Tuesday, May 30, 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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We conducted a cross-sectional analysis of data from the National Health and Nutrition Examination Survey (NHANES), a nationally representative cross-sectional survey of noninstitutionalized civilian residents of the United States, conducted continuously in 2-year cycles [18]. NHANES uses a complex sampling strategy with a multistage stratified probability cluster design to achieve a nationally representative sample. The survey consists of in-home interviews and a medical examination of approximately 10,000 children and adults at each 2-year cycle. The medical examination component is voluntarily completed by a subset of all participants. We used 2 cycles of NHANES for our evaluation, data collected in 2013–2014 and 2015–2016. These de-identified data are publicly available.
A total of 10,068 adults aged 20 to 75 completed the medical examination component during the 2 cycles. Of those, 7,784 (77%) adults without a self-reported history of CVD (congestive heart failure, coronary heart disease, angina pectoris, myocardial infarction, or stroke), who had complete measurement of all cardiovascular health components and covariates were included in the analysis. A total of 834 respondents were excluded because of a history of CVD, 863 because they were missing CVH components, and 1,448 because they were missing covariates. Respondents could be excluded for more than 1 reason. The most common missing covariates were depression status (n = 590) and household income (n = 521).
Exposure: sleep duration. Usual weekday or workday sleep duration was self-reported by participants. In 2013–2014, this information was elicited directly by asking for the usual hours of sleep on weekdays or workdays. In the 2015–2016 cycle, usual hours of sleep were calculated by asking respondents their normal bed time and wake time on weekdays or workdays. Sleep duration was categorized as <6 hours, 6 to <7 hours, 7 to <8 hours, 8 to <9 hours, and ≥9 hours.
Outcome: cardiovascular health score. Cardiovascular health was defined according to the AHA’s ideal CVH metrics [13]. These metrics consist of 7 modifiable health behaviors and factors that were scored as ideal (2 points), intermediate (1 point), or poor (0 points) for adults, as described previously. Participants self-reported their smoking status, frequency of physical activity, and use of medications to control blood pressure, cholesterol, or diabetes mellitus. Dietary habits were reported through one or two 24-hour recalls (single day or average intake across both recalls). Ideal diet was assessed with the AHA Healthy Diet Score [13] by measuring the intake of fruits and vegetables, whole grains, sodium, fish, and sugar-sweetened beverages. Total cholesterol, hemoglobin A1c, and blood pressure were measured by trained professionals as part of the NHANES medical examination component. Hemoglobin A1c was used as a proxy for fasting plasma glucose [19,20]; otherwise, we used the established CVH criteria [13]. Briefly, the ideal criteria were never smoking or quit smoking more than 12 months ago; BMI of <25.0 kg/m2; meeting 4 to 5 of the AHA Healthy Diet Score components; physical activity of ≥150 minutes per week of moderate exercise, ≥75 minutes per week of vigorous exercise, or ≥150 minutes per week of moderate and vigorous exercise; blood pressure of <120 mm Hg/<80 mm Hg without medication; total cholesterol of <200 mg/dl without medication; and hemoglobin A1c of <5.7% without medication. The total score and number of ideal categories met by each participant were summed, and the resulting CVH score was analyzed as both continuous and categorical. For our study, overall ideal CVH was defined as meeting ideal criteria for 5 to 7 components, intermediate CVH as 3 to 4 components, and poor overall CVH as meeting 0 to 2 components. For logistic regression models, we further dichotomized the overall CVH score to ideal (5–7 categories) or not ideal (0–4 categories).
Covariates. Covariates were selected a priori based on prior literature and substantive reasoning. Participant age, sex, race/ethnicity, education level, and marital status were self-reported. The ratio of monthly family income to poverty was used as a measure of socioeconomic status, categorized as ≤1.30, >1.30 to ≤1.85, and >1.85. This measure equates to the percentage above or below the federal poverty guidelines. Depression status was measured by the 9-item Patient Health Questionnaire depression screening instrument [21]. The questionnaire scores items on a behavioral frequency scale and then dichotomizes them to none or moderate depression (0–14 points) and moderately severe to severe depression (15–27 points). Binge alcohol use was defined as drinking ≥4 alcoholic drinks per day for women or ≥5 for men, 12 or more times a year. Use of prescription sleep aids was self-reported. Reported current use of any of the following medications was considered use of sleep aid, regardless of frequency: amitriptyline, butabarbital, chloral hydrate, doxepin, estazolam, eszopiclone, flurazepam, mirtazapine, quazepam, ramelteon, temazepam, trazodone, triazolam, zaleplon, and zolpidem [22]. Nonprescription sleep aid use was not documented.
For population level estimates, a 4-year sample weight was calculated by dividing in half the mobile examination center’s sample analytic weights for the 2 cycles. Descriptive statistics were calculated, accounting for the complex survey design. We calculated unweighted frequency and weighted estimated population proportions or means. We also calculated the weighted population prevalence of each component and mean where appropriate and made comparisons by using Pearson’s χ2 statistic or the Wald test that adjusted for the survey design. Available cases were used as a sensitivity analysis and compared with estimates from the complete cases. Survey-weighted multivariable logistic regression and linear regression were used to estimate the association between sleep duration and ideal CVH, controlling for covariates. Separate models were constructed controlling for demographic characteristics (age, sex, race, race/ethnicity, education level, family income-to-poverty ratio) and social/clinical factors (depression status, alcohol use, prescription sleep aid use). A final fully adjusted model included all covariates. All analyses were conducted in STATA IC 15.1 (StataCorp LLC) at the α = 0.05 level.
