Hindawi Publishing Corporation
Sleep Disorders
Volume 2014, Article ID 959152, 7 pages
http://dx.doi.org/10.1155/2014/959152
Research Article
Daytime Sleepiness: Associations with Alcohol Use and
Sleep Duration in Americans
Subhajit Chakravorty,1,2 Nicholas Jackson,3 Ninad Chaudhary,2,4 Philip J. Kozak,5
Michael L. Perlis,2 Holly R. Shue,6 and Michael A. Grandner2
1
MIRECC VISN-4, Philadelphia Veterans Afairs Medical Center, University & Woodland Avenues, Philadelphia, PA 19104, USA
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
3
University of Southern California, Los Angeles, CA 90033, USA
4
West Chester University of Pennsylvania, West Chester, PA 19383, USA
5
School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
6
Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
2
Correspondence should be addressed to Subhajit Chakravorty;
[email protected]
Received 30 June 2013; Revised 29 October 2013; Accepted 26 November 2013; Published 29 January 2014
Academic Editor: Michel M. Billiard
Copyright © 2014 Subhajit Chakravorty et al. his is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
he aim of the current analysis was to investigate the relationship of daytime sleepiness with alcohol consumption and sleep duration
using a population sample of adult Americans. Data was analyzed from adult respondents of the National Health and Nutritional
Examination Survey (NHANES) 2007-2008 (� = 2919) using self-reported variables for sleepiness, sleep duration, and alcohol
consumption (quantity and frequency of alcohol use). A heavy drinking episode was deined as the consumption of ≥5 standard
alcoholic beverages in a day. Logistic regression models adjusted for sociodemographic variables and insomnia covariates were used
to evaluate the relationship between daytime sleepiness and an interaction of alcohol consumption variables with sleep duration.
he results showed that daytime sleepiness was reported by 15.07% of the subjects. In univariate analyses adjusted for covariates,
an increased probability of daytime sleepiness was predicted by decreased log drinks per day [OR = 0.74 (95% CI, 0.58–0.95)],
a decreased log drinking frequency [0.90 (95% CI, 0.83–0.98)], and lower sleep duration [OR = 0.75 (95% CI, 0.67–0.84)]. An
interaction between decreased sleep duration and an increased log heavy drinking frequency predicted increased daytime sleepiness
(� = 0.004). hus, the efect of sleep duration should be considered when evaluating the relationship between daytime sleepiness
and heavy drinking.
1. Introduction
Daytime sleepiness is highly prevalent. 19.5% of Americans
sufer from moderate sleepiness and 11% sufer from severe
sleepiness [1]. hese prevalence rates are of concern given
that daytime sleepiness afects nearly every aspect of human
functioning and is a substantial risk factor for accidents and
injuries [2]. he combination of daytime sleepiness and atrisk vocations vulnerable to such negative efects magniies
the risk for adverse outcomes of accidents, for example,
sleepiness in truck drivers, airline pilots, medical personnel,
mass transit operators, and so forth [3]. he perils associated
with these conditions underscore the need to identify factors
that may serve to aggravate sleepiness, or may serve as vulnerability for sleepiness. One such condition may be the use of
or the abuse of alcohol.
To date, some studies have been undertaken to evaluate
the relationship between daytime sleepiness and alcohol
consumption. he outcomes from these studies were inconsistent. Acute drinking episodes were found to be associated
with complaints of sleepiness (as a component of hangover
symptoms) [4] and an acute impairment in objective measures of lying the following day (ater an acute drinking
episode) [5]. In contrast, increased alcohol consumption
2
(>7 drinks per week) has been shown to be associated with
a decreased likelihood of excessive daytime sleepiness in the
elderly [6]. hese studies difered in several ways, including
the following: the duration of alcohol use (i.e., acute versus
chronic use), the age of the cohort studied, and the sleep duration immediately prior to the study (or the typical total sleep
duration).
