Sleep hygiene and its association with daytime sleepiness, depressive symptoms, and quality of life in patients with mild obstructive sleep apnea

The impact of comprehensive healthy lifestyles on obstructive sleep apnea and the mediating role of BMI: insights from NHANES 2005-2008 and 2015-2018

OBJECTIVE

In this study, the associations between healthy lifestyles and obstructive sleep apnea (OSA) in middle-aged and elderly adults were investigated via data from the National Health and Nutrition Examination Survey (NHANES) for the periods of 2005-2008 and 2015-2018.

METHODS

A total of 6,406 participants aged 40 years and older were included in the analysis. Healthy lifestyle behaviors were assessed through diet quality, physical activity, sleep duration, alcohol consumption, smoking status, and body mass index (BMI). A composite healthy lifestyle score (ranging from 0 to 6) was created and categorized into insufficient (0-2), intermediate (3-4), and optimal (5-6) health groups. Weighted logistic regression models were used to examine the association between these lifestyle scores and OSA, adjusting for some demographic, socioeconomic, and clinical covariates. Additionally, mediation analysis was conducted to evaluate the role of BMI as a mediator in the relationship between the composite healthy lifestyle score and OSA, determining the proportion of the total effect mediated by BMI.

RESULTS

Participants were classified into insufficient (17.81%), intermediate (56.82%), and optimal (25.37%) lifestyle groups. Higher dietary quality (OR: 0.81, 95% CI: 0.66-0.99) and adequate weight (OR: 0.09, 95% CI: 0.07-0.11) were statistically associated with reduced OSA odds after adjustments, whereas the variables were not. Each one-point increase in the healthy lifestyle score was linked to a 33% reduction in OSA odds (OR: 0.67, 95% CI: 0.63-0.71). A significant linear trend was observed, with better adherence to healthy lifestyle correlating with lower odds of OSA (p for trend < 0.001). Compared with insufficient lifestyle, intermediate lifestyle was linked to a 27% reduction in OSA (OR: 0.73, 95% CI: 0.58-0.91), whereas optimal lifestyle was associated with a 74% reduction (OR: 0.26, 95% CI: 0.21-0.33). Mediation analysis revealed that BMI significantly mediated the relationship between healthy lifestyle score and OSA, accounting for approximately 59.2% of the total effect (P < 0.001). The direct effect of the healthy lifestyle score on OSA remained significant even when controlling for BMI (P < 0.001). Subgroup analyses confirmed consistent benefits across different demographic groups.

CONCLUSIONS

This study revealed that adherence to healthy lifestyles significantly reduces the odds of OSA, with optimal lifestyles leading to a marked decrease in the odds of OSA. Notably, BMI plays a critical mediating role in this relationship. These findings emphasize the importance of promoting healthy lifestyle interventions as a key strategy for the prevention and management of OSA.

Pediatric Obstructive Sleep Apnea: Diagnostic Challenges and Management Strategies

Pediatric obstructive sleep apnea (OSA) is a prevalent yet often underdiagnosed condition affecting 1-5% of children globally, with higher prevalence in populations such as those with Down syndrome and obesity. Characterized by recurrent upper airway obstruction during sleep, OSA can lead to serious health consequences, including neurocognitive deficits, behavioral issues, and cardiovascular complications. The diagnosis is complicated by symptom overlap with conditions like Attention-Deficit/Hyperactivity Disorder (ADHD) while polysomnography (PSG) remains the gold standard for diagnosis, access to this test is limited in many regions. Treatment options include lifestyle modifications, surgical interventions like adenotonsillectomy, and non-invasive approaches such as upper airway stenting for patients who are non-compliant with continuous positive airway pressure (CPAP) therapy. Evidence indicates that adenotonsillectomy significantly reduces the apnea-hypopnea index (AHI) in children with adenotonsillar hypertrophy, although residual OSA is common, particularly in high-risk populations like those with Prader-Willi syndrome. Recent studies have explored pharmacological treatments, advanced diagnostic techniques, and machine learning applications to improve outcomes. This review emphasizes the importance of a multidisciplinary, individualized approach to the management of pediatric OSA, highlighting the need for further research into innovative therapeutic strategies and long-term outcomes for affected children.

