Susan Kohl Malone

Early to Bed, Early to Rise? An Exploration of Adolescent Sleep Hygiene Practices

Cognition, memory, safety, mental health, and weight are all affected by inadequate sleep. Biological studies indicate significant changes in sleep architecture during adolescence, such as changes in melatonin secretion, and a need for greater total sleep time. Yet, social contexts and cultural values impinge on these changing biological sleep needs making adolescents vulnerable to the dangers of insufficient sleep. Sleep hygiene practices are purported as potential mediating factors between biological sleep needs and the sociocultural context of sleep. The purpose of this literature review is to highlight biological and social factors contributing to insufficient sleep in adolescents, to explore the evidence of several recommended sleep hygiene practices, and to stimulate further research about how adolescents negotiate their shifting biological sleep needs amid increasing social demands.

Characteristics Associated With Sleep Duration, Chronotype, and Social Jet Lag in Adolescents:

Sleep is a complex behavior with numerous health implications. Identifying sociodemographic and behavioral characteristics of sleep is important for determining those at greatest risk for sleep-related health disparities. In this cross-sectional study, general linear models were used to examine sociodemographic and behavioral characteristics associated with sleep duration, chronotype, and social jet lag in adolescents. One hundred and fifteen participants completed Phase I (self-reported sleep measures), and 69 of these participants completed Phase II (actigraphy-estimated sleep measures). Black adolescents had shorter free night sleep than Hispanics. Youth with later chronotypes ate fewer fruits and vegetables, drank more soda, were less physically active, and took more daytime naps. Based on these findings, recommendations for individual support and school policies are provided.

School Nurses Save Lives Can We Provide the Data

Vigilance has been central to nursing practice since Florence Nightingale. Often, the nurse’s work of surveillance goes unnoticed and the public never recognizes the value of the nurse’s work. The 1999 Institute of Medicine report on hospital deaths due to preventable errors has lifted the veil shrouding professional vigilance. But how to measure vigilance remained elusive, until the concept, failure to rescue (FTR), was proposed. FTR has taken a prominent role in health care since its adoption as a patient safety indicator by the Agency for Healthcare Research and Quality (AHRQ) and as a measure for nursing performance in acute care by the National Quality Forum (NQF). However, its applicability to school nursing has been unexplored. This article provides an initial review of the literature and an analysis of anecdotal stories and media accounts that illustrate professional vigilance in school nursing practice.

Improving the quality of students' dietary intake in the school setting

The dramatic increase in our understanding of the brain’s development throughout childhood has increased our knowledge of the significance of micronutrients, such as iron and vitamin B-12, for this development. Deficiencies of these micronutrients have been shown to have an impact on students’ cognitive development. Regardless of this knowledge, students continue to make unhealthy food choices and develop poor dietary habits. School environments are places where there is an opportunity to practice healthy eating habits. Yet many school policies fail to address the sale of foods of minimal nutritional value in the school setting. School nurses can play a vital role in planning policies at the local and national level that support and encourage healthy food environments, performing assessments of the nutritional status of students, and spearheading the implementation of evidence-based health promotion programs. It is time for school nurses to take the lead in efforts aimed at improving the quality of students’ dietary intake in the school setting.

Differences in morning–evening type and sleep duration between Black and White adults: Results from a propensity-matched UK Biobank sample

ABSTRACT Biological evidence suggests that ethno-racial differences in morning–evening type are possible, whereby Blacks may be more likely to be morning type compared to Whites. However, population-level evidence of ethno-racial difference in morning–evening type is limited. In an earlier study, we reported that morning type was more prevalent in Blacks compared to Whites in the United Kingdom (UK) Biobank cohort (N = 439 933). This study aimed to determine if these ethno-racial differences persisted after accounting for an even broader range of social, environmental and individual characteristics and employing an analytic approach that simulates randomization in observational data, propensity score modeling. Data from UK Biobank participants whose self-identified race/ethnicity was Black/Black British or White; who did not report daytime napping, shift work or night shift work; who provided full mental health information; and who were identified using propensity score matching were used (N = 2044). Each sample was strongly matched across all social, environmental and individual characteristics as indicated by absolute standardized mean differences <0.09 for all variables. The prevalence of reporting nocturnal short, adequate and long sleep as well as morning, intermediate and evening type among Blacks (n = 1022) was compared with a matched sample of Whites (n = 1022) using multinomial logistic regression models. Blacks had a 62% greater odds of being morning type [odds ratio (OR) = 1.620, 95% confidence interval (CI): 1.336–1.964, p < .0001] and a more than threefold greater odds of reporting nocturnal short sleep (OR = 3.453, 95% CI: 2.846–4.190, p < .0001) than Whites. These data indicate that the greater prevalence of morning type and short nocturnal sleep in Blacks compared to Whites is not fully explained by a wide range of social and environmental factors. If sleep is an upstream determinant of health, these data suggest that ethno-racially targeted public health sleep intervention strategies are needed.