he last of these issues is the role of sleep duration, which
is particularly important as an increased consumption of
alcohol has been independently associated with short sleep
duration in some prior epidemiological studies [7–9]. Sleep
duration has been investigated as a moderator in this relationship between alcohol consumption and sleepiness in a
few laboratory-based studies. Some of these studies involved
paradigms with partial sleep restriction and some with sleep
extension (longer than typical ad lib sleep). In the partial sleep
deprivation studies, Rupp and colleagues found that nocturnal
alcohol consumption prior to bedtime and in conjunction
with a partial sleep restriction increased the sleepiness at
night (as compared to those who did not consume alcohol)
[10]. Roehrs and colleagues found that despite an increase
in the sleep latency on the Multiple Sleep Latency Test
(MSLT) with partial sleep deprivation and moderate nocturnal alcohol consumption, no interaction between alcohol
consumption and sleep deprivation was seen [11]. Similarly, a
study by Horne and colleagues failed to show a diference in
daytime sleepiness in the sleep-deprived conditions, with or
without aternoon alcohol consumption, by using a diferent
paradigm [12]. In the sleep extension studies, Lumley and colleagues found no diferences in objective sleepiness on MSLT
in subjects with an 11-hour total time in bed and morning
alcohol consumption (as compared to normal sleep or partial
sleep deprivation conditions) [13]. In another study, Roehrs
and colleagues found that sleep extension with a 10-hour
time in bed and morning alcohol consumption showed a
decreased objectively measured sleepiness with a MSLT test
[14].
As can be seen from the above summary, the data to date
are mixed. If trends are evident it appears that heavy alcohol
consumption is associated with shorter sleep durations, and
objective daytime sleepiness may be associated with acute
alcohol use/alcohol abuse in association with sleep deprivation. hese indings must be considered tentative, as there
are only a few studies with mixed results, and the alcohol
measures are not well operationalized. With respect to the
alcohol measures, the variables used rarely allow for a comprehensive assessment that takes into account dose (amount
of alcohol per occasion), use frequency (number of occasions
using alcohol per day or week), and use in the hazardous
range (the presence of heavy drinking, and the frequency of
heavy drinking as deined as the use of ≥5 drinks per session)
[15, 16].
Accordingly, using a nationally representative sample, we
explored the interactions between self-reported alcohol consumption and sleep duration variables and their association
to daytime sleepiness while controlling for covariates and
symptoms related to several intrinsic sleep disorders.
Sleep Disorders
2. Methods
2.1. Design and Setting. his investigation utilized the 20072008 National Health and Nutrition Examination Survey
(NHANES). his annual survey, conducted by the Centers for
Disease Control and Prevention, assesses the demographic,
health, and nutritional characteristics in the US population
through in-person interviews, physical examinations, and
laboratory tests. he unweighted response rate for the overall sample was 78.4%. In order to compensate for underrepresentation, African Americans, Hispanics, and adults
over 60 were over-sampled [17].
2.2. Sample Size. Out of the initial participants (� = 10,149),
we excluded children and adolescents <18 years of age (� =
3921), those with a lifetime history of drug use (� = 1896),
those without response to outcome variables (� = 21), and
those missing data on predictor variables (� = 1079), and
covariates (� = 313). he inal sample consisted of 2919
subjects. Drug use history was assessed for any lifetime use
of marijuana, cocaine, methamphetamine, or illicit opiates
individually; the response was coded dichotomously as “yes”/
“no.’’
2.3. Measures
2.3.1. Sleep. (a) Daytime sleepiness (DS) was assessed with
the question, “In the past month, how oten did you feel excessively or overly sleepy during the day?” (b) Sleep Duration
(SD) was investigated with the question, “How much sleep
do you usually get at night on weekdays or workdays?” his
question was similar to that used in prior studies [18, 19]. (c)
Insomnia symptoms: (i) diiculty falling asleep (DFA) was
assessed using the question “In the past month, how oten did
you have trouble falling asleep?” (ii) diiculty maintaining
sleep (AWAK) was assessed with the question “In the past
month, how oten did you wake up during the night and
had trouble getting back to sleep?” (iii) Nonrestorative sleep
(NRS) was evaluated with the question,“In the past month,
how oten did you feel unrested during the day, no matter
how many hours of sleep you have had?” he responses to
the DS, SL, AWAK, and SQ variables were presented with
the following severity options: “0” (never), “1” (rarely: 1 time/
month), “2” (sometimes: 2–4 times/month), “3” (oten: 5–15
times/month), and “4” (almost always: 16–30 times/month).
he response to the SD variable was recorded as a number,
rounded to the nearest decimal point and was assessed as a
continuous variable.
