Research Article| Volume 58, P144-151, March 2023

The association of multidimensional sleep health with adiposity in heart failure with preserved ejection fraction

Published:December 11, 2022DOI:


      • There is a high prevalence of “poor sleep” across sleep health domains in HFpEF (16–78%).
      • Poorer sleep health was associated with greater BMI and intermuscular thigh fat in HFpEF patients.
      • Research is needed to determine whether sleep is a potential candidate for individual or adjunctive interventions to address obesity in HFpEF.



      There are bi-directional relationships between sleep disturbances and obesity, both of which are prevalent in patients with heart failure with preserved ejection fraction (HFpEF). However, little is known about the sleep-obesity association in HFpEF.


      To determine associations of multidimensional sleep health, night movement, sleep fragmentation, and sleep-disordered breathing (SDB) risk with overall and regional adiposity in HFpEF patients.


      Men and women with HFpEF (n = 49) were assessed via 14-day actigraphy, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale to derive multidimensional sleep health. SDB risk was assessed via Berlin Questionnaire. Body composition was measured using anthropometry; MRI quantification of epicardial, abdominal, liver, and thigh adipose tissue was performed in a subsample (n = 22). Spearman correlation (rs) and linear regression analyses (β coefficient) were used to estimate bivariate and age-adjusted associations.


      Multidimensional sleep health was inversely associated with BMI (rs = -0.50, p < .001; unadjusted: β = -4.00, 95%CI: -5.87, -2.13; age-adjusted: β = -2.48, 95%CI: -4.65, -0.30), thigh subcutaneous adipose tissue (rs = -0.50, p = .018; unadjusted: β = -36.95, 95%CI: -67.31, -6.59), and thigh intermuscular fat (age-adjusted: β = -0.24, 95%CI: -0.48, -0.01). Night movement and sleep fragmentation were associated with greater intermuscular thigh and lower liver fat. High SDB risk was associated with a higher visceral-to-subcutaneous ratio of abdominal adiposity and lower thigh adiposity.


      Adverse multidimensional sleep health is associated with higher adiposity measures in HFpEF patients. Further studies are needed to determine whether intervening on sleep could ameliorate excess adiposity or whether weight loss could improve sleep quality in HFpEF.


