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Table 1 describes the baseline characteristics of the adults stratified by napping duration. A total of 13,706 participants (6,676 men and 7,030 women, 49.5 ± 11.3 years old) were involved, with 1,526 CVD, 1,098 HTN, and 413 stroke incidents during the 97,415.82 person-years of follow-up (median follow-up, 6.1 years). The proportions of the population with napping duration of < 30, 30 to 60, and ≥ 60 min were 9.4%, 24.7%, and 15.6%, respectively. More than half of the participants lived in rural communities (56.8%) and were from the northern regions (59.2%). The participants had an average of 6.7 years of academic education, wherein > 20% were illiterate. Approximately 75.6% of adults responded “no” to participating in any physical activity, and over three-fifths were never-smokers (60.9%) and never-drinkers (77.2%). As regards nighttime sleep, participants who reported a sleep duration of < 6 h and ≥ 8 h per night accounted for 18.5% and 25.4%, respectively.
Items Total Nap duration 0 min < 30 min 30 to 60 min ≥ 60 min Population Persons, n 13,706 6,884 1,292 3,383 2,147 Incident CVD, n 1,526 665 147 428 286 Incident HTN, n 1,098 474 97 307 220 Incident stroke, n 413 183 31 132 67 Individual covariates Male, % 48.7 47.7 43.0 50.1 53.1 Age, years 49.5 ± 11.3 49.0 ± 11.3 48.4 ± 11.1 49.9 ± 11.3 50.1 ± 11.5 BMI, kg/m2 22.9 ± 3.3 22.4 ± 3.2 23.0 ± 3.3 22.9 ± 3.3 23.1 ± 3.3 Han ethnicity, % 93.5 91.3 95.6 95.3 95.9 Married, % 93.3 92.8 93.0 93.7 92.9 Urban, % 43.2 43.1 51.1 44.5 36.4 North, % 59.2 51.2 63.5 65.0 73.5 Educational attainment, % Illiteracy 22.4 25.4 15.8 19.0 21.8 1–6 years 26.3 26.2 22.1 26.3 29.0 7–12 years 46.1 44.6 52.6 48.2 46.4 > 12 years 5.2 3.8 9.5 6.5 2.7 Employment status, % Current 55.3 55.0 59.8 53.7 56.1 Former 28.6 27.8 27.3 30.9 28.3 Never 16.1 17.2 12.8 15.5 15.6 Annual household income, % Low 28.8 30.6 23.8 27.1 28.9 Medium 43.4 42.1 45.0 43.6 46.0 High 27.8 27.3 31.2 29.4 25.1 Physical activity, % 0 min/week 75.6 80.2 64.2 70.9 75.1 1–150 min/week 23.9 19.4 34.9 28.6 24.1 > 150 min/week 0.5 0.4 0.9 0.5 0.8 Smoking status, % Yes 39.0 38.1 33.9 39.5 44.8 No 60.9 61.9 66.1 60.5 55.2 Alcohol consumption, % Yes 22.8 21.3 21.5 23.4 27.4 No 77.2 78.7 78.6 76.6 72.7 Sleep duration, % < 6 hours/night 18.5 12.0 12.9 20.0 40.0 6 to 8 hours/night 56.1 57.3 59.2 59.4 45.0 ≥ 8 hours/night 25.4 30.8 27.9 20.6 15.0 Note. Data are presented using mean ± SD for continuous variables and percentages for categorical variables. BMI, body mass index; CVD, cardiovascular disease; HTN, hypertension. Table 1. Baseline characteristics of included participants (n = 13,706) by daytime napping
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Table 2 outlines the crude and adjusted HRs for the associations between daytime napping and CVD and HTN. Compared with non-nappers, both crude and multivariate models revealed higher risks of incident CVD and HTN in nappers ≥ 30 min and a greater risk of stroke in medium nappers (30–60 min), while no significant associations were found in short nappers (0–30 min). The trend analysis of nap-CVD associations demonstrated significantly elevated incident risks with napping duration. For instance, incident risks increased respectively by 22% (1.22, 1.08–1.39) for CVD and 21% (1.21, 1.04–1.41) for HTN in 30 to < 60 min nappers, with corresponding HRs of 1.27 (1.09–1.47) and 1.38 (1.16–1.65) among nappers ≥ 60 min.