2.3.2. Alcohol-Related Variables. he quantity of alcohol in
a drink was evaluated in terms of a standard alcoholic
drink [20]. he alcohol consumption variables used in this
investigation were in line with those used in prior studies,
and included the following [16, 21]: (a) drinks/day: this
variable was assessed with “In the past 12 months, on those
days that you drank alcoholic beverages, on an average,
how many drinks did you have?” (b) drinking frequency
was investigated using the question “In the past 12 months,
how oten did you drink any type of alcoholic beverage?”
(c) heavy drinking status was assessed using the question
Sleep Disorders
3
“In the past 12 months, on how many days did you have 5 or
more drinks of any alcoholic beverage?” (d) heavy drinking
frequency was evaluated using the question, “In the past 12
months, on how many days did you have 5 or more drinks
of any alcoholic beverage?” Drinks/day, drinking frequency
and binge-drinking frequency were recorded continuously
as number of days. Heavy drinking status was recorded
dichotomously, as “present” or “absent.’’
(StataCorp LP, Stata Statistical Sotware: Release 12. College
Station, TX).
2.3.3. Covariates. he variables included in these analyses
included, age, gender, race/ethnicity (White, Black/African
American, Hispanic, and other), marital status, education,
income, body mass index (BMI; objectively measured),
depression (over past two weeks), anxiety (days anxious in
past month), access to health insurance, physical health,
mental health, exercise, and smoking (smoking days in past
month). All the above-mentioned questions were assessed as
part of the NHANES interview with the responses being selfreported by the subjects.
3.2. Sleep-Related Characteristics. Daytime sleepiness was
reported by 15.07% of the subjects. he mean (SD) sleep
duration was 6.91 (SD = 1.36) hours. Amongst them, 56.72%
had sleep duration within the normal range (7-8 hours a
night), 36.12% had short sleep duration (≤6 hours a night),
and 7.16% had long sleep duration (≥8 hours a night), with
nonrestorative sleep being the commonest insomnia symptom (22.32%), Table 1.
2.4. Statistical Analysis. Two-year full sample weights were
used to adjust for unequal probability of being selected
among noncoverage or nonresponse population, as recommended [17]. Daytime sleepiness was assessed with the question, “In the past month, how oten did you feel excessively
or overly sleepy during the day?” Daytime sleepiness was
assessed as a dichotomous variable (“presence” or “absence”
of daytime sleepiness) based on the distribution of the
response. he sleep duration was assessed as a continuous variable. Alcohol consumption was assessed using four
variables, including, drinks/day, drinking frequency, heavy
drinking status, and heavy drinking frequency. Heavy drinking status was assessed as a dichotomous variable (“presence”
or “absence” of heavy drinking). he remaining 3 alcohol
variables were assessed as continuous variables, drinks/day,
drinking frequency, and heavy drinking frequency. Log�
transformation was conducted for the variables including,
drinks/day, drinking frequency, and heavy drinking frequency because of the skewness in the data, prior to the
bivariate and multivariable analyses. Some of the covariates were dichotomized because of the skewed distribution
and included insomnia variables (reporting a complaint ≥5
times a month/<5 times a month), depression, and anxiety
symptoms (symptoms <15 days/≥15 days over last month).
