Table 1.

Sleep and Cardiovascular Risk Factors organized by Category of Risk

First Author	Sample	Study Design	Sleep Measures	CV Risk Factors	Covariates	Results
Metabolic Syndrome and Multiple Risk Factors
IglayReger²³	37 obese U.S. adolescents, 54.1% female, ages 11–17; M =14.0 ± 0 yrs	cross- sectional	≥ 5 nights actigraphy- assessed sleep duration	MetS composite risk score	BMI, physical activity duration and intensity	↓sleep duration ↑ MetS composite risk score
Lee ²⁶	1187 Korean adolescents, 46.9% female, ages 12–18; M =15.0 ± .1 yrs	cross- sectional	self-reported sleep duration	MetS and MetS components	age, sex, household income, caloric intake, physical activity	↓sleep duration ↑BP, ↑BMI, ↑waist circumference ↓ triglycerides NS glucose, HDL-C, MetS
Azadbakht²⁴	5528 Iranian children ages 10–18; M =14.7 yrs	cross- sectional	parental report of sleep duration	BP, lipids, glucose, BMI %, physical activity	SES, family history, physical activity, BMI, age	all NS for multivariate analyses
Berentzen³⁶	1481 Dutch children ages 11–12; M =12.7 ± .4 yrs	cross- sectional	self-report time in bed on school day, sleep pattern, nighttime awakenings, trouble falling asleep, daytime sleepiness	cholesterol, HbA1c, BP	age, height, maternal education, puberty, screen time	↓ time in bed ↑ BMI, waist circumference ↑daytime sleepiness ↓HDL-C, ↑TC/HDL-C in girls only. NS boys no effects for BP, HbA1c
Rey-Lopez³⁷	699 European adolescents, 51.6% female, ages 12.5- 17.5; M =14.8 yrs	cross- sectional	self-reported sleep duration	HOMA-IR, triglycerides, TC, HDL-C, systolic BP	age, sex, SES, physical activity	all NS
Countryman²⁷	367 U.S. adolescents 27% female, 45.8% Hispanic, 30.8% Black, ages 15–17; M =16.1 ± .7 yrs	cross- sectional	latent sleep factor (composed of self-reported sleep duration over past 7 days, fatigue, & sleep quality)	latent MetS factor (composed of obesity, insulin resistance, lipids, and BP)	gender, parent education	In structural equation model, sleep was indirectly associated with increased risk of MetS via decreased aerobic fitness
Narang³⁹	4104 Canadian adolescents;51% male, M =14.6 ± .5 yrs	cross- sectional	self-reported sleep quality self-reported sleep duration	TC, HDL-C, non- HDL-C, prehypertension (≥90 - <95^th % based on age, sex, height) or hypertension (≥99^th %)	sex, family history of CVD, adiposity, nutrition, physical activity, screen time	↓sleep quality ↑ non-HDL-C ↑ hypertension NS TC NS HDL-C ↓self-report duration all NS
Kong²⁵	2053 Hong Kong children ages 6–18 years, M = 13.3 yrs	cross- sectional	self-reported sleep duration in full sample, actigraphy for 24 hrs in 138 children selected on obesity	lipids, metabolic syndrome	age, gender, BMI, pubertal stage	↓ self-reported duration ↑ TC and LDL-C in multivariate analyses in secondary students, NS for primary students; no report for actigraphy sleep, BP, glucose
Sung³⁸	133 obese U.S. adolescents in tertiary care weight management clinic, 66% female; ages 10–16 yrs. M=13.2 ± 1.8 yrs	cross- sectional	self-reported sleep duration, parent-reported sleep duration, 7 nights actigraphy- assessed sleep duration	MetS, MetS components (waist circumference, triglycerides, BP, HDL-c, glucose), HOMA-IR	age, gender, race, SES, BMI, obstructive apnea	↓self-report duration ↓ triglycerides NS for all others ↓parent-report duration ↓ HDL cholesterol NS for all others ↓actigraphy duration ↓ triglycerides NS for all others
Hitze³⁵	414 German children ages 6–20; M =13.0 ± 3.4 yrs	cross- sectional	self-report after 11, parent report before 11, cutoffs based on age	manual BP, lipids, glucose, leptin, adiponectin, HOMA-IR	age	↓sleep duration ↑insulin, HOMA-IR, leptin in girls. NS after adjustment for waist circumference; NS in boys
