Sleep Quality and Duration Before and After Bariatric Surgery

Effects of non-invasive ventilation on sleep in chronic hypercapnic respiratory failure

Chronic respiratory disease can exacerbate the normal physiological changes in ventilation observed in healthy individuals during sleep, leading to sleep-disordered breathing, nocturnal hypoventilation, sleep disruption and chronic respiratory failure. Therefore, patients with obesity, slowly and rapidly progressive neuromuscular disease and chronic obstructive airways disease report poor sleep quality. Non-invasive ventilation (NIV) is a complex intervention used to treat sleep-disordered breathing and nocturnal hypoventilation with overnight physiological studies demonstrating improvement in sleep-disordered breathing and nocturnal hypoventilation, and clinical trials demonstrating improved outcomes for patients. However, the impact on subjective and objective sleep quality is dependent on the tools used to measure sleep quality and the patient population. As home NIV becomes more commonly used, there is a need to conduct studies focused on sleep quality, and the relationship between sleep quality and health-related quality of life, in all patient groups, in order to allow the clinician to provide clear patient-centred information.

Comparison of three measures for insomnia in ischemic stroke patients: Pittsburgh sleep quality index, insomnia severity index, and Athens insomnia scale

Objective

This study investigated the consistency and determined the optimal threshold values of three scales in the diagnosis of insomnia of ischemic stroke (IS) patients.

Methods

Participants in this study consisted of 569 acute IS patients. All 569 patients completed the assessment of the three insomnia scales. Insomnia of IS patients were assessed by Pittsburgh sleep quality index (PSQI), Insomnia Severity Index (ISI), and Athens insomnia scale (AIS). Also, basic patient information, neurological function, and activities of daily living were assessed. General information was compared between the insomnia group and the no-insomnia group. Cronbach's α coefficients, Cohen's Kappa consistency, Receiver operating characteristic (ROC) curve and DeLong's test analysis were used to analyze the reliability and diagnostic validity of PSQI, ISI, and AIS.

Results

The PSQI and ISI showed high reliability with Cronbach's α of 0.875 and 0.858, respectively, while the AIS had an α coefficient of 0.734, demonstrating acceptable reliability. The PSQI, ISI, and AIS showed outstanding diagnostic ability with an AUC of 0.960 (95% CI: 0.946, 0.974), 0.911 (95% CI: 0.882, 0.941), and 0.876 (95% CI:0.837, 0.916). The best diagnostic cutoffs for PSQI, ISI, and AIS are ≥9, ≥15, and ≥8.

Conclusion

Each of the three questionnaires has advantages and disadvantages when assessing insomnia. In the evaluation of insomnia in IS patients, the best questionnaire selection should be made according to the purpose of clinical evaluation and considering the sensitivity and specificity.

Weight Loss and Sleep, Current Evidence in Animal Models and Humans

Sleep is a vital process essential for survival. The trend of reduction in the time dedicated to sleep has increased in industrialized countries, together with the dramatic increase in the prevalence of obesity and diabetes. Short sleep may increase the risk of obesity, diabetes and cardiovascular disease, and on the other hand, obesity is associated with sleep disorders, such as obstructive apnea disease, insomnia and excessive daytime sleepiness. Sleep and metabolic disorders are linked; therefore, identifying the physiological and molecular pathways involved in sleep regulation and metabolic homeostasis can play a major role in ameliorating the metabolic health of the individual. Approaches aimed at reducing body weight could provide benefits for both cardiometabolic risk and sleep quality, which indirectly, in turn, may determine an amelioration of the cardiometabolic phenotype of individuals. We revised the literature on weight loss and sleep, focusing on the mechanisms and the molecules that may subtend this relationship in humans as in animal models.

The impact of laparoscopic Roux-en-Y gastric bypass on sleep quality and duration after one year of follow-up

BACKGROUND AND AIMS

Several studies have shown the association between obesity and sleep. Roux-en-Y gastric bypass (RYGB) surgery may improve sleep disturbances in patients with obesity by influencing a variety of factors. This study aims to evaluate the impact of bariatric surgery on sleep quality.

METHODS

Patients with severe obesity referred to the obesity clinic of a center from September 2019 to October 2021 were collected. The patients were divided into two groups, depending on whether they underwent RYGB surgery. Medical comorbidities and self-report questionnaires regarding sleep quality, anxiety, and depression were collected at baseline and 1-year follow-up.

RESULTS

54 patients were included, including 25 in the bariatric surgery group and 29 in the control group. However, five patients in the RYGB surgery group and four patients in the control group were lost in the follow-up. Pittsburgh Sleep Quality Index (PSQI) was decreased from a mean of 7.7 to 3.8 in the bariatric surgery group (p-value<0.001). In contrast to the control group, the number of patients with obstructive sleep apnea was significantly reduced in the bariatric surgery group.

CONCLUSIONS

We showed a significant improvement in sleep quality following RYGB surgery. Obstructive sleep apnea, obesity/overweight, and depressive symptoms significantly improved in our study. There is a lack of a better understanding of the association between these factors and sleep quality following surgery. Therefore, further studies are recommended regarding this issue.

What Value of Sixth Month Excess Weight Loss (Postsleeve Gastrectomy) Is Necessary for Better Sleep Quality?

BACKGROUND

Obesity, caused by caloric intake over output, is a global health problem. The relationship between sleep and obesity is discussed in the literature. Little is known about the compliance of sleep quality and patients' weight loss. This study aimed to review how sleep quality is affected by bariatric surgery, assess whether compliance with sleep quality can be predicted after bariatric surgery, and establish its correlation with excess weight loss.

METHODS

A cross-sectional study was conducted for patients undergoing bariatric surgery (laparoscopic sleeve gastrectomy). Sleep quality was assessed with the Pittsburgh sleep quality index (PSQI) scale preoperatively and in the sixth postoperative month. A PSQI global score above 5 indicated poor sleep quality. Participants were divided into 2 groups: good and poor sleep quality. Receiver operating characteristics and logistic regression analysis were also performed to predict sleep quality.