Impacts of conservative treatment on the clinical manifestations of obstructive sleep apnea-systematic review and meta-analysis

INTRODUCTION

Obstructive sleep apnea (OSA) is a chronic disease with a high populational prevalence that is characterized as airway closure during sleep. Treatment is multidisciplinary and varies according to each case. Continuous positive airway pressure (CPAP), oral appliances, and surgery are the primary therapeutic options. Non-invasive conservative treatments such as sleep hygiene, positional therapy, physical exercises, and weight loss aim to reduce the worsening of the disease while being complementary to the invasive primary treatment.

OBJECTIVE

To analyze the impact of non-invasive conservative therapies on the clinical manifestations of OSA syndrome (OSA), compared with other interventions.

METHOD

This was a systematic review with meta-analysis. The searches were performed without filters for the time period, type of publication, or language. Randomized clinical trials on subjects over 18 years of age diagnosed with untreated OSA were included. Responses to non-invasive conservative treatment were compared with responses to the primary intervention. Primary outcomes were assessed using the Epworth Sleepiness Scale and/or Functional Outcomes of Sleep Questionnaire (FOSQ).

RESULTS

A total of eight studies were included in the review. The heterogeneity of the effect was estimated at 89.77%. Six studies compared conservative treatment with CPAP, one with oral appliances, and one with oropharyngeal exercises. Using the Epworth Sleepiness Scale measurements, the standardized difference in the estimated means, based on the random-effects model, was 0.457 (95% CI (1.082 to 0.169)) and the mean result did not differ significantly from zero (z = 1.43; p = 0.153). The conservative therapies assessed in this study improved the subjective quality of sleep, although the post-treatment ESE scores did not show significant results. The reduction in AHI and better outcomes in the evaluated domains, as well as in cognition and mood, were superior in the groups that received CPAP and IOD.

CONCLUSION

The most commonly used treatments of choice for OSA are invasive, including the use of CPAP, oral appliances, and surgeries, being the most utilized options. This study demonstrated that non-invasive conservative treatments, such as sleep hygiene, yield results as effective as invasive treatments. Further studies are needed to confirm this result and to predict whether invasive treatment can be used as the primary treatment or only as a supplement.

A Scoping Review of Sleep Apnea: Where Do We Stand?

Obstructive sleep apnea (OSA), a condition in which there is a recurrent collapse of the upper airway while sleeping, is a widespread disease affecting 5% to 10% people worldwide. Despite several advances in the treatment modalities for OSA, morbidity and mortality remain a concern. Common symptoms include loud snoring, gasping for air during sleep, morning headache, insomnia, hypersomnia, attention deficits, and irritability. Obese individuals, male gender, older age (65+), family history, smoking, and alcohol consumption are well recognized risk factors of OSA. This condition holds the ability to increase inflammatory cytokines, cause metabolic dysfunction, and increase the sympathetic output, all of which exacerbate OSA due to their effect on the cardiovascular system. In this review, we discuss its brief history, risk factors, complications, treatment modalities, and the role of clinicians in curbing its risk.

Evaluation of the sleep hygiene index and physical activity states of the elderly living in nursing homes

The aim: the sleep quality and physical performance play a vital role in older adults’ well-being to maintain good overall health. Therefore, the parameters that have a role in sleep and physical capacity are crucial to achieve a healthy aging outcome. In this study, we aimed at comparing the quality of sleep and physical activity state of the elderly living in 5 nursing homes. Methods: the 181 elderly individuals living in 5 nursing homes were included in this cross-sectional study. Physical activity, sleep hygiene index and demographics were analysed using SPPS 23.0. Results: overall, 68.5 % of the participants were male, and 31.5 % were female. There was no significant correlation between the sleep hygiene scores and physical activity states (p >0.05). Those who were divorced, those who were on at least one type of medication, those who smoked and those with poor perception of health had statistically significant difference in terms of the Sleep Hygiene Index (p<0.05). Conclusion: other than findings of the presented study that influence sleep and physical activity, the many other factors in different geographical areas or cultures could be a reason that is interrelated with sleep quality and physical performance of older adults. In this study, for primary care and family physicians to boost the sleep quality of the elderly, we recommend improving their health perception, quitting smoking, discontinuing unnecessary medications, and increasing their social interactions

Socioeconomic inequalities in pediatric obstructive sleep apnea

STUDY OBJECTIVES

To examine the association between multiple measures of socioeconomic status (SES) and objectively measured obstructive sleep apnea (OSA) in a Canadian pediatric population.

