Interplay of Objective Sleep Duration and Cardiovascular and Cerebrovascular Diseases on Cause-Specific Mortality

Nocturia, Sleep Quality, and Mortality: A Systematic Review and Meta-Analysis

PURPOSE

Nocturia is increasingly recognized as a significant factor influencing sleep quality and potentially linked to increased mortality risk. This meta-analysis aimed to systematically review and synthesize existing research investigating the relationship between nocturia, sleep quality, and mortality, in a single framework.

MATERIALS AND METHODS

A comprehensive systematic search across PubMed, Embase, and the Cochrane Library was conducted from the inception of each database until April 2, 2024, yielding studies investigating the methodological qualities and the relationship between nocturia and its impact on mortality and sleep quality. Risk of Bias was assessed using ROBINSE tool and RevMan 5.4 was used to analyze the results.

RESULTS

Of the 1,450 studies subjected to screening, 33 were selected for analysis. Fourteen studies examined the association between nocturia and mortality, and 19 studies investigated impact of nocturia on sleep quality. Significant associations were found between nocturia and both mortality (pooled risk ratio: 1.78, 95% confidence interval [CI]: 1.50-2.10) and poor sleep quality (pooled odds ratio: 3.05, 95% CI: 1.89-4.93). Patients with nocturia demonstrated significantly poorer sleep quality scores compared with controls (pooled standardized mean difference: 1.01, 95% CI: 0.55-1.47).

CONCLUSIONS

This meta-analysis underscores the significance of addressing nocturia as a public health concern owing to its association with poor sleep quality and increased mortality risk. It advocates for comprehensive patient care strategies for addressing nocturia, sleep quality, and mortality.

Association between mental health and insomnia in young soldiers: a mediation analysis of mental health literacy

BACKGROUND

Military personnel face more stresses and challenges, and they are at greater risk of insomnia compared to the general population. Mental health is one of the primary ways of managing insomnia. However, there are few studies regarding the mediator in the two variables among this population. This study aimed to investigate the insomnia, mental health literacy, and mental health in young soldiers, to explore the correlation of the three variables and to verify the mediating role of mental health literacy between mental health and insomnia.

METHODS

The cross-sectional study was conducted from March 2023 to March 2024. A total of 2375 soldiers was surveyed using the General Information Questionnaire, Insomnia Severity Index (ISI), 12-Item General Health Questionnaire (GHQ-12), and National Mental Health Literacy Questionnaire (NMHLQ). The data were processed using descriptive analysis, Mann-Whitney U test, Kruskal-Wallis H test, Spearman's correlation analysis, stepwise regression analysis, and a mediation analysis.

RESULTS

The questionnaire of 2297 participants was valid with an effective rate of 96.72%. The majority of participants were male (2281, 99.30%). The mean age of participants was 23.49 ± 2.51years (range 18-35). The total score of ISI was 1 (0, 5), with a high occurrence rate of insomnia at 14.85%. The mental health displayed a significant positive correlation with insomnia (r = 0.333, P<0.001). Furthermore, the mental health literacy and its two dimensions-NMHLQ-mental health awareness (NMHLQ-A) and NMHLQ-identification and response to mental illness (NMHLQ-I) exhibited significant negative correlations with both mental health and insomnia (r=-0.346∽-0.074, P<0.001). Before and after adjusted control variables, the NMHLQ-A and NMHLQ-I played partial mediating role between mental health and insomnia, and the mediating effect ratios attributable to the NMHLQ-A were 17.79% and 17.41%, whereas to the NMHLQ-I were 2.33% and 2.20%.

CONCLUSIONS

Our findings highlight the potential negative impacts of mental health literacy on the insomnia of young soldiers directly and indirectly. Especially, NMHLQ-A and NMHLQ-I play partial mediating role between mental health and insomnia. According to these findings, Psychological service workers can develop and implement highly individualized effective interventions to improve young soldiers' mental health and sleep quality.

Sleep Disordered Breathing and Subsequent Neuroimaging Markers of Brain Health in Hispanic/Latino Adults

BACKGROUND AND OBJECTIVES

Sleep disordered breathing (SDB) is a risk factor of stroke and Alzheimer disease and related dementias (ADRDs). Hispanic/Latino adults have higher risk of SDB and ADRDs, which emphasizes the need to better understand the association between SDB and brain health. Furthermore, results on SDB and brain aging are mixed, and there are limited data for Hispanic/Latino adults. The main goal of this study is to assess the association between SDB and brain MRI measures in a diverse Hispanic/Latino population.

METHODS

The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) is a community-based prospective cohort multisite (Bronx, Chicago, Miami, San Diego) study of diverse Hispanic/Latino adults in the United States. Participants underwent 1 night of unsupervised home testing with a sleep apnea test device at baseline. The SOL-Investigation of Neurocognitive Aging MRI, an ancillary study, recruited 2,667 HCHS/SOL participants (35-85 years) who underwent neuroimaging approximately 10 years after baseline sleep assessment. The main exposure was the respiratory event index (REI, 3% desaturation). Secondary exposures encompassed measures of oxygen saturation. Main outcomes included total brain, gray matter, white matter hyperintensity (WMH), and hippocampal volumes. Survey linear regression models were used to determine associations between SDB and brain MRI measures.

RESULTS

The mean age was 67.6 years, with a body mass index of 29.7, and 58.3% were female. We found that increased REI was associated with larger hippocampal volumes (bhippocampus = 0.006 [0.001-0.012]). These results were consistent with oxygen levels (minimum SpO2%) during sleep (bhippocampus = -0.013 [-0.021 to -0.004]). Lower oxygen levels (mean SpO2) during sleep were associated with enlarged WMH volumes (bWMH = -0.095 [-0.164 to -0.025]).

DISCUSSION

We found that SDB and worse oxygenation during sleep were linked to larger hippocampal volumes. These results underscore the complex relationships between sleep health and brain aging and warrant longitudinal follow-up, starting in middle age or earlier.

Cancer and Stress: Understanding the Connections and Interventions

Stress is ubiquitous in our modern society and contributes to many disease states. This narrative review describes the effect of stress/distress on cancer development and progression. Seminal randomized controlled trials, systematic reviews/meta-analyses, and distress management guidelines from the National Comprehensive Cancer Network (NCCN), the American Society of Clinical Oncology (ASCO), and the Society for Integrative LinearOncology (SIO) are highlighted. We describe the physiological effects of distress, distress assessment, and management. Psychological treatments are summarized. Evidence-based lifestyle modifications and integrative therapies are reviewed in detail, including mindfulness-based techniques, yoga, guided imagery, breathing techniques, hypnosis, exercise, music therapy, qigong/Tai Chi, eye movement desensitization and reprocessing, and improving sleep and heart rate variability. Recognition and treatment of distress can improve quality of life. More research is needed to determine the effects of managing distress on cancer outcomes, as well as the best type and duration of intervention, noting that the benefits of interventions may be specific for patients with different cancer types.

