Joint associations of physical activity and sleep duration with cognitive ageing: longitudinal analysis of an English cohort study

Association Between Physical Activity and Performance in Skill Learning Among Older Adults Based on Cognitive Function

BACKGROUND/OBJECTIVES

Most older adults experience cognitive and physical functioning problems; however, they require the ability to learn skills in response to age-related or social environmental changes for independent living. This study aimed to clarify the associations between age-related physical activity and performance in skill learning tasks based on cognitive function.

METHODS

Fifty-eight adults participated in this study and were divided into two groups: the control group (aged under 65 years) and older adult group (aged over 65). All the participants performed two-skill learning exercises based on cognitive function. Habitual exercise was measured using an accelerometer and a self-reported questionnaire.

RESULTS

At baseline, the scores on skill tasks were lower in the older adult group than in the control group and were associated with habitual exercise and motor performance. Skill acquisition, observed in both groups, was associated with age and self-reported physical activity. Retention of the acquired skill was not associated with habitual exercise, and it declined significantly in the older group.

CONCLUSIONS

Skill acquisition was maintained regardless of age; however, the ability to retain the acquired skills decreased among the older adults. Habitual physical activity was associated with skill acquisition but not the retention of the acquired skill. Significance/Implications: The study findings highlight the association between habitual exercise and motor skill learning in older adults, providing insight for practitioners in the rehabilitation and health care fields.

Deep learning-based prediction of individualized Real-time FSH doses in GnRH agonist long protocols

BACKGROUND

Individualizing follicle-stimulating hormone (FSH) dosing during controlled ovarian stimulation (COS) is critical for optimizing outcomes in assisted reproduction but remains difficult due to patient heterogeneity. Most existing models are limited to static predictions of initial doses and do not support real-time adjustments throughout stimulation.

METHODS

We developed a deep learning model that integrates cross-temporal and cross-feature encoding (CTFE) to predict personalized daily FSH doses in patients undergoing COS using the GnRH agonist long protocol. A total of 13,788 IVF/ICSI cycles conducted between January 2018 and December 2020 were retrospectively analyzed. Women with baseline antral follicle counts between 7 and 30 were included. Data were randomly divided into training (n = 6761), validation (n = 2898), and test (n = 4135) sets. The model encodes both static (e.g., age, BMI, basic hormone levels) and dynamic (e.g., follicle development, hormone trends during COS) variables across stimulation days. Final dose predictions were generated using a K-nearest neighbor algorithm applied to low-dimensional latent representations derived from the deep encoder layers.

RESULTS

The CTFE model achieved a dose classification accuracy of 0.737 (± 0.004) and a weighted F1-score of 0.732 (± 0.005) on the test set. On key stimulation days 1 and 5, the CTFE model significantly outperformed traditional LASSO regression models (F1-score: 0.832 vs 0.699 on day 1; 0.817 vs 0.523 on day 5; p < 0.001). Prediction performance was maintained beyond day 13 using a sliding window mechanism, despite reduced data availability in longer stimulation cycles.

CONCLUSIONS

This is the first study to apply a cross-temporal and cross-feature deep learning framework for daily, individualized FSH dose prediction across the full duration of COS. The model demonstrated superior performance over conventional approaches and offers a promising tool for standardizing COS management. Although currently limited by its retrospective, single-center design, the model may support future clinical decision-making and improve COS outcomes. Prospective, multicenter validation studies are warranted to confirm its utility and generalizability.

Longitudinal Proteomic Profiling of Cognition across an Aerobic Exercise Intervention

The physiological basis of cognitive decline remains largely uncharacterized. We identified a protein panel signature, in living humans, that correlates to improvement in neurocognition over a period of 5 years. Our signature is composed of complement proteins, coagulation cascade, and extracellular matrix regulators. In our cohort, SERPINF1 is associated with greater maximal oxygen uptake after an aerobic exercise intervention. Sleep quality is also a key factor in relation to inter-alpha-trypsin inhibitor heavy chain H2, which was associated with greater sleep efficiency. Additionally, we validate that the coagulation profile of decliners' plasma contains procoagulant agonists, leading to greater platelet activation. ANN NEUROL 2025;97:1007-1018.

The association between sleep quality and cognitive impairment among a multi-ethnic population of middle-aged and older adults in Western China: a multi-center cross-sectional study

Objective

This study aims to investigate the relationship between sleep quality and cognitive impairment in middle-aged and older adults living in Western China.

Methods

Baseline data from the West China Health and Aging Trend (WCHAT) study were utilized, with enrollment of participants aged 50 years or older. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), where a PSQI score > 5 indicated poor sleep quality. The cognitive status was evaluated using the 10-item Short Portable Mental Status Questionnaire (SPMSQ). Multinomial logistic regression was applied to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

Results

A total of 6,728 middle-aged and older adults dwelling in western China (age = 62.39 ± 8.925 years, 2,520 males and 4,208 females) were included in the analysis. The prevalence of mild cognitive impairment was 11.0%, with 4.3% having moderate to severe cognitive impairment. Poor sleep quality was found in 47.7% of participants. After adjusting for age, gender, education, marital status, and chronic disease, poor sleep quality (OR = 1.29, 95% CI: 1.1-1.52, p = 0.002) was associated with a higher risk of mild cognitive impairment. Among specific sleep dimensions, there is a significant association between high daytime dysfunction and mild cognitive impairment (adjusted OR = 1.96, 95% CI: 1.45-2.62) as well as moderate to severe cognitive impairment (adjusted OR = 3.15, 95% CI: 2.09-4.73) in the middle-aged and older adults residing in multi-ethnic areas of western China. Besides, a sleep duration of 6-7 h was associated with a reduced risk of mild cognitive impairment (OR = 0.80, 95% CI: 0.65-0.98) and moderate to severe cognitive impairment (OR = 0.71, 95% CI: 0.51-0.99). Stratified analysis showed that poor sleep quality-particularly daytime dysfunction-was significantly associated with moderate to severe cognitive impairment in Han (OR = 4.14, 95%CI: 1.65-10.23), Tibetan (OR = 3.45, 95% CI: 1.42-8.1), and Yi (OR = 4.04, 95%CI: 1.46-10.97) participants, but not in Uyghur and Qiang groups.

Conclusion

Sleep quality is significantly associated with cognitive impairment among middle-aged and older adults in Western China, particularly concerning the components of daytime dysfunction.

