Teresa Arora

Associations between specific technologies and adolescent sleep quantity, sleep quality, and parasomnias

OBJECTIVE We tested the hypothesis that weekday bedtime use of six technologies would be significantly associated with eight sleep parameters studied relating to sleep quantity, sleep quality, and parasomnias. METHODS In our cross-sectional study, we previously administered validated age-appropriate questionnaires (School Sleep Habits Survey, Technology Use Questionnaire). Participating adolescents (n=738; 54.5% boys) were aged 11-13 years and were from the Midlands region of the United Kingdom in 2010. RESULTS Frequent use of all technology types was significantly inversely associated with weekday sleep duration (hours). Frequent music listeners and video gamers had significantly prolonged sleep onset (β=7.03 [standard error {SE}, 2.66]; P<.01 and β=6.17 [SE, 2.42]; P<.05, respectively). Frequent early awakening was significantly associated with frequent use of all technology types. The greatest effect was observed in frequent television viewers (odds ratio [OR], 4.05 [95% confidence interval {CI}, 2.06-7.98]). Difficulty falling asleep was significantly associated with frequent mobile telephone use, video gaming, and social networking, with music listeners demonstrating the greatest effect (OR, 2.85 [95%CI, 1.58-5.13]). Music listeners were at increased risk for frequent nightmares (OR, 2.02 [95% CI, 1.22-3.45]). Frequent use of all technologies except for music and mobile telephones was significantly associated with greater cognitive difficulty in shutting off. Frequent television viewers were almost four times more likely to report higher sleepwalking frequency (OR, 3.70 [95% CI, 1.89-7.27]). CONCLUSIONS Frequent weekday technology use at bedtime was associated with significant adverse effects on multiple sleep parameters. If confirmed in other samples and longitudinally, improving sleep hygiene through better management of technology could enhance the health and well-being of adolescent populations.

An Investigation into the Strength of the Association and Agreement Levels between Subjective and Objective Sleep Duration in Adolescents

Study Objectives The majority of adolescent sleep research has utilized self-reported sleep duration and some have based information on a solitary question. Whilst some have claimed to have validated sleep survey data with objective actigraphy measures in adolescents, the statistical approach applied only demonstrates the strength of the association between subjective and objective sleep duration data and does not reflect if these different methods actually agree. Methods Data were collected as part of the Midlands Adolescents Schools Sleep Education Study (MASSES). Adolescents (n=225) aged 11-13 years provided estimates for weekday, weekend and combined sleep duration based on self-reported survey data, a 7-day sleep diary, and wrist-worn actigraphy. Results We assessed the strength of the relationship as well as agreement levels between subjective and objectively determined sleep duration (weekday, weekend and combined). Subjective diary sleep duration was significantly correlated with actigraphy estimates for weekday and weekend sleep duration r=0.30, p≤0.001 and r=0.31, p≤0.001 respectively. Pitman’s test demonstrated no significant difference in the variance between weekend sleep duration (r=0.09, p=0.16) and combined sleep duration (r=0.12, p=0.08) indicating acceptable agreement between actigraphy and sleep diary sleep duration only. Self-reported sleep duration estimates (weekday, weekend and combined) did not agree with actigraphy determined sleep duration. Conclusions Sleep diaries are a cost-effective alternative to survey/questionnaire data. Self-reported measures of sleep duration in adolescents do not agree with actigraphy measures and should be avoided where possible. Previous adolescent sleep studies that have utilized self-reported survey data may not provide a complete representation of sleep on the outcome measure of interest.

