The Journal of Nutrition. First published ahead of print November 19, 2014 as doi: 10.3945/jn.114.199919. The Journal of Nutrition Community and International Nutrition

Food Insecurity Is Associated with Poor Sleep Outcomes Among U.S. Adults1–3 Meng Ding,4 Margaret K Keiley,5 Kimberly B Garza,6 Patricia A Duffy,7 and Claire A Zizza4* Departments of 4Nutrition, Dietetics, and Hospitality Management, 5Human Development and Family Studies, 6Health Outcomes Research and Policy, and 7Agricultural Economics and Rural Sociology, Auburn University, Auburn, AL

Abstract Background: Although food insecure (FI) adults are at risk of chronic conditions, little research attention is given to their health behaviors, such as sleep. Objective: We examined the associations between adult food security status and sleep duration, sleep latency, and sleep Methods: Our population-based sample included 5637 men and 5264 women ($22 y) who participated in the NHANES 2005–2010. Food security status was assessed with USDAÕs 10-item adult Food Security Survey Module. Self-reported information about sleep duration, sleep latency, and sleep complaints to a health care professional were used as sleep outcomes. Multiple linear, stratified by sex, and logistic regression models were used to estimate the association between food security status and the 3 sleep outcomes. Results: Very low food secure (FS) women reported significantly shorter sleep duration than fully FS women (difference: 230 6 5.2 min; P < 0.01); however, no relation about sleep duration was observed among men. Among men participants who were marginally FS (4 6 1.1 min), low FS (4 6 1.7 min), and very low FS (5 6 1.8 min) reported significantly longer sleep latency than fully FS men (P < 0.05), but no association about sleep latency was observed among women. The divergent patterns in sleep duration and latency were likely because of our reference groups reporting undesirable sleep outcomes; Fully FS men reported inadequate sleep and fully FS women reported long sleep latency. Among both men and women, marginally FS (OR: 1.64; 95% CI: 1.24, 2.16), low FS (OR: 1.63; 95% CI: 1.16, 2.30), and very low FS (OR: 1.99; 95% CI: 1.36, 2.92) participants were more likely to report sleep complaints than their fully FS counterparts (P < 0.05). Conclusions: Poor sleep quantity and quality may predispose FI adults to adverse health outcomes. J Nutr doi: 10.3945/ jn.114.199919. Keywords: food insecurity, sleep, sex, hunger, low income, adults, NHANES

Introduction Findings from the 2012 Current Population Survey indicate that in the United States 14.1% of adults are food insecure (FI)8 and of those 5.3% are characterized as very low food secure (FS) (1). Food insecurity is widely recognized as a serious public health problem, because numerous studies that focus on U.S. adult populations have shown that food insecurity is associated with obesity (2), diabetes (3, 4), hypertension (5), hyperlipidemia

1 Supported in part by the Alabama Agricultural Experiment Station (ALA043) and Nutrition, Dietetics, & Hospitality Management Competitive Graduate Research Fellowship, Auburn University. 2 Author disclosures: M Ding, MK Keiley, KB Garza, PA Duffy, and CA Zizza, no conflicts of interest. 3 Supplemental Tables 1–6 are available from the ÔÔOnline Supporting MaterialÕÕ link in the online posting of the article and from the same link in the online table of contents at http://jn.nutrition.org. 8 Abbreviations used: FI, food insecure; FS, food secure; PIR, poverty income ratio; SES, socioeconomic status; SNAP, Supplemental Nutrition Assistance Program. * To whom correspondence should be addressed. E-mail: [email protected].