Association between plant-based diets and depression in older adults with heart disease: the mediating role of sleep disturbances

Background

Depression is not uncommon among older adults with heart diseases and is related to poor prognosis at clinical setting. We aim to explore the association between plant-based diets and depression in older adults with heart disease and further investigate the mediating role of sleep disturbances in this relationship.

Methods

A cross-sectional sample of 2039 older adults with heart diseases were recruited from the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS). Each individual completed assessments on dietary frequency, depression, sleep quality and duration. Plant-based diet index (PDI), healthy plant-based diet index (hPDI) and unhealthy plant-based diet index (uPDI) were calculated. Logistic regression models and restricted cubic spline curves (RCS) were employed to explore the relationship between plant-based diets and depression in older adults with heart disease. Meanwhile, mediation analysis was used to investigate the mediating roles of sleep quality and sleep duration.

Results

The higher the PDI (OR: 0.56, 95% CI: 0.36-0.88) and the hPDI (OR: 0.39, 95% CI: 0.24-0.62), the lower the risk of depression in older adults with heart disease. Conversely, the higher the uPDI, the higher the risk of depression (OR: 1.76, 95% CI: 1.07-2.92). RCS further confirmed a negative linear dose-response relationship between PDI, hPDI and depression in older adults with heart disease, and a positive trend was found between uPDI and depression. Notably, sleep quality (Indirect effect: -0.031, mediated proportion: 61%) partially mediated the relationship between PDI and depression. In the sex-based subgroup analysis, uPDI was only associated with a higher risk of depression in females.

Conclusion

This is the first study to suggest a significant negative relationship between plant-based diets and depression in older adults with heart disease. Sleep quality plays a mediating role in the association between plant-based diets and depression. Optimizing the dietary structure and improve sleep quality may help reduce the risk of depression in older adults with heart disease.

Impact of Insufficient or Excessive Sleep Duration on Cognitive Function After Stroke: The Norwegian Cognitive Impairment After Stroke Study

BACKGROUND

The impact of sleep duration on cognition, particularly in the context of poststroke cognitive impairment, is not fully understood. Therefore, our objective was to investigate how sleep duration after stroke predicts poststroke cognitive impairment.

METHODS AND RESULTS

Patients admitted with acute stroke between 2015 and 2017 were consecutively recruited to the Nor-COAST (Norwegian Cognitive Impairment After Stroke) study and invited to follow-up assessments at 3 and 18 months. Time in bed, used as a surrogate for sleep duration at 3 months post stroke, was measured using the activPAL thigh-worn sensor over a 3-day period. Sleep duration was categorized into 3 groups: <7 hours (insufficient), 7 to 9 hours (reference), and ≥9 hours (excessive). Cognitive impairment was assessed based on the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria at 3- and 18-month follow-up. Out of the 815 patients, we included 443 (54%) prestroke cognitive healthy with valid activPAL registration in this analysis. Mean±SD age was 71.2±11.4 years, 185 (42%) were women, 363 (82%) had prestroke modified Rankin Scale score <2, and 345 (78%) suffered a minor stroke (National Institutes of Health Stroke Scale score ≤5). On average, participants spent 8.3±1.4 hours in bed each night, 17.2% had a sleep duration <7 hours, and 25% slept more than 9 hours. Insufficient (odds ratio [OR], 3.6 [95% CI, 1.3-10.2], and OR, 1.4 [95% CI, 0.5-3.8]) and excessive (OR, 2.8 [95% CI, 1.1-7.5], and OR, 3.3 [95% CI, 1.3-8.1]) sleep duration were associated with an increased risk of cognitive impairment at 3- and 18-month follow-up, respectively.

CONCLUSIONS

Insufficient or excessive sleep duration was associated with poststroke cognitive impairment.

Unraveling the link between physical activity and cognitive function: the mediating impact of depressive symptoms

BACKGROUND

This study investigates the association between physical activity and cognitive function in adults aged 50 and older, with a focus on the mediating role of depressive symptoms.

METHODS

Data were drawn from Waves 7 to 9 of the English Longitudinal Study of Ageing (ELSA), including 5,499 participants aged 50 years and older. Cognitive function was assessed through measures of episodic memory, numeracy, and orientation. Physical activity was quantified using a composite measure combining the frequency of vigorous, moderate, and light exercise with their respective average metabolic equivalents. Depressive symptoms were evaluated using the CES-D-8 scale. Generalized estimating equations (GEE) were employed to examine the association between physical activity and cognitive function, while the Bootstrap method was utilized to evaluate the mediating role of depressive symptoms.

RESULTS

GEE analyses revealed that higher levels of physical activity were significantly associated with improved global cognitive function(β = 0.151, 95%CI: 0.118-0.183), episodic memory(β = 0.074, 95%CI: 0.058-0.090), numeracy(β = 0.033, 95%CI: 0.015-0.051), and orientation(β = 0.039, 95%CI: 0.022-0.057) (all P < 0.001). Physical activity also demonstrated a significant negative association with depressive symptoms(β=-0.402, 95%CI: -0.452 to -0.352) (P < 0.001), which, in turn, were linked to lower cognitive function. Notably, depressive symptoms mediated 8.46% of the association between physical activity and global cognitive function.

CONCLUSIONS

Greater engagement in physical activity is associated with better cognitive function, and this association is partially mediated by depressive symptoms. These findings underscore the importance of promoting physical activity to support cognitive health in older adults, with particular attention to its potential role in mitigating depressive symptoms.

Joint association of physical activity and night sleep duration with the risk of atherosclerotic cardiovascular disease

OBJECTIVES

To investigate the joint association of physical activity (PA) and sleep duration with the risk of atherosclerotic cardiovascular disease (ASCVD).

METHODS

A total of 111,714 participants who participated in health examinations were enrolled from the Kailuan Study between June 2006 and December 2009. Sleep duration was divided into three groups (short, healthy, and long). PA was categorized into physically inactive and physically active. Restricted cubic splines were used to analyze the associations of PA and sleep duration with ASCVD. Cox proportional hazards models were conducted to investigate the effects of PA and sleep duration on ASCVD risk, with their cross-product interaction terms tested on both multiplicative and additive scales.

