Physicians' Academy for Cardiovascular Education

Sleeping long enough further reduces CVD risk in people who have a healthy lifestyle

Literature - Hoevenaar-Blom MP, Spijkerman AMW, Kromhout D en Verschuren WMM - European Journal of Preventive Cardiology 3 July 2013

Sufficient sleep duration contributes to lower cardiovascular disease risk in addition to four traditional lifestyle factors: the MORGEN study

Hoevenaar-Blom MP, Spijkerman AMW, Kromhout D en Verschuren WMM
European Journal of Preventive Cardiology 3 July 2013 DOI: 10.1177/2047487313493057


Physical activity, diet, alcohol consumption and smoking have all been shown to be individually associated with incident cardiovascular disease (CVD). It has recently been shown that poor sleep duration is also an independent risk factor for CVD [1,2]. The only two studies who have included sleep duration as a risk factor as yet have shown independent associations of sleep with CVD risk, and a reduction in risk for a lifestyle score that takes sleep into account [3,4]. The additional impact of sleep on top of other healthy lifestyle factors was not assessed.
This study aimed to examine whether sufficient sleep duration (>7 hours) further reduces CVD incidence in addition to sufficient physical activity, a healthy diet, (moderate) alcohol consumption and non-smoking. The Monitoring Project on Risk Factors for Chronic Diseases (MORGEN) is a Dutch study that followed 6672 men and 7967 women to the first nonfatal CV event or death, during a mean period of 12 years.

Main results

  • In 10-14 years of follow-up, 607 composite CVD events occurred, of which 129 were fatal (21%), 367 (60%) were non-fatal myocardial infarctions and 111 were nonfatal strokes (18%).
  • Distribution of the number of healthy lifestyle factors was similar for men and women: 6% adhered to no or one healthy lifestyle factor, and 12% adhered to all five.
  • Non-smoking was strongly inversely associated with composite CVD (HR: 0.57, 95%CI: 0.48-0.67), just like sufficient sleep duration (HR: 0.78, 95%CI: 0.65-0.94) and (moderate) alcohol consumption (HR: 0.79, 95%CI: 0.63-0.98).
  • Non-smoking (HR: 0.61, 95%CI: 0.43-0.86) and sufficient sleep duration (HR: 0.57, 95%CI: 0.39-0.83) were strongly inversely associated with fatal CVD.
  • Adhering to an increasing number of healthy lifestyle factors was inversely related to fatal and composite CVD. The largest reduction in risk for two adjacent risk categories was seen between adhering to two healthy lifestyle factors as compared to one or none.
  • Adherence to all four healthy lifestyle factors was associated with a 57% lower risk of composite CVD (HR: 0.43, 95%CI: 0.31-0.59) and a 67% lower risk of fatal CVD (HR: 0.33, 95%CI:0.16-0.68). When adding sufficient sleep duration to adherence to all four healthy lifestyle factors, the CVD risk was even lower: HR: 0.35 (95%CI: 0.23-0.52) for composite CVD and HR: 0.17 (95%CI: 0.07-0.43) for fatal CVD.


Sleeping sufficiently in addition to adhering to all four traditional healthy lifestyle factors yielded a 65% lower risk of composite CVD and an 83% lower risk of fatal CVD. Although risk is low in people adhering to all four traditional healthy lifestyle factors, additional risk reduction can be obtained if one sleeps >7 hours.  If all patients would adhere to all five healthy lifestyle factors, 36% of composite CVD and 57% of fatal CVD could theoretically be prevented or postponed. 


1. Hoevenaar-Blom MP, Spijkerman AM, Kromhout D, et al. Sleep duration and sleep quality in relation to 12-year cardiovascular disease incidence: the MORGEN Study. Sleep 2011; 34: 1487–1492.
2. Cappuccio FP, Cooper D, D’Elia L, et al. Sleep duration predicts cardiovascular outcomes: a systematic review and meta-analysis of prospective studies. Eur Heart J 2011; 32: 1484–1492.
3. Odegaard AO, Koh WP, Gross MD, et al. Combined lifestyle factors and cardiovascular disease mortality in Chinese men and women: the Singapore Chinese health study. Circulation 2011; 124: 2847–2854.
4. Eguchi E, Iso H, Tanabe N, et al. Healthy lifestyle behaviours and cardiovascular mortality among Japanese men and women: the Japan collaborative cohort study. Eur Heart J 2012; 33: 467–477.

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