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Zheng YB, Huang YT, Gong YM, Li MZ, Zeng N, Wu SL, Zhang ZB, Tian SS, Yuan K, Liu XX, Vitiello MV, Wang YM, Wang YX, Zhang XJ, Shi J, Shi L, Yan W, Lu L, Bao YP. Association of lifestyle with sleep health in general population in China: a cross-sectional study. Transl Psychiatry 2024; 14:320. [PMID: 39098892 PMCID: PMC11298538 DOI: 10.1038/s41398-024-03002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 06/24/2024] [Accepted: 07/02/2024] [Indexed: 08/06/2024] Open
Abstract
The concept of a healthy lifestyle is receiving increasing attention. This study sought to identify an optimal healthy lifestyle profile associated with sleep health in general population of China. An online cross-sectional survey was conducted from June to July 2022. Six healthy lifestyle factors were assessed: healthy diet, regular physical exercise, never smoking, never drinking alcohol, low sedentary behavior, and normal weight. Participants were categorized into the healthy lifestyle (5-6 factors), average (3-4 factors), and unhealthy lifestyle groups (0-2 factors). The study's primary outcome was sleep health, which included sleep quality, duration, pattern, and the presence of any sleep disorder or disturbance, including insomnia, excessive daytime sleepiness, obstructive apnea syndrome, and narcolepsy. Multivariable logistic regression analysis was applied to explore lifestyles associated with the selected sleep health outcomes. 41,061 individuals were included, forming 18.8% healthy, 63.8% average, and 17.4% unhealthy lifestyle groups. After adjusting for covariates, participants with healthy lifestyle were associated with a higher likelihood of good sleep quality (OR = 1.56, 95% CI = 1.46-1.68), normal sleep duration (OR = 1.60, 95% CI = 1.49-1.72), healthy sleep pattern (OR = 2.15, 95% CI = 2.00-2.31), and lower risks of insomnia (OR = 0.66, 95% CI = 0.61-0.71), excessive daytime sleepiness (OR = 0.66, 95% CI = 0.60-0.73), and obstructive apnea syndrome (OR = 0.40, 95% CI = 0.37-0.43), but not narcolepsy (OR = 0.92, 95% CI = 0.83-1.03), compared to those with unhealthy lifestyle. This large cross-sectional study is the first to our knowledge to quantify the associations of a healthy lifestyle with specific aspects of sleep health. The findings offer support for efforts to improve sleep health by modulating lifestyle.
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Affiliation(s)
- Yong-Bo Zheng
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China
- Peking-Tsinghua Centre for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China
| | - Yue-Tong Huang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China
| | - Yi-Miao Gong
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China
| | - Ming-Zhe Li
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China
- Peking-Tsinghua Centre for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China
| | - Na Zeng
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, China
- School of Public Health, Peking University, Beijing, China
| | - Shui-Lin Wu
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, China
- School of Public Health, Peking University, Beijing, China
| | - Zhi-Bo Zhang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China
| | - Shan-Shan Tian
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China
| | - Kai Yuan
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China
| | - Xiao-Xing Liu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China
| | - Michael V Vitiello
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Yu-Mei Wang
- Institute of Brain Science and Brain-inspired Research, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 250117, China
| | - Yong-Xiang Wang
- Institute of Brain Science and Brain-inspired Research, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 250117, China
| | - Xiu-Jun Zhang
- School of Psychology, College of Public Health, North China University of Science and Technology, Tangshan, 063210, Hebei Province, China
| | - Jie Shi
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, China
| | - Le Shi
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China.
| | - Wei Yan
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China.
| | - Lin Lu
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Peking University, Beijing, China.
- Peking-Tsinghua Centre for Life Sciences and PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China.
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, China.
- Chinese Academy of Medical Sciences Research Unit (No. 2018RU006), Peking University, Beijing, China.
- Shandong Institute of Brain Science and Brain-inspired Research; Medical Science and Technology Innovation Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, 271016, China.
| | - Yan-Ping Bao
- National Institute on Drug Dependence and Beijing Key Laboratory of Drug Dependence, Peking University, Beijing, China.
- School of Public Health, Peking University, Beijing, China.