The Great Controversy of Obstructive Sleep Apnea Treatment for Cardiovascular Risk Benefit: Advancing the Science Through Expert Consensus. An Official American Thoracic Society Workshop Report

The prevalence of obstructive sleep apnea (OSA) is on the rise, driven by various factors including more sensitive diagnostic criteria, increased awareness, enhanced technology through at-home testing enabling easy and cost-effective diagnosis, and a growing incidence of comorbid conditions such as obesity. Treating symptomatic patients with OSA syndrome to enhance quality of life remains a cornerstone approach. However, there is a lack of consensus regarding treatment to improve cardiovascular disease (CVD) outcomes, particularly in light of overall negative results from several randomized controlled trials (RCT) indicating no benefit of positive airway pressure (PAP) therapy on primary and secondary CVD events. These RCTs were limited by suboptimal PAP adherence, use of composite CVD outcomes, and limited diversity and generalizability to Sleep Clinic patients. As such, this workshop assembled clinical experts, as well as researchers in basic and translational science, epidemiology, clinical trials, and population health to discuss the current state, and future research directions to guide personalized therapeutic strategies and future research directions in OSA. There was overall consensus among workshop participants that OSA represents a heterogeneous disease with variable endotypes and phenotypes, and heterogeneous responses to treatment. Future research should prioritize employing multi-modal therapeutic approaches within innovative and adaptive trial designs, focusing on specific subgroups of OSA patients hypothesized to benefit from a CVD perspective. Future work should also be inclusive of diverse populations and consider the life-course of OSA to better comprehend treatment strategies that can address the disproportionate impact of OSA on racially minoritized groups. Further, a more holistic approach to sleep must be adopted to include broader assessments of symptoms, sleep duration, and comorbid sleep and circadian disorders. Finally, it is imperative to establish a sleep research consortium dedicated to collecting raw data and biospecimens categorized by OSA subtypes. This will facilitate mechanistic determinations, foster collaborative research, and help bolster the pipeline of early-career researchers.

Negative health outcomes in long sleepers: The societal sleep restriction hypothesis

Society imposes work and school schedules, as well as social expectations, that militate against consistently obtaining more than 7-9 h of sleep every 24 h. For most but not all adults this sleep duration is adequate. But among those who consistently obtain more than 9 h of sleep per day ("long sleepers"), there likely exists a subpopulation of individuals who are nevertheless failing to obtain enough sleep to satisfy their physiological sleep needs - a consequence of "restricting" their daily sleep durations to whatever extent they can tolerate so as to conform as closely as possible to society's norms and expectations. It is hypothesized that the 'long sleep arm' of the seemingly paradoxical U-shaped relationship between sleep duration and negative health outcomes can be explained, at least in part, by the existence of a subpopulation of such 'sleep-restricted long sleepers.'

Molecular Mechanisms of Plant Extracts in Protecting Aging Blood Vessels

Plant Extracts (PE) are natural substances extracted from plants, rich in various bioactive components. Exploring the molecular mechanisms and interactions involved in the vascular protective effects of PE is beneficial for the development of further strategies to protect aging blood vessels. For this review, the content was obtained from scientific databases such as PubMed, China National Knowledge Infrastructure (CNKI), and Google Scholar up to July 2024, using the search terms "Plant extracts", "oxidative stress", "vascular aging", "endothelial dysfunction", "ROS", and "inflammation". This review highlighted the effects of PE in protecting aging blood vessels. Through pathways such as scavenging reactive oxygen species, activating antioxidant signaling pathways, enhancing respiratory chain complex activity, inhibiting mitochondrial-reactive oxygen species generation, improving nitric oxide bioavailability, downregulating the secretion of inflammatory factors, and activating sirtuins 1 and Nrf2 signaling pathways, it can improve vascular structural and functional changes caused by age-related oxidative stress, mitochondrial dysfunction, and inflammation due to aging, thereby reducing the incidence of age-related cardiovascular diseases.

Insomnia with objective but not subjective short sleep duration is associated with incident cardiovascular and/or cerebrovascular disease

STUDY OBJECTIVES

Insomnia with objective short sleep duration (ISSD) has been associated with cardiometabolic outcomes (ie, hypertension or diabetes). We examined whether ISSD, based on objective or subjective sleep measures, is associated with more serious health problems, such as incident cardiovascular and/or cerebrovascular disease (CBVD).

METHODS

1,258 men and women from the Penn State Adult Cohort (56.9% women, aged 48.3 ± 12.95 years) without CBVD at baseline were followed up for 9.21 ± 4.08 years. The presence of CBVD was defined as a history of diagnosis or treatment of heart disease and/or stroke. Insomnia was defined as a complaint of insomnia with a duration ≥ 1 year. Poor sleep was defined as a complaint of difficulty falling asleep, staying asleep, nonrestorative sleep, or early morning awakening. Objective short sleep duration was defined as < 6 hours' sleep based on polysomnography. Subjective short sleep duration was based on the median self-reported percentage of sleep time (ie, < 7 hours).

RESULTS

Compared with normal sleepers with normal sleep duration, the highest risk of incident CBVD was in the ISSD group (odds ratio = 2.46, 95% confidence interval = 1.04-5.79), and the second highest was in normal sleepers with short sleep duration (odds ratio = 1.68, 95% confidence interval = 1.11-2.54). The risk of incident CBVD was not significantly increased in poor sleepers or those with insomnia with normal sleep duration. Finally, insomnia with subjective short sleep duration was not associated with increased incident CBVD.

CONCLUSIONS

These data add to the cumulative evidence that ISSD, based on objective but not subjective measures, is the more severe biological phenotype of the disorder associated with incident CBVD.

CITATION

Pejovic S, Vgontzas AN, Fernandez-Mendoza J, et al. Insomnia with objective but not subjective short sleep duration is associated with incident cardiovascular and/or cerebrovascular disease. J Clin Sleep Med. 2024;20(7):1049-1057.

Mild-to-moderate obstructive sleep apnea and mortality risk in a general population sample: The modifying effect of age and cardiovascular/cerebrovascular comorbidity

About 5.4%-45.7% of the general population has mild-to-moderate obstructive sleep apnea (mmOSA), which is highly comorbid with cardiovascular and/or cerebrovascular diseases (CBVD). We examined the association between mmOSA and all-cause mortality and the modifying effect of age and CBVD. A total of 1681 adults 20-88 years old from the Penn State Adult Cohort (PSAC) (41.9% male) were followed up for 20.1 ± 6.2 years for all-cause mortality. Mild and moderate OSA were defined as an apnea/hypopnea index (AHI) 5-14.9 and 15-29.9 events/hour, respectively. CBVD was defined as a report of a physician diagnosis or treatment for heart disease and/or stroke. Cox proportional hazards regression models were used to estimate all-cause mortality adjusted for confounders. All-cause mortality risk was significantly increased in the mmOSA group in young and middle-aged adults (<60 years) (HR = 1.59, 95%CI 1.08-2.04) but not in older adults (≥60 years) (HR = 1.05, 95%CI 0.80-1.39). A synergistic effect between mmOSA and CBVD was stronger in those <60 years (HR = 3.82, 95%CI 2.25-6.48 in <60 years vs 1.86 95%CI 1.14-3.04 in ≥60 years). There was an additive effect between moderate OSA and hypertension in <60 but not in those ≥60 years. Mild OSA was associated with all-cause mortality only in the presence of CBVD. Mortality risk is increased in young and middle-aged adults with moderate OSA, whereas the mortality risk associated with mild OSA is elevated only, regardless of age, in the presence of comorbid CBVD. AHI cut-offs warranting treatment of mmOSA may need to be adjusted based on age and comorbidities.

