Associations of depression, sleep disorder with total and cause-specific mortality: A prospective cohort study

Association of depressive symptoms and sleep disturbances with survival among US adult cancer survivors

BACKGROUND

Depression and sleep disturbances are associated with increased risks of various diseases and mortality, but their impacts on mortality in cancer survivors remain unclear. The objective of this study was to characterize the independent and joint associations of depressive symptoms and sleep disturbances with mortality outcomes in cancer survivors.

METHODS

This population-based prospective cohort study included cancer survivors aged ≥ 20 years (n = 2947; weighted population, 21,003,811) from the National Health and Nutrition Examination Survey (NHANES) 2007-2018 cycles. Depressive symptoms and sleep disturbances were self-reported. Depressive symptoms were assessed using the Patient Health Questionnaire 9 (PHQ-9). Death outcomes were determined by correlation with National Death Index records through December 31, 2019. Primary outcomes included all-cause, cancer-specific, and noncancer mortality.

RESULTS

During the median follow-up of 69 months (interquartile range, 37-109 months), 686 deaths occurred: 240 participants died from cancer, 146 from heart disease, and 300 from other causes. Separate analyses revealed that compared with a PHQ-9 score (0-4), a PHQ-9 score (5-9) was associated with a greater risk of all-cause mortality (hazard ratio [HR], 1.28; 95% CI, 1.03-1.59), and a PHQ-9 score (≥ 10) was associated with greater risk of all-cause mortality (HR, 1.37; 95% CI, 1.04-1.80) and noncancer mortality (HR, 1.45; 95% CI, 1.01-2.10). Single sleep disturbances were not associated with mortality risk. In joint analyses, the combination of a PHQ-9 score ≥ 5 and no sleep disturbances, but not sleep disturbances, was associated with increased risks of all-cause mortality, cancer-specific mortality, and noncancer mortality. Specifically, compared with individuals with a PHQ-9 score of 0-4 and no sleep disturbances, HRs for all-cause mortality and noncancer mortality in individuals with a PHQ-9 score of 5-9 and no sleep disturbances were 1.72 (1.21-2.44) and 1.69 (1.10-2.61), respectively, and 2.61 (1.43-4.78) and 2.77 (1.27-6.07), respectively, in individuals with a PHQ-9 score ≥ 10 and no sleep disturbances; HRs for cancer-specific mortality in individuals with a PHQ-9 score ≥ 5 and no sleep disturbances were 1.95 (1.16-3.27).

CONCLUSIONS

Depressive symptoms were linked to a high risk of mortality in cancer survivors. The combination of a PHQ-9 score (≥ 5) and an absence of self-perceived sleep disturbances was associated with greater all-cause mortality, cancer-specific mortality, and noncancer mortality risks, particularly in individuals with a PHQ-9 score (≥ 10).

Associations of sleep disorders with all-cause and cause-specific mortality in cancer survivors: a cross-sectional analysis of the NHANES 2005-2016

BACKGROUND

The circadian clock and endoplasmic reticulum stress signaling play important roles in oncogenesis and development of cancer. Sleep disorders have been linked to an elevated risk of mortality in general populations. Nonetheless, the evidence for the sleep disorders-mortality association among cancer patients is limited. We aimed to prospectively investigate the association of sleep disorders with all-cause, cancer, and cardiovascular disease (CVD) mortality among cancer individuals.

