Progress in Cardiovascular NURSING (ISSN 0889-7204) is published Quarterly (March, May, July, Nov.) by CHF, Inc.
, Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2004 by CHF, Inc. All rights reserved. No
part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission
in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial
purposes, please contact Sarah Howell at showell@lejacq.com or 203.656.1711 x106.
Review Paper
The Impact of Daily Sleep Duration on Health:
A Review of the Literature
Gonzalo G. Alvarez, MD; Najib T. Ayas, MD, MPH
A healthy amount of sleep is paramount to leading
a healthy and productive lifestyle. Although chronic
sleep loss is common in today’s society, many people
are unaware of the potential adverse health effects of
habitual sleep restriction. Under strict experimental con-
ditions, short-term restriction of sleep results in a variety
of adverse physiologic effects, including hypertension,
activation of the sympathetic nervous system, impair-
ment of glucose control, and increased inflammation.
A variety of epidemiologic studies have also suggested
an association between self-reported sleep duration
and long-term health. Individuals who report both an
increased (>8 h/d) or reduced (<7 h/d) sleep duration
are at modestly increased risk of all-cause mortality,
cardiovascular disease, and developing symptomatic
diabetes. Although the data are not definitive, these stud-
ies suggest that sleep should not be considered a luxury,
but an important component of a healthful lifestyle.
(Prog Cardiovasc Nurs. 2004;19:56–59) ©2004 CHF, Inc.
From the University of British Columbia and Vancouver
General Hospital, Vancouver, BC, Canada
Address for correspondence:
Najib T. Ayas, MD, MPH, Assistant Professor of
Medicine, University of British Columbia; and
Respiratory Division, Department of Medicine,
Vancouver General Hospital, 2775 Heather Street,
Vancouver, BC, Canada V5Z 3J5
Manuscript received August 22, 2003;
revised October 17, 2003;
accepted October 23, 2003
www.lejacq.com
56 Progress in Cardiovascular NURSING
A dequate daily sleep is an important part of a
healthful and productive lifestyle; however, chron-
ic sleep restriction in today’s society is very common.
American adults only sleep an average of 6.85 hours
per night.1 Furthermore, only 37% of Americans report
obtaining ≥8 hours of sleep each night, and 31% of
adults report sleeping <6 hours each night.1
There are many potential explanations for the high
prevalence of sleep restriction. First, the demands of
today’s 24-hour society, including long work hours
and rotating night shift work, can lead to sleep restric-
tion.2 Second, family needs superimposed on work-
related responsibilities result in sleep restriction. Third,
increased time spent watching television and on the
Internet reduces the opportunity for sleep.1 Finally,
some individuals suffer from insomnia, a condition
characterized by an inability to fall asleep or stay
asleep.3 Although there are a number of causes of
insomnia, including a learned response, psychiatric/
medical disorders, and poor sleep habits, it is idio-
pathic in some patients.
It has been shown that sleep restriction can result
in excessive daytime sleepiness and reduced neuro-
cognitive function. More recently, it has been demon-
strated that this degree of sleep loss may have long-
term health consequences and may lead to premature
death, cardiovascular disease, and the development
of diabetes.4,5 In this article, we discuss the physiolog-
ic effects of short-term and long-term sleep restriction
and examine the relationship between sleep restric-
tion or sleep excess and a variety of health outcomes
such as all-cause mortality, coronary heart disease
(CHD), and diabetes.
SHORT-TERM PHYSIOLOGIC STUDIES OF
SLEEP RESTRICTION
Short-term sleep restriction has many adverse endo-
ID: 2422 crine and cardiovascular effects. Kato et al.6 subjected
Spring 2004
Progress in Cardiovascular NURSING (ISSN 0889-7204) is published Quarterly (March, May, July, Nov.) by CHF, Inc., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2004 by CHF, Inc. All rights reserved. No
part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission
in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial
purposes, please contact Sarah Howell at showell@lejacq.com or 203.656.1711 x106.
eight healthy subjects, six of whom were men and two
of whom were women aged 40±5 years, to one night of
normal sleep and one night of total sleep deprivation.
Subjects who were completely deprived of sleep had a
significantly higher systolic blood pressure following a
night of sleep deprivation compared with normal sleep
(129±8 mm Hg vs. 123±8 mm Hg). A similar study con-
cerning acute partial sleep deprivation was performed
by Tochikubo et al.7 in 18 male technical workers aged
23–48 years who slept only 3.6 hours had a signifi-
cantly increased blood pressure.
In a landmark study, Spiegel et al.8 studied 11
healthy men aged 18–27 years and subjected them to
six nights of 4 hours of sleep per night followed by six
nights of 10 hours of sleep per night (recovery sleep).
