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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Ours is the first description to our knowledge of an association between sleep duration and ideal CVH that used a nationally representative sample of US adults. In this cross-sectional evaluation, very short sleep of <6 hours and very long sleep of ≥9 hours were associated with decreased odds of ideal CVH and a significant decrease in mean CVH score after adjusting for demographic, clinical, and social factors. Because ideal CVH is related to the future risk of CVD, these findings provide evidence of associations between sleep duration and ideal CVH that require further investigation, including exploring causal associations that we were unable to assess in this cross-sectional study.
The overall prevalence of ideal CVH in this population is similar to past descriptions of adults. Globally, the prevalence of ideal CVH status overall is approximately 20% with estimates of between 15% and 20% for North American adults [23], which is similar to what we observed in our study. The proportion of US adults in our study sleeping 7 to <9 hours per night is consistent with prior estimates. Data from the Behavioral Risk Factor Surveillance System and the National Health Interview Survey estimated that about 60% of adults reported a sleep duration of this length [2,24], consistent with the estimated 59.6% of adults in our study.
Data on the association between sleep duration and ideal CVH is scarce, though some work has been done looking at sleep debt, sleep quality, and daytime sleepiness. In a sample of older women (mean age 72 years), sleep debt was associated with poor CVH, even after accounting for potentially confounding demographic and socioeconomic factors [16]. Poor sleep quality in a population of Ecuadoran adults, as measured by the Pittsburgh Sleep Quality Index [25], was associated with some components of the CVH metrics but was not associated with poor CVH status overall [26]. In that same population, excessive daytime sleepiness was also not associated with poor CVH status [27]. This is in contrast to substantial evidence of an association between incident cardiovascular disease and short sleep duration and, to a lesser extent, long sleep duration [5,6].
The relationship between sleep and CVH likely differs from the association between sleep and CVD previously described. The etiology behind the differences is unclear but may be related to a bi-directional association between sleep patterns and a person’s CVH metrics. The biologic mechanism for the effect of sleep duration on CVH has multiple pathways. Sleep duration is independently associated with several CVH metrics, such as weight status and hypertension, and with insulin sensitivity, which can lead to type 2 diabetes [5,6,28]. Poor sleep may also lead to changes in behavioral components such as increased frequency of smoking or decreased physical activity [29]. It is still unclear, however, whether less than ideal health in these components may also affect sleep duration in the reverse manner. Also unclear is whether ideal CVH can lead to better sleep quality.
We found evidence of associations between both very short and very long sleep duration and decreased odds of ideal CVH and a significant decrease in mean CVH score. Although the U-shaped association between sleep duration and CVD has been increasingly described [4–6,30], some studies have shown that long sleep duration is protective for CVD or found nonsignificant associations [30]. The biologic mechanism of long sleep duration and CVD or CVH is not as well understood as the mechanism of short sleep duration, especially because observed associations with long sleep durations may be related to reverse causality (eg, a result of CVD) or subclinical disease [30]. We did adjust for some possible explanatory factors such as depression and use of prescription sleep aids, but the potential for residual confounding or other bias may have affected the results in this study.
Our study had several strengths, including the large sample size and use of the nationally representative NHANES population. However, our study had limitations. Although the sample size was large enough to detect significant differences, we excluded a proportion of participants (1,468 of 9,252 [16%] eligible adults without prevalent CVD) because of missing data who otherwise would have been eligible for inclusion. However, when comparing all participants with available data to the analytic sample, we found no substantial differences. Sleep duration was assessed by self-report and included only assessment of weekday or workday sleep. In past studies, participant self-reported sleep durations were overestimated compared with objectively measured durations, especially by those with the shortest sleep durations [31]. Thus, misclassification is possible, though the direction of bias is likely toward the null because participants tended to overestimate instead of underestimate sleep. Additionally, several of the CVH metrics were also self-reported, including smoking status, physical activity, and dietary habits. The other components of the CVH metrics, however, were measured in a standardized manner with trained assessors as part of the NHANES data collection process. The cross-sectional study design does not allow for inferring causality between sleep duration and ideal CVH status. Finally, we could not account for other confounders such as sleep apnea and use of nonprescription sleep aids in our analysis.
Our study demonstrated an association between very short and very long sleep duration and reduced CVH, as suggested by decreased odds of ideal CVH and a decrease in mean CVH score. More work is needed to understand the implications of sleep duration and the metrics of CVH, including potential causal associations.
