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      The Joint Effect of Sleep Duration and Disturbed Sleep on Cause-Specific Mortality: Results from the Whitehall II Cohort Study

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          Abstract

          Background

          Both sleep duration and sleep quality are related to future health, but their combined effects on mortality are unsettled. We aimed to examine the individual and joint effects of sleep duration and sleep disturbances on cause-specific mortality in a large prospective cohort study.

          Methods

          We included 9,098 men and women free of pre-existing disease from the Whitehall II study, UK. Sleep measures were self-reported at baseline (1985–1988). Participants were followed until 2010 in a nationwide death register for total and cause-specific (cardiovascular disease, cancer and other) mortality.

          Results

          There were 804 deaths over a mean 22 year follow-up period. In men, short sleep (≤6 hrs/night) and disturbed sleep were not independently associated with CVD mortality, but there was an indication of higher risk among men who experienced both (HR = 1.57; 95% CI: 0.96–2.58). In women, short sleep and disturbed sleep were independently associated with CVD mortality, and women with both short and disturbed sleep experienced a much higher risk of CVD mortality (3.19; 1.52–6.72) compared to those who slept 7–8 hours with no sleep disturbances; equivalent to approximately 90 additional deaths per 100,000 person years. Sleep was not associated with death due to cancer or other causes.

          Conclusion

          Both short sleep and disturbed sleep are independent risk factors for CVD mortality in women and future studies on sleep may benefit from assessing disturbed sleep in addition to sleep duration in order to capture health-relevant features of inadequate sleep.

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          Most cited references28

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          Causal Diagrams for Epidemiologic Research

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            Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies.

            Increasing evidence suggests an association between both short and long duration of habitual sleep with adverse health outcomes. To assess whether the population longitudinal evidence supports the presence of a relationship between duration of sleep and all-cause mortality, to investigate both short and long sleep duration and to obtain an estimate of the risk. We performed a systematic search of publications using MEDLINE (1966-2009), EMBASE (from 1980), the Cochrane Library, and manual searches without language restrictions. We included studies if they were prospective, had follow-up >3 years, had duration of sleep at baseline, and all-cause mortality prospectively. We extracted relative risks (RR) and 95% confidence intervals (CI) and pooled them using a random effect model. We carried out sensitivity analyses and assessed heterogeneity and publication bias. Overall, the 16 studies analyzed provided 27 independent cohort samples. They included 1,382,999 male and female participants (followup range 4 to 25 years), and 112,566 deaths. Sleep duration was assessed by questionnaire and outcome through death certification. In the pooled analysis, short duration of sleep was associated with a greater risk of death (RR: 1.12; 95% CI 1.06 to 1.18; P < 0.01) with no evidence of publication bias (P = 0.74) but heterogeneity between studies (P = 0.02). Long duration of sleep was also associated with a greater risk of death (1.30; [1.22 to 1.38]; P < 0.0001) with no evidence of publication bias (P = 0.18) but significant heterogeneity between studies (P < 0.0001). Both short and long duration of sleep are significant predictors of death in prospective population studies.
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              Health inequalities among British civil servants: the Whitehall II study

              The Whitehall study of British civil servants begun in 1967, showed a steep inverse association between social class, as assessed by grade of employment, and mortality from a wide range of diseases. Between 1985 and 1988 we investigated the degree and causes of the social gradient in morbidity in a new cohort of 10,314 civil servants (6900 men, 3414 women) aged 35-55 (the Whitehall II study). Participants were asked to answer a self-administered questionnaire and attend a screening examination. In the 20 years separating the two studies there has been no diminution in social class difference in morbidity: we found an inverse association between employment grade and prevalence of angina, electrocardiogram evidence of ischaemia, and symptoms of chronic bronchitis. Self-perceived health status and symptoms were worse in subjects in lower status jobs. There were clear employment-grade differences in health-risk behaviours including smoking, diet, and exercise, in economic circumstances, in possible effects of early-life environment as reflected by height, in social circumstances at work (eg, monotonous work characterised by low control and low satisfaction), and in social supports. Healthy behaviours should be encouraged across the whole of society; more attention should be paid to the social environments, job design, and the consequences of income inequality.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                3 April 2014
                : 9
                : 4
                : e91965
                Affiliations
                [1 ]Department of Public Health, University of Copenhagen, Copenhagen, Denmark
                [2 ]Copenhagen Stress Research Center, Copenhagen, Denmark
                [3 ]Department of Epidemiology and Public Health, University College London, London, England
                [4 ]School of Social and Community Medicine, University of Bristol, Bristol, England
                Kagoshima University Graduate School of Medical and Dental Sciences, Japan
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: NHR M. Kumari TL M. Kivimaki MS JF. Analyzed the data: NHR. Contributed reagents/materials/analysis tools: NHR M. Kumari TL M. Kivimaki MS JF. Wrote the paper: NHR M. Kumari TL M. Kivimaki MS JF.

                Article
                PONE-D-13-43517
                10.1371/journal.pone.0091965
                3974730
                24699341
                075f0867-2074-4a8f-8522-0e35c4eecd0f
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 21 October 2013
                : 15 February 2014
                Page count
                Pages: 10
                Funding
                The UK Medical Research Council, British Heart Foundation, and the US National Institutes of Health (R01HL36310, R01AG013196) have supported collection of data in the Whitehall II Study. Meena Kumari is supported by the UK Dunhill Medical Trust and the National Heart, Lung and Blood Institute (R01HL36310); Mika Kivimäki by an ESRC professorship, UK, the Academy of Finland, and the EU New OSH ERA research programme; and Martin J. Shipley by the British Heart Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology and Life Sciences
                Physiology
                Physiological Processes
                Sleep
                Population Biology
                Population Metrics
                Death Rates
                Medicine and Health Sciences
                Epidemiology
                Cancer Epidemiology
                Cardiovascular Disease Epidemiology
                Epidemiology of Aging
                Research and Analysis Methods
                Research Design
                Clinical Research Design
                Cohort Studies

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                Uncategorized

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