Journal of the American Society of Hypertension 12(12) (2018) 867–879

Research Article
A dose-response association of night sleep duration
with hypertension in a Chinese rural population: the
Henan Rural Cohort Study
Haiqing Zhang, MSa,1, Yuqian Li, PhDb,1, Zhenxing Mao, PhDa, Min Liu, PhDc,
Wenqian Huo, PhDd, Ruihua Liu, MSa, Xiaotian Liu, PhDa, Runqi Tu, PhDa,
Kaili Yang, MSa, Xinling Qian, MSa, Jingjing Jiang, MSa, Xia Zhang, MSa,
Zhongyan Tian, MSa, Ronghai Bie, PhDa,*, and Chongjian Wang, PhDa,*
a
Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China;
b
Department of Clinical Pharmacology, School of Pharmaceutical Science, Zhengzhou University, Zhengzhou, Henan, PR China;
c
Department of Hypertension, Henan Provincial People’s Hospital, Zhengzhou, Henan, PR China; and
d
Department of Occupational and Environmental Health, College of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
Manuscript received April 27, 2018 and accepted October 13, 2018

Abstract

The purpose of the study was to determine if there was a relationship between night sleep duration and hypertension, and to
evaluate as to whether blood lipid levels played a role in this relationship. A total of 37,317 participants aged 18–79 years
were included in this study. Night sleep duration was classified as <5, 5-, 6-, 7-, 8-, 9-, and
10 hours. Logistic regression
and restricted cubic spline analysis was carried out to evaluate the association of sleep duration with hypertension. Compared
with reference sleep duration (7 hours), in males, the multivariate odds ratios (ORs) (95% confidence interval [95% CI]) of
the groups with longest sleep duration (
10 hours) and shortest sleep duration (<5 hours) for hypertension was 1.52 (1.25–
1.84) and 1.07 (0.80–1.44), respectively. Similarly, the longest sleep duration was associated with diagnosed hypertension
(1.21, 1.00–1.45) in females. The OR for an indirect effect of sleep duration through low-density lipoprotein cholesterol

Grant Support: This research was supported by the National
Natural Science Foundation of China (Grant NO: 81573243,
81602925), Henan Natural Science Foundation of China (Grant
NO: 182300410293), National Key Research and Development
Program Precision Medicine Initiative of China (Grant NO:
2016YFC0900803), Science and Technology Foundation for Inno-
vation Talent of Henan Province (Grant NO: 164100510021), Sci-
ence and Technology Innovation Talents Support Plan of Henan
Province Colleges and Universities (Grant NO: 14HASTIT035),
High-level Personnel Special Support Project of Zhengzhou Uni-
versity (Grant NO: ZDGD13001). The funders had no role in the
study design, data collection and analysis, decision to publish, or
preparation of the article.
Conflict of interest: None.
Supplemental Material can be found at www.ashjournal.
com.
Ethics approval: Ethical approval for this study was obtained
from the ‘‘Zhengzhou University Life Science Ethics Commit-
tee’’, and written informed consent was obtained from all partic-
ipants. Ethic approval code: [2015] MEC (S128)
Clinical Trial Registration: The Henan Rural Cohort Study has
been registered at Chinese Clinical Trial Registry (Registration
number: ChiCTR-OOC-15006699). http://www.chictr.org.cn/
showproj.aspx?proj¼11375
What is already known on this topic?
Previous studies have explored the effect between night sleep
duration and hypertension, but the studies covered populations and re-
gions are limited, especially in limited resource settings. The results
from these studies are inconsistent, as some studies did not find a rela-
tionship between sleep duration and hypertension.
What does this study add?
The present study shows that longer night sleep duration correlates
with a higher likelihood of undiagnosed and diagnosed hypertension
in the rural population. In addition, low-density lipoprotein cholesterol
appeared to mediate the effect of sleep duration on hypertension in
males.
*Corresponding authors: Dr Chongjian Wang, PhD and Dr
Ronghai Bie, PhD, Department of Epidemiology and Biostatistics,
College of Public Health, Zhengzhou University, 100 Kexue
Avenue, Zhengzhou, 450001 Henan, PR China. Tel: (86) 371-
67781452; Fax: (86) 371-67781919.
E-mails: bierh2012@126.com, tjwcj2005@126.com
1
Haiqing Zhang and Yuqian Li contributed equally to this work.

1933-1711/$ - see front matter Ó 2018 American Heart Association. All rights reserved.
https://doi.org/10.1016/j.jash.2018.10.005

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868 H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879

(LDL-C) on hypertension was 1.085 (95% CI 1.038–1.137). Overall, a 3.5% possibility of hypertension being associated with
sleep duration was attributable to LDL-C. In summary, a relationship between sleep duration and hypertension was observed
in this rural population. LDL-C appeared to partially mediate the effect of sleep duration on hypertension in males. J Am Soc
Hypertens 2018;12(12):867–879. Ó 2018 American Heart Association. All rights reserved.
Keywords: Dose-response association; hypertension; mediation effect; night sleep duration.

