0863 Age-categorized Trends In Self-reported Sleep Duration For The Non-institutionalized U.s. Civilian Population From 2004-2013: Considerations Of Racial/ethnic Variations

Abstract Introduction We examined age-categorized trends in self-reported sleep duration using data from the National Health Interview Survey (NHIS) 2004-2013 and explored how these trends may vary based on individuals’ race/ethnicity. Methods Study participants were aged 18-85 (N=258,158). Sleep duration within a 24-hour period on average was categorized as ≤ 6hrs (short-sleep), 7-8 hours (adequate-sleep), and ≥ 9hrs (long-sleep). Age was categorized as 18 - <26, 26 - <65 and 65 - 85. Racial categories included non-Hispanic Whites (NHW), Blacks/African Americans (AAs) and Hispanics. Adjusted multinomial logistic regression models examined trends in self-reported sleep duration across age-categories and assessed race/ethnic differences in these trends. Results Mean sleep duration (hrs.) across all years was 7.4, 7.0, and 7.5, for ages 18 - <26, 26 - <65 and 65 - 85, respectively and was relatively stable from 2004-2013. However, compared to individuals ages 18 - <26, those categorized as ages 26 - <65 were 55% more likely to be short sleepers while those ages 65 - 85 were 20% less likely to be short sleepers (P < .001 for all). Mean sleep duration was 7.2hrs, for NHW and 7.1hrs for AAs and Hispanics, and showed increasing trend toward short sleep beginning in 2007 through 2013 (P <.01 for trend). In the age 18 - <26 category, compared to whites, blacks and Hispanics were 35% and 29% more likely to be short sleepers, respectively. In the age 26 - <65 category, compared to whites, blacks and Hispanics were 35% and 21% more likely to be short sleepers, respectively. In the age 65 - 85 category, compared to whites, blacks were 19% more likely to be short sleepers (P < .001 for all). Conclusion Continued surveillance of population-level sleep trends among minority populations is essential as growing race/ethnic (age specific) disparities in self-reported sleep duration may have consequences for racial/ethnic health disparities. Support NIH/NIA/NHLBI (L30-AG064670, CIRAD P30AG059303 Pilot, T32HL129953, R01AG056531, R25HL105444, R25NS094093, K07AG05268503, R01HL142066, K23HL125939)

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Are U.S. adults reporting less sleep?: Findings from sleep duration trends in the National Health Interview Survey, 2004–2017

SLEEP ◽

10.1093/sleep/zsy221 ◽

2018 ◽

Vol 42 (2) ◽

Cited By ~ 20

Author(s):

Connor M Sheehan ◽

Stephen E Frochen ◽

Katrina M Walsemann ◽

Jennifer A Ailshire

Keyword(s):

Logistic Regression ◽

Sleep Duration ◽

Ethnic Differences ◽

National Health ◽

National Health Interview Survey ◽

Regression Models ◽

Multinomial Logistic Regression ◽

Logistic Regression Models ◽

Short Sleep ◽

Interview Survey

AbstractStudy ObjectivesTo document trends in self-reported sleep duration for the noninstitutionalized U.S. civilian population from 2004 to 2017 and examine how sleep trends vary by race/ethnicity.MethodsWe use data from the National Health Interview Survey (NHIS) for U.S. noninstitutionalized adults aged 18–84 from 2004 to 2017 (N = 398 382). NHIS respondents were asked how much they slept in a 24-hour period on average, which we categorized as ≤6 hr (short sleep), 7–8 hr (adequate sleep), and ≥9 hr (long sleep). We used multinomial logistic regression models to examine trends in self-reported sleep duration and assess race/ethnic differences in these trends. Our models statistically adjusted for demographic, socioeconomic, familial, behavioral, and health covariates.ResultsThe prevalence of short sleep duration was relatively stable from 2004 to 2012. However, results from multinomial logistic regression models indicated that there was an increasing trend toward short sleep beginning in 2013 (b: 0.09, 95% CI: 0.05–0.14) that continued through 2017 (b: 0.18, 95% CI: 0.13–0.23). This trend was significantly more pronounced among Hispanics and non-Hispanic blacks, which resulted in widening racial/ethnic differences in reports of short sleep.ConclusionsRecent increases in reports of short sleep are concerning as short sleep has been linked with a number of adverse health outcomes in the population. Moreover, growing race/ethnic disparities in short sleep may have consequences for racial and ethnic health disparities.