Gangwisch⁴⁰	14257 U.S. adolescents in ADD Health, 51% female, grades 7–12 at baseline	longitud- inal	self-report sleep duration at 2 times averaged	self-report of doctor diagnosing high cholesterol 6–7 years later	physical activity, emotional distress, BMI groups, age, sex, race, alcohol and smoking	↓sleep duration ↑cholesterol in females; NS in males. Test for sex interaction NS
Glucose and Insulin Metabolism Studies
Androutsos²⁹	2026 Greek children, 50.1% female, ages 9–13	cross- sectional	parental report of sleep duration	HOMA-IR	gender, Tanner stage, waist circumference, parent BMI, SES, birth weight	children with an unhealthy “lifestyle pattern,” consisting of ↓ sleep duration, ↑ screen time, and ↑sugary drink consumption, had ↑HOMA-IR
Zhu³⁴	118 healthy Chinese children and adolescents; 55.1% female, moderate-to-severe OSA excluded M=13.1 ± 3.3 yrs	cross- sectional	1 night PSG -TST -sleep efficiency	2-hr oral glucose tolerance test, insulin sensitivity (Matsuda index)	age, gender, BMI, pubertal status, AHI	↓TST ↑ glucose levels ↓ insulin sensitivity ↓sleep efficiency ↑ glucose levels ↓ insulin sensitivity ↓% stage 3 ↑glucose ↓insulin sensitivity
Matthews ³²	245 healthy U.S. adolescents, 56% African American, 53% female; ages 14–19 M = 15.7±1.3 yrs	cross- sectional	diary & actigraphy sleep duration for 1 week, fragmentation	HOMA-IR, glucose	age, race, gender, BMI, waist circumference	↓ nocturnal sleep ↑HOMA-IR stronger in males, effect due to weekday sleep ↑fragmentation ↑glucose
Javaheri ³⁰	471 U.S. adolescents in Cleveland Children’s Sleep and Health study; 50.7% female, 42.7% minority race; ages 13–19 M =15.7 ± 2.2 yrs	cross- sectional	actigraphy- assessed sleep duration	HOMA-IR	Model 2: age, sex, race, physical activity, preterm history Model 3: above + waist circumference	Model 2: curvilinear association of sleep duration with ↑HOMA-IR Model 3: only long sleep duration related to ↑HOMA-IR
Koren ³¹	62 obese U.S. adolescents, 54.8% African American, 37.1% White, 55% female; ages 8–17.5 M = 14.4 ± 2.1 yrs	cross- sectional	in clinic PSG TST, sleep stages	HOMA-IR, OGTT, IGI, WBISI	extent of obesity, OSA	curvilinear association of TST with ↑glucose and HbA1c; NS with HOMA-IR, WBISI, IGI; ↑N3 ↑IGI and AIRg (i.e., beta cell function)
Tian³³	619 obese & 617 nonobese Chinese children, matched by age; ages 3–6 M = 5.3 ± .9 yrs	cross- sectional	parent-reported sleep duration	fasting glucose, hyperglycemia (fasting glucose ≥ 100 mg/dL)	BMI, age, sex, birth weight, gestational age, systolic BP, parents’ education and BMI, breast- feeding, timing of food introduction, disease in past month, diet, sweetened beverage consumption, TV viewing, physical activity	↓ sleep duration ↑ glucose ↑ hyperglycemia in obese only Glucose NS after adjusting for waist circumference
Flint²⁸	40 obese U.S. children from weight clinic (32 with SDB), ages 3.5–18.5 M =12.3 ± 4.2 yrs	cross- sectional	in clinic PSG for sleep duration, efficiency, AHI, % stages	OGTT insulin and glucose, HOMA-IR, WBISI	None	<6 hr sleep ↑fasting and peak insulin, HOMA-IR, WBISI, and ↓ % REM in univariate analyses; did not report sleep efficiency
Blood Pressure Studies
Kuciene ⁴⁴	6940 Lithuanian children ages 12–15; M =13.4 yrs	cross- sectional	self-report TST	SBP, DBP (oscillometric) ≥90^th, ≥95^th %ile based on age, sex, height	BMI groups, physical activity, smoking, age, sex	Compared to ≥8hr, ↓ sleep ↑ risk for ≥90^th, ≥95^th % BP