METHODS

This was a cross-sectional study of 188 children (4-17 years, mean age 9.3 ± 3.5 years) prospectively recruited from two hospital sleep clinics in Canada, using multivariable-adjusted linear and logistic regression of five measures of SES including parental education, income, social class, geographic location, and perceived SES based on the MacArthur Scale of Subjective Social Status, assessed in relation to four polysomnographic OSA variables including apnea-hypopnea index, apnea index, mean oxygen saturation level, and oxygen desaturation index.

RESULTS

Overall, low household-level SES appeared to be associated with both frequency (apnea index ≥ 1 events/h) and severity (apnea-hypopnea index ≥ 5 events/h) of OSA in children, with maternal education showing the most consistent and significant associations. Specifically, children with mothers reporting less than high school education had nearly three times the odds of having OSA after controlling factors including body mass index (odds ratio 2.96 [95% confidence interval, 1.05-8.37]), compared to university-educated participants. Consistent associations were also observed for geographic location with less frequency and severity of OSA among nonurban children. Perceived SES was minimally inversely associated with our outcomes.

CONCLUSIONS

This cross-sectional, multicenter study demonstrated that SES factors are linked to the occurrence and severity of OSA in children. Results indicated the need to incorporate the screening of SES in the diagnostic process of pediatric OSA to provide more targeted intervention and patient-centered care.

CITATION

Park JW, Hamoda MM, Almeida FR, et al. Socioeconomic inequalities in pediatric obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):637-645.

The role of sleep hygiene in the risk of Shift Work Disorder in nurses

A high proportion (20%-30%) of shift workers experience Shift Work Disorder (SWD), characterized by chronic sleepiness and/or insomnia associated with work schedules. The reasons for individual variation in shift work tolerance are not well understood, however. The aim of this study was to identify individual factors that contribute to the risk of SWD. Nurses (n = 202) were categorized as low or high risk of SWD based on the Shift Work Disorder Questionnaire. Participants provided demographic and lifestyle information and completed the Sleep Hygiene Index (SHI) and Morningness-Eveningness Questionnaire (MEQ). High risk of SWD was associated with poorer sleep hygiene (SHI, 35.41 ± 6.19 vs. 31.49 ± 7.08, p < .0001) and greater eveningness (MEQ, 34.73 ± 6.13 vs. 37.49 ± 6.45, p = .005) compared to low risk. No other factors, including body mass index, marital status, having children, or caffeine or alcohol intake were significant. Logistic regression showed that SHI was the most significant contributing factor to SWD risk (odds ratio [OR] = 1.09, 95% confidence interval [CI] = 1.04 to 1.14). Standardized odds ratio further revealed that with every unit increase on the SHI score, the odds of being at high risk of SWD increased by 80% (OR = 1.84). Most individuals at high risk of SWD reported "always" or "frequently" going to bed at different times (79%) and waking at different times (83%; compared to 58%, p = .017, and 61%, p = .002, respectively for the low-risk group), as well as going to bed stressed/angry (67% vs. 41%, p < .0001) and/or planning/worrying in bed (54% vs. 22%, p < .0001). Interventions aimed at improving sleep hygiene practices and psychological health of shift workers may help reduce the risk of SWD.

Sleep hygiene, sleep-related problems, and their relations with quality of life in a primary-care population in southwest Saudi Arabia

BACKGROUND

Little is recognized about factors affecting poor sleep hygiene and relations of sleep problems with the quality of life among adults.

AIMS

To evaluate sleep hygiene, explore its associated factors, assess the prevalence of excessive daytime sleepiness (EDS) and insomnia, and their relations with sleep hygiene. Besides, correlate sleep problems with life quality.

METHODS

A representative sample of primary healthcare population was surveyed using questionnaires comprising sociodemographic characters, personal lifestyles, validated Arabic versions of Epworth sleepiness scales, Athens insomnia scale, short-form health survey questionnaire (SF-12), and developed Arabic sleep hygiene index (SHI).

