Sleep duration and total cancer mortality: a meta-analysis of prospective studies

Rest assured: High sleep efficiency reduces postoperative complications and opioid prescriptions in patients undergoing surgeries with gynecologic oncologists

OBJECTIVE

To assess the relationship between preoperative sleep efficiency (percentage of time asleep while in bed) and postoperative outcomes in gynecologic oncology patients.

METHODS

This is a secondary analysis of a prospective cohort study that included 90 patients undergoing gynecologic surgeries from March 2021 to November 2023. Preoperative sleep efficiency was measured via Oura rings over the seven days prior to surgery and analyzed as a continuous variable and in quartiles. Primary outcomes were 30-day postoperative complications, with secondary outcomes including total morphine milligram equivalents (MME) prescribed at discharge and pain scores on postoperative day 1 (POD1). Multivariable analyses controlled for age, body mass index, frailty status, neoadjuvant chemotherapy, use of preoperative sleep medications, and surgical approach.

RESULTS

Higher preoperative sleep efficiency was independently associated with fewer 30-day postoperative complications. On multivariable analysis, each 1 % increase in sleep efficiency was associated with 6 % lower adjusted odds of complications. (aOR: 0.94; 95 % CI: 0.89-0.996) and significantly lower total MME prescribed at discharge (β = -13.94; 95 % CI: -19.35 to -8.53). Patients in the highest sleep efficiency quartile (>89.0 %) had lower odds of experiencing a complication compared to those in the lowest quartile (aOR: 0.28; 95 % CI: 0.09-0.92). Sleep efficiency was not significantly associated with POD1 pain scores (β = -0.06; 95 % CI: -0.13 to 0.01).

CONCLUSION

Preoperative sleep efficiency is associated with fewer postoperative complications and lower MME prescribed at discharge. This may be modifiable risk factor to improve recovery and outcomes.

Association of sleep duration and all-cause and cancer-specific mortality: results of 2004 national health interview survey (NHIS)

Epidemiologic research has demonstrated a connection between the duration of sleep and the risk of overall mortality. This research investigates the correlation between sleep duration (SD) and the likelihood of all-cause and cancer-specific mortality among cancer patients, exploring the association between SD and mortality risk. The study used the National Health Interview Survey (NHIS) data from 2004, a U.S.-based survey linked to a mortality database up to December 31, 2019. A total of 26,976 participants based on cancer responses, including 2082 cancer patients and 24,894 non-cancer patients, were included in this study. Participants self-reported SD (categorized as ≤ 5, 6, 7, 8, 9, or ≥ 10 h/day) was used. The Cox proportional hazards model for mortality risk was performed with demographic adjustments. Mortality risk was higher in adults with and without cancer and extremes (insufficient or more than sufficient) of SD. A J-shaped association was found between SD and all-cause and cancer-specific mortality risk among cancer and non-cancer patients. Among the cancer patients, compared with the reference group (7 h/day), both shorter and longer SDs were associated with increased risk of all-cause and cancer-specific mortality (≤ 5 h/day, HR 1.48 CI [1.77, 1.88]; 8 h/day, HR 1.45 CI [1.23, 1.72]; 9 h/day, HR 1.53 CI [1.18,1.99], ≥ 10 h/day, HR 2.15 CI [1.66, 2.78]); except the SD 6 h/day, HR 1.14 CI [0.93, 1.40]. The analysis included 349,936 person-years of observation. This study suggests that sleeping too long and too short is associated with increased risk among patients with all-cause and cancer-specific mortality.

Oxidative stress and inflammation mediate the association between elevated oxidative balance scores and improved sleep quality: evidence from NHANES

Background

The association between oxidative stress, as measured by the Oxidative Balance Score (OBS), and sleep quality remains unclear. The primary objective of this investigation was to clarify this relationship and to explore the potential involvement of oxidative stress and inflammation.

Methods

Data from 15,198 participants in the National Health and Nutrition Examination Survey 2007-2014 were analyzed. Sleep quality indicators, including sleep disorder, trouble, and duration, were assessed. The OBS, comprising information on 16 dietary nutrients and 4 lifestyle factors, was then calculated. Multivariable logistic and linear regression models were employed to investigate the correlation between OBS and sleep quality. Additionally, mediation analyses were conducted to evaluate the potential effects of oxidative stress and inflammation.

Results

We demonstrated a correlation between an elevated OBS and reduced sleep disorders (OR, 0.72; 95% CI, 0.58-0.91; p = 0.0055), reduced sleep trouble (OR, 0.81; 95% CI, 0.69-0.96; p = 0.0174), and prolonged sleep duration (β 0.009; 95% CI, 0.0002-0.0160; p = 0.015) when comparing the highest and lowest tertiles. Dietary factors exhibited autonomous correlations with sleep duration, whereas lifestyle factors displayed independent associations with sleep trouble and sleep disorders. Moreover, the relationships between OBS and both sleep disorders and trouble were influenced by albumin, γ-glutamyl transferase, total bilirubin, and white blood cells, with combined mediation effects of 34.66 and 29.54%, respectively (both p < 0.001). Sensitivity analyses revealed a significant association between OBS and sleep disorder (p < 0.001).

Conclusion

This study revealed a positive correlation between an elevated OBS and improved sleep quality, manifested by decreased sleep disorders, mitigated sleep trouble, and prolonged sleep duration. This is potentially mediated by oxidative stress and inflammation. Therefore, the study underscores the importance of adopting a diet rich in antioxidants and healthy lifestyle choices to address sleep-related concerns, providing a novel avenue for enhancing overall sleep quality.

Associations between Life's Essential 8 and risks of all-cause and cardiovascular mortality in cancer survivors: A prospective cohort study from NHANES

BACKGROUND

Life's Essential 8 (LE8), an indicator of cardiovascular health (CVH), can predict overall and cardiovascular mortality in the general population. Considering that cancer survivors have a higher risk of cardiovascular disease (CVD), our study aimed to investigate the association between LE8 and the prognosis of cancer survivors.

