4 Categories of insuﬃcient rest/sleep Whole cohort 0 days 1–6 days 7–13 days 14–20 days 21–29 days 30 days P-trend Categories of insuﬃcient rest/sleep Men 0 days 1–6 days 7–13 days 14–20 days 21–29 days 30 days P-trend Women 0 days 1–6 days 7–13 days 14–20 days 21–29 days 30 days P-trend 377160 134596 106560 39751 44781 12152 39320 147300 57456 41088 14614 15989 4155 13988 229860 77140 65472 25137 28.792 7997 25322 Journal of Environmental and Public Health Table 2: Association between insuﬃcient rest/sleep and poor SRH. No. at risk No. with poor SRH Unadjusted odds ratio (95% conﬁdence intervals) Multivariable odds ratio (95% conﬁdence intervals)∗ ∗ Adjusted for sex (men, women), age (years), race-ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), education categories (<high school, high school, >high school), employment status (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), body mass index categories (<25, 25–29, ≥30 kg/m2), CVD (no, yes), depression (no, yes), and anxiety (no, yes). Table 3: Association between insuﬃcient rest/sleep and poor SRH, by gender. No. at risk No. with poor SRH Unadjusted odds ratio (95% conﬁdence intervals) Multivariable odds ratio (95% conﬁdence intervals)∗ 70778 23570 12190 6580 10580 3224 14634 26309 9970 4386 2175 3557 1011 5210 44469 13600 7804 4405 7023 2213 9424 ∗ Adjusted 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), body mass index categories (<25, 25–29, ≥30 kg/m2), CVD (no, yes), depression (no, yes), and anxiety (no, yes). 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]. How- ever, 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 per- ceived 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, drink- ing, 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 be- tween sleep and SRH and their results have been inconsistent. Segovia et al., in a study of 3,300 subjects from St. 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 [17]. However, the authors did not adjust for possible confounders such as ethnicity or depressive symp- toms. Steptoe et al., in a study of more than 17,000 university 1 (referent) 0.64 (0.61–.68) 0.89 (0.83–.95) 1.35 (1.28–1.43) 1.54 (1.41–1.67) 2.52 (2.39–2.65) <0.0001 1 (referent) 0.63 (.58–.68) 0.82 (.74–.91) 1.23 (1.13–1.35) 1.50 (1.30–1.73) 2.53 (2.33–2.75) <0.0001 1 (referent) 0.66 (.62–.70) 0.94 (.87–1.02) 1.45 (1.35–1.55) 1.55 (1.40–1.71) 2.48 (2.33–2.65) <0.0001 1 (referent) 1.03 (0.97–1.10) 1.45 (1.34–1.57) 2.12 (1.97–2.27) 2.32 (2.09–2.58) 2.71 (2.53–2.90) <0.0001 1 (referent) 1.06 (.97–1.17) 1.41 (1.24–1.61) 2.02 (1.81–2.25) 2.42 (2.03–2.90) 2.70 (2.42–3.00) <0.0001 1 (referent) 1.01 (.94–1.09) 1.50 (1.37–1.65) 2.21 (2.03–2.42) 2.26 (2.01–2.54) 2.72 (2.50–2.96) <0.0001