RESULTS

The questionnaire was completed by 100 subjects. All PSQI components, except the sixth (sleep medication) component, improved in patients at the sixth postoperative month versus baseline values. In the receiver operating characteristic analysis to test the availability of excess weight loss (EWL%) cutoff values relative to predict successful sleepers, 65.1 of the sixth month EWL% was found for the diagnosis of successful sleeper patients with 72.6% sensitivity and 63% specificity (area under the curve: 0.706, P =0.002, 95% CI, 0.586 to 0.825).

CONCLUSIONS

For patients undergoing weight loss surgery, while assessing the sixth postoperative month, the EWL% value over 65.1 was recommended for better sleep quality.

Sleep Quality Before and After Bariatric Surgery

PURPOSE

Sleep deprivation is associated with growth hormone deficiency and an elevated cortisol level, both of which have been linked to obesity. However, assessing sleep quality is often not established in the multidisciplinary peribariatric evaluation program. This study aimed to determine sleep quality in patients who are seeking or underwent bariatric surgery by using Pittsburgh Sleep Quality Index (PSQI) measurements.

MATERIALS AND METHODS

In this observational study, patients who underwent or were seeking bariatric surgery between April and November 2021 were included. Self-reported patients' demographics, operative techniques, and sleep quality measured by PSQI were collected. Baseline characteristics were compared between the preoperative group (PRE), patients who underwent surgery < 1.5 years ago (EARLY), and > 1.5 years ago (LATE). A multivariate linear regression model was built.

RESULTS

In total, 270 patients filled out the questionnaire of which 100 (37.1%) were preoperative, 87 (32.2%) early, and 83 (30.7%) late postoperative. The PSQI significantly improved in the EARLY group compared to PRE (4.8 vs 6.1). This effect disappeared in the LATE group (6.1) even though their body mass index was less. Linear regression revealed that age (p = 0.004) and body mass index (p = 0.003) predicted worse sleep quality.

CONCLUSION

Sleep quality improves early after bariatric surgery; however, this benefit does not seem to last in the long term. Other factors than weight regain should be considered for this finding, future studies with longer follow-up periods are recommended, including other variables associated with sleep quality such as health conditions and socioeconomic status.

The Prevalence of Depression and Anxiety in Post-bariatric Surgery Patients at King Khalid University Hospital, Riyadh

Background Obesity negatively impacts mental and physical health and is a leading cause of disease worldwide. Obesity affects 33% of Saudi adults, with 10% being morbidly obese (body mass index, BMI >40 kg/m²). This study explored the association between bariatric surgery (BS) and a predisposition or exacerbation of depressive and anxiety symptoms. Material and methods A cross-sectional study of patients who underwent bariatric surgery at the King Khalid University Hospital in Riyadh, Saudi Arabia, was conducted between February 2016 and December 2021. The patients were contacted by phone to complete a self-administered questionnaire on demographic information, chronic medical diseases, psychiatric diseases, body mass index, and type of bariatric surgery. In addition, they completed the patient health questionnaire-9 (PHQ-9) and general anxiety disorder-7 (GAD-7) questionnaire to screen for patients' depression and anxiety symptoms. Results The findings of the 367 BS patients showed that 20.7% of the patients were considered to have mild anxiety, 11.2% had moderate anxiety, and 8.7% had high anxiety levels. However, regarding depression, 46.9% had extremely low levels of depression, followed by mild depression in 29.4% and moderate depression in 11.2%. Furthermore, another 8.2% of BS patients had moderately high depression levels, and 4.4% had severe depression. The anxiety and depression levels of the patients in this study did not show any statistically significant changes postoperatively in the short, medium, or long term. On the other hand, almost all of the patients 97% who underwent bariatric surgery were satisfied with the outcome of their surgery. Conclusion Few BS patients had high symptoms of depression and anxiety. We recommend pre- and postoperative psychiatric assessment for all bariatric surgery patients as surgical protocol.

The association of 1-year weight loss from bariatric surgery and self-reported sleep: a prospective cohort

OBJECTIVE

This study examined the association of weight loss following bariatric surgery with self-reported sleep quality after accounting for other sleep-related factors.

METHODS

Participants were from the Bariatric Experience Long Term (BELONG) study. Participants completed a survey up to 6 months before surgery and approximately 1 year after surgery. The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality. One-year percentage total weight loss (%TWL) was determined from electronic medical records. Covariates included demographics, Charlson Comorbidity Index, geocoded variables to assess neighborhood quality, and physical activity. The authors assessed the association between %TWL at 1 year and PSQI component scores with separate cumulative logit models.

RESULTS

There were 997 participants in the analytic cohort. Participants were 86.2% women, 37.0% Hispanic, and 13.7% Black adults. Mean one-year %TWL was 26.3 (SD 8.7). Each 1% increase in %TWL was associated with a 3% better daytime dysfunction score (odds ratio = 1.03; 95% CI: 1.02-1.05) and a 2% better sleep quality score (odds ratio = 1.02; 95% CI: 1.00-1.03). No significant differences were found for the other PSQI components.

CONCLUSIONS

Weight loss from bariatric surgery was associated with better self-reported sleep at 1 year. For people undergoing bariatric surgery, there may be an added benefit of better sleep.

Exercise Training Program Improves Subjective Sleep Quality and Physical Fitness in Severely Obese Bad Sleepers

BACKGROUND

Sleep quality is an important modulator of neuroendocrine function, as sleep problems are related to metabolic and endocrine alterations.

OBJECTIVE

The main objective was to determine the effects of an exercise training program on the sleep quality of severely obese patients with sleep problems. The secondary objective was to determine the relationship between fitness and anthropometric parameters with sleep quality scores.

METHODS

Thirty severely obese patients participated in 16 weeks of PA intervention (age: 39.30 ± 11.62 y, BMI: 42.75 ± 5.27 kg/m²). Subjective sleep quality, anthropometric parameters, and fitness (i.e., handgrip strength and cardiorespiratory fitness) were measured.