METHODS

A total of 2191 cancer survivors were included from the National Health and Nutrition Examination Survey (2005-2018). LE8 scores, derived from eight individual metrics, were categorized into three groups: low (0-49), moderate (50-79), and high (80-100). Cox regression analysis, nonlinear analysis, sensitivity analysis, and subgroup analysis were conducted to explore the association between LE8 scores and mortality risks, adjusting for potential confounders.

RESULTS

During a median follow-up of six years, 479 deaths were recorded, including 118 CVD events and 156 cancer events. LE8 scores showed an inverse linear relationship with all-cause and cardiovascular mortality. A 10-point increase in LE8 scores was associated with a 25 % reduction in all-cause mortality (hazard ratio [HR], 0.75; 95 % CI, 0.66-0.85) and a 29 % reduction in cardiovascular mortality (HR, 0.71; 95 % CI, 0.57-0.89). Additionally, moderate CVH was linked to a lower risk of all-cause mortality (HR, 0.55; 95 % CI, 0.37-0.81), while high CVH was associated with an even lower risk (HR, 0.35; 95 % CI, 0.19-0.68). Similarly, moderate CVH demonstrated a decreased risk of cardiovascular mortality (HR, 0.31; 95 % CI, 0.15-0.63), with high CVH showing an even lower risk (HR, 0.23; 95 % CI, 0.09-0.58). However, LE8 scores was not associated with cancer-specific mortality.

CONCLUSIONS

A higher LE8 score was independently associated with a decreased risk of both all-cause and cardiovascular mortality in cancer survivors, underscoring the significance of optimizing CVH during the survivorship phase of cancer care.

Association of dietary oxidative balance score and sleep duration with the risk of mortality: prospective study in a representative US population

OBJECTIVE

We investigated the association between dietary oxidative balance score (DOBS) and mortality and whether this association can be modified by sleep duration.

DESIGN

We calculated DOBS to estimate the overall oxidative effects of the diet, with higher DOBS reflecting more antioxidant intake and less pro-oxidant intake. Cox proportional hazards models were employed to examine the associations between DOBS and all-cause, CVD and cancer mortality in the general population and people with different sleep durations.

SETTING

Prospective analysis was conducted using data from the US National Health and Nutrition Examination Survey (NHANES, 2005-2015).

PARTICIPANTS

A total of 15 991 US adults with complete information on dietary intake, sleep duration and mortality were included.

RESULTS

During a median follow-up of 7·4 years, 1675 deaths were observed. Participants in the highest quartile of DOBS were significantly associated with the lower risk of all-cause mortality (hazard ratio (HR) = 0·75; 95 % CI 0·61, 0·93) compared with those in the lowest. Furthermore, we found statistically significant interactions between DOBS and sleep duration on all-cause mortality (P interaction = 0·021). The inverse association between DOBS and all-cause mortality was significant in short sleepers (HR = 0·66, 95 % CI 0·48, 0·92), but not in normal and long sleepers.

CONCLUSIONS

Our study observed that higher DOBS was associated with lower all-cause mortality, and this association appeared to be stronger among short sleepers. This study provides nutritional guidelines for improving health outcomes in adults, especially for short sleepers.

Integrating sleep health into resilience research

Sleep is a biological necessity that is a critical determinant of mental and physical well-being. Sleep may promote resilience by enhancing an individual's biological preparedness to resist, adapt and recover from a challenge or stressor. This report analyzes currently active National Institutes of Health (NIH) grants focussed on sleep and resilience, specifically examining the design of studies that explore sleep as a factor that promotes health maintenance, survivorship, or protective/preventive pathways. A search of NIH R01 and R21 research project grants that received funding in Fiscal Years (FY) 2016-2021 and focussed on sleep and resilience was conducted. A total of 16 active grants from six NIH institutes met the inclusion criteria. Most grants were funded in FY 2021 (68.8%), used the R01 mechanism (81.3%), were observational studies (75.0%), and measured resilience in the context of resisting a stressor/challenge (56.3%). Early adulthood and midlife were most commonly studied and over half of the grants focussed on underserved/underrepresented populations. NIH-funded studies focussed on sleep and resilience, or the ways in which sleep can influence an individual's ability to resist, adapt, or recover from a challenging event. This analysis highlights an important gap and the need to expand research focussed on sleep as a promotor of molecular, physiological, and psychological resilience.

Sleep Duration, Comorbidities, and Mortality in Korean Health Examinees: A Prospective Cohort Study

OBJECTIVES

The association between long sleep duration and mortality is frequently attributed to the confounding influence of comorbidities. Nevertheless, past efforts to account for comorbidities have yielded inconsistent outcomes. The objective of this study was to evaluate this relationship using a large prospective cohort in Korea.

METHODS

The study included 114 205 participants from the Health Examinees Study, who were followed for a median of 9.1 years. A composite comorbidity score was developed to summarize the effects of 21 diseases. Using Cox proportional hazards regression, hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause, cancer, and cardiovascular mortality associated with sleep duration were estimated. These estimates were adjusted for socio-demographic factors, lifestyle factors, body mass index, and comorbidity score. Additionally, a stratified analysis by subgroups with and without comorbidities was conducted.

RESULTS

Throughout the follow-up period, 2675 deaths were recorded. After all adjustments, an association was observed between a sleep duration of 8 hours or more and all-cause mortality (HR, 1.10; 95% CI, 1.01 to 1.20). However, no such association was detected in the stratified analysis for the subgroups based on comorbidity status.

CONCLUSIONS

Long sleep duration was found to be associated with all-cause mortality among Koreans, even after adjusting for comorbidities. Additional studies are required to explore the mechanism underlying the association between sleep duration and major causes of mortality.

Irregular sleep and all-cause mortality: A large prospective cohort study

OBJECTIVES

Previous studies using objective parameters have shown that irregular sleep is associated with the disease incidence, progression, or mortality. This study aimed to determine the association between subjective sleep duration and sleep regularity, with mortality in a large population.

