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Pediatric Cardiology

Sleep Quality and Elevated Blood Pressure in Adolescents


Sogol Javaheri, MA; Amy Storfer-Isser, MS; Carol L. Rosen, MD; Susan Redline, MD, MPH

BackgroundWe assessed whether insufficient sleep is associated with prehypertension in healthy adolescents.
Methods and ResultsWe undertook a cross-sectional analysis of 238 adolescents, all without sleep apnea or severe
comorbidities. Participants underwent multiple-day wrist actigraphy at home to provide objective estimates of sleep patterns.
In a clinical research facility, overnight polysomnography, anthropometry, and 9 blood pressure measurements over 2 days
were made. Exposures were actigraphy-defined low weekday sleep efficiency, an objective measure of sleep quality (low
sleep efficiency 85%), and short sleep duration (6.5 hours). The main outcome was prehypertension (90th percentile for
age, sex, and height), with systolic and diastolic blood pressures as continuous measures as secondary outcomes.
Prehypertension, low sleep efficiency, and short sleep duration occurred in 14%, 26%, and 11% of the sample, respectively.
In unadjusted analyses, the odds of prehypertension increased 4.5-fold (95% CI, 2.1 to 9.7) in adolescents with low sleep
efficiency and 2.8-fold (95% CI, 1.1 to 7.3) in those with short sleep. In analyses adjusted for sex, body mass index percentile,
and socioeconomic status, the odds of prehypertension increased 3.5-fold (95% CI, 1.5. 8.0) for low sleep efficiency and
2.5-fold (95% CI, 0.9 to 6.9) for short sleep. Adjusted analyses showed that adolescents with low sleep efficiency had on
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average a 4.01.2-mm Hg higher systolic blood pressure than other children (P0.01).
ConclusionsPoor sleep quality is associated with prehypertension in healthy adolescents. Associations are not explained
by socioeconomic status, obesity, sleep apnea, or known comorbidities, suggesting that inadequate sleep quality is
associated with elevated blood pressure. (Circulation. 2008;118:1034-1040.)
Key Words: blood pressure epidemiology hypertension pediatrics sleep

H ypertension is an increasingly prevalent health problem


in adults and adolescents alike. Between 1988 and 1999,
prehypertension (ie, a blood pressure [BP] 90th percentile
compared with primary snorers.21 The Tucsons Childrens
Assessment of Sleep Apnea Study found that elevations in
systolic and diastolic BPs were independently associated with
for height, age, and sex) and hypertension were estimated to sleep efficiency, respiratory disturbance index (a measure of
increase in children by 2.3% and 1%, respectively.1 Child- sleep apnea), and obesity in 230 children 6 to 11 years of age.22
hood hypertension is associated with hypertension in adult- To the best of our knowledge, no studies have examined the
hood, a risk factor for cardiovascular disease incidence and association between insufficient sleep and BP in adolescents free
death.25 It also is associated with end-organ damage, notably of sleep apnea. In this report, we examine the relationship
left ventricular hypertrophy, in both children and adults.6,7 between prehypertension and systolic and diastolic BP levels
and objective measures of sleep quality and duration in a
Clinical Perspective p 1040 community-based cohort of adolescents. First, we hypothesize
that adolescents with poor sleep quality or short sleep duration
Several studies have implicated insufficient sleep as a risk
will be at increased odds of prehypertension. Second, we posit
factor for hypertension in adults.8 12 Although the cause is
that adolescents with short sleep duration or poor sleep quality
unclear, experimental studies indicate that shorter sleep
will have higher systolic and diastolic BP readings on average
results in metabolic and endocrine dysfunction, which may
compared with adolescents with better-quality sleep. We ex-
contribute to cardiovascular disease.1317 Studies in both adult cluded adolescents with clinically significant levels of sleep
and pediatric populations also have reported associations of apnea to minimize the influence of this exposure on BP and
shorter sleep duration with obesity and impaired glucose sleep duration measurement.
tolerance.14,18,19 These findings have a potentially large public
impact given the frequency of sleep curtailment.20 Methods
Few studies have addressed the relationship between sleep Study Population
and hypertension in children. A higher level of diastolic but not The sample was derived from the Cleveland Childrens Sleep and
systolic BP was reported in children with obstructive sleep apnea Health Study, a longitudinal cohort study. Data for this analysis are from

Received January 14, 2008; accepted July 7, 2008.


