Short Sleep Duration is Associated with Short Sleep Duration is Associated with Hypertension only among Women: A Hypertension only among Women: A Population-based StudyPopulation-based Study

Stranges S Stranges S **, Dorn JM , Dorn JM **, , Cappuccio FPCappuccio FP **, Donahue RP , Donahue RP **, ,

Hovey KM Hovey KM **, Kandala N-B , Kandala N-B **, Miller MA , Miller MA **, Trevisan M , Trevisan M **

**University of Warwick Medical School, UKUniversity of Warwick Medical School, UK

**State University of New York at Buffalo, USAState University of New York at Buffalo, USA

E.S.R.S. Glasgow 2008

Total and Cause-Specific MortalityTotal and Cause-Specific MortalityA decrease in sleep duration is associated with an increase in A decrease in sleep duration is associated with an increase in

mortality via cardiovascular deathsmortality via cardiovascular deaths (Ferrie JE et al. (Ferrie JE et al. SleepSleep 2007;30:1659-66) 2007;30:1659-66)

Cardio-Metabolic Risk Factors/DiseaseCardio-Metabolic Risk Factors/Disease

Obesity/Body Fat DistributionObesity/Body Fat Distribution (Gangwisch JE et al. (Gangwisch JE et al. SleepSleep 2005;28:1289-96 - Patel SR et al. 2005;28:1289-96 - Patel SR et al. A.J.E.A.J.E. 2006;164:947-54 – 2006;164:947-54 –

Stranges S et al. Stranges S et al. A.J.E.A.J.E. 2008;167:321-9 - Cappuccio FP et al. 2008;167:321-9 - Cappuccio FP et al. SleepSleep 2008;31:619-26) 2008;31:619-26)

Type 2 Diabetes Type 2 Diabetes

(Ayas NT et al. (Ayas NT et al. Diab CareDiab Care 2003;26:380-4 – Yaggi HK et al. 2003;26:380-4 – Yaggi HK et al. Diab CareDiab Care 2006;29:657-61) 2006;29:657-61)

Coronary Heart DiseaseCoronary Heart Disease

(Meisinger C et al. (Meisinger C et al. SleepSleep 2007;30:1121-7) 2007;30:1121-7)

Hypertension Hypertension

(Gangwisch JE et al. (Gangwisch JE et al. HypertensionHypertension 2006;47:833-9 - Cappuccio FP et al. 2006;47:833-9 - Cappuccio FP et al. HypertensionHypertension 2007;50:693-701 - 2007;50:693-701 - Stang A et al. Stang A et al. HypertensionHypertension 2008;51:e15-6) 2008;51:e15-6)

Sleep Duration & Chronic Disease Sleep Duration & Chronic Disease

Study AimsStudy Aims

To examine the cross-sectional association of To examine the cross-sectional association of

sleep duration with hypertensionsleep duration with hypertension

To perform gender-specific analyses with the To perform gender-specific analyses with the

inclusion of a number of potential inclusion of a number of potential

confounding variablesconfounding variables

SettingSetting• Erie & Niagara CountiesErie & Niagara Counties

Baseline examination (Sept 1996 – May 2001)Baseline examination (Sept 1996 – May 2001)• Eligible Participants: a) Eligible Participants: a) cancer free; b) cancer free; b) age 35-79 years age 35-79 years • Actual Participants: 4,065, random sample Actual Participants: 4,065, random sample • Participation rate: 59.5%Participation rate: 59.5%

Exclusion CriteriaExclusion Criteria• Self-reported history of prevalent CVD, ethnicity other than whiteSelf-reported history of prevalent CVD, ethnicity other than white• Included: 3,207 participants (56.5% women)Included: 3,207 participants (56.5% women)

General examinationGeneral examination• Resting blood pressure, BMI, waist circumference, abdominal heightResting blood pressure, BMI, waist circumference, abdominal height

Socio-demographicsSocio-demographics• Marital status, education, annual household incomeMarital status, education, annual household income

LifestyleLifestyle• Diet, drinking and smoking habits, physical activity, sleep habits Diet, drinking and smoking habits, physical activity, sleep habits

Health StatusHealth Status• SF-36 mental/physical, depressive symptoms (CES-D), diabetesSF-36 mental/physical, depressive symptoms (CES-D), diabetes

The Western New York Health StudyThe Western New York Health Study

Exposure: Sleep DurationExposure: Sleep DurationSeven-Day Physical Activity Recall questionnaire‘On the average, how many hours did you sleep each night in the last five weekday nights (Sunday-Thursday)?’