      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 Heart & Lung: The Journal of Cardiopulmonary and Acute Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Tsao C.W.
        • Aday A.W.
        • Almarzooq Z.I.
        • et al.
        Heart disease and stroke statistics-2022 update: a report from the American Heart Association.
        Circulation. 2022; 145: e153-e639
        • Goyal P.
        • Loop M.
        • Chen L.
        • et al.
        Causes and temporal patterns of 30-day readmission among older adults hospitalized with heart failure with preserved or reduced ejection fraction.
        J Am Heart Assoc. 2018; 7e007785
        • Shah K.S.
        • Xu H.
        • Matsouaka R.A.
        • et al.
        Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes.
        J Am Coll Cardiol. 2017; 70: 2476-2486
        • Heidenreich P.A.
        • Albert N.M.
        • Allen L.A.
        • et al.
        Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association.
        Circ Heart Fail. 2013; 6: 606-619
        • Yancy C.W.
        • Jessup M.
        • Bozkurt B.
        • et al.
        ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of America.
        J Am Coll Cardiol. 2017; 70: 776-803
        • Anker S.D.
        • Butler J.
        • Filippatos G.
        • et al.
        Empagliflozin in heart failure with a preserved ejection fraction.
        N Engl J Med. 2021; 385: 1451-1461
        • Powell-Wiley T.M.
        • Poirier P.
        • Burke L.E.
        • et al.
        Obesity and cardiovascular disease: a scientific statement from the American Heart Association.
        Circulation. 2021; 143: e984-e1010
        • Rao V.N.
        • Fudim M.
        • Mentz R.J.
        • Michos E.D.
        • Felker G.M.
        Regional adiposity and heart failure with preserved ejection fraction.
        Eur J Heart Fail. 2020; 22: 1540-1550
        • Romero Funes D.
        • Gutierrez Blanco D.
        • Botero-Fonnegra C.
        • et al.
        Bariatric surgery decreases the number of future hospital admissions for diastolic heart failure in subjects with severe obesity: a retrospective analysis of the US National Inpatient Sample database.
        Surg Obes Relat Dis. 2022; 18: 1-8
        • Kitzman D.W.
        • Brubaker P.
        • Morgan T.
        • et al.
        Effect of caloric restriction or aerobic exercise training on peak oxygen consumption and quality of life in obese older patients with heart failure with preserved ejection fraction: a randomized clinical trial.
        JAMA. 2016; 315: 36-46
        • Mikhalkova D.
        • Holman S.R.
        • Jiang H.
        • et al.
        Bariatric surgery-induced cardiac and lipidomic changes in obesity-related heart failure with preserved ejection fraction.
        Obesity. 2018; 26 (Silver Spring): 284-290
        • Muscogiuri G.
        • Barrea L.
        • Annunziata G.
        • et al.
        Obesity and sleep disturbance: the chicken or the egg?.
        Crit Rev Food Sci Nutr. 2019; 59: 2158-2165
        • Kato M.
        • Yamamoto K.
        Sleep disorder and heart failure with preserved ejection fraction.
        Heart Fail Clin. 2021; 17: 369-376
        • Khattak H.K.
        • Hayat F.
        • Pamboukian S.V.
        • Hahn H.S.
        • Schwartz B.P.
        • Stein P.K.
        obstructive sleep apnea in heart failure: review of prevalence, treatment with continuous positive airway pressure, and prognosis.
        Tex Heart Inst J. 2018; 45: 151-161
        • Parisi V.
        • Paolillo S.
        • Rengo G.
        • et al.
        Sleep-disordered breathing and epicardial adipose tissue in patients with heart failure.
        Nutr Metab Cardiovasc Dis. NMCD. 2018; 28: 126-132
        • Buysse D.J.
        Sleep health: can we define it? Does it matter?.
        Sleep. 2014; 37: 9-17
        • Brindle R.C.
        • Yu L.
        • Buysse D.J.
        • Hall M.H.
        Empirical derivation of cutoff values for the sleep health metric and its relationship to cardiometabolic morbidity: results from the Midlife in the United States (MIDUS) study.
        Sleep. 2019; 42: zsz116
        • Foldvary-Schaefer N.
        • Kaw R.
        • Collop N.
        • et al.
        Prevalence of undetected sleep apnea in patients undergoing cardiovascular surgery and impact on postoperative outcomes.
        J Clin Sleep Med. 2015; 11: 1083-1089
        • Ying W.
        • Sharma K.
        • Yanek L.R.
        • et al.
        Visceral adiposity, muscle composition, and exercise tolerance in heart failure with preserved ejection fraction.
        ESC Heart Fail. 2021; 8: 2535-2545
        • Ding J.
        • Visser M.
        • Kritchevsky S.B.
        • et al.
        The association of regional fat depots with hypertension in older persons of white and African American ethnicity.
        Am J Hypertens. 2004; 17: 971-976
        • VanWagner L.B.
        • Wilcox J.E.
        • Ning H.
        • et al.
        Longitudinal association of non-alcoholic fatty liver disease with changes in myocardial structure and function: the CARDIA study.
        J Am Heart Assoc. 2020; 9e014279
        • Flüchter S.
        • Haghi D.
        • Dinter D.
        • et al.
        Volumetric assessment of epicardial adipose tissue with cardiovascular magnetic resonance imaging.
        Obesity. 2007; 15 (Silver Spring): 870-878
        • Packer M.
        Epicardial adipose tissue may mediate deleterious effects of obesity and inflammation on the myocardium.
        J Am Coll Cardiol. 2018; 71: 2360-2372
        • Covassin N.
        • Singh P.
        • McCrady-Spitzer S.K.
        • et al.
        Effects of experimental sleep restriction on energy intake, energy expenditure, and visceral obesity.
        J Am Coll Cardiol. 2022; 79: 1254-1265
