Blood Pressure, 2012; 21: 45–57

ORIGINAL ARTICLE

Association between habitual sleep duration and blood pressure and
clinical implications: A systematic review

ELIZABETH DEAN1, ANDREA BLOOM2, MARGHERITA CIRILLO2, QUAN HONG2,
BRADLEY JAWL2, JEFFREY JUKES2, MANU NIJJAR2, SANJIN SADOVICH2 &
SELMA SOUSA BRUNO3
1Department

of Physical Therapy, Faculty of Medicine, University of British Columbia, Canada, 2Department of
Physical Therapy, Faculty of Medicine, University of British Columbia, Canada and 3Department of Physical Therapy,
Science Health Center, Federal University of Rio Grande of Norte, Natal, Brazil

Abstract
Elucidation of the association between short sleep duration and elevated blood pressure has implications for assessing and
managing hypertension in adults. Objective. To assess the relationship between sleep duration and blood pressure, and its role
in the etiology of hypertension. Methods. On a systematic search from MEDLINE, EMBASE, CINAHL, PEDro, PsychINFO
and grey literature were included articles with participants over 18 years, reported sleep duration, measured blood pressure or
diagnosed hypertension, and the relationship between sleep duration and blood pressure was analyzed. Results. Of 2522 articles
initially identified, 11 studies met the inclusion criteria. Sample sizes ranged from 505 to 8860 (aged  20–98 years). Five studies (aged  58–60 years) determined that sleep duration and blood pressure were unrelated. In younger adults, five studies
reported an association between short sleep duration and hypertension before adjustment for confounding variables; only
the findings from one study remained significant after adjustment. Two studies supported a sex association; women who sleep
less than 5–6 h nightly are at greater risk of developing hypertension. Conclusion. Sleep duration and blood pressure are
associated in both women and adults under 60 years. Controlled studies are needed to elucidate confounding factors and
the degree to which sleep profiles could augment diagnosis of hypertension and sleep recommendations to prevent or manage
hypertension.
Key Words: blood pressure, hypertension, sleep, sleep quality

Introduction
High blood pressure, estimated to cause 7.1 million
deaths worldwide annually (1), is a risk factor for ischemic heart disease, cerebrovascular disease, and cardiac
and renal failure (2). Over a quarter of the world’s adult
population was estimated to have hypertension in 2000;
this proportion is predicted to rise to 29% by 2025 (3).
In Canada, the 6-month healthcare cost for a single
patient with hypertension exceeds $3000, with drugs
accounting for more than 50% of the direct cost (4).
Although the need to integrate health promotion
and disease prevention strategies into biomedical care
is becoming better acknowledged in healthcare, some
authorities argue that a substantial gap persists between
knowledge and action (5). In line with this trend,
lifestyle factors and their modification are being

considered in preventing and managing hypertension
(2); however, these are unlikely to be maximally
exploited until the body of evidence supporting them
is firmly established. Given the economic and social
burdens associated with hypertension, the elucidation of the role of modifiable lifestyle risk factors in
prevalent conditions such as hypertension is justified
and highly compelling in terms of augmenting our
knowledge about effective, low risk, economical
approaches to its prevention and management.
The relationship between sleep and health has
become an increasing focus of scientific investigation
in part because of the impact of social factors on sleep
patterns. Artificial lighting and changes in stress and
social demands, for example, have contributed to
changes in sleep patterns over time (6); the average

Correspondence: Selma Sousa Bruno, Department of Physical Therapy, Science Health Center, Federal University of Rio Grande of Norte, Natal, Brazil,
and Visiting Professor, Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Canada. Tel:  55 (84) 3342 2000. Fax: (84)
3342 2001. E-mail: sbruno@ufrnet.br
(Received 13 March 2011; accepted 16 May 2011)
ISSN 0803-7051 print/ISSN 1651-1999 online © 2012 Scandinavian Foundation for Cardiovascular Research
DOI: 10.3109/08037051.2011.596320