Introduction
Hypertension has become a primary public health
concern globally, with growing prevalence in adults and
in children. Patients with hypertension are at greater risk
for myocardial infarction, coronary heart failure, and
stroke,1 and this may primarily be caused by the altered
function of the vascular endothelium.2 High salt intake,
obesity, and cigarette smoking have been proven to be the
main risk factors for hypertension, but there still remain un-
identified factors.3 One third of our life is spent sleeping,
which plays a vital role in our health. Increasingly, studies
are evaluating the association between sleep quality and
adverse health outcomes, including type II diabetes melli-
tus,4–6 coronary heart disease,7 and overall mortality.8
There are several studies that have examined the associ-
ation of hypertension and sleep duration. One study showed
that sleep duration of 8 hour or longer per night was asso-
ciated with hypertension in a Saudi Arabian population.9
Other studies have found no relationship between the dura-
tion of sleep and high blood pressure (BP) in the
elderly.10,11 A cross-sectional study involving a Korean
population reported the association of short sleep duration
and hypertension in nonobese premenopausal women.12 A
prospective study conducted in an affluent area of China
showed that shorter sleep duration was significantly associ-
ated with hypertension among younger participants, but the
sample size of the study was relatively small.13 A Chinese
study found that extreme sleep duration (>7 hours/night or
8–9 hours/night) increased the prevalence of hypertension
in middle-aged subjects.14 A study conducted on an elderly
rural population in China did not find significant associa-
tion of sleep duration and hypertension.15
In addition, it is reported that statin therapy can signifi-
cantly benefit secondary prevention of patients with hyper-
tension,16,17 suggesting that factors of serum lipids might
be potential risk factors for prevalent hypertension. Gang-
wisch et al.18 have showed that short sleep duration is asso-
ciated with a greater risk of hypercholesterolemia in
adolescents. Another study reported that sleep duration is
associated with serum lipid and lipoprotein levels among
Japanese adults.19 Thus, serum lipid profiles might be po-
tential moderators in the relationship between sleep dura-
tion and hypertension. As no prior study has reported on
whether serum lipid profiles mediate the association be-
tween sleep duration and hypertension, we asked what
mediator variables might exist in the association of sleep
duration and hypertension, and how much of the direct ef-
fect they might explain.
Change in sleep duration may contribute to adverse
physiological changes and increase morbidity.20 Studies
on relationship of night sleep duration and hypertension
are scarce,15,21,22 especially among undeveloped rural pop-
ulations in China. Thus, this study was conducted to
examine whether night sleep duration was associated with
undiagnosed and diagnosed hypertension in a Chinese rural
population aged 18–79 years. In addition, we hypothesized
that this relationship might be mediated by serum lipids,
which are known risk factors for hypertension.
Materials and Methods
Participants
The participants are from the Henan Rural Cohort Study
which was conducted in Suiping, Yuzhou, Yima, Tongxu,
and Xinxiang counties of Henan province and registered
in the Chinese Clinical Trial Registry (registration number:
ChiCTR-OOC-15006699).23,24 A total of 39,259 people
were recruited. Exclusion criteria for this study were
missing data on hypertension or night sleep duration
(n ¼ 71), being a night shift worker (n ¼ 1,544), and pa-
tients with tumors (n ¼ 327). We obtained a final sample
of 37,317 participants aged 18–79 years.
The protocol of this study was approved by the Ethics Com-
mittee of the Zhengzhou University Life Science Ethics Com-
mittee. Informed consent was obtained from all participants.
Covariate Variables
Data were collected by trained investigators in face-to-face
interviews. A structured questionnaire on demographic char-
acteristics (age, gender, and educational levels), lifestyle be-
haviors (physical activities, intake of high fat diet,
vegetables and fruit intake, high salt diet, smoking status,
and alcohol consumption), personal history of hypertension,
and family history of hypertension. Eating more than 500 g
of vegetables and fruits each day were defined as high vegeta-
bles and fruit intake, eating 75 g or more of meat from live
stock and poultry on average every day was defined as a
high fat diet, and a high salt diet was defined by self-
reported taste preferences. Marital status was classified as
married/cohabitation and single/divorced/separated/wid-
owed. Those who had smoked for at least half of one year
and no less than 1 cigarette per day were defined as smokers

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 H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879
and all other participants were classified as nonsmokers. Par-
ticipants consuming alcohol 12 or more times every year were
considered as drinkers and respondents were grouped as non-
drinkers (including abstinence) and current drinker. Physical
activity levels were divided into three categories: light, mod-
erate, and vigorous according to the criteria derived from the
International Physical Activity Questionnaire.25
Anthropometric variables were measured in light clothing
and without shoes. Weight and height were measured twice
for each person to the nearest 0.5 kg and 0.1 cm, according
to a standard protocol. Weight (kg) was divided by the
square of height (m2) to calculate body mass index (BMI).
Venous blood samples were drawn from participants who
had fasted overnight. Serum was separated through centri-
fugation with 2000 g rcf at room temperature for 10 minute
and stored at 20 C. Serum lipids included total choles-
terol, triglyceride, low-density lipoprotein cholesterol
(LDL-C) and high-density lipoprotein cholesterol were
measured by direct or enzymatic methods.
Assessment of Sleep Duration
Information about night sleep duration was collected using
the Pittsburgh Sleep Quality Index.26 Night sleep duration was
taken from the following question of the Pittsburgh Sleep
Quality Index: ‘‘How many hours of actual sleep duration
did you get at night during the past month?’’ People sleeping
for 7–8 hours were viewed as enjoying optimal sleep duration
according to a prospective study that showed duration of 7–8
hours was relatively normal.27 In addition, according to
another two previous studies,6,28 sleep duration was grouped
as <5 hour (shortest), 5–6, 6–7, 7–8 hours (reference), 8–9,
9–10, and
10 hours (longest). Furthermore, respondents
were asked the question: ‘‘Did you have the habit of taking
a nap after lunch over the past year?’’ Those who answered
yes were further asked how long they sleep every day.
Measurement of Blood Pressure
Participants were asked to avoid caffeine, exercise, and
smoking for at least 30 minute before measurement of BP.
Respondents were to rest quietly in a chair for at least 5 mi-
nutes before measuring BP and remained in rested state for
at least 30 seconds intervals between measurements. Three
BP recordings were obtained using an electronic sphygmo-
manometer (HEM-770AFuzzy, Omron, Japan) from the
bare right arm supported at the level of heart. The mean of
the three measurements was used for the analyses.
Definition of Hypertension
Hypertension was defined as systolic blood pressure
(SBP)
140 mm Hg and/or diastolic blood pressure
(DBP)
90 mm Hg, or self-reported hypertension diag-
nosed by physician and use of antihypertensive medicines
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869
during the past 2 weeks.3 Participants with hypertension
who did not report having hypertension were defined as un-
diagnosed hypertension, whereas those with reported hy-
pertension including those on antihypertensive were
defined as diagnosed hypertension.
Statistical Analysis
Data on baseline of the respondents are presented as
means (SD) for continuous variables and percentages for cat-
egorical variables. The t-test and chi-square test were used to
compare continuous and categorical variables, respectively,
among different categories of sleep duration. Analysis of
variance with covariates was performed to show age-
adjusted means of BP values. Age-adjusted prevalence of
hypertension was also presented. Multiple linear regression
models with SBP and DBP as continuous outcome variables
were created after adjusting for age, marital status, educa-
tional levels, average monthly income, smoking status,
drinking status, physical activity, intake of high fat diet,
high vegetables and fruit intake, high salt diet, family history
of hypertension, BMI, napping duration, and LDL-C. To
identify the relationship between night sleep duration and
the prevalence of hypertension, logistic regression models
were generated after adjusting for the same factors as in
the linear regression model. We examined potential gender
interactions by adding a multiplicative interaction term
into the models between sleep duration (hour) and gender.
A nonlinear trend was also tested by including a quadratic
term of sleep duration in the present study. A dose-
response association of sleep duration and hypertension
was analyzed by fitting restricted cubic spline logistic regres-
sion29 setting 3 knots placed at the 25th, 50th, and 75th per-
centiles of sleep duration, with 7 hour as the reference group.
Finally, the proportion of the association between night sleep
duration and hypertension was calculated by mediation anal-
ysis based on factors of blood lipids (including total choles-
terol, triglyceride, LDL-C, and high-density lipoprotein
cholesterol). Mediation analysis previously introduced else-
where30,31 was performed running the PROCESS for SPSS
that the single independent variable must be either contin-
uous or dichotomous. Only continuous mediator was al-
lowed in this program. In short, a significant total effect
guarantees the further evaluation of mediation. A statistical
difference found in indirect effect but not in direct effect
was called complete mediation. Partial mediation exists
when indirect and direct effects are significant. The propor-
tion explained by the mediator was computed with the for-
mula (indirect effect/total effect).32 All statistical analyses
were performed using SAS V.9.1 (SAS Institute) and SPSS
software, version 21.0 (SPSS Inc., Chicago). Two-tailed P
values < .05 were considered statistically significant in
this study.
870 H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879