Meininger⁴⁵	366 U.S. adolescents 53.6% female, 37% Black, 31% Hispanic, 29% White, ages 11–16	cross- sectional	24-hr actigraphy- assessed sleep (nighttime and daytime sleep duration)	24-hr ambulatory SBP and DBP on a school day	age, sex, racial/ethnic group, mother’s education, BMI, sexual maturation, physical activity, position and location during BP reading	↓nighttime sleep duration ↑ ambulatory SBP NS ambulatory DBP ↓daytime sleep duration ↑ ambulatory SBP ↑ ambulatory DBP
Paciência⁵²	1771 Portuguese 13 year-olds, 53.5% female	cross- sectional	self-reported sleep duration	prehypertension (BP > 90^th %ile for sex, age, and height)	females: BMI, caffeine intake, depression males: BMI, caffeine intake, sports	↑sleep duration females: ↑ BP males: NS
Archbold⁴¹	334 U.S. Hispanic & white children, 6–11 years; M =9.03 ± 1.63	longitud- inal for 5 years	in-home PSG- based SDB, TST	Obesity, BP ?	sex, ethnicity, age, change in obesity	↑obesity and ↓TST related to ? SBP; NS DBP
Mezick⁴⁶	246 healthy U.S. adolescents; 53.3% female, 56.5% Black; ages 14–19, M =15.7 ± 1.3 yrs	cross- sectional	7 nights actigraphy- assessed sleep duration; efficiency	24 hr ambulatory BP, nighttime ambulatory BP, daytime ambulatory BP	age, sex, race, BMI	↓sleep duration ↑ 24-hr SBP ↑ 24-hr DBP ↑ nighttime SBP ↑ nighttime DBP NS daytime SBP, DBP efficiency not related to BP
Guo⁵⁴	4902 Chinese children, ages 5–18, M = 10.9 ± 2.7 yrs	cross- sectional	parental report of TST	BP (mercury column) ≥ 90% for age, sex, height, or ≥ 120/80, hypertensive ≥ 95%	age, BMI, waist circumference, physical activity	↓TST ↑ SBP, DBP levels among boys 11–14 ↑ DBP among girls 11–14 ↓ DBP among boys 5–10 years. NS in other age groups
Bayer⁴⁹	7701 German children, 49% female, ages 3–10	cross- sectional	parental report of sleep duration standardized within age group	MAP (oscillometric)	BMI (age-, sex- specific), parental report of physical activity	↓ sleep duration ↑MAP, NS in multivariate analysis
Javaheri ⁴²	238 U.S. adolescents without clinical sleep apnea in Cleveland Children’s Sleep and Health study; 48.3% female, 45% White; M = 13.7± .7 yrs	cross- sectional	5–7 nights of actigraphy -sleep duration -sleep efficiency	prehypertension defined as BP ≥ 90^th percentile for sex, age, and height, continuous resting SBP and DBP	age, BMI, socio- economic status, models examining continuous BP outcomes also adjusted for sex, race, term status	↓sleep duration prehypertension, SBP, DBP all NS ↓ sleep efficiency ↑ prehypertension ↑ SBP ↑DBP associations replicated using PSG
Wells⁴⁷	4452 Brazilian adolescents, ages 10–12	cross- sectional	self-report bedtime & wake up time during week	oscillometric BP ≥120/80	physical activity, BMI groups, sex, SES, birth weight, length, maternal health habits	↓ sleep duration ↑SBP NS DBP
Sampei⁵³	117 Japanese children, ages 5–6	cross- sectional	parental report of sleep + teacher report of naps	mercury column BP	age, sex, BMI, school	↓TST ↓ SBP
Au⁴³	143 normal weight Chinese children and adolescents, 42% female, AHI ≥ 5 excluded, ages 10- 17.9; M = 14.3 ± 1.8 yrs	cross- sectional	1-night PSG -sleep time -sleep efficiency 7-day sleep diary duration	24-hr ambulatory BP -prePSG BP -in-bed BP -postPSG BP	age, gender, BMI, AHI, parental hypertension	↓PSG sleep time ↑ postPSG SBP NS other BP outcomes ↓PSG sleep efficiency ↑ in-bed SBP ↑ in-bed DBP ↑ postPSG DBP NS other BP outcomes ↓sleep diary duration ↑ prePSG SBP ↑ prePSG ↑ in-bed SBP ↑ in-bed DBP ↑ postPSG SBP NS postPSG DBP