Self-Reported Long Total Sleep Duration Is Associated With Metabolic Syndrome The Guangzhou Biobank Cohort Study

OBJECTIVE To examine the association between total sleep duration and the prevalence of metabolic syndrome (MetSyn) in older Chinese. RESEARCH DESIGN AND METHODS Cross-sectional analysis of baseline data from the Guangzhou Biobank Cohort Study (GBCS) was performed. Participants (n = 29,333) were aged ≥50 years. Risk of MetSyn and its components were identified for self-reported total sleep duration. RESULTS Participants reporting long (≥9 h) and short (<6 h) total sleep duration had increased odds ratio (OR) of 1.18 (95% CI 1.07–1.30) and 1.14 (1.05–1.24) for the presence of MetSyn, respectively. The relationship remained in long sleepers (OR 1.21 [1.10–1.34]) but diminished in short sleepers (0.97 [0.88–1.06]) after full adjustment. CONCLUSIONS Long sleep duration was associated with greater risk of MetSyn in older Chinese. Confirmation through longitudinal studies is needed. The mechanisms mediating the link between long sleep duration and MetSyn require further investigation.

Exploring the complex pathways among specific types of technology, self-reported sleep duration and body mass index in UK adolescents

Objective:To examine the independent associations between sleep duration, four technology types (computer use, mobile telephones, TV viewing and video gaming) and body mass index (BMI) z-score. We propose a theoretical path model showing direct effects of four technology types on BMI z-score and sleep duration as well as the indirect effects of each technology on BMI z-score while considering sleep duration as a mediator.Methods:Consenting adolescents (n=632; 63.9% girls, aged 11–18 years) were recruited to the Midlands Adolescent Schools sleep Education Study. The School Sleep Habits Survey (SSHS) and Technology Use Questionnaire (TUQ) were administered. Objective measures of height (cm) and weight (kg) were obtained for BMI z-score calculation.Results:Weekday use of all technology types was significantly associated with reduced weekday sleep duration after adjustment (β (computer use)=−0.38, P<0.01; β (mobile telephone)=−0.27, P<0.01; β (TV viewing)=−0.35, P<0.01; and β (video gaming)=−0.39, P<0.01). Use of all technology types, with the exception of mobile telephones, was significantly associated with increased BMI z-score after adjustment (β (computer use)=0.26, P<0.01; β (TV viewing)=0.31, P<0.01; and β (video gaming)=0.40, P<0.01). Our path model shows that weekday sleep duration was significantly and negatively associated with BMI z-score (β=−0.40, P<0.01).Conclusion:Weekday sleep duration potentially mediates the effects of some technologies on BMI z-score. If confirmed, improving sleep through better management of technology use could be an achievable intervention for attenuating obesity.

The complexity of obesity in UK adolescents: relationships with quantity and type of technology, sleep duration and quality, academic performance and aspiration

Technology use and ownership is highly prevalent in adolescents and has been previously linked to obesity, but bedtime use of contemporary, original and multiple device use is currently unexplored. Sleep duration is a potentially important contributor to obesity development, but other sleep parameters may be crucial and may contribute to a better understanding of obesity, although these are currently limited in adolescent samples. Adolescent obesity may have a negative impact on academic performance, but data are heterogeneous. Body mass index may also influence academic aspiration, but little is known about this potential relationship.

The Potential Association between Obstructive Sleep Apnea and Diabetic Retinopathy in Severe Obesity—The Role of Hypoxemia

Background Obstructive sleep apnea (OSA) is common in obese patients with type 2 diabetes mellitus (DM) and may contribute to diabetic microvascular complications. Methods To investigate the association between OSA, hypoxemia during sleep, and diabetic retinal complications in severe obesity. This was a prospective observational study of 93 obese patients mean (SD) age: 52(10) years; mean (SD) body mass index (BMI): 47.3(8.3) kg/m2) with DM undergoing retinal screening and respiratory monitoring during sleep. OSA was defined as apnea-hypopnea index (AHI) of ≥15 events/hour, resulting in two groups (OSA+ vs. OSA−). Results Forty-six patients were OSA+: median (95% CI) AHI = 37(23–74)/hour and 47 were OSA–ve (AHI = 7(4–11)/hour). Both groups were similar for ethnicity, BMI, cardiovascular co-morbidities, diabetes duration, HbA1c, and insulin treatment (p>0.05). The OSA+ group was significantly more hypoxemic. There was no significant difference between OSA+ and OSA− groups for the presence of retinopathy (39% vs. 38%). More OSA+ subjects had maculopathy (22% vs. 13%), but this did not reach statistical significance. Logistic regression analyses showed that AHI was not significantly associated with the presence of retinopathy or maculopathy (p>0.05). Whilst minimum oxygen saturation was not significantly associated with retinopathy, it was an independent predictor for the presence of maculopathy OR = 0.79 (95% CI: 0.65–0.95; p<0.05), after adjustment. Conclusions The presence of OSA, as determined by AHI, was not associated with diabetic retinal complications. In contrast, severity of hypoxemia during sleep (minimum oxygen saturations) may be an important factor. The importance of hypoxia in the development of retinal complications in patients with OSA remains unclear and further studies assessing the pathogenesis of hypoxemia in patients with OSA and diabetic retinal disease are warranted.

