Sleep Medicine 10 (2009) 1085–1089

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Sleep Medicine
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Original Article

Relationships of sleep duration with sleep disturbances, basic socio-demographic

factors, and BMI in Chinese people
Yu-Tao Xiang a,b,*, Xin Ma a, Jin-Yan Lu b, Zhuo-Ji Cai a, Shu-Ran Li c, Ying-Qiang Xiang a, Hong-Li Guo a,
Ye-Zhi Hou a, Zhen-Bo Li a, Zhan-Jiang Li a, Yu-Fen Tao a, Wei-Min Dang c, Xiao-Mei Wu a, Jing Deng a,
Kelly Y.C. Lai b, Gabor S. Ungvari b
a
Beijing Anding Hospital, Capital Medical University, Beijing, China
b
Department of Psychiatry, Chinese University of Hong Kong, Hong Kong SAR, China
c
Institute of Mental Health, Peking University, Beijing, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: This study aimed at determining the mean total sleep time (TST) and the relationship between
Received 7 January 2009 sleep duration and basic socio-demographic factors and BMI sleep problems in Chinese subjects.
Received in revised form 5 March 2009 Method: A total of 5926 subjects were randomly selected and interviewed using standardized assessment
Accepted 9 March 2009
tools.
Available online 12 May 2009
Results: The reported mean TST was 7.76 h. Short sleepers were significantly older than medium and long
sleepers. There were more urban residents who were short sleepers than medium and long sleepers.
Keywords:
Short sleepers reported more sleep problems than medium and long sleepers. Short and long sleepers
Long sleep syndrome
Short sleep syndrome
reported more psychiatric disorders than medium sleepers in both sexes, and short sleepers also had
China more major medical conditions in women. Short sleepers had a lower BMI than medium and long sleep-
Epidemiology ers after controlling for the effects of age and psychiatric disorders in women.
Community Conclusions: Nationwide epidemiologic surveys in China are needed to further explore the relationship
Insomnia between sleep duration and sleep problems.
Ó 2009 Elsevier B.V. All rights reserved.

1. Introduction
Previous studies have indicated that both short and long sleep
increase total mortality risk [1–5]. To date, the mechanism of this
association is unknown [2]. Buysse and Ganguli [6] suggested that
short sleep was due to several medical conditions or voluntary
sleep restriction; whereas long sleep was associated with other
sleep disturbances and a number of chronic medical and psychiat-
ric disorders. A similar U-shaped relationship between sleep dura-
tion and sleep complaints and BMI was also found [2,7,8]. These
associations between sleep duration and other clinical variables
have been posited as a clue to understanding the pathomechanism
of increased mortality [7].
Over the past decade, socioeconomic, cultural, and racial factors
have been found to have important impacts on sleep problems
[7,12]. The above-mentioned findings from Western countries
may not be applicable in other socio-cultural contexts, and there-
fore, investigations in Chinese populations are warranted. This
* Corresponding authors. Address: Department of Psychiatry, Shatin Hospital,
Shatin, N.T., Hong Kong SAR, China. Tel.: +852 2636 7748; fax: +852 2647 5321.
E-mail address: xyutly@cuhk.edu.hk (Y.-T. Xiang).
study set out to determine (1) the mean total sleep time (TST)
and (2) the rates of short, medium, and long sleepers in the Chinese
general population. The types of sleep duration defined according
to Heslop et al.’s criteria [1] include: short sleep: <7 h/day;
medium sleep: 7–8 h/day; long sleep: >8 h/day; and (3) the
relationships of short, medium, and long sleep with basic socio-
demographic factors, selected sleep problems, and BMI (kg/m2)
in Chinese people.
2. Methods
The method of the study, which was part of a large-scale epide-
miologic survey of the prevalence of psychiatric disorders in Bei-
jing, China, has been discussed in detail elsewhere [9,10]. Briefly,
the study was based on a stratified, multistage, systematic, and
probability sample of permanent residents in Beijing who were
15 years or older, lived with their family members, and had the
ability to comprehend the contents of the interview. The munici-
pality of Beijing was chosen because it comprises both urban and
rural areas. The study protocol was approved by the Human
Research and Ethics Committee of Beijing Anding Hospital. Written
consent was obtained from each subject.