Diseases Groups Age- and gender-adjusted model Multivariate modela HR (95% CI) P value P for trend HR (95% CI) P value P for trend CVD < 0.001 < 0.001 0 min 1 (Ref) 1 (Ref) < 30 min 1.17 (0.98 to 1.40) 0.087 1.07 (0.89 to 1.29) 0.448 30 to 60 min 1.29 (1.14 to 1.46) < 0.001 1.22 (1.08 to 1.39) 0.002 ≥ 60 min 1.36 (1.18 to 1.57) < 0.001 1.27 (1.09 to 1.47) 0.002 HTN < 0.001 < 0.001 0 min 1 (Ref) 1 (Ref) < 30 min 1.12 (0.90 to 1.40) 0.308 1.04 (0.83 to 1.30) 0.752 30 to 60 min 1.29 (1.12 to 1.50) 0.001 1.21 (1.04 to 1.41) 0.012 ≥ 60 min 1.48 (1.25 to 1.75) < 0.001 1.38 (1.16 to 1.65) < 0.001 Stroke 0.140 0.137 0 min 1 (Ref) 1 (Ref) < 30 min 0.89 (0.61 to 1.30) 0.544 0.96 (0.65 to 1.42) 0.845 30 to 60 min 1.39 (1.11 to 1.75) 0.004 1.39 (1.10 to 1.76) 0.006 ≥ 60 min 1.07 (0.80 to 1.43) 0.625 1.04 (0.77 to 1.40) 0.602 Note. aWe adjusted gender, age, BMI, ethnicity, marital status, residential region, geolocation, educational attainment, employment status, annual household income, physical activity, smoking status, alcohol consumption, and sleep duration. HR, hazard ratio; 95% CI, 95% confidence interval. Table 2. Effects of daytime napping on cardiovascular disease
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Table 3 and Table 4 summarize subgroup-specific estimates for associations of CVD and HTN risks with daytime napping. Overall, evident nap-incidence associations were consistently observed in 30+ min nappers, while nap-associated risks tended to be more profound among nappers with > 1 h/day. Significant trends for greater risks of CVD and HTN associated with longer naps were observed in all strata except for urban dwellers, south, and active physical exercise (Ptrend
> 0.05). Stratified analyses for stroke incidence are presented in Supplementary Table S1 (available in www.besjournal.com), where in associations with medium midday napping existed in female, older participants, underweight adults (BMI < 24 kg/m2), rural and north residents, smokers, non-drinkers, and long sleepers. Subgroup Hazard ratioa (95% CI) P for trend P for interaction < 30 min 30 to 60 min ≥ 60 min Gender 0.640 Male (n = 6,676) 1.03 (0.75 to 1.41) 1.20 (0.98 to 1.46) 1.38 (1.11 to 1.73)** 0.003 Female (n = 7,030) 1.09 (0.87 to 1.37) 1.25 (1.06 to 1.48)** 1.21 (0.98 to 1.49) 0.010 Age, years 0.539 30–49 (n = 7,411) 1.11 (0.80 to 1.55) 1.36 (1.08 to 1.73)** 1.23 (0.91 to 1.65) 0.028 ≥ 50 (n = 6,295) 1.08 (0.86 to 1.35) 1.17 (1.01 to 1.37)* 1.31 (1.10 to 1.56)** 0.001 BMI, kg/m² 0.382 < 24 (n = 9,449) 1.22 (0.96 to 1.57) 1.30 (1.10 to 1.54)** 1.32 (1.08 to 1.62)** 0.001 ≥ 24 (n = 4,257) 0.97 (0.74 to 1.29) 1.15 (0.95 to 1.40) 1.24 (0.99 to 1.55) 0.036 Residential region 0.191 Urban (n = 5,914) 1.00 (0.78 to 1.29) 1.08 (0.90 to 1.30) 1.09 (0.87 to 1.38) 0.344 Rural (n = 7,792) 1.17 (0.89 to 1.53) 1.34 (1.12 to 1.60)** 1.41 (1.15 to 1.72)** < 0.001 Geolocation 0.043 North (n = 8,120) 1.06 (0.84 to 1.34) 1.30 (1.11 to 1.53)** 1.33 (1.11 to 1.60)** < 0.001 South (n = 5,586) 1.11 (0.81 to 1.51) 1.09 (0.88 to 1.35) 1.14 (0.86 to 1.51) 0.283 Physical activity 0.189 Yes (n = 3,345) 1.10 (0.82 to 1.46) 1.11 (0.89 to 1.39) 1.01 (0.76 to 1.34) 0.642 No (n = 10,361) 1.03 (0.80 to 1.32) 1.26 (1.07 to 1.47)** 1.38 (1.16 to 1.65)*** < 0.001 Smoking status 0.790 Yes (n = 5,356) 1.02 (0.71 to 1.46) 1.34 (1.08 to 1.67)* 1.42 (1.12 to 1.81)** 0.001 No (n = 8,350) 1.10 (0.89 to 1.37) 1.18 (1.01 to 1.38)* 1.20 (0.99 to 1.46) 0.020 Alcohol consumption 0.007 Yes (n = 3,121) 1.29 (0.86 to 1.92) 1.11 (0.83 to 1.47) 1.46 (1.08 to 1.97)* 0.031 No (n = 10,585) 1.02 (0.83 to 1.26) 1.26 (1.09 to 1.45)** 1.18 (0.99 to 1.43) 0.001 Sleep duration, hours/night 0.168 < 7 (n = 5,599) 0.96 (0.69 to 1.33) 1.17 (0.96 to 1.42) 1.22 (0.97 to 1.52) 0.357 ≥ 7 (n = 8,072) 1.13 (0.90 to 1.42) 1.30 (1.09 to 1.55)** 1.30 (1.05 to 1.61)** 0.001 Note. aWe adjusted gender, age, BMI, ethnicity, marital status, residential region, educational attainment, employment status, annual household income, physical activity, smo, king status, alcohol consumption, and sleep duration. 95% CI, 95% confidence interval. *P < 0.05; **P < 0.01; ***P < 0.001. Table 3. Subgroup analysis for the association of nap duration with cardiovascular disease
Subgroup Hazard ratioa (95% CI) P for trend P for interaction < 30 min 30 to < 60 min ≥ 60 min Gender 0.670 Male (n = 6,676) 0.87 (0.60 to 1.28) 1.18 (0.94 to 1.48) 1.42 (1.11 to 1.83)*** 0.006 Female (n =7,030) 1.12 (0.84 to 1.49) 1.24 (1.01 to 1.52)** 1.36 (1.06 to 1.73)** 0.006 Age, years 0.092 30–49 (n = 7,411) 1.13 (0.76 to 1.69) 1.45 (1.09 to 1.92)*** 1.46 (1.03 to 2.05)** 0.006 ≥ 50 (n = 6,295) 1.01 (0.77 to 1.33) 1.13 (0.95 to 1.35) 1.38 (1.13 to 1.69)*** 0.003 BMI, kg/m² 0.396 < 24 (n = 9,449) 1.18 (0.87 to 1.61) 1.26 (1.02 to 1.55)** 1.46 (1.14 to 1.85)*** 0.001 ≥ 24 (n = 4,257) 0.95 (0.68 to 1.31) 1.20 (0.97 to 1.50) 1.38 (1.07 to 1.77)** 0.008 Residential region 0.244 Urban (n = 5,914) 1.08 (0.80 to 1.44) 1.06 (0.85 to 1.31) 1.20 (0.92 to 1.57) 0.230 Rural (n = 7,792) 0.97 (0.68 to 1.39) 1.37 (1.10 to 169)*** 1.52 (1.20 to 1.92)**** < 0.001 Geolocation 0.027 North (n = 8,120) 1.10 (0.82 to 1.47) 1.36 (1.11 to 1.66)*** 1.58 (1.26 to 1.97)**** < 0.001 South (n = 5,586) 1.99 (0.69 to 1.41) 1.08 (0.85 to 1.36) 1.15 (0.84 to 1.55) 0.351 Physical