During the sleep-deprived portion compared with the
recovery portion, patients demonstrated impaired glu-
cose tolerance, increased sympathetic nervous system
activity, higher evening cortisol levels, and reduced
leptin levels (an appetite-suppressing hormone). In a
recent study by Meier-Ewert et al.,9 partial sleep restric-
tion (4.2 hours of sleep per night) of 13 healthy subjects,
10 of whom were men and three of whom were women
with an age range of 21–35 years, increased levels of
C-reactive protein, a marker of systemic inflammation
and a risk factor for coronary artery disease.
Short-term sleep restriction results in myriad abnor-
mal physiologic changes, including reduced glucose
tolerance, increased blood pressure, activation of the
sympathetic nervous system, reduced leptin levels,
and increased inflammatory markers. Although the
magnitude of the physiologic changes found in these
short-term studies was modest, they provide a poten-
tial mechanism whereby long-term sleep restriction
may affect long-term health. However, the experiments
described above predominantly studied young, healthy
subjects and it is not known if similar changes would
be found in older subjects.
LONG-TERM SLEEP RESTRICTION AND MORTALITY
The adverse effects of long-term sleep restriction
have not been as well studied. Kripke et al.10 studied
more than 1.1 million men and women aged 30–102
years and found that individuals reporting <4.5 hours
per night in men and <3.5 hours in women were asso-
ciated with a 15% 6-year all-cause mortality rate.10
In addition, Wingard et al.11 in a study that included
men and women between ages 30 and 69 years found
that subjects who reported short (≤6 hours per night)
or long (≥9 hours) had an increased 9-year mortal-
ity rate when compared with persons who slept 7–8
hours per night when followed prospectively.11 The
relative risk (RR) was 1.7, and remained significant
even after adjustment for various covariates (RR=1.3
after adjustment). The study was not large enough to
Spring 2004
determine if short sleep, per se, was independently
associated with mortality.
LONG-TERM SLEEP RESTRICTION AND THE
DEVELOPMENT OF CHD AND DIABETES
Recently published data from the Nurses’ Health
Study (NHS) cohort sheds more light on the relation-
ship between sleep restriction and the development of
CHD.4 The NHS cohort was established in 1976 when
121,700 female, married registered nurses, aged 30–
55 years and residing in 11 large US states, completed
a mailed questionnaire on their medical history and
lifestyle. Follow-up questionnaires are sent to update
information every 2 years on potential risk factors and
to identify newly diagnosed cases of coronary and
other diseases.
On the 1986 questionnaire, subjects were asked
the following question: “Indicate total hours of actual
sleep in a 24-hour period.” Between 1986 and 1996
the incidence rates of CHD events were assessed in
more than 71,617 women 40–65 years of age who
answered this question and did not have a diagnosis
of cardiovascular disease in 1986. The primary end
point for this study was incident CHD events defined
as nonfatal myocardial infarction or fatal CHD.4
A total of 934 cases of CHD were recorded
during the 10-year prospective study. Women who
self-reported sleeping ≤5 hours per night had a sig-
nificantly increased risk of CHD. The age-adjusted RR
was 1.82 (95% confidence interval [CI], 1.34–2.41).
Despite adjustment for smoking status, body mass
index (BMI), alcohol consumption, physical activity,
shift work, menopausal status, depressed mood, aspi-
rin use, family history of myocardial infarction, snoring,
hypercholesterolemia, hypertension, and diabetes, the
association between sleeping less and CHD prevailed.
After adjustment for all of the aforementioned vari-
ables, the RR, although blunted, remained significant
at 1.39 (95% CI, 1.05–1.84).4
The same cohort was used to assess the relation-
ship between diabetes and sleep habits. A total of
1969 cases of diabetes were recorded over a 10-year
period (1986–1996).5 The age-adjusted RR of develop-
ing diabetes was 1.57 (95% CI, 1.28–1.92) for persons
who slept ≤5 hours a night; however, after adjusting
for shift work, hypercholesterolemia, hypertension,
smoking, snoring, exercise, alcohol use, depression,
postmenopausal hormone use, family history of dia-
betes, and BMI, the result was no longer significant
for persons who slept <5 hours a night. Much of the
reduction in RR was due to the confounding effect
of BMI. A possible explanation for the findings is
that a hormone that suppresses appetite, leptin, is
decreased in subjects who undergo short-term sleep
deprivation.12 Therefore if persons who are sleep
Progress in Cardiovascular NURSING 57
Progress in Cardiovascular NURSING (ISSN 0889-7204) is published Quarterly (March, May, July, Nov.) by CHF, Inc., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2004 by CHF, Inc. All rights reserved. No
part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission
in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial
purposes, please contact Sarah Howell at showell@lejacq.com or 203.656.1711 x106.
deprived have increased appetite they may tend to
gain weight, which would in turn contribute to the
development of diabetes.
