Social Science & Medicine 71 (2010) 1027e1036

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Short and long sleep are positively associated with obesity, diabetes,
hypertension, and cardiovascular disease among adults in the United States
Orfeu M. Buxton a,1, *, Enrico Marcelli b,1
a
b

Brigham and Womens Hospital, Department of Medicine, Harvard Medical School, Division of Sleep Medicine, BLI-438, 221 Longwood Avenue, Boston, MA 02115, United States
Department of Sociology and Center for Behavioral and Community Health Studies (BACH), San Diego State University, San Diego, CA, United States

a r t i c l e i n f o

a b s t r a c t

Article history:
Available online 16 June 2010

Research associates short (and to a lesser extent long) sleep duration with obesity, diabetes, and
cardiovascular disease; and although 7e8 h of sleep seems to confer the least health risk, these ndings
are often based on non-representative data. We hypothesize that short sleep (<7 h) and long sleep (>8 h)
are positively associated with the risk of obesity, diabetes, hypertension, and cardiovascular disease; and
analyze 2004e2005 US National Health Interview Survey data (n 56,507 observations, adults 18e85)
to test this. We employ multilevel logistic regression, simultaneously controlling for individual characteristics (e.g., ethnoracial group, gender, age, education), other health behaviors (e.g., exercise, smoking),
family environment (e.g., income, size, education) and geographic context (e.g., census region). Our
model correctly classied at least 76% of adults on each of the outcomes studied, and sleep duration was
frequently more strongly associated with these health risks than other covariates. These ndings suggest
a 7e8 h sleep duration directly and indirectly reduces chronic disease risk.
2010 Elsevier Ltd. All rights reserved.

Keywords:
USA
Body weight
Cardiovascular diseases
Diabetes
Hypertension
Metabolism
Obesity
Sleep disorders
Sleep duration
Sociogeographic
Social ecological model

The proportion of overweight and obese adults in the US has been

increasing for decades, with nearly two-thirds now overweight or
obese. Obesity predicts a broad range of health risks, including
diabetes, hypertension, cardiovascular disease (CVD), early mortality,
and lower quality of life (Ogden et al., 2006; Ogden, Yanovski, Carroll,
& Flegal, 2007). As actual causes of death, obesity, diabetes, hypertension, and CVD (McGinnis & Foege, 1993) are critical federal
research and public health priorities (U.S. Department of Health and
Human Services, 2000a: pp. B18-1eB18-17; U.S. Department of
Health and Human Services, 2000b: pp. B19-1eB19-42).
In addition to individual characteristics (e.g., age), a variety of
risk factors affecting obesity, diabetes, hypertension, and CVD have
been identied, including individual behaviors (e.g., diet, exercise,
smoking); access to insurance and care; and physical, economic,
and social environment (e.g., physical context, demographic
composition). For example, lower socioeconomic status has been
estimated to be associated with lower levels of treatment and

Abbreviation: Body mass index, BMI; Cardiovascular disease, CVD; Coronary

heart disease, CHD; C-reactive protein, CRP; High blood pressure, HBP; National
Health Interview Survey, NHIS
* Corresponding author. Tel.: 1 6175079177.
E-mail address: orfeu_buxton@hms.harvard.edu (O.M. Buxton).
1
Both authors contributed equally to this paper.
0277-9536/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2010.05.041

a higher prevalence of chronic disease morbidity/mortality

(Uchino, Cacioppo, & Kiecolt-Glaser, 1996). Far more limited
information supports the inuence of sociodemographic factors on
sleep duration (Hale, Peppard, & Young, 2007) and sleep disorders,
or on how these in turn are associated with or inuence health
outcomes (Bliwise, King, Harris, & Haskell, 1992; Patel, 2007).
Sleep duration and quality may contribute to the increasing incidence of chronic disease. The average sleep duration of US adults
appears to have fallen to nearly 7 h per night (Hale, 2005; Hale et al.,
2007; National Sleep Foundation, 2003; National Sleep Foundation,
2005; National Sleep Foundation, 2006; Roffwarg, Muzio, &
Dement, 1966). Insufcient sleep duration has been linked to
elevated body mass index (Hasler et al., 2004; Kohatsu et al., 2006),
weight gain (Patel et al., 2004; Patel & Hu, 2008), obesity (Cizza,
Skarulis, & Mignot, 2005; Gangwisch, Malaspina, Boden-Albala, &
Heymseld, 2005; Taheri, Lin, Austin, Young, & Mignot, 2004;
Vioque, Torres, & Quiles, 2000), metabolic dysfunction (Karlsson,
Knutsson, Lindahl, & Alfredsson, 2003), and diabetes mellitus (Ayas
et al., 2003; Gottlieb et al., 2005; Hayashino et al., 2007; Knutson,
Ryden, Mander, & Van Cauter, 2006; Mallon, Broman, & Hetta,
2005; Yaggi, Araujo, & McKinlay, 2006). Modulations of cardiovascular function by sleep duration have been demonstrated for elevations of blood pressure (Lusardi et al., 1999); (Meier-Ewert et al.,
2004), consistent with observed associations of sleep duration with
blood pressure (Gottlieb et al., 2006; Meier-Ewert et al., 2004; Sakata