Ethnic differences in sleep duration and morning–evening type in a population sample

ABSTRACT This cross-sectional population study examined associations of sleep duration and morning–evening type with sociodemographic and cardiometabolic disease in adults participating in the UK Biobank study (N = 439 933). Multivariable Poisson regression models of sleep duration and morning–evening type with a robust error variance were generated to estimate adjusted prevalence ratios and their 95% confidence intervals. All models were adjusted for sex, race, college attendance, employment status and age. Twenty five percent of the sample reported short sleep; 27% were morning, 64% intermediate and 9% evening type. Black ethnicity emerged as most strongly associated with sleep behavior. Short sleep was twice as prevalent, and morning versus intermediate type was 1.4 times more prevalent in Black than White participants. The greater prevalence of short sleep and morning type among Blacks suggests that sleep-based approaches to improving cardiometabolic outcomes may require a more multidimensional approach that encompasses adequate sleep and circadian alignment in this population.

Interactive effects of sleep duration and morning/evening preference on cardiovascular risk factors

Background Sleep duration and morningness/eveningness (circadian preference) have separately been associated with cardiovascular risk factors (i.e. tobacco use, physical inactivity). Interactive effects are plausible, resulting from combinations of sleep homeostatic and circadian influences. These have not been examined in a population sample. Methods Multivariable regression models were used to test the associations between combinations of sleep duration (short [≤6 h], adequate [7-8 h], long [≥9 h]) and morning/evening preference (morning, somewhat morning, somewhat evening, evening) with the cardiovascular risk factors of tobacco use, physical inactivity, high sedentary behaviour, obesity/overweight and eating fewer than 5 daily servings of fruit and vegetables, in a cross-sectional sample of 439 933 adults enrolled in the United Kingdom Biobank project. Results Participants were 56% female, 95% white and mean age was 56.5 (SD = 8.1) years. Compared with adequate sleep with morning preference (referent group), long sleep with evening preference had a relative odds of 3.23 for tobacco use, a 2.02-fold relative odds of not meeting physical activity recommendations, a 2.19-fold relative odds of high screen-based sedentary behaviour, a 1.47-fold relative odds of being obese/overweight and a 1.62-fold relative odds of <5 fruit and vegetable daily servings. Adequate sleep with either morning or somewhat morning preference was associated with a lower prevalence and odds for all cardiovascular risk behaviours except fruit and vegetable intake. Conclusions Long sleepers with evening preference may be a sleep phenotype at high cardiovascular risk. Further work is needed to examine these relationships longitudinally and to assess the effects of chronotherapeutic interventions on cardiovascular risk behaviours.

Social jet lag, chronotype and body mass index in 14–17-year-old adolescents

ABSTRACT The relationship between sleep duration and obesity in adolescents is inconclusive. This may stem from a more complex relationship between sleep and obesity than previously considered. Shifts toward evening preferences, later sleep–wake times and irregular sleep–wake patterns are typical during adolescence but their relationship to body mass index (BMI) has been relatively unexplored. This cross-sectional study examined associations between sleep duration, midpoint of sleep and social jet lag (estimated from 7 days of continuous actigraphy monitoring), and morningness/eveningness with BMIs (BMI z-scores) and waist-to-height ratios in 14–17-year-old adolescents. Seventy participants were recruited from ninth and tenth grades at a public high school. Participants’ characteristics were as follows: 74% female, 75% post-pubertal, 36% Hispanic, 38% White, 22% Black, 4% Asian and 64% free/reduced lunch participants with a mean age of 15.5 (SD, 0.7). Forty-one percent of the participants were obese (BMI ≥ 95th percentile); 54% were abdominally obese (waist-to-height ratio ≥ 0.5). Multivariable general linear models were used to estimate the association between the independent variables (school night sleep duration, free night sleep duration, midpoint of sleep (corrected), social jet lag and morningness/eveningness) and the dependent variables (BMI z-scores and waist-to-height ratios). Social jet lag is positively associated with BMI z-scores (p < 0.01) and waist-to-height ratios (p = 0.01). Midpoint of sleep (corrected) is positively associated with waist-to-height ratios (p = 0.01). After adjusting for social jet lag, school night sleep duration was not associated with waist-to-height ratios or BMI z-scores. Morningness/eveningness did not moderate the association between sleep duration and BMI z-scores. Findings from this study suggest that chronobiological approaches to preventing and treating obesity may be important for accelerating progress in reducing obesity rates in adolescents.

Measurement and Interpretation of Body Mass Index During Childhood and Adolescence

The landscape of childhood health and disease has changed over the past century, and school nurses are now in a unique position to address the conditions that lead to chronic disease, such as obesity. Measuring body mass index (BMI) during childhood and adolescence is the recommended method for screening and/or monitoring obesity in school communities. Yet changes in the size, proportion, and distribution of fat mass and fat-free mass during growth and development introduce challenges to interpreting BMI measurements. Understanding these challenges and ensuring accurate measurement techniques are the foundation for implementing school-based BMI measurement programs. This article will provide an overview of body composition during childhood and adolescence, introduce strategies to improve the accuracy of BMI measurements, and explore the school nurse’s role in BMI surveillance and/or screening activities.

Applying behavioral insights to delay school start times

&NA; Healthy People 2020 established a national objective to increase the proportion of 9th‐to‐12th‐grade students reporting sufficient sleep. A salient approach for achieving this objective is to delay middle and high school start times. Despite decades of research supporting the benefits of delayed school start times on adolescent sleep, health, and well‐being, progress has been slow. Accelerating progress will require new approaches incorporating strategies that influence how school policy decisions are made. In this commentary, we introduce four strategies that influence decision‐making processes and demonstrate how they can be applied to efforts aimed at changing school start time policies.