Sleep constitutes approximately one-third of an individual's lifetime and is essential for overall health. Poor sleep quality (PSQ) is associated with adverse health outcomes, particularly cardiovascular diseases (CVD) [1]. Studies indicate that individuals with PSQ face an elevated risk of CVD [2,3], but the underlying mechanisms remain poorly understood. Notably, the impact of PSQ on cardiovascular risk tends to increase during adolescence [4]. Evidence suggests that left ventricular diastolic function and structural deterioration may contribute to fatal cardiovascular consequences [5]. Therefore, investigating the association between sleep quality and cardiac structure in youths could offer valuable insights into preventing CVD, especially in those with PSQ. However, no study has directly explored the association in young population.

Sleep influences body weight and metabolism by regulating energy balance [6]. Insufficient sleep disrupts appetite regulation, altering adipokines such as leptin, adiponectin, retinol-binding protein 4 (RBP4), fibroblast growth factor 21 (FGF21), and insulin secretion [[7], [8], [9]]. Leptin signals the central nervous system to regulate appetite and energy expenditure [10], while adiponectin offers metabolic and cardiovascular benefits. Low adiponectin levels and its HMW isoforms are implicated in cardiometabolic diseases [11]. RBP4 is linked to insulin resistance (IR), visceral fat, and dyslipidemia, whereas FGF21 exerts glucose- and lipid-lowering effects [12]. Studies have revealed associations between adipokines and IR to cardiometabolic diseases [13,14], with appetite hormones and adipokines potentially mediating the effects of short sleep hours [7,9].

Based on previous studies, we hypothesize that dysregulated adipokines and insulin secretion/sensitivity could mediate the association between the PSQ score and abnormal cardiac structure, thereby affecting CVD. Therefore, through the Beijing Children and Adolescents Metabolic Syndrome (BCAMS) cohort, this study aims to investigate the associations between sleep quality and echocardiographic parameters in youths with cardiometabolic risk and examine the mediating and moderating roles of adipokines and insulin in this relationship.