1389-9457/$ - see front matter Ó 2009 Elsevier B.V. All rights reserved.
doi:10.1016/j.sleep.2009.03.002
1086 Y.-T. Xiang et al. / Sleep Medicine 10 (2009) 1085–1089

The recruitment of study subjects took place as follows. (1)
Neighborhood communities and village communities (NCs and
VCs) in urban and rural regions, respectively, are basic community
organizations with several hundreds of households in China. Fol-
lowing the method of a previous psychiatric epidemiologic survey
in Beijing [11], 2% of the total NCs and VCs in Beijing, i.e., 126 NCs
and VCs, with a total population of 313,356 persons were selected
using a random number table that took into account the popula-
tion and ratio of urban to rural residents in each of Beijing’s 18 dis-
tricts and counties. In Beijing, residents are categorized as either
urban or rural dwellers on their household cards, which are kept
by the local Public Security Bureau. (2) On the basis of the prede-
termined sampling interval and random starting points, 6267
households from the 126 NCs/VCs were selected from the house-
hold registry of the local Public Security Bureau. (3) The person
in each selected household aged above 15 years whose date of
birth was closest to April 1 was invited to participate in the study.
As planned, the subjects of the study accounted for approximately
2% of all the residents living in the 126 NCs and VCs.
Face to face household interviews were conducted. Socio-demo-
graphic data were collected with a questionnaire designed for the
study that inquired about TST, sleep disturbances, and major med-
ical conditions affecting the cardiovascular, respiratory, digestive,
hematological, endocrine, urinary, connective tissue, and nervous
systems. To determine TST in the past 12 months, subjects were
asked the following question: ‘‘On average, how many hours do
you sleep each night?” Reported sleep duration less than 2 or more
than 16 h each night was considered invalid information [2]. Three
DSM-IV-defined sleep problems were detected in this study, i.e.,
subjects were requested to answer ‘‘yes” or ‘‘no” to whether they
had experienced three basic forms of sleep disturbance lasting 2
weeks or longer in the past 12 months: first, difficulties initiating
sleep (DIS; specified as ‘‘it took you two hours or longer nearly every
night before you could fall sleep”); second, difficulties maintaining
sleep (DMS; specified as ‘‘you woke up nearly every night and took
an hour or more to get back to sleep”); and third, early morning
awakening (EMA; specified as ‘‘you woke up nearly every morning
at least two hours earlier than you wanted to”). These definitions
of sleep duration and insomnia have been used in recent studies
[7,12]. Participants’ heights and weights were measured by the
interviewers before the interviews and their BMIs were calculated.
The Chinese version of the Composite International Diagnostic
Interview-Version 1.0 (CIDI 1.0) that generates DSM-III-R diagno-
ses was used to identify major psychiatric disorders including alco-
hol dependence, schizophrenia, major depressive episode (MDE),
generalized anxiety disorder (GAD), and phobias. The Chinese ver-
sion of the CIDI 1.0 has satisfactory psychometric properties [13].
The interviews were conducted by 102 qualified psychiatrists se-
lected from 18 mental health services in Beijing. The interviewers
underwent training in epidemiological field work at a 10-day
workshop and were given a detailed manual on the study methods.
Data were analyzed using SPSS 13.0 for Windows. Comparisons
of the basic socio-demographic and clinical characteristics and
sleep problems of the different sleepers were performed by one-
way ANOVA or chi-square test as appropriate. If these tests were
significant, post-hoc tests were carried out. The level of statistical
significance was set at p < 0.01 to reduce the risk of Type I error
due to multiple tests.
3. Results
A total of 6251 subjects were approached and screened, with
5926 meeting the study criteria and being interviewed. Responses
were invalid for 17 rural residents (0.7%) and 35 urban residents
(1%), yielding a final sample of 5874.
The mean TST of the whole sample was 7.76 ± 1.22 h (95% CI:
7.73–7.79 h), and short and long sleepers accounted for 13.7%
(n = 806) and 20.8% (n = 1223) of the sample, respectively. There
were more men among medium sleepers (47.8%) than short
(42.7%) and long sleepers (43.2%; v2 = 12.3, df = 2, p = 0.002). Table

Table 1
Basic socio-demographic characteristics of the participants (n = 5874).