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O.M. Buxton, E. Marcelli / Social Science & Medicine 71 (2010) 1027e1036

et al., 2003) and CVD (Wingard & Berkman, 1983). And short sleep
duration is associated with premature mortality (Dew et al., 2003;
Kripke, Garnkel, Wingard, Klauber, & Marler, 2002; Mallon,
Broman, & Hetta, 2002; Patel et al., 2004; Wingard & Berkman, 1983).
Although seven-to-eight-hour sleep duration is generally
associated with the least health risk, results typically are based on
non-representative samples. Epidemiologic studies associate short
sleep with obesity and diabetes [reviewed in (Knutson & Van
Cauter, 2008; Spiegel, Knutson, Leproult, Tasali, & Van Cauter,
2005)], consistent with the results of laboratory studies of sleep
restriction or disruption (Spiegel, Leproult, LHermite-Balriaux,
et al., 2004; Spiegel, Leproult, & Van Cauter, 1999; Tasali, Leproult,
Ehrmann, & Van Cauter, 2008). Datasets with a sufcient number
of observations of long-sleeping individuals generally nd an
elevated risk of disease or mortality, with socioeconomic status as
a strong correlate, leading to the notion that too much sleep is also
a health risk (Patel, 2007). The US National Health and Nutrition
Examination Survey (NHANES) I national cohort follow-up data
from the early 1990s revealed an association of long sleep duration
with stroke and coronary heart disease (Qureshi, Giles, Croft, &
Bliwise, 1997) and a cross-sectional association of short sleep
duration with increased obesity (Gangwisch et al., 2005). There is
a compelling need to identify the long-term risks to human health
involving sleep or sleep disorders (Institute of Medicine, 2006).
We test the hypothesis that both short (<6 h) and long (>9 h)
self-reported sleep duration are positively associated with risk of
chronic diseases, obesity, diabetes, hypertension, and CVD using
a multilevel logistic regression approach inuenced by developments
in social epidemiology (Berkman, 2000; Committee on Assessing
Interactions among Social, Behavioral, and Genetic Factors in Health,
2006; Evans & Stoddart, 1990; Marcelli & Heer, 1997; Studenmund,
2006: pp. 449e451) that controls for other individual characteristics, health behaviors other than sleep, health insurance coverage,
family environment, and geographic context.
Methods
Source of data
We merged the Person, Adult Sample, Household, and Family
les of the 2004e2005 US National Health Interview Survey (NHIS:
http://www.cdc.gov/nchs/nhis.htm) at the individual level to
estimate the association between short or long sleep and obesity,
diabetes (type 2), high blood pressure (HBP), or CVD among US
residents aged 18e85. Data were collected by approximately 400
interviewers using standard computer-assisted personal interviewing (CAPI) procedures. Although the NHIS attempts to collect
data from all adult members of each randomly selected household
as part of the Family Core component, only one adult per family is
randomly selected for the Sample Adult questionnaire. This adult
responds directly unless he or she is physically or mentally
incapable, in which case a knowledgeable proxy is permitted to
answer (National Center for Health Statistics, 2006).
Of the 71,287 adults in the Person File in 2004, 31,263 remained
after merging with Adult Sample les. Of the 68,299 adults
included in the 2005 Person File, 31,383 remained, providing a total
initial sample size of 62,646. After dropping all observations for
those who did not provide a valid response for any variables in our
analysis (Table 1), our nal sample (56,507) is weighted using
NHIS-provided person-level sample weights.
Statistical methods
Consistent with a multifactorial, multilevel model of health
(Evans & Stoddart, 1990), and building on recent work on the

demography of sleep by Hale and colleagues (Hale, 2005; Hale

et al., 2007), we control for factors grouped into four analytical
categories e (1) individual sociodemographic and economic
characteristics (i.e., age, gender, ethnoracial group, nativity, marital
status, educational attainment, labor force participation, health
insurance coverage as a measure of medical care access); (2)
individual behaviors (i.e., smoking, alcohol consumption, vigorous
exercise); (3) individual health conditions (i.e., psychological
distress); and (4) extra-individual family and regional context (i.e.,
college-educated family member; census region). Inclusion of
a variable for whether a family member has been graduated from
college is included because research has shown that family environment can profoundly inuence health and socioeconomic
behavior, and consequently long-term health. While such an
approach does not investigate the within- and between-group
variable interactions likely to inuence our four health outcomes, it
does permit analysis of a random sample of the entire non-institutionalized U.S. adult civilian population to estimate the marginal
association of sleep on important chronic diseases. Although we
estimated how current smoking and moderate exercise were
associated with our four health outcomes, these are not included in
our nal models because they were not statistically signicant at
the 90 percent condence level, and alternative measures for these
health behaviors were signicant and included (e.g., vigorous
leisure-time physical activity, being a former smoker). Table 1 lists
the denitions, means, and standard deviations of all variables
included in the models. Importantly, although climate and other
place-based factors vary widely by geography and inuence the
four outcomes we study in this article, the NHIS data only provide
regional-level identiers. We control for these rather large aggregated areas in our models, but recognize that it would be better to
have lower-level geographic identiers.
We employ logistic regression to estimate whether respondents
answers to the following question e On average, how many hours
of sleep do you get in a 24-h period? ewere associated with having
been obese, diabetic, or having had HBP or CVD. We created three
categorical variables from the sleep variable, enabling us to
examine whether those who sleep less or more than is conventionally considered healthy were likely to have one of the four
health outcomes. Obesity is dened as a body mass index (BMI)
30 kg/m2. Our remaining three outcome variables are also
dichotomous and dened by respondents answers to the question
Have you EVER been told by a doctor or other health professional
that you had diabetes; HBP; or CVD (including coronary heart
disease (CHD), angina, heart attack, stroke or other heart condition)? The list of variables for each of our models included
comorbidity factors incrementally, such that the diabetes model
included obesity, the HBP model included obesity and diabetes, and
the CVD model included obesity, diabetes, and HBP.
We estimated how short sleep (<7 h/night) and long sleep (>8
h/night) were associated with each health outcome, employing
a sociogeographic model to incorporate potentially important
social and behavioral components often overlooked in more
traditional clinically-focused notions of cardiometabolic disorders.
Since responses were in integers only, comparisons of short and
long sleep are made to self-reported seven or 8 h of sleep per night.
Regression results are displayed in two ways. First, they are
reported together in four separate columns and in conventional
summary format as estimated parameter coefcients (Table 2).
Second, we transformed each regression coefcient into a change in
the probability of an outcome equaling one as the result of a oneunit change in an explanatory variable for each of our four
outcomes separately (Figs. 1e4). Each lled bar in these gures
represents an estimated relationship between an explanatory and
outcome variable that is statistically signicant at the noted level

