pii: sp- 00447-16
6078
COMMENTARY
Is Sleep Quality More Important than Sleep Duration for Public Health?
Commentary on Clark et al. Onset of impaired sleep and cardiovascular disease risk factors: a longitudinal study. SLEEP
2016;39(9):1709–1718.
Yu Sun Bin, PhD
Clinical and Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, Australia
In this issue of SLEEP, Clark and colleagues contribute an ex-
tremely large and well-conducted longitudinal study on the re-
lationship between poor sleep and cardiovascular risk.1 Using
three waves of data from the Finnish Public Sector Study and
linkage to electronic health records, the study authors exam-
ined if the onset of poor sleep was associated with the devel-
opment of hypertension, diabetes, and dyslipidemia in over
45,600 working-aged adults. The onset of poor sleep was the
transition to short or long sleep duration from 7–8 hours of
“normal” sleep, or the change from negligible to more than
weekly sleep disturbance over the course of 4 years. The out-
comes were based on medication reimbursements after physi-
cian confirmation of the diagnosis with the follow-up period
being up to 7 years after the onset of poor sleep.
Clark and colleagues’ comprehensive analyses showed that
the transition to short or long sleep duration was not signifi-
cantly linked to the development of hypertension, diabetes, or
dyslipidemia. The onset of sleep disturbance, however, pre-
dicted a roughly 20% risk increase for both hypertension and
dyslipidaemia, with no additional risk conferred for diabetes.
These findings for hypertension are generally consistent with
results from previous meta-analytic reviews,2,3 although the
null findings for diabetes are surprising and suggest the dia-
betes risk associated with poor sleep may be more modest than
previously estimated.4,5 Importantly, the study contributes new
data on the relationship between poor sleep and subsequent
dyslipidemia, an association for which there is much less evi-
dence. Previous longitudinal studies point to worse lipid pro-
files with short sleep duration6–8 and worse sleep quality,9 and
together with the rigorous results presented by Clark and col-
leagues, support a mechanistic chain connecting poor sleep to
subsequent cardiovascular disease via dyslipidemia.
There is much to like about the study by Clark and col-
leagues, including its ability to investigate both sleep duration
and sleep quality as health risk factors, its long follow-up, its
large sample size, and ability to control for many factors that
contribute to cardiovascular risk including smoking, physical
activity, body mass index, and existing physical and psychi-
atric conditions. By including only participants with normal
sleep durations and no sleep disturbance at the beginning of
the study, and excluding those with a history of sleep apnea,
heart disease, stroke, as well as the outcomes, the authors en-
sure that the development of poor sleep occurs before the de-
velopment of disease, thus bolstering the case for causality in
the findings.
The authors also conducted an impressive and thorough
set of sensitivity analyses, including but not limited to con-
sidering relative rather than absolute changes in sleep dura-
tion to account for individual- and age-related differences in
SLEEP, Vol. 39, No. 9, 2016
http://dx.doi.org/10.5665/sleep.
sleep need, excluding participants with preexisting use of sleep
medications, and restricting the study population to a healthy
subset without any history of chronic disease. Results from all
of these point to the robustness of the main findings: (1) that
sleep disturbance prospectively and independently predicts the
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development of hypertension and dyslipidaemia and (2) that
the quality of sleep appears a more important risk factor than
the quantity of sleep.
That sleep quality may be just as important, if not more im-
portant, than sleep duration in predicting future health is often
overlooked. Meta-analyses show the relative risk increase as-
sociated with short sleep and hypertension and diabetes to be
20% and 30%, respectively, while the same associations for
poor sleep quality range from 5% to 20% for hypertension and
upwards of 40% for diabetes, depending on how sleep distur-
bance is operationalized.5,10 Furthermore, there is very strong
evidence tying sleep quality to the development of mental dis-
orders: sleep disturbances more than double the risk of depres-
sion11 and anxiety.12–15
The conceptualisation of sleep as the distinct factors of du-
ration and quality appears to have begun in 1964 when Ham-
mond observed a relationship between sleep duration and
mortality in the first American Cancer Society Cohort.16 This
study revealed that those who had reported 7 hours sleep had
the lowest mortality after 2 years, with deaths increasing on
either side of this nadir. The study was one of the earliest, if
not the earliest, to imply that there existed an optimal sleep
duration, and that shorter and longer sleep durations were “un-
healthy.” These results appear to have driven subsequent re-
search on sleep duration and health outcomes. The study also
examined the predictive value of poor sleep quality and found
that insomnia was associated with excess mortality in men but
not women.16 However, sleep quality was largely neglected
until 1989, when Ford and Kamerow published a landmark
study demonstrating that insomnia greatly magnified the risk
of subsequent psychiatric disorders.14
As a result of this conceptual distinction, we have much
evidence connecting sleep duration to physical health out-
comes, and linking sleep quality to mental health, but know
relatively little about the impact of sleep disturbances on the
development of physical disease, or the contribution of short
and long sleep durations to mental health. It may be the case
that sleep disturbances are more important for psychological
outcomes, with sleep duration possibly playing a stronger role
for physical disorders, but this remains to be demonstrated by
further research.
The distinction between quality and duration might also
explain why population data on both sleep quality and sleep
duration are rarely available from the same source. As a
1629 Commentary—Bin
consequence, exploration of how sleep quality and sleep dura-
tion combine or interact to affect health has been limited. The
conceptual split of sleep into quality and duration appears so
well-established that even when information on both aspects
of sleep are available, it is unusual to see them considered to-
gether. To be clear this is not a criticism of the excellent study
by Clark and colleagues but a reflection of how duration and
quality are conceptualised so distinctly that we may have for-
gotten they are measures of the same underlying phenomenon.
An understanding of the role of both sleep quality and sleep
duration becomes doubly important when we are reminded
that they are inextricably linked. People with short and long
sleep durations are also those most likely to report sleep distur-
bances,17–19 with the same U-shape commonly seen for health
outcomes found in the relationship between sleep duration and
poor sleep quality. It is likely that the extremes of sleep dura-
tion capture poor sleep quality rather than objectively short or
long durations and that poor sleep quality is at least partly re-
sponsible for many of the U-shaped associations seen between
sleep duration and health risks.
A handful of studies show that the effects of sleep dura-
tion and sleep quality on health outcomes are not simply ad-
ditive,20,21 and support the case for considering both facets of
sleep where possible. Importantly, public health guidelines and
interventions for sleep duration will necessarily be based on
population norms and averages, and will not take into account
the large individual differences in sleep need. In contrast, in-
terventions to improve sleep quality may help all individuals,
albeit some to a greater degree than others.
Sleep quality and sleep duration remain valuable measures
of sleep because of their cost-effectiveness, low participant
burden, and intuitive interpretation. Re-integrating the con-
cepts of sleep quality and sleep duration to examine their in-
dependent and combined impact on health outcomes appears a
sensible and necessary step for understanding the contribution
of sleep as a whole to public health.
CITATION
Bin YS. Is sleep quality more important than sleep duration for
public health? SLEEP 2016;39(9):1629–1630.
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SUBMISSION & CORRESPONDENCE INFORMATION
Submitted for publication August, 2016
Accepted for publication August, 2016
Address correspondence to: Yu Sun Bin, Clinical and Population Perinatal
Health Research, Level 2, Building 52, Royal North Shore Hospital, Sydney,
NSW, Australia; Tel: +61 2 9462 9815; Email: yusun.bin@sydney.edu.au
DISCLOSURE STATEMENT
Dr. Bin has indicated no financial conflicts of interest.
1630 Commentary—Bin