From the Case School of Medicine (S.J., A.S.-I., C.L.R., S.R.) and Center for Clinical Investigation (A.S.-I., C.L.R., S.R.), Case Western Reserve University
School of Medicine; Department of Pediatrics, Rainbow Babies and Childrens Hospital (C.L.R.); and Case Center for Transdisciplinary Research on Energetics
and Cancer, Case Comprehensive Cancer Center and Department of Medicine, University Hospitals of Cleveland (A.S.-I., S.R.), Cleveland, Ohio.
The online-only Data Supplement can be found with this article at http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.108.766410/DC1.
Correspondence to Susan Redline, Case Western Reserve University, Cleveland, OH 44106-6003. E-mail sxr15@case.edu
2008 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.108.766410

1034
Javaheri et al Sleep and Blood Pressure in Adolescents 1035

238 adolescents free of severe illnesses who participated in an exami- the frequency with which they consumed caffeine after 6 PM during
nation performed between 2002 and 2006 aimed at participants 13 to 16 the past month; those reporting frequently or always consuming
years of age. Details of the study population have been reported caffeine were coded as consuming caffeine in the evening.
elsewhere23,24 and are reviewed in the online Data Supplement.
Statistical Analysis
Study Protocol Between-group differences for the binary outcome, prehypertension,
Adolescents underwent 5- to 7-day wrist actigraphy and completed a were assessed with the Pearson 2 test for categorical variables, the
daily sleep log at home during the week before a clinical research 2-sample t test for normally distributed variables, and the Wilcoxon
center examination and when free of acute illness. After this period rank-sum test for nonnormally distributed measures. To assess con-
of in-home monitoring, participants were studied in a dedicated founding, associations between the primary exposures, low sleep effi-
clinical research center where overnight polysomnography and ciency (85%) and short sleep duration (6.5 hours), and sociodemo-
physiological and anthropometric assessments were performed using graphic characteristics also were examined. Spearman and Pearson
a standardized protocol.23,25 Examinations at the research center correlations assessed the strength of the linear relationship between
began at approximately 5 PM and ended the following day at 11 AM. sleep characteristics obtained from polysomnography and actigraphy.
Informed consent was obtained from the childs legal guardian, and Logistic regression analyses were used to examine whether adolescents
written assent was obtained from the child. The study was approved with short sleep duration or low sleep efficiency were at increased odds
by the governing institutional review board. of prehypertension. Given the relatively small number of adolescents
with prehypertension, covariate adjustment was limited to the SES z
Measurements score and the 2 variables most strongly associated with prehypertension:
sex and BMI percentile. Multiple linear regression, adjusted for age, sex,
Actigraphy race, preterm status, BMI percentile, and SES z score, was used to
Sleep-wake estimation was made with wrist actigraphy (Octagonal examine the linear associations between sleep duration or sleep effi-
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Sleep Watch 2.01, Ambulatory Monitoring Inc, Ardsley, NY) analyzed ciency with continuously measured systolic and diastolic BP levels.
with the Action-W software and the time-above-threshold algorithm.24 Additional analyses included low sleep efficiency from the polysom-
Using weekday data (minimum, 3 days), we calculated mean sleep nography as the exposure. Residual confounding by snoring or the
duration and mean sleep efficiency, an objective measure of sleep apnea hypopnea index also was assessed by including these measures
continuity and quality defined as the percentage of time in bed estimated as covariates in the adjusted analyses.
to be asleep (ie, total time estimated to be asleep divided by the total The authors had full access to the data and take full responsibility
time in bed for the major sleep period times 100). Adolescents with a for the integrity of the data. All authors have read and agree to the