O.M. Buxton, E. Marcelli / Social Science & Medicine 71 (2010) 1027e1036

1029

Table 1
Descriptive Statistics, 2004e2005 National Health Interview Survey, USA

Variable denition
Health outcome
OBESE
Dummy 1 if BMI) >30
BMI
Height-adjusted body mass index kg/m2
DIABETES
Dummy 1 if told by a doctor that (s)he has diabetes
HBP
Dummy 1 if told by a doctor that (s)he has hypertension
CVD
Dummy 1 if told by a doctor that (s)he has cardiovascular disease
Demographic/risk factor
AGE
Subjects age in years since birth
AGESQ
Subjects age in years since birth, sqaured
MALE
Dummy 1 if subject is male
LATINO
Dummy 1 if subject's ethno-racial group Latino (of any race)
ASIAN
Dummy 1 if subjects ethno-racial group Asian
BLACK
Dummy 1 if subjects ethno-racial group African American or black
WHITE
Dummy 1 if subjects ethno-racial group white
OTHERG
Dummy 1 if subjects ethno-racial group another or multiple race
FOREIGNBORN
Dummy 1 if subject was born outside of the USA
MARRIED
Dummy 1 if subject is married
NOHIGHSCH
Dummy 1 if subject did not graduate from high school
HIGHSCH
Dummy 1 if subject graduated from high school or earned GED
COLLEGE
Dummy 1 if subject graduated from college
INLABFORCE
Dummy 1 if subject is employed or actively seeking work
Health behavior/characteristic
Dummy 1 if subject is covered by a private health insurance plan
PRIVINSR
PUBINSR
Dummy 1 if subject is covered by a public health insurance plan
NOINSR
Dummy 1 if subject is not covered by a health insurance plan
PASTSMKR
Dummy 1 if subject ever smoked >100 cigarettes & currently does not smoke
DRNKSPWK
Average number of alcoholic drinks consumed per week during previous year
EXERVGPWK
Number of times subject engaged in vigorous leisure-time physical acitivty each week
SLEEPLT7
Dummy 1 if average amount of sleep in a 24-our period < 7 h
SLEEP7_8
Dummy 1 if average amount of sleep in a 24-our period 7 or 8 h
SLEEPGT8
Dummy 1 if average amount of sleep in a 24-our period > 8 h
DISTRESS
Dummy 1 if Kessler 6-item, 24-point index > 13
Family environment
F_NOHIGHSCH
Dummy 1 if adult family member with the most education was not a high school graduate
F_HIGHSCH
Dummy 1 if adult family member with the most education was a high school graduate
F_COLLEGE
Dummy 1 if adult family member with the most education was a college graduate
F_HOMEOWN
Dummy 1 if family member owns home in which subject resides
Region/period
WEST
Dummy 1 if subject resided in a western state
MIDWEST
Dummy 1 if subject resided in a mid-western state
NORTHEAST
Dummy 1 if subject resided in a northeastern state
SOUTH
Dummy 1 if subject resided in a southern state
OBS2004
Dummy 1 if observation In 2004 National Health Interview Survey (NHIS) data
OBS2005
Dummy 1 if observation in 2005 National Health Interview Survey (NHIS) data

SD
e

24.3%
27.2
7.3%
25.2%
12.8%

e
e
e

45
2357
48.8%
12.5%
3.6%
10.9%
71.4%
1.6%
14.6%
57.7%
16.3%
57.9%
25.9%
68.4%

17
1736
e
e
e
e
e
e
e
e
e
e
e
e

69.2%
14.5%
16.3%
21.6%
2.7
1.4
28.6%
62.8%
8.6%
3.8%

e
e
e
e

5.9

Min
0
9.9
0
0
0

Max
1
88.6
1
1
1

18
324
0
0
0
0
0
0
0
0
0
0
0
0

85
7225
1
1
1
1
1
1
1
1
1
1
1
1

e
e
e
e

0
0
0
0
0
0
0
0
0
0

1
1
1
1
297
28
1
1
1
1

9.3%
55.0%
35.7%
71.3%

e
e
e
e

0
0
0
0

1
1
1
1

21.1%
24.6%
18.3%
36.0%
49.6%
50.4%

e
e
e
e
e
e

0
0
0
0
0
0

1
1
1
1
1
1

9.2
2.6

Note: Merged 2004 and 2005 Person, Adult Household and Family National Health Interview Survey (NHIS) data (N 56,507).

(see Table 2), and each empty bar represents an association that is
not statistically signicant at this level. We report parameter
coefcients rather than odds ratios in Table 2, and probabilistic
changes in Figs. 1e4, for two straightforward reasons. First,
reporting parameter coefcients permits one to show the sign of
the estimated association between each explanatory variable and
the dummy dependent variable explicitly rather than inferring it
from whether an odds ratio is greater or less than one. Second,
regardless of whether mathematically identical odds ratios or
parameter coefcients are reported, researchers eventually employ
the language of probability, and there are three well-known
methods for converting coefcients into probabilities (Liao, 1994;
Pampel, 2000; Petersen, 1985, Studenmund, 2006: pp. 449e451).
Detailed signicance levels for each explanatory variable, however,
are provided in Table 2, and were estimated using robust standard
errors (Huber, 1967: pp. 221e233).
Results
Approximately one-fourth (24.3%) of all adults who were 18-to85 years old in the United States in 2004 or 2005 according to NHIS
data are estimated to have been obese, and mean body mass index

was 27.2 kg/m2 (Table 1). A similar proportion (25.2%) are estimated
to have been told by a doctor that they had high blood pressure,
about 13% had been told they had a cardiovascular disease, and
seven percent had been told they had diabetes. The mean age of all
adults was 45 years, almost half were male (49%), and fully 71%
were non-Latino white. Latinos represented 12.5% of the sample,
non-Latino blacks represented 11%, and relatively small proportions were either non-Latino Asian (3.6%) or other (1.6%). Similar
proportions of U.S. adults were married or had been graduated
from high school (58%), and 26% had earned at least an undergraduate college degree. Most (68.4%) were either employed or
actively seeking work.
Results concerning health behaviors and characteristics show
that most (69.2%) adults were covered by a private health insurance
plan, and only 16% did not have insurance. Most importantly for
purposes of the current study, more than a fourth (28.6%) reported
sleeping less than 7 h nightly, and slightly fewer than one in ten
(8.6%) reported sleeping more than 8 h nightly. Only 3.8% are
estimated to have been experiencing serious psychological distress
as measured by the well-known K-6 scale.
Two family-level constructs e highest level of education
attained by a family member and homeownership e help us assess