METHODS

We assessed 3187 participants with cancer from the National Health and Nutrition Examination Survey 2005-2016 cohorts with a median follow-up time of 83.0 months. Multivariable Cox proportional hazards models estimated the adjusted hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

Multivariable Cox proportional hazards models showed that sleep disorders were associated with a higher risk of all-cause mortality (HR 1.23, 95%CI: 1.06,1.42), cancer mortality (HR 1.30, 95%CI: 1.02, 1.66), and cardiovascular disease mortality (HR 1.35, 95%CI: 1.02, 1.80). After the total group was stratified by gender, the high HRs were observed in men (P < 0.05), not in women. The correlation between sleep disorders and higher long-term mortality was also significant after individuals who died within 2 years of follow-up were excluded, with HR 1.24 (95%CI: 1.07, 1.45) in model I, HR 1.20 (95%CI: 1.02, 1.42) in model II for long-term all-cause mortality, HR (95%CI: 1.00, 1.74) in model I for long-term cancer mortality, and HR 1.5 (95%CI:1.12, 2.02) in model I, HR 1.45 (95%CI: 1.06, 1.99) in model II for long-term CVD mortality.

CONCLUSIONS

Sleep disorders were associated with a higher risk of all-cause mortality, cancer mortality, and CVD mortality, as well as long-term mortality in cancer patients. Our finding underlies the importance of screening for sleep disorders for all cancer survivors and the urge to integrate sleep health as an important part of cancer care more effectively. Male individuals may be particularly vulnerable and could benefit from more frequent screening.

Feeling too low to be active: Physical inactivity mediates the relationship between mental and physical health

BACKGROUND

Physical inactivity is one of the most influential and pervasive risk factors for health problems. Therefore, public health experts call for interventions to promote physical activity across the lifespan. This study aimed to examine the role of mental health in physical inactivity and the subsequent role of physical activity in various aspects of physical health.

METHODS

Data were collected in the third wave of the European Health Interview Survey (EHIS) in Slovenia. A nationally representative sample of 9,900 people (49.6% male) aged 15 years or more (M = 49.2; SD = 18.9 years) provided self-reports on depression (PHQ-8), subjective well-being (MHC-SF), physical (in)activity, bodily pain, long-standing activity limitations, their general health status, and possible chronic diseases.

RESULTS

The results of a path analysis showed that depression had a positive effect and well-being had a negative effect on physical inactivity, which in turn contributed to the likelihood of severe bodily pain, activity limitations, poor self-rated health, and multimorbidity. Depression and well-being contributed to health-related outcomes directly and indirectly through physical inactivity.

LIMITATIONS

Because of the cross-sectional design, this study is limited in its ability to draw causal conclusions. All health data were self-reported.

CONCLUSIONS

Results suggest that high levels of depression and low levels of subjective well-being may be an early warning sign of physical health problems. Interventions aimed at preventing or reducing mental health problems and promoting positive mental health may benefit not only mental health per se, but also prevent physical inactivity and, consequently, physical health problems.

Impact of 8 lifestyle factors on mortality and life expectancy among United States veterans: The Million Veteran Program

BACKGROUND

Lifestyle medicine has been proposed as a way to address the root causes of chronic disease and their associated health care costs.

OBJECTIVE

This study aimed to estimate mortality risk and longevity associated with individual lifestyle factors and comprehensive lifestyle therapy.

METHODS

Age- and sex-specific mortality rates were calculated on the basis of 719,147 veterans aged 40-99 y enrolled in the Veteran Affairs Million Veteran Program (2011-2019). Hazard ratios and estimated increase in life expectancy were examined among a subgroup of 276,132 veterans with complete data on 8 lifestyle factors at baseline. The 8 lifestyle factors included never smoking, physical activity, no excessive alcohol consumption, restorative sleep, nutrition, stress management, social connections, and no opioid use disorder.