Edward O. Bixler, PhD: from the Apollo project and chimpanzees to sleep epidemiology

What an honor to write about Dr. Edward O. Bixler's contributions to the sleep field. In 1967, Dr. Bixler published a case report on a chimpanzee with implanted brain electrodes while working at an Air Force base in New Mexico. A few years later, in 1971, he published on the sleep effects of flurazepam in individuals with insomnia together with Dr. Anthony Kales, data that he had collected when the Sleep Research & Treatment Center (SRTC) was housed at the University of California Los Angeles. Dr. Bixler, a meticulous scientist, learned from Dr. Kales, a devoted clinician, to study "the whole patient, and all aspects of sleep," a legacy that continued when the SRTC moved to Penn State in Hershey. Indeed, Dr. Bixler's tenure at Penn State from 1971 until 2019 kept the science of the SRTC focused on that premise and helped translate scientific evidence into clinical care. He not only contributed early to the pharmacology of sleep and the effects of hypnotics, but he was also a pioneer in "sleep epidemiology." His "Prevalence of sleep disorders in the Los Angeles metropolitan area" study of 1979 was the first rigorous epidemiological study on sleep disturbances. Starting in 1990, he established the Penn State Adult Cohort to estimate the prevalence and natural history of sleep-disordered breathing and other sleep disorders in adults. Inspired by life-course epidemiology, he established in 2001 the Penn State Child Cohort to estimate the same phenomena in children. This Living Legend paper captures and highlights Dr. Bixler's enduring legacy to sleep science.

Association of sleep characteristics with cardiovascular disease risk in adults over 40 years of age: a cross-sectional survey

Background

The relationship between sleep characteristics and cardiovascular disease (CVD) risk has yet to reach a consistent conclusion, and more research needs to be carried out. This study aimed to explore the relationship between snoring, daytime sleepiness, bedtime, sleep duration, and high-risk sleep patterns with CVD risk.

Methods

Data from the National Health and Nutrition Examination Survey (NHANES) 2015-2018 were collected and analyzed. Multivariable logistic regression was used to evaluate the relationship between snoring, daytime sleepiness, bedtime, sleep duration, high-risk sleep patterns, and CVD risk. Stratified analysis and interaction tests were carried out according to hypertension, diabetes and age.

Results

The final analysis contained 6,830 participants, including 1,001 with CVD. Multivariable logistic regression suggested that the relationship between snoring [OR = 7.37,95%CI = (6.06,8.96)], daytime sleepiness [OR = 11.21,95%CI = (9.60,13.08)], sleep duration shorter than 7 h [OR = 9.50,95%CI = (7.65,11.79)] or longer than 8 h [OR = 6.61,95%CI = (5.33,8.19)], bedtime after 0:00 [OR = 13.20,95%CI = (9.78,17.80)] compared to 22:00-22:59, high-risk sleep patterns [OR = 47.73,95%CI = (36.73,62.04)] and CVD risk were statistically significant. Hypertension and diabetes interacted with high-risk sleep patterns, but age did not.

Conclusions

Snoring, daytime sleepiness, excessive or short sleep duration, inappropriate bedtime, and high-risk sleep patterns composed of these factors are associated with the CVD risk. High-risk sleep patterns have a more significant impact on patients with hypertension and diabetes.

Age-related differences in the association of mild-to-moderate sleep apnea with incident cardiovascular and cerebrovascular diseases

BACKGROUND

Mild-to-moderate obstructive sleep apnea (mmOSA) is highly prevalent in the general population. However, studies on its association with incident cardiovascular and/or cerebrovascular disease (CBVD) are limited. We examined the association between mild-to-moderate OSA and incident cardiovascular and/or cerebrovascular (CBVD) in a general population sample, and whether age modifies this association.

METHODS

A total of 1173 adults from the Penn State Adult Cohort (20-88 years) without CBVD or severe OSA at baseline were followed-up after 9.2 (±4.1) years. Incident CBVD was defined based on a self-report of a physician diagnosis or treatment for heart disease and/or stroke. Logistic regression examined the association of mild-to-moderate OSA (AHI 5-29.9) with incident CBVD and the combined effect of mmOSA and MetS on incident CBVD after adjusting for multiple confounders.

RESULTS

Age significantly modified the association between mmOSA with incident CBVD (p-interaction = 0.04). Mild-to-moderate OSA was significantly associated with incident CBVD in adults aged <60 years (OR = 1.74, 95%CI = 1.06-2.88, p = 0.029), but not in adults aged ≥60 years (OR = 0.71, 95%CI = 0.39-1.27, p = 0.247). Even mild OSA (AHI 5-14.9) carried a significant risk for incident CBDV in adults aged <60 years (OR = 1.86, 95%CI = 1.05-3.28, p = 0.032). An additive effect was found between mmOSA and MetS with incident CBVD in those aged <65 years (OR = 3.84, 95%CI = 1.95-7.56, p<0.001).

CONCLUSIONS

The risk of incident CBVD is increased in young and middle-aged but not older adults with mmOSA, which may affect the way we currently diagnose and treat this highly prevalent sleep-related breathing disorder.

Impact of site, size and severity of ischemic cerebrovascular stroke on sleep in a sample of Egyptian patients a polysomnographic study

BACKGROUND

Sleep difficulties following a cerebrovascular stroke are an interesting topic in the scientific community. Following a brain ischemic insult, a variety of sleep problems can occur.

AIM OF WORK

To study the sleep architecture following stroke and to identify the impact of site, size and severity of ischemic cerebrovascular troke on sleep microstructure.

SUBJECTS AND METHODS

this was a case control study; polysomnogram was done for 93 patients admitted to the stroke unit at El- Hadara university hospital with the first ever ischemic stroke. NIHSS was calculated immediately and 1 month after stroke onset. 50 age matched control subjects with no evidence of central nervous system or major psychiatric disorder by history or clinical examination.

RESULTS

Total sleep time, sleep efficiency were lower in ischemic cerebrovascular stroke patients than in control group and this was statistically significant (p = .001* p = .0001* respectively). Arousal index limb movement index and snoring index were all higher among the ischemic cerebrovascular stroke group in comparison to the control group and this was statistically significant (p = .0001*p = .05*p = .0001). Both the REM(rapid eye movement) and REM latency were highest among brain stem stroke, and this was statistically significant p = .043*, p = .0.001*.cortical infarcts showed higher AHI (apnea hypopnea index)and this was statistically significant p = 0.002* Limb movement index was higher among sizable size stroke and this was statistically significant (p = 0.038). NIHSS National Institutes of Health Stroke Scale after 1 month follow up showed a significant indirect correlation with the lowest oxygen saturation during sleep (p = 0.047). Lowest oxygen saturation was lowest among sizable stokes and desaturation index was highest among sizable size strokes both were statistically significant p = 0.006. NIHSS2 had a significant negative correlation with the lowest oxygen saturation during sleep p = 0.047.

CONCLUSION

The microstructure of sleep is significantly impacted by cerebrovascular stroke. Brain stem strokes had the highest REM and REM latency, while cortical strokes had the highest moderate-to-severe AHI. Sizable strokes displayed increased indices of limb movement, desaturation, and oxygen saturation.

A prospective study of the association of weekend catch-up sleep and sleep duration with mortality in middle-aged adults

Health effects of weekend catch-up sleep (CUS) could differ depending on both the ability to obtain sufficient sleep during weekdays and amount of weekend CUS required to compensate for sleep lost during the week. Using data from 3128 middle-aged (40-64 years) participants of the Sleep Heart Health Study, we examined the longitudinal association of these two aspects of sleep with all-cause mortality. CUS was calculated as the difference in self-reported habitual sleep duration between weekends and weekdays, and classified into no, short (1 h), and long (2 h or more) CUS. Polysomnography-measured total sleep time, representing the ability to obtain sufficient sleep, was classified into short (< 360 min) or normal (≥ 360 min) sleep durations. We estimated multivariable-adjusted mortality hazard ratios (HRs) and 95% confidence intervals (CIs) for six groups divided by the extent of CUS and sleep duration. Participants were followed up for a median (interquartile range) of 12.3 (11.3-13.5) years. Short weekend CUS with normal sleep duration was associated with lower mortality compared to no CUS with normal sleep duration (HR, 0.48; 95% CI 0.27-0.83). When stricter cutoffs were applied for sleep durations, while the protective effect of short CUS with normal sleep duration (≥ 390 min) was strengthened (HR, 0.36; 95% CI 0.17-0.78), the harmful effect of short CUS with short sleep duration (< 330 min) emerged (HR, 1.84; 95% CI 1.08-3.14). Results highlight the importance of balancing sleep ability and CUS. Sufficient sleep may reduce weekday sleep debt and only a short CUS would be required on weekends, improving mortality in middle-aged adults.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41105-023-00460-6.