METHODS

Participants were from the Japan Multi-Institutional Collaborative Cohort study. We obtained information from each participant on sleep duration, sleep regularity, and demographics and overall lifestyle using self-administered questionnaires. We defined sleep regularity according to participants' subjective assessment of sleep/wake time regularity. Participants (n = 81,382, mean age: 58.1 ± 9.1years, males: 44.2%) were classified into 6 groups according to sleep duration and sleep regularity. Hazard ratios (HR) for time-to-event of death were calculated using the Cox proportional hazards model.

RESULTS

The mean follow-up period was 9.1 years and the mean sleep duration was 6.6 h/day. Irregular sleep significantly increased the risk of all-cause mortality in all models compared with regular sleep (HR 1.30, 95% confidence interval; CI, 1.18-1.44), regardless of sleep duration. Multivariable analysis of the 6 groups by sleep pattern (sleep regularity and duration) showed irregular sleep and sleep durations of <6 h/day, 6 to <8 h/day, or ≥8 h/day were associated with a 1.2-1.5-fold increases in mortality, compared to regular sleep and sleep duration of 6 to <8 h/day.

CONCLUSIONS

Our study shows an association between sleep irregularity and all-cause mortality in a large Japanese population. Our findings provide further confirmation of the need to consider not only sleep duration, but also the regularity aspect of sleep schedules.

Can physical activity eliminate the mortality risk associated with poor sleep? A 15-year follow-up of 341,248 MJ Cohort participants

BACKGROUND

This study examined the joint associations of sleep patterns and physical activity (PA) with all-cause, cardiovascular disease (CVD), and cancer mortality.

METHODS

A total of 341,248 adults (mean age = 39.7 years; men: 48.3%) were included in the study, with a 15-year follow-up. Participants reported sleep duration and disturbances (difficulty falling asleep, easily awakened, or use of sleeping medication). PA was classified into 4 levels: <7.5, 7.5-14.9, 15.0-29.9, and ≥30.0 metabolic equivalent hours per week (MET-h/week). To understand the joint associations of sleep patterns and PA with mortality, Cox proportional hazard models were conducted, with exposure variables combining sleep duration/disturbances and PA.

RESULTS

Compared with the reference group (sleeping 6-8 h/day), individuals who slept >8 h/day had higher risk for all-cause mortality (hazard ratio (HR) = 1.307, 95% confidence interval (95%CI): 1.248-1.369), CVD mortality (HR = 1.298, 95%CI: 1.165-1.445), and cancer mortality (HR = 1.128, 95%CI: 1.042-1.220). Short sleep duration was not associated with mortality risk. Increased risk of all-cause and CVD mortality was found in participants who had difficulty falling asleep (HR = 1.120, 95%CI: 1.068-1.175; HR = 1.163, 95%CI: 1.038-1.304, respectively), and used sleeping medication (HR = 1.261, 95%CI: 1.159-1.372; HR = 1.335, 95%CI: 1.102-1.618, respectively) compared with those who slept well. Long sleep duration and sleep disturbances were not associated with risk of all-cause and CVD mortality among individuals achieving a PA level of ≥15 MET-h/week, and in particular among those achieving ≥30 MET-h/week.

CONCLUSION

Long sleep duration, difficulty falling asleep, and use of sleeping medication were related to a higher risk of death. Being physically active at a moderate intensity for 25-65 min/day eliminated these detrimental associations.

Sleep duration and risk of cancer incidence and mortality: a pooled analysis of six population-based cohorts in Japan

Sleep duration is emerging as an important modifiable risk factor for morbidity and mortality. We assessed the association between sleep duration and cancer incidence and mortality among Japanese adults using data from six population-based cohorts with 271 694 participants. During a total follow-up period of about 5.9 million person-years, we identified 40 751 incident cancer cases and 18 323 cancer deaths. We computed study-specific hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression models and pooled the estimates using random-effects meta-analysis. Sleep duration of ≥ 10 h (vs. 7 h) was associated with increased risk of cancer incidence among women (HR 1.19, 95% CI 1.02-1.38), but not men, and increased risk of cancer mortality among men (HR 1.18, 95% CI 1.00-1.39) and women (HR 1.44, 95% CI 1.20-1.73). Sleep duration of ≤ 5 h (vs. 7 h) was not associated with cancer incidence and mortality. However, among post-menopausal women, sleep durations of both ≤ 5 h and ≥ 10 h (vs. 7 h) were associated with an increased risk of cancer mortality. Among Japanese adults, sleep duration of ≥ 10 h is associated with increased risk of cancer incidence and mortality among women and cancer mortality among men. This article is protected by copyright. All rights reserved.

Sleep During Oncological Treatment - A Systematic Review and Meta-Analysis of Associations With Treatment Response, Time to Progression and Survival

Introduction

Disrupted sleep and sleep-wake activity are frequently observed in cancer patients undergoing oncological treatment. These disruptions are often associated with aggravated symptom burden and diminished health-related quality of life that in turn may compromise treatment adherence and, thus, effectiveness. In addition, disrupted sleep has been linked to carcinogenic processes, which ultimately could result in worse prognostic outcomes.

Aims

Our aim was to systematically review and conduct a meta-analysis of studies examining the associations between sleep and sleep-wake activity and prognostic outcomes in cancer patients undergoing oncological treatment.

Methods

A comprehensive systematic search of English language papers was undertaken in June 2020 using PubMed, The Cochrane Library, and CINAHL. Two reviewers independently screened 4,879 abstracts. A total of 26 papers were included in the narrative review. Thirteen papers reporting hazard ratios reflecting associations between a dichotomized predictor variable (sleep) and prognostic outcomes were subjected to meta-analysis.