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O.M. Buxton, E. Marcelli / Social Science & Medicine 71 (2010) 1027e1036

Table 2
Logistic regression results for obesity, diabetes, high blood pressure, and cardiovascular disease (using Robust Standard Errors)
OBESE

DIABETES
RSE

HBP
RSE

CVD
RSE

RSE

Demographic/risk factor
AGE
AGESQ
MALE
LATINO
ASIAN
BLACK
OTHERG
FOREIGNBORN
MARRIED
HIGHSCH
COLLEGE
INLABFORCE

0.107
0.001
0.092
0.381
0.780
0.428
0.492
0.595
0.065
0.081
0.348
0.081

(0.008)a
(0.000)a
(0.038)b
(0.076)a
(0.233)a
(0.038)a
(0.063)a
(0.066)a
(0.024)a
(0.024)a
(0.068)a
(0.040)b

0.184
0.001
0.356
0.421
0.688
0.407
0.423
0.044
0.053
0.081
0.094
0.542

(0.014)a
(0.000)a
(0.033)a
(0.096)a
(0.090)a
(0.074)a
(0.057)a
(0.107)
(0.054)
(0.027)a
(0.125)
(0.059)a

0.114
0.001
0.034
0.112
0.364
0.409
0.185
0.241
0.053
0.095
0.142
0.227

(0.003)a
(0.000)a
(0.044)
(0.025)a
(0.079)a
(0.022)a
(0.064)a
(0.085)a
(0.026)b
(0.033)a
(0.049)a
(0.035)a

0.035
0.000
0.187
0.435
0.398
0.416
0.042
0.349
0.066
0.110
0.241
0.472

(0.008)a
(0.000)
(0.055)a
(0.034)a
(0.199)b
(0.022)a
(0.177)
(0.051)a
(0.024)a
(0.079)
(0.099)b
(0.053)a

Health behavior/characteristic
PRIVINSR
PUBINSR
PASTSMKR
DRNKSPWK
EXERVGPWK
3LEEPLT7
SLEEPGT8
DISTRESS
BMI
DIEABETES
HBP

0.020
0.148
0.224
0.009
0.058
0.322
0.136
0.291
e
e
e

(0.034)
(0.063)b
(0.019)a
(0.001)a
(0.008)a
(0.056)a
(0.036)a
(0.060)a
e
e
e

0.171
0.307
0.126
0.040
0.032
0.103
0.314
0.411
0.099
e
e

(0.109)
(0.110)a
(0.045)a
(0.008)a
(0.006)a
(0.042)b
(0.059)a
(0.142)a
(0.002)a
e
e

0.222
0.320
0.088
0.007
0.024
0.216
0.098
0.396
0.088
0.960
e

(0.059)a
(0.046)a
(0.033)a
(0.001)a
(0.003)a
(0.039)a
(0.037)a
(0.059)a
(0.003)a
(0.020)a
e

0.073
0.287
0.299
0.004
0.021
0.229
0.255
0.644
0.004
0.531
0.805

(0.048)
(0.041)a
(0.033)a
(0.003)
(0.011)b
(0.035)a
(0.034)a
(0.089)a
(0.002)c
(0.021)a
(0.039)a

Family environment
F_COLLEGE
F_HOMEOWN

0.249
0.054

(0.046)a
(0.012)a

0.152
0.116

(0.109)
(0.025)a

0.134
0.027

(0.029)a
(0.030)

0.047
0.233

(0.050)
(0.034)a

Region/period
WEST
MIDWEST
NORTHEAST
OBS2005

0.094
0.045
0.071
0.069

(0.012)a
(0.010)a
(0.008)a
(0.035)c

0.278
0.028
0.211
0.072

(0.022)a
(0.014)b
(0.008)a
(0.027)a

0.137
0.078
0.168
0.005

(0.014)a
(0.004)a
(0.011)a
(0.018)

0.053
0.014
0.054
0.014

(0.019)a
(0.005)a
(0.007)a
(0.040)

INTERCEPT

3.372

(0.205)a

11.132

(0.376)a

7.705

(0.084)a

3.940

(0.279)a

N (Weighted)
Percent Concordant Pairs

195,579,249
75.7%

195,579,249
92.7%

195,579,249
79.5%

195,579,249
87.6%

Note: Merged 2004 and 2005 Person, Adult, Household and Family National Health Interview Survey (NHIS) data (N 56,507). Logistic regression results with robust standard
errors (RSE) statistically signicant at the two-tailed p < 0.01 (a), p < 0.05 (b) or p < 0.10 (c) test level.

whether family environment may have inuenced the probability

of an individual having been obese, or having had diabetes, high
blood pressure or cardiovascular disease. Table 1 shows that
slightly more than one-third (35.7%) of all adults had a family
member who had earned a college degree, and more than half
(55%) had a family member who had graduated from high school.
Only about nine (9.3)% did not have a family member who had
either graduated from high school or college. A majority (71.3%),
however, resided in a home which someone in the family owned.
While more than one in ve of all adult residents lived in
a Western (21.1%) or mid-Western (24.6%) state, a plurality resided
in the South (36%) and fewer than one in ve resided in the
Northeast. Lastly, our sample is split evenly between 2004 (49.6%)
and 2005 (50.4%).
Measuring overall t of a logit model is not as straightforward as
is the case when performing conventional ordinary least squares
(OLS) regression analysis. Percent concordant pairs e that is, the
proportion of observations in a sample that a logit regression
equation explains correctly e is a standard method for characterizing how robustly a logit model explains variation in a dichotomous (dummy) dependent variable such as those we investigate
in this paper (Marcelli & Heer, 1997; Studenmund, 2006: pp.

