Research Article|Articles in Press

Association of longitudinal patterns of nighttime sleep duration and daytime napping duration with risk of multimorbidity

Published:April 18, 2023DOI:



      To determine whether longitudinal trajectories of nighttime sleep duration and daytime napping duration are related to subsequent multimorbidity risk. To explore whether daytime napping can compensate for negative effects of short nighttime sleep.


      The current study included 5262 participants from China Health and Retirement Longitudinal Study. Self-reported nighttime sleep duration and daytime napping duration were collected from 2011 to 2015. The 4-year sleep duration trajectories were conducted by group-based trajectory modeling. The 14 medical conditions were defined by self-reported physician diagnoses. Multimorbidity was diagnosed as participants with 2 or more of the 14 chronic diseases after 2015. Associations between sleep trajectories and multimorbidity were assessed by Cox regression models.


      During 6.69 years of follow-up, we observed multimorbidity in 785 participants. Three nighttime sleep duration trajectories and three daytime napping duration trajectories were identified. Participants with persistent short nighttime sleep duration trajectory had the higher risk of multimorbidity (hazard ratio = 1.37, 95% confidence interval: 1.06-1.77), compared with those with persistent recommended nighttime sleep duration trajectory. Participants with persistent short nighttime sleep duration and persistent seldom daytime napping duration had the highest risk of multimorbidity (hazard ratio = 1.69, 95% confidence interval: 1.16-2.46).