RESULTS

On the basis of 1.12 million person-years of follow-up, 34,247 deaths were recorded. Among veterans who adopted 1, 2, 3, 4, 5, 6, 7, and 8 lifestyle factors, the adjusted hazard ratios for mortality were 0.74 (0.60-0.90), 0.60 (95% CI: 0.49, 0.73), 0.50 (95% CI: 0.41, 0.61), 0.43 (95% CI: 0.35, 0.52), 0.35 (95% CI: 0.29, 0.43), 0.27 (95% CI: 0.22, 0.33), 0.21 (95% CI: 0.17, 0.26), and 0.13 (95% CI: 0.10, 0.16), respectively, as compared with veterans with no adopted lifestyle factors. The estimated life expectancy at age 40 y was 23.0, 26.5, 28.8, 30.8, 32.7, 35.1, 38.3, 41.3, and 47.0 y among males and 27.0, 28.8, 33.1, 38.0, 39.2, 41.4, 43.8, 46.3, and 47.5 y for females who adopted 0, 1, 2, 3, 4, 5, 6, 7, and 8 lifestyle factors, respectively. The difference in life expectancy at age 40 y was 24.0 y for male veterans and 20.5 y for female veterans when comparing adoption of 8-9 lifestyle factors.

CONCLUSIONS

A combination of 8 lifestyle factors is associated with a significantly lower risk of premature mortality and an estimated prolonged life expectancy.

Association of dietary oxidative balance score and sleep duration with the risk of mortality: prospective study in a representative US population

OBJECTIVE

We investigated the association between dietary oxidative balance score (DOBS) and mortality and whether this association can be modified by sleep duration.

DESIGN

We calculated DOBS to estimate the overall oxidative effects of the diet, with higher DOBS reflecting more antioxidant intake and less pro-oxidant intake. Cox proportional hazards models were employed to examine the associations between DOBS and all-cause, CVD and cancer mortality in the general population and people with different sleep durations.

SETTING

Prospective analysis was conducted using data from the US National Health and Nutrition Examination Survey (NHANES, 2005-2015).

PARTICIPANTS

A total of 15 991 US adults with complete information on dietary intake, sleep duration and mortality were included.

RESULTS

During a median follow-up of 7·4 years, 1675 deaths were observed. Participants in the highest quartile of DOBS were significantly associated with the lower risk of all-cause mortality (hazard ratio (HR) = 0·75; 95 % CI 0·61, 0·93) compared with those in the lowest. Furthermore, we found statistically significant interactions between DOBS and sleep duration on all-cause mortality (P interaction = 0·021). The inverse association between DOBS and all-cause mortality was significant in short sleepers (HR = 0·66, 95 % CI 0·48, 0·92), but not in normal and long sleepers.

CONCLUSIONS

Our study observed that higher DOBS was associated with lower all-cause mortality, and this association appeared to be stronger among short sleepers. This study provides nutritional guidelines for improving health outcomes in adults, especially for short sleepers.

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.

Oxidative balance scores and depressive symptoms: Mediating effects of oxidative stress and inflammatory factors

BACKGROUND

Few studies have examined the combined effects of dietary and lifestyle factors on depressive symptoms. This study aimed to evaluate the association between oxidative balance score (OBS) and depressive symptoms and the underlying mechanisms.

METHODS

A total of 21,283 adults from the 2007 to 2018 National Health and Nutrition Examination Survey (NHANES) were included. Depressive symptoms were defined as a total score of ≥10 on the Patient's Health Questionnaire (PHQ-9). Twenty dietary and lifestyle factors were selected to calculate the OBS. Multivariable logistic regression analyses were used to evaluate the association between OBS and depression risk. Mediation analyses were conducted to explore the roles of oxidative stress and inflammatory markers.

RESULTS

In multivariate model, a significant negative association was found between OBS and depression risk. Compared with those in OBS tertile 1, participants in tertile 3 had lower odds of developing depressive symptoms (OR:0.50; 95 % CI:0.40-0.62; P < 0.001). Restricted cubic splines showed a linear relationship between OBS and depression risk (P for nonlinearity = 0.67). Moreover, higher OBS was found to be associated with lower depression scores (β = -0.07; 95 % CI:-0.08, -0.05; P < 0.001). GGT concentrations and WBC counts mediated the association between OBS and depression scores by 5.72 % and 5.42 %, respectively (both P < 0.001), with a joint mediated effect of 10.77 % (P < 0.001).