Table 1
Demographic characteristics of participants in varied blood pressure situation status by gender
Variable Male
Normotensive All Hypertension P Undiagnosed Hypertension P Diagnosed Hypertension
N 9652 4822 2000 2822
Age (y), mean  SD 55.71  12.42 60.13  10.86 <.001 58.46  11.91 <.001 61.31  9.88
Married/cohabitation, n (%) 8691 (90.04) 4290 (88.97) .045 1788 (89.40) .384 2502 (88.66)
Educational levels, n (%) <.001 .020
Primary school or below 3256 (33.75) 1781 (36.93) 734 (36.70) 1047 (37.10)
Junior high school 4537 (47.03) 2137 (44.32) 877 (43.85) 1260 (44.65)
Senior high school or above 1855 (19.23) 904 (18.75) 389 (19.45) 515 (18.25)
Average income per month, n <.001 .016
(%)
<500 RMB 3496 (36.22) 1900 (39.40) 741 (37.05) 1159 (41.07)
500- RMB 3062 (31.72) 1544 (32.02) 681 (34.05) 863 (30.58)

1000 RMB 3094 (32.06) 1378 (28.58) 578 (28.90) 800 (28.35)
Smoker, n (%) 6869 (71.17) 3253 (67.46) <.001 1344 (67.20) <.001 1909 (67.65)
Drinker, n (%) 4961 (51.40) 2664 (55.25) <.001 1146 (57.30) <.001 1518 (53.79)
High vegetables and fruits 4459 (46.20) 1783 (36.98) <.001 700 (35.02) <.001 1083 (38.38)
intake, n (%)
High salt diet, n (%) 1831 (18.99) 1006 (20.89) .007 448 (22.47) <.001 558 (19.78)
High fat diet, n (%) 2541 (26.33) 1061 (22.00) <.001 506 (25.30) .342 555 (19.67)
Physical activity, n (%) <.001 <.001
Light 3110 (32.22) 2045 (42.41) 780 (39.00) 1265 (44.83)
Moderate 2770 (28.70) 1207 (25.03) 487 (24.35) 720 (25.51)
Vigorous 3772 (39.08) 1570 (32.56) 733 (36.65) 837 (29.66)
Family history of hypertension, n 1238 (12.83) 1270 (26.34) <.001 276 (13.80) .239 994 (35.22)
(%)
BMI(kg/m2), mean  SD 23.89  3.27 25.73  3.53 <.001 25.44  3.57 <.001 25.93  3.49
Night sleep duration(h), 7.70  1.25 7.85  1.32 <.001 7.89  1.32 <.001 7.82  1.32
mean  SD
Napping duration (min), 63.10  50.10 63.00  49.30 .910 59.15  48.73 .001 65.74  49.53
mean  SD
LDL-C (mmol/L), mean  SD 2.77  0.77 2.91  0.85 <.001 2.96  0.86 <.001 2.87  0.85
LDL-C, low-density lipoprotein cholesterol; BMI, body mass index; SD, standard deviation.

Results
Demographic Characteristics
Although we found no significant interactions (P > .05)
for the effect of night sleep duration on hypertension by
gender, we show the analyses stratified by gender because
previous studies reported a gender-specific association of
night sleep duration and hypertension.14,33 Table 1 presents
the demographic characteristics of the respondents. Among
the 37,317 participants (14,474 males and 22,843 females),
the mean age was 56.00  12.06 and 12,333 demonstrated
hypertension. The age-standardized prevalence of hyperten-
sion was 21.24% for males and 15.95% for females. The
age-standardized prevalence of undiagnosed and diagnosed
hypertension was 11.22% and 10.03% in males and 6.71%
and 9.25% in females, respectively. Compared with those
without hypertension, participants with hypertension had
longer night sleep duration, older age, lower education
level, were unmarried, had a higher BMI, less physical ac-
tivity, and higher serum LDL-C.
Prevalence of Hypertension
Age-adjusted SBP, DBP, and prevalence of hypertension
by gender within each category of sleep duration (Table S1)
is presented in Figure 1. The mean and 95% CI of age-
adjusted SBP and DBP values of the study subjects were
130.27 (128.78–131.75) and 80.86 (79.89–81.83) mm Hg
in males who had
10 hour night sleep duration, respec-
tively. Compared with those who had 7 hour sleep duration,
the subjects who had
10 hour sleep duration had signifi-
cantly higher SBP (127.40, 126.19–128.60) and DBP
(77.45, 76.72–78.17). The age-adjusted prevalence of hy-
pertension were 33.77% in group of <5 hour and 40.27%
in category of
10 hour in males, respectively. Similar re-
sults for females can be also observed (Table S2).