he relationships between daytime sleepiness (dependent
variable) and alcohol consumption variables were assessed
using multinomial logistic regression analyses. his relationship was assessed using three diferent models to adjust for
covariates. Model 1 assessed the crude relationship between
daytime sleepiness and the alcohol consumption variables or
sleep duration. Model 2 assessed the relationship in model
1, adjusted for the covariates mentioned above. Model 3
assessed for this relationship in Model 2, further adjusted
for insomnia symptoms. Interactive models evaluated for the
presence of 2-way interactions, of whether the efects of one
alcohol consumption variable depended on levels of a second
category, that is, the sleep duration in predicting daytime
sleepiness. Analyses were conducted using Stata version 12
3. Results
3.1. Subjects. he average subject in this study which was
middle-aged female, college graduate, who identiied herself
as of Caucasian race, non-Hispanic in ethnicity, married, was
overweight and had health insurance, Table 1.
3.3. Alcohol Consumption. he average subject reported an
alcohol consumption in the moderate range with a mean
(SD) alcohol consumption of 1.25 (SD = 2.28) drinks per day
within the last 12 months. Amongst those drinking alcohol
in the past 12 months, 9.77% of the respondents reported
heavy drinking (≥5 drinks a day), and with a heavy drinking
frequency of 4.23 (SD = 27.18) days of over the last 12 months,
Table 1.
3.4. he Relationship of Daytime Sleepiness with
Alcohol Consumption and Sleep Duration
3.4.1. Alcohol Consumption. Subjects with daytime sleepiness
reported lower alcohol consumption as compared to those
without daytime sleepiness (0.99 ± 1.65 drinks and 1.29 ± 2.38
drinks resp., � = 0.002). In analyses adjusted for sociodemographic variables and insomnia covariates, a decreased risk of
daytime sleepiness was predicted by log drinks per day, that
is, each percent increase in the number of alcoholic drinks
per day [OR = 0.74 (95% CI, 0.58–0.95), � = 0.019]. A similar
relationship of a decreased risk of daytime sleepiness was seen
with increased log drinking frequency, that is, each percent
increase in the frequency of drinking and with nonsigniicant
trends for log binge-drinking frequency predicting a lower
risk of daytime sleepiness, Table 2.
3.4.2. Sleep Duration. hose with daytime sleepiness
reported a lower sleep duration as compared to those without
daytime sleepiness (6.38 ± 1.63 hours and 7.00 ± 1.28 hours,
resp., � < 0.0001). In analyses adjusted for sociodemographic
variables and insomnia covariates, a decreased probability of
daytime sleepiness was predicted by higher sleep duration
[OR = 0.75 (95% CI, 0.67–0.84), � < 0.001], Table 2.
3.5. Interactions between Alcohol Consumption and Sleep
Duration on Daytime Sleepiness. In models adjusted for
covariates, an interaction between a decreased sleep duration
and an increased log frequency of binge-drinking predicted
increased daytime sleepiness (� = 0.004), such that with
each percent increase in the binge-drinking frequency and
4
Sleep Disorders
Table 1: Baseline demographics.
Variable
Age (years)
Gender
Female
Mean/%
53.1
57.84%
White
Black
Other
68.05%
10.20%
21.76%
Hispanic
Days with poor mental health (past month)
≥15 days (past month)
≥15 days (past month)
Moderate/vigorous exercise
14.71%
29.1
3.21
12.61%
6.01%
124
Education
College graduate
Less than high school
High school graduate
Some college education
26.51%
21.30%
25.88%
26.31%
Income (per year)
>75,000
<20,000
20,000–25,000
25,000–35,000
35,000–45,000
45,000–55,000
55,000–65,000
65,000–75,000
29.79%
17.24%
7.65%
12.45%
10.40%
8.78%
7.03%
6.66%
General heath
Excellent
Very good
Good
Poor
Very poor
16.77%
29.57%
34.31%
15.80%
3.55%
Marital status
Married
Widowed
Divorced/separated
Never married
Living with partner
63.04%
9.43%
11.11%
12.29%
4.13%
Insured
Present
Yes
Present
Sleep duration (hrs)
Diiculty falling asleep (DFA, ≥5 nights/month)
Diiculty maintaining sleep (AWAK, ≥5 nights/month)
Nonrestorative sleep (NRS, ≥5 nights/month)
85.35%
91.06%
11.03%
15.07%
6.91
16.05%
18.15%
22.32%
Drinks/day (past 12 months)
Drinking days (past 12 months)
Present (past 12 months)
Heavy drinking days (past 12 months)
1.25
40.9
9.77%
4.23
Race
Ethnicity
BMI (Kg/m2 )
Mental health
Anxiety
Depression
Exercise (in minutes)
Insurance status
Cafeine use
Smoker
Daytime sleepiness
Sleep duration
Insomnia symptoms
Alcohol quantity
Drinking frequency
Heavy drinking status
Heavy drinking frequency
S.D.: standard deviation.
