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Publication Briefs

Sleep Difficulties Associated with Risk Factors for Cardiovascular Disease among Younger Veterans and Active Duty Personnel

Mounting evidence suggests that sleep disturbance may play an important role in the development of cardiovascular disease (CVD), and Veterans are at increased risk for many of the behavioral, physiological, and psychiatric risk factors for CVD. This study examined the relationship between sleep difficulties and several CVD risk factors (i.e., smoking status, body mass index, self-reported hypertension, hypertension medication use, clinic-based blood pressure readings, symptoms of depression and PTSD, and diagnosis of depression and PTSD) among relatively younger Veterans and active duty personnel (n=1,855; mean age, 37 years) of the Iraq and Afghanistan wars. Sleep difficulties were defined as distress about trouble falling asleep (sleep onset) over the previous 7 days, and distress about restless or disturbed sleep (sleep maintenance) over the previous 7 days. Data for this study were collected between June 2005 and June 2011 and included computer-administered questionnaires and review of medical records.


  • Of the 1,855 participants in this study, 149 (8%) endorsed only sleep onset difficulties, 164 (9%) endorsed only sleep maintenance difficulties, and 762 (41%) endorsed both sleep onset and sleep maintenance difficulties.
  • Study participants with both sleep onset and maintenance difficulties had greater odds of being a current smoker, having a diagnosis of PTSD, having clinically significant PTSD symptoms, having a diagnosis of depression, and having clinically significant depression symptoms. The odds for these risk factors did not differ by race or age.
  • Having the combination of sleep onset and maintenance difficulties also was associated with elevated systolic blood pressure readings and increased likelihood of reporting a hypertension diagnosis among younger white Veterans.
  • Overall, study participants with sleep maintenance difficulties were older, while those having both sleep onset and maintenance difficulties were younger and reported more tours of duty. Veterans reporting sleep difficulties of any kind reported more symptoms of depression and PTSD.


  • Hypertension diagnoses were self-reported and no data were available to adjust outcomes for physical activity level, diet, or genetic factors.
  • Items used in this study to examine sleep difficulties were focused on "distress about" sleep difficulties and were used as proxies for percevied sleep difficulties.

Authors note that since sleep difficulties are associated with several CVD risk factors, improving sleep in this younger population may reduce the progression of disease and avert the increased incidence of CVD found in older Veterans.

This study was partly supported by the VISN 6 MIRECC. Dr. Ulmer is an HSR&D Career Development Awardee; she and Dr. Bosworth are part of HSR&D's Center for Health Services Research in Primary Care, Durham, NC.

PubMed Logo Ulmer C, Bosworth H, Germain A, et al. Associations between Sleep Difficulties and Risk Factors for Cardiovascular Disease in Veterans and Active Duty Military Personnel of the Iraq and Afghanistan Conflicts. Journal of Behavioral Medicine. March 27, 2015;e-Pub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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