Relevant articles were searched on Web of Science (1900 to present) to find more recent literature citing these articles. or “amount*”. (2) were not available in full text. Methods Search strategy We performed a systematic search of MEDLINE (1950 to present). Inclusion and exclusion criteria Studies were included if they (1) involved adult participants over 18 years or included separate analysis of those 18 years and older. or recorded a diagnosis of hypertension or use of antihypertensive medication. Conversely. and grey literature (ProQuest. “hour*”. . Related to this body of evidence are the results of several population-based studies that conclude sleep apnea is an independent risk factor for hypertension (16. Networked Digital Library of Theses and Dissertations. vs those below this age.gov. If a firm association exists. clinicaltrials. sleep prescription and sleep hygiene counseling could be adopted as a practical. depending on the database). Study selection flow chart. sleep disordered breathing. metabolic disease or cardiovascular disease. CINAHL (1982 to present). immune dysfunction (9). (3) measured blood pressure. PEDro. If such a relationship exists. Papers First). The search strategies used MeSH headings and keywords for “hypertension” or “blood pressure” and “sleep”. Studies of children were excluded from the analysis given their sleep requirements vary across developmental stages (19).15). The searches were limited to the English language and adults (18 or 19. A total of 2522 articles were identified for screening (Figure 1).17). or (3) were not available in English. (2) reported participants’ habitual sleep duration. a growing body of evidence supports the key role of sleep in overall health and wellbeing.11).46 E. Studies were excluded if they (1) exclusively analyzed populations with diagnosed sleep disorders. and (4) analyzed the relationship between habitual sleep duration and blood pressure. and a causal link has been proposed (18).7 h a night (7). our secondary purpose was to establish whether a direct relationship exists between habitual short sleep duration and hypertension. Although the optimal amount of sleep that people need has been debated (6). The primary purpose of this study was to conduct a literature review to evaluate systematically the evidence associating habitual sleep duration with blood pressure in adults. type II diabetes (10. American sleeps 6. EMBASE (1980 to present). In EMBASE and MEDLINE. “quantit*”. obesity (12) and mood disorders (13). nonpharmaceutical and economical intervention to prevent or mitigate hypertension as well as promote general health and wellbeing. This relationship remains to be firmly established for the general population. Dean et al. Short-term sleep deprivation studies support that reduced habitual sleep increases blood pressure (14. Initial searching was conducted in November 2009 with a final search in February 2010. suboptimal sleep has been associated with a myriad of health issues including coronary heart disease (8). Titles and abstracts yielded by search strategies (n = 2522) Articles excluded because neither title nor abstract was relevant for review (n = 2497) Duplicates removed (n = 6) Full-text articles reviewed (n = 19) Articles excluded for not meeting inclusion criteria (n = 8): Analyzed population with sleep-disordered breathing (n = 1) Did not include participants’ habitual sleep duration (n = 2) Did not analyze relationship between sleep and blood pressure (n = 4) Did not provide data or methods (n = 1) Publications included for systematic review (n = 11) Figure 1. PsychINFO (1800 to present). these results were filtered with keywords for sleep duration: “duration*”.

(22) Lopez-Garcia et al. Main findings Participants and study design There was marked variability among the source studies in how they represented and reported their results (Table IV). Age-related findings. test– retest. internal validity – confounding/selection bias (six items). Measurement of habitual sleep and blood pressure Table III compares studies with respect to measurement of habitual sleep and blood pressure measurement. All 11 source studies collected data on sleep quantity from self-report through means of interview or questionnaire. external validity (three items). 138 from PsycINFO. There were also marked inconsistencies across studies regarding the qualifications and experience of personnel taking blood pressure. included both sexes (except one study) and most had large sample sizes (Table II). our results reflect associations between habitual sleep duration and blood pressure across the adult lifespan. Studies generally compared sleep duration with a reference group whose nightly sleep was approximately 7 h.79.28. Hypertension was defined inconsistently across the source studies. (23) Cappuccio et al. 47 Table I. This index has been reported to be valid and reliable. country.82  2. The highest achievable score on the Downs and Black Quality Index is 32. (31) Lima-Costa et al. Table III also shows detailed information on the blood pressure and sleep data as well as hypertension definitions. the body position and resting state of the subjects prior to taking blood pressure. (32) Stranges et al. (27) Van den Berg et al. (26) Knutson et al. when it is applied to non-randomized studies. This review incorporates data from multiple countries. 11 source studies resulted. Several studies exclusively analyzed older adults (22. In an evaluation of this quality assessment tool (21). quality assessment scores derived from the Downs and Black Quality Index appear in Table I. the maximum score is reduced to 19 (20). 141 from CINAHL. Each article was reviewed independently by the two reviewers who used a customized screening tool. in the event of uncertainty or disagreement. and allows for assessment of both randomized and non-randomized studies. study design. irrelevant articles and duplicates were excluded. (25) Kawada et al.32). Two studies used wrist actigraphy in addition to self-report to measure sleep (28. Each review extracted independently date from articles and summarized as study. Methodological quality was assessed using the Downs and Black Quality Index (20). (24) Gangwisch et al. (28) 2006 2007 2008 2006 2008 2008 2009 2008 2009 2008 2007 8 9 9 9 9 7 9 7 9 8 9 0 0 2 2 2 0 2 2 2 1 2 5 8 5 8 5 4 8 3 8 7 5 13 17 16 19 16 11 19 12 19 16 16 Each paper was given a score of 0/5 on the power sub-scale. The reviewers aimed for consensus for study selection. and whether blood pressures were averaged (Table III). Each of these studies concluded that sleep duration is not associated with prevalent hypertension in this population before or Quality assessment For the source studies. Quality assessment scores based on the Downs and Black Quality Index of the source studies. however. Our initial search strategy yielded 2522 articles from six resources: 990 from MEDLINE. study size. and three from the Web of Science. The average score across all 11 studies is 15. After our stringent selection process. quantity of sleep and main findings. 1038 from EMBASE. (30) Choi et al.Sleep duration and blood pressure Data extraction and quality assessment All initial search results were screened independently by two reviewers for potentially relevant articles. internal validity – bias (seven items). Therefore. Results Study selection A flow chart of the study search and selection process appears in Figure 1. Several types of study designs were reflected in the source studies. Most studies adjusted their findings for multiple confounding variables. Studies were inconsistent regarding attention to the time of day for blood pressure measurement. Full-text review was then conducted on the resulting 19 studies with respect to the specific inclusion and exclusion criteria. criterion validity and respondent burden. inter-rater reliability. 212 from grey literature sources.31). The Downs and Black Quality Index is based on 27 items within five categories: study quality/reporting (10 items). (29) Hall et al. . subject age. and were mostly limited to older adults (Table I). and power (one item). The significance of the relationship between sleep duration and blood pressure often changed with adjustments suggesting a role for mediating variables. arm the blood pressure was taken. however. though the exact parameters varied. Study Study External Internal Total quality validity validity score Year (/11) (/3) (/13) (/32) Bjorvatn et al. a third person reviewed the article and discussed his or her assessment with the reviewers. it scored high for internal consistency.