RESULTS

Two groups were defined as good sleepers (n = 15, 38.06 ± 12.26, men = 1) and bad sleepers (n = 15, 40.53 ± 11.23, men = 3). The good sleeper group reported improvement in cardiorespiratory fitness (61.33 ± 68.75 m vs. 635.33 ± 98.91 m, p = 0.003) and handgrip strength (29.63 ± 9.29 kg vs. 31.86 ± 7.17 kg, p = 0.049). The bad sleeper group improved their cardiorespiratory fitness (472.66 ± 99.7 m vs. 611.33 ± 148.75 m, p = 0.001). In terms of sleep quality dimensions, the bad sleeper group improved their subjective sleep quality (p < 0.001), sleep latency (p = 0.045), sleep duration (p = 0.031), and habitual sleep efficiency (p = 0.015). Comparing the changes in both groups (∆), there were differences in subjective sleep quality scores (∆ = 2.23 vs. ∆ = -3.90, p = 0.002), where 86.6% of the bad sleeper group improved sleep quality (p = 0.030). An increase in handgrip strength was correlated to improving sleep quality scores (r = -0.49, p = 0.050).

CONCLUSIONS

Severely obese bad sleepers improved their subjective sleep quality, the components of sleep, and cardiorespiratory fitness through an exercise training program. Improvement in subjective sleep quality was linked to an increase in handgrip strength.

Syndrome Metabolic Markers, Fitness and Body Fat Is Associated with Sleep Quality in Women with Severe/Morbid Obesity

Background: Sleep is an important modulator of neuroendocrine function and glucose metabolism. Poor sleep quality is related to metabolic and endocrine alterations, including decreased glucose tolerance, decreased insulin sensitivity, and increased hunger and appetite. Objective: The aim of the present study was to determine the association between sleep quality with metabolic syndrome (MetS) markers, fitness and body fat of women with severe/morbid obesity. Methods: This cross-sectional study included 26 women with severe/morbid obesity. Fasting plasma glucose (FPG), high-density lipids (HDL-c), triglycerides (TGs), and the metabolic outcomes total cholesterol (Tc) and low-density lipids (LDL-c), systolic (SBP) and diastolic blood pressure (DBP), body composition and fitness were measured. Results: Poor sleep quality showed a positive association with body fat (%) ≥ 48.2 (OR; 8.39, 95% CI; 1.13–62.14, p = 0.037), morbid obesity (OR; 8.44, 95% CI; 1.15–66.0, p = 0.036), glucose ≥ 100 mg/dL (OR; 8.44, 95% CI; 1.15–66.0, p = 0.036) and relative handgrip strength ≤ 0.66 (OR; 12.2, 95% CI; 1.79–83.09, p = 0.011). Conclusion: sleep quality is associated with health markers in women with severe/morbid obesity.

Poor Sleep Associated with Clinically Severe Obesity Is Independent of OSA Status

PURPOSE

Obesity has been reported to be associated with short sleep duration. It follows that patients with a BMI >35kg/m² could be expected to have the poorest sleep. This poor sleep could be explained by the presence of obstructive sleep apnoea (OSA), although treatment with positive airway pressure (PAP) may modify this. The purpose of this study is to determine if patients attending for bariatric surgery have poor sleep independent of OSA status.

MATERIALS AND METHODS

Sleep duration and quality, using the Pittsburgh Sleep Quality Index (PSQI), was analysed in 203 patients undergoing bariatric surgery between June 2016 and May 2019 in a single centre. Anthropometric data on all patients were recorded as well as presence of OSA and PAP usage.

RESULTS

The bariatric population reported an average (standard deviation) sleep duration of 6.5 (1.6) h, and 67.9% of patients had a documented poor sleep quality (PSQI>5). The presence of OSA did not significantly influence either sleep duration (p=0.23) or sleep quality (p=0.5). On logistic regression, there was no significant relationship between sleep duration or sleep quality and the following variables: age, sex, and AHI. There was however a significant association between BMI and sleep quality (p= 0.007). PSQI was inversely associated with BMI. This equated to 1 kg/m² weight gain being associated with 0.097 decrease in PSQI score.

CONCLUSIONS

The presence of OSA does not influence either sleep duration or sleep quality in the bariatric surgical population. This suggests that clinically severe obesity itself may cause poor sleep.

Poor Sleep Quality Decreases Concurrent Training Benefits in Markers of Metabolic Syndrome and Quality of Life of Morbidly Obese Patients

Background: Sleep quality (SQ) plays a role in multiple activities of daily living, but little is known about its role in concurrent training [CT, high-intensity interval (HIIT) plus resistance training (RT)] adaptations for metabolic syndrome (MetS) and health-related quality of life (HRQoL) markers. The aim of the present study was to determine the effects of a 20-week CT programme on MetS and HRQoL markers according to the SQ of morbidly obese patients. Methods: Twenty-nine morbidly obese patients were allocated to one of two groups: good sleep quality (GSQ, n = 15, 38.07 ± 12.26 years) and poor sleep quality (PSQ, n = 14, 40.79 ± 11.62 years). HRQoL, body mass index, waist circumference (WC), systolic and diastolic blood pressure (SBP and DBP, respectively), and plasma outcomes were measured. Results: The GSQ group reported significant changes (pre- vs. post-intervention) in WC (114.0 ± 3.1 vs. 110.4 ± 3.4 cm, p = 0.012), SBP (137.0 ± 4.3 vs. 125.6 ± 1.8 mmHg, p = 0.006), and HRQoL general health (51.33 ± 21.08 vs. 64.33 ± 16.24, p = 0.020). By contrast, the PSQ group showed significant changes only in SQ (9.00 ± 2.42 vs. 5.36 ± 2.84, p = 0.004). Conclusions: Morbidly obese PSQ patients showed a lower response for improving MetS and HRQoL markers after a 20-week CT programme than GSQ peers. However, there was a greater effect size for decreasing WC and SBP in favour of the GSQ compared with the PSQ group, suggesting that there are limitations to CT benefits on these outcomes in the PSQ group. These results call for more complex future studies.