activity 0.040 Yes (n = 3,345) 1.14 (0.82 to 1.58) 1.06 (0.81 to 1.38) 1.01 (0.73 to 1.41) 0.824 No (n=10,361) 0.91 (0.66 to 1.24) 1.27 (1.06 to 1.53)** 1.57 (1.28 to 1.93)**** < 0.001 Smoking status 0.538 Yes (n = 5,356) 0.84 (0.53 to 1.33) 1.34 (1.04 to 1.73)** 1.50 (1.14 to 1.99)*** 0.002 No (n = 8,350) 1.11 (0.86 to 1.44) 1.15 (0.95 to 1.39) 1.32 (1.05 to 1.65)** 0.015 Alcohol consumption 0.272 Yes (n = 3,121) 1.25 (0.78 to 2.01) 1.23 (0.89 to 1.70) 1.56 (1.11 to 2.20)** 0.016 No (n = 10,585) 0.98 (0.76 to 1.27) 1.21 (1.02 to 1.43)** 1.34 (1.09 to 1.64)*** 0.004 Sleep duration, hours/night 0.370 < 7 (n = 5,599) 0.86 (0.57 to 1.29) 1.13 (0.90 to 1.43) 1.34 (1.04 to 1.72)** 0.023 ≥ 7 (n = 8,072) 1.11 (0.85 to 1.46) 1.31 (1.06 to 1.62)** 1.41 (1.10 to 1.79)*** 0.001 Note. aWe adjusted gender, age, BMI, ethnicity, marital status, residential region, educational attainment, employment status, annual household income, physical activity, smoking status, alcohol consumption, and sleep duration. 95% CI, 95% confidence interval. *P < 0.05; **P < 0.01; ***P < 0.001; ****P < 0.0001. Table 4. Subgroup analysis for the association of nap duration with hypertension
In gender-specific associations, both men and women exhibited increased risks with longer napping duration (Ptrend < 0.02). Generally, larger risks were identified in adults aged 30–49 years, particularly for HTN, with a p value for interaction of 0.092. Higher nap-associated risks mainly existed in participants with lower BMI (< 24 kg/m2), except for HTN in 60+ min nappers. We found some evidence of regional differences in nap-CVD associations, where increased risks occurred in rural and northern residents only. Specifically, significant effect modification by geolocation (north China versus south China) was identified for total CVD (P = 0.043) and HTN (P = 0.027).
Our results also highlighted that the nap-CVD association was modified by physical activity, with larger incident risks found among physically inactive adults. Smokers and alcohol drinkers were observed to have higher CVD risks induced by longer napping. Specifically, the incidence of CVD and HTN remarkably increased among smokers with 30+ min naps, while risks elevated significantly only in drinkers who napped ≥ 60 min. Moreover, associations of long napping duration with CVDs appear to be more evident among adults who had longer nocturnal sleep. For instance, 30–60 min of napping resulted in 30% (9%–55%) and 31% (6%–62%) higher risks of CVD and HTN in adults who slept ≥ 7 h/night, respectively, corresponding to insignificant HRs of 1.17 (0.96–1.42) and 1.13 (0.90–1.43) in those slept < 7 h/night.