pregnancy and the use of insulin. (30) 2007 Country Study design Study size Subject age Population source Norway Cross-sectional 8860 40–45 UK Cross-sectional 5766. non-institutionalized US citizens). those missing actigraphy data. all 55 in district of Rotterdam invited to participate) . Table II. (22) 2008 Brazil Cross-sectional Lopez-Garcia et al. glucocorticoid. Excluded: pregnant women. not enough time fasting National Health and Nutrition Examination Survey (civilian. First author Year Bjorvatn et al. Women: 1567 Longitudinal (mean 5-year follow-up) Cross-sectional 3691. 81. antiarrhythmic. taking antihypertensive medications at baseline. all born in Hordaland county 1953–1957) Whitehall II Study. schizophrenia or psychotic illness. Western NY Health Study (Erie or Niagara County. (24) 2008 Korea Gangwisch et al. Men: 2686. (32) 2009 Spain Cross-sectional 3686 Longitudinal (2-year follow-up) Comparative cross-sectional 890 Stranges et al. white population subset). Women: 1005 Hordaland Health Study data (population-based.7% of population 60 years old) Population-based cohort representative of non-institutionalized Spanish population 60 years old Normotensive population from crosssectional study Whitehall II Study (white British civil servants). psychotropic or weight-loss medications Male employees of an electronics company. Excluded: those with diagnosed hypertension or blood pressure 140/90 mmHg at baseline University of Pittsburgh’s Adult Health and Behavior (AHAB) registry (Southwestern Pennsylvania. Excluded: ethnic groups other than white (n  612) Normotensive population from cross-sectional study 35–55 4222 20 Longitudinal (8–10-year follow-up) 4810 25–74 USA Cross-sectional 1214 30–54 2008 Japan Cross-sectional 4941 36–60 2009 USA Cross-sectional 578 33–45 Choi et al. USA: 35–79 58–98 Portion of Korean National Health and Nutrition Survey (nationally representative survey). (31) Longitudinal (5-year follow-up) 505 (535 for incident hyper-tension analysis) 1423 Lima-Costa et al. Men: 4199. Excluded: those on medications for metabolic syndrome. principally Allegheny county). USA van den Berg et al. dyslipidemia. and/or diabetes mellitus Chicago participants of CARDIA (Coronary Artery Risk Development in Young Adults) Study. white and African American sub-populations. Excluded: those with atherosclerosis. Excluded: past medical history of hypertension. white British civil servants. Excluded: incomplete data. Description of the samples of the source studies. or missing a measure of DBP at baseline or follow-up Excluded: as above  those on antihypertensive medications at follow-up Bambui Health Aging Study (communitybased cohort in Bambui city.48 E. (25) 2008 Kawada et al. NY. Dean et al. missing data on sleep or fasting time. USA: 3027 5058 60–95 60 UK: 45–69. chronic kidney or liver disease. (28) 2007 Netherlands Cross-sectional UK: 6472. ethnic groups other than white Rotterdam Study (population-based cohort study. neurological disorder. (27) 2008 UK. (23) 2007 Cappuccio et al. (29) 2006 USA Hall et al. (26) Knutson et al.

