sleep loss , long - term sleep deprivation , and insufficient rest / sleep are pervasive problems in developed countries today . short sleep duration and insufficient rest / sleep reduced sleep has been found to be associated with increased risk of diabetes mellitus , hypertension , cardiovascular disease ( cvd ) , and cardiovascular and all - cause mortality [ 15 ] . similarly , self - rated health ( srh ) has been shown to be a consistent predictor of cardiovascular disease and cardiovascular and overall mortality [ 69 ] . self - rated health ( srh ) is a commonly used subjective measure of health used in epidemiological studies as well as a secondary outcome in clinical trials to examine changes in subjective health status [ 610 ] . epidemiological studies from several countries and social and cultural settings have shown that srh is a valid and consistent predictor of cvd and cardiovascular and overall mortality [ 69 ] . due to its predictive ability of future risk of mortality as well as objective health outcomes , an institute of medicine ( iom ) report in 2001 recommended the inclusion of srh measurement in national surveys in the usa as a way of tracking the subjective health status of americans . however , the mechanisms underlying the reported association between srh and cvd and mortality are not known . it is possible that at least part of the association between insufficient sleep and mortality may be mediated by poor srh  although , to our knowledge , no study has examined this topic . in this context , we examined association between insufficient rest / sleep and srh in a large multiethnic survey of us adults after adjusting for main confounders . the behavioral risk factor surveillance system ( brfss ) is a federally funded , nationally representative survey of the civilian , noninstitutionalized , adult population aged 18 years or older . the survey is designed and conducted annually by the cdc in collaboration with the state health departments to monitor health - related behaviors and risk factors in the us population . the survey selects state - specific probability samples of households using a multistage cluster design to produce a nationally representative sample . the brfss uses random - digit dialing within blocks of telephone numbers to identify a probability sample of households with telephones in each state . in each household , one adult is randomly identified and interviewed . all 50 states , in addition to the district of columbia , and the three us territories participated in the 2008 brfss . detailed description of the brfss survey sample selection and study methodology are available online . in 2008 , all participants provided informed consent and this study was approved by the west virginia university institutional review board .    to examine the association between insufficient rest / sleep and srh , out of the 408,068 brfss participants who were aged 18 years and not pregnant , we further excluded subjects with missing information on variables included in the multivariable model , including insufficient rest / sleep , srh , body mass index , smoking , education , employment , physical activity , or physician - diagnosed cardiovascular disease . this resulted in 377,160 subjects with complete covariate data for the current analysis .    in 2008 , brfss included a new question on self - rated health , which asks ,  would you say that in general your health is excellent , very good , good , fair , poor , or do not know / not sure ?  srh is also termed general health  because it refers to an individual 's perception of his or her own health . the srh continuum has been shown to be a reliable indicator of a person 's objective or true health status . a negative association between srh and all - cause mortality has also been established . the 2008 brfss survey included the question ,  during the past 30 days , for about how many days have you felt you did not get enough rest or sleep ?  data from all sites were aggregated , and the numbers of days of perceived insufficient rest or sleep were categorized into six groups as zero days , 16 days , 713 days , 1420 days , 2129 days , and 30 days . this question was previously tested and validated in the 2006 brfss survey in four states ( delaware , hawaii , new york , and rhode island ) . also , national estimates of insufficient rest or sleep according to these categories have been recently published by the cdc . age , gender , race / ethnicity , smoking status , alcohol intake , level of education , employment status , income , and physical activity were assessed using a standardized questionnaire . individuals who had not smoked 100 cigarettes in their lifetimes were classified as never smokers ; those who had smoked 100 cigarettes in their lifetimes were classified as former smokers or current smokers based on their response to the question on current smoking . heavy alcohol drinking was defined as men who reported having more than 2 drinks per day , or more than 1 drink per day for women . education was categorized into below high school , high school , or above high school education . employment status was categorized as employed , unemployed , retired , unable to work , homemaker , or student . body mass index ( bmi ) was categorized into < 25 , 2529 , 30  kg / m . subjects were classified as having no regular exercise if they reported not to be participating in any physical activities such as running , calisthenics , golf , gardening , or walking for exercise during the previous month . people married at the time of the survey were classified as married , while widows and divorcees were coded as unmarried . the annual household income variable was reported in quintiles as follows : less