Categories
S.D.
17.4
6.6
7.30
187
1.36
2.28
85.8
27.18
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5
Table 2: Associations of daytime sleepiness with alcohol variables and sleep duration.
Predictor
Subgroup
Log drinks/day
Log drinking frequency
Alcohol
Heavy drinking status
Log heavy drinking frequency
Sleep duration
Hours
Model 1
OR (95% CI)
P
0.72 (0.58–0.90) 0.0046
0.87 (0.81–0.93)
0.0001
0.68 (0.43–1.07)
0.0971
0.87 (0.74–1.02)
0.0805
0.71 (0.64–0.80) <0.0001
Model 2
OR (95% CI)
0.78 (0.60–1.01)
0.91 (0.84–0.99)
0.76 (0.48–1.21)
0.89 (0.75–1.06)
0.75 (0.67–0.84)
Model 3
OR (95% CI)
P
0.74 (0.58–0.95)
0.0197
0.90 (0.83–0.98)
0.0129
0.71 (0.45–1.11)
0.1311
0.88 (0.75–1.04)
0.1366
0.75 (0.67–0.84) <0.0001
P
0.0557
0.0297
0.2471
0.1891
<0.0001
OR: odds ratio, CI: conidence interval, P: P value, and mo: months.
Model 1: unadjusted model.
Model 2: adjusted for age, BMI, gender, race, marital status, education, income, depression, insurance, health status, anxiety, mental health, and exercise.
Model 3: model 2 + insomnia status.
Table 3: Daytime sleepiness and its association with an interaction of alcohol consumption variables on sleep duration.
Moderating variable
Log drinks/day
Log drinking frequency
Heavy drinking status
Log heavy drinking frequency
Model 1 (P)
0.131
0.323
0.059
0.005
Model 2 (P)
0.627
0.628
0.286
0.003
Model 3 (P)
0.626
0.602
0.289
0.004
0.8
0.6
0.4
0.2
5
ks
)
0.0
0.0
0.2
0.4
2
1
12
0
dr
3
4
6
Sleep
durat 8
10
ion (h
rs)
≥5
2
in
4
da
ys
he association between subjective sleepiness as it relates to
alcohol consumption and sleep duration from a population
perspective is currently unknown. In this study, we explored
this relationship using data from the 2007-2008 NHANES
survey using self-reported measures. In univariate analyses,
the presence of daytime sleepiness was inversely associated
with the drinks per day, drinking frequency, and sleep
duration. In the inal model adjusted for covariates, an interaction between heavy drinking frequency and sleep duration
predicted daytime sleepiness, such that an increased probability of daytime sleepiness was reported with each percent
increase in the frequency of heavy drinking and a decrease in
the sleep duration (in hours).
Short sleep duration has been linked with heavy alcohol
consumption on one hand [7–9] and with daytime drowsiness on the other hand [22, 23]. Heavy alcohol consumption
has been linked with next day symptoms of tiredness [24],
and with an impaired performance [5]. It is therefore possible
that sleepiness is reliably produced with a higher intensity and
periodicity of alcohol consumption along with insuicient
habitual sleep duration. he sleep duration may be decreased
by the heavy alcohol consumption itself, or from insuiciency
based on the need or opportunity of functioning in a 24hour society, and/or the presence of intrinsic sleep disorders
like insomnia or obstructive sleep apnea syndrome. In light
1.0
g(
4. Discussion
1.2
Lo
a decrease in the sleep duration in hours, there was an
increased probability of reporting daytime sleepiness; see
Table 3, and Figure 1. No signiicant interactions between
other alcohol consumption variables and sleep duration
predicted daytime sleepiness.