      In this study, persistent short nighttime sleep duration trajectory was associated with subsequent multimorbidity risk. Daytime napping could compensate for the risk of insufficient night sleep.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Sleep Health: Journal of the National Sleep Foundation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Miner B.
        • Kryger M.H.
        Sleep in the aging population.
        Sleep Med Clin. 2017; 12: 31-38
        • Mander B.A.
        • Winer J.R.
        • Walker M.P.
        Sleep and human aging.
        Neuron. 2017; 94: 19-36
        • Rodriguez J.C.
        • Dzierzewski J.M.
        • Alessi C.A.
        Sleep problems in the elderly.
        Med Clin N Am. 2015; 99: 431-439
        • Li C.
        • Shang S.
        Relationship between sleep and hypertension: findings from the NHANES (2007-2014).
        Int J Environ Res Public Health. 2021; 18: 7867
        • Wang C.
        • Bangdiwala S.I.
        • Rangarajan S.
        • et al.
        Association of estimated sleep duration and naps with mortality and cardiovascular events: a study of 116, 632 people from 21 countries.
        Eur Heart J. 2019; 40: 1620-1629
        • Leng Y.
        • Redline S.
        • Stone K.L.
        • Ancoli-Israel S.
        • Yaffe K.
        Objective napping, cognitive decline, and risk of cognitive impairment in older men.
        Alzheimers Dement. 2019; 15: 1039-1047
        • Xiao Q.
        • Arem H.
        • Pfeiffer R.
        • Matthews C.
        Prediagnosis sleep duration, napping, and mortality among colorectal cancer survivors in a large US cohort.
        Sleep. 2017; 40
        • Chen G.
        • Tang K.
        • Chen F.
        • et al.
        Afternoon nap and nighttime sleep with risk of micro- and macrovascular disease in middle-aged and elderly population.
        Int J Cardiol. 2015; 187: 553-555
        • Mantua J.
        • Spencer R.M.C.
        Exploring the nap paradox: are mid-day sleep bouts a friend or foe?.
        Sleep Med. 2017; 37: 88-97
        • Xu X.
        • Mishra G.D.
        • Jones M.
        Evidence on multimorbidity from definition to intervention: an overview of systematic reviews.
        Ageing Res Rev. 2017; 37: 53-68
        • Nicholson K.
        • Rodrigues R.
        • Anderson K.K.
        • Wilk P.
        • Guaiana G.
        • Stranges S.
        Sleep behaviours and multimorbidity occurrence in middle-aged and older adults: findings from the Canadian Longitudinal Study on Aging (CLSA).
        Sleep Med. 2020; 75: 156-162
        • Ruiz-Castell M.
        • Makovski T.T.
        • Bocquet V.
        • Stranges S.
        Sleep duration and multimorbidity in Luxembourg: results from the European Health Examination Survey in Luxembourg, 2013-2015.
        BMJ Open. 2019; 9e026942
        • Reis C.
        • Dias S.
        • Rodrigues A.M.
        • et al.
        Sleep duration, lifestyles and chronic diseases: a cross-sectional population-based study.
        Sleep Sci. 2018; 11: 217-230
        • Wang Y.M.
        • Song M.
        • Wang R.
        • et al.
        Insomnia and multimorbidity in the community elderly in China.
        J Clin Sleep Med. 2017; 13: 591-597
        • He L.
        • Biddle S.J.H.
        • Lee J.T.
        • et al.
        The prevalence of multimorbidity and its association with physical activity and sleep duration in middle aged and elderly adults: a longitudinal analysis from China.
        Int J Behav Nutr Phys Act. 2021; 1877
        • Sindi S.
        • Pérez L.M.
        • Vetrano D.L.
        • et al.
        Sleep disturbances and the speed of multimorbidity development in old age: results from a longitudinal population-based study.
        BMC Med. 2020; 18382
        • Kyprianidou M.
        • Panagiotakos D.
        • Kambanaros M.
        • Makris K.C.
        • Christophi C.A.
        Quality of sleep in the Cypriot population and its association with multimorbidity: a cross-sectional study.
        Front Public Health. 2021; 9693332
        • Ohayon M.M.
        • Carskadon M.A.
        • Guilleminault C.
        • Vitiello M.V.
        Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan.
        Sleep. 2004; 27: 1255-1273
        • Wang Y.H.
        • Wang J.
        • Chen S.H.
        • et al.
        Association of longitudinal patterns of habitual sleep duration with risk of cardiovascular events and all-cause mortality.
        JAMA Netw Open. 2020; 3e205246
        • Sabia S.
        • Fayosse A.
        • Dumurgier J.
        • et al.
        Association of sleep duration in middle and old age with incidence of dementia.
        Nat Commun. 2021; 122289
        • Yi S.J.
        • Jeong Y.M.
        • Kim J.H.
        Relationship between sleep duration trajectories and self-rated depressive symptoms in South Koreans with physical disabilities.
        Healthcare [Basel]. 2021; 9
        • Chen J.
        • Patel S.R.
        • Redline S.
        • et al.
        Weekly sleep trajectories and their associations with obesity and hypertension in the Hispanic/Latino population.
        Sleep. 2018; 41
        • Zhao Y.
        • Hu Y.
        • Smith J.P.
        • Strauss J.
        • Yang G.
        Cohort profile: the China Health and Retirement Longitudinal Study (CHARLS).
        Int J Epidemiol. 2014; 43: 61-68
        • Jones B.L.
        • Nagin D.S.
        A note on a stata plugin for estimating group-based trajectory models.
        Sociol Methods Res. 2013; 42: 608-613
        • Nagin D.S.
        • Odgers C.L.
        Group-based trajectory modeling in clinical research.
        Annu Rev Clin Psychol. 2010; 6: 109-138
        • Nguena Nguefack H.L.
        • Pagé M.G.
        • Katz J.
        • et al.
        Trajectory modelling techniques useful to epidemiological research: a comparative narrative review of approaches.
        Clin Epidemiol. 2020; 12: 1205-1222
        • Helbig A.K.
        • Stöckl D.
        • Heier M.
        • et al.
        Relationship between sleep disturbances and multimorbidity among community-dwelling men and women aged 65-93 years: results from the KORA Age Study.
        Sleep Med. 2017; 33: 151-159
        • Pan Z.
        • Huang M.
        • Huang J.
        • Yao Z.
        • Lin Z.
        Association of napping and all-cause mortality and incident cardiovascular diseases: a dose-response meta analysis of cohort studies.
        Sleep Med. 2020; 74: 165-172
        • Häusler N.
        • Haba-Rubio J.
        • Heinzer R.
        • Marques-Vidal P.
        Association of napping with incident cardiovascular events in a prospective cohort study.
        Heart. 2019; 105: 1793-1798
        • Lin J.F.
        • Li F.D.
        • Chen X.G.
        • et al.
        Association of postlunch napping duration and night-time sleep duration with cognitive impairment in Chinese elderly: a cross-sectional study.
        BMJ Open. 2018; 8e023188
        • Faraut B.
        • Nakib S.
        • Drogou C.
        • et al.
        Napping reverses the salivary interleukin-6 and urinary norepinephrine changes induced by sleep restriction.
        J Clin Endocrinol Metab. 2015; 100: E416-426
        • Huang T.
        • Mariani S.
        • Redline S.
        Sleep irregularity and risk of cardiovascular events: the multi-ethnic study of atherosclerosis.
        J Am Coll Cardiol. 2020; 75: 991-999
        • Dzierzewski J.M.
        • Donovan E.K.
        • Kay D.B.
        • Sannes T.S.
        • Bradbrook K.E.
        Sleep inconsistency and markers of inflammation.
        Front Neurol. 2020; 111042
        • Huang T.
        • Redline S.
        Cross-sectional and prospective associations of actigraphy-assessed sleep regularity with metabolic abnormalities: the multi-ethnic study of atherosclerosis.
        Diabetes Care. 2019; 42: 1422-1429
        • Fang Y.
        • Forger D.B.
        • Frank E.
        • Sen S.
        • Goldstein C.
        Day-to-day variability in sleep parameters and depression risk: a prospective cohort study of training physicians.
        NPJ Digit Med. 2021; 428
        • Li X.
        • Pang X.
        • Liu Z.
        • et al.
        Joint effect of less than 1h of daytime napping and seven to 8h of night sleep on the risk of stroke.
        Sleep Med. 2018; 52: 180-187
        • Zhou L.
        • Yu K.
        • Yang L.
        • et al.
        Sleep duration, midday napping, and sleep quality and incident stroke: the Dongfeng-Tongji cohort.
        Neurology. 2020; 94: e345-e356
        • Han X.
        • Liu B.
        • Wang J.
        • et al.
        Long sleep duration and afternoon napping are associated with higher risk of incident diabetes in middle-aged and older Chinese: the Dongfeng-Tongji cohort study.
        Ann Med. 2016; 48: 216-223
        • Friedman E.
        • Shorey C.
        Inflammation in multimorbidity and disability: an integrative review.
        Health Psychol. 2019; 38: 791-801
        • Ferrucci L.
        • Fabbri E.
        Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty.
        Nat Rev Cardiol. 2018; 15: 505-522
        • Besedovsky L.
        • Lange T.
        • Haack M.
        The sleep-immune crosstalk in health and disease.
        Physiol Rev. 2019; 99: 1325-1380
        • Faraut B.
        • Boudjeltia K.Z.
        • Vanhamme L.
        • Kerkhofs M.
        Immune, inflammatory and cardiovascular consequences of sleep restriction and recovery.
        Sleep Med Rev. 2012; 16: 137-149