sleep efficiency 85% were considered to have low sleep efficiency. manuscript as written.
Given the lack of data on cutoffs for defining short sleep duration in this
age, we used the lowest decile of mean sleep duration on weekdays to Results
define short sleep duration, which approximated 6.5 hours. Characteristics of the analytic sample are shown in Table 1.
Blood Pressure The average participant was 13.70.7 years of age. As
Three BP readings were obtained at each of 3 times (9 PM [supine] designed, the sample had an 50% representation of boys,
the night of the polysomnography and 8 AM [supine] and 9:30 AM blacks, and children born prematurely. One fifth of the
[sitting] the following morning) following published guidelines.23 sample was overweight. Approximately one-fourth reported
After a 10-minute rest period, BP was obtained by trained nurses
using a calibrated sphygmomanometer. The mean systolic and their household income as less than $20 000 per year.
diastolic BP values used in primary analyses were based on the Sixty-one adolescents (26%) had low sleep efficiency. Aver-
average of all 9 measurements. Prehypertension was identified if the age weekday sleep duration was 7.71 hours, and 11% of the
systolic and/or diastolic BP was 90th percentile for age, sex, and sample slept 6.5 hours.
height.4 Hypertension was defined as systolic or diastolic BP 95th Sample characteristics stratified by prehypertension also are
percentile. One adolescent using antihypertensive medication was
classified as having hypertension. shown in Table 1. Overall, 33 children (14%) met the criteria for
prehypertension, including 19 who had prehypertension and 14
Other Measurements who were hypertensive. Compared with normotensive adoles-
A rigid stadiometer was used to measure height, and a calibrated cents, those with prehypertension tended to more often be male,
digital scale was used to measure weight. Body mass index (BMI)
was calculated by dividing the weight in kilograms by height in tended to have a higher BMI, and were more frequently from
meters squared and converted into age- and sex-adjusted percentiles neighborhoods with a low median income (P0.05 to 0.10).
(http://www.cdc.gov/growthcharts/). Overweight was defined as Both low sleep efficiency (P0.0001) and short sleep duration
BMI 95th percentile. Adolescents who were reported to snore (P0.06) were 2-fold more prevalent in those with prehyper-
loudly at least 1 to 2 times per week during the past month were tension compared with normotensive adolescents.
categorized as snorers. The apnea hypopnea index was defined as
all obstructive apneas and hypopneas with a 3% desaturation per The distribution of various BP measures is further detailed
sleep hour from the polysomnogram. Socioeconomic status (SES) in Table 2. Using the mean of 9 BP readings, we classified
measures included parent report of educational level and family 11% of the sample as having elevated systolic BP and 5%
income. Additionally, the census tract of the childs residence when as having elevated diastolic BP. All measures of systolic BP
initially enrolled in the study was linked to the corresponding 2000 were significantly higher among the adolescents with low
US Census Bureau database, and median income of the census tract
was ascertained (http://wagda.lib.washington.edu/data/type/census/). sleep efficiency compared with those with higher sleep
A composite SES z score was created by averaging the sample z efficiency. Adolescents with low sleep efficiency also had a
scores for these 3 measures. Tanner staging was performed by a higher prevalence of elevated diastolic BP and had higher 8
physician to determine pubertal status.26,27 Preterm status was AM diastolic BP values. Adolescents with short sleep duration
ascertained from birth records and defined as a gestational age 37 did not differ from those with longer sleep duration in regard
weeks. Attention deficit hyperactivity disorder (ADHD) was defined
as parent-reported doctors diagnosis of ADHD and either currently to systolic BP but had a higher average diastolic BP and
present condition or medication/stimulant use for ADHD during the higher prevalence of elevated diastolic BP (24.0% versus
past year. Using a standardized questionnaire, adolescents reported 2.4%; P0.001).
1036 Circulation September 2, 2008