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 H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879 871

Table 1 (continued)
Male Female
P Normotensive All Hypertension P Undiagnosed Hypertension P Diagnosed Hypertension P
15,332 7511 2722 4789
<.001 52.41  12.12 61.04  9.29 <.001 59.54  10.14 <.001 61.89  8.67 <.001
.033 14,005 (91.34) 6421 (85.49) <.001 2385 (87.62) <.001 4036 (84.28) <.001
.004 <.001 <.001 <.001
7216 (47.07) 4901 (65.26) 1659 (60.97) 3242 (67.70)
5955 (38.84) 2053 (27.34) 837 (30.76) 1216 (25.39)
2160 (14.09) 556 (7.40) 225 (8.27) 331 (6.91)
<.001 <.001 <.001 <.001

5128 (33.45) 3054 (40.66) 1032 (37.91) 2022 (42.22)

5185 (33.82) 2514 (33.47) 967 (35.53) 1547 (32.30)
5019 (32.74) 1943 (25.87) 723 (26.56) 1220 (25.48)
<.001 4343 (28.33) 1880 (25.03) <.001 644 (23.66) <.001 1236 (25.81) <.001
.025 508 (3.31) 145 (1.93) <.001 49 (1.80) <.001 96 (2.00) <.001
<.001 6748 (44.01) 2659 (35.40) <.001 953 (35.01) <.001 1706 (35.62) <.001
.351 2537 (16.56) 1222 (16.29) .603 450 (16.56) .993 772 (16.14) .491

<.001 2610 (17.02) 846 (11.26) <.001 346 (12.71) <.001 500 (10.44) <.001
<.001 <.001 <.001 <.001
4226 (27.56) 2598 (34.59) 847 (31.12) 1751 (36.56)
7126 (46.48) 2994 (39.86) 1093 (40.15) 1901 (39.70)
3980 (25.96) 1919 (25.55) 782 (28.73) 1137 (23.74)
<.001 2595 (16.93) 2095 (27.89) <.001 425 (15.61) .091 1670 (34.87) <.001

<.001 24.45  3.40 26.19  3.73 <.001 25.73  3.74 <.001 26.45  3.70 <.001
<.001 7.74  1.25 7.84  1.33 <.001 7.87  1.26 <.001 7.82  1.37 <.001

.014 53.46  50.60 54.67  50.03 .087 51.54  49.07 .061 56.45  50.49 <.001

<.001 2.82  0.80 3.07  0.87 <.001 3.13  0.87 <.001 3.03  0.87 <.001

Association Between Night Sleep Duration and
Hypertension
To further examine the association between sleep dura-
tion and hypertension, analyses were performed using
continuous SBP and DBP as outcomes by fitting multilin-
ear regression models. Positive relationships between long
sleep duration and either SBP or DBP were found in males
(Table 2). ORs and 95% CIs for hypertension associated
with varied sleep duration are presented in Table 3, which
suggests that longest sleep duration (
10 hours) is related
to higher odds of hypertension than in the reference group
(7-hours) in the fully adjusted model in males (OR ¼ 1.52,
95% CI: 1.25–1.84). In the case of longer sleep duration,
there was a 68% (95% CI: 32%–114%) and 32% (95% CI:
3%–69%) elevated prevalence for undiagnosed and diag-
nosed hypertension, respectively, in males. Compared
with reference (7-), ORs and 95% CIs of all hypertension
(OR 1.11, 95% CI: 0.95–1.30), undiagnosed hypertension
(0.99, 0.79–1.24), and diagnosed hypertension (1.21,
1.00–1.45) were observed in those with a
10 hour sleep
duration among females. A U-shaped dose-response asso-
ciation between sleep duration and hypertension was
found in males (P for quadratic term <.001). The dose-
response relationships of sleep duration with hypertension
were further demonstrated through the restricted cubic
spline curves in Figure 2, which suggests that the preva-
lence of diagnosed hypertension may be higher with
longer sleep duration in males (P for non-linear
trend ¼ .040), but not in females (P for non-linear
trend ¼ .307).
Mediation Effects
According to the theory of mediation analysis, mediation
effects were measured in males using as factors serum lipid
values. The result is presented in Figure 3. The estimated
OR for hypertension with longer sleep duration (total

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872 H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879

Figure 1. Age-adjusted SBP (A, B), DBP (C, D) and prevalence of hypertension (E, F) according to varied night sleep duration by
gender. SBP, systolic blood pressure; DBP, diastolic blood pressure.