RESULTS

During 13.05 ± 3.16 years of follow-up, 10,408 participants developed ASCVD. Restricted cubic spline analysis revealed a nonlinear dose-response relationship between sleep duration and ASCVD risk among physically inactive participants (Pnonlinear <0.05). Both additive and multiplicative interactions between physical activity and sleep duration were observed in their effects on ASCVD risk (Pinteraction < 0.05). Compared with participants who had healthy sleep duration and were physically active, those with unhealthy sleep duration and physical inactivity exhibited a significantly higher risk of ASCVD [short sleep duration: HR (95 %CI) = 1.19 (1.09, 1.30); long sleep duration: HR (95 % CI) = 1.10 (0.90, 1.34)]. However, physically active participants in both the short and long sleep duration groups exhibited a reduced risk of ASCVD.

CONCLUSIONS

Engaging in sufficient PA can reduce the risk of ASCVD in individuals with short sleep duration. Therefore, simultaneously maintaining healthy sleep duration and engaging in PA may effectively prevent ASCVD.

The joint effects of sleep duration and exercise habit on all-cause mortality among Chinese older adult: a national community-based cohort study

Abstract

This study examines the combined effects of sleep duration and exercise habits on all-cause mortality in older Chinese adults using data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS).

Methods

Data were collected from 7231 residents aged 60 and above from the CLHLS. Participants were categorized based on their sleep duration (short sleep: <6 hours, normal sleep: 6-8 hours, and long sleep: >8 hours) and exercise habits (physically active, physically inactive, inactive-to-active, and active-to-inactive). The analysis was conducted over three follow-up periods (2011, 2014, and 2018). Cox proportional hazards regression models were used to assess the associations between sleep duration, exercise habits, and all-cause mortality.

Results

The results showed that compared to short sleepers, individuals with normal sleep (6-8 hours) had a slightly reduced risk of death, although this reduction was not statistically significant (HR = 0.97, 95% CI 0.87-1.08). In contrast, long sleepers (>8 hours) had a significantly higher risk of mortality (HR = 1.28, 95% CI 1.16-1.43). Regarding exercise habits, regular exercise or transitioning from inactivity to exercise significantly reduced mortality risk compared to those who did not exercise (HR = 0.74, 95% CI 0.66-0.83 and HR = 0.88, 95% CI 0.80-0.97, respectively). Notably, exercise habits did not significantly impact mortality among short sleepers, regardless of gender. However, both men and women with normal or long sleep experienced significant mortality benefits from regular exercise. Additionally, older women who transitioned from a sedentary lifestyle to physical activity during periods of long sleep demonstrated lower mortality rates.

Conclusion

Both sleep duration and exercise habits are associated with mortality risk among older Chinese adults, with notable gender differences in their combined effects. Targeted health policies that encourage improved sleep and exercise habits, while considering gender-specific needs, are essential to reduce mortality and enhance quality of life in this population.

Associations Between Sleep Duration and Activity of Daily Living Disability Among Older Adults in China: Cross-Sectional Study

Background

China has the largest elderly population globally; the growth rate of the aged tendency of the population was higher than that of Western countries. Given the distinctions in historical, ethnic, and economic status as well as socio-cultural background, Chinese adults had different sleep patterns compared with adults in other countries. Considering the heavy disease burden caused by activities of daily living (ADL) disability, we conducted a cross-sectional analysis using data from the China Health and Retirement Longitudinal Study (CHARLS) to test the hypothesis that individuals with short and longer sleep duration are more likely to have ADL disability.

Objective

ADL disability is a common condition affecting the quality of life among older people. This study aimed to explore the associations between sleep duration and ADL disability among middle-aged and older adults in China.

Methods

This cross-sectional study used data from 17,607 participants from the 2018 CHARLS (from 2018 to 2020), an ongoing representative survey of adults aged 45 years or older and their spouses. Self-reported sleep duration per night was obtained from face-to-face interviews. The ADL was measured using a 6-item summary assessed with an ADL scale that included eating, dressing, getting into or out of bed, bathing, using the toilet, and continence. Multiple generalized linear regression models-adjusted for age, sex, education, marital status, tobacco and alcohol use, depression, place of residence, sensory impairment, self-reported health status, life satisfaction, daytime napping, chronic disease condition, and sample weights-were used.

Results

Data were analyzed from 17,607 participants, of whom 8375 (47.6%) were men. The mean (SD) age was 62.7 (10.0) years. Individuals with 4 hours or less (odds ratio [OR] 1.91, 95% CI 1.60-2.27; P<.001), 5 hours (OR 1.33, 95% CI 1.09-1.62; P=.006), 9 hours (OR 1.48, 95% CI 1.13-1.93; P<.001), and 10 hours or more (OR 1.88, 95% CI 1.47-2.14; P<.001) of sleep per night had a higher risk of ADL disability than those in the reference group (7 hours per night) after adjusting for several covariates. Restricted cubic splines analysis suggested a U-shaped association between sleep duration and ADL disability. When sleep duration fell below 7 hours, an increased sleep duration was associated with a significantly low risk of ADL disability, which was negatively correlated with sleep duration until it fell below 7 hours (OR 0.83, 95% CI 0.79-0.87; P<.001). When sleep duration exceeded 7 hours, the risk of ADL disability would increase facing prolonged sleep duration (OR 1.19, 95% CI 1.12-1.27; P<.001). ADL disability should be monitored in individuals with insufficient (≤4 or 5 hours per night) or excessive (9 or ≥10 hours per night) sleep duration.

Unlabelled

In this study, a U-shaped association between sleep duration and ADL disability was found. Future longitudinal studies are needed to establish temporality and examine the mechanisms of the associations between sleep duration and ADL disability.

Independent associations of sleep and physical activity with cognition are mediated by hippocampal microstructure in middle-aged and older adults

Sleep and physical activity levels are both associated with cognitive performance among older adults; however, the brain mechanisms underlying these beneficial relationships remain poorly understood. This study investigated cross-sectional associations of actigraphic estimates of physical activity and sleep with cognition and diffusion imaging-based measures of medial temporal lobe (MTL) gray matter microstructural integrity in adults free of dementia. Participants were 132 older adults from the Biomarkers of Cognitive Decline Among Normal Individuals (BIOCARD) cohort study (119 cognitively unimpaired and 13 with mild cognitive impairment; mean age=70.8 years). Multiple linear regression analyses assessed the relationships between total volume of physical activity (TVPA), total sleep time (TST), and sleep efficiency (SE) with cognitive performance and MTL microstructural integrity. Results indicated that greater TVPA and SE were both independently associated with higher hippocampal and parahippocampal microstructure integrity (indicated by lower mean diffusivity) and better visuospatial processing abilities, independent of the volume of these structures and of amyloid burden, measured by positron emission tomography. Additionally, higher hippocampal microstructure statistically mediated the independent associations of physical activity and sleep with visuospatial abilities, independent of MTL volume and Aβ load. These findings suggest that physical activity and sleep are independently associated with cognitive performance, and that hippocampal microstructural integrity may be an underlying mechanism supporting these associations.