Table 1. Sample Characteristics


All Normotensive Prehypertension
(n238) (n205) (n33) P
Characteristics
Age, y 13.70.7 13.70.7 13.70.9 0.9782
Male, n (%) 123 (51.7) 101 (49.3) 22 (66.7) 0.0634
White race, n (%) 107 (45.0) 94 (45.9) 13 (39.4) 0.4887
Preterm status, n (%) 136 (57.1) 115 (56.1) 21 (63.6) 0.4167
Loud snoring, n (%) 41 (17.8) 36 (18.2) 5 (15.6) 0.7259
ADHD, n (%) 17 (7.2) 13 (6.4) 4 (12.1) 0.2683
Caffeine consumption after 6 PM, n (%) 61 (25.9) 53 (26.1) 8 (24.2) 0.8204
BMI percentile 72.2 (47.193.8) 70.9 (45.292.8) 87.9 (63.196.8) 0.0536
Overweight (BMI percentile 95th), n (%) 50 (21.0) 40 (19.5) 10 (30.3) 0.1579
Tanner stage 4, n (%) 172 (73.5) 148 (73.6) 24 (72.7) 0.9131
SES measures
Household income, n (%)
$20 000
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62 (27.9) 53 (27.8) 9 (29.0)


$20 000$49 999 64 (28.8) 51 (26.7) 13 (41.9) 0.2689
$50 000 96 (43.2) 87 (45.5) 9 (29.0)
Neighborhood median income census tract, $1000 38.6 (23.652.4) 41.0 (24.155.2) 30.9 (23.243.1) 0.0617
Caregiver education, n (%) 0.5803
High school 19 (8.2) 15 (7.6) 4 (12.1)
High school or GED 47 (20.4) 41 (20.7) 6 (18.2)
High school 165 (71.4) 142 (71.7) 23 (69.7)
SES z score 0.000.80 0.030.81 0.170.74 0.1763
Actigraphy sleep characteristics, n (%)
Low sleep efficiency (85%) 61 (25.6) 43 (21.0) 18 (54.6) 0.0001
Short sleep (6.5 h) 25 (10.5) 18 (8.8) 7 (21.2) 0.0585
Sleep duration, n (%)33
6.5 h 25 (10.5) 18 (8.8) 7 (21.2)
6.517.49 h 75 (31.5) 65 (31.7) 10 (30.3) 0.1644
7.508.49 h 87 (36.6) 78 (38.0) 9 (27.3)
8.5 h 51 (21.4) 44 (21.5) 7 (21.2)
Sleep duration, h 7.711.03 7.750.99 7.461.23 0.1367
Polysomnography sleep characteristics
Arousal index 7.4 (6.09.4) 7.4 (6.19.4) 7.5 (6.010.4) 0.8343
Time in stage 34, % 33.811.6 34.111.4 32.313.0 0.4005
Time in REM, % 17.94.8 17.94.8 17.54.9 0.6563
Sleep efficiency, % 90.4 (85.594.0) 91.1 (86.594.2) 85.9 (80.389.6) 0.0002
Sleep efficiency (85%), n (%) 55 (23.1) 40 (19.5) 15 (45.5) 0.0010
GED indicates general educational development. Values are mean (%) or median (interquartile range) as appropriate.

To assess confounding, associations among the sleep (r0.13, P0.04), as was the correlation between mean
exposures and sociodemographic characteristics were exam- weekday sleep duration and sleep duration from the night of
ined (see the online Data Supplement). Adolescents with low the polysomnography (r0.06, P0.37). Approximately
sleep efficiency had a higher BMI, were more often male, and one third (32.8%) of adolescents with low sleep efficiency as
were from households with lower incomes and lower levels assessed on actigraphy also had low sleep efficiency from the
of caregiver education. These characteristics were not signif- polysomnography.
icantly associated with short sleep duration. Approximately Results of the logistic regression models of the association
two thirds (68.0%) of adolescents with short sleep duration between each sleep measure and the odds of prehypertension
also had low sleep efficiency, whereas 27.9% of adolescents are shown in Tables 3 and 4. After adjustment for sex, BMI
with low sleep efficiency also had short sleep duration. The percentile, and SES z score, those with low sleep efficiency
correlation between mean weekday sleep efficiency and sleep had 3.5 times the odds of prehypertension compared with
efficiency from the night of the polysomnography was low those without low sleep efficiency (95% CI, 1.54 to 7.96).
Javaheri et al Sleep and Blood Pressure in Adolescents 1037