The Prevalence and Severity of Obstructive Sleep Apnea in Severe Obesity: The Impact of Ethnicity

STUDY OBJECTIVES The South Asian population is at increased risk of cardiovascular disease. We compared the prevalence and severity of obstructive sleep apnea (OSA) in South Asians and white Europeans with severe obesity. METHODS Data from consecutive patients attending a specialist weight management service were analyzed. Self-reported age, gender, and ethnicity were recorded. Objective measurements of blood pressure, body mass index (BMI), and apneahypopnea index (AHI) were also acquired. RESULTS A total of 308 patients (72.7% women; 13% South Asian) were included, with mean age and BMI of 46 ± 12 y and 49 ± 8 kg/m2, respectively. South Asians had significantly increased prevalence of OSA compared to white Europeans (85% vs. 66% [p = 0.017]) and were more likely to have severe OSA (42.5% vs. 21.6% [p = 0.015]). South Asians had significantly higher median AHI (24 events/h: interquartile range [IQR] 9.3-57.6 vs. 9 events/h: IQR 3.4-26.6; p < 0.01), significantly lower minimum oxygen saturation (76%: IQR 64% to 84% vs. 83%: IQR 77% to 87%; p < 0.01), and spent a significantly greater amount of time < 90% oxygen saturation (8.4%: IQR 1.0% to 24.3% vs. 2.4%: IQR 0.2% to 16.0%; p = 0.03). South Asian ethnicity, independent of demographics, BMI, and comorbidities, was associated with β = 1.84 (95% CI: 1.27-2.65) increase in AHI+1 compared to white Europeans. Furthermore, we confirmed other independent OSA risk factors including increasing age, BMI, and male gender (all p < 0.001). CONCLUSIONS Severely obese South Asians had significantly greater prevalence and severity of OSA than white Europeans. OSA may contribute to increased cardiovascular risk in South Asians compared to white Europeans with severe obesity. Mechanisms mediating the observed associations between these ethnicities require further investigation.

The Impact of Sleep Debt on Excess Adiposity and Insulin Sensitivity in Patients with Early Type 2 Diabetes Mellitus

STUDY OBJECTIVES We examined cross-sectional and prospective associations between sleep debt and adiposity measures, as well as homeostatic model assessment-insulin resistance (HOMA-IR) in early type 2 diabetes. METHODS Prospective data analysis from participants of a randomized controlled trial based on an intensive lifestyle intervention (usual care, diet, or diet and physical activity). Data were collected at baseline, 6 months, and 12 months post-intervention. The study was performed across five secondary care centers in the United Kingdom. Patients (n = 593) with a recent diagnosis of type 2 diabetes were recruited. Objective height and weight were ascertained for obesity status (body mass index [BMI]; ≥ 30 kg/m(2)), waist circumference (cm) for central adiposity, and fasting blood samples drawn to examine insulin resistance (IR). Seven-day sleep diaries were used to calculate weekday sleep debt at baseline, calculated as average weekend sleep duration minus average weekday sleep duration. RESULTS At baseline, compared to those without weekday sleep debt, those with weekday sleep debt were 72% more likely to be obese (OR = 1.72 [95% CI:1.03-2.88]). At six months, weekday sleep debt was significantly associated with obesity and IR after adjustment, OR = 1.90 (95% CI:1.10-3.30), OR = 2.07 (95% CI:1.02-4.22), respectively. A further increase at 12 months was observed for sleep debt with obesity and IR: OR = 2.10 (95% CI:1.14-3.87), OR = 3.16 (95% CI:1.38-7.24), respectively. For every 30 minutes of weekday sleep debt, the risk of obesity and IR at 12 months increased by 18% and 41%, respectively. CONCLUSIONS Sleep debt resulted in long-term metabolic disruption, which may promote the progression of type 2 diabetes in newly diagnosed patients. Sleep hygiene/education could be an important factor for future interventions to target early diabetes.