effect, 1.089; 95% CI, 1.040, 1.139) was comprised of the
direct effect of sleep duration (OR, 1.085; 95% CI, 1.038,
1.137) and the indirect effect mediated by serum LDL-C
(OR, 1.003; 95% CI, 1.001, 1.005) in males subjects.
Approximately 3.5% (95% CI, 2.6%–3.8%) of the
increased odds of hypertension related to sleep duration
was attributable to higher LDL-C (Table S3). We found
that no other factors of blood lipids mediated significantly
the association between sleep duration and hypertension
(data not show).
Discussion
This study demonstrated that there is a dose-response asso-
ciation between night sleep duration and hypertension in adult
males and that serum LDL-C is a mediating effect in the rela-
tionship between sleep duration and hypertension in these sub-
jects. The present study is the first to focus on the sleep-
hypertension association as well as mediation effects on sleep
duration and hypertension in a Chinese rural population.
Located in the central area of China, Henan province
with a population of 94 million in 2015 is an important
agricultural province and its rural population accounts for
53% of the total population. One previous study showed
that the age-standardized prevalence of hypertension in
adults was 20.94% for males and 18.85% for females.34
We observed an association of sleep duration with age-
adjusted BP values using analysis of variance, a method
of controlling for confounders, which was used in previous
studies.35,36 The results of this study demonstrated that
longer habitual night sleep duration is strongly associated
with elevated BP in a Chinese rural population, which is
consistent with a previous report.37 This effect was not sig-
nificant in the group with short sleep duration.
A U-shaped trend showing a correlation between sleep
duration and hypertension is not statistically significant
in the present study, in contrast to what was found in other
studies37,38; this might be because of the relatively fewer
participants in our study who had less than 5 hour of sleep
duration. The finding of an elevated prevalence of hyper-
tension with longer sleep duration is similar to that of
earlier studies,39 which reported that longer sleep duration
(at least 9 hour) was associated with an increased preva-
lence of hypertension. Furthermore, our findings revealed
the importance of a comprehensive examination of poten-
tial confounding mediators and factors when examining
the association between sleep duration and hypertension.
The effect sizes were attenuated after adjustment for a se-
ries of factors including general characteristics and behav-
ioral lifestyles. Several studies33,40–43 noted that short

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 Table 2
Association of night sleep duration with systolic and diastolic blood pressures
BP Night Sleep Duration, (h)
<5
10
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5- 6- 7- 8- 9-
SBP
Male
All hypertension

H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879
Model 1 0.29 (2.67, 2.09) 0.77 (2.26, 0.71) 0.74 (1.64, 0.15) 0 2.07 (1.28, 2.85) 2.81 (1.77, 3.85) 5.92 (4.32, 7.52)
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.

Model 2 1.29 (3.62, 1.05) 0.72 (2.13, 0.69) 0.66 (1.51, 0.19) 0 1.66 (0.91, 2.41) 1.89 (0.89, 2.90) 4.77 (3.20, 6.34)
Undiagnosed hypertension
Model 1 0.22 (2.14, 2.58) 0.36 (1.83, 1.12) 0.54 (1.43, 0.36) 0 1.82 (1.04, 2.61) 2.54 (1.49, 3.59) 4.48 (2.82, 6.15)
Model 2 1.18 (3.36, 1.01) 0.78 (2.14, 0.57) 0.44 (1.26, 0.38) 0 1.49 (0.77, 2.21) 1.75 (0.79, 2.71) 4.34 (2.85, 5.82)
Diagnosed hypertension
Model 1 1.81 (4.00, 0.38) 0.65 (1.97, 0.67) 0.37 (1.16, 0.43) 0 1.33 (0.62, 2.04) 1.42 (0.47, 2.37) 3.75 (2.26, 5.24)
Model 2 0.38 (2.53, 1.76) 0.62 (1.96, 0.72) 0.31 (1.12, 0.50) 0 1.36 (0.64, 2.07) 1.74 (0.78, 2.70) 3.28 (1.75, 4.81)
Female
All hypertension
Model 1 0.92 (1.26, 3.09) 0.79 (2.18, 0.60) 0.03 (0.87, 0.80) 0 0.41 (0.27, 1.10) 3.10 (2.19, 4.01) 6.02 (4.59, 7.44)
Model 2 0.12 (1.96, 2.20) 0.69 (1.98, 0.60) 0.48 (1.26, 0.30) 0 0.00 (0.64, 0.64) 2.05 (1.19, 2.91) 2.64 (1.24, 4.04)
Undiagnosed hypertension
Model 1 1.81 (0.35, 3.97) 0.56 (1.95, 0.83) 0.21 (0.63, 1.05) 0 0.36 (0.33, 1.05) 2.63 (1.70, 3.55) 6.29 (4.85, 7.73)
Model 2 2.36 (4.22, 0.50) 2.23 (3.42, 1.04) 0.86 (1.57, 0.14) 0 0.34 (0.24, 0.93) 1.29 (0.50, 2.07) 1.91 (0.67, 3.14)
Diagnosed hypertension
Model 1 2.35 (4.17, 0.52) 1.78 (2.92, 0.65) 0.93 (1.61, 0.25) 0 0.23 (0.33, 0.79) 1.03 (0.27, 1.78) 0.52 (0.72, 1.77)
Model 2 1.44 (3.28, 0.40) 2.00 (3.18, 0.81) 0.65 (1.37, 0.06) 0 0.33 (0.26, 0.92) 1.01 (0.22, 1.80) 2.41 (1.17, 3.66)
DBP
Male
All hypertension
Model 1 0.11 (1.64, 1.41) 0.69 (1.64, 0.26) 0.56 (1.13, 0.02) 0 0.46 (0.04, 0.96) 0.20 (0.47, 0.87) 1.86 (0.83, 2.88)
Model 2 0.95 (2.52, 0.61) 0.87 (1.82, 0.08) 0.70 (1.27, 0.13) 0 0.34 (0.16, 0.84) 0.01 (0.67, 0.68) 1.79 (0.74, 2.85)
Undiagnosed hypertension
Model 1 0.11 (1.62, 1.40) 0.53 (1.48, 0.41) 0.40 (0.98, 0.17) 0 0.31 (0.19, 0.81) 0.32 (0.36, 0.99) 1.23 (0.16, 2.30)
Model 2 0.22 (1.61, 1.17) 0.87 (1.73, 0.01) 0.49 (1.01, 0.03) 0 0.57 (0.11, 1.03) 0.77 (0.15, 1.38) 2.60 (1.66, 3.55)
Diagnosed hypertension
Model 1 0.84 (2.28, 0.60) 0.86 (1.73, 0.01) 0.55 (1.07, 0.03) 0 0.52 (0.06, 0.99) 0.69 (0.06, 1.31) 2.60 (1.62, 3.58)
Model 2 0.07 (1.43, 1.30) 0.78 (1.64, 0.07) 0.40 (0.91, 0.12) 0 0.45 (0.00, 0.91) 0.82 (0.21, 1.44) 1.85 (0.87, 2.82)
Female
All hypertension
Model 1 0.26 (1.45, 0.93) 1.01 (1.77, 0.24) 0.19 (0.65, 0.27) 0 0.04 (0.34, 0.41) 0.73 (0.23, 1.23) 1.18 (0.40, 1.96)
Model 2 1.04 (2.24, 0.15) 0.89 (1.63, 0.15) 0.47 (0.92, 0.02) 0 0.09 (0.45, 0.28) 0.31 (0.19, 0.80) 0.22 (0.59, 1.02)
Undiagnosed hypertension
Model 1 0.23 (0.96, 1.42) 0.87 (1.64, 0.10) 0.05 (0.51, 0.41) 0 0.06 (0.32, 0.44) 0.66 (0.15, 1.17) 1.36 (0.57, 2.16)
Model 2 0.78 (1.87, 0.30) 1.20 (1.90, 0.50) 0.48 (0.90, 0.06) 0 0.14 (0.20, 0.48) 0.54 (0.08, 1.00) 0.58 (0.14, 1.30)