Age and gender disparities in joint associations of physical activity and sleep duration with depressive symptoms trajectories: a longitudinal analysis of Chinese middle-aged and older adults

OBJECTIVES

The combined effects of physical activity and sleep duration on depressive symptoms trajectories, and age and gender disparities remain inadequately understood. The objective of this study was to identify the joint relationship of physical activity and sleep duration with depressive symptoms trajectories in Chinese middle-aged and older adults, and explored disparities in the joint associations.

METHOD

This longitudinal analysis draws upon data from the China Health and Retirement Longitudinal Study. The analysis comprised 35063 observations. Linear mixed-effect models were employed to discern independent and joint correlation of physical activity and sleep duration with depressive symptoms trajectories.

RESULTS

Chinese middle-aged and older adults showed increasing depressive symptoms trajectory. Physical activity and sleep duration interplayed to impact depressive symptoms trajectory in different ways. Compared to participants engaged in lower physical activity and short sleep, depressive symptom trajectories of those with higher physical activity and optimal sleep, and higher physical activity and short sleep increased less rapidly among group aged 60-70 years, as well as in women group.

CONCLUSION

This study emphasized the importance of combining interventions targeting habits of physical activity and sleep for middle-aged and older adults to improve their mental health, especially for women and those aged 60-70 years.

Effects of physical multimorbidity on cognitive decline trajectories among adults aged 50 years and older with different wealth status: a 17-year population-based cohort study

This study aimed to investigate the effects of physical multimorbidity on the trajectory of cognitive decline over 17 years and whether vary across wealth status. The study was conducted in 9035 respondents aged 50+ at baseline from nine waves (2002-2019) of the English Longitudinal Study of Aging. A latent class analysis was used to identify patterns of physical multimorbidity, and mixed multilevel models were performed to determine the association between physical multimorbidity and trajectories of cognitive decline. Joint analyses were conducted to further verify the influence of wealth status. Four patterns of physical multimorbidity were identified. Mixed multilevel models with quadratic terms of time and status/patterns indicated significant non-linear trajectories of multimorbidity on cognitive function. The magnitude of the association between complex multisystem patterns and cognitive decline increased the most as follow-up progressed. Individuals with high wealth and hypertension/diabetes patterns have significantly lower composite global cognitive z scores over time as compared with respiratory/osteoporosis patterns. Physical multimorbidity at baseline is associated with the trajectory of cognitive decline, and the magnitude of the association increased over time. The trend of cognitive decline differed in specific combinations of wealth status and physical multimorbidity.

Cross sectional associations of physical activity and sleep with mental health among Chinese university students

OBJECTIVE

This study aimed to examine the levels of physical activity (PA), sleep, and mental health (MH), specifically depression, anxiety, and stress, among Chinese university students. It also aimed to analyze the influencing factors of MH, providing a theoretical foundation for developing intervention programs to improve college students' mental health.

METHODS

A stratified, clustered, and phased sampling method was employed. In September 2022, a survey was conducted among 36,756 university students from 104 higher education institutions across 31 provinces, autonomous regions, and municipalities in China. The participants' PA behaviors, sleep patterns, depressive symptoms (use the CES-D), anxiety symptoms (use the GAD-7), smoking and drinking behaviors, and demographic information were assessed through an online questionnaire using Questionnaire Star software.

RESULTS

A total of 30,475 valid questionnaires were completed. The proportion of university students engaging in light-intensity PA was 77.6%. The prevalence of insufficient sleep was 39.5%, whereas the prevalence of poor sleep quality was 16.7%. The prevalence of depressive symptoms was 10%, and the prevalence of anxiety symptoms was 23.3%. Binary logistic regression analysis revealed that engaging in moderate to high-intensity PA and having sufficient and high-quality sleep were associated with a lower likelihood of depressive symptoms (OR = 0.207-0.800, P < 0.01), whereas appropriate sleep duration and higher sleep quality were associated with a lower likelihood of anxiety symptoms (OR = 0.134-0.827, P < 0.001).

CONCLUSION

The intensity of PA among university students is predominantly light, and the reported rate of insufficient sleep is relatively high. Moderate to high-intensity PA and sufficient high-quality sleep may alleviate MH issues among college students, with an interaction effect observed among PA, sleep, and depression symptoms. Future studies should further explore targeted interventions combining PA and sleep behaviors to enhance the MH of university students.

The Cross-Sectional Association Between Multimorbidity and Sleep Quality and Duration Among the Elderly Community Dwellers in Northwest China

Background

Multimorbidity, defined as the coexistence of two or more chronic diseases, is highly prevalent among the elderly population and is associated with adverse outcomes. However, little is known about its relationship with sleep issues, particularly in this demographic. Therefore, this study aimed to investigate its association with sleep quality and duration among the elderly.

Methods

This cross-sectional study was conducted in Emin County, Xinjiang, China, which included a population aged 60 years and above. We employed the Pittsburgh Sleep Quality Index (PSQI) score to assess sleep quality and duration. Multimorbidity was determined through self-reports, physical examination, blood tests, and imaging. Logistic regression analyses were used to explore the association between multimorbidity and sleep patterns, adjusting for confounders.

Results

A total of 8205 elderly participants were included, of whom 66.8% suffered from multimorbidity. Participants with multimorbidity exhibited higher total PSQI scores [6 (3,9)], and a higher percentage of poor sleep quality (50.6%), compared to those without multimorbidity. Multimorbidity was significantly associated with the presence of poor sleep quality (OR = 1.27, 95% CI: 1.14-1.41, P < 0.001) before and after adjusting for confounders. The risk of having poor sleep quality significantly increased as the number of multimorbidities increased. The OR (95% CI) values were 1.16 (1.02,1.32) for two diseases, 1.54 (1.26,1.90) for ≥5 diseases. In the adjusted model for total participants, having four diseases (OR = 1.26, 95% CI: 1.05-1.51, p = 0.013) and five or more diseases (OR = 1.29, 95% CI: 1.03-1.61, p = 0.029) were associated with shorter sleep duration. Furthermore, those with five or more diseases associated with longer sleep duration (OR = 1.40, 95% CI: 1.00-1.95, p = 0.057).

