Bhs Masterclass Sleep

7/30/2019 Bhs Masterclass Sleep

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8th Hypertension Masterclass

Sleep Deprivation and Chronic Disease

Francesco P CappuccioMD MSc FRCP FFPH FAHA

Professor of Cardiovascular Medicine & Epidemiology

Clinical Sciences Research Institute

Warwick Medical School, Coventry, UK


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How many hours per night

do you usually sleep?

0

50

Less

than

5h

6h

7h

8h

9h

ormore

0% 0% 0%0%0%

1. Less than 5h

2. 6h

3. 7h4. 8h

5. 9h or more


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Sleep Duration Time Trends in US Adults

9.0

7.56.8

0.0

1.0

2.0

3.0

4.0

5.0

6.07.0

8.0

9.0

10.0

1910 1975 2005

Hrs per night

National Sleep Found ation. Sleep in America Poll


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Sleep duration in British Adults

(1967/2003)

Groeg er JA et al. J Sleep Res . 2004; 13:359-71

1967

2003


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How much did you score

at the ESS questionnaire?

0

50

10orle

ss

11-16

17

ormore

0% 0%0%

1. 10 or less

2. 11-163. 17 or more


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Fragmented Sleep

(Sleep Disruption)

Insufficient Sleep

(Sleep Deprivation)

Excessive Daytime Sleepiness (EDS)

Neurobehavioral

deficitscognitive/executive function

attention/concentration

Cardio-metabolicappetite regulation

high blood pressure

Increased Morbidity / Mortality

Decreased Quality of Life

Performance deficitserrors/accuracy


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Cardio-Metabolic Risk Factors

Obesity/body fat distribution

Type 2 Diabetes Mellitus

Hypertension

Total and Cause-Specific Mortality

Coronary Heart Disease

Short Sleep Duration & Chronic Diseases


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Card io-Metabol ic Risk Facto rs:

Obesity


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Obesity Epidemic and Sleep Duration

7.5

6.8

9.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

1910 1975 2005

Sleep duration in US adults

25.2

26.9

23.0

21.0

22.0

23.0

24.0

25.0

26.0

27.0

28.0

1910 1975 2005

BMI in US adults


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Short Sleep Duration and Metabolic Hormones

Taheri S et al. PLoS Med. 2004; 1:210-7

Leptin Ghrelin

-15.5%

+14.9%


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Sleep Deprivation and Appetite Regulation

-18% leptin; +28% ghrelin+24% hunger/appetite

Spieg el K et al. Ann Intern Med . 2004; 141:846-50


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Short Sleep Duration (


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Odds Ratio0.67 1 1.55 10Combined

Stranges (2008)Fogelholm (Women) (2007)Fogelholm (men) (2007)Tuomilehto (2007)

Ko (2007)Chaput (women) (2007)Chaput (men) (2007)Bjorvatn (2007)

Watari (women) (2006)Watari (men) (2006)Vahtera (2006)Moreno (2006)

Singh (2005)Gangwisch3 (2005)Gangwisch2 (2005)Gangwisch1 (2005)

Bjorkelund (2005)Hasler (2004)Cournot (2004)Kripke (2002)Shigeta (2001)Vioque (2000)

Short Sleep Duration (


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Sleep Deprivation & Obesity:Potential Mechanisms

ObesitySleepDeprivation

Patel SR et al. Obesi ty; 2008; in pres s


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-2

-1.5

-1

-0.5

0

0.5

1

1.5

2


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-0.6

-0.4

-0.2

0

0.2

0.4

0.6


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Type 2 Diabetes


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Sleep Duration and Risk ofDiabetes

The Massachusetts Male Agin g Study (n=1,139)

0

1

2

3

4

5

6

8

Hours of Sleep

RelativeRis

k

Yaggi HK et al. Diabetes Care 2006; 29:657-61

1.95(0.95-4.01)

3.12(1.53-6.37)


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Sleep Duration and Risk ofDiabetes

The Nurses Health Study (n=70,026)

0

0.5

1

1.5

2

8

Hours of Sleep

RelativeRis

k

Ay as NT et al. Diabetes Care 2003; 26:380-4

1.18(0.96-1.44)

1.29(1.05-1.59)