873
(continued)
874 H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879

sleep duration could enhance the incidence of hyperten-

0.16 (0.60, 0.92)

Model 2: adjusted for age, high salt diet, high vegetables and fruits intake, high fatty diet, physical activity, marital status, smoking status, drinking status, educational levels,
0.84 (0.11, 1.57)
sion, in contrast to our findings. Possible reasons are dif-
ferences in the study populations including living region,
belonging to a different race, having different cultural
backgrounds and lifestyles,44 age differences13 and even

10

gender differences (eg, some included only women).

Several studies explored the association between sleep
0.41 (0.05, 0.87)
0.46 (0.01, 0.92)

duration and hypertension stratified by gender, but statis-

tical differences were not found in males with longer sleep
SBP, systolic blood pressure; DBP, diastolic blood pressure, LDL-C, low-density lipoprotein cholesterol; BMI, body mass index; BP, blood pressure.

durations, again inconsistent with our results.13,14 For the

gender-specific relationship the underlying mechanisms
are not clear, and there are several possible explanations.
9-

One potential reason is that gender discrepancies in health

may be explained by the differences in educational
0.10 (0.24, 0.44)
0.14 (0.21, 0.48)

level.45 In addition, it is possible that the psychosocial

factors and stress differ in males and females. Finally,
males may suffer greater fatigue because work conditions
often differ between genders. Accordingly, males may
have greater susceptibility to hypertension.
8-

Mediation effects were analyzed in relation to sleep

duration and hypertension using as factors serum lipid
7-

0
0

levels. We found that serum LDL-C acted as a mediator

0.57 (0.99, 0.15)

in the effect of sleep duration and hypertension. LDL-C

0.36 (0.78, 0.06)

mediates a part of the association of sleep duration and hy-

pertension, which indicates that this association may be ex-
plained by mechanism of sleep.
average monthly income, family history of hypertension, napping duration, BMI and LDL-C.

Possible mechanisms that might account for the relation-

ship between sleep duration and hypertension have been re-
ported in a variety of previous studies, although they are
6-

controversial.42 Several hypotheses have been put forward.

0.88 (1.57, 0.19)
1.06 (1.76, 0.36)

Primarily, it might be because of changes in normal BP

change as determined by circadian rhythms. The fall in
BP during sleep might be weakened because of insufficient
sleep.46 Moreover, short sleep duration might reduce the
secretion of melatonin leading to an elevated BP.47 There
has been little literature discussing the potential mecha-
5-

nisms behind the association of long sleep duration with

Night Sleep Duration, (h)

hypertension. Long-term long sleep duration might be

1.20 (2.31, 0.08)

linked to poor sleep quality,48 which might be associated

0.33 (1.41, 0.75)

with gender differences. Thus, future research is needed

to elicit the mechanism by which long sleep duration pro-
motes hypertension.
The strengths of this study include elaborate epidemio-
logic profiles, thorough analysis of the association between
<5

sleep duration and undiagnosed and diagnosed hyperten-

sion. The assessment of the mediating effect of serum lipids
Diagnosed hypertension

on the relationship between sleep duration and hyperten-

sion is particularly novel. In addition, few studies have
Model 1: unadjusted.

studied rural populations, who form a large proportion of

Table 2 (continued )

Chinese population and have peculiar lifestyle including

Model 1
Model 2

sleep habits.
Several limitations should not be overlooked in this
study. First, this was a cross-sectional study, and there is
the possibility of reversed causality. Second, some nonhy-
BP

pertensive subjects may inevitably be misclassified as

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Table 3
The relationship between night sleep duration and prevalent hypertension
Hypertension Night Sleep Duration, (h) Py for Trend

H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879
<5 5- 6- 7- 8- 9-
10
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.