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Spousal Educational Attainment and Sleep Duration Among American Older Adults

The Journals of Gerontology Series B ◽

10.1093/geronb/gbaa206 ◽

2020 ◽

Author(s):

Connor Sheehan ◽

Masumi Iida

Keyword(s):

High School ◽

Older Adults ◽

Educational Attainment ◽

Sleep Duration ◽

Multinomial Logistic Regression ◽

Social Characteristics ◽

Logistic Regression Models ◽

Short Sleep ◽

Highly Educated ◽

Interaction Terms

Abstract Objectives Sleep has consistently been shown to have a dyadic nature among married older adults; however, less is known about the influence of a spouses’ social characteristics on one’s own sleep. Focusing on older adults, we examined the association between one’s spouses’ educational attainment and one’s own sleep duration. Method We used the 2004–2018 National Health Interview Survey (NHIS) to analyze heterosexual married adults aged 50–84 (N = 89,180). Respondents reported typical sleep duration in a 24-hr period, which was categorized as short (≤6 hr), normal (7–8 hr), or long (≥9 hr). We fit multinomial logistic regression models predicting these categories of sleep duration and accounted for demographic, household socioeconomic characteristics, and health/health behaviors. Using interaction terms, we tested if the association varied by the respondent’s gender and educational attainment. Results Older adults married to spouses with college or more education had significantly lower relative risk of short sleep than those whose spouses had some college, high school, or less than high school education, net of the covariates including their own education. The benefit of higher levels of spousal education was significantly more protective against short sleep for women and more highly educated older adults. Discussion Older adults married to spouses with high levels of education reported more favorable sleep durations, but this benefit was significantly stronger for women and the highly educated which has important implications for their aging. These findings suggest that social inequality may condition the dyadic nature of sleep for heterosexual married older adults.

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Sleep duration and napping in relation to colorectal and gastric cancer in the MCC-Spain study

Scientific Reports ◽

10.1038/s41598-021-91275-3 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Kyriaki Papantoniou ◽

Gemma Castaño-Vinyals ◽

Ana Espinosa ◽

Michelle C. Turner ◽

Vicente Martín-Sánchez ◽

...

Keyword(s):

Gastric Cancer ◽

Sleep Duration ◽

Night Shift ◽

Work History ◽

Logistic Regression Models ◽

Short Sleep ◽

Long Sleep ◽

Adjusted Logistic Regression ◽

Population Controls ◽

Control Study

AbstractSleep duration is a novel and potentially modifiable risk factor for cancer. We evaluated the association of self-reported sleep duration and daytime napping with odds of colorectal and gastric cancer. We included 2008 incident colorectal cancer cases, 542 gastric cancer cases and 3622 frequency-matched population controls, recruited in the MCC-Spain case–control study (2008–2013). Sleep information, socio-demographic and lifestyle characteristics were obtained through personal interviews. Multivariable adjusted logistic regression models were used to estimate odds ratios (OR) with 95% confidence intervals (CI) for cancer, across categories of sleep duration (≤ 5, 6, 7, 8, ≥ 9 hours/day), daytime napping frequency (naps/week) and duration (minutes/nap). Compared to 7 hours of sleep, long sleep was associated with increased odds of colorectal (OR≥9 hours: 1.59; 95%CI 1.30–1.94) and gastric cancer (OR≥9 hours: 1.95; 1.37–2.76); short sleep was associated with increased odds of gastric cancer (OR≤5 hours: 1.32; 0.93–1.88). Frequent and long daytime naps increased the odds of colorectal (OR6–7 naps/week, ≥30 min: 1.32; 1.14–1.54) and gastric cancer (OR6–7 naps/week, ≥30 min: 1.56; 1.21–2.02). Effects of short sleep and frequent long naps were stronger among participants with night shift-work history. Sleep and circadian disruption may jointly play a role in the etiology of colorectal and gastric cancer.