Physical Activity, Sedentary Behavior, and Sleep Before and After Bariatric Surgery and Associations with Weight Loss Outcome

PURPOSE

Physical activity, sedentary behavior, and sleep have been linked to the likelihood of maintaining healthy body weight. This study aimed to determine objectively measured movement behaviors before and up to 18 months after bariatric surgery and to investigate whether preoperative levels of these movement behaviors and potential changes of these behaviors were associated with changes in body weight and boy composition.

MATERIALS AND METHODS

Accelerometer determined total physical activity, moderate-to-vigorous physical activity (MVPA), light physical activity, sedentary behavior, and sleep (for six consecutive days and seven nights) were assessed approximately 3 months and 1-2 weeks before surgery as well as 6 and 18 months after surgery (n = 41). Body weight and body composition (waist circumference, fat mass, and fat-free mass) were determined at each visit.

RESULTS

Mean weight loss 18 months after surgery was 42.0 ± 1.9 kg. There were no pre- to postoperative improvements in physical activity, sedentary behavior, or sleep. However, greater increases in levels of total physical activity and time spent in MVPA from 3 months before to 6 months after surgery predicted better weight loss and larger reductions in fat mass and waist circumference. Unexpectedly, a lower level of physical activity and a higher level of sedentary behavior before surgery predicted better weight loss outcomes.

CONCLUSION

Objectively measured movement behaviors do not improve after bariatric surgery despite a substantial weight loss. However, increasing total physical activity and/or more time spent in MVPA after surgery may increase weight loss and lead to favorable changes in body composition.

Sleep disturbance and insomnia in individuals seeking bariatric surgery

BACKGROUND

Sleep disturbance is well established in individuals with obesity, and the relationship between poor sleep and obesity is supported by population, longitudinal, experimental, and intervention studies. However, the prevalence and characteristics of poor sleep in individuals seeking bariatric surgery have thus far been poorly examined.

OBJECTIVES

We sought to characterize self-reported sleep parameters in individuals seeking bariatric surgery and to compare these data with controls.

SETTING

Two Academic Medical Centers, United States, and an online survey of healthy controls.

METHOD

Individuals seeking bariatric surgery (n = 427) completed presurgical psychological evaluations at 2 comprehensive bariatric surgery programs. Data on medical co-morbidities and from self-report questionnaires on sleep quality, insomnia, anxiety, and depression were abstracted from charts. Data from controls (n = 180) were collected using an online survey tool and compared with bariatric cases.

RESULTS

Across study sites, 40.4% of bariatric cases took at least 30 minutes to fall asleep, 46.7% had insufficient total sleep time (<6.5 hr), 65.1% reported general poor sleep quality, and 30.8% reported clinically significant insomnia symptoms. Approximately 20% of the variance in poor sleep quality and insomnia was explained by body mass index, obstructive sleep apnea, anxiety, and depression. Cases and controls were similar, although bariatric cases reported significantly poorer sleep efficiency.

CONCLUSIONS

Our results suggest that similar to a control population, the majority of patients seeking bariatric surgery are experiencing sleep difficulties. Presurgical assessment and treatment of sleep problems may be beneficial to patients and may help improve weight loss treatment outcomes. Optimally, assessment would include 1 of the 2 self-report questionnaires used herein, and treatment would involve Cognitive Behavioral Therapy for Insomnia. Future research assessing sleep patterns with objective measurement tools and evaluating the impact of sleep on postsurgical outcomes is warranted.

Sleep Duration and Timing in the Medium- to Long-Term Post-Bariatric Surgery

Sleep duration improves short-term following bariatric surgery; however, little is known about its association with bodyweight medium- to long-term post-surgery. The purpose of this study was to describe sleep duration and its relationship with BMI and body composition. Forty-nine individuals, with a BMI of 36.6 ± 9.8 kg/m², regained 26.4 ± 17.8% of their lost weight 9.5 ± 3.3 years post-surgery (range 3-16 years). Sleep logs and ActivPAL3 accelerometers were used to assess sleep duration. Participants averaged 7.9 ± 1.6 h/day and 8.5 ± 1.7 h/day of sleep for weekdays and weekends, respectively (P < 0.01). A positive association between delta weekend-weekday sleep timing midpoint with BMI (β = 0.03, 95% CI = 0.01, 0.06; P = 0.01) was noted in the multivariable-adjusted model. On average, this sample achieved recommended sleep durations medium- to long-term post-surgery. Having an earlier sleep timing midpoint during the weekend may be associated with lower BMI.

The Diagnosis and Treatment of Snoring in Adults

BACKGROUND

Snoring in adults is a common cause of distress for patients and their bedpartners and calls for appropriate counseling, diagnostic evaluation, and treatment.

METHODS

A systematic literature search in the PubMed, Cochrane Library, Web of Science Core Collection, and ClinicalTrials.gov databases was carried out in February 2018 and yielded pertinent publications from 2000 onward. The guideline was created according to the methodological requirements of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der wissenschaft- lichen medizinischen Fachgesellschaften, AWMF).

RESULTS

The diagnostic evaluation of snoring is based on the history and phyical examination. In certain situations, a specialized sleep study should be performed to obtain objec- tive findings. The recommended methods of conservative treatment include, in particular, positioning therapy and weight loss. Mandibular protrusion splints can lessen snoring in suitable cases. If breathing through the nose is impaired, rhinological or rhinosurgical treatment is recommended; for certain anatomical abnormalities of the soft palate, a suitable minimally invasive surgical procedure can be considered. The level of the available evidence is low, as most of the under- lying clinical studies involved small patient groups and short follow-up.

CONCLUSION

In the treatment of snoring, evidence-based recommendations derived from the findings of randomized trials can be given for selected situations, yet the overall state of the evidence on many diagnostic and therapeutic tech- niques remains limited.