Conclusion

There is a significant association between multimorbidity and poor sleep quality in older community dwellers, which may provide clues for disease prevention.

Associations between sleep duration, depression status, and cognitive function among Chinese elderly: A community-based study

BACKGROUND

The associations of sleep duration and depressive status on cognitive function among the elderly remain controversial. This study aimed to investigate the associative effects and mediating mechanisms between sleep duration and depressive status on cognitive function in elderly adults.

METHODS

Participants were recruited from cross-sectional and cohort surveys of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). We identified thresholds for sleep duration and depression and used logistic regression to explore their independent and joint effects on cognitive impairment. Further, we analyze the mediating effects of depressive status on the association between sleep duration and cognitive function.

RESULTS

Of 13840 elderly (median age: 84 years, female: 54.6 %), 2835 (20.5 %) had cognitive impairment. Compared with those who slept 6-8 h, the ORs (95%CIs) for those who slept < 6 h and > 8 h were 0.98 (0.85, 1.12) and 1.48 (1.32, 1.66). Compared with non-depressed, the OR (95%CI) for the depressed participants was 1.74 (1.53, 1.98). Compared with those with sleep 6-8 h and none-depression, those with sleep > 8 h and depression had the highest odds of cognitive impairment (OR = 2.40, 95%CI: 1.88-3.07). Additionally, Compared with those who slept 6-8 h, the associations between depression-mediated short and long sleep and cognitive impairment were 51.1 % and 6.5 %, respectively.

LIMITATIONS

Cross-sectional studies require caution in the interpretation of causal associations.

CONCLUSIONS

Long sleep and depression were independently and jointly associated with higher odds of cognitive impairment among the Chinese elderly, and short sleep increased the risk of cognitive impairment by promoting the prevalence of depression.

Exploring the relationship of sleep duration on cognitive function among the elderly: a combined NHANES 2011-2014 and mendelian randomization analysis

BACKGROUND

As one of the key features of sleep, sleep duration (SD) has been confirmed to be associated with multiple health outcomes. However, the link between SD and cognitive function (CF) is still not well understood.

METHODS

We employed a combined approach utilizing data from the National Health and Nutrition Examination Survey (NHANES 2011-2014) and Mendelian Randomization (MR) methods to investigate the relationship between SD and CF. In the NHANES cross-sectional analysis, the association between these variables was primarily examined through multivariate linear regression to explore direct correlations and utilized smoothing curve fitting to assess potential nonlinear relationships. To ensure the robustness of our findings, subgroup analyses were also conducted. MR analysis was used to assess the causal relationship between SD and sleeplessness on CF. After excluding confounding factors, univariate and multivariate MR were performed using inverse variance weighting (IVW) as the main analysis method, and sensitivity analysis was performed.

RESULTS

The results of our cross-sectional study indicate a notable negative association between SD and CF, forming an inverted U-shaped curve with the inflection point occurring at SD = 6 h. This relationship remains consistent and robust across subgroup analyses differentiated by variables such as age, levels of physical activity, and frequency of alcohol intake. In MR analysis, IVW analysis showed no causal relationship between SD and sleeplessness on CF (Both P > 0.05).

CONCLUSION

Cross-sectional studies suggest the existence of an inverted U-shaped correlation between SD and CF among the elderly. However, MR analysis did not reveal a causal relationship between SD and CF, which the lack of nonlinear MR analysis may limit. These findings provide evidence from a sleep perspective for optimizing cognitive strategies in older adults.

Validation of intrinsic capacity and healthy sleep pattern in middle-aged and older adults: a longitudinal Chinese study assessing healthy ageing

OBJECTIVES

Intrinsic capacity (IC), a multidimensional construct encompassing mental and physical capacities, has been established in the aging framework by the World Health Organization. However, the detailed relationship between IC and Chinese sleep patterns (nighttime sleep and post-lunch naps) remains inadequately elucidated.

METHODS

Participants in this study were individuals aged ≥45 years residing in China, included in the China Health and Retirement Longitudinal Study (CHARLS). We analyzed 4 years of CHARLS data from the first wave (May 2011-March 2012) to the second wave (July 2015-January 2016). Data from these waves were utilized for longitudinal analysis. Self-reported data included nighttime sleep and nap duration, along with other baseline characteristics. The IC evaluation involved physical examinations and blood tests. Initially, linear regression was used to assess the relationship between total sleep duration, nighttime sleep duration, nap duration, and IC change between the two waves that were determined by marginal effects (ME) and their corresponding 95% confidence intervals (CIs). Regression splines were employed to explore potential nonlinear associations. Subgroup and sensitivity analyses were conducted to investigate the heterogeneity of IC change under specific conditions and the robustness of our results. Mediation analysis was performed to identify potential factors mediating the relationship between sleep patterns and IC change.

RESULTS

Both excessive (>10 h) (total, ME: -1.12; 95% CI: -1.61, -0.64; nighttime, ME: -1.44; 95% CI: -2.29, -0.59) and insufficient (<6 h) sleep duration (total, ME: -0.43; 95% CI: -0.68, -0.18; nighttime, ME: -0.50; 95% CI: -0.73, -0.27) negatively impacted IC change. Moderate naps (≤60 min) mitigated the decline in IC change (ME: 0.28; 95% CI: 0.07, 0.49). IC values decreased at the slowest rate when nap time constituted one-seventh of total sleep time. The onset of dyslipidemia partially mediated the association between naps (≤60 min) and IC change (P =  0.02).

CONCLUSIONS

These findings suggest that maintaining a healthy sleep pattern of 6-8 h of nighttime or total sleep, along with a post-lunch nap of ≤60 min, helps preserve optimal IC or delay its decline. This is particularly beneficial for cognitive, psychological, and locomotion performance among middle-aged and older adults.

Personality and sleep quality among nursing interns: Traditional Chinese medicine constitution as a mediator and sedentary time as a moderator

Aims

This study investigated whether the relationship between neuroticism and sleep quality in nursing interns is mediated by traditional Chinese medicine (TCM) constitution. In addition, the study examined whether sedentary behaviour affects this mediating model.

