Independent and joint associations of sleep duration and physical activity with cardiovascular disease: a cross-sectional study of 1.6 million US adults

Abstract

Background Sleep duration and physical activity are intertwined determinants of cardiovascular health, yet their joint impact remains unclear. This study evaluated their independent, joint, and interactive associations with cardiovascular disease using a rigorous confounding adjustment framework. Methods We analyzed pooled data from 1,577,591 US adults in the Behavioral Risk Factor Surveillance System (2014–2022). Inverse probability of treatment weighting and doubly robust logistic regression were used. Additive interaction was assessed via RERI. Results Both short sleep (odds ratio, 1.26; 95% confidence interval, 1.22–1.30) and long sleep (odds ratio, 1.17; 95% confidence interval, 1.13–1.21) were independently associated with prevalent cardiovascular disease, as was physical inactivity (odds ratio, 1.11; 95% confidence interval, 1.09–1.14). The joint effect of short sleep and inactivity conferred the highest risk (odds ratio, 1.38; 95% confidence interval, 1.31–1.44). The relative excess risk due to interaction was −0.03 (95% confidence interval, −0.11 to 0.06), indicating additive, independent risks without synergy. Conclusion By applying a rigorous adjustment framework, this study provides actionable, population-level evidence that moves beyond simple risk factor identification. Public health strategies should integrate sleep hygiene and physical activity into holistic “24-h movement” prescriptions.