449e451). Our models correctly classied respondents on each of

the four outcomes as follows: the percent concordant pairs for
obesity was 75.7%, for diabetes it was 92.7%, for HBP it was 79.5%,
and for CVD it was 87.6%. These overall model t statistics, as well
as those for individual explanatory variables, are reported in
Table 2, but below we will focus our discussion on their probabilistic interpretation (Figs. 1e4).
Obesity
The relative (normalized) probability of having been obese
associated with a one-unit change in each explanatory variable is
depicted in Fig. 1. As can be seen, all but one variable (having had
private insurance) were statistically signicant, and most were at
the 99 percent condence level (p < 0.01). Table 2 reports signicance levels for all explanatory variables. Respondents surveyed in
2005 had a slightly higher probability of having been obese than
those in 2004, reecting the secular trend of increasing obesity rates.
Both short (6%) and long sleep (3%) duration were signicantly
associated with obesity, relative to sleeping seven to 8 h. Residing in
the northeast or west was associated with a one and two percent
lower probability of having been obese, and residing in the Midwest

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1031

Probability of obesity
-15%

less likely <--5%

--> more likely

5%

15%

25%

35%

live in the west

live in the northeast

Census Region

live in the midwest

family member w/college education
Family
Environment

family own home

married

Time Control

2005 survey (vs 2004)

asian
foreign-born
age
male
Individual-level
Characteristics

psychological distress
latino
black
other ethnoracial group
college education
labor force participant
high school education (no college)

Individual-level
factors (other)

private health insurance

public health insurance
regular vigorous exercise
number of drinks/week

Individual
Health
Behaviors

long sleep duration >8 hours/night

former smoker
short sleep duration <7 hours/night

Fig. 1. Logistic Regression of Having Been Obese among Adults on Geographic and Family Environment factors, Individual Characteristics and Behaviors, and Individual Health
Behaviors, United States, 2004e2005 (NHIS). Obesity is dened by a Body Mass Index > 30 kg/m2. Probability estimates are normalized to the same scale by converting beta
coefcients to probabilities (see Methods). All statistically signicant factors (p < 0.05) are shown, and depicted by lled bars. The Control of 2005 Survey (vs 2004) had p < 0.10. The
variable AGESQ was associated with a 34.2% probability, or a lesser probability of obesity.

was associated with a 2% higher probability of having been obese

than residing in the southern census region. Among family-level
factors, having a college-educated family member was associated
with a 5% lower probability of obesity. Being married was positively
associated with obesity (augmenting the probability of obesity by
nearly 2% relative to single status). Relatively exogenous individuallevel characteristics were strongly associated with the probability of
obesity; Asian heritage (relative to non-Latino white) and foreignborn status (relative to US-born) conferred a 14% and 11% relative
reduction in the probability of obesity, respectively. Age was associated with a one percent increase per year in the probability of
obesity, on average, but it is important to note that age is top-coded
at 85 years. Compared with females, males had a 1% greater probability of obesity. Exhibiting psychological distress was associated
with a 5% greater probability of being obese. Of other individuallevel factors, having a college or high school education was associated with a nearly 5% or 2% lower probability of being obese
(respectively) compared with not having graduated from high
school. Public health insurance coverage was associated with a 3%
increased probability of being obese compared with having no
insurance, and as noted above access to private insurance was not
signicant.
Of individual health behaviors, regular vigorous exercise was
associated with a 2% reduction in the probability of obesity. Associations with alcohol consumption were statistically signicant but
nearly zero. Being a former smoker was associated with a 4%
increase in the probability of obesity, and being a current smoker
was an insignicant factor, relative to nonsmoker, in all of our
models. We therefore excluded the latter smoking metric from our
nal models.

Diabetes
Fig. 2 depicts estimated associations between each explanatory
variable in our model and the probability of a diagnosis of type 2
diabetes. The model is identical to the obesity model, except that
BMI is included. And once again we show all estimated probabilistic
associations: empty bars indicate those that are estimated to be
statistically insignicant at the p < 0.10 level, and all lled bars
except that concerning having resided in a mid-Western state
(MIDWEST, p < 0.05) are signicant at the 99 percent condence
level (p < 0.01). It is important to emphasize that both short and
long sleep were adversely and strongly associated with obesity, and
that this e in addition to the relatively large direct independent
effect sleep is estimated to have on diabetes (reported below) e
represents an potential indirect effect of sleep on being diagnosed
with diabetes. Respondents surveyed in 2005 were more likely to
have had diabetes than respondents in 2004, reecting the secular
trend of increasing rates of diabetes diagnosis (0.5%), independent
of all other variables. Relative to the obesity model, several significant factors became insignicant in the diabetes model (having e
or having a family member with e a college education, being
currently married, and being foreign-born). In addition, the inuence of individual factors is generally reduced, and two factors
change direction (living in the Midwest from positive to negative
association, and Asian heritage from strong negative to positive
association). Both short and long sleeping are positively associated
with the probability of a diabetes diagnosis.
In general, it also appears that residing in a state that is not in
the South is associated with a reduced probability of having had
diabetes (2%, 1%, and <1%, respectively). Of the family environment

O.M. Buxton, E. Marcelli / Social Science & Medicine 71 (2010) 1027e1036

1032

Probability of diabetes
less likely <-- --> more likely
-15%

-5%

5%

15%

25%

35%

live in the west

live in the northeast

Census Region

live in the midwest

family member w/college education
family own home
married

Family
Environment
Time Control

2005 survey (vs 2004)

BMI
asian
foreign-born
age
male
psychological distress

Individual
Characteristics

latino
black
other ethnoracial group
college education
laborforce participant
high school education (not college)

Individual-level
factors (other)

public insurance
regular vigorous exercise
number of drinks/week
long sleep duration >8 hours/night
former smoker