2. or regular use of antihypertensive medication Self-report questionnaire Average of 2 readings Defined htn as SBP or DBP  130/85 mmHg Self-report questionnaire N/A Measured 3 times Defined htn as SBP  140 mmHg or DPB  90 mmHg.Sleep duration and blood pressure 49 Table III. or reported cause of death Defined high BP as SBP  130 mmHg. asked separately about sleep duration on weeknights (SundayThursday) and weekend nights (Friday. BP measured in a seated position following 10 min rest. or use of antihypertensive medication Self-report questionnaire “How many hours of sleep do you usually get a night (or when you usually sleep)?” Self-report through in-person interview conducted by trained interviewers Hours per night slept over the past 7 days. Used oscillometric sphygmomanometer. Calculated sleep during workweek and during free time independently “How many hours of sleep do you have on an average week night?” (Continued) . No reading taken if maximum cuff inflation 160 mmHg Choi et al. 1st and 5th Korotkoff sounds to indicate SBP and DBP. Two measurements taken consecutively on morning after a 12-h fast. Two SBP and 2 DBP measurements with a 5 min interval between readings 1. or DBP  85 mmHg. Study BP measurement technique Bjorvatn et al. 2. (25) 1. 2. Three automated BP measurements. lowest reading retained Defined high BP as SBP  130 mmHg and/or  85 mmHg Self-report Sleep duration calculated as total time in bed (from bedtime to rise time) minus self-reported sleep latency. 3. Right arm in seated position after 5 min rest. hospital record. In seated position following 10 min rest. then BP was not re-measured. 2. Saturday). (24) Gangwisch et al. Measurement of sleep and blood pressure variables. Relaxed sitting position following 2 min rest. respectively 1. (26) 1. Weekly average reported sleep duration calculated as the weighted average of weeknight and weekend values N/A Calculation of BP Hall et al. 3. Measured twice after 3 min interval if initial reading  130/85 mmHg. or self-report of physician diagnosis. Three BP measures using standard mercury manometer. 3. If initial reading was under 130/85 mmHg. 2. 2. (23) 1. 2. Onset of 1st and 5th Korotkoff sounds used to represent SBP and DBP 1. (29) Specific question posed and/or technique used to analyze sleep data Definition of htn or high BP Method of sleep data collection Averaged final 2 of 3 readings Defined high BP as SBP 140 mmHg or DPB 90 mmHg Self-report via selfadministered questionnaire Averaged final 2 of 3 readings Defined htn as SBP/ DBP  140/90 mmHg. (30) 1. Three BP measurements taken at the same sitting. Mercury sphygmomanometer used on right arm Average of 2 readings Kawada et al. No talking during measurements Cappuccio et al.

Used Hawksley random-0 sphygmomanometer and digital BP monitor which were calibrated against each other for consistency Lima-Costa et al. or self-reported physician diagnosis Stranges et al. or DBP 90 mmHg. wake up. Definition of htn or high BP Method of sleep data collection Averaged final 2 of 3 readings Defined htn as SBP 140 mmHg. (31) 1. (27) 1. 3. respectively Averaged final 2 of 3 readings Defined htn as SBP/ DBP  140/90 mmHg. Measured after 5 min rest in seated position using mercury sphygmomanometer Average of 6 readings Defined htn as SBP 140 mmHg.50 E. Measured 6 times at level of heart in right arm at 2 min intervals. “During the last month. Weekend sleeping habits determined by use of similar question to above. leave the bed?”. or use of antihypertensive medication Self-report during clinical exam and wrist actigraphy monitor N/A Average of 2 out of 3 readings Defined htn as SBP 140 mmHg. 2. Whitehall II study: “How many hours of sleep do you have on an average weeknight?”. at what time did you: lay down to sleep. Self-reported questions about sleep duration and quality during clinical exam 1. get asleep. or use of antihypertensive medication Self-report LopezGarcia et al. in the workdays and without considering the weekends. or use of antihypertensive medication. Actigraphy for three consecutive days on 2 occasions approximately 1 year apart. Self-report through home based personal interview at baseline. (Continued). how many hours did you sleep each night during the last 5 weekday nights (Sunday– Thursday)?” (Continued) . 2. or regular use of antihypertensive medication 1. 1st and 5th Korotkoff sounds used for SBP and DBP. Usual sleep duration determined by formula “How many hours do you usually sleep per day (including sleep at night and during the day)?” Analyzed data from two sources where the following questions were posed: 1. Sitting position using mercury sphygmomanometer. Western NY study: “On the average. Dean et al. 2. 2. (32) 1. or DPB 90 mmHg. 2. (22) Specific question posed and/or technique used to analyze sleep data 1. 2. Readings taken three times after 5 min rest. Phone interview at follow-up Self-report questionnaire Study BP measurement technique Calculation of BP Knutson et al. Table III. or DBP 90 mmHg. 2.