Background

The importance of sleep quality for nursing interns cannot be overstated. Previous studies have demonstrated that neuroticism negatively affects sleep quality. However, little is known about the path of the relationship between neuroticism and sleep quality among nursing interns.

Design

A cross-sectional study was conducted in Central and South China.

Methods

A total of 630 nursing interns participated in this study. Neuroticism, TCM constitution, sleep quality, and sedentary behaviour were measured using reliable and valid questionnaires. Data were analysed using the PROCESS macro in SPSS.

Results

Neuroticism significantly predicted the Pittsburgh Sleep Quality Index (PSQI; β = 0.144, P < 0.001). Neuroticism exerted a significant indirect effect on the PSQI through gentleness and damp heat constitution (β = 0.265, 95 % CI [0.214, 0.315]). In addition, sedentary time moderated this mediation model. Sedentary time marginally moderated the direct pathway from neuroticism to the PSQI (B = -0.025, 95 % CI [-0.046, -0.004]) and the pathway from neuroticism to the damp heat constitution (B = 0.175, 95 % CI [0.021, 0.329]) in the nursing interns.

Conclusion

TCM constitution mediates the relationship between neuroticism and sleep quality. Given the moderating effect of sedentary behaviour, targeting sedentary behaviour can be an effective approach to improve the sleep quality of nursing interns.

Diurnal patterns of accelerometer-measured physical activity and sleep and risk of all-cause mortality: a follow-up of the National Health and Nutrition Examination Surveys (NHANES)

BACKGROUND

Physical activity and sleep are established modifiable lifestyle factors, but the optimal time of the day of these behaviours for health is unknown. This study examined the independent and joint associations of diurnal patterns of physical activity and sleep with all-cause mortality.

METHODS

This prospective cohort study included 6,673 participants who have attended the accelerometer assessment in the 2011-2014 National Health and Nutrition Examination Surveys (NHANES). Diurnal patterns of accelerometer-measured physical activity and sleep were identified using K-means clustering analysis. All-cause mortality was ascertained from the accelerometer measurement to December 31, 2019 (median follow-up 6.8 years). Survey-weighted Cox proportional hazard models were performed to estimate the independent and joint associations of diurnal patterns of physical activity and sleep with all-cause mortality.

RESULTS

Diurnal patterns identified were: early-morning (32.4%), midday (42.5%), and late-afternoon (25.1%) for physical activity; and irregular sleep (37.4%), morning lark (33.6%), and night owl (29.0%) for sleep. After adjusting for volume of physical activity, sleep duration and other potential covariates, the early-morning physical activity pattern (hazard ratio 1.36, 95% confidence interval 1.13-1.64) and irregular sleep pattern (1.42, 1.01-1.99) were independently associated with higher risk of all-cause mortality, compared with midday physical activity and morning lark sleep patterns, respectively. In addition, participants with the combined pattern of early-morning physical activity and irregular sleep had higher risk of all-cause mortality compared to those with midday physical activity combined with a morning lark sleep pattern (1.92, 1.33-2.78). Several sociodemographic differences were observed in the strength of these associations.

CONCLUSIONS

Wearable activity-rest monitoring data showed that peak physical activity in the early morning and irregular sleep diurnal patterns are associated with increased mortality risk, and the combination of these patterns further exaggerated the risk. Public health program should acknowledge that the diurnal patterns of physical activity and sleep, in addition to their duration and frequency, may play a crucial role in lifestyle-based health promotion and management strategies.

A Compensatory Role of Physical Activity in the Association Between Sleep and Cognition

We synthesize evidence investigating the hypothesis that greater engagement in physical activity (PA) may compensate for some of the negative cognitive consequences associated with poor sleep in older adults. Potential mechanistic pathways include glymphatic clearance, influences on depression, and other comorbidities. The evidence base is largely cross-sectional and observational, and further experimental studies are required.

The Relationship between Sleep and Physical Activity by Age, Race, and Gender

Cardiometabolic diseases remain the leading cause of death in the United States. Lifestyle factors contribute the majority of risk for these diseases. Although diet and exercise have been the primary focus of research on modifiable behaviors to target for interventions to prevent cardiometabolic disease, recent evidence suggests that sleep also plays an important role. Indeed, the updated American Heart Association campaign includes sleep as one of its "Essential Eight". This review details the reciprocally reinforcing positive relationship between sleep and daytime physical activity behaviors and explores how this relationship differs based on age, gender and race. For example, interventions to improve moderate intensity physical activity may be particularly beneficial to women, older adults, and Black Americans, who are at increased risk for sleep disturbances. Communicating to Americans the importance of managing their time to meet current physical activity and sleep recommendations is a challenge given that there are so many competing behaviors consuming large amounts of time (e.g., social media, gaming), but is critical given the importance of these behaviors for cardiometabolic health.

Associations of objective sleep duration and physical activity with risk of heart failure: A prospective cohort study

OBJECTIVE

This study aimed to investigate the independent and joint associations of accelerometer-derived sleep duration and physical activity (PA) in different intensities with the risk of incident heart failure (HF).

METHODS

The study included 89,572 participants (mean age 62.2 ± 7.8 years, 42.8% male) from the UK Biobank. Sleep duration (short: <6 h/day; normal: 6-8 h/day; long: >8 h/day) and PA [total PA, light PA (LPA), moderate-to-vigorous PA (MVPA), vigorous PA (VPA)] were measured using accelerometers over 7 days. MVPA and VPA were categorized according to the World Health Organization's recommended levels, while LPA and total PA were categorized based on the median. HF cases were identified through hospital records or death registries.

RESULTS

Over a 7-year follow-up period, 1324 participants (2.1%; incidence rate, 2.1 per 1000 person-years) developed HF. Short, but not long, sleep duration was linked to a 33% increased risk of HF [hazard ratio (HR) 1.33, 95% confidence interval (CI): 1.11-1.59]. This increased risk associated with short sleep could be mitigated by increasing PA, especially to the levels of recommended MVPA or VPA. In joint analyses, compared to participants meeting the recommended MVPA and with normal sleep duration, those not meeting the MVPA recommendation and with short sleep had the highest HF risk (HR 1.78, 95% CI: 1.42-2.25).

