Research Article| Volume 1, ISSUE 3, P158-165, September 2015

Download started.


Geographic distribution of insufficient sleep across the United States: a county-level hotspot analysis

Published:August 10, 2015DOI:



      Insufficient sleep is associated with cardiometabolic risk and neurocognitive impairment. Determinants of insufficient sleep include many social and environmental factors. Assessment of geographic hot/coldspots may uncover novel risk groups and/or targets for public health intervention. The aim of this study was to discern geographic patterns in the first data set to include county-level sleep data.


      The 2009 Behavioral Risk Factor Surveillance System was used. Insufficient sleep was assessed with a survey item and dichotomized. Data from n = 2231 counties were available. Tests for significant spatial concentrations of high/low levels of insufficient sleep (hotspots/coldspots) used the Getis-Ord G* statistic of local spatial concentration, chosen due to the nature of missing data.


      Eighty-four counties were hotspots, with high levels of insufficient sleep (P < .01), and 45 were coldspots, with low insufficient sleep (P < .01). Hotspots were found in Alabama (1 county), Arkansas (1), Georgia (1), Illinois (1), Kentucky (25), Louisiana (1), Missouri (4), Ohio (7), Tennessee (12), Texas (9), Virginia (6), and West Virginia (16). Coldspots were found in Alabama (1 county), Georgia (2), Illinois (6), Iowa (6), Michigan (2), Minnesota (1), North Carolina (1), Texas (7), Virginia (12), and Wisconsin (6). Several contiguous hotspots and coldspots were evident. Notably, the 17 counties with the highest levels of insufficient sleep were found in a contiguous set at the intersection of Kentucky, Tennessee, Virginia, and West Virginia (all P < .0002).