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Alruwaili A, Alanazy ARM. The Effect of Shift Work on Sleep Patterns of Paramedics in Saudi Arabia. J Multidiscip Healthc 2024; 17:2857-2869. [PMID: 38881751 PMCID: PMC11180460 DOI: 10.2147/jmdh.s458512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/22/2024] [Indexed: 06/18/2024] Open
Abstract
Purpose Shift work poses significant sleep health challenges for paramedics, affecting their ability to respond effectively in emergencies. This study aimed to evaluate the impact of shift work on sleep parameters among paramedics in Saudi Arabia, identifying key factors influencing insomnia. Patients and Methods A cross-sectional, online survey was conducted, gathering data on sociodemographic characteristics, work-related factors, sleep duration, and insomnia among paramedics in Saudi Arabia. The Athens Insomnia Scale was used to define insomnia. The association between shift work and sleep parameters was examined. Predictors of insomnia were identified through logistic regression models by inspecting the adjusted odds ratio (aOR). Results 1076 Saudi paramedics were included, most of whom were 26-35 years old, males, married, had a Bachelor's degree, worked in hospital-based settings for private agencies in rural areas, and had 6-10 years of experience. Occupational stress was reported by 52.96% of paramedics. All shift work characteristics (working hours, number of shifts, work schedule, and off-work days) were significantly associated with insomnia (p=0.0001). The multivariate regression revealed that work setting (aOR=18.71, p=0.02), coffee consumption (aOR=36.83, p=0.01), work schedule (aOR=21.93, p=0.01), and time to bed (aOR=0.01, p=0.01), sleep duration (aOR=0.03, p=0.03), and occupation stress (aOR=9.31, p=0.001) were predictors for insomnia. Conclusion Our findings underscores the need for targeted interventions to mitigate the adverse effects of shift work on sleep health among paramedics.
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Affiliation(s)
- Abdullah Alruwaili
- Emergency Medical Services Program, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, 31982, Saudi Arabia
- King Abdullah International Medical Research Center, Al Ahsa, 31982, Saudi Arabia
- Ministry of National Guard - Health Affairs, Al Ahsa, 31982, Saudi Arabia
| | - Ahmed Ramdan M Alanazy
- Emergency Medical Services Program, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, 31982, Saudi Arabia
- King Abdullah International Medical Research Center, Al Ahsa, 31982, Saudi Arabia
- Ministry of National Guard - Health Affairs, Al Ahsa, 31982, Saudi Arabia
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Arab A, Karimi E, Garaulet M, Scheer FAJL. Dietary patterns and insomnia symptoms: A systematic review and meta-analysis. Sleep Med Rev 2024; 75:101936. [PMID: 38714136 PMCID: PMC11179690 DOI: 10.1016/j.smrv.2024.101936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 05/09/2024]
Abstract
We aimed to systematically review and synthesize the available evidence regarding the link between dietary patterns and insomnia symptoms among the general population using observational studies. We reviewed 16,455 references, of which 37 studies met inclusion criteria with a total sample size of 591,223. There was a significant association of the Mediterranean diet (OR: 0.86; 95 % CI, 0.79, 0.93; P < 0.001; I2 = 32.68 %), a high-quality diet (OR: 0.66; 95 % CI, 0.48, 0.90; P = 0.010; I2 = 84.62 %), and an empirically-derived healthy dietary pattern (OR: 0.91; 95 % CI, 0.85, 0.98; P = 0.010; I2 = 57.14 %) with a decreased risk of insomnia symptoms. Moreover, the dietary glycemic index (OR: 1.16; 95 % CI, 1.08, 1.25; P < 0.001; I2 = 0.0 %), the dietary glycemic load (OR: 1.10; 95 % CI, 1.01, 1.20; P = 0.032; I2 = 74.36 %), and an empirically-derived unhealthy dietary pattern (OR: 1.20; 95 % CI, 1.01, 1.42; P = 0.040; I2 = 68.38 %) were linked with a higher risk of insomnia symptoms. Most individual studies were of good quality (NOS) but provided very low certainty of evidence (GRADE). Consistent data reveals that following healthy diets is associated with decreased insomnia symptoms prevalence, while adherence to an unhealthy pattern is associated with an increased prevalence of insomnia symptoms.
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Affiliation(s)
- Arman Arab
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA; Medical Chronobiology Program, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA, USA.
| | - Elham Karimi
- Research Development Center, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Marta Garaulet
- Department of Physiology, Regional Campus of International Excellence, University of Murcia, Murcia, Spain; Biomedical Research Institute of Murcia, IMIB-Arrixaca-UMU, University Clinical Hospital, Murcia, Spain.
| | - Frank A J L Scheer
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA; Medical Chronobiology Program, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA, USA.