CONCLUSIONS

Accelerometer-derived short, but not long, sleep duration was associated with a higher risk of incident HF. Engaging in sufficient PA, especially recommended MVPA or VPA, can partially mitigate this risk.

Associations between sleep duration trajectories and cognitive decline: A longitudinal cohort study in China

OBJECT

The relationship between sleep duration trajectories and cognitive decline remains uncertain. This study aims to examine the connections between various patterns of sleep duration and cognitive function.

METHODS

Group-based trajectory modeling (GBTM) was employed to identify longitudinal trajectories of sleep duration over four-year follow-up period, while considering age, sex and nap duration as adjustments. Logistic regression was utilized to analyze the association between sleep trajectories and cognition, with odds ratios (OR) and 95 % confidence intervals (CI) reported. Subgroup analyses based on various demographic characteristics were conducted to explore potential differences in sleep trajectories and cognitive decline across different population subgroups.

RESULTS

A total of 5061 participants were followed for four years, and three sleep duration trajectories were identified: high increasing (n = 2101, 41.6 %), stable increasing (n = 2087, 40.7 %), and low decreasing (n = 873, 17.7 %). After adjustment for basic demographic information, health status, and baseline cognition, the high increasing trajectory was found to be associated with cognitive decline in terms of global cognition (OR:1.52,95 %CI:1.18-1.96), mental intactness (OR:1.36,95 %CI:1.07-1.73) and episodic memory (OR:1.33, 95 %CI:1.05-1.67), as compared to stable increasing trajectory. These associations were particularly prominent among the non-elderly population (≤65 years) and those without depressive symptoms.

CONCLUSION

This study suggests that both high increasing and low decreasing sleep duration trajectories are linked to cognitive decline, as compared to the stable increasing trajectory. Long-term attention to changes in sleep duration facilitates early prevention of cognitive decline.

Threshold effect of physical exercise on its association to diabetes mellitus in short sleep population: evidence from a nationwide study

BACKGROUND

The prevalence of diabetes mellitus (DM) is a significant public health concern, especially among individuals with short sleep duration. Understanding the relationship between physical exercise and DM in this population is crucial for developing effective prevention strategies. However, the presence of a potential threshold effect of exercise on DM risk remains unclear.

METHODS

Using data from the National Health and Nutrition Examination Survey (NHANES) spanning from 2007 to 2018, this population-based study investigated the association between physical exercise and DM in individuals with short sleep duration (no more than 7 hours per night). Weighted logistic regression analyses were conducted, adjusting for demographic and lifestyle factors. Additionally, a two-piecewise linear regression model was employed to identify any threshold effect of exercise on DM risk.

RESULTS

This study included 15,092 participants identified with short sleep duration. Demographic characteristics stratified by DM status indicate higher prevalence among certain groups, such as middle-aged and older adults, males, and non-Hispanic Whites. The analysis revealed an inverse association between exercise levels and DM prevalence among the short sleep population. In the fully adjusted model, individuals engaging in sufficient exercise (> 600 MET-minutes/week) exhibited significantly reduced odds of developing DM [OR (95% CI): 0.624(0.527,0.738), p < 0.001]. Furthermore, the segmented regression model identified an inflection point at 2000 MET-minutes/week, below which a significant correlation between exercise and DM was observed.

CONCLUSIONS

This study provides evidence of a threshold effect of physical exercise on its association with DM in individuals with short sleep duration. Tailored exercise interventions targeting this population may help mitigate DM risk and improve overall health outcomes. Further research is warranted to validate these findings and explore optimal exercise thresholds for DM prevention strategies.

Healthy lifestyle and cognitive decline in middle-aged and older adults residing in 14 European countries

Studies examining lifestyle and cognitive decline often use healthy lifestyle indices, making it difficult to understand implications for interventions. We examined associations of 16 lifestyles with cognitive decline. Data from 32,033 cognitively-healthy adults aged 50-104 years participating in prospective cohort studies of aging from 14 European countries were used to examine associations of lifestyle with memory and fluency decline over 10 years. The reference lifestyle comprised not smoking, no-to-moderate alcohol consumption, weekly moderate-plus-vigorous physical activity, and weekly social contact. We found that memory and fluency decline was generally similar for non-smoking lifestyles. By contrast, memory scores declined up to 0.17 standard deviations (95% confidence interval= 0.08 - 0.27) and fluency scores up to 0.16 standard deviations (0.07 - 0.25) more over 10 years for those reporting smoking lifestyles compared with the reference lifestyle. We thus show that differences in cognitive decline between lifestyles were primarily dependent on smoking status.

Sleep and physical activity measures are associated with resting-state network segregation in non-demented older adults

Greater physical activity and better sleep are associated with reduced risk of cognitive decline and dementia among older adults, but little is known about their combined associations with measures of brain function and neuropathology. This study investigated potential independent and interactive cross-sectional relationships between actigraphy-estimated total volume of physical activity (TVPA) and sleep patterns [i.e., total sleep time (TST), sleep efficiency (SE)] with resting-state functional magnetic resonance imaging (rs-fMRI) measures of large scale network connectivity and positron emission tomography (PET) measures of amyloid-β. Participants were 135 non-demented older adults from the BIOCARD study (116 cognitively normal and 19 with mild cognitive impairment; mean age = 70.0 years). Using multiple linear regression analyses, we assessed the association between TVPA, TST, and SE with connectivity within the default-mode, salience, and fronto-parietal control networks, and with network modularity, a measure of network segregation. Higher TVPA and SE were independently associated with greater network modularity, although the positive relationship of SE with modularity was only present in amyloid-negative individuals. Additionally, higher TVPA was associated with greater connectivity within the default-mode network, while greater SE was related to greater connectivity within the salience network. In contrast, longer TST was associated with lower network modularity, particularly among amyloid-positive individuals, suggesting a relationship between longer sleep duration and greater network disorganization. Physical activity and sleep measures were not associated with amyloid positivity. These data suggest that greater physical activity levels and more efficient sleep may promote more segregated and potentially resilient functional networks and increase functional connectivity within specific large-scale networks and that the relationship between sleep and functional networks connectivity may depend on amyloid status.