Can Healthy Sleep Improve Long-Term Bariatric Surgery Outcomes? Results of a Pilot Study and Call for Further Research

Healthy sleep is associated with lower body weight and could improve and sustain weight loss following bariatric surgery. To support this premise, preliminary data on the relation between sleep duration and quality and long-term weight change in a subsample of participants from the Longitudinal Assessment of Bariatric Surgery are presented. Results indicate a relation between sleep duration and BMI and percent weight loss 9 years after surgery. Additionally, sleep quality explained 25% of the variance in weight change between 6- and 9-year follow-up visits. These data from a small exploratory study, in combination with the known effects of sleep on energy balance, suggest that sleep may play an important role in both immediate and sustained weight loss following bariatric surgery. Herein, a model of the proposed bidirectional relation between sleep and weight loss is presented as well as a call for systematic investigations of the influence of sleep on long-term weight management following bariatric surgery.

Depression and Anxiety: Lack of Associations with an Inadequate Diet in a Sample of Pregnant Women with a History of Bariatric Surgery-a Multicenter Prospective Controlled Cohort Study

BACKGROUND

Anxiety and depression levels are higher in obese compared to those in normal weight pregnant women. The aims of this study are to examine anxiety and depression in pregnancy following bariatric surgery and to compare with obese pregnant controls considering the dietary intake of polyunsaturated fatty acids (PUFA), folate, and vitamin B₁₂.

METHODS

Anxiety (State-Trait Anxiety Inventory) and depression (Edinburgh Postnatal Depression Scale) were examined in the first (T1) and third (T3) pregnancy trimester in 54 women with bariatric surgery and 25 obese. T1 and T3 dietary intake of PUFA, folate, and vitamin B₁₂ intake was assessed using a 3-day food record. Mixed models with a compound symmetry covariance structure and regression models were applied.

RESULTS

About half of the women with surgery had high state and trait anxiety scores (≥ 40), which did not significantly change during pregnancy. Every 10-kg postoperative weight loss was associated with an increase in T1 state and trait anxiety with respectively 2.7 and 2.3 points. A smoking woman had a 8.6-point higher state anxiety score than a non-smoking woman in T1. In T3, every additional hour of sleep was associated with a decrease in trait anxiety score with 1.59 points. Anxiety and depression scores were not associated with and could not be explained by inadequate PUFAs, folate, and vitamin B₁₂ intakes. Anxiety scores were higher following surgery than those in untreated obesity at both time points.

CONCLUSION

Pregnancy following bariatric surgery induces high levels of anxiety that are not associated with an inadequate maternal diet.

Examining Sleep Quality Following Sleeve Gastrectomy Among Patients with Loss-of-Control Eating

BACKGROUND

Sleep is associated with post-bariatric surgical outcomes; however, little is known about sleep in bariatric patients with loss-of-control (LOC) eating, a consistent predictor of poorer weight outcomes. This study examined sleep quality and clinical correlates in sleeve gastrectomy patients with LOC eating.

METHODS

Participants (N = 145) were treatment-seeking post-operative sleeve gastrectomy patients with LOC eating. Eating-disorder features were assessed with the Eating Disorder Examination-Bariatric Surgery Version Interview (EDE-BSV) and participants completed established measures assessing sleep, health-related quality of life, perceived stress, depression, and night eating.

RESULTS

58.6% of participants were characterized with "poor" sleep. Poor sleep quality was significantly associated with greater eating-disorder psychopathology, physical and mental functioning, night eating, perceived stress, and less % excess weight loss (EWL); these findings remained significant after controlling for %EWL and race. Regression analyses, adjusting for correlated variables, revealed that sleep quality significantly predicted mental functioning.

CONCLUSIONS

Poor sleep quality was common among post-operative sleeve gastrectomy patients with LOC eating. Sleep quality was significantly associated with eating-disorder psychopathology, less post-operative weight loss, and psychosocial and physical functioning problems. These findings suggest the importance of assessment and treatment of sleep problems following sleeve gastrectomy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02259322.

Improvement in upright and supine lung mechanics with bariatric surgery affects bronchodilator responsiveness and sleep quality

Obesity and weight-loss have complex effects on respiratory physiology, but these have been insufficiently studied, particularly at early time points following weight-loss surgery and in the supine position. We evaluated 15 severely obese female participants before, and 5 weeks and 6 months after bariatric surgery using the Pittsburgh Sleep Quality Index (PSQI), spirometry, plethysmography, and oscillometry to measure respiratory system mechanics. Oscillometry and spirometry were conducted in the upright and supine position, and pre- and post-bronchodilation with 200µg of salbutamol. At 5 weeks post-surgery, weight-loss was 11.9±2.7kg with no effect on spirometric outcomes and a slight effect on oscillometric outcomes. However, at 6 months, weight-loss was 21.4±7.1kg with a 14.1±6.1% and 17.8±5.4% reduction in upright and supine Rrs,6, respectively. Ers also decreased by 25.7±9.4% and 20.2±7.2% in the upright and supine positions. No changes were observed in spirometry, but sleep quality improved from PSQI of 8.4±3.5 to 4.1±2.9. Bronchodilator responsiveness was low at baseline but increased significantly post-surgery, and this response was comparable to the improvement in Rrs produced by weight-loss. Modeling the impedance spectra with a two-compartment model demonstrated that improvements in lung mechanics with weight-loss begin in the upper or central compartment of the lungs and progress to include the peripheral compartment. Respiratory mechanics are impaired in the severely obese and is associated with poor sleep quality, but these improved substantially with weight-loss. Our data provide new evidence that severely obese individuals may have poor sleep quality due to abnormal respiratory mechanics that weight-loss improves.