        • St-Onge M.-.P.
        • Shechter A.
        Sleep disturbances, body fat distribution, food intake and/or energy expenditure: pathophysiological aspects.
        Horm Mol Biol Clin Investig. 2014; 17: 29-37
        • Zhu B.
        • Shi C.
        • Park C.G.
        • Zhao X.
        • Reutrakul S.
        Effects of sleep restriction on metabolism-related parameters in healthy adults: a comprehensive review and meta-analysis of randomized controlled trials.
        Sleep Med Rev. 2019; 45: 18-30
        • St-Onge M.P.
        Sleep-obesity relation: underlying mechanisms and consequences for treatment.
        Obes Rev. 2017; 18: 34-39
        • Tasali E.
        • Wroblewski K.
        • Kahn E.
        • Kilkus J.
        • Schoeller D.A.
        Effect of sleep extension on objectively assessed energy intake among adults with overweight in real-life settings: a randomized clinical trial.
        JAMA Intern Med. 2022; 182: 365-374
        • Thomson C.A.
        • Morrow K.L.
        • Flatt S.W.
        • et al.
        Relationship between sleep quality and quantity and weight loss in women participating in a weight-loss intervention trial.
        Obesity. 2012; 20 (Silver Spring): 1419-1425
        • Chaput J.-.P.
        • Tremblay A.
        Sleeping habits predict the magnitude of fat loss in adults exposed to moderate caloric restriction.
        Obes Facts. 2012; 5: 561-566
        • Elder C.R.
        • Gullion C.M.
        • Funk K.L.
        • Debar L.L.
        • Lindberg N.M.
        • Stevens V.J.
        Impact of sleep, screen time, depression and stress on weight change in the intensive weight loss phase of the LIFE study.
        Int J Obes. 2012; 36 (London): 86-92
        • Sawamoto R.
        • Nozaki T.
        • Furukawa T.
        • et al.
        Higher sleep fragmentation predicts a lower magnitude of weight loss in overweight and obese women participating in a weight-loss intervention.
        Nutr Diabetes. 2014; 4: e144
        • Wang X.
        • Sparks J.R.
        • Bowyer K.P.
        • Youngstedt S.D.
        Influence of sleep restriction on weight loss outcomes associated with caloric restriction.
        Sleep. 2018; (41:10.1093/sleep/zsy027)
        • Nedeltcheva A.V.
        • Kilkus J.M.
        • Imperial J.
        • Schoeller D.A.
        • Penev P.D.
        Insufficient sleep undermines dietary efforts to reduce adiposity.
        Ann Intern Med. 2010; 153: 435-441
        • Kline C.E.
        • Chasens E.R.
        • Bizhanova Z.
        • et al.
        The association between sleep health and weight change during a 12-month behavioral weight loss intervention.
        Int J Obes. 2021; 45: 639-649
        • Wilding J.P.H.
        • Batterham R.L.
        • Calanna S.
        • et al.
        Once-weekly semaglutide in adults with overweight or obesity.
        N Engl J Med. 2021; 384: 989-1002
        • Ashrafian H.
        • Toma T.
        • Rowland S.P.
        • et al.
        Bariatric surgery or non-surgical weight loss for obstructive sleep apnoea? A systematic review and comparison of meta-analyses.
        Obes Surg. 2015; 25: 1239-1250
        • Ross K.M.
        • Graham Thomas J.
        • Wing R.R
        Successful weight loss maintenance associated with morning chronotype and better sleep quality.
        J Behav Med. 2016; 39: 465-471
        • Ji Y.
        • Liang Y.
        • Mak J.C.W.
        • Ip M.S.M.
        Obstructive sleep apnea, intermittent hypoxia and non-alcoholic fatty liver disease.
        Sleep Med. 2022; 95: 16-28
        • Chung J.
        • Goodman M.
        • Huang T.
        • Bertisch S.
        • Redline S.
        Multidimensional sleep health in a diverse, aging adult cohort: concepts, advances, and implications for research and intervention.
        Sleep Health. 2021; 7: 699-707
        • Haykowsky M.J.
        • Nicklas B.J.
        • Brubaker P.H.
        • et al.
        Regional adipose distribution and its relationship to exercise intolerance in older obese patients who have heart failure with preserved ejection fraction.
        J Am Coll Cardiol Heart Fail. 2018; 6: 640-649
        • Haykowsky M.J.
        • Kouba E.J.
        • Brubaker P.H.
        • Nicklas B.J.
        • Eggebeen J.
        • Kitzman D.W.
        Skeletal muscle composition and its relation to exercise intolerance in older patients with heart failure and preserved ejection fraction.
        Am J Cardiol. 2014; 113: 1211-1216
        • Kitzman D.W.
        • Shah S.J.
        The HFpEF obesity phenotype: the elephant in the room.
        J Am Coll Cardiol. 2016; 68: 200-203
        • Singareddy R.
        • Vgontzas A.N.
        • Fernandez-Mendoza J.
        • et al.
        Risk factors for incident chronic insomnia: a general population prospective study.
        Sleep Med. 2012; 13: 346-353
        • Leinum C.J.
        • Dopp J.M.
        • Morgan B.J.
        Sleep-disordered breathing and obesity: pathophysiology, complications, and treatment.
        Nutr Clin Pract. 2009; 24: 675-687
        • Baker F.C.
        • Yűksel D.
        • de Zambotti M.
        • Attarian H.
        • Viola-Saltzman M.
        Sex differences in sleep.
        Sleep Disorders in Women: A Guide to Practical Management. Cham. Springer International Publishing, 2020: 55-64 (Available at)
        • Chang E.
        • Varghese M.
        • Singer K.
        Gender and sex differences in adipose tissue.
        Curr Diabetes Rep. 2018; 18 (69–69)
        • Beale A.L.
        • Meyer P.
        • Marwick T.H.
        • Lam C.S.P.
        • Kaye D.M.
        Sex differences in cardiovascular pathophysiology: why women are overrepresented in heart failure with preserved ejection fraction.
        Circulation. 2018; 138: 198-205