Wednesday, March 29, 2023
| Characteristic | Unweighted, No. | Weighteda |
|---|---|---|
| Age, mean, y | 7,784 | 44.5 (43.8–45.2) |
| Sex | ||
| Male | 3,704 | 48.5 (47.3–49.7) |
| Female | 4,080 | 51.5 (50.3–52.7) |
| Race/ethnicity | ||
| Non-Hispanic white | 2,882 | 65.5 (59.9–70.6) |
| Non-Hispanic black | 1,606 | 10.9 (8.5–13.9) |
| Hispanic | 2,111 | 15.2 (11.7–19.4) |
| Non-Hispanic other | 1,185 | 8.4 (7.1–10.1) |
| Education level | ||
| High school diploma or less | 3,247 | 33.4 (30.1–36.9) |
| Some college | 2,447 | 33.3 (31.2–35.5) |
| College graduate or above | 2,090 | 33.3 (29.4–37.5) |
| Marital status | ||
| Married or coupled | 4,760 | 64.9 (62.7–67.0) |
| Widowed, divorced, or separated | 1,387 | 15.3 (13.9–16.7) |
| Never married | 1,637 | 19.8 (18.0–21.8) |
| Family income-to-poverty ratio | ||
| ≤1.3 | 2,755 | 24.4 (21.4–27.6) |
| >1.3 to ≤1.85 | 1,082 | 11.7 (10.5–13.0) |
| >1.85 | 3,947 | 64.0 (60.2–67.6) |
| Moderately severe or severe depression | 235 | 2.6 (2.2–3.1) |
| Binge drinking once a month or moreb | 1,217 | 17.8 (16.1–19.5) |
| Prescription sleep aid use | 267 | 4.3 (3.5–5.2) |
| Sleep duration, h | ||
| <6 | 862 | 9.0 (8.2–9.9) |
| 6 to <7 | 1,571 | 18.5 (17.3–19.8) |
| 7 to <8 | 2,135 | 30.4 (28.9–31.9) |
| 8 to <9 | 2,112 | 28.6 (27.5–29.7) |
| ≥9 | 1,104 | 13.5 (12.3–14.7) |
| Overall CVH score | ||
| Mean | 6,985c | 8.0 (7.9–8.1) |
| Ideal (5–7 components) | 1,156 | 17.8 (16.3–19.4) |
| Intermediate (3–4 components) | 2,947 | 42.1 (40.9–43.3) |
| Poor (0–2 components) | 3,200 | 40.1 (38.4–41.9) |
Table 1. Estimated Weighted Population Characteristics and Prevalence of Sleep and Cardiovascular Health Among US Adults Aged 20–75 (N = 7,784), National Health and Nutrition Examination Survey, 2013–2016
Abbreviations: CI, confidence interval; CVH, cardiovascular health.
a Values are percentage (95% confidence interval) unless otherwise indicated. Because of survey weighting, proportions differ from calculations based on the unweighted number. Percentages may not total to 100% because of rounding.
b Binge drinking was defined as more than 4 drinks per day for women or more than 5 drinks per day for men.
c Mean score excluded those who were missing 1 or more CVH components.
| Component | Definitiona | Weighted Sleep Duration, mean or % (95% CI) | P Valueb | ||||
|---|---|---|---|---|---|---|---|
| <6 h | 6 to <7 h | 7 to <8 h | 8 to <9 h | ≥9 h | |||
| Overall CVH scorec | |||||||
| Mean | NA | 7.4 (7.2–7.6) | 7.9 (7.8–8.0) | 8.2 (8.1–8.4) | 8.1 (7.9–8.3) | 7.7 (7.4–8.0) | <.001 |
| Ideal | 5–7 | 11.1 (8.3–14.7) | 17.9 (15.9–20.0) | 19.1 (17.1–21.3) | 20.1 (17.8–22.6) | 15.5 (12.7–18.7) | .01 |
| Intermediate | 3–4 | 41.2 (36.0–46.6) | 41.5 (38.5–44.7) | 43.6 (40.6–46.7) | 41.9 (39.3–44.7) | 41.0 (37.6–44.5) | |
| Poor | 0–2 | 47.8 (43.0–52.6) | 40.6 (37.9–43.3) | 37.3 (34.4–40.2) | 38.0 (35.1–41.0) | 43.6 (39.4–47.8) | |
| Smoking | |||||||
| Ideal | Never smoker or quit ≥12 months ago | 47.9 (41.7–54.2) | 56.0 (52.2–59.8) | 63.2 (60.5–65.7) | 60.3 (57.1–63.4) | 57.0 (52.5–61.4) | <.001 |
| Intermediate | Smoked ≥100 cigarettes and quit <12 months ago | 21.6 (17.7–25.9) | 21.6 (18.8–24.8) | 22.0 (19.4–24.7) | 23.7 (21.3–26.2) | 19.2 (16.4–22.3) | |