than $ 15,000 , $ 15,000$24,999 , $ 25,000$34,999 , $ 35,000$49,999 , $ 50,000 or more . depression ( description used in brfss questionnaire : depression , major depression , dysthymia , or minor depression ) and anxiety ( description used in brfss questionnaire : acute stress disorder , anxiety , generalized anxiety disorder , obsessive - compulsive disorder , panic disorder , phobia , posttraumatic stress disorder , or social anxiety disorder ) were categorized into dichotomous , yes / no variables . perceived insufficient rest / sleep was categorized into six groups as zero days , 16 days , 713 days , 1420 days , 2129 days , and 30 days . we used logistic regression models to calculate odds ratio ( ( or ) ( 95% confidence interval ( ci ) ) of the outcome of interest associated with increasing categories of insufficient rest / sleep , taking zero days of insufficient rest / sleep as the referent category . we used two logistic regression models : the unadjusted model and the multivariable model , adjusting for sex ( men , women ) , age ( years ) , race - ethnicity ( non - hispanic white , non - hispanic black , hispanic , other ) , education categories ( < high school , high school , > high school ) , ( employed , unemployed , retired , unable to work , homemaker , student ) , income category ( quintiles ) , marital status ( no , yes ) , smoker ( never , former , current ) , heavy drinker ( no , yes ) , no regular exercise ( yes , no ) , bmi ( < 25 , 2529 , 30  kg / m ) , cvd ( no , yes ) , depression ( no , yes ) , and anxiety ( no , yes ) . trends in the or of the outcome across increasing insufficient rest / sleep category were determined by modeling these categories as an ordinal variable . appropriate brfss survey weights that account for unequal probabilities of selection , oversampling , and nonresponse were applied for all analyses using sudaan ( version 8.0 ; research triangle institute , research triangle park , nc ) and sas ( version 9.2 ; sas institute , cary , nc ) software ; ses were estimated using the taylor series linearization method . table 1 presents characteristics of the study population . nearly half of the study population were women , and about 17% were 65 years of age or older . over 60% of study participants had above high school education and approximately the same percentage were employed . about 57% were current smokers , 5.3% were heavy drinkers , 63.1% were overweight or obese , and 25% reported no regular exercise . finally , 8.6% of study subjects fell into the lowest income quintile and 8.2% reported having cvd . figure 1 presents the unadjusted distribution of srh by categories of insufficient rest / sleep . percentage of those with good srh decreases across increasing categories of insufficient rest / sleep , whereas the opposite is true for individuals with poor srh . table 2 presents the association between increasing categories of insufficient rest / sleep and poor srh . we found that in the unadjusted model , a positive association between increasing categories of insufficient rest / sleep and poor srh was evident only from 14 days of insufficient rest / sleep . however , with multivariable adjustment , a linear dose - response association was evident ( p - trend < 0.0001 ) . tables 3 , 4 , 5 , and 6 present the association between insufficient rest / sleep and poor srh within stratified subgroups of gender , age , bmi , and race - ethnicity categories . we found that the positive association between insufficient rest / sleep and poor srh persisted across all these stratified subgroups . also , there was no statistically significant interaction between insufficient rest / sleep and srh by age group , gender , or race / ethnciity ( all p - interactions > 0.10 ) . in a multiethnic , representative sample of us adults , increasing categories of insufficient rest / sleep were shown to be positively associated with poor srh overall and the association persisted when stratified by ( 1 ) gender , ( 2 ) age , ( 3 ) bmi , and ( 4 ) race - ethnicity . the positive association was present even when adjusting for confounding factors such as sex , age , race - ethnicity , education , employment status , income level , marital status , smoking , heavy drinking , exercise , bmi , depression , and anxiety . our results indirectly suggest that poor srh may be a mediator of the association between insufficient sleep and cvd and mortality [ 6 , 7 , 9 , 14 ] . however , this hypothesis needs to be directly tested in a future study that simultaneously measures insufficient rest / sleep , srh , as well as cvd and mortality outcomes . internal validity for the detected association between perceived insufficient rest / sleep and poor srh is high due to the magnitude of association , its independence from potential confounders such as sex , age , race - ethnicity , smoking , drinking , bmi , depression , and others . the presence of a positive dose - response trend and the persistence of the association in stratified analyses by subgroups of gender , age , bmi , and race - ethnicity suggest that our findings are not due to chance . only a few studies have examined the association between sleep and srh and their results have been inconsistent . john 's metropolitan area in canada , found an association between sleep duration of less than 7 hours or greater than 8 hours and poor srh . however , the authors did not adjust for possible confounders such as ethnicity or depressive symptoms . steptoe et al . , in a study of more than 17,000 university students , found an association between only short sleep duration and poor srh . a study by jean - louis et al . found no association between sleep duration and poor srh , but this study used a sample of