RESULTS

A total of 401 adults participated in the study. The average SHI score was 17.25 ± 7.33. Poorer sleep hygiene was significantly detected in younger age, unmarried, unemployed, smokers, and energy drinks consumers (P < 0.05). Positive significant correlations were correlated with cellphone and video-gaming duration. About 56.61% and 39.90% of participants suffered insomnia symptoms and EDS, respectively. Significant poorer SHI was detected among insomnia and EDS sufferers. Negative significant correlations were observed between scores of both components of SF-12 and EDS, insomnia, and SHI.

CONCLUSION

Significant negative associations were detected between SHI, EDS, insomnia, and both components of life quality. The role of sleep hygiene education programs in the promotion of sleep and quality of life need to be considered.

The Effect of Sleep Hygiene and Sleep Deterioration on Quality of Life in Shiftworking Healthcare Professionals

Introduction

Deterioration in sleep quality and sleep hygiene may result in impairments on mental and physical health leading to deterioration of quality of life (QoL) in healthcare shift workers. We aimed to determine the presence of sleep deterioration as well as poor sleep hygiene, and if any, the effects of these on health-related outcomes.

Methods

This study prospectively included healthcare professionals who did and did not work shifts (n=90 and n=66, respectively). The participants completed the Pittsburgh Sleep Quality Index (PSQI), Sleep Hygiene Index (SHI), Epworth Daytime Sleepiness Scale (EDSS), Short Form-36 quality of life scale (SF-36), and the Beck depression (BD) and Beck anxiety (BA) scales.

Results

Although the total PSQI scores showed a tendency to increase in shift workers, no significant differences were observed in total scores as well as subdivisions, except for an increase in sleep latency. Increased SHI total score in shift workers were represent more deteriorated sleep hygiene behavior (p=0.002). Increased needs of daytime nap, variability of both go and get out of bed and stay in bed longer than usual were recorded respectively (p: 0.001, p: 0.001, p: 0.001, p: 0.001, p: 0.001). SHI had prominent effects on QoL parameters such as vitality (r=-0.284, p=0.007), social function (r=-0.323, p=0.002), mental health (r=-0.274, p=0.009), and calculated mental component total score (r=-0.302, p=0.004).

Conclusion

In our study, we clearly detected prolonged sleep latency and poor sleep hygiene in shift workers which should be responsible for the deterioration of QoL.

Redesigning Care for OSA

Constrained by a limited supply of specialized personnel, health systems face a challenge in caring for the large number of patients with OSA. The complexity of this challenge is heightened by the varied clinical presentations of OSA and the diversity of treatment approaches. Innovations such as simplified home-based care models and the incorporation of nonspecialist providers have shown promise in the management of uncomplicated patients, producing comparable outcomes to the resource-intensive traditional approach. However, it is unclear if these innovations can meet the needs of all patients with OSA, including those with mild disease, atypical presentations, and certain comorbid medical and mental health conditions. This review discusses the diversity of needs in OSA care, the evidence base behind recent care innovations, and the potential limitations of each innovation in meeting the diversity of care needs. We propose how these innovations can fit within the stepped care and hub and spoke models in a way that addresses the full spectrum of OSA, and we discuss future research directions to assess the deployment of these innovations.

Clinical and Polysomnographic Correlates of Subjective Sleepiness in Mild Obstructive Sleep Apnea

Purpose

The decision to treat mild obstructive sleep apnea (OSA) often hinges on the presence of subjective daytime sleepiness. This study was done to identify clinical and polysomnographic features which correlate with subjective sleepiness in mild OSA.

Methods

Utilizing data from the Apnea Positive Pressure Long-term Efficacy Study, 199 participants with mild OSA were identified. Participants were grouped as "sleepy" or "non-sleepy" based on their responses to a question regarding excessive daytime sleepiness, and Epworth Sleepiness Scores. We compared demographic, clinical and baseline polysomnographic data between the groups.