Short sleepers (n = 806) Medium sleepers (n = 3845) Long sleepers (n = 1223) Statistics Post-hoc analysesa
A B C
Mean (SD) Mean (SD) Mean (SD) F df p value
Men (n = 2709)
Age (years) 50.7 (15.6) 46.4 (16.6) 46.5 (19.1) 9.7 2.2706 <0.001 <0.001 <0.001 NSc
BMI 24.3 (4.0) 24.2 (3.9) 23.8 (3.9) 3.3 2.2706 0.036 – – –
N (%) N (%) N (%) v2 df p value
Urban 240 (69.8) 1102 (60.0) 285 (54.0) 21.7 2 <0.001 0.001 <0.001 NS
DIS 64 (18.6) 77 (4.2) 26 (4.9) 105.8 2 <0.001 <0.001 <0.001 NS
DMS 68 (19.8) 90 (4.9) 26 (4.9) 104.8 2 <0.001 <0.001 <0.001 NS
EMA 52 (15.1) 45 (2.4) 16 (3.0) 110.2 2 <0.001 <0.001 <0.001 NS
Psychiatric disordersb 131 (38.1) 416 (22.6) 165 (31.3) 44.0 2 <0.001 <0.001 NS <0.001
Major medical condition(s) 119 (34.6) 498 (27.1) 151 (28.6) 8.0 2 0.018
Mean (SD) Mean (SD) Mean (SD) F df p value
Women (n = 3165)
Age (years) 55.2 (15.9) 46.2 (15.7) 47.8 (17.5) 57.4 2.3162 <0.001 <0.001 <0.001 NS
BMI 23.7 (4.0) 24.1 (4.1) 24.1 (4.4) 1.6 2.3162 0.20
N (%) N (%) N (%) v2 df p value
Urban 299 (64.7) 1159 (57.7) 325 (46.8) 40.7 2 <0.001 0.006 <0.001 NS
DIS 136 (29.4) 146 (7.3) 44 (6.3) 214.9 2 <0.001 <0.001 <0.001 NS
DMS 153 (33.1) 174 (8.7) 58 (8.3) 222.3 2 <0.001 <0.001 <0.001 NS
EMA 103 (22.3) 98 (4.9) 33 (4.7) 175.4 2 <0.001 <0.001 <0.001 NS
Psychiatric disordersb 198 (42.9) 340 (16.9) 190 (27.3) 152.0 2 <0.001 <0.001 <0.001 <0.001
Major medical condition(s) 226 (48.9) 701 (34.9) 217 (31.2) 41.3 2 <0.001 <0.001 <0.001 NS
a
A, short vs. medium; B, short vs. long sleepers; C, medium vs. long sleepers.
b
Psychiatric disorders include alcohol dependence, schizophrenia, major depressive episode, generalized anxiety disorder, and phobias.
c
No significant difference at level of 0.01.
 Y.-T. Xiang et al. / Sleep Medicine 10 (2009) 1085–1089 1087

Table 2 and the study period across different studies precludes direct
Relationship between sleep duration and age. comparisons.
Age Short sleepers Medium sleepers Long sleepers Short sleepers were older than medium and long sleepers in this
group (n = 806) (n = 3845) (n = 1223) study in both sexes, supporting Western findings that insomnia in-
N (%) N (%) N (%) creases in the elderly [17]. A number of studies [1,2,18–25] demon-
15–24 48 (8.3) 402 (69.6) 128 (22.1) strated that a decrease in sleep duration was associated with
25–34 51 (6.8) 503 (66.7) 200 (26.5) elevated BMI. However, in this study short sleep was significantly
35–44 136 (10) 929 (68.2) 297 (21.8)
45–54 193 (16.0) 828 (68.5) 187 (15.5)
associated with decreased BMI after adjusting for the confounding
55–64 143 (17.2) 566 (68.1) 122 (14.7) effects of age in women. There is no explanation for this striking
P65 235 (20.6) 617 (54.1) 289 (25.3) finding which needs to be replicated.
More urban than rural residents were short sleepers in both
sexes. Possible reasons for this include relatively higher stress lev-
els and noisy environments in urban areas of China. Compared
1 shows the basic socio-demographic and clinical characteristics of with medium sleepers, short sleepers in this study were more
the subjects by sex. There were significant differences between the likely to have psychiatric and major medical conditions, which is
three groups with respect to age, urban abode, each of the three also in keeping with Western findings [6,26]. In this study, how-
sleep problems, and the presence of psychiatric disorders in both ever, short sleepers were significantly older than medium sleepers
sexes, while significant differences were found between the three in both sexes, which might have confounding effects on the associ-
groups in medical conditions in women. Post-hoc analyses are also ation between sleep duration and medical conditions. After con-
presented in Table 1. trolling for the potential confounding effect of age, the
There was no significant difference between the three groups in association between short sleep and medical conditions in both
BMI in either sex, just a trend in women after controlling for the sexes remained significant.
potential effect of age and psychiatric disorders (F(2,3160) = 4.0, Long sleepers were more likely to suffer from psychiatric disor-
p = 0.019). Post-hoc analysis revealed that short sleepers had a ders in both sexes, which were reported earlier [6]. The sedative ef-
lower BMI than medium sleepers (p = 0.008), whereas no signifi- fects of psychotropic drugs could partly explain this association
cant difference was found between medium and long sleepers [27]. A number of earlier studies suggested that long sleep was also
(p = 0.82) and short and long sleepers (p = 0.012). associated with increased mortality [3–5,28]. The connection be-
Table 2 shows the relationship between sleep duration and age, tween medical conditions and long sleep is far from clear [4,7],
and Table 3 presents the prevalence of sleep problems and lifetime although there is some evidence that long sleep might increase
major psychiatric disorders and the mean total sleep time in short, the risk of diabetes mellitus and coronary heart disease [28,29].
medium, and long sleepers. Fig. 1 depicts the relationship between This study failed to find a significant association between long
sleep problems and total sleep time. Fig. 2 summarizes the rela- sleep and major medical conditions. In line with earlier findings
tionship between major psychiatric disorders and total sleep time. [26,29], in this study short sleep was associated with more fre-
Fig. 3 shows the relationship between BMI and total sleep time by quent major medical conditions in women.
sex. Similar to previous findings [2,7,8], in this study the sleep prob-
lem rates approximately followed a U-shaped distribution across
4. Discussion hours of total sleep time. However, in contrast to previous reports
that both short and long sleepers reported significantly more sleep
The mean TST (7.76 h) found in this study was in line with fig- problems than medium sleepers [7], univariate analysis revealed
ures reported from Japan (7.8 h in men and 7.4 h in women) [14], that DIS, DMS, and EMA were more common only in short sleepers
but somewhat longer than the results in the USA (6.99 h in general in both sexes. This finding seems to support the notion that socio-
population) [7], the Shandong province of China (7.1 h in the el- cultural and racial factors could have an impact on sleep patterns
derly) [15], and Hong Kong (7.06 h in an adult working sample) [30].
[16]. Short and long sleepers accounted for 13.9% and 21.4% of The results should be interpreted with caution due to certain
the study sample, respectively, which is inconsistent with the cor- limitations. First, the study involved only residents of Beijing, one
responding figures of other countries: 19.7% and 7.6% in the USA of the most developed metropolitan areas of China, and the results
[2], and 13.8% and 5.4% in Japan [1]. It should be noted, however, may not be applicable to other regions of the country, which has 56
that the lack of agreement in standard definitions of short and long ethnic groups that differ significantly in socio-cultural and eco-
sleep patterns, discrepancies in sampling and interview methods, nomic environments. Second, as the study was a spin-off of a