One study reported no relationship between short sleep (6 h vs 7–8 h) and elevated blood pressure in participants who were between 30 and 54 years of age (25). However. SBP. the relationship was attenuated with full adjustment. another study reported that the prevalence of elevated blood pressure was significantly higher (p  0. Two blood pressure measurements in sitting at right brachial artery with random-0 sphygmomanometer Calculation of BP Average of 2 readings Definition of htn or high BP Defined htn as SBP  160 mmHg. A Japanese study focusing on metabolic syndrome examined the relationship between sleep duration and hypertension in young male workers (between . One study reported that the risk of being diagnosed with hypertension was twice as high in subjects under 60 years of age who slept 5 or fewer hours nightly (HR  2. sleep durations of 5–5. respectively). DBP. Two studies reported no relationship between sleep and blood pressure in participants under 60 years of age (25.56. blood pressure. 2. Two studies analyzed age groups separately and provided data for those over 60 years of age (24. OR  1.03–2. and when adjusted for age and employment (6 h a night OR  1. pulse rate and gender (29). systolic blood pressure. or DBP  100 mmHg.Sleep duration and blood pressure 51 Table III. 95% CI 1. a significant association with changes in diastolic blood pressure remained ( p  0.70.79) (29). p  0. Study BP measurement technique van den Berg et al.30) (29). 95% CI 1. after adjustment for confounding variables (Table IV).31. In a fully adjusted model. Another study compared 6 h with 6 h for men 36–60 years of age and reported no significant difference with respect to exhibiting higher blood pressure (26).16. They reported a relationship between hypertension and short sleep duration (6 h) in women in the WNYH study in models adjusting for only age and sex (OR  1. Adjusting for variables modestly attenuated this relationship but it remained significant for subjects between 32 and 59 years of age who slept 5 or fewer hours nightly (HR  1.65–2.01). alcohol and salt consumption.94–2.07–2. p  0.009) with sleep duration 5 h for subjects between 20 and 59 years of age (24). or current use of antihypertensive medication Method of sleep data collection Self-report by way of in-person home interview. p  0.001). and wrist actigraphy Specific question posed and/or technique used to analyze sleep data 1.75) (30). (Continued).07–2.03). One study conducted a cross-cultural comparison between the Whitehall II study (UK) and the Western New York Health (WNYH) study for correlates of sleep duration (27). however.58–2. This relationship remained significant after a 5-year follow-up in unadjusted analyses.08–3.99 h became negatively associated with systolic blood pressure. Sex-related findings.47. 5 h per night OR  1. 95% CI 0. This relationship was no longer significant. One reported no association between sleep duration and elevated blood pressure for subjects over 60 years of age (24). One study reported that short sleep duration (5 h) was associated with hypertension only in women in a fully adjusted model (odds ratio. Interestingly.13–2. physical activity. “During the past month.50). smoking. (28) 1. After full adjustment. In an unadjusted analysis. when the model was adjusted for daytime sleepiness.70.07–2.94. CI 1.32–2. sleeping 9 h or more (hazard ratio (HR): 1.14). sleep duration of 5 h was positively related to blood pressure (23). how many hours of actual sleep did you get at night?”. 95% CI 1.10. sex and race (31). Wrist actigraphy over 5–7 consecutive nights. the association was no longer significant.80.19–2. 95% confidence interval. the associations were no longer significant after accounting for cardiovascular risk factors and psychiatric co-morbidity (OR  1. short sleep duration was associated with higher blood pressure when adjusted for age.72.54.56.27. No association between sleep duration and blood pressure was detected in men in cross-sectional or longitudinal analysis.63. 95% CI 1.26). there was an association in both studies (OR  1.60. Similarly. short sleep duration was associated with incident hypertension and each hour of sleep reduction increased the odds by 37%. Whitehall II 95% CI 1. OR  1. In an unadjusted analysis for a population between 40 and 45 years of age. actigraphy algorithm used on raw data BP. In the fully adjusted models.42. At a 5-year follow-up. diastolic blood pressure.99 h and 6–6. depression. 95% CI 1. There was no association reported for men. WNYH 95% CI 1.02.29). 95% CI 0. The other study reported an increased likelihood of hypertension in older adults (60–85 years of age). however. In a study of adults between 33 and 45 years of age. 95% CI 1.