Short sleep (<6 hours)

Mid-range sleep (6-8 hours)

Long sleep (>8 hours)

Outcome: Prevalent HypertensionOutcome: Prevalent HypertensionSystolic BP Systolic BP ≥≥ 140 mmHg, 140 mmHg, OROR Diastolic BP Diastolic BP ≥≥ 90 mmHg, 90 mmHg, OROR on antihypertensive medication at the on antihypertensive medication at the

baseline visitbaseline visit

Statistical analysisStatistical analysis

Multivariable logistic regression

Model 1Model 1: age, education, marital status, household income: age, education, marital status, household income

Model 2Model 2: M1 + BMI/waist, drinking/smoking, physical activity: M1 + BMI/waist, drinking/smoking, physical activity

Model 3Model 3: M2 + SF-36 mental/physical, depressive symptoms: M2 + SF-36 mental/physical, depressive symptoms

Odds ratiosOdds ratios of prevalent HTN comparing short and long duration of sleep vs. mid-range category of prevalent HTN comparing short and long duration of sleep vs. mid-range category

Exposure: Sleep DurationExposure: Sleep DurationSeven-Day Physical Activity Recall questionnaire‘On the average, how many hours did you sleep each night in the last five weekday nights (Sunday-Thursday)?’

Short sleep (<6 hours)

Mid-range sleep (6-8 hours)

Long sleep (>8 hours)

Outcome: Prevalent HypertensionOutcome: Prevalent HypertensionSystolic BP Systolic BP ≥≥ 140 mmHg, 140 mmHg, OROR Diastolic BP Diastolic BP ≥≥ 90 mmHg, 90 mmHg, OROR on antihypertensive medication at the on antihypertensive medication at the

baseline visitbaseline visit

Statistical analysisStatistical analysis

Multivariable logistic regression

Model 1Model 1: age, education, marital status, household income: age, education, marital status, household income

Model 2Model 2: M1 + BMI/waist, drinking/smoking, physical activity: M1 + BMI/waist, drinking/smoking, physical activity

Model 3Model 3: M2 + SF-36 mental/physical, depressive symptoms: M2 + SF-36 mental/physical, depressive symptoms

Odds ratiosOdds ratios of prevalent HTN comparing short and long duration of sleep vs. mid-range category of prevalent HTN comparing short and long duration of sleep vs. mid-range category

Exposure: Sleep DurationExposure: Sleep DurationSeven-Day Physical Activity Recall questionnaire‘On the average, how many hours did you sleep each night in the last five weekday nights (Sunday-Thursday)?’

Short sleep (<6 hours)

Mid-range sleep (6-8 hours)

Long sleep (>8 hours)

Outcome: Prevalent HypertensionOutcome: Prevalent HypertensionSystolic BP Systolic BP ≥≥ 140 mmHg, 140 mmHg, OROR Diastolic BP Diastolic BP ≥≥ 90 mmHg, 90 mmHg, OROR on antihypertensive medication at the on antihypertensive medication at the

baseline visitbaseline visit

Statistical analysisStatistical analysis

Multivariable logistic regression

Model 1Model 1: age, education, marital status, household income: age, education, marital status, household income

Model 2Model 2: M1 + BMI/waist, drinking/smoking, physical activity: M1 + BMI/waist, drinking/smoking, physical activity

Model 3Model 3: M2 + SF-36 mental/physical, depressive symptoms: M2 + SF-36 mental/physical, depressive symptoms

Odds ratiosOdds ratios of prevalent HTN comparing short and long duration of sleep vs. mid-range category of prevalent HTN comparing short and long duration of sleep vs. mid-range category

0

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50

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90

<6h 6-8h >8h0

5

10

15

20

25

30

35

40

Overall On Rx No Rx

Men (n=1,317) Women (n=1,710)