Results

Nineteen of the 26 eligible studies on a total of 7,092 cancer patients reported associations between poorer sleep and poorer response to treatment, shorter time to progression, and/or reduced overall survival, but were highly heterogeneous with respect to the sleep and outcome parameters investigated. Meta-analysis revealed statistically significant associations between poor self-reported sleep and reduced overall survival (HR = 1.33 [95% CI 1.09-1.62], k = 11), and shorter time to progression (HR = 1.40 [95% CI 1.23-1.59], k = 3) and between poor objectively assessed sleep and reduced overall survival (HR = 1.74 [95% CI 1.05-2.88], k = 4).

Conclusion

The current findings indicate that disturbed sleep during treatment may be a relevant behavioral marker of poor cancer prognosis. The limited number of studies, the common use of single item sleep measures, and potential publication bias highlight the need for further high quality and longitudinal studies.

Adherence to a healthy sleep pattern is associated with lower risks of all-cause, cardiovascular and cancer-specific mortality

BACKGROUND

Individual unhealthy sleep behaviours have been associated with increased risks of all-cause mortality and deaths due to cardiovascular disease (CVD) or cancer. The evidence regarding the association of sleep patterns with these risks is limited.

OBJECTIVE

To examine the associations of sleep patterns with all-cause, CVD and cancer mortality in a large prospective cohort.

METHODS

This prospective cohort study included 283,443 adults from UK Biobank without CVD and cancer at baseline. We created a healthy sleep score and sleep patterns combining five individual sleep behaviours.

RESULTS

During a mean (standard deviation) of 8.9 (1.1) years (2.5 million person-years) of follow up, a total of 7936 all-cause deaths, 762 CVD-caused deaths, and 4540 cancer-caused deaths occurred during follow up. One point increase of the healthy sleep score was associated with a 4-11% lower risk of all-cause mortality (Hazard Ratio [HR], 0.94; 95% CI, 0.92-0.96), CVD mortality (HR, 0.89; 95% CI, 0.83-0.95) and cancer mortality (HR, 0.96; 95% CI, 0.93-0.99), with adjustment for age, sex, assessment centres, smoking status, alcohol intake status, socioeconomic status and physical activity. Compared with participants with an unfavourable sleep pattern, those with a favourable sleep pattern had 24-42% lower risks of all-cause and CVD mortality. The association with all-cause mortality tended to be stronger among underweight participants and those with insufficient physical activity.

CONCLUSIONS

A healthy sleep pattern was associated with lower risks of all-cause mortality and mortality from CVD and cancer. Our findings highlight the importance of improving overall sleep behaviours in lowering mortality.

Both increased and decreased sleep duration over time are associated with subsequent cancer development

PURPOSE

Changes in sleep duration have been reported to correlate with lifestyle-related diseases in humans. However, equivalent studies regarding the effects of sleep on cancer progression are lacking. This study aimed to determine whether or not increase or decrease in sleep duration over time is associated with subsequent cancer development.

METHODS

A large-scale, retrospective cohort study was conducted at a preventive medicine health center at a general community hospital in Tokyo, Japan. All participants who underwent health checkups at the hospital between January 2005 and December 2018 were included. The primary study outcome was development of any type of cancer according to the slope of sleep duration over the study period. The Cox proportional hazard model was used to adjust the outcomes based on potential covariates.

RESULTS

Of 15,025 participants, 7,692 (51.2%) were men. The mean age (standard deviation) was 66.0 (7.5) years. During a median follow-up of 2,588 (interquartile range: 1,583-3,695) days, 1,396 (9.3%) participants developed cancer of any type. Compared to hazard ratio in the stable sleep duration group (- 0.1 to + 0.1 h/day in 1 year), both greatly decreased (less than - 0.2 h/day in 1 year; hazard ratio (HR), 2.13; 95% confidence interval (CI), 1.72-2.62) and increased (more than + 0.2 h/day in 1 year; HR, 2.55; 95% CI 2.14-3.04) groups showed significantly higher hazard ratio for the development of any type of cancer.

CONCLUSION

Both increased and decreased sleep duration over time are associated with subsequent cancer development.

Association of Sleep Duration With All- and Major-Cause Mortality Among Adults in Japan, China, Singapore, and Korea

IMPORTANCE

The association between long sleep duration and mortality appears stronger in East Asian populations than in North American or European populations.

OBJECTIVES

To assess the sex-specific association between sleep duration and all-cause and major-cause mortality in a pooled longitudinal cohort and to stratify the association by age and body mass index.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of individual-level data from 9 cohorts in the Asia Cohort Consortium was performed from January 1, 1984, to December 31, 2002. The final population included participants from Japan, China, Singapore, and Korea. Mean (SD) follow-up time was 14.0 (5.0) years for men and 13.4 (5.3) years for women. Data analysis was performed from August 1, 2018, to May 31, 2021.

EXPOSURES

Self-reported sleep duration, with 7 hours as the reference category.

MAIN OUTCOMES AND MEASURES

Mortality, including deaths from all causes, cardiovascular disease, cancer, and other causes. Sex-specific hazard ratios (HRs) and 95% CIs were estimated using Cox proportional hazards regression with shared frailty models adjusted for age and the key self-reported covariates of marital status, body mass index, smoking status, alcohol consumption, physical activity, history of diabetes and hypertension, and menopausal status (for women).

RESULTS

For 322 721 participants (mean [SD] age, 54.5 [9.2] years; 178 542 [55.3%] female), 19 419 deaths occurred among men (mean [SD] age of men, 53.6 [9.0] years) and 13 768 deaths among women (mean [SD] age of women, 55.3 [9.2] years). A sleep duration of 7 hours was the nadir for associations with all-cause, cardiovascular disease, and other-cause mortality in both men and women, whereas 8 hours was the mode sleep duration among men and the second most common sleep duration among women. The association between sleep duration and all-cause mortality was J-shaped for both men and women. The greatest association for all-cause mortality was with sleep durations of 10 hours or longer for both men (hazard ratio [HR], 1.34; 95% CI, 1.26-1.44) and women (HR, 1.48; 95% CI, 1.36-1.61). Sex was a significant modifier of the association between sleep duration and mortality from cardiovascular disease (χ25 = 13.47, P = .02), cancer (χ25 = 16.04, P = .007), and other causes (χ25 = 12.79, P = .03). Age was a significant modifier of the associations among men only (all-cause mortality: χ25 = 41.49, P < .001; cancer: χ25 = 27.94, P < .001; other-cause mortality: χ25 = 24.51, P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that sleep duration is a behavioral risk factor for mortality in both men and women. Age was a modifier of the association between sleep duration in men but not in women. Sleep duration recommendations in these populations may need to be considered in the context of sex and age.