only 273 california residents . the current study found a significant association between insufficient sleep and poor srh using a sample size of 377,160 , which is the largest study on this topic to date . also , due to our large sample size , we were able to conduct detailed subgroup analyses by gender , age , race - ethnicity , and bmi and confirm that the sleep - srh association was present consistently within these subgroups . studies have reported that poor srh is an independent predictor of mortality [ 9 , 14 ] . a corollary observation is that at least part of the association between poor srh and mortality may be mediated by insufficient sleep . also , insufficient rest / sleep may be related to sleep deficiency , which has been recently shown by sorensen et al . to be related to multiple health outcomes as well as poor srh . the sleep deficiency / sleep adequacy constructs are similar to insufficient sleep but have historically been assessed using the medical outcomes study sleep scale . there is a need for future studies to examine the relation between similar measures of insufficient sleep and sleep adequacy and how they may jointly influence multiple health and well - being outcomes . strengths of the study include its large sample size , standardized data collection methods , and the availability of data on potentially confounding conditions such as bmi , depression , and anxiety . also , the sample is nationally representative , with study samples from all 50 us states , the district of columbia , and the three territories , men and women , and all race - ethnicities , which increases the study 's generalizability . therefore , assertions about temporality or causation such as a sleep duration recommendations can not be established here . second , all brfss data are self - reported , which may lead to misclassification and therefore biased estimates . third , the 2008 brfss did not include items on potential confounders such as shift work , sleep disorders , or relevant medication usage , which therefore were not controlled in this analysis . some respondents may have conceptualized true sleep when self - reporting , while others may have considered sleep plus rest , such as time spent watching television . the subjectivity makes comparison to studies of objective measures of insufficient sleep , including polysomnography , difficult . fifth , the global srh measure is also subjective and nonspecific , characteristics that may be viewed as limitations . however , the srh measure 's reliability and repeatability has been confirmed in multiple studies across several continents and various cultural settings [ 13 , 22 ] . furthermore , srh has the potential to capture dimensions of health that are not covered in traditional , objective clinical examinations , which are more likely to be focussed around a particular organ system ( e.g. , cardiovascular system or gastrointestinal system ) , and may also account for slowly progressing diseases that evade clinical diagnoses . therefore , unfortunately , we are not able to examine if the relationship between insufficient sleep and poor srh is modified by habitual sleep duration . finally , the insufficient rest / sleep item newly included in the 2008 brfss has not been widely used or tested and therefore its reliability and validity remains questionable . however , widely tested and validated sleep quality instruments such as the pittsburgh sleep quality index and the epworth sleepiness scale do include similar items on perceived rest / sleep . future studies examining the association between the insufficient rest / sleep brfss item and objectively measured sleep duration ( e.g. , actigraphy ) are needed . future research should also include longitudinal studies to establish causation potentially including sleep duration interventions .    in summary , in a multiethnic , nationally representative sample of us adults , increasing categories of perceived insufficient rest / sleep was found to be positively associated with poor srh . this association persisted independent of sex , age , race - ethnicity , education , employment , income , marital status , smoking , heavy alcohol intake , lack of exercise , overweight / obese bmi , cvd , depression , and anxiety . based on this study , self - reported insufficient rest / sleep appears to be a strong predictor of srh .
reduced sleep has been found to be associated with increased risk of diabetes mellitus , hypertension , cardiovascular disease ( cvd ) , and mortality . 
 self - rated health ( srh ) has been shown to be a predictor of cvd and mortality . 
 however , study of the association between insufficient sleep and srh is limited . 
 we examined participants > 18 years of age ( n = 377 , 160 ) from a representative , cross - sectional survey ( 2008 brfss ) . self - reported insufficient sleep in the previous 30 days was categorized into six groups . 
 the outcome was poor srh . 
 we calculated odds ratios ( ( or ) ( 95% confidence interval ( ci ) ) of increasing categories of insufficient rest / sleep , taking zero days of insufficient sleep as the referent category . 
 we found a positive association between increasing categories of insufficient sleep and poor srh , independent of relevant covariates . in the multivariable - adjusted model , compared to 0 days insufficient sleep , the or ( 95% ci ) of poor srh was 1.03 ( 0.971.10 ) for 16 days , 1.45 ( 1.341.57 ) for 713 days , 2.12 ( 1.972.27 ) for 1420 days , 2.32 ( 2.092.58 ) for 2129 days , and and 2.71 ( 2.532.90 ) for 30 days of insufficient sleep in the prior 30 days ( p - trend < 0.0001 ) . in a nationally representative sample , 
 increasing categories of insufficient sleep were associated with poor srh .