      Geographic distribution of insufficient sleep in the United States is uneven. Some areas (most notably parts of Appalachia) experience disproportionately high amounts of insufficient sleep and may be targets of intervention. Further investigation of determinants of geographic variability needs to be explored, which would enhance the utility of these data for development of public health campaigns.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Sleep Health: Journal of the National Sleep Foundation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Colten H.R.
        • Altevogt B.M.
        • Institute of Medicine Committee on Sleep Medicine and Research
        Sleep disorders and sleep deprivation: an unmet public health problem.
        Institute of Medicine: National Academies Press, Washington, DC2006
        • Grandner M.A.
        • Patel N.P.
        • Hale L.
        • Moore M.
        Mortality associated with sleep duration: the evidence, the possible mechanisms, and the future.
        Sleep Med Rev. 2010; 14: 191-203
        • Grandner M.A.
        • Patel N.P.
        • Gehrman P.R.
        • Perlis M.L.
        • Pack A.I.
        Problems associated with short sleep: bridging the gap between laboratory and epidemiological studies.
        Sleep Med Rev. 2010; 14: 239-247
        • Knutson K.L.
        Does inadequate sleep play a role in vulnerability to obesity?.
        Am J Hum Biol. 2012; 24: 361-371
        • Knutson K.L.
        Sleep duration and cardiometabolic risk: a review of the epidemiologic evidence.
        Best Pract Res Clin Endocrinol Metab. 2010; 24: 731-743
        • Buxton O.M.
        • Marcelli E.
        Short and long sleep are positively associated with obesity, diabetes, hypertension, and cardiovascular disease among adults in the United States.
        Soc Sci Med. 2010; 71: 1027-1036
        • Altman N.G.
        • Izci-Balserak B.
        • Schopfer E.
        • et al.
        Sleep duration versus sleep insufficiency as predictors of cardiometabolic health outcomes.
        Sleep Med. 2012; 13: 1261-1270
        • Roth II, T.C.
        • Rattenborg N.C.
        • Pravosudov V.V.
        The ecological relevance of sleep: the trade-off between sleep, memory and energy conservation.
        Philos Trans R Soc Lond B Biol Sci. 2010; 365: 945-959
        • Grandner M.A.
        • Patel N.P.
        • Gehrman P.R.
        • et al.
        Who sleeps better? Socioeconomic differences in reports of sleep disturbance.
        Sleep. 2009; 32 ([Abstract Supplement]): A422-A423
        • Park S.E.
        • Kim H.M.
        • Kim D.H.
        • Kim J.
        • Cha B.S.
        • Kim D.J.
        The association between sleep duration and general and abdominal obesity in Koreans: data from the Korean National Health and Nutrition Examination Survey, 2001 and 2005.
        Obesity (Silver Spring). 2009; 17: 767-771
        • Gangwisch J.E.
        • Heymsfield S.B.
        • Boden-Albala B.
        • et al.
        Sleep duration as a risk factor for diabetes incidence in a large U.S. sample.
        Sleep. 2008; 30: 1667-1673
        • Gangwisch J.E.
        • Malaspina D.
        • Boden-Albala B.
        • Heymsfield S.B.
        Inadequate sleep as a risk factor for obesity: analyses of the NHANES I.
        Sleep. 2005; 28: 1289-1296
        • Hale L.
        • Hill T.D.
        • Burdette A.M.
        Does sleep quality mediate the association between neighborhood disorder and self-rated physical health?.
        Prev Med. 2010; 51: 275-278
        • Hill T.D.
        • Burdette A.M.
        • Hale L.
        Neighborhood disorder, sleep quality, and psychological distress: testing a model of structural amplification.
        Health Place. 2009; 15: 1006-1013
        • Bird C.E.
        • Seeman T.
        • Escarce J.J.
        • et al.
        Neighbourhood socioeconomic status and biological “wear and tear” in a nationally representative sample of US adults.
        J Epidemiol Community Health. 2010; 64: 860-865
        • Hale L.
        • Do D.P.
        Racial differences in self-reports of sleep duration in a population-based study.
        Sleep. 2007; 30: 1096-1103
        • Hale L.
        • Do D.P.
        Sleep and the inner city: how race and neighborhood context relate to sleep duration.
        Population Association of America Annual Meeting Program. 2006
        • Centers for Disease Control
        Overview: BRFSS 2009.
        CDC, Washington, DC2009
        • Edinger J.D.
        • Wyatt J.K.
        • Stepanski E.J.
        • et al.
        Testing the reliability and validity of DSM-IV-TR and ICSD-2 insomnia diagnoses. Results of a multitrait-multimethod analysis.
        Arch Gen Psychiatry. 2011; 68: 992-1002
        • Grandner M.A.
        • Jackson N.J.
        • Pigeon W.R.
        • Gooneratne N.S.
        • Patel N.P.
        State and regional prevalence of sleep disturbance and daytime fatigue.
        J Clin Sleep Med. 2012; 8: 77-86
        • Grandner M.A.
        • Martin J.L.
        • Patel N.P.
        • et al.
        Age and sleep disturbances among american men and women: data from the U.S. behavioral risk factor surveillance system.
        Sleep. 2012; 35: 395-406
        • Grandner M.A.
        • Hale L.
        • Jackson N.
        • Patel N.P.
        • Gooneratne N.S.
        • Troxel W.M.
        Perceived racial discrimination as an independent predictor of sleep disturbance and daytime fatigue.
        Behav Sleep Med. 2012; 10: 235-249
        • Grandner M.A.
        • Patel N.P.
        • Perlis M.L.
        • et al.
        Obesity, diabetes, and exercise associated with sleep-related complaints in the American population.
        J Public Health. 2011; 19: 463-474
        • Grandner M.A.
        • Patel N.P.
        • Gehrman P.R.
        • et al.
        Who gets the best sleep? Ethnic and socioeconomic factors related to sleep disturbance.
        Sleep Med. 2010; 11: 470-479
        • Grandner M.A.
        • Jackson N.J.
        • Pak V.M.
        • Gehrman P.R.
        Sleep disturbance is associated with cardiovascular and metabolic disorders.
        J Sleep Res. 2012; 21: 427-433
        • Getis A.
        • Ord J.K.
        The analysis of spatial association by use of distance statistics.
        Geogr Anal. 1992; 24: 189-206
        • Daly H.
        Simple SAS, macros for the calculation of exact binomial and poisson confidence limits.
        Comput Biol Med. 1992; 22: 351-361
        • Pancoska P.
        • Buch S.
        • Cecchetti A.
        • et al.
        Family networks of obesity and type 2 diabetes in rural Appalachia.
        Clin Transl Sci. 2009; 2: 413-421
        • Tessaro I.
        • Smith S.L.
        • Rye S.
        Knowledge and perceptions of diabetes in an Appalachian population.
        Prev Chronic Dis. 2005; 2: A13
        • Borak J.
        • Salipante-Zaidel C.
        • Slade M.D.
        • Fields C.A.
        Mortality disparities in Appalachia: reassessment of major risk factors.
        J Occup Environ Med. 2012; 54: 146-156
        • Kariisa M.
        • Seiber E.
        Distribution of cardiovascular disease and associated risk factors by county type and health insurance status: results from the 2008 Ohio Family Health Survey.
        Public Health Rep. 2015; 130: 87-95
        • Blackley D.
        • Behringer B.
        • Zheng S.
        Cancer mortality rates in Appalachia: descriptive epidemiology and an approach to explaining differences in outcomes.
        J Community Health. 2012; 37: 804-813
        • Hendryx M.
        • O'Donnell K.
        • Horn K.
        Lung cancer mortality is elevated in coal-mining areas of Appalachia.
        Lung Cancer. 2008; 62: 1-7
        • Wade W.A.
        • Petsonk E.L.
        • Young B.
        • Mogri I.
        Severe occupational pneumoconiosis among West Virginian coal miners: one hundred thirty-eight cases of progressive massive fibrosis compensated between 2000 and 2009.
        Chest. 2011; 139: 1458-1462
        • Casto B.C.
        • Sharma S.
        • Fisher J.L.
        • Knobloch T.J.
        • Agrawal A.
        • Weghorst C.M.
        Oral cancer in Appalachia.
        J Health Care Poor Underserved. 2009; 20: 274-285
        • Halverson J.A.
        • Bischak G.
        Underlying socioeconomic factors influencing health disparities in the Appalachian region.
        Mary Babb Randolph Cancer Center, West Virginia University, Morgantown, WV2008
        • Grandner M.A.
        • Chakravorty S.
        • Perlis M.L.
        • Oliver L.
        • Gurubhagavatula I.
        Habitual sleep duration associated with self-reported and objectively determined cardiometabolic risk factors.
        Sleep Med. 2014; 15: 42-50
        • Grandner M.A.
        Addressing sleep disturbances: an opportunity to prevent cardiometabolic disease?.
        Int Rev Psychiatry. 2014; 26: 155-176
        • McKnight-Eily L.R.
        • Liu Y.
        • Perry G.S.
        • et al.
        Perceived insufficient rest or sleep among adults—United States, 2008.
        MMWR Morb Mortal Wkly Rep. 2009; 58: 1175-1179