Sleep and physical activity in relation to all-cause, cardiovascular disease and cancer mortality risk

OBJECTIVES

Although both physical inactivity and poor sleep are deleteriously associated with mortality, the joint effects of these two behaviours remain unknown. This study aimed to investigate the joint association of physical activity (PA) and sleep with all-cause and cause-specific mortality risks.

METHODS

380 055 participants aged 55.9 (8.1) years (55% women) from the UK Biobank were included. Baseline PA levels were categorised as high, medium, low and no moderate-to-vigorous PA (MVPA) based on current public health guidelines. We categorised sleep into healthy, intermediate and poor with an established composited sleep score of chronotype, sleep duration, insomnia, snoring and daytime sleepiness. We derived 12 PA-sleep combinations, accordingly. Mortality risks were ascertained to May 2020 for all-cause, total cardiovascular disease (CVD), CVD subtypes (coronary heart disease, haemorrhagic stroke, ischaemic stroke), as well as total cancer and lung cancer.

RESULTS

After an average follow-up of 11.1 years, sleep scores showed dose-response associations with all-cause, total CVD and ischaemic stroke mortality. Compared with high PA-healthy sleep group (reference), the no MVPA-poor sleep group had the highest mortality risks for all-cause (HR (95% CIs), (1.57 (1.35 to 1.82)), total CVD (1.67 (1.27 to 2.19)), total cancer (1.45 (1.18 to 1.77)) and lung cancer (1.91 (1.30 to 2.81))). The deleterious associations of poor sleep with all outcomes, except for stroke, was amplified with lower PA.

CONCLUSION

The detrimental associations of poor sleep with all-cause and cause-specific mortality risks are exacerbated by low PA, suggesting likely synergistic effects. Our study supports the need to target both behaviours in research and clinical practice.

Associations of sleep duration and quality with incident cardiovascular disease, cancer, and mortality: a prospective cohort study of 407,500 UK biobank participants

OBJECTIVE

Few studies have investigated the associations of sleep duration and sleep quality with incident cardiovascular diseases (CVDs), cancer, and mortality in the same large population. This study aimed at estimating the independent risk factors of long or short sleep durations and several typical characteristics of poor sleep quality for incident CVDs, cancer, and mortality.

METHODS

In this prospective cohort study, 407 500 individuals were enrolled. Cox proportional hazards models were used to calculate the adjusted hazard ratios and 95% confidence intervals (HR, 95%CI) of associations of sleep duration and quality with incident CVDs, cancer, and mortality.

RESULTS

Compared with the sleep duration of 7 h, sleep duration of ≤5 h and ≥9 h were both associated with higher risk of all-cause mortality (HR = 1.25, 95% CI: 1.16-1.34 and HR = 1.30, 95% CI: 1.22-1.38, respectively), CVD mortality (HR = 1.27, 95% CI: 1.09-1.49 and HR = 1.32, 95% CI: 1.16-1.50, respectively), and CVD incidence (HR = 1.23, 95% CI: 1.16-1.31 and HR = 1.08, 95% CI: 1.02-1.15, respectively). Additionally, long sleep duration (≥9 h) was associated with a higher risk of cancer mortality (HR = 1.19, 95% CI: 1.10-1.30) and cancer incidence (HR = 1.08, 95% CI: 1.04-1.12). Moreover, CVD incidence was significantly associated with snoring, insomnia and narcolepsy, increasing the risk by 7%, 26%, and 20%, respectively.

CONCLUSION

Long sleep durations may substantially increase the risk of mortality and morbidity. Snoring, insomnia, and narcolepsy were independent risk factors for incident CVD.

The Association Between Habitual Sleep Duration and Mortality According to Sex and Age: The Japan Public Health Center-based Prospective Study

BACKGROUND

Short and long sleep durations are associated with mortality outcomes. The association between sleep duration and mortality outcomes may differ according to sex and age.

METHODS

Participants of the Japan Public Health Center-based prospective study (JPHC Study) were aged 40-69 years and had completed a detailed questionnaire on lifestyle factors. Sex- and age-stratified analyses on the association between habitual sleep duration and mortality from all-causes, cardiovascular diseases (CVD), cancer and other causes included 46,152 men and 53,708 women without a history of CVD or cancer. Cox proportional hazards regression models, adjusted for potential confounders, were used to determine hazard ratios and 95% confidence intervals.

RESULTS

Mean follow-up time was 19.9 years for men and 21.0 years for women. In the multivariable sex-stratified models, some categories of sleep durations ≥8 hours were positively associated with mortality from all-causes, CVD, and other causes in men and women compared with 7 hours. The sex- and age-stratified analyses did not reveal any major differences in the association between sleep duration and mortality outcomes in groups younger and older than 50 years of age. The only exception was the significant interaction between sleep duration and age in women for mortality from other causes.

CONCLUSIONS

Sleep durations ≥8 hours are associated with mortality outcomes in men and women. Age may be an effect modifier for the association between sleep duration and mortality from other causes in women.

Association of sleep duration with all-cause and disease-specific mortality in US adults

BACKGROUND

Previous studies revealed inconsistent findings regarding the association between sleep duration and all-cause and disease-specific mortality. This study aimed to clarify the association of sleep duration with mortality using a large population-based prospective cohort study from the USA.