(5, 6), and heart disease (5). FI adults are also more likely to experience poorer mental health (7, 8) and depression (5, 9) than their FS counterparts. Although FI adults are recognized as a vulnerable population, the intricate causal mechanisms by which food insecurity predisposes one to adverse health outcomes are not adequately identified. Modifiable, lifestyle-related health behaviors, such as poor diet quality, smoking, physical inactivity, and inadequate sleep, are identified as risk factors for many chronic conditions and for premature mortality (10). Researchers have hypothesized that shifts in dietary quantity and quality associated with food insecurity (8, 11) may promote an inflammatory state in the body and an increased susceptibility to infection (12). Few studies have assessed the lifestyle-related behaviors, other than dietary, of FI populations (13). Sleep is an ancestral and primitive behavior for almost everyone on a daily basis (14). Because of longer working hours, more shift work, and the 24/7 availability of food and recreational activities, the average number of hours of sleep has declined over the past century (15, 16). Buysse et al. (17)

ã 2015 American Society for Nutrition. Manuscript received July 10, 2014. Initial review completed July 24, 2014. Revision accepted October 24, 2014. doi: 10.3945/jn.114.199919.

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complaints reported to a health care professional.

Methods Sample. The NHANES of the National Center for Health Statistics are cross-sectional, nationally representative health and nutrition surveys of the noninstitutionalized U.S. civilian population. The NHANES are complex multistage probability samples, and details about the recruitment and survey design of these samples are published elsewhere (30). We combined data from the 2005–2006, 2007–2008, and 2009–2010 waves of NHANES (men: n = 15,401; women: n = 15,633). Adults aged $22 y (n = 15,961) were included in the analytic sample so we could compare population-adjusted means to age-based Healthy People 2020 recommendations (31). We excluded pregnant (n = 417) and breastfeeding women (n = 93) because they were likely to have disrupted sleep patterns. We excluded participants who reported taking medication for insomnia, sleep apnea, sleep automatism, sleep walking disorder, and shift work sleep disorder (n = 1194). Participants who did not have complete information on food security status (n = 152) and sleep outcomes (n = 20) were excluded. We further excluded participants (n = 953) who reported being diagnosed with a sleep disorder. Our analytic sample then included participants with complete information on age, poverty income ratio (PIR) (missing: n = 1061), BMI; missing: n = 591), mental health (missing: n = 511), household size, race/ethnicity, education level (missing: n = 9), marital status (missing: n = 7), work schedule (missing: n = 3), general health condition (missing: n = 4), smoking status (missing: n = 5), alcohol consumption (missing: n = 20), and menopause status (only for women) (missing: n = 20). The analytic sample included 5637 men and 5264 women from the analysis of sleep duration and sleep complaints. The analysis of sleep latency was based on the 2005–2006 and 2007–2008 waves of NHANES because the 2009–2010 wave did not include this item. The analytic sample for sleep latency was 3617 men and 3363 women. 2 of 7

Ding et al.

Details about NHANES participantsÕ consents are published elsewhere (32). The protocol for this study was approved by the Institutional Review Board, Office of Human Subjects Research, Auburn University. Food security status. NHANES 2005–2010 included the Food Security Survey Module, which is a well-validated questionnaire that measures the presence of food insecurity at the household level during the past 12 mo (33). We used participantsÕ responses to the 10 household adult items in the 18-item scale, because the remaining 8 items were specific for children (34). Thus, we considered a participant to be fully FS if 0 items in the scale were answered affirmatively and marginally FS if 1– 2 items were affirmative. We further classified FI participants as low FS if 3–5 items were affirmative and very low FS if 6–10 items were affirmative. Low and very low food security classifications were referred to as food insecurity (33). Sleep outcomes. Questions on sleep were asked during the household interview with the use of the Computer-Assisted Personal Interview system (34). We used questions about self-reported sleep duration, sleep latency, and sleep complaints as outcome variables. Participants were asked how many hours of sleep they usually got at night on weekdays or workdays. ParticipantsÕ answers ranged from 1 to 11 h, and participants who reported $12 h were coded as 12 h (34). Inadequate sleep was classified as participants reporting

Food insecurity is associated with poor sleep outcomes among US adults.

Although food insecure (FI) adults are at risk of chronic conditions, little research attention is given to their health behaviors, such as sleep...
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