Sensitivity analyses (Supplementary Table S2 available in www.besjournal.com) demonstrated the robustness of our main findings that nap ≥ 30 min was associated with an increased risk of CVD events. In terms of total CVD outcome in relation to napping duration of 30 to < 60 min, the risk estimates kept unchanged when we excluded CVD cases diagnosed in the initial first year after the baseline study or excluded those aged > 75 years, with HRs ranging from 1.22 (1.08, 1.39) to 1.23 (1.09, 1.40) (model 1) and 1.25 (1.10, 1.42) (model 2), respectively. The estimated HRs slightly increased when restricting our analysis to participants without changes in daytime-napping behaviors, while our main findings remained [HR = 1.38 (1.20, 1.57), model 3].
Diseases Groups HR (95% CI) Main model Model 1 Model 2 Model 3 CVD < 30 min 1.07 (0.89, 1.29) 1.10 (0.92, 1.33) 1.10 (0.91, 1.33) 1.25 (1.03, 1.51)* 30 to 60 min 1.22 (1.08, 1.39)** 1.23 (1.09, 1.40)** 1.25 (1.10, 1.42)** 1.38 (1.20, 1.57)*** ≥ 60 min 1.27 (1.09, 1.47)** 1.28 (1.11, 1.48)*** 1.33 (1.15, 1.54)*** 1.42 (1.22, 1.66)*** HTN < 30 min 1.04 (0.83, 1.30) 1.04 (0.83, 1.30) 1.05 (0.84, 1.31) 1.14 (0.90, 1.45) 30 to 60 min 1.21 (1.04, 1.41)* 1.22 (1.05, 1.42)** 1.23 (1.06, 1.44)** 1.36 (1.16, 1.60)*** ≥ 60 min 1.38 (1.16, 1.65)*** 1.41 (1.19, 1.67)*** 1.44 (1.12, 1.71)*** 1.57 (1.31, 1.88)*** Stroke < 30 min 0.96 (0.65, 1.42) 1.01 (0.69, 1.49) 1.04 (0.71, 1.54) 1.06 (0.70, 1.59) 30 to 60 min 1.39 (1.10, 1.76)** 1.40 (1.11, 1.77)** 1.43 (1.13, 1.81)** 1.52 (1.19, 1.95)*** ≥ 60 min 1.04 (0.77, 1.40) 1.06 (0.79, 1.42) 1.09 (0.81, 1.47) 1.14 (0.84, 1.55) Note. Abbreviations: HR, hazard ratio; CI, confidence interval; CVDs, cardiovascular diseases; HTN, hypertension. Model 1: restricting our study outcomes beyond the initial first year. Model 2: restricting participants aged < 75 years. Model 3: restricting the analysis to adults who had not changed daytime-napping behaviors during follow-ups. *P < 0.05, **P < 0.01, ***P < 0.001. Table S2. Sensitive analysis of hazard ratios (95% CIs) for incident CVDs associated with napping duration, by excluding those who developed outcomes in 1 year after baseline survey, study participants aged > 75 years and participants who had changed daytime-napping behaviors during follow-ups
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The authors declare they have no conflicts of interest.