METHODS

We used data from the National Health Interview Survey (2004-2014) linked to National Death Index records to 31 December 2015. A total of 284 754 participants aged ≥18 years were included. Self-reported sleep duration (average time slept in a 24-hour period) was categorised into seven groups: ≤4 hours, 5 hours, 6 hours, 7 hours (reference), 8 hours, 9 hours and ≥10 hours. Study outcomes included all-cause, cardiovascular disease-specific and cancer-specific mortality. Cox proportional hazards models were used to examine the association between sleep duration and mortality.

RESULTS

During a median follow-up of 5.25 years, we identified 20 872 deaths, of which 4 129 were cardiovascular disease-related and 5 217 were cancer-related. Compared with 7 hours/day of sleep, both short and long sleep durations were associated with an increased risk of all-cause mortality (≤4 hours: HR=1.46, 95% CI=1.33-1.61; 5 hours: HR=1.22, 95% CI=1.13-1.32; 6 hours: HR=1.10, 95% CI=1.05-1.17; 8 hours: HR=1.22, 95% CI=1.17-1.28; 9 hours: HR=1.41, 95% CI=1.31-1.51; ≥10 hours: HR=2.00, 95% CI=1.88-2.13). Similar results were observed for cardiovascular disease-specific and cancer-specific mortality.

CONCLUSIONS

Our study indicates that both short (≤6 hours/day) and long (≥8 hours/day) sleep durations increase the risk of mortality compared with sleep of 7 hours/day. A normal sleep duration (about 7 hours) every day is recommended for health benefits.

Sleep Disturbance during Infection Compromises Tfh Differentiation and Impacts Host Immunity

Although the influence of sleep quality on the immune system is well documented, the mechanisms behind its impact on natural host immunity remain unclear. Meanwhile, it has been suggested that neuroimmune interactions play an important role in this phenomenon. To evaluate the impact of stress-induced sleep disturbance on host immunity, we used a murine model of rapid eye movement sleep deprivation (RSD) integrated with a model of malaria blood-stage infection. We demonstrate that sleep disturbance compromises the differentiation of T follicular helper cells, increasing host susceptibility to the parasite. Chemical inhibition of glucocorticoid (Glcs) synthesis showed that abnormal Glcs production compromised the transcription of Tfh-associated genes resulting in impaired germinal center formation and humoral immune response. Our data demonstrate that RSD-induced abnormal activation of the hypothalamic-pituitary-adrenal axis drives host susceptibility to infection. Understanding the impact of sleep quality in natural resistance to infection may provide insights for disease management.

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REM sleep deprivation (RSD) worsens malaria induced by Plasmodium yoelii infection

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RSD decreases germinal center formation and impairs specific antibody production

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Exacerbated glucocorticoid production impairs T lymphocyte differentiation

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The relationship between sleep and immunity is a target for malaria management

The association between sleep duration and chronic diseases: a population-based cross-sectional study

OBJECTIVES

To examine the cross-sectional relationship between sleep duration and 11 chronic diseases (risk of obesity, depression, diabetes, asthma, COPD, arthritis, kidney, CHD, stroke, and cancer [excluding skin cancer]) by using data from Behavioral Risk Factor Surveillance System.

METHODS

Using data from the 2013, 2014 and 2016 Behavioral Risk Factor Surveillance System, a total sample consisted of 1,191,768 participants. Logistic regression models were constructed to calculate OR and 95% confidence intervals (CI) for the association between sleep duration and 11 chronic diseases. In addition, we also conducted subgroup analysis based on age and gender.

RESULTS

In multi-adjusted model, the positive association between extremely short or long sleep duration and risk of chronic diseases was significant (P < 0.05) with the exception of skin cancer (P = 0.14 and P = 0.43). There are stronger association between extremely short or long sleep duration and obesity, diabetes, asthma, chronic obstructive pulmonary disease, arthritis, kidney, coronary heart disease, stroke, and cancer in women and aged 18-64 years old.

CONCLUSIONS

Our results indicated a higher risk of common chronic diseases due to short or long sleep duration in women and aged 18-64 years. Further studies are needed to demonstrate these association.

Dyadic effects of distress on sleep duration in advanced cancer patients and spouse caregivers

OBJECTIVE

Short sleep duration is a common problem for both advanced cancer patients and their spouse caregivers. Sleep and distress have been shown to be interdependent in patient-caregiver and spouse dyads, yet virtually, no work has explored the dyadic effects of psychological distress on sleep in advanced cancer patients and spouse caregivers. The goal of the present study was to examine the dyadic impact of anxiety and depression on sleep duration in a sample of advanced cancer patients and their spouse caregivers. It was hypothesized that, for both patients and caregivers, anxiety and depression in individuals would be associated with sleep duration in both themselves (actor effects) and in their spouses (partner effects).

METHOD

Advanced cancer patients and their spouse caregivers (N = 87 dyads) completed cross-sectional questionnaires assessing demographic variables, subjective health, subjective sleep duration, and anxiety and depression symptoms.

RESULTS

Controlling for sex, age, and subjective health, individuals' anxiety was negatively associated with their own and their partner's sleep duration. No significant actor or partner effects were found for depression.

CONCLUSIONS

Results provided partial support for hypotheses. Although past work has demonstrated links between subjective sleep disturbance and anxiety/psychological distress, this is one of the first studies to examine partner effects of distress on sleep disturbance in advanced cancer patients and spouse caregivers.

A validation study of a consumer wearable sleep tracker compared to a portable EEG system in naturalistic conditions

OBJECTIVE

To compare a wearable device, the Fitbit Versa (FV), to a validated portable single-channel EEG system across multiple nights in a naturalistic environment.

METHODS

Twenty participants (10 men and 10 women) aged 25-67 years were recruited for the present study. Study duration was 14 days during which participants were asked to wear the FV daily and nightly. The study intended to reproduce free-living conditions; thus, no guidelines for sleep or activity were imposed on the participants. A total of 138 person-nights, equivalent to 76,539 epochs, were used in the validation process. Sleep measures were compared between the FV and portable EEG using Bland-Altman plots, paired t-tests and epoch-by-epoch (EBE) analyses.