Joint Associations of Device-Measured Sleep Duration and Efficiency With All-Cause and Cause-Specific Mortality: A Prospective Cohort Study of 90 398 UK Biobank Participants

BACKGROUND

Both sleep duration and efficiency are essential for health outcomes. However, few studies have considered the effects of both sleep duration and efficiency on predicting the risks of mortality. This study investigated the independent and joint associations of accelerometer-measured sleep duration and efficiency with all-cause and cause-specific mortality.

METHODS

The UK Biobank is a cohort study of over 500 000 individuals recruited between 2006 and 2010. This study included participants wearing wrist accelerometers for 7 consecutive days between February 2013 and December 2015. Mortality was ascertained by the national death registries.

RESULTS

Of the 90 398 participants (age, 62.4 [7.8] years, 43.5% male) who were included, 2 685 deaths were reported within a median follow-up duration of 6.4 years. Both accelerometer-measured short (adjusted hazard ratios, 1.27; 95% confidence interval [CI]: 1.11-1.45) and long sleep duration (adjusted hazard ratios, 1.16; 95% CI: 1.06-1.28) were positively associated with the risks of all-cause mortality. Lower sleep efficiency was associated with an increased risk of all-cause and cause-specific mortality. Significant interaction existed between accelerometer-measured sleep duration and efficiency for the risk of all-cause mortality (Pinteraction = .001), participants with long sleep duration and lower sleep efficiency had a double mortality risk compared with those with higher sleep efficiency and normal sleep duration (adjusted hazard ratios = 2.11; 95% CI: 1.44-3.09).

CONCLUSIONS

Accelerometer-measured short/long sleep duration and lower sleep efficiency were associated with increased risks of mortality. Sleep efficiency modified the effects of long sleep duration on survival.

Prediction of Liver Steatosis and Fibrosis Based on Clinical Variables Using a Large National Survey Database

Background

Vibration-controlled transient elastography (VCTA) and controlled attenuation parameter (CAP) are used more frequently to diagnose liver fibrosis and steatosis among nonalcoholic fatty liver disease patients. However, limited robust data are available on the clinical variables strongly related to these disorders and who needs to be referred for screening.

Methods

We used the National Health and Nutritional Examination Survey 2017-2018 database to identify the clinical predictors strongly related to liver steatosis and advanced fibrosis. Baseline comparisons among these groups were made based on widely accepted cutoffs. Linear and logistic regressions were performed to identify the associations between the clinical variables and liver steatosis and fibrosis. We used adaptive lasso regression, gradient-boosted model, and decision trees to determine clinical variables strongly related to these outcomes. A Naïve Byes classifier and decision trees were used to calculate the predicted probabilities of liver steatosis and fibrosis.

Results

32% of our population had evidence of liver steatosis using 294 dB/m as a cutoff. An increase in age, serum triglyceride, and body mass index were associated with a statistically significant increase in liver steatosis; in contrast, females had statistically significantly lower values for liver steatosis by 15 points in the multivariable linear regression model. Serum LDL, smoking, and systolic and diastolic blood pressure are poorly associated with liver steatosis in the adaptive lasso regression. On the other hand, sex, tobacco use, metabolic energy expenditure, and serum triglyceride are the least associated with liver fibrosis based on decision tree analysis and a gradient-boosted model. In decision trees, people with a body mass index above 30 and HbA1c above 5.7 have a 72% likelihood of liver steatosis compared to 14% for people with a body mass index below 30. On the other hand, people with a body mass index above 41 have a 38% likelihood of liver fibrosis.

Conclusion

Body mass index, hemoglobin A1c, serum triglyceride level, sex, and age could provide a good prediction for liver steatosis, while body mass index, blood pressure, platelet counts, hemoglobin A1c, serum LDL, or HDL are highly associated with liver fibrosis and should be used as an initial screening tool prior referral for VCTE/CAP.

Sleep disorder, Mediterranean diet, and all-cause and cause-specific mortality: a prospective cohort study

BACKGROUND

There is a bidirectional effect between sleep disorders and Mediterranean diet (MED), but the joint effect of MED and sleep disorders on mortality is unclear. The aim of this study was to investigate whether there is a synergistic effect of adherence to MED and sleep disorders on all-cause and cause-specific mortality.

METHODS

The study included 23,212 individuals in the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2014. A 9-point evaluation score, alternative Mediterranean diet (aMED) index was used to assess adherence to MED. Sleep disorder and hours of sleep were assessed by structured questionnaires. Cox regression models were used to assess the relationship between sleep disorders, aMED and all-cause mortality, cause-specific mortality (cardiovascular-related death, cancer-related death). The interaction effect of sleep disorders with aMED on mortality was further assessed.

RESULTS

Results showed that participants with lower aMED and presence of sleep disorders had significantly higher risk of all-cause mortality and cardiovascular-related mortality (HR, 2.16, 95% CI, 1.49-3.13, P < 0.0001; HR, 2.68, 95% CI, 1.58-4.54, P = 0.0003). A significant interaction effect was found between aMED and sleep disorders on cardiovascular mortality (p for interaction = 0.033). No significant interaction existed between aMED and sleep disorders on all-cause mortality (p for interaction = 0.184) and cancer-related mortality (p for interaction = 0.955).

CONCLUSIONS

Poorer adherence to MED and sleep disorders synergistically increased long-term all-cause mortality and cardiovascular mortality in NHANES population.

Socioeconomic Background and Self-Reported Sleep Quality in Older Adults during the COVID-19 Pandemic: An Analysis of the English Longitudinal Study of Ageing (ELSA)

The COVID-19 pandemic negatively impacted sleep quality. However, research regarding older adults' sleep quality during the pandemic has been limited. This study examined the association between socioeconomic background (SEB) and older adults' sleep quality during the COVID-19 pandemic. Data on 7040 adults aged ≥50 were acquired from a COVID-19 sub-study of the English Longitudinal Study of Ageing (ELSA). SEB was operationalized using educational attainment, previous financial situation, and concern about the future financial situation. Sociodemographic, mental health, physical health, and health behavior variables were included as covariates. Chi-squared tests and binary logistic regression were used to examine associations between SEB and sleep quality. Lower educational attainment and greater financial hardship and concerns were associated with poor sleep quality. The relationship between educational attainment and sleep quality was explained by the financial variables, while the relationship between previous financial difficulties and sleep quality was explained by physical health and health behavior variables. Greater financial concerns about the future, poor mental health, and poor physical health were independent risk factors for poor sleep quality in older adults during the pandemic. Healthcare professionals and service providers should consider these issues when supporting older patients with sleep problems and in promoting health and wellness.

The association between daytime sleep and general obesity risk differs by sleep duration in Iranian adults

BACKGROUND

Sleep duration and daytime napping and obesity are related to adiposity; however, it is not clear whether the association between daytime napping and adiposity measures can differ by sleep duration.

AIM

To clarify the association between daytime napping and general and abdominal obesity based on sleep duration of participants.