| Poor | Current smoker | 30.6 (25.6–36.1) | 22.4(19.4–25.7) | 14.9 (12.7–17.5) | 16.0 (13.7–18.7) | 23.8 (20.3–27.8) | |
| Body mass index (kg weight/height in m2) | |||||||
| Mean | NA | 30.6 (30.1–31.1) | 29.6 (29.0–3.2) | 29.1 (28.6–29.5) | 29.0 (38.4–29.5) | 29.0 (28.4–29.7) | <.001 |
| Ideal | <25.0 kg/m2 | 23.3 (19.3–27.8) | 27.0 (23.9–30.4) | 30.1 (27.6–32.8) | 30.4 (26.5–34.6) | 31.2 (27.3–35.3) | .03 |
| Intermediate | 25.0–29.9 kg/m2 | 30.1 (26.0–34.7) | 32.6 (29.6–35.7) | 32.9 (30.1–35.9) | 32.7 (30.2–35.3) | 30.3 (27.0–33.9) | |
| Poor | ≥30.0 kg/m2 | 46.6 (41.6–51.6) | 40.4 (37.0–43.8) | 37.0 (34.2–39.8) | 36.9 (33.2–40.8) | 38.5 (34.0–43.3) | |
| Dietd | |||||||
| Ideal | 4–5 components | 0 | 0 | 0 | 0 | 0.1 (0.0–0.6) | .10 |
| Intermediate | 2–3 components | 22.3 (17.2–28.3) | 24.4 (21.2–28.0) | 26.8 (23.9–29.9) | 25.7 (22.7–28.9) | 20.2 (17.4–23.2) | |
| Poor | 0–1 components | 77.7 (71.7–82.8) | 75.6 (72.0–78.8) | 73.2 (70.1–76.1) | 74.3 (71.1–77.3) | 79.7 (76.6–82.5) | |
| Physical activity, min/wk | |||||||
| Mean | NA | 168.9 (144.0–193.7) | 165.9 (150.8–180.9) | 165.6 (147.2–184.0) | 171.8 (154.1–189.5) | 166.6 (136.0–197.2) | .98 |
| Ideal | ≥150 min moderate and/or vigorous or ≥75 min vigorous | 34.0 (29.7–38.6) | 39.1 (35.8–42.5) | 43.1 (39.3–47.0) | 41.9 (38.4–45.5) | 37.2 (32.0–42.7) | .03 |
| Intermediate | 1–149 min moderate and/or vigorous or 1–74 min vigorous | 17.1 (14.3–20.3) | 16.7 (13.9–20.0) | 16.3 (14.2–18.7) | 19.2 (17.0–21.7) | 14.6 (11.7–18.1) | |
| Poor | None | 49.0 (45.3–52.7) | 44.2 (40.5–47.9) | 40.6 (37.5–43.8) | 38.9 (35.3–42.6) | 48.2 (42.9–53.6) | |
| Blood pressure, mm Hg | |||||||
| Systolic, mean | NA | 122.3 (120.7–123.8) | 121.3 (120.2–122.4) | 120.5 (119.6–121.4) | 121.3 (120.4–122.2) | 121.8 (120.3–123.2) | .25 |
| Diastolic, mean | NA | 71.9 (70.8–73.1) | 70.9 (70.1–71.7) | 70.6 (69.8–71.4) | 70.5 (69.6–71.3) | 70.3 (69.1–71.5) | .16 |
| Ideal | <120/<80 untreated | 43.7 (39.5–48.0) | 44.0 (40.7–47.3) | 47.1 (43.6–50.6) | 46.7 (44.2–49.2) | 42.0 (38.3–45.8) | .24 |
| Intermediate | SBP 120–139 or DBP 80–89 or treated to goal | 46.0 (41.6–50.5) | 48.3 (45.2–51.5) | 45.5 (42.1–49.0) | 45.0 (42.7–47.2) | 48.1 (43.4–52.8) | |
| Poor | SBP ≥140 or DBP ≥90 | 10.3 (7.1–14.8) | 7.7 (6.2–9.6) | 7.4 (6.3–8.7) | 8.3 (6.7–10.3) | 9.9 (7.0-13.9) | |
| Total cholesterol, mg/dl | |||||||
| Mean | NA | 191.9 (187.6–196.3) | 189.6 (186.6–192.7) | 192.1 (190.0–194.2) | 195.4 (192.1–198.7) | 193.0 (188.5–197.4) | .07 |
| Ideal | <200 untreated | 50.6 (45.3–55.9) | 55.4 (51.3–59.4) | 50.1 (46.9–53.3) | 49.0 (44.9–53.2) | 48.6 (44.7–52.5) | .02 |
| Intermediate | 200–239 or treated to goal | 39.3 (34.5–44.4) | 34.5 (30.9–38.1) | 38.5 (35.1–42.1) | 36.2 (33.0–39.5) | 36.7 (32.3–41.3) | |
| Poor | ≥240 | 10.1 (8.3–12.4) | 10.2 (8.2–12.5) | 11.4 (9.5–13.5) | 14.8 (12.7–17.1) | 14.7 (11.5–18.6) | |
| Hemoglobin A1c, % | |||||||
| Mean | NA | 5.7 (5.6–5.7) | 5.6 (5.6–5.7) | 5.5 (5.5–5.6) | 5.6 (5.5–5.6) | 5.6 (5.5–5.7) | .01 |
| Ideal | <5.7 untreated | 66.1 (61.1–70.9) | 70.8 (67.8–73.7) | 74.3 (71.6–76.8) | 72.9 (70.1–75.5) | 65.8 (59.7–71.4) | .008 |