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Elevation of evening cortisol levels predisposing to

insulin resistance

Increase in sympathetic tone, inhibiting pancreatic

function and leading to increased glucose intolerance

Weight gain and reduction in leptin

Reduction of testosterone levels

Sleep Deprivation & Diabetes:Potential Mechanisms


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Hypertension


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Sleep duration and incident Hypertension

NHANES-I

0

0.5

1

1.5

2

2.5

9

Hours of Sleep

HazardRatio

Gangwis h J E et al. Hypertension 2006; 47:833-9

Men & Women, 32-59 years , n=3,620

1.60(1.19-2.14)


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8th Hypertension Masterclass Cappu cc io FP et al. Hypertens ion 2007:50:694-701

Sleep duration and prevalent Hypertension

The Wh itehall II Study

0.70

1.00.92

0.74

0.0

0.5

1.0

1.5

2.0

RelativeRisk

0.86 0.921.0

1.12

0.88

0.0

0.5

1.0

1.5

2.0

=9

RelativeRisk

Hours sleep

Women, n=1,567

Men, n=4,199

1.72(1.07-2.75)

P= 0.037


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8th Hypertension Masterclass Cappu cc io FP et al. Hypertens ion 2007:50:694-701

Sleep duration and incident Hypertension

The Wh itehall II Study

1.42

0.99 1.071.31

1.0

0.0

0.5

1.0

1.5

2.0

RelativeRisk

1.11

0.13

0.891.01.02

0.0

0.5

1.0

1.5

2.0

=9

RelativeRisk

Hours sleep

Women, n=1,005

Men, n=2,686


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8th Hypertension Masterclass Stranges S et al. 2008; (und er review)

Sleep duration and prevalent Hypertension

The Western New Yo rk Health Study

0.69

1.0

0.0

0.5

1.0

1.5

2.0

RelativeRisk

1.01.39

0.88

0.0

0.5

1.0

1.5

2.0

RelativeRisk

Hours sleep

Women, n=1,710

Men, n=1,317

1.61(1.08-2.41)

8


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Increased BP load resulting from prolongation of higher BP

whilst awake

Truncation of the BP dip during sleep Prolonged activation of sympathetic nervous system

Increased renal sodium retention

Gender-specific effects? Confounding?

Sleep Deprivation & Hypertension:Potential Mechanisms


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Total and cause-spec if ic mortali ty


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8th Hypertension Masterclass Krip ke DF et al. Arch Gen Psy chiatry 2002;59:131-136

The U-Shaped Association betweenSleep Duration and TotalMortality

The Cancer Prevent ion Study II

Women, n=636,095 Men , n=480,841


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All-Cause mortality by hours of sleepThe Wh itehall II Study

0

1

2

3

4

< 5h

(56 deaths)7h

(256 deaths)

8h

(87 deaths)

Hazard Ratio (95% CI)

Age-adjusted

Fully adjusted

6h

(160 deaths)

> 9h

(7 deaths)

Phase 1 (1985-88) n=9,781

0

1

2

3

4

< 5h

(29 deaths)7h

(112 deaths)

8h

(74 deaths)


Age-adjusted

Fully adjusted

6h

(61 deaths)

> 9h

(16 deaths)

Phase 3 (1991-93) n=7,729

Ferrie JE et al. Sleep 2007; 30:1659-66


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All-Cause mortality from Phase 3 by changes in

hours sleep between Phase 1 and Phase 3

0

1

2

3

4

RefIncrease from 5 or 6h

(55 deaths)

Decrease from 6, 7 or 8h

(57 deaths)

Increase from 7 or 8h

(58 deaths)


Age-adjusted

Fully adjusted



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0

1

2

3

4


(16 deaths)


(24 deaths)


(12 deaths)


Age-adjusted

Fully adjusted

CVD mortality from Phase 3 by changes in hours

sleep between Phase 1 and Phase 3



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0

1

2

3

4


(38 deaths)


(33 deaths)


(45 deaths)


Age-adjusted

Fully adjusted

Non-CVD mortality from Phase 3 by changes in

hours sleep between Phase 1 and Phase 3



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Summary

Either a decrease in sleep duration from a regular 6, 7or 8h per night or an increase from a regular 7 or 8hper night predict all-cause mortality