SUBJECTS AND METHODS

This cross-sectional study was conducted on 1,683 individuals (837 men and 846 women) aged ≥ 35 years. Height, weight and waist circumference (WC) were measured according to the standard protocols. Body mass index (BMI) was calculated. Self-reported sleep duration (in a 24-hour cycle) was recorded. The odds of general and abdominal obesity were compared between nappers and non-nappers, stratified by their sleep duration (≤ 6 h, 6-8 h, ≥ 8 h).

RESULTS

The mean (SD) age of participants was 47.48 ± 9.35 years. Nappers with a short sleep duration (≤ 6 h) had greater BMI and higher risk for overweight/obesity compared with counterpart non-nappers after adjustment for potential confounders (OR = 1.61, 95% CI = 1.07-2.41). In subjects with moderate sleep duration (6-8 h), nappers had a tendency towards higher BMI in comparison with non-nappers (28.04 ± 0.25 vs. 26.93 ± 0.51 kg/m²; p = 0.05), however, no significant difference was observed for the risk of obesity. Daytime napping was not related to the risk of obesity in long sleepers. No significant association was observed for abdominal obesity measures.

CONCLUSIONS

Daytime napping is associated with increased risk of overweight/obesity in short sleepers. However, in subjects with longer sleep duration, it is not related to the risk of overweight/obesity.

Mindfulness-based therapy for insomnia for older adults with sleep difficulties: a randomized clinical trial

OBJECTIVE

Poor sleep is a modifiable risk factor for multiple disorders. Frontline treatments (e.g. cognitive-behavioral therapy for insomnia) have limitations, prompting a search for alternative approaches. Here, we compare manualized Mindfulness-Based Therapy for Insomnia (MBTI) with a Sleep Hygiene, Education, and Exercise Program (SHEEP) in improving subjective and objective sleep outcomes in older adults.

METHODS

We conducted a single-site, parallel-arm trial, with blinded assessments collected at baseline, post-intervention and 6-months follow-up. We randomized 127 participants aged 50-80, with a Pittsburgh Sleep Quality Index (PSQI) score ⩾5, to either MBTI (n = 65) or SHEEP (n = 62), both 2 hr weekly group sessions lasting 8 weeks. Primary outcomes included PSQI and Insomnia Severity Index, and actigraphy- and polysomnography-measured sleep onset latency (SOL) and wake after sleep onset (WASO).

RESULTS

Intention-to-treat analysis showed reductions in insomnia severity in both groups [MBTI: Cohen's effect size d = -1.27, 95% confidence interval (CI) -1.61 to -0.89; SHEEP: d = -0.69, 95% CI -0.96 to -0.43], with significantly greater improvement in MBTI. Sleep quality improved equivalently in both groups (MBTI: d = -1.19; SHEEP: d = -1.02). No significant interaction effects were observed in objective sleep measures. However, only MBTI had reduced WASO_actigraphy (MBTI: d = -0.30; SHEEP: d = 0.02), SOL_actigraphy (MBTI: d = -0.25; SHEEP: d = -0.09), and WASO_PSG (MBTI: d = -0.26; SHEEP (d = -0.18). There was no change in SOL_PSG. No participants withdrew because of adverse effects.

CONCLUSIONS

MBTI is effective at improving subjective and objective sleep quality in older adults, and could be a valid alternative for persons who have failed or do not have access to standard frontline therapies.

The effect and relative importance of sleep disorders for all-cause mortality in middle-aged and older asthmatics

BACKGROUND

Previous studies observed that sleep disorders potentially increased the risk of asthma and asthmatic exacerbation. We aimed to examine whether excessive daytime sleepiness (EDS), probable insomnia, objective short sleep duration (OSSD), and obstructive sleep apnea (OSA) affect all-cause mortality (ACM) in individuals with or without asthma.

METHODS

We extracted relevant data from the Sleep Heart Health Study established in 1995-1998 with an 11.4-year follow-up. Multivariate Cox regression analysis with a proportional hazards model was used to estimate the associations between ACM and four sleep disorders among asthmatic patients and individuals without asthma. Dose-response analysis and machine learning (random survival forest and CoxBoost) further evaluated the impact of sleep disorders on ACM in asthmatic patients.

RESULTS

A total of 4538 individuals with 990 deaths were included in our study, including 357 asthmatic patients with 64 deaths. Three multivariate Cox regression analyses suggested that OSSD (adjusted HR = 2.67, 95% CI: 1.23-5.77) but not probable insomnia, EDS or OSA significantly increased the risk of ACM in asthmatic patients. Three dose-response analyses also indicated that the extension of objective sleep duration was associated with a reduction in ACM in asthmatic patients compared to very OSSD patients. Severe EDS potentially augmented the risk of ACM compared with asthmatics without EDS (adjusted HR = 3.08, 95% CI: 1.11-8.56). Machine learning demonstrated that OSSD of four sleep disorders had the largest relative importance for ACM in asthmatics, followed by EDS, OSA and probable insomnia.

CONCLUSIONS

This study observed that OSSD and severe EDS were positively associated with an increase in ACM in asthmatic patients. Periodic screening and effective intervention of sleep disorders are necessary for the management of asthma.

The association between subjective-objective discrepancies in sleep duration and mortality in older men

A discrepancy in subjective and objective estimations of sleep duration, which often diverge, could have long-term adverse effects on health outcomes in older adults. Using data from 2674 older adult men (≥ 65 years of age) of the Osteoporotic Fractures in Men Sleep Study, we assessed the longitudinal association between misperception index (MI), calculated as MI = (objective sleep duration - subjective sleep duration)/objective sleep duration, and all-cause mortality. During the follow-up with a mean (standard deviation) of 10.8 (4.2) years, 1596 deaths were observed. As a continuous variable, MI showed a linear relationship with all-cause mortality after adjusting for multiple covariates, including polysomnography-measured objective sleep duration [fully adjusted hazard ratio (HR), 0.69; 95% confidence interval [CI], 0.56-0.84]. As a categorical variable, the lowest MI quartile (vs. the interquartile MI range) was associated with increased mortality (fully adjusted HR, 1.28; 95% CI, 1.12-1.46), whereas the highest MI quartile was not associated with mortality (fully adjusted HR, 0.97; 95% CI, 0.85-1.11). The subjective overestimation of sleep duration may be a risk factor for all-cause mortality in older men. Future studies should examine why subjective overestimation of sleep duration is associated with all-cause mortality from a physiological perspective.

Associations Between Incident Asthma With Comorbidity Profiles, Night Sleep Duration, and Napping Duration Trajectories: A 7-Year Prospective Study

Objectives: We aim to determine whether comorbidity profiles, night sleep duration, and napping duration trajectories were associated with incident asthma in Chinese adults. Methods: A total of 7,655 community-dwelling individuals were included in this study. Latent class/profile analysis(LCA/LPA) identified comorbidity profiles, night sleep duration, and napping duration trajectories. A generalized additive model with binomial regression assessed the associations between incident asthma with sleep trajectories. Results: During a 7-year follow-up period, 205 individuals were newly diagnosed with asthma. LPA identified four trajectories of night sleep duration: dominant short (n = 2,480), dominant healthy-long (n = 1,405), long decreasing (n = 1875), and short increasing (n = 1895). We also found three trajectories of napping duration: short increasing (n = 3,746), stable normal (n = 1,379), and long decreasing (n = 2,530). We found three comorbidity profiles: dominant heart diseases or risks (n = 766), multiple disorders (n = 758), and minimal or least disorders (n = 6,131). Compared with dominant short night sleep duration, three other trajectories were associated with significantly decreasing incident asthma. Minimal or least disorders profile was associated with a significant reduction of new-onset asthma than two other comorbidity profiles in dominant short night sleep duration. Conclusion: Our findings suggested that a dominant short night sleep duration trajectory potentially increases incident asthma in Chinese adults.