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Frequency of Seeing People Walk and Aerobic Physical Activity Among Latino Adults

Journal of Physical Activity and Health ◽

10.1123/jpah.2019-0200 ◽

2020 ◽

Vol 17 (2) ◽

pp. 211-216 ◽

Cited By ~ 1

Author(s):

Rosenda Murillo ◽

Pooja Agrawal ◽

Sheila Berenji-Jalaei ◽

Elizabeth Vasquez ◽

Sandra Echeverria

Keyword(s):

Physical Activity ◽

Multinomial Logistic Regression ◽

Neighborhood Context ◽

Cross Sectional ◽

Latino Men ◽

Behavioral Norms ◽

Logistic Regression Models ◽

Aerobic Activity ◽

Interview Survey ◽

Racial Ethnic

Background: Little research has examined gender differences in the association of seeing others exercise, in the neighborhood context, with physical activity, particularly for diverse racial/ethnic groups. The authors examined the association between frequency of seeing people walk and aerobic activity by gender among Latinos. Methods: The authors used cross-sectional 2015 National Health Interview Survey data on Latino participants ≥18 years (n = 5147). Multinomial logistic regression models estimated the association between seeing people walk and level of aerobic physical activity. Results: Men reporting seeing people walk every 2 to 3 days and every day were more likely to meet the aerobic activity recommendation (odds ratio [OR] 2.02; 95% confidence interval [CI], 1.05–3.89 and OR 1.96; 95% CI, 1.23–3.14, respectively). Among women, those seeing people walk every day and every 2 to 3 days were likely to engage in some aerobic activity (OR 1.88; 95% CI, 1.26–2.80 and OR 2.16; 95% CI, 1.23–3.18, respectively) and meet the recommendation (OR 1.73; 95% CI, 1.24–2.42 and OR 1.66; 95% CI, 1.03–2.67, respectively). Women seeing people walk about once a week were also likely to engage in some activity (OR 3.06; 95% CI, 1.59–5.89). Conclusions: Among Latino men and women, seeing people walk is associated with meeting the aerobic activity guideline. Results suggest that adoption of physical activity may in part be driven by neighborhood-level behavioral norms and by inference characteristics of the neighborhood that support walking.

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Abstract P336: The Association Between Goal-Striving Stress, Sleep Duration and Sleep Quality in the Jackson Heart Study

Circulation ◽

10.1161/circ.137.suppl_1.p336 ◽

2018 ◽

Vol 137 (suppl_1) ◽

Author(s):

Loretta Cain ◽

LáShauntá Glover ◽

Dayna Johnson ◽

Mario Sims

Keyword(s):

Sleep Quality ◽

Sleep Duration ◽

Poor Sleep ◽

Jackson Heart Study ◽

Poor Sleep Quality ◽

Short Sleep Duration ◽

Logistic Regression Models ◽

Short Sleep ◽

Goal Striving ◽

Heart Study

Introduction: Research shows that compared to non-Hispanic whites, African Americans (AAs) have poorer sleep quality, lower mean sleep duration, and a higher prevalence of sleep-disordered breathing. AAs also report more frequent exposures to certain stressors over the life course, which may impact physiological processes that may impair sleep. Goal-striving-stress (GSS), the discrepancy between aspiration and achievement, weighted by the subjective probability of success, and the level of disappointment experienced if goals are not reached, may be an important stressor among AA’s that may influence sleep; however this has yet to be explored. The objective of this study was to assess the relationship between GSS and sleep duration and sleep quality in AAs. Hypothesis: We assessed the hypothesis that high (versus low) GSS would be associated with short or long sleep duration and poor sleep quality. Methods: We utilized data from the baseline exam of the Jackson Heart Study (JHS; n=5306), an AA sample of women and men, 35-84 years old. There were a total of 5082 participants in the sample; 63.34% female with a mean age of 55.30 (± 12.75) and mean sleep duration of 6.43 hours (±1.51). The sample was categorized into GSS tertiles: low (n=2121), moderate (n=1716), high (n=1296). Participants self-reported sleep duration (hours) and rated their sleep quality. Sleep duration was categorized as short ( < 6 hours), normal (7 or 8 hours) and long ( > 9 hours). Sleep quality was categorized as high (good/very good/excellent) and low (fair/poor). Logistic regression models were used to obtain odds ratios (OR, 95% confidence interval-CI) to assess the associations of GSS levels with sleep duration and sleep quality categories. Models were adjusted for sex, age, socioeconomic status, health behaviors, discrimination, and health outcomes. Results: Significant results showed that participants who reported high (versus low) GSS had a 29% increased odds [1.29 (1.10, 1.52)] of short (versus normal) sleep after full adjustment. Participants who reported high (versus low) GSS had a 42% increased odds [1.42 (1.20, 1.67)] of low (versus high) sleep quality after full adjustment. Conclusion In conclusion, the deficit between goal aspiration and achievement is associated with short sleep duration and poor sleep quality. Potential interventions should consider the extent to which GSS may contribute to the development of short sleep duration and poor sleep quality.