year Study design Sleep reference (h/day) Data analysis/adjusted variables Bjorvatn et al.50]. Step 2: gender. smoking. Consistent. ethnicity.79]). Model 4: model 3  obesity.54 [1. Results not significant after adjustment for cardiovascular risk factors and psychiatric comorbidities U-shaped relationship between sleep and htn for subjects under age of 60.75].94 [95% CI 1.52 E. Model 2: daytime sleepiness. 5 h: OR  1. Fully adjusted: as above plus alcohol consumption.72 [95% CI:1.10 [95% CI 1. educational attainment. significant inverse associations (p 0. smoking. sex. BMI. (24) Cross-sectional 7 Gangwisch et al. Table IV.60 [1.99 h associated with decreased risk of high SBP.003). pulse rate. Step 3: BMI. in fully adjusted models No consistent pattern of association in men. physical activity.03–2. SBP: no relationship between sleep duration and SBP 140 mmHg. lowest incidence at 7 h. First author.99 h became significantly negatively related to SPB.99 h and 6–6.623) Unadjusted: significantly increased risk of diagnosis in all sleeping 5 h with younger age group (32–59) (HR  2.99 h and 6–6. Significantly higher incidence of htn in women sleeping 5 h in unadjusted and reduced model analysis (6 h: OR  1. diabetes Adjusted for age. Model 3: model 2  education. DBP: 5 h significantly related to DBP 90 mmHg. (23) Cross-sectional 7–7.07–2.14] No relationship between sleep and mean BP in unadjusted or adjusted analysis (Continued) . sleep duration free time. with a significant inverse linear trend across decreasing hours of sleep (p  0. depression. salt consumption.99 Cappuccio et al. Crude logistic regression analyses using sleep duration (workweek) as the predictor for systolic blood pressure (140 mmHg vs 140 mmHg) and diastolic blood pressure (90 mmHg vs 90 mmHg).19–2. BMI Reduced model: adjusted for age and employment. BP significantly differed (p  0. DBP: no duration significantly related No consistent pattern of association in men. gender.009) with sleep duration 5 h for subjects under 60.05) between duration of sleep and either SBP or pulse pressure only among women. Controlled.56 [95% CI 1.27].30]. race. Significantly higher prevalence of htn in women sleeping 5 h in fully adjusted model (OR  1. physical activity. depression. smoking. cardiovascular disease drugs. Fully adjusted: relationship attenuated but still significant for 5 h. use of hypnotics Longitudinal (5-year follow-up) As above Choi et al.037). No difference for subjects over 60 (p  0. age. p  0. Short Form-36 mental and physical health score. alcohol consumption. Adjusted logistic regression analysis controlling for gender. smoker. smoking. physical activity. (25) Cross-sectional 7–8 Unadjusted Model 1: Unadjusted. low-density lipoprotein cholesterol and symptoms of depression Main findings Unadjusted. especially young (32–59) HR  1. (30) Cross-sectional 7 8 Hierarchical linear regression analysis: Step 1: unadjusted sleep duration. Sleep duration 5–5. (29) Longitudinal (8–10-year follow-up) 7–8 Hall et al. Adjusted variables and main findings of the source studies. both SBP and DBP were higher with shorter sleep durations.07–2. Dean et al. htn in older adults 60–86 associated with sleeping 9 h HR  1.58–2. these associations were no longer significant. SBP: 5–5.08–3.

sleep duration.09). Model 2: age. CI. Full: partial  snoring. number of social ties. and physical activity As above First author. OR. In fully adjusted models.47] p  0. BMI.01] No association between sleep and htn. 6. year Longitudinal (5 years) Lima-Costa et al.32–2. significantly associated with change in DBP (p  0.70 p  0. odds ratio. education level. (31) Cross-sectional Continuous variable Adjusted for drinking. Study design Sleep reference (h/day) Data analysis/adjusted variables Kawada et al.02). low vs. eating breakfast. hypertension. (22) Cross-sectional 7 8 Lopez-Garcia et al. day time sleepiness. significant association of short sleep duration and htn in women. Full adjustment: no significant association between sleep duration and SBP (p  0. sleep duration was not associated with SBP or DBP htn. consumption. smoking.001. sex. daytime napping Main findings Sleeping 6 h not significantly associated with high BP (OR  1. diabetes mellitus. snacking frequency. diastolic blood pressure. even using a lower cut-off value for htn. arousal from sleep at night. myocardial infarction. current smoker. hazard ratio. Full adjustment: sleep duration not associated with change in SBP (p  0.70 [WNY 1. number of chronic disease. Short Form-36 score. (Continued).07–2. depression. and increased odds of incident htn (OR  1. alcohol use. BMI. socioeconomic status. In multivariable linear analysis. AND 5-year change in smoking. Model 2: model 1BMI.96–1. coffee.07) or DBP (p  0. sleep medication use. income. alcohol. or pulse pressure No association between sleep duration and incident htn. BMI. alcohol consumption. 7 for actigraphy group Model 1: unadjusted. (27) Comparative crosssectional van den Berg et al. Whitehall 1. depressive symptoms. No association between sleep duration and SBP. race. before or after adjustment. (26) Cross-sectional 6 vs 6 Knutson et al.05–1. physical activity. Result unchanged when analysis repeated for men and women separately Significant relationship between hypertension and short sleep duration (6h) in women in the WNYH study in models adjusting for only age and sex OR:1. BMI Partial adjustment: age. DBP (p  0. smoking.03).13–2.001). DBP. diabetes mellitus). BMI. depression symptoms.09) Partial adjustment: short sleep associated with smaller decreases or increases in SBP (p  0. gender.37 [95% CI 1. (28) Cross-sectional 6–8 7. depressive symptoms.02. body mass index.90–1. physical activity. diabetes mellitus. anxiolytic intake As above Analyzed correlates of sleep duration including marital status. perceived health. Model 3: 2  skin color. systolic blood pressure. (32) Cross-sectional 7 Longitudinal (2-year follow-up) Stranges et al. DBP. confidence interval. high physical activity. . or using a htn cut-off of 160/100 mmHg or systolic htn only.006) and DBP (p  0.Sleep duration and blood pressure 53 Table IV. SBP. adjusted odds ratio for age and sleep Model 1: age. current alcohol.3 [0. education.001).31]) Partial adjustment: shorter sleep durations significantly associated with higher SBP (p  0. 8 for self-report. and hypnotic or sedative meds Adjusted for age. gender. HR.12 [0. smoking status. sex. increased odds of htn attenuated (OR  1.75]) Usual sleep duration not associated with prevalent htn in unadjusted or adjusted models No association between sleep duration and prevalent htn.80 [1. stroke. physical activity.56 p  0.78]): 1-h sleep reduction  37% increase in odds. in both studies OR  1.