Results

The prevalence of subjective sleepiness was 74.4%. The sleepy group was younger (46.1 ± 12.6 vs. 53.3 ± 13.1 years, p=0.001), reported lower quality of life (4.5 ± 0.69 vs. 4.9 ± 0.61, p=0.0002), had higher depression scores (5.4 ± 4.7 vs. 3.1 ± 3.5, p=0.003) and reported more naps per week (2.6 ± 2.9 vs. 1.3 ± 1.9, p=0.01). Total sleep time and sleep efficiency were notably higher in the sleepy (254.2 ± 106 vs. 220.4 ± 114 min, p=0.08) and (80.2 ± 12.6 vs. 75.7 ± 14.9 %, p=0.06), approaching statistical significance. The non-sleepy group had slightly higher apnea hypopnea index (AHI: 12.2 ± 1.5 vs. 11.2 ± 2.4 events/hour, p=0.01) and worse desaturation indices.

Conclusions

Subjective sleepiness in mild OSA is associated with younger age, worsened mood and quality of life. This study suggests that evidence of increased sleep drive on polysomnography may correlate with subjective sleepiness in mild OSA.

Sleeping, sleeping environments, and human errors in South Korean male train drivers

Objectives

Reducing human errors caused by daytime sleepiness among train drivers is important to prevent train accidents. Our purpose of the study was to investigate the association among sleep, workplace sleeping environments, and human errors.

Methods

We recruited 144 South Korean train drivers belongs to the Korean Railroad Corporation. This cross‐sectional data was analyzed to investigate the association of insomnia (insomnia severity index), sleep quality (Pittsburgh sleep quality index), obstructive sleep apnea (Berlin questionnaire), and daytime sleepiness (Epworth scale) with human error and near‐miss experiences. We examined whether human error and near‐miss events were associated with various sleeping environments at work and at home after adjusting for the sleep indices.

Results

The experience of human errors was associated with insomnia and daytime sleepiness, and near‐miss events were associated with insomnia among South Korean drivers. Sleeping environments including cold temperature and odor were related to both human errors and near‐miss events among South Korean train drivers, after adjusted for age, working years, shiftwork, obesity, smoking, binge drinking, regular exercise, caffeine consumption, sleep quality, severity of insomnia, obstructive sleep apnea, and daytime sleepiness.

Conclusions

The train drivers’ workplace sleeping environment is significantly associated with human error events and near‐miss events after adjusting for sleep quality, insomnia, obstructive sleep apnea, and daytime sleepiness. To prevent train accidents caused by human errors, more attention is necessary for improving workplace sleeping environments.

Sleep Hygiene Index: Psychometric Characteristics and Usefulness as a Screening Tool in a Sample of Nigerian Undergraduate Students

STUDY OBJECTIVES

The objectives of this study were to investigate the psychometric properties of the Sleep Hygiene Index (SHI) and determine its capacity to screen for poor sleep quality in a nonclinical sample of Nigerian university students.

METHODS

A total of 348 students appropriately completed the SHI, the Morningness-Eveningness Questionnaire (MEQ), the Pittsburgh Sleep Quality Index (PSQI), and the Epworth Sleepiness Scale (ESS).

RESULTS

The internal consistency (Cronbach alpha) of the SHI was .64 and its construct validity was modestly satisfactory. It had a significant negative correlation with the MEQ (r = -.170, P < .001) and positive correlations with global PSQI (r = .289, P < .001) and ESS (r = .219, P < .001) scores. Prior to the factor analysis, our sample was randomly divided into two. In one half of the sample (sample 1), exploratory factor analysis of the SHI items yielded a three-factor model. Confirmatory factor analysis on the other half (sample 2) corroborated this model with satisfactory indices of fitness (c² = 67.805; df = 55; c²/df = 1.233; P = .115; goodness of fit index = .943; Tucker-Lewis index = .958; incremental fit index = .972; comparative fit index = .970; root mean square error of approximation = .037). A cutoff total score of 16 on the SHI had the best sensitivity (77.0%) and specificity (47.5%) to identify students who were categorized as experiencing poor sleep quality, according to the PSQI (area under the curve = 0.65, 95% confidence interval = 0.59-0.71).

CONCLUSIONS

The SHI exhibited satisfactory psychometric properties as a self-rated assessment instrument in the evaluation of sleep hygiene and as a screening instrument for poor sleep quality among Nigerian undergraduate students.

