EDITORIAL http://dx.doi.org/10.5665/sleep.3910

Sleep Duration and Mortality Risk

Commentary on Tsai et al. Long sleep duration associated with a higher risk of increased arterial stiffness in males. SLEEP 2014;37:1315-1320. Clifton Addison, PhD1; Brenda Jenkins, MPH, PhD1; Monique White, MPH, PhD2; Donna Antoine LaVigne, PhD, MSEd, MPH1 Jackson Heart Study/Center of Excellence for Minority Health and Health Disparities, College of Public Service, Jackson State University, Jackson, MS; 2Jackson State University, Jackson, MS


In this issue of SLEEP, Tsai and colleagues1 report findings on their study that examined the relationship between long sleep duration and increased arterial stiffness. The research examined the association between sleep duration and arterial stiffness among adults of different ages, adding to the findings from a previous study conducted only with an elderly sample. This research generated data that could be useful beyond the specific hypotheses and questions for this study. Tsai et al. found differences based on gender. Their study revealed that long sleep duration was associated with a higher risk of increased arterial stiffness in males and not in females. They found that sleep duration was different for participants with and without increased arterial stiffness in males, but not in females. Sleep Duration and Health Outcomes Researchers hold diverse views about the impact of sleep patterns on health outcomes. Even though it is widely believed that sleep duration is related to health status, the degree and the direction of the relationship between sleep duration and mortality risk are still heavily debated. The findings by Tsai et al. that long sleep duration was associated with a higher risk of increased arterial stiffness2 are consistent with other research studies that have concluded that sleep duration may also have some relationship with various cardiovascular disease risks, including obesity, hypertension, diabetes, and metabolic syndrome. However, there are published studies showing that both long and short sleep duration could be associated with cardiovascular disease.3-9 Others have explained the paradox that both short and long sleep duration are predictors of cardiovascular outcomes by proposing that short sleep duration is related to a greater risk of developing or dying of coronary heart disease (CHD), and long sleep duration is related to a greater risk of CHD, stroke, and total cardiovascular disease (CVD).10 Still, others reported that long sleepers, not short sleepers, were at increased risk of cardiovascular-related mortality.9 Short and long sleep durations also have a relationship with elevated blood pressure which is linked to arterial stiffness.11 While many researchers believe that short and long sleep durations have an impact on health,12 some emphasize that a 7–8 hour sleep duration, which is considered normal, would directly and indirectly reduce chronic disease risk.13 Submitted for publication June, 2014 Accepted for publication June, 2014 Address correspondence to: Clifton Addison, PhD, Jackson Heart Study, College of Public Service, Jackson State University, 350 W. Woodrow Wilson Dr., Jackson, MS; E-mail: [email protected] SLEEP, Vol. 37, No. 8, 2014

Measurement of Arterial Stiffness Pulse-wave velocity (PWV) is a known indicator of arterial stiffness, and elevated PWV is associated with the development of atherosclerotic diseases.14-15 A simple noninvasive automatic method for measuring brachial-ankle PWV is the baPWV that has recently been developed.16 The study by Tsai et al.1 used brachial-ankle PWV (baPWV) and is one of a few that have examined the relationship between sleep duration and arterial stiffness using brachial-ankle PWV (baPWV), which is a convenient way to measure arterial stiffness using a pressure cuff wrapped over the limbs while the subject is in a supine position. Research evidence supports the use of baPWV because it has a similar degree of association with cardiovascular risk factors and clinical events as the traditional cfPWV. Understanding Sleep Duration and Cardiovascular Health Risk It has been widely reported that the public health burden caused by cardiovascular disease (CVD) adversely affects individuals financially, emotionally, and physically. This burden has been excessive in the case of African Americans.17 According to the CDC, in 2010, African Americans were 30 percent more likely to die from heart disease, compared to non-Hispanic Whites, and African American women were 1.6 times as likely as non-Hispanic White women to have high blood pressure.18 The wide range of health disparities among African Americans led to the implementation of the Jackson Heart Study (JHS), a large, single-site, longitudinal cohort study, to understand the etiology of CVD among African-Americans.19 It is important to understand the role of sleep duration in arterial thickness and other CVD risk factors in all populations. An examination of sleep duration among African Americans in the Jackson Heart Study and its relationship to chronic conditions, like arterial stiffness, can provide vital information about health risks and the cardiovascular health of this population. The African American population can benefit from heightened awareness of the risk factors that are associated with obesity and CVD20 which in some cases could be preventable. The research by Tsai et al.1 has demonstrated that sleep duration and baPWV measures could be good indicators of health risks. Since sleep problems have been hypothesized to contribute toward obesity and other chronic diseases, longitudinal analyses are needed to examine the impact of sleep duration on cardiovascular outcomes in African Americans because both reduced and increased sleep duration are linked to hypertension, diabetes, obesity, and other chronic diseases. A longitudinal study will provide data that can be examined to explain the impact of sleep duration on disease. It would also be of


Editorial—Addison et al.