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Zhang X, Yang Z, Du L, Xiong C, Wang Z, Pan Y, He Q, Chen S, Cui L. Associations of accelerometer-measured physical activity, sedentary behavior with self-reported insomnia in older women: Does pattern matter? Sleep Med 2023; 104:58-63. [PMID: 36906996 DOI: 10.1016/j.sleep.2023.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/25/2023] [Accepted: 02/16/2023] [Indexed: 03/02/2023]
Abstract
AIMS Insomnia is a common sleep disorder that widely occurs in older population, especially older women. This study aims to investigate the associations between accelerometer-measured physical activity (PA) and sedentary behavior (SB) patterns with insomnia in older Chinese women. METHODS Cross-sectional data derived from the baseline survey of the Physical Activity and Health in Older Women Study were analyzed for 1112 older women aged 60 to 70. Insomnia was evaluated using Athens Insomnia Scale. PA and SB patterns were measured through an accelerometer. Multivariate logistic regression was used to investigate associations of PA and SB patterns with insomnia. RESULTS All SB variables were positively associated with insomnia, with multivariate-adjusted ORs of 1.24, 1.19 and 1.19 for 60-min increase of total SB, 10min-bouted SB and 30min-bouted SB, respectively. Total LPA and bouted LPA were negatively associated with insomnia, with multivariate-adjusted ORs of 0.90 and 0.89 for 30-min increase of total LPA and bouted LPA, respectively. CONCLUSION Avoiding SB and encouraging LPA engagement may hold promise in preventing insomnia and promoting sleep in older population. Future studies with experimental study design and follow-up periods are warranted to illustrate the causal associations.
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Affiliation(s)
- Xianliang Zhang
- School of Physical Education, Shandong University, Jinan, 250061, China.
| | - Zikun Yang
- School of Physical Education, Shandong University, Jinan, 250061, China.
| | - Litao Du
- School of Physical Education, Shandong University, Jinan, 250061, China.
| | | | - Ziwen Wang
- School of Physical Education, Huanggang Normal University, Huanggang, 438000, China.
| | - Yang Pan
- School of Physical Education, Shandong University, Jinan, 250061, China.
| | - Qiang He
- School of Physical Education, Shandong University, Jinan, 250061, China.
| | - Si Chen
- School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China.
| | - Lili Cui
- School of Physical Education, Shandong University, Jinan, 250061, China.
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Tarabzoni O, Samman AM, Hilabi A, Alrasheed A, Alkhamis MA, Alnumani MS, Al harbi FS, Alraddadi A, Almuklass AM. The Influence of Diet, Water Intake, Exercise, Education Level, and Income on the Quality of Sleep in the Saudi Population: A Cross-Sectional Study. Cureus 2022; 14:e24074. [PMID: 35573539 PMCID: PMC9097761 DOI: 10.7759/cureus.24074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 11/05/2022] Open
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Kechribari I, Kontogianni MD, Georgoulis M, Lamprou K, Critselis E, Vagiakis E, Yiannakouris N. Association of adherence to the Mediterranean diet and physical activity habits with the presence of insomnia in patients with obstructive sleep apnea. Sleep Breath 2021; 26:89-97. [PMID: 33813674 DOI: 10.1007/s11325-021-02351-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 01/29/2023]
Abstract
PURPOSE Insomnia and obstructive sleep apnea (OSA) are among the most prevalent sleep disorders and frequently co-occur, defining the sleep apnea-insomnia syndrome. However, data exploring associations between insomnia and lifestyle habits in patients with OSA are lacking. Therefore, the aim of the present study was to investigate potential associations between insomnia presence and individual lifestyle parameters in patients with mild/moderate-to-severe OSA evaluated by attended polysomnography. METHODS These are secondary analyses, using data from a cross-sectional study among 269 Greek patients with OSA. Clinical, anthropometric, socioeconomic, and lifestyle data were collected for all participants. Insomnia presence was evaluated through the validated psychometric instrument "Athens Insomnia Scale" (AIS). Adherence to the Mediterranean diet was estimated with the MedDietScale index and physical activity habits were assessed through a validated questionnaire. Backward stepwise multiple logistic regression analysis was used to estimate the association between lifestyle habits (i.e., adherence to the Mediterranean diet and physical activity) and the likelihood of having insomnia, while adjusting for potential confounders. RESULTS Of 269 patients newly diagnosed with OSA (aged 21-70 years; 73% men), 146 (54%) were categorized as having insomnia. In multivariable models, higher adherence to the Mediterranean diet and engagement in physical activity for ≥ 30 min/day were both associated with a lower likelihood of having insomnia (odds ratio (95% confidence intervals): 0.40 (0.18-0.91) and 0.49 (0.28-0.86), respectively). CONCLUSIONS Results add to the limited data on the role of lifestyle in insomnia and should be further explored both in epidemiological and clinical studies.