Individual
Health
Behaviors

short sleep duration <7 hours/night

Fig. 2. Logistic Regression of Having Diabetes among Adults on Geographic and Family Environment factors, Individual Characteristics and Behaviors, and Individual Health
Behaviors, United States, 2004e2005 (NHIS). Diabetes dened from respondent self-report of a physician diagnosis. Probability estimates are normalized to the same scale by
converting beta coefcients to probabilities (see Methods). All statistically signicant factors (p < 0.05) are shown, and depicted by lled bars; open symbols represent nonsignicant variables retained from earlier models for comparison. The variable AGESQ was associated with a 14.7% probability, or a lesser probability of obesity.

factors, only someone in the respondents family owning a home

was associated with a reduced probability of having had diabetes.
Individual characteristics were most strongly associated with
increased probability of having diabetes: Latino and non-Latino
Asian, black, and other (Native American) ethnoracial groups were
more likely to have had diabetes (5%, 3%, 3%, and 3%, respectively)
than non-Latino whites.
Age was associated with a slightly higher probability of having
diabetes (<1%). Males were 2% more likely than females to have
diabetes. Of the other individual-level factors, labor force participation and high school education were negatively associated with
the probability of having diabetes (4% and 0.5%, respectively),
whereas access to public insurance was positively associated with
the probability of diabetes (2%) and private insurance was insignicant). Of the individual health behaviors, the amount of exercise
per week and number of alcohol drinks per week were positively
associated with a reduced likelihood of diabetes, though magnitude
was small (0.2%, 0.1%). Former smoker status, long sleep duration,
and short sleep duration were signicantly associated with an
increased probability of diabetes (2%, 1% and 1%, respectively).
High blood pressure
Fig. 3 depicts all estimated associations between all explanatory
variables and the probability of a having received an HBP diagnosis.
All lled bars are signicant at the p < 0.01 level except that
reported for having been married (p < 0.05). In this model, there
was no appreciable change from 2004 to 2005 surveys in the
probability of HBP, independent of other factors. The highest

likelihood of HBP (11%) was conferred by a diabetes diagnosis. As in

the obesity model, the effects on risk of HBP of both short and long
sleep were statistically signicant relative to sleeping 7e8 h and
had the largest positive associations of Individual Health Behaviors
(2.4%, 1.1%, respectively).
As was the case with diabetes, residing outside of the South, was
associated with a reduced probability of having HBP (1.9%, 1.5%,
0.9%, respectively). Of the family environment-level factors,
residing in a family-owned home and having a family member with
a college education were associated with a reduced probability of
HBP. Among individual characteristics, being foreign-born was
associated with a 2.7% lower probability of having HBP than being
native-born. Ethnoracial groups exhibited some changes in relative
risks compared with the obesity and diabetes model. Latinos were
less likely to have HBP (1.3%) than black, Asian, and Other (e.g.,
Native American) ethnoracial groups, who had a greater likelihood
of HBP (4.6%, 4.1%, 2.1%, respectively) than non-Latino whites.
Psychological distress was also associated with an increased
likelihood of HBP (4.4%), as was age (0.4%/year). Of the other
individual-level factors, labor force participation and having
attended college or at least high school reduced the likelihood of
HBP. Obesity derived from BMI was slightly positively associated
with HBP. Access to private or public health insurance conferred an
elevated risk of HBP. Diabetes diagnosis was strongly associated
with an HBP diagnosis (10.7%).
Among individual health behaviors, greater regular vigorous
exercise was associated with only a slightly reduced risk of HBP;
and former smoker status was associated with an increased
probability.

O.M. Buxton, E. Marcelli / Social Science & Medicine 71 (2010) 1027e1036

1033

Probability of high blood pressure

less likely <-- --> more likely

-5%

0%

5%

10%

15%

20%

live in the northeast

live in the west
live in the midwest

Census Region

family member w/college education

married
family own home

Family
Environment

2005 survey (vs 2004)

Time Control

foreign-born
latino
male
age
other ethnoracial group

Individual
Characteristics

asian
psychological distress
black
labor force participant
college education
high school education (no college)
Body Mass Index (BMI)
private health insurance

Individual-level
factors (other)

public health insurance

Diabetes
regular vigorous exercise
number of drinks/week
former smoker

Individual
Health
Behaviors

long sleep duration >8 hours/night

short sleep duration <7 hours/night

Fig. 3. Logistic Regression of Having High Blood HBP among Adults on Geographic and Family Environment factors, Individual Characteristics and Behaviors, and Individual Health
Behaviors, United States, 2004e2005 (NHIS). High blood HBP dened from respondent self-report of a physician statement. Probability estimates are normalized to the same scale
by converting beta coefcients to probabilities (see Methods). All statistically signicant factors (p < 0.05) are shown, and depicted by lled bars; open symbols represent nonsignicant variables retained from earlier models for comparison). The variable AGESQ was associated with a 10.7% probability, or a lesser probability of obesity.

Cardiovascular disease
Fig. 4 depicts estimated associations with all explanatory
variables and the probability of having been diagnosed with a CVD.
The model is identical to the HBP model, except that HBP is now
included. And all lled bars are signicant at the 99% condence
level except the following four: ASIAN, COLLEGE, and EXERVGPWK
(p < 0.05), and BMI (p < 0.10). The highest likelihood of CVD was
associated with having diabetes (10%) or HBP (9%). In general, the
CVD model results were highly similar to the results for the HBP
model, except for access to private health insurance, which was not
signicant for CVD. Both short and long sleeping were independently associated with an increased probability of having a CVD
diagnosis (2.5% and 1.1%, respectively).
Discussion
In all models, compared with sleeping 7e8 h/night, both short
and long sleep were signicantly associated with the probability of
obesity, diabetes, HBP, and CVD at the 99% condence level. Our
logistic regression estimates simultaneously control for all variables
shown in Table 1 and for sample clustering at the regional level to
provide relatively conservative estimates (using robust standard
errors). However, NHIS data are cross-sectional and self-reported;
thus we are unable to estimate the extent to which sleep is inuenced by (rather than inuencing) our four health outcomes. That