Cardiovascular correlates of sleep apnea phenotypes: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Background

Identifying Obstructive Sleep Apnea (OSA) phenotypes among middle-aged and older Hispanics/Latinos can facilitate personalized care, better inform treatment decisions, and could lead to improved clinical outcomes.

Methods

We focused on middle-aged and older adults (ages ≥45–74 years at baseline) with an apnea-hypopnea index (AHI) ≥5 from the HCHS/SOL (2008–2011) (unweighted n = 3,545). We used latent class analyses (LCA) to identify empirical and clinically meaningful OSA phenotypes. Sleep variables included AHI, percent sleep time SpO2<90%, Epworth Sleepiness Scale (ESS), Women’s Health Initiative Insomnia Rating Scale (WHIIRS) score, self-reported average sleep duration, restless legs symptoms, napping frequency, and self-reported sleep quality. We used survey logistic and Poisson regression to test the associations between our OSA phenotypes and prevalent and incident cardiovascular measures (cardiovascular disease, heart failure, Stroke/TIA, hypertension, diabetes, and the Framingham Cardiovascular Risk Score).

Results

Average AHI, ESS, WHIIRS, and sleep duration were 18.1±19.5, 6.3±6.1, 7.4±6.6, and 7.8±1.7 hours, respectively, and 2.9% had zero percent time SpO2 <90%. We identified a three-class solution that clustered individuals into (1) insomnia OSA (44.3%), (2) asymptomatic mild OSA, (36.2%) and (3) symptomatic OSA (19.5%). Elevated WHIIRS and AHI scores primarily drove classification into groups one and three, respectively. In covariate adjusted models, OSA phenotypes were differentially associated with prevalence (baseline and seven years later) and incidence of cardiovascular measures.

Conclusions

OSA subtypes in diverse U.S. Hispanic/Latino adults have different cardiovascular complications. More targeted research, that takes these variations into account, could help ameliorate Hispanic/Latino sleep and cardiovascular health disparities.

Association of healthy sleep pattern with the risk of cardiovascular disease and all-cause mortality among people with diabetes: A prospective cohort study

AIMS

This study aimed to assess the association of healthy sleep pattern with the risk of cardiovascular disease and all-cause mortality among people with diabetes.

METHODS

Our study included 12,770 individuals from the UK Biobank at baseline. Sleep patterns were defined by a combination of five sleep behaviors (chronotype, sleep duration, snoring, insomnia, and excessive daytime sleepiness). The competing risk models were used to estimate the relationship between sleep patterns and CVD (including coronary heart disease [CHD] and stroke) in individuals with diabetes. To examine the association between sleep patterns and all-cause mortality risk, we utilized the flexible parametric Royston-Parmar proportion-hazard models.

RESULTS

We recorded 2627 CVD events, which includes 1999 CHD and 903 S events, and 1576 all-cause mortality events. Compared to those with poor sleep pattern, individuals having healthy sleep pattern have a 24% lower CVD risk (p < 0.001), a 26% lower CHD risk (p = 0.001), a 25% lower stroke risk (p = 0.036), and a 21% lower all-cause mortality risk (p = 0.020).

CONCLUSIONS

Adherence to healthy sleep pattern has been significantly related to cardiovascular disease and all-cause mortality risk reduction among people with diabetes.

The Nursing Effect of Individualized Management on Patients With Diabetes Mellitus Type 2 and Hypertension

It focused on clinical effects of individualized nursing and health education (INHE) on patients with diabetes mellitus type 2 (T2DM) and hypertension. 68 patients were randomly rolled into two groups, 34 cases in the control group (group A) received routine nursing and remaining 34 cases in the experimental group (group B) received INHE. The disease knowledge mastery (DKM) and the effect of rehabilitation nursing of patients were compared. The results suggested that DKM of patients in group B was obviously greater (P < 0.05). The total effective rate (TER) in group B was 91.45%, which was observably greater than that (76.35%) in group A (P < 0.05). After nursing, the fasting plasma glucose (FPG), 2-hour postprandial glucose (2h PG), systolic blood pressure (SBP), and diastolic blood pressure (DBP) levels of all patients decreased, and those in group B were much lower (P < 0.05). Scores of the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) of the two groups were 56.34 ± 8.12 points and 56.33 ± 8.01 points in group A, respectively; and those in group B were 42.52 ± 6.77 points and 41.71 ± 7.23 points, respectively; and they were all decreased and those in the group B were obviously smaller (P < 0.05). In summary, INHE can effectively improve the psychological cognition of patients with T2DM and hypertension and strengthen the control of blood pressure and blood sugar.

Sleep problems among sexual minorities: a longitudinal study on the influence of the family of origin and chosen family

BACKGROUND

There is growing evidence that lesbian, gay, and bisexual (LGB) adults experience more sleep problems than the general population. As LGB individuals experience a significantly greater risk of family rejection and low family support, our study investigates the role of family support as a potential determinant of LGB sleep problems over a prolonged period, and whether friend support (i.e. chosen family) can mitigate the effect of low family support. Given the importance of sleep on mental and physical health, study results may help shed light on persistent health disparities across sexual orientations.

METHODS

Our sample included 1703 LGB individuals from the UK Household Longitudinal Study (UKHLS). Mixed-effect logistic regressions were used to estimate the effect of family and friend support on the development of sleep problems after 24 months while controlling for potential confounders. A modified Pittsburgh Sleep Quality Index was used to measure 1) presence of any sleep problems, 2) short sleep duration, and 3) poor sleep quality.

RESULTS

Family support at baseline was independently associated with all sleep problems in our study after 24-months: 1 SD increase in family support was associated with a 0.94 times lower risk of sleep problems (95% C.I = 0.90-0.98), a 0.88 times lower risk of short sleep duration (95% C.I = 0.81-0.95), and a 0.92 times lower risk of sleep quality (95% C.I = 0.93-0.98). Support from one's chosen family (proxied by friend support) did not mitigate the effects of low family support on sleep problems.

CONCLUSIONS

Our study found a consistent effect of family support across all sleep outcomes along with evidence of a persistent effect after 24 months. Our findings point to the importance of targeting family support in designing interventions aimed at reducing LGB sleep problems.

Sex differences in childhood sleep and health implications

CONTEXT

Sleep is critical for optimal childhood metabolic health and neurodevelopment. However, there is limited knowledge regarding childhood sex differences in sleep, including children with neurodevelopmental disorders, and the impact of such differences on metabolic health.

OBJECTIVE

To evaluate if sex differences in childhood sleep exist and if sleep associates with metabolic health outcomes equally by sex. Using autism spectrum disorder (ASD) as a case study, we also examine sleep sex differences in children with a neurodevelopmental disorder.

METHODS

A narrative review explored the literature focussing on sex differences in childhood sleep.

RESULTS

Sex differences in sleep were not detected among pre-adolescents. However, female adolescents were more likely to report impaired sleep than males. Childhood obesity is more common in males. Shorter sleep duration may be associated with obesity in male pre-adolescents/adolescents; although findings are mixed. ASD is male-predominant; yet, there was an indication that pre-adolescent female children with ASD had more impaired sleep.

CONCLUSION

Sex differences in sleep appear to emerge in adolescence with more impaired sleep in females. This trend was also observed among pre-adolescent female children with ASD. Further research is needed on sex differences in childhood sleep and metabolic health and the underlying mechanisms driving these differences.