Hannon⁴⁸	49 obese, nondiabetic U.S. adolescents, 48.1% female, 57.1% White, 40.7% Black, ages 12–18; M = 14.4 yrs	cross- sectional	1-night PSG -REM % -SWS % -TST -sleep latency -time to REM	resting oscillometric BP assessed morning after PSG.	age or pubertal stage, sex, race, BMI, AHI	↓REM % ↑ SBP ↑ DBP ↓SWS % ↑ SBP ↑ DBP NS for other sleep parameters
Reactivity/HRV Studies
Mezick⁵⁶	79 healthy normal weight U.S. college students, 100% male, ages 18–29, M = 19 ± 2.0 yrs	cross- sectional	7 nights actigraphy- assessed sleep duration	HR reactivity, BP reactivity, HRV reactivity, HR recovery, BP recovery, HRV recovery	age, race, BMI, daily caffeine, daily nicotine, stress task appraisals, naps	↓ duration NS HR reactivity NS SBP reactivity NS DBP reactivity ↑HRV-HF reactivity ↑ HR recovery NS SBP recovery ↑ DBP recovery NS HRV-HF recovery
Martikainen⁵⁵	241–274 Finnish 8- year-olds (number varied by outcome)	cross- sectional	sleep disturbance, Scales: 6 subscale scores (yes/no at least 1 sleep problem 2- 3x per week)	Cardiovascular reactivity, Ambulatory BP 24 hours	sex, age, height, BMI, start time, education, maternal licorice pregnancy yes/no	excessive somnolence ↑HF-HRV at rest SDB ↑ CO + HR reactivity
Williams⁵⁷	98 U.S. college students; 50% female, 74% White, 7% Latino/a, M = 23 ± 5.8 yrs	cross- sectional	prior month sleep quality, prior night sleep quality & TST	HR reactivity, SBP reactivity, DBP reactivity	baseline CV parameters	↓prior month quality NS HR reactivity NS SBP reactivity ↓ DBP reactivity ↓prior night quality all NS ↓prior night TST all NS (marginal effect on SBP reactivity)
Michels⁵⁸	334 Belgian children, 47% female, ages 5–11, actigraphy in subsample of N = 165	cross- sectional and longitudinal	parent-reported sleep duration, actigraphy- assessed latency, TST, efficiency	resting HRV, (HF- HRV and HF/LF ratio)	age, sex, physical activity, parental education, stress	↓parent-reported sleep duration NS HF-HRV NS LF/HF ratio ↑actigraphy latency ↓HF-HRV ↑LF/HF ratio ↓actigraphy efficiency NS HF-HRV ↑ LF/HF ratio ↓actigraphy TST NS HF-HRV ↑ LF/HF ratio longitudinal results replicated cross- sectional results
El-Sheikh⁵⁹	224 U.S. children, 64% European American, 36% African American, 46% female, ages 8–10	cross- sectional	7 nights actigraphy- TST, sleep activity, wake after sleep onset	resting RSA, vagal withdrawal during stress	age, sex, race, BMI, asthma	↑ Wake after sleep onset ↑ vagal withdrawal during stress all other main effects NS ↓ resting RSA and ↑ vagal withdrawal during stress interacted to predict ↑ wake after sleep onset, ↑ sleep activity TST NS
Elmore- Staton⁶⁰	29 U.S. preschoolers; 31% female, 64% European American, ages 3–5, M=3.99 ± .69 yrs	cross- sectional	actigraphy- assessed TST, efficiency, sleep activity	resting RSA	age, sex, ethnicity	↓ sleep efficiency & ↑ sleep activity ↓ RSA trend for ↓ TST, ↓ RSA
Martikainen⁵⁰	231–265 Finnish 8 year olds (number varied by outcome)	cross- sectional	actigraphy- TST, efficiency, fragmentation	CV reactivity, ambulatory BP	sex, age, height, BMI, maternal licorice during pregnancy, parental education	all NS
Shaikh⁵¹	489 Gujarti Indian adolescents; 42% female, ages 16–19	cross- sectional	self-reported sleep duration (≥ 7 vs. < 7 hrs)	resting BP, DBP reactivity	none reported	those sleeping <7 hrs had higher DBP reactivity vs. those sleeping ≥ 7 hrs; resting SBP and DBP were NS
El-Sheikh⁶¹	41 U.S. children, 44% female, ages 6–12; M = 10.06 ± 1.74 yrs	cross- sectional	4 nights actigraphy- TST, sleep efficiency, self-reported sleep-wake problems and sleepiness	resting RSA, vagal withdrawal during stress	gender, age, puberty status	↓TST ↓ vagal withdrawal during stress ↑ sleep-wake problems ↑ resting RSA, ↓ vagal withdrawal during stress sleep efficiency NS