said, although many individual-level characteristics and behaviors

were signicantly associated with at least some of the four
outcomes, some were not signicant in all models (open bars Figs.
1e4); short or long sleep duration were both signicant in all
models. In most cases, the relationships between short or long
sleep duration and these four outcomes were even stronger than
better-established predictors of these chronic metabolic/CVD
outcomes. Sleep duration measures were also strongly associated
with various health risks relative to family and geographic
variables. Importantly, we are not suggesting that family and spatial
variables viewed collectively are more important than all behaviors. Our estimates simply suggest that sleep has a relatively larger
association with our four health outcomes than particular variables
within other analytical categories. Finally, we observed not only
direct and independent relationships between sleep duration and
chronic disease; we also observed an indirect relationship,
for example, on CVD, in that obesity, diabetes, and HBP were
signicantly associated with CVD, and sleep was independently
associated with each. Increasing the proportion of the population
achieving 7e8 h of daily sleep may reduce chronic disease risk in US
adults, but only to the extent that reverse causation is absent.
As described in time-use studies (1965, 1975, 1985, 1999), mean
sleep duration was 7.7 h, somewhat longer than the current estimate of 7.2 h (Hale, 2005; Hale et al., 2007). Here, the prevalence of
short and long sleeping (29% and 9%, respectively; see Table 1) was
highly concordant with estimates from the above time-use diary

1034

O.M. Buxton, E. Marcelli / Social Science & Medicine 71 (2010) 1027e1036

Probability of cardiovascular disease (CVD)

less likely <-- --> more likely

-5%

0%

5%

10%

15%

20%

live in the northeast

live in the west

Census Region

live in the midwest

family member w/college education
married

Family
Environment

family own home

2005 survey (vs 2004)

Time Control

foreign-born
latino
male
age
other ethnoracial group

Individual
Characteristics

asian
`

psychological distress
black
labor force participant
college education
high school education (no college)
Body Mass Index (BMI)
private health insurance

Individual-level
factors (other)

public health insurance

High blood pressure
Diabetes
regular vigorous exercise
number of drinks/week
former smoker
long sleep duration >8 hours/night

Individual
Health
Behaviors

short sleep duration <7 hours/night

Fig. 4. Logistic Regression of Having Cardiovascular Disease among Adults on Geographic and Family Environment factors, Individual Characteristics and Behaviors, and Individual
Health Behaviors, United States, 2004e2005 (NHIS). CVD dened from respondent self-report of a physician diagnosis of cardiovascular and circulatory diseases including stroke.
Probability estimates are normalized to the same scale by converting beta coefcients to probabilities (see Methods). All statistically signicant factors (p < 0.05) are shown (family
own a home F_HOMEOWN p < 0.10), and depicted by lled bars; open symbols represent non-signicant variables retained from earlier models for comparison. The variable AGESQ
was associated with a 10.5% probability, or a lesser probability of obesity.

study [24.6% and 9.5%, respectively; (Hale, 2005; Hale et al., 2007)]
but discordant with estimates from another sample [14.4% and
23.9%, respectively; (Basner et al., 2007; Hale & Do, 2007)]. Rather
than considering short or long sleeping separately, extremes of
sleep duration may be a more useful designation of sleep-related
predictors of chronic disease. In the current analyses, short and
long sleeping are consistently associated with increased risk of
chronic disease independent of individual characteristics and
socioeconomic factors.
Multiple known obesity risk factors were identied in our study,
but how might sleep duration independently inuence body
weight? Insufcient sleep duration has been linked to higher BMI
(Hasler et al., 2004; Kohatsu et al., 2006), weight gain (Patel et al.,
2004; Patel & Hu, 2008), and obesity (Cizza et al., 2005;
Gangwisch et al., 2005; Taheri et al., 2004; Vioque et al., 2000). A
laboratory-based study in young men controlling for food intake by
means of a constant, eucaloric intravenous infusion revealed that
sleep-restricted subjects reported greater hunger and physiologic
drive for eating in the form of lower blood levels of leptin and higher
ghrelin (Spiegel, Leproult, et al., 2004). In a cross-sectional sample,
short sleep duration was similarly associated with lower leptin and
higher ghrelin levels, as well as higher BMI (Taheri et al., 2004). These
data support the hypothesis that short sleep duration may inuence
weight by increasing the drive to eat. This has been extended in
a recent clinical study in middle-aged subjects imposing 5.5 h per
night compared to 8.5 h per night of time in bed in a crossover design.

With ad libitum palatable meals, ghrelin and leptin measures of

hunger and satiety were the same in both conditions because the
subjects chose to eat on average about 200 kcal more of food in the
form of snacks, supporting a role for adequate sleep duration in the
control of eating behavior (Nedeltcheva et al., 2009).
Furthermore, physiologic changes in metabolism due to sleep
restriction in young men include alterations of glucose metabolism
and hormonal changes (Spiegel et al., 2000; Spiegel, Leproult,
LHermite-Balriaux, et al., 2004; Spiegel, Tasali, Penev, & Van
Cauter, 2004; Spiegel et al., 1999; Spiegel, Tasali, et al., 2004) that
would tend to increase the likelihood of obesity, visceral adiposity,
and diabetes in the long term. Far less is understood about the role of
long sleeping in the development of obesity, above and beyond the
impact of sleep-disordered breathing, depression, or side effects of
medication that cause both an increase in weight and sleep
duration.
Epidemiologic studies support associations between short sleep
duration (Ayas et al., 2003; Mallon et al., 2005; Yaggi et al., 2006),
long sleep duration (Yaggi et al., 2006), insomnia (Nilsson, Roost,
Engstrom, Hedblad, & Berglund, 2004), and sleep-disordered
breathing (Punjabi et al., 2004) and type 2 diabetes. Interestingly, the
causal pathway between short sleep and diabetes may involve
weight gain, as concluded by Ayas et al.: the association between
a reduced self-reported sleep duration and diabetes diagnosis could
be due to confounding by BMI, or sleep restriction may mediate its
effects on diabetes through weight gain. Sleep restriction may be an