Table 2. BP in Subgroups Defined by Sleep Quality


Sleep Efficiency 85% Sleep Efficiency 85% Mean Sleep Duration Mean Sleep Duration
(n177) (n61) P 6.5 h (n213) 6.5 h (n25) P
Systolic BP
Systolic BP percentile 61.2 (42.777.8) 71.2 (53.191.1) 0.0012 63.2 (46.780.8) 66.4 (42.277.4) 0.9109
Elevated systolic BP (90th 11 (6.2) 16 (26.2) 0.0001 23 (10.8) 4 (16.0) 0.5005
percentile), n (%)
Mean systolic BP, mm Hg* 112.67.5 118.49.9 0.0001 113.87.9 116.512.6 0.3185
9 PM 114.68.8 121.911.7 0.0001 116.09.2 120.815.4 0.1420
8 AM 111.48.7 116.69.4 0.0001 112.68.9 114.010.9 0.4726
9:30 AM 111.98.2 116.811.5 0.0028 113.08.7 114.613.8 0.5635
Diastolic BP
Diastolic BP percentile 54.8 (41.670.6) 58.1 (42.674.3) 0.1695 55.2 (41.670.6) 58.0 (46.070.8) 0.3127
Elevated diastolic BP 5 (2.8) 6 (9.8) 0.0350 5 (2.4) 6 (24.0) 0.0003
(90th percentile), n (%)
Mean diastolic BP, mm Hg* 65.76.2 67.47.4 0.0816 65.86.3 68.68.2 0.0463
9 PM 64.19.1 65.211.0 0.4719 64.19.3 67.212.0 0.1224
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8 AM 66.37.1 68.47.1 0.0416 66.67.2 69.16.6 0.0908


9:30 AM 66.77.1 68.59.0 0.1661 66.97.2 69.510.5 0.2308
Prehypertension, n (%) 15 (8.5) 18 (29.5) 0.0001 26 (12.2) 7 (28.0) 0.0585
Hypertension, n (%) 5 (2.8) 9 (14.8) 0.0019 9 (4.2) 5 (20.0) 0.0089
Values are meanSD or median (interquartile values) as appropriate.
*Average of all 9 values.