Male
All hypertension
Patients*/n 85/246 215/691 716/2489 1585/4980 1377/3865 588/1624 256/579
Model 1 1.13 (0.86–1.48) 0.97 (0.81–1.15) 0.86 (0.78–0.96) 1.00 1.19 (1.08–1.30) 1.21 (1.08–1.37) 1.70 (1.43–2.02) <.001
Model 2 1.07 (0.80–1.44) 0.94 (0.78–1.13) 0.87 (0.78–0.98) 1.00 1.13 (1.03–1.25) 1.11 (0.97–1.26) 1.52 (1.25–1.84) <.001
Undiagnosed hypertension
Patients*/n 28/189 87/563 294/2067 660/4055 573/3061 239/1275 119/442
Model 1 0.89 (0.59–1.35) 0.94 (0.74–1.20) 0.85 (0.73–0.99) 1.00 1.18 (1.05–1.34) 1.19 (1.01–1.40) 1.89 (1.51–2.37) <.001
Model 2 0.84 (0.55–1.27) 0.94 (0.73–1.20) 0.87 (0.75–1.02) 1.00 1.15 (1.01–1.30) 1.13 (0.96–1.34) 1.68 (1.32–2.14) <.001
Diagnosed hypertension
Patients*/n 57/218 128/604 422/2195 925/4320 804/3292 349/1385 137/460
Model 1 1.30 (0.95–1.77) 0.99 (0.80–1.21) 0.87 (0.77–0.99) 1.00 1.19 (1.06–1.32) 1.24 (1.07–1.42) 1.56 (1.26–1.92) <.001
Model 2 1.34 (0.94–1.90) 0.92 (0.72–1.16) 0.88 (0.76–1.02) 1.00 1.12 (0.99–1.27) 1.10 (0.94–1.30) 1.32 (1.03–1.69) .010
Female
All hypertension
Patients*/n 128/373 290/975 1140/3518 2353/7532 2186/6765 1020/2753 394/927
Model 1 1.15 (0.92–1.43) 0.93 (0.81–1.08) 1.06 (0.97–1.15) 1.00 1.05 (0.98–1.13) 1.29 (1.18–1.42) 1.63 (1.42–1.87) <.001
Model 2 0.87 (0.68–1.12) 0.82 (0.69–0.96) 0.97 (0.88–1.07) 1.00 1.02 (0.94–1.10) 1.11 (1.00–1.24) 1.11 (0.95–1.30) <.001
Undiagnosed hypertension
Patients*/n 34/279 100/785 392/2770 886/6065 811/5390 383/2116 116/649
Model 1 0.81 (0.56–1.17) 0.85 (0.68–1.07) 0.96 (0.85–1.10) 1.00 1.04 (0.93–1.15) 1.29 (1.13–1.47) 1.27 (1.03–1.57) <.001
Model 2 0.67 (0.46–0.98) 0.79 (0.63–1.00) 0.94 (0.82–1.07) 1.00 1.03 (0.93–1.15) 1.15 (1.00–1.32) 0.99 (0.79–1.24) <.001
Diagnosed hypertension
Patients*/n 94/339 190/875 748/3126 1467/6646 1375/5954 637/2370 278/811
Model 1 1.35 (1.06–1.73) 0.98 (0.83–1.16) 1.11 (1.00–1.23) 1.00 1.06 (0.98–1.15) 1.30 (1.17–1.45) 1.84 (1.58–2.15) <.001
Model 2 0.99 (0.75–1.31) 0.84 (0.69–1.02) 1.00 (0.89–1.13) 1.00 1.00 (0.91–1.10) 1.07 (0.94–1.21) 1.21 (1.00–1.45) .034
LDL-C, low-density lipoprotein cholesterol; BMI, body mass index.
Model 1: unadjusted.
Model 2: adjusted for age, high salt diet, high vegetables and fruits intake, high fatty diet, physical activity, marital status, smoking status, drinking status, educational levels,
average monthly income, family history of hypertension, napping duration, BMI, and LDL-C.
* The number of people with hypertension.
y
Quadratic trend test.

875
876 H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879

Figure 2. Odds ratios (ORs; solid lines) and 95% confidence intervals (CIs, dashed lines) of night sleep duration for hypertension (A, B),
undiagnosed (C, D) and diagnosed hypertension (E, F) from restricted cubic splines. Adjusted for age, physical activity, high salt diet,
high vegetables and fruit intake, high fat diet, marital status, smoking status, alcohol consumption status, educational level, average
monthly income, family history of hypertension, napping duration, BMI, and LDL-C. LDL-C, low-density lipoprotein cholesterol;
BMI, body mass index.

hypertensive patients, which would lead to information
bias. Third, the data of sleep duration were self-reported,
which might introduce recall bias. However, previous
research has found good correlation between self-reported
sleep duration and sleep duration measured by polysom-
nography or actigraphy.49 Therefore, future prospective
and polycentric studies are needed to identify this
association.
In conclusion, this study found that longer sleep duration
might contribute to the increased prevalence of hyperten-
sion and higher BP in a Chinese rural population. A
dose-response association between night sleep duration
and hypertension was found in this population. Moreover,
LDL-C slightly mediates the association of sleep duration
and hypertension among males, and further studies are
necessary to clarify this mechanism. Longer sleep duration

Figure 3. Mediation analysis to examine

the association between night sleep dura-
tion and hypertension through LDL-C in
males. Adjusted for age, high salt diet,
high vegetables and fruit intake, high fat
diet, marital status, physical activity,
smoking status, alcohol consumption sta-
tus, educational level, average monthly
income, family history of hypertension,
napping duration, and BMI. LDL-C,
low-density lipoprotein cholesterol;
BMI, body mass index.

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 H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879
may not be beneficial for health. It is suggested that people
should develop a good sleeping habits to prevent longer or
shorter night sleep duration.
Acknowledgments
The authors especially are grateful to the participants, all
research staff of the present study and administrators for
their support during the study. The authors would like to
acknowledge Tanko Abdulai and Prof. Ling Wang for
English-language editing.
Authors’ contributions: During the research, C.W. and
R.B. designed the study. H.Z., Y.L., Z.M., M.L.,W.H.,
R.L., X.L., R.T., K.Y., X.Q., J.J., X.Z. and Z.T. directed
the collection of the data. R.L. and Y.L. analyzed the
data. H.Z. and Y.L. wrote the article. R.L., X.L. and X.Q.
provided writing assistance. All authors read and approve
this version of the article.
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 879.e1
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Table S1
Age-adjusted BP values of all, undiagnosed, and diagnosed hypertension by gender
BP Night Sleep Duration, (h) P for Trend