| Intermediate | 5.7–6.4 or treated to goal | 30.2 (25.5–35.3) | 26.0 (23.1–29.1) | 23.2 (21.0–25.6) | 24.5 (22.2–26.9) | 30.8 (25.6–36.6) | |
| Poor | ≥6.5 | 3.7 (2.5–5.4) | 3.2 (2.4–4.4) | 2.5 (1.7–3.7) | 2.6 (1.9–3.5) | 3.4 (2.3–4.9) | |
Table 2. Weighted Mean and Population Prevalence of Overall CVH Score and Individual Components Stratified By Sleep Duration Among US Adults Aged 20–75 (N = 7,784), National Health and Nutrition Examination Survey, 2013–2016
Abbreviations: CI, confidence interval; CVH, cardiovascular health; DBP, diastolic blood pressure; NA, not applicable; SBP, systolic blood pressure.
a Component definitions and scoring used were those previously described by Lloyd-Jones et al. with modification of hemoglobin A1c as a proxy for fasting plasma glucose [13]. The specific definitions used in this analysis are presented.
b P value calculated from adjusted Wald or Pearson’s χ2 tests that were corrected for the survey design.
c The CVH score comprises 7 components: smoking, body mass index, diet, physical activity, blood pressure, total cholesterol, and hemoglobin A1c (used as a proxy for fasting plasma glucose) [13]. Each component was scored as ideal (2 points), intermediate (1 point), or poor (0 points) based on guidelines described by Lloyd-Jones et al [13]. The continuous overall CVH score was calculated by summing the 7 components scores. Ideal CVH was defined as meeting ideal criteria for 5 to 7 of the components.
d American Heart Association Healthy Diet Score includes ≥4.5 cups of fruits or vegetables a day; two 3.5-ounce servings of fish per week; ≥3 one-ounce equivalent servings of whole grains per day; <1,500 mg of sodium per day; ≤36 ounces of sugar-sweetened beverages per week.
| Sleep Duration, No. of Hours | Model 1a Estimate (95% CI) | Model 2b Estimate (95% CI) | Model 3c Estimate (95% CI) | Model 4d Estimate (95% CI) |
|---|---|---|---|---|
| Odds of ideal CVH | ||||
| <6 | 0.53 (0.39 to 0.72) | 0.63 (0.45 to 0.87) | 0.56 (0.41 to 0.77) | 0.65 (0.47 to 0.90) |
| 6 to <7 | 0.90 (0.76 to 1.07) | 0.97 (0.80 to 1.18) | 0.91 (0.76 to 1.09) | 0.97 (0.80 to 1.19) |
| 7 to <8 | 1 [Reference] | |||
| 8 to < 9 | 1.03 (0.82 to 1.28) | 0.95 (0.74 to 1.23) | 1.04 (0.84 to 1.30) | 0.96 (0.75 to 1.23) |
| ≥9 | 0.75 (0.58 to 0.98) | 0.70 (0.53 to 0.93) | 0.78 (0.60 to 1.02) | 0.72 (0.55 to 0.94) |
| Mean differences in CVH score, mean | ||||
| <6 | −0.80 (−1.04 to −0.55) | −0.48 (−0.69 to −0.27) | −0.69 (−0.94 to −0.45) | −0.41 (−0.61 to −0.20) |
| 6 to <7 | −0.31 (−0.45 to −0.17) | −0.21 (−0.34 to −0.08) | −0.3 (−0.44 to −0.16) | −0.2 (−0.33 to −0.06) |
| 7 to <8 | [Reference] | |||
| 8 to < 9 | −0.15 (−0.36 to 0.06) | −0.18 (−0.39 to 0.03) | −0.12 (−0.32 to 0.07) | −0.16 (−0.36 to 0.03) |
| ≥9 | −0.51 (−0.78 to −0.24) | −0.38 (−0.63 to −0.13) | −0.45 (−0.70 to −0.19) | −0.33 (−0.57 to −0.09) |
Table 3. Association Between Sleep Duration Categories and Ideal CVH in Sequential Adjusted Logistic and Linear Regression Models Among US Adults Aged 20–75 (N = 7,784), National Health and Nutrition Examination Survey, 2013–2016
Abbreviations: CI, confidence interval; CVH, cardiovascular health; OR, odds ratio.