Depression and obesity: can the cycle be broken?

Obesity and depression are conditions that have been linked through a great number of interesting mechanisms. To fully understand the implications of treatment choices it is necessary to continue to investigate the physiology of these two conditions. By examining the background of these problems and considering factors such as stress response, neurological change and systemic inflammation, we propose a cycle linking depression and obesity. With reference to this cycle, we discuss management options, focusing particularly on prescribing choices and current guidelines. An assessment of the medication options is provided demonstrating that prescribing choices can have a significant impact on ongoing physical health. The aim of this discussion is to raise awareness of current research and progress and to see whether the cycle of depression and obesity can be broken.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Psychometric Properties of the Persian Version of Sleep Hygiene Index in the General Population

BACKGROUND

Inadequate sleep hygiene may result in difficulties in daily functioning; therefore, reliable scales for measuring sleep hygiene are important.

OBJECTIVES

The purpose of this study was to assess the psychometric properties of the Persian version of the Sleep Hygiene Index (SHI).

MATERIALS AND METHODS

From April 2014 to May 2015, 1280 subjects, who were selected by cluster random sampling in Kermanshah province, filled out the SHI, Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), and insomnia severity index (ISI). A subset of the participants (20%) repeated the SHI after a four to six-week interval to measure test-retest reliability. Then, we computed the Pearson product-moment correlation coefficients of SHI against PSQI, ESS and ISI, to demonstrate the construct validity of the SHI. The factor structure of the SHI was evaluated by explanatory factor analysis.

RESULTS

The interclass correlation coefficient was 0.89, and SHI was found to have good test-retest reliability (r = 0.89, P < 0.01). The SHI was positively correlated with the total score of the PSQI (r = 0.60, P < 0.01), ESS (r = 0.62, P < 0.01) and ISI (r = 0.60, P < 0.01). Exploratory factor analysis extracted three factors, namely "sleep-wake cycle behaviors" (four items), "bedroom factors" (three items), and "behaviors that affect sleep" (six items).

CONCLUSIONS

The Persian version of the SHI can be considered a reliable tool for evaluating sleep hygiene in the general population.

Upper Airway Resistance Syndrome Patients Have Worse Sleep Quality Compared to Mild Obstructive Sleep Apnea

Purpose

To compare sleep quality and sustained attention of patients with Upper Airway Resistance Syndrome (UARS), mild Obstructive Sleep Apnea (OSA) and normal individuals.

Methods

UARS criteria were presence of excessive daytime sleepiness (Epworth Sleepiness Scale—ESS—≥ 10) and/or fatigue (Modified Fatigue Impact Scale—MFIS—≥ 38) associated to Apnea/hypopnea index (AHI) ≤ 5 and Respiratory Disturbance Index (RDI) > 5 events/hour of sleep or more than 30% of total sleep time with flow limitation. Mild OSA was considered if the presence of excessive daytime sleepiness (ESS ≥ 10) and/or fatigue (MFIS ≥ 38) associated to AHI ≥ 5 and ≤ 15 events/hour. “Control group” criteria were AHI < 5 events/hour and RDI ≤ 5 events/hour and ESS ≤ 9, without any sleep, clinical, neurological or psychiatric disorder. 115 individuals (34 UARS and 47 mild OSA patients and 34 individuals in “control group”), adjusted for age, gender, body mass index (BMI) and schooling years, performed sleep questionnaires and sustained attention evaluation. Psychomotor Vigilance Task (PVT) was performed five times (each two hours) from 8 a.m. to 4 p.m.

Results

UARS patients had worse sleep quality (Functional Outcomes of Sleep Questionnaire—FOSQ—and Pittsburgh Sleep Quality Index—PSQI: p < 0.05) and more fatigue than mild OSA patients (p = 0.003) and scored significantly higher in both Beck inventories than “control group” (p < 0.02). UARS patients had more lapses early in the morning (in time 1) compared to the results in the afternoon (time 5) than mild OSA (p = 0.02). Mild OSA patients had more lapses in times 2 than in time 5 compared to “control group” (p = 0.04).

Conclusions

UARS patients have a worse sleep quality, more fatigue and a worse early morning sustained attention compared to mild OSA. These last had a worse sustained attention than controls.