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Associations of Urinary Phytoestrogen Concentrations with Sleep Disorders and Sleep Duration among Adults

Nutrients ◽

10.3390/nu12072103 ◽

2020 ◽

Vol 12 (7) ◽

pp. 2103 ◽

Cited By ~ 1

Author(s):

Jing Sun ◽

Hong Jiang ◽

Weijing Wang ◽

Xue Dong ◽

Dongfeng Zhang

Keyword(s):

Sleep Disorders ◽

Sleep Duration ◽

Multinomial Logistic Regression ◽

Cross Sectional Study ◽

Current Evidence ◽

Relative Risk Ratio ◽

Cross Sectional ◽

Short Sleep ◽

Long Sleep ◽

Normal Sleep

Current evidence on the relationship of phytoestrogens with sleep is limited and contradictory. In particular, studies on individual phytoestrogens and sleep have not been reported. Thus, this study aimed to appraise the associations of individual phytoestrogens with sleep disorders and sleep duration. This cross-sectional study comprising 4830 adults utilized data from the National Health and Nutrition Examination Survey 2005–2010. Phytoestrogens were tested in urine specimens. Sleep disorders and sleep duration were based on a self-reported doctor’s diagnosis and usual sleep duration. The main analyses utilized logistic and multinomial logistic regression models and a restricted cubic spline. In the fully adjusted model, compared with tertile 1 (lowest), the odds ratios (95% confidence intervals (CIs)) of sleep disorders for the highest tertile of urinary concentrations of enterolactone, enterodiol, and O-desmethylangolensin were 0.64 (0.41–1.00), 1.54 (1.07–2.21), and 1.89 (1.26–2.85), respectively. Linear inverse, approximatively linear positive, and inverted L-shaped concentration–response relationships were found between enterolactone, enterodiol, and O-desmethylangolensin and sleep disorders, respectively. Compared with normal sleep (7–8 h/night), the relative risk ratio (RRR) (95% CI) of very short sleep for enterolactone was 0.56 (0.36–0.86), and the RRR (95% CI) of long sleep risk for genistein was 0.62 (0.39–0.99). Furthermore, negative associations of genistein with sleep disorders and enterolactone with long sleep risk, as well as positive associations of enterodiol with both long and very short sleep, were observed in the stratified analysis by age or gender. Finally, a notable finding was that urinary O-desmethylangolensin concentration was positively related to sleep disorders in both females aged 40–59 years and non-Hispanic Whites but inversely associated with sleep disorders in both females aged 60 years or over and other Hispanics. Our findings suggested that enterolactone and genistein might be beneficial for preventing sleep disorders or non-normal sleep duration among adults, and enterodiol might be adverse toward this goal. However, the association of O-desmethylangolensin with sleep disorders might be discrepant in different races and females of different ages.

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Peruvians’ sleep duration: analysis of a population-based survey on adolescents and adults

10.7287/peerj.preprints.166 ◽

2013 ◽

Author(s):

Rodrigo M. Carrillo-Larco ◽

Antonio Bernabé-Ortiz ◽

J. Jaime Miranda ◽

Jorge Rey de Castro

Keyword(s):