Cardiopulmonary coupling-derived sleep quality is associated with improvements in blood pressure in patients with obstructive sleep apnea at high-cardiovascular risk

OBJECTIVE

Investigate if changes in objective sleep quality index (SQI) assessed through cardiopulmonary-coupling analysis impacts blood pressure (BP) in patients with obstructive sleep apnea at high-cardiovascular risk.

METHODS

Secondary analysis of ECG and pulse-oximetry-[oxygen saturation (SpO2)] data from the Heart Biomarker Evaluation in Apnea Treatment study, multicenter, controlled trial in patients with cardiovascular disease and moderate-severe obstructive sleep apnea, randomly assigned to intervention of healthy lifestyle and sleep hygiene education (HLSE; control group), continuous positive airway pressure (CPAP) or nocturnal supplemental oxygen (NSO). Participants with good-quality ECG-signal and SpO2-signal (n = 241) were included.

RESULTS

CPAP-therapy significantly improved BP, with net average improvement in mean arterial blood pressure during sleep (MAP) when compared with nocturnal supplemental oxygen-therapy or healthy lifestyle and sleep education-therapy, -3.92 (P = 0.012) and -3.83 (P = 0.016), respectively. When stratified on the basis of baseline-SQI, CPAP-therapy improves 24-h MAP -3.02 (P = 0.030) and MAP -5.00 (P = 0.001), in patients with compromised baseline-SQI (SQI < 55). Stratifying the cohort based on changes in SQI during the study period (SQI-SQI), controlling for sex, age over 60, apnea-hypopnea index, SpO2 less than 80%, baseline BP and cardiovascular disease, significant differences are observed comparing the groups that Improved-SQI (SQI < 55, SQI ≥ 55) and Declined-SQI (SQI ≥ 55, SQI < 55) in MAP -4.87 (P = 0.046) and mean diastolic blood pressure (MDP) -4.42 (P = 0.026) as well as MAP -6.36 (P = 0.015), mean systolic blood pressure wake (MSP) -7.80 (P = 0.048) and MDP -5.64 (P = 0.009), respectively. Improved SQI reflects the magnitude of positive effect on BP which is reached mostly through initiation of CPAP-therapy.

CONCLUSION

Cardiopulmonary coupling-derived sleep quality impacted 24-h MAP and MDP, as well as BP during wake, in patients participating in the Heart Biomarker Evaluation in Apnea Treatment-study.

Timing and Length of Nocturnal Sleep and Daytime Napping and Associations With Obesity Types in High-, Middle-, and Low-Income Countries

IMPORTANCE

Obesity is a growing public health threat leading to serious health consequences. Late bedtime and sleep loss are common in modern society, but their associations with specific obesity types are not well characterized.

OBJECTIVE

To assess whether sleep timing and napping behavior are associated with increased obesity, independent of nocturnal sleep length.

DESIGN, SETTING, AND PARTICIPANTS

This large, multinational, population-based cross-sectional study used data of participants from 60 study centers in 26 countries with varying income levels as part of the Prospective Urban Rural Epidemiology study. Participants were aged 35 to 70 years and were mainly recruited during 2005 and 2009. Data analysis occurred from October 2020 through March 2021.

EXPOSURES

Sleep timing (ie, bedtime and wake-up time), nocturnal sleep duration, daytime napping.

MAIN OUTCOMES AND MEASURES

The primary outcomes were prevalence of obesity, specified as general obesity, defined as body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 or greater, and abdominal obesity, defined as waist circumference greater than 102 cm for men or greater than 88 cm for women. Multilevel logistic regression models with random effects for study centers were performed to calculate adjusted odds ratios (AORs) and 95% CIs.

RESULTS

Overall, 136 652 participants (81 652 [59.8%] women; mean [SD] age, 51.0 [9.8] years) were included in analysis. A total of 27 195 participants (19.9%) had general obesity, and 37 024 participants (27.1%) had abdominal obesity. The mean (SD) nocturnal sleep duration was 7.8 (1.4) hours, and the median (interquartile range) midsleep time was 2:15 am (1:30 am-3:00 am). A total of 19 660 participants (14.4%) had late bedtime behavior (ie, midnight or later). Compared with bedtime between 8 pm and 10 pm, late bedtime was associated with general obesity (AOR, 1.20; 95% CI, 1.12-1.29) and abdominal obesity (AOR, 1.20; 95% CI, 1.12-1.28), particularly among participants who went to bed between 2 am and 6 am (general obesity: AOR, 1.35; 95% CI, 1.18-1.54; abdominal obesity: AOR, 1.38; 95% CI, 1.21-1.58). Short nocturnal sleep of less than 6 hours was associated with general obesity (eg, <5 hours: AOR, 1.27; 95% CI, 1.13-1.43), but longer napping was associated with higher abdominal obesity prevalence (eg, ≥1 hours: AOR, 1.39; 95% CI, 1.31-1.47). Neither going to bed during the day (ie, before 8pm) nor wake-up time was associated with obesity.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that late nocturnal bedtime and short nocturnal sleep were associated with increased risk of obesity prevalence, while longer daytime napping did not reduce the risk but was associated with higher risk of abdominal obesity. Strategic weight control programs should also encourage earlier bedtime and avoid short nocturnal sleep to mitigate obesity epidemic.

Insomnia with objective short sleep duration is associated with cognitive impairment: a first look at cardiometabolic contributors to brain health

STUDY OBJECTIVES

Insomnia with objective short sleep duration has been previously associated with adverse cardiometabolic health outcomes as well as poorer cognitive performance in otherwise noncognitively impaired adults. However, studies demonstrating an increased prevalence of cognitive impairment (CI) in this insomnia phenotype are lacking.

METHODS

We analyzed data from Penn State Adult Cohort (N = 1,524; 48.9 ± 13.4 years; 53.4% women). Self-reported sleep difficulty was defined as normal sleep (n = 899), poor sleep (n = 453), and chronic insomnia (n = 172). Objective short sleep duration was defined as less than 6-h of sleep, based on in-lab, 8-h polysomnography. CI (n = 155) and possible vascular cognitive impairment (pVCI, n = 122) were ascertained using a comprehensive neuropsychological battery. Analyses adjusted for age, sex, race, education, body mass index, apnea/hypopnea index, smoking, alcohol, psychoactive medication, and mental and physical health problems.

RESULTS

Participants who reported poor sleep or chronic insomnia and slept objectively less than 6 hours were associated with a 2-fold increased odds of CI (OR = 2.06, 95% confidence limits [CL] = 1.15-3.66 and OR = 2.18, 95% CL = 1.07-4.47, respectively) and of pVCI (OR = 1.94, 95% CL = 1.01-3.75 and OR = 2.33, 95% CL = 1.07-5.06, respectively). Participants who reported poor sleep or chronic insomnia and slept objectively more than 6 hours were not associated with increased odds of either CI (OR = 0.72, 95% CL = 0.30-1.76 and OR = 0.75, 95% CL = 0.21-2.71, respectively) or pVCI (OR = 1.08, 95% CL = 0.42-2.74 and OR = 0.76, 95% CL = 0.16-3.57, respectively).

CONCLUSIONS

Insomnia with objective short sleep duration is associated with an increased prevalence of CI, particularly as it relates to cardiometabolic health (i.e. pVCI). These data further support that this insomnia phenotype may be a more biologically severe form of the disorder associated with cardiovascular, cerebrovascular, and neurocognitive morbidity.

Smoke at night and sleep worse? The associations between cigarette smoking with insomnia severity and sleep duration

OBJECTIVE

Insomnia is a clinically verified nicotine withdrawal symptom. As nicotine is a stimulant, it is plausible that smoking at night could disturb sleep more than smoking at earlier times of the day, but this remains empirically unclear. This study examined smoking status and its associations with insomnia severity and sleep duration while considering the potential role of smoking time.