Baseline Characteristics (n=3,027)Baseline Characteristics (n=3,027)

Hypertension (%)Sleep categories (%)

Covariates by Sleep Duration CategoriesCovariates by Sleep Duration Categories (Women n=1,710 (Women n=1,710))

VariableVariable < 6 hours< 6 hours 6-8 hours6-8 hours > 8 hours> 8 hours PP

Age (years)Age (years) 56.756.7 55.455.4 58.458.4 SS

Pre-menopausal (%)Pre-menopausal (%) 28.328.3 34.834.8 29.329.3 NSNS

Education (years)Education (years) 12.912.9 13.713.7 13.313.3 SS

Unmarried (%)Unmarried (%) 38.638.6 28.428.4 25.025.0 SS

Lowest Income (%)Lowest Income (%) 45.645.6 32.332.3 27.527.5 SS

BMI (kg/mBMI (kg/m22)) 29.629.6 27.727.7 27.927.9 SS

Waist (cm)Waist (cm) 90.690.6 85.685.6 87.887.8 SS

Physical activity (h/week)Physical activity (h/week) 5.25.2 5.05.0 5.15.1 NSNS

Current Drinker (%)Current Drinker (%) 50.550.5 64.964.9 56.556.5 SS

Current Smoker (%)Current Smoker (%) 18.418.4 14.614.6 16.316.3 NSNS

Diabetes (%)Diabetes (%) 6.66.6 6.86.8 6.86.8 NSNS

SF-36 Physical ScoreSF-36 Physical Score 44.944.9 49.649.6 45.845.8 SS

SF-36 Mental ScoreSF-36 Mental Score 50.450.4 52.652.6 52.652.6 SS

Depressive symptoms (%)Depressive symptoms (%) 21.821.8 9.79.7 15.915.9 SS

Covariates by Sleep Duration CategoriesCovariates by Sleep Duration Categories (Men n=1,317) (Men n=1,317)

VariableVariable < 6 hours< 6 hours 6-8 hours6-8 hours > 8 hours> 8 hours PP

Age (years)Age (years) 54.954.9 57.257.2 63.663.6 SS

Education (years)Education (years) 13.413.4 14.114.1 13.813.8 SS

Unmarried (%)Unmarried (%) 22.522.5 14.914.9 17.317.3 SS

Lowest Income (%)Lowest Income (%) 28.928.9 23.223.2 31.231.2 NSNS

BMI (kg/mBMI (kg/m22)) 28.728.7 28.128.1 28.728.7 NSNS

Waist (cm)Waist (cm) 99.399.3 98.198.1 100.7100.7 NSNS

Physical activity (h/week)Physical activity (h/week) 5.45.4 5.35.3 5.25.2 NSNS

Current Drinker (%)Current Drinker (%) 72.272.2 76.576.5 77.577.5 NSNS

Current Smoker (%)Current Smoker (%) 23.623.6 13.613.6 19.819.8 SS

Diabetes (%)Diabetes (%) 8.78.7 9.79.7 11.511.5 NSNS

SF-36 Physical ScoreSF-36 Physical Score 49.349.3 50.750.7 47.447.4 SS

SF-36 Mental ScoreSF-36 Mental Score 51.751.7 54.254.2 55.355.3 SS

Depressive symptoms (%)Depressive symptoms (%) 12.812.8 4.94.9 2.92.9 SS

Odds Ratios (OR) of Hypertension in WomenOdds Ratios (OR) of Hypertension in Women

ModelModel <6h<6h 6-8h6-8h >8h>8h

Model 1 Model 1

(SES)(SES)

1.771.77

(1.26-2.48)(1.26-2.48)

1.001.00 1.051.05

(0.61-1.80)(0.61-1.80)

Model 1: age, education, marital status, household income

Odds Ratios (OR) of Hypertension in WomenOdds Ratios (OR) of Hypertension in Women

ModelModel <6h<6h 6-8h6-8h >8h>8h

Model 1 Model 1

(SES)(SES)

1.771.77

(1.26-2.48)(1.26-2.48)

1.001.00 1.051.05

(0.61-1.80)(0.61-1.80)