The precise mechanism explaining this sex-specific relationship is not known. several mechanisms can be proposed by which habitual short sleep duration could elevate blood pressure. other populations are underrepresented. With respect to the age-related association between habitual short sleep duration and blood pressure. and observed that sleeping 6 h a day was not associated with hypertension (OR  1. Obesity and hypertension. Also. The second main relationship was sex-specific. isolating one condition from another when interpreting data is difficult.28. More waking time may also lead to greater opportunity to engage in unhealthy behaviors that influence blood pressure (e.28.12. While this index is useful in . and the control of confounding variables.54 E. and that stimulate arousal and negatively impact the cardiovascular and cerebrovascular systems (40. Studies have shown that there is no relationship between short sleep duration and hypertension in women 60 years (28. Second.29.32). to determine directionality warrants detailed study. poor dietary habits. In our systematic review. 95% CI 0. First.32) reporting age-related findings (either before or after attenuation of variables) scored either 16 (24. They are lower during sleep. higher credence was given to higher scoring articles. in turn. some conditions associated with habitual short sleep duration may only be detected after a period of latency.30). The quality of our results directly reflects the quality of the source studies. prolonged periods of wake time could predispose an individual to unnatural increases in blood pressure and heart rate with less reprieve time (40). In interpreting the data. Given the variability among studies. is controversial (14). Discussion Among the studies we reviewed. Table I shows that four of the five studies (24. The metabolic syndrome and its components also have been associated with sleep duration (23.90–1. are often related co-morbid conditions (37).29. Hence. This study used 6 h of sleep as its reference group. thus. Use of the Downs and Black Quality Index for quality assessment provided a profile of each study alerting the reviewers to its methodological strengths and weaknesses (20). methods of measuring blood pressure and sleep duration. Second. two relationships emerged that highlighted age.32) on the Downs and Black Quality Index. short sleep duration and hypertension were unrelated in people 60 years old (22.24).31). the relationship between short sleep duration and blood pressure is consistent with research supporting that short sleep duration has effects on lifestyle-related conditions such as metabolic syndrome and obesity (23–26. This. which were among the highest scores for quality assessment. Despite these discrepancies.32). these findings could inform the practices of a number of health care practitioners who could address sleep as a modifiable risk factor in mitigating these prevalent and costly chronic conditions. First. where women who slept 5–6 h each night were at higher likelihood of hypertension (17. the evidence supported an association between the likelihood of hypertension among individuals 60 years of age who slept 5 h each night (24. lifestyle changes associated with retirement in high-income countries from where the source studies originated may allow for more opportunities for relaxation to compensate for short night-time sleep durations (28). The quality of these studies adds credibility to their results. Furthermore.24. In adjusted models.g.31). One explanation may be the role of hormonal and psychosocial changes associated with menopause (30).35). subsequent increases in blood pressure and adverse vascular remodeling (39). hypertension and other systemic conditions is complex.and sex-specific effects.32). while one scored 12 (22).38). Our findings are of interest because they are relevant to diverse populations with chronic conditions. caffeine consumption. our results may be applicable to adults living in a range of countries. blood pressure and heart rate naturally follow a diurnal pattern.29. individuals with disorders such as hypertension. thus. and each component is likely interrelated. especially muscle sympathetic nerve activity. however. the relationship between obesity and sleep duration is generally well established (36). Mechanisms have been proposed for an agerelated association between habitual sleep duration and blood pressure. data collection. Sleep-disordered breathing is associated with short sleep duration. there was heterogeneity in sample sizes. leads to vessel constriction. Given the complexity of these relationships. 36 and 60 years of age) (26). Although the effect of sleep deprivation on neural cardiovascular control. exposure to emotional stress). In a young middle-aged population (between 33 and 45 years of age).28) or 19 (29. one study reported that the association between sleep and blood pressure was comparable for men and women (31).30). and hypertension is highly co-morbid with sleep apnea (34. the strongest relationship between habitual short sleep duration (5 h or 6 h) and hypertension seems to be among younger women between 30 and 60 years of age. short-term sleep deprivation has been reported to increase the activity of the sympathetic nervous system. Dean et al. The relationship between habitual sleep duration. Several studies analyzed data from elderly men and women and reported that sleep duration and blood pressure were not associated in either sex (28. obesity and diabetes are less likely to survive into their later years (29).41). The synthesis of catecholamines is augmented via activation of the suprachiasmatic nucleus (15. Most studies collected data from populations in the northern hemisphere.