Effects of obesity therapies on sleep disorders

Obesity is a significant risk factor for obstructive sleep apnea syndrome (OSAS), and has also been linked to reductions in sleep quality and quantity. Weight loss has been shown to be an effective treatment for improving OSAS; however, there is a high degree of variability in improvements of OSAS in response to weight loss. There are three modalities of obesity therapies: 1) lifestyle modification, which includes changes in dietary intake and physical activity, along with behavioral interventions; 2) pharmacologic agents; and 3) bariatric surgery. Individuals have a highly variable response to the various obesity interventions, and maintenance of weight loss can be especially challenging. These factors influence the effect of weight loss on sleep disorders. There is still a need for large, well-controlled studies examining short- and long-term efficacy of weight loss modalities and their impact on long-term treatment of OSAS and other sleep parameters, particularly in youth. Nonetheless, given our current knowledge, weight reduction should always be encouraged for people coping with obesity, OSAS, and/or sleep disruptions and resources identified to assist patients in choosing a weight loss approach that will benefit them the most.

Obesity, Hypersomnolence, and Quality of Sleep: the Impact of Bariatric Surgery

PURPOSE

Obesity is commonly associated with poor sleep, excessive daytime sleepiness (EDS) and depressive mood but the impact of bariatric surgery on these conditions is incompletely understood. This study aimed to investigate the course of EDS and sleep quality in bariatric surgery patients in relation with changes in body weight and depressive symptoms.

METHODS

In patients consecutively submitted to bariatric surgery, baseline and postoperative sleep quality were evaluated by the Pittsburgh Sleep Quality Index (PSQI), excessive daytime sleepiness by the Epworth Sleepiness Scale (ESS), risk for OSA by the Berlin Questionnaire (BQ), and depressive symptoms by the Beck Depression Inventory-Short Form (BDI). Comorbidities were assessed by interview and chart review.

RESULTS

Sixty patients (M/F = 9/51) with a mean (±SD) age of 34.7 ± 9.2 years and body mass index (BMI) of 46.04 ± 7.52 kg/m² were studied. Bariatric surgery improved PSQI score (6.4 ± 3.8 versus 4.1 ± 2.8; p < 0.001), ESS score (8.1 ± 4.7 versus 6.0 ± 3.3; p < 0.001), BDI score (9.8 ± 7.0 versus 4.7 ± 4.6; p = 0.001), and risk for OSA (68.3 versus 5%). Twelve of the 18 subjects with baseline EDS (ESS ≥ 10) developed normal ESS score after surgery. In these subjects, significant postoperative improvement in depressive symptoms score was observed (12.0 ± 9.0 versus 5.5 ± 5.0; p = 0.041), in contrast to the remaining six cases with persistent EDS, who showed no significant change in these symptoms (5.5 ± 5.0 versus 3.2 ± 3.1; p = 0.416).

CONCLUSION

Bariatric surgery has a beneficial effect on sleep quality and EDS. Postoperative improvement in EDS can be related to a reduction in depressive symptoms.

Effect of biliopancreatic diversion on sleep quality and daytime sleepiness in patients with obesity and type 2 diabetes

OBJECTIVE

The poor quality of sleep and the deprivation thereof have been associated with disruption of metabolic homeostasis, favoring the development of obesity and type 2 diabetes (T2DM). We aimed to evaluate the influence of biliopancreatic diversion (BPD) surgery on sleep quality and excessive daytime sleepiness of obese patients with T2DM, comparing them with two control groups consisting of obese and normal weight individuals, both normal glucose tolerant.

SUBJECTS AND METHODS

Forty-two women were divided into three groups: LeanControl (n = 11), ObeseControl (n = 13), and ObeseT2DM (n = 18). The LeanC and ObeseC groups underwent all tests and evaluations once. The ObeseT2DM underwent BPD and were reassessed after 12 months. Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were applied before and 12 months after BPD.

RESULTS

Before surgery, there was less daytime sleepiness in LeanC group (p = 0.013) compared with ObeseC and T2DMObese groups. The two obese groups did not differ regarding daytime sleepiness, demonstrating that the presence of T2DM had no influence on daytime sleepiness. After surgery, the daytime sleepiness (p = 0.002) and the sleep quality (p = 0.033) improved. The score for daytime sleepiness of operated T2DMObese group became similar to LeanC and lower than ObeseC (p = 0.047).

CONCLUSION

BPD surgery has positively influenced daytime sleepiness and sleep quality of obese patients with T2DM, leading to normalization of daytime sleepiness 12 months after surgery. These results reinforce previously identified associations between sleep, obesity and T2DM in view of the importance of sleep in metabolic homeostasis, quality of life and health.

Preventing Weight Gain Improves Sleep Quality Among Black Women: Results from a RCT

BACKGROUND

Obesity and poor sleep are highly prevalent among Black women.

PURPOSE

We examined whether a weight gain prevention intervention improved sleep among Black women.

METHODS

We conducted a randomized trial comparing a 12-month weight gain prevention intervention that included self-monitoring through mobile technologies and phone coaching to usual care in community health centers. We measured sleep using the Medical Outcomes Study Sleep Scale at baseline, 12 months, and 18 months. The scale examines quantity of sleep, sleep disturbance, sleep adequacy, daytime somnolence, snoring, shortness of breath, and global sleep problems (sleep problem indices I and II).

RESULTS

Participants (n = 184) were on average 35.4 years and obese (BMI 30.2 kg/m²); 74% made <$30,000/year. At baseline, average sleep duration was 6.4 (1.5) hours. Controlling for weight change and sleep medication, the intervention group reported greater improvements in sleep disturbance [-8.35 (-16.24, -0.45)] and sleep problems at 12 months: sleep problem index I [-8.35 (-16.24, -0.45)]; sleep problem index II [-8.35 (-16.24, -0.45)]. However, these findings did not persist at 18 months.

CONCLUSIONS

Preventing weight gain may afford clinical benefit on improving sleep quality.

TRIAL REGISTRATION NUMBER

The trial was registered with the ClinicalTrials.gov database (NCT00938535).

