Short Sleep Duration is Associated with
Hypertension only among Women: A
Population-based Study
Stranges S *, Dorn JM *, Cappuccio FP *, Donahue RP *,
Hovey KM *, Kandala N-B *, Miller MA *, Trevisan M *
*University of Warwick Medical School, UK
*State University of New York at Buffalo, USA
E.S.R.S. Glasgow 2008
Sleep Duration & Chronic Disease
Total and Cause-Specific Mortality
A decrease in sleep duration is associated with an increase in
mortality via cardiovascular deaths (Ferrie JE et al. Sleep 2007;30:1659-66)
Cardio-Metabolic Risk Factors/Disease
Obesity/Body Fat Distribution
(Gangwisch JE et al. Sleep 2005;28:1289-96 - Patel SR et al. A.J.E. 2006;164:947-54 –
Stranges S et al. A.J.E. 2008;167:321-9 - Cappuccio FP et al. Sleep 2008;31:619-26)
Type 2 Diabetes
(Ayas NT et al. Diab Care 2003;26:380-4 – Yaggi HK et al. Diab Care 2006;29:657-61)
Coronary Heart Disease
(Meisinger C et al. Sleep 2007;30:1121-7)
Hypertension
(Gangwisch JE et al. Hypertension 2006;47:833-9 - Cappuccio FP et al. Hypertension 2007;50:693-701 Stang A et al. Hypertension 2008;51:e15-6)
Study Aims
To examine the cross-sectional association of
sleep duration with hypertension
To perform gender-specific analyses with the
inclusion of a number of potential
confounding variables
The Western New York Health Study
Setting
• Erie & Niagara Counties
Baseline examination (Sept 1996 – May 2001)
• Eligible Participants: a) cancer free; b) age 35-79 years
• Actual Participants: 4,065, random sample
• Participation rate: 59.5%
Exclusion Criteria
• Self-reported history of prevalent CVD, ethnicity other than white
• Included: 3,207 participants (56.5% women)
General examination
• Resting blood pressure, BMI, waist circumference, abdominal height
Socio-demographics
• Marital status, education, annual household income
Lifestyle
• Diet, drinking and smoking habits, physical activity, sleep habits
Health Status
• SF-36 mental/physical, depressive symptoms (CES-D), diabetes
Exposure: Sleep Duration
Seven-Day Physical Activity Recall questionnaire
‘On the average, how many hours did you sleep each night in the last five weekday nights (SundayThursday)?’
 Short sleep (<6 hours)
 Mid-range sleep (6-8 hours)
 Long sleep (>8 hours)
Outcome: Prevalent Hypertension
Systolic BP ≥ 140 mmHg, OR Diastolic BP ≥ 90 mmHg, OR on antihypertensive medication at the baseline
visit
Statistical analysis
Multivariable logistic regression
Model 1: age, education, marital status, household income
Model 2: M1 + BMI/waist, drinking/smoking, physical activity
Model 3: M2 + SF-36 mental/physical, depressive symptoms
Odds ratios of prevalent HTN comparing short and long duration of sleep vs. mid-range category
Exposure: Sleep Duration
Seven-Day Physical Activity Recall questionnaire
‘On the average, how many hours did you sleep each night in the last five weekday nights (SundayThursday)?’
 Short sleep (<6 hours)
 Mid-range sleep (6-8 hours)
 Long sleep (>8 hours)
Outcome: Prevalent Hypertension
Systolic BP ≥ 140 mmHg, OR Diastolic BP ≥ 90 mmHg, OR on antihypertensive medication at the baseline
visit
Statistical analysis
Multivariable logistic regression
Model 1: age, education, marital status, household income
Model 2: M1 + BMI/waist, drinking/smoking, physical activity
Model 3: M2 + SF-36 mental/physical, depressive symptoms
Odds ratios of prevalent HTN comparing short and long duration of sleep vs. mid-range category
Exposure: Sleep Duration
Seven-Day Physical Activity Recall questionnaire
‘On the average, how many hours did you sleep each night in the last five weekday nights (SundayThursday)?’