Description and preliminary results from a structured specialist behavioural weight management group intervention: Specialist Lifestyle Management (SLiM) programme

Background Specialist Lifestyle Management (SLiM) is a structured patient education and self-management group weight management programme. Each session is run monthly over a 6-month period providing a less intensive long-term approach. The groups are patient-centred incorporating educational, motivational, behavioural and cognitive elements. The theoretical background, programme structure and preliminary results of SLiM are presented. Subjects/methods The study was a pragmatic service evaluation of obese patients with a body mass index (BMI) ≥35 kg/m2 with comorbidity or ≥40 kg/m2 without comorbidity referred to a specialist weight management service in the West Midlands, UK. 828 patients were enrolled within SLiM over a 48-month period. Trained facilitators delivered the programme. Preliminary anonymised data were analysed using the intention-to-treat principle. The primary outcome measure was weight loss at 3 and 6 months with comparisons between completers and non-completers performed. The last observation carried forward was used for missing data. Results Of the 828 enrolled within SLiM, 464 completed the programme (56%). The mean baseline weight was 135 kg (BMI=49.1 kg/m2) with 87.2% of patients having a BMI≥40 kg/m2 and 12.4% with BMI≥60 kg/m2. The mean weight change of all patients enrolled was −4.1 kg (95% CI −3.6 to −4.6 kg, p=0.0001) at the end of SLiM, with completers (n=464) achieving −5.5 kg (95% CI −4.2 to −6.2 kg, p=0.0001) and non-completers achieving −2.3 kg (p=0.0001). The majority (78.6%) who attended the 6-month programme achieved weight loss with 32.3% achieving a ≥5% weight loss. Conclusions The SLiM programme is an effective group intervention for the management of severe and complex obesity.

How many sleep diary entries are needed to reliably estimate adolescent sleep

Study Objectives To investigate (1) how many nights of sleep diary entries are required for reliable estimates of five sleep-related outcomes (bedtime, wake time, sleep onset latency [SOL], sleep duration, and wake after sleep onset [WASO]) and (2) the test-retest reliability of sleep diary estimates of school night sleep across 12 weeks. Methods Data were drawn from four adolescent samples (Australia [n = 385], Qatar [n = 245], United Kingdom [n = 770], and United States [n = 366]), who provided 1766 eligible sleep diary weeks for reliability analyses. We performed reliability analyses for each cohort using complete data (7 days), one to five school nights, and one to two weekend nights. We also performed test-retest reliability analyses on 12-week sleep diary data available from a subgroup of 55 US adolescents. Results Intraclass correlation coefficients for bedtime, SOL, and sleep duration indicated good-to-excellent reliability from five weekday nights of sleep diary entries across all adolescent cohorts. Four school nights was sufficient for wake times in the Australian and UK samples, but not the US or Qatari samples. Only Australian adolescents showed good reliability for two weekend nights of bedtime reports; estimates of SOL were adequate for UK adolescents based on two weekend nights. WASO was not reliably estimated using 1 week of sleep diaries. We observed excellent test-rest reliability across 12 weeks of sleep diary data in a subsample of US adolescents. Conclusion We recommend at least five weekday nights of sleep dairy entries to be made when studying adolescent bedtimes, SOL, and sleep duration. Adolescent sleep patterns were stable across 12 consecutive school weeks.