Subgroup Hazard ratioa (95% CI) P for trend P for interaction < 30 min 30 to 60 min ≥ 60 min Gender 0.339 Male (n = 6,676) 0.81 (0.42 to 1.58) 1.36 (0.96 to 1.91) 1.17 (0.78 to 1.75) 0.183 Female (n = 7,030) 1.08 (0.67 to 1.75) 1.39 (1.01 to 1.93)* 0.86 (0.54 to 1.37) 0.549 Age, years 0.815 30–49 (n = 7,411) 0.67 (0.26 to 1.71) 1.20 (0.70 to 2.04) 0.75 (0.36 to 1.54) 0.810 ≥ 50 (n = 6,295) 1.07 (0.70 to 1.64) 1.43 (1.10 to 1.86)** 1.13 (0.81 to 1.58) 0.077 BMI, kg/m2 0.464 < 24 (n = 9,449) 0.71 (0.41 to 1.22) 1.39 (1.06 to 1.84)* 0.91 (0.63 to 1.33) 0.417 ≥ 24 (n = 4,257) 1.47 (0.82 to 2.61) 1.30 (0.84 to 2.02) 1.30 (0.77 to 2.19) 0.227 Residential region 0.351 Urban (n = 5,914) 0.88 (0.49 to 1.57) 1.18 (0.81 to 1.73) 0.99 (0.59 to 1.67) 0.653 Rural (n = 7,792) 1.05 (0.62 to 1.77) 1.59 (1.17 to 2.16)** 1.09 (0.75 to 1.59) 0.108 Geolocation < 0.001 North (n = 8,120) 0.94 (0.60 to 1.46) 1.32 (1.00 to 1.74)* 0.89 (0.63 to 1.26) 0.695 South (n = 5,586) 0.95 (0.43 to 2.13) 1.33 (0.84 to 2.13) 1.44 (0.78 to 2.65) 0.139 Physical activity 0.787 Yes (n = 3,345) 0.84 (0.42 to 1.69) 1.51 (0.98 to 2.33) 0.81 (0.42 to 1.53) 0.570 No (n = 10,361) 1.07 (0.67 to 1.71) 1.31 (0.98 to 1.73) 1.08 (0.77 to 1.52) 0.240 Smoking status 0.380 Yes (n = 5,356) 0.73 (0.33 to 1.61) 1.61 (1.11 to 2.34)* 1.19 (0.76 to 1.86) 0.104 No (n = 8,350) 1.08 (0.69 to 1.69) 1.29 (0.95 to 1.75) 0.91 (0.60 to 1.38) 0.602 Alcohol consumption 0.751 Yes (n = 3,121) 0.69 (0.24 to 1.97) 1.31 (0.79 to 2.17) 1.12 (0.64 to 1.99) 0.449 No (n = 10,585) 1.04 (0.68 to 1.58) 1.43 (1.10 to 1.86)** 1.02 (0.71 to 1.45) 0.165 Sleep duration, hours/night 0.364 < 7 (n = 5,599) 0.70 (0.36 to 1.37) 0.97 (0.69 to 1.37) 0.84 (0.55 to 1.26) 0.528 ≥ 7 (n = 8,072) 1.12 (0.69 to 1.80) 1.86 (1.35 to 2.57)*** 1.20 (0.78 to 1.86) 0.012 Note. aWe adjusted gender, age, BMI, ethnicity, marital status, residential region, educational attainment, employment status, annual household income, physical activity, smoking status, alcohol consumption, and sleep duration. 95% CI, 95% confidence interval. *P < 0.05; **P < 0.01; ***P < 0.001. Table S1. Subgroup analysis for the association of nap duration with stroke
Associations of Daytime Napping with Incident Cardiovascular Diseases and Hypertension in Chinese Adults: A Nationwide Cohort Study
doi: 10.3967/bes2022.004
- Received Date: 2021-05-30
- Accepted Date: 2021-11-15
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Key words:
Daytime napping / - Cardiovascular disease /
- Hypertension /
- Adults /
- Sleep duration
Abstract:
Citation: | WANG Lu, WANG Ke, LIU Lin Jiong, ZHANG Yuan Yuan, SHU Hai Nan, WANG Kai, ZHOU Pei Xuan, ZHANG Yun Quan. Associations of Daytime Napping with Incident Cardiovascular Diseases and Hypertension in Chinese Adults: A Nationwide Cohort Study[J]. Biomedical and Environmental Sciences, 2022, 35(1): 22-34. doi: 10.3967/bes2022.004 |