METHODS

Data were derived from the Sleep and Healthy Activity Diet Environment and Socialization study, a community-based study of 1007 adults (nnonsmokers = 818; nsmokers = 189) aged 22-60 from the Philadelphia area. Smoking status and time of smoking were self-reported. Insomnia was assessed with the Insomnia Severity Index and categorized as none, mild, and moderate-to-severe. Sleep duration was assessed with one item from the National Health and Nutrition Examination Survey and categorized as very short, short, normal, and long. Ordinal and multinomial logistic regressions were used to determine the association of smoking status including smoking time with insomnia severity and sleep duration controlling for sociodemographic covariates.

RESULTS

Compared to nonsmoking, smoking was associated with experiencing increased insomnia (odds ratio = 2.5, 95% confidence interval [CI] 1.9, 3.4, P < .001) as well as very short (relative risk ratio = 1.9, 95% CI 1.1, 3.3) and short (relative risk ratio = 1.5, 95% CI 1.0, 2.3) sleep (vs normal sleep duration). Night-time smoking was significantly associated with greater insomnia and shorter sleep duration.

CONCLUSIONS

Findings provide evidence that smoking is associated with increased insomnia severity and shorter sleep duration, particularly nightly smoking. Sleep health should be considered in smoking cessation efforts.

Profile of gut flora in hypertensive patients with insufficient sleep duration

Recently, the contribution of both insufficient sleep duration and gut microbiome dysbiosis to hypertension (HTN) have been revealed, yet the profile of gut flora in hypertensive patients with insufficient sleep duration remains unknown. To examine this condition, the specific shifts in the fecal microbiome of 53 participants with or without HTN were investigated. The patients were divided into those who slept short (≤6 h) or optimal (6-9 h) duration per day. Comprehensive metagenomic sequencing analysis of fecal specimens was performed in healthy controls with sufficient sleep (s-CTR, n = 10), healthy controls with insufficient sleep (ins-CTR, n = 6), hypertensive patients with sufficient sleep (s-HTN, n = 25), and HTNs complicated by short sleep duration (ins-HTN, n = 12). We found that the α-diversity and β-diversity were quite similar between s-HTN and ins-HTN. Similarities were also observed in the enterotype distribution between s-HTN and ins-HTN subjects. In addition, the enrichment of gut bacteria was evident, such as Fusobacterium mortiferum and Roseburia inulinivorans in ins-HTN subjects. Several functional modules that were distinct between s-HTN and ins-HTN subjects were identified, which were unique to hypertensive patients with insufficient sleep duration. Overall, the data demonstrated that the gut microbial features were largely maintained in hypertensive participants with insufficient sleep duration.

Elucidating the Relationship Between Insomnia, Sex, and Cardiovascular Disease

Sex differences in cardiovascular disease (CVD) mortality have been attributed to differences in pathophysiology between men and women and to disparities in CVD management that disproportionately affect women compared to men. Similarly, there has been investigation of differences in the prevalence and presentation of insomnia attributable to sex. Few studies have examined how sex and insomnia interact to influence CVD outcomes, however. In this review, we summarize the literature on sex-specific differences in the prevalence and presentation of insomnia as well as existing research regarding the relationship between insomnia and CVD outcomes as it pertains to sex. Research to date indicate that women are more likely to have insomnia than men, and there appear to be differential associations in the relation between insomnia and CVD by sex. We posit potential mechanisms of the relationship between sex, insomnia and CVD, discuss gaps in the existing literature, and provide commentary on future research needed in this area. Unraveling the complex relations between sex, insomnia, and CVD may help to explain sex-specific differences in CVD, and identify sex-specific strategies for promotion of cardiovascular health. Throughout this review, terms “men” and “women” are used as they are in the source literature, which does not differentiate between sex and gender. The implications of this are also discussed.

The Association Between Sleep Duration, Asthma-Related Episodes/Attacks and Emergency Department Visits

BACKGROUND

Inadequate sleep duration potentially increases the risk of allergic asthma; yet, the effect of different sleep duration on asthma-related episodes/attacks and emergency department (ED) visits has remained unclear. The purpose of this study is to evaluate the association between sleep duration, asthma-related episodes/attacks and ED visits.

METHODS

This study included 1526 asthma participants from the Behavioral Risk Factor Surveillance System Questionnaire during 2013-2017. Self-reported sleep duration was classified into three groups: ≤6 h (short), 7 h to 8 h (optimal) and ≥9 h (long). Generalized additive model with binomial or Poisson regression was used to complete all statistical analyses.

RESULTS

During a 12-month period, 857 participants reported acute episodes/attacks of asthma, and 279 participants reported asthma-related ED visits. Asthmatics with ED visits harbored significantly lower mean sleep duration (6.50 h vs 7.01 h, adjusted OR=0.93, 95% CI: 0.88-0.98) than those without episodes/attacks. After adjusting the potential confounding factors, the participants with long sleep duration were associated with lower risk of asthma-related episodes/attacks (adjusted OR=0.59, 95% CI: 0.41-0.86) than those with short sleep duration. The prevalence (adjusted OR=0.67, 95% CI: 0.47-0.94) and frequency (adjusted OR=0.83, 95% CI: 0.69-0.9996) of asthma-related ED visits among short sleepers were significantly higher than that among optimal sleepers. The differences of asthma-related episodes/attacks and ED visits between long and optimal sleepers were statistically insignificant.

CONCLUSION

Our study demonstrated that asthmatics with short sleep duration were associated with highest prevalence of asthma-related episodes/attacks and ED visits among the three sleep duration groups.

Interplay of Objective Sleep Duration and Cardiovascular and Cerebrovascular Diseases on Cause-Specific Mortality

Background Cardiovascular and cerebrovascular diseases (CBVDs) and cancer are leading causes of death. Short sleep is a potential contributor to health; however, its role in predicting mortality associated with cardiometabolic risk factors (CMRs) and CBVD remains poorly understood. We tested whether objective short sleep duration increases the risk of mortality associated with CMRs and CBVD. Methods and Results A total of 1654 adults (aged 20-74 years) from the Penn State Adult Cohort (47.5 years, 52.5% women, and 89.8% white) whose cause of death was determined after 19.2 years (5.2 years). CMR was defined as stage 2 hypertension and/or type 2 diabetes mellitus on the basis of blood pressure and glucose levels or a report of diagnosis or treatment for these conditions. CBVD was defined as a report of diagnosis or treatment for heart disease and/or stroke. Objective short sleep duration was defined as polysomnographic total sleep time <6 hours. Cox proportional hazard models estimated multivariable-adjusted hazard ratios (HRs) and 95% CIs. Risk of all-cause mortality associated with CMR or CBVD was significantly modified by objective sleep duration (P<0.05), and it was significantly higher in subjects who slept <6 hours (HR, 2.14 [95% CI, 1.52-3.02] and HR, 3.17 [95% CI=2.16-4.65], respectively). In subjects who slept <6 hours, CMR was associated with a 1.83 higher (95% CI, 1.07-3.13) risk of CBVD mortality and CBVD with a 2.92 higher (95% CI, 1.28-6.65) risk of cancer mortality. In subjects who slept ≥6 hours, CMR was not significantly associated with CBVD mortality (HR, 1.35; 95% CI, 0.70-2.63) nor was CBVD significantly associated with cancer mortality (HR, 0.55; 95% CI, 0.18-1.64). Conclusions Objective short sleep duration predicts the all-cause mortality prognosis of middle-aged adults with CMR and the cancer-specific mortality prognosis of those with CBVD.