RESULTS

The FV showed no significant bias with the EEG for the global sleep measures time in bed (TIB) and total sleep time (TST), and for calculated sleep efficiency (cSE = [TST/TIB] x 100). The FV had 92.1% sensitivity, 54.1% specificity, and 88.5% accuracy with a Cohen's kappa of 0.41, but a prevalence- and bias adjusted kappa of 0.77. The predictive values for sleep (PVS; positive predictive value) and wakefulness (PVW; negative predictive value) were 95.0% and 42.0%, respectively. The FV showed significant bias compared to the portable EEG for time spent in specific sleep stages, for SE as provided by FV, for sleep onset latency, sleep period time, and wake after sleep onset.

CONCLUSIONS

The consumer sleep tracker could be a useful tool for measuring sleep duration in longitudinal epidemiologic naturalistic studies albeit with some limitations in specificity.

Development and Testing of an Integrated Score for Physical Behaviors

PURPOSE

Interest in a variety of physical behaviors (e.g., exercise, sitting time, sleep) in relation to health outcomes creates a need for new statistical approaches to analyze the joint effects of these distinct but inter-related physical behaviors. We developed and tested an integrated physical behavior score (PBS).

METHODS

National Institutes of Health-American Association of Retired Persons Diet and Health Study participants (N = 163,016) completed a questionnaire (2004-2006) asking about time spent in five exercise and nonexercise physical activities, two sedentary behaviors (television and nontelevision), and sleep. In half of the sample, we used shape-constrained additive regression to model the relationship between each behavior and survival. Maximum logit scores from each of the eight behavior-survival functions were summed to produce a PBS that was proportionally rescaled to range from 0 to 100. We examined predictive validity of the PBS in the other half-sample using Cox Proportional Hazards models after adjustment for covariates for all-cause and cause-specific mortality.

RESULTS

In the testing sample, over an average of 6.6 yr of follow-up, 8732 deaths occurred. We found a strong graded decline in risk of all-cause mortality across quintiles of PBS (Q5 vs Q1 hazard ratio [95% CI] = 0.53 [0.49, 0.57]). Risk estimates for the PBS were higher than any of the components in isolation. Results were similar but stronger for cardiovascular disease (Q5 vs Q1 = 0.42 [0.39, 0.48]) and other mortality (Q5 vs Q1 = 0.42 [0.36, 0.48]). The relationship between PBS and mortality was observed in stratified analyses by median age, sex, body mass index, and health status.

CONCLUSIONS

We developed a novel statistical method generated a composite physical behavior that is predictive of mortality outcomes. Future research is needed to test this approach in an independent sample.

Bridging the Reciprocal Gap between Sleep and Fruit and Vegetable Consumption: A Review of the Evidence, Potential Mechanisms, Implications, and Directions for Future Work

A substantial burden of disease and mortality globally is attributable to both sleep disruption and low intakes of fruit and vegetable (FV) and there is increasing mechanistic and epidemiological evidence to support a reciprocal relationship between the two. This review provides an overview of experimental and observational studies assessing the relations between sleep and FV consumption from 52 human adult studies. Experimental studies are currently limited and show inconsistent results. Observational studies support a non-linear association with adults sleeping the recommended 7–9 hours/day having the highest intakes of FV. The potential mechanisms linking sleep and FV consumption are highlighted. Disrupted sleep influences FV consumption through homeostatic and non-homeostatic mechanisms. Conversely, FV consumption may influence sleep through polyphenol content via several potential pathways. Few human experimental studies have examined the effects of FV items and their polyphenols on sleep and there is a need for more studies to address this. An appreciation of the relationship between sleep and FV consumption may help optimize sleep and FV consumption and may reduce the burden of chronic diseases. This review provides implications for public health and directions for future work.

Association between total sleep time and all cancer mortality: non-linear dose-response meta-analysis of cohort studies

OBJECTIVE

Appropriate total sleep time is reported to be associated with several important health outcomes. However, the relationship between total sleep time and all cancer mortality is not well defined because of inconsistent results from published studies, and no dose-response meta-analysis was performed to evaluate the exact dose-response relationship.

METHODS

We conducted a literature search of PubMed and Web of Science to identify all relevant epidemiological studies published before August 9, 2018. We performed categorical and non-linear dose-response meta-analyses to quantify the association between total sleep time and all cancer mortality.

RESULTS

Finally, we included 14 cohort studies in the present meta-analyses enrolling 866,877 participants with 43,021 cancer deaths. We found that total sleep time less than seven hours was not significantly associated with increased risk of all cancer mortality [relative risk (RR) = 1.02; 95% confidence interval (CI) = 0.99-1.05]. However, four to five hours total sleep time was related to an 8% increased risk of all cancer mortality (RR = 1.08; 95% CI = 1.02-1.13) in dose-response meta-analysis. Furthermore, long total sleep time (≥8 hours) was weakly associated with all cancer mortality (RR = 1.05; 95% CI = 1.02-1.08). However, the increment in total sleep time longer than nine hours was notably associated with an increased risk of cancer mortality.

CONCLUSION

The current meta-analysis provides evidence of a positive association between total sleep time of four to five hours and total sleep time longer than eight hours with the risk of all cancer mortality among the general population. Additional studies are needed to establish causality.

The association between sleep duration and cancer-specific mortality: a systematic review and meta-analysis

PURPOSE

In this systematic review and meta-analysis, we aimed to estimate cancer-specific mortality and all-cause mortality among cancer survivors associated with both short (typically 5 or 6 h/night) and long (typically 9 or 10 h/night) sleep duration (versus recommendations), separately by sex, cancer site, and sampling frame.

METHODS

We completed a systematic literature search in five databases and captured relevant literature published through December 2018. Two reviewers independently screened 9,823 records and 32 studies were included representing over 73,000 deaths in cancer survivors. Estimates for short and long sleep duration compared to 'recommended' were pooled using random-effects models.