H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879
<5 5- 6- 7- 8- 9-
10
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Male
SBP (mm Hg), mean (95% CI)
All hypertension 125.39 125.51 125.58 126.19 127.75 127.70 130.27 <.001
(123.12–127.67) (124.15–126.87) (124.87–126.30) (125.68–126.69) (127.17–128.32) (126.81–128.59) (128.78–131.75)
Undiagnosed hypertension 120.32 121.22 121.38 121.98 123.35 123.14 125.63 <.001
(118.07–122.58) (119.92–122.53) (120.69–122.06) (121.50–122.47) (122.79–123.91) (122.27–124.01) (124.15–127.11)
Diagnosed hypertension 122.76 122.67 122.62 123.01 124.35 124.43 125.96 <.001
(120.50–125.02) (121.31–124.03) (121.91–123.34) (122.50–123.51) (123.77–124.93) (123.53–125.33) (124.40–127.51)
DBP (mm Hg), mean (95% CI)
All hypertension 78.55 77.83 77.95 78.54 79.13 79.07 80.86 <.001
(77.07–80.04) (76.94–78.71) (77.48–78.42) (78.21–78.87) (78.75–79.50) (78.49–79.65) (79.89–81.83)
Undiagnosed hypertension 75.53 75.44 75.56 76.29 76.78 76.69 78.68 <.001
(74.01–77.05) (74.56–76.32) (75.10–76.02) (75.96–76.62) (76.41–77.16) (76.10–77.27) (77.68–79.68)
Diagnosed hypertension 76.63 76.11 76.21 76.65 77.05 77.19 78.19 <.001
(75.16–78.10) (75.22–76.99) (75.75–76.68) (76.31–76.98) (76.67–77.43) (76.60–77.78) (77.17–79.20)
Female
SBP (mm Hg), mean (95% CI)
All hypertension 123.24 123.35 125.10 125.64 125.82 126.73 127.40 <.001
(121.35–125.14) (122.18–124.52) (124.49–125.72) (125.22–126.07) (125.38–126.27) (126.03–127.43) (126.19–128.60)
Undiagnosed hypertension 117.70 118.23 119.38 120.20 120.21 120.94 120.38 <.001
(115.86–119.55) (117.13–119.33) (118.79–119.96) (119.80–120.59) (119.79–120.63) (120.27–121.61) (119.17–121.59)
Diagnosed hypertension 120.95 120.32 122.11 122.44 122.66 123.28 124.68 <.001
(119.07–122.84) (119.16–121.49) (121.49–122.73) (122.01–122.86) (122.21–123.10) (122.57–123.99) (123.46–125.90)
DBP (mm Hg), mean (95% CI)
All hypertension 76.18 75.77 76.77 77.05 77.05 77.41 77.45 <.001
(75.03–77.32) (75.06–76.48) (76.40–77.14) (76.80–77.31) (76.78–77.32) (76.99–77.83) (76.72–78.17)
Undiagnosed hypertension 73.19 73.53 74.08 74.60 74.51 74.72 74.47 <.001
(72.02–74.36) (72.84–74.23) (73.71–74.45) (74.35–74.85) (74.25–74.78) (74.30–75.15) (73.71–75.24)
Diagnosed hypertension 75.07 74.31 75.33 75.49 75.52 75.80 76.05 <.001
(73.93–76.22) (73.60–75.03) (74.96–75.71) (75.23–75.75) (75.25–75.79) (75.37–76.23) (75.31–76.80)
SBP, systolic blood pressure; DBP, diastolic blood pressure; BP, blood pressure.
 Table S2
Age-adjusted prevalence of hypertension by gender
Prevalence Night Sleep Duration, (h) P for Trend
<5
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5- 6- 7- 8- 9-
Male (%)
All hypertension 33.77 31.55 29.17 31.99 34.70 33.51 40.27 <.001
(28.10–39.95) (28.14–35.18) (27.39–31.02) (30.69–33.32) (33.19–36.24) (31.24–35.86) (36.31–44.35)

H. Zhang et al. / Journal of the American Society of Hypertension 12(12) (2018) 867–879
Undiagnosed hypertension 14.46 15.46 14.32 16.31 18.36 17.80 25.13 <.001
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(10.16–20.18) (12.70–18.70) (12.87–15.90) (15.20–17.49) (17.03–19.77) (15.82–19.98) (21.34–29.34)

Diagnosed hypertension 24.70 20.95 19.17 20.96 22.64 21.70 24.90 <.001
(19.43–30.86) (17.85–24.42) (17.55–20.90) (19.75–22.22) (21.22–24.12) (19.63–23.92) (21.24–28.95)
Female
(%)
All hypertension 27.39 26.08 30.50 29.97 30.16 31.58 32.48 <.001
(23.15–32.08) (23.39–28.96) (28.93–32.11) (28.89–31.08) (29.00–31.33) (29.78–33.43) (29.43–35.68)
Undiagnosed hypertension 9.20 10.70 12.79 13.40 13.53 14.75 13.13 <.001
(6.57–12.73) (8.82–12.93) (11.61–14.07) (12.56–14.29) (12.63–14.48) (13.34–16.29) (10.91–15.72)
Diagnosed hypertension 19.80 17.21 20.86 19.58 19.71 20.22 22.55 <.001
(16.10–24.11) (14.92–19.77) (19.44–22.35) (18.60–20.59) (18.67–20.79) (18.64–21.90) (19.86–25.49)

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Table S3
Mediation analysis of the relationship between night sleep duration and hypertension by LDL-C
Mediation Analysis Parameter Estimate OR (95% CI)
(95% CI)
All hypertension
Total effect 0.085 (0.039, 0.130) 1.089 (1.040, 1.139)
Direct effect—path 0.082 (0.037, 0.128) 1.085 (1.038, 1.137)
c
Path a 0.022 (0.006, 0.038) -
Path b 0.112 (0.058, 0.165) 1.119 (1.060, 1.179)
Indirect effect— 0.003 (0.001, 0.005) 1.003 (1.001, 1.005)
path ab
LDL-C, low-density lipoprotein cholesterol; BMI, body mass index.
Adjusted for age, high salt diet, high vegetables, and fruit intake, high fatty diet, physical activity, marital status, smoking status, drinking
status, educational level, average monthly income, family history of hypertension and napping duration, BMI.
Path ab coefficients represent 10,000 bootstrapped samples and bias-corrected 95% CIs.

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