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

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: ) Cardio-Metabolic Risk Factors/Disease Obesity/Body Fat Distribution (Gangwisch JE et al. Sleep 2005;28: Patel SR et al. A.J.E. 2006;164: – Stranges S et al. A.J.E. 2008;167: 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: Cappuccio FP et al. Hypertension 2007;50: Stang A et al. Hypertension 2008;51:e15-6) Sleep Duration & Chronic Disease

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

Setting Erie & Niagara Counties Erie & Niagara Counties Baseline examination (Sept 1996 – May 2001) Eligible Participants: a) cancer free; b) age years Eligible Participants: a) cancer free; b) age years Actual Participants: 4,065, random sample Actual Participants: 4,065, random sample Participation rate: 59.5% Participation rate: 59.5% Exclusion Criteria Self-reported history of prevalent CVD, ethnicity other than white Self-reported history of prevalent CVD, ethnicity other than white Included: 3,207 participants (56.5% women) Included: 3,207 participants (56.5% women) General examination Resting blood pressure, BMI, waist circumference, abdominal height Resting blood pressure, BMI, waist circumference, abdominal heightSocio-demographics Marital status, education, annual household income Marital status, education, annual household incomeLifestyle Diet, drinking and smoking habits, physical activity, sleep habits Diet, drinking and smoking habits, physical activity, sleep habits Health Status SF-36 mental/physical, depressive symptoms (CES-D), diabetes SF-36 mental/physical, depressive symptoms (CES-D), diabetes The Western New York Health Study

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 (Sunday- Thursday)?’  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 (Sunday- Thursday)?’  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 (Sunday- Thursday)?’  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) Variable Women n=1,710 Men n=1,317 Age (years) Education (years) Marital Status (% unmarried) Household Income (%<$30,000) BMI (kg/m 2 ) Waist circumference (cm) Physical activity (h/week) Current Drinker (%) Current Smoker (%) Diabetes (%) SF-36 Physical Score SF-36 Mental Score Depressive symptoms (%)

Baseline Characteristics (n=3,027) Hypertension (%)Sleep categories (%)

Covariates by Sleep Duration Categories (Women n=1,710 ) Variable < 6 hours 6-8 hours > 8 hours P Age (years) S Pre-menopausal (%) NS Education (years) S Unmarried (%) S Lowest Income (%) S BMI (kg/m 2 ) S Waist (cm) S Physical activity (h/week) NS Current Drinker (%) S Current Smoker (%) NS Diabetes (%) NS SF-36 Physical Score S SF-36 Mental Score S Depressive symptoms (%) S

Covariates by Sleep Duration Categories (Men n=1,317) Variable < 6 hours 6-8 hours > 8 hours P Age (years) S Education (years) S Unmarried (%) S Lowest Income (%) NS BMI (kg/m 2 ) NS Waist (cm) NS Physical activity (h/week) NS Current Drinker (%) NS Current Smoker (%) S Diabetes (%) NS SF-36 Physical Score S SF-36 Mental Score S Depressive symptoms (%) S

Odds Ratios (OR) of Hypertension in Women Model<6h6-8h>8h Model 1 (SES)1.77( ) ( ) Model 1: age, education, marital status, household income

Odds Ratios (OR) of Hypertension in Women Model<6h6-8h>8h Model 1 (SES)1.77( ) ( ) Model 2 (CVD risk factors) 1.68( ) ( ) Model 2: M1 + BMI/waist, drinking/smoking, physical activity

Odds Ratios (OR) of Hypertension in Women Model<6h6-8h>8h Model 1 (SES)1.77( ) ( ) Model 2 (CVD risk factors) 1.68( ) ( ) Model 3 (Fully-adjusted)1.61( ) ( ) Model 3: M2 + SF-36 mental/physical, depressive symptoms

Odds Ratios (OR) of Hypertension in Women Model<6h6-8h>8h Pre-menopausal women Model ( ) ( ) Post-menopausal women Model ( ) ( )

Odds Ratios (OR) of Hypertension in Men Model<6h6-8h>8h Model 1 (SES)0.93( ) ( ) Model 2 (CVD risk factors) 0.90( ) ( ) Model 3 (Fully-adjusted)0.88( ) ( )

Summary Short sleep duration associated with hypertension only in womenShort sleep duration associated with hypertension only in women This association was independent of SES, CVD risk factors, general health status, and psychiatric co- morbiditiesThis association was independent of SES, CVD risk factors, general 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? 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: Potential Mechanisms

Conclusions Sleep deprivation may produce more detrimental effects on cardiovascular health in women than menSleep deprivation may produce more detrimental effects on cardiovascular health in women than men Need for mechanistic/prospective evidenceNeed for mechanistic/prospective 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 status/quality of lifeShort sleep duration as a marker of health status/quality of life