changes. Adults are sleeping less to get more work accomplished and are staying up later to watch television or use the Internet (NSF, 2005b).

Sleep Loss Affects Health

In the past 10 or more years, research has overturned the dogma that sleep loss has no health effects, apart from daytime sleepiness. The studies discussed in this section suggest that sleep loss (less than 7 hours per night) may have wide-ranging effects on the cardiovascular, endocrine, immune, and nervous systems, including the following:

  • Obesity in adults and children

  • Diabetes and impaired glucose tolerance

  • Cardiovascular disease and hypertension

  • Anxiety symptoms

  • Depressed mood

  • Alcohol use

Many of the studies find graded associations, insofar as the greater the degree of sleep deprivation, the greater the apparent adverse effect (although the difference may not reach statistical significance). Another common finding is the relationship that adverse effects occur with either short or long sleep duration, as compared to a sleep time of 7 to 8 hours. This type of association is often described as a U-shaped relationship. It should be noted, however, that the majority of these studies are observational in nature, and thus definite causal inferences cannot be made. The associations observed in some studies might be subject to different types of biases, such as temporal (or “reverse causality”) bias, whereby sleep loss might be a manifestation or a symptom of the disease in question. The latter is most likely in cross-sectional studies but could also affect associations observed in cohort studies, particularly when they are relatively short term and/or when the disease under investigation has a long preclinical phase. In the discussion that follows, and wherever possible, potential physiological mechanisms behind epidemiological associations and that support the plausibility of a true causal relationship are noted.

Sleep Loss Is Associated with Obesity

When a person sleeps less than 7 hours a night there is a dose-response relationship between sleep loss and obesity: the shorter the sleep, the greater the obesity, as typically measured by body mass index (BMI)—weight in kilograms divided by height in meters squared. Although most studies were cross-sectional, one prospective study was a 13-year cohort study of nearly



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