Short sleep duration was associated with a 2.8-fold increased systolic and diastolic BPs compared with sleep efficiency
odds of prehypertension in unadjusted analyses (95% CI, 1.07 (Table 6).
to 7.34), but this association was modestly attenuated after
adjustment for sex, BMI percentile, and SES z score (odds Additional Analyses
ratio [OR], 2.54; 95% CI, 0.93, 6.90). The primary analyses also were repeated with low sleep
The unadjusted and adjusted associations between contin- efficiency ascertained via polysomnography as the exposure.
uously measured systolic and diastolic BP levels with sleep Consistent with the results of the primary analysis, after
efficiency are shown in Table 5. After adjustment for age, adjustment for sex, BMI percentile, and SES z score, those
sex, race, term status, BMI percentile, and SES z score, the with polysomnography sleep efficiency 85% had nearly 3
model predicts that each 5% increase in sleep efficiency was times the odds of prehypertension as those with better sleep
associated with a 1.50.40-mm Hg decrease in systolic BP (OR, 2.83; 95% CI, 1.28, 6.24). Also consistent with the
(P0.001). Weaker associations were observed between results of the actigraphy-defined sleep exposures, in adjusted
sleep efficiency and diastolic BP; ie, each 5% increase in analyses, each 1% increase in sleep efficiency was associated
sleep efficiency was associated with a 0.650.35-mm Hg with a 0.200.06-mm Hg decrease in systolic BP (P0.001).
decrease in diastolic BP (P0.05). When low sleep effi- Similarly, those with low polysomnography sleep efficiency
ciency was modeled as a dichotomous exposure, the adjusted had systolic BP that was 3.261.25 mm HG higher on
model estimates that adolescents with low sleep efficiency average compared with those with better sleep (P0.01).
had a mean systolic BP that was on average 3.99 Although analyses were restricted to children without
1.24 mm Hg higher compared with those with higher sleep clinically significant sleep apnea, additional analyses as-
efficiency (P0.002). Including sleep duration as a continu- sessed potential residual confounding by snoring or the
ously measured covariate did not alter the primary associa- apnea hypopnea index (ie, in an apnea hypopnea index
tions of sleep efficiency and BP (data not shown). range of 0 to 4.9). The results show that loud snoring was not
Similar to the models of prehypertension, sleep duration significantly associated with prehypertension, systolic BP, or
was more weakly associated with continuously measured diastolic BP. In contrast, although the apnea hypopnea index

Table 3. Association Between Low Sleep Efficiency and Odds of Prehypertension


Unadjusted OR (95% CI) P Adjusted OR (95% CI) P
Low sleep efficiency (85%) 4.52 (2.119.70) 0.0001 3.50 (1.547.96) 0.0028
Male 1.78 (0.784.04) 0.1702
BMI percentile (per 10-unit increase) 1.08 (0.931.26) 0.3098
SES z score 0.85 (0.511.42) 0.5339
1038 Circulation September 2, 2008

Table 4. Association Between Short Sleep and Odds of Prehypertension


Unadjusted OR (95% CI) P Adjusted OR (95% CI) P
Short sleep (6.5 h) 2.79 (1.077.34) 0.0366 2.54 (0.936.90) 0.0679
Male 2.20 (0.994.88) 0.0523
BMI percentile (per 10-unit increase) 1.13 (0.981.31) 0.1042
SES z score 0.75 (0.461.23) 0.2526

