Sleep as a Vital Sign? Why Primary Care May Need to Rethink Its Approach

Sleep has often been seen as just lifestyle advice in primary care, usually addressed after more urgent health issues. But new evidence shows that sleep is a key factor for cardiometabolic and mental health outcomes.

This raises the question of whether sleep should be treated more like a clinical vital sign than a lifestyle add-on.

• Recent studies show a stronger link between short sleep and higher risks of hypertension, type 2 diabetes, obesity, and depression. Importantly, these risks seem to be present even in patients with normal blood results.

• Sleep disruption is also linked to impaired glucose metabolism, increased sympathetic activity and elevated inflammatory markers; changes that may precede detectable pathology in routine testing.

For primary care clinicians, this has practical implications. Patients presenting with fatigue, low mood or non-specific symptoms are often reassured when investigations come back normal. However, without assessing sleep quality and duration, we may be missing an early driver of disease rather than the absence of one.

Practical suggestions:

• Including a quick sleep assessment in regular consultations can quickly identify at-risk patients.

  In the last 2-4 weeks:

  1. How many hours of sleep do you usually get on a typical night?

  2. Do you have difficulty falling asleep, staying asleep, or waking too early?

  3. Do you wake feeling refreshed?

  4. Does poor sleep affect your daytime function, mood, concentration, pain, appetite, or work?

  5. Has anyone noticed loud snoring, choking/ gasping, or pauses in your breathing during sleep?

A "yes" to questions 2, 4 or 5 should prompt a more focused assessment.

• Framing sleep as a key part of health, like smoking, alcohol, and exercise, could boost patient involvement. This is especially true when it connects to real benefits, such as energy, mood, and long-term heart health.

Clinical evidence is evolving. Sleep could be a chance for earlier intervention in primary care, even before the guidelines change. Treating sleep as a vital sign, rather than an afterthought, could shift conversations from reassurance to disease prevention.

For more detailed sleep assessment, clinicians may consider validated tools such as the Insomnia Severity Index for insomnia severity and STOP-Bang where obstructive sleep apnoea is suspected.

References:

1. Direksunthorn, T. Sleep and cardiometabolic health: A narrative review of epidemiological evidence, mechanisms, and interventions. International Journal of General Medicine. 2025;18:5831–5843. doi:10.2147/IJGM.S563616

2. St-Onge MP, Aggarwal B, Fernandez-Mendoza J, et al. Multidimensional sleep health: Definitions and implications for cardiometabolic health: A scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2025;18(5):e000139. doi:10.1161/HCQ.0000000000000139

3. St-Onge MP, Grandner MA, Brown D, et al. Sleep duration and quality: Impact on lifestyle behaviors and cardiometabolic health. Circulation. 2016;134(18):e367–e386. doi:10.1161/CIR.0000000000000444

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