Laparoscopic Sleeve Gastrectomy Improves Excessive Daytime Sleepiness and Sleep Quality 6 Months Following Surgery: A Prospective Cohort Study

Introduction

Obstructive sleep apnea (OSA) is one of the most important co-morbid conditions related with morbid obesity. Bariatric procedures are associated with significant improvement in OSA. The aim of the current study was to evaluate the effect of bariatric surgery on daytime sleepiness and quality of sleep in patients that had undergone laparoscopic sleeve gastrectomy.

Methods

Fifty-nine patients were prospectively enrolled in the study. Pre-operative and post-operative (6 months) demographics, medical history, weight, and height of the patients were recorded, and patients were asked to complete Pittsburg Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) questionnaires. OSA screenings were performed using the STOP-Bang questionnaire.

Results

The mean age of the patients was 37.1 ± 1.2 years and 76% were female. Pre-operative and post-operative median (range) BMIs were 47 kg/m² (39–67 kg/m²) and 35 kg/m² (25–44 kg/m²), respectively (P < 0.001). The mean ± standard deviation excess weight loss was 51.6 ± 13.2%. In univariate analysis, total PSQI, STOP-Bang, and ESS scores were found to significantly improve 6 months after surgery (all P < 0.001). Multivariate mixed-model analysis showed a high correlation between the decrease in BMI and all key predictors. Mixed-model analysis revealed that every 1 kg/m² decrease in BMI was associated with a 0.32, 0.13, and 0.26 improvements in PSQI, STOP-Bang, and ESS scores, respectively (all P < 0.001).

Conclusion

Laparoscopic sleeve gastrectomy is associated with rapid weight loss and improvements in sleep quality, daytime sleepiness, and the risk of OSA 6 months after surgery.

Early detection of changes in lung mechanics with oscillometry following bariatric surgery in severe obesity

Obesity is associated with respiratory symptoms that are reported to improve with weight loss, but this is poorly reflected in spirometry, and few studies have measured respiratory mechanics with oscillometry. We investigated whether early changes in lung mechanics following weight loss are detectable with oscillometry. Furthermore, we investigated whether the changes in lung mechanics measured in the supine position following weight loss are associated with changes in sleep quality. Nineteen severely obese female subjects (mean body mass index, 47.2 ± 6.6 kg/m(2)) were evaluated using spirometry, oscillometry, plethysmography, and the Pittsburgh Sleep Quality Index before and 5 weeks after bariatric surgery. These tests were conducted in both the upright and the supine position, and pre- and postbronchodilation with 200 μg of salbutamol. Five weeks after surgery, weight loss of 11.5 ± 2.5 kg was not associated with changes in spirometry and plethysmography, with the exception of functional residual capacity. There were also no changes in upright respiratory system resistance (Rrs) or reactance following weight loss. Importantly, however, in the supine position, weight loss caused a substantial reduction in Rrs. In addition, sleep quality improved significantly and was highly correlated with the reduction in supine Rrs. Prior to weight loss, subjects did not respond to the bronchodilator when assessed in the upright position with either spirometry or oscillometry; however, with modest weight loss, bronchodilator responsiveness returned to the normal range. Improvements in lung mechanics occur very early after weight loss, mostly in the supine position, resulting in improved sleep quality. These improvements are detectable with oscillometry but not with spirometry.

Successful weight loss maintenance associated with morning chronotype and better sleep quality

It is not known whether individuals successful at long term weight loss maintenance differ in chronotype (i.e., being a "morning" or "evening" person) or sleep habits compared to those who are overweight and obese. We compared Morningness-Eveningness Questionnaire (MEQ) and Pittsburgh Sleep Quality Index scores of 690 National Weight Control Registry (NWCR) members (73 % female, 93 % white, age = 51.7 ± 12.5, BMI = 26.4 ± 5.1) to 75 enrollees in two behavioral weight loss interventions (INT; 77 % female, 88 % white, age = 55.7 ± 10.4, BMI = 36.2 ± 4.7). Controlling for age, MEQ scores were higher in NWCR than INT, p = .004, such that more NWCR than INT were morning-types and fewer were evening types, p = .014. Further, NWCR participants reported better sleep quality, longer sleep duration, and shorter latency to sleep onset compared to INT, ps < .05, and fewer NWCR participants reported <6 or <7 h of sleep, ps < .01. Future studies should examine if these factors change as a result of weight loss or are predictors of weight outcome.

Sleep architecture following a weight loss intervention in overweight and obese patients with obstructive sleep apnea and type 2 diabetes: relationship to apnea-hypopnea index

STUDY OBJECTIVES

To determine if weight loss and/ or changes in apnea-hypopnea index (AHI) improve sleep architecture in overweight/ obese adults with type 2 diabetes (T2D) and obstructive sleep apnea (OSA).

METHODS

This was a randomized controlled trial including 264 overweight/ obese adults with T2D and OSA. Participants were randomized to an intensive lifestyle intervention (ILI) or a diabetes and support education (DSE) control group. Measures included anthropometry, AHI, and sleep at baseline and year-1, year-2, and year-4 follow-ups.

RESULTS

Changes in sleep duration (total sleep time [TST]), continuity [wake after sleep onset (WASO)], and architecture stage 1, stage 2, slow wave sleep, and REM sleep) from baseline to year 1, 2, and 4 did not differ between ILI and DSE. Repeated-measure mixed-model analyses including data from baseline through year-4 for all participants demonstrated a significant positive association between AHI and stage 1 sleep (p < 0.001), and a significant negative association between AHI and stage 2 (p = 0.01) and REM sleep (p < 0.001), whereas changes in body weight had no relation to any sleep stages or TST. WASO had a significant positive association with change in body weight (p = 0.009).

CONCLUSIONS

Compared to control, the ILI did not induce significant changes in sleep across the 4-year follow-up. In participants overall, reduced AHI in overweight/ obese adults with T2D and OSA was associated with decreased stage 1, and increased stage 2 and REM sleep. These sleep architecture changes are more strongly related to reductions in AHI than body weight, whereas WASO may be more influenced by weight than AHI.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00194259.