does not confound the association between the outcomes and not men8; another study showed no association of hypertension
the sleep exposures, it was associated with increased odds of and sleep duration in the elderly, a group with a high prevalence
prehypertension after adjustment for low sleep efficiency, of morbidities.29 Because adolescents with major comorbidities,
sex, and BMI percentile; ie, for each 1-unit increase in the including those with clinically significant levels of sleep apnea,
apnea hypopnea index, the odds of prehypertension in- were excluded from our analyses (to minimize confounding and
creased by 47% (OR, 1.47; 95% CI, 1.00 to 2.17). Similarly, to reduce measurement error), it is unlikely that major confound-
the apnea hypopnea index was significantly associated with ing resulting from medical illnesses, medications, or sleep-
systolic BP in adjusted models; after adjustment for subject related hypoxemia explains the strong association between low
characteristics and low sleep efficiency, for each 1-unit sleep efficiency and elevated BP. Given that the association
increase in the apnea hypopnea index, mean systolic BP between BP and low sleep efficiency persisted even after
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increases by 1.65 mm Hg on average (P0.009). adjustment for average sleep duration, our findings also suggest
that recurrent arousals or awakenings from sleep (which reduce
Discussion sleep efficiency) are associated with elevated BP. Our findings
To the best of our knowledge, this is the first reported associa- are consistent with a report from a sample of preadolescent
tion between low sleep efficiency and short sleep duration children studied with single-night polysomnography that dem-
objectively measured in the childs usual sleep environment with onstrated an association between low sleep efficiency and
elevated BP (prehypertension or hypertension) in adolescents elevated BP after adjustment for the apnea hypopnea index.22
without clinically significant levels of sleep apnea. Specifically, The 3.5-fold increased odds of prehypertension or hyper-
adolescents with poor sleep quality, as measured by a sleep tension in children with low sleep efficiency, if causal,
efficiency of 85%, were at 3.5-fold increased odds of being suggests associations with a potential large public health
prehypertensive or hypertensive. Similar findings were observed impact. Although the overall prevalence of low sleep effi-
when single-night polysomnography was used to quantify sleep ciency in general pediatric samples is unknown, our preva-
efficiency. The association between low sleep efficiency and lence of 26% is likely an underestimate given the exclusion of
prehypertension persisted even after adjustment for sex, SES, children with sleep disorders and significant comorbidities.
and adiposity. The results did not change appreciably after Our finding of an increased prevalence of low sleep effi-
adjustment for snoring or the apnea hypopnea index. Short ciency among vulnerable population subgroups such as
sleep duration also was associated with a 2.5-fold increase in the poorer children and those of minority ethnicity may be of
odds of prehypertension or hypertension. However, it was not special concern because these groups are known to be at risk
clear whether this association was attributable to the low sleep for hypertension and other adverse health outcomes.
efficiency found in a majority of the adolescents with short sleep Low sleep efficiency was associated with an average
duration. adjusted increase in systolic BP of 4 mm Hg. Although
In adults, poor sleep quality identified by questionnaires has limited data are available in children to interpret the clinical
been reported in association with an increased prevalence of significance of this absolute elevation, large cohort studies
hypertension12 and an increased rate of nondipper hyperten- suggest a log-linear increase in morbidity in association with
sion.28 However, poor sleep quality in adults often occurs in the incremental changes in systolic BP.30
presence of primary sleep disorders such as sleep apnea or Short sleep duration was associated with a 2.5-fold increased
insomnia or secondary to numerous comorbidities. Therefore, odds of prehypertension, an association attributable partly to low
adult studies reporting associations with disturbed or reduced sleep efficiency. Short sleep duration has been increasing in all
sleep and hypertension have been cautiously interpreted because ages31 and is associated with an increased risk for obesity.13,16 18
of concerns about residual confounding.10 One large prospective Thus, efforts to optimize sleep in childhood may improve the BP
study reported associations of short sleep duration in women but profile of children through obesity-dependent and -independent

Table 5. Association Between Actigraphy Sleep Efficiency Table 6. Association Between Actigraphy Sleep Duration
(per 1% Increase) and Continuously Measured BP (per 1-Hour Increase) and Continuously Measured BP
Unadjusted Adjusted* Unadjusted Adjusted*

SE P SE P SE P SE P
Systolic BP 0.420.07 0.0001 0.300.08 0.0002 Systolic BP 1.740.53 0.0012 0.980.52 0.06
Diastolic BP 0.130.06 0.03 0.130.07 0.05 Diastolic BP 0.600.41 0.15 0.410.44 0.34
*Adjusted for age, sex, race, term status, BMI percentile, and SES z score. *Adjusted for age, sex, race, term status, BMI percentile, and SES z score.
Javaheri et al Sleep and Blood Pressure in Adolescents 1039