a Model 1: Unadjusted.
b Model 2: Adjusted for demographic factors of weighted age quartiles, sex, race/ethnicity, education level, and family income-to-poverty ratio category.
c Model 3: Adjusted for social and clinical factors of depression status, binge alcohol use, and prescription sleep aid use.
d Model 4: Fully adjusted model including factors from Models 2 and 3.
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Short or long sleep duration is a risk factor for cardiovascular disease, but the association between sleep duration and cardiovascular health is unclear. Our objective was to quantify the association between sleep duration and ideal cardiovascular health (CVH) in US adults. We hypothesized that very short (<6 h) and very long (≥9 h) sleep duration were associated with poorer CVH compared with sleep lasting 7 to <8 hours.
We conducted a cross-sectional evaluation of the nationally representative National Health and Nutrition Examination Survey in 2 cycles (2013–2014 and 2015–2016). Participants were 7,784 cardiovascular disease–free US adults aged 20 to 75. Self-reported sleep duration was categorized as <6 hours, 6 to <7 hours, 7 to <8 hours, 8 to <9 hours, and ≥9 hours. The American Heart Association’s ideal CVH metrics were used to determine the number of ideal CVH components, dichotomized as ideal (5–7 components) or not ideal (0–4 components). Survey-weighted logistic and linear regression models were used to determine the association between sleep duration and ideal CVH.
The weighted prevalences of those who slept 7 to <8 hours were 30.4%, very short sleep duration (<6 h), 9.0%, and very long duration (≥9 h), 13.5%. Only 21.3% of the population had ideal CVH. Compared with 7 to <8 hours, very short duration (OR = 0.65; 95% confidence interval [CI], 0.47–0.90) and very long duration (OR = 0.72; 95% CI, 0.55–0.94) were associated with decreased odds of ideal CVH. We confirmed findings by using linear regression.
Very short and very long sleep duration were associated with decreased odds of ideal CVH and lower mean CVH scores. Future research should focus on clarifying causal associations between sleep duration and ideal CVH.
Approximately 60% of US adults report sleeping the recommended 7 to 9 hours per night [1,2]. The consequences of unhealthy sleep, which include risk of chronic diseases, productivity loss, and fatigue-related performance concerns, have been described as a critical public health problem [3]. Meta-analyses show a U-shaped association between short and long sleep duration and risk of developing cardiovascular disease (CVD) [4–6]. Potential mechanisms for this association with short sleep include dysregulation of appetite hormones [7], glucose intolerance [4], the up-and-down regulation of gene expression [8], and circadian rhythm misalignment [9], which may result in inflammatory conditions and development of other CVD risk factors such as hypertension [10,11]. The biologic mechanism of increased risk from long sleep is less clear and may be related to sleep fragmentation, depression, or underlying poor health [12].
Little evidence exists regarding the association between healthy sleep and a widely used metric for the general state of well-being of the cardiovascular system called ideal cardiovascular health (CVH). In 2010, the American Heart Association (AHA) defined ideal CVH on the basis of 7 modifiable factors: smoking, body mass index (BMI) (weight in kg divided by height in m2), diet, physical activity, blood pressure, fasting blood glucose, and total cholesterol [13]. Each CVH component is scored as ideal, intermediate, or poor on the basis of established cut points [13]. Meeting the ideal criteria for 5 to 7 components is associated with a reduced risk of developing CVD [14,15].
Sleep debt is associated with poor CVH [16], and very short sleep duration is associated with increased odds of CVD risk factors such as hypertension and obesity [17]. Because the association between ideal CVH and sleep duration remains unclear, our objective was to quantify that association among a nationally representative sample of US adults. We hypothesized that very short (<6 h) and very long (≥9 h) sleep duration were associated with decreased odds of ideal CVH.