Sleep Duration ◽

Rural Areas ◽

Multivariable Analysis ◽

Secondary Analysis ◽

Population Level ◽

Educational Status ◽

Sleep Habits ◽

Cross Sectional ◽

Short Sleep ◽

Long Sleep

Sleep duration, either short or long, has been associated with diseases such as obesity, type-2 diabetes and cardiovascular diseases. Characterizing the prevalence and patterns of sleep duration at the population-level, especially in resource-constrained settings, will provide informative evidence on a potentially modifiable risk factor. The aim of this study was to explore the patterns of sleep duration in the Peruvian adult and adolescent population, together with its socio-demographic profile. This is a cross-sectional study, secondary analysis of the Use of Time National Survey conducted in 2010. Weighted means and proportions were used to describe sleep duration according to socio-demographic variables. Poisson regressions, taking into account the multistage sampling design of the survey, were used to calculate crude and adjusted prevalence ratios (PR) and 95% confidence intervals (95% CI). Main outcomes were short- (<6 hours) and long-sleep duration (≥9 hours). A total of 12,424 observations, mean age 35.8 years (SD ±17.7), 50.6% males, were included in the analysis. On average, Peruvians slept 7.7 hours (95% CI 7.4-8.0) on weekdays and 8.0 hours (95% CI 7.8-8.1) during weekends. The proportions of short- and long-sleep, during weekdays, were 4.3% (95% CI 2.9%-6.3%) and 22.4% (95% CI 14.9%-32.1%), respectively. Regarding urban and rural areas, a much higher proportion of short-sleep was observed in the former. On the multivariable analysis, compared to regular-sleepers (≥6 to <9 hours), short-sleepers were twice more likely to be older and to have higher educational status, and 50% more likely to be currently employed. Similarly, relative to regular-sleep, long-sleepers were more likely to have a lower socioeconomic status as per educational attainment. In this nationally representative sample, the sociodemographic profile of short-sleep contrasts the long-sleep. These scenarios in Peru, as depicted by sleeping duration, differ from patterns reported in other high-income settings and could serve as the basis to inform and to improve sleep habits in the population.

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Temporal Trends in Racial and Ethnic Disparities in Sleep Duration in the United States: A National Health Interview Survey Analysis from 2004 to 2018

10.1101/2021.10.31.21265202 ◽

2021 ◽

Author(s):

César Caraballo ◽

Shiwani Mahajan ◽

Javier Valero-Elizondo ◽

Daisy Massey ◽

Yuan Lu ◽

...

Keyword(s):

Sleep Duration ◽

Ethnic Differences ◽

Household Income ◽

National Health Interview Survey ◽

Temporal Trends ◽

Ethnic Disparities ◽

Short Sleep ◽

Long Sleep ◽

Interview Survey ◽

Racial Ethnic

Importance: Minoritized racial and ethnic groups are generally more likely to experience sleep deficiencies. It is unclear how these sleep duration disparities have changed over recent years. Objective: To determine 15–year trends in the racial and ethnic differences in self–reported sleep duration among adults in the US. Design: Serial cross–sectional study. Setting: National Health Interview Survey from years 2004–2018. Participants: 429,195 non–institutionalized adults. Exposures: Self–reported race, ethnicity, household income, and sex/gender. Main Outcomes: Temporal trends and racial/ethnic differences in short– and long–sleep duration (≤6 and ≥10 hours in a 24–hour period, respectively) and racial/ethnic differences in the relationship between sleep duration and age. Results: The study sample consisted of 429,195 individuals (mean age 46.5 [SE, 0.08] years; 51.7% female) of which 5.1% identified as Asian, 11.8% as Black, 14.7% as Latino/Hispanic, and 68.5% as White. In 2004, the adjusted estimated prevalence of short–sleep duration and long–sleep duration, respectively, were 31.3% and 2.5% among Asian individuals, 35.3% and 6.4% among Black individuals, 27.0% and 4.6% among Latino/Hispanic individuals, and 27.8% and 3.5% among White individuals. Over the study period, there was a significant increase in the short sleep prevalence among Black, Latino/Hispanic, and White individuals (P≤0.02 for each), whereas prevalence of long sleep changed significantly only among Latino/Hispanic individuals (–1.4 points, P=0.01). In 2018, compared with White individuals, short sleep prevalence among Black and Latino/Hispanic individuals was higher by 10.7 points and 2.6 points, respectively (P≤0.02 each), and long sleep prevalence among Black people was significantly higher by 1.4 points (P=0.01). These racial/ethnic disparities were the greatest among women and among those with middle/high household income. Over the study period, Black individuals younger than 60 years old had the highest prevalence of short sleep compared with those of the same age; and Black individuals had a higher long–sleep duration prevalence than White individuals across all age groups. Conclusions: From 2004 to 2018, the prevalence of unrecommended sleep duration was persistently higher among Black individuals. The Black–White disparities were highest among women, individuals who had middle or high income, and among young or middle–aged adults.