Hawthorne effect with transient behavioral and biochemical changes in a randomized controlled sleep extension trial of chronically short-sleeping obese adults: implications for the design and interpretation of clinical studies

OBJECTIVE

To evaluate the effects of study participation per se at the beginning of a sleep extension trial between screening, randomization, and the run-in visit.

DESIGN

Subjects were screened, returned for randomization (Comparison vs. Intervention) after 81 days (median), and attended run-in visit 121 days later.

SETTING

Outpatient.

PATIENTS

Obese (N = 125; M/F, 30/95; Blacks/Whites/Other, N = 73/44/8), mean weight 107.6±19.7 kg, <6.5 h sleep/night.

INTERVENTION

Non-pharmacological sleep extension.

MEASUREMENTS

Sleep duration (diaries and actigraphy watch), sleep quality (Pittsburgh Sleep Quality Index), daily sleepiness (Epworth Sleepiness Scale), fasting glucose, insulin and lipids.

RESULTS

Prior to any intervention, marked improvements occurred between screening and randomization. Sleep duration increased (diaries: 357.4 ±51.2 vs. 388.1±48.6 min/night; mean±SD; P<0.001 screening vs. randomization; actigraphy: 344.3 ±41.9 vs. 358.6±48.2 min/night; P<0.001) sleep quality improved (9.1±3.2 vs. 8.2±3.0 PSQI score; P<0.001), sleepiness tended to improve (8.9±4.6 vs. 8.3±4.5 ESS score; P = 0.06), insulin resistance decreased (0.327±0.038 vs. 0.351±0.045; Quicki index; P<0.001), and lipids improved, except for HDL-C. Abnormal fasting glucose (25% vs. 11%; P = 0.007), and metabolic syndrome (42% vs. 29%; P = 0.007) both decreased. In absence of intervention, the earlier metabolic improvements disappeared at the run-in visit.

LIMITATIONS

Relatively small sample size.

CONCLUSIONS

Improvements in biochemical and behavioral parameters between screening and randomization changed the "true" study baseline, thereby potentially affecting outcome. While regression to the mean and placebo effect were considered, these findings are most consistent with the "Hawthorne effect", according to which behavior measured in the setting of an experimental study changes in response to the attention received from study investigators. This is the first time that biochemical changes were documented with respect to the Hawthorne effect. The findings have implications for the design and conduct of clinical research.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00261898.

The complex associations among sleep quality, anxiety-depression, and quality of life in patients with extreme obesity

INTRODUCTION

Sleep duration and quality have been associated with obesity. Sleep disturbance has been reported to be associated with stress and depression among non-obese populations, but these relationships have not been previously examined in the obese population. The objective of the current study was to examine the complex associations among sleep disturbance, quality of life, anxiety, and depression in a patient sample with severe obesity.

METHODS

Two hundred seventy consecutively recruited patients with a mean body mass index (BMI) of 47.0 kg/m² were studied. The correlation coefficient, multiple linear regressions, and structural equation modeling (SEM) analysis were used to evaluate the association between the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Impact of Weight on Quality of Life-Lite (IWQOL-Lite) and Hospital Anxiety and Depression Scale (HADS).

RESULTS

The mean (standard deviation; SD) PSQI score was 8.59 (5.11), and mean ESS score was 8.84 (5.79). After controlling for potential confounders, poor sleep quality and excessive daytime sleepiness were found to be significantly associated of all the components of IWQOL-Lite; physical function (β = -0.32, β = -0.27; P < 0.01), self-esteem (β = -0.23, β = -0.30; P < 0.05), sexual-life (β = -0.30, β = -0.35; P < 0.05), public distress (β = -0.39, β = -0.39; P < 0.01), and work (β = -0.26, β = -0.48; P < 0.01). We also found that the PSQI global score had a positive significant association with anxiety (β = 0.29; P = 0.01) and depression (β = 0.31; P = 0.01) components of HADS.

CONCLUSION

Poor sleep quality was strongly associated with mood disturbance and poor quality of life among extremely obese patients. Future interventions are needed to address sleep disturbance to prevent further development of psychological co-morbidity and potentially worsening of obesity among these individuals.

Disadvantageous shift in energy balance is primarily expressed in high-quality sleepers after a decline in quality sleep because of disturbance

BACKGROUND

Epidemiologic studies have shown an inverse or U-shaped relation between sleep duration and body mass index (BMI; in kg/m(2)). Moreover, associations between energy balance (EB) and characteristics of quality sleep (QS) have recently been reported.

OBJECTIVE

We assessed the relation between total energy expenditure (TEE) as well as substrate oxidation and QS after disturbed compared with nondisturbed sleep in EB.

DESIGN

Fifteen healthy men (mean ± SD BMI: 24.1 ± 1.9; age: 23.7 ± 3.5 y) were included in a randomized crossover study. TEE and substrate oxidation were measured twice for 48 h in a respiration chamber, whereas slow-wave sleep (SWS), rapid eye movement (REM)-sleep, total sleeping time (TST), sleep stage 2 (S2), and QS [(SWS + REM) ÷ TST × 100%] were determined by using electroencephalography. During 2 nights, sleep (2330-0730) was either disturbed or nondisturbed (control).

RESULTS

Positive correlations were shown for TEE, activity-induced energy expenditure corrected for body mass (AEE/BM), respiratory quotient (RQ), and carbohydrate oxidation with QS and SWS during nondisturbed sleep. Fat oxidation was inversely correlated with QS and SWS. RQ and carbohydrate oxidation were inversely related to REM sleep. During the disturbed condition SWS, REM, TST, and S2 were reduced, and positive correlations were shown between TEE and AEE/BM with QS. The reduction in QS was stronger in high-quality sleepers; QS reduction was positively associated with increases in energy intake, TEE, and EB.

CONCLUSION

A disadvantageous shift in energy balance is primarily expressed in high-quality sleepers after a decline in QS because of disturbance, implying that good sleepers are most liable to a positive energy balance because of sleep disturbance. This trial was registered at ISRCTN as NTR1919.