pathways. Further work is needed to dissect the relative influ- cholamines36 and abnormalities in sympathovagal balance,37
ences of sleep curtailment from sleep disruption on health and abnormal secretion of vasoactive hormones, including
outcomes, which will be important in determining whether endothelin, vasopressin, and aldosterone.38 Experimental
future interventions would be best directed at improving sleep sleep disruption has been associated with elevated BP in sleep
time, sleep consolidation, or both. in normal subjects.39 Although some experimental models
The cause of low sleep efficiency in healthy adolescents is suggest that sustained elevations in BP require sleep frag-
unclear. Sensitivity analyses did not indicate an association mentation to occur in a background of intermittent hypox-
between low sleep efficiency and common childhood disor- emia40 (as occurs with sleep apnea), sleep fragmentation may
ders such as asthma or ADHD or caffeine or tobacco use, nor be associated with elevated BP even in adults with a low
were these variables confounders in the association between apnea hypopnea index41 or with simple snoring.11 Prospec-
sleep efficiency and BP (data not shown). It is possible that tive and interventional studies are needed to provide further
unknown psychological disorders may have confounded our evidence of causality and to address whether improving sleep
results, but this seems unlikely given the strong associations quality and duration reduces BP and risk of hypertension.
and community sampling design.
Although children with significant sleep apnea were excluded Conclusions
from our analyses, the apnea hypopnea index (in a range of 0 to Extensive analyses using objective measures of sleep quality
4.9) was significantly associated with prehypertension and sys- and duration and multiple measures of BP provide evidence for
tolic BP after adjustment for sleep efficiency. This suggests that a strong association of low sleep efficiency with increased risk of
even mild sleep-disordered breathing may contribute to abnor- prehypertension and hypertension in a healthy sample of ado-
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mal BP levels, a result consistent with reports of more severely lescents. Our data suggest that low sleep efficiency may be
affected children from sleep clinic samples.21 associated more consistently with prehypertension than short
Strengths of this report are the inclusion of a community- sleep duration. Future research is needed to address whether
based sample of children, minimizing referral biases, and the prevention of hypertension in children should include not only
use of objective measures of sleep duration and multiple weight management and exercise but also optimization of sleep.
measures of BP, minimizing measurement error and reporting Our data underscore the need to monitor the quantity and quality
biases. By characterizing numerous risk factors and comor- of sleep as part of health supervision in children.
bidities, we were able to restrict the analytical sample to
children without disorders likely to confound associations Sources of Funding
with sleep quality. Although former preterm children were This work was supported by National Institutes of Health (NIH)
overrepresented by design, there was no evidence of any grants HL07567, HL60957, RO1 NR02707, M01 RR00080, and
1U54CA116867.
differences in the exposures, responses, or associations be-
tween preterm and full-term children, suggesting that our Disclosures
results should be generalizable to other pediatric samples. Dr Rosen has received a subcontract from Advanced Brain Moni-
There are no established cutoffs to define thresholds of toring Inc to provide clinical research services funded through NIH
sleep duration or sleep efficiency that increase morbidity in Small Business Innovative Research and has received honoraria for
adolescents. In adults, sleep durations of 6 hours have been society-sponsored educational talks. Dr Redline has received a
subcontract from Cleveland Medical Devices Inc to provide clinical
associated with a variety of adverse health outcomes,15,19,32,33
research services as part of NIH Small Business Innovative Research
and sleep efficiencies of 85% are considered low. Our funding. The other authors report no conflicts.
choice for defining short sleep duration as 6.5 hours was to
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CLINICAL PERSPECTIVE
Childhood hypertension is a risk factor for adult hypertension and for target-organ damage. Early recognition and intervention
of childhood hypertension are believed to be important in reducing the risk of cardiovascular morbidity in adulthood. Traditional
approaches for intervention focus on the role of overweight as a contributing cause of hypertension and include weight reduction,
increased physical activity, and nutritional changes. The present report identifies a significant association between increased
blood pressure and poor sleep quality (ie, increased wake time during the sleep period), found in 26% of a community sample
of adolescents. Independent of obesity, sex, and socioeconomic status and unrelated to sleep apnea, adolescents with poor sleep
had a 3.5-fold increased risk of prehypertension or hypertension. This finding suggests that approaches for optimizing sleep
quality and duration in children may complement other behavioral approaches for preventing or treating pediatric hypertension.
Monitoring sleep quality and duration in children as part of their health supervision may help to identify children who are at risk
for both sleep problems and hypertension and who would benefit from behavioral interventions aimed at improving sleep.
Sleep Quality and Elevated Blood Pressure in Adolescents
Sogol Javaheri, Amy Storfer-Isser, Carol L. Rosen and Susan Redline

Circulation. 2008;118:1034-1040; originally published online August 18, 2008;


doi: 10.1161/CIRCULATIONAHA.108.766410
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