O.M. Buxton, E. Marcelli / Social Science & Medicine 71 (2010) 1027e1036

independent risk factor for developing diabetes. (Ayas et al., 2003)

This mediation via BMI has not been detected in all cross-sectional
studies, (e.g., Yaggi et al., 2006), the relative risk of diabetes in short
sleepers (6 h/night) was not substantially modied by BMI. Laboratory studies of sleep restriction described above include changes
in glucose metabolism that increase diabetes risk. It has been
hypothesized that the relationship between sleep duration and
metabolic disorders may be related to chronic inammation
markers, as has been identied for the inammatory marker
C-reactive protein (CRP) in a laboratory study (Gottlieb et al., 2006;
Meier-Ewert et al., 2004; Sakata et al., 2003) and a cross-sectional
study (Williams, Hu, Patel, & Mantzoros, 2007). Furthermore, in
a cross-sectional study of diabetics excluding those with frequent
pain, both self-reported sleep duration and sleep quality were
related to severity of diabetes, with glycemic control indexed by
HbA1c levels (Ayas et al., 2003; Gottlieb et al., 2005; Hayashino et al.,
2007; Knutson et al., 2006; Mallon et al., 2005; Yaggi et al., 2006).
We found consistent associations between extremes of sleep
duration and both HBP and CVD (controlling for HBP). Laboratory
studies have revealed that restricting sleep duration semichronically increases resting blood pressure, CRP levels (Meier-Ewert
et al., 2004), cortisol levels (Spiegel, Leproult, LHermiteBalriaux, et al., 2004; Spiegel, Tasali, et al., 2004; Spiegel et al.,
1999; Tasali et al., 2008) and sympathetic nervous system activity
(Spiegel, Leproult, LHermite-Balriaux, et al., 2004; Spiegel et al.,
1999; Spiegel, Tasali, et al., 2004; Tasali et al., 2008). Less information is available to address the direction of causality for longer
sleep duration, independent of sleep disorders such as sleep apnea
or psychiatric disorders such as depression that have been shown
to lead to chronic disease. Consistent with ndings that familial
sources of social support appear to be related to better blood
pressure regulation (Uchino et al., 1996), we observed that several
family-level factors (e.g., college-education family member, being
married) are positively associated with the absence of HBP. Affective and anxiety disorders and chronic stress are related to CVD risk
(Rozanski, Blumenthal, & Kaplan, 1999). Lifestyle factors are
routinely addressed clinically, but psychosocial factors are less
commonly appreciated (Rozanski, Blumenthal, Davidson, Saab, &
Kubzansky, 2005). Area-level factors, socioeconomic status, and
education were associated with CVD markers (Metcalf et al., 2008),
but we noted an independent association of sleep duration and CVD
risk (Williams et al., 2007).
Sleep disorders that disrupt sleep continuity (e.g., sleep-disordered breathing) have been linked increased risk of metabolic
(Punjabi et al., 2004) and cardiovascular dysfunction (Mehra et al.,
2006) and also predict early mortality (Dew et al., 2003; Kripke
et al., 2002; Mallon et al., 2002; Patel et al., 2004; Wingard &
Berkman, 1983). Insomnia, a sleep disorder that reduces sleep
quality and duration, has been linked to insulin resistance and
glucose intolerance (Punjabi et al., 2004), diabetes (Gottlieb et al.,
2005; Hasler et al., 2004), and early mortality (Dew et al., 2003;
Sakata et al., 2003).
Because these data are self-reported and not directly measured,
it is possible that systematic bias has inuenced data on sleep
duration (Lauderdale, Knutson, Yan, Liu, & Rathouz, 2008), many of
the predictor variables, or even the presence or absence of the
chronic disease outcome. Diabetes, hypertension, and CVD may go
undiagnosed for years before frank symptoms elicit a diagnosis.
Although the percentage of concordant pairs reected the robust
predictive capacity of the variables used, uncaptured variance
remains, and more proximate measures might better explain the
probability of the outcome, particularly if those measures were
objectively assessed. For example, sleep-disordered breathing
might explain HBP or CVD better than sleep duration alone in the
long-sleeping group. Self-reported sleep duration is a limitation

1035

compared to objective measurements, recall bias is a possibility,

and responses were limited (fractions of an hour were not allowed),
which likely reduced sensitivity. No questions enabled estimation
of sleep disorders, especially sleep-disordered breathing and
insomnia, prevalent disorders that might inuence sleep duration.
The associations we observed may be evidence of reverse causality;
respondents with diabetes, cardiovascular, hypertension and
obesity may suffer from disturbed sleep that leads to either shorter
duration of sleep or longer sleep duration as a result of fragmentation of sleep (Al Delaimy, Manson, Willett, Stampfer, & Hu, 2002;
Zee & Turek, 2006). NHIS does not include dietary behaviors that
play a role in chronic disease risk.
A clear need exists for consistent and accurate sleep duration
data collection on future NHIS and other representative samplings
of population health, including adults as well as adolescents, and
sleep disorder information. Longitudinal assessment of sleep
duration and quality, in association with objectively-measured
health status, are urgent priorities for future research (Institute of
Medicine, 2006).
Acknowledgements
This work was supported by a pilot grant to both authors from
the RWJ Health & Society Program, Harvard School of Public Health.
For their assistance with the data analysis and manuscript preparation, we thank Louisa Holmes, Keith Malarick, Vanessa Castro,
and Andrea Muirhead. Relationships with corporate entities: These
relationships have no presumed overlap with this manuscript, did
not fund this work, and are not beneted by the manuscript, but are
listed in the interest of complete disclosure. These relationships
include Investigator-initiated research support from Cephalon Inc.
(>2 years ago) and Sepracor Inc. (current and within the last 24
months); an unrestricted educational grant from Takeda Pharmaceuticals (>3 years ago); Consulting fees and/or honoraria from
Dinsmore LLC (2010), Sepracor Inc.(2008 and earlier), and Takeda
Pharmaceuticals (2008 and earlier).
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