In eight of the 11 articles reviewed. non-randomized studies. Given there are compelling explanations associating reduced habitual sleep duration and blood pressure. psychological disorders. alcohol intake. good agreement has been reported in the literature between self-reported sleep duration. We recommend that future studies examining the relationship between habitual sleep duration and hypertension incorporate consistent methodology. apneas). Common among the studies was the lack of randomization. however.g. psychoses and dementia). Cross-sectional studies allow for comparison of variables at the same time points. not to mention the importance of restorative sleep on health and function. the applicability of our main findings of this systematic review needs to be interpreted cautiously. and control for confounders to help build evidence of causality. respiratory or metabolic diseases (45). they are more susceptible to bias than experimental studies and cannot establish causality. sleep disordered breathing (e. should be taken at a consistent time each day using a standardized technique. Acknowledgments The investigators acknowledge the support and assistance of Charlotte Beck. Dr Stanley Coren.43). The methodology across source studies was inconsistent.g. One final limitation is reflected in the interpretation of the data. and actigraphic monitoring or the gold standard polysomnography (40. type II diabetes mellitus. However. caffeine intake. and cardiovascular. Growing evidence supports that short habitual sleep duration is associated with metabolic disorders such as obesity. Dr Lara Boyd. These should include repeated objective measures of blood pressure and habitual sleep duration. diabetes and hypertension (33). smoking. physical activity. if not measured objectively. then formal assessment of sleep quality and quantity warrants being assessed and potentially managed as conscientiously as an individual’s functional capacity. The following are recommended for exclusion from future studies as they may interfere with identifying a directional relationship: sleep disorders (e. The timing and averaging of measurements. All the source studies were cross-sectional and/or longitudinal in design. Studies also differed with respect to their definitions of high blood pressure or hypertension (Table III). the scores of the studies in our review were low.25. If sleep duration is a modifiable risk factor for hypertension and subsequently cardiovascular disease. sleep disorders related to mental and/or neurological conditions (e. the maximum achievable score is 19 (20). this limitation could have affected the recorded prevalence or incidence of high blood pressure or hypertension. Representative prospective studies with adequate sample size and long-term duration are indicated.g. observation of the effect of longer sleep durations in sleep-deprived individuals with hypertension could be useful to help elucidate this relationship. . habitual sleep duration and blood pressure are associated specifically in women and adults under 60 years of age. There were also discrepancies among studies as to the confounding variables for which investigators chose to control. obesity. while longitudinal studies allow for the reporting of more observations over time. Various exclusion criteria should also be considered when designing future studies related to sleep. sex. Dean Giustini. diet. however we reviewed strictly observational studies. Thus. should be assessed in a standardized manner such as with a self-report sleep diary. the index has questions pertaining to experimental methods. 55 interventions involving sleep hygiene whilst visiting a health care professional could serve to blunt this rising trend of high blood pressure and its sequelae. Given their observational nature.23. blood pressure was measured by trained professionals using standard sphygmomanometers. and the degree to which profiles of patients’ habitual sleep could augment the diagnosis of hypertension and inform sleep recommendations to prevent or manage hypertension. Commonly. cancer. Future research needs to standardize and control these variables. The following variables are known to affect blood pressure: age. Controlled studies are needed to elucidate the factors that apparently confound this relationship. socioeconomic status. Dr Michael Bodner. In the assessment of longitudinal. Another limitation across studies was the use of self-report as a measure of habitual sleep duration. approximately 21% of study sample sizes comprised the extremes (6 h and 8 h) of reported habitual sleep duration (22. for example. However. these methodological limitations negatively impacted scores on the Downs and Black Quality Index. mental status (as measured by Short Form-36). Sleep duration. that home and ambulatory blood pressures are more valid is a consideration for future studies (44). Ultimately. Dr Teresa Liu-Ambrose and Dr Darlene Reid. however. To conclude. Although conducting randomized controlled trials that impose short sleep duration on healthy individuals is unethical. and blinding of researchers and participants. Blood pressure measurement was consistent in one respect and that was related to blood pressure being taken by someone other than the subject. race. salt and potassium intake. Blood pressure measures.28–32). varied across studies. family history of hypertension (45). dyssomnias and parasomnias).Sleep duration and blood pressure examining both observational and experimental studies.

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