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Association of Sleep Duration and Overweight/Obesity among Children in China

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17061962 ◽

2020 ◽

Vol 17 (6) ◽

pp. 1962 ◽

Cited By ~ 1

Author(s):

Jing Fan ◽

Caicui Ding ◽

Weiyan Gong ◽

Fan Yuan ◽

Yan Zhang ◽

...

Keyword(s):

Sleep Duration ◽

Family Income ◽

Multinomial Logistic Regression ◽

Continuous Variable ◽

Normal Weight ◽

Overweight And Obesity ◽

Short Sleep Duration ◽

Short Sleep ◽

Restricted Cubic Splines ◽

Positive Effect

To investigate the association of sleep duration with overweight and obesity among children aged 6 to 17 years in China, 2010–2012 data from the China National Nutrition and Health Surveillance (CNHHS) were analyzed. A total of 35,414 children were recruited in the survey. Body mass index (BMI) was converted into three categories: normal weight, overweight and obesity. In multinomial logistic regression model, sleep duration was divided into four groups: very short, short, recommended and long. In restricted cubic splines (RCS), sleep duration was examined as a continuous variable in relation to overweight and obesity. In the very short and short groups, sleep duration was a risk factor for obesity after adjusting for the potential impacts of age, gender, residence, family income, leisure sedentary behavior (SB) and leisure exercise, with OR (Odds Ratio) = 3.01 (95% CI (confidence interval): 2.19–4.15) and OR = 1.24 (95% CI: 1.14–1.35), respectively. The adjusted OR of overweight for short sleep duration relative to a recommended sleep duration was 1.17(95% CI: 1.09–1.26). No significant associations of very short sleep with overweight, of long sleep duration with overweight and obesity were found. The RCS curves between sleep duration and overweight and obesity were both inverted J-shaped. To conclude, the shorter the sleep duration, the higher the risk of overweight and obesity in children. Increasing sleep duration would have a positive effect on reducing overweight and obesity rates in Chinese children.

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Abstract 039: Insomnia And Short Sleep Uniquely Predict Obesity, Hypertension, And Diabetes

Circulation ◽

10.1161/circ.143.suppl_1.039 ◽

2021 ◽

Vol 143 (Suppl_1) ◽

Author(s):

Adam Knowlden ◽

Michael A Grandner

Keyword(s):

Regression Models ◽

Sleep Problems ◽

Population Level ◽

Cardiometabolic Health ◽

Epidemiological Evidence ◽

Logistic Regression Models ◽

Short Sleep ◽

Health And Nutrition ◽

History Of ◽

Obesity Hypertension

Background: Epidemiological evidence of short sleep’s (<6 hours) association with negative cardiometabolic health outcomes continues to mount; yet, the complex relationship between sleep and health is still not well-understood. Sleep problems, such as short sleep (SS) and insomnia (IN), are often analyzed as a singular construct at the population level; however, it has been proposed that, although these two sleep problems likely overlap, they are separate phenomena. The purpose of this study was to: (1) determine if SS and IN were independent constructs; and to (2) evaluate whether SS and IN predicted obesity, hypertension, and diabetes. Methods: Analyses were based on the 2015-2016 National Health and Nutrition Examination Survey (NHANES). NHANES employs a complex, multistage, probability sampling design to survey a representative sample of non-institutionalized U.S. adults (≥18 years). Data related to short (<6), normal (7-8), and long (9+) sleep duration, insomnia (present: mild, moderate, severe), hypertension (present: previous hypertension/hypertension medications/blood pressure in the hypertensive range), and diabetes (present: history of diabetes/fasting blood sugar of 130+) were extracted for analysis. Age, sex, and obesity (body mass index, 30.0+) were entered as covariates into the models. Results: Among the subjects, 0.08% were normal sleepers with IN; 0.21% were SS with insomnia; and, 0.59% had IN with SS. Table 1 summarizes the multivariate and stratified logistic regression models of SS and IN predicting obesity, hypertension, and diabetes. Conclusions: Findings from this study suggested SS and IN are independent constructs, uniquely predicting obesity, hypertension, and diabetes. SS and IN neither mediated nor moderated one another, implying these two sleep outcomes are not additive in nature, but are instead separate health problems. The distinction between SS and IN may have important epidemiological and clinical implications.

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