Model 2 Model 2

(CVD risk factors)(CVD risk factors)

1.681.68

(1.17-2.41)(1.17-2.41)

1.001.00 0.870.87

(0.47-1.60)(0.47-1.60)

Model 2: M1 + BMI/waist, drinking/smoking, physical activity

Odds Ratios (OR) of Hypertension in WomenOdds Ratios (OR) of Hypertension in Women

ModelModel <6h<6h 6-8h6-8h >8h>8h

Model 1 Model 1

(SES)(SES)

1.771.77

(1.26-2.48)(1.26-2.48)

1.001.00 1.051.05

(0.61-1.80)(0.61-1.80)

Model 2 Model 2

(CVD risk factors)(CVD risk factors)

1.681.68

(1.17-2.41)(1.17-2.41)

1.001.00 0.870.87

(0.47-1.60)(0.47-1.60)

Model 3Model 3

(Fully-adjusted)(Fully-adjusted)

1.611.61

(1.08-2.41)(1.08-2.41)

1.001.00 0.800.80

(0.41-1.55)(0.41-1.55)

Model 3: M2 + SF-36 mental/physical, depressive symptoms

Odds Ratios (OR) of Hypertension in WomenOdds Ratios (OR) of Hypertension in Women

ModelModel <6h<6h 6-8h6-8h >8h>8h

Pre-menopausal womenPre-menopausal women

Model 3Model 3 2.772.77(1.23-6.25)(1.23-6.25)

1.001.00 1.071.07(0.22-5.12)(0.22-5.12)

Post-menopausal womenPost-menopausal women

Model 3Model 3 1.401.40(0.88-2.23)(0.88-2.23)

1.001.00 0.750.75(0.36-1.57)(0.36-1.57)

Odds Ratios (OR) of Hypertension in MenOdds Ratios (OR) of Hypertension in Men

ModelModel <6h<6h 6-8h6-8h >8h>8h

Model 1 Model 1

(SES)(SES)

0.930.93

(0.65-1.32)(0.65-1.32)

1.001.00 1.271.27

(0.78-2.07)(0.78-2.07)

Model 2 Model 2

(CVD risk factors)(CVD risk factors)

0.900.90

(0.62-1.31)(0.62-1.31)

1.001.00 1.211.21

(0.73-2.02)(0.73-2.02)

Model 3Model 3

(Fully-adjusted)(Fully-adjusted)

0.880.88

(0.59-1.32)(0.59-1.32)

1.001.00 1.361.36

(0.78-2.37)(0.78-2.37)

SummarySummary

• Short sleepShort sleep duration associated with hypertension only in duration associated with hypertension only in

womenwomen

• ThisThis association was independent of SES, CVD risk factors, association was independent of SES, CVD risk factors,

general health status, and psychiatric co-morbiditiesgeneral health status, and psychiatric co-morbidities

• Stronger in pre-menopausal womenStronger in pre-menopausal women

• Increased BP load while awakeIncreased BP load while awake

• Activation of sympathetic nervous systemActivation of sympathetic nervous system

• Increased renal sodium retentionIncreased renal sodium retention

Gender-specific effects?Gender-specific effects?

• Hormonal influences/psychosocial stressorsHormonal influences/psychosocial stressors

• Differential self-reporting of sleep habitsDifferential self-reporting of sleep habits

• Confounding/co-morbiditiesConfounding/co-morbidities

• Consider limitations of cross-sectional studiesConsider limitations of cross-sectional studies

Sleep Deprivation & Hypertension:Sleep Deprivation & Hypertension:Potential MechanismsPotential Mechanisms

ConclusionsConclusions

• Sleep deprivation may produce more detrimental Sleep deprivation may produce more detrimental

effects on cardiovascular health in women than meneffects on cardiovascular health in women than men

• Need for mechanistic/prospectiveNeed for mechanistic/prospective evidence evidence

• Objective assessment of sleep changes over timeObjective assessment of sleep changes over time

• Better understanding of determinants of sleep durationBetter understanding of determinants of sleep duration

• Short sleep duration as a marker of health Short sleep duration as a marker of health

status/quality of life status/quality of life