Probability of daytime sleepiness
P: P value.
Model 1: unadjusted model.
Model 2: adjusted for age, BMI, gender, race, marital status, education, income, depression, insurance, health status, anxiety, mental health, and exercise.
Model 3: model 2 + insomnia status.
0.6
0.8
1.0
Figure 1: Surface model of the interaction between heavy drinking
frequency and sleep duration on daytime sleepiness.
of the above it is easier to comprehend our indings of an
interaction between heavy drinking and a decreased sleep
duration predicting sleepiness.
Evaluating this relationship from another perspective, it
is possible that ater the alcohol is metabolized in the latter
half of the night, the sleep is shallow and fragmented sleep as
shown previously [24, 25]. his shallow and/or fragmented
6
sleep may lead the subject to a state of subacute sleep deprivation with continued heavy drinking over time, leading to
complaints of daytime sleepiness [4]. Our results difer from
those of Pack and colleagues [6] as their study did not account
for the sleep duration or for any heavy drinking and showed
results similar to our bivariate analysis. In addition, our
study adjusted for the efect of gender as a covariate, as well
as body mass index and insomnia symptoms in the analyses.
Some of the limitations associated with this study include
the following: the cross-sectional nature of the study precludes determination of the cause and efect between the
variables; the dichotomous nature of sleepiness complaint
prevents us from diferentiating relationships associated with
varying intensities of the daytime sleepiness; the lack of
additional data on the drinking pattern across genders (in a
calendar format) over the past year (in days, months, or years)
or the pattern of drinking on weekdays versus weekends; and
the lack of data on the circadian pattern of sleep and sleepiness as well as cafeine and alcohol consumption. Despite its
weaknesses, this is one of the irst studies at the population
level that shows the presence of a complex relationship between alcohol consumption and sleep duration, on daytime
sleepiness.
In conclusion, an inverse relationship of the probability
of daytime sleepiness with the intensity and the frequency
of alcohol consumption was seen in adult respondents from
a nationally representative US sample. Once the duration of
sleep was factored in, an interaction between the frequency
of heavy drinking and sleep duration predicted an increased
probability of daytime sleepiness. hese results extend the
indings from prior laboratory-based studies to a population
sample. Future studies will need to further clarify this complex relationship further using more detailed information
on alcohol use, sleepiness in the context of circadian phase
and the ascending versus the descending limbs of alcohol
concentrations as seen in a prior laboratory study [26], and
the association with hangover symptoms. In addition, studies
are also warranted to tease apart the role of gender diferences
in this relationship considering the gender related diferences
in sleepiness and alcohol consumption.
Conflict of Interests
None of the authors (Subhajit Chakravorty, Nicholas Jackson,
Michael A. Grandner, Ninad Chaudhary, Philip J. Kozak,
Holly R. Shue, and Michael L. Perlis) have reported any actual
or any potential conlict of interests with the subject matter of
the paper.
Authors’ Contribution
Subhajit Chakravorty conceptualized, analyzed, and drated
the paper. Nicholas Jackson worked in data analyses and collaborated with the drating of this paper. Ninad Chaudhary
collaborated with the drating of this paper. Philip J. Kozak
collaborated with the drating of this paper. Michael L. Perlis
collaborated in conceptualization and drating this paper.
Holly R. Shue collaborated with the drating of this paper.
Sleep Disorders
Michael A. Grandner collaborated in conceptualizing the
study, analyzing the data, and drating of this paper.
Acknowledgments
he content of this publication does not represent the views
of the Department of Veterans Afairs, the United States
Government, or any of the collaborating institutions.
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