Table 3
Sleep problems, lifetime major psychiatric disorders, and mean total sleep time in short, medium, and long sleepers (n = 5874).

Short sleepers (n = 806) Medium sleepers (n = 3845) Long sleepers (n = 1223)

Prevalence 95% CI Prevalence 95% CI Prevalence 95% CI
DIS 24.8 21.8–27.8 5.8 5.1–6.5 5.7 4.4–7.0
DMS 27.4 24.3–30.5 6.9 6.1–7.7 6.9 5.5–8.3
EMA 19.2 16.5–22.0 3.7 3.1–4.3 4.0 2.9–5.1
Alcohol dependence 0.5 0.01–1.0 0.3 0.1–0.4 0.3 0–0.5
Schizophrenia 0.9 0.2–1.5 0.3 0.1–0.5 0.9 0.4–1.4
Major depressive episode 17.6 15.0–20.3 4.6 3.9–5.3 4.5 3.3–5.7
Generalized anxiety disorder 4.7 3.3–6.2 1.0 0.7–1.4 0.6 0.2–1.0
Phobia 1.5 0.7–2.3 0.8 0.5–1.1 1.1 0.6–1.7
Mean 95% CI Mean 95% CI Mean 95% CI
BMI in men 24.3 23.9–24.7 24.3 24.1–24.8 23.8 23.5–24.1
BMI in women 23.8 23.4–24.1 24.2 24.0–24.3 24.2 23.9–24.5
1088 Y.-T. Xiang et al. / Sleep Medicine 10 (2009) 1085–1089

90 large-scale psychiatric epidemiologic survey (similar to recent

80 studies [7,12], of which only three were DSM-IV-specified), rela-
Percentage of sleep problems

tively severe sleep problems were identified. More sleep distur-

70
bances, such as snoring and apneas, should be inquired about in
60 future studies. Third, sleep duration and sleep disturbances were
50 only reported by the participants and not recorded or observed.
This might have constituted a bias because there is only a modest
40
correlation between reported and recorded sleep [31]. Fourth, the
30 study was cross-sectional, therefore the causality of the relation-
20 ships between sleep duration and socio-demographic factors and
10 BMI could not be explored.
In conclusion, given the significant associations of short sleep
0
1 2 3 4 5 6 7 8 9 10 11 12 13 with insomnia and psychiatric and major medical conditions, more
Hours of TST attention should focus on people with short sleep. National surveys
DIS DMS EMA to explore the situation in areas other than Beijing are warranted.

Fig. 1. The relationship between sleep problems and mean total sleep time.
Acknowledgements

This study was supported by grants from the Beijing Municipal

Science and Technology Commission (No. H010910130112-
35 200100528) and National Natural Science Foundation of China
(No. 30800367).
30 The authors declare no conflicts of interest.
Lifetime prevalence

25
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