 Short sleep (<6 hours)
 Mid-range sleep (6-8 hours)
 Long sleep (>8 hours)
Outcome: Prevalent Hypertension
Systolic BP ≥ 140 mmHg, OR Diastolic BP ≥ 90 mmHg, OR on antihypertensive medication at the baseline
visit
Statistical analysis
Multivariable logistic regression
Model 1: age, education, marital status, household income
Model 2: M1 + BMI/waist, drinking/smoking, physical activity
Model 3: M2 + SF-36 mental/physical, depressive symptoms
Odds ratios of prevalent HTN comparing short and long duration of sleep vs. mid-range category
Baseline Characteristics (n=3,027)
Sleep categories (%)
Hypertension (%)
90
40
80
35
70
30
60
25
50
20
40
15
30
20
10
10
5
0
0
<6h
6-8h
>8h
Overall
On Rx
Men (n=1,317)
No Rx
Women (n=1,710)
Covariates by Sleep Duration Categories (Women n=1,710)
Variable
< 6 hours
6-8 hours
> 8 hours
P
Age (years)
56.7
55.4
58.4
S
Pre-menopausal (%)
28.3
34.8
29.3
NS
Education (years)
12.9
13.7
13.3
S
Unmarried (%)
38.6
28.4
25.0
S
Lowest Income (%)
45.6
32.3
27.5
S
BMI (kg/m2)
29.6
27.7
27.9
S
Waist (cm)
90.6
85.6
87.8
S
Physical activity (h/week)
5.2
5.0
5.1
NS
Current Drinker (%)
50.5
64.9
56.5
S
Current Smoker (%)
18.4
14.6
16.3
NS
Diabetes (%)
6.6
6.8
6.8
NS
SF-36 Physical Score
44.9
49.6
45.8
S
SF-36 Mental Score
50.4
52.6
52.6
S
Depressive symptoms (%)
21.8
9.7
15.9
S
Covariates by Sleep Duration Categories (Men n=1,317)
Variable
< 6 hours
6-8 hours
> 8 hours
P
Age (years)
54.9
57.2
63.6
S
Education (years)
13.4
14.1
13.8
S
Unmarried (%)
22.5
14.9
17.3
S
Lowest Income (%)
28.9
23.2
31.2
NS
BMI (kg/m2)
28.7
28.1
28.7
NS
Waist (cm)
99.3
98.1
100.7
NS
Physical activity (h/week)
5.4
5.3
5.2
NS
Current Drinker (%)
72.2
76.5
77.5
NS
Current Smoker (%)
23.6
13.6
19.8
S
Diabetes (%)
8.7
9.7
11.5
NS
SF-36 Physical Score
49.3
50.7
47.4
S
SF-36 Mental Score
51.7
54.2
55.3
S
Depressive symptoms (%)
12.8
4.9
2.9
S
Odds Ratios (OR) of Hypertension in Women
Model
<6h
6-8h
>8h
Model 1
1.77
1.00
1.05
(SES)
(1.26-2.48)
(0.61-1.80)
Model 1: age, education, marital status, household income
Odds Ratios (OR) of Hypertension in Women
Model
<6h
6-8h
>8h
Model 1
1.77
1.00
1.05
(SES)
Model 2
(CVD risk factors)
(1.26-2.48)
1.68
(0.61-1.80)
1.00
(1.17-2.41)
0.87
(0.47-1.60)
Model 2: M1 + BMI/waist, drinking/smoking, physical activity
Odds Ratios (OR) of Hypertension in Women
Model
<6h
6-8h
>8h
Model 1
1.77
1.00
1.05
(SES)
Model 2
(CVD risk factors)
Model 3
(Fully-adjusted)
(1.26-2.48)
1.68
(0.61-1.80)
1.00
(1.17-2.41)
1.61
(0.47-1.60)
1.00
(1.08-2.41)
0.87
0.80
(0.41-1.55)
Model 3: M2 + SF-36 mental/physical, depressive symptoms
Odds Ratios (OR) of Hypertension in Women
Model
<6h
6-8h
>8h
Pre-menopausal women
Model 3
2.77
(1.23-6.25)
1.00
1.07
(0.22-5.12)
Post-menopausal women
Model 3
1.40
(0.88-2.23)
1.00
0.75
(0.36-1.57)
Odds Ratios (OR) of Hypertension in Men
Model
<6h
6-8h
>8h
Model 1
0.93
1.00
1.27
(SES)
Model 2
(CVD risk factors)
Model 3
(Fully-adjusted)
(0.65-1.32)
0.90
(0.78-2.07)
1.00
(0.62-1.31)
0.88
(0.59-1.32)
1.21
(0.73-2.02)
1.00
1.36
(0.78-2.37)
Summary
• Short sleep duration associated with hypertension only in
women
• This association was independent of SES, CVD risk
factors, general health status, and psychiatric comorbidities
• Stronger in pre-menopausal women
Sleep Deprivation & Hypertension:
Potential Mechanisms
• Increased BP load while awake
• Activation of sympathetic nervous system
• Increased renal sodium retention
Gender-specific effects?
• Hormonal influences/psychosocial stressors
• Differential self-reporting of sleep habits
• Confounding/co-morbidities
• Consider limitations of cross-sectional studies
Conclusions
•
Sleep deprivation may produce more detrimental
effects on cardiovascular health in women than men
•
Need for mechanistic/prospective evidence
•
Objective assessment of sleep changes over time
•
Better understanding of determinants of sleep duration
•
Short sleep duration as a marker of health
status/quality of life