quality has sweeping implications for human health, making Eastern Kentucky’s chronic restlessness a public health crisis. But without more research, without some understanding of what’s driving the phenomenon, it’s almost impossible to intervene in a meaningful way. Sleep experts in Appalachia are calling on others to join the investigation. Because if sleep can be restored to Eastern Kentucky, it could be restored anywhere.
Out of Control
Almost from the start, the study didn’t go as expected.
Moloney’s team set out to pinpoint some of the social factors that could be driving sleep issues in Eastern, Kentucky. They intended to compare six hotspot counties — counties with sleep health well below the national average — to six control counties. The control counties were similar in geography, demographics, and earnings, but believed to have better sleep health.
“Spoiler alert, our hypothesis that there would be differences between the hotspot and non-hotspot counties… disproven,” Moloney said.
In fact, the results showed the rates in control counties were no better than in the counties believed to have the worse sleep issues. And the rate of sleep disorders in all counties — both hotspots and controls — were significantly higher than researchers expected.
More than 50% of respondents reported obstructive sleep apnea, which is a biologically driven condition common in men and people with obesity. Another 65% reported insomnia, which is largely driven by social factors and belief systems. And another 44% reported general insufficient sleep.
And these soaring rates, they’re probably still “an underrecognition of the real problem,” said Sunil Sharma, MD, chief of Pulmonary, Critical Care & Sleep Medicine at West Virginia University who also studies sleep disparities in Appalachia. The data for the study were collected digitally, meaning Eastern Kentuckians without broadband access couldn’t be included. The issues of sleep health likely go farther than the researchers could measure, Sharma said.
Unchecked, this kind of chronic sleep deprivation wreaks havoc on a person’s and a region’s well-being. Lack of sleep has been linked to increased risks of obesity, cardiovascular disease, diabetes, certain types of cancer, and all-cause mortality, all conditions for which Eastern Kentuckians exceed the national averages. Poor sleep is also linked to mental health challenges, including anxiety, depression, and impaired emotional regulation.
But the power of sleep is also a reason for hope, Moloney said. “I have this working hypothesis that if we can improve people’s sleep, we can really reduce these negative health outcomes.”
Sleep Inequity
And a deeper look at insomnia, showed potential connections to finance challenges. Among the respondents who made $20,000 or less, insomnia rates escalated to almost 83%.
“The lack of finances, that brings a lot of stress into people’s lives,” Moloney said. And in eastern Kentucky, where an estimated 24% live below the poverty line —$33,000 for a family of four — that leaves a lot of people at risk of wakeful nights.
”If they don’t know how they’re going to get food on the table or get the next tankful of gas that’s a very, very stressful state to be in, ” Moloney said. Stress then begets things like worry and rumination, fear of the future, and regret about the past — all things that “quite literally keep people up at night,” she said.
But money isn’t the only problem. Even respondents who made over $100,000 still had an insomnia rate of 44%, well above the national average. Other social factors, such as low social support, smoking, living alone, and unemployment were predictors of poor sleep health. And trauma history was linked to both sleep apnea and insomnia.
“There are very high trauma rates in this population,” Moloney said. For many in Eastern Kentucky, life is already stressful and then a traumatizing event happens: a spouse is lost, a grandchild moves in, thousands were displaced in the 2022 floods.
The brain’s response to these traumatizing events is often rumination, the process of thinking and thinking about a negative event or a stressor. “It thinks it’s protecting you,” Moloney said of the brain. But in reality, many people are left with a cascade of thoughts they can’t turn off even when they’re tired.
A National Appeal
“To me, it’s a tragedy that we know these things are happening,” but we don’t have a good explanation for why, Moloney said. “There should be many more of us in the sleep research field and the social behavioral sciences. who are focused on this region, in my opinion.”
Sharma agreed. He said that many sleep medicine physicians are shocked to learn that his home of West Virginia, is the most sleep deprived state in the country, not the busy urban centers of coasts. The research in Eastern Kentucky, should have “national appeal,” he said. A better understanding of sleep in Appalachia could change how we understand and treat sleep everywhere. “If we can improve sleep here, that’s a winning lottery ticket for every other place,” he said.
According to experts, there’s very much hope. With more information, the right sleep interventions have the potential to be an extremely effective — and low cost — way to offer Eastern Kentuckians relief from sleeplessness and also the host of mental, physical, financial and relational challenges that sleeplessness perpetuates. Already, solutions like app-based cognitive behavioral therapy and in-hospital sleep education have been shown to dramatically improve sleep quality.
“I know from my research and from others that if we can improve people’s sleep, we can improve their lives, “ Moloney said. “Their stress will go down, and their health will improve. This is my long-term investment and goal for the region is to get more research done so that we have clear answers as to why people aren’t sleeping.
Donavyn Coffey is a Kentucky-based journalist covering healthcare and technology, with a particular interest in how innovations play out in rural places. Her work has appeared in Wired, TIME, Scientific American, Popular Science, and Vogue, among others.
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