Association between exposure to chemical mixtures and epigenetic ageing biomarkers: Modifying effects of thyroid hormones and physical activity

Evidence on the effects of internal chemical mixture exposures on biological age is limited. It also remains unclear whether hormone homeostasis and lifestyle factors can modify such a relationship. Based on the Biomarkers for Air Pollutants Exposure (BAPE) study, which involved healthy older adults aged 60-69 years in China, we found that chemical mixture exposures, including metals, polycyclic aromatic hydrocarbons (PAHs), per- and polyfluoroalkyl substances (PFASs), phthalates (PAEs), and organophosphate esters (OPEs), were significantly associated with shortened DNAmTL and accelerated SkinBloodClock, in which PFASs and OPEs in blood were the primary contributors to DNAmTL, while metals and PAEs had relatively higher contributions in urine. Furthermore, lower levels of thyroxin appeared to exacerbate the adverse effects of environmental chemicals on epigenetic ageing but relatively higher levels of physical activity had the beneficial impact. These findings may have important implications for the development of healthy ageing strategy and aged care policy, particularly in light of the global acceleration of population ageing.

Joint associations of sleep duration and physical activity with cognitive impairment among rural elderly over 65 years old: a cross-sectional study

BACKGROUND

During the long preclinical phase of dementia, accelerated cognitive impairment is regarded as a cardinal marker. Thus, the identification of risk factors for cognitive impairment is of great significance for dementia prevention. This study aims to examine the joint associations of sleep duration and physical activity with cognitive impairment among rural elderly over 65 years old, and provide suggestions for improving the cognitive function in rural elderly over 65 years old.

METHODS

A cross-sectional study was conducted in rural Nanjing by recruiting 1147 individuals aged above 65 years. Cognitive function was assessed using the brief community screening instrument for dementia. Physical activity was assessed using the Global Physical Activity Questionnaire. Data were analyzed by multivariate logistic regression models, and a significant difference was set at P < 0.05.

RESULTS

Compared with participants with proper sleep duration and sufficient physical activity, participants with short sleep duration and insufficient physical activity (odds ratio (OR): 1.820; 95% CI: 1.265 ~ 2.618), long sleep duration and sufficient physical activity (OR: 2.428; 95% CI: 1.137 ~ 5.183) showed an increased likelihood of cognitive impairment.

CONCLUSIONS

Inappropriate sleep duration combined with insufficient physical activity was associated with a significantly higher likelihood of cognitive impairment in rural elderly over 65 years old.

Actigraphy Estimated Sleep Moderates the Relationship between Physical Activity and Cognition in Older Adults

Background and Aims

Physical inactivity and poor sleep are common in older adults and may interact to contribute to age- and disease-related cognitive decline. However, prior work regarding the associations among physical activity, and cognition in older adults is primarily limited to subjective questionnaires that are susceptible to inaccuracies and recall bias. Therefore, this study examined whether objectively measured physical activity and sleep characteristics, each estimated using actigraphy, are independently or interactively associated with cognitive performance.

Methods

The study included 157 older adults free of dementia (136 cognitively unimpaired; 21 MCI; M age = 71.7) from the BIOCARD cohort.

Results

Using multiple linear regression, cognition was regressed on estimated total volume of physical activity (TVPA), sleep efficiency (SE), wake after sleep onset (WASO), and total sleep time (TST) (adjusted for age, sex, education, diagnosis, vascular risk factors, and Apolipoprotein E (APOE)-e4 genetic status). Models were also run for domain-specific cognitive composite scores. TVPA and SE each were positively associated with a global cognitive composite score. TVPA was positively associated with executive function and language composites, and SE was positively related to executive function, visuospatial, and language composites. Importantly, a TVPA by SE interaction (p = 0.015) suggested that adults with the poorest SE experienced the greatest benefit from physical activity in relation to global cognition. The other sleep metrics were unrelated to cognitive performance.

Conclusion

These results suggest that TVPA and SE may synergistically benefit cognition in older adults.

Knowledge structure and future research trends of body-mind exercise for mild cognitive impairment: a bibliometric analysis

Background

Mild cognitive impairment (MCI) is a common neurodegenerative disorder that poses a risk of progression to dementia. There is growing research interest in body-mind exercise (BME) for patients with MCI. While we have observed a rapid growth in interest in BME for MCI over the past 10 years, no bibliometric analysis has investigated the knowledge structure and research trends in this field. Consequently, the objective of this research is to conduct a bibliometric analysis of global publications of BME for MCI from 2013 to 2022.

Methods

A total of 242 publications in the field of BME for MCI were retrieved from the Web of Science Core Collection. Bibliometric analysis, including performance analysis, science mapping, and visualization, was performed using CiteSpace, VOSviewer, and Microsoft Excel.

Results

Publications and citations in the field of BME for MCI have shown a rapidly increasing trend over the last decade. Geriatrics & Gerontology, and Neurosciences were the most frequently involved research categories. China (78 documents) and the USA (75 documents) contributed to the largest number of publications and had the strongest international collaborative networks. Fujian University of Traditional Chinese Medicine contributed to the largest number of publications (12 documents), and Chen, L of this institution was the most prolific author (12 documents). Frontiers in Aging Neuroscience (16 documents), and JOURNAL OF ALZHEIMER'S DISEASE (12 documents) were the most prolific journals. Tai Chi and Baduanjin, as specific types of BME, were the hotspots of research in this field, while evidence synthesis and guidelines might be future research trends.

Conclusion

In the last decade, there has been a rapid growth in scientific activities in the field of BME for MCI. The results of this study provide researchers and other stakeholders with knowledge structure, hotspots, and future research trends in this field.

The Effect of Physical Activity on Sleep Quality and Sleep Disorder: A Systematic Review

Regular physical activity has several health benefits, including improved sleep quality and symptoms of sleep disorders. With the known benefits of moderate-intensity activities to sleep quality and a growing interest in using physical activity as a treatment approach for different sleep disorders, we conducted a systematic review to provide evidence-based data on the association between physical activity and sleep. A systematic search was carried out in PubMed, Embase, MEDLINE (Medical Literature Analysis and Retrieval System Online), Google Scholar, and Scopus, using predetermined search terms (Medical Subject Headings (MeSH) terms) and keywords. The included studies focused on exploring the effect of physical activity on sleep quality and sleep disorders or the association between physical activity and sleep outcomes. Relevant data were extracted, and the quality of the studies was evaluated using suitable methods. The collected findings were synthesized and discussed. The findings of this systematic review have potential implications for healthcare, public health policies, and health promotion.