LIMITATIONS

This study was a cross-sectional design making it difficult to infer a causal association.

CONCLUSIONS

OBS is negatively associated with depression, which may be mediated in part by oxidative stress and inflammation.

Association of sleep complaints with all-cause and heart disease mortality among US adults

Introduction

Compared with sleep disorders, no consensus has been reached on whether a subjective complaint of having trouble sleeping is associated with increased all-cause and heart disease mortality risk. Previous studies displayed considerable heterogeneity in population disease characteristics and duration of follow-up. Therefore, the aims of this study were to examine the relationship between sleep complaints and all-cause and heart disease mortality and whether the associations were influenced by follow-up time and population disease characteristics. In addition, we aimed to figure out the influence of the joint effects of sleep duration and sleep complaints on mortality risk.

Methods

The present study utilized data from five cycles of the National Health and Nutrition Examination Survey (NHANES) (2005~2014) linked with the most updated 2019 National Death Index (NDI). Sleep complaints were determined by answers to "Have you ever told a doctor or other health professional that you have trouble sleeping?" and "Have you ever been told by a doctor or other health professional that you have a sleep disorder?". Those who answered 'Yes' to either of the aforementioned two questions were considered as having sleep complaints.

Results

A total of 27,952 adult participants were included. During a median follow-up of 9.25 years (interquartile range, 6.75-11.75 years), 3,948 deaths occurred and 984 were attributable to heart disease. A multivariable-adjusted Cox model revealed that sleep complaints were significantly associated with all-cause mortality risk (HR, 1.17; 95% CI, 1.07-1.28). Subgroup analysis revealed that sleep complaints were associated with all-cause (HR, 1.17; 95% CI, 1.05-1.32) and heart disease (HR, 1.24; 95% CI, 1.01-1.53) mortality among the subgroup with cardiovascular disease (CVD) or cancer. In addition, sleep complaints were more strongly associated with short-term mortality than long-term mortality. The joint analysis of sleep duration and sleep complaints showed that sleep complaints mainly increased the mortality risk in those with short (< 6 h/day, sleep complaints HR, 1.40; 95% CI, 1.15-1.69) or recommended (6-8 h/day, sleep complaints HR, 1.15; 95% CI, 1.01-1.31) sleep duration group.

Discussion

In conclusion, sleep complaints were associated with increased mortality risk, indicating a potential public benefit of monitoring and managing sleep complaints in addition to sleep disorders. Of note, persons with a history of CVD or cancer may represent a potentially high-risk group that should be targeted with a more aggressive intervention of sleep problems to prevent premature all-cause and heart disease death.

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.

Psychological Profiles of Treatment-Seeking Adults with Overweight and Obesity: A Cluster Analysis Approach

BACKGROUND

Overweight and obesity are associated with depression and well-being. Some psychological characteristics play a role in explaining well-being and depression in obesity and in identifying specific patient profiles. However, subtyping individuals with overweight/obesity based on variables like self-esteem or stress has not often been done. Therefore, our objective was to explore the psychological profiles of treatment-seeking individuals overweight or with obesity and to compare their depression and well-being.

METHODS

Data regarding eating self-efficacy, well-being, depression, physical hunger, self-esteem, body satisfaction and perceived stress in individuals with overweight/obesity were collected from the ESTEAM cohort. Hierarchical cluster analysis and mean comparisons were performed on female (n = 1427) and male samples (n = 310).

RESULTS

Three psychological profiles were identified in both samples. The "High psychological concerns" profile and the "Low psychological concerns" profile were identical in both samples. The third profile, "Bodily concerns", differed by sex and was characterized by appearance dissatisfaction for women and by appearance and eating concerns for men. The "Low psychological concerns" profile presented the highest well-being and the lowest depression scores in both samples.

DISCUSSION

The findings support the hypothesis of the heterogeneity of individuals with overweight and obesity and suggest sex-related therapeutic approaches.