A decrease in sleep duration affects all-causemortality via increases in cardiovascular deaths

An increase in sleep duration affects overall mortalityvia an increase in non-cardiovascular deaths

Sleep changes over time may represent more reliablemeasures to assess the impact of sleep on health


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Coronary Heart Disease


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Coronary Heart Disease by hours of sleepThe MONICA Stud y

1.401.341.05 1.0

0.0

0.5

1.0

1.5

2.0

2.5

3.0

RelativeRisk

1.051.22

1.071.01.13

0.0

0.5

1.0

1.5

2.0

=9

Re

lativeRisk

Hours sleep

Women, n=3,388

Men , n=3,508

2.98(1.48-6.03)

Meisin ger C et al. Sleep 2007; 30:1121-27


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Coronary Heart Disease by hours of sleepThe Nurses Health Study

1.091.18

1.0

0.0

0.5

1.0

1.5

2.0

=9

Relative

Risk

Hours sleep

1.45(1.10-1.92)

Ay as NT et al. Arc h Intern Med 2003; 163:205-9

1.38(1.03-1.86)

Wom en, n=71,617


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Summary

Both short and long sleep duration may be associatedwith more detrimental effects on cardiovascular healthin women than men

The biological mechanisms underlying theseassociations are unclear

High blood pressure may represent one mechanism

linking short sleep duration with increased risk of CHD,at least in women


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Co-morbidities of sleep disorders (psychiatric/chronic conditions)

Bidirectional relationship (reverse causality/temporality?)

Confounding by other lifestyle behaviors

Sleep as marker of health status vs. risk factor

Biological plausibility

Objective assessment of sleep changes over time

Unresolved issues


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SLEEP, HEALTH & SOCIETYUniversity of Warwick Medical School

[email protected]

Leads: FP Cappuccio & E Peile

Warwic k Team: MA Miller, S Stranges, N-B Kandala, FM Taggart, C Ji, A Currie,

G Ward, A Bakewell, A Lowe, D Cooper

Col laborators:

Warwick: S Williams, D Banejee,

RCP: R Pounder

UCL : MG Marmot, E Brunner, M Kumari, M Shipley, JE Ferrie

Surrey: D-J Djik, S Archer

Harvard: C Czeisler, S Lockley, C Landrigan

Naples: P Strazzullo, G Barba

Buffa lo: JM Dorn, RP Donahue, M Trevisan

Funding: Cephalon Inc., Wingate Foundation, Whitehall II,

RDF University of Warwick, NHS Workforce


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8th Hypertension Masterclass Groeger JA et al. J Sleep Res . 2004; 13:359-71

Average sleep duration in a survey

of ~2,000 British Adults


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Co-morbidities of Sleep Disorders

Sleep diso rders Co-morb idi t ies

Insomnia Psychiatric Disorders

Sleep Apnoea Cardiopulmonary Disease

Restless Legs Syndrome Musculoskeletal Conditions

Short sleep duration (behavioural) Cancer


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Co-morbidities of Sleep Disorders

36.0

52

69

0

10

20

30

40

50

60

70

80

None 1 to 3 4 or more

Number of Medical Conditions

%S

leeppro

blems

Foley D et al. Psyc hos om Res . 2004; 56:497-502


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8th Hypertension Masterclass Gale SM et al. J Nutr 2004; 134:295-8

LACK OF SLEEP

less

more


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Objective assessment of sleep changes over time

More prospective evidence

Better understanding of determinants of sleep duration

Better control for confounders/co-morbidities

Experimental evidence on biological plausibility

Need for further research


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Short sleep duration Long sleep duration

Low SES/Unhealthy lifestyle/

Poor general health statusCo-Morbidities/Elderly

Appetite dysregulation/

Impaired glucose homeostasis

CVD/Metabolic alterations

Increased morbidity/mortality/

Reduced quality of life

Inflammatory/neurovegatative/hormonal responses

Depression/Poor general health status

Putative pathways

Sleep Deprivation & Diabetes:


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Sleep Deprivation & Diabetes:Potential Mechanisms

Diabetes

Acute sleep

deprivationChronic sleep

deprivation

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