great interest to determine if sleep duration is a function of a diseased state, or if the presence of disease impacts the quality of sleep and sleep duration. In a large cohort study like the Jackson Heart Study, it would be possible to investigate whether long-term sleep habits are associated with the development of diseases by monitoring the sleep habits and disease patterns over long periods of time in participants who are initially healthy. This type of research may make it possible to explore whether it would be possible to modify a person’s sleep habits/duration in order to reduce the chances of developing diseases prematurely. Applying Community Prevention Strategies While undiagnosed and under-diagnosed sleep disorders can create a substantial public health burden, knowledge of sleep patterns and their relationship to the development of chronic diseases like arterial stiffness can significantly expand our existing knowledge about African-American health issues. Community health promotion activities can be implemented to play a key role in disease prevention and awareness of preventable risk factors that can have widespread implications on quality of life, physical well-being, and daily functioning.21 Sleep duration is a potentially modifiable risk factor and community-based interventions can educate the community about the development, progression, prevention, and treatment of cardiovascular disease, arterial stiffness, and sleep disorders. CITATION Addison C, Jenkins B, White M, LaVigne DA. Sleep duration and mortality risk. SLEEP 2014;37(8):1279-1280. DISCLOSURE STATEMENT This was not an industry supported study. The Jackson Heart Study Graduate Training and Education Center has received funding from the NIH/NHLBI, Contract Award Number: HHSN268201300049C; the Jackson Heart Study Community Outreach Center has received funding from the NIH/NHLBI, Contract Award Number: HHSN268201300050C; and Jackson State University Center of Excellence in Minority Health and Health Disparities has received funding from the NIH/NIMHD, Project Number: 1P20MD006899-01. The authors have indicated no financial conflicts of interest. REFERENCES

1. Tsai TC, Wu JS, Yang YC, Huang YH, Lu FH, Chang CJ. Long sleep duration associated with a higher risk of increased arterial stiffness in males. Sleep 2014;37:1315–20.

SLEEP, Vol. 37, No. 8, 2014


2. Redline S, Yenokyan G, Gottlieb DJ, et al. Obstructive sleep apnea hypopnea and incident stroke: the Sleep Heart Health Study. Am J Respir Crit Care Med 2010;182:269–77. 3. Gangwisch JE, Heymsfield SB, Boden-Albala B, et al. Short sleep duration as a risk factor for hypertension: analyses of the first National Health and Nutrition Examination Survey. Hypertension 2006;47:833–9. 4. Gottlieb DJ, Redline S, Javier Nieto F, et al. Association of usual sleep duration with hypertension: the Sleep Heart Health Study. Sleep 2006;29:1009–14. 5. Ferrie JE, Shipley MJ, Cappuccio FP, et al. A prospective study of change in sleep duration: associations with mortality in the Whitehall II cohort. Sleep 2007;30:1659–66. 6. Wolff B, Volzke H, Schwahn C, Robinson D, Kessler C, John U. Relation of self-reported sleep duration with carotid intima-media thickness in a general population sample. Atherosclerosis 2008;196:727–32. 7. Ikehara S, Iso H, Date C, et al. Association of sleep duration with mortality from cardiovascular disease and other causes for Japanese men and women: the JACC study. Sleep 2009;32:295–301. 8. Krueger PM, Friedman EM. Sleep duration in the United States: a crosssectional population-based study. Am J Epidemiol 2009;169:1052–63. 9. Gallicchio L, Kalesan B. Sleep duration and mortality: a systematic review and meta-analysis. J Sleep Res 2009;18:148–58. 10. Cappuccio FP, Cooper D, D’Elia L, Strazzullo P, Miller MA. Sleep duration predicts cardiovascular outcomes: a systematic review and metaanalysis of prospective studies. Eur Heart J 2011;32:1484–92. 11. Nagai M, Hoshide S, Nishikawa M, Shimada K, Kario K. Sleep duration and insomnia in the elderly: associations with blood pressure variability and carotid artery remodeling. Am J Hypertens.2013;26:981–9. 12. Anic GM, Titus-Ernstoff L, Newcomb PA, Trentham-Dietz A, Egan, KM. Sleep duration and obesity in a population-based study. Sleep Med 2010;11:447–51. 13. Buxton OM, Marcelli E. Short and long sleep are positively associated with obesity, diabetes, hypertension, and cardiovascular disease among adults in the United States. Soc Sci Med 2010:71:1027–36. 14. Yoshioka E, Saijo Y, Kita T, et al. Relation between self-reported sleep duration and arterial stiffness: a cross-sectional study of middle-aged Japanese civil servants. Sleep 2011;34:1681–86. 15. Tomiyama H, Yamashina A, Arai T, et al. Influences of age and gender on results of noninvasive brachial-ankle pulse wave velocity measurement–a survey of 12517 subjects. Atherosclerosis 2003;166:303–9. 16. Yamashina A, Tomiyama H, Takeda K, et al. Validity, reproducibility, and clinical significance of noninvasive brachial-ankle pulse wave velocity measurement. Hypertens Res 2002;25:359–64. 17. Campbell-Jenkins BW, Addison CC, Young L, Anugu P, Wilson G, Sarpong D. Development of the Jackson Heart Study Coordinating Center. Int J Environ Res Public Health 2009;6:1597–608. 18. Schiller JS, Lucas JW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2011. National Center for Health Statistics. Vital Health Stat 10(256). 2012. 19. Addison CC, Jenkins BW, Sarpong D, et al. Relationship between medication use and cardiovascular disease health outcomes in the Jackson Heart Study. Int J Environ Res Public Health 2011;8:2505–15. 20. Boutouyrie P, Tropeano AI, Asmar R, et al. Aortic stiffness is an independent predictor of primary coronary events in hypertensive patients: a longitudinal study. Hypertension 2002;39:10–5. 21. Antoine LaVigne D, Addison CC, Campbell Jenkins BW, et al. The impact of organized community capacity building on health risk practices in an African American community. J Behav Health 2012;2:159–66.

Editorial—Addison et al.

Sleep duration and mortality risk.

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