RESULTS

Pooled hazards ratios for short and long sleep duration for all-cancer-specific mortality were 1.03 (95% CI 1.00-1.06) and 1.09 (95% CI 1.04-1.13), respectively. In subgroup analyses by cancer site, statistically significant increased risks were found for both short and long sleep durations for lung cancer-specific mortality. These associations were maintained when stratified by sex and sampling frame. There were no statistically significant associations found between either short or long sleep duration and breast, colorectal, ovarian, or prostate cancer-specific mortality. Statistically significant increases in all-cause mortality were observed with long sleep duration in breast cancer survivors (1.38; 95% CI 1.16-1.64) with no significant associations found for colorectal or liver/pancreatic cancers.

CONCLUSIONS

We observed that long sleep duration increases cancer-specific mortality for all-cancers and lung cancers, while all-cause mortality is increased for breast cancer survivors. Limitations were found within the existing literature that need to be addressed in future studies in order to improve the understanding regarding the exact magnitude of the effect between sleep duration and site-specific mortality.

The association between physical and mental chronic conditions and napping

The objectives of this study were to assess the associations among various physical and mental chronic conditions and napping. A cross-sectional epidemiological survey was proposed within the NutriNet-Santé population-based e-cohort launched in France in 2009. Participants were 43,060 French volunteers aged 18 y and over with Internet access. A self-report questionnaire assessing sleep characteristics was administered in 2014. The main outcome (dependent) variable was weekday or weekend napping (yes/no). The main exposure (independent) variables were overweight/obesity, hypertension, diabetes, anxiety and depressive disorders, incident major cardiovascular diseases (myocardial infarction, stroke, unstable angina), and incident cancer (breast and prostate). The associations of interest were investigated with multivariable logistic regression analysis. No significant associations were found between major cardiovascular diseases or breast or prostate cancer and napping. Instead, we found that napping was more common among males (46.1%) than among females 36.9% (p < 0.0001). Individuals who were overweight or obese or had hypertension, diabetes, depression or anxiety disorders had an increased likelihood of napping compared with their healthy peers. The adjusted ORs ranged from 1.14 to 1.28″. In conclusion, most chronic conditions were independently associated with napping. Future longitudinal analyses are needed to elucidate causality.

Sleep Duration and Risk of Fatal Coronary Heart Disease, Sudden Cardiac Death, Cancer Death, and All-Cause Mortality

BACKGROUND

Sleep duration has been shown to be associated with all-cause mortality; however, its relationship with cause-specific fatal events remains uncertain. We examined the relationship between sleep duration and risk of fatal coronary heart disease, sudden cardiac death, cancer-related death, and all-cause mortality.

METHODS

Sleep duration was self-reported at baseline examinations performed between March 20, 1984, and December 5, 1989, in 2361 men aged 42-61 years from the Kuopio Ischemic Heart Disease study. Of these, 1734 (73.4%) men were free from coronary heart disease and cancer at baseline.

RESULTS

A total of 802 all-cause deaths, 202 fatal coronary heart disease events, 141 sudden cardiac events, and 229 cancer-related deaths were reported during a median follow-up of 25.9 (interquartile range, 20.6-28.2) years. Multivariable adjusted hazard ratios comparing the top quartile (>10 hours) of sleep duration vs the bottom quartile (<8 hours) was 1.19 (95% confidence interval [CI], 1.01-1.43) for all-cause mortality, 1.27 (95% CI, 0.88-1.84) for fatal coronary heart disease, 1.20 (95% CI, 0.78-1.86) for sudden cardiac death, and 1.29 (95% CI, 0.92-1.80) for cancer death. No differences in association of sleep duration with outcomes were found in clinically relevant subgroups, including age, history of coronary heart disease, body mass index, physical activity, and C-reactive protein levels.

CONCLUSIONS

Longer duration of sleep was associated with significantly increased all-cause mortality. The mechanistic link between these findings remains to be explored further.

Sleep duration, lifestyles and chronic diseases: a cross-sectional population-based study

Background

Adequate sleep is essential for health. Both, short and long sleep durations are associated to worse quality of life and poor health outcomes. Portugal represents a specific population model, since according to European statistics it has high rates of chronic diseases like depression, hypertension, diabetes and stroke; and low quality of life as well as low index of physical activity, while in parallel it has some other good health indicators such as: low age-standardized mortality for both genders, nutrition in terms of energy and fruit consumption, smoking and alcohol, obesity and overweight prevalence. The aim of this study was to characterize health and chronic diseases, lifestyles and quality of life in subjects with short and long sleep duration.

Methods

A population-based cross-sectional evaluation of the third wave of follow-up of the EpiDoC Cohort was carried between 2015-2016. A sample of 5,436 adults ≥18 years, representative of the national population, self-reported their daily total sleep time. Associations between short sleep duration (SSD ≤5h), long sleep duration (LSD≥9h) and independent variables were determined.

Results

The prevalence for SSD was high (20.7%) and the LSD (5.9%) was low. Being older, with lower education, retired and unemployed were associated to SSD and LSD (p<0.01). Being obese was associated to SSD as well as hypertension, gastrointestinal disease and hypercholesterolemia (p<0.01). SSD and LSD, were associated with diabetes (p<0.01 and p=0.03) and depression (p<0.01 and p=0.02) respectively. Cardiovascular disease (p<0.01) was associated to LSD. Multimorbidity (p<0.01) was associated to SSD. Worse quality of life and bad physical function were associated to SSD and LSD, as well as being hospitalized in the previous 12 months (p<0.01).

Conclusions

Socio-demographic, physical activity and chronic diseases were associated to reduction and extension of sleep duration. There was no association between rheumatic diseases and cancer with sleep duration, as found in other studies. This study emphasizes the burden of self-reported SSD for Portugal, its consequences to health and the need to increase sleep awareness campaigns enhancing the importance of sleep in health. Furthermore, it emphasizes that chronic diseases risks are dependent on multiple parameters which varying in different countries or regions, imply the need of regional studies and interventions.