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Affiliation(s)
- Ioanna Kechribari
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 70 El. Venizelou Street, 17671, Athens, Greece.
| | - Meropi D Kontogianni
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 70 El. Venizelou Street, 17671, Athens, Greece
| | - Michael Georgoulis
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 70 El. Venizelou Street, 17671, Athens, Greece
| | - Kallirroi Lamprou
- Center of Sleep Disorders, 1st Department of Critical Care, "Evangelismos" General Hospital, Athens, Greece
| | - Elena Critselis
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 70 El. Venizelou Street, 17671, Athens, Greece
| | - Emmanouil Vagiakis
- Center of Sleep Disorders, 1st Department of Critical Care, "Evangelismos" General Hospital, Athens, Greece
| | - Nikos Yiannakouris
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 70 El. Venizelou Street, 17671, Athens, Greece.
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Bowden Davies KA, Pickles S, Sprung VS, Kemp GJ, Alam U, Moore DR, Tahrani AA, Cuthbertson DJ. Reduced physical activity in young and older adults: metabolic and musculoskeletal implications. Ther Adv Endocrinol Metab 2019; 10:2042018819888824. [PMID: 31803464 PMCID: PMC6878603 DOI: 10.1177/2042018819888824] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/22/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Although the health benefits of regular physical activity and exercise are well established and have been incorporated into national public health recommendations, there is a relative lack of understanding pertaining to the harmful effects of physical inactivity. Experimental paradigms including complete immobilization and bed rest are not physiologically representative of sedentary living. A useful 'real-world' approach to contextualize the physiology of societal downward shifts in physical activity patterns is that of short-term daily step reduction. RESULTS Step-reduction studies have largely focused on musculoskeletal and metabolic health parameters, providing relevant disease models for metabolic syndrome, type 2 diabetes (T2D), nonalcoholic fatty liver disease (NAFLD), sarcopenia and osteopenia/osteoporosis. In untrained individuals, even a short-term reduction in physical activity has a significant impact on skeletal muscle protein and carbohydrate metabolism, causing anabolic resistance and peripheral insulin resistance, respectively. From a metabolic perspective, short-term inactivity-induced peripheral insulin resistance in skeletal muscle and adipose tissue, with consequent liver triglyceride accumulation, leads to hepatic insulin resistance and a characteristic dyslipidaemia. Concomitantly, various inactivity-related factors contribute to a decline in function; a reduction in cardiorespiratory fitness, muscle mass and muscle strength. CONCLUSIONS Physical inactivity maybe particularly deleterious in certain patient populations, such as those at high risk of T2D or in the elderly, considering concomitant sarcopenia or osteoporosis. The effects of short-term physical inactivity (with step reduction) are reversible on resumption of habitual physical activity in younger people, but less so in older adults. Nutritional interventions and resistance training offer potential strategies to prevent these deleterious metabolic and musculoskeletal effects. IMPACT Individuals at high risk of/with cardiometabolic disease and older adults may be more prone to these acute periods of inactivity due to acute illness or hospitalization. Understanding the risks is paramount to implementing countermeasures.
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Affiliation(s)
| | - Samuel Pickles
- Institute of Ageing and Chronic Disease,
University of Liverpool, Liverpool, UK
- Obesity and Endocrinology Research Group,
Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Victoria S. Sprung
- Research Institute for Sport and Exercise
Science, Liverpool John Moores University, Liverpool, UK
- Institute of Ageing and Chronic Disease,
University of Liverpool, Liverpool, UK
- Obesity and Endocrinology Research Group,
Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Graham J. Kemp
- Institute of Ageing and Chronic Disease,
University of Liverpool, Liverpool, UK
- Liverpool Magnetic Resonance Imaging Centre
(LiMRIC), University of Liverpool, Liverpool, UK
| | - Uazman Alam
- Institute of Ageing and Chronic Disease,
University of Liverpool, Liverpool, UK
- Obesity and Endocrinology Research Group,
Aintree University Hospital NHS Foundation Trust, Liverpool, UK
- Pain Research Institute, University of
Liverpool, Liverpool, UK
- Division of Endocrinology, Diabetes and
Gastroenterology, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Royal
Liverpool and Broadgreen University NHS Hospitals Trust, Liverpool, UK
| | - Daniel R. Moore
- Faculty of Kinesiology and Physical Education,
University of Toronto, Toronto, ON, Canada
| | - Abd A. Tahrani
- Institute of Metabolism and Systems Research,
College of Medical and Dental Sciences, University of Birmingham,
Birmingham, UK
- Centre of Endocrinology, Diabetes and
Metabolism (CEDAM), Birmingham Health Partners, Birmingham UK
- Department of Diabetes and Endocrinology,
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Daniel J. Cuthbertson
- Institute of Ageing and Chronic Disease,
University of Liverpool, Liverpool, UK
- Obesity and Endocrinology Research Group,
Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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