To determine whether severity of diabetes was
associated with sleep duration, symptomatic cases of
diabetes were also analyzed. A total of 1187 symptom-
atic cases of diabetes occurred over this time period.5
The age-adjusted RR was 1.84 (95% CI, 1.43–2.35) in
persons who slept ≤5 hours a night, and this increased
risk persisted even after adjustment for BMI and other
variables (RR, 1.34; 95% CI, 1.04–1.72). There are a
number of limitations to these two studies.4,5 First,
the studies only included women, and therefore, the
results may not apply to men. Second, people may
develop sleep disturbance from undiagnosed CHD
or diabetes. In other words, abnormal sleep habits
may be a consequence of disease rather than cause
the disease (reverse causation). Third, although an
attempt was made to adjust for potential confound-
ers, the presence of residual confounding cannot be
excluded. Fourth, sleep duration was based on self-
reports rather than objective measures of sleep dura-
tion such as polysomnography.
LONG SLEEPERS
Individuals who report >8 hours of sleep are also at
risk of adverse health effects. Qureshi et al.13 studied
7884 persons older than age 31 years, of whom 8.5%
self-reported >8 hours of sleep per night. The group
that reported >8 hours sleep had an incidence of
stroke that was 50% greater than that of people sleep-
ing 6–8 hours per night. The study also attempted to
associate coronary disease with long sleep duration;
however, after adjusting for differences in age, race,
gender, education, cigarette smoking, BMI, serum
cholesterol level, systolic blood pressure, and diabetes
mellitus, the association was not significant (RR, 1.4;
95% CI, 0.9–2.2). The study was able to demonstrate
that all-cause mortality was increased in long sleepers
(RR, 1.3; 95% CI, 1.1–1.5). Also, Kripke et al.10 showed
that subjects who reported >8.5 hours of sleep per
night also had an increased mortality risk.
Data from the NHS also support a relationship
between long sleep duration and the development
of diabetes and coronary disease. The age-adjusted
RR for developing CHD in persons reporting sleeping
≤9 hours per day was 1.57 (95% CI, 1.18–2.11). The
relationship between long sleep duration and CHD
remained significant (RR, 1.37; 95% CI, 1.02–1.85)
even after adjustment for a variety of potential con-
founders. Similarly, the RR of developing diabetes was
1.47 (95% CI, 1.19–1.80) for those who slept ≥9 hours
and remained significant after adjustment for a variety
of confounders (RR, 1.29; 95% CI, 1.05–1.59).
58 Progress in Cardiovascular NURSING
The association between increased long sleep
duration and adverse health is consistent over a num-
ber of studies. The underlying mechanisms for this
association are unclear. One possible explanation is
that an unrecognized confounder could lead to poor
health and an increased need for sleep. An example
of such a confounder might be obstructive sleep
apnea. Sleep apnea is independently associated with
decreased glucose tolerance, cardiovascular disease,
and is known to cause hypersomnolence.14,15 Second,
long sleep duration may be an early symptom of dis-
ease, possibly predating its official diagnosis. Third,
long sleep duration could directly lead to poor health.
Although this hypothesis is consistent with these stud-
ies, there is no plausible biologic explanation for such
a cause-and-effect relationship.
SUMMARY
It is commonly believed that the average person
requires 7–8 hours of sleep each night. The concept of
7–8 hours of sleep is supported by several epidemio-
logic studies that indicate that this duration of sleep is
associated with the lowest mortality and morbidity.
Research demonstrates that experimentally induced
short-term sleep restriction of healthy volunteers
results in a number of adverse physiologic sequelae,
including reduced glucose tolerance, increased blood
pressure, activation of the sympathetic nervous sys-
tem, reduced leptin levels, and increased inflammatory
markers. Consistent with these physiologic studies,
epidemiologic research demonstrate that a short self-
reported sleep duration is modestly associated with
symptomatic diabetes, CHD, and mortality. Although
these findings are suggestive, further physiologic and
epidemiologic studies are needed to better define the
relationships between sleep duration and health, and
to understand the underlying pathogenic mechanisms.
Nonetheless, these studies suggest that sleep should
not be considered a luxury, but instead one of the pil-
lars of a healthful lifestyle.
Long sleep duration is also associated with an
increased risk of long-term health effects. The reasons
for this association are currently unclear. Potentially,
future studies that better define these participants
from a physiologic and biochemical perspective could
lead to a logical explanation for this increased risk.
That is, more in depth physiologic and biochemical
assessment of long sleepers using polysomnography
to measure objective sleep duration and indices of
sleep fragmentation (respiratory disturbance index,
arousal index), and biochemical markers (C-reactive
protein, leptin levels) could allow us to understand bet-
ter why long sleepers are at increased risk of adverse
health outcomes.
Spring 2004
Progress in Cardiovascular NURSING (ISSN 0889-7204) is published Quarterly (March, May, July, Nov.) by CHF, Inc., Three Parklands Drive, Darien, CT 06820-3652. Copyright ©2004 by CHF, Inc. All rights reserved. No
part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission
in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial
purposes, please contact Sarah Howell at showell@lejacq.com or 203.656.1711 x106.

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Spring 2004 Progress in Cardiovascular NURSING 59